Symptom Levels in Care-Seeking Bangladeshi and Nepalese Adults With Advanced Cancer

A Global Collaboration to Develop and Pilot Test a Mobile Application to Improve Cancer Pain Management in Nepal

Introduction

Quality palliative care, which prioritizes comfort and symptom control, can reduce global suffering from non-communicable diseases, such as cancer. To address this need, the Nepalese Association of Palliative Care (NAPCare) created pain management guidelines (PMG) to support healthcare providers in assessing and treating serious pain. The NAPCare PMG are grounded in World Health Organization best practices but adapted for the cultural and resource context of Nepal. Wider adoption of the NAPCare PMG has been limited due to distribution of the guidelines as paper booklets.

Methods

Building on a long-standing partnership between clinicians and researchers in the US and Nepal, the NAPCare PMG mobile application (“app”) was collaboratively designed. Healthcare providers in Nepal were recruited to pilot test the app using patient case studies. Then, participants completed a Qualtrics survey to evaluate the app which included the System Usability Scale (SUS) and selected items from the Mobile App Rating Scale (MARS). Descriptive and summary statistics were calculated and compared across institutions and roles. Regression analyses to explore relationships (α = 0.05) between selected demographic variables and SUS and MARS scores were also conducted.

Results

Ninety eight healthcare providers (n = 98) pilot tested the NAPCare PMG app. Overall, across institutions and roles, the app received an SUS score of 76.0 (a score > 68 is considered above average) and a MARS score of 4.10 (on a scale of 1 = poor, 5 = excellent). 89.8% (n = 88) “agreed” or “strongly agreed” that the app will help them better manage cancer pain. Age, years of experience, and training in palliative care were significant in predicting SUS scores (p-values, 0.0124, 0.0371, and 0.0189, respectively); institution was significant in predicting MARS scores (p = 0.0030).

Conclusion

The NAPCare PMG mobile app was well-received, and participants rated it highly on both the SUS and MARS. Regression analyses suggest end-user variables important to consider in designing and evaluating mobile apps in lower resourced settings. Our app design and pilot testing process illustrate the benefits of cross global collaborations to build research capacity and generate knowledge within the local context.

Symptoms in Nepali Patients with Incurable Cancers: Implications for Interventions

Aim:

The poor quality and limited extent of palliative care services are of concern across the globe. To identify and measure patients' symptoms in Nepal, using a cell phone questionnaire platform, the investigators conducted and previously reported a cross-sectional study of Nepali adults. The unreported details of pain and other symptoms in these study data are here considered together with possible explanations and implications for interventions to lessen these symptoms.

Methods:

In a “snapshot” cross-sectional study of patients under regular care in three tertiary care Nepalese centers, we questioned 383 patients with incurable cancers using a 15-item cell phone-validated instrument to describe their major current symptoms and their intensities. The distributions of 11 symptom-level scores and the correlations between pain and different symptom scores were determined.

Results:

Thirty-eight percent of the population (142/383) had maximal pain scores which were in the severe range, and 25% (97/383) had such scores where they were evaluated. Patients reported moderate-to-severe tiredness 48% (183/383), depression 45% (172/383), anxiety 56% (217/383), poor appetite 64% (246/383), sleep quantity 64% (246/383), and sleep quality 64% (247/383).

Conclusions:

The significant fractions of patients with severe maximal and at-evaluation pain scores suggest that inadequate recognition and treatment of such symptoms characterized care of these regularly seen patients. The high fractions of patients with mood and sleep disturbances support this reading, suggesting helplessness and hopelessness, all addressable with psychosocial, environmental, and nontoxic, inexpensive pharmacological interventions.

Symptoms In Bangladeshi Patients with Incurable Cancers: Implications for Interventions

Aims:

The poor state of palliative care in low- and middle-income countries has been termed a global crisis by the Lancet Commission on Palliative Care. The investigators previously reported on a cross-sectional study of symptoms in 640 Bangladeshi adults with incurable cancers. Usual levels of pain were high. The not-reported details of pain and other symptoms offered an opportunity to consider explanations and implications for interventions to lessen these symptoms.

Methods:

At one visit, 640 Bangladeshi patients completed a symptom questionnaire. The distributions of 12 symptom level scores and the correlations between pain and different symptom scores were determined.

Results:

The population had significantly high and functionally compromising average usual pain scores, but low percentages of patients with very high and low pain scores. The distributions of scores for multiple symptoms were all skewed to higher mid-scale levels and modestly high (≥0.6) correlations of pain with nausea, anxiety, lack of appetite, constipation, and sleep quality were seen.

Conclusions:

While the types and direct effects of the cancers, the young age distribution, and the true symptomatic status of this Bangladeshi population studied may explain the described characteristics, the observations deserve exploration of other causes with specific therapeutic implications. These patients appear to have been partially treated for pain, and in particular, environmental factors such as extreme heat and its consequences appear more likely causes of moderate levels of multiple symptoms, which collectively magnified patients' suffering. Greater attention to gastrointestinal symptoms and sleep disturbance, in particular, seems indicated.