Building bridges to care: A co-created community palliative care package for resource-limited settings

Palliative care (PC) needs are substantial in Nigeria, yet access to specialist PC services remains limited, particularly in rural and peri-urban communities.

To co-create an implementation-ready, community-delivered PC package for rural Nigerian settings without PC specialists and specify its components, delivery roles, and referral pathways.

Sequential explanatory mixed-methods, participatory co-creation design in which quantitative prioritization informed qualitative refinement.

Participants (health professionals, traditional and religious leaders, patients, caregivers, advocates, and policymakers) used Mentimeter® to generate and rank feasible non-pharmacologic components, followed by an adapted Group Model Building (GMB) process to identify key health-system and sociocultural determinants, specify the most appropriate delivery settings and cadres, and define delivery processes and referral pathways to basic PC providers at facilities. The process included three pre-workshop virtual sessions (n=51) and a 5-day in-person GMB workshop in Enugu, Nigeria (n=45), with diverse participants from all six geopolitical regions recruited via the ICON-3 Practice-Based Research Network. Outputs were refined through participant validation and technical expert review to enhance feasibility and implementation readiness.

Participants prioritized effective pain and symptom relief, strengthened communication and shared decision-making, intentional engagement of religious leaders, and improved community-primary care collaboration. The resulting package comprises three components (pain and symptom management, psychosocial support, spiritual care) delivered via a hub-and-spoke model in which CHEWs/CHAs serve as community "Anchors," while facility-based basic PC providers and tertiary specialists provide oversight and manage complex cases. Key barriers included limited training and stigma, medication access constraints, and weak referral systems; proposed solutions emphasized training with supportive supervision, improved medicines access/financing and strengthened referral pathways and community support structures.

A participant-designed, task-shared, hub-linked community PC package is feasible in principle for Nigerian settings without PC specialists and provides an implementation-ready blueprint for feasibility testing, adaptation, and scale-up planning.