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Holland KN, Hubbard J, Mphande M, Robson I, Phiri K, Onoya D, Chikuse E, Dovel K, Choko A. Implementation of Male-Specific Motivational Interviewing in Malawi: An Assessment of Intervention Fidelity and Barriers to Scale-Up. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.09.24.24314326. [PMID: 39399024 PMCID: PMC11469461 DOI: 10.1101/2024.09.24.24314326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/15/2024]
Abstract
Introduction Treatment interruption (TI), defined as >28 days late for ART appointment, is one of the greatest challenges in controlling southern African HIV epidemics. Negative client-provider interactions remain a major reason for TI and barrier for return to care, especially for men. Motivational interviewing (MI) facilitates client-driven counseling and improves client-provider interactions by facilitating equitable, interactive counseling that helps clients understand and develop solutions for their unique needs. Fidelity of MI counseling in resource-constrained health systems is challenging. Methods We developed a male-specific MI curriculum for Malawian male TI clients. Four psychosocial counselors (PCs, a high-level Malawian counseling cadre) received a 2.5-day curriculum training and job-aid to guide MI counseling approaches. They participated in monthly phone-based discussions with their manager about MI-based solutions to challenges faced. PCs implemented the MI curriculum with men >15 years who were actively experiencing TI. Clients were found at home (through tracing) or at the facility (for those who returned to care on their own). MI counseling sessions were recorded, transcribed, translated into English, and coded in Atlas.ti v9. MI quality was assessed using a modified version of the validated Motivational Interviewing Treatment Integrity tool. The tool has two measures: 1) counts of key MI behaviors throughout the session (questions, reflections, etc.); and 2) overarching scores (using a five-point scale) that characterize three MI dimensions for an entire counseling session (cultivating change talk, partnership, and empathy). Results 44 MI sessions were recorded and analyzed between 4/1/22-8/1/22. 64% of counseling sessions focused on work and travel as the main reason for TI. 86% of sessions yielded client-driven, tailored solutions for overcoming TI. PCs implemented multiple MI behaviors very well: asking questions, giving information, simple reflections, and client affirmation. Few PCs used complex reflection, emphasized autonomy, or sought collaboration with clients. Among overarching MI dimensions, HCWs scored high in partnership (promoting client-driven discussions) and cultivating change talk (encouraging client-driven language and behavior change confidence) but scored sub-optimal in empathy. Only 5 sessions had confrontational/negative PC attitudes. Conclusions PCs implemented MI with fidelity and quality resulting in tailored, actionable plans for male re-engagement in HIV treatment in Malawi. Clinical Trial Number NCT05137210 and NCT04858243.
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Beres LK, Underwood A, Le Tourneau N, Kemp CG, Kore G, Yaeger L, Li J, Aaron A, Keene C, Mallela DP, Khalifa BAA, Mody A, Schwartz SR, Baral S, Mwamba C, Sikombe K, Eshun‐Wilson I, Geng EH, Lavoie MC. Person-centred interventions to improve patient-provider relationships for HIV services in low- and middle-income countries: a systematic review. J Int AIDS Soc 2024; 27:e26258. [PMID: 38740547 PMCID: PMC11090778 DOI: 10.1002/jia2.26258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 04/16/2024] [Indexed: 05/16/2024] Open
Abstract
INTRODUCTION Person-centred care (PCC) has been recognized as a critical element in delivering quality and responsive health services. The patient-provider relationship, conceptualized at the core of PCC in multiple models, remains largely unexamined in HIV care. We conducted a systematic review to better understand the types of PCC interventions implemented to improve patient-provider interactions and how these interventions have improved HIV care continuum outcomes and person-reported outcomes (PROs) among people living with HIV in low- and middle-income countries. METHODS We searched databases, conference proceedings and conducted manual targeted searches to identify randomized trials and observational studies published up to January 2023. The PCC search terms were guided by the Integrative Model of Patient-Centeredness by Scholl. We included person-centred interventions aiming to enhance the patient-provider interactions. We included HIV care continuum outcomes and PROs. RESULTS We included 28 unique studies: 18 (64.3%) were quantitative, eight (28.6.%) were mixed methods and two (7.1%) were qualitative. Within PCC patient-provider interventions, we inductively identified five categories of PCC interventions: (1) providing friendly and welcoming services; (2) patient empowerment and improved communication skills (e.g. supporting patient-led skills such as health literacy and approaches when communicating with a provider); (3) improved individualized counselling and patient-centred communication (e.g. supporting provider skills such as training on motivational interviewing); (4) audit and feedback; and (5) provider sensitisation to patient experiences and identities. Among the included studies with a comparison arm and effect size reported, 62.5% reported a significant positive effect of the intervention on at least one HIV care continuum outcome, and 100% reported a positive effect of the intervention on at least one of the included PROs. DISCUSSION Among published HIV PCC interventions, there is heterogeneity in the components of PCC addressed, the actors involved and the expected outcomes. While results are also heterogeneous across clinical and PROs, there is more evidence for significant improvement in PROs. Further research is necessary to better understand the clinical implications of PCC, with fewer studies measuring linkage or long-term retention or viral suppression. CONCLUSIONS Improved understanding of PCC domains, mechanisms and consistency of measurement will advance PCC research and implementation.
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Affiliation(s)
- Laura K. Beres
- Johns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
- Centre for Infectious Disease Research in Zambia (CIDRZ)LusakaZambia
| | - Ashley Underwood
- Washington University in St. Louis School of MedicineSt LouisMissouriUSA
| | - Noelle Le Tourneau
- Washington University in St. Louis School of MedicineSt LouisMissouriUSA
| | | | - Gauri Kore
- Johns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
| | - Lauren Yaeger
- Washington University in St. Louis School of MedicineSt LouisMissouriUSA
| | - Jingjia Li
- Johns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
| | - Alec Aaron
- Johns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
| | | | | | | | - Aaloke Mody
- Centre for Infectious Disease Research in Zambia (CIDRZ)LusakaZambia
| | | | - Stefan Baral
- Johns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
| | - Chanda Mwamba
- Centre for Infectious Disease Research in Zambia (CIDRZ)LusakaZambia
| | | | | | - Elvin H. Geng
- Washington University in St. Louis School of MedicineSt LouisMissouriUSA
| | - Marie‐Claude C. Lavoie
- Center for International Health Education and BiosecurityUniversity of Maryland School of MedicineBaltimoreMarylandUSA
- Institute of Human VirologyUniversity of Maryland School of MedicineBaltimoreMarylandUSA
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Ahmed MH, Ahmed F, Abu-Median AB, Panourgia M, Owles H, Ochieng B, Ahamed H, Wale J, Dietsch B, Mital D. HIV and an Ageing Population-What Are the Medical, Psychosocial, and Palliative Care Challenges in Healthcare Provisions. Microorganisms 2023; 11:2426. [PMID: 37894084 PMCID: PMC10608969 DOI: 10.3390/microorganisms11102426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 09/24/2023] [Accepted: 09/26/2023] [Indexed: 10/29/2023] Open
Abstract
The continuing increase in patient numbers and improvement in healthcare provisions of HIV services in the UK, alongside the effectiveness of combined antiretroviral therapy (cART), has resulted in increasing numbers of the ageing population among people living with HIV (PLWH). It is expected that geriatricians will need to deal with many older people living with HIV (OPLWH) as life expectancy increases. Therefore, geriatric syndromes in OPLWH will be similar to the normal population, such as falls, cognitive decline, frailty, dementia, hypertension, diabetes and polypharmacy. The increase in the long-term use of cART, diabetes, dyslipidaemia and hypertension may lead to high prevalence of cardiovascular disease (CVD). The treatment of such conditions may lead to polypharmacy and may increase the risk of cART drug-drug interactions. In addition, the risk of developing infection and cancer is high. OPLWH may develop an early onset of low bone mineral density (BMD), osteoporosis and fractures. In this review, we have also provided potential psychosocial aspects of an ageing population with HIV, addressing issues such as depression, stigma, isolation and the need for comprehensive medical and psychosocial care through an interdisciplinary team in a hospital or community setting. OPLWH have a relatively high burden of physical, psychological, and spiritual needs and social difficulties, which require palliative care. The holistic type of palliative care that will improve physical, emotional and psychological wellbeing is discussed in this review.
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Affiliation(s)
- Mohamed H. Ahmed
- Department of Medicine and HIV Metabolic Clinic, Milton Keynes University Hospital NHS Foundation Trust, Eaglestone, Milton Keynes MK6 5LD, UK
- Department of Geriatric Medicine, Milton Keynes University Hospital NHS Foundation Trust, Eaglestone, Milton Keynes MK6 5LD, UK
| | - Fatima Ahmed
- Tele-Geriatric Research Fellowship, Geriatric Division, Family Medicine Department, Michigan State University, East Lansing, MI 48824, USA
| | - Abu-Bakr Abu-Median
- Leicester School of Allied Health Sciences, Faculty of Health and Life Sciences, De Montfort University, Leicester LE1 9BH, UK
| | - Maria Panourgia
- Department of Geriatric Medicine, Milton Keynes University Hospital NHS Foundation Trust, Eaglestone, Milton Keynes MK6 5LD, UK
| | - Henry Owles
- Department of Geriatric Medicine, Milton Keynes University Hospital NHS Foundation Trust, Eaglestone, Milton Keynes MK6 5LD, UK
| | - Bertha Ochieng
- Leicester School of Allied Health Sciences, Faculty of Health and Life Sciences, De Montfort University, Leicester LE1 9BH, UK
| | - Hassan Ahamed
- Tele-Geriatric Research Fellowship, Geriatric Division, Family Medicine Department, Michigan State University, East Lansing, MI 48824, USA
| | - Jane Wale
- Department of Palliative Medicine, Milton Keynes University Hospital NHS Foundation Trust, Eaglestone, Milton Keynes MK6 5LD, UK
| | - Benjamin Dietsch
- Department of Palliative Medicine, Milton Keynes University Hospital NHS Foundation Trust, Eaglestone, Milton Keynes MK6 5LD, UK
| | - Dushyant Mital
- Department of HIV and Blood Borne Virus, Milton Keynes University Hospital NHS Foundation Trust, Eaglestone, Milton Keynes MK6 5LD, UK
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What Does Joy in Living Mean to Elderly Residents of Nursing Homes in Singapore? RELIGIONS 2022. [DOI: 10.3390/rel13050469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The rapid ageing of Singapore’s population has led to the phenomenon of more elderly spending more total years in nursing homes. This study aimed to explore the meaning of Joy in Living to elderly residents of nursing homes in Singapore, the enabling and disenabling conditions to Joy in Living in nursing homes and how Person-centered Care can support Joy in Living in nursing homes. The concept of Joy in Living is used in this study as it is unique to an individual elderly’s experience; The study employed hermeneutical phenomenological research methodology to allow for the exploration of Joy in Living in lived experiences of elderly residents through in-depth sixteen semi-structured interviews with elderly residents and six participant observations of three nursing homes (pre and post interviews) between July 2021 and November 2021; Seven themes for Joy in Living experiences to flourish were identified, including “supportive nursing home environment and practices”, “connectedness through meaningful relationships”, “meaningful daily living”, “fulfil the need for spiritual care”, “personal control”, “desire to be free from worries”, and “adapting to changes”, each of which explains a facet of Joy in Living experiences of the elderly residing in nursing homes. These themes include the enabling and disenabling conditions to Joy in Living in nursing homes; Focusing efforts and resources on enabling the seven themes, including fulfilling the need for spiritual care will allow Joy in Living experiences of elderly to flourish in nursing homes. This in turn promotes better psychosocial well-being of the elderly and better living environments where nursing home residents may enjoy satisfactory accommodation while spending their remaining years in joy.
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Spiritual Needs as Expressed by People Living with HIV: A Systematic Review. RELIGIONS 2022. [DOI: 10.3390/rel13040342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
It has been previously demonstrated that religiosity and spirituality can help support people living with HIV. Despite this, little work has been undertaken on this theme. Using the PRISMA methodology, we reviewed academic literature from 2008 to 2020 to summarize how people living with HIV define spiritual needs. We found fifty-nine distinct types of approach that were related to this theme and were grouped into four main categories: religious needs, social needs, existential needs, and emotional needs. Religious needs were more frequently cited, including individual prayers, the ingestion of miraculous medicines, and so on. The study calls attention to the concept’s multidimensionality and the cultural differences in the included papers. It reveals the need of each culture to research, to find an adequate meaning of spirituality, and to cater to the spiritual needs for people living with HIV as part of their healthcare, before setting health policies.
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Lazarus JV, Safreed-Harmon K, Kamarulzaman A, Anderson J, Leite RB, Behrens G, Bekker LG, Bhagani S, Brown D, Brown G, Buchbinder S, Caceres C, Cahn PE, Carrieri P, Caswell G, Cooke GS, Monforte AD, Dedes N, Del Amo J, Elliott R, El-Sadr WM, Fuster-Ruiz de Apodaca MJ, Guaraldi G, Hallett T, Harding R, Hellard M, Jaffar S, Kall M, Klein M, Lewin SR, Mayer K, Pérez-Molina JA, Moraa D, Naniche D, Nash D, Noori T, Pozniak A, Rajasuriar R, Reiss P, Rizk N, Rockstroh J, Romero D, Sabin C, Serwadda D, Waters L. Consensus statement on the role of health systems in advancing the long-term well-being of people living with HIV. Nat Commun 2021; 12:4450. [PMID: 34272399 PMCID: PMC8285468 DOI: 10.1038/s41467-021-24673-w] [Citation(s) in RCA: 76] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 07/01/2021] [Indexed: 02/06/2023] Open
Abstract
Health systems have improved their abilities to identify, diagnose, treat and, increasingly, achieve viral suppression among people living with HIV (PLHIV). Despite these advances, a higher burden of multimorbidity and poorer health-related quality of life are reported by many PLHIV in comparison to people without HIV. Stigma and discrimination further exacerbate these poor outcomes. A global multidisciplinary group of HIV experts developed a consensus statement identifying key issues that health systems must address in order to move beyond the HIV field's longtime emphasis on viral suppression to instead deliver integrated, person-centered healthcare for PLHIV throughout their lives.
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Affiliation(s)
- Jeffrey V Lazarus
- Barcelona Institute for Global Health (ISGlobal), Hospital Clínic, University of Barcelona, Barcelona, Spain.
| | - Kelly Safreed-Harmon
- Barcelona Institute for Global Health (ISGlobal), Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Adeeba Kamarulzaman
- University of Malaya, Kuala Lumpur, Malaysia
- International AIDS Society (IAS), Geneva, Switzerland
| | - Jane Anderson
- Homerton University Hospital NHS Foundation Trust, London, United Kingdom
| | | | - Georg Behrens
- Medizinische Hochschule Hannover (MHH), Hannover, Germany
| | | | - Sanjay Bhagani
- Royal Free London NHS Trust and University College London, London, United Kingdom
| | - Darren Brown
- Chelsea and Westminster NHS Foundation Trust, London, United Kingdom
| | - Graham Brown
- Centre for Social Impact, University of New South Wales, Sydney, Australia
| | - Susan Buchbinder
- Bridge HIV, San Francisco Department of Public Health, San Francisco, United States
| | - Carlos Caceres
- Center for Research in Sexuality, AIDS and Society, Universidad Peruana Cayetano Heredia, Lima, Peru
| | | | - Patrizia Carrieri
- Aix Marseille Univ, Inserm, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l'Information Médicale, ISSPAM, Marseilles, France
| | - Georgina Caswell
- Global Network of People Living with HIV (GNP+), Cape Town, South Africa
| | | | | | | | - Julia Del Amo
- National Plan on AIDS, Ministry of Health, Madrid, Spain
| | | | | | | | - Giovanni Guaraldi
- Modena HIV Metabolic Clinic, Università degli studi di Modena e Reggio Emilia, Modena, Italy
| | - Tim Hallett
- Imperial College London, London, United Kingdom
| | | | | | - Shabbar Jaffar
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | | | - Marina Klein
- McGill University Health Centre Research Institute, Montreal, Canada
| | - Sharon R Lewin
- Department of Infectious Diseases, The University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
- Victorian Infectious Diseases Service, The Royal Melbourne Hospital at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
- Department of Infectious Diseases, The Alfred and Monash University, Melbourne, Australia
| | - Ken Mayer
- Fenway Health and Harvard Medical School, Boston, United States
| | - Jose A Pérez-Molina
- Infectious Diseases Department, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | | | - Denise Naniche
- Barcelona Institute for Global Health (ISGlobal), Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Denis Nash
- City University of New York Graduate School of Public Health and Health Policy, New York City, United States
| | - Teymur Noori
- European Centre for Disease Control and Prevention, Solna, Sweden
| | - Anton Pozniak
- Chelsea and Westminster NHS Foundation Trust, London, United Kingdom
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Peter Reiss
- Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
| | | | | | - Diana Romero
- City University of New York Graduate School of Public Health and Health Policy, New York City, United States
| | | | - David Serwadda
- Makerere University School of Public Health, Kampala, Uganda
| | - Laura Waters
- Central and North West London NHS Trust, London, United Kingdom
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Le Dai D, Pham TVA, Bui TTH, Than TNH, Pham VT, Luong NK, Harding R, Krakauer EL. Symptom prevalence, burden and correlates among people living with HIV in Vietnam: a two-centre self-report study. AIDS Care 2021; 34:887-893. [PMID: 34133248 DOI: 10.1080/09540121.2021.1922577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Physical and psychological symptoms among people living with HIV (PLWH) adversely affect quality of life and treatment adherence. Study objectives were: (i) to determine validity and reliability of a Vietnamese translation of the Memorial Symptom Assessment Scale-Short Form (MSAS-SF) among PLWH in Vietnam; (ii) to measure prevalence and burden of physical and psychological symptoms using the MSAS-SF including the Global Distress Index (GDI), Physical Distress subscale (PHYS), and Psychological Distress subscale (PSY); (iii) to identify symptom burden risk factors. We recruited 567 patients. Cronbach's alpha scores were: total MSAS-SF 0.91, GDI 0.83, PHYS 0.85, PSYCH 0.81. The scale showed good discriminant validity (low vs high function) (p < 0.001). The mean number of symptoms was 7.66, and the most prevalent were "worrying" (41.6%), "lack of energy" (40.6%), "feeling irritable" (40.4%), and "feeling sad" (39.2%). Monthly income below the poverty line was independently associated with increased: GDI,, PHYS, and PSY and a greater number of symptoms. The Vietnamese version of the MSAS-SF is valid to measure symptom prevalence and burden in HIV-positive populations. Here is a high symptom prevalence and burden among PLWH in Vietnam, especially those living in poverty, and a great need for palliative care integrated with HIV treatment.
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Affiliation(s)
- Duong Le Dai
- Department of Palliative Care, University of Medicine and Pharmacy, Ho Chi Minh, Vietnam.,Department of Geriatrics - Palliative Care, University Medical Centre, Ho Chi Minh, Vietnam
| | - Thi Van Anh Pham
- Department of Infectious Diseases, Hai Phong University of Medicine and Pharmacy, Hai Phong, Vietnam
| | - Thi Thanh Huyen Bui
- Department of Palliative Care, University of Medicine and Pharmacy, Ho Chi Minh, Vietnam.,City Children's Hospital, Ho Chi Minh City, Vietnam
| | - The Ngoc Ha Than
- Department of Palliative Care, University of Medicine and Pharmacy, Ho Chi Minh, Vietnam.,Department of Geriatrics - Palliative Care, University Medical Centre, Ho Chi Minh, Vietnam
| | - Van Thuc Pham
- Hai Phong University of Medicine and Pharmacy, Hai Phong, Vietnam
| | - Ngoc Khue Luong
- Administration of Medical Services, Ministry of Health, Hanoi, Vietnam
| | - Richard Harding
- Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, Cicely Saunders Institute, King's College London, UK
| | - Eric L Krakauer
- Department of Palliative Care, University of Medicine and Pharmacy, Ho Chi Minh, Vietnam.,Department of Global Health and Social Medicine, Harvard Medical School, USA.,Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston, USA
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Oluyase AO, Higginson IJ, Yi D, Gao W, Evans CJ, Grande G, Todd C, Costantini M, Murtagh FEM, Bajwah S. Hospital-based specialist palliative care compared with usual care for adults with advanced illness and their caregivers: a systematic review. HEALTH SERVICES AND DELIVERY RESEARCH 2021. [DOI: 10.3310/hsdr09120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background
Most deaths still take place in hospital; cost-effective commissioning of end-of-life resources is a priority. This review provides clarity on the effectiveness of hospital-based specialist palliative care.
Objectives
The objectives were to assess the effectiveness and cost-effectiveness of hospital-based specialist palliative care.
Population
Adult patients with advanced illnesses and their unpaid caregivers.
Intervention
Hospital-based specialist palliative care.
Comparators
Inpatient or outpatient hospital care without specialist palliative care input at the point of entry to the study, or community care or hospice care provided outside the hospital setting (usual care).
Primary outcomes
Patient health-related quality of life and symptom burden.
Data sources
Six databases (The Cochrane Library, MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature, PsycINFO and CareSearch), clinical trial registers, reference lists and systematic reviews were searched to August 2019.
Review methods
Two independent reviewers screened, data extracted and assessed methodological quality. Meta-analysis was carried out using RevMan (The Cochrane Collaboration, The Nordic Cochrane Centre, Copenhagen, Denmark), with separate synthesis of qualitative data.
Results
Forty-two randomised controlled trials involving 7779 participants (6678 patients and 1101 unpaid caregivers) were included. Diagnoses of participants were as follows: cancer, 21 studies; non-cancer, 14 studies; and mixed cancer and non-cancer, seven studies. Hospital-based specialist palliative care was offered in the following models: ward based (one study), inpatient consult (10 studies), outpatient (six studies), hospital at home or hospital outreach (five studies) and multiple settings that included hospital (20 studies). Meta-analyses demonstrated significant improvement favouring hospital-based specialist palliative care over usual care in patient health-related quality of life (10 studies, standardised mean difference 0.26, 95% confidence interval 0.15 to 0.37; I
2 = 3%) and patient satisfaction with care (two studies, standardised mean difference 0.36, 95% confidence interval 0.14 to 0.57; I
2 = 0%), a significant reduction in patient symptom burden (six studies, standardised mean difference –0.26, 95% confidence interval –0.41 to –0.12; I
2 = 0%) and patient depression (eight studies, standardised mean difference –0.22, 95% confidence interval –0.34 to –0.10; I
2 = 0%), and a significant increase in the chances of patients dying in their preferred place (measured by number of patients with home death) (seven studies, odds ratio 1.63, 95% confidence interval 1.23 to 2.16; I
2 = 0%). There were non-significant improvements in pain (four studies, standardised mean difference –0.16, 95% confidence interval –0.33 to 0.01; I
2 = 0%) and patient anxiety (five studies, mean difference –0.63, 95% confidence interval –2.22 to 0.96; I
2 = 76%). Hospital-based specialist palliative care showed no evidence of causing serious harm. The evidence on mortality/survival and cost-effectiveness was inconclusive. Qualitative studies (10 studies, 322 participants) suggested that hospital-based specialist palliative care was beneficial as it ensured personalised and holistic care for patients and their families, while also fostering open communication, shared decision-making and respectful and compassionate care.
Limitation
In almost half of the included randomised controlled trials, there was palliative care involvement in the control group.
Conclusions
Hospital-based specialist palliative care may offer benefits for person-centred outcomes including health-related quality of life, symptom burden, patient depression and satisfaction with care, while also increasing the chances of patients dying in their preferred place (measured by home death) with little evidence of harm.
Future work
More studies are needed of populations with non-malignant diseases, different models of hospital-based specialist palliative care, and cost-effectiveness.
Study registration
This study is registered as PROSPERO CRD42017083205.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 12. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Adejoke O Oluyase
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King’s College London, London, UK
| | - Irene J Higginson
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King’s College London, London, UK
| | - Deokhee Yi
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King’s College London, London, UK
| | - Wei Gao
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King’s College London, London, UK
| | - Catherine J Evans
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King’s College London, London, UK
| | - Gunn Grande
- School of Health Sciences, University of Manchester, Manchester, UK
- Manchester Academic Health Science Centre, Manchester, UK
| | - Chris Todd
- School of Health Sciences, University of Manchester, Manchester, UK
- Manchester Academic Health Science Centre, Manchester, UK
- Manchester University NHS Foundation Trust, Manchester, UK
| | - Massimo Costantini
- Palliative Care Unit, Azienda Unità Sanitaria Locale – Istituto di Ricovero e Cura a Carattere Scientifico (USL-IRCCS), Reggio Emilia, Italy
| | - Fliss EM Murtagh
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King’s College London, London, UK
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Sabrina Bajwah
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King’s College London, London, UK
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9
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Giusti A, Nkhoma K, Petrus R, Petersen I, Gwyther L, Farrant L, Venkatapuram S, Harding R. The empirical evidence underpinning the concept and practice of person-centred care for serious illness: a systematic review. BMJ Glob Health 2020; 5:e003330. [PMID: 33303515 PMCID: PMC7733074 DOI: 10.1136/bmjgh-2020-003330] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 10/21/2020] [Accepted: 10/23/2020] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Person-centred care has become internationally recognised as a critical attribute of high-quality healthcare. However, the concept has been criticised for being poorly theorised and operationalised. Serious illness is especially aligned with the need for person-centredness, usually necessitating involvement of significant others, management of clinical uncertainty, high-quality communication and joint decision-making to deliver care concordant with patient preferences. This review aimed to identify and appraise the empirical evidence underpinning conceptualisations of 'person-centredness' for serious illness. METHODS Search strategy conducted in May 2020. Databases: CINAHL, Embase, PubMed, Ovid Global Health, MEDLINE and PsycINFO. Free text search terms related to (1) person-centredness, (2) serious illness and (3) concept/practice. Tabulation, textual description and narrative synthesis were performed, and quality appraisal conducted using QualSyst tools. Santana et al's person-centred care model (2018) was used to structure analysis. RESULTS PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow data: n=12,446 studies screened by title/abstract, n=144 full articles assessed for eligibility, n=18 studies retained. All studies (n=18) are from high-income countries, and are largely of high quality (median score 0.82). The findings suggest that person-centred care encompasses the patient and family being respected, given complete information, involved in decision-making and supported in their physical, psychological, social and existential needs. The studies highlight the importance of involving and supporting family/friends, promoting continuation of normality and self-identity, and structuring service organisation to enable care continuity. CONCLUSION Person-centred healthcare must value the social network of patients, promote quality of life and reform structurally to improve patients' experience interacting with the healthcare system. Staff must be supported to flexibly adapt skills, communication, routines or environments for individual patients. There remains a need for primary data investigating the meaning and practice of PCC in a greater diversity of diagnostic groups and settings, and a need to ground potential components of PCC within broader universal values and ethical theory.
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Affiliation(s)
- Alessandra Giusti
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
- King's Global Health Institute, King's College London, London, UK
| | - Kennedy Nkhoma
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Ruwayda Petrus
- School of Applied Human Sciences, University of KwaZulu-Natal College of Humanities, Durban, South Africa
| | - Inge Petersen
- School of Applied Human Sciences, University of KwaZulu-Natal College of Humanities, Durban, South Africa
| | - Liz Gwyther
- School of Public Health and Family Medicine, University of Cape Town Faculty of Health Sciences, Cape Town, Western Cape, South Africa
| | - Lindsay Farrant
- School of Public Health and Family Medicine, University of Cape Town Faculty of Health Sciences, Cape Town, Western Cape, South Africa
| | | | - Richard Harding
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
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Bajwah S, Oluyase AO, Yi D, Gao W, Evans CJ, Grande G, Todd C, Costantini M, Murtagh FE, Higginson IJ. The effectiveness and cost-effectiveness of hospital-based specialist palliative care for adults with advanced illness and their caregivers. Cochrane Database Syst Rev 2020; 9:CD012780. [PMID: 32996586 PMCID: PMC8428758 DOI: 10.1002/14651858.cd012780.pub2] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Serious illness is often characterised by physical/psychological problems, family support needs, and high healthcare resource use. Hospital-based specialist palliative care (HSPC) has developed to assist in better meeting the needs of patients and their families and potentially reducing hospital care expenditure. There is a need for clarity on the effectiveness and optimal models of HSPC, given that most people still die in hospital and also to allocate scarce resources judiciously. OBJECTIVES To assess the effectiveness and cost-effectiveness of HSPC compared to usual care for adults with advanced illness (hereafter patients) and their unpaid caregivers/families. SEARCH METHODS We searched CENTRAL, CDSR, DARE and HTA database via the Cochrane Library; MEDLINE; Embase; CINAHL; PsycINFO; CareSearch; National Health Service Economic Evaluation Database (NHS EED) and two trial registers to August 2019, together with checking of reference lists and relevant systematic reviews, citation searching and contact with experts to identify additional studies. SELECTION CRITERIA We included randomised controlled trials (RCTs) evaluating the impact of HSPC on outcomes for patients or their unpaid caregivers/families, or both. HSPC was defined as specialist palliative care delivered by a palliative care team that is based in a hospital providing holistic care, co-ordination by a multidisciplinary team, and collaboration between HSPC providers and generalists. HSPC was provided to patients while they were admitted as inpatients to acute care hospitals, outpatients or patients receiving care from hospital outreach teams at home. The comparator was usual care, defined as inpatient or outpatient hospital care without specialist palliative care input at the point of entry into the study, community care or hospice care provided outside of the hospital setting. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. We assessed risk of bias and extracted data. To account for use of different scales across studies, we calculated standardised mean differences (SMDs) with 95% confidence intervals (CIs) for continuous data. We used an inverse variance random-effects model. For binary data, we calculated odds ratio (ORs) with 95% CIs. We assessed the evidence using GRADE and created a 'Summary of findings' table. Our primary outcomes were patient health-related quality of life (HRQoL) and symptom burden (a collection of two or more symptoms). Key secondary outcomes were pain, depression, satisfaction with care, achieving preferred place of death, mortality/survival, unpaid caregiver burden, and cost-effectiveness. Qualitative data was analysed where available. MAIN RESULTS We identified 42 RCTs involving 7779 participants (6678 patients and 1101 caregivers/family members). Twenty-one studies were with cancer populations, 14 were with non-cancer populations (of which six were with heart failure patients), and seven with mixed cancer and non-cancer populations (mixed diagnoses). HSPC was offered in different ways and included the following models: ward-based, inpatient consult, outpatient, hospital-at-home or hospital outreach, and service provision across multiple settings which included hospital. For our main analyses, we pooled data from studies reporting adjusted endpoint values. Forty studies had a high risk of bias in at least one domain. Compared with usual care, HSPC improved patient HRQoL with a small effect size of 0.26 SMD over usual care (95% CI 0.15 to 0.37; I2 = 3%, 10 studies, 1344 participants, low-quality evidence, higher scores indicate better patient HRQoL). HSPC also improved other person-centred outcomes. It reduced patient symptom burden with a small effect size of -0.26 SMD over usual care (95% CI -0.41 to -0.12; I2 = 0%, 6 studies, 761 participants, very low-quality evidence, lower scores indicate lower symptom burden). HSPC improved patient satisfaction with care with a small effect size of 0.36 SMD over usual care (95% CI 0.41 to 0.57; I2 = 0%, 2 studies, 337 participants, low-quality evidence, higher scores indicate better patient satisfaction with care). Using home death as a proxy measure for achieving patient's preferred place of death, patients were more likely to die at home with HSPC compared to usual care (OR 1.63, 95% CI 1.23 to 2.16; I2 = 0%, 7 studies, 861 participants, low-quality evidence). Data on pain (4 studies, 525 participants) showed no evidence of a difference between HSPC and usual care (SMD -0.16, 95% CI -0.33 to 0.01; I2 = 0%, very low-quality evidence). Eight studies (N = 1252 participants) reported on adverse events and very low-quality evidence did not demonstrate an effect of HSPC on serious harms. Two studies (170 participants) presented data on caregiver burden and both found no evidence of effect of HSPC (very low-quality evidence). We included 13 economic studies (2103 participants). Overall, the evidence on cost-effectiveness of HSPC compared to usual care was inconsistent among the four full economic studies. Other studies that used only partial economic analysis and those that presented more limited resource use and cost information also had inconsistent results (very low-quality evidence). Quality of the evidence The quality of the evidence assessed using GRADE was very low to low, downgraded due to a high risk of bias, inconsistency and imprecision. AUTHORS' CONCLUSIONS Very low- to low-quality evidence suggests that when compared to usual care, HSPC may offer small benefits for several person-centred outcomes including patient HRQoL, symptom burden and patient satisfaction with care, while also increasing the chances of patients dying in their preferred place (measured by home death). While we found no evidence that HSPC causes serious harms, the evidence was insufficient to draw strong conclusions. Although these are only small effect sizes, they may be clinically relevant at an advanced stage of disease with limited prognosis, and are person-centred outcomes important to many patients and families. More well conducted studies are needed to study populations with non-malignant diseases and mixed diagnoses, ward-based models of HSPC, 24 hours access (out-of-hours care) as part of HSPC, pain, achieving patient preferred place of care, patient satisfaction with care, caregiver outcomes (satisfaction with care, burden, depression, anxiety, grief, quality of life), and cost-effectiveness of HSPC. In addition, research is needed to provide validated person-centred outcomes to be used across studies and populations.
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Affiliation(s)
- Sabrina Bajwah
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Adejoke O Oluyase
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Deokhee Yi
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Wei Gao
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Catherine J Evans
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Gunn Grande
- School of Health Sciences, University of Manchester, Manchester, UK
- Manchester Academic Health Science Centre, Manchester, UK
| | - Chris Todd
- School of Health Sciences, University of Manchester, Manchester, UK
- Manchester Academic Health Science Centre, Manchester, UK
- Manchester University NHS Foundation Trust, Manchester, UK
| | | | - Fliss E Murtagh
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Irene J Higginson
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
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Pöyhiä RTI, Mwalumuli EO, Mtega AC, Vegula JJ. Sustainability of Palliative Care in a Rural Hospital in Tanzania: A Longitudinal and Prospective 4-Year Study. J Palliat Care 2020; 35:192-198. [PMID: 31973645 DOI: 10.1177/0825859719892083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Palliative care has been developed in recent years in many sub-Saharan countries in Africa due to activities of African Association for Palliative Care. Palliative care units have been established also in most hospitals in Tanzania. Yet very little is known about their functions. Long-term studies about the sustainability of palliative care have not been carried out. METHODS The attitudes of 101 members of hospital staff and persons in charge of palliative care services of Ilembula District Designated Hospital (IDDH), Tanzania, were assessed using a modified and prevalidated questionnaire annually in 2014 to 2017. The inquiries were executed on randomly allocated days. Also, the patient and economy registries were analyzed. Additional qualitative data were obtained in personal interviews and during observational visits twice a year at the IDDH. RESULTS Ilembula District Designated Hospital has a true multiprofessional palliative care team, which provides services in the hospital, in the villages, and at homes. The activities are based on careful 5-year planning and budgeting. Up to 17 villages have been included in the services. Ninety-five percent of the patients were HIV infected. Short-acting morphine oral solution was the only available strong opioid. The hospital staff evaluated palliative care as good or excellent; 50% of the staff would need more support in the end-of-life care. CONCLUSIONS A sustainable palliative care service can be built in a Tanzanian rural hospital if an advanced planning and budgeting are made. In Tanzania, the biggest group of palliative care patients are still HIV-infected individuals. There is a lack of opioids in the country.
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Affiliation(s)
- Reino Torsti Ilmari Pöyhiä
- Department of Oncology, Division of Palliative Care, University of Turku, Turku, Finland.,Kauniala Hospital, Kauniainen, Finland
| | - Emmanuel Owden Mwalumuli
- Departments of Palliative Care and Aministration, Ilembula District Designated Hospital, Ilembula, Tanzania
| | - Aida Charles Mtega
- Departments of Palliative Care and Aministration, Ilembula District Designated Hospital, Ilembula, Tanzania
| | - Jackson John Vegula
- Departments of Palliative Care and Aministration, Ilembula District Designated Hospital, Ilembula, Tanzania
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Nkhoma K, Ahmed A, Alli Z, Sherr L, Harding R. Is symptom prevalence and burden associated with HIV treatment status and disease stage among adult HIV outpatients in Kenya? A cross-sectional self-report study. AIDS Care 2019; 31:1461-1470. [PMID: 30913897 DOI: 10.1080/09540121.2019.1595514] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
People with HIV experience a high prevalence and burden of physical and psychological symptoms throughout their disease trajectory. These have important public and clinical health implications. We aimed to measure: the seven-day period prevalence of symptoms, the most burdensome symptoms, and determine if self-reported symptom burden is associated with treatment status, clinical stage and physical performance. We conducted a cross-sectional study among adult (aged at least 18 years) patients with HIV, attending HIV outpatient care in Kenya. Data was gathered through self-report using the Memorial Symptom Assessment Scale-Short Form (MSAS-SF), file extraction (sociodemographic data, treatment status, CD4 count, clinical stage) and through observation using the Karnofsky Performance Scale (KPS). Multivariable ordinal logistic regression assessed the association of symptom burden (MSAS-SF) controlling for demographic and clinical variables. Of the 475 participants approached, 400 (84.2%) participated. Ordinal logistic regression showed that being on HIV treatment was associated lower global distress index (in quartiles) (odds ratio .45, 95% CI .23 to .88; p = 0.019). Pain and symptom burden still persist in the era of antiretroviral therapy. Routine clinical practice should incorporate assessment and management of pain and symptoms irrespective of disease stage and treatment status in order to achieve the proposed fourth "90" in the UNAIDS 90-90-90 targets (that is good quality of life).
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Affiliation(s)
- Kennedy Nkhoma
- Faculty of Nursing Midwifery and Palliative Care, King's College London, Cicely Saunders Institute of Palliative Care Policy and Rehabilitation , London , UK
| | | | - Zipporah Alli
- Kenya Hospices and Palliative Care Association , Nairobi , Kenya
| | - Lorraine Sherr
- Institute for Global Health, University College London , London , UK
| | - Richard Harding
- Faculty of Nursing Midwifery and Palliative Care, King's College London, Cicely Saunders Institute of Palliative Care Policy and Rehabilitation , London , UK
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Harding R. Palliative care as an essential component of the HIV care continuum. Lancet HIV 2018; 5:e524-e530. [PMID: 30025682 DOI: 10.1016/s2352-3018(18)30110-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 05/11/2018] [Accepted: 05/17/2018] [Indexed: 11/26/2022]
Abstract
Although antiretroviral therapy has reduced mortality among people with HIV, inadequate treatment coverage, ageing, and the increasing incidence of organ failure and malignancies mean that high-quality care should include care at the end of life. This Review summarises the epidemiology of HIV in relation to mortality, and the symptoms and concerns of people with AIDS and those living with HIV who have either related or unrelated advanced comorbidities. In response to the evidence of a need for palliative care, the principles and practice of palliative care are described, and the evidence for its effectiveness and cost-effectiveness is appraised. The core practices of palliative care offer a mechanism to enhance the person-centred nature of HIV care; I identify the gaps in this type of care, and present evidence for effective models of care to address these. I detail the policies that prompt governments and health systems to respond to the palliative care needs of their population. Finally, I conclude this Review with evidence-based recommendations to improve the delivery of, and access to, high-quality HIV care until the end of life, reducing unnecessary suffering while optimising person-centred outcomes.
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Affiliation(s)
- Richard Harding
- Department of Palliative Care, Policy, and Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery, and Palliative Care, Cicely Saunders Institute, King's College London, London, UK.
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Kargbo RB. Novel Triterpenone for Treatment of Viral Diseases-HIV Inhibitors. ACS Med Chem Lett 2018; 9:298-299. [PMID: 29670689 DOI: 10.1021/acsmedchemlett.8b00113] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Indexed: 01/16/2023] Open
Affiliation(s)
- Robert B Kargbo
- Usona Institute, 277 Granada Drive, San Luis Obispo, California 93401-7337, United States
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