Mobile devices in palliative care services: a methodological approach to identifying use and implementation

The use of mobile devices is developing in palliative care services, promising enhancements to patient care and service delivery. However, mobile device use is not well documented in the research literature even though it is necessary to understand how its use is developing in the medical field. Therefore, an online survey was developed in English, French and Arabic and distributed across palliative care providers in the 33 out of 54 countries in Africa where palliative care services are present. The survey gathered information about the service provided where a respondent was based, and a framework was presented to respondents documenting the different stages of palliative care delivery (ie, diagnosis, referral, up to bereavement care). For each stage of delivery, participants were asked to outline how they currently use mobile devices and to specify any perceived barriers and benefits to mobile device development at their site, alongside thoughts on priorities for future research development. The results of this survey, and the priorities it indicates, will be presented

The role, impact, and support of informal caregivers in the delivery of palliative care for patients with advanced cancer: A multi-country qualitative study

Background: Cancer is increasing in its prevalence in sub-Saharan Africa. Informal caregivers are key to supporting engagement and interaction with palliative care services, but limited literature on their role impedes development of supportive interventions. Aim: We aimed to understand the role, impact, and support of informal caregivers of patients with advanced cancer when interacting with palliative care services in Nigeria, Uganda, and Zimbabwe. Design: Secondary analysis of qualitative interview transcripts. The dataset was assessed for fit and relevance and framework approach was used. Setting/participants: Interview transcripts of informal caregivers included participants aged over 18 years of age recruited from palliative care services across participating countries. Results: A total of 48 transcripts were analyzed. Mean age was 37 (range 19–75) with equal numbers of men and women. Five themes emerged from the data: (1) caregivers are coordinators of emotional, practical, and health service matters; (2) caregiving comes at a personal social and financial cost; (3) practical and emotional support received and required; (4) experience of interacting and liaising with palliative care services; and (5) barriers and recommendations relating to the involvement of palliative care. Conclusions: The role of informal caregivers is multi-faceted, with participants reporting taking care of the majority of medical, physical, financial, and emotional needs of the care recipient, often in the face of sacrifices relating to employment, finances, and their own health and social life. Efforts to develop comprehensive cancer control plans in sub-Saharan Africa must take account of the increasing evidence of informal caregiver needs

Towards person-centered quality care for children with life-limiting and life-threatening illness: self-reported symptoms, concerns and priority outcomes from a multi-country qualitative study

Abstract Background: Paediatric life-limiting and life-threatening conditionslife-limiting conditions place significant strain on children, families and health systems. Given high service use among this population, it is essential that care addresses their main symptoms and concerns. Aim: This study aimed to identify the symptoms, concerns, and other outcomes that matter to children with life-limiting conditions and their families in sub-Saharan Africa.Setting and participants: Cross-sectional qualitative study in Kenya, Namibia, South Africa and Uganda. Children/caregivers of children aged 0-17 years with life-limiting conditions were purposively sampled by age, sex, and diagnosis. Children aged 7 and above self-reported; caregiver proxies reported for children below 7 and those aged 7 and above unable to self-report.Results: 120 interviews were conducted with children with life-limiting conditions (n=61 age range 7-17 years), and where self-report was not possible caregivers (n=59) of children (age range 0-17). Conditions included advanced HIV (22%), cancer (19%), heart disease (16%) endocrine, blood and immune disorders (13%), neurological conditions (12%), sickle cell anaemia (10%) and renal disease (8%). Outcomes identified included: physical concerns – pain and symptom distress; psycho-social concerns – family and social relationships, ability to engage with age-appropriate activities (e.g., play, school attendance); existential concerns – worry about death, and loss of ambitions,health care quality– child- and adolescent-friendly services. Priority psycho-social concerns and health service factors varied by age.Conclusion: This study bridges an important knowledge gap regarding symptoms, concerns and outcomes that matter to children living with life-limiting conditions and their families and informs service development and evaluation

APCA Atlas of Palliative Care in Africa

BACKGROUND Since Wright & Clark’s book on palliative care in Africa in 2006, there has not been a comprehensive overview describing the state of palliative care development in African countries. AIMS To describe the current state of palliative care (PC) development in Africa according to the WHO’s Public Health Strategy for integrating PC: policies, availability and access to medicines, education, and service provision. METHODS Qualitative interviews were conducted with 16 Country Experts (March-August 2016). From those interviews, 367 indicators were derived, 130 after exclusion criteria and content analysis were performed. The Country Experts rated the indicators for validity & feasibility, a 14-member international committee of experts participated in a two-round modified UCLA-RAND Delphi consensus, and the co-authors (November-December 2016) ranked the indicators. The final 19 indicators were further defined and sent to 66 Key Country Informants from 51 African countries (January-March 2017). RESULTS Surveys were received from 89% (48/54) of African countries. Uganda, South Africa, and Kenya have the highest number of specialised hospice and PC services (71% of identified PC services); 19% (9/48) have no identified hospice and PC services. 22% (12/48) indicated having stand-alone PC policies, and 42% (20/48) reported having a dedicated person for PC in the Ministry. Zambia, Uganda, South Africa, Kenya, Ghana, and Egypt reported some official form of physician accreditation. Opioid consumption per capita was low (75% countries had <1 mg consumption/capita/year) compared to the global average (43mg/capita/year), with highest consumption in Mauritius, South Africa, Namibia, and Morocco. 54% (26/48) reported having a national PC association. CONCLUSIONS This study shows that there is limited PC development in Africa, but there is also a significant improvement in the number of countries with hospice and PC services, compared to previous reports. Improvements in advocacy were identified, with more than half of countries reporting a national PC association. Governments need to take the steps to improve education, increase the number of services, and ensure safe access to opioids

An analysis of palliative care development in Africa: a ranking based on region-specific macro-indicators

CONTEXT: To date, there is no study comparing palliative care (PC) development among African countries. OBJECTIVE: To analyze comparatively PC development in African countries based on region-specific indicators. METHODS: Data were obtained from the APCA Atlas of PC in Africa and a comparative analysis conducted. Nineteen indicators were developed and defined through qualitative interviews with African PC experts and a two-round modified Delphi consensus process with international experts on global PC indicators. Indicators were grouped by the WHO public health strategy for PC dimensions. These indicators were then sent as a survey to key informants in 52/54 African countries. Through an expert weighting process and ratings from the modified Delphi, weights were assigned to each indicator. RESULTS: Surveys were received from 89% (48/54) of African countries. The top three countries in overall PC development were, in order, Uganda, South Africa, and Kenya. Variability existed by dimension. The top three countries in specialized services were Uganda, South Africa, and Nigeria; in policies, it was Botswana followed by parity among Ethiopia, Rwanda, and Swaziland; in medicines, it was Swaziland, South Africa, then Malawi; in education, it was equivalent between Uganda and Kenya, then Ghana and Zambia. CONCLUSION: Uganda, South Africa, and Kenya are the highest performing countries and were the only ones with composite scores greater than 0.5 (50%). However, not one country universally supersedes all others across all four PC dimensions. The breakdown of rankings by dimension highlights where even high-performing African countries can focus their efforts to further PC development

Stakeholder perspectives and requirements to guide the development of digital technology for palliative cancer services: a multi-country, cross-sectional, qualitative study in Nigeria, Uganda and Zimbabwe

Introduction: Coverage of palliative care in low and middle-income countries is very limited, and global projections suggest large increases in need. Novel approaches are needed to achieve the palliative care goals of Universal Health Coverage. This study aimed to identify stakeholders’ data and information needs and the role of digital technologies to improve access to and delivery of palliative care for people with advanced cancer in Nigeria, Uganda and Zimbabwe. Methods: We conducted a multi-country cross-sectional qualitative study in sub-Saharan Africa. In-depth qualitative stakeholder interviews were conducted with N = 195 participants across Nigeria, Uganda and Zimbabwe (advanced cancer patients n = 62, informal caregivers n = 48, health care professionals n = 59, policymakers n = 26). Verbatim transcripts were subjected to deductive and inductive framework analysis to identify stakeholders needs and their preferences for digital technology in supporting the capture, transfer and use of patient-level data to improve delivery of palliative care. Results: Our coding framework identified four main themes: i) acceptability of digital technology; ii) current context of technology use; iii) current vision for digital technology to support health and palliative care, and; iv) digital technologies for the generation, reporting and receipt of data. Digital heath is an acceptable approach, stakeholders support the use of secure data systems, and patients welcome improved communication with providers. There are varying preferences for how and when digital technologies should be utilised as part of palliative cancer care provision, including for increasing timely patient access to trained palliative care providers and the triaging of contact from patients. Conclusion: We identified design and practical challenges to optimise potential for success in developing digital health approaches to improve access to and enhance the delivery of palliative cancer care in Nigeria, Uganda and Zimbabwe. Synthesis of findings identified 15 requirements to guide the development of digital health approaches that can support the attainment of global health palliative care policy goals

Understanding data and information needs for palliative cancer care to inform digital health intervention development in Nigeria, Uganda and Zimbabwe: protocol for a multicountry qualitative study

Introduction: Palliative care is a clinically and cost‐effective component of cancer services in sub-Saharan Africa (SSA). Despite the significant need for palliative cancer care in SSA, coverage remains inadequate. The exploration of digital health approaches could support increases in the quality and reach of palliative cancer care services in SSA. However, there is currently a lack of any theoretical underpinning or data to understand stakeholder drivers for digital health components in this context. This project addresses this gap through engaging with key stakeholders to determine data and information needs that could be supported through digital health interventions. Methods and analysis: This is a multicountry, cross-sectional, qualitative study conducted in Nigeria, Uganda and Zimbabwe. In-depth interviews will be conducted in patients with advanced cancer (n=20), caregivers (n=15), health professionals (n=20) and policy-makers (n=10) in each of the three participating countries. Data from a total of 195 interviews will transcribed verbatim and translated into English before being imported into NVivo software for deductive framework analysis. The analysis will seek to understand the acceptability and define mechanisms of patient-level data capture and usage via digital technologies. Ethics and dissemination: Ethics approvals have been obtained from the Institutional Review Boards of University of Leeds (Ref: MREC 18–032), Research Council of Zimbabwe (Ref: 03507), Medical Research Council of Zimbabwe (Ref: MRCZ/A/2421), Uganda Cancer Institute (Ref: 19–2018), Uganda National Council of Science and Technology (Ref: HS325ES) and College of Medicine University of Lagos (Ref: HREC/15/04/2015). The project seeks to determine optimal mechanisms for the design and development of subsequent digital health interventions to support development, access to, and delivery of palliative cancer care in SSA. Dissemination of these findings will occur through newsletters and press releases, conference presentations, peer-reviewed journals and social media. Trial registration number: ISRCTN1572771

Project OPUS: Development and evaluation of an electronic platform for pain management education of medical undergraduates in resource-limited settings

Introduction Pain is a very frequent symptom that is reported by patients when they present to health professionals but remains undertreated or untreated, particularly in low-resource settings including Nigeria. Lack of training in pain management remains the most significant obstacle to pain treatment alongside an inadequate emphasis on pain education in undergraduate medical curricula, negatively impacting on subsequent care of patients. This study aimed to determine the effect of a 12-week structured e-Learning course on the knowledge of pain management among Nigerian undergraduate medical students. Methods Prospective, multisite, pre-post study conducted across five medical colleges in Nigeria. Structured modules covering aspects of pain management were delivered on an e-Learning platform. Pre- and post-test self-assessments were carried out in the 12-week duration of the study. User experience questionnaires and qualitative interviews were conducted via instant messaging to evaluate user experiences of the platform. User experience data was analysed using the UEQ Data Analysis Tool and Framework Analysis. Results A total of 216 of 659 eligible students completed all sections of the e-Learning course. Participant mean age was 23.52 years, with a slight female predominance (55.3%). Across all participants, an increase in median pre- and post-test scores occurred, from 40 to 60 (Z = 11.3, p<0.001, effect size = 1.3), suggestive of increased knowledge acquisition relating to pain management. Participants suggested e-Learning is a valuable approach to delivering pain education alongside identifying factors to address in future iterations. Conclusion e-Learning approaches to pain management education can enhance traditional learning methods and may increase students’ knowledge. Future iterations of e-Learning approaches will need to consider facilitating the download of data and content for the platform to increase user uptake and engagement. The platform was piloted as an optional adjunct to existing curricula. Future efforts to advocate and support integration of e-Learning for pain education should be two-fold; both to include pain education in the curricula of medical colleges across Nigeria and the use of e-Learning approaches to enhance teaching where feasible. Methods: Prospective, multisite, pre-post study conducted across five medical colleges in Nigeria. Structured modules covering aspects of pain management were delivered on an e-Learning platform. Pre- and post-test self-assessments were carried out in the 12-week duration of the study. User experience questionnaires and qualitative interviews were conducted via instant messaging to evaluate user experiences of the platform. User experience data was analysed using the UEQ Data Analysis Tool and Framework Analysis. Results: A total of 216 of 659 eligible students completed all sections of the e-Learning course. Participant mean age was 23.52 years, with a slight female predominance (55.3%). Across all participants, an increase in median pre- and post-test scores occurred, from 40 to 60 (Z=11.3, p<0.001, effect size=1.3), suggestive of increased knowledge acquisition relating to pain management. Participants suggested e-Learning is a valuable approach to delivering pain education alongside identifying factors to address in future iterations. Conclusion: e-Learning approaches to pain management education can enhance traditional learning methods and may increase students’ knowledge. Future iterations of e-Learning approaches will need to consider facilitating the download of data and content for the platform to increase user uptake and engagement. The platform was piloted as an optional adjunct to existing curricula. Future efforts to advocate and support integration of e-Learning for pain education should be two-fold; both to include pain education in the curricula of medical colleges across Nigeria and the use of e-Learning approaches to enhance teaching where feasible