The impact of socioeconomic inequality on access to health care for patients with advanced cancer: A qualitative study.

Objective: In Canada, populations experiencing socioeconomic inequality have lower rates of access to screening and diagnosis and higher mortality rates than people from higher-income areas. Limited evidence exists concerning their experiences when living with advanced cancer. We explored how socioeconomic inequality shapes the experiences of patients with advanced cancer. Methods: We utilized a qualitative study design that combined tenets of hermeneutic phenomenological inquiry and critical theory. Four individuals with advanced cancer from low-income neighborhoods, three family members, and six cancer care providers were accrued through a tertiary cancer center in a western Canadian city. One-on-one interviews and brief notes were used for data collection. Data were analyzed through thematic analysis. Results: Three interrelated themes were identified: 'Lack of access to socioeconomic supports,' 'Gaps in access to health care resources and services,' and 'Limited access to symptom relief.' Patients experienced inadequate finances, housing, and transportation. Most patients lived alone and had limited family and social support. Patients reported lack of knowledge of available resources and health system navigation issues, including communication problems with providers and among levels of care. Cancer care providers and patients described issues achieving symptom relief as well as challenges associated with extensive disease. Conclusions: Study findings suggest that socioeconomic inequality interferes with the ability of persons with advanced cancer to access health care and contributes to less optimal cancer outcomes. Socioeconomic inequality may increase symptom severity. Findings call for the development of tailored interventions for populations with advanced cancer and socioeconomic inequality.

Inequities in access to palliative and end-of-life care in the black population in Canada: a scoping review.

BACKGROUND: Improving equity and early access to palliative care for underserved populations in Canada is a priority. Little is known regarding access to palliative and end-of-life care in the Black population. METHODS: We undertook a scoping review using the framework by Arksey and O'Malley to identify knowledge, access gaps, and experiences of palliative and end-of-life care among Blacks living with life-limiting illnesses in Canada. Primary studies, discussion papers, books, and reports were considered eligible. We followed a comprehensive search strategy developed by an information scientist. Searches were performed in the following bibliographic databases: Medline, EMBASE, PsycINFO via OVID, CINAHL via EBSCOhost, Scopus and Cochrane Library via Wiley. The search strategy was derived from three main concepts: (1) Black people; (2) Canada and Canadian provinces; (3) Palliative, hospice, or end-of-life care. No publication date or language limits were applied. Titles and abstracts were screened for eligibility by one reviewer and full text by two independent reviewers. RESULTS: The search yielded 233 articles. Nineteen articles were selected for full-text review, and 7 articles met the inclusion criteria. These studies were published between 2010 and 2021, and conducted in the provinces of Ontario and Nova Scotia only. Studies used both quantitative and qualitative methods and included cancer decedents, next of kin, family caregivers and religious leaders. Sample sizes in various studies ranged from 6 - 2,606 participants. Included studies reported a general lack of understanding about palliative and end-of-life care, positive and negative experiences, and limited access to palliative and end-of-life care for Blacks, across all care settings. CONCLUSION: Findings suggest limited knowledge of palliative care and inequities in access to palliative and end-of-life care for Blacks living with life-limiting illnesses in 2 Canadian provinces. There is an urgent need for research to inform tailored and culturally acceptable strategies to improve understanding and access to palliative care and end-of-life care among Blacks in Canada.

Increasing access to palliative care for patients with advanced cancer of African and Latin American descent: a patient-oriented community-based study protocol.

BACKGROUND: Cancer disparities are a major public health concern in Canada, affecting racialized communities of Latin American and African descent, among others. This is evident in lower screening rates, lower access to curative, and palliative-intent treatments, higher rates of late cancer diagnoses and lower survival rates than the general Canadian population. We will develop an Access to Palliative Care Strategy informed by health equity and patient-oriented research principles to accelerate care improvements for patients with advanced cancer of African and Latin American descent. METHODS: This is a community-based participatory research study that will take place in two Canadian provinces. Patients and community members representatives have been engaged as partners in the planning and design of the study. We have formed a patient advisory council (PAC) with patient partners to guide the development of the Access to Palliative Care Strategy for people of African and Latin American descent. We will engage100 participants consisting of advanced cancer patients, families, and community members of African and Latin American descent, and health care providers. We will conduct in-depth interviews to delineate participants' experiences of access to palliative care. We will explore the intersections of race, gender, socioeconomic status, language barriers, and other social categorizations to elucidate their role in diverse access experiences. These findings will inform the development of an action plan to increase access to palliative care that is tailored to our study population. We will then organize conversation series to examine together with community partners and healthcare providers the appropriateness, effectiveness, risks, requirements, and convenience of the strategy. At the end of the study, we will hold knowledge exchange gatherings to share findings with the community. DISCUSSION: This study will improve our understanding of how patients with advanced cancer from racialized communities in Canada access palliative care. Elements to address gaps in access to palliative care and reduce inequities in these communities will be identified. Based on the study findings a strategy to increase access to palliative care for this population will be developed. This study will inform ways to improve access to palliative care for racialized communities in other parts of Canada and globally.

Nurse-led adult palliative care models in low- and middle-income countries: A scoping review.

AIMS: To map evidence on the nature and extent of use of nurse-led palliative care models in low- and middle-income countries serving adults with life-limiting conditions. DESIGN: A scoping review of the literature was undertaken. DATA SOURCES: A systematic search was performed from database inception to March 2022 in: Medline, EMBASE, CINAHL, Wiley Cochrane Library, SCOPUS, Web of Science, SciELO and Global Health. Main search terms included: Nurse-led AND Palliative care AND Low-and middle-income countries. Grey literature was searched from Proquest Dissertations and Theses Global, the World Health Organization and selected palliative care websites. We searched the reference list of included articles for additional studies. REVIEW METHODS: We used the framework by Arksey and O'Malley and the PRISMA-ScR guidelines. Titles and abstracts were screened by one reviewer and full text by two reviewers. Thematic analysis was used to synthesize data and results are presented descriptively using themes and categories. RESULTS: Eighteen studies were included, with majority from Sub-Saharan Africa (10/20). Three nurse-led palliative care models emerged: nurse-led empowering care, nurse-led symptom control and nurse-led multicomponent palliative care. They served particularly cancer and HIV patients and were delivered in person or by telehealth care. Reported outcomes were adherence to therapy, improved self-care ability, improved quality of life and increased access to palliative. CONCLUSIONS: The use of nurse-led palliative care in low- and middle-income countries is in its developing stages and seems feasible. Nursing roles in in low- and middle-income countries need to be expanded by developing advanced practice nurses and nurse practitioner programmes, with palliative care content. More impact evaluation studies on the use of nurse-led palliative care models in these countries are needed. IMPACT: This review highlights nurse-led care models that can enhance access and quality of life of patients with life-limiting conditions in low- and middle-income countries.

Psychosocial distress and the quality of life of cancer patients in two health facilities in Cameroon.

BACKGROUND: Psychosocial distress interferes with the ability to cope effectively with cancer, its physical symptoms and treatment. This in turn leads to poor outcomes in patients. OBJECTIVE: The aim of this study was to assess the level of psychosocial distress, emotional distress and the quality of life of cancer patients in two health facilities in Cameroon. METHODS: This study used a cross-sectional hospital-based design. The study was carried out over a period of three months from July-September 2020. The sample size was 120 cancer patients. A consecutive sampling technique was used to select participants. Three validated questionnaires were used: DT, HADS and EORTC QLQ-C30 to assess, psychosocial distress, emotional distress and quality of life respectively. Results were presented using descriptive (frequency, percentage, mean) and inferential statistics (Chi square, Pearson's correlation, ANOVA). Data were analysed with SPSS version 21. All statistics were considered significant at an alpha value set at 0.05 level. RESULTS: The majority of patients 83 (69.2%) presented with clinically significant distress, with financial difficulties 87 (72.5%), fatigue 83 (69.2%), transportation 73 (60.8%) and difficulties with work/school 69(57.5%) being the most reported problems. Fifty nine (50.0%) and 56(47.5%) had moderate to severe anxiety and depression symptoms respectively. Overall on HADS, 67 patients (56.8%) presented with emotional distress. The quality of life was fair, with a mean of 52.4 ± 21.3.There was a statistically significant negative relationship (P < 0.0001), between psychosocial distress and quality of life of patients. CONCLUSION: Cancer patients suffer from psychosocial distress, which has a negative relationship on their quality of life. It is important that healthcare professionals working in these settings, assess psychosocial distress early in patients with cancer to improve the quality of care and enhance quality of life.

Management of cellulitis and the role of the nurse: a 5-year retrospective multicentre study in Fako, Cameroon.

OBJECTIVE: This was a 5 year retrospective study of patients' hospital records to find out how patients with cellulitis are managed and the care provided by nurses to these patients in some hospitals in Fako, Cameroon. RESULTS: Of the 236 cases of cellulitis identified from a study of hospital records, 202 were included in the study. Most of the participants (55%) were female and the mean (SD) age was 43 (1.1) years. Cellulitis accounted for 2.3% of admissions in this study. The predisposing factors identified were; the presence of trauma (60.5%), HIV infection (18.6%), alcohol consumption (8.4%) and tobacco use (4.8%). Commonly recorded complications were necrosis (32.2%), sepsis (23%), abscess formation (19.5%), and ulcer development (19.5%). Medical management was with antibiotic therapy, including mostly penicillin (26.5%), aminoglycoside (22.1%), nitroimidazole (20.2%) and cephalosporin (19.6%). Debridement (46.7%), and incision and drainage (44.4%) were the most implemented surgical interventions. Nursing care, as found in patients' hospital records were predominantly on medication administration (98.0%), vital signs assessment (90.5%) and patient assessment (53%). Cellulitis therefore was found among a substantial number of patients and management was predominantly with combination antibiotics therapy and inadequate nursing care.

Preregistration nursing students' experiences of a palliative care course in a resource-poor setting.

BACKGROUND: Palliative care education for non-specialist health professionals is an important strategy for widening access to palliative care. AIM: To describe Cameroonian nursing students' experiences and perceptions of the strengths and weaknesses of a palliative care course, with a view to refining the course. METHODS: Three focus groups were conducted with 23 students, and data were analysed thematically using the framework approach. RESULTS: The students reported connecting with their past personal and professional experiences in the care of patients with palliative care needs during the course. The main course strength reported was its use of a variety of interactive educational strategies, such as role plays, group discussions and case studies. The course's main reported weakness was the lack of supervised clinical practice in palliative care. CONCLUSION: The use of a variety of interactive educational strategies-including supervised clinical practice-is considered by nursing students as vital to enhancing learning in palliative care education. However, the lack of supervised palliative care clinical practice opportunities is a challenge in Cameroon.

A qualitative evaluation of the impact of a palliative care course on preregistration nursing students' practice in Cameroon.

BACKGROUND: Current evidence suggests that palliative care education can improve preregistration nursing students' competencies in palliative care. However, it is not known whether these competencies are translated into students' practice in the care of patients who are approaching the end of life. This paper seeks to contribute to the palliative care evidence base by examining how nursing students in receipt of education report transfer of learning to practice, and what the barriers and facilitators may be, in a resource-poor country. METHODS: We utilised focus groups and individual critical incident interviews to explore nursing students' palliative care learning transfer. Three focus groups, consisting of 23 participants and 10 individual critical incident interviews were conducted with preregistration nursing student who had attended a palliative care course in Cameroon and had experience caring for a patient approaching the end of life. Data was analysed thematically, using the framework approach. RESULTS: The results suggest that nursing students in receipt of palliative care education can transfer their learning to practice. Students reported recognizing patients with palliative care needs, providing patients with physical, psychosocial and spiritual support and communicating patient information to the wider care team. They did however perceive some barriers to this transfer which were either related to themselves, qualified nurses, the practice setting or family caregivers and patients. CONCLUSION: The findings from this study suggest that nursing student in receipt of palliative care education can use their learning in practice to provide care to patients and their families approaching the end of life. Nevertheless, these findings need to be treated with some caution given the self-reported nature of the data. Demonstrating the link between preregistration palliative care education and patient care is vital to ensuring that newly acquired knowledge and skills are translated and embedded into clinical practice. This study also has implications for advocating for palliative care policies and adequately preparing clinical placement sites for students' learning and transfer of learning.

A modified systematic review of research evidence about education for pre-registration nurses in palliative care.

BACKGROUND: We undertook a modified systematic review of research regarding educational approaches to and effectiveness of pre-registration palliative care nursing, to inform the development of a short course in palliative care for pre-registration nursing students in Cameroon. The aim of this review was to examine educational approaches applied to pre-registration palliative care nursing education and their effectiveness, and to discuss implications for the development of palliative care curricula in resource-poor countries. METHOD: A modified systematic review of research on palliative care educational interventions, conducted with pre-registration student nurses was undertaken. Relevant literature was gathered from CINAHL, EMBASE, MEDLINE and PsychINFO databases for the period 2000-2013. Inclusion was limited to studies of educational interventions evaluating the effectiveness and outcomes of palliative and end of life care education with pre-registration student nurses. RESULTS: 17 studies were found, all of which were conducted in resource-rich countries: United States of America, Canada, Australia, and United Kingdom. Palliative care nursing education at pre-registration level is either delivered as a discrete course within the curriculum or palliative care content is embedded into other nursing specialty courses throughout the wider curriculum. Palliative care education is delivered to students at a variety of stages in their nursing program, using a mix of both didactic and experiential educational strategies. Course facilitators span palliative care specialists, educators who have attended 'train-the-trainer' courses in palliative care, and nurses with hospice experience. Education is underpinned by transformative and experiential learning theories and reported as effective in improving students' attitudes towards care of the dying. CONCLUSION: The educational strategies identified in this review may be applicable to resource-poor countries. However, there are challenges in transferability because of the lack of availability of specialist palliative care practitioners who can serve as educators, specialist palliative care units/institutions for experiential learning, funds to design and use high fidelity simulations, and palliative care textbooks and other educational materials. There is thus a need for innovative educational strategies that can bridge these barriers in resource-poor countries. There is also a need for further research into how palliative care education impacts on pre-registration student nurses' knowledge and practice.