title: 'Peace' and 'life worthwhile' as measures of spiritual well-being in African palliative care: a mixed-methods study.
abstract: BACKGROUND
  Patients with incurable, progressive disease receiving palliative care in sub-Saharan Africa experience high levels of spiritual distress with a detrimental impact on their quality of life. Locally validated measurement tools are needed to identify patients' spiritual needs and evaluate and improve spiritual care, but up to now such tools have been lacking in Africa. The African Palliative Care Association (APCA) African Palliative Outcome Scale (POS) contains two items relating to peace and life worthwhile. We aimed to determine the content and construct validity of these items as measures of spiritual wellbeing in African palliative care populations.
  
  
  METHODS
  The study was conducted at five palliative care services, four in South Africa and one in Uganda. The mixed-methods study design involved: (1) cognitive interviews with 72 patients, analysed thematically to explore the items' content validity, and (2) quantitative data collection (n = 285 patients) using the POS and the Spirit 8 to assess construct validity.
  
  
  RESULTS
  (1) Peace was interpreted according to the themes 'perception of self and world', 'relationship to others', 'spiritual beliefs' and 'health and healthcare'. Life worthwhile was interpreted in relation to 'perception of self and world', 'relationship to others' and 'identity'. (2) Conceptual convergence and divergence were also evident in the quantitative data: there was moderate correlation between peace and Spirit 8 spiritual well-being (r = 0.46), but little correlation between life worthwhile and Spirit 8 spiritual well-being (r = 0.18) (both p < 0.001). Correlations with Spirit 8 items were weak to moderate.
  
  
  CONCLUSIONS
  Findings demonstrate the utility of POS items peace and life worthwhile as distinct but related measures of spiritual well-being in African palliative care. Peace and life worthwhile are brief and simple enough to be integrated into routine practice and can be used to measure this important but neglected outcome in this population.
authors.affiliation: King's College London, Department Palliative Care, Policy and Rehabilitation, Cicely Saunders Institute, Bessemer Road, Denmark Hill, London SE5 9PJ, UK. lucy.selman@kcl.ac.uk
authors.forename: Lucy
authors.initials: L
authors.lastname: Selman
authors.forename: Peter
authors.initials: P
authors.lastname: Speck
authors.forename: Marjolein
authors.initials: M
authors.lastname: Gysels
authors.forename: Godfrey
authors.initials: G
authors.lastname: Agupio
authors.forename: Natalya
authors.initials: N
authors.lastname: Dinat
authors.forename: Julia
authors.initials: J
authors.lastname: Downing
authors.forename: Liz
authors.initials: L
authors.lastname: Gwyther
authors.forename: Thandi
authors.initials: T
authors.lastname: Mashao
authors.forename: Keletso
authors.initials: K
authors.lastname: Mmoledi
authors.forename: Tony
authors.initials: T
authors.lastname: Moll
authors.forename: Lydia Mpanga
authors.initials: LM
authors.lastname: Sebuyira
authors.forename: Barbara
authors.initials: B
authors.lastname: Ikin
authors.forename: Irene J
authors.initials: IJ
authors.lastname: Higginson
authors.forename: Richard
authors.initials: R
authors.lastname: Harding
mesh_terms: D017954:Africa South of the Sahara; D000369:Aged, 80 and over; D044383:Black People; D005260:Female; D006801:Humans; D008297:Male; D010166:Palliative Care / Q000379:methods / Q000523:psychology*; D011788:Quality of Life; D012107:Research Design; D012924:Social Conditions; D029181:Spirituality; D011795:Surveys and Questionnaires; D014454:Uganda