Cancer kills more people than HIV, malaria and tuberculosis combined, and over 70% of cancer deaths occur in the world's poorest countries. Throughout low and middle-income countries (LMICs), non-communicable diseases (NCD), including cancer, are a rapidly growing concern. It is estimated that by 2030 cancer incidence will more than double in LMICs, and 9 million people will die each year from the disease. The majority of patients in LMICs present with late-stage, incurable cancer and need quality pain management. Palliative care is a health care specialty that has evolved to holistically address the symptom management needs of patients and families coping with life-limiting illness, such as advanced cancer. A foundational principle of palliative care is quality pain management. However, in many LMICs this is complicated by a lack of knowledge among healthcare providers and difficulty obtaining effective pain relief medications, such as morphine. Nepal is a low-income country with a growing cancer burden and significant palliative care needs. In 2009, the Nepalese Association of Palliative Care (NAPCare) was formed by community stakeholders and healthcare providers to address the growing need for palliative care within the country. NAPCare has been instrumental in building educational capacity related to palliative care in Nepal, in part by creating Pain Management Guidelines (PMG) based on World Health Organization (WHO) standards and grounded in the Nepalese context. The longitudinal and sustained efforts of NAPCare demonstrate a readiness to embark on the next level of palliative care development ? moving the research enterprise forward. Research has been proposed as a fifth pillar in the WHO Public Health Strategy for Palliative Care, but very little palliative care research has been conducted in LMICs, where palliative care needs are most pressing. Mobile technology (`mHealth') offers a scalable and sustainable approach to address this critical health gap. This proposal partners oncology palliative care leaders of NAPCare with oncology/palliative care and global health researchers at the University of Virginia to leverage mHealth to improve the delivery of palliative care and cancer pain management in Nepal. Our efforts will establish a model for NCD implementation research and research capacity building that generalizes to other LMICs and low- resource settings. Using principles of Community Based Participatory Research (CBPR) within 4 diverse oncology care settings in Nepal we aim to: 1) Assess and describe contextual barriers and facilitators that influence adherence to the PMG; 2) Design and pilot test a decision support mHealth `app' for oncology providers that will promote PMG implementation; and 3) Integrate tailored Research Enhancement Activities (REA) to strengthen research capacity within Nepal, including relevant course work, intensive mentoring, and creation of a `Virtual Library' of research resources relevant to the LMIC context.

Public Health Relevance

The exploding burden of cancer in low and middle-income countries is a global public health crisis. In countries such as Nepal, over 70% of patients are diagnosed with late-stage cancer and desperately need quality pain management. Testing mobile technology (`mHealth') to improve pain management in Nepal strengthens research capacity within the country, and also provides a scalable model to improve cancer pain management and implement cancer control research in similar low resource settings.

National Institute of Health (NIH)
Fogarty International Center (FIC)
Exploratory/Developmental Grants (R21)
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Special Emphasis Panel (ZRG1)
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Levintova, Marya
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University of Virginia
Schools of Nursing
United States
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