Palliative care in sub-Saharan Africa

Knowledge, Self-Efficacy, and Correlates in Palliative and End-of-Life Care: Quantitative Insights from Final-Year Nursing and Medical Students in a Mixed-Methods Study

Introduction

About a decade after the introduction of palliative care teaching for undergraduate nurses and medical students in Uganda, no research has examined students' knowledge and self-efficacy to provide palliative and end-of-life care and their correlates.

Aims

To: (1) estimate final-year undergraduate nursing and medical students' knowledge of and self-efficacy to provide palliative and end-of-life care, (2) identify correlates of knowledge and self-efficacy to provide palliative and end-of-life care.

Design

A multicentre cross-sectional quantitative study.

Setting/participants

Final-year undergraduate medical and nursing students in eight medical and nursing schools in Uganda. Instruments included biodata sheet, the Palliative Care Quiz for Nursing questionnaire and the Palliative Care Self-Efficacy scale. Statistical analyses were performed using STATA version 14.0.

Results

The mean age of the participants (n = 466) was 24.45 ± 3.31 years. Participants' knowledge of palliative care scores was low in all domains 'Philosophy and principles of palliative care' 1.46 ± 0.93 (range: 0-4), 'Psychosocial and spiritual care' 0.61 ± 0.73 (range: 0-3) and 'Management of pain and other symptoms' 6.32 ± 1.75 (range: 0-13). Predictors of knowledge were Gender (p = 0.0242), course of study (p = 0.0001) and religion (p = 0.0338). Participants had very low self-efficacy scores in the three domains of the Palliative Care Self-Efficacy scale.

Conclusion

Participants generally demonstrated limited knowledge and insufficient self-efficacy in providing palliative and end-of-life care. There is a need to integrate and strengthen practical, pedagogical and experiential teaching, review the palliative care curriculum. Future evaluative, longitudinal and interventional as well as qualitative studies are needed to gain deeper insights into this topic.

Advancing opioid stewardship in low-middle-income countries: challenges and opportunities

The increased utilization of opioids in low- and middle-income countries (LMICs) presents a growing threat of opioid-related abuse, misuse and diversion. Pharmacists, as integral members of healthcare teams, are responsible for dispensing and monitoring opioid use and hold a pivotal role in opioid stewardship within LMICs. This commentary describes the potential and multifaceted roles of pharmacists in opioid stewardship in resource-constrained settings and highlights appropriate strategies for promoting responsible opioid utilization. Opioid stewardship involves prioritising evidence-based prescribing, management and practices for pain management. It includes measures such as incorporating prescription drug monitoring programmes for appropriate opioid prescription, implementing safe disposal through drug take-back programmes, promoting non-opioid pain management, addressing the opioid addiction stigma, tapering opioid dose, educating patients and caregivers, establishing drug information centers, providing rehabilitative services and integrating collaboration with communities and experts. The combined difficulties of restricted access to healthcare resources and services coupled with low levels of literacy worsen the susceptibility to opioid abuse, misuse, and diversion in LMICs. Early detection, assessment and implementation of interventions to optimise opioid use are imperative for ensuring safe and effective opioid utilization, thereby mitigating the risks of overdose and addiction. The involvement of pharmacists in promoting safe and effective opioid utilization through education, monitoring, collaboration, and policy advocacy serves as a critical component in bridging existing gaps in opioid stewardship within LMICs.

Unlocking timely palliative care: assessing referral practices and barriers at a ghanaian teaching hospital

BACKGROUND

The need for primary care physicians to be heavily involved in the provision of palliative care is growing. International agencies and practice standards advocate for early palliative care and the use of specialized palliative care services for patients with life-threatening illnesses. This study was conducted to investigate physicians' referral practices and perceived barriers to timely referral at the Korle Bu Teaching Hospital.

METHODS

A cross-sectional study design was employed using a convenience sampling technique to recruit 153 physicians for the study. Data on socio-demography, referral practices, timing and perceived barriers were collected using a structured questionnaire. Binary Logistic regression using crude and adjusted odds was performed to determine the factors associated with late referral. Significance was set at p < 0.05.

RESULTS

The prevalence of late referral was reported to be 68.0%. There were poor referral practices among physicians to palliative care services, and the major barriers to late referral were attributed to the perception that referring to a palliative care specialist means that the physician has abandoned his patient and family members' decisions and physicians' personnel choices or opinions on palliative care.

CONCLUSION

The healthcare system needs tailored interventions targeted at improving physicians' knowledge and communication strategies, as well as tackling systemic deficiencies to facilitate early and appropriate palliative care referrals. It is recommended that educational programs be implemented, palliative care training be integrated into medical curricula and culturally sensitive approaches be developed to address misconceptions surrounding end-of-life care.

Cognition and attitudes of hospice care among healthcare providers: a case study of Sichuan Province

BACKGROUND

Under the background of the increasing aging population and cancer burden in China, the role of hospice care has become increasingly prominent. The government has paid more attention to the development of hospice care and set up pilot hospitals to promote hospice care. Moreover, healthcare providers play a leading role in hospice care services. To improve the quality of hospice care, the National Health Commission of the People's Republic of China proposed to set up hospice care training bases in municipal or above-level hospitals with hospice care or relevant work foundations, and train healthcare providers on hospice care. This study aimed to investigate the current situation of cognition and attitudes about hospice care among healthcare providers and provide a theoretical basis for hospital training.

METHODS

We used a quantitative design. A questionnaire survey was conducted among 1591 healthcare providers from August 2022 to November 2022. SPSS 22.0 software was used to analyze the data.

RESULTS

As a significant way of continuing education for healthcare providers, hospital training hasn't been effectively exploited in hospice care education. The average score of hospice care knowledge among participants was (7.74 ± 2.242) and the average score of hospice care attitudes among participants was (4.55 ± 1.503). According to multivariate linear regression analysis, sex (p < 0.001), education levels (p < 0.001), and professional titles (p = 0.018) of participants had significant difference on the score of hospice care knowledge; education levels (p = 0.009) and professional titles (p = 0.016) of participants had significant difference on the score of hospice care attitudes.

CONCLUSIONS

There were some misunderstandings about hospice care among healthcare providers and their attitudes towards hospice care were inactive. It's suggested that hospitals should carry out professional and systematic education courses to help healthcare providers understand hospice care correctly, and participate in hospice care services actively.

Improving bereavement outcomes in Zimbabwe: results of a feasibility cluster trial of the 9-cell bereavement tool

CONTEXT

Despite high mortality rates from both communicable and non-communicable diseases, bereavement is under-researched in African countries. The 9-cell bereavement tool was designed to assist individuals to reflect on their feelings about bereavement and identify resources in families and communities to manage bereavement. This study aimed to determine the feasibility of implementing the 9-cell bereavement tool and recruitment to experimental evaluation.

METHODS

A feasibility cluster randomized trial with embedded qualitative interviews was conducted in two comparable neighbourhoods in Chitungwiza, Zimbabwe. Community leaders identified potential community lay bereavement supporters (interventionists). Each community lay bereavement supporter recruited two to three recently bereaved community members (trial participants). Following baseline data collection, the communities were randomly allocated to intervention or wait-list control. Self-administered questionnaires were completed at T0 (month 0), T1 (3 months) and T2 (6 months). Grief, mental health and social support were assessed. Focus group discussions with selected interventionists described training impact and intervention processes. Quantitative and qualitative analyses were performed.

RESULTS

Implementation of the nine-cell bereavement tool and recruitment to experimental evaluation were successful. Implementation of the tool and the recruitment of study participants were conducted within the intended timeframe of 3 weeks. In line with the suggested sample size, the study was able to recruit and retain at least 75% of the trial participants for the total duration of the study.

CONCLUSION

The feasibility cluster trial was successfully implemented and assessed. Through the published protocol, the literature review and the results of this study, it has been noted that there is an urgent need to carry out a full trial in this subject matter, not only as a contribution to the currently sparse literature in this regard, but for the enormous potential public health benefit in supporting and saving lives in many more under-resourced and under-supported countries.

TRIAL REGISTRATION

Protocol registration: http://www.isrctn.com/ISRCTN16484746 . Protocol publication: https://pilotfeasibilitystudies.biomedcentral.com/articles/10.1186/s40814-019-0450-5.

Perspectives, perceived self-efficacy, and preparedness of newly qualified physicians' in practising palliative care-a qualitative study

BACKGROUND

Dealing with life-limiting illnesses, death, dying and grief, is uncharted territory for medical graduates. It is a field that is heavily influenced by cultural, religio-spiritual and social factors. This adds complexity to palliative and end-of-life-care, which challenges newly qualified physicians and requires the formation of appropriate knowledge, skills, and attitudes in junior doctors. This study aimed to obtain insight into the perspectives, perceived self-efficacy, and preparedness of newly qualified Nigerian physicians in practising palliative care and identify potential variables influencing them.

METHODS

The study was a cross-sectional, multi-centre survey of newly qualified Nigerian physicians, using semi-structured, in-depth qualitative interviews. The data were analysed by applying content-structuring qualitative content analysis.

RESULTS

Forty semi-structured interviews were conducted with medical house officers at two tertiary institutions in Nigeria. The perceived self-efficacy and preparedness of newly qualified Nigerian physicians in practising palliative care were reported to be higher in areas of family involvement, and pain and symptom management than in areas of breaking bad news, prognosis, and diagnosing dying. Major influences on the young physicians' perceived self-efficacy and preparedness in practising palliative care were socio-economic circumstances of a resource-limited setting and cultural-religious considerations. In addition, the perceived impact of palliative care education and experience was documented.

CONCLUSIONS

This study offers valuable insights into the perceived self-efficacy and preparedness of newly qualified physicians and reveals the influence of socio-cultural and socio-economic variables in Nigeria. Evidence of the social, cultural, and religio-spiritual dimensions of palliative care is indispensable for culturally sensitive care. These results could aid in the development of appropriate knowledge, skills, and attitudes in newly qualified physicians through culturally and contextually appropriate palliative care training measures. The results may be applicable to other sub-Saharan African settings and may be used to improve future palliative care education, training, and practice.

A Socio-Ecological Framework for Cancer Prevention in Low and Middle-Income Countries

Cancer incidence and mortality rates continue to rise globally, a trend mostly driven by preventable cancers occurring in low-and middle-income countries (LMICs). There is growing concern that many LMICs are ill-equipped to cope with markedly increased burden of cancer due to lack of comprehensive cancer control programs that incorporate primary, secondary, and tertiary prevention strategies. Notably, few countries have allocated budgets to implement such programs. In this review, we utilize a socio-ecological framework to summarize primary (risk reduction), secondary (early detection), and tertiary (treatment and survivorship) strategies to reduce the cancer burden in these countries across the individual, organizational, community, and policy levels. We highlight strategies that center on promoting health behaviors and reducing cancer risk, including diet, tobacco, alcohol, and vaccine uptake, approaches to promote routine cancer screenings, and policies to support comprehensive cancer treatment. Consistent with goals promulgated by the United Nations General Assembly on Noncommunicable Disease Prevention and Control, our review supports the development and implementation of sustainable national comprehensive cancer control plans in partnership with local communities to enhance cultural relevance and adoption, incorporating strategies across the socio-ecological framework. Such a concerted commitment will be necessary to curtail the rising cancer and chronic disease burden in LMICs.

Prevalence of Life-Limiting and Life-Threatening Illness and Associated Palliative Care Needs Among Hospital Inpatients in Sudan

CONTEXT

Evidence is needed to inform expansion of hospital-based palliative care in low and middle-income countries.

OBJECTIVES

This study aimed to measure need for palliative care among adult inpatients at five hospitals in Sudan. Objectives were to 1) measure point prevalence of life-limiting and life-threatening illness (LL/LTI); 2) determine patient insight into diagnosis and prognosis; 3) assess palliative care-related symptoms and concerns.

METHODS

In this two-day census, data were extracted from charts on documented LL/LTI for each occupied bed. For patients with LL/LTI, self-report data was collected on symptoms, concerns and understanding of diagnosis and prognosis using Integrated African Palliative Outcome Scale (IAPOS).

RESULTS

1) Prevalence of LL/LTI in general hospitals was 30.9%-70.5%. 2) n = 439 patients gave self-report data (response rate 89.8%). Mean age was 52.3 (SD 17.8), 59% of patients correctly knew their diagnosis, and 36% knew their illness was progressive. Those with a non-cancer diagnosis were significantly less likely to know their prognosis (28.4% vs 40.7% respectively, P = 0.012). 3) Family anxiety was most burdensome (56.7% scoring on the two most severe categories on a 6-point Likert), followed by pain (52.4%), poor mobility (40.5%), patient worry (39.9%), and fatigue (36.9%). Patients unaware of prognosis had higher total IAPOS scores than those aware their prognosis was progressive, 38.9 (SD = 15.6) (t = -3.297, P = 0.001, mean difference = -5.010, 95% CI: -7.997, -2.023).

CONCLUSION

Care for those with life-limiting and life-threatening illness places a significant occupancy burden on public hospitals. Communication skills are required to provide patients with insight, and core palliative care skills for acute hospital clinicians are needed to manage the high burden of symptoms and concerns.

Design and Evaluation of a Novel Mobile Phone Application to Improve Palliative Home-Care in Resource-Limited Settings

CONTEXT

Mobile health (mHealth) provides an opportunity to use internet coverage in low- and middle-income countries to improve palliative care access and quality.

OBJECTIVES

This study aimed to design a mobile phone application (app) to enable or improve communication between family caregivers, community caregivers, and palliative care teams; to evaluate its acceptability, processes, and mechanisms of action; and to propose refinements.

METHODS

A codesign process entailed collaboration between a Project Advisory Group and collaborators in India, Uganda, and Zimbabwe. We then trained community and family caregivers to use an app to communicate patient-reported outcomes to their palliative care providers each week on a data dashboard. App activity was monitored, and qualitative in-depth interviews explored experience with the app and its mechanisms and impact.

RESULTS

N = 149 caregivers participated and uploaded n = 837 assessments of patient-reported outcomes. These data were displayed to the palliative care team on an outcomes dashboard on n = 355 occasions. Qualitative data identified: 1) high acceptability and data usage; 2) improved understanding by team members of patient symptoms and concerns; 3) a need for better feedback to caregivers, for better prioritisation of patients according to need, for enhanced training and support to use the app, and for user-led recommendations for ongoing improvement.

CONCLUSION

An outcomes-focused app and data dashboard are acceptable to caregivers and health-care professionals. They are beneficial in identifying, monitoring, and communicating patient outcomes and in allocating staff resource to those most in need.

Preferences of quality delivery of palliative care among cancer patients in low- and middle-income countries: A review

BACKGROUND

All forms of cancer pose a tremendous and increasing problem globally. The prevalence of cancer across the globe is anticipated to double over the next two decades. About 50% of most cancer cases are expected to occur in low- and middle-income countries (LMICs), where there is a greater disproportionate level in mortality. Access to effective and timely care for cancer patients remains a challenge, especially in LMICs due to late disease diagnosis and detection, coupled with the limited availability of appropriate therapeutic options and delay in proper interventions.

METHODOLOGY

This study explored several mixed-method researches and randomized trials that addressed the preferences of quality delivery of palliative care among cancer patients in LMICs. A designated set of keywords such as Palliative Care; Preferences; Cancer patients; Psycho-social Support; End-of-life Care; Low and Middle-Income Countries were inserted on electronic databases to retrieve articles. The databases include PubMed, Scinapse, Medline, The Google Scholar, Academic search premier, SAGE, and EBSCO host.

RESULTS

Findings from this review discussed the socioeconomic and behavioral factors, which address the quality delivery of palliative care among cancer patients. These factors if measured with acceptance level in cancer patients could help to address areas that need improvement from the stage of disease diagnosis to the end-of-life.

SIGNIFICANCE OF THE RESULTS

Valuable collaborations among international and local health institutions are needed to build and implement a systematic framework for palliative care in LMICs. Policies and programs that are country and culturally specific, encompassing both theoretical and practical models of care in the milieu of existing quandaries should be developed.

Palliative Care in the Greater China Region: A Systematic Review of Needs, Models, and Outcomes

CONTEXT

There is rapidly increasing need for palliative care in Greater China because of rapidly aging populations.

OBJECTIVES

This study aimed to systematically review and appraise evidence for palliative care needs, models of care, interventions, and outcomes in Greater China.

METHODS

Four databases (MEDLINE, EMBASE, CINAHL, and PsycINFO) were searched, with hand searching of local journals and databases. Narrative synthesis was applied to the qualitative and quantitative evidence.

RESULTS

Nineteen qualitative studies and 47 quantitative studies were retained. With respect to care needs, nine themes were synthesized: pain control, reduced aggressive end-of-life care, truth telling, physical, emotional, and spiritual supports, and achieving preferred place of care/death. Informal caregivers expressed their needs for education and burden reduction. Health care professionals called for training and national policy support. Twenty-four studies evaluated interventions, mostly among patients with advanced cancer. Positive effects were suggested for improvements in quality of life, pain, anxiety and depression, readmission rate, and costs. Models of care evaluated were mostly specialist palliative care delivered in various settings (hospitals, residential care, and home). Outcome measures used were grouped into six categories of construct: quality of life, pain, physical assessment, psychospiritual assessment, quality of care, and implementation assessment. Limited rigorous randomized controlled trials are available to document intervention outcomes, and some problems (such as high attrition rates) reduced the strength of the evidence.

CONCLUSION

Palliative care services within Greater China should pay more attention to management of nonmalignant disease and to integration into primary services. Policy support is key to establishing culturally appropriate person-centered services.

Barriers to the Provision and Utilization of Palliative Care in Africa: A Rapid Scoping Review

Palliative care (PC) has continued to be less available, underutilized, and unintegrated in many of the healthcare systems, especially in Africa. This scoping review synthesized existing published papers on adult PC in Africa, to report the barriers to PC and to assess the methodologies used in these studies. Eight electronic databases and Google Scholar were searched to identify relevant studies published between 2005 and 2018. Overall, 42 publications (34 empirical studies and 9 reviews) that reported issues related to barriers to adult PC were selected. Three themes identified were individual-level, system-level, and relational barriers. The studies reviewed predominantly utilized cross-sectional and retrospective study design, underscoring the need for more studies employing qualitative design. Findings highlight the need for health education, training opportunities, more funding, communication, and timely referral. Future works could focus on underlying factors to these barriers and ethno-religious perspectives to PC in Africa.

Palliative and End-of-Life Care in a Small Caribbean Country: A Mortality Follow-back Study of Home Deaths

CONTEXT

Empirical information on circumstances of dying from advanced illness in developing countries remains sparse. Evidence indicates that out-of-hospital end-of-life care can have significant benefits such as increased satisfaction for the patient and caregivers and cost-effective for a health-care system. Services that are aimed to deliver care at private homes may be a good model for low- and middle-income countries or other low-resourced settings.

OBJECTIVES

To examine specialized, generalist, and informal palliative care provision and to describe the end-of-life care goals and treatments received.

METHOD

A mortality follow-back study with data obtained from general practitioners certifying a random sample of death certificates of adult decedents who died between March and August 2018. The questionnaire inquired about the characteristics of care and treatment preceding death.

RESULTS

Three hundred nine questionnaires were mailed, and the response rate was 31% (N = 96), of which 76% were nonsudden deaths. Of these cases, 27.4% received no palliative care, 39.7% received it from a general practitioner, and 6.8% from a specialized palliative care service. Comfort maximization (60.3%) was the main goal of care in the last week of life, and analgesics (53.4%) were the predominant treatment for achieving this goal. In addition, 60.3% received informal palliative care from a family member.

CONCLUSION

The largest part of end-of-life care at home in Trinidad and Tobago is provided by family members, whereas professional caregivers feature less prominently. To ensure quality in end-of-life care, better access to analgesics is needed, and adequate support and education for family members as well as general practitioners are highly recommended.

Approaches to integrating palliative care into African health systems: a qualitative systematic review

Africa is characterized by a high burden of disease and health system deficits, with an overwhelming and increasing demand for palliative care (PC). Yet only one African country is currently considered to have advanced integration of palliative care into medical services and generalized PC is said to be available in only a handful of others. The integration of PC into all levels of a health system has been called for to increase access to PC and to strengthen health systems. Contextually appropriate evidence to guide integration is vital yet limited. This qualitative systematic review analyses interventions to integrate PC into African health systems to provide insight into the 'how' of PC integration. Forty articles were identified, describing 51 different interventions. This study found that a variety of integration models are being applied, with limited best practices being evaluated and repeated in other contexts. Interventions typically focused on integrating specialized PC services into individual or multiple health facilities, with only a few examples of PC integrated at a population level. Four identified issues could either promote integration (by being present) or block integration (by their absence). These include the provision of PC at all levels of the health system alongside curative care; the development and presence of sustainable partnerships; health systems and workers that can support integration; and lastly, placing the client, their family and community at the centre of integration. These echo the broader literature on integration of health services generally. There is currently a strong suggestion that the integration of PC contributes to health system strengthening; however, this is not well evidenced in the literature and future interventions would benefit from placing health systems strengthening at the forefront, as well as situating their work within the context of integration of health services more generally.

A Review of the Current State of Hospice Care in China

PURPOSE OF REVIEW

This review was undertaken to analyze the main reasons behind the limited development of hospice care in China, and to put forward some suggestions.

RECENT FINDINGS

Although the Chinese government has increased its support for hospice care in recent years, however, owing to the lack of education around hospice care and the heavy influence of the traditional Chinese Confucian concept of "filial piety," many individuals resist hospice care. Moreover, due to impaired patient rights, inadequate composition of hospice care teams, unbalanced geographical distribution, and limited service range, the development of hospice care in China is hindered. Hospice care education and continued training should be popularized and the government should strengthen the legal structure of the medical system to protect the rights of patients, families, and medical staff to promoting social support for hospice care. Through graded diagnosis and referral systems in medical institutions to integrate medical resources and expand the range of hospice care services.

Randomized control trial of advanced cancer patients at a private hospital in Kenya and the impact of dignity therapy on quality of life

Background

Palliative care is a modality of treatment that addresses physical, psychological and spiritual symptoms. Dignity therapy, a form of psychotherapy, was developed by Professor Harvey Chochinov, MD in 2005.The aim of the study was to assess the effect of one session of dignity therapy on quality of life in advanced cancer patients.

Methods

This was a randomized control trial of 144 patients (72 in each arm) randomized into group 1 (intervention arm) and group 2 (control arm). Baseline ESAS scores were determined in both arms following which group 1 received Dignity therapy while Group 2 received usual care only. Data collected was presented as printed (Legacy) documents to group 1 participants. These documents were a summary of previous discussions held. Post intervention ESAS scores were obtained in both groups after 6 weeks. Analysis was based on the intention to treat principle and descriptive statistics computed. The main outcome was symptom distress scores on the ESAS (summated out of 100 and symptom specific scores out of 10). The student T-test was used to test for difference in ESAS scores at follow up and graphs were computed for common cancers and comorbidities.

Results

Of the 144 (72 patients in each arm) patients randomized, 70%were female while 30% were male with a mean age of 50 years. At 6 weeks, 11 patients were lost to follow up, seven died and 126 completed the study. The commonly encountered cancers were gastrointestinal cancers (43%, p = 0.29), breast cancer (27.27% p = 0.71) and gynaecologic cancers (23% p = 0.35). Majority of the patients i.e. 64.3% had no comorbidities.

The primary analysis results showed higher scores for the DT group (change in mean = 1.57) compared to the UC group (change in mean = − 0.74) yielding a non-statistically significant difference in change scores of 1.44 (p = 0.670; 95% CI − 5.20 to 8.06). After adjusting for baseline scores, the mean (summated) symptom distress score was not significant (GLM p = 0.78). Dignity therapy group showed a trend towards statistical improvement in anxiety (p = 0.059). The largest effects seen were in improvement of appetite, lower anxiety and improved wellbeing (Cohen effect size 0.3, 0.5 and 0.31 respectively).

Conclusion

Dignity therapy showed no statistical improvement in overall quality of life. Symptom improvement was seen in anxiety and this was a trend towards statistical significance (p = 0.059).

Trial registration

Trial registration number PACTR201604001447244 retrospectively registered with Pan African Clinical trials on 28th January 2016.

Family experiences of oncological palliative and supportive care in children: can we do better?

AIMS

Families were interviewed as a quality improvement assessment for palliative and supportive care services for children.

METHODS

This exploratory qualitative study of family members of children with cancer was conducted at an academic hospital in central South Africa and a grounded theory approach was used. Face-to-face interviews using a semi-structured interview guide were conducted with 16 family members of 16 children.

FINDINGS

Parents felt supported by the healthcare professionals who were caring for their child, but several shortcomings were identified. These included erratic psychosocial support, minimal financial support and poor parental access to basic needs and food provision, preventable errors in procedures and a lack of support available for siblings. It is also worth noting that healthcare professionals did not always seem sufficiently equipped to attend to palliative care patients.

CONCLUSION

Strategies to improve supportive and palliative care are needed for children with cancer and their families in a hospital setting. The interviews identified a number of themes and current shortcomings that should be considered to improve services.

The increased need for palliative cancer care in Sub-Saharan Africa

Although palliative care as a discipline in high income countries is maturing, it is still somewhat in its infancy in sub-Saharan Africa, an area where this type of care is needed the most: more than 80% of people in urgent need of palliative care live in low- and middle-income countries (LMICs). We will describe why the development of palliative care in LMICs is increasingly essential, and how it is currently still underdeveloped. In this manuscript, we discuss the challenges in organizing palliative care in LMICs in regard to the four WHO palliative care pillars: policy, education, medication, and implementation. We will illustrate how several Sub-Saharan African countries are increasingly able to provide palliative care analyzed in terms of these pillars. Ultimately, scientific research and cost-effectiveness analyses of well-developed palliative programs, should encourage both local and international governments and authorities to provide more capital and human recourses for palliative care in the future.

Pharmacists' knowledge, attitude and involvement in palliative care in selected tertiary hospitals in southwestern Nigeria

BACKGROUND

The growing number of people living with life-limiting illness is a global health concern. This study therefore aimed to explore the involvement of pharmacists in selected tertiary hospitals in Nigeria in palliative care (PC). It also sought to evaluate their knowledge and attitude to PC as well as factors that hinder pharmacists' participation in PC.

METHOD

Questionnaire-guided survey among pharmacists working in three-tertiary hospitals in southwestern Nigeria. The self-administered questionnaire comprised 18-item general knowledge questions related to PC, attitude statements with 5-point Likert-scale options and question-items that clarify extent of involvement in PC and barriers to participation. Overall score by pharmacists in the knowledge and attitude domains developed for the purpose of this study was assigned into binary categories of "adequate" and "inadequate" knowledge (score > 75% versus≤75%), as well as "positive" and "negative" attitude (ranked score > 75% versus≤75%), respectively. Descriptive statistics, Mann-Whitney-U and Kruskal-Wallis tests were used for analysis at p < 0.05.

RESULTS

All the 110 pharmacists enrolled responded to the questionnaire, given a response rate of 100%. Overall, our study showed that 23(21.1%) had adequate general knowledge in PC, while 14(12.8%) demonstrated positive attitude, with 45(41.3%) who enjoyed working in PC. Counselling on therapy adherence (100;90.9%) was the most frequently engaged activity by pharmacists; attending clinical meetings to advise health team members (45;40.9%) and giving educational sessions (47;42.7%) were largely cited as occasionally performed duties, while patient home visit was mostly cited (60;54.5%) as a duty not done at all. Pharmacists' unawareness of their need in PC (86;79.6%) was a major factor hindering participation, while pharmacists with PC training significantly felt more relaxed around people receiving PC compared to those without training (p = 0.003).

CONCLUSION

Hospital pharmacists in selected tertiary care institutions demonstrate inadequate knowledge, as well as negative attitude towards PC. Also, extent of involvement in core PC service is generally low, with pharmacists' unawareness of their need in PC constituting a major barrier. Thus, a need for inclusion of PC concept into pharmacy education curriculum, while mandatory professional development programme for pharmacists should also incorporate aspects detailing fundamental principles of PC, in order to bridge the knowledge and practice gaps.

Improving access to palliative care for patients with cancer in Africa: 25 years of Hospice Africa

All cancer care must target the needs of the whole population, not just the few who reach curative services. This paper will refer to palliative care in Uganda and in the countries now aware of the need for palliative care. Human Rights Watch has declared that doctors who are aware that we can control cancer pain and are not doing it or taking steps to make it happen, are considered to be torturers (Human Rights Watch (2009) Please, do not make us suffer any more... Accessed 11 July 2019).

As Uganda celebrates 25 years since the introduction of palliative care, is it now time to harvest the principles that have been applied in policies and services from the Government of Uganda? This has brought Uganda to the same level as the developed world as stage 4b palliative care (PC) services [1]. These policies and services need to be promoted to caring governments in Africa, and suitably adapted to the needs of each African country, with a plan for them to progress over the next 5 years. These steps will ensure standards, economic viability and cultural appropriateness.

Let palliative care reach at least 50% of cancer patients in need in Africa by 2023.

Improving bereavement outcomes in Zimbabwe: protocol for a feasibility cluster trial of the 9-cell bereavement tool

Background

The high burden of bereavement in sub-Saharan Africa is largely attributable to HIV, cancer, and other non-communicable diseases. However, interventions to improve grief and bereavement are rare. Given high rates of mortality in the context of weak health systems, community lay members are well placed to provide peer bereavement support. The 9-cell bereavement tool was developed in Zimbabwe to improve community members’ capacity to support the bereaved. This study aims to determine the feasibility of implementing the 9-cell bereavement tool and recruitment to experimental evaluation.

Methods/design

This feasibility cluster randomized trial with embedded qualitative interviews will be conducted in two comparable neighborhoods in Zimbabwe. Community leaders from each neighborhood will identify 25 potential community lay bereavement supporters, each of whom will recruit 2–3 bereaved community members into the trial. The intervention will be randomly allocated to one community, and the second community will form a wait-list control (n ≥ 75 in each community cluster). Recruitment is estimated to take place over 3 weeks. Measures at T0 (baseline, i.e., week 0), T1 (midline, i.e., week 14 or 3 months post-baseline) and T2 (endline, i.e., week 27 or 3 months post-midline) will address mental health, social support, and levels of grief per individual. Qualitative data will describe lay supporters’ views of intervention training and delivery, and participants’ experience of bereavement support.

Discussion

This is the first documented trial evaluating a bereavement intervention in sub-Saharan Africa. Recruitment, retention, and measurement data will determine the feasibility of a full trial.

Trial registration

ISRCTN, ISRCTN16484746. Registered 6 February 2018

Tramadol: a valuable treatment for pain in Ghana and Nigeria

OBJECTIVE

Pain management is unsatisfactory worldwide, particularly in developing countries where access to opioids is restricted and cost is an issue. It is a major concern in West Africa and we therefore undertook a survey of pain experts to obtain a better understanding of the problems in the region.

METHODS

Medical practitioners involved in pain management, identified via professional networks, were interviewed to share their experience in treating moderate-to-severe pain in West Africa. The questionnaire was based on an existing version modified to meet African conditions. Additionally, informal focus group meetings with palliative care physicians and pharmacists were conducted.

RESULTS

A total of 11 questionnaires were returned. All respondents were physicians who reported availability of opioids in their clinics, but access to morphine was challenging and not possible in some rural settings. Obligatory maintenance of detailed records was considered a burden. The main concern raised was the risk of misuse/addiction. Seven of 11 respondents reported that they would use tramadol as an alternative to strong opioids if required and, interestingly, 9 of 11 considered it to be an essential medicine. Based on personal experience, the respondents noted that some properties of tramadol make it a key pain treatment option in West Africa (strong/fast-acting, better tolerated than NSAIDs, less addictive than other opioids and relatively inexpensive).

CONCLUSIONS

Most stakeholders who completed the survey indicated that tramadol was essential to provide optimal pain management in the absence of access to strong opioids.

Qualitative situational analysis of palliative care for adolescents with cancer and HIV in South Africa: healthcare worker perceptions

OBJECTIVES

The unmet palliative care need is intensified in resource-limited countries where there is inequitable access to healthcare and adolescents and young adults (AYA) fall between the cracks of paediatric and adult services. We aimed to examine palliative care for AYA with cancer and/or HIV in South Africa.

DESIGN

Individual and small group interviews using process mapping.

SETTING

Data were collected between November 2016 and March 2017 with staff from government hospitals, hospices and clinics from three provinces of South Africa.

PARTICIPANTS

Health and social care professionals (n=30) (eg, physicians, nurses, social workers, psychologists) from KwaZulu-Natal, Western Cape and Gauteng provinces.

METHODS

In this qualitative situational analysis study, participants were recruited to interviews and process mapping used to try and identify palliative care pathways of AYA with palliative care needs. We developed a thematic framework using a deductive approach to analyse the interview data.

RESULTS

Palliative care pathways were not easily identifiable, ambiguous and varied and participants reported on their experiences and perceptions of service provision. Participants expressed that resource challenges limited the service provision. A need for nurse prescribing of pain relief at community level was mentioned as AYA are reluctant to use hospitals and clinics. Lack of (1) palliative care education among professionals, (2) public awareness and (3) adolescent-specific care posed a challenge to service provision.

CONCLUSIONS

The changing burden of HIV and increase in cancer prevalence calls for integration of palliative care in mainstream health services. Despite good policies, the pragmatic aspect of training professionals will influence a change in practice. The main task will be to absorb palliative care philosophy and practice at all levels of care to avoid overburdening the care system and to integrate it in community care programmes.

Palliative Care Development in Africa: Lessons From Uganda and Kenya

PURPOSE

Despite increased access to palliative care in Africa, there remains substantial unmet need. We examined the impact of approaches to promoting the development of palliative care in two African countries, Uganda and Kenya, and considered how these and other strategies could be applied more broadly.

METHODS

This study reviews published data on development approaches to palliative care in Uganda and Kenya across five domains: education and training, access to opioids, public and professional attitudes, integration into national health systems, and research. These countries were chosen because they are African leaders in palliative care, in which successful approaches to palliative care development have been used.

RESULTS

Both countries have implemented strategies across all five domains to develop palliative care. In both countries, successes in these endeavors seem to be related to efforts to integrate palliative care into the national health system and educational curricula, the training of health care providers in opioid treatment, and the inclusion of community providers in palliative care planning and implementation. Research in palliative care is the least well-developed domain in both countries.

CONCLUSION

A multidimensional approach to development of palliative care across all domains, with concerted action at the policy, provider, and community level, can improve access to palliative care in African countries.

Exploring Education and Training Needs in Palliative Care among Family Physicians in Mumbai: A Qualitative Study

Context:

Patients with chronic life-limiting conditions on palliative care (PC) prefer to be treated at home. Medical care by family physicians (FPs) reduces demand on costly and busy hospital facilities. Working of PC team in collaboration with FPs is thus helpful in home-based management of patients.

Aims:

This study aimed at exploring the extent of knowledge of FPs about PC and the need for additional training.

Settings and Design:

Semi-structured interviews were conducted with ten FPs from two suburbs of Mumbai, currently served by home care services of a tertiary cancer care center.

Subjects and Methods:

Data were digitally recorded, transcribed, and analyzed using exploratory analysis followed by content analysis to develop thematic codes.

Results and Conclusions:

FPs perceive PC as symptom control and psychological support helpful in managing patients with advanced life-limiting illnesses. Further training would help them in PC provision. Such training programs should preferably focus on symptom management and communication skills. There is a need for further research in designing a training module for FPs to get better understanding of the principles of PC.

Factors Affecting Palliative Care Development in Africa: In-Country Experts' Perceptions in Seven Countries

CONTEXT

Factors contributing to and impeding palliative care (PC) development in Africa can provide insights into current strategies for advancing PC.

OBJECTIVES

To identify key factors affecting PC development in African countries from in-country PC experts' perspectives.

METHODS

About 16 PC experts from seven African countries undertook semistructured interviews on PC development in their respective countries. An interpretive description approach was adopted, with data analyzed using constant comparison.

RESULTS

Emerged themes included drivers, strengths, challenges, and aspirations for PC development in Africa. Drivers included advocates and pioneering organizations, HIV/AIDS, culture of caregiving, and the World Health Assembly PC resolution. Strengths included community health workers, the special role of nurses, diversity of services, and short training courses. Challenges included lack of PC education; lack of standardization in implementation; limited availability of and/or accessibility to morphine; poverty and disease burden; and lack of funding for PC. Aspirations included integration of PC, specialization in PC, nurse prescribing, and strong partnerships with Ministries of Health. Factors already highlighted in the literature were only briefly discussed.

CONCLUSION

The key factors underpinning PC development in the seven countries contributed to the beginnings of PC in Africa, fueled by advocates who built on existing strengths to maximize opportunities. However, the current approach is at high risk in terms of its sustainability, and strategies for maximizing existing resources and growing infrastructure support are needed moving forward.

Paracetamol clinical dosing routine leads to paracetamol underexposure in an adult severely ill sub-Saharan African hospital population: a drug concentration measurement study

Background

Hospitals in sub-Saharan Africa (SSA) continue to receive high numbers of severely ill (HIV-infected) patients with physical pain that may suffer from hepatic and renal dysfunction. Paracetamol is widely used for pain relief in this setting but it is unknown whether therapeutic drug concentrations are attained. The aim of this study was to assess the occurrence of therapeutic, sub-therapeutic and toxic paracetamol concentrations in SSA adult hospital population.

Methods

In a cross-sectional study, plasma paracetamol concentrations were measured in patients with an oral prescription in a referral hospital in Mozambique. From August to November 2015, a maximum of four blood samples were drawn on different time points for paracetamol concentration measurement and biochemical analysis. Study endpoints were the percentage of participants with therapeutic (≥ 10 and ≤ 20 mg/L), sub-therapeutic (< 10 mg/L) and toxic (> 75 mg/L) concentrations.

Results

Seventy-six patients with a median age of 37 years, a body mass index of 18.2, a haemoglobin concentration of 10.3 g/dL and an albumin of 29 g/L yielded 225 samples. 13.4% of participants had one or more therapeutic paracetamol concentrations. 86.6% had a sub-therapeutic concentration at all time points and 70.2% had two or more concentrations below the lower limit of quantification. No potentially toxic concentrations were found.

Conclusions

Routine oral dosing practices in a SSA hospital resulted in substantial underexposure to paracetamol. Palliation is likely to be sub-standard and oral palliative drug pharmacokinetics and dispensing procedures in this setting need further investigation.

A scoping review of palliative care for children in low- and middle-income countries

BACKGROUND

Ninety-eight percent of children needing palliative care live in low- and middle-income countries (LMICs), and almost half of them live in Africa. In contrast to the abundance of data on populations in high income countries, the current data on populations in LMICs is woefully inadequate. This study aims to identify and summarize the published literature on the need, accessibility, quality, and models for palliative care for children in LMICs.

METHODS

A scoping review was performed following the method of Arksey and O'Malley. Systematic searches were conducted on PubMed and Google Scholar using the main keywords, 'children AND palliative care OR terminal care OR hospice OR end of life AND developing countries OR LMICs.' Additional publications were obtained by handsearching. Papers were only included if they reported on the need, accessibility, quality, and models for palliative care for children in LMICs.

RESULTS

Fifteen papers met the inclusion criteria for review. Of these, 10 assessed need, seven examined availability and/or accessibility, one assessed quality, and one examined the models. We found an urgent need for palliative care, particularly in the training for health workers and improving poor availability and/or accessibility to palliative care in terms of factors such as medication and bereavement support. The best practice models demonstrated feasibility and sustainability through cooperation with governments and community organizations. The quality of pain management and emotional support was lower in LMICs compared to HICs.

CONCLUSION

Although we found limited evidence in this review, we identified common challenges such as the need for further training for health workers and greater availability of opioid analgesics. While efforts to change the current systems and laws applying to children in LMICs are important, we should also tackle underlying factors including the need to raise awareness about palliative care in public health and improve the accuracy of data collection.

"We never speak about death." Healthcare professionals' views on palliative care for inpatients in Tanzania: A qualitative study

ABSTRACTObjective:Little is known about the current views and practices of healthcare professionals (HCPs) in Sub-Saharan Africa (SSA) regarding delivery of hospital palliative care. The present qualitative study explored the views of nursing staff and medical professionals on providing palliative and end-of-life care (EoLC) to hospital inpatients in Tanzania.

METHOD

Focus group discussions were conducted with a purposive sample of HCPs working on the medical and pediatric wards of the Kilimanjaro Christian Medical Centre, a tertiary referral hospital in northern Tanzania. Transcriptions were coded using a thematic approach.

RESULTS

In total, 32 healthcare workers were interviewed via 7 focus group discussions and 1 semistructured interview. Four major themes were identified. First, HCPs held strong views on what factors were important to enable individuals with a life-limiting diagnosis to live and die well. Arriving at a state of "acceptance" was the ultimate goal; however, they acknowledged that they often fell short of achieving this for inpatients. Thus, the second theme involved identifying the "barriers" to delivering palliative care in hospital. Another important factor identified was difficulty with complex communications, particularly "breaking bad news," the third theme. Fourth, participants were divided about their personal preferences for "place of EoLC," but all emphasized the benefits of the hospital setting so as to enable better symptom control.

SIGNIFICANCE OF RESULTS

Despite the fact that all the HCPs interviewed were regularly involved in providing palliative and EoLC, they had received limited formal training in its provision, although they identified such training as a universal requirement. This training gap is likely to be present across much of SSA. Palliative care training, particularly in terms of communication skills, should be comprehensively integrated within undergraduate and postgraduate education. Research is needed to develop culturally appropriate curricula to equip HCPs to manage the complex communication challenges that occur in caring for a diverse inpatient group with palliative care needs.

Symptom Burden and Functional Dependencies Among Cancer Patients in Botswana Suggest a Need for Palliative Care Nursing

BACKGROUND

Palliative care and cancer nursing in sub-Saharan Africa is hampered by inadequate clinical resources and evidence base but is central to symptom management amid the growing cancer burden.

OBJECTIVE

The aim of this study is to describe symptom burden and functional dependencies of cancer patients in Botswana using the Memorial Symptom Assessment Scale-Short Form (MSAS-SF) and Enforced Social Dependency Scale (ESDS).

METHODS

A cross-sectional multisite study was conducted in Gaborone, Botswana, from June to August 2013 using MSAS-SF, ESDS, and Eastern Cooperative Oncology Group (ECOG) performance status at 1 time point. Descriptive statistics, tests of association, correlation, and scale validity were used.

RESULTS

Among the 100 cancer patients, 65 were women, 21 were inpatients, 48 were human immunodeficiency virus-positive, 23 had gynecological malignancies, 34 had stage 4 disease, and 54 received chemotherapy only. Sixty-four reported pain; 54, neuropathies; 51, weight loss; and 51, hunger. Most distressing symptoms were weight loss, body image, skin changes, and pain. Recreational/social role was most affected by cancer. Cronbach's α for both the MSAS-SF and ESDS was .91. Variations in means for MSAS-SF and ESDS were associated with ECOG grade 2 (P < .05); the ECOG moderately correlated (0.35) with MSAS-SF (P < .01). No associations with human immunodeficiency virus status were found.

CONCLUSIONS

Patients reported distressing levels of cancer pain, weight loss, hunger, and dependency in recreational/social activities. The Setswana translations of the MSAS-SF and ESDS were found reliable to assess cancer patients' symptoms and function.

IMPLICATIONS FOR PRACTICE

Nurses trained in palliative care are needed to meet cancer patients' pain and symptom management care needs.

Comprehensive Human Papillomavirus Genotyping in Cervical Squamous Cell Carcinomas and Its Relevance to Cervical Cancer Prevention in Malawian Women

PURPOSE

Cervical squamous cell carcinoma (SCC) continues to be a significant cause of cancer morbidity and is the third leading cause of cancer-related death in women worldwide. In sub-Saharan Africa, cervical cancer is not only the most common female cancer but also the leading cause of cancer-related deaths in women. Malawi, in particular, has the highest burden of cervical cancer. With the increasing use of human papillomavirus (HPV) vaccination, documenting the prevalent HPV types in those high-risk populations is necessary to both manage expectations of HPV vaccination and guide future vaccine development.

MATERIALS AND METHODS

In this study, we performed HPV typing on 474 cervical SCC samples and analyzed the potential impact of HPV vaccination in this population.

RESULTS

Ninety-seven percent of tumors were positive for at least one HPV type, and 54% harbored more than one HPV type. HPV 16 was the most common type (82%), followed by HPV 18 (34%), HPV 35 (24%), and HPV 31 (12%). A vaccine against HPV 16 and 18 would ideally prevent 53% of cervical SCC, and the nonavalent HPV vaccine (covering HPV 16, 18, 31, 33, 45, 52, and 58) would prevent 71% of cervical SCC in Malawi (assuming 100% vaccine efficacy). The main reason for a lack of coverage was high prevalence of HPV 35, which was also present as a single infection in a small subset of patients.

CONCLUSION

Although any HPV vaccination in this population would likely prevent a significant proportion of cervical cancer, the nonavalent vaccine would provide better coverage. Furthermore, investigation of the role of HPV 35 in this population, including possible cross-protection with other HPV types, should be pursued.

An assessment of the HIV/TB knowledge and skills of home-based carers working in the North West province in South Africa: a cross-sectional study

Background

Home-based carers (HBCs) play a critical role in ensuring the success of the primary health care re-engineering strategy in South Africa. Their role includes ensuring improved access to and delivery of primary health care at the household level, and better co-ordination and improved linkages between community and health facilities for HIV/TB services. The objective of this study was to assess the knowledge, skills, challenges and training needs of HBCs involved in HIV/TB care in one sub-district in the North-West province of South Africa.

Methods

We conducted a descriptive, cross-sectional study in which 157 HBCs were interviewed to assess their knowledge and skills regarding HIV and TB. Data were collected using a pre-tested semi-structured questionnaire. Quantitative and qualitative data were analysed using SPSS statistical software and thematic analysis respectively.

Results

One hundred and forty-four (92%) of the interviewees were female and 13 (8%) were male. The median age of the participants was 35 years (interquartile range (IQR): 22–27). The median score for knowledge of both HIV and TB questions was 66% (IQR: 57–75). In general, HIV knowledge scores were higher than TB knowledge scores (73% versus 66%). A significant association was found between knowledge scores and formal training (p < 0.05), and knowledge scores and highest educational levels (p < 0.05). Irrespective of knowledge, HBCs reported providing a variety of services to support HIV/TB services in the communities in which they worked. HBCs also reported facing various challenges in their jobs related to stigma and the social contexts in which they work.

Conclusion

The study showed that the overall knowledge of HBCs was limited, given the skills required and the services they provide. Given the increasing role of HBCs in various health initiatives, targeted interventions are required to support and improve their competencies and service provision.

Factors that influence advance directives completion amongst terminally ill patients at a tertiary hospital in Kenya

Background

An advance directive (AD) is a written or verbal document that legally stipulates a person’s health care preference while they are competent to make decisions for themselves and is used to guide decisions on life-sustaining treatment in the event that they become incapacitated. AD can take the form of a living will, a limitation of care document, a do-not-resuscitate order, or an appointment of a surrogate by durable power of attorney. The completion rate of AD varies from region to region, and it is influenced by multiple factors. The objectives of this study were to determine the proportion of terminally ill patients with AD and to identify the factors that influence the completion of AD amongst terminally ill patients at a tertiary hospital in Kenya.

Methods

The study was a retrospective survey. All available records of terminally ill patients seen at Aga Khan University Hospital, Nairobi, between July 2010 and December 2015, and that met the inclusion criteria were included in the study.

Results

In total, 216 records of terminally ill patients were analyzed: 89 records were of patients that had AD and 127 records were of patients that did not have AD. The proportion of terminally ill patients that had completed AD was 41.2%. The factors that were associated with the completion of AD on bivariate analysis were history of ICU admission, history of endotracheal intubation, functional status of the patient, the medical specialty taking care of the patient, patient’s caregiver discussing the AD with the patient, and a palliative specialist review. On multivariate regression analysis, discussion of AD with a caregiver and patient’s functional impairment were the factors with statistically significant association with completion of AD.

Conclusions

The proportion of terminally ill patients that had AD in their medical records was significant. However, most terminally ill patients did not have AD. Our data, perhaps the first on the subject in East Africa, suggest that most of the factors associated with AD completion mirrored those seen in other regions of the world. Discussion between patient and their physician and patient’s functional impairment were the factors independently associated with completion of AD. Therefore, physicians need to be aware of the importance of discussions of AD with their patients.

Cervical cancer prevention and treatment research in Africa: a systematic review from a public health perspective

BACKGROUND

Women living in Africa experience the highest burden of cervical cancer. Research and investment to improve vaccination, screening, and treatment efforts are critically needed. We systematically reviewed and characterized recent research within a broader public health framework to organize and assess the range of cervical cancer research in Africa.

METHODS

We searched online databases and the Internet for published articles and cervical cancer reports in African countries. Inclusion criteria included publication between 2004 and 2014, cervical cancer-related content pertinent to one of the four public health categories (primary, secondary, tertiary prevention or quality of life), and conducted in or specifically relevant to countries or regions within the African continent. The study design, geographic region/country, focus of research, and key findings were documented for each eligible article and summarized to illustrate the weight and research coverage in each area. Publications with more than one focus (e.g. secondary and tertiary prevention) were categorized by the primary emphasis of the paper. Research specific to HIV-infected women or focused on feasibility issues was delineated within each of the four public health categories.

RESULTS

A total of 380 research articles/reports were included. The majority (54.6 %) of cervical cancer research in Africa focused on secondary prevention (i.e., screening). The number of publication focusing on primary prevention (23.4 %), particularly HPV vaccination, increased significantly in the past decade. Research regarding the treatment of precancerous lesions and invasive cervical cancer is emerging (17.6 %), but infrastructure and feasibility challenges in many countries have impeded efforts to provide and evaluate treatment. Studies assessing aspects of quality of life among women living with cervical cancer are severely limited (4.1 %). Across all categories, 11.3 % of publications focused on cervical cancer among HIV-infected women, while 17.1 % focused on aspects of feasibility for cervical cancer control efforts.

CONCLUSIONS

Cervical cancer research in African countries has increased steadily over the past decade, but more is needed. Tertiary prevention (i.e. treatment of disease with effective medicine) and quality of life of cervical cancer survivors are two severely under-researched areas. Similarly, there are several countries in Africa with little to no research ever conducted on cervical cancer.

Development and pilot evaluation of a home-based palliative care training and support package for young children in southern Africa

Background

The leading cause of death among young children in southern Africa is complications due to HIV infection and, in South Africa, over a third of all deaths of children younger than five are associated with HIV infection. There is a great and urgent need for children’s palliative care in Africa, whether HIV-related or not. It is often not possible for sick children and their carers to attend clinics and hospitals cannot accommodate children for long periods of time. As a result children are often cared for in their own homes where caregivers require support to provide informed and sensitive care to reduce children’s suffering. Home-care places a heavy burden on families, communities and home- and community-based care workers.

Methods

This project involved the development and pilot evaluation of a training and support package to guide home and community-based care workers to help caregivers of seriously ill young children at home in southern Africa. A number of research methods were used, including a cross-sectional survey of content experts using the Delphi technique, participatory action research with photo elicitation and qualitative thematic analysis.

Results

Because the palliative care needs of these children are complex, the package focuses on delivering 9 key messages essential to improving the quality of care provided for young children. Once the key messages were developed, culturally relevant stories were constructed to enhance the understanding, retention and enactment of the messages. The various research methods used, including literature reviews, the Delphi technique and photo-elicitation ensured that the content included in the package was medically sound and culturally relevant, acceptable, feasible, and comprehensive. The end product is a home-based paediatric palliative care training and support package in English designed to help train community workers who are in a position to support families to care for very sick young children at home as well as to support families in looking after a very sick child.

Conclusion

A pilot study to assess the training and support package found it to be useful in delivering the key messages to caregivers. The training component was found to be feasible. It is concluded that the package offers a practical means of integrating palliative care with home-based care. Further implementation and evaluation is needed to establish its utility and impact.

Electronic supplementary material

The online version of this article (doi:10.1186/s12904-016-0114-7) contains supplementary material, which is available to authorized users.

A palliative care link nurse programme in Mulago Hospital, Uganda: an evaluation using mixed methods

Background

Integrating palliative care (PC) and empowering the health care workforce is essential to achieve universal access to PC services. In 2010, 46 % of patients in Mulago Hospital, Uganda had a life limiting illness, of whom 96 % had PC needs. The university/hospital specialist PC unit (Makerere/Mulago Palliative Care Unit –MPCU) implemented a link-nurse model to empower hospital nurses to provide generalist PC. Over two years, 27 link nurses were trained and mentored and 11 clinical protocols developed. The aim of the study was to evaluate the impact of the palliative care link nurse programme at Mulago Hospital

Methods

An evaluation approach utilising mixed methods was used integrating qualitative and quantitative data including: pre and post course assessment confidence ratings; course evaluation forms; audit of clinical guidelines availability; review of link-nurse activity sheets/action plans; review of MPCU patient documentation; Most Significant Change (MSC); individual and focus group interviews.

Results

A significant difference was seen in nurses’ confidence after the training (p < 0.001). From July 2012 to December 2013, link nurses identified 2447 patients needing PC, of whom they cared for 2113 (86 %) and referred 334 (14 %) to MPCU. Clinical guidelines/protocols were utilised in 50 % of wards. Main themes identified include: change in attitude; developing new skills and knowledge; change in relationships; improved outcomes of care, along with the challenges that they experienced in integrating PC. Since the start of the programme there has been an increase in PC patients seen at the hospital (611 in 2011 to 1788 in 2013).

Conclusion

The link-nurse programme is a practical model for integrating PC into generalist services. Recommendations have been made for ongoing development and expansion of the programme as an effective health systems strengthening approach in similar healthcare contexts, as well as the improvement in medical and nursing education.

A qualitative evaluation of the impact of a palliative care course on preregistration nursing students' practice in Cameroon

Background

Current evidence suggests that palliative care education can improve preregistration nursing students’ competencies in palliative care. However, it is not known whether these competencies are translated into students’ practice in the care of patients who are approaching the end of life. This paper seeks to contribute to the palliative care evidence base by examining how nursing students in receipt of education report transfer of learning to practice, and what the barriers and facilitators may be, in a resource-poor country.

Methods

We utilised focus groups and individual critical incident interviews to explore nursing students’ palliative care learning transfer. Three focus groups, consisting of 23 participants and 10 individual critical incident interviews were conducted with preregistration nursing student who had attended a palliative care course in Cameroon and had experience caring for a patient approaching the end of life. Data was analysed thematically, using the framework approach.

Results

The results suggest that nursing students in receipt of palliative care education can transfer their learning to practice. Students reported recognizing patients with palliative care needs, providing patients with physical, psychosocial and spiritual support and communicating patient information to the wider care team. They did however perceive some barriers to this transfer which were either related to themselves, qualified nurses, the practice setting or family caregivers and patients.

Conclusion

The findings from this study suggest that nursing student in receipt of palliative care education can use their learning in practice to provide care to patients and their families approaching the end of life. Nevertheless, these findings need to be treated with some caution given the self-reported nature of the data. Demonstrating the link between preregistration palliative care education and patient care is vital to ensuring that newly acquired knowledge and skills are translated and embedded into clinical practice. This study also has implications for advocating for palliative care policies and adequately preparing clinical placement sites for students’ learning and transfer of learning.

The needs, models of care, interventions and outcomes of palliative care in the Caribbean: a systematic review of the evidence

BACKGROUND

Palliative care provision is expanding in low and middle income countries. Services are developing in the Caribbean in response to the region's ageing population, the significant burden of cancer, non-communicable diseases and HIV/AIDS. Appraisal of the existing evidence on palliative care needs, models of care, interventions and outcomes in the Caribbean is essential to inform emerging practice and future research.

METHODS

Systematic review and narrative synthesis. Following implementation of a search strategy, titles, abstracts and full texts were screened. Data from nine studies were synthesized. The Qualsyst tools were used to assess the quality of quantitative and qualitative studies. Data were extracted into a common table, and themes were generated from the available peer review evidence using narrative synthesis.

RESULTS

Nine papers were retained for appraisal. Eight papers described palliative care needs in the Caribbean. The needs for analgesia, support for patients, education and training of staff in palliative care and palliative care services were identified in the literature. Models of care for palliative care in the Caribbean were not described in great depth (n = 2 papers) and no intervention studies were found. Outcomes of palliative care such as quality of life, quality of care, and patient's preferred place of care and death were identified from six papers. Quantitative methodology was used in seven of the nine papers in this review. One paper used a mixed methodology design, and one a qualitative approach.

CONCLUSIONS

Research from the Caribbean highlights the need for health care policy, training of staff, education, and access to analgesia and palliative care support services in this region. This sparse evidence must be taken into consideration with cultural beliefs and preferences of the Caribbean population in order to achieve improved outcomes for patients, their caregivers and health care professionals. This underscores the importance for more research in the field of palliative care in the Caribbean.

Home-based rehabilitation interventions for adults living with HIV: a scoping review

Home-based rehabilitation (HBR) has been shown to improve the lives of people living with a wide range of chronic diseases in resource-rich settings. This may also be a particularly effective strategy in resource-poor settings, where access to institution-based rehabilitation is limited. This review aimed to summarise and discuss the evidence related to the effectiveness of home-based rehabilitation (HBR) interventions designed specifically for adults living with HIV. A scoping review methodology was employed, involving systematic search techniques and appraisal of appropriate evidence. English-language journal articles that assessed the quality of life or functional ability outcomes of HBR interventions for adults living with HIV were considered for this review. Out of an initial 1 135 publications retrieved from the search of databases, six articles met this review's inclusion criteria. While this review highlights the scarcity of empirical evidence related to HBR interventions for adults living with HIV, the findings of these six articles are that HBR is a safe management option that may confer a number of physical and psychological benefits for this population. Future research on HBR interventions should include a wider range of assessment measures, including cost-benefit analyses and specific tools designed to assess the functional ability and participation in activities of daily living of participants involved in these programmes. In particular, more research on HBR is required in resource-poor environments, such as sub-Saharan Africa where HIV is endemic, to assess whether this is a feasible strategy that is both effective and practical in the areas that may need it most.

EAPC White Paper on outcome measurement in palliative care: Improving practice, attaining outcomes and delivering quality services - Recommendations from the European Association for Palliative Care (EAPC) Task Force on Outcome Measurement

BACKGROUND

Outcome measurement plays an increasing role in improving the quality, effectiveness, efficiency and availability of palliative care.

AIM

To provide expert recommendations on outcome measurement in palliative care in clinical practice and research.

METHODS

Developed by a European Association for Palliative Care Task Force, based on literature searches, international expert workshop, development of outcome measurement guidance and international online survey. A subgroup drafted a first version and circulated it twice to the task force. The preliminary final version was circulated to wider expert panel and 28 international experts across 20 European Association for Palliative Care member associations and the European Association for Palliative Care Board of Directors and revised according to their feedback. The final version was approved by the European Association for Palliative Care Board for adoption as an official European Association for Palliative Care position paper.

RESULTS

In all, 12 recommendations are proposed covering key parameters of measures, adequate measures for the task, introduction of outcome measurement into practice, and national and international outcome comparisons and benchmarking. Compared to other recommendations, the White Paper covers similar aspects but focuses more on outcome measurement in clinical care and the wider policy impact of implementing outcome measurement in clinical palliative care. Patient-reported outcome measure feedback improves awareness of unmet need and allows professionals to act to address patients' needs. However, barriers and facilitators have been identified when implementing outcome measurement in clinical care that should be addressed.

CONCLUSION

The White Paper recommends the introduction of outcome measurement into practice and outcomes that allow for national and international comparisons. Outcome measurement is key to understanding different models of care across countries and, ultimately, patient outcome having controlled for differing patients characteristics.

Provision of Palliative Care in Low- and Middle-Income Countries: Overcoming Obstacles for Effective Treatment Delivery

Despite being declared a basic human right, access to adult and pediatric palliative care for millions of individuals in need in low- and middle-income countries (LMICs) continues to be limited or absent. The requirement to make palliative care available to patients with cancer is increasingly urgent because global cancer case prevalence is anticipated to double over the next two decades. Fifty percent of these cancers are expected to occur in LMICs, where mortality figures are disproportionately greater as a result of late detection of disease and insufficient access to appropriate treatment options. Notable initiatives in many LMICs have greatly improved access to palliative care. These can serve as development models for service scale-up in these regions, based on rigorous evaluation in the context of specific health systems. However, a multipronged public health approach is needed to fulfill the humane and ethical obligation to make palliative care universally available. This includes health policy that supports the integration of palliative care and investment in systems of health care delivery; changes in legislation and regulation that inappropriately restrict access to opioid medications for individuals with life-limiting illnesses; education and training of health professionals; development of a methodologically rigorous data and research base specific to LMICs that encompasses health systems and clinical care; and shifts in societal and health professional attitudes to palliative and end-of-life care. International partnerships are valuable to achieve these goals, particularly in education and research, but leadership and health systems stewardship within LMICs are critical factors that will drive and implement change.

Understanding Models of Palliative Care Delivery in Sub-Saharan Africa: Learning From Programs in Kenya and Malawi

The need for palliative care has never been greater. From being significantly present in only five African countries in 2004, palliative care is now delivered in nearly 50% of African countries; however, less than 5% of people in need receive it. To scale-up palliative care, we need greater knowledge about how different models of palliative care work within different health systems. A case study evaluation was undertaken in Kenya and Malawi to define the models used, contextualize them, and identify challenges, best practices, and transferable lessons for scale-up. Visits were made to seven sites and, using an audit tool, data were collected from program staff, hospital staff, and local stakeholders, and care observed as appropriate. Three models of palliative care service delivery were identified, which supports the existing literature, that is, specialist, district hospital level, and community level. However, in looking further, findings show that the major determinants for each model were a set of philosophical questions and assumptions underpinning each and influencing staff and patient decision-making, planning, and allocation of resources. The health system structure and the beliefs about palliative care determined, and were determined most by, referrals, the patient journey, the centeredness of the model, and role definition and training. The models are also closely associated with the physical setting of services. Understanding how the services have developed because of, and indeed despite the geographical setting and the system level, provides us with a different set of indicators of program structure incorporated into the three models. The analysis of models provides pointers to future planning for palliative care.

Reported availability and gaps of pediatric palliative care in low- and middle-income countries: a systematic review of published data

BACKGROUND

The majority of young people in need of palliative care live in low- and middle-income countries, where curative treatment is less available.

OBJECTIVE

We systematically reviewed published data describing palliative care services available to young people with life-limiting conditions in low- and middle-income countries and assessed core elements with respect to availability, gaps, and under-reported aspects.

METHODS

PubMed, CINAHL, EMBASE (1980-2013), and secondary bibliographies were searched for publications that included patients younger than 25 years with life-limiting conditions and described palliative care programs in low- and middle-income countries. A data extraction checklist considered 15 items across seven domains: access, education/capacity building, health system support, pain management, symptom management, end-of-life care, and bereavement. Data were aggregated by program and country.

RESULTS

Of 1572 records, 238 met criteria for full-text review; 34 qualified for inclusion, representing 30 programs in 21 countries. The median checklist score was 7 (range, 1-14) of 10 reported (range, 3-14). The most pervasive gaps were in national health system support (unavailable in 7 of 17 countries with programs reporting), specialized education (unavailable in 7 of 19 countries with programs reporting), and comprehensive opioid access (unavailable in 14 of 21 countries with programs reporting). Underreported elements included specified practices for pain management and end-of-life support.

CONCLUSION

Comprehensive pediatric palliative care provision is possible even in markedly impoverished settings. Improved national health system support, specialized training and opioid access are key targets for research and advocacy. Application of a checklist methodology can promote awareness of gaps to guide program evaluation, reporting, and strengthening.