Contexts, mechanisms and outcomes of home-based palliative care implementation in low- and middle-income countries: A realist review.

BACKGROUND

In 2015, an estimated 16.4 million people in low-and-middle-income countries (LMICs) died with serious health-related suffering requiring palliative care. Yet access to palliative care remains limited in LMICs, where the gaps are greatest. Home-based palliative care (HBPC) has been shown to improve access, enhance quality of life and reduce costs. However, evidence on implementing HBPC across the diverse contexts of LMICs remains scarce.

AIM: To identify which strategies, in which contexts, trigger which mechanisms to produce successful implementation outcomes for HBPC in LMICs.

DATA SOURCES AND

METHODS

Following RAMESES standards, we conducted a realist review to refine an initial programme theory developed through WHO documentation and the CFIR. We searched six databases (MEDLINE, PsycINFO, CINAHL, EMBASE, Global Health, and CENTRAL) for home-based palliative care in LMICs. Evidence was selected based on relevance, richness, and rigour, using 17 "if-then" statements to synthesise Context-Mechanism-Outcome-Configurations (CMOCs).

RESULTS

In LMICs, patients with advanced illness and caregivers experience substantial multidimensional unmet needs within health systems that are underfunded and fragmented. We identified five CMOCs in which HBPC was found to be acceptable, feasible, and sustainable. (1) Community engagement: Programmes that actively engaged community members and local civil organisations reduced stigma surrounding palliative care, strengthened collective ownership, and improved programme acceptability and sustainability. (2) Volunteer involvement: Training community-rooted caregivers created trusted bridges between services and families, enhancing volunteer commitment and long-term viability. (3) Nurse leadership: Empowering nurses through training and expanded roles increased professional confidence and trust from patients and families, supporting delivery in resource-constrained settings. (4) Multidisciplinary team: Collaborative team care alleviated feelings of abandonment, fostered hope and reciprocity; encouraged patients and families to contribute back to programmes. (5) Holistic and uninterrupted support for caregivers: Continuous and holistic support for family carers improved confidence in home caregiving and enabled end-of-life care at home.

CONCLUSION

Shared contextual similarities across LMICs suggest these components could support HBPC implementation in diverse resource constrained settings and potential for cross-national learning. To maximise successful implementation, investment for HBPC should prioritise enhancing community capacity and developing nurse leadership within the team care model.