The “Spirit 8” successfully captured spiritual well-being in African palliative care: factor and Rasch analysis

A case study of an individual participant data meta-analysis of diagnostic accuracy showed that prediction regions represented heterogeneity well

The diagnostic accuracy of a screening tool is often characterized by its sensitivity and specificity. An analysis of these measures must consider their intrinsic correlation. In the context of an individual participant data meta-analysis, heterogeneity is one of the main components of the analysis. When using a random-effects meta-analytic model, prediction regions provide deeper insight into the effect of heterogeneity on the variability of estimated accuracy measures across the entire studied population, not just the average. This study aimed to investigate heterogeneity via prediction regions in an individual participant data meta-analysis of the sensitivity and specificity of the Patient Health Questionnaire-9 for screening to detect major depression. From the total number of studies in the pool, four dates were selected containing roughly 25%, 50%, 75% and 100% of the total number of participants. A bivariate random-effects model was fitted to studies up to and including each of these dates to jointly estimate sensitivity and specificity. Two-dimensional prediction regions were plotted in ROC-space. Subgroup analyses were carried out on sex and age, regardless of the date of the study. The dataset comprised 17,436 participants from 58 primary studies of which 2322 (13.3%) presented cases of major depression. Point estimates of sensitivity and specificity did not differ importantly as more studies were added to the model. However, correlation of the measures increased. As expected, standard errors of the logit pooled TPR and FPR consistently decreased as more studies were used, while standard deviations of the random-effects did not decrease monotonically. Subgroup analysis by sex did not reveal important contributions for observed heterogeneity; however, the shape of the prediction regions differed. Subgroup analysis by age did not reveal meaningful contributions to the heterogeneity and the prediction regions were similar in shape. Prediction intervals and regions reveal previously unseen trends in a dataset. In the context of a meta-analysis of diagnostic test accuracy, prediction regions can display the range of accuracy measures in different populations and settings.

The Meaning of Healing to Adult Patients with Advanced Cancer

BACKGROUND

This study aimed to explore the meaning of healing from the perspective of adult patients with advanced cancer.

METHODS

We conducted a secondary analysis of data from a primary study which used a cognitive interview approach to assess the face and content validity of a spiritual and psychological healing measure (NIH-HEALS). This analysis focused on responses to the question, "What does the term 'healing' mean to you?" Data were de-identified, transcribed verbatim, and imported in NVivo for thematic analysis in line with interpretive phenomenological methods.

RESULTS

Thirty-five adults with advanced cancer participated in the study. We identified nine major themes: acceptance, surrender, faith, hope, peace, freedom from suffering (e.g., pain, problems, or other bothersome factors), overcoming/transcending disease, positive emotions (e.g., happiness), recovery from illness or disease. One participant discussed healing as synonymous with death, and two associated it with social relations and social support.

CONCLUSION

Themes from patients' responses suggest subjective and varied definitions of healing which encompass physical, social, spiritual, and psychological domains of well-being, distinct from the physical cure of disease. Clinicians should adopt a holistic, person-centered approach to care, attending to bodily, psychosocial, spiritual, and emotional needs to help patients find meaning in their experiences, nourish resilience, and experience a sense of healing-as they define it.

Prevalence of Life-Limiting and Life-Threatening Illness and Associated Palliative Care Needs Among Hospital Inpatients in Sudan

CONTEXT

Evidence is needed to inform expansion of hospital-based palliative care in low and middle-income countries.

OBJECTIVES

This study aimed to measure need for palliative care among adult inpatients at five hospitals in Sudan. Objectives were to 1) measure point prevalence of life-limiting and life-threatening illness (LL/LTI); 2) determine patient insight into diagnosis and prognosis; 3) assess palliative care-related symptoms and concerns.

METHODS

In this two-day census, data were extracted from charts on documented LL/LTI for each occupied bed. For patients with LL/LTI, self-report data was collected on symptoms, concerns and understanding of diagnosis and prognosis using Integrated African Palliative Outcome Scale (IAPOS).

RESULTS

1) Prevalence of LL/LTI in general hospitals was 30.9%-70.5%. 2) n = 439 patients gave self-report data (response rate 89.8%). Mean age was 52.3 (SD 17.8), 59% of patients correctly knew their diagnosis, and 36% knew their illness was progressive. Those with a non-cancer diagnosis were significantly less likely to know their prognosis (28.4% vs 40.7% respectively, P = 0.012). 3) Family anxiety was most burdensome (56.7% scoring on the two most severe categories on a 6-point Likert), followed by pain (52.4%), poor mobility (40.5%), patient worry (39.9%), and fatigue (36.9%). Patients unaware of prognosis had higher total IAPOS scores than those aware their prognosis was progressive, 38.9 (SD = 15.6) (t = -3.297, P = 0.001, mean difference = -5.010, 95% CI: -7.997, -2.023).

CONCLUSION

Care for those with life-limiting and life-threatening illness places a significant occupancy burden on public hospitals. Communication skills are required to provide patients with insight, and core palliative care skills for acute hospital clinicians are needed to manage the high burden of symptoms and concerns.

The Process of Spiritual Care

The aim of this article is to illustrate and outline an understanding of spiritual care as a process involving a number of organically linked phases: (1) the identification of spiritual needs and resources, (2) understanding the patient's specific needs, (3) developing the individual spiritual care treatment plan, hereunder involving the relevant healthcare/spiritual care professionals, (4) the provision of spiritual care, and (5) evaluating the spiritual care provided. The focus on spiritual care in healthcare research has increased throughout the past decades, showing that existential, spiritual, and/or religious considerations and needs increase with life-threatening illness, that these needs intensify with the severity of disease and with the prospect of death. Furthermore, research has shown that spiritual care increases quality of life, but also that failing to provide spiritual care leads to increased chance of depression and lowered health conditions. The World Health Organization accordingly emphasizes that providing spiritual care is vital for enhancing quality-of-life. Looking at spiritual care as a process suggests that working within a defined conceptual framework for providing spiritual care, is a recommendable default position for any institution where spiritual care is part of the daily work and routines. This so, especially because looking at spiritual care as a process highlights that moving from identifying spiritual needs in a patient to the actual provision of spiritual care, involves deliberate and considered actions and interventions that take into account the specific cultural and ontological grounding of the patient as well as the appropriate persons to provide the spiritual care. By presenting spiritual care as a process, we hope to inspire and to contribute to the international development of spiritual care, by enabling sharing experiences and best-practices internationally and cross-culturally. This so to better approach the practical and daily dimensions of spiritual care, to better address and consider the individual patient's specific spiritual needs, be they secular, spiritual and/or religious. In the final instance, spiritual care has only one ambition; to help the individual human being through crisis.

Understanding data and information needs for palliative cancer care to inform digital health intervention development in Nigeria, Uganda and Zimbabwe: protocol for a multicountry qualitative study

INTRODUCTION

Palliative care is a clinically and cost-effective component of cancer services in sub-Saharan Africa (SSA). Despite the significant need for palliative cancer care in SSA, coverage remains inadequate. The exploration of digital health approaches could support increases in the quality and reach of palliative cancer care services in SSA. However, there is currently a lack of any theoretical underpinning or data to understand stakeholder drivers for digital health components in this context. This project addresses this gap through engaging with key stakeholders to determine data and information needs that could be supported through digital health interventions.

METHODS AND ANALYSIS

This is a multicountry, cross-sectional, qualitative study conducted in Nigeria, Uganda and Zimbabwe. In-depth interviews will be conducted in patients with advanced cancer (n=20), caregivers (n=15), health professionals (n=20) and policy-makers (n=10) in each of the three participating countries. Data from a total of 195 interviews will transcribed verbatim and translated into English before being imported into NVivo software for deductive framework analysis. The analysis will seek to understand the acceptability and define mechanisms of patient-level data capture and usage via digital technologies.

ETHICS AND DISSEMINATION

Ethics approvals have been obtained from the Institutional Review Boards of University of Leeds (Ref: MREC 18-032), Research Council of Zimbabwe (Ref: 03507), Medical Research Council of Zimbabwe (Ref: MRCZ/A/2421), Uganda Cancer Institute (Ref: 19-2018), Uganda National Council of Science and Technology (Ref: HS325ES) and College of Medicine University of Lagos (Ref: HREC/15/04/2015). The project seeks to determine optimal mechanisms for the design and development of subsequent digital health interventions to support development, access to, and delivery of palliative cancer care in SSA. Dissemination of these findings will occur through newsletters and press releases, conference presentations, peer-reviewed journals and social media.

TRIAL REGISTRATION NUMBER

ISRCTN15727711.

Palliative care as an essential component of the HIV care continuum

Although antiretroviral therapy has reduced mortality among people with HIV, inadequate treatment coverage, ageing, and the increasing incidence of organ failure and malignancies mean that high-quality care should include care at the end of life. This Review summarises the epidemiology of HIV in relation to mortality, and the symptoms and concerns of people with AIDS and those living with HIV who have either related or unrelated advanced comorbidities. In response to the evidence of a need for palliative care, the principles and practice of palliative care are described, and the evidence for its effectiveness and cost-effectiveness is appraised. The core practices of palliative care offer a mechanism to enhance the person-centred nature of HIV care; I identify the gaps in this type of care, and present evidence for effective models of care to address these. I detail the policies that prompt governments and health systems to respond to the palliative care needs of their population. Finally, I conclude this Review with evidence-based recommendations to improve the delivery of, and access to, high-quality HIV care until the end of life, reducing unnecessary suffering while optimising person-centred outcomes.

Patients' and caregivers' needs, experiences, preferences and research priorities in spiritual care: A focus group study across nine countries

BACKGROUND

Spiritual distress is prevalent in advanced disease, but often neglected, resulting in unnecessary suffering. Evidence to inform spiritual care practices in palliative care is limited.

AIM

To explore spiritual care needs, experiences, preferences and research priorities in an international sample of patients with life-limiting disease and family caregivers.

DESIGN

Focus group study.

SETTING/PARTICIPANTS

Separate patient and caregiver focus groups were conducted at 11 sites in South Africa, Kenya, South Korea, the United States, Canada, the United Kingdom, Belgium, Finland and Poland. Discussions were transcribed, translated into English and analysed thematically.

RESULTS

A total of 74 patients participated: median age 62 years; 53 had cancer; 48 were women. In total, 71 caregivers participated: median age 61 years; 56 were women. Two-thirds of participants were Christian. Five themes are described: patients' and caregivers' spiritual concerns, understanding of spirituality and its role in illness, views and experiences of spiritual care, preferences regarding spiritual care, and research priorities. Participants reported wide-ranging spiritual concerns spanning existential, psychological, religious and social domains. Spirituality supported coping, but could also result in framing illness as punishment. Participants emphasised the need for staff competence in spiritual care. Spiritual care was reportedly lacking, primarily due to staff members' de-prioritisation and lack of time. Patients' research priorities included understanding the qualities of human connectedness and fostering these skills in staff. Caregivers' priorities included staff training, assessment, studying impact, and caregiver's spiritual care needs.

CONCLUSION

To meet patient and caregiver preferences, healthcare providers should be able to address their spiritual concerns. Findings should inform patient- and caregiver-centred spiritual care provision, education and research.

Exploring urban health in Cape Town, South Africa: an interdisciplinary analysis of secondary data

BACKGROUND

With modern information technology, an overwhelming amount of data is available on different aspects of societies. Our research investigated the feasibility of using secondary data sources to get an overview of determinants of health and health outcomes in different population strata of Cape Town, a large city of South Africa.

METHODS

The methodological approach of secondary-data analysis was similar in the different disciplines: Biological Anthropology, Public Health, Environmental Health, Mental Health, Palliative Care, Medical Psychology and Sociology at the University of Freiburg and Public Health at the University of Cape Town. The teams collected information on Cape Town through Internet searches and published articles. The information was extracted, analyzed, condensed, and jointly interpreted.

RESULTS

Data show the typical picture of a population in epidemiological and demographic transition exposed to often difficult social, mental, and physical environmental conditions. Comparison between low and higher socioeconomic districts demonstrated that the former had higher air pollution, poorer water quality, and deficient sanitary conditions in addition to sub-optimal mental health services and palliative care.

CONCLUSION

Although important information gaps were identified, the data draw attention to critical public health interventions required in poor health districts, and to motivate for pro-equity policies.

Cervical cancer prevention and treatment research in Africa: a systematic review from a public health perspective

BACKGROUND

Women living in Africa experience the highest burden of cervical cancer. Research and investment to improve vaccination, screening, and treatment efforts are critically needed. We systematically reviewed and characterized recent research within a broader public health framework to organize and assess the range of cervical cancer research in Africa.

METHODS

We searched online databases and the Internet for published articles and cervical cancer reports in African countries. Inclusion criteria included publication between 2004 and 2014, cervical cancer-related content pertinent to one of the four public health categories (primary, secondary, tertiary prevention or quality of life), and conducted in or specifically relevant to countries or regions within the African continent. The study design, geographic region/country, focus of research, and key findings were documented for each eligible article and summarized to illustrate the weight and research coverage in each area. Publications with more than one focus (e.g. secondary and tertiary prevention) were categorized by the primary emphasis of the paper. Research specific to HIV-infected women or focused on feasibility issues was delineated within each of the four public health categories.

RESULTS

A total of 380 research articles/reports were included. The majority (54.6 %) of cervical cancer research in Africa focused on secondary prevention (i.e., screening). The number of publication focusing on primary prevention (23.4 %), particularly HPV vaccination, increased significantly in the past decade. Research regarding the treatment of precancerous lesions and invasive cervical cancer is emerging (17.6 %), but infrastructure and feasibility challenges in many countries have impeded efforts to provide and evaluate treatment. Studies assessing aspects of quality of life among women living with cervical cancer are severely limited (4.1 %). Across all categories, 11.3 % of publications focused on cervical cancer among HIV-infected women, while 17.1 % focused on aspects of feasibility for cervical cancer control efforts.

CONCLUSIONS

Cervical cancer research in African countries has increased steadily over the past decade, but more is needed. Tertiary prevention (i.e. treatment of disease with effective medicine) and quality of life of cervical cancer survivors are two severely under-researched areas. Similarly, there are several countries in Africa with little to no research ever conducted on cervical cancer.

Assessment of spiritual suffering in the cancer context: A systematic literature review

OBJECTIVE

An important goal of cancer medicine is relief of patients' suffering. In view of the clinical challenges of identifying suffering patients, we sought to identify valid instruments for assessing the spiritual suffering of people diagnosed with cancer.

METHOD

A systematic review of the literature was conducted in the Medline, Embase, the Cochrane Library, and PsycINFO databases seeking assessment instruments that measure either suffering or one of its synonyms or symptoms. The psychometric properties of the identified measures were compared.

RESULTS

A total of 90 articles were identified that supplied information about 58 measures. The constructs examined were: suffering, hopelessness/demoralization, hope, meaning, spiritual well-being, quality of life where a spiritual/existential dimension was included, distress in the palliative care setting and pain, distress or struggle of a spiritual nature. The Pictorial Representation of Illness and Self Measure (PRISM) (patient completed) was the most promising measure identified for measuring the burden of suffering caused by illness due to its ease of use and the inclusion of a subjective component.

SIGNIFICANCE OF RESULTS

Although the appropriateness of any measure for the assessment of spiritual suffering in cancer patients will depend on the context in which it is intended to be utilized, the PRISM is promising for measuring the burden of suffering due to illness.

A psychometric evaluation of the functional assessment of chronic illness therapy-palliative care (FACIT-Pal) scale with palliative care samples in three African countries

CONTEXT

Although sub-Saharan Africa suffers the greatest burden of progressive illness, there are few outcome measures with adequate properties to measure needs and outcomes.

OBJECTIVES

To examine the psychometric properties of the Functional Assessment of Chronic Illness Therapy-Palliative Care (FACIT-Pal) among people receiving palliative care in three African countries.

METHODS

Adult patients in South Africa, Kenya, and Uganda gave self-reported data to the core FACIT-G plus Pal subscale. Data were subjected to factor analysis, corrected item-total correlations, and Cronbach's α for full scale and subscales.

RESULTS

The resulting four factors bear a strong similarity to the original Functional Assessment of Cancer Therapy-General in our sample of 461: physical symptoms, functional well-being, friends and family, and emotional well-being. Cronbach's α for the full 27-item scale was 0.90 and for the physical well-being, social/family well-being, emotional well-being, and functional well-being subscales, it was 0.83, 0.78, 0.80, and 0.87, respectively. Varimax rotation of the 19-item FACIT-Pal scale showed three clear interpretable factors. Factor 1, a sense of purpose and meaning in life; Factor 2, physical symptoms; and Factor 3, social integration. For the 19-item FACIT-Pal, Cronbach's α was 0.81, and individual corrected item-total correlations ranged from 0.24 to 0.61. Cronbach's α for the eight items comprising Factor 1 (meaning in life) was 0.83. For the other two factors, it was 0.70 (physical symptoms, six items) and 0.68 (social integration, three items).

CONCLUSION

The FACIT-Pal is a reliable multidimensional scale for people with life-limiting incurable diseases in sub-Saharan Africa, and the observed factors are interpretable and clinically meaningful.

Palliative care-related self-report problems among cancer patients in East Africa: a two-country study

PURPOSE

Palliative care-related problems have not been measured in Africa in line with the WHO definition. This study aimed to measure the three-day period intensity of multidimensional problems (physical, psychological, social, and spiritual) among advanced cancer patients in Kenya and Uganda.

METHODS

Adults with advanced malignant disease gave self-report data to the African Palliative Outcome Scale (POS).

RESULTS

Among 210 respondents, more than half had an underlying HIV diagnosis (51.9 %). The worst ranked POS items were pain and information. In three multivariable ordinal logistic regression models with the 3 POS factors as dependent variables, for the first model (factor 1 physical and psychological well-being), as age increased, the well-being also improved (B = 0.022, p = 0.037), and as physical function score worsened, factor score also worsened (B = -0.685, p < 0.001). In the second model (factor 2 interpersonal well-being), a trend toward significance was found for gender, with being male predicting a higher (better) factor score (B = 0.502, p = 0.067). For the third model (factor 3 existential and spiritual), increasing age was predictive of higher (better) factor score (B = 0.023, p = 0.032), and worsening function was predictive of lower (worse) factor score (B = -0.543, p < 0.001).

CONCLUSIONS

This novel data revealed pain and information to plan for the future to affect patients most severely, underlining the importance of analgesia and social support. HIV infection did not affect the level of need. Our data suggest increasing need as function declines; therefore, home-based models with adequate family support are essential.

Spirituality and religion among HIV-infected individuals

Spirituality and religion are important to many people living with HIV (PLWH). Recent research has focused on special populations (ethnic-minorities, women, and youth), spirituality/religion measurement, mediating/moderating mechanisms, and individual and community-level interventions. Spirituality/religion in PLWH has been refined as a multidimensional phenomenon, which improves health/quality of life directly and through mediating factors (healthy behaviors, optimism, social support). Spirituality/religion helps people to cope with stressors, especially stigma/discrimination. Spiritual interventions utilizing the power of prayer and meditation and addressing spiritual struggle are under way. Faith-based community interventions have focused on stigma and could improve individual outcomes through access to spiritual/social support and care/treatment for PLWA. Community engagement is necessary to design/implement effective and sustainable programs. Future efforts should focus on vulnerable populations; utilize state-of-the-art methods (randomized clinical trials, community-based participatory research); and, address population-specific interventions at individual and community levels. Clinical and policy implications across geographic settings also need attention.

A hospital-based palliative care service for patients with advanced organ failure in sub-Saharan Africa reduces admissions and increases home death rates

CONTEXT

Despite emerging data of cost savings under palliative care in various regions, no such data have been generated in response to the high burden of terminal illness in Africa.

OBJECTIVES

This evaluation of a novel hospital-based palliative care service for patients with advanced organ failure in urban South Africa aimed to determine whether the service reduces admissions and increases home death rates compared with the same fixed time period of standard hospital care.

METHODS

Data on admissions and place of death were extracted from routine hospital activity records for a fixed period before death, using standard patient daily expense rates. Data from the first 56 consecutive deaths under the new service (intervention group) were compared with 48 consecutive deaths among patients immediately before the new service (historical controls).

RESULTS

Among the intervention and control patients, 40 of 56 (71.4%) and 47 of 48 (97.9%), respectively, had at least one admission (P < 0.001). The mean number of admissions for the intervention and control groups was 1.39 and 1.98, respectively (P < 0.001). The mean total number of days spent admitted for intervention and control groups was 4.52 and 9.3 days, respectively (P < 0.001). For the intervention and control patients, a total of 253 and 447 admission days were recorded, respectively, with formal costs of $587 and $1209, respectively. For the intervention and control groups, home death was achieved by 33 of 56 (58.9%) and nine of 48 (18.8%), respectively (P ≤ 0.001).

CONCLUSION

These data demonstrate that an outpatient hospital-based service reduced admissions and improved the rate of home deaths and offers a feasible and cost-effective model for such settings.

'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.

Traditional healers' views of the required processes for a "good death" among Xhosa patients pre- and post-death

CONTEXT

South Africa faces enormous HIV-related mortality and increasing cancer incidence. Traditional healers are the preferred source of advice and care in Africa, and this is true for the large Xhosa ethnic group.

OBJECTIVES

To provide more appropriate multidimensional, culturally suitable care at the end of life; this study aimed to identify the care needs and cultural practices of Xhosa patients and families at the end of life, from the perspective of traditional healers.

METHODS

The study design was qualitative and cross-sectional. The research took place in a 300 km radius around East London, Eastern Cape, South Africa. Interviewees were Xhosa individuals who were recognized by their communities as traditional healers. Data from two focus groups and eight individual interviews were analyzed, using an inductive thematic approach.

RESULTS

Data were elicited around the facilitation of a good death in terms of care needs before death and important rituals after death. Care needs before death focused on relief of psychosocial suffering; the importance of the spoken word at the deathbed; and the importance of a relationship and spiritual connection at the end of life. There were broad similarities across the rituals described after death, but these rituals were recognized to differ according to family customs or the dying person's wishes.

CONCLUSION

Awareness of potential needs at the end of life can assist clinicians to understand the choices of their patients and develop effective end-of-life care plans that improve the outcomes for patients and families.

'Peace' and 'life worthwhile' as measures of spiritual well-being in African palliative care: a mixed-methods study

Background

Patients with incurable, progressive disease receiving palliative care in sub-Saharan Africa experience high levels of spiritual distress with a detrimental impact on their quality of life. Locally validated measurement tools are needed to identify patients’ spiritual needs and evaluate and improve spiritual care, but up to now such tools have been lacking in Africa. The African Palliative Care Association (APCA) African Palliative Outcome Scale (POS) contains two items relating to peace and life worthwhile. We aimed to determine the content and construct validity of these items as measures of spiritual wellbeing in African palliative care populations.

Methods

The study was conducted at five palliative care services, four in South Africa and one in Uganda. The mixed-methods study design involved: (1) cognitive interviews with 72 patients, analysed thematically to explore the items’ content validity, and (2) quantitative data collection (n = 285 patients) using the POS and the Spirit 8 to assess construct validity.

Results

(1) Peace was interpreted according to the themes ‘perception of self and world’, ‘relationship to others’, ‘spiritual beliefs’ and ‘health and healthcare’. Life worthwhile was interpreted in relation to ‘perception of self and world’, ‘relationship to others’ and ‘identity’. (2) Conceptual convergence and divergence were also evident in the quantitative data: there was moderate correlation between peace and Spirit 8 spiritual well-being (r = 0.46), but little correlation between life worthwhile and Spirit 8 spiritual well-being (r = 0.18) (both p < 0.001). Correlations with Spirit 8 items were weak to moderate.

Conclusions

Findings demonstrate the utility of POS items peace and life worthwhile as distinct but related measures of spiritual well-being in African palliative care. Peace and life worthwhile are brief and simple enough to be integrated into routine practice and can be used to measure this important but neglected outcome in this population.