Extension for Community Healthcare Outcomes-Palliative Care in Africa Program: Improving Access to Quality Palliative Care

Development and evaluation of an online training program for palliative care in India

BACKGROUND

Palliative care training at the undergraduate level is poor in India. With the need for palliative care rising in India and globally, it is possible to train physicians in resource-limited settings in palliative care via online training programs owing to ease of access and convenience. However, there is limited evidence available from India on the development and implementation of such a training program. This study aims to describe the development of an online training program offered by the Trivandrum Institute of Palliative Sciences (TIPS), Kerala, and the impact of the program on the confidence of physicians in managing various palliative care needs of their patients.

METHODS

The course was developed by an interdisciplinary expert team from TIPS. The course content was made keeping in mind the local sociocultural factors in India and was peer-reviewed by two external experts. The program was started in 2018 and updated and revised over the years. Currently, the program has 20 sessions, each lasting for 90 min. The course content was disseminated using project-ECHO's (Extension of Community Health Outcomes) telementoring model. To assess the impact of the training program, self-reported change in confidence from twenty-two batches of physicians, trained from January 2020 to August 2023. Feedback from participants was also assessed to identify areas of improvement in the training program.

RESULTS

A total of 1159 physicians were trained during the study period. At the end of the course, 51.2% of the participants completed the evaluation survey and had a statistically significant (p < 0.05) improvement in confidence in pain, gastrointestinal symptoms and breathlessness management, morphine prescription, and psychosocial communication. The duration of each session and the entire course was reported to be ideal by 88.6% and 87.9% of participants, respectively.

CONCLUSION

Our results show that online training can be effectively used to build confidence in physicians in managing various palliative care needs.

TRIAL REGISTRATION

Not applicable.

Childhood Cancer Survivorship Care in Limited Resource Settings: A Narrative Review and Strategies to Promote Global Health Equity

The WHO Global Initiative for Childhood Cancer, prompted by the marked inequity of survival across the globe, aims to increase survival rates in low- and middle-income countries to 60% by 2030. In tandem with this effort, implementing survivorship-focused care is crucial to mitigate late effects and prevent early mortality beyond the 5-year survival end point. The observed burden of secondary malignancies, cardiovascular disease, and other chronic health conditions in adult survivors of childhood cancer in high-income countries provides guidance to generate evidence in limited-resource settings. The implementation of risk stratification tools, population health management, and development of contextually relevant health care delivery models, within the current landscape of survivorship care in Latin America, Africa, and Asia as examples, are vital to continue the momentum to ensure equitable care and quality of life for all survivors of childhood cancer. This narrative review informed by expert opinion serves as a call to action for survivors, advocacy groups, health professionals, health systems, governments, and global organizations to look beyond the 5-year survival benchmark.

Children's palliative care perceptions and educational needs among healthcare professionals in humanitarian settings

OBJECTIVES

Explore humanitarian healthcare professionals' (HCPs) perceptions about implementing children's palliative care and to identify their educational needs and challenges, including learning topics, training methods, and barriers to education.

METHODS

Humanitarian HCPs were interviewed about perspectives on children's palliative care and preferences and needs for training. Interviews were transcribed, coded, and arranged into overarching themes. Thematic analysis was performed using qualitative description.

RESULTS

Ten healthcare workers, including doctors, nurses, psychologists, and health-project coordinators, were interviewed. Participants identified key patient and family-related barriers to palliative care in humanitarian settings, including misconceptions that palliative care was synonymous with end-of-life care or failure. Health system barriers included time constraints, insufficient provider knowledge, and a lack of standardized palliative care protocols. Important learning topics included learning strategies to address the stigma of serious illness and palliative care, culturally sensitive communication skills, and pain and symptom management. Preferred learning modalities included interactive lectures, role-play/simulation, and team-based case discussions. Participants preferred online training for theoretical knowledge and in-person learning to improve their ability to conduct serious illness conversations and learn other key palliative care skills.

SIGNIFICANCE OF RESULTS

Palliative care prevents and relieves serious illness-related suffering for children with life-threatening and life-limiting conditions; however, most children in humanitarian settings are not able to access essential palliative care, leading to preventable pain and suffering. Limited palliative care knowledge and skills among HCPs in these settings are significant barriers to improving access to palliative care. Humanitarian HCPs are highly motivated to learn and improve their skills in children's palliative care, but they require adequate health system resources and training. These findings can guide educators in developing palliative care education packages for humanitarian HCPs.

Online palliative care education and mentorship in Nepal: Project ECHO - a novel approach to improving knowledge and self-efficacy among interprofessional health-care providers

BACKGROUND

Palliative care access in Nepal is severely limited, with few health-care providers having training and skills to pain management and other key aspects of palliative care. Online education suggests an innovation to increase access to training and mentoring, which addresses common learning barriers in low- and middle-income countries. Project ECHO (Extensions for Community Health Care Outcomes) is a model of online education which supports communities of practices (COPs) and mentoring through online teaching and case discussions. The use of online education and Project ECHO in Nepal has not been described or evaluated.

SETTING

An online course, consisting of 14 synchronous weekly palliative care training sessions was designed and delivered, using the Project ECHO format. Course participants included health-care professionals from a variety of disciplines and practice settings in Nepal.

OBJECTIVES

The goal of this study was to evaluate the impact of a virtual palliative care training program in Nepal on knowledge and attitudes of participants.

METHODS

Pre- and post-course surveys assessed participants' knowledge, comfort, and attitudes toward palliative care and evaluated program acceptability and barriers to learning.

RESULTS

Forty-two clinicians, including nurses (52%) and physicians (48%), participated in program surveys. Participants reported significant improvements in their knowledge and attitudes toward core palliative care domains. Most participants identified the program as a supportive COP, where they were able to share and learn from faculty and other participants.

CONCLUSION

Project ECHO is a model of online education which can successfully be implemented in Nepal, enhancing local palliative care capacity. Bringing together palliative care local and international clinical experts and teachers supports learning for participants through COP. Encouraging active participation from participants and ensuring that teaching addresses availability and practicality of treatments in the local health-care context addresses key barriers of online education.

SIGNIFICANCE OF RESULTS

This study describes a model of structured virtual learning program, which can be implemented in settings with limited access to palliative care to increase knowledge and attitudes toward palliative care. The program equips health-care providers to better address serious health-related suffering, improving the quality of life for patients and their caregivers. The program demonstrates a model of training which can be replicated to support health-care providers in rural and remote settings.

Using Project ECHO to deliver a tele-mentoring and teaching program on palliative care in South Asia: Interpretive description of participants' experiences with a community of practice for learning

OBJECTIVES

To explore the learning experiences of participants (learners and teachers), in a yearlong tele-teaching and mentoring program on pediatric palliative care, which was conducted using the Project ECHO (Extension for Community Healthcare Outcomes) model and consisted of 27 teaching and clinical case discussion sessions for palliative medicine residents in India and Bangladesh. The goal of the study is to explore how participation and learning is motivated and sustained for both residents and teachers, including the motivators and challenges to participation and learning in a novel online format.

METHODS

Qualitative interviews with ECHO participants, including learners and teachers were conducted. Interviews were recorded and transcribed. Thematic analysis of interview data was conducted within an interpretive description approach.

RESULTS

Eleven physicians (6 residents, 5 teachers) participated in interviews. Key elements of the ECHO program which participants identified as supporting learning and participation include small group discussions, a flipped classroom, and asynchronous interactions through social media. Individual learner characteristics including effective self-reflection and personal circumstances impact learning. Providing opportunities for a diverse group of learners and teachers, to interact in communities of practice (COP) enhances learning. Three major themes and 6 subthemes describing learning processes were identified. Themes included (1) ECHO program structure, (2) learner characteristics, and (3) COP. Subthemes included flipped classroom, breakout rooms, learning resources, personal circumstances, self-awareness of learning needs, and community interactions.

SIGNIFICANCE OF RESULTS

Project ECHO suggests a novel model to train health providers, which is effective in low- and middle-income countries. Online learning programs can lead to learning through community of practice when learners and teachers are able to interact and engage in peer support and reflective practice. Educators should consider incorporating small group discussions, a flipped classroom design, and opportunities for asynchronous interactions to enhance learning for participants in online learning programs.

Evolution of Telehealth-Its Impact on Palliative Care and Medication Management

Palliative care plays a crucial role in enhancing the quality of life for individuals facing serious illnesses, aiming to alleviate suffering and provide holistic support. With the advent of telehealth, there is a growing interest in leveraging technology to extend the reach and effectiveness of palliative care services. This article provides a comprehensive review of the evolution of telehealth, the current state of telemedicine in palliative care, and the role of telepharmacy and medication management. Herein we highlight the potential benefits, challenges, and future directions of palliative telemedicine. As the field continues to advance, the article proposes key considerations for future research, policy development, and clinical implementation, aiming to maximize the advantages of telehealth in assisting individuals and their families throughout the palliative care journey. The comprehensive analysis presented herein contributes to a deeper understanding of the role of telehealth in palliative care and serves as a guide for shaping its future trajectory.

Project ECHO for Cancer Care: a Scoping Review of Provider Outcome Evaluations

The Project ECHO model of telementoring has been used for the past 10 years to expand access to specialized cancer care. This scoping review identifies evidence for the model's ability to improve provider outcomes, synthesizing findings from existing studies within Moore et al.'s (2009) framework for continuing medical education outcomes. We search two large research databases and a collection maintained by Project ECHO staff for articles that focus on cancer ECHO programs, involve primary data collection, and were published between December 1, 2016, and November 30, 2021. We identified 25 articles for inclusion in our scoping review. Most articles reported results for outcomes related to program participation: attendance, satisfaction, and learning. Yet, just under half reported changes in provider practices. Results demonstrate widespread participation and improved learning resulting from ECHO programs focused on cancer care. There is also evidence of improved practices related to HCV vaccination and palliative care. We highlight examples of best practices as well as opportunities to improve provider outcome evaluations for cancer ECHO programs.

Applying the Project ECHO Model to Support Implementation and Sustainment of Cognitive Behavioral Therapy for Psychosis

INTRODUCTION

Project Extension for Community Healthcare Outcomes (ECHO) is a teleconsultation model that leverages technology to sustain specialized interventions in underresourced settings. We present the application of the ECHO model to longitudinal training and consultation for community behavioral health providers learning to deliver cognitive behavioral therapy for psychosis, an evidence-based psychotherapy for individuals with psychotic disorders that has poorly penetrated the US mental health system.

METHODS

We analyzed within-group change over practitioners' 6-month ECHO participation cycle using the Expanded Outcomes Framework. We evaluated outcomes associated with participation, satisfaction, knowledge acquisition, performance, patient symptom severity, and functional impairment.

RESULTS

In the first 3 years, the cognitive behavioral therapy for psychosis ECHO Clinics supported 150 providers from 12 community agencies. Forty percent did not complete the 6-month ECHO calendar, most commonly due to separation from their agency. Participants reported high degrees of satisfaction. Declarative and procedural knowledge increased over the 6-month period. Of the 24 providers who received a fidelity review, 87.5% met or exceeded the competency benchmark within the 6-month period. Clinical outcomes reflected reductions in hallucinations, negative symptoms, depression, mania, and functional impairment, but no reductions were detected in delusions, disorganized speech, or abnormal psychomotor behavior.

DISCUSSION

ECHO Clinics offer a mode of providing continuous access to expert instruction, peer-to-peer consultation, and case-based learning that other workforce training models lack. Our evaluation suggests that the ECHO model supports continuous professional development for practitioners, most of whom had indicated inadequate preparation for their role. We observed improved learner and select patient outcomes.

An evaluation of the disparities affecting the underdiagnosis of pediatric cancer in Western Kenya

INTRODUCTION

Western Kenya is home to approximately 24 million people, with 10 million children under the age of 15 years.¹ Based on estimates of cancer incidence in similar populations from around the world, approximately 1500 patients should be diagnosed with pediatric cancer each year. This article describes the international collaboration that investigates potential barriers preventing the effective diagnosis of pediatric patients with cancer.

METHODS

Here, we describe a multidisciplinary and sequential approach to better evaluate the complex factors affecting the lack of appropriate diagnosis of pediatric cancer in Western Kenya.

RESULTS

Internal review at a large tertiary hospital noted 200-250 patients were diagnosed annually, suggesting the remaining 75%-80% of patients go undiagnosed and do not receive treatment. Following our screening process at a local referring hospital, 41 malaria slides demonstrated both morphologic and genetic evidence of leukemia. Knowledge assessments of local providers at referring institutions suggested a lack of education and training as the factors that contribute to lower rates of diagnosis.

DISCUSSION

Through a multi-step approach, our teams were better able to isolate potential issues impeding the appropriate and timely diagnosis of pediatric cancer in Kenya.

Project ECHO: Enhancing palliative care for primary care occupational therapists and physiotherapists in Ireland

Project ECHO (Extension for Community Healthcare Outcomes) uses videoconferencing technology to support and train healthcare professionals (HCPs) remotely. A 4-month fortnightly ECHO programme was developed and implemented to enhance palliative care provision by primary care therapists. Teaching and case-based discussions were facilitated by palliative care specialists. A mixed-methods cohort study was used to evaluate the project. ECHO participants completed pre- and post-programme questionnaires regarding their knowledge and skills across key palliative care domains. Focus groups were held before programme commencement to explore participants' attitudes and experiences of palliative care and after programme conclusion to explore their experiences of ECHO. Twenty-six primary care HCPs commenced the ECHO programme. Mean scores in self-rated confidence in knowledge and skill improved significantly (p < .002) following the programme. Twenty-one primary care HCPs completed the post-ECHO surveys and scores of self-rated confidence in knowledge and skills were significantly higher than pre-ECHO scores. Ninety-five percent of participants (n = 19) reported ECHO met their learning needs and was an effective format to enhance clinical knowledge. Eighty-five percent of participants (n = 17) would recommend ECHO to their colleagues. Project ECHO improved palliative care knowledge and skills of primary care HCPs in Ireland, with potential to address the growing need for integrated palliative care services.

Using Virtual Learning to Develop Palliative Care Skills Among Humanitarian Health Workers in the Rohingya Refugee Response in Bangladesh

BACKGROUND

Palliative care is an essential component of health responses in humanitarian settings, yet it remains largely unavailable in these settings, due to limited availability of palliative care training for healthcare professionals. Online training programs which connect experts to clinicians in the field have been proposed as an innovative strategy to build palliative care capacity humanitarian settings.

OBJECTIVE

To describe the implementation and evaluate the impact of delivering palliative care education using an established virtual learning model (Project ECHO) for healthcare clinicians working in the Rohingya refugee response in Bangladesh. Program acceptability and the impacts on learners' self-reported knowledge, comfort, and practice changes were evaluated.

METHODS

Using the Project ECHO model, an education program consisting of 7 core sessions and monthly mentoring sessions was developed. Each session included a didactic lecture, case presentation and interactive discussion. Surveys of participants were conducted before and after the program to assess knowledge, confidence, and attitudes about palliative care as well as learning experiences from the program.

RESULTS

This virtual palliative care training program engaged 250 clinicians, including nurses (35%), medical assistants (28%) and physicians (20%). Most participants rated the program as a valuable learning experience (96%) that they would recommend to their colleagues (98%). Participants reported improvements in their knowledge and comfort related to palliative care after participation in the program, and had improved attitudes towards palliative care with demonstrated statistical significance (p < 0.05).

CONCLUSIONS

Virtual training is a feasible model to support healthcare providers in a humanitarian health response. Project ECHO can help to address the urgent need for palliative care in humanitarian responses by supporting healthcare workers to provide essential palliative care to the growing number of individuals with serious health-related suffering in humanitarian settings.

The role of digital health in palliative care for people living with HIV in sub-Saharan Africa: A systematic review

Background

In 2018, 26.6 million people were living with HIV in sub-Saharan Africa. Palliative care services are recommended for people living with HIV at all stages from diagnosis through to end-of-life. However, the provision of palliative care in sub-Saharan Africa is limited, leading to little or no access for the majority of patients. Digital technologies in sub-Saharan Africa present an opportunity to improve access to palliative care for people living with HIV in the region. This review synthesised literature on digital health interventions for palliative care for people living with HIV in sub-Saharan Africa and assessed their effects on patient outcomes.

Methods

Literature searches were conducted in MEDLINE, Embase, PsycINFO and Global Health. Inclusion and exclusion criteria were applied. Two independent reviewers conducted study screening, data extraction and quality appraisal. A narrative synthesis was performed to draw together and report findings across heterogeneous studies. Reporting of this review follows the Preferred Reporting Items for Systematic Review and Meta-Analysis checklist.

Results

Out of 4117 records, 25 studies were included, covering 3592 people living with HIV, across 21 countries. Studies included three randomised controlled trials, three qualitative, three pre- and post-test, two observational, two case series, six cross-sectional and six mixed methods studies. Telemedicine was the most reported digital health intervention, with 12 studies demonstrating the effectiveness of digital health interventions.

Conclusion

Emerging evidence suggests digital health interventions can be effective in facilitating patient-provider communication and health professional decision-making as a part of palliative care for people living with HIV. There is a need for further development and evaluation of digital health interventions alongside determining optimal approaches to their implementation as a part of palliative care provision in sub-Saharan Africa.

Training on adequate use of opioid analgesics in West and Central Africa: a neglected step on the way to access to essential medicines?

Alleviating acute and chronic pain is a moral imperative for health professionals and health systems, and it requires adequate access to and use of essential opioid analgesics. However, this is still a neglected issue in global health, with striking inequalities in opioids availability between high and low- and middle-income countries. Countries most affected by lack of access are those with a fragile political situation and weak regulatory and healthcare systems. The main threats to accessibility, availability and affordability are situated at different levels: legislation and policy, financing, knowledge and cultural behavior, erroneous beliefs, and training and education. Among these threats, the lack of (adequate) training and education seems to be a cross-cutting issue. Exploring the current body of knowledge about training and educational activities related to use of opioid analgesics and palliative care, is helpful to understand gaps and to delineate priorities for setting up adequate interventions. When applied to West and Central Africa, this exercise reveals that there is little information (easily) available in the public domain. The African Palliative Care Association (APCA) appears to be the leading provider of capacity building activities in this region for key stakeholders, including national authorities, healthcare professionals and the general population; it is also very active in publishing and communicating about these issues. However, apart from APCA, there is little information on training programs’ contents and long-term outcomes. Furthermore, trainings rarely target important stakeholders such as lawmakers, regulators, supply officers and the lay public (i.e., patients, caregivers, community leaders and members of the society as a whole). Hence, it is urgent to fill the existing gaps in training and educational activities to improve access to essential opioid analgesics in West and Central Africa, involving different stakeholders at the national and regional level. Furthermore, such experiences should be published and made publicly available to allow for mutual learning and further upscale.

Use of Project ECHO Telementoring Model in Continuing Medical Education for Pediatricians in Vietnam: Preliminary Results

The ECHO (Extension for Community Health Outcomes) model has been introduced and implemented in several hospitals and health programs in Vietnam since 2015. In 2018, Vietnam National Children’s Hospital (VNCH) officially implemented the ECHO model to provide continuing medical education (CME) credits on pediatrics topics for medical staff in its satellite hospitals and health centers in the Northern region of Vietnam. This paper presents preliminary results of the ECHO program at VNCH. Methods included pre- and post-program assessments of pediatricians’ clinical knowledge, self-efficacy, and professional satisfaction. The analysis compared the differences between pre/post scores descriptively. Knowledge of participants increased by 22.5% points on average. More than 90% of Project ECHO-Pediatrics participants experienced increased confidence. Overall, there was an improvement in participants’ self-efficacy in the post-training compared to the pre-training (range 14.7%-22.6% difference from pre-training). All participants improved on their results in the clinical test immediately after the training and maintained it after 3 months. The study demonstrated the ability Project ECHO to improve healthcare worker knowledge and satisfaction.

Preferences of quality delivery of palliative care among cancer patients in low- and middle-income countries: A review

BACKGROUND

All forms of cancer pose a tremendous and increasing problem globally. The prevalence of cancer across the globe is anticipated to double over the next two decades. About 50% of most cancer cases are expected to occur in low- and middle-income countries (LMICs), where there is a greater disproportionate level in mortality. Access to effective and timely care for cancer patients remains a challenge, especially in LMICs due to late disease diagnosis and detection, coupled with the limited availability of appropriate therapeutic options and delay in proper interventions.

METHODOLOGY

This study explored several mixed-method researches and randomized trials that addressed the preferences of quality delivery of palliative care among cancer patients in LMICs. A designated set of keywords such as Palliative Care; Preferences; Cancer patients; Psycho-social Support; End-of-life Care; Low and Middle-Income Countries were inserted on electronic databases to retrieve articles. The databases include PubMed, Scinapse, Medline, The Google Scholar, Academic search premier, SAGE, and EBSCO host.

RESULTS

Findings from this review discussed the socioeconomic and behavioral factors, which address the quality delivery of palliative care among cancer patients. These factors if measured with acceptance level in cancer patients could help to address areas that need improvement from the stage of disease diagnosis to the end-of-life.

SIGNIFICANCE OF THE RESULTS

Valuable collaborations among international and local health institutions are needed to build and implement a systematic framework for palliative care in LMICs. Policies and programs that are country and culturally specific, encompassing both theoretical and practical models of care in the milieu of existing quandaries should be developed.

Building a Sustainable Comprehensive Multiple Myeloma Program in Western Kenya

Despite improved treatment strategies for multiple myeloma (MM), patient outcomes in low- and middle-income countries remain poor, unlike high-income countries. Scarcity of specialized human resources and diagnostic, treatment, and survivorship infrastructure are some of the barriers that patients with MM, clinicians, and policymakers have to overcome in the former setting. To improve outcomes of patients with MM in Western Kenya, the Academic Model Providing Access to Healthcare (AMPATH) MM Program was set up in 2012. In this article, the program's activities, challenges, and future plans are described distilling important lessons that can be replicated in similar settings. Through the program, training on diagnosis and treatment of MM was offered to healthcare professionals from 35 peripheral health facilities across Western Kenya in 2018 and 2019. Access to antimyeloma drugs including novel agents was secured, and pharmacovigilance systems were developed. Finally, patients were supported to obtain health insurance in addition to receiving peer support through participation in support group meetings. This article provides an implementation blueprint for similar initiatives aimed at increasing access to care for patients with MM in underserved areas.

Is the National Health Insurance Scheme helping pregnant women in accessing health services? Analysis of the 2014 Ghana demographic and Health survey

BACKGROUND

Increasing the use of healthcare is a significant step in improving health outcomes in both the short and long term. However, the degree of the relationship between utilization of health services and health outcomes is affected by the quality of the services rendered, the timeliness of treatment and follow-up care. In this study, we investigated whether the National Health Insurance Scheme (NHIS) is helping pregnant women in accessing health services in Ghana.

METHODS

Data for the study were obtained from the women's file of the 2014 Ghana Demographic and Health Survey. All women with birth history and aged 15-49  constituted our sample (n = 4271). We employed binary logistic regression analysis in investigating whether the NHIS was helping pregnant women in accessing health service. Statistical significance was set at <0.05.

RESULTS

Most women had subscribed to the NHIS [67.0%]. Of the subscribed women, 78.2% indicated that the NHIS is helping pregnant women in accessing healthcare. Women who had subscribed to the NHIS were more likely to report that it is helping pregnant women in accessing health service [aOR = 1.70, CI = 1.38-2.10]. We further noted that women who had at least four antenatal visits were more likely to indicate that NHIS is helping pregnant women in accessing health services [aOR = 3.01, CI = 2.20-4.14]. Women with secondary level of education [aOR= 1.42; CI: 1.04-1.92] and those in the richest wealth quintile [aOR = 3.51; CI = 1.94-6.34] had higher odds of indicating that NHIS is helping pregnant women in accessing healthcare. However, women aged 45-49 [aOR = 0.49; CI = 0.26-0.94], women in the Greater Accra [aOR = 0.29; CI = 0.16-0.53], Eastern [aOR = 0.12; CI = 0.07-0.21], Northern [aOR = 0.29; CI = 0.12-0.66] and Upper East [aOR = 0.17; CI = 0.09-0.31] regions had lower odds of reporting that NHIS is helping pregnant women in accessing health services.

CONCLUSION

To enhance positive perception towards the use of health services among pregnant women, non-subscribers need to be encouraged to enrol on the NHIS. Together with non-governmental organizations dedicated to maternal and child health issues, the Ghana Health Service's Maternal and Child Health Unit could strengthen efforts to educate pregnant women on the importance of NHIS in maternity care.