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Carson L, Petricca K, Denburg A. The promise of POSIT: Real-world application of the Paediatric Oncology System Integration Tool. J Cancer Policy 2024; 39:100454. [PMID: 37989453 DOI: 10.1016/j.jcpo.2023.100454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 10/14/2023] [Accepted: 11/13/2023] [Indexed: 11/23/2023]
Abstract
Childhood cancer presents significant acute and long-term challenges for patients,families, communities, and health systems. Although meaningful strides have been made in research and treatment, severe outcome disparities prevail between low- and middle-income countries (LMICs) and high-income countries (HICs), with childhood cancer survival rates lower than 20% in LMICs, as compared with over 80% across many HICs. In recent years, greater emphasis has been placed on health system strengthening as a means to develop domestic policy and capacity for sustainable improvements in childhood cancer outcomes in LMICs. In pursuit of a systems approach to childhood cancer in LMICs, our research team developed the Paediatric Oncology System Integration Tool (POSIT)-the first comprehensive framework for the design and evaluation of childhood cancer systems. Since its development, POSIT has been applied in an exploration of key determinants of access to essential childhood cancer medicines across two separate multi-site studies. In this commentary, we explore the value of the POSIT framework and toolkit as a constructive systems-level guide for examining interactions between childhood cancer-specific programs and encompassing health system. socio-political, and economic contexts.
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Affiliation(s)
- Laura Carson
- Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, ON, Canada
| | - Kadia Petricca
- Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, ON, Canada
| | - Avram Denburg
- Department of Paediatrics, Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada.
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2
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Tafazoli A, Cronin-Wood K. Pediatric Oncology Hospice: A Comprehensive Review. Am J Hosp Palliat Care 2024:10499091241227609. [PMID: 38225192 DOI: 10.1177/10499091241227609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2024] Open
Abstract
Pediatric hospice is a new terminology in current medical literature. Implementation of pediatric hospice care in oncology setting is a vast but subspecialized field of research and practice. However, it is accompanied by substantial uncertainties, shortages and unexplored sections. The lack of globally established definitions, principles, and guidelines in this field has adversely impacted the quality of end-of-life experiences for children with hospice needs worldwide. To address this gap, we conducted a comprehensive review of scientific literature, extracting and compiling the available but sparse data on pediatric oncology hospice from the PubMed database. Our systematic approach led to development of a well-organized structure introducing the foundational elements, highlighting complications, and uncovering hidden gaps in this critical area. This structured framework comprises nine major categories including general ideology, population specifications, role of parents and family, psychosocial issues, financial complications, service locations, involved specialties, regulations, and quality improvement. This platform can serve as a valuable resource in establishing a scientifically reliable foundation for future experiments and practices in pediatric oncology hospice.
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Affiliation(s)
- Ali Tafazoli
- Healthcare administration program, St Lawrence College, Kingston Campus, ON, Canada
- Hospice Kingston, Queen's University, Kingston, ON, Canada
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, ON, Canada
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3
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Salako O, Enyi A, Miesfeldt S, Kabukye JK, Ngoma M, Namisango E, LeBaron V, Sisimayi C, Ebenso B, Lorenz KA, Wang Y, Ryan Wolf J, van den Hurk C, Allsop M. Remote Symptom Monitoring to Enhance the Delivery of Palliative Cancer Care in Low-Resource Settings: Emerging Approaches from Africa. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:7190. [PMID: 38131741 PMCID: PMC10743024 DOI: 10.3390/ijerph20247190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 11/10/2023] [Accepted: 12/12/2023] [Indexed: 12/23/2023]
Abstract
This paper brings together researchers, clinicians, technology developers and digital innovators to outline current applications of remote symptom monitoring being developed for palliative cancer care delivery in Africa. We outline three remote symptom monitoring approaches from three countries, highlighting their models of delivery and intended outcomes, and draw on their experiences of implementation to guide further developments and evaluations of this approach for palliative cancer care in the region. Through highlighting these experiences and priority areas for future research, we hope to steer efforts to develop and optimise remote symptom monitoring for palliative cancer care in Africa.
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Affiliation(s)
- Omolola Salako
- Radiation Biology, Radiotherapy and Radiodiagnosis (RBRR) Digital Health Hub, College of Medicine, Lagos University Teaching Hospital, Lagos 102215, Nigeria;
| | | | - Susan Miesfeldt
- Medical Oncology, Maine Medical Center, MaineHealth Cancer Care Center, Scarborough, ME 04106, USA;
| | - Johnblack K. Kabukye
- Uganda Cancer Institute, Upper Mulago Hill Road, Kampala P.O. Box 3935, Uganda;
- Swedish Program for ICT in Developing Regions (SPIDER), Department of Computer and Systems Sciences (DSV), Stockholm University, 164 55 Stockholm, Sweden
| | - Mamsau Ngoma
- Ocean Road Cancer Institute, Dar es Salaam P.O. Box 3592, Tanzania;
| | - Eve Namisango
- African Palliative Care Association, Kampala P.O. Box 72518, Uganda;
| | - Virginia LeBaron
- School of Nursing, University of Virginia, Charlottesville, VA 22903, USA;
| | - Chenjerai Sisimayi
- Department of Mathematics and Applied Mathematics, University of Johannesburg, Johannesburg 2006, South Africa;
| | - Bassey Ebenso
- School of Medicine, University of Leeds, Leeds LS2 9LU, UK;
| | - Karl A. Lorenz
- Ci2i, United States Department of Veterans Affairs, Menlo Park, CA 94025, USA;
- Primary Care and Population Health, Stanford School of Medicine, Stanford, CA 94305, USA
| | - Yan Wang
- School of Nursing, University of Pittsburgh, Pittsburgh, PA 15213, USA;
| | - Julie Ryan Wolf
- Departments of Dermatology and Radiation Oncology, School of Medicine and Dentistry, University of Rochester Medical Center, Rochester, NY 14642, USA;
| | - Corina van den Hurk
- R&D Department, Netherlands Comprehensive Cancer Organisation, 3501 DB Utrecht, The Netherlands;
| | - Matthew Allsop
- School of Medicine, University of Leeds, Leeds LS2 9LU, UK;
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Palumbo N, Tilly A, Namisango E, Ntizimira C, Thambo L, Chikasema M, Rodin G. Palliative care in Malawi: a scoping review. BMC Palliat Care 2023; 22:146. [PMID: 37789372 PMCID: PMC10548577 DOI: 10.1186/s12904-023-01264-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Accepted: 09/13/2023] [Indexed: 10/05/2023] Open
Abstract
BACKGROUND Universal access to palliative care remains a distant goal in many low resource settings, despite the growing evidence of its benefits. The unmet need for palliative care is evident in Africa, but great strides in palliative care development have occurred in several African countries. Located in sub-Saharan Africa, Malawi has been regarded as an exemplar of progress in this area that is achievable in a low resource region. This scoping review examined the literature on the development and state of palliative care in Malawi according to the pillars of health care policy, medicine availability, education, implementation, research activity, and vitality of professionals and advocates. METHODS A scoping review was conducted of the MEDLINE, Embase, Global Health, CINAHL, Web of Science and PsycINFO databases, as well as grey literature sources. Articles were included if they explored any aspect of palliative care in Malawi. RESULTS 114 articles were identified that met the inclusion criteria. This literature shows that Malawi has implemented diverse strategies across all pillars to develop palliative care. These strategies include creating a national stand-alone palliative care policy; integrating palliative care into the curricula of healthcare professionals and developing training for diverse service providers; establishing systems for the procurement and distribution of opioids; implementing diverse models of palliative care service delivery; and launching a national palliative care association. Malawi has also generated local evidence to inform palliative care, but several research gaps were identified. CONCLUSIONS Malawi has made considerable progress in palliative care development, although initiatives are needed to improve medicine availability, access in rural areas, and socioeconomic support for patients and their families living with advanced disease. Culturally sensitive research is needed regarding the quality of palliative care and the impact of therapeutic interventions.
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Affiliation(s)
- Natalie Palumbo
- Schulich School of Medicine and Dentistry, Western University, 1151 Richmond St, London, ON, Canada
| | - Alyssa Tilly
- Division of General Medicine and Clinical Epidemiology and Palliative Care Program, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Eve Namisango
- African Palliative Care Association, Kampala, Uganda
- Cicely Saunders Institute, King's College London, London, UK
| | | | - Lameck Thambo
- Palliative Care Association of Malawi, Lilongwe, Malawi
| | | | - Gary Rodin
- Department of Supportive Care, Princess Margaret Hospital, University Health Network, Toronto, ON, Canada.
- Princess Margaret Hospital, University Health Network, Global Institute of Psychosocial, Palliative and End-of-Life Care (GIPPEC), University of Toronto, Toronto, ON, Canada.
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada.
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5
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Siddiqui MF, Nohra L, Saleh M, Thakkar K, Trivedi R, Moujally SN, Deeb H, Nicolas G, Emmanuel N. Pediatric Oncology, Palliative Care and Low- or Middle- Income Countries: A Call for Action. Glob Pediatr Health 2023; 10:2333794X231188591. [PMID: 37492651 PMCID: PMC10363861 DOI: 10.1177/2333794x231188591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 05/30/2023] [Accepted: 06/28/2023] [Indexed: 07/27/2023] Open
Abstract
Pediatric oncology, which includes cancer screening and therapy in children, poses significant challenges in low- and middle-income countries (LMICs). Palliative care improves children's and their families' quality of life. In LMICs, palliative care resources are scarce, resulting in poor symptom management, psychological support, and spiritual care. All relevant English-language articles on pediatric palliative oncology were searched in PubMed, Google Scholar, Scopus, and Medline databases using the following keywords: "Pediatric Oncology," "Pediatric Palliative Oncology," "Pediatric Palliative Care," "Palliative Care," "Child Cancer," and "Lower- and Middle-Income Countries." This study highlights the significance of incorporating palliative care early in therapy and the recommendations may improve the competence of information provided by medical professionals to patients and families. LMICs have the potential to improve overall treatment and outcomes for child cancer patients and their families by prioritizing the integration of palliative care, guaranteeing a compassionate and dignified attitude toward the disease.
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Affiliation(s)
| | - Lea Nohra
- Faculty of Medical Science, Lebanese University, Beirut, Lebanon
| | - Mustafa Saleh
- Faculty of Medical Science, Lebanese University, Beirut, Lebanon
| | - Keval Thakkar
- Medstar Georgetown University Hospital, Washington, DC, USA
| | - Rishika Trivedi
- Himalayan Institute of Medical Sciences, Dehradun, Uttarakhand, India
| | | | - Hadeel Deeb
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Gregory Nicolas
- Hospital das Clinicas of the Faculty of Medicine of the University of Sao Paulo, Sao Paulo, Brazil
| | - Nancy Emmanuel
- Hospital das Clinicas of the Faculty of Medicine of the University of Sao Paulo, Sao Paulo, Brazil
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Abayneh M, Rent S, Ubuane PO, Carter BS, Deribessa SJ, Kassa BB, Tekleab AM, Kukora SK. Perinatal palliative care in sub-Saharan Africa: recommendations for practice, future research, and guideline development. Front Pediatr 2023; 11:1217209. [PMID: 37435165 PMCID: PMC10331424 DOI: 10.3389/fped.2023.1217209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 06/13/2023] [Indexed: 07/13/2023] Open
Abstract
Worldwide, sub-Saharan Africa has the highest burden of global neonatal mortality (43%) and neonatal mortality rate (NMR): 27 deaths per 1,000 live births. The WHO recognizes palliative care (PC) as an integral, yet underutilized, component of perinatal care for pregnancies at risk of stillbirth or early neonatal death, and for neonates with severe prematurity, birth trauma or congenital anomalies. Despite bearing a disproportionate burden of neonatal mortality, many strategies to care for dying newborns and support their families employed in high-income countries (HICs) are not available in low-and-middle-income countries (LMICs). Many institutions and professional societies in LMICs lack guidelines or recommendations to standardize care, and existing guidelines may have limited adherence due to lack of space, equipment, supplies, trained professionals, and high patient load. In this narrative review, we compare perinatal/neonatal PC in HICs and LMICs in sub-Saharan Africa to identify key areas for future, research-informed, interventions that might be tailored to the local sociocultural contexts and propose actionable recommendations for these resource-deprived environments that may support clinical care and inform future professional guideline development.
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Affiliation(s)
- Mahlet Abayneh
- Department of Pediatrics and Child Health, St Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Sharla Rent
- Duke Department of Pediatrics, Duke School of Medicine, Durham, NC, United States
- Duke Global Health Institute, Durham, NC, United States
| | - Peter Odion Ubuane
- Department of Pediatrics, Lagos State University Teaching Hospital (LASUTH), Ikeja, Lagos, Nigeria
| | - Brian S. Carter
- Division of Neonatology and Bioethics Center, Children’s Mercy Hospital, Kansas City, MO, United States
- Department of Pediatrics and Department of Medical Humanities and Bioethics, Universityof Missouri-Kansas City School of Medicine, Kansas City, MO, United States
| | - Solomie Jebessa Deribessa
- Department of Pediatrics and Child Health, St Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Betelehem B. Kassa
- College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Atnafu Mekonnen Tekleab
- Department of Pediatrics and Child Health, St Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Stephanie K. Kukora
- Division of Neonatology and Bioethics Center, Children’s Mercy Hospital, Kansas City, MO, United States
- Department of Pediatrics and Department of Medical Humanities and Bioethics, Universityof Missouri-Kansas City School of Medicine, Kansas City, MO, United States
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Amonoo HL, Abdul-Rahim SA, Atobrah D, Addo-Mensah D, Longley RM, Jacobo MC, Pirl WF. Psychosocial oncology in Sub-Saharan Africa: Lessons from Ghana. Psychooncology 2023; 32:139-147. [PMID: 35584290 DOI: 10.1002/pon.5965] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Hermioni L Amonoo
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Department of Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Salisu A Abdul-Rahim
- National Radiotherapy, Oncology, and Nuclear Medicine Center, Korle-Bu Teaching Hospital, Accra, Ghana
| | - Deborah Atobrah
- Institute of African Studies, University of Ghana, Accra, Ghana
| | - Dorothy Addo-Mensah
- Department of Adult Health, School of Nursing and Midwifery, University of Cape-Coast, Cape-Coast, Ghana
| | - Regina M Longley
- Department of Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Michelle C Jacobo
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - William F Pirl
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
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Rosa WE, Ahmed E, Chaila MJ, Chansa A, Cordoba MA, Dowla R, Gafer N, Khan F, Namisango E, Rodriguez L, Knaul FM, Pettus KI. Can You Hear Us Now? Equity in Global Advocacy for Palliative Care. J Pain Symptom Manage 2022; 64:e217-e226. [PMID: 35850443 PMCID: PMC9482940 DOI: 10.1016/j.jpainsymman.2022.07.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 06/27/2022] [Accepted: 07/08/2022] [Indexed: 10/17/2022]
Abstract
Evidence-based advocacy underpins the sustainable delivery of quality, publicly guaranteed, and universally available palliative care. More than 60 million people in low- and middle-income countries (LMICs) have no or extremely limited access to either palliative care services or essential palliative care medicines (e.g., opioids) on the World Health Organization Model List. Indeed, only 12% of the global palliative care need is currently being met. Palliative care advocacy works to bring this global public health inequity to light. Despite their expertise, palliative care practitioners in LMICs are rarely invited to health policymaking tables - even in their own countries - and are underrepresented in the academic literature produced largely in the high-income world. In this paper, palliative care experts from Bangladesh, Colombia, Egypt, Sudan, Uganda, and Zambia affiliated with the International Association for Hospice & Palliative Care Advocacy Focal Point Program articulate the urgent need for evidence-based advocacy, focusing on significant barriers such as urban/rural divides, cancer-centeredness, service delivery gaps, opioid formulary limitations, public policy, and education deficits. Their advocacy is situated in the context of an emerging global health narrative that stipulates palliative care provision as an ethical obligation of all health systems. To support advocacy efforts, palliative care evaluation and indicator data should assess the extent to which LMIC practitioners lead and participate in global and regional advocacy. This goal entails investment in transnational advocacy initiatives, research investments in palliative care access and cost-effective models in LMICs, and capacity building for a global community of practice to capture the attention of policymakers at all levels of health system governance.
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Affiliation(s)
- William E Rosa
- Department of Psychiatry and Behavioral Sciences (W.E.R.), Memorial Sloan Kettering Cancer Center, New York, New York, USA; Institute for Advanced Study of the Americas, University of Miami (W.E.R. and F.M.K.), Coral Gables, Florida, USA.
| | - Ebtesam Ahmed
- Department of Clinical Health Professions (E.A.), St. John's University College of Pharmacy and Health Sciences, Queens, New York, USA; MJHS Institute for Innovation in Palliative Care (E.A.), New York, New York, USA
| | | | - Abidan Chansa
- National Palliative Care Program (A.C.), Ministry of Health, Lusaka, Zambia
| | - Maria Adelaida Cordoba
- Pediatric Palliative Section (M.A.C.), Fundación Hospital Pediátrico de La Misericordia, Bogotá, Colombia; Department of Pediatrics (M.A.C.), Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | - Rumana Dowla
- Palliative Medicine Cancer Care Centre (R.D.), United Hospital, Dhaka, Bangladesh
| | - Nahla Gafer
- Integrated Palliative and Oncology Unit (N.G.), Khartoum Oncology Hospital, Khartoum, Sudan
| | - Farzana Khan
- Fasiuddin Khan Research Foundation (F.K.), Uttara, Dhaka, Bangladesh; Global Health Academy (F.K.), University of Edinburgh, Scotland, United Kingdom
| | - Eve Namisango
- African Palliative Care Association (E.N.), Kampala, Uganda; Department of Palliative Care and Rehabilitation (E.N.), Cicely Saunders Institute, King's College, London, United Kingdom
| | - Luisa Rodriguez
- Department of Anesthesia (L.R.), Pain and Palliative Medicine, Universidad de La Sabana, Chia, Colombia; Asociación Colombiana de Cuidados Paliativos (L.R.), Bogotá, Colombia
| | - Felicia Marie Knaul
- Institute for Advanced Study of the Americas, University of Miami (W.E.R. and F.M.K.), Coral Gables, Florida, USA; Department of Public Health Sciences (F.M.K.), University of Miami Miller School of Medicine, Miami, Florida, USA; Tómatelo a Pecho, Mexico City (F.M.K.), Mexico; Fundación Mexicana para la Salud (F.M.K.), Mexico City, Mexico
| | - Katherine I Pettus
- International Association for Hospice and Palliative Care (K.I.P.), Houston, Texas, USA
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Chinyundo K, Casas J, Bank R, Abenawe C, Gaolebale B, Nakirulu A, Maifale-Mburu G, Hesselgrave J, Butia M, Bakulumpagi D, Nassanga I, Higgins J, Hockenberry M. Delphi Method to Develop a Palliative Care Tool for Children and Families in Sub-Saharan Africa. J Pain Symptom Manage 2022; 63:962-970. [PMID: 35202729 DOI: 10.1016/j.jpainsymman.2022.02.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 02/09/2022] [Accepted: 02/15/2022] [Indexed: 11/15/2022]
Abstract
CONTEXT In sub-Saharan Africa, there is no standardized approach to pediatric palliative care assessment. Because of this, there is a critical demand for evidence-based assessment tools that identify the specialized needs of children and their families requiring palliative care in developing countries. OBJECTIVES To develop a standardized approach to pediatric palliative care (PPC) assessment that includes an individualized plan of care for use in sub-Saharan Africa. METHODS A Delphi method approach used five rounds to explore core elements that define the essential assessment attributes mandatory for providing excellence in PPC. Using the Delphi method, the consensus from 11 PPC experts was obtained during four Delphi rounds regarding the most important questions to include in a PPC assessment tool and plan of care. During the final Delphi round 5, the expert consensus was confirmed in a separate group of 36 childhood cancer/palliative care clinical providers. RESULTS Five core elements were developed as the foundation for a PPC assessment. A symptom assessment tool was developed that includes 15 symptoms that PPC experts agreed occurred more than 65% of the time in their patients. CONCLUSION The Delphi method was an effective tool to develop a consensus on a PPC assessment tool to use with children and their families in sub-Saharan Africa. This standardized approach will enable the collection of data to drive outcomes and research.
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Affiliation(s)
- Kamusisi Chinyundo
- Global HOPE Botswana (K.C.), Gaborone, Botswana; Baylor College of Medicine (J.C., J.H., M.H.), Houston, Texas, USA; Texas Children's Hospital (J.C., J.H.), Houston, Texas, USA; Global HOPE Malawi (R.B, M.B.), Lilongwe, Malawi; Global HOPE Uganda (A.N., D.B., I.N.), Kampala, Uganda; Princess Marina Hospital (B.G., G.M.M.), Gaborone, Botswana
| | - Jessica Casas
- Global HOPE Botswana (K.C.), Gaborone, Botswana; Baylor College of Medicine (J.C., J.H., M.H.), Houston, Texas, USA; Texas Children's Hospital (J.C., J.H.), Houston, Texas, USA; Global HOPE Malawi (R.B, M.B.), Lilongwe, Malawi; Global HOPE Uganda (A.N., D.B., I.N.), Kampala, Uganda; Princess Marina Hospital (B.G., G.M.M.), Gaborone, Botswana
| | - Rhahim Bank
- Global HOPE Botswana (K.C.), Gaborone, Botswana; Baylor College of Medicine (J.C., J.H., M.H.), Houston, Texas, USA; Texas Children's Hospital (J.C., J.H.), Houston, Texas, USA; Global HOPE Malawi (R.B, M.B.), Lilongwe, Malawi; Global HOPE Uganda (A.N., D.B., I.N.), Kampala, Uganda; Princess Marina Hospital (B.G., G.M.M.), Gaborone, Botswana
| | - Cosiate Abenawe
- Global HOPE Botswana (K.C.), Gaborone, Botswana; Baylor College of Medicine (J.C., J.H., M.H.), Houston, Texas, USA; Texas Children's Hospital (J.C., J.H.), Houston, Texas, USA; Global HOPE Malawi (R.B, M.B.), Lilongwe, Malawi; Global HOPE Uganda (A.N., D.B., I.N.), Kampala, Uganda; Princess Marina Hospital (B.G., G.M.M.), Gaborone, Botswana
| | - Babe Gaolebale
- Global HOPE Botswana (K.C.), Gaborone, Botswana; Baylor College of Medicine (J.C., J.H., M.H.), Houston, Texas, USA; Texas Children's Hospital (J.C., J.H.), Houston, Texas, USA; Global HOPE Malawi (R.B, M.B.), Lilongwe, Malawi; Global HOPE Uganda (A.N., D.B., I.N.), Kampala, Uganda; Princess Marina Hospital (B.G., G.M.M.), Gaborone, Botswana
| | - Annet Nakirulu
- Global HOPE Botswana (K.C.), Gaborone, Botswana; Baylor College of Medicine (J.C., J.H., M.H.), Houston, Texas, USA; Texas Children's Hospital (J.C., J.H.), Houston, Texas, USA; Global HOPE Malawi (R.B, M.B.), Lilongwe, Malawi; Global HOPE Uganda (A.N., D.B., I.N.), Kampala, Uganda; Princess Marina Hospital (B.G., G.M.M.), Gaborone, Botswana
| | - Goitseone Maifale-Mburu
- Global HOPE Botswana (K.C.), Gaborone, Botswana; Baylor College of Medicine (J.C., J.H., M.H.), Houston, Texas, USA; Texas Children's Hospital (J.C., J.H.), Houston, Texas, USA; Global HOPE Malawi (R.B, M.B.), Lilongwe, Malawi; Global HOPE Uganda (A.N., D.B., I.N.), Kampala, Uganda; Princess Marina Hospital (B.G., G.M.M.), Gaborone, Botswana
| | - Joy Hesselgrave
- Global HOPE Botswana (K.C.), Gaborone, Botswana; Baylor College of Medicine (J.C., J.H., M.H.), Houston, Texas, USA; Texas Children's Hospital (J.C., J.H.), Houston, Texas, USA; Global HOPE Malawi (R.B, M.B.), Lilongwe, Malawi; Global HOPE Uganda (A.N., D.B., I.N.), Kampala, Uganda; Princess Marina Hospital (B.G., G.M.M.), Gaborone, Botswana
| | - Mercy Butia
- Global HOPE Botswana (K.C.), Gaborone, Botswana; Baylor College of Medicine (J.C., J.H., M.H.), Houston, Texas, USA; Texas Children's Hospital (J.C., J.H.), Houston, Texas, USA; Global HOPE Malawi (R.B, M.B.), Lilongwe, Malawi; Global HOPE Uganda (A.N., D.B., I.N.), Kampala, Uganda; Princess Marina Hospital (B.G., G.M.M.), Gaborone, Botswana
| | - Deogratius Bakulumpagi
- Global HOPE Botswana (K.C.), Gaborone, Botswana; Baylor College of Medicine (J.C., J.H., M.H.), Houston, Texas, USA; Texas Children's Hospital (J.C., J.H.), Houston, Texas, USA; Global HOPE Malawi (R.B, M.B.), Lilongwe, Malawi; Global HOPE Uganda (A.N., D.B., I.N.), Kampala, Uganda; Princess Marina Hospital (B.G., G.M.M.), Gaborone, Botswana
| | - Immaculate Nassanga
- Global HOPE Botswana (K.C.), Gaborone, Botswana; Baylor College of Medicine (J.C., J.H., M.H.), Houston, Texas, USA; Texas Children's Hospital (J.C., J.H.), Houston, Texas, USA; Global HOPE Malawi (R.B, M.B.), Lilongwe, Malawi; Global HOPE Uganda (A.N., D.B., I.N.), Kampala, Uganda; Princess Marina Hospital (B.G., G.M.M.), Gaborone, Botswana
| | - Jennifer Higgins
- Global HOPE Botswana (K.C.), Gaborone, Botswana; Baylor College of Medicine (J.C., J.H., M.H.), Houston, Texas, USA; Texas Children's Hospital (J.C., J.H.), Houston, Texas, USA; Global HOPE Malawi (R.B, M.B.), Lilongwe, Malawi; Global HOPE Uganda (A.N., D.B., I.N.), Kampala, Uganda; Princess Marina Hospital (B.G., G.M.M.), Gaborone, Botswana
| | - Marilyn Hockenberry
- Global HOPE Botswana (K.C.), Gaborone, Botswana; Baylor College of Medicine (J.C., J.H., M.H.), Houston, Texas, USA; Texas Children's Hospital (J.C., J.H.), Houston, Texas, USA; Global HOPE Malawi (R.B, M.B.), Lilongwe, Malawi; Global HOPE Uganda (A.N., D.B., I.N.), Kampala, Uganda; Princess Marina Hospital (B.G., G.M.M.), Gaborone, Botswana
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