"I know he controls cancer": the meanings of religion among Black Caribbean and White British patients with advanced cancer

Living and dying between cultural traditions in African & Caribbean Heritage families: a constructivist grounded theory

BACKGROUND

Ethnic differences influence end-of-life health behaviours and use of palliative care services. Use of formal Advance care planning is not common in minority ethnic heritage communities. Older adults expect and trust their children to be their decision makers at the end of life. The study aim was to construct a theory of the dynamics that underpin end-of-life conversations within families of African and Caribbean heritage. This is a voice not well represented in the current debate on improving end-of-life outcomes.

METHODS

Using Charmaz's constructivist grounded theory approach, a purposive sample of elders, adult-children, and grandchildren of African and Caribbean Heritage were recruited. In-person and online focus groups were conducted and analysed using an inductive, reflexive comparative analysis process. Initial and axial coding facilitated the creation of categories, these categories were abstracted to constructs and used in theory construction.

RESULTS

Elders (n = 4), adult-children (n = 14), and adult grandchildren (n = 3) took part in 5 focus groups. A grounded theory of living and dying between cultural traditions in African and Caribbean heritage families was created. The constructs are (a) Preparing for death but not for dying (b) Complexity in traditions crosses oceans (c) Living and dying between cultures and traditions (d) There is culture, gender and there is personality (e) Watching the death of another prompts conversations. (f) An experience of Hysteresis.

DISCUSSION

African and Caribbean cultures celebrate preparation for after-death processes resulting in early exposure to and opportunities for discussion of these processes. Migration results in reforming of people's habitus/ world views shaped by a mixing of cultures. Being in different geographical places impacts generational learning-by-watching of the dying process and related decision making.

CONCLUSIONS

Recognising the impact of migration on the roles of different family members and the exposure of those family members to previous dying experiences is important. This can provide a more empathetic and insightful approach to partnership working between health care professionals and patients and families of minority ethic heritage facing serious illness. A public health approach focusing on enabling adult-children to have better end of life conversations with their parents can inform the development of culturally competent palliative care.

The Use of Religious Capital as a Coping Strategy in Self-care by Type 2 Diabetes Patients in a Ghanaian Hospital

Given the importance Ghanaians attribute to spirituality and religiosity in terms of disease causation and management, this study explored the use of religious capital as a coping strategy by individuals with type 2 diabetes mellitus in self-care at the Techiman Holy Family Hospital Diabetes Clinic in the Bono East Region of Ghana. An exploratory descriptive qualitative research design was employed for the study. Semi-structured interviews were conducted with a convenience sample of twenty-seven (27) individuals recruited from the diabetes clinic. Content analysis was employed to find themes, which included: (1) Use of Prayer and Fasting for Courage from God, (2) Reliance on God as the Creator of Human Beings who Cures and Heals Diseases in the Body, (3) God as Source of life in times of Illness (Drawing life from God in times of illness), (4) Faith and Hope in God, and (5) Doctors and Nurses as Substitutes for God. The findings advocate the need to incorporate religiosity and spirituality into the provision of healthcare for individuals with diabetes to help them live productive lives.

Spiritual coping behaviors among injured urban black men in Philadelphia

PURPOSE

High rates of firearm injury among urban Black men in the US can lead to long physical and psychological recovery times, worsened by limited access to mental health services. Spirituality can propel positive thoughts, actions, perceptions and behaviors about self and others yet how it is used among Black men recovering from firearm injury is underexplored. This study examined the role of spirituality in the recovery of Black male survivors of firearm injury.

METHOD

Ten injured urban Black men in Philadelphia were interviewed using descriptive phenomenology. A subset of participants from the Emotional Responses and Recovery from Injury in Urban Black Men study who agreed to be recontacted for future studies were enrolled. Informed consent was obtained, semi-structured interviews were conducted via phone and were audiotaped, transcribed, and de-identified. Thematic content analysis was used to understand perceptions of spirituality and to identify spiritual coping behavior themes.

RESULTS

Findings suggest that injured urban Black men engaged in theistic and non-theistic spiritual activities that resulted in positive character development, reduced risk of re-injury, hope, improved mental health and social bonds.

CONCLUSION

Spirituality may serve as a protective factor against firearm re-injury or retaliation by promoting desired behaviors and mental health among injured urban Black men. Combining culturally sensitive spiritual resources and psychotherapy may lead to effective trauma-informed care in addressing spiritual and existential challenges of injured urban Black men who may find spirituality important.

Investigating ethnic inequalities in hearing aid use in England and Wales: a cross-sectional study

OBJECTIVE

To establish whether ethnic inequalities exist in levels of self-reported hearing difficulty and hearing aid use among middle-aged adults.

DESIGN

Cross-sectional data from the UK Biobank resource.

STUDY SAMPLE

164,460 participants aged 40-69 who answered hearing questions at an assessment centre in England or Wales.

RESULTS

After taking into account objectively assessed hearing performance and a corresponding correction for bias in non-native English speakers, as well as a range of correlates including demographic, socioeconomic, and health factors, there were lower levels of hearing aid use for people from Black African (OR 0.36, 95% CI 0.17-0.77), Black Caribbean (OR 0.38, 95% CI 0.22-0.65) and Indian (OR 0.60, 95% CI 0.41-0.86) ethnic groups, compared to the White British or Irish group. Men from most ethnic minority groups and women from Black African, Black Caribbean and Indian groups were less likely to report hearing difficulty than their White British or Irish counterparts.

CONCLUSIONS

For equivalent levels of hearing loss, the use of hearing aids is lower among ethnic minority groups. Inequalities are partly due to lower levels of self-reported hearing difficulty among minority groups. However, even when self-reported hearing difficulty is considered, hearing aid use remains lower among many ethnic minority groups.

Unique Considerations in Early Detection, Risk, and Awareness of Endometrial Cancer in Black Women

Endometrial cancer is the most common gynecologic cancer in the United States. Over the last several decades, the incidence of aggressive tumors, and thus the rate of death from disease, has increased significantly. The population most affected by these epidemiologic shifts are Black women. Symptom awareness, lack of treatment access, and failure of providers to provide guideline-concordant care are just some of the drivers behind these changes. Race as a social construct has historically categorized women into groups that are not reflective of the nuanced personalization that is required for cancer prevention strategies and targeted cancer treatments. There is, however, an increasing understanding that disaggregation by place of birth and social context are important to understand care-seeking behaviors, genetic drivers of disease, and factors that lead to deleterious outcomes. In this review, we will focus on specific individual-level influences that impact disease diagnosis and care-seeking among Black women, recognizing that the global disparities which exist in this disease encompass multiple domains. Such considerations are crucial to understanding drivers of self-efficacy and to develop programs for knowledge awareness and empowerment within a framework that is both useful and acceptable to these diverse communities at risk.

Researching minoritised communities in palliative care: An agenda for change

BACKGROUND

Palliative care access, experiences and outcomes of care disadvantage those from ethnically diverse, Indigenous, First nation and First people communities. Research into this field of inquiry raises unique theoretical, methodological, and moral issues. Without the critical reflection of methods of study and reporting of findings, researchers may inadvertently compromise their contribution to reducing injustices and perpetuating racism.

AIM

To examine key evidence of the place of minoritised communities in palliative care research to devise recommendations that improve the precision and rigour of research and reporting of findings.

METHODS

Narrative review of articles identified from PubMed, CINAHL and Google Scholar for 10 years augmented with supplementary searches.

RESULTS

We identified and appraised 109 relevant articles. Four main themes were identified (i) Lack of precision when working with a difference; (ii) 'black box epidemiology' and its presence in palliative care research; (iii) the inclusion of minoritised communities in palliative care research; and (iv) the potential to cause harm. All stymie opportunities to 'level up' health experiences and outcomes across the palliative care spectrum.

CONCLUSIONS

Based on the findings of this review palliative care research must reflect on and justify the classification of minoritised communities, explore and understand intersectionality, optimise data quality, decolonise research teams and methods, and focus on reducing inequities to level up end-of-life care experiences and outcomes. Palliative care research must be forthright in explicitly indentifying instances of structural and systemic racism in palliative care research and engaging in non-judgemental debate on changes required.

Barriers and facilitators to accessing and utilising post-treatment psychosocial support by Black men treated for prostate cancer-a systematic review and qualitative synthesis

PURPOSE

To synthesise findings from published studies on barriers and facilitators to Black men accessing and utilising post-treatment psychosocial support after prostate cancer (CaP) treatment.

METHODS

Searches of Medline, Embase, PsycInfo, Cochrane Database of Systematic Reviews and Central, CINAHL plus and Scopus were undertaken from inception to May 2021. English language studies involving Black men aged ≥18 and reporting experiences of, or suggestions for, psychosocial support after CaP treatment were included. Low or moderate quality studies were excluded. Searches identified 4,453 articles and following deduplication, 2,325 were screened for eligibility. Two independent reviewers carried out screening, quality appraisal and data extraction. Data were analysed using thematic synthesis.

RESULTS

Ten qualitative studies involving 139 Black men were included. Data analysis identified four analytical constructs: experience of psychosocial support for dealing with treatment side effects (including impact on self-esteem and fear of recurrence); barriers to use of psychosocial support (such as perceptions of masculinity and stigma around sexual dysfunction); facilitators to use of psychosocial support (including the influence of others and self-motivation); and practical solutions for designing and delivering post-treatment psychosocial support (the need for trusted healthcare and cultural channels).

CONCLUSIONS

Few intervention studies have focused on behaviours among Black CaP survivors, with existing research predominantly involving Caucasian men. There is a need for a collaborative approach to CaP care that recognises not only medical expertise but also the autonomy of Black men as experts of their illness experience, and the influence of cultural and social networks.

Self-Management in Older Pakistanis Living With Multimorbidity in East London

In this article, we explore how older British Pakistani people experience multimorbidity (defined as the coexistence of two or more medical conditions) and engage with self-management within the context of their life histories and relationships. We conducted biographical narrative interviews in Urdu and/or English with 15 first-generation Pakistani migrants living with multimorbidity, at their homes in East London. Our analysis showed that the triadic construct of family, faith, and health was central to how participants made sense of their lives, constituting notions of "managing" in the context of multimorbidity. For Pakistani patients, the lived experience of health was inseparable from a situated context of family and faith. Our findings have implications for existing public health strategies of self-management, underpinned by neoliberal discourses that focus on individual responsibility and agency. Health care provision needs to better integrate the importance of relationships between family, faith, and health when developing services for these patients.

Feasibility and acceptability of a culturally adapted advance care planning intervention for people living with advanced cancer and their families: A mixed methods study

BACKGROUND

Increasing evidence shows that advance care planning is effective in improving outcomes. However, its applicability and acceptability outside Western cultures remain unknown. Examination of relevant cultural adaptations is required prior to wider adoption.

AIM

To examine the feasibility and acceptability of a culturally adapted advance care planning intervention in a Taiwanese inpatient hospital for advanced cancer patients, family members and healthcare professionals.

METHODS

A single-group, non-controlled, mixed methods feasibility study guided by a previously developed logic model. The culturally adapted advance care planning intervention represented a one-time intervention, comprising pre-advance care planning preparation and follow-up consultation. Qualitative interviews explored participants' view on their involvement in the study. Patients' medical records were examined to assess intervention fidelity. Findings from both data sets were integrated following analysis.

RESULTS

N = 29 participants (n = 10 patients; n = 10 family members and n = 9 healthcare professionals) participated in the intervention, of who 28 completed follow-up interviews. Of the 10 advance care planning interventions delivered, most components (n = 10/13) were met. Key contextual moderators influencing the intervention feasibility included: (1) resource constraints resulting in increased workload; (2) care decisions informed by relatives' experiences of care; (3) the requirement for financial and policy support; and (4) a presumption for end-of-life care provision and surrogate decision-making. Six areas of intervention refinement were identified for future research.

CONCLUSION

Implementing a culturally adapted advance care planning intervention in an inpatient hospital setting in Taiwan is possible. The participants reported the intervention to be acceptable. However, careful attention to the conceptual underpinning using local primary data is imperative for its success.

Religious Belief and Social Support Among Cancer Patients in Saudi Arabia

Background People with cancer usually experience some degree of depression, anxiety, and fear, as if embracing the fact that cancer has become part of their lives. Additionally, religious beliefs can influence a patient's support system, as well as the patient's own emotional response, behavior, and decision-making, which can create a conflict with medical treatment. The objective of this study was to assess cancer patients' religious beliefs and social support. Methods A cross-sectional study was conducted in 294 adult patients at the Comprehensive Cancer Center of King Fahad Medical City in Riyadh, Saudi Arabia. Patients were interviewed using the System of Belief Inventory (SBI-15R) questionnaire, and responses were noted in the survey form. Results The majority (82.3%) of patients were newly diagnosed with cancer and in the treatment phase, whereas 9.9% were in the metastatic phase. The total mean score of the SBI-15R scale was 27.9. The mean score of the social support subscale was 13.1 ± 1.68, whereas the mean score for the beliefs and practice subscale was 29.7 ± 0.81. For the social support subscale, a statistically significant difference was found in age (P < 0.001), gender (P < 0.001), and occupation (P = 0.009). However, for the beliefs and practice subscale, a statistically significant difference was found only with gender (P = 0.001).  Conclusions This study concluded that social support is important for the study participants, and they were attached to their beliefs and cultural practices, as indicated by the high total mean score on the SBI-15R. Understanding this topic is important in order for healthcare organizations to provide holistic patient care.

Perspectives of elders and their adult children of Black and minority ethnic heritage on end-of-life conversations: A meta-ethnography

BACKGROUND

People of Black and minority ethnic heritage are more likely to die receiving life supporting measures and less likely to die at home. End-of-life care decision making often involves adult children as advance care planning is uncommon in these communities. Physicians report family distress as being a major factor in continuing with futile care.

AIM

To develop a deeper understanding of the perspectives of elders of Black and minority ethnic heritage and their children, about end-of-life conversations that take place within the family, using a meta-ethnographic approach.

DESIGN

Systematic interpretive exploration using the process of meta-ethnography was utilised.

DATA SOURCES

CINAHL, MEDLINE, PubMed and PsycINFO databases were searched. Inclusion criteria included studies published between 2005 and 2019 and studies of conversations between ethnic minority elders and family about end-of-life care. Citation snowballing was used to ensure all appropriate references were identified. A total of 13 studies met the inclusion criteria and required quality level using Critical Appraisal Skills Programme.

RESULTS

The following four storylines were constructed: 'My family will carry out everything for me; it is trust'; 'No Mum, don't talk like that'; 'I leave it in God's hands'; and 'Who's going to look after us?' The synthesis reflected the dichotomous balance of trust and burden avoidance that characterises the perspectives of Black and minority ethnic elders to end-of-life care planning with their children.

Methods for overcoming barriers in palliative care for ethnic/racial minorities: a systematic review

OBJECTIVES

Ethnic/racial minority groups are less likely to discuss issues involving end-of-life treatment preferences and utilize palliative care or hospice services. Some barriers may be differences in language, religion, lower levels of health literacy, or less access to healthcare services and information. The purpose of this article is to conduct a systematic review on interventional studies that investigated methods to overcome the barriers faced by ethnic/racial minorities when accessing end-of-life services, including completing advanced directives, accepting palliative care, and enrolling in hospice.

METHODS

Literature searches using four standard scientific search engines were conducted to retrieve articles detailing original research in an interventional trial design. All studies were conducted in an outpatient setting, including primary care visits, home visits, and dialysis centers. Target populations were those identified from ethnic or racial minorities.

RESULTS

Nine articles were selected to be included in the final review. All were full-text English language articles, with target populations including African Americans, Hispanic or Latinos, and Asian or Pacific Islanders. Measured outcomes involved level of comfort in discussing and knowledge of palliative care services, desire for aggressive care at the end-of-life, completion of advance directives, and rate of enrollment in hospice.

SIGNIFICANCE OF RESULTS

Three main avenues of interventions included methods to enhance patient education, increase access to healthcare, or improve communication to establish better rapport with target population. Studies indicate that traditional delivery of healthcare services may be insufficient to recruit patients from ethnic/racial minorities, and outcomes can be improved by implementing tailored interventions to overcome barriers.

Culture and Palliative Care: Preferences, Communication, Meaning, and Mutual Decision Making

Palliative care is gaining acceptance across the world. However, even when palliative care resources exist, both the delivery and distribution of services too often are neither equitably nor acceptably provided to diverse population groups. The goal of this study was to illustrate tensions in the delivery of palliative care for diverse patient populations to help clinicians to improve care for all. We begin by defining and differentiating culture, race, and ethnicity, so that these terms-often used interchangeably-are not conflated and are more effectively used in caring for diverse populations. We then present examples from an integrative literature review of recent research on culture and palliative care to illustrate both how and why varied responses to pain and suffering occur in different patterns, focusing on four areas of palliative care: the formation of care preferences, communication patterns, different meanings of suffering, and decision-making processes about care. For each area, we provide international and multiethnic examples of variations that emphasize the need for personalization of care and the avoidance of stereotyping beliefs and practices without considering individual circumstances and life histories. We conclude with recommendations for improving palliative care research and practice with cultural perspectives, emphasizing the need to work in partnerships with patients, their family members, and communities to identify and negotiate culturally meaningful care, promote quality of life, and ensure the highest quality palliative care for all, both domestically and internationally.

The sociology of cancer: a decade of research

Biomedicine is often presented as the driving force behind improvements in cancer care, with genomics the latest innovation poised to change the meaning, diagnosis, treatment, prevention and lived experience of cancer. Reviewing sociological analyses of a diversity of patient and practitioner experiences and accounts of cancer during the last decade (2007-17), we explore the experiences of, approaches to and understandings of cancer in this period. We identify three key areas of focus: (i) cancer patient experiences and identities; (ii) cancer risk and responsibilities and (iii) bioclinical collectives. We explore these sociological studies of societal and biomedical developments and how sociologists have sought to influence developments in cancer identities, care and research. We end by suggesting that we extend our understanding of innovations in the fields of cancer research to take better account of these wider social and cultural innovations, together with patients, activists' and sociologists' contributions therein.

Spiritual Well-being in Patients With Metastatic Colorectal Cancer Receiving Noncurative Chemotherapy: A Qualitative Study

BACKGROUND

Spiritual well-being (SWB) is an important quality-of-life dimension for cancer patients in the palliative phase. Therefore, it is important for healthcare professionals to recognize the concept of SWB from the patient's point of view. A deeper understanding of how patients experience and reflect upon these issues might influence patient care.

OBJECTIVES

The aim of this study was to explore SWB in colorectal cancer patients receiving chemotherapy in the palliative phase.

METHODS

We used a qualitative method of in-depth interviews and a hermeneutic editing approach for the analyses and interpretations.

RESULTS

Twenty colorectal cancer patients in the palliative phase, aged 34 to 75 years, were included: 12 patients were receiving first-line chemotherapy, and 8 patients were receiving second-line chemotherapy. Through empirical analyses, we identified subthemes according to the SWB dimensions defined by the European Organisation for Research and Treatment of Cancer quality-of-life group. Under the SWB dimension, (i) relationships with self and others, we identified the subthemes: (a) strategies for inner harmony and (b) sharing feelings with significant others. Under the dimension, (ii) existential issues, we identified the subtheme (c) coping with end-of-life thoughts. Under the dimension, (iii) specifically religious and/or spiritual beliefs and practices, we identified the subtheme (d) seeking faith as inner support.

CONCLUSION

Knowledge about cancer patients' use of different strategies to increase their SWB may help healthcare professionals to guide patients through this vulnerable phase.

IMPLICATION FOR PRACTICE

Healthcare professionals need sufficient courage and willingness to share their patients' thoughts, beliefs, and grief to be able to guide patients toward improving their SWB.

African American elders' psychological-social-spiritual cultural experiences across serious illness: an integrative literature review through a palliative care lens

Disparities in palliative care for seriously ill African American elders exist because of gaps in knowledge around culturally sensitive psychological, social, and spiritual care. The purpose of this integrative literature review is to summarize the research examining African American elders' psychological, social, and spiritual illness experiences. Of 108 articles, 60 quantitative, 42 qualitative, and 6 mixed methods studies were reviewed. Negative and positive psychological, social, and spiritual experiences were noted. These experiences impacted both the African American elders' quality of life and satisfaction with care. Due to the gaps noted around psychological, social, and spiritual healing and suffering for African American elders, palliative care science should continue exploration of seriously ill African American elders' psychological, social, and spiritual care needs.

Supportive Care: Communication Strategies to Improve Cultural Competence in Shared Decision Making

Historic migration and the ever-increasing current migration into Western countries have greatly changed the ethnic and cultural patterns of patient populations. Because health care beliefs of minority groups may follow their religion and country of origin, inevitable conflict can arise with decision making at the end of life. The principles of truth telling and patient autonomy are embedded in the framework of Anglo-American medical ethics. In contrast, in many parts of the world, the cultural norm is protection of the patient from the truth, decision making by the family, and a tradition of familial piety, where it is dishonorable not to do as much as possible for parents. The challenge for health care professionals is to understand how culture has enormous potential to influence patients' responses to medical issues, such as healing and suffering, as well as the physician-patient relationship. Our paper provides a framework of communication strategies that enhance crosscultural competency within nephrology teams. Shared decision making also enables clinicians to be culturally competent communicators by providing a model where clinicians and patients jointly consider best clinical evidence in light of a patient's specific health characteristics and values when choosing health care. The development of decision aids to include cultural awareness could avoid conflict proactively, more productively address it when it occurs, and enable decision making within the framework of the patient and family cultural beliefs.

Ethnic differences in cancer symptom awareness and barriers to seeking medical help in England

BACKGROUND

Ethnic differences in cancer symptom awareness and barriers to seeking medical help in the English population are not fully understood. We aimed to quantify these differences, to help develop more effective health campaigns, tailored to the needs of different ethnic groups.

METHODS

Using a large national data set (n=38 492) of cross-sectional surveys that used the Cancer Research UK Cancer Awareness Measure, we examined how cancer symptom awareness and barriers varied by ethnicity, controlling for socio-economic position, age and gender. Data were analysed using multivariable logistic regression.

RESULTS

Awareness of cancer symptoms was lower in minority ethnic groups than White participants, with the lowest awareness observed among Bangladeshis and Black Africans. Ethnic minorities were more likely than White British to report barriers to help-seeking. South Asians reported the highest emotional barriers, such as lack of confidence to talk to the doctor, and practical barriers, such as worry about many other things. The Irish were more likely than the White British to report practical barriers, such as being too busy to visit a doctor. White British participants were more likely than any other ethnic group to report that they would feel worried about wasting the doctor's time. Overall, Black Africans had the lowest barriers. All differences were statistically significant (P<0.01 level), after controlling for confounders.

CONCLUSIONS

Our findings suggest the need for culturally sensitive and targeted health campaigns, focused on improving recognition of cancer symptoms among ethnic minorities. Campaigns should tackle the specific barriers prevalent in each ethnic group.

Black African and Caribbean British Communities' Perceptions of Memory Problems: "We Don't Do Dementia."

Objectives

We aimed to identify and explore the barriers to help-seeking for memory problems, specifically within UK Black African and Caribbean communities.

Method

We purposively recruited participants from community groups and subsequent snowball sampling, to achieve a maximum variation sample and employed thematic analysis. Our qualitative semi-structured interviews used a vignette portraying a person with symptoms of dementia, and we asked what they or their family should do. We stopped recruiting when no new themes were arising.

Results and significance

We recruited 50 people from a range of age groups, country of origin, time in the UK, religion and socio-economic background. Some of the barriers to presentation with dementia have been reported before, but others were specific to this group and newly identified. Many people recognised forgetfulness but neither that it could be indicative of dementia, nor the concept of dementia as applying to them. Dementia was viewed as a white person’s illness. Participants felt there was little point in consulting a doctor for forgetfulness. Many thought that seeing a GP was only for severe problems. Some said that their culture was secretive and highly valued privacy of personal affairs and therefore did not want to discuss what they regarded as a private and stigmatising problem with a GP. Participants did not appreciate their GP could refer to memory services who have more time and expertise. They were concerned about harm from medication and compulsory institutionalisation. Care should be from the family. Any intervention should emphasise the legitimacy of seeing a doctor early for memory concerns, that dementia is a physical illness which also occurs in the Black community, that help and time are available from memory services whose role is to prolong independence and support families in caring.

Culture and spirituality: essential components of palliative care

Palliative care advocates a holistic, multiprofessional approach to the care of people with life-threatening disease. In addition to the control of physical symptoms attention should also be paid to psychosocial, cultural and spiritual aspects of the patient's experience of illness. Guidance documents and research evidence reflect the complexity of the patient's journey and the need to regularly assess these areas of need over time. Cultural background can shape how patients respond to life-threatening illness, as can the beliefs held by the patients, whether religious or more broadly spiritual. Research evidence shows the importance of identifying and addressing cultural and spiritual aspects of care held by patients, families and staff. These are often neglected in clinical practice due to the focus on biomedical concerns and staff discomfort in engaging with beliefs and culture. Recent studies have highlighted gaps in the research, and some methodological difficulties and indicate many patients welcome healthcare staff enquiring about the importance of their beliefs and culture. Identifying research priorities is necessary to guide future research and strengthen the evidence base.

Cancer fear and fatalism among ethnic minority women in the United Kingdom

Background:

Cancer fear and fatalism are believed to be higher in ethnic minorities and may contribute to lower engagement with cancer prevention and early detection. We explored the levels of cancer fear and fatalism in six ethnic groups in the United Kingdom and examined the contribution of acculturation and general fatalism.

Methods:

A cross-sectional survey of 720 White British, Caribbean, African, Indian, Pakistani, and Bangladeshi women (120 of each) was conducted. Three items assessed cancer fear and two cancer fatalism. Acculturation was assessed using (self-reported) migration status, ability to speak English, and understanding of health leaflets; general fatalism with a standard measure.

Results:

Relative to White British women, African and Indian women were more fearful of cancer, Bangladeshi women less fearful, and Pakistani and Caribbean women were similar to White British women. Cancer fatalism was higher in all the ethnic minority groups compared with White British women. Less acculturated women were less likely to worry (ORs 0.21–0.45, all P<0.05) or feel particularly afraid (ORs 0.11–0.31, all P<0.05) but more likely to feel uncomfortable about cancer (ORs 1.97–3.03, all P<0.05). Lower acculturation (ORs 4.30–17.27, P<0.05) and general fatalism (OR 2.29, P<0.05) were associated with the belief that cancer is predetermined.

Conclusions:

In general, cancer fear and fatalism are more prevalent among ethnic minority than White British women and even more so in less acculturated ethnic minorities. This may affect their participation in cancer prevention and early detection.

From Disease to Holiness: Religious-based health remedies of Italian folk medicine (XIX-XX century)

BACKGROUND

The relationship between spirituality, religion and medicine has been recognized since antiquity. Despite large differences in their history, society, economy and cultures human communities shared a common belief that spirituality and religion played an important role in the healing of diseases.

METHODS

The study of religious remedies used by Italian folk medicine in order to treat diseases was based on a review of literature sources compiled between the late nineteenth century and the early to mid twentieth century.

RESULTS

This approach lead to the unearthing of heterogeneous healing methods that have been divided into different categories: Saints, Pilgrimages, Holy Water/Blessed Oil, Blessings, Religious Objects, Contact, Signs, Formulas and The Religious Calendar. Some of these practices, partly still performed in Italy, are a part of the landscape of the official Catholic Church, others come out of a process of syncretism between the Catholic Religion, the magic world and pre-Christian rituals.

CONCLUSIONS

The vastus corpus of religious remedies, highlighted in the present work, shows the need for spirituality of the sick and represent a symbolic framework, that works as a filter, mediates, containing the pain that constantly fills everyone's lives in remote ages even in the third millennium. All of this confirms how important the health-workers know and interpret these existential needs from anthropological and psychological points of view.

Exploring meanings of illness causation among those severely affected by multiple sclerosis: a comparative qualitative study of Black Caribbean and White British people

Background

Illness attributions, particularly for those living with life limiting illnesses, are associated with emotional adjustment or psychological distress. Few studies have examined attributions among people severely affected by multiple sclerosis (PwMS), and specifically among from diverse communities. This study aimed to explore and compare the presence and construction of meanings among Black Caribbean and White British PwMS.

Methods

Cross sectional qualitative interviews were conducted among Black Caribbean (BC) and White British (WB) PwMS with an EDSS of ≥6.0 (severe disease). Data were analysed using the framework approach.

Results

15 BC and 15 WB PwMS were interviewed. Attributions were complex with most PwMS reporting multiple explanations. Uncertainty, represents the first theme surrounding the aetiology of MS where participants constantly rehearsed the “why me?” question in relation to their illness, a number expressing considerable frustration. The second theme, ‘logical and scientific’, was voiced more often by WB PwMS and accounts for a range of genetic/viral influences, stress, environmental and lifestyle factors. Third, the ‘supernatural’ illness attribution theme departs from a biomedical perspective and was reported often among BC PwMS. This theme included the sub-categories of tests of faith and divine punishment, a view although exclusive to BC participants but was sometimes in conflict with notions of modernity.

Conclusion

Our findings identify evidence of cross-cultural and intra-group diversity in relation to MS causation. A greater professional awareness of the processes used by PwMS from diverse communities to make sense of their situation will enable health care professionals to facilitate effective support for those in their care and channel relevant psychosocial resources to them. This requires heightened skills in communication and cultural competency.

End-of-life preferences in Afro-Caribbean older adults: a systematic literature review

Research suggests that older Blacks tend to prefer more aggressive treatment as they transition toward the end of life. African and Afro-Caribbean immigrants and their offspring are the fastest growing segments of the Black population in the United States. With the increasing population of Black older adults, the cost of end-of-life care is rising. This article presents a review of the literature on the end-of-life preferences of Afro-Caribbean older adults. Findings suggest that Afro-Caribbean older adults make end-of-life decisions with a significant emphasis on family structure, religion/spirituality, cultural identity, migration, and communication. Concerns regarding the meaning of end-of-life preparation and hospice are often viewed in ways that differ from that of healthcare providers. Future research is needed to investigate this process in the Afro-Caribbean older adult subset.

The practice of hope: a longitudinal, multi-perspective qualitative study among South Asian Sikhs and Muslims with life-limiting illness in Scotland

OBJECTIVES

We explored the role of faith and religious identities in shaping end of life experiences in South Asian Muslims and Sikhs with life-limiting illnesses.

DESIGN

Secondary analysis of data from a longitudinal, multi-perspective qualitative study of the experience of life-limiting illness and access to palliative care services among South Asian Sikhs and Muslims in Scotland. Up to three semi-structured interviews were conducted with 25 participants, 15 family members and 20 health care professionals over a period of 18 months. Analysis was informed by Mattingly's theory on hope.

RESULTS

Hope emerged as a central construct in the accounts of illness constructed by the participants as they struggled to make sense of and uphold a meaningful life. Clinical encounters and, for some, religious beliefs served as sources of hope for participants. Hope unfolded as an active process that enabled them to live with the personal and in particular the social ramifications of their illness. Changing images of hope were formulated and reflected as illness progressed or treatments failed. These ranged from hoping for cure, prolonged life, the regaining of lost capabilities needed to fulfil social roles, or at times death when suffering and the consequences for the family became too hard to bear.

CONCLUSIONS

For those suffering from a life-limiting illness, sustaining hope is a complex challenge. The social character of hope is evident as it focuses on envisioning a life that is worth living, not only for oneself, but most importantly for social relations. Continuity in care at the end of life and a holistic approach is important in order to enable patients to articulate complex and changing notions of hope that at times are silenced within families, and for patients to feel confident in discussing the possible role of religious beliefs in shaping personal notions of hope.

Health-related religious rituals of the Greek Orthodox Church: their uptake and meanings

AIM

To examine the uptake of religious rituals of the Greek Orthodox Church by relatives of patients in critical condition in Greece and to explore their symbolic representations and spiritual meanings.

BACKGROUND

Patients and their relatives want to be treated with respect and be supported for their beliefs, practices, customs and rituals. However nurses may not be ready to meet the spiritual needs of relatives of patients, while the health-related religious beliefs, practices and rituals of the Greek Orthodox Christian denomination have not been explored.

METHOD

This study was part of a large study encompassing 19 interviews with 25 informants, relatives of patients in intensive care units of three large hospitals in Athens, Greece, between 2000 and 2005. In this paper data were derived from personal accounts of religious rituals given by six participants.

RESULTS

Relatives used a series of religious rituals, namely blessed oil and holy water, use of relics of saints, holy icons, offering names for pleas and pilgrimage.

CONCLUSION

Through the rituals, relatives experience a sense of connectedness with the divine and use the sacred powers to promote healing of their patients.

IMPLICATIONS FOR NURSING MANAGEMENT

Nurse managers should recognize, respect and facilitate the expression of spirituality through the practice of religious rituals by patients and their relatives.

Progression, symptoms and psychosocial concerns among those severely affected by multiple sclerosis: a mixed-methods cross-sectional study of Black Caribbean and White British people

Objective

Multiple sclerosis is now more common among minority ethnic groups in the UK but little is known about their experiences, especially in advanced stages. We examine disease progression, symptoms and psychosocial concerns among Black Caribbean (BC) and White British (WB) people severely affected by MS.

Design

Mixed methods study of 43 BC and 43 WB people with MS (PwMS) with an Expanded Disability Status Scale (EDSS) ≥6 involving data from in clinical records, face-to-face structured interviews and a nested-qualitative component. Progression Index (PI) and Multiple Sclerosis Severity Score (MSSS) were calculated. To control for selection bias, propensity scores were derived for each patient and adjusted for in the comparative statistical analysis; qualitative data were analysed using the framework approach.

Results

Median EDSS for both groups was (6.5; range: 6.0–9.0). Progression Index (PI) and Multiple Sclerosis Severity Score (MSSS) based on neurological assessment of current EDSS scores identified BC PwMS were more likely to have aggressive disease (PI F = 4.04, p = 0.048, MSSS F = 10.30, p<0.001). Patients’ reports of the time required to reach levels of functional decline equivalent to different EDSS levels varied by group; EDSS 4: BC 2.7 years v/s WB 10.2 years (U = 258.50, p = 0.013), EDSS 6∶6.1 years BC v/s WB 12.7 years (U = 535.500, p = 0.011), EDSS 8: BC 8.7 years v/s WB 10.2 years. Both groups reported high symptom burden. BC PwMS were more cognitively impaired than WB PwMS (F = 9.65, p = 0.003). Thematic analysis of qualitative interviews provides correspondence with quantitative findings; more BC than WB PwMS referred to feelings of extreme frustration and unresolved loss/confusion associated with their rapidly advancing disease. The interviews also reveal the centrality, meanings and impact of common MS-related symptoms.

Conclusions

Delays in diagnosis should be avoided and more frequent reviews may be justified by healthcare services. Culturally acceptable interventions to better support people who perceive MS as an assault on identity should be developed to help them achieve normalisation and enhance self-identity.

Ethnic differences and socio-demographic predictors of illness perceptions, self-management, and metabolic control of type 2 diabetes

Objectives

This study investigated ethnic differences in diabetes-specific knowledge, illness perceptions, self-management, and metabolic control among black-African, black-Caribbean,and white-British populations with type 2 diabetes. The study also examined associations between demographic/disease characteristics and diabetes-specific knowledge, illness perceptions, self-management, and metabolic control in each of the three ethnic groups.

Design

Cross-sectional

Setting

Diabetes/retinal screening clinics in Hackney and Brent, London.

Methods

Black-African, black-Caribbean and white-British populations with type 2 diabetes were asked to participate. Questionnaires measuring demographic/disease characteristics, diabetes-specific knowledge, self-management, and illness perceptions were used for data collection. Data for glycated hemoglobin (HbA_1c) and microvascular complications were obtained from medical records. Ethnic differences in diabetes-related measures were estimated using analysis of variance/covariance. Multiple regression techniques were used to determine relationships between demographic/disease characteristics and measured diabetes-related outcomes.

Results

Three hundred and fifty-nine patients participated in the study. White-British participants had high diabetes-specific knowledge compared to their black-African and black-Caribbean counterparts. Black-Africans reported better adherence to self-management recommendations than the other ethnic groups. Compared to the white-British patients, black-African and black-Caribbean participants perceived diabetes as a benign condition that could be cured. Educational status and treatment category were determinants of diabetes-specific knowledge in all three ethnic groups. However, different demographic/disease characteristics predicted adherence to self-management recommendations in each ethnic group.

Conclusion

Clearly, there is disease (diabetes) knowledge-perception variation between different ethnic groups in the UK which may partly influence overall disease outcome. It is plausible to recommend screening, identifying, and dispelling misconceptions about diabetes among ethnic minority patients by health care professionals as well as emphasizing the importance of self-management in managing chronic diseases such as diabetes.

Administering a two-stage spiritual assessment in healthcare settings: a necessary component of ethical and effective care

AIM

This article delineates rationales for administering a spiritual assessment as a universal component of care.

BACKGROUND

The notion that nurses should identify and address patients' spiritual needs remains controversial, particularly in the UK where criticisms derived from secularization theory have appeared in the literature.

EVALUATION

To respond to these criticisms and to develop rationales supportive of spiritual assessment, I draw upon scholarship from a variety of disciplines including social work, sociology, and medicine.

KEY ISSUES

Five rationales are posited to support the concept of universal spiritual assessments: professional ethics, patient autonomy, knowledge of patients' worldviews, the identification of spiritual assets, and accrediting and governmental requirements. Criticisms based on secularization theory are discussed and analysed.

CONCLUSION

A two-stage spiritual assessment - consisting of a brief preliminary assessment followed, if necessary, by a comprehensive assessment - provides a mechanism to efficiently identify patients' spiritual needs.

IMPLICATIONS FOR NURSING MANAGEMENT

As key members of the healthcare team, nurse managers are ideally situated to ensure that all patients receive a spiritual assessment as a routine component of care. In so doing, they help ensure the provision of ethical and effective care to the diverse spiritual groups that will continue to populate the UK for the foreseeable future.

Asthma medication adherence: the role of God and other health locus of control factors

BACKGROUND

Medication adherence is an important determinant of disease outcomes, yet medication use on average tends to be low among patients with chronic conditions, including asthma. Although several predictors of non-adherence have been assessed, more research is needed on patients' beliefs about God and how these relate to medication use.

OBJECTIVE

To examine the relationship between perceptions about "God's" role in health and other locus of control factors with inhaled corticosteroid (ICS) adherence among asthma patients.

METHODS

Participants were from a clinical trial to improve ICS adherence and were 5-56 years old, had a diagnosis of asthma, and were receiving ICS medication. Baseline adherence was estimated from electronic prescription and pharmacy fill records. Patients were considered to be adherent if ICS use was ≥80% of prescribed. A baseline survey with the Multidimensional Health Locus of Control scale was used to assess five sources (God, doctors, other people, chance, and internal).

RESULTS

Medication adherence was low (36%). Patients' who had a stronger belief that God determined asthma control were less likely to be adherent (odds ratio [OR] 0.82, 95% confidence interval [CI] 0.70-0.96). This relationship was stronger among African American (OR 0.68, 95% CI0.47-0.99) compared to white patients (OR 0.89, 95% CI 0.75-1.04), and among adults (OR 0.81, 95% CI 0.69-0.96) compared to children (OR 0.84, 95% CI 0.58-1.22).

CONCLUSION

Patients' belief in God's control of health appears to be a factor in asthma controller use, and therefore should be considered in physician-patient discussions concerning course of treatment.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT00459368.

"God must have been sleeping": faith as an obstacle and a resource for Rwandan genocide survivors in the United States

In 1994, 1 million Rwandans were violently killed in only 100 days. Devastating for some Rwandan survivors was the significant role that some Catholic parishes and leaders took in ignoring, facilitating, and even perpetuating the genocide. This article seeks to understand how Rwandan genocide survivors draw on religion as they negotiate their postgenocide identities in the United States and comprehend their current faiths, beliefs, and practices. Based on qualitative interviews with Rwandan survivors now located within the United States, I argue that the experiences of religiosity postgenocide serve as both an obstacle and a resource in postgenocide life, creating significant individual and local ramifications for community engagement, reconciliation, and trauma recovery.

African and Black Caribbean origin cancer survivors: a qualitative study of the narratives of causes, coping and care experiences

OBJECTIVES

Although there is evidence in the U.S.A. and U.K. to suggest that ethnic minority groups have an inferior experience of cancer care, few studies investigate ethnic disparities in satisfaction and care experiences among survivors. Patients' illness perceptions (lay explanations for illness) and coping styles (emotional and behavioural) are influenced by ethnicity-related cultural beliefs and expectations. Depressive illness or fears of recurrence of cancer may also lead to poorer recovery and function. This paper investigates whether ethnic influences explain different coping behaviours, care experiences and help-seeking behaviours.

DESIGN

Eight participants of African or Black Caribbean origin were recruited from a London support group for a series of qualitative in-depth interviews. The interviews were recorded and transcribed, and the transcripts analysed using a framework method of qualitative data analysis. The emergent themes were tested and documented to reflect the issues of importance to patients.

RESULTS

Lay explanations of causes of cancer were complex and diverse reflecting cultural influences and the impact of contact with health professionals. Generally, positive views about cancer care were found, especially at the secondary care level. Primary care attracted mixed views. In contrast to American studies, no acknowledgement of discrimination on the basis of ethnicity was reported. The need to be resilient and think positively were widely acknowledged as coping strategies. Some coped by avoiding contemplation of their condition or diagnosis. Religious beliefs and practices provided coping mechanisms for some, and a means to improve confidence and avoid distressing contemplation about their condition. Family, friends and charitable groups also provided emotional and practical support.

CONCLUSIONS

Subjects were generally satisfied with their care; different coping styles included positive attitudes, minimisation of difficulties or more realistic consideration of the impact of cancer.

Health care behaviours and beliefs in Hasidic Jewish populations: a systematic review of the literature

Cultural issues impact on health care, including individuals' health care behaviours and beliefs. Hasidic Jews, with their strict religious observance, emphasis on kabbalah, cultural insularity and spiritual leader, their Rebbe, comprise a distinct cultural group. The reviewed studies reveal that Hasidic Jews may seek spiritual healing and incorporate religion in their explanatory models of illness; illness attracts stigma; psychiatric patients' symptomatology may have religious content; social and cultural factors may challenge health care delivery. The extant research has implications for clinical practice. However, many studies exhibited methodological shortcomings with authors providing incomplete analyses of the extent to which findings are authentically Hasidic. High-quality research is required to better inform the provision of culturally competent care to Hasidic patients.

'It don't make sense to worry too much': the experience of prostate cancer in African-Caribbean men in the UK

The incidence of prostate cancer among African-Caribbean men in the UK is three times that among men from the majority population. Little attention, however, has been given to the perceptions and experiences of treatment and care of men from these communities with prostate cancer. This qualitative study is the first such investigation, situating men's accounts within the context of their personal history and social environment. Using a community-based, snowball sampling method, 16 first generation African-Caribbean men living in Central England were recruited. Similarities and divergence in men's experience were identified through thematic analysis of interview transcripts. Men's responses to their situation were influenced by aspects of migration and historical context as well as culture. While medical treatment was highly valued, common difficulties were compounded by problems of health professional-patient communication, stereotyping and insensitivity of some staff. Lack of coordination between services and agencies adversely affected the well-being of frail men and widowers. Findings suggest the need for a more proactive approach to giving and eliciting information combined with cultural diversity training. More systematic referral procedures and information exchange between African-Caribbean men with prostate cancer and their general practitioner, hospital, social care and voluntary agencies, churches and community organisations are indicated.

'The greatest thing in the world is the family': the meaning of social support among black Caribbean and white British patients living with advanced cancer

PURPOSE

Little is known about the perceptions and meanings of social support among black and minority ethnic groups living with advanced cancer in the UK. The aim of this study was to explore social support networks and their meaning among Black Caribbean and White British patients living with advanced cancer.

METHOD

Semi-structured interviews were conducted with 26 Black Caribbean and 19 White British cancer patients and analysed using the framework approach.

RESULTS

In all, 25 of 26 Black Caribbean and 18 of 19 White British participants volunteered views on the presence of social support in their lives. The presence of a spouse or partners was an indispensable feature within the social support networks in both ethnic groups. More Black Caribbean than White British participants referred to the presence of social networks made through their church communities as being a source of practical and emotional support.

CONCLUSIONS

We recommend that when health and social-care professionals perform an assessment interview with patients from cultural backgrounds different to their own, opportunities should be made for patients to express information about their social support networks. This will help them to better understand their place alongside statutory services. Spouses and partners should be given greater recognition of their contribution in order to continue with their important role.

The experience of using complementary therapies after a diagnosis of cancer: a qualitative synthesis

This article describes a qualitative synthesis of published research on cancer patients' experiences of complementary therapies. We conducted a systematic search for qualitative studies on this subject published between 1998 and 2007. Twenty-six refereed journal articles met the inclusion criteria. These 26 articles were repeatedly read by the research team and key concepts emerging from them were identified. Differences and variations were examined in association with treatment, therapy type and by stage of cancer (early stage, mid-treatment, advanced cancer, palliative care and long term 'survivors'). Six overarching concepts were located, which describe the key aspects of patients' experiences of the use of complementary and alternative medicine after a diagnosis of cancer: Connection; Control; Well-being; Transformation; Integration; and Polarization. These are described in a 'line of argument' synthesis, and differences associated with treatment type and stage of disease are noted. The findings are presented in a table showing the six concepts according to treatment type and stage; as a composite story; and in a diagrammatic model showing the individual, practitioner and organizational levels. The synthesis identified various specific ways in which complementary therapies supported cancer patients, as well as occasional negative effects. The most notable barrier was the perceived polarization of complementary therapies and biomedicine; patients reported better experiences in integrated settings.

Fear of dying in an ethnically diverse society: cross-sectional studies of people aged 65+ in Britain

Aim

To examine fears about dying in an ethnically diverse population sample, and a more homogeneous population sample, aged 65 and over.

Methods

Personal interviews with people aged 65+ living at home responding to two Office for National Statistics Omnibus Surveys in Britain, and two Ethnibus Surveys of ethnically diverse populations in Britain.

Results

Ethnically diverse respondents were more likely than British population respondents to express fears about dying on all measures used. Respondents in both samples with better, compared with worse, quality of life had significantly reduced odds of having extreme fears of dying (ethnically diverse sample, OR 0.924 (95% CI 0.898 to 0.951); British population sample, OR 0.981 (95% CI 0.966 to 0.996); both p<0.001). In the latter sample only, older age was protective (OR 0.957; 95% CI 0.930 to 0.985; p<0.001), whereas in the Ethnibus sample, having a longstanding illness (OR 2.024; 95% CI 1.158 to 3.535; p<0.05) and having more relatives to help them (OR 1.134; 95% CI 1.010 to 1.274; p<0.05) increased fears about dying.

Conclusions

Enabling older people to express fears about dying is likely to be important when planning supportive end-of-life care. Practitioners should not assume that fears about dying are the same in different social groups, or that extensive family support is protective against such anxiety. Older people from ethnic minorities had more anxieties about dying than others, and were more likely to express fears the more extensive their family support. These findings have implications for commissioners and practitioners of primary and secondary care.

Cost-effectiveness of lenalidomide in multiple myeloma

Lenalidomide represents the first drug in a novel class of agents known as IMiDs. It has both direct antimyeloma activity and an indirect effect acting through the microenvironment. In the relapsed/refractory setting, lenalidomide has been demonstrated to be highly active, producing partial and complete responses that translate into improved survival. Generally, the drug is well tolerated and more recently this agent has been used in combination with steroids, chemotherapy agents and other novel agents that have further enhanced its efficacy in clinical trials. However, the cost of this and other novel agents is significantly greater than previously used chemotherapy protocols, which in turn means that they have fallen under the scrutiny of regulatory bodies such as NICE. It is important that researchers understand the instruments used by these bodies to come to decisions regarding cost-effectiveness if patients are not to be disadvantaged by not being given access to these active new agents. This article outlines the models used by health economists and assesses their potential shortcomings. It also suggests alternative methods and identifies areas of research where improvements might be achieved.

Psychological well-being and quality of care: a factor-analytic examination of the palliative care outcome scale

CONTEXT

The Palliative Care Outcome Scale (POS) is a widely used outcome measure in palliative care research, and has good psychometric properties. It has been used for clinical or research purposes in specialist cancer centers, nursing homes, day hospice units, and hospice settings in a growing number of countries. However, the POS has not yet been examined using factor analysis.

OBJECTIVE

The aim of the present study was to examine the internal factor structure of the POS.

METHODS

Confirmatory and exploratory factor analyses were used for secondary analysis of two existing POS data sets of British patients, most of whom were cancer patients.

RESULTS

We began with a confirmatory factor analysis (CFA), which indicated that the POS is not a unidimensional scale. This was followed by an exploratory factor analysis that suggested two factors-one reflecting a psychological well-being dimension and the other consisting of three items relating to the standard of professional care. A similar two-factor structure also was identified in the second sample using CFA.

CONCLUSION

The POS appears to capture two factors, psychological status and quality of care, and to have three items that function independently (family anxiety, symptoms, and pain control). Our findings suggest that future evaluations of palliative care services should include assessment not only of symptoms and well-being or quality of life, but also of quality of care, and that unidimensional measures will not capture all relevant aspects in palliative care.

Working with older people from black and minority ethnic groups who have depression: From margin to mainstream

Despite the growing evidence base about depression and anxiety and its application to service settings and practice, we are short of practice examples about what works and for whom. This applies to older people in general but particularly to groups, such as people from black and minority ethnic backgrounds. This article discusses policy and legislative encouragements to think about equality of access and diversity issues in mental health services and wider mental health promotion activities. It analyses recent research and policy documents in the context of demographic change and practice. It argues that the context of personalisation in England may provide new opportunities to consider what older people will find most acceptable and effective in meeting their needs, but notes the challenges that this will bring to community‐based organisations and specialist services.

'Quite an awkward situation to be in': perceptions of patients, carers and health and social care professionals of the supportive cancer care in British military personnel stationed in Germany

GOALS OF WORK

This paper reports findings from a study which identified the nature and volume of supportive care received by British military services personnel and their dependents who experience cancer and are based in Germany. The objectives were to (1) identify any gaps in the provision of supportive care, (2) determine the potential for additional supportive care services (local or remote), and (3) identify any educational or development issues for DMWS personnel.

MATERIALS AND METHODS

Interviews and focus groups were conducted with people with cancer (n = 7), informal carers (n = 6), British health care professionals employed by British Forces in Germany (n = 8), German health care professionals (n = 3), senior military personnel (n = 6) and army support personnel (n = 5). Analysis of the data was thematic and focused on accounts of care related to core issue identified in the UK's National Institute of Health and Clinical Excellence (NICE) guidelines (24).

MAIN RESULTS

The paper explores the difficulties which British military personnel experience in their cancer care. The shortfalls in best practice are discussed in the framework of NICE guidelines focusing on communication, information, psychosocial care and coordination of care/inter-agency working. Significant gaps in the supportive care service provision are apparent

CONCLUSIONS

The limited assessment and discussion of patients' supportive care needs suggests key areas for service improvement for providers both within the British Military in Germany, and in the services provided by German organisations. These findings highlight issues that should be considered by those providing supportive care for marginalised patient groups, such as patients and carers from different cultures.