End of life care in sub-Saharan Africa: a systematic review of the qualitative literature

Palliative Care in Sub-Saharan Africa: A Narrative Review

Background: As a person nears the end of their life, culture and ethnicity increasingly drive preferences and priorities for care. Understanding these preferences and priorities is fundamental to health care professionals' goals to respect decision making and support the individual throughout this phase of life. Across Africa, several countries are in the initial stages of implementing palliative care services in their burgeoning health care systems. Moving forward, it is imperative to consider cultural similarities and differences when compared with the Western world, where the field of palliative care evolved, to create a tailored palliative care approach that is consistent with African culture. In palliative care, understanding cultural preferences and priorities requires communication between the patient and the provider and is a crucial step toward a successful implementation in Africa. A paternalistic patient-provider relationship is the current leading model in sub-Saharan Africa.1 Aim: This narrative review explores the prevalence of paternalism and explores its appropriateness and necessity in the current application of palliative care in sub-Saharan African countries. Methods: This narrative review was conducted using four databases as well as hand searching of relevant articles sourced from references of already selected articles. A total of 730 articles were identified. Fourteen articles met the inclusion/exclusion criteria set for this narrative review. Results: In sub-Saharan Africa, the leading patient-provider relationship was determined to be paternalistic. Reasons for this were language, education, cultural norms and expectations, lack of time, and benevolence. Conclusions: The implementation of palliative care often relies on communication of patient desires and goals. Consideration is needed to determine how a provider can appropriately know these factors in a paternalistic relationship.

"A Soft Death": Perceptions and Attitudes Toward Palliative Care in Senegal

Background and Objectives

Palliative care (PC) is a specialty medical service that aims to address the bio-psycho-social-spiritual needs of patients with serious illnesses and their care partners. Despite the value of PC, its expansion in Sub-Saharan Africa has been uneven and particularly underdeveloped in Senegal due to variability in access to training resources and funding. This study sought to understand the current landscape of PC services in Senegal and the barriers and opportunities in its growth.

Research Design and Methods

Semistructured interviews were conducted with six PC clinicians, four caregivers of people with serious illnesses, one driver for a PC service, and one public health professor, all native to Senegal. Questions addressed their experience delivering or receiving PC, perceptions of barriers to implementation and access, and recommendations for additional resources and initiatives. Interviews were translated and transcribed from French into English. Transcripts were qualitatively coded for concepts during open and focused coding to identify themes.

Results

Five themes were identified: (1) the current landscape of PC, (2) barriers to implementing PC, (3) strategies and philosophies in care, (4) unique features of Senegalese culture, and (5) the future of PC.

Discussion and Implications

Our findings demonstrate that PC in Senegal remains an underresourced and underutilized specialty medical service, but work is being done by personally committed clinicians. Results can inform PC expansion by highlighting important cultural factors influencing care in Senegal, as well as the need to expand training opportunities for clinicians, increase education of other medical providers and the public about the nature of PC, integrate PC into the healthcare system, and expand research to evaluate the impact of these resources. PC has the potential to be an important force for improving the quality of life for Senegalese patients and their care partners.

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.

Qualitative research in physiotherapy: A systematic mapping review of 20 years literature from sub-Saharan Africa

STUDY AIM

To summarize the current state and quality of qualitative research conducted by physiotherapists in sub-Saharan Africa (SSA).

METHODS

We systematically searched multiple databases from 2000 to December 2020 and included peer-reviewed qualitative studies conducted by physiotherapists in SSA countries. Two reviewers independently screened citations, extracted data, and assessed the quality of the included studies using the 45-items checklist by Lundgren, and colleagues. Conventional content analysis was employed to create physiotherapy subject areas from the included studies.

RESULTS

We included 114 studies, a majority of 84 (74%) conducted in South Africa. Included studies were categorized into five subject areas: sports (n = 2), disability (n = 16), professional practice (n = 24), education and training (n = 36), and care provision (n = 36). We rated 74 (65%), 29 (25%), and 11 (10%) of the included research as low reporting quality, moderate- and high reporting quality, respectively. There was a significant lack of reporting on researchers' team characteristics, reflexivity, and member checking.

CONCLUSION

We conclude that the reporting of published qualitative studies in SSA shows variable quality, albeit mostly low, focused mainly on care provision, education, and training. Physiotherapy-researchers are encouraged to report reflexive practice and member checking when conducting qualitative research.

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.

Care of Older Persons in Eastern Africa: A Scoping Review of Ethical Issues

Introduction

The aging population is rapidly increasing globally, with 80% of the older population living in low- and middle-income countries. In Eastern African countries, there exists an incongruence between readiness-economically, structurally, politically, and culturally-to create a conducive environment for healthy aging, which implies public health as well as ethical concerns. The aim of this scoping review was to explore existing evidence addressing the various ethical issues in connection with elder care in the region of Eastern Africa.

Methods

We searched six databases (Africa-Wide Information, AgeLine, CINHAL, MEDLINE, APA PsycInfo, and SocINDEX) to identify peer-reviewed journal articles that could meet some eligibility criteria such as being a peer-reviewed journal article written in English, having been published in any year until July 2020, and focusing on ethical issues in the care of older people aged 60 years and older from Eastern Africa. We also searched for additional evidence in the references of included papers and web-based platforms. We included 24 journal articles and analyzed them using the inductive content analysis approach.

Results

The included articles represent seven (38.9%) of the 18 countries in the Eastern African region. The articles covered six ethical concerns: lack of government attention to older persons (n = 14, 58.3%), inaccessibility of health care services (n = 13, 54.2%), loneliness and isolation (n = 11, 45.8%), gender inequalities in old age (n = 9, 37.5%), mistreatment and victimization (n = 8, 33.3%), and medical errors (n = 2, 8.3%).

Conclusion

This scoping review summarized ethical issues arising in relation to providing care for older persons in the Eastern African context. In light of the rapid increase in the number of older persons in this region, it is critical for governments and responsible bodies to implement and accelerate efforts promptly to generate more evidence to inform programs and policies that improve the health and wellbeing of older persons. Further research is needed to inform global health efforts that aim at improving the lives of older persons, particularly in low- and middle-income countries.

Clinical Trial Registration

https://osf.io/sb8gw, identifier: 10.17605/OSF.IO/SB8GW.

How health systems can adapt to a population ageing with HIV and comorbid disease

As people age with HIV, their needs increase beyond solely managing HIV care. Ageing people with HIV, defined as people with HIV who are 50 years or older, face increased risk of both age-regulated comorbidities and ageing-related issues. Globally, health-care systems have struggled to meet these changing needs of ageing people with HIV. We argue that health systems need to rethink care strategies to meet the growing needs of this population and propose models of care that meet these needs using the WHO health system building blocks. We focus on care provision for ageing people with HIV in the three different funding mechanisms: President's Emergency Plan for AIDS Relief and Global Fund funded nations, the USA, and single-payer government health-care systems. Although our categorisation is necessarily incomplete, our efforts provide a valuable contribution to the debate on health systems strengthening as the need for integrated, people-centred, health services increase.

Factors Associated With Coverage of Health Insurance Among Women in Malawi

Introduction

Access to healthcare for the vulnerable groups including women has long been a theme encouraged worldwide from the first general assembly on health to the current sustainable development goals. Despite many countries having a free public healthcare system, there are inequalities in access to care and significant out-of-pocket spending, pushing most women into poverty against the principles of universal health coverage. Coverage of Malawian women with health insurance is poor; thus, there is limited cushioning and high risk of poverty, as women bear costs of care as primary caregivers. There is need to explore determinants of coverage of health insurance among women in Malawi to inform health policy.

Methodology

This study was quantitative in nature, using cross-sectional secondary data from the 2015 to 2016 Malawi Demographic and Health Survey involving women aged between 15 and 49 years. We assessed factors associated with insurance coverage by comparing women with and without insurance schemes using binary logistic regression. Analysis was done using STATA statistical package version 13.

Results

The analysis included a total of 24,562 women with a mean age of 28 SD (9.3). Of these cases, 1.5% had health insurance. High education attainment, occupation, and wealth were significantly associated with health insurance ownership, with all having p-values of < 0.01. On the other hand, a woman's residence, marital status, and who heads a household were not associated with ownership of health insurance significantly.

Conclusion

Education, occupation, and wealth have a key role in influencing a woman's choice in owning health insurance. This informs policymakers and health insurance providers on how best to approach women's health financing and factors to target in social security programs and health insurance products that speak to women's needs and capacity.

Setting priorities for ageing research in Africa: A systematic mapping review of 512 studies from sub-Saharan Africa

Background

In 2040, the older population's growth rate in sub-Saharan Africa (SSA) will be faster than those experienced by developed nations since 1950. In preparation for this growth, the National Institute on Aging commissioned the National Academies' Committee on Population to organize a workshop on advancing aging research in Africa. This meeting provided a platform for discussing some areas requiring improvement in aging research in SSA regions. We believed that conducting a systematic review of peer-reviewed articles to set priorities for aging research in SSA is warranted. Therefore, this article is the first in a Four-Part series that summaries the types and trends of peer-reviewed studies in SSA.

Methods

This systematic mapping review followed the Search-Appraisal-Synthesis-Analysis Framework. We systematically searched multiple databases from inception till February 2021 and included peer-reviewed articles conducted with/for older adults residing in SSA. Conventional content analysis was employed to categorize studies into subject-related areas.

Results

We included 512 studies (quantitative = 426, qualitative = 71 and mixed-method = 15). Studies were conducted in 32 countries. Quantitative studies included were observational studies: cross-sectional (n = 250, 59%), longitudinal (n = 126, 30%), and case-control (n = 12, 3%); and experimental studies: pre-post design (n = 4, 1%), randomized control trial (RCT, n = 12, 3%); and not reported (n = 21, 5%). Fifteen qualitative studies did not state their study design; where stated, study design ranged from descriptive (n = 14, 20%), ethnography (n = 12, 17%), grounded theory (n = 7, 10%), narrative (n = 5, 7%), phenomenology (n = 10, 14%), interpretative exploratory (n = 4, 6%), case studies (n = 4, 6%). Of the 15 mixed-method studies, seven did not state their mixed-method design. Where stated, design includes concurrent (n = 1), convergent (n = 1), cross-sectional (n = 3), informative (n = 1), sequential exploratory (n = 1) and retrospective (n = 2). Studies were classified into 30 (for quantitative studies) and seven (for qualitative and mixed-method) subject-related areas. HIV/AIDs-related and non-communicable diseases-related studies were the most predominant subject-related areas. No studies explored the transdisciplinary co-production of interventions.

Conclusions

There are glaring gaps in ageing research in SSA, especially mixed-methods and RCTs. A large number of studies focused on HIV/AIDs and non-communicable disease-related studies. National and international funding agencies should set up priority funding competitions for transdisciplinary collaborations in ageing research.

Setting priorities for ageing research in Africa: A systematic mapping review of 512 studies from sub-Saharan Africa

BACKGROUND

In 2040, the older population's growth rate in sub-Saharan Africa (SSA) will be faster than those experienced by developed nations since 1950. In preparation for this growth, the National Institute on Aging commissioned the National Academies' Committee on Population to organize a workshop on advancing aging research in Africa. This meeting provided a platform for discussing some areas requiring improvement in aging research in SSA regions. We believed that conducting a systematic review of peer-reviewed articles to set priorities for aging research in SSA is warranted. Therefore, this article is the first in a Four-Part series that summaries the types and trends of peer-reviewed studies in SSA.

METHODS

This systematic mapping review followed the Search-Appraisal-Synthesis-Analysis Framework. We systematically searched multiple databases from inception till February 2021 and included peer-reviewed articles conducted with/for older adults residing in SSA. Conventional content analysis was employed to categorize studies into subject-related areas.

RESULTS

We included 512 studies (quantitative = 426, qualitative = 71 and mixed-method = 15). Studies were conducted in 32 countries. Quantitative studies included were observational studies: cross-sectional (n = 250, 59%), longitudinal (n = 126, 30%), and case-control (n = 12, 3%); and experimental studies: pre-post design (n = 4, 1%), randomized control trial (RCT, n = 12, 3%); and not reported (n = 21, 5%). Fifteen qualitative studies did not state their study design; where stated, study design ranged from descriptive (n = 14, 20%), ethnography (n = 12, 17%), grounded theory (n = 7, 10%), narrative (n = 5, 7%), phenomenology (n = 10, 14%), interpretative exploratory (n = 4, 6%), case studies (n = 4, 6%). Of the 15 mixed-method studies, seven did not state their mixed-method design. Where stated, design includes concurrent (n = 1), convergent (n = 1), cross-sectional (n = 3), informative (n = 1), sequential exploratory (n = 1) and retrospective (n = 2). Studies were classified into 30 (for quantitative studies) and seven (for qualitative and mixed-method) subject-related areas. HIV/AIDs-related and non-communicable diseases-related studies were the most predominant subject-related areas. No studies explored the transdisciplinary co-production of interventions.

CONCLUSIONS

There are glaring gaps in ageing research in SSA, especially mixed-methods and RCTs. A large number of studies focused on HIV/AIDs and non-communicable disease-related studies. National and international funding agencies should set up priority funding competitions for transdisciplinary collaborations in ageing research.

Women's experiences of advanced breast cancer in a resource-limited Arab context: A Stakian multi-case study

OBJECTIVE

Breast cancer is the most common cancer for women, globally. Women are more likely to present with more advanced cancer and palliative care needs in low-resource contexts. There is limited research on Arab, Muslim and African women's experiences of advanced breast cancer. The aim of this study was to explore and understand the experiences of advanced breast cancer in the Islamic Republic of Mauritania.

METHODS

Using a constructivist Stakian multi-case study approach, eight cases were constructed with women with advanced breast cancer (n = 8), family members (n = 10) and health professionals (n = 9). Data were collected longitudinally (up to nine months per case) and included semi-structured interviews and audio-journals. Data from 58 interviews and 31 journal entries were thematically analysed.

RESULTS

Three key themes were identified: 1. Destiny: Maure women appreciate that Allah is all powerful and maintains control over their destinies and their breast cancer. 2. Patience & Acceptance: a fear of causing offence to Allah influences how women express their experiences of breast cancer and its treatments. 3. Journeying in search of a cure: Maure women have limitled access to information around their cancer and its treatments. Women use their own observations and interpretations to understand their breast cancer and guide their pursuit of treatment and a cure.

CONCLUSION

Maure women feel reassured that life and cure remain possible because of Allah's sustenance; but are aware that the gift of life is fragile. They experience restricted power over how they express negative experiences, access to information, and healthcare decisions.

The role, impact, and support of informal caregivers in the delivery of palliative care for patients with advanced cancer: A multi-country qualitative study

BACKGROUND

Cancer is increasing in its prevalence in sub-Saharan Africa. Informal caregivers are key to supporting engagement and interaction with palliative care services, but limited literature on their role impedes development of supportive interventions.

AIM

We aimed to understand the role, impact, and support of informal caregivers of patients with advanced cancer when interacting with palliative care services in Nigeria, Uganda, and Zimbabwe.

DESIGN

Secondary analysis of qualitative interview transcripts. The dataset was assessed for fit and relevance and framework approach was used.

SETTING/PARTICIPANTS

Interview transcripts of informal caregivers included participants aged over 18 years of age recruited from palliative care services across participating countries.

RESULTS

A total of 48 transcripts were analyzed. Mean age was 37 (range 19-75) with equal numbers of men and women. Five themes emerged from the data: (1) caregivers are coordinators of emotional, practical, and health service matters; (2) caregiving comes at a personal social and financial cost; (3) practical and emotional support received and required; (4) experience of interacting and liaising with palliative care services; and (5) barriers and recommendations relating to the involvement of palliative care.

CONCLUSIONS

The role of informal caregivers is multi-faceted, with participants reporting taking care of the majority of medical, physical, financial, and emotional needs of the care recipient, often in the face of sacrifices relating to employment, finances, and their own health and social life. Efforts to develop comprehensive cancer control plans in sub-Saharan Africa must take account of the increasing evidence of informal caregiver needs.

Real-world ethics in palliative care: A systematic review of the ethical challenges reported by specialist palliative care practitioners in their clinical practice

BACKGROUND

Ethical issues arise daily in the delivery of palliative care. Despite much (largely theoretical) literature, evidence from specialist palliative care practitioners about day-to-day ethical challenges has not previously been synthesised. This evidence is crucial to inform education and adequately support staff.

AIM

To synthesise the evidence regarding the ethical challenges which specialist palliative care practitioners encounter during clinical practice.

DESIGN

Systematic review with narrative synthesis (PROSPERO registration CRD42018105365). Quality was dual-assessed using the Mixed-Methods Appraisal Tool. Tabulation, textural description, concept mapping and thematic synthesis were used to develop and present the narrative.

DATA SOURCES

Seven databases (MEDLINE, Philosopher's Index, EMBASE, PsycINFO, LILACS, Web of Science and CINAHL) were searched from inception to December 2019 without language limits. Eligible papers reported original research using inductive methods to describe practitioner-reported ethical challenges.

RESULTS

A total of 8074 records were screened. Thirteen studies from nine countries were included. Challenges were organised into six themes: application of ethical principles; delivering clinical care; working with families; engaging with institutional structures and values; navigating societal values and expectations; philosophy of palliative care. Challenges related to specific scenarios/contexts rather than the application of general ethical principles, and occurred at all levels (bedside, institution, society, policy).

CONCLUSION

Palliative care practitioners encounter a broad range of contextual ethical challenges, many of which are not represented in palliative care ethics training resources, for example, navigating institutional policies, resource allocation and inter-professional conflict. Findings have implications for supporting ethical practice and training practitioners. The lack of low- and middle- income country data needs addressing.

A Mixed Methods Approach of End-of-Life Care, Social Rites, and Bereavement Outcomes: A Transnational Perspective

The current article focused on examining the potential benefits of the End-of-Life (EoL) informal caregiving, communication, and ritualistic behaviors in adaptation to the conjugal bereavement across two different cultural-background contexts: France and Togo, West Africa. The investigation adopted a transnational approach including a total of 235 bereaved spouses. Despite the variation in the length of time since death, no significant difference was found between the Togolese and French bereaved with respect to the level of complicated grief symptoms. However, the Togolese bereaved perceived a significant postloss growth, fostered by EoL communication with the dying and the performance of ritualistic behaviors. In the French sample, bereaved individuals who had experienced more intimate communication with their dying spouse reported a high level of postloss growth. Moreover, findings showed that EoL caregiving without ritualistic support or communication is associated with poor postbereavement outcomes. These findings suggest a clinical need to promote informal caregiving to the dying, communication with the dying, and ritualistic support during the process of dying as entangled components of EoL care.

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.

Good death: An exploratory study on perceptions and attitudes of patients, relatives, and healthcare providers, in northern Tanzania

IMPORTANCE

In the Kilimanjaro region of Tanzania, there are no advance care planning (ACP) protocols being used to document patient preferences for end-of-life (EoL) care. There is a general avoidance of the topic and contemplating ACP in healthcare-limited regions can be an ethically complex subject. Nonetheless, evidence from similar settings indicate that an appropriate quality of life is valued, even as one is dying. What differs amongst cultures is the definition of a 'good death'.

OBJECTIVE

Evaluate perceptions of quality of death and advance EoL preparation in Moshi, Tanzania.

DESIGN

13 focus group discussions (FGDs) were conducted in Swahili using a semi-structured guide. These discussions were audio-recorded, transcribed, translated, and coded using an inductive approach.

SETTING

Kilimanjaro Christian Medical Centre (KCMC), referral hospital for northern Tanzania.

PARTICIPANTS

A total of 122 participants, including patients with life-threatening illnesses (34), their relatives/friends (29), healthcare professionals (29; HCPs; doctors and nurses), and allied HCPs (30; community health workers, religious leaders, and social workers) from KCMC, or nearby within Moshi, participated in this study.

FINDINGS

In characterizing Good Death, 7 first-order themes emerged, and, of these themes, Religious & Spiritual Wellness, Family & Interpersonal Wellness, Grief Coping & Emotional Wellness, and Optimal Timing comprised the second-order theme, EoL Preparation and Life Completion. The other first-order themes for Good Death were Minimal Suffering & Burden, Quality of Care by Formal Caregivers, and Quality of Care by Informal Caregivers.

INTERPRETATION

The results of this study provide a robust thematic description of Good Death in northern Tanzania and they lay the groundwork for future clinical and research endeavors to improve the quality of EoL care at KCMC.

Support for families of isolated or deceased COVID-19 patients in sub-Saharan Africa

Aside the direct effect of the COVID-19 on infected patients, this infectious disease outbreak has various psychological consequences. These mental health repercussions pertain to the general population of uninfected individuals, and particularly families of isolated or deceased COVID-19 patients. This aspect is of substantial interest amid sub-Saharan African communities, considering the key place and cultural significance of mourning and funerals in these settings. In this commentary, we discuss on the issue of psychological and social support of COVID-19 patients' families, by taking into account some sub-Saharan African cultural considerations.

Grief and Bereavement in Parents After the Death of a Child in Low- and Middle-Income Countries

While great strides have been made in improving childhood mortality, millions of children die each year with significant health-related suffering. More than 98% of these children live in low- and middle-income countries (LMICs). Efforts have been made to increase access to pediatric palliative care (PPC) services to address this suffering in LMICs through policy measures, educational initiatives, and access to essential medicines. However, a core component of high-quality PPC that has been relatively neglected in LMICs is grief and bereavement support for parents after the death of their child. This paper reviews the current literature on parental grief and bereavement in LMICs. This includes describing bereavement research in high-income countries (HICs), including its definition, adverse effect upon parents, and supportive interventions, followed by a review of the literature on health-related grief and bereavement in LMICs, specifically around: perinatal death, infant mortality, infectious disease, interventions used, and perceived need. More research is needed in grief and bereavement of parents in LMICs to provide them with the support they deserve within their specific cultural, social, and religious context. Additionally, these efforts in LMICs will help advance the field of parental grief and bereavement research as a whole.

The financing of stand-alone palliative Care Services in Uganda: analysis of the implications for sustainability

Background

Sustainable funding is key for ensuring the quality and coverage of palliative care services. This study examined the sources of funding for stand-alone palliative care services in Uganda as well as their services financial sustainability plans.

Methods

Researchers conducted a cross sectional survey of all stand-alone palliative care organizations that have operated for five or more years. Researchers administered a questionnaire survey and interviews on the audited financial statements, services provided and sustainability plans.

Results

Nine of the stand-alone palliative care organizations surveyed had operated for five to 25 years. 93% of the funding for palliative care services comes from donations; while 7% is from income generating activities. 94% of the donations are from external sources. The Government of Uganda’s major contribution is in the form of medicines, training and payment of taxes. All the organizations had good financial records. Six of the fifteen Hospices/palliative care providers had sustainability plans included in their operational manuals. The older organizations (those that had been operational for more than 10 years) had better resource mobilization capacity and strategies.

Conclusion

The majority of stand-alone palliative care organizations in Uganda are largely donor funded. They have considerable financial sustainability and fund-raising capacity. Government support is in the form of medicines and training. Based on this study findings, the capacity of the stand-alone palliative care services to raise funds should be increased. The Government of Uganda should include palliative care in the national health system and increase funding for these services.

Illness Understanding and End-of-Life Care Communication and Preferences for Patients With Advanced Cancer in South Africa

Purpose

The understanding of patients with cancer of their condition and their wishes regarding care as they approach end of life (EoL) have been studied more in high-income countries than in low- and middle-income countries (LMICs).

Patients and Methods

Data were analyzed from a cohort study (N = 221) of patients with advanced cancer who were recruited from a palliative care center in Soweto, South Africa (LMIC), between May 2016 and June 2017. Patients were asked about their understanding of their illness, estimated life expectancy, EoL care communication, and EoL care preferences.

Results

Only 13 patients (5.9%) acknowledged that they were terminally ill; nine patients (4.1%) estimated accurately that they had months, not years, left to live. A total of 216 patients (97.7%) reported that they had not had an EoL care discussion with their physician, and 170 patients (76.9%) did not want to know their prognosis even if the doctor knew it. Most patients preferred comfort care (72.9%; n = 161) to life-extending care (14.0%; n = 31), and did not want to be kept alive using extreme measures (80.5%; n = 178) or have their doctors do everything possible to extend their lives (78.3%; n = 173). Finally, 127 patients (57.5%) preferred to die at home, and 51 (23.1%) preferred to die in the hospital. Most patients (81.0%; n = 179) had funeral plans.

Conclusion

South African patients demonstrated less awareness of the fact that they were terminally ill, were less likely to have discussed their prognosis with their doctor, and more strongly preferred comfort care to life-extending EoL care than US and other LMIC patients in prior research. These differences highlight the need for culturally appropriate, patient-centered EoL care for South African patients with advanced cancer as well as to determine individual preferences and needs in all EoL settings.

Understanding the Organization of Hospital-Based Palliative Care in a Nigerian Hospital: An Ethnographic Study

Context

Organization and delivery of palliative care (PC) services vary from one country to another. In Nigeria, PC has continued to develop, yet the organization and scope of PC is not widely known by most clinicians and the public.

Objectives

The aim of the study is to identify PC services available in a Nigerian Hospital and how they are organized.

Methods

This ethnographic study, utilized documentary analysis, participant observation, and ethnographic interviews (causal chat during observation and individual interviews) to gather data from members of PC team comprising doctors (n = 10), nurses (n = 4), medical social workers (n = 2), a physiotherapist, and a pharmacist, as well nurses from the oncology department (n = 3). Data were analyzed using Spradley's framework for ethnographic data analysis.

Results

PC was found to be largely adult patient-centered. A hospital-based care delivery model, in the forms of family meetings, in- and out-patients' consultation services, and a home-based delivery model which is primarily home visits conducted once in a week, were the two models of care available in the studied hospital. The members of the PC team operated two shift patterns from 7:00 am to 2.00 pm and a late shift from 2:00 pm to 7:00 pm instead of 24 h service provision.

Conclusions

Although PC in this hospital has made significant developmental progress, the organization and scope of services are suggestive of the need for more development, especially in manpower and collaborative care. This study provided knowledge that could be used to improve the clinical practice of PC in various cross-cultural Nigerian societies and other African context, as well as revealing areas for PC development.

Aging and HIV-Related Caregiving in Sub-Saharan Africa: A Social Ecological Approach

BACKGROUND AND OBJECTIVES

We reviewed the literature on older adults (OAs) who are caring for persons living with HIV/AIDS in sub-Saharan Africa (SSA), with the goal of adapting models of caregiver stress and coping to include culturally relevant and contextually appropriate factors specific to SSA, drawing on both life course and cultural capital theories.

RESEARCH DESIGN AND METHODS

A systematic literature search found 81 articles published between 1975 and 2016 which were reviewed using a narrative approach. Primary sources of articles included electronic databases and relevant WHO websites.

RESULTS

The main challenge of caregiving in SSA reflects significant financial constraints, specifically the lack of necessities such as food security, clean water, and access to health care. Caregiving is further complicated in SSA by serial bouts of caring for multiple individuals, including adult children and grandchildren, in the context of high levels of stigma associated with HIV. Factors promoting caregiver resilience included spirituality, bidirectional (reciprocal) caregiving, and collective coping strategies.

DISCUSSION AND IMPLICATIONS

The creation of a theoretical model of caregiving which focuses more broadly on the sociocultural context of caregiving could lead to new ways of developing interventions in low-resources communities.

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

Palliative Care in Botswana: Progress and Challenges

Palliative care is an essential aspect of care for patients with serious illness and their families, but a large proportion of the world's population, particularly in developing countries like Botswana, do not have access to it. In Botswana and other developing countries, palliative care is often sporadic and lacks comprehensive delivery owing to a lag between policies and practice and a lack of knowledge about palliative care among health care professionals and communities. In this article, the progress of palliative care in Botswana is discussed by first evaluating at the relevance of palliative care in Botswana given the burden of diseases and resources available for disease management. Second, the palliative care delivery models and their successes and shortcomings in Botswana context are discussed. Third, the Botswana palliative care services are viewed on a global scale to illuminate progress and areas that need improvement. Thereafter, using a case as a reference, this article highlights the challenges faced by Botswana palliative care services. Finally, some areas that can be targeted to improve palliative care services in Botswana and possible solutions are discussed. Overall, palliative care is at infancy stage in Botswana and many opportunities exist in education, research, and resource support to transform it into a full-fledged service.

A Prospective Cohort Study of Factors Associated With Place of Death Among Patients With Late-Stage Cancer in Southern Africa

CONTEXT

Identifying factors that affect terminally ill patients' preferences for and actual place of death may assist patients to die wherever they wish.

OBJECTIVE

The objective of this study was to investigate factors associated with preferred and actual place of death for cancer patients in Johannesburg, South Africa.

METHODS

In a prospective cohort study at a tertiary hospital in Johannesburg, South Africa, adult patients with advanced cancer and their caregivers were enrolled from 2016 to 2018. Study nurses interviewed the patients at enrollment and conducted postmortem interviews with the caregivers.

RESULTS

Of 324 patients enrolled, 191 died during follow-up. Preferred place of death was home for 127 (66.4%) and a facility for 64 (33.5%) patients; 91 (47.6%) patients died in their preferred setting, with a kappa value of congruence of 0.016 (95% CI = -0.107, 0.139). Factors associated with congruence were increasing age (odds ratio [OR]: 1.03, 95% CI: 1.00-1.05), use of morphine (OR: 1.87, 95% CI: 1.04-3.36), and wanting to die at home (OR: 0.44, 95% CI: 0.24-0.82). Dying at home was associated with increasing age (OR 1.03, 95% CI 1.00-1.05) and with the patient wishing to have family and/or friends present at death (OR 6.73, 95% CI 2.97-15.30).

CONCLUSION

Most patients preferred to die at home, but most died in hospital and fewer than half died in their preferred setting. Further research on modifiable factors, such as effective communication, access to palliative care and morphine, may ensure that more cancer patients in South Africa die wherever they wish.

Cancer incidence in older adults in selected regions of sub-Saharan Africa, 2008-2012

Although the countries of Sub-Sharan Africa represent among the most rapidly growing and aging populations worldwide, no previous studies have examined the cancer patterns in older adults in the region as a means to inform cancer policies. Using data from Cancer Incidence in Five Continents, we describe recent patterns and trends in incidence rates for the major cancer sites in adults aged ≥60 years and in people aged 0-59 for comparison in four selected population-based cancer registries in Kenya (Nairobi), the Republic of South Africa (Eastern Cape Province), Uganda (Kyadondo country), and Zimbabwe (Harare blacks). Over the period 2008-2012, almost 9,000 new cancer cases were registered in older adults in the four populations, representing one-third of all cancer cases. Prostate and esophageal cancers were the leading cancer sites in older males, while breast, cervical and esophageal cancers were the most common among older females. Among younger people, Kaposi sarcoma and non-Hodgkin lymphoma were common. Over the past 20 years, incidence rates among older adults have increased in both sexes in Uganda and Zimbabwe while rates have stabilized among the younger age group. Among older adults, the largest rate increase was observed for breast cancer (estimated annual percentage change: 5% in each country) in females and for prostate cancer (6-7%) in males. Due to the specific needs of older adults, tailored considerations should be given to geriatric oncology when developing, funding and implementing national and regional cancer programmes.

Perceptions of palliative care in a lower middle-income Muslim country: A qualitative study of health care professionals, bereaved families and communities

BACKGROUND:

Palliative care has been successfully integrated into many Muslim-majority countries, most frequently in urbanised areas with developed health care systems. Less is known as to how the concept of palliative care is perceived by Muslim populations and health workers in rural, resource-limited contexts.

AIM:

This study seeks to explore whether the principles of palliative care are congruent with the perspectives of health professionals, families and communities in rural areas of the Islamic Republic of Mauritania, in West Africa.

DESIGN:

A qualitative research design was employed underpinned by a constructionist paradigm. Data were collected through 31 interviews and 8 focus groups. Data were analysed using thematic analysis.

SETTING/PARTICIPANTS:

A total of 76 participants were recruited from across rural Mauritania; 33 health care professionals, 12 recently bereaved family members and 31 community leaders. Data collection occurred during training events in the capital and visits to villages and rural health posts.

RESULTS:

Three major themes were identified. First, there is a perceived lack of congruency between an illness which limits life and the strong belief in destiny. The second theme describes the perceived barriers to communication of issues relating to palliative care. Finally, a good death is described, framed within the interplay of religious faith and cultural practices.

CONCLUSION:

The palliative care ethos is viewed positively by the majority of participants. The need to understand and respect a Muslim individual’s faith does not diminish our obligation to personalise palliative care provided for them and their family.

Returning home to die or leaving home to seek health care? Location of death of urban and rural residents in Burkina Faso and Senegal

Background: In sub-Saharan Africa, the literature on end of life is limited and focuses on place of death as an indicator of access and utilization of health-care resources. Little is known about population mobility at the end of life.

Objective: To document the magnitude, motivations and associated factors of short-term mobility before death among adults over 15 years of age in Burkina Faso and Senegal.

Methods: The study was based on deaths of adult residents reported in three Health and Demographic Surveillance System (HDSS) sites in urban (Ouagadougou) and semi-rural areas (Kaya) of Burkina Faso, and rural areas of Senegal (Mlomp). After excluding deaths from external causes, the analysis covered, respectively, 536 and 695 deaths recorded during the period 2012–2015 in Ouagadougou and Kaya. The period was extended to 2000–2015 in Mlomp, with a sample of 708 deaths. Binary logistic regressions were used to examine the effects of socio-demographic characteristics on place of death (health facility or not) and location of death (within or outside the HDSS).

Results: In Mlomp, Kaya and Ouagadougou, respectively 20.6%, 5.3% and 5.9% of adults died outside the HDSS site. In Mlomp and Kaya, these deaths were more likely to occur in a health facility than deaths that occurred within the site. The reverse situation was found in Ouagadougou. Age is the strongest determinant of mobility before death in Mlomp and Kaya. In Mlomp, young adults (15–39) were 10 times more likely to die outside the site than adults in the 60–79 age group. In Ouagadougou, non-natives were three times more likely to die outside the city than natives.

Conclusions: At the end of life, some rural residents move to urban areas for medical treatment while some urban dwellers return to their village for supportive care. These movements of dying individuals may affect the estimation of urban/rural mortality differentials.

The Experiences of Muslim Family Members of Critically Ill Patients During End-of-Life Care in Saudi Arabia: A Qualitative Phenomenological Study

The aim of this study was to identify the needs, beliefs, and practices of Muslim family members during the end-of-life care for a family member in the intensive care unit (ICU) in Saudi Arabia. This was a phenomenological study using in-depth individual interviews to gather data. Ten family members of adult ICU patients receiving end-of-life care were interviewed. The experiences of family members during end-of-life care were reflected in four major themes: (a) the spirituality of death, (b) family’s need for information, (c) being there, and (d) the ICU environment. Participants placed high value on religious practices such as prayer, and appreciated when these practices could be accommodated in the ICU. Family participants also detailed their need for frequent communication and opportunities to ask questions about the care of their critically ill loved one. Being able to spend as much time as desired in close proximity to the critically ill patient particularly as the end of life approaches was also important, with participants suggesting that visitation times should be waived. Finally, family participant suggested that changes were needed to the ICU environment to make accommodating large families easier and more comfortable particularly when they wish to spend significant time at the bedside of their loved one. Family should be prioritized as an extension of the care provided to critically ill ICU patients, particularly those approaching end of life. A model of care should be introduced to deliver supportive and holistic care during the end-of-life care journey, supported by appropriate education regarding family care at the end of life.

Integrating palliative care into national health systems in Africa: a multi-country intervention study

BACKGROUND

The WHO is calling for the integration of palliative care in all health care settings globally.

METHODS

A 3.5-year program was implemented in 12 government hospitals, three each in Kenya, Rwanda, Uganda and Zambia. A four-pillared approach of advocacy, staff training, service delivery strengthening and international and regional partnership working was utilized. A baseline assessment was undertaken to ascertain needs, and 27 indicators were agreed to guide and evaluate the intervention. Data were also collected through surveys, interviews and focus groups.

RESULTS

Palliative care was integrated into all 12 hospital settings to various degrees through concurrent interventions of these four approaches. Overall, 218 advocacy activities were undertaken and 4153 community members attended awareness training. 781 staff were equipped with the skills and resources to cascade palliative care through their hospitals and into the community. Patients identified for palliative care increased by a factor of 2.7. All 12 hospitals had oral morphine available and consumption increased by a factor of 2.4 over two years. Twenty-two UK mentors contributed 750 volunteer days to support colleagues in each hospital transfer knowledge and skills.

CONCLUSIONS

Integration of palliative care within different government health services in Africa can be achieved through agreed interventions being delivered concurrently. These include advocacy at Ministry, Provincial and District level, intensive and wide-ranging training, clinical and support services supported by resources, including essential medicines, and an investment in partnerships between hospital, district and community.

Providing Palliative Care in Rural Nepal: Perceptions of Mid-Level Health Workers

Introduction:

Nepal is beginning to develop palliative care services across the country. Most people live in rural areas, where the Mid-Level Health Workers (MHWs) are the major service providers. Their views on providing palliative care are most important in determining how the service is organized and developed.

Aim:

This study aims to ascertain the perceptions of MHWs about palliative care in their local community, to inform service development.

Methods:

A qualitative descriptive design, using focus group discussions, was used to collect data from a rural district of Makwanpur, 1 of the 75 districts of Nepal. Twenty-eight MHWs participated in four focus group discussions. The data were analyzed using content analysis.

Result:

Four themes emerged from the discussion: (i) suffering of patients and families inflicted by life-threatening illness, (ii) helplessness and frustration felt when caring for such patients, (iii) sociocultural issues at the end of life, and (iv) improving care for patients with palliative care needs.

Conclusion:

MHWs practicing in rural areas reported the suffering of patients inflicted with life-limiting illness and their family due to poverty, poor access, lack of resources, social discrimination, and lack of knowledge and skills of the health workers. While there are clear frustrations with the limited resources, there is a willingness to learn among the health workers and provide care in the community.

What do humanitarian emergency organizations do about palliative care? A systematic review

BACKGROUND

Humanitarian emergency organizations have only recently integrated care for non-communicable diseases into their relief action. The needs for palliative care in emergencies are still largely unmet.

OBJECTIVE

A systematic review of health programmes run by international humanitarian organizations that take palliative care and/or enhanced pain control into account.

METHODS

Electronic databases were searched for publications of health programmes providing palliative care and/or enhanced pain control in emergency situations. Health departments of major international organizations and experts were contacted for relevant information.

RESULTS

One publication on pain treatment in amputees in Freetown, Sierra Leone, fulfilled the selection criteria. International humanitarian organizations shared information on their programmes in the Democratic Republic of the Congo, Haiti, Kenya and Ukraine/Russia.

CONCLUSIONS

There is very little information available on palliative care and/or enhanced pain control in emergency settings. First programmes have just been initiated in the field. More emphasis on sharing experiences and publication could accelerate a broader integration of palliative care into humanitarian programmes.

HIV Case Management Support Service Is Associated with Improved CD4 Counts of Patients Receiving Care at the Antiretroviral Clinic of Pantang Hospital, Ghana

BACKGROUND

Factors associated with individual patient-level management of HIV have received minimal attention in sub-Saharan Africa. This study determined the association between support services and cluster of differentiation 4 (CD4) counts among HIV patients attending ART clinic in Ghana.

METHODOLOGY

This was a cross-sectional study involving adults with HIV recruited between 1 August 2014 and 31 January 2015. Data on support services were obtained through a closed-ended personal interview while the CD4 counts data were collected from their medical records. Data were entered into EpiData and analyzed using Stata software.

RESULTS

Of the 201 patients who participated in the study, 67% (129/191) received case management support service. Counseling about how to prevent the spread of HIV (crude odds ratio (cOR) (95% confidence interval (CI)) (2.79 (1.17-6.68)), mental health services (0.2 (0.04-1.00)), and case management support service (2.80 (1.34-5.82))) was associated with improved CD4 counts of 350 cells/mm3 or more. After adjusting for counseling about how to prevent the spread of HIV and mental health services, case management support service was significantly associated with CD4 counts of 350 cells/mm3 or more (aOR = 2.36 (CI = 1.01-5.49)).

CONCLUSION

Case management support service for HIV patients receiving ART improves their CD4 counts above 350 cells/mm3. Incorporating HIV case management services in ART regimen should be a priority in sub-Saharan Africa.

Socio-cultural contexts of end- of- life conversations and decisions: bereaved family cancer caregivers' retrospective co-constructions

Background

End-of-life communication becomes increasingly difficult in terminal cancer, which inevitably entails conversations around dying and death. In resource-limited areas, the context of end-of-life communication is usually home-based palliative care comprising mostly women in the family who play critical roles as informal caregivers. This article examined the content and contexts of family end-of-life conversations and decisions based on the retrospective accounts of a sample of bereaved women family cancer caregivers in Nairobi, Kenya.

Method

An interpretative phenomenological analysis approach was utilized to explore pertinent end-of-life communication themes. Four mini focus group interviews with a total of 13 participants [n = 5; n = 3; n = 3; n = 2] were conducted.

Results

Two end-of-life themes, advance directives as preparedness for death, and initiating death talk were examined. Findings (a) illustrate the role of family dynamics in influencing the nature of end-of-life conversations and decisions (b) demonstrate the transitional nature of family caregiver roles, and (c) underscore the paradox of the critical role played by family members in palliative care versus their ill preparedness in dealing with end-of-life issues.

Conclusions

Findings are relevant in informing palliative psychosocial interventions and specifically the concerns and decisions of cancer patients and their families. This prompts further engagement with the question of how to equip family caregivers in resource-limited contexts for end of life care. Methodologically, these results demonstrate the possibility of simultaneous elucidation of individual experiences, interactive co-constructions and the socio-cultural contexts of experiences and meaning making processes in IPA research.

Palliative care needs of patients living with end-stage kidney disease not treated with renal replacement therapy: An exploratory qualitative study from Blantyre, Malawi

Background

The burden of end-stage kidney disease (ESKD) in sub-Saharan Africa is increasing rapidly but the palliative care needs of patients living with ESKD are not well described. Resource limitations at both health system and patient level act as major barriers to patients receiving renal replacement therapy (RRT) in the form of dialysis. We undertook an exploratory qualitative study to describe the palliative care needs of patients with ESKD who were not receiving RRT, at a government teaching hospital in Blantyre, Malawi.

Methods

A qualitative, explorative and descriptive design was used. Study participants were adults aged > 18 years with an estimated glomerular filtration rate < 15 ml/min on two separate occasions, three months apart, who either chose not to have or were not deemed suitable for RRT. Data were collected by means of semi-structured interviews.

Results

In October and November 2013, interviews were conducted with 10 adults (7 women with median age of 60.5 years). All were hypertensive and four were on treatment for HIV. Four themes emerged from the data: changes in functional status because of physical symptoms, financial challenges impacting hospital care, loss of role within the family and the importance of spiritual and cultural beliefs.

Conclusion

This study reports on four thematic areas which warrant further quantitative and qualitative studies both in Malawi and other low-resource settings, where a growing number of patients with ESKD unable to access RRT will require palliative care in the coming years.

Adult mortality in sub-saharan Africa, Zambia: Where do adults die?

Place of death remains an issue of growing interest and debate among scholars as an indicator of quality of end-of-life care in developed countries. In sub-Saharan Africa, however, variations in place of death may suggest inequalities in access to and the utilization of health care services that should be addressed by public health interventions. Limited research exists on factors associated with place of death in sub-Saharan Africa. The study examines factors associated with the place of death among Zambian adults aged 15–59 years using the 2010–2012 sample vital registration with verbal autopsy survey (SAVVY) data, descriptive statistics and multivariate logistic regression analysis. Results show that more than half of the adult deaths occurred in a health facility and two-fifths died at home. Higher educational attainment, urban versus rural residence, and being of female gender were significant predictors of the place of death. Improvement in educational attainment and investment in rural health facilities and the health care system as a whole may improve access and utilization of health services among adults.

•

We examined factors associated with place of death among adults aged 15–59 in Zambia.

•

Health facility remains the common place of death in Zambia followed by the deceased's home.

•

High proportion of adults still dying at home indicates a lack of access to and the utilization of health care services.

•

Educational attainment, sex, and urban-rural residence were strong predictors of the place of death.

•

Variations in place of death by population background characteristics among adult decedents may suggest inequalities in access and utilization of health services.

Common or multiple futures for end of life care around the world? Ideas from the 'waiting room of history'

Around the world there is growing interest in the manner in which care is delivered to people at the end of life. However, there is little unanimity on what constitutes a 'good death' and the appropriate societal responses to the issue of delivering culturally relevant and sustainable forms of end of life care in different settings are not subjects of broad agreement. In this critical conceptual paper we focus on the emerging narratives of global palliative care and offer an assessment of their implications. We relate this to calls to improve end of life care across jurisdictions and settings, attempts to map and grade the development of palliative care provision, and to the emergence of a widely recognised global 'quality of death index'. We consider an alternative approach to framing this debate, drawn from a subaltern and post-colonial studies perspective and suggest that adopting a truly global perspective will require acceptance of the plurality of past and present local problems and issues relating to end of life care, as well as the plural possibilities of how they might be overcome. In that context, we would not aim to universalise or privilege one particular global future for end of life care. Instead of homogenising end of life interventions, we seek to be open to multiple futures for the care of the dying.

Ambiguous care: siblings and the economies of HIV-related care in Zambia

While kinship used to be considered a backbone of the creation of mutual obligations for care in pre-industrial societies, economic and social change has altered how care is provided. Notwithstanding changing kinship obligations, relatives continue to provide much of the care for those in need. In this article, I consider the active production of relationships among siblings through individual biographies, to understand how mutual obligations are created and affect the care provided to HIV-positive persons. I draw on two phases of ethnographic research conducted in Zambia, in Southern Province and Lusaka, between 2002 and 2011. Findings revealed that siblings are normally considered an important source of support, but their willingness and capacity to provide support may be limited by resource constraints and biographical experiences. Helping or not is at the conjunction of kinship-based obligations and a sense of connectedness, deriving from the history of growing up together, often in the context of disrupted families. The experiences of siblings in their past reach beyond individual histories. Structural factors jeopardise the support between and within generations, and must be addressed while promoting social protection programmes.

Dying Care Interventions in the Intensive Care Unit

PURPOSE

Providing high-quality end-of-life care is a challenging area in intensive care practice. The aim of the current study was to assess the practice of registered nurses (RNs) with respect to dying care and spiritual support interventions in intensive care units (ICUs) in the Czech Republic (CR) and find correlations between particular factors or conditions and the frequency of NIC interventions usage.

DESIGN AND METHODS

A cross-sectional, descriptive study was designed. A questionnaire with Likert scales included the particular activities of dying care and spiritual support interventions and an evaluation of the factors influencing the implementation of the interventions in the ICU. The group of respondents consisted of 277 RNs working in 29 ICUs in four CR regions. The Mann-Whitney U test and Pearson correlation coefficient were used for statistical evaluation.

FINDINGS

The most and least frequently reported RN activities were "treat individuals with dignity and respect" and "facilitate discussion of funeral arrangements," respectively. The frequencies of the activities in the biological, social, psychological, and spiritual dimensions were negatively correlated with the frequency of providing care to dying patients. A larger number of activities were related to longer lengths of stay in the ICU, higher staffing, more positive opinions of the RNs regarding the importance of education in a palliative care setting, and attending a palliative care education course.

CONCLUSIONS

The psychosocial and spiritual activities in the care of dying patients are used infrequently by RNs in CR ICUs. The factors limiting the implementation of palliative care interventions and strategies improving implementation warrant further study.

CLINICAL RELEVANCE

Assessment of nursing activities implemented in the care of dying patients in the ICU may help identify issues specific to nursing practice.

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.

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

OBJECTIVE

Cancer incidence and mortality are increasing in Africa, which is leading to greater demands for palliative care. There has been little progress in terms of research, pain management, and policies related to palliative care. Palliative care in Africa is scarce and scattered, with most African nations lacking the basic services. To address these needs, a guiding framework that identifies care needs and directs palliative care services could be utilized. Therefore, using the supportive care framework developed by Fitch (Fitch, 2009), we here review the literature on palliative care for patients diagnosed with cancer in Africa and make recommendations for improvement.

METHOD

The PubMed, Scopus, CINAHL, Web of Science, Embase, PsycINFO, Social Sciences Citation Index, and Medline databases were searched. Some 25 English articles on research from African countries published between 2004 and 2014 were selected and reviewed. The reviewed literature was analyzed and presented using the domains of the supportive care framework.

RESULTS

Palliative care patients with cancer in Africa, their families, and caregivers experience increasing psychological, physical, social, spiritual, emotional, informational, and practical needs. Care needs are often inadequately addressed because of a lack of awareness as well as deficient and scattered palliative care services and resources. In addition, there is sparse research, education, and policies that address the dire situation in palliative care.

SIGNIFICANCE OF RESULTS

Our review findings add to the existing body of knowledge demonstrating that palliative care patients with cancer in Africa experience disturbing care needs in all domains of the supportive care framework. To better assess and address these needs, holistic palliative care that is multidomain and multi-professional could be utilized. This approach needs to be individualized and to offer better access to services and information. In addition, research, education, and policies around palliative care for cancer patients in Africa could be more comprehensive if they were based on the domains of the supportive care framework.

Telemedicine's Potential to Support Good Dying in Nigeria: A Qualitative Study

OBJECTIVES

This qualitative study explores Nigerian health care professionals' concepts of good dying/a good death and how telemedicine technologies and services would fit the current Nigerian palliative care practice.

MATERIALS AND METHODS

Supported by the Centre for Palliative Care Nigeria (CPCN) and the University College Hospital (UCH) in Ibadan, Nigeria, the authors organized three focus groups with Nigerian health care professionals interested in palliative care, unstructured interviews with key role players for palliative care and representatives of telecom companies, and field visits to primary, secondary and tertiary healthcare clinics that provided palliative care. Data analysis consisted of open coding, constant comparison, diagramming of categorizations and relations, and extensive member checks.

RESULTS

The focus group participants classified good dying into 2 domains: a feeling of completion of the individual life and dying within the community. Reported barriers to palliative care provision were socio-economic consequences of being seriously ill, taboos on dying and being ill, restricted access to adequate medical-technical care, equation of religion with medicine, and the faulty implementation of palliative care policy by government. The addition of telemedicine to Nigeria's palliative care practice appears problematic, due to irregular bandwidth, poor network coverage, and unstable power supply obstructing interactivity and access to information. However, a tele-education 'lite' scenario seemed viable in Nigeria, wherein low-tech educational networks are central that build on non-synchronous online communication.

DISCUSSION

Nigerian health care professionals' concepts on good dying/a good death and barriers and opportunities for palliative care provision were, for the greater part, similar to prior findings from other studies in Africa. Information for and education of patient, family, and community are essential to further improve palliative care in Africa. Telemedicine can only help if low-tech solutions are applied that work around network coverage problems by focusing on non-synchronous online communication.

Stressors and resources of caregivers of patients with incurable progressive illness in sub-Saharan Africa

Family caregivers are central to palliative care in sub-Saharan Africa. Yet although supporting caregivers requires a comprehensive understanding of caregiver burden, there has been little research into this topic in Africa. Using the Stress Process Model to investigate the burden experienced by caregivers in South Africa and Uganda, we interviewed 37 caregivers and analyzed the data thematically. Caregivers' primary stressors related to day-to-day patient care and emotional support; secondary stressors included financial hardship, family responsibilities, and social isolation. Caregivers' social, relational, spiritual, and psychological resources mediated the effects of these stressors. Strengthening one resource strengthened others, but the failure of one resource hindered other resources, exacerbating burden. In providing caregiver support, policymakers and service providers should focus on enhancing caregivers' resources as well as alleviating their stressors.

'My dreams are shuttered down and it hurts lots'-a qualitative study of palliative care needs and their management by HIV outpatient services in Kenya and Uganda

BACKGROUND

Despite the huge burden of HIV in sub-Saharan Africa, there is little evidence of the multidimensional needs of patients with HIV infection to inform the person-centred care across physical, psychological, social and spiritual domains stipulated in policy guidance. We aimed to describe the problems experienced by people with HIV in Kenya and Uganda and the management of these problems by HIV outpatient services.

METHODS

Local researchers conducted in depth qualitative interviews with HIV patients, caregivers and service staff at 12 HIV outpatient facilities (6 in Kenya, 6 in Uganda). Interview data were analysed thematically.

RESULTS

189 people were interviewed (83 patients, 47 caregivers, 59 staff). The impact of pain and symptoms and their causes (HIV, comorbidities, treatment side-effects) were described. Staff reported that effective pain relief was not always available, particularly in Kenya. Psychosocial distress (isolation, loneliness, worry) was exacerbated by stigma and poverty, and detrimentally affected adherence. Illness led to despair and hopelessness. Provision of counselling was reported, but spiritual support appeared to be less common. Neither pain nor psychosocial problems were routinely reported to service staff. Collaboration with local hospices and income-generation activities for patients were highlighted as useful.

CONCLUSIONS

The findings demonstrate the multiple and interrelated problems associated with living with HIV and how psychosocial and spiritual distress can contribute to 'total pain' in this population. In line with the palliative care approach, HIV care requires holistic care and assessment that take into account psychological, socioeconomic and spiritual distress alongside improved access to pain-relieving drugs, including opioids.

The emotional and spiritual well-being of hospice patients in Botswana and sources of distress for their caregivers

BACKGROUND

Little regional data exists on the distress of people nearing the end of their lives and their caregivers.

OBJECTIVE

The purpose of this study was to describe the quality of life and the emotional and spiritual well-being of people at the end of life and the sources of distress for their primary caregivers in Gaborone, Botswana, in order to inform further development of hospice services.

DESIGN

This study employed a mixed-methods design.

SETTING/SUBJECTS

Twenty-eight primary caregivers who cared for an adult who passed away fewer than 14 months prior to the interview date and in the care of a nongovernmental hospice in Botswana were interviewed between June and August 2012.

MEASUREMENTS

Semistructured interviews and the Quality of Death and Dying questionnaire (QODD) were used. Quantitative descriptive analysis and qualitative content analysis were performed.

RESULTS

Quality of life of decedents was poor. Emotional and spiritual distress persist at high rates even for those receiving support from a nongovernmental hospice (NGH). Caregiver distress arises from practical needs, including lack of food, clothing, and shelter, the need for assistance physically caring for their loved one, and from emotional and spiritual concerns.

CONCLUSIONS

The practical, physical, emotional, and spiritual needs of people at the end of life in Botswana and their caregivers are not being fully met, with poor overall quality of life among the dying. More research is needed to explore how hospice and home health services and the services of spiritual leaders can be expanded to meet their needs.

Novel open-source electronic medical records system for palliative care in low-resource settings

BACKGROUND

The need for palliative care in sub-Saharan Africa is staggering: this region shoulders over 67% of the global burden of HIV/AIDS and cancer. However, provisions for these essential services remain limited and poorly integrated with national health systems in most nations. Moreover, the evidence base for palliative care in the region remains scarce. This study chronicles the development and evaluation of DataPall, an open-source electronic medical records system that can be used to track patients, manage data, and generate reports for palliative care providers in these settings.DataPall was developed using design criteria encompassing both functional and technical objectives articulated by hospital leaders and palliative care staff at a leading palliative care center in Malawi. The database can be used with computers that run Windows XP SP 2 or newer, and does not require an internet connection for use. Subsequent to its development and implementation in two hospitals, DataPall was tested among both trained and untrained hospital staff populations on the basis of its usability with comparison to existing paper records systems as well as on the speed at which users could perform basic database functions. Additionally, all participants evaluated this program on a standard system usability scale.

RESULTS

In a study of health professionals in a Malawian hospital, DataPall enabled palliative care providers to find patients' appointments, on average, in less than half the time required to locate the same record in current paper records. Moreover, participants generated customizable reports documenting patient records and comprehensive reports on providers' activities with little training necessary. Participants affirmed this ease of use on the system usability scale.

CONCLUSIONS

DataPall is a simple, effective electronic medical records system that can assist in developing an evidence base of clinical data for palliative care in low resource settings. The system is available at no cost, is specifically designed to chronicle care in the region, and is catered to meet the technical needs and user specifications of such facilities.