Abstract
Background: In the context of Africa and other resource-limited settings, there is a necessity to address the unique challenges faced by dysphagic patients and to better understand how healthcare professionals, including speech language pathologists (SLPs), can provide contextually and culturally responsive care given our unique healthcare context.
Objectives: Therefore, this scoping review aims to map and synthesise evidence relating to dysphagia research in Africa to understand trends as well as research and clinical gaps.
Method: An electronic search of CINAHL, Medline, Academic Search Premier, Global Health, PubMed was conducted in May 2024. Peer-reviewed, English-language articles published between 2015 and 2024 were retrieved. A total of 627 articles were screened, and 61 were included in the final review.
Results: Broadly, 60.7% of the articles stemmed from SA with 62.3% being conducted by SLPs. The articles predominantly focused on practice (n = 39, 63.9%) but also looked at aspects around prevalence, screening, assessment and teaching and learning. Research on dysphagia in Africa highlights the diverse patient populations affected by the condition and the need for interdisciplinary work.
Conclusion: There is a strong trend towards patient descriptions and the need for describing local data and developing tools that are appropriate for our contexts, but the gaps strongly highlight the need for multidisciplinary involvement in dysphagia, which is not being conducted.
Contribution: This study provides some insight into research being conducted in the African continent, including current trends and areas of future research.
Keywords: Africa; dysphagia; scoping review; speech therapy; South Africa.
Introduction
Dysphagia is recognised as a significant global health issue, affecting an estimated 8% of the world’s population (Rajati et al., 2022). The systematic review by Rajati et al. (2022) indicated that Africa has the highest prevalence of oropharyngeal dysphagia with a 64% prevalence rate. This is a significant statistic. Dysphagia (both developmental and acquired) affects 16%–23% of the general population globally, rising to 27% in those over 76 years (Clavé & Shaker, 2015; Lefton-Greif et al., 2024; Smithard, 2016). Dysphagia is heterogeneous and can result from a variety of medical conditions. For South Africa, there is a quadruple burden of disease profile, which depicts the general landscape of the most prevalent health conditions, including communicable diseases, non-communicable diseases, trauma and violence-related injuries as well as maternal and child health aspects (Pillay-van Wyk et al., 2016). These conditions can all result in the development of dysphagia but the lack of prevalence data limits the true understanding of the impact (Mophosho & Lydall, 2023; Said et al., 2023). Similar challenges can be assumed for other African countries. Prevalence data for dysphagia are not available for African countries, although recent studies have shown that the prevalence of dysphagia is similar to the global context, if not higher in African countries (Jayes et al., 2024; Rajati et al., 2022).
Given that the medical sequelae of dysphagia are significant, which can lead to an increase in hospital stay, decreased quality of life for the patient and possibly even death, it must be assessed and managed timeously and effectively (Coutts, 2019). Typically, the speech language therapist (SLT) is the primary medical team member to assess and manage the dysphagia but because of its heterogeneity, it cannot be managed in isolation (Rumbach et al., 2016). How the SLT works within a larger multidisciplinary team (MDT) within the African context is not yet understood and is aimed to be explored within this review. Given the complexities of resource scarcity in the healthcare context in Africa, our decision-making paradigms and practice patterns differ greatly from the Global North, and thus research from these areas cannot be directly transferred to our context; therefore, creating the need for contextualised research to ensure that our practices are relevant and responsive Pillay & Kathard, 2015. This contextual responsiveness is also an aim of this review.
A further contextual complication is that Africa remains the poorest continent globally (Maathai, 2010), which significantly impacts its healthcare system, patients and staffing. On a larger scale, Africa represents 11%–13% of the world’s population and bears a disproportionate 24% of the global disease burden (Azevedo, 2017). As a result, only 3% of the global health workforce is based in Africa, yet they are responsible for serving over 24% of the population (Hollingworth et al., 2023). In South Africa particularly, 82% of the population requires the use of the public healthcare system, yet the majority of healthcare workers work in the private sector (STATSSA, 2018). This imbalance negatively affects the identification and efficient practice of dysphagia management in this context. Therefore, these contextual restraints further support the need for understanding how dysphagia is researched and practiced in this context.
Looking at the International Classification of Functioning (World Health Organization, 2002), eating forms an intricate part of not only an individual’s physiology to sustain life but is also part of their culture and religion. If their ability to swallow has been affected, this has serious and often negative impacts on their daily functioning as members of a family and their community engagement as well as impacts on their caregivers (Solomon & Coutts, 2020). Given the vastness of cultures and religions in Africa and the role that food plays in each of them, this needs to be considered by healthcare practitioners who work in dysphagia. Threats (2007) discusses how the ICF can be used to better understand the impact of dysphagia on the functioning of an individual. Eating and drinking are important activities intrinsically tied to identity and community (Leslie & Lisiecka, 2020). Across societies, people have different understandings and considerations around meal preparation, eating and aspects around ceremonies and dining experiences. An example of this is the cultural manifestations of palliative care and its influence on dysphagia management – particularly post stroke. In many African cultures, there are different reasons a person may refuse to eat which could be linked to spiritual or religious reasons, and this may impact on the ways in which counselling and treatment are being provided, particularly considerations around diet modifications and tube feeding (Grant et al., 2011). Therefore, in a culturally and religiously diverse setting such as Africa, these aspects need to be taught and considered as part of the assessment and management of dysphagia to manage a patient ethically and holistically.
Given this backdrop, there is a necessity to address the unique challenges faced by dysphagic patients and to better understand how SLTs together with the MDT can provide contextually responsive care within our unique and often challenging context (Jayes et al., 2024). Understanding current research trends is critical to developing standardised practices for teaching, assessing and managing dysphagia in Africa. This knowledge can lead to improved outcomes for individuals with dysphagia and contribute to the global understanding of this condition. Therefore, this scoping review aims to map and synthesise evidence of dysphagia research in Africa to understand our current research trends as well as clinical and teaching gaps.
Research methods and design
A scoping review methodology as suggested by Arksey and O’Malley (2005) was chosen, given the research aim. This framework involves five stages: (1) identifying the research question, (2) identifying relevant studies, (3) study selection, (4) charting the data and (5) collating, summarising and reporting the results used to conduct the scoping review. An ethics waiver was received from the University of the Witwatersrand.
The primary aim was to generate a comprehensive scoping review of research that has been conducted in Africa between 2015 and 2024. The objectives were to determine current clinical as well as teaching and learning trends regarding dysphagia in Africa and to highlight any gaps or areas of future research. The studies that were included in this review needed to meet the following inclusion criteria: published between 2015 and 2024 in accredited peer-reviewed journals, preferably printed in English, studies needed to be conducted in Africa and needed to have a primary focus on dysphagia. Studies could have been conducted by any profession and in any healthcare context.
Data sources and search strategy
A systematic electronic search for articles was conducted in May 2024 by Dr Skye Adams and Dr Kim Coutts, and all articles until then were included. Six databases were used: CINAHL, Medline, Academic Search Premier, Global Health, PubMed, as well as the first five pages of Google Scholar. The databases were chosen as they were most likely to have publications related to the topic. While Medline and PubMed both provide access to biomedical and health-related research, they differ in scope and indexing. Both databases were included to ensure no relevant records were overlooked, particularly pre-publication articles available on PubMed. To maintain a systematic and replicable approach, the Google Scholar search strategy involved screening the first five pages of results for each search term combination, as research indicates that most relevant and high-quality results are captured within this range. The search strategy, encompassing all identified keywords and index terms, was customised for each database or information source. BOOLEAN operators (AND and OR) as well as truncation were used in the search strings using subject headings (MeSH), and keywords with proximity operators, respectively. The search strategy included subject headings for dysphagia (MeSH) in PubMed and either subject headings for countries and continents or country names. Some articles contained authors from multiple countries or regions within one paper. However, the countries had to be clearly delineated to be included and therefore, it was possible to have an article that had multiple countries or regions.
Study selection
The current review included published peer-reviewed journal articles, was limited to primary study designs (qualitative, quantitative and mixed-method approaches) and excluded grey literature, other reviews and non-academic sources. Grey literature and non-academic sources were excluded from the study to ensure the use of high-quality, reliable and peer-reviewed academic sources, maintaining focus and reproducibility within the constraints of time and resources.
Following the database searches conducted in June 2024 (SNA), all identified peer-reviewed results were collated and uploaded into Mendeley. All duplicates were removed. The initial search results yielded the following results: PubMed (n = 175), Medline (n = 126), CINAHL allied and nursing (n = 34), Global Health (n = 55), Academic Search Premier (n = 58), African Journal Archive (139) and Google Scholar articles from the first five pages (n = 40). Titles and abstracts were screened by two independent reviewers (K.C. and S.N.A.), with an additional reviewer providing an independent secondary review for assessment against the inclusion and exclusion criteria. Peer-reviewed results that did not meet the inclusion criteria were excluded. Articles were excluded if they did not focus on dysphagia (e.g. articles focused on stroke or nutritional intake only), were not conducted in Africa or were other systematic/scoping review methodologies. Any disagreements that arose between the reviewers were resolved through discussion and input from an independent reviewer until consensus was achieved. An iterative approach to study screening and selection was employed to emphasise a more inclusive final list of studies where after each round of screening, the authors met to provide feedback, and any adjustments were made. All articles were accessed electronically.
Quality assurance
Quality was assessed using Quality Assessment for Diverse Studies (QuADS) to assess the methodological quality of the included studies whether qualitative, quantitative or mixed designs (Harrison et al., 2021). The QuADS is composed of 13 items for mixed methodology. Each study is scored on every item (0 = not at all; 1 = very slightly; 2 = moderately; and 3 = complete), and the total score was subsequently converted into a percentage. The QuADS was used as it allows for a comparison between the diverse methodologies used by providing a mean score. This method was selected for its reliability and validity when assessing the quality of diverse study designs. The QuADS is also the only tool that can be applied to mixed designs. Both investigators (K.C. and S.N.A.) assessed the quality of the included studies using the QuADS. Any discrepancy was discussed, and a consensus was reached.
The QuADS tool (Online Appendix Table 1-A1) revealed varying levels of quality. The average rating for the articles was 57% with a maximum of 92% and minimum of 18%. The authors noted that perhaps the quality of the articles was slightly lower because of the journal requirements and limited word counts, thus reducing some of the rationales needed in the methodology. Case studies had the lowest scores. Additionally, many studies may have been exploratory in nature, focusing on emerging themes without robust validation of tools or methods. The QuADS tool did not allow for adequate methodological quantification for these types of studies as it is more of a quantitative-focused tool. This also could have contributed to the lower quality outcomes. In the African context, resource limitations, the absence of standardised tools and the reliance on subjective assessments could also contribute to lower QuADS scores. Therefore, all studies were included regardless of their score.
Charting the data
The data charting template was created by K.C. and S.N.A. The data extracted included specific details about the study objectives to highlight current trends, gaps and future directions. The initial draft of the chart underwent a pilot test using three randomly selected articles. These were reviewed independently by each author, and with the support of an independent reviewer. Following minor revisions based on the pilot test feedback, the finalised chart was then used independently by both reviewers. Agreement between the two reviewers was 90% during the screening process. Any disagreements were resolved by consensus. As a scoping review methodology is iterative, this allowed for an adjustment to be made regarding the inclusion of relevant studies during consensus discussions (Levac et al., 2010).
Collating, summarising and reporting the results
After extraction, the findings from the included studies were separated, grouped, abstracted and categorised into themes. Independent categorisation based on the study objectives, challenges and supports was conducted by the two reviewers. A content thematic analysis was conducted using Braun and Clark’s framework (Braun & Clarke, 2006). Two reviewers extracted information from each article, grouped and labelled findings, categorised themes and summarised general trends on research in dysphagia in Africa. The broad themes were related to the objectives of the study. The authors developed a code book (x) that provided different codes and descriptions, showing the relevant articles and the frequency of each code. Similar codes were then collated and organised into themes and sub-themes. Prominent themes from the reviewers were then selected, relabelled and finalised after a comprehensive review and discussion between both reviewers.
Ethical considerations
This article followed all ethical standards for research without direct contact with human or animal subjects.
Results
This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) (Moher et al., 2009). The initial search yielded 627 articles, and 333 duplicates were removed. No new articles were found through the review of the reference lists. Then, 294 article titles and abstracts were screened for relevance, and 176 were excluded for the following reasons: focus was not on dysphagia, not from Africa, used a review methodology. The full texts of 79 articles were then screened for eligibility, and 61 articles were included in the final review (Figure 1).
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FIGURE 1: Preferred reporting items for systematic reviews and meta-analysis flow diagram for scoping reviews (PRISMA-ScR). |
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Characteristics of the included studies
A summary of all articles is presented in Table 1. Articles were from seven different countries (see Figure 2). More than half were from South Africa (n = 37, 60.7%), whilst others were from Egypt, Namibia, Tunisia, Burkina Faso, Kenya, and Nigeria. South Africa and Egypt appear to contribute the most to dysphagia research in Africa, with other countries contributing less frequently. The majority of studies were written by SLTs (n = 38, 62.3%), with the others being written by different specialists in the field of medicine (n = 16, 26.2%) and nursing (n = 7, 11.5%). Professional distribution regarding multidisciplinary authorship was determined using the first author.
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FIGURE 2: Figure showing countries and number of publications. |
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| TABLE 1: Characteristics of studies identified and included through database research (N = 61). |
| TABLE 1 (Continues…): Characteristics of studies identified and included through database research (N = 61). |
| TABLE 1 (Continues…): Characteristics of studies identified and included through database research (N = 61). |
| TABLE 1 (Continues…): Characteristics of studies identified and included through database research (N = 61). |
| TABLE 1 (Continues…): Characteristics of studies identified and included through database research (N = 61). |
| TABLE 1 (Continues…): Characteristics of studies identified and included through database research (N = 61). |
| TABLE 1 (Continues…): Characteristics of studies identified and included through database research (N = 61). |
| TABLE 1 (Continues…): Characteristics of studies identified and included through database research (N = 61). |
| TABLE 1 (Continues…): Characteristics of studies identified and included through database research (N = 61). |
| TABLE 1 (Continues…): Characteristics of studies identified and included through database research (N = 61). |
| TABLE 1 (Continues…): Characteristics of studies identified and included through database research (N = 61). |
The methodology types used in the articles were divided into quantitative (n = 42, 68.9%), qualitative (n = 13, 21.3%) and mixed methods (n = 6, 9.8%). The most popular quantitative methods used were survey designs (n = 5) and cross-sectional comparative studies (n = 10). In terms of the qualitative studies, descriptive studies (n = 10) were the most popular. Record reviews were the studies that tended to use mixed method designs. Sample sizes ranged from 1 to 4312, including those with dysphagia, healthcare professional perspectives and patient records.
The proportion of studies that reported subjective outcomes or objective outcomes depended on the specialty of the authors and article aims. The articles predominantly focused on practice (n = 39, 63.9%) but also looked at aspects around prevalence (n = 8, 13.1), screening (n = 6, 9.8%), assessment (n = 7, 11.5%) and teaching and learning (n = 1, 1.7%). Practice included studies that looked at the perceptions of healthcare professionals and caregivers, the development of tools and guidelines for the management of dysphagia, other medical conditions and the prevalence of dysphagia in certain populations.
Current trends in dysphagia research in Africa
The most common trends observed in the research related to (1) Participant descriptions, (2) Prevalence studies, (3) Screening and assessment, (4) Practice patterns and (5) Teaching and learning. These are all described in more detail further in the text.
Participant descriptions
Participants focused predominantly on adult patients (n = 36, 59%) with others including a paediatric (n = 16, 26.2%) or a more general dysphagia focus (n = 9, 14.8%). Research on dysphagia in Africa highlights the diverse patient populations affected by the condition, including those with cancer, neurological disorders and paediatric feeding difficulties. Eight studies (13.1%) focused on stroke patients with the other studies looking more broadly at patients with varying conditions presenting with dysphagia. Paediatric populations were also of concern, as described by Krüger et al. (2019) and Schie et al. (2020) who examined breastfeeding skills and feeding characteristics of newborn infants and children in South Africa. Across these studies, patient descriptions emphasised the necessity of tailored assessment, interventions and access to care based on specific health conditions and the socioeconomic realities of the African healthcare setting.
Prevalence studies
Nine (14.8%) studies explored the prevalence of dysphagia in different patient populations (Abubakar & Jamoh, 2017; Ali et al., 2022; Darwish et al., 2024; Diendéré et al., 2018; Ebrahim et al., 2018; Kritzinger et al., 2019; Ndiema et al., 2023; Schoeman & Kritzinger, 2017). Prevalence was explored in both adult and paediatric populations with several studies looking at the prevalence of oropharyngeal dysphagia in neonates (Kritzinger et al., 2019; Krüger et al., 2019; Schoeman & Kritzinger, 2017). These findings speak to the limited number of studies focusing on prevalence or epidemiology in the African context.
Screening and assessment
Effective screening methods for dysphagia are crucial in improving early detection and treatment, particularly in Africa, where resources are often limited. Thirteen (21.3%) of the studies explored different screening or assessments measures (Blokland et al., 2021; Kater & Seedat, 2023; Nel & Omar, 2019; Ostrofsky & Seedat, 2016; Pike et al., 2016; Sheikhany et al., 2022; Viviers et al., 2016, 2017, 2019; Zakaria et al., 2018; Zayed et al., 2023). Studies on screening explored the presence of dysphagia in diabetic patients (Zakaria et al., 2018), stroke patients (Ostrofsky & Seedat, 2016), laryngectomy patients (Blokland et al., 2021), dementia patients (Youssef et al., 2021) and patients with coronavirus disease 2019 (COVID-19) (Zayed et al., 2023). Several studies explored the development or adaptation of assessment and screeners to identify dysphagia and/or swallowing function (Blokland et al., 2021; Kater & Seedat, 2023; Ostrofsky & Seedat, 2016; Sabry & Abou-Elsaad, 2023; Sheikhany et al., 2022), as well as the reliability and validity of certain assessments (Viviers et al., 2016, 2017, 2019). Because of the lack of more objective assessments, studies also looked at the development of non-invasive markers to screen for paediatric oropharyngeal dysphagia (Aziz et al., 2023).
Practice patterns
Majority of the studies looked at practice patterns in relation to dysphagia (n = 31, 50.8%) (Andrews & Pillay, 2017; Bardien et al., 2021; Bhim et al., 2021; Chinniah & Mody, 2017; Cloete et al., 2022; Coutts & Solomon, 2020; Coutts & Sayed, 2023; Ghammam et al., 2019a, 2019b; Hoosain et al., 2024; Kaylor & Singh, 2023; Knight et al., 2020; Krüger et al., 2019; Malan et al., 2023; Naidoo et al., 2024; Neille & Selikson, 2021; Norman et al., 2024; Pierpoint & Pillay, 2020; Pullen et al., 2024; Rhoda et al., 2015; Robbertse & De Beer, 2020; Schie et al., 2020; Seedat & Penn, 2016; Seedat & Strime, 2022; Solomon & Coutts, 2020; Visser et al., 2018; Viviers et al., 2020; Mahgoub et al., 2024). Practice patterns included the exploration of SLTs practices in evaluating dysphagia (Andrews & Pillay, 2017; Cloete et al., 2022; Seedat & Penn, 2016). Studies also explored the clinical decision-making process around the assessment and management of dysphagia (Coutts & Pillay, 2021).
Practice patterns also included the description of swallowing in different populations (Hoosain et al., 2024; Kaylor & Singh, 2023; Krüger et al., 2019; Malan et al., 2023; Pullen et al., 2024; Schie et al., 2020), working within a collaborative care model with nurses and doctors (Alaraifi et al., 2021; Bardien et al., 2021; Knight et al., 2020; Pierpoint & Pillay, 2020; Rhoda et al., 2015; Robbertse & De Beer, 2020; Seedat & Strime, 2022; Visser et al., 2018). Studies that explored the understanding of dysphagia in professions such as nursing found that nurses tended to have a limited understanding of dysphagia and communication disorders, but had a good medical understanding of the terminology around dysphagia and that nurses and doctors did not always know about signs of dysphagia and the role of the SLT (Hady et al., 2023; Knight et al., 2020; Ndiema et al., 2024; Pierpoint & Pillay, 2020; Rhoda et al., 2015; Robbertse & De Beer, 2020). In addition, there was insufficient knowledge about non-overt symptoms and signs of dysphagia (Hady et al., 2023). All the aforementioned studies highlighted the importance of MDT practice and training and this limited collaborative care.
Practice patterns also included case report studies on how dysphagia was identified/assessed/managed with specific patients (Chinniah & Mody, 2017; Ghammam et al., 2019a, 2019b) and the exploration of third-party disability through caregiver experiences with persons with dysphagia (Coutts & Solomon, 2020; Coutts & Sayed, 2023; Naidoo et al., 2024; Neille & Selikson, 2021; Norman et al., 2024; Solomon & Coutts, 2020; Viviers et al., 2020). Caregiver experiences included parents and other primary caregivers for both adult and paediatric populations. Studies found that all caregivers felt they had a role to play in the decision-making progress around those they care for with dysphagia but were often excluded and required more support from all members of the healthcare team.
Teaching and learning
There was only one study that explored dysphagia in relation to teaching and learning (Catania et al., 2023). The study focused on undergraduate SLT students and explored the factors perceived to enhance critical thinking and assist with the transition from theoretical knowledge to clinical practice.
Discussion
Research in Africa
The study highlights the current trends in dysphagia research in Africa. Our findings show that there is a paucity of research on dysphagia in the African context given the number of studies that were included in this review. As researchers working in the African context, the authors felt that it is important that SLTs produce research that can be used to extend and challenge existing theory and current practice guidelines, which often stem from the Global North. Despite the opportunity for research in the African setting, there has not been much published research from this context. From 627 articles, only 61 were included for final review. There may be several reasons for the number of articles included in the review, particularly around our current search strategy and the exclusion of grey literature. For instance, it is also important to acknowledge the limitations related to publication and acceptance in mainstream journals. This review is limited to published articles in peer-reviewed journals, and it does not imply that dysphagia research is not occurring in Africa; rather, it suggests that much of this research may not be getting published (Jayes et al., 2024). Many African researchers struggle to publish their findings because of high article processing charges and language and linguistic bias with majority of articles published in Africa coming from English-speaking African countries (Asubiaro & Onaolapo, 2023). Additionally, many journals may not find the research conducted in Africa to be contextually relevant to the Global South where majority of journals originate. Many international journals also have specific requirements that may not be appropriate when conducting research in the African context because of the context, participants and the research infrastructure (Olatunji et al., 2023). As a result, many submissions do not make it beyond the initial editor’s desk review as it often requires changes to comply more with Eurocentric views and western understandings of dysphagia (Draper et al., 2023; Jayes et al., 2024; Klingebiel & Stadler, 2015; Salihu Shinkafi, 2020). The current study highlighted the majority of research coming from South Africa and the inability to generalise findings to the broader African context. Reasons for more research from South Africa could be attributed to better funding, resources and academic support at these institutions in comparison to other African universities (Asubiaro & Onaolapo, 2023). Research from Africa is imperative to scrutinise changes to policy and ensuring findings are contextually and culturally responsive (Kasprowicz et al., 2020). Therefore, this article highlights the need to capacitate research from African researchers in our context and try to establish ways to support and provide appropriate platforms to share research findings. Ensuring that this new knowledge is freely available is imperative for transformation.
The clinical landscape shaping research, practice and teachings
The clinical context of Africa’s complex healthcare systems has shaped the direction of research, with prominent themes centred on patient descriptors, the development of screening tools and practice patterns. The majority of studies were conducted in South Africa, with other research spanning Egypt, Namibia, Tunisia, Burkina Faso, Kenya, Ghana and Nigeria. These countries have distinct cultural, political, socioeconomic and linguistic landscapes, highlighting the urgent need for research led by African scholars to ensure that practices are contextually responsive. Such research should integrate indigenous knowledge systems to provide a more comprehensive understanding of dysphagia in these diverse contexts (Asubiaro & Onaolapo, 2023; Andrews & Pillay, 2017). Furthermore, these findings highlight the need to establish African-centered indices publication costs, and infrastructure to better support and amplify African research and scholars, particularly to ensure publication of African research in reputable and high-impact journals (Morris et al., 2023).
The need for interdisciplinary research
While dysphagia is a key area in SLT (Eng & Speyer, 2021), the interdisciplinary nature of this research, involving medicine and nursing, underscores the necessity of context-specific investigations in the African context as seen by multiple studies in this review (Bardien et al., 2021; Knight et al., 2020; Pierpoint & Pillay, 2020; Rhoda et al., 2015; Robbertse & De Beer, 2020; Seedat & Strime, 2022; Visser et al., 2018). Ebrahim et al. (2018) provide a clear example of the importance of interdisciplinary nature in understanding dysphagia-related health consequences in post-stroke pneumonia and the role of the nurses. Nursing staff are critical and were often the focus of research. Nurses support patients by identifying patients who are at risk for swallowing difficulties and managing SLT recommendations around positioning (Rowe et al., 2024). Given that the African context is a resource-constrained setting and that there is a limited number of SLTs, the most effective manner for dysphagia to be screened and identified early is with the use of other members of the MDT.
An MDT approach is important to improve patient outcomes, reduce length and cost of hospital stay and reduce patient load (Atkinson, 2022; Taberna et al., 2020) which are all critical within a resource-constrained setting (Jayes et al., 2024). However, the current review highlighted the lack of MDT support in managing patients with dysphagia and the limited knowledge the nurses had on the scope of SLT and dysphagia assessment and management (Knight et al., 2020; Robbertse & De Beer, 2020). This is significant as interdisciplinary work is not only seen as an advantage for the African context but globally as well (McGinnis et al., 2019) and highlights an opportunity for future research and collaborations across disciplines.
Research methodologies in dysphagia
Studies utilised different methodologies, with the majority using quantitative methods. This variety is advantageous as the data obtained from varying methodologies have helped to create a comprehensive picture of dysphagia in Africa. Given the significant gaps in our understanding of dysphagia in Africa, there is a need to have a variety of methodologies to address these gaps. Quantitative studies are essential to gain an understanding of patient demographics and assessment tools. However, many of the limitations in the studies were around the small sample size and inability to generalise findings. There was one study by Schie et al. (2020) that had the largest cohort study and good generalisability of findings which was conducted through a record review at a hospital in South Africa. This study highlights the need and opportunities for necessary collaborations for universities and hospitals to be able to work together, particularly within an African context where funds for research and access to participants are often difficult (Klingebiel & Stadler, 2015; Salihu Shinkafi, 2020). Additionally, while prevalence studies are important, research has indicated the importance of using qualitative research methods in an African context. According to Watermeyer and Neille (2022) using qualitative methods can help decolonise research practices by acknowledging and addressing the unique social, cultural and historical contexts of African populations. Given the ICF framework and the diversity of our context, qualitative research is imperative to understand patient experiences and needs, which can then be addressed in dysphagia teachings, practices and policies. This approach is essential for ensuring that research and clinical practices are truly transformative and effective in Africa.
Clinical tools
The review identified several studies that focused on screening and assessment, which are crucial components in the evaluation of swallowing physiology and the management of dysphagia (Elluru, 2024; Etges et al., 2014; Wilkinson et al., 2021). In Africa, the use of instrumental assessment tools, like videofluoroscopy (VFSS) or fibreoptic endoscopic evaluation of swallowing (FEES), is often challenging because of resource constraints and the fact that clinicians are reliant on more non-instrumental methods of assessment. Therefore, developing and adapting appropriate screening tools is essential. International tools may not always be suitable because of differences in populations, environments and healthcare systems, highlighting the need for contextually relevant assessments (Ostrofsky & Seedat, 2016). This development is crucial to ensure that screening tools are culturally and contextually appropriate, enhancing their effectiveness and reliability in African settings. Research on this needs to continue but access to this research for clinicians needs to be a focus to ensure that practices are contextually responsive.
Teaching and learning in dysphagia
Alarmingly, there was only one study that focused on aspects around teaching and learning in the field of dysphagia in Africa (Catania et al., 2023). There were also no studies that looked at how we can teach across fields of study, potentially addressing the need for interdisciplinary teaching in dysphagia which could translate into improved interdisciplinary practices. This needs to be addressed. Increasing the knowledge of nursing and other healthcare professionals related to the detection of swallowing difficulties may have a direct impact on patient outcomes (Blackwell & Littljohns, 2010) and should be better utilised in the African context and requires further exploration.
Limitations of the study
We recognise the need to address the limitations of this review, which was intended as an initial foundation for further research. The current review did not incorporate any grey literature, which may have excluded studies that are not published in peer-reviewed journals such as student theses and service delivery reports, highlighting the need for a more comprehensive review. We also acknowledge the language limitations of including only English articles and the fact that many African countries speak a multitude of languages. These limitations highlight that there may be additional dysphagia researches in Africa that were not included in the current review.
Conclusion
Dysphagia is prevalent in Africa and is influenced by the unique African socio-economic, cultural diversity and healthcare challenges. Research on dysphagia in Africa remains underfunded and under-represented on a global scale, and the primary source of research in Africa stems from South Africa, which under-represents the continent. Current research trends have largely focused on clinical practice, yet there is a critical gap in studies addressing teaching and learning in this field. This imbalance highlights the urgent need to prioritise educational and interdisciplinary research to enhance capacity-building and improve patient outcomes in this complex setting. Furthermore, addressing these gaps will require a collaborative and interdisciplinary approach, bridging gaps between professions, sectors and disciplines. By fostering partnerships and supporting locally driven research, the field can better respond to the unique realities of dysphagia in Africa, ultimately contributing to more contextually responsive care.
Acknowledgements
Competing interests
The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. The authors, S.N.A. and K.C., serve as an guest editors for the topical collection titled ‘Dysphagia Research in Africa: Trends and Gaps Leading to Afrocentric Innovations’ of this journal. The peer review process for this submission was handled independently, and the authors had no involvement in the editorial decision-making process for this manuscript. The authors have no other competing interests to declare.
Authors’ contributions
S.N.A. and K.C. conceptualised the idea for the research as well as the design and methodology adopted. S.N.A. was the lead author in the writing up of the manuscript for publication with input from K.C. S.N.A. and K.C. read and approved the final article.
Funding information
This research was supported by the Consortium for Advanced Research Training in Africa (CARTA). CARTA is jointly led by the African Population and Health Research Center and the University of the Witwatersrand and funded by the Carnegie Corporation of New York (Grant numbers: G-21-58722 and G-PS-23-60922), Sida (Grant number: 16604), Norwegian Agency for Development Cooperation (Norad) (Grant number: QZA-21/0162), Oak Foundation (Grant number: OFIL-24-091) and the Science for Africa Foundation to the Developing Excellence in Leadership, Training and Science in Africa (DELTAS Africa) programme (reference number: Del-22-006) with support from Wellcome and the UK Foreign, Commonwealth and Development Office and is part of the EDCPT2 programme supported by the European Union. The statements made and views expressed are solely the responsibility of the author.
Data availability
Data sharing is not applicable to this article as no new data were created or analysed in this study.
Disclaimer
The views and opinions expressed in this article are those of the authors and are the product of professional research. The article does not necessarily reflect the official policy or position of any affiliated institution, funder, agency or that of the publisher. The authors are responsible for this article’s results, findings and content.
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