FORM RDC/1A

(Revised December 2018)

THE Hong Kong POLYTECHNIC UNIVERSITY

RESEARCH DEGREE PROPOSAL

(To be typewritten by the Applicant)

Note: Please note that the information given in this form will only be used for processing this application.

1. Name of Proposed Chief Supervisor (if applicable): Professor Dr. MOLASIOTIS, Alex

2. Project Title:

An exploration the Palestinian Health Care System Readiness of Provision Palliative Care Services
for Adult Patients with Cancer: A Mixed-Methods Study

3. Project Objectives: (Purpose of proposed investigation)

The purpose of this mixed method study is to develop knowledge base about palliative care of
cancer patients in Gaza hospitals, to identify the barriers and facilitators of provision PC services at
Palestinian Health Care System, and; to draw upon these findings to develop policy
recommendations. The results will help to develop and refine services to address the gaps in PC of
cancer care that exist. This research will be conducted to answer the following questions:
This research will be conducted to answer the following questions:
- What are the barriers and facilitators of provision PC services of cancer patients at hospital
setting?
- How can the identified issue will be addressed to inform policy and clinical guidelines in the
environment?

4. Scope and Background of Research:

(Please identify key issues/problems to be addressed)

Cancer, or abnormal cell growth, includes more than 100 different diseases of unknown etiology
(American Cancer Society, 2018). It is an increasingly significant reason of morbidity and mortality
all over the world (Bray et al., 2018). Globally, there is an increase in cancer incidence; in 2018,
about 18.1 million new cases of cancer were diagnosed all over the world. In the same year, cancer
accounted for about 9.6 million deaths; 70% of deaths occur in low-and-middle-income countries
(World Health Organization, 2018).
Palliative Care (PC) is considered the most a holistic and appropriate approach and one of the
services relevant to all life-threatening diseases (Gomez-Batiste et al., 2013). Cancer, one of these
diseases that cannot always be cured completely, but definitely, a lot can be done to make the lives of
oncology patients meaningful and productive (Ref). It is also defined as “an approach that improves
the quality of life of patients and their families through the prevention and relief of suffering by
means of early identification and impeccable assessment and treatment of pain and other problems,
physical, psychosocial and spiritual (Stjernsward, Foley, & Ferris, 2007; World Health Organization,
2017). Therefore, the main core of PC is to relieve symptoms that appeared by cancer progress and
life in a comfortable way rather than cure of patients (Kaye et al., 2015; World Health Organization,
2018). Due to transitional chance in the population growth in the world and living longer years, the
need of PC is increased and application of these services is urgently required to adopt (Centeno,
Lynch, Donea, Rocafort, & Clark, 2013).

Despite the early adoption of PC in Middle East regions in 1990 (Al-Shahri, 2002; Nixon, 2004), the
growing and development looks slow and access to it service limited to some regions (Al-Shahri,
2002).

Palestine one of those countries that fall in Middle East regions. The situation in Palestine especially
Gaza Strip is completely different. The Gaza Strip is different from other parts of the world. Firstly,
it is among the most densely populated areas on earth; it has a population of 2.2 million living in an
area of 365 km2 (1). Secondly the free movement of citizens is restricted with the Israeli and
Egyptian blockade (2). Thirdly the political tensions and divisions and associated austerity measures
make the ongoing access to health care for patients with cancer extremely difficult. In Palestine,
cancer currently ranks as the third major cause of morbidity and mortality (3). Colorectal, breast,
and lung cancers are the most common type of cancers among adults. The total numbers of
registered cancer cases in the Gaza Strip during 2001-2010 were 7,480, with an average of 748
newly-diagnosed cases per annum. Cancer diagnosis tend to be later with at least 60% of cancer
cases being diagnosed at Stage III or IV (4). Limited resources, lack of access to healthcare facilities
and cultural beliefs contribute to the later cancer diagnosis.

Three hospitals in Gaza provide cancer care. Cancer care whist it is improving in Palestinian
hospitals, services like palliative care, targeted cancer therapies, and bone-marrow transplantation
are limited (5). Furthermore, the shortage of specialist physicians, limited availability of
chemotherapy, and radiotherapy compound the situation. Political divisions also play a role in the
chronic shortage of medication, suboptimum financial and administrative coordination, inadequate
infrastructure and healthcare human resources. Some patients travel to Israel or Egypt for cancer
treatments however restrictions on travel add stress to their cancer treatment journey (2). These
issues put patients at an increased risk of 1) a later diagnosis of cancer 2) slower access or reduced
access to treatments 3) increased risk of medical complications and 4) increased disease
burden/morbidity. Taking a summative perspective on this situation, patients with cancer residing in
Gaza have many “unmet needs” on the cancer trajectory; the challenge is to categories and highlight
what these are.

This mixed method study aims to develop knowledge base about palliative care of cancer patients in
Gaza hospitals, to identify the barriers and facilitators of provision PC services at Palestinian Health
Care System, and; to draw upon these findings to develop policy recommendations. The results will
help to develop and refine services to address the gaps in PC of cancer care that exist. Through the
completion of the study, the researcher expects to raise the attention of governmental institutions,
health care providers, cancer patients and families and society of the need for PC which help to
reduce the negative impact associated with the disease process and its long-term treatments. The
researcher is expecting to stimulate changes in the provision palliative care of supportive cancer care
that will help cancer patients in the Gaza Strip. In addition, the new information gleaned can be
compared between Hong Kong and the Middle-East.

The numerous challenges related to providing palliative care in a hospital setting are also
reflected in nursing practice. The challenges seem to be related to organizational and cultural
factors, but knowledge on these in a general setting is sparse.

In order to explore whether palliative care in hospitals is alienating and selective with regard to
cancer patients, there is a need for more research on how the palliative care is practised in a
Danish hospital setting in departments which do not specialise in palliative care. Furthermore, it
has not yet been demonstrated whether the existing evaluation programmes have had an effect
on the quality of general palliative care in the hospital. Lack of validated methods and knowledge
on sustainable solutions for the palliative care is missing. This is all leading to the aims
of this study.
 Form RDC/1A (page 2)

5. Research Methodology:

Study Design
The study will be conducted using a mixed methods approach, using a 2‐phase sequential mixed‐
methods design with a quantitative phase followed by a qualitative phase. Phase (1): will involve a
cross‐sectional survey. In this phase, a pilot-tested instrument will be developed for the purpose of
this research will be administered to population sample of to explore the barriers and facilitators to
provision PC. Survey research is the most dominant form of research in social sciences, as it
provides for efficient collection of data over broad populations (Dillman, 2011). The instrument
developed for this research was an attitude scale, as this is one established method of asking
participants about value, beliefs, and opinions (Ajzen, 2002). Phase (2) will used a translational
research approach to translate the survey findings into policy recommendations that have clinical
application. This will be achieved by conducting focus group interviews with stakeholders and policy
makers to discuss and contextualize the survey findings with the theoretical framework utilized by
this research. The interface of data analysis from these two phases aimed to develop research
findings that have direct application to health policy in cancer care. Data triangulation will provide
better understanding of the research problem and will strengthen research findings.

The mixed-method approach used for this research will provide an opportunity to study a multitude
of variables associated with palliative care practice, from both a population and applied perspective
that would otherwise be overlooked using a more traditional methodological approach (Mertens,
2014). Caracelli and Greene (1993) describe a category of mixed methods research as conducting
analyses separately, and then engaging in the integration of findings during the interpretation phase
of the research: this study is an example of this methodological approach, in that quantitative and
qualitative data from this study will analysed and reported separately, but the results from each were
considered together in the discussion of the study findings.

The analytical framework presented in Figure (x) will illustrates the research steps undertaken in this
study. The research approach was informed by the theoretical and empirical literature discussed in
the previous chapter.
Sampling
The study will include 3 groups;
1)Patients (n=400) with a cancer diagnosis (stage II, III, or IV) of one of three tumor types (breast, colorectal, and
lung), aged between 18-80 years will be randomly selected from the Palestinian Cancer Registry database.
2) Family caregivers: patients will be asked to select caregivers whom they have the closest contact with during the
disease period (n=400).
3) Cancer service providers who work at oncology centers at Al-Shifa Hospital and European Gaza Hospital (EGH) will
be invited to participate in the study.
Data Collection
For quantitative data collection, surveys will be administered to patients with cancer and their caregivers. Multiple
instruments will be used to measure study variables including:
1) Socio-demographic questions
2) Psychosocial Needs Inventory Questionnaire
3) Quality of life survey (SF-36)
4) Cancer- and Cancer Treatment-related Symptom Scale
5) Hospital Anxiety and Depression Scale.
For qualitative data collection, nine patient focus groups will be conducted as follows: groups divided according to
gender (males vs females); cancer types; and age (<45, or >45). Patients will be accessed from two cancer care
centers (EGH or Al-Shifa hospital).
For family caregivers, the study will include focus groups (n=4); including caregivers for patients treated at EGH, and
the second will include caregivers for patients treated at Al-Shifa hospital.
Key informant interviews with be conducted with cancer service providers in the two cancer centers e.g. oncologists,
general physician, and specialist nurses
.
Data Entry and Analysis
The SPSS statistical package will be used for quantitative data analysis. To evaluate the influence of
demographic, clinical characteristics, QOL, cancer symptoms on psychosocial needs we will use
multivariate linear regression analyses.
Open coding thematic analysis methods will be used to analyse the transcripts of the focus group and
the in-depth interviews.
Categorisation of related ideas, and comparison and integration between the quantitative and the
qualitative findings will be performed to create rich items for discussion.
6. Project Significance and Value:
/...3
 Form RDC/1A (page 3)

7. Details of Any External Collaboration:

In these circumstances, are there likely to be any complications associated with the
publication of your thesis? Give details.

8. Declaration of the Applicant

I wish to register for a research degree on the basis of the proposal given in this Form
(RDC/1A).

I understand that, during the period of my registration with the University, I may not be a
candidate for any other degree or award.

I understand that, except with the specific permission of the Research Committee, I must
prepare and defend my thesis in English. (You are required to seek permission if another
language, which is considered more appropriate to the subject, is to be used in the
presentation of the thesis. Please submit the justification together with this application.)

I undertake to abide by the general regulations of the University.

Signature Date

Name

During the application period

After completing Sections 1 to 8, the applicant should upload this form to the eAdmission
system at www.polyu.edu.hk/admission.

After admission
RPg students should submit this form to the General Office of the Department after
completing Sections 1 to 8.
/...4
 Form RDC/1A (page 4)
For internal use only. Applicants should leave Sections 9 and 10 blank.

9. Endorsement by the Proposed Chief Supervisor

9a. Research Ethics/ Safety Approval

[For ethics approval, Chief Supervisor / Temporary Chief Supervisor please read the
Ethical Clearance for Research or Teaching Projects or Investigations Involving Human
Subjects, which are available at Section V of the Handbook for Projects and Grants at
https://www.polyu.edu.hk/ro/staff/handbooks/HD_PG.pdf , and make sure that ethics
approval is obtained if your project involves human subjects. For safety approval, please
read the policy and procedures for safety approval available at the Health, Safety &
Environment Office Homepage. Please attach the approval letter where appropriate.]

I confirm that approval:

* has been * is not required * will be obtained
Obtained before the start
of the project

Human Research Ethics

Animal Research Ethics

Biological Safety

Ionizing Radiation Safety

Non-ionizing Radiation Safety

Chemical Safety

(* Please tick as appropriate)

9b. Research Facilities and Space

I confirm, to the best of my knowledge, that adequate facilities and space are
available to enable the student to conduct and complete the research programme
in an efficient and safe manner.

I would like to request the following additional research facilities and/or space to
enable the student to conduct and complete the research programme in an
efficient and safe manner:

Research Facilities

Space (Other than the

regular space provided by
the Department for RPg
students)

Signature Department/School
(^ Chief Supervisor / Temporary Chief Supervisor)

Name Date
(^ Chief Supervisor / Temporary Chief Supervisor)
(^ Please delete as appropriate)

Form RDC/1A (page 5)

10. Recommendation of Head of Affiliated Department in the University

I support this application and understand, on the basis of the Chief Supervisor’s
endorsement, that adequate research facilities and space are available to enable
the student to conduct and complete the research programme in an efficient and
safe manner.

I support this application and agree to provide the additional research facilities
and/or space, as requested by the Chief Supervisor in section 9b above, to enable
the student to conduct and complete the research programme in an efficient and
safe manner.

Signature Date
(Head of Department/Dean of School)

~ The completed form should be kept by the General Office of the Department. ~
RDC/1A

Ajzen, I. (2002). Constructing a TPB questionnaire: Conceptual and methodological considerations.

Al-Shahri, M. (2002). The future of palliative care in the Islamic world. The Western journal of medicine, 176(1), 60-
61.
American Cancer Society. (2018). Cancer Facts & Figures 2018. 250 Williams Street, NW, Atlanta, GA
Bray, F., Ferlay, J., Soerjomataram, I., Siegel, R. L., Torre, L. A., & Jemal, A. (2018). Global cancer statistics 2018:
GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J
Clin, 68(6), 394-424. doi:doi:10.3322/caac.21492
Caracelli, V. J., & Greene, J. C. (1993). Data analysis strategies for mixed-method evaluation designs. Educational
evaluation and policy analysis, 15(2), 195-207.
Centeno, C., Lynch, T., Donea, O., Rocafort, J., & Clark, D. (2013). EAPC Atlas of Palliative Care in Europe 2013 -
Full Edition. 385
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49. doi:10.1080/J354v17n03_05
Stjernsward, J., Foley, K. M., & Ferris, F. D. (2007). The public health strategy for palliative care. J Pain Symptom
Manage, 33(5), 486-493. doi:10.1016/j.jpainsymman.2007.02.016
World Health Organization. (2017). Definition of Palliative Care. Geneva; 2002. In.
World Health Organization. (2018). Cancer. PRESS RELEASE N° 263.