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Yao JS, Kibu OD, Asahngwa C, Ngo NV, Ngwa W, Jasmin HM, Gobina RM, Foretia DA. A scoping review on the availability and utilization of essential opioid analgesics in Sub-Saharan Africa. Am J Surg 2023; 226:409-421. [PMID: 37024407 DOI: 10.1016/j.amjsurg.2023.03.013] [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: 02/01/2023] [Revised: 03/08/2023] [Accepted: 03/13/2023] [Indexed: 03/28/2023]
Abstract
BACKGROUND Management of acute, post-operative, and chronic pain requires access to and availability of opioids. While often oversupplied in high-income countries, significant shortages exist in low- and middle-income countries. We conducted a scoping review on availability and usage of opioids in Sub-Saharan Africa (SSA). METHODS The five-stage approach of Arksey and O'Malley (2005) was used. MEDLINE via PubMed, EMBASE, and SCOPUS were search and results categorized into themes: 1) Local/regional availability and supply, 2) Consumption patterns, 3) Legislation and policy, 4) Costs and financing, 5) Knowledge and cultural beliefs, and 6) Education and training. RESULTS 6923 studies were identified from which 69 (1%) met inclusion criteria. Five key findings were: 1) Significant shortages exist, especially in rural areas, 2) Non-opioid analgesics commonly used as first-line acute pain management, 3) Barriers to market entry and bureaucratic processes prevent local production, 4) Significant knowledge gaps/myths exist amongst healthcare practitioners on opioid use, and 5) Continuous education and short courses will be critical. CONCLUSIONS Major challenges significantly limit availability and utilization of essential opioids in SSA. Reforms needed to upscale training and education, increase uptake by professionals, and increase market entry.
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Affiliation(s)
- Jane S Yao
- College of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Odette D Kibu
- Division of Health Policy and Research, Nkafu Policy Institute, Yaoundé, Cameroon; Department of Public Health, University of Buea, Cameroon; Faculty of Health Science, University of Buea, Cameroon
| | - Constantine Asahngwa
- Division of Health Policy and Research, Nkafu Policy Institute, Yaoundé, Cameroon; Department of Anthropology, University of Yaoundé 1, Yaoundé, Cameroon
| | - Ngo V Ngo
- Division of Health Policy and Research, Nkafu Policy Institute, Yaoundé, Cameroon
| | - Wilfred Ngwa
- Division of Health Policy and Research, Nkafu Policy Institute, Yaoundé, Cameroon
| | - Hilary M Jasmin
- Health Science Library, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Ronald M Gobina
- Division of Health Policy and Research, Nkafu Policy Institute, Yaoundé, Cameroon; Health Science Library, University of Tennessee Health Science Center, Memphis, TN, USA; Buea Regional Hospital, Buea, Cameroon
| | - Denis A Foretia
- Division of Health Policy and Research, Nkafu Policy Institute, Yaoundé, Cameroon; Center for Multicultural and Global Health, University of Tennessee Health Science Center, Memphis, TN, USA; Global Surgery Institute, University of Tennessee Health Science Center, Memphis, TN, USA; Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA.
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Gafer N, Marhoom M, Siddig S, Ali H, Mursi M, Harðardóttir D, Harding R. Prevalence of Life-Limiting and Life-Threatening Illness and Associated Palliative Care Needs Among Hospital Inpatients in Sudan. J Pain Symptom Manage 2022; 63:124-130. [PMID: 34256089 DOI: 10.1016/j.jpainsymman.2021.07.001] [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: 04/15/2021] [Revised: 06/30/2021] [Accepted: 07/07/2021] [Indexed: 11/24/2022]
Abstract
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.
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Affiliation(s)
- Nahla Gafer
- Khartoum Oncology Hospital (N.G., S.S.), Sudan
| | | | | | - Halima Ali
- National Cancer Institute (H.A.), Wad Madani, Sudan
| | | | - Daney Harðardóttir
- Florence Nightingale Faculty of Nursing Midwifery and Palliative Care (D.H., R.H.), King's College London, Cicely Saunders Institute, UK.
| | - Richard Harding
- Florence Nightingale Faculty of Nursing Midwifery and Palliative Care (D.H., R.H.), King's College London, Cicely Saunders Institute, UK
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Ayede AI. Neonatal pain management in sub-Saharan Africa. THE LANCET CHILD & ADOLESCENT HEALTH 2020; 4:713-714. [PMID: 32735784 DOI: 10.1016/s2352-4642(20)30244-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 07/20/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Adejumoke Idowu Ayede
- Department of Paediatrics, College of Medicine, University of Ibadan and University College Hospital, Ibadan, Nigeria.
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Ahmed A, Afshan G, Irshad Khan R, Afzal B, Jamali S, Farooq N, Saleem S, Naeem R, Khan U. Managing acute pain in HIV+/AIDS patients: knowledge and practice trends among emergency physicians of major tertiary care centers of a developing country. BMC Res Notes 2020; 13:255. [PMID: 32456673 PMCID: PMC7249315 DOI: 10.1186/s13104-020-05095-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 05/18/2020] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE To assess knowledge and practice trends in managing acute pain in patients infected with human immunodeficiency virus (HIV+) or having acquired immunodeficiency syndrome (AIDS) among emergency physicians of four tertiary care hospitals. Acute pain management in such patients is complex because of multiple concomitant painful conditions related to their disease. After obtaining ethical approval and written informed consent, emergency physicians were requested to fill out a questionnaire. RESULTS Out of 84 physicians who participated, 49 had managed HIV+/AIDS patients during the preceding year. Out of the 49, 30 (61.2%) physicians stated that they used a combination of analgesics for acute pain in these patients. Forty-two (50%) out of the 84 participants believed that routine doses of opioids were adequate for pain relief, while 42 (50%) agreed that pain management was more complex in these patients mainly due to presence of multiple coexisting problems and psychological issues. Only 26 (31%) respondents considered that pain was under-reported and under-treated in these patients, mainly because physicians were more focused on patients' other disease related complications and issues. Formulation of guidelines are recommended for effective acute pain management in these patients encompassing associated issues, including concomitant painful conditions, opioid dependence, psychiatric problems, etc.
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Affiliation(s)
- Aliya Ahmed
- Department of Anaesthesiology, 2nd-Floor Private Wing, Aga Khan University, Stadium Road, P.O. Box 3500, Karachi, 74800, Pakistan.
| | - Gauhar Afshan
- Department of Anaesthesiology, 2nd-Floor Private Wing, Aga Khan University, Stadium Road, P.O. Box 3500, Karachi, 74800, Pakistan
| | - Robyna Irshad Khan
- Department of Anaesthesiology, 2nd-Floor Private Wing, Aga Khan University, Stadium Road, P.O. Box 3500, Karachi, 74800, Pakistan
| | - Badar Afzal
- Department of Emergency Medicine, Aga Khan University, Karachi, Pakistan
| | - Seemin Jamali
- Accident and Emergency Department, Jinnah Postgraduate Medical Centre, Karachi, Pakistan
| | - Nighat Farooq
- Accident and Emergency Department, Civil Hospital Karachi, Karachi, Pakistan
| | - Sarosh Saleem
- Paediatrics Department, Indus Hospital, Karachi, Pakistan
| | - Rubaba Naeem
- Department of Emergency Medicine, Aga Khan University, Karachi, Pakistan
| | - Uzma Khan
- Department of Emergency Medicine, Aga Khan University, Karachi, Pakistan
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Zeru T, Gerensea H, Berihu H, Zeru M, Wubayehu T. Nurses practice towards palliative care in Shire Endasilasie health facilities, Northern Ethiopia: a cross-sectional study. Pan Afr Med J 2020; 35:110. [PMID: 32637008 PMCID: PMC7321685 DOI: 10.11604/pamj.2020.35.110.18648] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2019] [Accepted: 09/11/2019] [Indexed: 12/17/2022] Open
Abstract
Introduction The public health strategy of the World Health Organization for palliative care is to increase access to palliative care services by integrating it with the healthcare systems. Therefore, the value of palliative care service provision by nurses who deliver the majority of care to chronical patients is an important issue. The objective of the study is assessing nurses' practice of palliative care. Methods A facility based cross-sectional study was carried out among 278 nurses working in governmental health facilities of Shire Endasilasie town, Tigray region, Ethiopia from February to June 2018. The questionnaire was revised based on the findings of the pre-test. The collected data was checked for its completeness, consistency, and accuracy before analysis. Data were entered and analyzed using SPSS version 22. The final result was reported using text and tables. Results A total of 278 nurses were included in the study and the response rate was 100%. The majority of the participants (71.9%) were females and the mean age of the respondents was 32.08 years (range from 20 to 60). Approximately two-thirds (74.8%) of the respondents had poor knowledge of palliative care practice. Half of the study participants reported emotional support gained as primary psychological support. Commonly used drugs for severe pain were paracetamol or ibuprofen 202 (72.2%) and 47.8% nurses focus on quality patient pain assess. Conclusion The majority of the nurses had a poor practice of palliative care.
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Affiliation(s)
- Teklay Zeru
- Department of Pediatric Nursing, School of Nursing, College of Health Science and Comprehensive Specialized Hospital, Aksum University, Tigray, Ethiopia
| | - Hadgu Gerensea
- Department of Pediatric Nursing, School of Nursing, College of Health Science and Comprehensive Specialized Hospital, Aksum University, Tigray, Ethiopia
| | - Hagos Berihu
- Department of Maternity and Reproductive Health, School of Nursing, College of Health Science and Comprehensive Specialized Hospital, Aksum University, Tigray, Ethiopia
| | - Mebrahtom Zeru
- Department of Biomedical Science, College of Health Sciences, Adigrat University, Adigrat, Tigray, Ethiopia
| | - Tewolde Wubayehu
- Department of Pediatrics, School of Medicine, College of Health Science and Comprehensive Specialized Hospital, Aksum University, Tigray, Ethiopia
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Ooms GI, Klatser P, van den Ham HA, Reed T. Barriers to Accessing Internationally Controlled Essential Medicines in Uganda: A Qualitative Study. J Pain Symptom Manage 2019; 58:835-843.e1. [PMID: 31302261 DOI: 10.1016/j.jpainsymman.2019.07.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 06/28/2019] [Accepted: 07/03/2019] [Indexed: 10/26/2022]
Abstract
CONTEXT Access to internationally controlled essential medicines is a problem worldwide. More than five billion people cannot access opioids for pain and palliative care or do not have access to surgical care or anesthetics, 25 million people living with epilepsy do not have access to their medicines, and 120,000 women die annually owing to postpartum hemorrhage. In Uganda, access to controlled medicines is also problematic, but a lack of data on factors that influence access exists. OBJECTIVES The objective of this study was to identify the social, cultural, and regulatory barriers that influence access to internationally controlled essential medicines in Uganda. METHODS Semistructured interviews with 15 key stakeholders with knowledge on controlled medicines from relevant institutions in Uganda. Interviews were transcribed verbatim and analyzed using the Access to Medicines from a Health System Perspective framework. RESULTS Barriers in accessing controlled medicines were experienced owing to lack of prioritization, difficulties in finding the balance between access and control, deficiencies in the workings of the estimate and distribution system, lack of knowledge, inadequate human resources, expenses related to use and access, and stigma. It was believed that some abuse of specific controlled medicines occurred. CONCLUSION The findings of this research indicate that to improve access to internationally controlled essential medicines in Uganda, health system strengthening is needed on multiple fronts. Active engagement and concerted efforts are needed from all stakeholders to ensure access and prevent abuse.
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Affiliation(s)
- Gaby Isabelle Ooms
- Health Action International, Amsterdam, The Netherlands; WHO Collaborating Centre for Pharmaceutical Policy and Regulation, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, The Netherlands.
| | | | - Hendrika A van den Ham
- WHO Collaborating Centre for Pharmaceutical Policy and Regulation, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, The Netherlands
| | - Tim Reed
- Health Action International, Amsterdam, The Netherlands
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Abstract
INTRODUCTION Palliative care coverage and opioid consumption in India are relatively low compared with global data. The literature suggests commonplace concealment and collusion in withholding information, but these hypotheses lack evidence. OBJECTIVES This study aimed to develop an explanatory evidence-based model of stigma, communication and access to cancer palliative care in India that can be used to develop, test and implement future interventions. DESIGN This cross-sectional qualitative study sampled advanced cancer patients (n=10), their family caregivers (n=10) and oncologists (n=10). Grounded theory procedures were utilised to analyse transcripts, and a theoretical model generated. SETTING A tertiary teaching hospital in South India. RESULTS The model explains how stigma associated with communicating a diagnosis of advanced cancer is enacted by treating oncologists, family members and community. This leads to patient expectations of cure and futile treatment uptake. Patients commonly only present needs with respect to pain, not within psychological, social or spiritual domains, likely due to the lack of patients' insight into their diagnosis and prognosis. As a result of oncologists' and families' unwillingness to disclose the prognosis, and patient focus on pain due to their lack of insight, palliative care clinicians view their services as under-utilised, and patients perceive palliative care as a pain management service that is not 'different' from other clinical services. Advanced care needs and purchase of futile treatments lead to lost employment among families, increased family debt and high care costs, which are rarely disclosed due to their unwillingness to discuss their needs. CONCLUSION Our novel theoretical model is an essential first step to ensure that complex interventions are plausible, with mechanisms of action that address the needs of relevant stakeholders. A family-centred approach with an oncology workforce skilled in communication and an enabled patient population could increase access to palliative care, and improved outcomes may be attainable.
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Affiliation(s)
- Richard Harding
- Florence Nightingale Faculty of Nursing Midwifery and Palliative Care, Department of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
- Department of Pain and Palliative Medicine, St John's Medical College Hospital, Bangalore, Karnataka, India
| | - Shoba Nair
- Department of Pain and Palliative Medicine, St John's Medical College Hospital, Bangalore, Karnataka, India
| | - Maria Ekstrand
- Division of Prevention Science- Department of Medicine, University of California San Francisco, San Franscisco, California, USA
- St John's Research Institute, Bangalore, Karnataka, India
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EVANS CATHERINEJ, ISON LUCY, ELLIS‐SMITH CLARE, NICHOLSON CAROLINE, COSTA ALESSIA, OLUYASE ADEJOKEO, NAMISANGO EVE, BONE ANNAE, BRIGHTON LISAJANE, YI DEOKHEE, COMBES SARAH, BAJWAH SABRINA, GAO WEI, HARDING RICHARD, ONG PAUL, HIGGINSON IRENEJ, MADDOCKS MATTHEW. Service Delivery Models to Maximize Quality of Life for Older People at the End of Life: A Rapid Review. Milbank Q 2019; 97:113-175. [PMID: 30883956 PMCID: PMC6422603 DOI: 10.1111/1468-0009.12373] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Policy Points We identified two overarching classifications of integrated geriatric and palliative care to maximize older people's quality of life at the end of life. Both are oriented to person-centered care, but with differing emphasis on either function or symptoms and concerns. Policymakers should both improve access to palliative care beyond just the last months of life and increase geriatric care provision to maintain and optimize function. This would ensure that continuity and coordination for potentially complex care needs across the continuum of late life would be maintained, where the demarcation of boundaries between healthy aging and healthy dying become increasingly blurred. Our findings highlight the urgent need for health system change to improve end-of-life care as part of universal health coverage. The use of health services should be informed by the likelihood of benefits and intended outcomes rather than on prognosis. CONTEXT In an era of unprecedented global aging, a key priority is to align health and social services for older populations in order to support the dual priorities of living well while adapting to a gradual decline in function. We aimed to provide a comprehensive synthesis of evidence regarding service delivery models that optimize the quality of life (QoL) for older people at the end of life across health, social, and welfare services worldwide. METHODS We conducted a rapid scoping review of systematic reviews. We searched MEDLINE, CINAHL, EMBASE, and CDSR databases from 2000 to 2017 for reviews reporting the effectiveness of service models aimed at optimizing QoL for older people, more than 50% of whom were older than 60 and in the last one or two years of life. We assessed the quality of these included reviews using AMSTAR and synthesized the findings narratively. RESULTS Of the 2,238 reviews identified, we included 72, with 20 reporting meta-analysis. Although all the World Health Organization (WHO) regions were represented, most of the reviews reported data from the Americas (52 of 72), Europe (46 of 72), and/or the Western Pacific (28 of 72). We identified two overarching classifications of service models but with different target outcomes: Integrated Geriatric Care, emphasizing physical function, and Integrated Palliative Care, focusing mainly on symptoms and concerns. Areas of synergy across the overarching classifications included person-centered care, education, and a multiprofessional workforce. The reviews assessed 117 separate outcomes. A meta-analysis demonstrated effectiveness for both classifications on QoL, including symptoms such as pain, depression, and psychological well-being. Economic analysis and its implications were poorly considered. CONCLUSIONS Despite their different target outcomes, those service models classified as Integrated Geriatric Care or Integrated Palliative Care were effective in improving QoL for older people nearing the end of life. Both approaches highlight the imperative for integrating services across the care continuum, with service involvement triggered by the patient's needs and likelihood of benefits. To inform the sustainability of health system change we encourage economic analyses that span health and social care and examine all sources of finance to understand contextual inequalities.
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Affiliation(s)
- CATHERINE J. EVANS
- King's College London, Cicely Saunders Institute of Palliative CarePolicy and Rehabilitation
- Sussex Community NHS Foundation TrustBrighton General Hospital
| | - LUCY ISON
- King's College London, Cicely Saunders Institute of Palliative CarePolicy and Rehabilitation
| | - CLARE ELLIS‐SMITH
- King's College London, Cicely Saunders Institute of Palliative CarePolicy and Rehabilitation
| | - CAROLINE NICHOLSON
- King's College London, Florence Nightingale Faculty of NursingMidwifery & Palliative Care
- St Christopher's Hospice
| | - ALESSIA COSTA
- King's College London, Florence Nightingale Faculty of NursingMidwifery & Palliative Care
| | - ADEJOKE O. OLUYASE
- King's College London, Cicely Saunders Institute of Palliative CarePolicy and Rehabilitation
| | - EVE NAMISANGO
- King's College London, Cicely Saunders Institute of Palliative CarePolicy and Rehabilitation
| | - ANNA E. BONE
- King's College London, Cicely Saunders Institute of Palliative CarePolicy and Rehabilitation
| | - LISA JANE BRIGHTON
- King's College London, Cicely Saunders Institute of Palliative CarePolicy and Rehabilitation
| | - DEOKHEE YI
- King's College London, Cicely Saunders Institute of Palliative CarePolicy and Rehabilitation
| | - SARAH COMBES
- King's College London, Florence Nightingale Faculty of NursingMidwifery & Palliative Care
| | - SABRINA BAJWAH
- King's College London, Cicely Saunders Institute of Palliative CarePolicy and Rehabilitation
| | - WEI GAO
- King's College London, Cicely Saunders Institute of Palliative CarePolicy and Rehabilitation
| | - RICHARD HARDING
- King's College London, Cicely Saunders Institute of Palliative CarePolicy and Rehabilitation
| | - PAUL ONG
- World Health Organisation Centre for Health Development
| | - IRENE J. HIGGINSON
- King's College London, Cicely Saunders Institute of Palliative CarePolicy and Rehabilitation
| | - MATTHEW MADDOCKS
- King's College London, Cicely Saunders Institute of Palliative CarePolicy and Rehabilitation
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Nkhoma K, Norton C, Sabin C, Winston A, Merlin J, Harding R. Self-management Interventions for Pain and Physical Symptoms Among People Living With HIV: A Systematic Review of the Evidence. J Acquir Immune Defic Syndr 2018; 79:206-225. [DOI: 10.1097/qai.0000000000001785] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Harding R. Palliative care as an essential component of the HIV care continuum. Lancet HIV 2018; 5:e524-e530. [PMID: 30025682 DOI: 10.1016/s2352-3018(18)30110-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 05/11/2018] [Accepted: 05/17/2018] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Richard Harding
- Department of Palliative Care, Policy, and Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery, and Palliative Care, Cicely Saunders Institute, King's College London, London, UK.
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Namisango E, Allsop MJ, Powell RA, Friedrichsdorf SJ, Luyirika EBK, Kiyange F, Mukooza E, Ntege C, Garanganga E, Ginindza-Mdluli MN, Mwangi-Powell F, Mondlane LJ, Harding R. Investigation of the Practices, Legislation, Supply Chain, and Regulation of Opioids for Clinical Pain Management in Southern Africa: A Multi-sectoral, Cross-National, Mixed Methods Study. J Pain Symptom Manage 2018; 55:851-863. [PMID: 29155288 DOI: 10.1016/j.jpainsymman.2017.11.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Revised: 11/07/2017] [Accepted: 11/07/2017] [Indexed: 11/23/2022]
Abstract
CONTEXT Sub-Saharan Africa faces an increasing incidence and prevalence of life-limiting and life-threatening conditions. These conditions are associated with a significant burden of pain linked to high morbidity and disability that is poorly assessed and undertreated. Barriers to effective pain management partly relate to lack of access to opioid analgesia and challenges in their administration. OBJECTIVES To identify country-specific and broader regional barriers to access, as well as the administration of opioids, and generate recommendations for advancing pain management in Southern Africa. METHODS A parallel mixed methods design was used across three countries: Mozambique, Swaziland, and Zimbabwe. Three activities were undertaken: 1) a review of regulatory and policy documentation, 2) group interviews, and 3) a self-administered key informant survey. RESULTS Barriers to accessing opioid analgesics for medical use include overly restrictive controlled medicines' laws; use of stigmatizing language in key documents; inaccurate actual opioid consumption estimation practices; knowledge gaps in the distribution, storage, and prescription of opioids; critical shortage of prescribers; and high out-of-pocket financial expenditures for patients against a backdrop of high levels of poverty. CONCLUSION Policies and relevant laws should be updated to ensure that the legislative environment supports opioid access for pain management. Action plans for improving pain treatment for patients suffering from HIV or non-communicable diseases should address barriers at the different levels of the supply chain that involve policymakers, administrators, and service providers.
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Affiliation(s)
- Eve Namisango
- African Palliative Care Association, Kampala, Uganda; Uganda and King's College London, Cicely Saunders Institute, London, UK.
| | - Matthew J Allsop
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | | | - Stefan J Friedrichsdorf
- Department of Pain Medicine, Palliative Care and Integrative Medicine, Children's Hospitals and Clinics of Minnesota, University of Minnesota, Minneapolis, Minnesota, USA
| | - Emmanuel B K Luyirika
- African Palliative Care Association, Kampala, Uganda; Uganda and King's College London, Cicely Saunders Institute, London, UK
| | - Fatia Kiyange
- African Palliative Care Association, Kampala, Uganda; Uganda and King's College London, Cicely Saunders Institute, London, UK
| | | | | | | | | | | | | | - Richard Harding
- King's College London, Cicely Saunders Institute, London, UK
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Symptom Burden and Functional Dependencies Among Cancer Patients in Botswana Suggest a Need for Palliative Care Nursing. Cancer Nurs 2017; 39:E29-38. [PMID: 25881812 DOI: 10.1097/ncc.0000000000000249] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Palliative care and cancer nursing in sub-Saharan Africa is hampered by inadequate clinical resources and evidence base but is central to symptom management amid the growing cancer burden. OBJECTIVE The aim of this study is to describe symptom burden and functional dependencies of cancer patients in Botswana using the Memorial Symptom Assessment Scale-Short Form (MSAS-SF) and Enforced Social Dependency Scale (ESDS). METHODS A cross-sectional multisite study was conducted in Gaborone, Botswana, from June to August 2013 using MSAS-SF, ESDS, and Eastern Cooperative Oncology Group (ECOG) performance status at 1 time point. Descriptive statistics, tests of association, correlation, and scale validity were used. RESULTS Among the 100 cancer patients, 65 were women, 21 were inpatients, 48 were human immunodeficiency virus-positive, 23 had gynecological malignancies, 34 had stage 4 disease, and 54 received chemotherapy only. Sixty-four reported pain; 54, neuropathies; 51, weight loss; and 51, hunger. Most distressing symptoms were weight loss, body image, skin changes, and pain. Recreational/social role was most affected by cancer. Cronbach's α for both the MSAS-SF and ESDS was .91. Variations in means for MSAS-SF and ESDS were associated with ECOG grade 2 (P < .05); the ECOG moderately correlated (0.35) with MSAS-SF (P < .01). No associations with human immunodeficiency virus status were found. CONCLUSIONS Patients reported distressing levels of cancer pain, weight loss, hunger, and dependency in recreational/social activities. The Setswana translations of the MSAS-SF and ESDS were found reliable to assess cancer patients' symptoms and function. IMPLICATIONS FOR PRACTICE Nurses trained in palliative care are needed to meet cancer patients' pain and symptom management care needs.
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Rukewe A, Afuwape OO, Ugheoke A, Fatiregun AA. Single-shot lamina thoracic paravertebral block with ketofol for modified radical mastectomy. Local Reg Anesth 2016; 9:83-86. [PMID: 27785098 PMCID: PMC5063483 DOI: 10.2147/lra.s116102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
We describe the use of single-shot lamina thoracic paravertebral block (TPVB) with sedation for a 56-year-old female patient who had modified radical mastectomy with axillary clearance. Two years ago, she suffered vocal cord palsy post thyroidectomy, which was managed with tracheostomy. The tracheostomy tube was removed 8 months later, leaving the patient with persistent hoarseness of voice and left vocal cord palsy. She declined general anesthesia and consented for TPVB. The surgery lasted 95 minutes and was successfully completed with TPVB. Her vital signs were stable during the operation. She had low pain scores, minimal opioid use, early alimentation, and no postoperative nausea and vomiting and was discharged early. We present the anesthetic management of this case in our setting, where TPVB under ultrasound guidance and modern drug-delivery systems for sedation are unavailable.
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Affiliation(s)
- Ambrose Rukewe
- Department of Anaesthesia & Critical Care, Faculty of Medicine, University of Botswana, Gaborone, Botswana
| | | | - Austin Ugheoke
- Department of Anaesthesia, University College Hospital, Ibadan
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Woolley RJ, Velink A, Phillips RO, Thompson WA, Abass KM, van der Werf TS, de Zeeuw J, Stienstra Y. Experiences of Pain and Expectations for Its Treatment Among Former Buruli Ulcer Patients. Am J Trop Med Hyg 2016; 95:1011-1015. [PMID: 27621302 DOI: 10.4269/ajtmh.16-0419] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Accepted: 08/07/2016] [Indexed: 01/21/2023] Open
Abstract
Buruli ulcer (BU) is one of the 17 neglected tropical diseases for which the World Health Organization has adopted resolutions to improve treatment. BU was previously described as a relatively painless condition; however, recent research has indicated that some patients experience substantial pain. The objective of this study was to explore patients' experiences of pain and their expectations for its treatment. Semistructured interviews were conducted in a BU-endemic region of Ghana. Interviews were held with former BU patients (N = 20) and community controls (N = 19). Former patients were asked about BU-related pain and their expectations for its treatment. The interviews were conducted in October 2014, and were audiotaped, translated and transcribed into English, and then qualitatively analyzed. Of the 20 former BU patients interviewed, 19 (95%) reported experiencing pain, with patients reporting pain as a consequence of the ulcer and wound management. Some participants expressed pain through crying, whereas others did not openly express pain, sometimes because they feared the repercussions of doing so. Patients wanted to receive pain relief; however, many were unable to name a medication. Nonpharmaceutical options were cited as being an alternative. Many BU patients experience pain; however, former patients and community members alike appear to have a limited knowledge about available pain relief. A low-cost alternative to medication may be the use of nonpharmaceutical means for pain relief. Routine pain assessment may reduce patients' fear and unwillingness to express pain. Awareness of such issues will be valuable when implementing a BU pain relief guideline.
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Affiliation(s)
- Rebecca J Woolley
- University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Anita Velink
- University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | | | | | | | - Tjip S van der Werf
- Department of Internal Medicine/Infectious Diseases Groningen, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Janine de Zeeuw
- Department of Internal Medicine/Infectious Diseases Groningen, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Ymkje Stienstra
- Department of Internal Medicine/Infectious Diseases Groningen, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
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Namisango E, Ntege C, Luyirika EBK, Kiyange F, Allsop MJ. Strengthening pharmaceutical systems for palliative care services in resource limited settings: piloting a mHealth application across a rural and urban setting in Uganda. BMC Palliat Care 2016; 15:20. [PMID: 26895882 PMCID: PMC4759774 DOI: 10.1186/s12904-016-0092-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Accepted: 02/10/2016] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Medicine availability is improving in sub-Saharan Africa for palliative care services. There is a need to develop strong and sustainable pharmaceutical systems to enhance the proper management of palliative care medicines, some of which are controlled. One approach to addressing these needs is the use of mobile technology to support data capture, storage and retrieval. Utilizing mobile technology in healthcare (mHealth) has recently been highlighted as an approach to enhancing palliative care services but development is at an early stage. METHODS An electronic application was implemented as part of palliative care services at two settings in Uganda; a rural hospital and an urban hospice. Measures of the completeness of data capture, time efficiency of activities and medicines stock and waste management were taken pre- and post-implementation to identify changes to practice arising from the introduction of the application. RESULTS Improvements in all measures were identified at both sites. The application supported the registration and management of 455 patients and a total of 565 consultations. Improvements in both time efficiency and medicines management were noted. Time taken to collect and report pharmaceuticals data was reduced from 7 days to 30 min and 10 days to 1 h at the urban hospice and rural hospital respectively. Stock expiration reduced from 3 to 0.5% at the urban hospice and from 58 to 0% at the rural hospital. Additional observations relating to the use of the application across the two sites are reported. CONCLUSIONS A mHealth approach adopted in this study was shown to improve existing processes for patient record management, pharmacy forecasting and supply planning, procurement, and distribution of essential health commodities for palliative care services. An important next step will be to identify where and how such mHealth approaches can be implemented more widely to improve pharmaceutical systems for palliative care services in resource limited settings.
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Affiliation(s)
- Eve Namisango
- African Palliative Care Association, Kampala, Uganda.
| | | | | | - Fatia Kiyange
- African Palliative Care Association, Kampala, Uganda.
| | - Matthew J Allsop
- Academic Unit of Palliative Care, Leeds Institute of Health Sciences, Faculty of Medicine and Health, University of Leeds, Leeds, UK.
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16
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Tamannai M, Kaah J, Mbah G, Ndimba J, D'Souza C, Wharin P, Hesseling PB. An evaluation of a palliative care outreach programme for children with Burkitt lymphoma in rural Cameroon. Int J Palliat Nurs 2015. [DOI: 10.12968/ijpn.2015.21.7.331] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Mona Tamannai
- Paediatrician, Universitätsmedizin Berlin
- Nurses, Banso Baptist Hospital
| | - Joel Kaah
- Nurse Assistant, Banso Baptist Hospital, Cameroon
- Nurses, Banso Baptist Hospital
| | | | | | - Catherine D'Souza
- Registrar, Nottingham University Hospitals, UK
- Nurses, Banso Baptist Hospital
| | - Paul Wharin
- Trustee, Beryl Thyer Memorial Africa Trust, UK
- Nurses, Banso Baptist Hospital
| | - Peter B Hesseling
- Emeritus Professor, Stellenbosch University, South Africa
- Nurses, Banso Baptist Hospital
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17
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Nkhoma K, Seymour J, Arthur A. An Educational Intervention to Reduce Pain and Improve Pain Management for Malawian People Living With HIV/AIDS and Their Family Carers: A Randomized Controlled Trial. J Pain Symptom Manage 2015; 50:80-90.e4. [PMID: 25666517 DOI: 10.1016/j.jpainsymman.2015.01.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Revised: 12/23/2014] [Accepted: 01/07/2015] [Indexed: 11/17/2022]
Abstract
CONTEXT Advances being made in improving access to HIV drugs in resource-poor countries mean HIV patients are living longer, and, therefore, experiencing pain over a longer period of time. There is a need to provide effective interventions for alleviating and managing pain. OBJECTIVES To assess whether a pain educational intervention compared with usual care reduces pain severity and improves pain management in patients with HIV/AIDS and their family carers. METHODS This was a randomized, parallel group, superiority trial conducted at HIV and palliative care clinics of two public hospitals in Malawi. A total of 182 adults with HIV/AIDS (Stage III or IV) and their family carers participated; carer participants were those individuals most involved in the patient's unpaid care. The educational intervention comprised a 30 minute face-to-face meeting, a leaflet, and a follow-up telephone call at two weeks. The content of the educational intervention covered definition, causes, and characteristics of pain in HIV/AIDS; beliefs and myths about pain and pain medication; assessment of pain; and pharmacological and nonpharmacological management. The primary outcome was average pain severity measured by the Brief Pain Inventory-Pain Severity subscale. Assessments were recorded at baseline before randomization and at eight weeks after randomization. RESULTS Of the 182 patient/carer dyads randomly allocated, 157 patient/carer dyads completed the trial. Patients in the intervention group experienced a greater decrease in pain severity (mean difference = 21.09 points, 95% confidence interval = 16.56-25.63; P < 0.001). CONCLUSION A short pain education intervention is effective in reducing pain and improving pain management for Malawian people living with HIV/AIDS and their family carers.
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Affiliation(s)
- Kennedy Nkhoma
- Sue Ryder Care Centre for the Study of Supportive, Palliative and End of Life Care, Division of Nursing, Queen's Medical Centre, Nottingham, United Kingdom
| | - Jane Seymour
- Sue Ryder Care Centre for the Study of Supportive, Palliative and End of Life Care, Division of Nursing, Queen's Medical Centre, Nottingham, United Kingdom.
| | - Antony Arthur
- School of Health Sciences, University of East Anglia, Norwich, United Kingdom
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18
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Downing J, Jassal SS, Mathews L, Brits H, Friedrichsdorf SJ. Pediatric pain management in palliative care. Pain Manag 2015; 5:23-35. [DOI: 10.2217/pmt.14.45] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
SUMMARY The management of pain in pediatric palliative care (PPC) is essential. Whilst the field of pain management has developed over the years, much of what is done in PPC is based on anecdotal evidence or adult studies. This review explores recent developments in pain management in PPC, in particular the WHO guidelines on the pharmacological treatment of persisting pain in children with medical illnesses. Key issues discussed include the definition, assessment, pharmacological and integrative management of pain, availability of medications, education and research. Whilst advances have been made, including publication of the guidelines, significant gaps exist in terms of the evidence base, education and access to essential medications and both interdisciplinary and international collaboration are required to meet these gaps.
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Affiliation(s)
- Julia Downing
- International Children's Palliative Care Network & Makerere University, Kampala, Uganda
| | | | - Lulu Mathews
- Department of Pediatrics, Calicut Medical College & Institute of Palliative Medicine, Calicut, India
| | - Hanneke Brits
- Department of Family Medicine, Bloemfontein, South Africa
| | - Stefan J Friedrichsdorf
- University of Minnesota Medical School & Department of Pain Medicine, Palliative Care & Integrative Medicine, Children's Hospitals & Clinics of Minnesota, Minneapolis, MN, USA
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19
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de Villiers M, Maree JE, van Belkum C. The influence of chronic pain on the daily lives of underprivileged South Africans. Pain Manag Nurs 2014; 16:96-104. [PMID: 25434498 DOI: 10.1016/j.pmn.2014.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Revised: 04/29/2014] [Accepted: 05/01/2014] [Indexed: 11/16/2022]
Abstract
Chronic pain is a major public health problem that changes lives and has devastating consequences for the person experiencing the pain, the family, and society. Living with chronic pain is not easy, especially in South Africa where the public health care system, serving 80% of the population, fails people suffering from chronic pain. The purpose of the study was to explore how experiencing chronic pain influenced the daily lives of underprivileged patients receiving nursing care at the palliative care clinic serving a resource-poor community in Tshwane, South Africa. A qualitative descriptive phenomenologic design was selected for the study. Nine purposively selected community members, registered as patients at the palliative care clinic and who suffered chronic pain, participated in the study. In-depth interviews were conducted and Tesch's coding process was used to analyze the data. Data gathering and analysis were done concurrently to determine data saturation. Four themes arose from the data: pain as a multidimensional experience, the influence of pain on physical activities, the psychosocial influence of pain, and the influence of pain on spirituality. Participants' experience of pain tells of severe suffering that hindered them in performing activities of daily living. Participants were confronted with total pain and were caught in a vicious circle where pain was responsible for severe suffering and their suffering added to their pain. However, strong religious beliefs improved pain and gave hope for the future.
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Affiliation(s)
- Martjie de Villiers
- Adelaide Tambo School of Nursing Science, Tshwane University of Technology, Pretoria, South Africa
| | - Johanna Elizabeth Maree
- Department of Nursing Education, University of the Witwatersrand, Johannesburg, South Africa.
| | - Corrien van Belkum
- Adelaide Tambo School of Nursing Science, Tshwane University of Technology, Pretoria, South Africa
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20
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Siegert R, Selman L, Higginson IJ, Ali Z, Powell RA, Namisango E, Mwangi-Powell F, Gwyther L, Gikaara N, Harding R. A psychometric evaluation of the functional assessment of chronic illness therapy-palliative care (FACIT-Pal) scale with palliative care samples in three African countries. J Pain Symptom Manage 2014; 48:983-91. [PMID: 24742786 DOI: 10.1016/j.jpainsymman.2014.01.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2013] [Revised: 01/17/2014] [Accepted: 02/07/2014] [Indexed: 12/22/2022]
Abstract
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.
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Affiliation(s)
- Richard Siegert
- Department of Psychology, Auckland University of Technology, Auckland, New Zealand
| | - Lucy Selman
- Department of Palliative Care, Policy & Rehabilitation, King's College London, Cicely Saunders Institute, London, United Kingdom
| | - Irene J Higginson
- Department of Palliative Care, Policy & Rehabilitation, King's College London, Cicely Saunders Institute, London, United Kingdom
| | - Zippy Ali
- Kenya Hospices and Palliative Care Association, Nairobi, Kenya
| | | | - Eve Namisango
- African Palliative Care Association, Kampala, Uganda
| | | | - Liz Gwyther
- Hospice Palliative Care Association of South Africa, Cape Town, South Africa; The School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Nancy Gikaara
- African Palliative Care Association, Kampala, Uganda
| | - Richard Harding
- Department of Palliative Care, Policy & Rehabilitation, King's College London, Cicely Saunders Institute, London, United Kingdom.
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21
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Chetty S, Baalbergen E, Bhigjee AI, Kamerman P, Ouma J, Raath R, Raff M, Salduker S. Clinical practice guidelines for management of neuropathic pain: expert panel recommendations for South Africa. S Afr Fam Pract (2004) 2014. [DOI: 10.1080/20786204.2013.10874323] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Affiliation(s)
- S Chetty
- Department of Anaesthesiology, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg
| | - E Baalbergen
- Life Vincent Pallotti Rehabilitation Unit, Pinelands, Cape Town
| | - AI Bhigjee
- Department of Neurology, Nelson R Mandela School of Medicine, Mayville, University of KwaZulu-Natal, Durban
| | - P Kamerman
- Brain Function Research Group, School of Physiology, University of the Witwatersrand, Johannesburg
| | - J Ouma
- Department of Neurosurgery, University of the Witwatersrand, Johannesburg
| | - R Raath
- Jacaranda Hospital, Muckleneuk, Pretoria
| | - M Raff
- Christiaan Barnard Memorial Hospital, Cape Town
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22
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Murthy S, Antwi-Kusi A, Jabir AR, Ofori-Amanfo G. Patient and practitioner perspectives on postoperative pain control in Kumasi, Ghana. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2014. [DOI: 10.1080/22201173.2013.10872904] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- S Murthy
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, USA
| | - A Antwi-Kusi
- Department of Anaesthesia and Intensive Care, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - AR Jabir
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Duke University School of Medicine, Durham, USA
| | - G Ofori-Amanfo
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Duke University School of Medicine, Durham, USA
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Cleary J, Powell RA, Munene G, Mwangi-Powell FN, Luyirika E, Kiyange F, Merriman A, Scholten W, Radbruch L, Torode J, Cherny NI. Formulary availability and regulatory barriers to accessibility of opioids for cancer pain in Africa: a report from the Global Opioid Policy Initiative (GOPI). Ann Oncol 2014; 24 Suppl 11:xi14-23. [PMID: 24285225 DOI: 10.1093/annonc/mdt499] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
With nearly 1.1 billion inhabitants living in more than 50 countries, Africa is the world's poorest and most socioeconomically underdeveloped continent. Despite some advances for individual states, many African countries have very low opioid consumption and, overall, the continent has the lowest consumption per capita of any in the world. This article presents the findings of the first systematic study of the availability and accessibility of opioids for the management of cancer pain across the continent. Data are reported on the availability and accessibility of opioids for the management of cancer pain in 25 of 52 countries, with 744 million of the region's 1127 million people (66%) covered by the survey. Many countries had severely restricted formularies of opioids and only 15 of 25 had morphine available in oral IR, CR and injectable formulations. Even when opioids are on formulary they are often unavailable, and access is significantly impaired by widespread over-regulation that is pervasive across the region.
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Affiliation(s)
- J Cleary
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
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Harding R, Selman L, Ali Z, Powell RA, Namisango E, Mwangi-Powell F, Gwyther L, Gikaara N, Higginson IJ, Siegert RJ. Wellbeing among sub-Saharan African patients with advanced HIV and/or cancer: an international multicentred comparison study of two outcome measures. Health Qual Life Outcomes 2014; 12:80. [PMID: 24885695 PMCID: PMC4063229 DOI: 10.1186/1477-7525-12-80] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2014] [Accepted: 05/22/2014] [Indexed: 01/09/2023] Open
Abstract
Background Despite the high mortality rates of HIV and cancer in sub-Saharan Africa, there are few outcome tools and no comparative data across conditions. This study aimed to measure multidimensional wellbeing among advanced HIV and/or cancer patients in three African countries, and determine the relationship between two validated outcome measures. Methods Cross-sectional self-reported data from palliative care populations in Kenya, Uganda and South Africa using FACIT-G+Pal and POS measures. Results Among 461 participants across all countries, subscale “social and family wellbeing” had highest (best) score. Significant country effect showed lower (worse) scores for Uganda on 3 FACIT G subscales: Physical, Social + family, and functional. In multiple regression, country and functional status accounted for 21% variance in FACIT-Pal. Worsening functional status was associated with poorer POS score. Kenyans had worse POS score, followed by Uganda and South Africa. Matrix of correlational coefficients revealed moderate correlation between the POS and FACIT-Pal core scale (0.60), the FACIT-G and POS (0.64), and FACIT-G + Pal with POS (0.66). Conclusions The data reveal best status for family and social wellbeing, which may reflect the sample being from less individualistic societies. The tools appear to measure different constructs of wellbeing in palliative care, and reveal different levels of wellbeing between countries. Those with poorest physical function require greatest palliative and supportive care, and this does not appear to differ according to diagnosis.
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Affiliation(s)
- Richard Harding
- Department of Palliative Care, Policy & Rehabilitation, King's College London, Cicely Saunders Institute, Bessemer Road, London SE5 9PJ, UK.
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25
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Harding R, Simms V, Penfold S, Downing J, Powell RA, Mwangi-Powell F, Namisango E, Moreland S, Gikaara N, Atieno M, Kataike J, Nsubuga C, Munene G, Banga G, Higginson IJ. Availability of essential drugs for managing HIV-related pain and symptoms within 120 PEPFAR-funded health facilities in East Africa: a cross-sectional survey with onsite verification. Palliat Med 2014; 28:293-301. [PMID: 23885009 DOI: 10.1177/0269216313498637] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND World Health Organization's essential drugs list can control the highly prevalent HIV-related pain and symptoms. Availability of essential medicines directly influences clinicians' ability to effectively manage distressing manifestations of HIV. AIM To determine the availability of pain and symptom controlling drugs in East Africa within President's Emergency Plan for AIDS Relief-funded HIV health care facilities. DESIGN Directly observed quantitative health facilities' pharmacy stock review. We measured availability, expiration and stock-outs of specified drugs required for routine HIV management, including the World Health Organization pain ladder. SETTING A stratified random sample in 120 President's Emergency Plan for AIDS Relief-funded HIV care facilities (referral and district hospitals, health posts/centres and home-based care providers) in Kenya and Uganda. RESULTS Non-opioid analgesics (73%) and co-trimoxazole (64%) were the most commonly available drugs and morphine (7%) the least. Drug availability was higher in hospitals and lower in health centres, health posts and home-based care facilities. Facilities generally did not use minimum stock levels, and stock-outs were frequently reported. The most common drugs had each been out of stock in the past 6 months in 47% of facilities stocking them. When a minimum stock level was defined, probability of a stock-out in the previous 6 months was 32.6%, compared to 45.5% when there was no defined minimum stock level (χ (2) = 5.07, p = 0.024). CONCLUSION The data demonstrate poor essential drug availability, particularly analgesia, limited by facility type. The lack of strong opioids, isoniazid and paediatric formulations is concerning. Inadequate drug availability prevents implementation of simple clinical pain and symptom control protocols, causing unnecessary distress. Research is needed to identify supply chain mechanisms that lead to these problems.
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Affiliation(s)
- Richard Harding
- 1Department of Palliative Care, Policy & Rehabilitation, Cicely Saunders Institute, King's College London, London, UK
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Kassa H, Murugan R, Zewdu F, Hailu M, Woldeyohannes D. Assessment of knowledge, attitude and practice and associated factors towards palliative care among nurses working in selected hospitals, Addis Ababa, Ethiopia. BMC Palliat Care 2014; 13:6. [PMID: 24593779 PMCID: PMC3975866 DOI: 10.1186/1472-684x-13-6] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2012] [Accepted: 02/19/2014] [Indexed: 11/30/2022] Open
Abstract
Background To provide quality care at the end of life or for chronically sick patients, nurses must have good knowledge, attitude and practice about palliative care (PC). In Ethiopia PC is new and very little is known about the type of services offered and the readiness of nurses to provide PC. Methods A cross sectional quantitative study design was carried out using 341 nurses working in selected hospitals in Addis Ababa from January 2012 to May 2012. Systematic random sampling was the method employed to select two governmental and two non-governmental hospitals. The researchers used triangulation in their study method making use of: Frommelt’s Attitude Toward Care of the Dying (FATCOD) Scale, Palliative Care Quiz for Nursing (PCQN) and practice questions. This led to enhanced validity of the data. EPI-INFO and SPSS software statistical packages were applied for data entry and analysis. Result Of the total 365 nurses selected, a response rate of 341 (94.2%) were registered. Out of the total study participants, 104 (30.5%) had good knowledge and 259 (76%) had favorable attitude towards PC. Medical and surgical wards as well as training on PC were positively associated with knowledge of nurses. Institution, individuals’ level of education, working in medical ward and the training they took part on PC were also significantly associated with the attitude the nurses had. Nurses working in Hayat Hospital (nongovernmental) had a 71.5% chance of having unfavorable attitude towards PC than those working in Black Lion Hospital (governmental). Regarding their knowledge aspect of practice, the majority of the respondents 260 (76.2%) had poor implementation, and nearly half of the respondents had reported that the diagnosis of patients was usually performed at the terminal stage. In line with this, spiritual and medical conditions were highly taken into consideration while dealing with terminally ill patients. Conclusion The nurses had poor knowledge and knowledge aspect of practice, but their attitude towards PC was favorable. Recommendations are that due attention should be given towards PC by the national health policy and needs to be incorporated in the national curriculum of nurse education.
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Affiliation(s)
- Hiwot Kassa
- Department of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia.
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27
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Harding R, Albertyn R, Sherr L, Gwyther L. Pediatric palliative care in sub-saharan Africa: a systematic review of the evidence for care models, interventions, and outcomes. J Pain Symptom Manage 2014; 47:642-51. [PMID: 23972573 DOI: 10.1016/j.jpainsymman.2013.04.010] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2013] [Revised: 04/21/2013] [Accepted: 04/25/2013] [Indexed: 10/26/2022]
Abstract
CONTEXT The progressive disease burden among children in sub-Saharan Africa means the provision of palliative care is essential and should be provided alongside treatment where it is available. OBJECTIVES To systematically review the evidence for pediatric palliative care models, interventions, and outcomes to appraise the state of the science and inform best practice. METHODS A systematic review search strategy was implemented in eight electronic databases, the search results reported using a PRISMA statement, and findings tabulated. RESULTS In terms of evidence of palliative care provision and outcomes, only five articles were identified. These represent a small range of acute, community, and hospice care and offer some limited guidance on the development and delivery of services. CONCLUSION Pediatric palliative care is a pressing clinical and public health challenge in sub-Saharan Africa. Explicit evidence-based models of service development, patient assessment, and evidence for control of prevalent problems (physical, psychological, social, spiritual, and developmental) are urgently needed. Greater research activity is urgently required to ensure an evidence-based response to the enormous need for pediatric palliative care in sub-Saharan Africa.
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Affiliation(s)
- Richard Harding
- Department of Palliative Care, Policy & Rehabilitation, King's College London, Cicely Saunders Institute, London, United Kingdom.
| | - Rene Albertyn
- Department of Paediatric Surgery, Red Cross Children's Hospital, Cape Town, South Africa
| | - Lorraine Sherr
- Infection & Population Health, Institute of Epidemiology & Health, Faculty of Population Health Sciences, University College London, London, United Kingdom
| | - Liz Gwyther
- Hospice Palliative Care Association of South Africa, Cape Town, South Africa; School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
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Streid J, Harding R, Agupio G, Dinat N, Downing J, Gwyther L, Ikin B, Mashao T, Mmoledi K, Moll AP, Sebuyira LM, Higginson IJ, Selman L. Stressors and resources of caregivers of patients with incurable progressive illness in sub-Saharan Africa. QUALITATIVE HEALTH RESEARCH 2014; 24:317-328. [PMID: 24583654 DOI: 10.1177/1049732314523682] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Family caregivers are central to palliative care in sub-Saharan Africa. Yet although supporting caregivers requires a comprehensive understanding of caregiver burden, there has been little research into this topic in Africa. Using the Stress Process Model to investigate the burden experienced by caregivers in South Africa and Uganda, we interviewed 37 caregivers and analyzed the data thematically. Caregivers' primary stressors related to day-to-day patient care and emotional support; secondary stressors included financial hardship, family responsibilities, and social isolation. Caregivers' social, relational, spiritual, and psychological resources mediated the effects of these stressors. Strengthening one resource strengthened others, but the failure of one resource hindered other resources, exacerbating burden. In providing caregiver support, policymakers and service providers should focus on enhancing caregivers' resources as well as alleviating their stressors.
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Parker R, Stein DJ, Jelsma J. Pain in people living with HIV/AIDS: a systematic review. J Int AIDS Soc 2014; 17:18719. [PMID: 24560338 PMCID: PMC3929991 DOI: 10.7448/ias.17.1.18719] [Citation(s) in RCA: 151] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2013] [Revised: 12/13/2013] [Accepted: 01/17/2014] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION Pain is one of the most commonly reported symptoms in people living with HIV/AIDS (PLWHA). However, wide ranges of pain prevalence have been reported, making it difficult to determine the relative impact of pain in PLWHA. A systematic review of the literature was conducted to establish the prevalence and characteristics of pain and to explore pain management in PLWHA. METHODS Studies that included cross-sectional data were included in the search, which was conducted in April 2012. Databases searched using a time limit of March 1982 to March 2012 included PubMed, Scopus, Africa-wide: NIPAD, CINAHL, PsychARTICLES, PSYCINFO, PSYCHIATRYONLINE, ScienceDirect and Web of Science. Search terms selected were "pain" and "HIV" or "acquired immune deficiency syndrome." Two reviewers independently screened all citation abstracts for inclusion. Methodological quality was evaluated using a standardized 11-item critical appraisal tool. RESULTS After full text review, 61 studies fulfilled the inclusion criteria. Prevalence of pain ranged from a point prevalence of 54% (95%CI 51.14-56.09) to 83% (95%CI 76-88) using a three-month recall period. The reported pain was of moderate-to-severe intensity, and pain was reported in one to two and a half different anatomical sites. Moderate levels of pain interference with function were reported. All nine studies reporting on the adequacy of pain management recorded marked under-treatment of pain. DISCUSSION The studies reviewed reported that pain commonly presents at multiple pain sites with a range of severity suggesting that there are several differing pathological processes contributing to pain at one time. The interplay of variables associated with pain suggests that the biopsychosocial model of pain is an appropriate paradigm from which to view pain in PLWHA and from which to approach the problem, explore causes and establish effective treatment. CONCLUSIONS The results highlight that pain is common in PLWHA at all stages of the disease. The prevalence rates for pain in PLWHA do not appear to have diminished over the 30 years spanning the studies reviewed. The body of work available in the literature thus far, while emphasizing the problem of pain, has not had an impact on its management.
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Affiliation(s)
- Romy Parker
- Department of Health & Rehabilitation Sciences, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa;
| | - Dan J Stein
- Department of Psychiatry & Mental Health, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Jennifer Jelsma
- Department of Health & Rehabilitation Sciences, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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Downing J, Gomes B, Gikaara N, Munene G, Daveson BA, Powell RA, Mwangi-Powell FN, Higginson IJ, Harding R. Public preferences and priorities for end-of-life care in Kenya: a population-based street survey. BMC Palliat Care 2014; 13:4. [PMID: 24529217 PMCID: PMC3936799 DOI: 10.1186/1472-684x-13-4] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2013] [Accepted: 02/12/2014] [Indexed: 01/03/2023] Open
Abstract
Background End-of-life care needs are great in Africa due to the burden of disease. This study aimed to explore public preferences and priorities for end-of-life care in Nairobi, Kenya. Methods Population-based street survey of Kenyans aged ≥18; researchers approached every 10th person, alternating men and women. Structured interviews investigated quality vs. quantity of life, care priorities, preferences for information, decision-making, place of death (most and least favourite) and focus of care in a hypothetical scenario of serious illness with <1 year to live. Descriptive analysis examined variations. Results 201 individuals were interviewed (100 women) representing 17 tribes (n = 90 44.8%, Kikuyu). 56.7% (n = 114) said they would always like to be told if they had limited time left. The majority (n = 121, 61.4%) preferred quality of life over quantity i.e. extending life (n = 47, 23.9%). Keeping a positive attitude and ensuring relatives/friends were not worried were prioritised above having pain/discomfort relieved. The three most concerning problems were pain (45.8%), family burden (34.8%) and personal psychological distress (29.8%). Home was both the most (51.1% n = 98) and least (23.7% n = 44) preferred place of death. Conclusion This first population-based survey on preferences and priorities for end-of-life care in Africa revealed that psycho-social domains were of greatest importance to the public, but also identified variations that require further exploration. If citizens’ preferences and priorities are to be met, the development of end-of-life care services to deliver preferences in Kenya should ensure an holistic model of palliative care responsive to individual preferences across care settings including at home.
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Penfold S, Simms V, Downing J, Powell RA, Mwangi-Powell F, Namisango E, Moreland S, Atieno M, Gikaara N, Kataike J, Kwebiha C, Munene G, Banga G, Higginson IJ, Harding R. The HIV basic care package: where is it available and who receives it? Findings from a mixed methods evaluation in Kenya and Uganda. AIDS Care 2014; 26:1155-63. [PMID: 24512641 DOI: 10.1080/09540121.2014.882489] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
An evidence-based basic care package (BCP) of seven interventions (Family testing, Cotrimoxazole, Condoms, Multivitamins, Access to safe water treatment, Isoniazid preventive therapy (IPT), and Insecticide-treated bednet) has been advocated to prevent infections among people with HIV in low-income settings. We examined the availability and receipt of the BCP in HIV outpatient clinics in Kenya and Uganda. A survey of 120 PEPFAR-funded facilities determined the services offered. At each of the 12 largest facilities, a longitudinal cohort of 100 patients was recruited to examine care received and health status over three months. The full BCP was offered in 14% (n = 17/120) of facilities; interventions most commonly offered were Support for family testing (87%) and Condoms (87%), and least commonly IPT (38%). Patients (n = 1335) most commonly reported receiving Cotrimoxazole (57%) and Multivitamins (36%), and least commonly IPT (4%), directly from the facility attended. The BCP (excluding Isoniazid) was received by 3% of patients directly from the facility and 24% from any location. BCP receipt was associated with using antiretroviral therapy (ART; OR 1.1 (95% CI 1.0-1.1), receipt from any location) but not with patient gender, wealth, education level or health. The BCP should be offered at more HIV care facilities, especially Isoniazid, and to more people irrespective of ART use. Coordinating local BCP suppliers could help improve availability through addressing logistical challenges or reducing costs.
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Affiliation(s)
- Suzanne Penfold
- a Cicely Saunders Institute , King's College London , London , UK
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Huang KTL, Owino C, Gramelspacher GP, Monahan PO, Tabbey R, Hagembe M, Strother RM, Njuguna F, Vreeman RC. Prevalence and correlates of pain and pain treatment in a western Kenya referral hospital. J Palliat Med 2013; 16:1260-7. [PMID: 24032753 DOI: 10.1089/jpm.2013.0080] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Pain is often inadequately evaluated and treated in sub-Saharan Africa (SSA). OBJECTIVE We sought to assess pain levels and pain treatment in 400 hospitalized patients at a national referral hospital in western Kenya, and to identify factors associated with pain and pain treatment. DESIGN Using face-validated Kiswahili versions of two single-item pain assessment tools, the Numerical Rating Scale (NRS) and the Faces Pain Scale-Revised (FPS-R), we determined patients' pain levels. Additional data collected included patient demographics, prescribed analgesics, and administered analgesics. We calculated mean pain ratings and pain management index (PMI) scores. RESULTS Averaged between the NRS and FPS-R, 80.5% of patients endorsed a nonzero level of pain and 30% of patients reported moderate to severe pain. Older patients, patients with HIV, and cancer patients had higher pain ratings. Sixty-six percent of patients had been prescribed analgesics at some point during their hospitalization, the majority of which were nonopioids. A majority of patients (66%) had undertreated pain (negative scores on the PMI). CONCLUSION This study shows that hospitalized patients in Kenya are experiencing pain and that this pain is often undertreated.
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Affiliation(s)
- Kristin T L Huang
- 1 USAID - Academic Model Providing Access to Healthcare (AMPATH) , Eldoret, Kenya
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Nkhoma K, Seymour J, Arthur A. An educational intervention to reduce pain and improve pain management for Malawian people living with HIV/AIDS and their family carers: study protocol for a randomised controlled trial. Trials 2013; 14:216. [PMID: 23849502 PMCID: PMC3717041 DOI: 10.1186/1745-6215-14-216] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2013] [Accepted: 07/03/2013] [Indexed: 11/29/2022] Open
Abstract
Background Many HIV/AIDS patients experience pain often due to advanced HIV/AIDS infection and side effects of treatment. In sub-Saharan Africa, pain management for people with HIV/AIDS is suboptimal. With survival extended as a direct consequence of improved access to antiretroviral therapy, the prevalence of HIV/AIDS related pain is increasing. As most care is provided at home, the management of pain requires patient and family involvement. Pain education is an important aspect in the management of pain in HIV/AIDS patients. Studies of the effectiveness of pain education interventions for people with HIV/AIDS have been conducted almost exclusively in western countries. Methods/design A randomised controlled trial is being conducted at the HIV and palliative care clinics of two public hospitals in Malawi. To be eligible, patient participants must have a diagnosis of HIV/AIDS (stage III or IV). Carer participants must be the individual most involved in the patient’s unpaid care. Eligible participants are randomised to either: (1) a 30-minute face-to-face educational intervention covering pain assessment and management, augmented by a leaflet and follow-up telephone call at two weeks; or (2) usual care. Those allocated to the usual care group receive the educational intervention after follow-up assessments have been conducted (wait-list control group). The primary outcome is pain severity measured by the Brief Pain Inventory. Secondary outcomes are pain interference, patient knowledge of pain management, patient quality of life, carer knowledge of pain management, caregiver motivation and carer quality of life. Follow-up assessments are conducted eight weeks after randomisation by palliative care nurses blind to allocation. Discussion This randomised controlled trial conducted in sub-Saharan Africa among people living with HIV/AIDS and their carers will assess whether a pain education intervention is effective in reducing pain and improving pain management, quality of life and carer motivation. Trial registration Current Controlled Trials ISRCTN72861423.
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Affiliation(s)
- Kennedy Nkhoma
- Sue Ryder Care Centre for the Study of Supportive, Palliative and End of Life Care, School of Nursing, Midwifery and Physiotherapy, University of Nottingham, Queen's Medical Centre, Nottingham NG7 2UH, UK
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O'Brien M, Mwangi-Powell F, Adewole IF, Soyannwo O, Amandua J, Ogaja E, Okpeseyi M, Ali Z, Kiwanuka R, Merriman A. Improving access to analgesic drugs for patients with cancer in sub-Saharan Africa. Lancet Oncol 2013; 14:e176-82. [PMID: 23561749 DOI: 10.1016/s1470-2045(12)70343-1] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
WHO expects the burden of cancer in sub-Saharan Africa to grow rapidly in coming years and for incidence to exceed 1 million per year by 2030. As a result of late presentation to health facilities and little access to diagnostic technology, roughly 80% of cases are in terminal stages at the time of diagnosis, and a large proportion of patients have moderate to severe pain that needs treatment with opioid analgesics. However, consumption of opioid analgesics in the region is low and data suggest that at least 88% of cancer deaths with moderate to severe pain are untreated. Access to essential drugs for pain relief is limited by legal and regulatory restrictions, cultural misperceptions about pain, inadequate training of health-care providers, procurement difficulties, weak health systems, and concerns about diversion, addiction, and misuse. However, recent initiatives characterised by cooperation between national governments and local and international non-governmental organisations are improving access to pain relief. Efforts underway in Uganda, Kenya, and Nigeria provide examples of challenges faced and innovative approaches adopted and form the basis of a proposed framework to improve access to pain relief for patients with cancer across the region.
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Affiliation(s)
- Megan O'Brien
- Global Access to Pain Relief Initiative, Union for International Cancer Control and American Cancer Society, Washington, DC 20004, USA.
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Dekker AM, Amon JJ, le Roux KW, Gaunt CB. "What is killing me most": chronic pain and the need for palliative care in the Eastern Cape, South Africa. J Pain Palliat Care Pharmacother 2013; 26:334-40. [PMID: 23216172 DOI: 10.3109/15360288.2012.734897] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Palliative care and the provision of pain relief medicine are essential components of health care, yet little research has been conducted on access to pain medicine in rural areas of sub-Saharan Africa. The objective of this study was to examine patient experiences and health care provider attitudes towards chronic pain and palliative care in Eastern Cape Province, South Africa. The study used a mixed-methods approach to evaluate experience of chronic pain in a district hospital and associated clinics. Questionnaires and in-depth interviews were conducted with 45 current and former patients receiving care and 26 health care providers. Forty-six percent (n = 19) of patients rated their pain in the last month as severe. Thirty-nine percent (n = 17) of individuals stated that they had never been provided with an explanation for the cause of their pain. Multiple regression analysis found that being female, not having received a social welfare grant, and not having received an explanation for the cause of pain were associated with higher ratings of pain (P < .10 for each variable). Factors inhibiting the provision of palliative care included insufficient access and availability of pain medication and providers' association of palliative care with end-of-life care. Adequate pain relief is often deprioritized in a busy health care setting. Ensuring patients receive sufficient relief for their pain requires interventions at clinical and policy levels, including the provision of needed pain medication and training in palliative care for all providers.
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Affiliation(s)
- Annette M Dekker
- Woodrow Wilson School of Public and International Affairs, Princeton University, Princeton, New Jersey, USA.
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Gilson AM, Maurer MA, Lebaron VT, Ryan KM, Cleary JF. Multivariate analysis of countries' government and health-care system influences on opioid availability for cancer pain relief and palliative care: more than a function of human development. Palliat Med 2013; 27:105-14. [PMID: 23104512 DOI: 10.1177/0269216312461973] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Many international governmental and nongovernmental organizations regard unrelieved cancer pain as a significant global public health problem. Although opioids such as morphine are considered essential medicines in the provision of palliative care and for treating cancer pain, especially when the pain is severe, low- and middle-income countries often lack such medications. AIM The primary aim of this study was to examine countries' government and health-care system influences on opioid availability for cancer pain and palliative care, as a means to identify implications for improving appropriate access to prescription opioids. DESIGN A multivariate regression of 177 countries' consumption of opioids (in milligrams/death from cancer and AIDS) contained country-level predictor variables related to public health, including Human Development Index, palliative care infrastructure, and health system resources and expenditures. RESULTS Results were highly explanatory (adjusted R(2) = 82%) and Human Development Index was the most predictive variable when controlling for all other factors in the statistical model (B = 11.875, confidence interval = 10.216, 13.534, p < 0.0001). CONCLUSIONS Study findings demonstrate that a limited number of predictor variables characterizing a country's government and health-care system infrastructure can explain its opioid consumption level, with the greatest influence being very high Human Development Index. However, Human Development Index is not the most policy-relevant factor, and this finding should be reconciled against the reality that many countries with low or medium Human Development Index have succeeded in creating and sustaining a health-care system to strengthen cancer pain care and palliative care, including through the appropriate use of essential prescription opioids.
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Affiliation(s)
- Aaron M Gilson
- Pain & Policy Studies Group, University of Wisconsin Carbone Cancer Center, University of Wisconsin, Madison, WI, USA
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Current state of palliative and end-of-life care in home versus inpatient facilities and urban versus rural settings in Africa. Palliat Support Care 2013; 11:425-42. [DOI: 10.1017/s1478951512000612] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractObjective:Because palliative care in sub-Saharan Africa may not fit the style of delivery of palliative care in the global north, exploring the evidence can serve to reduce existing barriers and help streamline national policies that determine the optimal setting to implement formal palliative and end-of-life services.Method:A search was conducted in Ovid MEDLINE®, PubMed, and Google Scholar databases using the search terms nursing care, terminal care, end of life care, palliative care, dying, death, hospice, opioids, morphine, Africa, sub-Saharan Africa, caregivers, and place of death. Eighty-seven relevant articles were found using the search terms. Of these, 22 matched inclusion criteria and were reviewed.Results:Opioid availability and distribution is best accessed at the inpatient level, and hence, pain and end-of-life symptoms are best managed at the inpatient level. Despite the great need, nurses’ lack of prescription power in the home-based setting is a shortcoming. Home deaths have not been adequately studied, but research suggests that palliative care generally causes economic strain, psychosocial distress on family members, and increased risk of transmission of communicable disease. Hospice is understudied but shows favorable outcomes.Significance of results:Funding and research need to focus on development of inpatient palliative and hospice care units in urban areas. In rural areas, the priority should be a home-based care model that involves nurses who are privileged to prescribe opioids and adjunctive medication therapies.
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Namisango E, Harding R, Atuhaire L, Ddungu H, Katabira E, Muwanika FR, Powell RA. Pain among ambulatory HIV/AIDS patients: multicenter study of prevalence, intensity, associated factors, and effect. THE JOURNAL OF PAIN 2012; 13:704-13. [PMID: 22748803 DOI: 10.1016/j.jpain.2012.04.007] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/27/2011] [Revised: 04/05/2012] [Accepted: 04/30/2012] [Indexed: 12/01/2022]
Abstract
UNLABELLED This study aimed to determine the prevalence, intensity, associated factors, and effect of pain among ambulatory HIV/AIDS patients. Three-hundred two adult ambulatory HIV/AIDS patients were consecutively recruited from HIV/AIDS outpatient clinics at 2 teaching hospitals in Uganda. The presence and intensity of pain were self-reported using the Brief Pain Inventory (BPI); symptom data were collected using the Memorial Symptom Assessment Scale (MSAS-SF); and quality of life (QOL) was assessed using the Medical Outcome Scale-HIV. Forty-seven percent reported pain in the 7 days prior to the survey and pain was a symptom at the time of diagnosis for 68%. On the 0 to 10 numeric scale, 53% reported mild pain (1-4 rating), 20% reported moderate pain (5-6 rating) while 27% reported severe pain (7-10 rating). Gender was not associated with pain intensity, but reduced functional performance, increasing number of symptoms, advanced HIV disease , physical symptom distress (MSAS-SF), and number of health comorbidities were significantly associated with pain intensity (P < .04). Increasing pain intensity was associated with greater functional ability impairment (BPI functional interference index) and poorer QOL. Pain is a common symptom among ambulatory HIV/AIDS patients and has a debilitating effect on QOL. There is a significant unmet need for pain relief in the population. PERSPECTIVE This article discusses the characteristics and effect of pain on function and QOL in East African patients. It also contributes information on characteristics of HIV/AIDS adult patients in the East Africa demonstrating the aspects in which pain is similar across different cultures.
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Affiliation(s)
- Eve Namisango
- African Palliative Care Association, Kampala, Uganda.
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Huang KT, Owino C, Vreeman RC, Hagembe M, Njuguna F, Strother RM, Gramelspacher GP. Assessment of the face validity of two pain scales in Kenya: a validation study using cognitive interviewing. BMC Palliat Care 2012; 11:5. [PMID: 22512923 PMCID: PMC3393614 DOI: 10.1186/1472-684x-11-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2011] [Accepted: 04/18/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Patients in sub-Saharan Africa commonly experience pain, which often is un-assessed and undertreated. One hindrance to routine pain assessment in these settings is the lack of a single-item pain rating scale validated for the particular context. The goal of this study was to examine the face validity and cultural acceptability of two single-item pain scales, the Numerical Rating Scale (NRS) and the Faces Pain Scale-Revised (FPS-R), in a population of patients on the medical, surgical, and pediatric wards of Moi Teaching and Referral Hospital in Kenya. METHODS Swahili versions of the NRS and FPS-R were developed by standard translation and back-translation. Cognitive interviews were performed with 15 patients at Moi Teaching and Referral Hospital in Eldoret, Kenya. Interview transcripts were analyzed on a question-by-question basis to identify major themes revealed through the cognitive interviewing process and to uncover any significant problems participants encountered with understanding and using the pain scales. RESULTS Cognitive interview analysis demonstrated that participants had good comprehension of both the NRS and the FPS-R and showed rational decision-making processes in choosing their responses. Participants felt that both scales were easy to use. The FPS-R was preferred almost unanimously to the NRS. CONCLUSIONS The face validity and acceptability of the Swahili versions of the NRS and FPS-R has been demonstrated for use in Kenyan patients. The broader application of these scales should be evaluated and may benefit patients who currently suffer from pain.
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Affiliation(s)
- Kristin Tl Huang
- USAID - Academic Model Providing Access to Healthcare (AMPATH), P,O, Box 4806, Eldoret, Kenya.
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Harding R, Selman L, Agupio G, Dinat N, Downing J, Gwyther L, Mashao T, Mmoledi K, Moll T, Sebuyira LM, Ikin B, Higginson IJ. Prevalence, burden, and correlates of physical and psychological symptoms among HIV palliative care patients in sub-Saharan Africa: an international multicenter study. J Pain Symptom Manage 2012; 44:1-9. [PMID: 22658471 DOI: 10.1016/j.jpainsymman.2011.08.008] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2011] [Revised: 08/10/2011] [Accepted: 09/01/2011] [Indexed: 10/28/2022]
Abstract
CONTEXT Despite HIV remaining life limiting and incurable, very little clinical research focus has been given to the prevalence and related burden of physical and psychological symptoms for those accessing palliative care. Despite evidence of problems persisting throughout the trajectory and alongside treatment, scant attention has been paid to these manageable problems. OBJECTIVES This study aimed to measure the seven-day period prevalence and correlates of physical and psychological symptoms, and their associated burden, in HIV-infected individuals attending palliative care centers in sub-Saharan Africa. METHODS Consecutive patients in five care centers across two countries completed the Memorial Symptom Assessment Scale-Short Form, with additional demographic and disease-oriented variables. RESULTS Two hundred twenty-four patients participated. The most common symptoms were pain in the physical dimension (82.6%) and worry in the psychological dimension (75.4%). Interestingly, 71.4% reported hunger. Women, and those with worse physical function, were more likely to experience burden. However, being on antiretroviral therapy (ART) was not associated with global, physical, or psychological symptom burden. CONCLUSION This study is the first to report physical and psychological symptom burden in HIV-infected populations receiving palliative care in sub-Saharan Africa. Despite increasing access to ART, these burdensome and manageable problems persist. The assessment of these problems is essential alongside assessment of ART virological outcomes.
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Affiliation(s)
- Richard Harding
- Department of Palliative Care, Policy, and Rehabilitation and The Cicely Saunders Institute of Palliative Care, King's College London, London, United Kingdom.
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Simms V, Higginson IJ, Harding R. Integration of palliative care throughout HIV disease. THE LANCET. INFECTIOUS DISEASES 2012; 12:571-5. [PMID: 22691838 DOI: 10.1016/s1473-3099(12)70085-3] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
People with HIV have a high burden of pain and physical, psychological, and social difficulties that can be managed effectively with palliative care. However, most individuals do not have access to this type of care. Palliative care is holistic patient-centred management of life-limiting progressive disorders and is recognised by WHO as an essential element of HIV care, from diagnosis to end of life. Historically, palliative care and HIV care were linked closely, but misconceptions divide the two disciplines today. Palliative care can augment patients' outcomes and boost adherence to antiretroviral treatments and life expectancy. In much of the world, services providing palliative care are isolated, and most individuals in need have no access to this care. The commitment to provide palliative care for all people with HIV can be fulfilled if clinical workers are trained in this therapeutic approach and if care is delivered at community level, with support for family caregivers.
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Affiliation(s)
- Victoria Simms
- London School of Hygiene and Tropical Medicine, London, UK.
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Mphahlele NR, Mitchell D, Kamerman PR. Pain in ambulatory HIV-positive South Africans. Eur J Pain 2011; 16:447-58. [PMID: 22337525 DOI: 10.1002/j.1532-2149.2011.00031.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2011] [Indexed: 11/05/2022]
Abstract
We investigated the prevalence and intensity of pain, factors associated with having pain, and analgesic medications employed in a population consisting predominantly of Black African and female human immunodeficiency virus (HIV)-positive individuals attending outpatient clinics in a rural (n = 125; 79% female; 100% Black African) and a metropolitan (n = 396; 75% female; 94% Black African) area of South Africa. Pain intensity, interference and treatment were assessed using the Wisconsin Brief Pain Questionnaire. Seventy-two percent of rural participants and 56% of metropolitan participants had pain at the time of the interview, and this pain was moderate to severe in intensity in 60% of rural participants and 59% of metropolitan participants. Forty-six percent of rural participants and 61% of metropolitan participants had multiple pain sites. The most common pain sites in rural participants were the abdomen (30%), chest (26%), head (19%) and genitals (15%), while in the metropolitan cohort the head (39%), feet (33%), chest (30%) and abdomen (20%) were the most common sites. In the rural cohort, antiretroviral therapy was independently associated with reduced risk of pain, while in the metropolitan cohort increasing age was weakly, but independently associated with having pain. Pharmacological management of pain was poor, with 29% of rural participants and 55% of metropolitan participants with pain not receiving any treatment. Of those receiving treatment, no participants were receiving strong opioids, and only 3% of metropolitan participants were receiving a weak opioid. Thus, HIV-related pain is common and is poorly treated in both the rural and metropolitan setting in South Africa.
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Affiliation(s)
- N R Mphahlele
- Brain Function Research Group, School of Physiology, Faculty of Health Sciences, University of the Witwatersrand, 7 York Road, Parktown, 2193, South Africa
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Kamerman PR, Mitchell D. Current perspectives on HIV-related pain and its management: insights from sub-Saharan Africa. Pain Manag 2011; 1:587-96. [DOI: 10.2217/pmt.11.65] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
SUMMARY Sub-Saharan Africa is the region worst affected by the HIV epidemic and we estimate that at least 10 million HIV-positive individuals in sub-Saharan Africa live with significant pain related to their disease. Until recently there was a lack of studies specifically addressing pain related to HIV infection in sub-Saharan Africa, which limited our understanding of the scope of the problem. Here we describe the current nature of the epidemic of HIV-related pain in sub-Saharan Africa, including the systematic under-recognition and undertreatment of the pain.
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Affiliation(s)
| | - Duncan Mitchell
- Brain Function Research Group, School of Physiology, Faculty of Health Sciences, University of the Witwatersrand, 7 York Road, Parktown, 2193, South Africa
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Harding R, Selman L, Agupio G, Dinat N, Downing J, Gwyther L, Mashao T, Mmoledi K, Sebuyira LM, Ikin B, Higginson IJ. The prevalence and burden of symptoms amongst cancer patients attending palliative care in two African countries. Eur J Cancer 2011; 47:51-6. [DOI: 10.1016/j.ejca.2010.08.003] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2010] [Revised: 08/04/2010] [Accepted: 08/06/2010] [Indexed: 11/16/2022]
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Harding R, Simms V, Penfold S, McCrone P, Moreland S, Downing J, Powell RA, Mwangi-Powell F, Namisango E, Fayers P, Curtis S, Higginson IJ. Multi-centred mixed-methods PEPFAR HIV care & support public health evaluation: study protocol. BMC Public Health 2010; 10:584. [PMID: 20920241 PMCID: PMC2955697 DOI: 10.1186/1471-2458-10-584] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2010] [Accepted: 09/29/2010] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND A public health response is essential to meet the multidimensional needs of patients and families affected by HIV disease in sub-Saharan Africa. In order to appraise current provision of HIV care and support in East Africa, and to provide evidence-based direction to future care programming, and Public Health Evaluation was commissioned by the PEPFAR programme of the US Government. METHODS/DESIGN This paper described the 2-Phase international mixed methods study protocol utilising longitudinal outcome measurement, surveys, patient and family qualitative interviews and focus groups, staff qualitative interviews, health economics and document analysis. Aim 1) To describe the nature and scope of HIV care and support in two African countries, including the types of facilities available, clients seen, and availability of specific components of care [Study Phase 1]. Aim 2) To determine patient health outcomes over time and principle cost drivers [Study Phase 2]. The study objectives are as follows. 1) To undertake a cross-sectional survey of service configuration and activity by sampling 10% of the facilities being funded by PEPFAR to provide HIV care and support in Kenya and Uganda (Phase 1) in order to describe care currently provided, including pharmacy drug reviews to determine availability and supply of essential drugs in HIV management. 2) To conduct patient focus group discussions at each of these (Phase 1) to determine care received. 3) To undertake a longitudinal prospective study of 1200 patients who are newly diagnosed with HIV or patients with HIV who present with a new problem attending PEPFAR care and support services. Data collection includes self-reported quality of life, core palliative outcomes and components of care received (Phase 2). 4) To conduct qualitative interviews with staff, patients and carers in order to explore and understand service issues and care provision in more depth (Phase 2). 5) To undertake document analysis to appraise the clinical care procedures at each facility (Phase 2). 6) To determine principle cost drivers including staff, overhead and laboratory costs (Phase 2). DISCUSSION This novel mixed methods protocol will permit transparent presentation of subsequent dataset results publication, and offers a substantive model of protocol design to measure and integrate key activities and outcomes that underpin a public health approach to disease management in a low-income setting.
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Affiliation(s)
- Richard Harding
- King's College London, Cicely Saunders Institute Department of Palliative Care, Policy and Rehabilitation School of Medicine at Guy's, King's and St Thomas' Hospitals Bessemer Road, London SE5 9PJ, UK
| | - Victoria Simms
- King's College London, Cicely Saunders Institute Department of Palliative Care, Policy and Rehabilitation School of Medicine at Guy's, King's and St Thomas' Hospitals Bessemer Road, London SE5 9PJ, UK
| | - Suzanne Penfold
- King's College London, Cicely Saunders Institute Department of Palliative Care, Policy and Rehabilitation School of Medicine at Guy's, King's and St Thomas' Hospitals Bessemer Road, London SE5 9PJ, UK
| | - Paul McCrone
- King's College London Department of Health Service and Population Research Institute of Psychiatry Box P024, De Crespigny Park London, SE5 8AF, UK
| | - Scott Moreland
- Futures Group One Thomas Circle, NW, Suite 200 Washington DC 20005, USA
| | - Julia Downing
- African Palliative Care Association PO Box 72518 Kampala, Uganda
| | - Richard A Powell
- African Palliative Care Association PO Box 72518 Kampala, Uganda
| | | | - Eve Namisango
- African Palliative Care Association PO Box 72518 Kampala, Uganda
| | - Peter Fayers
- University of Aberdeen Department of Public Health, School of Medicine Polwarth Building Foresterhill, Aberdeen AB25 2ZD, UK
| | - Siân Curtis
- MEASURE Evaluation Project Carolina Population Center University of North Carolina at Chapel Hill, CB 8120 Chapel Hill, NC 27599, USA
| | - Irene J Higginson
- King's College London, Cicely Saunders Institute Department of Palliative Care, Policy and Rehabilitation School of Medicine at Guy's, King's and St Thomas' Hospitals Bessemer Road, London SE5 9PJ, UK
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