Unmasking the Practices of Nurses and Intercultural Health in Sub-Saharan Africa: A Useful Way to Improve Health Care?

In 2001 and 2013, the World Health Organization (WHO) published the WHO Traditional Medicine Strategy 2002-2005 and 2014-2023, respectively, to address policy, ethics, quality, and integration of complementary health therapies (CHT). Despite the adoption of these strategic frameworks, sub-Saharan African (SSA) countries largely run dualistic and inclusive health care system. A recent article published in Complementary Therapies in Clinical Practice analyzed the role of practicing nurses in CHT integration and intercultural health in an SSA country setting. Drawing on the Complementary and Alternative Medicine Health Belief Questionnaire, the study specifically examined nurses' knowledge, practices, and attitudes toward CHT. The study revealed that nurses had low knowledge about CHT, which reflected in their ineptitude to engage in professional practices of CHT. In spite of the knowledge deficit, nurses generally held favorable attitudes toward CHT and the majority supported the need for "safe" and evidence-based integrative model. Efforts to improve CHT-related knowledge of nurses may enhance medical integration in SSA. This commentary proposes novel political will and investment in CHT education and research as well as an inclusion of CHT modules in the nurses' training programs; viabilities to achieve intercultural health and improved care in SSA.

Complementary Health Therapies: Classification and Global Utilization Trends

Already today the acceptance and utilization of complementary health therapies (CHT) appear a major health care consideration in both richer and low-income countries around the world, and there is little doubt that the topic will rise further on public health and social policy agendas. In her introductory remarks to the WHO Traditional Medicine Strategy 2014-2023, Dr Margaret Chan described the potential role and significance of CHT and why governments and health care leaders should invest in its development through scientific research and intercultural health care paradigm—“practices and approaches in health care that tie indigenous medicine and biomedicine, where both are considered as complementary.”[1-3]

CHT refers to a broad set of health care approaches, practices, knowledge, beliefs, and products that are neither part of a country’s own health care tradition nor fully integrated into the dominant national health system.[1,4] The National Center for Complementary and Integrative Health recently classified CHT under wide-ranging parent modalities: biologically based therapies (such as herbal medicines and nutritional supplements), mind-body approaches (such as meditation and yoga), manipulative therapies (such as chiropractic and massage), energy therapies (such as biofeedback technique, therapeutic touch, and reiki) and whole medical methods (such as naturopathy and ayurveda).[5,6] These approaches of CHT are being accessed in dealing with a variety of disease burden and to manage health among populations. CHT improves emotional and physical well-being, vitalizes immunity, reduces the side effects of some conventional therapies, and also improves life satisfaction[7,8] and therefore have implications for public health in sub-Saharan Africa (SSA).

Although CHT has existed since long, there is compelling evidence that the past few decades have seen a remarkable growth in the global interest in CHT with proven instances in ensuring quality of life of many people, both adults and infants/children.[4,9] The recent years have also witnessed an upsurge in CHT use among older persons in particular, given an unprecedented aging of the global population and the associated widespread functional disabilities, noncommunicable conditions as well as deferring mental/psychological health challenges.[10] Indeed, the wide-ranging and increasing prevalence of CHT uptake among populations with diverse socioeconomic and cultural characteristics have been recognized and well documented in social and complementary health–related literature.[1,11-15]

Specifically, while more than 100 million consumers use CHT in Europe,[1] the National Center for Complementary and Integrative Health[4] estimates that about two in five adults and one in every nine children patronize some forms of CHT in the United States. Attention to CHT is also ever increasing in other high-income countries where conventional medicine is almost predominant in the national health care system. For example, the World Health Organization[1] estimates that between 60% and 86% of the respective populations in the Republic of Korea, Singapore, Hong Kong, Australia, and Japan, commonly rely on CHT. More important, the World Medicines Situation report suggests that between 70% and 95% of the populations in low- and middle-income countries turn to various forms of CHT and that every culture in these contexts almost thrives on certain CHT products and practices.[1] In countries such as Vietnam and Greater China where CHT is often an integral part of the health system, as many as 9 in 10 individuals have ever received CHT for various reasons. In SSA, various independent national surveys report about 90% of people of Ethiopia and Burundi, 85% South Africans, 75% Malians, 70% Rwandans, Beninese, and Ghanaians depend on CHT for primary care needs[16,17] particularly in the wake of escalating health care costs and perceived adverse events of some conventional therapies.

Despite the almost wholesale utilization rates, health care practitioners and users over the years have been wrestling about the conflicting evidence of the efficacy, safety and quality of many CHT products and practices, particularly in SSA. The urgency to ensure consumer’s safety from CHT care has resulted in legislation being passed to at least professionalize and streamline CHT practices in many countries.[18] The WHO Traditional Medicine Strategy 2014–2023 was, therefore, developed to encourage and support all member countries in harnessing the potential contribution of CHT to health and patient-centered care. The framework was designed to promote safe and effective use of CHT through regulation and a cohesive approach to intercultural health[1,11] especially in SSA, where formal health systems are often constrained by inequitable access and inadequate funding.

Nurses and the Intercultural Health in SSA

Intercultural health care is arguably one of the most commonly conjured pathways and the best practices to robust health care delivery[7,19]; it is a cornerstone of well-being and health status[20] in which healthy population and economic development evaluations interconnect. In the past few years, many SSA countries, like other low- and middle-income countries, adopted and experimented with certain levels of integration between CHT and mainstream national health system. Nevertheless, these countries appear to practice medical coexistence rather than a truly integrative medical system.[20] Indeed, medical integration agendas in SSA need to take cognizance of individual- and institutional-level participation as well as culturally acceptable care provided by health care professionals and nurses in particular who are often in direct link with patients.[21] Most integrative policy frameworks in SSA appear purposeful but lack real quality.

Research has shown that experiences and knowledge on, a positive attitude to, and professional practice of CHT modalities among nurses and some other health care professionals may be critical in achieving intercultural health care policies in SSA.[7,11,20] Nurses, therefore, play a critical role in providing credible medical information to patients. Nurses are required to be adequately informed with sufficient understanding and knowledge about CHT therapies toward intercultural health care delivery. Indeed, understanding the knowledge and attitude toward health care professionals about CHT is a critical step toward successful execution of intercultural health policy. In this regard, based on the Complementary and Alternative Medicine Health Belief Questionnaire (CHBQ). Gyasi et al[7,11] in recent seminal articles published in volume 29 of Complementary Therapies in Clinical Practice, and volume 24 of Journal of Complementary and Alternative Medine respectively interrogated the knowledge bases, personal and professional practices, and attitudes toward CHT integration among registered nurses for the first time in a predominantly urban SSA context.

Based on the compelling findings, practicing nurses in SSA generally do not reveal adequate knowledge on the various approaches of CHT and, therefore, lack the confidence to advise clients in CHT methods. This reflected in an overall poor personal and professional practices of CHT by the nurses (Table 1). This provides credence to the chronic dearth of incorporation of theoretical and practical modules of CHT therapies in nursing education and training programs in SSA despite the view that nursing practice is prerequisite for a successful implementation of intercultural health care policy. Although reports from the United States and Italy[22] indicate burgeoning knowledge of nurses on CHT, the limited CHT-related knowledge among nurses has also been shown in some other richer countries, including Australia[23] and the United Kingdom[24] particularly in relation to key benefits and the adverse advent of CHT methods mostly used by patients. Unfortunately, the current levels of CHT education in medical schools especially in SSA are not adequately positioned to enable CHT-related knowledge development among nurses. Therefore, there is the need for a comprehensive CHT education in SSA medical curricula.

Table 1.

Knowledge, Practices, and Attitude Toward Complementary Health Therapies.a

Variable	% (n = 210)	Performance Score, Mean ± SD
Knowledge		38.39 ± 10.11
High	4.3
Medium	50.5
Low	45.2
Personal practices		32.97 ± 10.78
High	3.3
Medium	30.0
Low	66.7
Professional practices		33.14 ± 10.35
High	9.0
Medium	32.4
Low	58.6
Attitude		72.78 ± 12.50
Positive	68.6
Indifferent	6.2
Negative	25.2

aSource: Gyasi et al.[7]

Interestingly, Gyasi et al[7] noted significantly positive relationships of CHT-related knowledge and professional and personal practices of CHT among nurses in the SSA context (Figures 1 and 2). In addition, nurses with higher nursing educational training (degree and beyond) exhibited higher CHT-related knowledge. These findings suggest that nursing education and training on CHT seem important to improve nurses’ knowledge and nursing practices of CHT. It has been argued that incorrect dispensing of therapies and medical errors due to low knowledge levels of nurses may lead to poor health outcomes.[3,11,25] Nursing education programs and curricula in SSA, need a rigorous review to embrace detailed CHT modules. This may serve as a critical link in a chain of interventions needed for ensuring safe and effective use of common CHT methods for intercultural health care. Adaptation of this framing by the health policy makers and implementers in SSA may provide fertile grounds to empowering nurses in clinical practices of CHT.

Figure 1.

Correlation of nurses’ knowledge and professional practices of complementary health therapies (CHT). Source: Gyasi et al. [7,11]

Figure 2.

Correlation of nurses’ knowledge and personal practices of complementary health therapies (CHT). Source: Gyasi et al. [7,11]

Perhaps counterintuitive to the low knowledge and practices of CHT, the nurses demonstrated an overwhelming performance attitudinal score suggesting a favorable attitude toward CHT (Table 1) especially in relation to the efficacy dimension. Increasingly also, nurses assumed many of the CHT strategies as “safe” and constitute an integral part of their family- and cultural- health circumstances, perhaps due to the view that CHT is natural, and to a larger extent, neutral.[3] The general positive attitudes and perceptions of CHT among practicing nurses in the SSA context were also recently confirmed by some richer country studies.[26,27] More important, the nurses expressed keen interest in the integration of CHT into the formal mainstream health care systems and the majority strongly endorsed any immediate intercultural health practices with a holistic view of health. Moreover, like the formal health training course structure, nurses opted to be offered the required training modalities which may adequately improve their CHT-related knowledge and routine practices of CHT strategies in nurses’ training schools, colleges, and universities.

Conclusions

Nurses showed CHT-related knowledge deficits and poor CHT practices but they held positive attitudes toward CHT. However, these positive attitudes are microlevel subjective opinions which may lack the potency to directly elicit evidence-based interventions in CHT integration. Goodwill of the government and health care leaders in policy to improve CHT education among nurses may lead to the desired intercultural health in SSA. Moreover, I argue for the need to further explore the ethics, safety, and quality control issues of CHT. Pharmacological research, standardization and clinical practice guidelines for CHT are required to strengthen nurses’ confidence and drive to recommend CHT to improve patients’ health in the spirit of intercultural health care in SSA.