Teaching Biomedical Statistics to Nurse-Practitioners in Sub-Saharan Africa—The Example of “Intention to Treat” Shows Our Challenges and Dilemmas
Affiliation(s)
1 Department of Anaesthesia and Intensive Care, College of Medicine, University of Malawi, Blantyre, Malawi. 2 Department of Obstetrics, College of Medicine, University of Malawi, Blantyre, Malawi.
1 Department of Anaesthesia and Intensive Care, College of Medicine, University of Malawi, Blantyre, Malawi. 2 Department of Obstetrics, College of Medicine, University of Malawi, Blantyre, Malawi.
ABSTRACT
Introduction: African nurse practitioners experience specific challenges, when faced with complex clinical trials implemented in their country. Method: Teaching challenges for African nurse practitioners were extracted from courses we conducted in Malawi. Participants attending the courses were nurse practitioners at various stages of their education ranging from nurses and medical assistants to the clinical officer with a BSc degree. Results: We identified four dilemmas for our participants: the “Taliban dilemma”, the “significance dilemma”, the “drop-out dilemma” and the “reality dilemma”. These dilemmas lead to five teaching challenges in the African context. Challenges in the context are theoretical complexity, imposed opinions, hierarchical implications, African enthusiasm and mysticism. Conclusions: The nurse practitioners, working in remote district hospitals need specific support to be able to scrutinize research papers which are meant to be implemented in their hospitals in order to secure their cooperation and dedication.
Introduction: African nurse practitioners experience specific challenges, when faced with complex clinical trials implemented in their country. Method: Teaching challenges for African nurse practitioners were extracted from courses we conducted in Malawi. Participants attending the courses were nurse practitioners at various stages of their education ranging from nurses and medical assistants to the clinical officer with a BSc degree. Results: We identified four dilemmas for our participants: the “Taliban dilemma”, the “significance dilemma”, the “drop-out dilemma” and the “reality dilemma”. These dilemmas lead to five teaching challenges in the African context. Challenges in the context are theoretical complexity, imposed opinions, hierarchical implications, African enthusiasm and mysticism. Conclusions: The nurse practitioners, working in remote district hospitals need specific support to be able to scrutinize research papers which are meant to be implemented in their hospitals in order to secure their cooperation and dedication.
Cite this paper
Pollach, G. , Graf, U. and Place, D. (2014) Teaching Biomedical Statistics to Nurse-Practitioners in Sub-Saharan Africa—The Example of “Intention to Treat” Shows Our Challenges and Dilemmas. International Journal of Clinical Medicine, 5, 1221-1227. doi: 10.4236/ijcm.2014.519156.
Pollach, G. , Graf, U. and Place, D. (2014) Teaching Biomedical Statistics to Nurse-Practitioners in Sub-Saharan Africa—The Example of “Intention to Treat” Shows Our Challenges and Dilemmas. International Journal of Clinical Medicine, 5, 1221-1227. doi: 10.4236/ijcm.2014.519156.
References
[1] Holmes, K.Y. and Dodd, B.A. (2012) Teaching Statistics Using Classic Psychology Research: An Activities-Based Approach. Teaching Statistics, 34, 13-17.
http://dx.doi.org/10.1111/j.1467-9639.2011.00499.x [2] Maitland, K., Kiguli, S., Opoka, R.O., et al. (2011) Mortality after Fluid Bolus in African Children with Severe Infection. New England Journal of Medicine, 364, 2483-2495.
http://dx.doi.org/10.1056/NEJMoa1101549 [3] Montori, V.M. and Guyatt, G.H. (2001) Intention-to-Treat-Principle. CMAJ, 165, 1339-1341. [4] Ruiz-Canela, M., Martinez-Gonzalez, M.A. and de Irala-Estevez, J. (2000) Intention to Treat Analysis Is Related to Methodological Quality. BMJ, 320, 1007-1008.
http://dx.doi.org/10.1136/bmj.320.7240.1007 [5] Hollis, S. and Campbell, F. (1999) What Is Meant by Intention to Treat Analysis? Survey of Published Randomized Controlled Trials. BMJ, 319, 670-674.
http://dx.doi.org/10.1136/bmj.319.7211.670 [6] Montedori, A., Bonacini, M.I., Casazza, G., Luchetta, M.L., Duca, P., Cozzolino, F. and Abraha, I. (2011) Modified versus Standard Intention-to-Treat Reporting: Are There Differences in Methodological Quality, Sponsorship, and Findings in Randomized Trials? A Cross-Sectional Study. Trials, 12, 58.
http://dx.doi.org/10.1186/1745-6215-12-58 [7] Dallal, G.E. (1998) The Little Handbook of Statistical Practice.
www.jerrydallal.com/LHSP/LHSP.HTM [8] Gupta, S. (2011) Intention-to-Treat Concept: A Review. Perspectives in Clinical Research, 2, 109-112.
http://dx.doi.org/10.4103/2229-3485.83221 [9] Schulz, K.F., Grimes, D.A., Altman, D.G. and Hayes, R.J. (1996) Blinding and Exclusions after Allocation in Randomised Controlled Trials: Survey of Published Parallel Group Trials in Obstetrics and Gynaecology. BMJ, 312, 742-744.
http://dx.doi.org/10.1136/bmj.312.7033.742 [10] Schulz, K.F. and Grimes, D.A. (2002) Sample Size Slippages in Randomised Trials: Exclusions and the Lost and Wayward. Lancet, 359, 781-785.
http://dx.doi.org/10.1016/S0140-6736(02)07882-0 [11] European Coronary Surgery Study Group (1979) Coronary-Artery Bypass Surgery in Stable Angina Pectoris. Survival at Two Years. Lancet, 313, 889-893.
http://dx.doi.org/10.1016/S0140-6736(79)91372-2 [12] Pollach, G. (1994) Personal Experiences in Kismayo General Hospital. Kismayo, Somalia. [13] Tamura, H. (1990) Modelling of Statistical Investigation. Teaching Statistics, 12, 84-85. [14] Schiffner, R., Schiffner-Rohe, J., Gerstenhauer, M., Hofstädter, F., Landthaler, M. and Stolz, W. (2001) Differences in Efficacy between Intention-to-Treat and Per-Protocol Analyses for Patients with Psoriasis Vulgaris and Atopic Dermatitis: Clinical and Pharmacoeconomic Implications. British Journal of Dermatology, 144, 1154-1160.
http://dx.doi.org/10.1046/j.1365-2133.2001.04234.x [15] Horwitz, R., Viscoli, C., Donaldson, R.M., Murray, C.J., Ransohoff, D.F., Berkman, L., et al. (1990) Treatment Adherence and Risk of Death after Myocardial Infarction. The Lancet, 336, 542-545.
http://dx.doi.org/10.1016/0140-6736(90)92095-y [16] Deng, C.Q. (2014) Intention-to-Treat and Modified Intention-to-Treat Analysis in Clinical Trials. PPD Development Research Triangle Park, NC 27560.
http://webspace.webring.com/people/eu/um3826/ITT JSM2004.ppt [17] Piaggio, G., Elbourne, D.R., Altmann, D.G., Pocock, S.J. and Evans, S.J., CONSORT Group (2006) Reporting of Non-Inferiority and Equivalence Randomized Trials: An Extension of the CONSORT Statement. JAMA, 295, 1152-1160.
http://dx.doi.org/10.1001/jama.295.10.1152 [18] Williams, A.S. (2012) Statistics Anxiety and Instructor Immediacy. Journal of Statistics Education, 18, 1-18.
http://www.amstat.org/publications/jse/v18n2/williams.pdf [19] Wagler, A. and Wagler, R. (2013) Randomizing Roaches: Exploring the “Bugs” of Randomization in Experimental Design. Teaching Statistics, 36, 13-20. [20] Derry, S., Levin, J.R., Osana, H.P., Jones, M.S. and Peterson, M. (2000) Fostering Students Statistical and Scientific Thinking: Lessons Learned from an Innovative College Course. American Educational Research Journal, 37, 747-773.
http://dx.doi.org/10.3102/00028312037003747 [21] Sawilowsky, S.S. (2004) Teaching Random Assignment: Do You Believe It Works? Journal of Modern Applied Statistical Methods, 3, 221-226. [22] Molyneux, C.S., Wassenaar, D.R., Peshu, N. and Marsh, K. (2005) “Even If They Ask You to Stand by a Tree All Day, You Will Have to Do It (Laughter)…!”: Community Voices on the Notion and Practice of Informed Consent for Biomedical Research in Developing Countries. Social Science & Medicine, 61, 443-454.
http://dx.doi.org/10.1016/j.socscimed.2004.12.003 [23] Lu, Y. and Henning, K.S.S. (2012) Are Statisticians Cold-Blooded Bosses? A New Perspective on the “Old” Concept of Statistical Population. Teaching Statistics, 35, 66-71.
http://dx.doi.org/10.1111/j.1467-9639.2012.00524.x [24] Chance, B.L. (2002) Components of Statistical Thinking and Implications for Instruction and Assessment. Journal of Statistics Education, 10, 1-18.
[1] Holmes, K.Y. and Dodd, B.A. (2012) Teaching Statistics Using Classic Psychology Research: An Activities-Based Approach. Teaching Statistics, 34, 13-17.
http://dx.doi.org/10.1111/j.1467-9639.2011.00499.x [2] Maitland, K., Kiguli, S., Opoka, R.O., et al. (2011) Mortality after Fluid Bolus in African Children with Severe Infection. New England Journal of Medicine, 364, 2483-2495.
http://dx.doi.org/10.1056/NEJMoa1101549 [3] Montori, V.M. and Guyatt, G.H. (2001) Intention-to-Treat-Principle. CMAJ, 165, 1339-1341. [4] Ruiz-Canela, M., Martinez-Gonzalez, M.A. and de Irala-Estevez, J. (2000) Intention to Treat Analysis Is Related to Methodological Quality. BMJ, 320, 1007-1008.
http://dx.doi.org/10.1136/bmj.320.7240.1007 [5] Hollis, S. and Campbell, F. (1999) What Is Meant by Intention to Treat Analysis? Survey of Published Randomized Controlled Trials. BMJ, 319, 670-674.
http://dx.doi.org/10.1136/bmj.319.7211.670 [6] Montedori, A., Bonacini, M.I., Casazza, G., Luchetta, M.L., Duca, P., Cozzolino, F. and Abraha, I. (2011) Modified versus Standard Intention-to-Treat Reporting: Are There Differences in Methodological Quality, Sponsorship, and Findings in Randomized Trials? A Cross-Sectional Study. Trials, 12, 58.
http://dx.doi.org/10.1186/1745-6215-12-58 [7] Dallal, G.E. (1998) The Little Handbook of Statistical Practice.
www.jerrydallal.com/LHSP/LHSP.HTM [8] Gupta, S. (2011) Intention-to-Treat Concept: A Review. Perspectives in Clinical Research, 2, 109-112.
http://dx.doi.org/10.4103/2229-3485.83221 [9] Schulz, K.F., Grimes, D.A., Altman, D.G. and Hayes, R.J. (1996) Blinding and Exclusions after Allocation in Randomised Controlled Trials: Survey of Published Parallel Group Trials in Obstetrics and Gynaecology. BMJ, 312, 742-744.
http://dx.doi.org/10.1136/bmj.312.7033.742 [10] Schulz, K.F. and Grimes, D.A. (2002) Sample Size Slippages in Randomised Trials: Exclusions and the Lost and Wayward. Lancet, 359, 781-785.
http://dx.doi.org/10.1016/S0140-6736(02)07882-0 [11] European Coronary Surgery Study Group (1979) Coronary-Artery Bypass Surgery in Stable Angina Pectoris. Survival at Two Years. Lancet, 313, 889-893.
http://dx.doi.org/10.1016/S0140-6736(79)91372-2 [12] Pollach, G. (1994) Personal Experiences in Kismayo General Hospital. Kismayo, Somalia. [13] Tamura, H. (1990) Modelling of Statistical Investigation. Teaching Statistics, 12, 84-85. [14] Schiffner, R., Schiffner-Rohe, J., Gerstenhauer, M., Hofstädter, F., Landthaler, M. and Stolz, W. (2001) Differences in Efficacy between Intention-to-Treat and Per-Protocol Analyses for Patients with Psoriasis Vulgaris and Atopic Dermatitis: Clinical and Pharmacoeconomic Implications. British Journal of Dermatology, 144, 1154-1160.
http://dx.doi.org/10.1046/j.1365-2133.2001.04234.x [15] Horwitz, R., Viscoli, C., Donaldson, R.M., Murray, C.J., Ransohoff, D.F., Berkman, L., et al. (1990) Treatment Adherence and Risk of Death after Myocardial Infarction. The Lancet, 336, 542-545.
http://dx.doi.org/10.1016/0140-6736(90)92095-y [16] Deng, C.Q. (2014) Intention-to-Treat and Modified Intention-to-Treat Analysis in Clinical Trials. PPD Development Research Triangle Park, NC 27560.
http://webspace.webring.com/people/eu/um3826/ITT JSM2004.ppt [17] Piaggio, G., Elbourne, D.R., Altmann, D.G., Pocock, S.J. and Evans, S.J., CONSORT Group (2006) Reporting of Non-Inferiority and Equivalence Randomized Trials: An Extension of the CONSORT Statement. JAMA, 295, 1152-1160.
http://dx.doi.org/10.1001/jama.295.10.1152 [18] Williams, A.S. (2012) Statistics Anxiety and Instructor Immediacy. Journal of Statistics Education, 18, 1-18.
http://www.amstat.org/publications/jse/v18n2/williams.pdf [19] Wagler, A. and Wagler, R. (2013) Randomizing Roaches: Exploring the “Bugs” of Randomization in Experimental Design. Teaching Statistics, 36, 13-20. [20] Derry, S., Levin, J.R., Osana, H.P., Jones, M.S. and Peterson, M. (2000) Fostering Students Statistical and Scientific Thinking: Lessons Learned from an Innovative College Course. American Educational Research Journal, 37, 747-773.
http://dx.doi.org/10.3102/00028312037003747 [21] Sawilowsky, S.S. (2004) Teaching Random Assignment: Do You Believe It Works? Journal of Modern Applied Statistical Methods, 3, 221-226. [22] Molyneux, C.S., Wassenaar, D.R., Peshu, N. and Marsh, K. (2005) “Even If They Ask You to Stand by a Tree All Day, You Will Have to Do It (Laughter)…!”: Community Voices on the Notion and Practice of Informed Consent for Biomedical Research in Developing Countries. Social Science & Medicine, 61, 443-454.
http://dx.doi.org/10.1016/j.socscimed.2004.12.003 [23] Lu, Y. and Henning, K.S.S. (2012) Are Statisticians Cold-Blooded Bosses? A New Perspective on the “Old” Concept of Statistical Population. Teaching Statistics, 35, 66-71.
http://dx.doi.org/10.1111/j.1467-9639.2012.00524.x [24] Chance, B.L. (2002) Components of Statistical Thinking and Implications for Instruction and Assessment. Journal of Statistics Education, 10, 1-18.