A systematic review exploring palliative care for families who are forced migrants

First generation migrants' experiences of terminal illness: a systematic review of diasporic dying

BACKGROUND

Migration is an established global phenomenon. While many newly arrived migrants have better health than the general population of the country they have moved to, migrants also have their own healthcare needs and face particular issues when diagnosed with a terminal illness. First generation migrants are less likely to have social, financial, and medical supports when faced with a terminal illness. These factors make first generation migrants an important group to understand in order to inform service commissioning and delivery.

METHODS

The systematic review was an international qualitative evidence synthesis of English language papers from 2000 to 2023. The primary research question underpinning this novel review was: What are the experiences of first-generation migrants who live with or who are supporting a relative with a terminal illness in the country to which they have moved? Databases (MEDLINE; CINAHL; PsycINFO; SocIndex; Web of Science) were searched in August 2023. Records of 1593 publications were screened, resulting in 39 included papers. CASP was used to inform quality appraisal.

RESULTS

First generation migrants struggled with accessing suitable health services and treatments. Structural barriers, such as lack of support for translation/interpreting and for navigating care was visible alongside limited social support networks. Financial precarity ran as a thread through the data, with participants needing to work while unwell, and being unable to return to their country of origin for their own death or to bear witness to the deaths of relatives. First generation migrants experienced caregiving through the lens of difference; maintaining autonomy in the country they would die in, intersected with cultural practices and expectations such as not sharing the prognosis, and mis-matched ideas regarding quality of care provided. The identity of 'migrant' is heterogenous, poorly defined, and may have resulted in identifying studies conducted in the global north.

CONCLUSIONS

Diasporic dying is not a new phenomenon, yet services and policies fail to meet people's needs. Services urgently need to identify and dismantle structures which uphold and perpetuate inequality, including this population who suffer multiple disadvantages and risks.

PROTOCOL REGISTRATION

CRD42023457054.

Opportunities and practices supporting responsive health care for forced migrants: lessons from transnational practice and a mixed-methods systematic review

Background

For those displaced across borders, significant adversity before, during and after displacement journeys, including attitudes and structures in countries of transit and arrival, contributes to considerable risk of poor physical and mental health, and poor and exclusionary experiences of health care.

Objectives

We aimed to understand the opportunities and practices that can support better healthcare responses for forced migrants.

Design

We integrated (1) local stakeholder perspectives, from workshops and dialogue; (2) evidence and knowledge from a mixed-methods systematic review; and (3) learning from five case examples from current international practice.

Review methods and data sources

We ran database searches (American Psychological Association PsycINFO, EMBASE, the Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature, MEDLINE, National Institute for Health and Care Research Journals Library) in February 2022, searched relevant agency websites and conducted backward and forward citation searches, extracted data, assessed methodological quality and integrated qualitative and quantitative findings.

Case examples

We studied three services in the UK, one in Belgium and one in Australia, conducting semistructured interviews with providers, collaborators and service users, and making site visits and observations if possible.

Results

The review identified 108 studies. We identified six domains of impact: (1) benefit from and creation of community, including linkages with formal (health) services; (2) the formation of networks of care that included traditional and non-traditional providers; (3) proactive engagement, including conducting care in familiar spaces; (4) considered communication; (5) informed providers and enhanced attitudes; and (6) a right to knowledge (respecting the need of new arrivals for information, knowledge and confidence in local systems). The case examples drew attention to the benefits of a willingness to innovate and work outside existing structures, 'micro-flexibility' in interactions with patients, and the creation of safe spaces to encourage trust in providers. Other positive behaviours included engaging in intercultural exchange, facilitating the connection of people with their cultural sphere (e.g. nationality, language) and a reflexive attitude to the individual and their broader circumstances. Social and political structures can diminish these efforts.

Limitations

Review: wide heterogeneity in study characteristics presented challenges in drawing clear associations from the data. Case examples: we engaged only a small numbers of service users and only with service users from some services.

Conclusions

We found that environments that enable good health and enable people to live lives of meaning are vital. We found that these environments require flexibility and reflexivity in practice, intercultural exchange, humility and a commitment to communication. We suggest that a broader range of caring practitioners can, and should, through intentional and interconnected practice, contribute to the health care of forced migrants. Opening up healthcare systems to include other state actors (e.g. teachers and settlement workers) and a range of non-state actors, who should include community leaders and peers and private players, is a key step in this process.

Future work

Future work should focus on the health and health service implications of immigration practices, the inclusion of peers in a range of healthcare roles, alliance-building across unlikely collaborators and the embedding of intercultural exchange in practice.

Study registration

This study is registered as PROSPERO (CRD42021271464).

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR132961) and is published in full in Health and Social Care Delivery Research; Vol. 13, No. 13. See the NIHR Funding and Awards website for further award information.

Cultural or Spiritual End-of-Life Practice Preference Assessment and Documentation: Identifying Current Practice in Pediatric Hospice

Communities use rituals at end of life to foster a peaceful death, ensure passage to the afterlife, and grieve their lost loved ones. Studies report fear of misunderstanding or impeding rituals as a barrier to accepting hospice care. However, there has been little research on cultural and spiritual rituals in the setting of hospice care or how patient preference should be assessed, documented, and supported by hospice staff. This project sought to identify the current practice for assessment of cultural or spiritual end-of-life practice preferences, and the documentation of those preferences, within pediatric hospice programs in a Midwestern state. In surveys of 2 pediatric hospice programs, employee respondents reported routine assessment (97.3%) and routine documentation (70.3%) of cultural or spiritual end-of-life practice preferences. Most respondents reported documentation was written by various disciplines and in various locations in the medical record. Additionally, a retrospective chart review was performed including decedents of 1 pediatric hospice program over a 5-year period. Documentation affirming familial spiritual beliefs was identified in 75.9% of charts, of which, only 12.2% had documentation regarding end-of-life-specific spiritual needs. Standardized documentation practices may help foster equitable hospice care for all patients by ensuring care providers are aware of the patient and/or family's end-of-life spiritual needs.

Mechanisms and attitudes in responsive healthcare for forced migrant communities: a qualitative study of transnational practice

OBJECTIVES

To understand the opportunities and practices that can support responsive healthcare for forced migrant communities.

DESIGN

A qualitative study of five transnational case examples of services actively working to improve access and experiences of care for forced migrant communities, which is one strand of the MORRA Study.

SETTING

Five services (Australia, Belgium, UK) providing a range of care (primary care, health advocacy, education and support, holistic health screening, care planning/coordination, transcultural mental healthcare). Delivered through state and not-for-profit structures in initial and contingency accommodation sites, health clinics and community spaces. Data collection took place between July and October 2022.

PARTICIPANTS

47 participants including forced migrants using or having used one of the five services, service leads, clinical and non-clinical workers (paid and volunteer), interpreters and service partners. Services supported recruitment of a crude representative sample of worker roles and service users/clients. Participants were required to speak one of nine languages for which we had translated study materials.

MAIN OUTCOME MEASURES

Experiences, practices, knowledges, skills and attributes of workers; experiences of forced migrants engaging in services.

RESULTS

Services showed a willingness to innovate and work outside existing practice and organisational structures, including a 'microflexibility' in their interactions with patients, and through the creation of safe spaces that encouraged trust in providers. Other positive behaviours included engaging in intercultural exchange; facilitating the connection of people with their cultural sphere (eg, nationality, language) and a reflexive attitude to the individual and their broader circumstances. Social and political structures can diminish these efforts.

CONCLUSIONS

Environments that enable good health and support forced migrants to live lives of meaning are vital components of responsive care. This requires flexibility and reflexivity in practice, intercultural exchange, humility, and a commitment to communication. A broader range of caring practitioners can, and should, through intentional and interconnected communities of care, contribute to the healthcare of forced migrants. Opening up healthcare systems to include other state actors such as teachers and settlement workers and a range of non-state actors that should include community leaders and peers and private players is a key step in this process. Future work should focus on the health and health service implications of immigration practices; the inclusion of peers in a range of healthcare roles; alliance-building across unlikely collaborators and the embedding of intercultural exchange in practice.

Exploring the experiences of children's palliative care for forced migrant families in the United Kingdom: an interpretative phenomenological study

Introduction

This study focused on understanding the experiences of forced migrant families and the health care professionals who care for them within palliative care. Palliative care for children requires an active, holistic approach to care, with a focus upon improving quality of life. Forced migrant families encounter a range of additional challenges including the loss of family, belongings, and all sources of familiarity and support. The difficulties of navigating complex bureaucratic systems can confound access and communication difficulties.

Methods

Interpretative Phenomenological Analysis methodology was used in this study to privilege participant perspectives and apply an active in-depth cyclical process of reflection and reflexivity. Advisory group members provided expertise in childhood illness, palliative care and forced migration, throughout the study. The Silences Framework offered novel theoretical and philosophical concepts, which helped to situate and prioritise the "silences" within the marginalised discourses of forced migration and palliative care. Seven family members and seven health care professional participants were interviewed from hospital, hospice and community palliative care settings in the UK.

Results

Four overarching themes were identified related to experiences of loss and grief, communication, faith and coping strategies and alienation and discrimination. Compassionate, empathetic, family-centred care which valued family belief systems and coping strategies, optimised care. Learning with and from families was described by all participants, which enhanced understanding and fostered mutual respect. However, barriers included poor access to services and resources, protocol-led care, limited time with families, communication barriers and staff burnout.

Discussion

The findings suggest the need for a specific educational pathway for palliative care professionals to include spiritual care provision, cultural humility, and moral reasoning. Interdisciplinary education including the use of lived-experience expert insights is also advocated. Sufficient time to build relationships, the importance of interpreter support and the need for better access to hospice care for forced migrant families is also recommended.

What do family caregivers of patients with life-threatening diseases need from healthcare professionals? A qualitative study

OBJECTIVES

To explore the common ground of what family caregivers need in their various roles (caregiver, care recipient and patient's partner, child or friend) from healthcare professionals across healthcare settings and disease trajectories.

DESIGN

Interviews were conducted with family caregivers of patients with life-threatening diseases who were treated at home, in hospitals, nursing homes or hospices between 2017 and 2022. Reflexive thematic analysis was performed.

SETTING/PARTICIPANTS

63 family caregivers of 65 patients were interviewed. Of the patients, 36 (55%) had COVID-19 and 29 (45%) had other life-threatening diseases (eg, advanced cancer, dementia). The majority of family caregivers were women (83%) and children of the patient (56%).

RESULTS

Three themes were developed regarding family caregivers' core needs across their different roles: (1) 'feeling seen and valued', (2) 'experiencing trust in the provided care' and (3) 'experiencing guidance and security'. Actions of healthcare professionals that meet those needs relate to their contact and relationship with family caregivers, information provision, practical and emotional support, the care for the patient and facilitating the connection between family caregivers and patients.

DISCUSSION

Healthcare professionals should be trained in meeting family caregivers' core needs, in which their (collaborative) relationship with them plays an important role. Efforts to meet the core needs should be incorporated into healthcare organisations' workflows, and future research should investigate related barriers and facilitators.

Meta-synthesis of ethnic minority families' experiences of children's palliative care across developed countries

OBJECTIVES

Meeting the needs of people accessing healthcare from ethnic minority (EM) groups is of great importance. An insight into their experience is needed to improve healthcare providers' ability to align their support with the perspectives and needs of families. This review provides insight into how families from EM backgrounds experience children's palliative care (CPC) by answering the question, "What are the experiences of EM families of children's palliative care across developed countries?"

METHODS

A systematic search of articles from 6 databases (Scopus, Medline, Web of Science, APA PsycINFO, CINAHL, and Global Health) with no limit to the date of publication. The search was conducted twice, first in June 2022 and again in December 2022. The extracted data were analyzed using thematic synthesis.

RESULTS

Eight studies explored the experiences of families of EM in different high-income countries. Four themes were identified: unmet needs leading to communication gaps, accessibility of hospital services and resources, the attitude of healthcare workers, and the need for survival as an immigrant.

SIGNIFICANCE OF RESULTS

Overall, the study shows EM families rely heavily on healthcare professionals' cultural competence in delivering palliative care for their children. There is an interplay between EM families' culture, spiritual ties, communication, and social needs from this review. Understanding how to bridge the communication gap and how families use their culture, faith, and spirituality to manage their pain, and grief and improve their quality of life would be extremely beneficial for healthcare practitioners in increasing their support to EM families accessing CPC.

Palliative care needs of people and/or their families with serious and/or chronic health conditions in low- or middle-income country (LMIC) humanitarian settings-a systematic scoping review protocol

BACKGROUND

Palliative care in low- or middle-income country (LMIC) humanitarian settings is a new area, experiencing a degree of increased momentum over recent years. The review contributes to this growing body of knowledge, in addition to identifying gaps for future research. The overall aim is to systematically explore the evidence on palliative care needs of patients and/or their families in LMIC humanitarian settings.

METHODS

Arksey and O'Malley's (Int J Soc Res Methodol. 8:19-32, 2005) scoping review framework forms the basis of the study design, following further guidance from Levac et al. (Implement Sci 5:1-9, 2010), the Joanna Briggs Institute (JBI) Peters et al. (JBI Reviewer's Manual JBI: 406-452, 2020), and the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) from Tricco et al. (Ann Intern Med 169:467-73, 2018). This incorporates a five-step approach and the population, concept, and context (PCC) framework. Using already identified key words/terms, searches for both published research and gray literature from January 2012 to October 2022 will be undertaken using databases (likely to include Cumulative Index of Nursing and Allied Health (CINAHL), MEDLINE, Embase, Global Health, Scopus, Applied Social Science Index and Abstracts (ASSIA), Web of Science, Policy Commons, JSTOR, Library Network International Monetary Fund and World Bank, Google Advanced Search, and Google Scholar) in addition to selected pre-print sites and websites. Data selection will be undertaken based on the inclusion and exclusion criteria and will be reviewed at each stage by two reviewers, with a third to resolve any differences. Extracted data will be charted in a table. Ethical approval is not required for this review.

DISCUSSION

Findings will be presented in tables and diagrams/charts, followed by a narrative description. The review will run from late October 2022 to early 2023. This is the first systematic scoping review specifically exploring the palliative care needs of patients and/or their family, in LMIC humanitarian settings. The paper from the review findings will be submitted for publication in 2023.

Culturally sensitive neonatal palliative care: a critical review

Although there are known disparities in neonatal and perinatal deaths across cultural groups, less is known about how cultural diversity impacts neonatal palliative care. This article critically reviews available literature and sets out key questions that need to be addressed to enhance neonatal palliative care provision for culturally diverse families. We begin by critically reviewing the challenges to recording, categorizing and understanding data which need to be addressed to enable a true reflection of the health disparities in neonatal mortality. We then consider whose voices frame the current neonatal palliative care agenda, and, importantly, whose perspectives are missing; what this means in terms of limiting current understanding and how the inclusion of diverse perspectives can potentially help address current inequities in service provision. Utilizing these insights, we make recommendations towards setting a research agenda, including key areas for future enquiry and methodological and practice-based considerations.

Opportunities to Improve Awareness of Antimicrobial Resistance Through Social Marketing: A Systematic Review of Interventions Targeting Parents and Children

Lack of knowledge from parents concerning the appropriate use of antimicrobials leads to poor treatment choices and mismanagement of antimicrobials for their children. Social marketing (SM) strategies have the potential to help parents access useful information on the appropriate use of antimicrobials. Still, its application in interventions targeting antimicrobial/antibiotic resistance awareness is minimal. This study explores the use of SM in antimicrobial/antibiotic awareness campaigns (AACs) to identify opportunities for SM approaches in developing future communication interventions targeting parents and children. We conduct a systematic review of interventions targeting parents and children between 2000 and 2022. Articles meeting the selection criteria were assessed against social marketing benchmark criteria (SMBC). We identified 6978 original records, 16 of which were included in the final review. None of the articles explicitly identified SM as part of their interventions. Twelve interventions (75%) included 1 to 4 (out of 8) benchmark criteria, while four (25%) had 5-8 benchmarks in their interventions. Of the interventions with less than four benchmark criteria, six studies (50%) reported a positive effect direction outcome, and six studies (50%) reported negative/no change direction on the outcome of interests. Meanwhile, all interventions with five or more SMBC resulted in a positive effect direction in their outcomes. In this review, the use of SM has shown promising results, indicating opportunities for future antimicrobial resistance (AMR) interventions that incorporate social marketing benchmark criteria to improve intervention outcomes.

Reimagining a children's palliative care educational programme for registered nurses in response to the COVID-19 pandemic

BACKGROUND

Children with life-limiting conditions are a unique population with multiple health and social care needs. Key literature indicates the need for education to support registered nurses providing care, including palliative care, to these children. In response to the COVID-19 pandemic, a palliative care programme was converted to an online programme, adopting a blended approach between national and regional facilitators.

OBJECTIVES

To assess nurses' satisfaction with a re-designed palliative care programme centred around the care of children with life-limiting conditions, including their perceptions of the online format.

DESIGN AND METHODS

A descriptive correlational design and online survey was used to explore the participants' perception of the content and online delivery of the Care of the Child with a Life-Limiting Condition programme. Nine sessions, comprised of five national and four regional webinars, were delivered.

RESULTS

Attendees registered (n = 169) from throughout the Republic of Ireland, with 130 attending all webinars. Attendees stated online delivery of education increased their accessibility to highly qualified experts. The short, concise nature of sessions was well received. Online delivery and recorded sessions contributed to convenience with the ability to access and process information in attendees' own time being welcomed. However, the negative impact of losing face-to-face interactions was noted, including the opportunity to build relationships with colleagues caring for children with life-limiting conditions.

CONCLUSIONS

Results suggest that the redesigned online programme contributed to participants' knowledge, encouraged participation and increased accessibility. An e-Learning model enables specialised education to be more equitable and accessible, ensuring regional areas are not disadvantaged due to geographical remoteness from tertiary educational centres. However, the lack of face-to-face contact was acknowledged as a hindrance to socialisation and networking. When developing future programmes, focus should be put on creating opportunities for networking and social development to compensate for the lack of face-to-face contact.

Risk factors associated with quadbike crashes: a systematic review

Background

Quadbikes or all-terrain vehicles are known for their propensity for crashes resulting in injury, disability, and death. The control of these needless losses resulting from quadbike crashes has become an essential contributor to sustainable development goals. Understanding the risk factors for such injuries is essential for developing preventive policies and strategies. The aim of this review was to identify the risk factors associated with quadbike crashes at multiple levels through a systematic review of a wide range of study designs.

Methods

The study incorporated a mixed-method systematic review approach and followed the PRISMA 2020 guidelines for reporting systematic reviews, including a peer reviewed  protocol. This systematic review included observational studies investigating the risk factors associated with quadbike crashes, injuries, or deaths. Seven electronic databases were searched from inception to October 2021. Studies were screened and extracted by three researchers. Quality appraisal was conducted using the Mixed Methods Appraisal Tool (MMAT). Due to extensive heterogeneity, meta-analysis was not conducted. All the risk factors have been presented in a narrative synthesis for discussion following the guidelines for Synthesis without Meta-analysis (SWiM).

Results

Thirty-nine studies combining an aggregate of 65,170 participants were included in this systematic review. The results indicate that modifiable risk factors, such as the increasing age of driving initiation, reducing substance use, and the use of organized riding parks, could reduce quadbike injuries. Riding practices such as avoiding passengers, avoiding nighttime riding, and using helmets could significantly reduce crashes and injuries among riders. Vehicle modifications such as increasing the wheelbase and limiting engine displacement could also help reduce crash incidence. Traditional interventional methods, such as legislation and training, had a weak influence on reducing quadbike injuries.

Conclusion

Multiple risk factors are associated with quadbike injuries, with most of them modifiable. Strengthening policies and awareness to minimize risk factors would help in reducing accidents associated with quadbikes.

PROSPERO registration number CRD42020170245

Paramedics delivering palliative and end-of-life care in community-based settings: A systematic integrative review with thematic synthesis

BACKGROUND

There is a growing demand for community palliative care and home-based deaths worldwide. However, gaps remain in this service provision, particularly after-hours. Paramedicine may help to bridge that gap and avoid unwanted hospital admissions, but a systematic overview of paramedics' potential role in palliative and end-of-life care is lacking.

AIM

To review and synthesise the empirical evidence regarding paramedics delivering palliative and end-of-life care in community-based settings.

DESIGN

A systematic integrative review with a thematic synthesis was undertaken in accordance with Whittemore and Knafl's methodology. Prospero: CRD4202119851.

DATA SOURCES

MEDLINE, CINAHL, PsycINFO and Scopus databases were searched in August 2020 for primary research articles published in English, with no date limits applied. Articles were screened and reviewed independently by two researchers, and quality appraisal was conducted following the Mixed-Methods Appraisal Tool (2018).

RESULTS

The search retrieved 5985 articles; 23 articles satisfied eligibility criteria, consisting of mixed-methods (n = 5), qualitative (n = 7), quantitative descriptive (n = 8) and quantitative non-randomised studies (n = 3). Through data analysis, three key themes were identified: (1) Broadening the traditional role, (2) Understanding patient wishes and (3) Supporting families.

CONCLUSIONS

Paramedics are a highly skilled workforce capable of helping to deliver palliative and end-of-life care to people in their homes and reducing avoidable hospital admissions, particularly for palliative emergencies. Future research should focus on investigating the efficacy of palliative care clinical practice guideline implementation for paramedics, understanding other healthcare professionals' perspectives, and undertaking health economic evaluations of targeted interventions.