Healthcare Providers’ Knowledge and Their Perceived Factors Influencing Cancer Palliative Care Services in Kwazulu-natal

Background: Healthcare providers spend most of their time in direct care of critically ill patients. The family members of the critically ill patients are not spared from managing physical, psychological, emotional and spiritual symptoms, yet many of them feel anxious and unprepared to care for palliative patients. The purpose of this study was to determine healthcare providers’ knowledge and perceived factors influencing cancer palliative care (PC) services in the selected sites of Durban and Pietermaritzburg, KZN. Methods: This was a mixed methods study using a structured questionnaire and focus group discussions (FGDs) for quantitative and qualitative aspects, respectively. All healthcare providers were selected through convenience sampling, based on being relevant to the study objectives. Twenty-seven healthcare providers participated in structured questionnaires with eight being further selected to participate in an FGD based on being information-rich. IBM SPSS Statistics (v.25) and NVIVO 12 Pro software were used to analyze quantitative and qualitative data, respectively. Results: The mean (+SD) age of the 27 participants was 42.52 (+11.37) years and about 48.1% were within the age-group 31–40 years. The majority of participants were females (77.7%) and were married (59.5%). More than four-fifths (81.5%) had attended up to tertiary level as the highest level of education, 85.1% were permanently employed and 96.3% were from urban areas. The majority of participants had been trained in PC (70.4%), 55.5% had less than five years’ experience working as palliative healthcare providers and 51.8% rated their experience of caring for cancer patients as good. Perceived barriers in patients

seeking PC, included three themes, namely: (1) effects of intra-departmental collaboration, (2) caregivers' perspectives regarding the complexities of PC seeking barriers and (3) innate factors that sustain the community caregivers' motivation.  (2). On the other hand, cancer and other non-communicable diseases (NCDs) are compounding the disease burden, with the reports indicating that approximately one in five deaths in SSA is due to cancer (3,4). By 2050, the lifetime risk of cancer in SSA is expected to increase by 50-60%, and the annual number of cases will rise from 650 000 to 2.2 million (5). These projections call for a rethink of how PC services can be interactively packaged into the healthcare systems.

Conclusion
PC is defined by the World Health Organization (WHO) as "an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual" (6). This definition illustrates that the goal of PC is to improve the quality of life of a terminally ill person while relieving their suffering and not necessarily curing them of their illness. In addition, PC is applicable in the early course of illness in conjunction with other forms of therapies like radiotherapy and chemotherapy that are intended to prolong life (7). Therefore PC is an essential component of public health services in SSA; however, the current provision in the region is patchy, and the coverage is poor (8).
Successful models of hospital and community-home-based PC services in the region have been described, but also significant challenges have been observed (9). These include a lack of access to essential drugs, poor social conditions (10), a lack of collaboration among the stakeholders from the Department of Health and a lack of trained palliative healthcare providers (11). Furthermore, SSA studies have documented that healthcare providers in PC are inadequately prepared to care for patients in pain (12). Several reasons for the lack of preparation have been identified, including absence of curriculum content related to pain management, and faculty attitudes and beliefs related to pain (13). One of the important factors influencing the successful delivery of PC is the healthcare providers' knowledge and experience, which determine not only their procedure but also their behaviour during the evaluation and treatment of patients (11,14).
A major barrier to further development of PC in South Africa is the lack of data to inform service provision (15). PC research in South Africa has predominantly focused on opioid availability and the physical aspects of care, such as the assessment of pain and other symptoms, while neglecting the improvement of PC education for healthcare providers (16). Palliative medicine is of great relevance in the field of medical education through its emphasis on complex symptom controls, whole-patient care, an interdisciplinary team approach, enhanced communication skills and support programs for the bereaved (17).
A public health strategy, as recommended by the WHO, offers the best approach for translating knowledge and skills into evidence-based, cost-effective interventions that can reach everyone in need of PC in low-and-middle income countries (LMICs) (18). The WHO pioneered a public health strategy (PHS) for integrating PC into a country's health care system (18). The WHO PHS addresses 1) appropriate policies; 2) adequate drug availability; 3) education of policy makers, healthcare providers, and the public; and 4) implementation of PC services at all levels throughout the society (19). The education of healthcare providers has a great influence on their knowledge, which acts as a foundation for better clinical practice (20). Therefore, the purpose of this study was to determine healthcare providers' knowledge and perceived factors influencing cancer PC services in KZN.

Methods
This was a mixed methods study using structured questionnaires and FGDs for quantitative and qualitative aspects, respectively. The quantitative aspect was a cross-sectional study aimed at assessing healthcare providers' knowledge

Recruitment and eligibility
Quantitative component: All healthcare providers were selected through convenience sampling. For the purpose of this study, healthcare providers refer to medical officers, radiologists, social workers, nurses, CCGs, a traditional healer and a spiritual healer. Convenience sampling has been defined as accidental sampling or opportunity sampling. The researcher included those participants who were easy or convenient to approach (21). Participants were eligible if they were aged 18 and above and working as palliative healthcare providers in the oncology units, hospices and at a community level.
Qualitative component: Participants were recruited from the CCGs who attended the MLCCP palliative care training, held from 12 th -16 th November 2018. All participants were above the age of 18 years and involved in caring for patients with NCDs, especially cancer.

Data collection
Quantitative component: Data was collected through an interviewer-administered questionnaire, which took place at a private in-patient room to protect participants' privacy. The questionnaire was adapted from those presented in published work and took about 10-12 minutes to complete. None of the participants reported feeling discomfort or distress while the questionnaire was administered.
Qualitative component: An FGD was conducted in a separate room to protect the participants' privacy and to stimulate them to engage freely on the issues raised during the discussions. The FGD took about two hours to complete, but was enjoyable to the participants, as per their expressions at the end of the session.

Data analysis
Quantitative data analysis: Data was entered into REDcap (v.8.11.7) (21) and then exported to IBM SPSS Statistics (v.25) (22) for analysis. Data was further checked for possible errors and missing values. For descriptive analysis, sociodemographic data was summarized into tables. This included age, gender, marital status, level of education, employment status, geographical area, whether they had received PC training or not, years of working as a palliative healthcare provider and rating of care for PC patients.
Qualitative data analysis: NVIVO 12 Pro software (23) was used to analyze qualitative data. Thematic analysis was used to analyze the transcript of the FGD with CCGs, a traditional healer and a spiritual healer. Patterns were identified from the transcript of the healthcare providers' experiences of providing PC services and their perceived factors influencing cancer PC services.

Participant characteristics
A total of 27 participants took part in this study, the mean (± SD) age was 42.52 (± 11.37) years and 48.1% were within the age group 31-40 years. The majority of participants were females (77.7%) and 59.5% were married. More than four-fifths (81.5%) had attended up to tertiary level as the highest level of education; 85.1% were permanently employed; and 96.3% were from urban areas. In terms of whether or not they had been trained in PC, the majority cited that they had received training (70.4%), 55.5% had less than five years' experience working as palliative healthcare providers and 51.8% rated their experience of caring for cancer patients as good (Table:1).

Quantitative Findings
Healthcare providers' knowledge about palliative care and years of experience working as a trained palliative healthcare provider An over-whelming majority of healthcare providers with working experience of 5-10 years rated their knowledge of PC as good compared to one third that rated it as fair. For those that had experience of 15 years or above, two-thirds rated themselves as having a good knowledge of PC and similarly, one third rated their knowledge as fair.
Conversely, less than half of those with 11-15 years' experience rated themselves as having good knowledge of PC and close to two-thirds rated themselves as possessing fair knowledge of PC. Among those who had less than five years' experience working as palliative healthcare providers, more than half rated their PC knowledge as fair. Less than half rated their knowledge as good. However, due to the small sample size, the level of significance was not tested. The researcher relied on their self-reported knowledge which was not further verified through an appropriate instrument (Fig: 3).

Thematic analysis of the focus group discussion
Analysis of the FGD transcripts elucidated the perceived barriers in patients seeking PC, culminating in three themes, namely: (1) effects of inter-departmental collaboration, (2)

Effects of departmental collaboration challenges on the community caregivers' performance
This theme emerged from discussing the challenges faced by CCGs. It was also noted that these challenges negatively affected the CCGs' self-worth, in so far as caring for the sick is concerned. The nurses and other stakeholders of the DoH were particularly implicated in the infliction of a sense of worthlessness felt by CCGs.

Innate factors that sustain the community caregiver motivation
Despite the challenges which CCGs endure during the course of performing their duties, they reported some innate factors that kept them motivated to carry on. Further to the identified themes, participants were asked to list their expectations from the stakeholders, and these were the things they raised. Furthermore, based on the previous studies, perceived discrimination even in the absence of socio-economic disadvantages was associated with three-fold to ninefold increased odds for refraining from seeking PC (30). The significant interaction effect of frequent discrimination and severe socio-economic disadvantage on refraining from seeking palliative care was more statistically consistent among women than men (31). This is also supported by a study conducted among Asian patients who reported underutilizing PC services because they held traditional beliefs about the illness and preferred to self-manage cancer symptoms, a phenomenon common in the general population, worldwide (32).

Study strengths and limitations
A particularly strong aspect of this study was the use of mixed methods, which provided results that have a broader perspective of the overall issue or research problem. One of the important limitations was the fact that the assessment of healthcare providers' knowledge was based on self-reporting, rather than using standardized instruments. We are also unable to generalize the findings of the research because of its sampling technique which yielded a smaller than anticipated number of participants being recruited, with limited variables being included in the quantitative assessment. The views of healthcare personnel in clinics and hospitals were not included, as these healthcare providers were not part of the FGDs.

Conclusion
In conclusion, the findings of this study demonstrated that palliative healthcare providers have varying levels of competencies and that the perceived complexities of PC seeking barriers among patients with cancer are associated with low levels of PC seeking behaviour. Initiatives to support ongoing advocacy, education and training for healthcare providers are essential for improving awareness, skills and knowledge to deliver effective PC services.

Ethics approval and consent to participate
The study was approved by the University of KwaZulu-Natal Biomedical Research

Ethics Committee (REF: BE374/18) and Department of Health National Research
Ethics Committee (KZ_201810_039). Ethics committees approved the written informed consent which was obtained from all the participants prior to participating in the study.

Consent for publication
Not Applicable