Approaches to integrating palliative care into African health systems: a qualitative systematic review

Knowledge, attitudes, and barriers: Palliative Care services for women with HIV in resource-limited settings

BACKGROUND

Women living with HIV (WLWH) in low- middle-income countries (LMICs) face increased mortality risks from comorbidities despite progress in antiretroviral therapy. Palliative care (PC) is vital for these patients, yet its integration in LMICs, such as Nigeria, is suboptimal due to unique challenges.

OBJECTIVE

This study investigated the knowledge, perceived barriers, and facilitators influencing PC integration into routine HIV care within healthcare (HC) settings.

METHODOLOGY

A cross-sectional survey was conducted among WLWH in twelve HC facilities throughout Nigeria. Data collection involved surveys focused on PC knowledge, attitudes, facilitators, and barriers. Logistic regression analyses were employed to examine the data.

RESULTS

This study revealed significant gaps in knowledge and attitudes towards PC among HIV + women at NISA-MIRCs. Over 90% were unaware of PC services, but many saw its potential to offer hope (55%) and improve quality of life (56.5%). The key predictors of PC knowledge included education, occupation, religion, having fewer children, urban residence, type of residence, and having a high income (p < .05). Despite the willingness to access PC, barriers such as negative HC worker attitudes, perceived high cost, and limited decision autonomy could hinder integration. Facilitators included low-cost services, positive HCW attitudes, physician recommendations, and perceived necessity for personal well-being.

CONCLUSION

Knowledge gaps, diverse attitudes, and significant barriers highlight the need for targeted PC interventions for WLWH. Tailoring educational programs, addressing cost barriers, and improving healthcare infrastructure are crucial to enhancing PC accessibility and quality. These findings can guide policymakers and HC practitioners toward more effective and inclusive care strategies.

"My Home Away From Home": Community Support for International Pediatric and Young Adult Patients and Their Families in End-of-Life Care and Bereavement

Background: Foreign national patients and families can face life-limiting illness and end-of-life care far from home; this palliative need has not been well described. Case Description: We present a case of a 20-year-old Ugandan patient diagnosed with metastatic alveolar rhabdomyosarcoma who presented to a pediatric academic medical center in California. Despite treatment, her disease progressed and she was unable to return to Uganda due to symptom burden. The patient and her family met regularly with palliative care during their hospital stay; the palliative approach included cross-cultural sharing, connecting across differences, and fostering community. The family additionally cultivated a support system within the hospital and local African communities. This was illustrated in the memory album the patient created, and in her family's extensive bereavement support. Conclusions: This case explores opportunities for individualized psychosocial care and community-based support to enhance palliative care for foreign national patients and families.

Online palliative care curriculum: contextual adaptation for Nigerian healthcare workers

OBJECTIVES

This study reports on a yearlong sequence of three periodic, virtual trainings in primary palliative care for healthcare professionals across Nigeria. Our overall objective was to determine the impact of the full course on participants' attitudes, knowledge, skills and plans to implement and deliver palliative care in their local contexts.

METHODS

The curriculum for this programme was codeveloped by a team of USA and Nigerian palliative care professionals and delivered via three 3-day virtual sessions. Daily surveys, knowledge tests and end-of-training surveys were administered to participants electronically. Demographics, knowledge scores, confidence levels and self-reported achievement were analysed using descriptive statistics.

RESULTS

Pretraining and post-training knowledge scores showed significant improvement with average gains of 10.3 percentage points in training 1 (p<0.001) to 11.7 percentage points in training 2 (p=0.01). More than three-quarters of participants improved their test scores. Most participants (89.4%-100%) agreed that they had achieved the daily learning objectives across all trainings. Nearly 100% of participants reported that they felt more empowered as healthcare workers, more confident in their decision-making and more comfortable communicating with patients and other healthcare workers about palliative care.

CONCLUSIONS

Healthcare workers in Nigeria demonstrated increased knowledge and confidence in providing palliative care as a result of an adapted virtual training programme. Further research is needed to (1) demonstrate feasibility for online trainings in similar resource-limited settings and (2) evaluate impact on patient-centred outcomes.

Palliative care in a rural subdistrict in South Africa: A 4-year critical review

BACKGROUND

Palliative care (PC) is a priority in South Africa, focussing on integrating PC into primary health care. Few examples exist showing how this is done. In 2018, a rural PC project was implemented, which subsequently evolved into an integrated service between the hospital and the community.

AIM

The aim was to review the PC project over 4 years.

SETTING

The setting was the George subdistrict of the Garden Route district in South Africa. Community-based services were offered to all patients with PC needs by three non-governmental organisations who deliver home community-based care via community health workers. They were supplemented by primary health care clinics, an intermediate care facility and two hospitals.

METHODS

This was a retrospective descriptive study. Inpatient ward round data and patient referrals between 2018 and 2022 were analysed using descriptive statistics. Variables included patient demographics, diagnosis, home visits and place of death.

RESULTS

A total of 819 patients were referred. Inpatients were reviewed on weekly ward rounds by a multidisciplinary team. The most common diagnosis was cancer (57%). Home visits enabled patient follow-ups, of which 152 were recorded.

CONCLUSION

The programme has become sustainable and integrated in the public healthcare system. Contributing factors included dedicated staff, using simple tools and continuous training. The findings may be useful to PC programmes in similar contexts elsewhere.Contribution: This work adds new knowledge to the field of PC in an underresourced rural healthcare environment in sub-Saharan Africa, by describing how system-wide integration of a new service was navigated to become sustainable.

Perceptions of Learners and Specialists Toward ECHO Palliative Care Project in Thailand

INTRODUCTION

The Extension of Community Health Outcomes (ECHO) is a global movement that aims to decentralize the knowledge of specialists to primary care. A pilot, ECHO palliative care project in Thailand, was introduced to enhance the implementation of palliative care practice.

OBJECTIVE

To assess learners' and palliative care specialists' perceptions toward the ECHO palliative care project to improve and expand the project in the future.

SETTING

A total of 15 hospitals in 7 provinces in Northern Thailand, including provincial and district hospitals.

METHODS

A qualitative study was conducted among learners (primary care providers) and palliative care specialists who participated in the pilot program. Semi-structured interviews were used to explore the potential impact of the project on clinical practice, the strengths and weaknesses of the ECHO program and platform in the Thai context, and suggestions for expansion. Thematic analysis was used for qualitative analysis. Pre- and post-confidence scores, using a 5-point Likert Scale, for palliative care practice among learners were analyzed using paired T-tests.

RESULTS

Twenty participants were interviewed: 15 learners and 5 palliative care specialists. The confidence in practicing palliative care after participating in the ECHO palliative care project significantly increased for the learners, from 2.93 (95% CI, 2.49-3.38) to 3.93 (95% CI, 3.68-4.19) points (P = .003). Three themes emerged through the process evaluation of the pilot ECHO palliative care project: (1) applicable lessons that can translate to practice, (2) an effective learning program and assessable platform, and (3) suggestions for expansion.

CONCLUSION

The ECHO palliative care project increased confidence in providing palliative care for primary care providers in Thailand. Through capacity building, participants reported applying the knowledge to improve local health services and develop a network for consultations and referrals. There is potential for expansion of the ECHO palliative care project in Thailand.

Remote Symptom Monitoring to Enhance the Delivery of Palliative Cancer Care in Low-Resource Settings: Emerging Approaches from Africa

This paper brings together researchers, clinicians, technology developers and digital innovators to outline current applications of remote symptom monitoring being developed for palliative cancer care delivery in Africa. We outline three remote symptom monitoring approaches from three countries, highlighting their models of delivery and intended outcomes, and draw on their experiences of implementation to guide further developments and evaluations of this approach for palliative cancer care in the region. Through highlighting these experiences and priority areas for future research, we hope to steer efforts to develop and optimise remote symptom monitoring for palliative cancer care in Africa.

Providers' Competencies and Management Practices for Traditional Palliative Cancer Care Service Delivery in Kenya

Background

Many people in developing countries are struggling with chronic diseases yet traditional health services remain under-utilized in the quest for universal health care. Thousands patronize these outlets for care yet little is known about provider's competence and how these competencies inform palliative care decisions and practices. The study documented traditional health practitioners (THPs) competencies and practices for traditional palliative cancer care service delivery in Kenya.

Methods

This study utilized mixed-methods design and was undertaken in major towns across Kenya. A total of 201 Traditional health practitioners were purposely sampled, and interviewed. Five in-depth interviews and 6 focus group discussions were conducted. Quantitative data were analyzed using SPSSv22 while thematic and discourse analysis was carried out for qualitative data.

Results

Majority (92.7%) of the THPs provided general traditional health services. Nearly half of the respondents (47.7%, n = 92) stated that they had received their knowledge and abilities through divine gifting, 71 (36.8%) lineage, 61 (31.6%) apprenticeship, and 39 (20.2%) formal study. Palliative care was determined by patient state and followed consultation with caregivers for 165 (85.5%) of respondents. For 160 respondents (83%), management practices involved a mix of patient examination, conventional medical tests, herbal medicine administration, follow-up or referral. Positive feedback consisted of symptom reduction and function recovery.

Conclusion

Core competencies identified include: knowledge acquisition and specialization, assessment, diagnosis and disclosure, decision making, treatment, follow-up, and referral. Traditional palliative care providers share common health-related beliefs, practices and abilities that influence how they approach and make decisions regarding the health management of their patients, despite marked ethnic diversity. The shared pathways offer a chance to develop a cogent traditional palliative care service delivery model and health policy framework to promote its integration within the health workforce. The leading unmet requirements are knowledge of intellectual property rights, disclosure frameworks, and ethical regulation principles.

Barriers to accessing internationally controlled essential medicines in sub-saharan Africa: A scoping review

BACKGROUND

Access to internationally controlled essential medicines (ICEMs), medicines that are listed on both the World Health Organization's Essential Medicines List and one of three international drug control conventions, remains problematic in Sub-Saharan Africa (SSA). Previous reviews have focused only on specific ICEMs or ICEM-related healthcare fields, but none have focused on all ICEMs as a distinct class. This scoping review therefore aims to identify the barriers to accessing ICEMs across all relevant healthcare fields in SSA.

METHODS

A scoping review was conducted across indexing platforms Embase, PubMed, Scopus and Web of Science of studies published between January 1 2012 and February 1 2022. Articles were eligible if they mentioned barriers to accessing ICEMs and/or ICEM-related healthcare fields, if studies were conducted in SSA, or included data on an SSA country within a multi-country study. The review was guided by the Access to Medicines from a Health System Perspective framework.

RESULTS

The search identified 5519 articles, of which 97 met the inclusion criteria. Many barriers to access were reported and were common across the ICEMs drug class. Main barriers were: at the individual level, the lack of knowledge about ICEMs; at the health service delivery level, low availability, stockouts, affordability, long distances to health facilities, insufficient infrastructure to store and distribute ICEMs, and lack of ICEM knowledge and training among healthcare workers; at the health sector level, lack of prioritisation of ICEM-related healthcare fields by governments and subsequent insufficient budget allocation. Cross-cutting, governance-related barriers pertained to lack of proper quantification systems, cumbersome procurement processes, and strict national laws controlling ICEMs, leading to overly restrictive prescription practices.

CONCLUSION

This review showed that there are a multitude of barriers to accessing ICEMs in SSA across all health system levels. Many of the barriers identified are applicable to all ICEMs, highlighting the importance of tackling barriers for this entire class of drugs together.

"I Am a Human": A Process Evaluation of a Nurse-Led Community-Based, Palliative Care Program in Liberia, West Africa

Liberia is a postwar, post-Ebola, and low-income nation in West Africa with minimal to no palliative care access. In 2017, Partners In Health in collaboration with the Liberian Ministry of Health invested in the development of a nurse-led, community-based palliative care team in southeastern Maryland County at JJ Dossen Memorial Hospital. Between 2017 and 2022, the 9-member team (8 nurses, 1 physician assistant) has enrolled 142 patients under their care. This is a qualitative process evaluation eliciting the experiences, perspectives, and attitudes of patients with cancer to inform future palliative care program delivery improvement and development. Using an exploratory design, n = 8 participants were interviewed using a semi-structured guide. The sample had a mean age of 48 years with an average palliative care clinic enrollment period of 22.5 weeks at the time of interview. The interdisciplinary coding team used an applied thematic text analysis approach and identified 5 themes: history and disease progression, follow-up clinic services, psychological distress and its sources, social support, and spiritual and cultural beliefs. Implications emphasize the need for increased community engagement, primary palliative care capacity development of clinical colleagues in the region, and the support of local and national decision-makers to prioritize palliative care service expansion.

Benefits of integrating palliative care: a qualitative exploration of the perspectives of palliative care providers in a tertiary health facility in Ghana

Background

Integration of palliative care (PC) services entails combining administrative, organisational, clinical and service elements to ensure continuity of care between all parties participating in the care network of patients. There is a need to understand the benefits of integrating PC to inform policy making and advance advocacy, especially in resource-constrained settings such as Ghana where PC is sub-optimally implemented. Yet, existing research in Ghana is sparse on what benefits are likely to be experienced as a result of integrating PC.

Objective

The study explored service providers' perspectives on the benefits of integrating PC in Ghana.

Design

The design was an exploratory descriptive qualitative research design.

Methods

A total of seven in-depth interviews were conducted using semi-structured interview guides. The data were managed using NVivo-12. Inductive thematic analysis was carried out following Haase's modification of Colaizzi's approach to qualitative research analysis. The study follows the COREQ guidelines and the ICMJE recommendations.

Result

Two main themes emerged: patient-related outcomes, and system/institution-related outcomes. For the patient-related outcomes, the following sub-themes emerged: restored hope, appreciated care and better preparation for the end of life (EoL). The emerging sub-themes under the system/institution-related outcomes include the following: early initiation of care, enhanced communication between primary healthcare providers and the PC team and strengthening staff capacity to provide PC services.

Conclusion

In conclusion, there are substantial benefits to be experienced from integrating PC. For the patients, it would restore shattered hopes, result in appreciated care and better preparation for the EoL. For the healthcare system, it would promote early initiation of care, enhance communication between primary healthcare providers and the PC team and strengthen service providers' capacity to provide PC services. This study, thus, furthers the case for a more integrated PC service in Ghana.

The changing dynamics of community care and support in rural Malawi: The impact on Women's health and wellbeing at end of life

In this critical ethnographic study, we examined women's end of life experiences in Malawi, one of the few countries in the world with a national palliative care policy. Specifically, we explored how women's and their caregivers' experiences were shaped by family and community care, and material needs. Interviews and observations with female clients of a non-governmental organization in rural Central Malawi, and with their caregivers, revealed that community-level support was both precarious and critical. We found three main themes: (1) I stay with them well, (2) we eat together, and (3) everyone is for themselves. The analysis illustrates the centrality of community care, social in/exclusion, and availability of stable food, shelter, medical, and caregiving resources on health and wellbeing at end of life. We provide recommendations to strengthen community care opportunities and women's resource bases.

'I am Dying a Slow Death of White Guilt': Spiritual Carers in a South African Hospice Navigate Issues of Race and Cultural Diversity

Culturally appropriate spiritual care is increasingly recognised as a crucial component of spiritual care. As part of a larger study, we were interested in cultural and racial issues as experienced by spiritual carers in a hospice in Cape Town, South Africa. We conducted one-on-one interviews and focus group discussions with a cohort of spiritual care workers, who, being volunteers and relatively privileged South Africans, discussed their sensitivity to cultural issues, but also mentioned a host of political, racial and identity issues which profoundly affect their work. The data suggest that the concept of culturally appropriate care must be understood and acted on contextually. We note that the work of transformation of care cannot be separated from broader questions of social inequality and change.

Developing Community-Based Palliative Care Services for People Living with HIV in Africa

ABSTRACT

Africa continues to be disproportionately affected by HIV/AIDS. Poor access to medical care, limited access to antiretroviral drugs, and lack of supportive care for persons who are symptomatic lead to disease progression. Community-based palliative care services are effective in providing supportive services throughout the course of the illness, but palliative care services are limited in Africa. This article presents a theoretical approach to developing community-based palliative care services to bridge this gap.

Digital health in oncology in Africa: A scoping review and cross-sectional survey

BACKGROUND

Low- and middle-income countries, especially in Africa, face a growing cancer burden. Adoption of digital health solutions has the potential to improve cancer care delivery and research in these countries. However, the extent of implementation and the impact of digital health interventions across the cancer continuum in Africa have not been studied.

AIMS

To describe the current landscape of digital health interventions in oncology in Africa.

METHODS

We conducted a scoping literature review and supplemented this with a survey. Following the PRISMA for Scoping Reviews guidelines, we searched literature in PubMed and Embase for keywords and synonyms for cancer, digital health, and African countries, and abstracted data using a structured form. For the survey, participants were delegates of the 2019 conference of the African Organization for Research and Training in Cancer.

RESULTS

The literature review identified 57 articles describing 40 digital health interventions or solutions from 17 African countries, while the survey included 111 respondents from 18 African countries, and these reported 25 different digital health systems. Six articles (10.5%) reported randomized controlled trials. The other 51 articles (89.5%) were descriptive or quasi-experimental studies. The interventions mostly targeted cancer prevention (28 articles, 49.1%) or diagnosis and treatment (23 articles, 40.4%). Four articles (7.0%) targeted survivorship and end of life, and the rest were cross-cutting. Cervical cancer was the most targeted cancer (25 articles, 43.9%). Regarding WHO classification of digital interventions, most were for providers (35 articles, 61.4%) or clients (13, 22.8%), while the others were for data services or cut across these categories. The interventions were mostly isolated pilots using basic technologies such as SMS and telephone calls for notifying patients of their appointments or results, or for cancer awareness; image capture apps for cervical cancer screening, and tele-conferencing for tele-pathology and mentorship. Generally positive results were reported, but evaluation focused on structure and process measures such as ease of use, infrastructure requirements, and acceptability of intervention; or general benefits e.g. supporting training and mentorship of providers, communication among providers and clients, and improving data collection and management. No studies evaluated individualized clinical outcomes, and there were no interventions in literature for health system managers although the systems identified in the survey had such functionality, e.g. inventory management. The survey also indicated that none of the digital health systems had all the functionalities for a comprehensive EHR, and major barriers for digital health were initial and ongoing costs, resistance from clinical staff, and lack of fit between the EHR and the clinical workflows.

CONCLUSION

Digital health interventions in oncology in Africa are at early maturity stages but promising. Barriers such as funding, fit between digital health tools and clinical workflows, and inertia towards technology, shall need to be addressed to allow for advancement of digital health solutions to support all parts of the cancer continuum. Future research should investigate the impact of digital health solutions on long-term cancer outcomes such as cancer mortality, morbidity and quality of life.

Timely community palliative and end-of-life care: a realist synthesis

BACKGROUND

Community-based and home-based palliative and end-of-life care (PEoLC) services, often underpinned by primary care provision, are becoming increasingly popular. One of the key challenges associated with them is their timely initiation. The latter requires an accurate enough prediction of how close to death a patient is.

METHODS

Using 'realist synthesis' tools, this review sought to develop explanations of how primary care and community PEoLC programmes generate their outcomes, with the explanations presented as context-mechanism-outcome configurations. Medline, Embase, CINAHL, PsycINFO, Web of Science, ASSIA, Sociological Abstracts and SCIE Social Care Online were originally searched. A multistage process of focusing the review was employed, with timely identification of the EoL stage and timely initiation of associated services representing the final review focus. Synthesised sources included 21 full-text documents and 324 coded abstracts, with 253 'core contents' abstracts generating >800 codes.

RESULTS

Numerous PEoLC policies and programmes are embedded in a framework of Preparation and Planning for Death and Dying, with identification of the dying stage setting in motion key systems and services. This is challenged by: (1) accumulated evidence demonstrating low accuracy of prognostic judgements; (2) many individuals' orientation towards Living and Hope; (3) expanding grey zones between palliative and curative care; (4) the complexity of referral decisions; (5) the loss of pertinent information in hierarchical relationships and (6) the ambiguous value of having 'more time'.

CONCLUSION

Prioritising temporal criteria in initiating PEoLC services is not sufficiently supported by current evidence and can have significant unintended consequences.

PROSPERO REGISTRATION NUMBER

CRD42018097218.