Using a supportive care framework to understand and improve palliative care among cancer patients in Africa

Use of inpatient palliative care in metastatic testicular cancer patients undergoing critical care therapy: insights from the national inpatient sample

To test for rates of inpatient palliative care (IPC) in metastatic testicular cancer patients receiving critical care therapy (CCT). Within the Nationwide Inpatient Sample (NIS) database (2008-2019), we tabulated IPC rates in metastatic testicular cancer patients receiving CCT, namely invasive mechanical ventilation (IMV), percutaneous endoscopic gastrostomy tube (PEG), dialysis for acute kidney failure (AKF), total parenteral nutrition (TPN) or tracheostomy. Univariable and multivariable logistic regression models addressing IPC were fitted. Of 420 metastatic testicular cancer patients undergoing CCT, 70 (17%) received IPC. Between 2008 and 2019, the rates of IPC among metastatic testicular cancer patients undergoing CCT increased from 5 to 19%, with the highest rate of 30% in 2018 (EAPC: + 9.5%; 95% CI + 4.7 to + 15.2%; p = 0.005). IPC patients were older (35 vs. 31 years, p = 0.01), more frequently had do not resuscitate (DNR) status (34 vs. 4%, p < 0.001), more frequently exhibited brain metastases (29 vs. 17%, p = 0.03), were more frequently treated with IMV (76 vs. 53%, p < 0.001) and exhibited higher rate of inpatient mortality (74 vs. 29%, p < 0.001). In multivariable analyses, DNR status (OR 10.23, p < 0.001) and African American race/ethnicity (OR 4.69, p = 0.003) were identified as independent predictors of higher IPC use. We observed a significant increase in rates of IPC use in metastatic testicular cancer patients receiving CCT, rising from 5 to 19% between 2008 and 2019. However, this rates remain lower compared to metastatic lung cancer patients, indicating the need for further awareness among clinicians treating metastatic testicular cancer. The increase in IPC rates for metastatic testicular cancer patients receiving CCT indicates a need for ongoing education and awareness among healthcare providers. This could enhance the integration of IPC in the treatment of advanced cancer, potentially improving quality of life and care outcomes for survivors.

Impact of cancer diagnosis and treatment: a qualitative analysis of strains, resources and coping strategies among elderly patients in a rural setting in Ghana

BACKGROUND

Rurality is fraught with numerous difficulties including a lack of advanced health facilities to provide health services, and an absence of specialist cancer services, and qualified personnel, among others. These factors exacerbate the challenges of elderly patients diagnosed with cancer and further pose limitations to activities/instrumental activities of daily living. Yet, there is limited scholarship on the strains that affect elderly patients diagnosed with cancer and the resources that helps them to overcome them. This study explores the strains, resources, and coping strategies of elderly patients diagnosed with cancer and undergoing treatment in rural Ghana.

METHODS

An exploratory, descriptive qualitative design was adopted. Purposive sampling was used to recruit 20 individuals to participate in in-depth interviews. The collected data was analysed inductively using Collaizi's framework. QSR NVivo-12 was used in managing the data.

RESULTS

The results were grouped into two main categories, namely: strains and resources. Within the category of strains, three main themes with their corresponding sub-themes emerged: cancer-related strains (systemic side effects from treatment, altered physical appearance and body image, and experience of pain), elderly strains (altered functional ability, limited social interactions and participation, psycho-emotional reactions, limited/restricted economic participation, and financial strains), and health system strains (negative attitude and insensitive communication, delay in diagnosis, lack of geriatric oncology care, lack of community-based specialist cancer centre and long travel distance to access care, and limited availability of essential cancer medicines and other radiations services). Four types of resources were available to cancer patients: personal resources, family resources, community resources, and healthcare systems resources.

CONCLUSION

In conclusion, elderly patients diagnosed with cancer experience physical, economic, psychological, and emotional strains that threaten their health and well-being. However, they are able to leverage family, community, and health system-related resources to navigate through the strains. There is, therefore, a need to expand advanced health facilities with geriatric oncology units and specialists to improve access to cancer care in rural areas. The government needs to assist elderly persons with costs associated with their diagnosis and treatment through the expansion of the National Health Insurance Scheme to include this as part of the benefits package.

Needs for supporting women undergoing termination of pregnancy for fetal anomaly: A phenomenological study based on the cognitive-emotional-behavioral framework

OBJECTIVE

To determine and describe the needs of women undergoing termination of pregnancy for fetal anomaly (TOPFA) in China.

STUDY DESIGN

Qualitative study with semi-structured interviews. Consolidated Criteria for Reporting Qualitative Studies checklist was used for reporting.

SETTING

Three general hospitals and one special hospital in Changsha, Hunan, China.

PARTICIPANTS

12 women who had undergone TOPFA and 12 healthcare providers who had experienced in caring for these women.

METHODS

This study was based on the cognitive-emotional-behavioral framework (CEBF) of women who had to undergo TOPFA. Twenty-four participants (12 women and 12 healthcare providers) were recruited from two hospitals in China. Semi-structured face-to-face interviews were conducted based on interview guides. ATLAS.ti software was used to encode and analyze data. Qualitative content analysis was also applied.

FINDINGS

Four themes emerged: information, emotional, professional psychological, and social supports. Each theme was subdivided into four phases for a detailed description of the temporal order (denial, confirmation, decision-making, and recovery phases) within the framework.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Our study analyzes the four needs of women who underwent TOPFA and the specifics of each need at different phases based on the CEBF. The importance of offering professional psychological support, detailed information, timely emotional support, and comprehensive social support for these women is illustrated. This study contributes to the understanding of women's needs, hence providing a theoretical basis for the construction of supportive programs.

Barriers and Facilitators to Supportive Care Implementation in Advanced Disease Prostate Cancer Survivors: A Theory-Informed Scoping Review

BACKGROUND

Individualized supportive care is recommended to manage the debilitating effects of advanced prostate cancer and its treatments. Yet, the implementation of supportive care in practice remains inconsistent.

OBJECTIVE

The aim of this study was to synthesize the barriers and facilitators to implementing supportive care interventions after identifying supportive care interventions for advanced prostate cancer survivors.

METHODS

PubMed, SCOPUS, CINAHL Complete, ProQuest, and PsycINFO were searched for relevant studies published between 2011 and 2020. Studies were included if they reported on a supportive care intervention and included a description of implementation barriers and/or facilitators. The Theoretical Domains Framework was used to characterize implementation barriers and facilitators.

RESULTS

Of the 620 articles identified, 13 met all prespecified inclusion criteria. Primary barriers were related to the domains of environmental context and resources (eg, limited resources), knowledge (eg, insufficient knowledge on efficacy of supportive care), and beliefs about capabilities (eg, lack of confidence in materials). Facilitators fell under environmental context and resources (partnerships with local services), reinforcement (eg, partners inclusion), and skills (eg, delivery by professionals).

CONCLUSIONS

This scoping review highlights barriers and facilitators that affect supportive care implementation. Future research that focuses on overcoming barriers and maximizing facilitators is needed to improve, modify, or supplement existing supportive care implementation practices.

IMPLICATIONS FOR PRACTICE

As the number of advanced prostate cancer survivors continues to increase, supportive care must become the standard of care. Future interventions must incorporate increased knowledge and funding, alternative delivery models, and consistent use of specialty nurses.

Supportive care interventions and quality of life in advanced disease prostate cancer survivors: An integrative review of the literature

BACKGROUND

Supportive care interventions can improve quality of life and health outcomes of advanced prostate cancer survivors. Despite the high prevalence of unmet needs, supportive care for this population is sparse.

METHODS

The databases PubMed, SCOPUS, CINAHL, and ProQuest were searched for relevant articles. Data were extracted, organized by thematic matrix, and categorized according to the seven domains of the Supportive Care Framework for Cancer Care.

RESULTS

The search yielded 1678 articles, of which 18 were included in the review and critically appraised. Most studies were cross-sectional with small, non-diverse samples. Supportive care interventions reported for advanced prostate cancer survivors are limited with some positive trends. Most outcomes were symptom-focused and patient self-reported (e.g., anxiety, pain, self-efficacy) evaluated by questionnaires or interview. Interventions delivered in group format reported improvements in more outcomes.

CONCLUSIONS

Additional supportive care intervention are needed for men with advanced prostate cancer. Because of their crucial position in caring for cancer patients, nurse scientists and clinicians must partner to research and develop patient-centered, culturally relevant supportive care interventions that improve this population's quality of life and health outcomes. Efforts must concentrate on sampling, domains of needs, theoretical framework, guidelines, and measurement instruments.

Intervention en soins de soutien auprès de survivants du cancer prostatique avancé : Revue intégrative de la littérature

Contexte

Pour les survivants du cancer prostatique avancé, les interventions en soins de soutien peuvent améliorer la qualité de vie et les résultats cliniques. Même si ces patients ont très fréquemment des besoins non satisfaits, peu de soins de soutien leur sont prodigués.

Méthodologie

Les bases de données PubMed, SCOPUS, CINAHL et ProQuest ont été interrogées à la recherche d’articles pertinents. Les données ont été extraites, organisées par élément thématique et classées selon les sept domaines du Cadre des soins de soutien pour les soins en oncologie.

Résultats

La recherche a permis de relever 1 678 articles, dont 18 ont été inclus dans la revue et ont fait l’objet d’une évaluation critique. La plupart des études étaient transversales avec de petits échantillons non diversifiés. Les interventions en soins de soutien rapportées pour les survivants du cancer prostatique avancé sont limitées, mais tendent à être positives. La plupart des critères étaient axés sur les symptômes déclarés par les patients (ex. anxiété, douleur, auto-efficacité), et évalués au moyen de questionnaires ou d’entretiens. Les interventions réalisées en groupe ont donné de meilleurs résultats.

Conclusions

Les hommes atteints d’un cancer prostatique avancé ont besoin d’interventions supplémentaires en soins de soutien. En raison de leur rôle essentiel dans les soins aux patients cancéreux, les chercheurs en sciences infirmières et les infirmières cliniciennes doivent faire équipe pour trouver et élaborer des interventions en soins de soutien axées sur le patient et adaptées à la culture qui améliorent la qualité de vie et les résultats cliniques. Il faut centrer les efforts sur l’échantillonnage, les domaines des besoins, le cadre théorique, les lignes directrices et les instruments de mesure.

[Treatment of cancer pain in Mali: Experience of the mother-child medical oncology service of the CHU in Bamako]

Two hundred patients were refereed for advanced cancer to the oncology department of Luxembourg Hospital in Bamako. All these patients reported intense pain (88 %) which was only treated before admission by OMS level 1 analgesics. It clearly shows that cancer pain is undertreated in Malian peripheral sanitary structures. After evaluation of the pain by analog visual and verbal scales patients, the appropriate analgesic drugs such as morphine (OMS level 3) were given. A control of the pain was obtained in all the patients (100 %) with a dramatic improvement in quality of life. This study emphasizes the need for a pain control program at the Malian state level with a basic education of care givers, hospital-centric networks and access to morphine and opioids at the different levels involved in cancer management.

What constitutes a palliative care need in people with serious illnesses across Africa? A mixed-methods systematic review of the concept and evidence

BACKGROUND

Clarity on what constitutes a palliative care need is essential to ensure that health systems and clinical services deliver an appropriate response within Universal Health Coverage.

AIM

To synthesise primary evidence from Africa for palliative care needs among patients and families with serious illness.

DESIGN

We conducted a mixed methods systematic review with sequential synthesis design. The protocol was registered with PROSPERO (CRD42019136606) and included studies were quality assessed using Mixed Method Appraisal Tool.

DATA SOURCES

Six global literature databases and Three Africa-specific databases were searched up to October 2020 for terms related to palliative care, serious illnesses and Africa. Palliative care need was defined as multidimensional problems, symptoms, distress and concerns which can benefit from palliative care.

RESULTS

Of 7810 papers screened, 159 papers met eligibility criteria. Palliative care needs were mostly described amongst patients with HIV/AIDS (n = 99 studies) or cancer (n = 59), from East (n = 72) and Southern (n = 89) Africa. Context-specific palliative care needs included managing pregnancy and breastfeeding, preventing infection transmission (physical); health literacy needs, worry about medical bills (psychological); isolation and stigma, overwhelmed families needing a break, struggling to pay children's school fees and selling assets (social and practical needs); and rites associated with cultural and religious beliefs (spiritual).

CONCLUSIONS

Palliative care assessment and care must reflect the context-driven specific needs of patients and families in Africa, in line with the novel framework. Health literacy is a crucial need in this context that must be met to ensure that the benefits of palliative care can be achieved at the patient-level.

Development and Psychometric Testing of the Supportive Care Needs Scale for Patients with Tuberculosis (SCN-TB)

PURPOSE

Patients affected by tuberculosis have diverse unmet supportive care needs (SCN) that may seriously affect their treatment adherence. Accurately assessing patients' SCN is important for providing efficient patient-centred care, but few instruments are suitable for use in clinical practice. Therefore, the purpose of this study was to develop an SCN scale for patients with tuberculosis (SCN-TB) and to evaluate its psychometrical properties.

PATIENTS AND METHODS

Based on the SCN framework, the SCN-TB was designed via a literature review, Delphi consultation and pilot study. Then, 550 patients from four tuberculosis specialist hospitals in Shaanxi Province were enrolled by convenience sampling to further test the validity and reliability of the SCN-TB.

RESULTS

A total of 518 patients completed the survey. The final scale encompasses 25 items in five domains: physical, practical, psycho-emotional, social, and informational. The content validity for the scale was 0.93, with that for each item ranging from 0.80 to 1.00. Five factors that explained 80.38% of the variance were identified in exploratory factor analysis. A five-factor model was then confirmed with confirmatory factor analysis using maximum likelihood estimation with bootstrapping. The model fit indices were χ ²/df=1.062 (Bollen-Stine χ ²=281.382, df=265, p<0.001), CFI=0.997, RMSEA=0.016, SRMR=0.053, NFI=0.951, and GFI=0.929. All factors had acceptable convergent and discriminant validity. The Cronbach's α, split-half, and test-retest reliability coefficients of the scale were 0.884, 0.883, and 0.854, respectively.

CONCLUSION

The SCN-TB is a valid and reliable theory based tool for assessing the needs of patients with tuberculosis and can be applied in both clinical practice and research.

Qualitative Analysis of Palliative Care for Pediatric Patients With Cancer at Bugando Medical Center: An Evaluation of Barriers to Providing End-of-Life Care in a Resource-Limited Setting

Purpose Palliative care remains an urgent, neglected need in the developing world. Global disparities in end-of-life care for children, such as those with advanced cancers, result from barriers that are complex and largely unstudied. This study describes these barriers at Bugando Medical Center, one of three consultant hospitals in Tanzania, to identify areas for palliative care development suitable to this context. Methods In-depth interviews were conducted with 20 caregivers of pediatric patients with cancer and 14 hospital staff involved in pediatric end-of-life care. This was combined with 1 month of participant observation through direct clinical care of terminally ill pediatric patients. Results Data from interviews as well as participant observation revealed several barriers to palliative care: financial, infrastructure, knowledge and cultural (including perceptions of pediatric pain), and communication challenges. Although this study focused on barriers, what also emerged were the unique advantages of end-of-life care in this setting, including community cohesiveness and strong faith background. Conclusion This study provides a unique but focused description of barriers to palliative care common in a low-resource setting, extending beyond resource needs. This multidisciplinary qualitative approach combined interviews with participant observation, providing a deeper understanding of the logistical and cultural challenges in this setting. This new understanding will inform the design of more effective-and more appropriate-palliative care policies for young patients with cancer in the developing world.

Evaluation of the Quality of Dying and Death Questionnaire in Kenya

PURPOSE

A culturally appropriate, patient-centered measure of the quality of dying and death is needed to advance palliative care in Africa. We therefore evaluated the Quality of Dying and Death Questionnaire (QODD) in a Kenyan hospice sample and compared item ratings with those from a Canadian advanced-cancer sample.

METHODS

Caregivers of deceased patients from three Kenyan hospices completed the QODD. Their QODD item ratings were compared with those from 602 caregivers of deceased patients with advanced cancer in Ontario, Canada, and were correlated with overall quality of dying and death ratings.

RESULTS

Compared with the Ontario sample, outcomes in the Kenyan sample (N = 127; mean age, 48.21 years; standard deviation, 13.57 years) were worse on 14 QODD concerns and on overall quality of dying and death (P values ≤ .001) but better on five concerns, including interpersonal and religious/spiritual concerns (P values ≤ .005). Overall quality of dying was associated with better patient experiences with Symptoms and Personal Care, interpersonal, and religious/spiritual concerns (P values < .01). Preparation for Death, Treatment Preferences, and Moment of Death items showed the most omitted ratings.

CONCLUSION

The quality of dying and death in Kenya is worse than in a setting with greater PC access, except in interpersonal and religious/spiritual domains. Cultural differences in perceptions of a good death and the acceptability of death-related discussions may affect ratings on the QODD. This measure requires revision and validation for use in African settings, but evidence from such patient-centered assessment tools can advance palliative care in this region.

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.

Chronic illness needing palliative care in Kinshasa hospitals, Democratic Republic of the Congo (DRC)

BACKGROUND

Chronic illnesses are a major public health problem in low-income countries. In the Democratic Republic of the Congo (DRC), few data are available, especially in palliative care. In this context, the present study aimed at describing the patterns of diseases in Kinshasa hospitals as well as risk factors associated with patients' evolving status and length of hospital stay.

METHODS

A prospective study was conducted in ten hospitals of Kinshasa, over a 1-year period. A total of 2699 patients with a chronic condition (non-communicable diseases (NCD) and/or AIDS) were consecutively enrolled in the study between January and December, 2013.

RESULTS

Out of 2699 patients studied, 36.9% were suffering from cardiovascular diseases, 29.7% from comorbidity and 17.5% from AIDS. 27.5% of patients died while hospitalized, and 67.4% were lost to follow-up. The risk factors independently associated with death in hospitals were AIDS (adjusted OR = 2.2) and age over 65 years old (adjusted OR = 1.7). Peri-urban and rural areas were significantly associated with a mean adjusted hospital stay longer than 3 days. The length of stay (LOS) was shorter for women and patients living in urban areas. Patients survived for a median of 10 days (range 7-20 days).

CONCLUSIONS

This study reveals the high proportion of patients suffering from advanced chronic diseases, including cardiovascular diseases, AIDS and comorbidity. It demonstrates the need for palliative care (PC) in medical practices in Kinshasa, the capital of the Democratic Republic of the Congo.