Setting the stage for communication skills training in Rwandan cancer care: a qualitative study of local priorities and key contextual factors.

BACKGROUND: The burden of advanced cancer is rising in Africa. Cancer care involves complex conversations between providers, patients, and families. International guidelines recommend communication skills training for all cancer care providers, and patient-provider communication and training needs are strongly influenced by culture. As oncology and palliative care capacity expand in African settings such as Rwanda, participatory research is needed to culturally adapt communication skills training to best fit local contexts. METHODS: Guided by the Cultural Adaptation Process model, this study aimed to set the stage for adaptation and implementation of serious illness communication skills training in the Rwandan context. We conducted focus group discussions with interdisciplinary cancer care providers at Butaro Hospital in Rwanda to understand their communication training priorities and describe pertinent contextual factors. The focus groups were audio-recorded, transcribed, and analyzed using the framework method of thematic analysis. RESULTS: A total of 17 cancer care providers participated in one of three focus groups, including six physicians, seven nurses, two psychologists, and two social workers. Participants identified delivering bad news and responding to emotion as the most challenging aspects of clinical communication and the highest priorities for training. They expressed concerns about the psychological toll of difficult conversations on providers, advocating for future trainings to include burnout mitigation strategies. Participants described several key contextual factors that should inform adaptations of communication training for Rwandan cancer care. These include barriers common to low-resource settings as well as several local assets: interdisciplinary collaboration, dedicated clinical psychologists, group counseling sessions, peer support among patients, and strong community networks. Several findings will be directly applied to the design of an initial pilot communication training in Rwanda. Areas requiring further investigation and opportunities to broaden the scope of communication interventions beyond patient-provider encounters were identified. CONCLUSIONS: This study sets the stage for adapted communication skills training in Rwanda that is guided by the priorities and recommendations of local cancer care providers. Several pertinent cultural and structural factors were identified that are common across diverse African settings. Therefore, our training adaptations, as well as the methodology used for adaptation, have the potential for widespread reach.