Palliative care development in Africa: how can we provide enough quality care?

Depressive Symptoms and Palliative Care Concerns Among Patients With Non-communicable Diseases in Two Southern African Countries

CONTEXT

Non-communicable diseases (NCDs), associated with health-related suffering, can benefit from palliative care in resource-limited settings, where over four-fifths of these deaths occur.

OBJECTIVE

To measure the prevalence of depressive symptoms, palliative care-related concerns, physical and other psychological symptoms among adult patients with NCDs in Malawi and Namibia.

METHODS

This multi-center, cross-sectional study consecutively recruited outpatients from four tertiary referral hospitals. Stepwise regression analysis was used to assess factors associated with physical and psychological symptom burden.

RESULTS

Among 457 participants, primary diagnosis was cancer (n=147, 32%); cardiovascular disease (CVD) (n=130, 28%), chronic respiratory disease (CRESD) (n=73, 16%) or diabetes (n=107, 23%). Over half were female (58.9%; n=269), mean age was 48 (SD=15.7). Clinically significant psychological distress was identified among cancer (57.2%), diabetes (57.0%), CRESD (45.2%) and CVD patients (43.1%), with criterion for major depression symptoms met for cancer (42.9%), diabetes (39.2%), CVD (30.0%) and CRESD (28.8%). Most severe palliative care concerns were: first sharing feelings (i.e., not at all/not very often), reported by CVD (28%), CRESD (23%), cancer (22%) and diabetes (21%) patients; second help and advice (i.e., none/very little), among cancer (28%), CVD (26%), diabetes (22%), and CRESD (16%) patients. High prevalence of moderate-to-severe pain was reported (cancer 54%, CVD 41%, CRESD 38%, diabetes 38%). Functional status, age, and presence of comorbidities were associated with physical and psychological symptom distress.

CONCLUSION

Given the high burden of physical and psychosocial symptoms and symptom distress, the findings highlight the need for integrated person-centered palliative care for NCDs to optimize care outcomes.

Research attitudes, practice and literacy among Kenyan palliative care healthcare professionals: an observational, cross-sectional online survey

BACKGROUND

While research is needed to advocate for implementation of global agendas to strengthen palliative care, healthcare professionals' research literacy must improve to bridge the gap between evidence and practice. A resurgent focus on North-South power disparities, means attention should also focus on understanding low- and middle-income countries' local agency to implement palliative care research agendas.

METHODS

An observational, cross-sectional online survey among Kenyan palliative healthcare professionals currently working at any of the palliative and hospice care organizations operational during January - December 2019, using descriptive statistics.

RESULTS

Among the 93 survey respondents, participants were mainly nurses (50.54%; n = 47). Regarding research attitudes: all agreed/strongly agreed research was important for their professional work. Over nine-tenths (91.21%; n = 83) reported having the skills to conduct research, and 91.30% (n = 84) wanted to conduct research in their clinical work. 90% (90.21%; n = 83) reported supervisory support to conduct research. A comparable proportion (90.22%; n = 83) would undertake research if they could find funding. Regarding research practice: over two-thirds (70.65%; n = 65) reported ever having had a mentor who encouraged them to do research, while approximately half (50.59%; n = 43) reported reading evidence-based journal articles about once per month and attending monthly in-house meetings on palliative care (56.79%; n = 46). Regarding research literacy: while over two-fifths of respondents described their current research literacy level as 'none' or 'beginner' (44.56%; n = 41), a comparable proportion described it as 'intermediate' (45.65%; n = 42), with 9 (9.78%) stating it was 'advanced'.

CONCLUSION

The majority of palliative healthcare professionals report having interest, skills and support at work to conduct palliative care research, with a low-to-medium level of research literacy. The current study explored palliative care staff attitudes to, experience in, and literacy with the research process, which is necessary to creating a dialogue on implementing research findings. This study also adds to the global empowerment agenda, addressing inequities in research opportunities and local capacity to own and undertake palliative care research.

Palliative care education and training in Liberia: A qualitative exploration of current state and challenges to further development

BACKGROUND

Palliative care is an integral approach to enhancing patients' overall quality of life by taking into account their entire lives and addressing any suffering they may be experiencing. Thus, palliative care education and training should be advanced. However, palliative care training and education in Liberia have just started, and their development warrants further investigation.

OBJECTIVE

This research aimed to explore the state of palliative care education in Liberia and highlight its barriers and challenges.

METHODS

A descriptive qualitative exploratory study design was adopted in this study. Semi-structured interviews were conducted with ten male lecturers and four female nurses to gain in-depth insight into their perspectives on palliative care education. Thematic analysis with NVivo 12 plus was used for data analysis.

RESULTS

Four themes emerged from the data: 1) the need for palliative education (lack of healthcare professionals, government support, regular workshops, integration, and interprofessional education on palliative care), 2) palliative care barriers (lack of curriculum implementation, lack of experience, lack of government actions, and poor infrastructures), 3) the level of student knowledge (senior and junior level, same educational level, and regular teaching materials), and 4) the roles of health care professionals (attention on palliative care, providing education on pain, and public awareness).

CONCLUSION

The study findings may serve as input to develop palliative care education and training in Liberia. The identified gaps must be filled, and critical barriers must be overcome if the area of palliative care needs to be advanced. However, the comprehensive knowledge gathered in this study can be used by nurses, lecturers, and multidisciplinary teams to achieve the effectiveness of palliative care for patients.

Developing Macroindicators of Palliative Care Development in Africa: A Process with In-Country and International Experts

BACKGROUND

Indicators specific to the African context are important to measure palliative care (PC) development accurately.

OBJECTIVE

To describe the process used to develop a set of PC macroindicators for Africa.

DESIGN

Open-ended interviews on national PC development were conducted with five African Country Experts. Indicators were rated (1-4) by 14 Country Experts for validity and feasibility. An additional 11 interviews were conducted to ensure indicator saturation. Indicators scoring ≥3 proceeded to a modified two-round RAND/UCLA Delphi with global experts on PC development (International Committee). Finally, indicators were ranked by the project team.

SETTING/SUBJECTS

Sixteen country experts from 7 African countries and 14 International Committee members.

RESULTS

One hundred three indicators were rated by Country Experts, and 58 proceeded to the Delphi. Thirty-eight indicators were rated as important by the International Committee, and the project team ranked 19 of these as most important. Service indicators (n = 6) included the number of types of services most important in Africa (e.g., hospices, home based) and coverage. Policy indicators (n = 4) included the existence of PC in national policies, guidelines, and budget and a responsible person. Education indicators (n = 3) consisted of inclusion of PC in medical and nursing curricula and recognition as a specialty. Medicine indicators (n = 4) focused on morphine availability, consumption, and prescribing barriers. Vitality indicators (n = 2) reflected the existence of a national association and its activity.

CONCLUSION

The process to develop African-specific PC indicators resulted in 19 indicators that were used to measure PC development as a comparative baseline for development in African countries.

Advancing palliative care in the Uganda health system: an evidence-based policy brief

OBJECTIVES

This paper describes the development and findings for a policy brief on "Advancing the Integration of Palliative Care into the National Health System" and the subsequent use of this report.

METHODS

Key stakeholders involved with palliative care helped identify the problem and potential policy solutions to scale up these services within the health system. A working group of national stakeholder representatives and external reviewers commented on and contributed to successive drafts of the report. Research describing the problem, policy options and implementation considerations was identified by reviewing government documents, routinely collected data, electronic literature searches, contact with key informants, and reviewing the reference lists of relevant documents that were retrieved.

RESULTS

The palliative burden is not only high but increasing due to the rise in population and life expectancy. A few options for holistic, supportive care include: Home-based care increases chances of a peaceful death for the terminally ill surrounded by their loved ones; supporting informal caregivers improves their quality of life and discharge planning reduces unscheduled admissions and has the potential to free up capacity for acute care services. A combination of strategies is needed to effectively implement the proposed options as discussed further in this article.

CONCLUSIONS

The policy brief report was used as a background document for two stakeholder dialogues whose main outcome was that a comprehensive national palliative care policy should be instituted to include all the options, which need to be integrated within the public health system. A draft policy is now in process.

The current situation in education and training of health-care professionals across Africa to optimise the delivery of palliative care for cancer patients

The need for palliative care education remains vital to contribute to the quality of life of patients, both adults and children, with cancer in Africa. The number of patients with cancer continues to rise, and with them the burden of palliative care needs. Palliative care has been present in Africa for nearly four decades, and a number of services are developing in response to the HIV/AIDS epidemic. However, the needs of cancer patients remain a challenge. Education and training initiatives have developed throughout this time, using a combination of educational methods, including, more recently, e-learning initiatives. The role of international and national organisations in supporting education has been pivotal in developing models of education and training that are robust, sustainable, and affordable. Developing a material for education and professional development needs to continue in close collaboration with that already in production in order to optimise available resources. Seeking ways to evaluate programmes in terms of their impact on patient care remains an important part of programme delivery. This article reviews the current situation.

Formulary availability and regulatory barriers to accessibility of opioids for cancer pain in Africa: a report from the Global Opioid Policy Initiative (GOPI)

With nearly 1.1 billion inhabitants living in more than 50 countries, Africa is the world's poorest and most socioeconomically underdeveloped continent. Despite some advances for individual states, many African countries have very low opioid consumption and, overall, the continent has the lowest consumption per capita of any in the world. This article presents the findings of the first systematic study of the availability and accessibility of opioids for the management of cancer pain across the continent. Data are reported on the availability and accessibility of opioids for the management of cancer pain in 25 of 52 countries, with 744 million of the region's 1127 million people (66%) covered by the survey. Many countries had severely restricted formularies of opioids and only 15 of 25 had morphine available in oral IR, CR and injectable formulations. Even when opioids are on formulary they are often unavailable, and access is significantly impaired by widespread over-regulation that is pervasive across the region.

Public preferences and priorities for end-of-life care in Kenya: a population-based street survey

Background

End-of-life care needs are great in Africa due to the burden of disease. This study aimed to explore public preferences and priorities for end-of-life care in Nairobi, Kenya.

Methods

Population-based street survey of Kenyans aged ≥18; researchers approached every 10th person, alternating men and women. Structured interviews investigated quality vs. quantity of life, care priorities, preferences for information, decision-making, place of death (most and least favourite) and focus of care in a hypothetical scenario of serious illness with <1 year to live. Descriptive analysis examined variations.

Results

201 individuals were interviewed (100 women) representing 17 tribes (n = 90 44.8%, Kikuyu). 56.7% (n = 114) said they would always like to be told if they had limited time left. The majority (n = 121, 61.4%) preferred quality of life over quantity i.e. extending life (n = 47, 23.9%). Keeping a positive attitude and ensuring relatives/friends were not worried were prioritised above having pain/discomfort relieved. The three most concerning problems were pain (45.8%), family burden (34.8%) and personal psychological distress (29.8%). Home was both the most (51.1% n = 98) and least (23.7% n = 44) preferred place of death.

Conclusion

This first population-based survey on preferences and priorities for end-of-life care in Africa revealed that psycho-social domains were of greatest importance to the public, but also identified variations that require further exploration. If citizens’ preferences and priorities are to be met, the development of end-of-life care services to deliver preferences in Kenya should ensure an holistic model of palliative care responsive to individual preferences across care settings including at home.

Developing children's palliative care in Africa through beacon centres: lessons learnt

Much progress has been made in the provision of palliative care across sub-Saharan Africa, however much still remains to be done, particularly in the area of children's palliative care (CPC). The Beacon Centres programme was set up in 2009, aimed at improving access to CPC in South Africa, Uganda and Tanzania through more and better-trained health professionals and CPC clinical services of a high standard. Having identified sites in each country to develop into CPC Beacon Centres, Navigators were identified who would be the 'champions' for CPC in those sites and lead a programme of training, mentorship and support. Five navigators (2 in Uganda and Tanzania and 1 in South Africa) were trained between September and December 2009. Following this they undertook CPC needs assessments at the 3 centres and set up and delivered a six-month CPC training programme, providing mentorship and support to students to enable them to integrate CPC into their workplaces. To date, 188 participants have commenced the six-month course, with 80 having completed it. CPC has been integrated into the activities of the centres and a CPC virtual resource centre set up in South Africa. The achievements from the Beacon project have been great and the work of the navigators immense, but as in all projects it has not been without its challenges. Lessons learnt include issues around: the focus of the project; the length and nature of the training; assessment; accreditation; the choice of navigators; mentoring; administrative support; co-ordination; the choice of project sites; and the integration of CPC into services. The need for CPC is not going to go away and it is therefore important that models of scaling-up are found that are not only practical, feasible, affordable and sustainable, but that focus on the outcome of improved CPC for all those who need it. It is hoped that the lessons shared from the Beacon Project will help in developing and implementing such models.