Search

Abstract Background: While research is needed to advocate for implementation of global agendas to strengthen palliative care, healthcare professionals’ research literacy must improve to bridge the gap between evidence and practice. A resurgent focus on North-South power disparities, means attention should also focus on understanding low- and middle-income countries’ local agency to implement palliative care research agendas. Methods: An observational, cross-sectional online survey among Kenyan palliative healthcare professionals currently working at any of the palliative and hospice care organizations operational during January – December 2019, using descriptive statistics. Results: Among the 93 survey respondents, participants were mainly nurses (50.54%; n = 47). Regarding research attitudes: all agreed/strongly agreed research was important for their professional work. Over nine-tenths (91.21%; n = 83) reported having the skills to conduct research, and 91.30% (n = 84) wanted to conduct research in their clinical work. 90% (90.21%; n = 83) reported supervisory support to conduct research. A comparable proportion (90.22%; n = 83) would undertake research if they could find funding. Regarding research practice: over two-thirds (70.65%; n = 65) reported ever having had a mentor who encouraged them to do research, while approximately half (50.59%; n = 43) reported reading evidence-based journal articles about once per month and attending monthly in-house meetings on palliative care (56.79%; n = 46). Regarding research literacy: while over two-fifths of respondents described their current research literacy level as ‘none’ or ‘beginner’ (44.56%; n = 41), a comparable proportion described it as ‘intermediate’ (45.65%; n = 42), with 9 (9.78%) stating it was ‘advanced’. Conclusion: The majority of palliative healthcare professionals report having interest, skills and support at work to conduct palliative care research, with a low-to-medium level of research literacy. The current study explored palliative care staff attitudes to, experience in, and literacy with the research process, which is necessary to creating a dialogue on implementing research findings. This study also adds to the global empowerment agenda, addressing inequities in research opportunities and local capacity to own and undertake palliative care research.

Background: After decades of paternalistic health service provision, National Health Service users in the United Kingdom are encouraged to express preferences for services; 'the patient is king'. Whilst the mental health service user voice is encouraged in multiple forums, it is in satisfaction research (especially using the survey method) as a commentary on services provided that it is primarily heard. However, methodological concerns exist regarding the use of satisfaction surveys as a measure of healthcare quality.Aim: To discuss the arguments against and for using satisfaction surveys in mental health research.Method: A review of the existing literature on satisfaction surveys.Results: There are a number of significant criticisms of satisfaction surveys and their continued use in mental health research.Conclusions: Despite these criticisms, the limitations of satisfaction surveys do not merit their abandonment. The authors indicate possible future directions for the satisfaction research agenda. [ABSTRACT FROM AUTHOR]

Background: During the COVID-19 pandemic in the United Kingdom, multiple aspects of everyday human existence were disrupted. In contrast, almost all levels of educational learning continued, albeit with modifications, including adaptation to virtual-or online-classroom experiences. This pedagogic transition also occurred in the National Institute of Health and Care Research Applied Research Collaboration Northwest London's (NIHR ARC NWL) Improvement Leader Fellowship, an annual programme focusing on quality improvement (QI). This qualitative study aimed to understand how these changes impacted the Fellows' learning experience., Methods: We explored the experiences of two cohorts of programme Fellows (n = 18, 2020-2021 and n = 15, 2021-2022) with focus groups, analysed under a constructivist qualitative research paradigm., Results: The two primary and four sub-themes that emerged were: Online QI learning experience (benefits and challenges) and Implementing online QI learning (facilitators and barriers). While benefits had three further sub-themes (i.e., digital flexibility, connection between learners, and respite from impact of COVID-19), challenges had four (i.e., lack of interaction, technological challenges and digital exclusion, human dimension, and digital fatigue). While the facilitators had three sub-themes (i.e., mutual and programmatic support, online resource access, and personal resilience), barriers had one (i.e., preventing implementation and lack of protected time)., Conclusion: Despite challenges to in-person ways of working, online learning generally worked for action-orientated QI learning, but changes are needed to ensure the effectiveness of future use of virtual learning for QI. Understanding the challenges of the translation of learning into action is crucial for implementation learning, gaining insight into how improvement Fellows navigated this translation when learning remotely and implementing directly in their workplace is key to understanding the evolving nature of implementation over the pandemic years and beyond., (© 2024. The Author(s).)

Background and Objectives: In 2027, Canadians whose only medical condition is an untreatable mental illness and who otherwise meet all eligibility criteria will be able to request Medical Assistance in Dying (MAiD). This study investigates the attitudes of undergraduate students towards widening the scope of MAiD for physical illness for certain psychiatric conditions. We were interested in understanding if age, information, and type of mental illness influenced undergraduates' acceptance or rejection of MAiD for mental illness (MAiD-MI)., Method: 413 undergraduate students participated in this study which examined the factors that correlate with the acceptance or rejection of MAiD-MI. Four scenarios were presented in which age (older or younger) and illness type (depression or schizophrenia) were manipulated. Demographic questions and measures assessing personality, religion, and attitudes towards euthanasia were administered. Questions assessing participants' general understanding of MAiD and their life experiences with death and suicide were also asked., Results: Most of the participants accepted MAiD-MI for both depression and schizophrenia. As hypothesized, support for MAiD-MI was higher for patients with schizophrenia than for depression. Also as hypothesized, support was higher for older patients than for younger patients. Variables such as religion, personality and political affiliation were also associated with acceptance or rejection of MAiD-MI. Finally, consistent with our hypotheses, participants' understanding of MAiD and experiences with death and suicide was predictive of support for MAiD-MI., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

The social system of animals involves a complex interplay between physiology, natural history, and the environment. Long relied upon discrete categorizations of "social" and "solitary" inhibit our capacity to understand species and their interactions with the world around them. Here, we use a globally distributed camera trapping dataset to test the drivers of aggregating into groups in a species complex (martens and relatives, family Mustelidae , Order Carnivora ) assumed to be obligately solitary. We use a simple quantification, the probability of being detected in a group, that was applied across our globally derived camera trap dataset. Using a series of binomial generalized mixed-effects models applied to a dataset of 16,483 independent detections across 17 countries on four continents we test explicit hypotheses about potential drivers of group formation. We observe a wide range of probabilities of being detected in groups within the solitary model system, with the probability of aggregating in groups varying by more than an order of magnitude. We demonstrate that a species' context-dependent proclivity toward aggregating in groups is underpinned by a range of resource-related factors, primarily the distribution of resources, with increasing patchiness of resources facilitating group formation, as well as interactions between environmental conditions (resource constancy/winter severity) and physiology (energy storage capabilities). The wide variation in propensities to aggregate with conspecifics observed here highlights how continued failure to recognize complexities in the social behaviors of apparently solitary species limits our understanding not only of the individual species but also the causes and consequences of group formation., Competing Interests: Competing interests statement:The authors declare no competing interest.

Local authorities are central to the implementation of English Integrated Care Systems' health inequalities agendas, embedding public health into population health management planning. They work with partners to deliver a range of 'health determinant' services and facilities for people in a defined geographic area. This work is substantially premised on the use of cross-sectoral data that is linked at the individual level, readily available, longitudinal and contemporaneous. However, multiple challenges exist to such data availability. This paper elaborates upon these challenges to local authority public health systems and their potential solutions., Competing Interests: Statement of conflicts of interest: The authors declare they have no conflicts of interest.

Objectives: Minimal information is available about the quality of dying and death in Uganda and Kenya, which are African leaders in palliative care. We investigated the quality of dying and death in patients with advanced cancer who had received hospice care in Uganda or Kenya., Methods: Observational study with bereaved caregivers of decedents (Uganda: n  = 202; Kenya: n  = 127) with advanced cancer who had received care from participating hospices in Uganda or Kenya. Participants completed the Quality of Dying and Death questionnaire and a measure of family satisfaction with cancer care (FAMCARE)., Results: Quality of Dying and Death Preparation and Connectedness subscales were most frequently rated as good to almost perfect for patients in both countries (45.5% to 81.9%), while Symptom Control and Transcendence subscales were most frequently rated as intermediate (42.6% to 60.4%). However, 35.4% to 67.7% of caregivers rated overall quality of dying and overall quality of death as terrible to poor. Ugandan caregivers reported lower Preparation, Connectedness, and Transcendence ( p < .001). Controlling for covariates, overall quality of dying was associated with better Symptom Control in both countries ( p < .001) and Transcendence in Uganda ( p = .010); overall quality of death, with greater Transcendence in Uganda ( p = .004); and family satisfaction with care, with better Preparation in Uganda ( p = .004)., Significance of Results: Findings indicate strengths in spiritual and social domains of the quality of dying and death in patients who received hospice care in Uganda and Kenya, but better symptom control is needed to improve this outcome in these countries.

Background: The COVID-19 pandemic exposed the health equity gap between and within countries. Western countries were the first to receive vaccines and mortality was higher among socially deprived, minority and indigenous populations. Surprisingly, many sub-Saharan countries reported low excess mortalities. These countries share experiences with community organization and participation in health. The aim of this article was to analyse if and how this central role of people can promote a successful pandemic response., Methods: This analysis was partly based on local and national experiences shared during an international and Latin American conference on person-and people-centred care in 2021. Additionally, excess mortality data and pandemic control-relevant data, as well as literature on the pandemic response of countries with an unexpected low excess mortality were consulted., Results: Togo, Mongolia, Thailand and Kenya had a seven times lower mean excess mortality for 2020 and 2021 than the United States of America. More successful pandemic responses were observed in settings with experience in managing epidemics like Ebola and HIV, well-established community networks, a national philosophy of mutual aid, financial government assistance, more human resources for primary care and paid community health workers., Discussion: Since trust in authorities and health needs vary greatly, local strategies are needed to complement national and international pandemic responses. Three key levers were identified to promote locally-tailored pandemic management: well-organized communities, community-oriented primary care, and health information systems. An organized community structure stems from a shared ethical understanding of humanity as being interconnected with each other and the environment. This structure facilitates mutual aid and participation in decision making. Community-oriented primary care includes attention for collective community health and ways to improve health from its roots. A health information system supports collective health and health equity analysis by presenting health needs stratified for social deprivation, ethnicity, and community circumstances., Conclusions: The difference in excess mortality between countries during the COVID-19 pandemic and various country experiences demonstrate the potential of the levers in promoting a more just and effective health emergency response. These same levers and strategies can promote more inclusive and socially just health systems., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Background: Palliative care (PC) can reduce symptom distress and improve quality of life for patients and their families experiencing life-threatening illness. While the need for PC in Kenya is high, PC service delivery and research is limited. Qualitative research is needed to explore potential areas for PC research and support needed to enable that research. This insight is critical for informing a national PC research agenda and mobilizing limited resources for conducting rigorous PC research in Kenya., Objectives: To explore perceptions of priority areas for PC research and support needed to facilitate rigorous research from the perspective of Kenyan PC providers and leaders., Methods: Focus groups (FGs) were conducted in November and December of 2018 using a semi-structured interview guide. FGs were audio-recorded, transcribed, and analyzed using a thematic content analysis approach., Results: Three FGs were conducted (n = 22 participants). Ten themes related to PC research emerged, including research on: 1) beliefs about death, disease, and treatment to inform PC; 2) awareness about PC, 3) integration of PC within the health system; 4) understanding caregiver experiences and needs; 5) community health volunteers (CHVs) and volunteer programs; 6) evaluation of costs and benefits of PC; 7) treatment approaches, including complementary and alternative medicine (CAM) and advanced diagnostics at end of life; 8) other suggestions for research, 9) populations in need of PC research; and 10) resources for enabling research., Conclusions: Kenyan PC providers and leaders identified key areas requiring increased scientific inquiry and critical resources needed to enable this research. These findings can help to focus future PC research in Kenya and encourage funding agencies to prioritize the issues identified., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Context: Non-communicable diseases (NCDs), associated with health-related suffering, can benefit from palliative care in resource-limited settings, where over four-fifths of these deaths occur., Objective: To measure the prevalence of depressive symptoms, palliative care-related concerns, physical and other psychological symptoms among adult patients with NCDs in Malawi and Namibia., Methods: This multi-center, cross-sectional study consecutively recruited outpatients from four tertiary referral hospitals. Stepwise regression analysis was used to assess factors associated with physical and psychological symptom burden., Results: Among 457 participants, primary diagnosis was cancer (n=147, 32%); cardiovascular disease (CVD) (n=130, 28%), chronic respiratory disease (CRESD) (n=73, 16%) or diabetes (n=107, 23%). Over half were female (58.9%; n=269), mean age was 48 (SD=15.7). Clinically significant psychological distress was identified among cancer (57.2%), diabetes (57.0%), CRESD (45.2%) and CVD patients (43.1%), with criterion for major depression symptoms met for cancer (42.9%), diabetes (39.2%), CVD (30.0%) and CRESD (28.8%). Most severe palliative care concerns were: first sharing feelings (i.e., not at all/not very often), reported by CVD (28%), CRESD (23%), cancer (22%) and diabetes (21%) patients; second help and advice (i.e., none/very little), among cancer (28%), CVD (26%), diabetes (22%), and CRESD (16%) patients. High prevalence of moderate-to-severe pain was reported (cancer 54%, CVD 41%, CRESD 38%, diabetes 38%). Functional status, age, and presence of comorbidities were associated with physical and psychological symptom distress., Conclusion: Given the high burden of physical and psychosocial symptoms and symptom distress, the findings highlight the need for integrated person-centered palliative care for NCDs to optimize care outcomes., (Copyright © 2022 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.)

In April 2022, the Intergovernmental Panel on Climate Change stated clearly that without immediate and deep reductions in greenhouse gas emissions, it would be impossible to limit global temperature rise to 1.5 °C above pre-industrial levels. A growing body of research shows an increasing reaction to witnessing or experiencing current climate impacts and concern regarding apparent inaction in response, manifests as negative cognitive, emotional, and behavioural responses, including eco-anxiety. This commentary contends that nature-based activities (NBAs) have a potentially important, but currently neglected, role to play in supporting those experiencing eco-anxiety. However, existing research limitations hinder their adoption in the United Kingdom's social prescribing agenda and they remain a largely untapped therapeutic resource that need to be mainstreamed into clinical and social care provision. The paper calls for investment in research that advances our understanding of the individual and community benefits of NBAs, the longevity of their impact, and their associated, comparative and opportunity costs.

Background: The Children's Palliative Care Outcome Scale (C-POS) is the first measure developed for children with life-limiting and -threatening illness. It is essential to determine whether the measure addresses what matters to children, and if they can comprehend and respond to its items., Aim: To determine the face and content validity, comprehensiveness, comprehensibility, acceptability and feasibility, and implementability of the C-POS., Design: Mixed methods (1) Content validation : mapping C-POS items onto an evidence-based framework from prior evidence; (2) Comprehensiveness, comprehensibility, acceptability feasibility, and implementability : qualitative in-depth and cognitive interviews with a purposive sample of children and young people ( n  = 6), family caregivers ( n  = 16), and health workers ( n  = 12) recruited from tertiary facilities in Kenya, South Africa, and Uganda., Results: (1) C-POS content mapped on to palliative care domains for (a) children (i.e. physical (e.g. symptoms), social (e.g. play/socialize), psychological (e.g. happy)) and (b) families (i.e. psychological (e.g. worry), social (e.g. information), and help and advice ). (2) C-POS items were well understood by children and their caregivers, acceptable, and relevant. Completion time was a median of 10 min, patients/caregivers and health workers reported that using the C-POS improved their communication with children and young people. Methodological and content issues included: (i) conceptual gap in the spiritual/existential domain; (ii) further consideration of developmental, age-appropriate items in the social and psychological domains, and (iii) linguistic complexity and difficulty in proxy rating., Conclusion: C-POS items capture the core symptoms and concerns that matter to children and their families. C-POS is feasible, comprehensible, and acceptable for use in clinical settings; areas for further development and improvement are identified.

The authors' aim was to examine if the nature of female genital mutilation/cutting (FGM/C) in Somaliland is changing and any contributing factors. In this mixed method qualitative study the researchers used 24 focus groups, 20   key informant interviews and 28 in-depth interviews with multiple stakeholders. We found a shift from the pharaonic to Sunna cut, an age decrease at which FGM/C is performed and an increase in its medicalization. Shift in cut type and medicalization appears to be partly a response to the medical narrative of anti-FGM/C campaigns, partly an intertwining of messaging regarding health risks and religious norms. We recommend a need to consider programs that reflect upon the utility and appropriateness of moving the dominant narrative to issues around the right to bodily integrity and bodily autonomy, and melding that messaging with the Islamic discourse on protecting health that focuses on collective welfare.

Background and Objectives: In 2016, Medical Assistance in Dying (MAiD) became legal in Canada for those suffering a grievous and untreatable medical condition. Currently, it is not available to minors or to those with an untreatable mental illness, although it is likely the scope of MAiD will be widened to include persons with severe and untreatable mental illnesses. However, little is known about the factors predicting acceptance or rejection of MAiD for persons with either a grievous medical condition or an untreatable mental illness. Methods: A survey was administered to 438 undergraduate students to examine factors associated with their acceptance or rejection of MAiD. The survey included four different scenarios: a young or old person with an untreatable medical condition, and a young or old person with an untreatable mental illness. Demographic questions (age, sex, religion, etc), personality measures, and an attitude towards euthanasia scale were also administered, as well as questions assessing participants' general understanding of MAiD and their life experiences with death and suicide. Results/Conclusion: Overall, most of the Canadian undergraduate participants accepted MAiD for both terminally ill and mentally ill patients; however, different variables, such as age, religion, and ethnicity, predicted the acceptance or rejection of MAiD for each scenario.

Objective: To gain exploratory insights into the multifaceted, lived experience impact of COVID-19 on a small sample of ethnic minority healthcare staff to cocreate a module of questions for follow-up online surveys on the well-being of healthcare staff during the pandemic., Design: A cross-sectional design using two online focus groups among ethnic minority healthcare workers who worked in care or supportive roles in a hospital, community health or primary care setting for at least 12 months., Participants: Thirteen healthcare workers (11 female) aged 26-62 years from diverse ethnic minority backgrounds, 11 working in clinical roles., Results: Five primary thematic domains emerged: (1) viral vulnerability , centring around perceived individual risk and vulnerability perceptions; (2) risk assessment , comprising pressures to comply, perception of a tick-box exercise and issues with risk and resource stratification; (3) interpersonal relations in the workplace , highlighting deficient consultation of ethnic minority staff, cultural insensitivity, need for support and collegiate judgement; (4) lived experience of racial inequality , consisting of job insecurity and the exacerbation of systemic racism and its emotional burden; (5) community attitudes , including public prejudice and judgement, and patient appreciation., Conclusions: Our novel study has shown ethnic minority National Health Service (NHS) staff have experienced COVID-19 in a complex, multidimensional manner. Future research with a larger sample should further examine the complexity of these experiences and should enumerate the extent to which these varied thematic experiences are shared among ethnic minority NHS workers so that more empathetic and supportive management and related occupational practices can be instituted., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ.)

Despite the relative consensus in the self-management literature that personal resolutions are not an effective stand-alone tactic for self-control, some individuals seem capable of using them to exert a remarkable level of control over their behavior. One such individual was Mahatma Gandhi, the famous Indian statesman. Gandhi often used personal resolutions-or "vows"-to commit himself to a range of challenging behaviors, such as extreme diets, sexual abstinence, and fasting. Similarly, Prince Pückler-Muskau, a celebrated 19th-Century adventurer, landscape designer and travel author, described using personal resolutions to unfailingly accomplish numerous tasks in his everyday life. In this article, we examine the historical writings of Gandhi and Pückler-Muskau concerning their use of resolutions. We describe three defining characteristics of their resolutions, which we will refer to as unbreakable resolutions , and outline Gandhi's advice for making and keeping such resolutions. Our analysis suggests that the effectiveness of unbreakable resolutions may be primarily due to the temporally extended contingencies of reinforcement associated with their use, and can be usefully interpreted from the perspective of delay-discounting and say-do correspondence models of self-control. The implications of this examination for understanding the concept of willpower and for enhancing modern research into self-control training are also discussed. Based on this analysis, we additionally offer a tentative set of guidelines on how to make and keep unbreakable resolutions., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Powell, Schmaltz and Radke.)

Competing Interests: Competing interests: None declared.

Purpose: The burden of cancer disproportionately affects low- and middle-income countries. Low 5-year survival figures for children with cancer in low-income countries are due to late presentation at diagnosis, treatment abandonment, absence of sophisticated multidisciplinary care, and lack of adequate resources. The reasons for late presentation are partly due to limited awareness of cancer symptoms, high treatment costs, and facility-level barriers to timely access to treatment. Given the systemic challenges, the regional need for palliative oncology care for children care is high. Despite the enormity of the need for palliative oncology for children with cancer in Africa, its level of development remains poor. This paper presents the evidence on the status of palliative oncology care for children in sub-Saharan Africa., Methods: This review provides an overview of the current status of palliative oncology care for children in sub-Saharan Africa, using the WHO building blocks for health systems strengthening as reference points, before proposing a forward-looking prioritized agenda for its development., Results: We noted that survival rates for children with cancer remain much poorer in Africa compared with developed countries and palliative oncology care resources are scant. Our results also show low coverage for palliative oncology care services for children, lack of a critical mass of health workers with the skills to deliver the care, a lack of robust documentation of the burden of cancer, widespread lack of access to essential controlled medicines, limited funding from government and limited coverage for palliative oncology care in most cancer control plans., Conclusion: This review highlights priority areas for action that align to the WHO health system building blocks for strengthening health systems., Competing Interests: Vivienne MulemaConsulting or Advisory Role: Beyond Logistics LimitedNo other potential conflicts of interest were reported.

Objectives: To review and synthesize the existing evidence on bereavement care, within the United Kingdom (UK), for ethnic minority communities in terms of barriers and facilitators to access; models of care; outcomes from, and satisfaction with, service provision., Design: A systematic review adopting a framework synthesis approach was conducted. An electronic search of the literature was undertaken in MEDLINE, Embase, PsycINFO, Social Work Abstract and CINAHL via EBSCO, Global Health, Cochrane library, the Trip database and ProQuest between 1995 and 2020. Search terms included bereavement care, ethnic minority populations and the UK setting., Results: From 3,185 initial records, following screening for eligibility, and full-text review of 164 articles, seven studies were identified. There was no research literature outlining the role of family, friends and existing networks; and a real absence of evidence about outcomes and levels of satisfaction for those from an ethnic minority background who receive bereavement care. From the limited literature, the overarching theme for barriers to bereavement care was 'unfamiliarity and irregularities'. Four identified subthemes were 'lack of awareness'; 'variability in support'; 'type and format of support'; and 'culturally specific beliefs'. The overarching theme for facilitators for bereavement care was 'accessibility' with the two subthemes being 'readily available information' and 'inclusive approaches'. Three studies reported on examples of different models of care provision., Conclusions: This review reveals a stark lack of evidence about bereavement care for ethnic minority populations. In particular, understanding more about the role of family, friends and existing support systems, alongside outcomes and satisfaction will begin to develop the evidence base underpinning current provision. Direct user-representation through proactive engagement and co-design approaches may begin to determine the most appropriate models and format of bereavement care for ethnic minority communities to inform service design and delivery., Competing Interests: The authors have declared that no competing interests exist.

Identifying reforms that minimize US healthcare costs is imperative. This commentary explores one intervention with potential cost-saving implications that has received comparably minimal consideration: spiritual care provision. It highlights the staff and patient costing benefits of spiritual care in addressing spiritual distress and urges practical policy and research initiatives to maximize its impact.

Watson and Rayner's (1920) attempt to condition a fear of furry animals and objects in an 11-month-old infant is one of the most widely cited studies in psychology. Known as the Little Albert study, it is typically presented as evidence for the role of classical conditioning in fear development. Some critics, however, have noted deficiencies in the study that suggest that little or no fear conditioning actually occurred. These criticisms were primarily based on the published reports of the study. In this article, we present a detailed analysis of Watson's (1923) film record of the study to determine the extent to which it provides evidence of conditioning. Our findings concur with the view that Watson and Rayner's conditioning procedure was largely ineffective, and that the relatively weak signs of distress that Albert does display in the film can be readily accounted for by such factors as sensitization and maturational influences. We suggest that the tendency for viewers to perceive the film as a valid demonstration of fear conditioning is likely the result of expectancy effects as well as, in some cases, an ongoing mistrust of behaviorism as dehumanizing and manipulative. Our analysis also revealed certain anomalies in the film which indicate that Watson engaged in some "literary license" when editing it, most likely with a view toward using the film mainly as a promotional device to attract financial support for his research program. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

While great strides have been made in improving childhood mortality, millions of children die each year with significant health-related suffering. More than 98% of these children live in low- and middle-income countries (LMICs). Efforts have been made to increase access to pediatric palliative care (PPC) services to address this suffering in LMICs through policy measures, educational initiatives, and access to essential medicines. However, a core component of high-quality PPC that has been relatively neglected in LMICs is grief and bereavement support for parents after the death of their child. This paper reviews the current literature on parental grief and bereavement in LMICs. This includes describing bereavement research in high-income countries (HICs), including its definition, adverse effect upon parents, and supportive interventions, followed by a review of the literature on health-related grief and bereavement in LMICs, specifically around: perinatal death, infant mortality, infectious disease, interventions used, and perceived need. More research is needed in grief and bereavement of parents in LMICs to provide them with the support they deserve within their specific cultural, social, and religious context. Additionally, these efforts in LMICs will help advance the field of parental grief and bereavement research as a whole., Competing Interests: The authors declare no conflict of interest.

Background: Volunteers play a significant role in supporting hospice and palliative care in Africa, but little is known about the types of volunteers, their motivations and roles in service delivery., Methods: Palliative care experts from 30 African countries were invited to participate in an online survey, conducted in English and French, that consisted of 58 questions on: socio-demographics, the activities, motivation and coordination of volunteers, and an appraisal of recent developments in volunteering. The questionnaire was pre-tested in Uganda. Quantitative data was analysed descriptively with SPSS v22; answers on open-ended questions were analysed using content analysis., Results: Twenty-five respondents from 21 countries replied to the questionnaire. The typical volunteer was reported to be a female aged between 30 and 50 years. Volunteer roles included, among others: direct patient assistance, providing psychosocial / spiritual support, and assisting patients' families. Respondents considered altruism, civic engagement and personal gain (for a professional career) as volunteers' most significant motivational drivers. One in two respondents noted that recruiting volunteers is easy, and cooperation with the communities was often mentioned as helpful. Trainings mostly occurred before the first assignment, with topics covering the palliative care concept, care, psychosocial support and team work. Half of respondents described recent overall volunteering developments as positive, while the other half described problems primarily with financing and motivation. Most volunteers received transportation allowances or bicycles; some received monetary compensation., Conclusions: The findings show a wide range of volunteering in palliative care. We identified volunteers as typically 30-50 years old, non-professional females, motivated by altruism, a sense of civic engagement and personal gain. Palliative care services benefit from volunteers who take on high workloads and are close to the patients. The main challenges for volunteer programmes are funding and the long-term motivation of volunteers.

Background: Female genital mutilation/cutting (FGM/C) negatively impacts the wellbeing of girls and women throughout their lifecycle. In Somalia, FGM/C prevalence is nearly universal (98%) among females aged 15-49 years, with infibulation prevalence at 77%. Whilst there is need to engage healthcare workers in the prevention and management of FGM/C, minimal information exists indicating healthcare systems' capacity to fulfil this role. This study explored factors impacting the capacity of the Somaliland healthcare system to prevent the medicalization, and manage the complications of, FGM/C., Methods: A cross-sectional qualitative study using semi-structured key informant interviews, conducted in the Somali language, was undertaken in the Maroodi Jeex and Awdal regions of Somaliland, in rural and urban Borama and Hargeisa districts in December 2016. A total of 20 interviews were conducted with healthcare workers comprised of medical doctors, nurses, midwives and system administrators. Transcribed and translated interview data were analysed using the template analysis approach., Results: Healthcare workers reported understanding the adverse impact of FGM/C on the health of girls and women. However, they faced multiple contextual challenges in their preventative and management roles at the individual level, e.g., they lacked specific formal training on the prevention and management of FGM/C complications and its medicalization; institutional level, e.g., many facilities lacked funding and equipment for effective FGM/C management; and policy level, e.g., no national policies exist on the management of FGM/C complications and against its medicalization., Conclusion: Healthcare systems in urban and rural Somaliland have limited capacity to prevent, diagnose and manage FGM/C. There is a need to strengthen healthcare workers' skill deficits through training and address gaps in the health system by incorporating the care of girls and women with FGM-related complications into primary healthcare services through multi-sectoral collaboration and coordination, establishing clinical guidelines for FGM/C management, providing related equipment, and enacting policies to prevent the medicalization of the practice.

Background: Paediatric life-limiting and life-threatening conditions (life-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: A total of 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) were included. 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 s ymptom 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.

Purpose: A culturally appropriate, patient-centered measure of the quality of dying and death is needed to advance palliative care in Africa. We therefore evaluated the Quality of Dying and Death Questionnaire (QODD) in a Kenyan hospice sample and compared item ratings with those from a Canadian advanced-cancer sample., Methods: Caregivers of deceased patients from three Kenyan hospices completed the QODD. Their QODD item ratings were compared with those from 602 caregivers of deceased patients with advanced cancer in Ontario, Canada, and were correlated with overall quality of dying and death ratings., Results: Compared with the Ontario sample, outcomes in the Kenyan sample (N = 127; mean age, 48.21 years; standard deviation, 13.57 years) were worse on 14 QODD concerns and on overall quality of dying and death ( P values ≤ .001) but better on five concerns, including interpersonal and religious/spiritual concerns ( P values ≤ .005). Overall quality of dying was associated with better patient experiences with Symptoms and Personal Care, interpersonal, and religious/spiritual concerns ( P values < .01). Preparation for Death, Treatment Preferences, and Moment of Death items showed the most omitted ratings., Conclusion: The quality of dying and death in Kenya is worse than in a setting with greater PC access, except in interpersonal and religious/spiritual domains. Cultural differences in perceptions of a good death and the acceptability of death-related discussions may affect ratings on the QODD. This measure requires revision and validation for use in African settings, but evidence from such patient-centered assessment tools can advance palliative care in this region.

Introduction: Palliative care (PC) services in the African region need to adapt to manage rising numbers of patients with cancer or other life-limiting conditions. Mobile phone use in healthcare delivery (mHealth) is at an early stage of development for PC, but may provide new approaches to supporting patients regionally, particularly those with non-communicable diseases., Methods: We conducted an online survey of 51 PC providers across 21 countries in the African region to identify: (i) current mHealth use in PC service delivery; (ii) potential barriers to mHealth use; and (iii) provider priorities for research development., Results: mHealth approaches were reported across 71.4% of services in which respondents were based. Barriers to mHealth research include patients not having access to phones, mobile network access, and limited access to expertise and hardware required for mHealth. Research priorities were identified which included exploring ways of incorporating mHealth into patient care and ensuring access and relevance of mHealth for patients and health professionals., Discussion: mHealth approaches are present across PC services in the African region, but so too are barriers to their use. Further work is required to explore how existing mHealth activities might be further developed and aligned with priority areas for PC development. Crucially, user engagement that seeks to understand the preferences and priorities of patients with PC needs, their caregivers, and those involved in the provision of PC should remain central to these efforts.

Background: Evidence on patient-reported outcomes of newly diagnosed HIV patients is scarce, and largely cross-sectional. This prospective cohort study describes the prevalence of, and changes in, patient-reported outcomes in the three months after HIV diagnosis, in 11 HIV outpatient centres in Kenya and Uganda., Methods: Adults were recruited within 14 days of result, completing self-report measures four times at monthly intervals. Multilevel mixed-effects linear regression (quality of life continuous outcomes) and ordinal logistic regression (symptoms and concerns categorical outcomes) modelled change over time, with repeated observations grouped within individuals adjusted for demographic/clinical characteristics, and multiple imputation for missing data., Results: 438 adults were enrolled and 234 (53·4%) initiated ART. Improvement was found for MOS-HIV physical health (from 46·3 [95% CI 45·1-47·3], to 53·7 [95% CI 52.8-54·6], p < 0.001), and mental health (from 46·4 [95% CI 45·5-47·3] to 54·5 [95% CI 53·7-55·4], p < 0.001). POS subscale 'interpersonal problems' improved but remained burdensome (OR = 0·91, 95% CI = 0·87-0·94, p < 0.001; 22·7% reported severe problems at final time point). The scores for the existential POS subscale (OR = 0·95, 95% CI = 0.90-1·00, p = 0.056) and physical/psychological problems POS subscale (OR = 0·97, 95% CI = 0.92-1·02, p = 0.259) did not improve. Participants who initiated ART had worsening physical/psychological (OR = 0·64, 95% CI = 0·41-0·99, p = 0·045) and interpersonal problems (OR = 0·64, 95% CI = 0·42-0·96, p = 0·033)., Conclusion: Although some self-reported outcomes improve over time, burden of interpersonal problems remains substantial and existential concerns do not improve.

Background: While the overall incidence of hepatitis A has declined markedly since the introduction of a vaccine, sporadic cases and outbreaks of the disease continue to occur., Objective: Our aim was to evaluate the effectiveness of an electronic health record (EHR) provider alert as part of an outbreak-control vaccination program implemented in the emergency department (ED)., Methods: We conducted a retrospective study assessing the impact of a Best Practice Alert (BPA) built into an EHR to prompt providers when a patient was homeless to consider hepatitis A vaccination in the ED. Data were collected over three 6-month time periods: a historical control period, a pre-intervention period, and an intervention period., Results: There were no vaccinations given in the ED in the historical period, which increased to 465 after the implementation of the BPA. During the implementation period, there were 1,482 visits identified among 1,131 patients that met the inclusion criteria. Of these, there were 1,147 (77.5%) visits where the patient either received the vaccine in the ED, had already received the vaccine, or it was not indicated due to the current medical issue. There were also 333 (22.5%) visits where the BPA was active for potential vaccination eligibility, but did not receive it in the ED., Conclusions: We leveraged an informatics tool developed within our EHR to identify high-risk patients and remind providers of the availability of vaccination in the ED. Using these tools enabled providers to increase vaccination efforts within our ED to help control the community-wide outbreak., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Purpose: Despite increased access to palliative care in Africa, there remains substantial unmet need. We examined the impact of approaches to promoting the development of palliative care in two African countries, Uganda and Kenya, and considered how these and other strategies could be applied more broadly., Methods: This study reviews published data on development approaches to palliative care in Uganda and Kenya across five domains: education and training, access to opioids, public and professional attitudes, integration into national health systems, and research. These countries were chosen because they are African leaders in palliative care, in which successful approaches to palliative care development have been used., Results: Both countries have implemented strategies across all five domains to develop palliative care. In both countries, successes in these endeavors seem to be related to efforts to integrate palliative care into the national health system and educational curricula, the training of health care providers in opioid treatment, and the inclusion of community providers in palliative care planning and implementation. Research in palliative care is the least well-developed domain in both countries., Conclusion: A multidimensional approach to development of palliative care across all domains, with concerted action at the policy, provider, and community level, can improve access to palliative care in African countries.

Context: To date, there is no study comparing palliative care (PC) development among African countries., Objectives: To analyze comparatively PC development in African countries based on region-specific indicators., Methods: Data were obtained from the African PC Association Atlas of PC in Africa, and a comparative analysis was 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 World Health Organization public health strategy for PC dimensions. These indicators were then sent as a survey to key informants in 52 of 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 of 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; and 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., (Copyright © 2018 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Current coverage of palliative care services in sub-Saharan Africa (SSA) remains woefully inadequate, but harnessing mHealth could be one approach to facilitate greater service coverage and engagement with patients with life-limiting progressive disease., Aims: A systematic literature review to identify the development and use of mHealth in palliative care services in SSA., Methods: 13 electronic databases from 1990 to 2015 were searched alongside the manual searching of journals and citation searching of included article reference lists. Articles were assessed against inclusion and exclusion criteria and study details extracted and tabulated by two researchers. Studies were plotted against a modified WHO mHealth and ICT framework to classify how they are targeting health system strengthening., Results: Of the 1110 articles identified, 5 met the inclusion criteria, describing mHealth use in Nigeria, Uganda, Kenya and Malawi. Descriptive analysis has shown that existing mHealth interventions for palliative care services in SSA are limited in number and are being developed for use at the palliative treatment, guidance and coordination stage of care provision. Levels of detail about the development and structure of interventions are low., Conclusions: mHealth interventions for palliative care in SSA are limited. This is an opportune time to explore how evidence-based mHealth interventions could form part of the evolving palliative care services in the region., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Determining how species coexist is critical for understanding functional diversity, niche partitioning and interspecific interactions. Identifying the direct and indirect interactions among sympatric carnivores that enable their coexistence is particularly important to elucidate because they are integral for maintaining ecosystem function. We studied the effects of removing nine fishers (Pekania pennanti) on their population dynamics and used this perturbation to elucidate the interspecific interactions among fishers, grey foxes (Urocyon cinereoargenteus) and ringtails (Bassariscus astutus). Grey foxes (family: Canidae) are likely to compete with fishers due to their similar body sizes and dietary overlap, and ringtails (family: Procyonidae), like fishers, are semi-arboreal species of conservation concern. We used spatial capture-recapture to investigate fisher population numbers and dynamic occupancy models that incorporated interspecific interactions to investigate the effects members of these species had on the colonization and persistence of each other's site occupancy. The fisher population showed no change in density for up to 3 years following the removals of fishers for translocations. In contrast, fisher site occupancy decreased in the years immediately following the translocations. During this same time period, site occupancy by grey foxes increased and remained elevated through the end of the study. We found a complicated hierarchy among fishers, foxes and ringtails. Fishers affected grey fox site persistence negatively but had a positive effect on their colonization. Foxes had a positive effect on ringtail site colonization. Thus, fishers were the dominant small carnivore where present and negatively affected foxes directly and ringtails indirectly. Coexistence among the small carnivores we studied appears to reflect dynamic spatial partitioning. Conservation and management efforts should investigate how intraguild interactions may influence the recolonization of carnivores to previously occupied landscapes., (© 2017 The Authors. Journal of Animal Ecology © 2017 British Ecological Society.)

Context: Factors contributing to and impeding palliative care (PC) development in Africa can provide insights into current strategies for advancing PC., Objectives: To identify key factors affecting PC development in African countries from in-country PC experts' perspectives., Methods: About 16 PC experts from seven African countries undertook semistructured interviews on PC development in their respective countries. An interpretive description approach was adopted, with data analyzed using constant comparison., Results: Emerged themes included drivers, strengths, challenges, and aspirations for PC development in Africa. Drivers included advocates and pioneering organizations, HIV/AIDS, culture of caregiving, and the World Health Assembly PC resolution. Strengths included community health workers, the special role of nurses, diversity of services, and short training courses. Challenges included lack of PC education; lack of standardization in implementation; limited availability of and/or accessibility to morphine; poverty and disease burden; and lack of funding for PC. Aspirations included integration of PC, specialization in PC, nurse prescribing, and strong partnerships with Ministries of Health. Factors already highlighted in the literature were only briefly discussed., Conclusion: The key factors underpinning PC development in the seven countries contributed to the beginnings of PC in Africa, fueled by advocates who built on existing strengths to maximize opportunities. However, the current approach is at high risk in terms of its sustainability, and strategies for maximizing existing resources and growing infrastructure support are needed moving forward., (Copyright © 2018 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.)

Context: Sub-Saharan Africa faces an increasing incidence and prevalence of life-limiting and life-threatening conditions. These conditions are associated with a significant burden of pain linked to high morbidity and disability that is poorly assessed and undertreated. Barriers to effective pain management partly relate to lack of access to opioid analgesia and challenges in their administration., Objectives: To identify country-specific and broader regional barriers to access, as well as the administration of opioids, and generate recommendations for advancing pain management in Southern Africa., Methods: A parallel mixed methods design was used across three countries: Mozambique, Swaziland, and Zimbabwe. Three activities were undertaken: 1) a review of regulatory and policy documentation, 2) group interviews, and 3) a self-administered key informant survey., Results: Barriers to accessing opioid analgesics for medical use include overly restrictive controlled medicines' laws; use of stigmatizing language in key documents; inaccurate actual opioid consumption estimation practices; knowledge gaps in the distribution, storage, and prescription of opioids; critical shortage of prescribers; and high out-of-pocket financial expenditures for patients against a backdrop of high levels of poverty., Conclusion: Policies and relevant laws should be updated to ensure that the legislative environment supports opioid access for pain management. Action plans for improving pain treatment for patients suffering from HIV or non-communicable diseases should address barriers at the different levels of the supply chain that involve policymakers, administrators, and service providers., (Copyright © 2017 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.)