Palliative Care Research in a Developing Country: A Scoping Review

INTRODUCTION

The World Health Organization (WHO) describes palliative care as a field that aims to relieve suffering and improve the quality of life of patients and families dealing with any type of life-threatening illness.^[1] Although it has been established as part of essential care, palliative care is still inaccessible to many patients. Annually, approximately 56.8 million people require palliative care, but only approximately 14% receive it.^[2] This is expected to be worse in low-to-middle-income countries (LMICs) such as the Philippines. The palliative care workforce, out-of-pocket costs and low opioid availability are the main factors hindering palliative care in the country.^[3] Among the many efforts to reduce this gap is research. A collaborative study regarding the implementation of paediatric palliative care programs highlighted the lack of research capacity in terms of palliative care in LMICs.^[4] This poses a significant barrier to improving palliative care delivery in the country.

This study conducted a scoping review to answer the following questions:

1. How many Filipino research papers regarding palliative care were published between January 1994 and November 2024?

2. What research methodologies were utilised?

3. What are the common factors among published papers?

4. What domains of palliative care were focused on by the research publications?

5. What are the gaps in the current status of research output in the Philippines?

MATERIALS AND METHODS

The authors conducted a scoping review using the methodology proposed by Khalil et al.^[5] and following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

RESULTS

The utilised search strategy identified 289 records. A manual search of the bibliographies identified 11 records. All identified records were screened by two reviewers at the title/abstract level. After screening and removing duplicates, 66 articles remained. These articles were assessed for scoping review eligibility using the inclusion and exclusion criteria. Of these, 20 articles were excluded because they (1) did not focus on palliative care or (2) did not have an author affiliated with an institution in the Philippines. The selection process is summarised in Figure 1.

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Figure 1:

Study selection and screening.

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Number of Philippine palliative care publications

The review identified 46 Philippine palliative care research published between January 1994 and November 2024. The 40 publications in the past decade (2015–2024) were significantly greater than the nine publications from the previous two decades (1994–2014). This signifies an increasing publishing trend in the field. Figure 2 shows the increasing trend.

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Figure 2:

Philippine palliative care research publications (1994– 2024).

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Article types

Approximately 32% of the records identified were cross-sectional studies involving surveys and questionnaires. Thirteen per cent were correspondences, editorials or opinion pieces. Another 10% were literature reviews. Only 8% were retro/prospective analyses. Two articles were case series/reports. There was one clinical practice guideline released by the American Society of Clinical Oncology. There were no randomised clinical trials identified. Figure 3 shows the distribution of records according to type.

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Figure 3:

Distribution of publications according to research methodology.

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Affiliated institutions

The majority of the authors were affiliated with the main training institutions in the country. The institution with the most publications is the University of the Philippines, with 13 (28%) studies published. This was followed by the Medical City, with 6 (13%) publications. Two correspondences were published from Verbum Dei, a Catholic missionary fraternity. Most authors came from the National Capital Region, accounting for 87% of the publications. The remaining 13% is distributed across other regions. Figure 4 shows the distribution of publications according to geographic location.

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Figure 4:

Distribution of publications according to geographic location.

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DISCUSSION

This review revealed an increasing publication trend in terms of Palliative Care in the Philippines. The increasing number of publications may correlate with the establishment of training programs for palliative care in the country. Training programs abroad also opened up to Filipinos, further contributing to this progress. This trend may also be due to the first global resolution of palliative care by the World Health Assembly, which was released in 2014. The resolution calls on the member states to improve access to palliative care, leading to increased awareness. This trend is similar to that reported in reviews in Australia^[7] and Malawi.^[8] However, the magnitude of the increase in the trend is significantly smaller. Compared with global research, progress in Philippine research is still severely lacking. The majority of the studies utilised surveys and questionnaires. This is most likely related to the more qualitative nature of palliative services. This finding highlights the importance of standardised and validated questionnaires. The Tagalog version of the Functional Assessment of Chronic Illness Therapy-Pallaitive-14 is a good example of a quality of life measuring tool that was successfully translated into the Filipino language. A study by Bagcivan et al. emphasised that adequate measurement of quality of life is essential for evaluating illness effects and the impact of treatment.^[9] Since the main goal of palliative care is to improve quality of life, the need for proper tools and questionnaires for measurement should be addressed. One of the publications reviewed in this study dealt with the reliability of a validated questionnaire translated into the local language.

Another finding of this review is that a significant portion of the publications were published in collaboration with other countries. This could be due to the initiatives of higher income countries to make palliative care universally accessible. This may also correlate with the availability of research grants in other countries. A study performed by Alotaibi revealed that one of the most common barriers to research publication is the lack of financial support.^[10] Collaboration with a country with more access to research grants allows Filipinos to produce more publications.

The majority of publications identified came from academic or training institutions. This reflects the role of having formal training programs for palliative care in promoting research publications. Among the institutions identified, the University of the Philippines had the most papers produced. This institution is one of the main hospitals in the country and has a fellowship program for palliative care. Another finding was the unequal geographical distribution of the publications. Most of the publications were from the National Capital Region. This reflects the impact of training programs since the majority of the established training institutions are in this region.

An analysis of the study population revealed that knowledge regarding Palliative Care in the Philippines is still mostly limited to cancer patients. In addition, most studies have focused primarily on pain management and advanced care planning. These findings correlate with the findings from the study of Hidalgo-Andrade et al., which highlighted the lack of knowledge regarding palliative care.^[11] The study revealed that most have a misconception that palliative care should be given only when a cure is no longer possible and that palliative care is synonymous with pain management. None of the included publications dealt with loss, grief, bereavement or professional resilience, which highlights the gap in knowledge in the holistic services of palliative care. Only two studies focused on the paediatric age group. This correlates with the current status of the training programs in the country. At present, the Philippines does not have a formal fellowship training program for paediatric palliative care.

A limitation of this review is that it does not include papers that were not published. Most of the research outputs in the country are not published due to the lack of funding and misaligned goals regarding research output. The majority are conducted as a requirement for the completion of training programs; hence, publication as a goal lacks incentives. Further studies should attempt to include unpublished research outputs. This would provide data for analysing the barriers to research publications in the Philippines.

CONCLUSION

This scoping review revealed the status of Philippine publications regarding palliative care. In doing so, it highlights the impact of global initiatives on palliative care in the Philippines. Research collaborations allow LMICs to have access to resources that are only available in more developed countries. This review also emphasised the importance of developing standardised and validated tools for measuring quality of life. Bridging this gap would result in further improvement in the research output of the country as well as improvement in the delivery of palliative care services. The distribution of publications in terms of geography and institutions highlights the importance of establishing formal training programs for palliative care in empowering research development. At present, the country does not have a fellowship program for paediatric palliative care, which is reflected in the lack of research in this age group. Finally, the data from this review further highlight the gaps in knowledge regarding the holistic role of palliative care. It identified neglected domains of palliative care, such as dealing with grief and professional resilience. There is vast potential for future research in these domains.