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Abstract

Introduction/Objectives:

Systematic identification of persons with palliative care needs constitutes a major challenge for promoting palliative care in all levels of the health system, including primary care. The aim of this study was to translate, cross-culturally adapt, and content validate Supportive and Palliative Care Indicators Tool (SPICT) for use in the Greek primary care context. Secondary objectives were to probe the use of SPICT-GR in exemplary case vignettes, to discuss the clarity and comprehensibility of its content as well as the appropriateness, acceptability, and feasibility of the tool within the Greek primary care.

Methods:

The Greek translation and cross-cultural adaptation of SPICT™ followed World Health Organization recommendations for translation and adaptation of instruments. For this purpose a working group was set up consisting of 2 senior researchers, a primary care professional with postgraduate training in Palliative Medicine and a general practitioner (GP) with special interest in primary palliative care. Three focus groups comprised of health professionals (n = 23) working in primary care settings participated in the pilot testing phase. Participants also completed a questionnaire including rating their perceptions on tool’s utility and feasibility as well as on the clarity and relevance of its items. Thematic analysis was used for focus groups discussions on how the tool was perceived and interpreted by health professionals in a Greek healthcare context and descriptive statistics for the quantitative analysis of the questionnaire data.

Results:

The majority assessed the tool as useful (65%), considered its implementation in primary care as feasible (91%) and rated its items as “relevant” or “very relevant” and “clear” or “very clear.” Three themes emerged from focus groups discussions: Guiding clinical practice and facilitating collaboration; promoting comprehensive care and awareness for palliative care; applicability in and suitability for primary care.

Conclusions:

SPICT-GR™ was identified as a practical and applicable tool for primary care, a source of guidance for the comprehensive identification of patients’ palliative care needs, promoting awareness on palliative care and facilitating a shared language among health care professionals.

Keywords

supportive and palliative care indicators tool SPICT primary care palliative and supportive care cross-cultural adaptation Greece focus groups

Introduction

Primary care professionals play a key role in the provision of supportive and palliative care as people facing chronic debilitating conditions especially those with diagnoses other than cancer, including the frail elderly, require longstanding support at home and in the community.^1
-3 Systematic identification of persons with palliative care needs has been recognized as major challenge for promoting palliative care in all levels of the health system, including primary care.^4,5 Failure on timely recognition of eligible persons results in depriving families of the advantages of proactive response to their multilevel needs, adversely impacting thus their quality of life.^6
-8 Primary care has a great potential to provide comprehensive palliative care, including home-based services, to ensure coordination and continuity of care, facilitate advance care planning, and support liaison for secondary services.⁴ Several tools have been developed for the systematic assessment of persons with palliative care needs in primary care,^7,9 among which Supportive and Palliative Care Indicators Tool (SPICT™) has been shown to timely identify persons at risk of deteriorating health.¹⁰

SPICT™ was developed in 2010 by the Primary Care Research Group of the University of Edinburgh with the purpose to support health care professionals identifying people who could benefit from a supportive and palliative care approach.¹¹ It is a clinical and practice-oriented tool comprising of 3 sections: (a) general indicators denoting poor or deteriorating health (ie, unplanned hospital admissions or progressive weight loss), (b) clinical indicators of 1 or more life-limiting conditions (eg, cancer, dementia/frailty, neurological, heart/vascular disease, and respiratory disease), and (c) recommendations for possible next steps (eg, review of current treatment and medication and agreement on a current and future care plan).

SPICT™ has been translated and culturally adapted in twelve languages, including Spanish,¹² Germnan,¹³ Italian,¹⁴ Danish,¹⁵ and Swedish¹⁶ and used in both inpatient and primary care contexts^17
-20 and by a range of health professionals.^21,22 SPICT has been validated across Europe and worldwide^23
-26 and in different settings including primary care^14,15,17 and proved a practical tool improving recognition of persons’ supportive and palliative care needs,^23,27
-29 facilitating timely symptom management, reviewing goals of care, and advance care planning.^20,22 According to Afshar et al²⁸ a review of current treatment/medication (76%), reaching agreement on current and future care plan with the patient and the family (55%), and engaging in early introduction of advance care planning (41%), were the most frequently initiated palliative care actions motivated by application of SPICT in primary care. Furthermore, Lunardi et al²² showed that the use of SPICT demonstrated a statistical significant improvement in professionals’ confidence and abilities to recognize deteriorating and frail individuals approaching end of life.

The aim of this study was to translate, cross-culturally adapt, and content validate SPICT (version 2019) for use in the Greek primary care context. Secondary objectives were to probe the use of SPICT-GR in exemplary case vignettes, to discuss the clarity and comprehensibility of its content as well as the appropriateness, acceptability, and feasibility of the tool within the Greek primary care.

Methods

Setting

A working group was established, consisting of 2 senior researchers (E.S and A.L), a primary care professional with postgraduate training in Palliative Medicine (M.B.) and a GP with special interest in primary palliative care (D.K.).

Design

The Greek translation and cross-cultural adaptation of SPICT™ followed World Health Organization recommendations for the translation and adaptation of instruments included in the relevant guidance provided by the original research group³⁰ comprising of the subsequently detailed steps and presented in Figure 1.

Figure 1.

Overview of the translation and cultural adaptation process.

A mixed methods design was used for the testing of the tool involving a quantitative component comprising a semi-structured questionnaire and Content Validity Index (CVI) calculation, and a qualitative component involving focus groups discussions on which cultural adaptation and content validation was based following the principles of thematic analysis^31,32 and the consolidated criteria for reporting qualitative research (COREQ).³³

Step 1: Forward translation : One independent translator, a health professional familiar with medical terminology and English-speaking health scientific terminology whose mother tongue was Greek, prepared the forward translation.

Step 2: Expert panel review : Expert panel comprised by the translator, members of the working group and a bilingual (in English and Greek) researcher, evaluated the forward translation so as to identify and resolve inadequate expressions. Panel members discussed extensively the translation of the term “palliative” as in Greek language 2 terms are currently in use, however for reasons of brevity, it was decided to keep 1 term (taking into account the recommendation made by the Academy of Athens Research Center of Scientific Terms and Neologisms for the most “preferable” term, personal communication).

Step 3: Back translation and revision : The revised version was back translated by an independent translator proficient in English and with no prior knowledge of the tool. Problematic areas were discussed by the expert panel and consensus was reached favoring conceptual and cultural over linguistic equivalence. Τhe resulting version was submitted to pre-testing and focus groups discussions.

Step 4: This step was divided in 2 phases accomplished on line (due to public health restrictions) between January and November 2021 and conducted as follows:

4a. Pretesting: A pre-test took place in January 2021 during which a convenience group of 7 health professionals experienced in caring for persons with life-limiting conditions in the context of primary care, were invited to preliminary assess the translated document and probe its use by appraising 4 model case vignettes (see Supplemental Material) which were developed based on literature and clinical experience in primary care for assessing the palliative care needs of patients. Participants also completed an anonymous online questionnaire rating on a 4-point Likert scale (1 = not at all, 4 = very) each item for relevancy and clarity, the case vignettes for their clarity and appropriateness in primary care as well as their intention of implementing the tool and their perceptions on its utility and feasibility, also documenting the time required to assess case vignettes with and without the tool. Demographic data were also included in this form.

4b. Focus groups pilot testing : Three focus groups were conducted from March to November 2021 so as to explore how the tool was perceived and interpreted by health professionals in a Greek healthcare context, by probing its use in exemplary case vignettes, discussing the clarity and comprehensibility of its content as well as its appropriateness, acceptability, and feasibility within the Greek primary care context. Based on convenience sampling, 30 primary care professionals were invited by mail and 23 professionals consented to participate in the study. Inclusion criteria for focus groups participants were that they were health professionals working in primary care (General Practitioners/Family Doctors and Health Visitors) and providing care to people with chronic/life-limiting conditions. Exclusion criteria were provision of services to children as well as to adults with conditions other than chronic and life-limiting. Group discussions lasted about 60 to 90 min each, were conducted in Greek and moderated by the 2 first authors (M.B. and E.S.). Detailed field notes were recorded during and directly after each session. At the beginning of each group discussion, participants were given an overview of the definition and basic principles of palliative care so as to have a common basis for reference. They were invited to comment on whether palliative care would be beneficial for the sample case vignettes, without using SPICT-GR and after the presentation of the tool, with the use of it. Main question that guided focus group discussions was the following: How do you see the use and implementation of SPICT-GR in your clinical practice in the primary care context? Participants also completed the online anonymous questionnaire used for pretesting.

Step 5: Finalizing SPICT-GR: Based on the findings of the previous step, the final revision of SPICT-GR was conducted and its proofreading was checked.

Step 6: Documentation : All steps of the process were documented, including all versions of the document, recommendations by the expert panel, findings of pretesting and focus groups, and the modifications adopted in the final version. The SPICT™ program team was continuously informed about the process and feedback was provided upon request. The final SPICT™-GR was submitted to the SPICT™ program to be available from its website.

Data Analysis

Analysis of the focus groups discussions was conducted using thematic analysis. According to this methodology^31,32 transcriptions were independently and repeatedly read line-by-line by 2 researchers (M.B and E.S) to ensure validity. Initial codes were grouped into potential themes which were reviewed by the other working group members (D.K. and A.L) so as to refine thematic categories, discuss alternative codes and themes through repeated data examination, achieve data saturation, and reach consensus on the final themes. Regular meetings, reflection, and discussion between co-authors were used to explore and minimize bias. The development of potential themes and all further analysis were performed manually. Analysis was conducted in Greek and the quotes selected were translated by the authors. Reporting of qualitative data followed COREQ criteria. Quantitative data were analyzed by using descriptive statistics, involving calculation of the CVI which was used as a complementary measure.^34,35 Content Validity Index for Item (I-CVI) was calculated by dividing the number of respondents who rated each indicator with 3 to 4 by the total number of respondents for this indicator and Content Validity Index for Scale (S-CVI) was calculated by using the S-CVI/Average (I-CVIs ≥ 0.78 and S-CVI/Ave ≥ 0.90 designate excellent content validity).³⁴

Ethics

The study was approved by the Research Ethics Committee of the University of West Attica. Translation and adaptation rights were provided by the SPICT™ International Program. All respondents were informed both verbally and in writing about the study and their participation and provided written informed consent. When analyzing and presenting the results, data were treated according to the principles of confidentiality.

Results

Findings From Pre-Testing

The pre-test convenience group comprised of 7 health professionals (3 health visitors, 2 GPs, and 2 researchers; females n = 4, median age = 43 years). Case vignettes were rated as very clear (median = 4). Participants evaluated the vignettes A and B as very representative of persons with life limiting conditions that meet in their clinical practice in primary care, while case vignettes C and D were considered less representative, a fact understandable as similar cases in Greece are mainly cared for in hospital settings given the absence of primary palliative care services. The median time for evaluating the case vignettes by using the tool was 10 min (range: 4-15 min). Participants made several suggestions on improving the wording of the case vignettes and considered confusing the phrasing of 3 tool items, also rated as “a little clear.” For example, the expression “Liver transplant is not possible,” was regarded as leading to the assumption that transplantation might not be feasible for health care system reasons; therefore, wording was changed to “Liver transplantation is not indicated.” Based on the feedback received, the phrasing of case vignettes was ameliorated and the problematic item expressions were revised, prior to their use in focus groups.

Findings From Pilot-Testing (Focus Groups)

The 3 focus groups comprised of 23 primary care professionals, as follows: Group A: n = 7, Group B: n = 7, and Group C: n = 9. Participants in the 3 focus groups did not show any statistically significant differences in their sociodemographic characteristics. Participants’ demographics are shown on Table 1.

Table 1.

Characteristics of the Participants in the Focus Groups (n = 23).

Sex
Female	18
Male	5
Age (years)
31-35	1
36-40	5
41-45	3
46-50	4
51-55	8
56-60	2
Profession
General practitioner/family doctor	6
Health visitor	17
Work place in primary care
Health center	15
Municipality center	5
Other	3
Work experience (years)
0-5	1
6-10	6
11-20	7
21-30	5
>31	4
Attendance of courses on palliative care
Yes	13
No	10
Types of courses
Conferences and seminars	11
Undergraduate studies	0
Postgraduate studies	1
Life-long learning	1
Previous experience in using tools for assessing the needs of the chronically ill
Yes	0
No	23

According to questionnaire responses on their perceptions of the tool, all participants stated that they would use SPICT in their clinical practice, the majority (65%) considered it useful in their daily work, assessed its implementation in primary care as feasible (91%) and rated the tool items as “relevant” or “very relevant” and “clear” or “very clear.” I-CVIs ranged between 0.78 and 0.96 and S-CVI/Ave was 0.97 for item clarity and 0.95 for item relevance. The median time for rating all case vignettes was 5 min without the tool and 10 min by using it (average of 2.5 min for each case). As shown on Table 2, after using SPICT-GR more participants were able to recognize patients’ palliative needs in model vignettes, revising thus their initial subjective appraisal, although the results did not reach statistical significance. Particularly for case vignette B, without SPICT-GR 18 participants (78.2%) considered palliative care as appropriate while by using SPICT-GR this number increased to 21 (91.3%). No further semantic or conceptual modifications of the items were suggested by focus group participants.

Table 2.

Appraisal by Focus Groups Participants Whether Palliative Care Would be Beneficial for the Patients in Case Vignettes With and Without SPICT-GR (n = 23).

Case vignettes	Without SPICT-GR		With SPICT-GR
Case vignettes	Yes (%)	No (%)	Yes (%)	No (%)
A	22 (95.6)	1 (4.3)	23 (100)	0 (0)
B	18 (78.2)	5 (21.7)	21 (91.3)	2 (8.69)
C	23 (100)	0 (0)	22 (95.6)	1 (4.3)
D	21 (91.3)	2 (8.69)	23 (100)	0 (0)
	Mean (SD)	Mean (SD)	Mean (SD)	Mean (SD)
	21 (1.87)	2 (1.87)	22.25 (0.829)	0.75 (0.829)

McNemar-Test compared the groups; P < .05; results were not significant.

The following 3 themes emerged from the analysis of focus groups discussions.

Theme 1: Guiding clinical practice and facilitating collaboration

Participants recognized the potency of the tool to guide them in their everyday clinical practice in identifying the palliative and supportive care needs of people with life-limiting conditions, defining goals of care, setting priorities and decision-making, and developing and organizing their care plan. They also appreciated that the tool could support and not substitute their clinical intuition and judgment.

It provides a context where the health care professional can take action with definite goals; it is useful for assessing persons’ care needs, and also for the development and evaluation of their care plan. (Respondent 5)

The tool can guide me in my everyday clinical practice in decision- making, e.g. in relation to referring persons and families to various services and also maintaining the continuity of their care. (Respondent 3)

I would see it not only as an assessment but also as a ‘support tool’- it helps me support my clinical intuition. . . With the tool, you can confirm what you suspect. (Respondent 21)

Respondents also reported that using the tool to assess model cases motivated them to consider each person’s needs in relation to the challenges posed by his/her deteriorating health status and also to reflect on the particularities of sick person’s situation, including the needs of carers, gaining thus further insight about the case.

By using the tool, I focused more carefully on the case scenarios by paying more attention to the dimension of severity and progressive frailty; I had not focused on this aspect while appraising scenarios without the tool. (Respondent 8)

It turns attention towards both the broader milieu and the particular care needs of the persons. Take for example a lady suffered from stoke: where does she feel vulnerable, how she could be supported, what is the situation with the carers? I mean that the tool helps me to go deeper in the case. (Respondent 20)

Participants acknowledged that the tool enabled them to assess vignettes in a structured, detailed, and organized way; moreover, they felt that incorporating the tool in routine practice could familiarize them with this particular “way of thinking” which could be helpful in other chronic health conditions beyond those included in the tool.

It promotes thinking on the case in a structured, organized, well-defined way. (Respondent 7)

It fosters a way of thinking which can be useful for other conditions [that may require palliative/supportive care] not included in current version. (Respondent 20)

Respondents also considered the tool as having the potential to create a common frame of reference for health care professionals working with families facing life-limiting conditions, hence promoting and facilitating interprofessional collaboration, both in the context of primary care and during person’s transitions in the health system.

It can ‘create’ a common language between us - we can therefore be on the same ‘wave length’, we all can have a common ground. (Respondent 15)

If it becomes an everyday tool, we will all be sharing common steps; we will all have a common line, we can create a shared language. In this way, we will all have a common goal. (Respondent 14)

Theme 2: Promoting comprehensive care and awareness for palliative care

Respondents considered that the tool could promote comprehensive care by prompting them to see “the whole picture” so as not to miss any dimensions that might not have been identified in routine consultation should they have not been motivated to seek. In particular, they remarked that during assessing model cases the tool “brought to view” care dimensions that are not usually straightforwardly “visible” in routine clinical practice, favoring thus professional’s broader vision on the case and hence a more holistic approach.

The tool is not medically-focused; it highlights views and needs which we would miss if the health professional would stay with person’s medical needs, e.g. paying attention to the broader psychosocial and financial issues. (Respondent 21)

It brings to view symptoms and aspects that are not straightforwardly ‘visible’. Ι could identify more aspects, those that cannot ‘come into view’ through simple clinical examination. (Respondent 8)

Quite frequently in routine practice, there is much pressure and you have to focus on person’s request, the reason why he/she asked to see you. . . it might be that those times you can’t give the necessary priority to other issues which may be, on the other hand, decisive. (Respondent 3)

Attention to the psychosocial dimensions of serious illness and frailty was mentioned in particular, as participants recognized that profound sensitization on this care aspect is not commonplace in Greek health care settings. Concurrently, participants working in settings wherein prominence is given to psychosocial issues reported that the tool could ensure that physical aspects of care would also be thoroughly assessed and responded to.

It highlights psychosocial issues for which not adequate sensitization exists in this country. (Respondent 12)

We tend to see only the ‘Psy’ factor and by doing so we might leave out other serious needs and problems- the tool ‘turns’ us to those aspects as well. It also draws attention to co-morbidity, especially in health contexts where other conditions, i.e. apart from the psychiatric ones, do not usually comprise our main focus. As for those at the terminal phase, we are not familiar with their care and sometimes we feel desperate while the team tends to concentrate on the medical issues; however, with the tool we could provide care in a comprehensive way. (Respondent 22)

Respondents also perceived that the tool could promote palliative care by both clarifying the criteria for the appropriate selection of eligible persons and raising awareness for this approach, while it could also contribute to dismissing common misunderstandings regarding palliative care, such as that it is primarily appropriate for those with severe pain or suffering from cancer.

I was astonished with the [model] cases showing different persons in need of palliative care. . . We are used to connect palliative care with cancer. . . (Respondent 11)

We tend to identify palliative care with pain, while the tool draws attention to multiple aspects of palliative/supportive care. Pain can be just the surface. . . (Respondent 7)

Theme 3: Applicability in and suitability for primary care

Participants discussed the application and relevance of the tool in the context of primary care in Greece while they confirmed that it covers the common chronic conditions, including the frail elderly, that “first line” health professionals usually meet in their everyday practice. Participants noted that it is a tool easy to use, clear, and understandable, and they felt that they can easily become familiar with its application while its structure and brevity could facilitate its implementation in routine practice.

It is brief, comprehensive, understandable and adequately detailed. Should it be more analytical, it would be unmanageable. Brief and clear are also the recommendations on how to organize care provision as e.g. avoiding polypharmacy to the best possible degree. (Respondent 14)

Its format facilitates its use . . .it’s a ‘visual’ tool. (Respondent 1)

Participants characterized the tool as time-saving because it fosters obtaining a great deal of information by appropriately organizing assessment in short time and increasing familiarization with its use. This was particularly valued given the understaffed and busy primary health care settings in this country.

The tool offers an organized approach in responding to our cases so as to save time during needs assessment. It helps me to get more data and information during the assessment of person’s health, in less time. It was very quick for me to go through it [when appraising the scenarios]: it can function as a ‘check-list’. (Respondent 23)

Sometimes we refer to work overload and that in this context tools might be needless; however, it is not matter of space and time, usually referred as barriers; it is the way [we do things] that matters; sensitized professionals will properly organize their work and also save time from problems which could face later [if important aspects are left out due to time pressure]. (Respondent 15)

If the tool is incorporated in routine clinical practice, it could soon become a ‘rule of thumb’. (Respondent 18)

Respondents appreciated the tool’s focus on prevention and anticipatory care as they recognized in these aspects core elements already present in their clinical work in primary care. They also commented on the appropriateness of the tool in the context of person–centered care and personal relationships formed with people with chronic conditions and their families in primary care, given the long term care they provide to them in this setting.

Τhe tool would be very functional in primary care given that our approach in this context is already person- focused. (Respondent 23)

I find very helpful the recommendations on formulating the care plan- which is an integral part of the work of health visitors. The tool also highlights the importance of health visitors’ networking role and skills. (Respondent 8)

Respondents also noted the tool’s potential to be applied in different settings in primary care and beyond, while those involved in the education of future primary health care professionals could see the possibility of also using the tool in this context.

In our community inpatient rehabilitation center, it could be used when persons are first registered as well as when we prepare their returning home. This kind of assessment could actually become a requirement for the resident to return home. (Respondent 18)

It can become a tool for home care visits. It can also be used for follow up visits. We can re-visit the tool whenever new issues arise, or changes appear in the person’s health condition. (Respondent 8)

We could also see an educational use of the tool, as it can contribute to raising the awareness of future primary care professionals to the needs of persons with chronic and advanced illness and also to the needs of family members. In this way, students could familiarize themselves with the recognition of the full spectrum of needs, a fact that could be achieved after long experience and effort if they only had to wait until the exercise of their profession (i.e. the tool can sensitize them in advance). It could act as an ‘introduction’ to situations that the students will meet during their professional career in primary and community care. (Respondent 19)

Participants recognized shortcomings of the Greek health care system as possible barriers of using SPICT™-GR, such as the lack of primary palliative care services and their limited availability in the rest of health system, and the deficient interconnection of services; nevertheless, they acknowledged that incorporating the tool in clinical practice could highlight these unfavorable situations, making thus prominent the need for state initiatives on promoting palliative care.

Implementation seems difficult to me due to deficiencies in state health system and the lack of public care services for people needing palliative and supportive care in this country. (Respondent 10)

The tool highlights the huge need for palliative and supportive services for persons with life-limiting conditions in our country. (Respondent 7)

Finally, participants provided suggestions on improving the usability of the tool (such as: available in digital form, including “yes/no” option per item, or a cut-off/scoring value), extending the recommendations section (eg, adding the option of home care visits, or assessing children’s support needs facing loved one’s advancing illness), while they also suggested a version addressing the palliative care needs of children, adolescents, and young adults.

Discussion

SPICT™-GR was assessed as a tool useful, applicable, and appropriate for primary care and a source for guidance to health professionals including all the necessary information to support them in identifying the supportive and palliative care needs of persons and their carers, defining goals of care, setting priorities, organizing their care plan, and facilitating decision-making. Supporting comprehensive care, endorsing interdisciplinary collaboration and raising awareness for palliative care were also identified as elements significant for the Greek primary care context.

Participants appreciated tool’s brevity, clarity, and comprehensiveness as characteristics which would facilitate its implementation, a finding also raised in SPICT translation and adaptation studies in other languages.^{13
-16,23,24,28} In the process of developing SPICT-GR, there was no need to make extensive semantic or conceptual modifications which is common in SPICT adaptations in other languages, particularly in non-European countries^17,36 Participants also deemed the tool practical, feasible, and helpful, characteristics underlined by SPICT applicability studies in various settings and populations.^13,23,27
-29

The tool was considered as complementary and not replacing participants’ clinical judgment, a finding which contrasts with the Danish version validation study¹⁵ where a concern was raised for the tool formulated as directives. All participants in our study stated that they would incorporate the tool in their clinical practice despite that none had experience in using a tool for assessing the needs of persons with chronic debilitating conditions, a finding also noted in the adaptation study of the Italian version.¹⁴

Instrument utility was also assessed by administration time, considered an important factor for the feasibility and application of the tool in daily practice and under pragmatic conditions. Completion time complied with time needed with other versions of SPICT in the context of primary care^12,13 as well as with other tools used for the identification of persons with palliative care needs in this context.⁷ While time constrains in primary care might affect the use of assessment tools, exploring needs in an organized way, which the tool promotes, along with increasing familiarization with its use, as respondents explicitly stated, will ultimately save time.^13,14,36

The potency of the tool to motivate comprehensive and holistic care by bringing to view aspects not straightforwardly “visible” during routine practice, was another important point raised by participants, also indicated in other SPICT validation studies.^13,37 In particular, respondents in the development of the German version stated that the use of the tool supported health professionals “seeing the big picture”¹³ while in a later study respondents conveyed that application of SPICT conducted to sharpening health professionals’ view.³⁷ Participants in our study also perceived that using the tool could endorse a “common language” among health care professionals facilitating thus interprofessional collaboration, a finding which aligns with the tool’s potential to function as a collaborative interdisciplinary tool supported in SPICT validation studies in other languages.^15,16 For example, participants in the study of Pham et al¹⁶ stated that the tool supported different professionals in speaking the same language, which could be used as a basis for multidisciplinary collaboration. Enhancing cooperation is particularly important for the Greek health care context, as deficiencies in multiprofessional collaboration have been identified as impediments for integrated primary health care in this country, including palliative care.^38,39

Participants confirmed findings from other studies about the tool’s potential to promote awareness for palliative care,^13,16 while in line with the study of Pham et al¹⁶ they perceived that it could also defeat usual misconceptions about palliative care, as that it is appropriate only for persons facing cancer and for those at the end of life. This identified potency of SPICT is also important because, although palliative care is traditionally indentified with cancer, the proportion of people with non cancer palliative care needs are significantly higher; indeed, in the study of Sudhakaran et al²⁵ the most common conditions identified by SPICT in community settings were cardiovascular conditions, dementia, and frailty while participants in the study of developing SPICT-DE shared the opinion that the tool has a great potential to increase awareness for palliative care issues, particularly for persons with chronic nonmalignant conditions.¹³ This finding is also important as misunderstandings of the role and scope of palliative care, common as well among health care professionals in Greece^40,41 comprise a significant barrier to the early and timely identification of all persons who could benefit from this approach.

Primary care professionals recognised central elements of their routine clinical practice that are relevant with palliative care, while not describing their work as such, like preventive care and anticipatory planning, a finding also indicated by other SPICT validation studies^15,16 For example, in the study of Bergenholtz et al¹⁵ respondents appraising the Danish version of SPICT recognised that they were actually dealing with the tool content during their everyday practice but they had not thought of or described their work as palliative care. This finding is also supported by research on the attitudes of primary care providers on early palliative care in Greece, where participants stated that although already providing essential elements of palliative care they did not consider themselves as actually implementing this type of care.³⁹

The need of a score or cut-off value to quantify the necessity for palliative care which was suggested in our study has also been raised in other SPICT validation studies.^13,15,23,42 Although SPICT is not including a cut-off value, research confirms that palliative care should be considered when ≥2 general indicators and ≥1 clinical indicators are detected.^23,42,43 Furthermore, it has been recognised as an advantage of SPICT to focus on care needs as pronounced by the sick person and the family rather than scoring, as it can better facilitate introducing palliative and supportive care.¹⁹

Key Implications for Future Policy, Practice, and Research

SPICT™-GR has been translated, culturally adapted, and content validated to be available for use in the Greek primary care context. Implementation of the tool could improve identification of persons with unmet palliative and supportive care needs while by promoting a structured way of thinking on palliative care needs assessment, it could be useful in other conditions beyond those included. This study highlights the need to consider “latent” instrument potentials such as increasing the visibility of the multiple dimensions of care, and promoting an organized way of thinking on recognizing unmet palliative care needs. Furthermore, the role of the tool to foster a shared language among health providers is important given that suboptimal collaboration and communication between health-care professionals have been identified as barriers to effective palliative care in the community.^44,45

SPICT™-GR could be integrated into national strategies, future palliative care policies and guidelines, as well as in training and continuous education programs of health professionals in this country. The involvement of primary care providers in the identification of palliative care needs and advance planning by building on their existing skills and expertise could promote palliative care with concurrent rational use of human resources, which might be particularly important for developing countries. Furthermore, introduction of the tool in Greek primary care could motivate health care professionals’ awareness for palliative care and also challenge common misconceptions about this approach. Future studies could seek whether using the tool might have an impact on professionals’ attitudes toward palliative care. Aforementioned aspects could comprise essential foundations for the organization and implementation of primary palliative care services in countries such as Greece where relevant initiatives are currently under development.

Strengths and Limitations

This is the first time an assessment tool on the early identification of individuals with unmet palliative care needs is translated and cultural adapted in the Greek health care context. The participation of health care providers with central role in primary care, such as General Practitioners/Family Doctors and Health Visitors, is regarded as strength of this study. Community health professionals, although having appropriate skills, knowledge, and roles that could advance primary palliative care, have traditionally been under-represented in primary palliative care initiatives; therefore, we consider strength of this study to include them as potential SPICT-GR users. We also see the multidisciplinary sample as strength, considering as the discussion of different professionals’ perceptions on utility, feasibility, and handing of SPICT™-GR as valuable for future implementation strategies.

One limitation of this study is the application of model case vignettes; however, while in daily clinical practice a variety of different conditions might be faced, the selected vignettes were considered realistic and representative. Given the limited training on palliative care in Greece, a User Guide might be appropriate so as to support clinicians for using the tool including information on its purpose and actions to be taken by providing examples. Another limitation is the gender imbalance in the focus groups as the majority of participants were females as well as the profession imbalance as the majority of them were Health Visitors. It is also a limitation of this study that the tool was not directly tested on the eligible patient population while participants’ attitudes were not measured. Future studies could concern SPICT™-GR application and validation in different health settings, its use by various health specialties and impact on patient-reported outcomes.

Conclusions

SPICT-GR was assessed as a tool suitable and applicable in the Greek primary health care context, and a source of guidance to primary care professionals for comprehensively identifying patients’ unmet palliative care needs, including frail elderly. It was also appreciated for its potency to create a common frame of reference among health care professionals and increase awareness on the palliative care needs of persons with chronic and life-limiting conditions.

Supplemental Material

sj-docx-1-jpc-10.1177_21501319241245842 – Supplemental material for Palliative Care in the Community: The Greek Version of the Supportive and Palliative Care Indicators Tool (SPICT™)

Supplemental material, sj-docx-1-jpc-10.1177_21501319241245842 for Palliative Care in the Community: The Greek Version of the Supportive and Palliative Care Indicators Tool (SPICT™) by Maria Bouri, Evanthia Sakellari, Dimitrios Krentiris and Areti Lagiou in Journal of Primary Care & Community Health

Footnotes

Acknowledgements

We would like to thank the primary care clinicians who enthusiastically participated in this research study and provided valuable insights on the feasibility and applicability of SPICT™-GR in the Greek primary health care context. We would also like to thank the lead of SPICT™ International Program, Dr Kirsty Boyd, Reader in Palliative Care at the University of Edinburgh, for all the support and feedback she generously provided throughout this research project.

Author Contributions

All authors contributed to study conception and design. Material preparation, data collection and analysis were performed by M.B, E.S, and D.K. under the supervision of A.L. E.S., and M.B. moderated the focus groups discussions. The first draft of the manuscript was written by M.B. and E.S. All authors commented and reviewed on previous versions of the manuscript. All authors read and approved the final manuscript.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The author(s) received no financial support for the research and authorship of this study. The publication of the article in OA mode was financially supported in part by HEAL-Link.

Ethical Approval,Data Management,and Participant Consent

The study was approved by the Research Ethics Committee of the University of West Attica (Ref. No 30542—05/05/2020). Supportive and Palliative Care Indicators Tool (SPICT)-GR was translated and adapted with permission from the SPICT International programme (; communication with the Program Lead, Dr Boyd, on 29/4/2020). Data are securely stored per regulation of the University of West Attica and are not available according to participant consent. All participants provided written consent before their inclusion in the study.

ORCID iD

Maria Bouri

Supplemental Material

Supplemental material for this article is available online.

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