Received: 5 April 2022

| Revised: 14 June 2022

| Accepted: 24 August 2022

DOI: 10.1002/cam4.5213

RESEARCH ARTICLE

Regional adaptation of the education in palliative and

end-­of-­life Care Pediatrics (EPEC-­Pediatrics) curriculum
in Eurasia

Michael J. McNeil1 | Bella Ehrlich1,2 | Taisiya Yakimkova1 | Huiqi Wang1 |

Volha Mishkova3 | Zhanna Bezler4 | Ella Kumirova5,6,7,8,9 | Arshia Madni1 |
Narine Movsisyan10 | Karen Williams1 | Baglan Baizakova11 | Marina Borisevich3 |
Georgia Chatman1 | Indira Erimbetova12 | Ximena Garcia Quintero1 |
Rodica Golban | Brandi Kirby | Paola Nunez | Radhikesh Ranadive1 |
13 1 1

Nadezhda Sakhar14 | Jason Sonnenfelt1 | Alisa Volkova15 | Daniel Moreira1 |

Stefan J. Friedrichsdorf | Joanne Wolfe | Stacy Remke | Joshua Hauser |
16 17 18 19

Meenakshi Devidas1 | Justin N. Baker1 | Asya Agulnik1

1
St. Jude Children's Research Hospital, Memphis, Tennessee, USA
2
Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
3
Belarusian Research Center for Pediatric Oncology, Hematology and Immunology, Minsk, Belarus
4
Belarusian Clinical Center of Palliative Care for Children, Minsk, Belarus
5
Dmitry Rogachev National Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
6
Russian Scientific Center of Roengenology and Radiology, Moscow, Russia
7
Pyrogov Medical University, Moscow, Russia
8
Morozovskaya Children's City Clinical Hospital, Moscow, Russia
9
N.N. Blokhin National Medical Research Center of Oncology, Moscow, Russia
10
Yerevan State Medical University After Mkhitar Heratsi, Yerevan, Armenia
11
George Washington University, The Milken Institute School of Public Health, Washington, District of Columbia, USA
12
The Republican Center for Hematology and Blood Transfusion, Tashkent, Uzbekistan
13
Institute of Oncology of Republic of Moldova, Moldova, Chisinau
14
Republican Scientific and Practical Center for Pediatric Surgery, Minsk, Belarus
15
Raisa Gorbacheva Memorial Research Institute for Pediatric Oncology, Hematology and Transplantation, St. Petersburg, Russia
16
Benioff Children's Hospitals, University of California San Francisco, San Francisco, California, USA
17
Dana Farber Cancer Institute, Boston, Massachusetts, USA
18
University of Minnesota, Minneapolis, Minnesota, USA
19
Northwestern University, Chicago, Illinois, USA

Justin N. Baker and Asya Agulnik are Co-­Senior Authors

This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided
the original work is properly cited.
© 2022 The Authors. Cancer Medicine published by John Wiley & Sons Ltd.

Cancer Medicine. 2023;12:3657–3669.  wileyonlinelibrary.com/journal/cam4 | 3657

 |

20457634, 2023, 3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/cam4.5213 by Cochrane Colombia, Wiley Online Library on [21/06/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
3658    MCNEIL et al.

Correspondence
Justin N. Baker, Division of Quality
of Life and Palliative Care, 262 Danny
Thomas Place MS260, Memphis,
TN 38105, USA.
Email: justin.baker@stjude.org
Funding information
American Lebanese Syrian Associated
Charities
Abstract
Background: Pediatric palliative care (PPC) is a priority to improve pediatric
hematology oncology (PHO) care in Eurasia. However, there are limited regional
opportunities for PPC education. We describe the adaptation and implementa-
tion of a bilingual end-­user Education in Palliative and End-­of-­Life Care (EPEC)-­
Pediatrics course for PHO clinicians in Eurasia.
Methods: Due to COVID-­19, this course was delivered virtually, consisting of pre-
recorded, asynchronous lectures, and a bilingual workshop with interactive lectures
and small group sessions. A pre–­postcourse design was used to evaluate the knowl-
edge acquisition of the participants including their knowledge alignment with World
Health Organization (WHO) guidance, ideal timing of palliative care, and comfort in
providing palliative care to their patients. Questions were mostly quantitative with
multiple choice or Likert scale options, supplemented by free-­text responses.
Results: A total of 44 (76%) participants from 14 countries completed all compo-
nents of the course including pre-­and postcourse assessments. Participant align-
ment with WHO guidance improved from 75% in the pre-­to 90% in the postcourse
assessments (p < 0.001). After participation, 93% felt more confident controlling the
suffering of children at the end of life, 91% felt more confident in prescribing opioids
and managing pain, and 98% better understood how to hold difficult conversations
with patients and families. Most participants (98%) stated that they will change their
clinical practice based on the skills and knowledge gained in this course.
Conclusions: We present a successful regional adaptation of the EPEC-­Pediatrics
curriculum, including novel delivery of course content via a virtual bilingual for-
mat. This course resulted in significant improvement in participant attitudes and
knowledge of PPC along with an understanding of the ideal timing of palliative
care consultation and comfort in providing PPC to children with cancer. We plan to
incorporate participant feedback to improve the course and repeat it annually to im-
prove access to high-­quality palliative care education for PHO clinicians in Eurasia.

KEYWORDS
education, Eurasia, pediatric oncology, pediatric palliative care

1 | I N T RO DU CT ION symptom management, quality of life, communication,

The World Health Organization (WHO) defines palliative
care as the prevention and relief of physical, developmen-
tal, psychosocial, and spiritual suffering of patients and
their families facing life-­threatening illness.1 Early inte-
gration of palliative care is recognized by the WHO as an
“ethical responsibility” for children with life-­threatening
illness regardless of resource constraints.2,3 Worldwide,
more than 21 million children would benefit from pediat-
ric palliative care (PPC) services,4 however, access to PPC
is limited, especially in low-­and middle-­income countries
(LMICs).5–­7 Children with cancer are a unique patient
population who experience high symptom burden result-
ing in poor quality of life.8–­12 Early integration of PPC
into childhood cancer care has been shown to improve
and reduce patient and caregiver suffering.13–­15
While there are structural barriers to PPC delivery in
resource-­constrained settings, lack of formal education in
PPC remains a significant challenge.16–­18 A potential in-
tervention is the Education in Palliative and End-­of-­life
Care (EPEC)-­Pediatrics curriculum, a 24-­module course
addressing principles of PPC including pain and symp-
tom management, grief and bereavement, and commu-
nication, delivered via a combined online-­and in-­person
training. In addition to PPC content, adult learning the-
ory is included for participants to become “Trainers” and
disseminate course content to colleagues.19–­24 Since 2012,
1517 clinicians from 100 countries/territories from all
six continents have participated in this curriculum, and
1027 became EPEC-­Pediatric “Trainers.” The curriculum

MCNEIL et al.
has been adapted for large-­scale dissemination in Canada
and Latin America with translation to French and
Spanish.19–­22 In addition to “Train-­the-­Trainer” courses,
EPEC-­ Pediatrics also offers “End-­ User” courses which
teach principles of PPC to a multidisciplinary audience to
improve direct clinical care.
The Eurasian Regional Program, or EurADO (Eurasian
Alliance in Pediatric Oncology), is a collaboration be-
tween St. Jude Children's Research Hospital and pediatric
hematology-­oncology centers, foundations, and clinicians
in 15 countries in Central Asia and Eastern Europe to im-
prove care for children with cancer in Eurasia.25 In 2017,
EurADO identified palliative care as a regional priority.26,27
To study barriers to palliative care integration, EurADO
conducted the “Assessing Doctors' Attitudes on Palliative
Treatment” (ADAPT) study in 11 Eurasian countries.
Identified barriers included delayed integration of PPC
into pediatric oncology practice, low access to home-­based
PPC services, and misalignment of physician knowledge
with WHO guidance.28,29 This misalignment included
considering palliative care as synonymous with end-­of-­life
care, concerns that involvement of PPC in patient care in-
creased parental anxiety, and lack of comfort addressing
physical and emotional symptoms of children with cancer.
Subsequently, a virtual EPEC-­Pediatrics end-­user course
was developed to teach PPC principles to Eurasian clini-
cians emphasizing gaps identified by the ADAPT study
supplemented with a participant needs assessment.
The objective of this report is to describe the impact of
the adapted EPEC-­Pediatrics course on participant knowl-
edge of PPC including alignment with WHO guidance,
understanding of standard components of palliative care,
ideal versus actual timing of palliative care, and comfort
level in providing palliative care in the clinical setting.
Additionally, we assessed the effectiveness and feasibility
of a novel bilingual virtual course format.
2 | M ET H ODS
2.1 | IRB approval
This study was approved by the Institutional Review
Board at St. Jude Children's Research Hospital as cat-
egory 2 exempted research including educational tests
and survey procedures [SJ-­EPECPEDS (FWA00004775)].
Participation in the course resulted in implied consent.
2.2 | Course design
The EPEC-­Pediatrics Eurasia course was developed
based on findings from the Eurasian ADAPT study
|
20457634, 2023, 3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/cam4.5213 by Cochrane Colombia, Wiley Online Library on [21/06/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
   3659
supplemented with input from the EurADO supportive
care working group including regional experts in pediatric
oncology, hospice and palliative medicine, pain medicine,
and medical education.28,29 The specific course learning
objectives were to (1) understand the elements of pallia-
tive care and recognize its importance in childhood can-
cer care, (2) become proficient in practical applications of
pain and symptom management, (3) gain skills in effective
communication with patients and families, and (4) iden-
tify tools for self-­care. The EurADO working group evalu-
ated ADAPT data and EPEC-­Pediatrics content to identify
10 modules as high-­yield topics for the region (Table S1).
Additionally, these 10 modules were adjusted to account
for the unique cultural context of the region by regional
palliative care experts. For example, some medications
were added or omitted based on availability in the region,
or sensitivity to cultural views of discussion of prognosis
with the child was considered in developing the material.
2.3 | Course delivery
The 10 EPEC-­Pediatrics modules were recorded as didactic
lectures by three palliative care experts from St. Jude (MM,
JB, and KW); slides and voice-­over audio were then trans-
lated into Russian (TY and VM). The course was composed
of 3 weeks of online content (15 total hours, March 1–­March
19, 2021) via Cure4Kids, a free web-­based distance-­learning
platform with an integrated learning management system.30
A subsequent 5-­day synchronous virtual workshop (10 total
hours, March 22–­26, 2021) using the videoconferencing
platform Zoom (See Table S2).31 Each workshop day was
composed of 1 h of interactive didactic lecture led by a pal-
liative care expert with simultaneous translation followed
by the second hour of small group practical sessions of
skill-­development activities led by EPEC-­Pediatrics-­trained
Eurasian facilitators in Russian or English. An English-­
speaking EPEC-­Pediatrics expert co-­facilitator assisted the
small group with simultaneous translation to allow for bi-
directional discussion. Examples of the skill-­development
activities included a case-­based experience teaching the
principles of dyspnea, role play for communication, and
wellness exercises during the self-­care small group sessions.
2.4 | Course participants
Course participants were physicians, nurses, and psy-
chologists who care for children with cancer recruited
from Eurasian institutions that collaborate with the
St. Jude Global Eurasian Regional Program25 or the World
Health Organization Global Initiative in Childhood
Cancer (WHO GICC).32 Letters of invitation were sent to
 |
3660   
collaborating regional leaders who distributed the invita-
tion for participation in the course to their colleagues.
2.5 | Survey development
We used a pre–­postassessment design to evaluate the par-
ticipant experience .33 Assessment items were developed
based on the ADAPT survey.28,29 The precourse assessment
included demographics and questions assessing alignment
with WHO guidance1.through 15 statements that agreed
or disagreed with WHO guidelines.28 Additional sections
assessed understanding of standard accepted components
of palliative care, ideal versus actual timing of palliative
care consultation, and comfort in providing palliative
care to their patients (see Figure S1). The assessment was
developed in English, translated to Russian, reviewed by
regional experts, and back-­translated to ensure construct
consistency.34 The postcourse assessment included similar
questions to the precourse assessment with the addition
of questions evaluating participant confidence in deliver-
ing components of palliative care after the course and an
overall course evaluation (see Figure S2). Both assessments
were mostly quantitative with multiple-­choice or Likert-­
scale options, supplemented by several free-­text questions
(See Table S3 for Course Conceptual Framework). The as-
sessments were distributed using the Qualtrics electronic
platform,35 with the precourse assessment in February
2021 and the postcourse assessment in April 2021.
2.6 | Statistical analysis
Descriptive statistics were used to summarize partici-
pant demographics. Differences in pre-­and postassess-
ment samples were identified using McNemar's test and
20457634, 2023, 3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/cam4.5213 by Cochrane Colombia, Wiley Online Library on [21/06/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
MCNEIL et al.
Symmetry test. As in the ADAPT study, the 5-­point Likert
scale was collapsed into two categories (disagree and agree)
to compare the pre-­and postresults of the 15 statements
assessing alignment to WHO guidance, with the neutral
response categorized as not in alignment.28 Each partici-
pant's percent alignment to WHO guidance was then cal-
culated as the number of statements in alignment out of 15
total, and the mean percent alignment was calculated for
the pre-­and postcourse assessments. McNemar's test was
used for multiple-­choice questions assessing the timing of
palliative care consultation. The symmetry test was used
to compare comfort levels in providing palliative care pre-­
and posttest; delta change was calculated by the difference
between posttest and pretest means. SAS software, version
9.4 was used for all quantitative analyses36 and a p-­value
of <0.05 was considered statistically significant. The free-­
text responses were translated to English from Russian by
a bilingual native speaker (BE). Due to the concise nature
of free-­text responses, thematic content analysis was con-
ducted by one author (MJM). Responses were organized
according to the presence of specific concepts that were
subsequently grouped into themes for content analysis.
3 | RESULTS
3.1 | Participant demographics
Seventy clinicians from 23 institutions in 14 countries ap-
plied to the course, with 58 ultimately enrolling and 47
submitting all course components (see Table S4 for demo-
graphics of participants who did not complete the course).
Three participants had incomplete pre-­or postcourse as-
sessments so 44 (75.9%) participants were used for final
analysis (Figure 1). Most were pediatric hematologists/
oncologists (63.6%); few reported previous palliative care
F I G U R E 1 Participating countries
from Eurasia: Participating countries with
a darker color associated with a larger
number of participants per country.
 |

20457634, 2023, 3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/cam4.5213 by Cochrane Colombia, Wiley Online Library on [21/06/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
MCNEIL et al.    3661

TABLE 1 Participant demographics

training (15.9%) and most did not have access to PPC con-
sultation at their institution (63.6%). Most participants (n = 44),
(86.4%) had at least one patient die, with over a third Demographics overall sample No. (%)
(36.4%) having more than five patients die in their care Country
within the previous year (Table 1). Almost half (45.4%) of Armenia 1 (2.3)
participants felt burdened by their inability to control the Azerbaijan 1 (2.3)
suffering of children at the end of life, 20.5% felt burned
Belarus 5 (11.4)
out by their work, and 15.9% felt more callous toward peo-
Kazakhstan 5 (11.4)
ple since starting their current work (Table 1).
Moldova 2 (4.5)
Poland 1 (2.3)
3.2 | Alignment with WHO Romania 6 (13.6)
Russia 8 (18.2)
The mean participant alignment with WHO guidance prior Serbia 2 (4.5)
to the workshop was 74.5% (range 25.0%–­97.7%, standard Tajikistan 2 (4.5)
deviation 22.1%) which improved postcourse to a mean Ukraine 6 (13.6)
alignment of 90.3% (range 52.3%–­100.0%, standard devia-
Uzbekistan 5 (11.4)
tion [SD] of 12.1%, p < 0.01). Of the 15 WHO statements,
Age
8 had a statistically significant improvement between the
pre-­and postcourse assessments; the remaining 7 had <35 17 (38.6)
precourse WHO alignment of over 89.6% (Table 2). The 35–­50 21 (47.7)
individual median improvement for alignment was 15.9 51–­65 6 (13.6)
percentage points (range: 2.2–­40.9%). The four most com- >65 0
mon precourse misconceptions were (1) it is difficult to Sex
know when a patient with cancer would most benefit from Female 36 (81.8)
meeting the palliative care team, (2) palliative care is syn- Male 8 (18.2)
onymous with “end-­of-­life” care, (3) palliative care for chil-
Primary medical specialty
dren with cancer can be delivered by healthcare workers of
Pediatric hematology and/or oncology 28 (63.6)
all disciplines, not only by palliative care specialists and (4)
early consultation with palliative care causes increased pa- Pediatric anesthesia/ intensive care 5 (11.4)
rental burden and anxiety. Participant scores improved by Pediatric palliative care 3 (6.8)
at least a 20-­percentage points in the postcourse evaluation. General pediatrician 1 (2.3)
a
Other: (please specify) 7 (15.9)
Primary institution
3.3 | Components and timing of Children's Hospital 23 (52.3)
palliative care Cancer Hospital 19 (43.2)
Children's Hospice 1 (2.3)
Participants also broadened their description of the com- b
Other: (please describe) 1 (2.3)
ponents of palliative care for children with cancer pre-­
and postcourse (Figure 2A). Approximately 50% or less Years of experience
of respondents identified certain components as a part 0–­10 years 18 (40.9)
of palliative care in the precourse assessments, which ≥11 years 26 (59.1)
were significantly higher after the course, including spir- Previous training in palliative care
itual support to the patient and family (50.0% vs. 88.6%, No 37 (84.1)
p < 0.01), aid in family decision-­making around treatment Yes 7 (15.9)
options (47.7% vs. 77.3%, p < 0.01), and help clarify goals of
Access to palliative care consultation
care for the patient and family (45.5% vs. 70.5%, p < 0.01).
No 28 (63.6)
When asked about the ideal timing of palliative care
Yes 16 (36.4)
consultation for a child with cancer assuming unlimited
resources, more participants felt palliative care should be I have felt burdened by my inability to control the suffering of
children at the end of life
involved from diagnosis (79.5%) in the postcourse com-
pared with the precourse assessment (34.1%, p < 0.01,
Figure 2B). Additionally, in the postcourse assessment (Continues)
 |

20457634, 2023, 3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/cam4.5213 by Cochrane Colombia, Wiley Online Library on [21/06/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
3662    MCNEIL et al.

TABLE 1 (Continued) TABLE 1 (Continued)

(n = 44), (n = 44),
Demographics overall sample No. (%) Demographics overall sample No. (%)
Disagree 5 (11.4) General pediatrician 1 (2.3)
a
Sometimes 19 (43.2) Other (please specify) 7 (15.9)
Agree 20 (45.4) Primary institution
I feel burned out by my work Children's Hospital 23 (52.3)
Disagree 12 (27.3) Cancer Hospital 19 (43.2)
Sometimes 23 (53.3) Children's Hospice 1 (2.3)
Agree 9 (20.5) Other (please describe)b 1 (2.3)
I have become more callous toward people since I took this job Years of experience
Disagree 25 (56.8) 0–­10 years 18 (40.9)
Sometimes 12 (27.3) ≥11 years 26 (59.1)
Agree 7 (15.9) Previous training in palliative care
How many pediatric patients in your care (<18 years old) died No 37 (84.1)
in the last 12 months? Yes 7 (15.9)
0 patients 6 (13.6) Access to palliative care consultation
1–­5 patients 22 (50.0) No 28 (63.6)
≥6 patients 16 (36.4) Yes 16 (36.4)
(n = 44), I have felt burdened by my inability to control the suffering of
Demographics overall sample No. (%) children at the end of life
Country Disagree 5 (11.4)
Armenia 1 (2.3) Sometimes 19 (43.2)
Azerbaijan 1 (2.3) Agree 20 (45.4)
Belarus 5 (11.4) I feel burned out by my work
Kazakhstan 5 (11.4) Disagree 12 (27.3)
Moldova 2 (4.5) Sometimes 23 (53.3)
Poland 1 (2.3) Agree 9 (20.5)
Romania 6 (13.6) I have become more callous toward people since I took this job
Russia 8 (18.2) Disagree 25 (56.8)
Serbia 2 (4.5) Sometimes 12 (27.3)
Tajikistan 2 (4.5) Agree 7 (15.9)
Ukraine 6 (13.6) How many pediatric patients in your care (less than 18 years
old) died in the last 12 months?
Uzbekistan 5 (11.4)
0 patients 6 (13.6)
Age
1–­5 patients 22 (50.0)
<35 17 (38.6)
≥6 patients 16 (36.4)
35–­50 21 (47.7)
51–­65 6 (13.6) aOther specialties: Nurses, psychologists.
bOther institution: General Hospital.
>65 0
Sex
Female 36 (81.8) fewer participants stated that the ideal timing for consul-
Male 8 (18.2) tation was at the time of complex or high symptoms com-
pared with the precourse assessment (70.5% vs. 47.7%,
Primary medical specialty
p < 0.01).
Pediatric hematology and/or oncology 28 (63.6)
When asked to provide examples of something they
Pediatric anesthesia/ intensive care 5 (11.4)
will do differently in the future, many participants em-
Pediatric palliative care 3 (6.8) phasized the importance of implementing palliative care
 |

20457634, 2023, 3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/cam4.5213 by Cochrane Colombia, Wiley Online Library on [21/06/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
MCNEIL et al.    3663

TABLE 2 Percent change in alignment with WHO guidance before and after EPEC pediatrics course

Statements Pre (N = 44) Post (N = 44) Delta between Post and Pre p value
It is difficult to know when a patient with cancer would most benefit from meeting the palliative care team (collapsed
neutral into agree)
Disagreea 17 (38.6) 35 (79.5) 40.9 <0.001*
Agree 27 (61.4) 9 (20.5)
Palliative care is synonymous with “end-­of-­life” care (collapsed neutral into agree)
Disagreea 23 (52.3) 37 (84.1) 31.8 <0.001*
Agree 21 (47.7) 7 (15.9)
Palliative care for children with cancer can be delivered by healthcare workers of all disciplines, not only by palliative
care specialists (collapsed neutral into disagree)
Disagree 19 (43.2) 6 (13.6) 0.002*
a
Agree 25 (56.8) 38 (86.4) 29.6
Early consultation with palliative care causes increased parental burden and anxiety (collapsed neutral into agree)
a
Disagree 11 (25.0) 23 (52.3) 27.3 0.005*
Agree 33 (75.0) 21 (47.7)
Palliative care is incompatible with curative care (collapsed neutral into agree)
Disagreea 32 (72.7) 43 (97.7) 25 0.002*
Agree 12 (27.3) 1 (2.3)
Involving palliative care suggests the oncologist has failed in the mission to cure the patient (collapsed neutral into
agree)
Disagreea 34 (77.3) 42 (95.5) 18.2 0.01*
Agree 10 (22.7) 2 (4.5)
Involving the palliative care team early has negative effects on the relationship between the oncologist and the patient
and family (collapsed neutral into agree)
Disagreea 34 (77.3) 41 (93.2) 15.9 0.03*
Agree 10 (22.7) 3 (6.8)
Palliative care is appropriate at any stage of treatment in a child with high-­risk cancer (collapsed neutral into disagree)
Disagree 12 (27.3) 5 (11.4) 0.07*
a
Agree 32 (72.7) 39 (88.6) 15.9
Palliative care can be integrated with disease-­directed therapy (collapsed neutral into disagree)
Disagree 6 (13.6) 2 (4.5) 0.15*
a
Agree 38 (86.4) 42 (95.5) 9.1
Involvement of palliative care undermines the role of the pediatric oncologist as the physician in charge of patient care
(collapsed neutral into agree)
Disagreea 40 (90.9) 44 (100.0) 9.1 0.045*
Agree 4 (9.1) 0
Early integration of palliative care for all children diagnosed with cancer would decrease patient suffering (collapsed
neutral into disagree)
Disagree 3 (6.8) 0 0.08*
Agreea 41 (93.2) 44 (100.0) 6.8
Early integration of pediatric palliative care with cancer care would improve interdisciplinary communication (collapsed
neutral into disagree)
Disagree 4 (9.1) 2 (4.5) 0.41*
Agreea 40 (90.9) 42 (95.5) 4.6

(Continues)
 |

20457634, 2023, 3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/cam4.5213 by Cochrane Colombia, Wiley Online Library on [21/06/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
3664    MCNEIL et al.

TABLE 2 (Continued)

Statements Pre (N = 44) Post (N = 44) Delta between Post and Pre p value
Children with cancer who receive palliative care die earlier than those who do not (collapsed neutral into agree)
Disagreea 41 (93.2) 43 (97.7) 4.5 0.32*
Agree 3 (6.8) 1 (2.3)
Children with advanced and incurable cancer often suffer at the end of life (collapsed neutral into disagree)
Disagree 3 (6.8) 3 (6.8) 1.00*
Agreea 41 (93.2) 41 (93.2) 0
Involvement of palliative care during cancer therapy gives greater attention to the quality ofss life and symptom
management (e.g., pain, constipation, dyspnea, fatigue) (collapsed neutral into disagree)
Disagree 1 (2.3) 2 (4.5) 0.56*
a
Agree 43 (97.7) 42 (95.5) −2.2
a
Correct response. Collapsed into two categories (collapse neutral into incorrect response based on whether agree or disagree is the correct answer or not):
Statements organized from the largest positive delta change toward alignment to WHO guidance answer to the lowest delta change toward WHO guidance.
*McNemar's Test.

earlier in the patient's care: “For me, the statement that the
involvement of a palliative team is possible at the time of
diagnosis was a discovery. I agree that talking with parents
about palliative care early will facilitate communication at
different stages of the disease. I am going to inform doc-
tors about this, to spread the necessary information about
palliative for parents. It's not easy, because the mentality
and attitude towards the very word ‘palliative’ is not very
simple in our country, and the ‘doctor-­patient’ communi-
cation is very upsetting” (Ukraine) (Table S5).
3.4 | Comfort and confidence in
providing palliative care to patients
In the precourse assessment, 59.1% of participants re-
ported feeling comfortable assessing and treating the
physical needs of pediatric patients with serious incurable
illness, which increased to 75.0% after the course (p = 0.03)
(Table S6). While not statistically significant, there were
improvements in the postcourse comfort in addressing the
emotional needs of patients (72.7% pretest, 86.4% posttest,
p = 0.2) and in addressing the grief and bereavement of
families (43.2% pretest, 68.2% posttest, p = 0.7).
After participating in the course, most participants felt
more confident in their ability to control the suffering of
children at the end-­of-­life (93.2%) and to prescribe opi-
oids and manage pain (90.9%); they also better understood
possible solutions to providing palliative care for children
with cancer (97.7%) and how to hold difficult conversations
with patients and families (97.7%) (Table 3). In free-­text
responses, many participants described the importance of
self-­care and the prevention of burnout as key takeaways
from the course; “I have been working in oncology for
28 years. I keep in touch with many already cured patients,
as well as with the parents of children who have died. I value
them, but I understand that I need to learn to love myself
and devote more time to my family.” (Belarus) (Table S5).
3.5 | Course assessment
All participants reported the course provided them with new
skills relevant to their clinical practice, and 97.7% stated that
they will change their clinical practice based on knowledge
gained in the course. Finally, 95.5% of participants stated
that the course met or exceeded expectations (Table 3).
In free-­text responses, several participants described
plans to apply the pain and symptom management, psy-
chosocial support, and communication skills gained during
the course (Table S5). When asked what they enjoyed most
about the course, some participants described specific lec-
tures or small group skill-­development sessions. The most
common theme, however, focused on the unique struc-
ture of the course and the benefit of the small-­group skill-­
development activities where participants were able to learn
from content experts and from each other: “I liked the possi-
bility of hearing all the voices, with less or more experience,
and the fact that there was no bad answer” (Romania).
Suggestions to improve the course included using
more case examples, increasing time for discussion, and
allowing more interaction with other participants. Other
participants were hopeful that this course could be held
in-­person in the future.
4 | DISC USSION
The benefits of early integration of palliative care in the
management of children with life-­ threatening condi-
tions have been widely described, especially in children
with cancer.9–­12,37 However, significant barriers to early
 |

20457634, 2023, 3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/cam4.5213 by Cochrane Colombia, Wiley Online Library on [21/06/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
MCNEIL et al.    3665

(A) 100.00%
**
**
**

80.00% **
**
Percent of Respondents

60.00%

40.00%

20.00%

0.00%
Clarify the goals of Aid in family Spiritual support Communicate bad Communication Transitions to Reducing pain and Psychological
care decision-making news between the patient/ hospice or home at suffering support
family and medical end-of-life
team

Pre Post
(B)
90.0%

**
80.0%
**
**
70.0%

60.0%
Percent of Respondents

50.0%

40.0%

30.0%

20.0%

10.0%

0.0%
At the me of cancer At the me of cancer At the me of At the me of When there are no At the end of life Palliave care
diagnosis for all diagnosis for disease relapse or complex or high longer curave consultaon is never
paents paents at high-risk progression symptom burden therapeuc opons necessary in
of relapse or (pain, suffering) available pediatric cancer care
progression

Pre Post

F I G U R E 2 (A) Changes in Participation Perception of Palliative Care Role After EPEC Pediatrics Course: Results of pre-­and postcourse
assessments of participant descriptions of the role of palliative care for children with cancer. The precourse survey results are in blue
and the postcourse survey results are in orange. Statistically significant changes in responses occurred for those roles discussing goals of
care, communication, and decision-­making among others (p < 0.05). (B) Changes in Ideal Timing of Palliative Care After EPEC Pediatrics
Course: Ideal timing of initial palliative care consultation for participants in both the precourse survey and postcourse survey responses.
Respondents were instructed to choose all options that applied. The figure shows the percentage of physicians who indicated each option
and the statistically significant difference between the two groups. Comparing the earliest selected timing option (converted to a numeric
scale), physicians indicated that the ideal timing for an initial palliative care consultation for a child.
 |

20457634, 2023, 3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/cam4.5213 by Cochrane Colombia, Wiley Online Library on [21/06/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
3666    MCNEIL et al.

T A B L E 3 Percent confidence in patient care after participation

reported feeling less burdened by their work.28,29 Similarly,
in EPEC pediatrics course
course participants nearly unanimously reported improve-
Postcourse survey ment in their self-­perceived ability to control the suffering
I feel more confident in my knowledge of opioid prescription of children under their care, provide integrated palliative
and pain management for children with cancer care, and conduct difficult conversations. These findings
Disagree 1 (2.3) have important potential implications for addressing the
Neutral 3 (6.8) highly prevalent and urgent issue of burnout and com-
passion fatigue among clinicians caring for children with
Agree 40 (90.9)
cancer –­especially during the COVID19 pandemic as
I feel more confident in my ability to control the suffering of
healthcare professionals are strained by increasing work-
children at the end of life
load and uncertainty from the ongoing pandemic.40–­42
Disagree 0
Our successful experience may be used to guide future
Neutral 3 (6.8)
regional adaptation of the EPEC-­Pediatrics curriculum to
Agree 41 (93.2) improve clinician knowledge and engage collaboration in
I better understand possible solutions on how to provide better PPC globally.43,44 Additionally, this method can inform the
palliative care for children with cancer design and structure of future courses.21
Disagree 0 Due to the ongoing COVID-­19 pandemic, this course
Neutral 1 (2.3) was delivered virtually, including a novel bilingual asyn-
Agree 43 (97.7) chronous/synchronous format using an education plat-
I better understand how to hold difficult conversations with form (Cure4Kids). Several key features led to the success
patients and their families and participate in decision-­ of this course. First, the curriculum was based on data
making and planning for the end of life from recent research identifying regional knowledge
Disagree 0 gaps28 with additional input from regional experts who
Neutral 1 (2.3) understand the local context. In addition, expert regional
Agree 43 (97.7) bilingual facilitators allowed for contextually appropriate
delivery of course content. Second, the unique bilingual
The course provided me with new knowledge and skills that are
relevant to my clinical practice asynchronous/synchronous format allowed participants
to review course materials at their individual pace and
Disagree 0
simultaneous translation of live sessions allowed for real-­
Neutral 0
time discussion between English and Russian speakers.
Agree 44 (100.0)
This ensured a better understanding of course content and
The course provided me with knowledge and skills that will encouraged the participation of all individuals, regardless
CHANGE my clinical practice
of language skills, in the small-­group skill-­development
Disagree 0 activities. This bilingual format was successful in fostering
Neutral 1 (2.3) a rich learning environment as demonstrated by partici-
Agree 43 (97.7) pants highlighting the small group sessions and opportu-
In terms of your expectations, the course was nities to learn from each other in their course evaluation.
Below expectations 2 (4.5) While other virtual training in palliative care have been
Met expectations 16 (36.4) developed,45,46 our experience shows that this bilingual
format is feasible and effective among diverse and geo-
Above expectations 26 (59.1)
graphically separate participants. The virtual format is
also notably more cost-­effective, with decreased travel and
integration of PPC exist, especially in LMICs.16,18,38,39 The lodging needs.
current paper describes a successful approach to address This work has several limitations. Only 75.9% of en-
some of these barriers through the implementation of a rolled participants completed both pre-­and postcourse
novel bilingual virtual end-­user course. Following this assessments, preventing us from evaluating the knowl-
course, participants demonstrated improvement in un- edge acquisition of all participants. However, we wanted
derstanding of ideal timing of palliative care integration, to accurately assess the impact of the entire course, and
alignment with WHO guidance, use of multimodal anal- therefore, felt it appropriate to exclude those that did
gesia, and confidence in communication and self-­care. not complete all the course materials. Additionally, we
Earlier studies by our research team demonstrated physi- do not evaluate improvements in clinical outcomes but
cians with previous training in PPC felt more comfortable rather self-­perceived improvement in clinician knowl-
addressing the palliative care needs of their patients and edge and confidence/comfort. Due to the limitation in

MCNEIL et al.
capturing the clinical impact of improvement in knowl-
edge, this is a common strategy employed in educational
research.47,48 Furthermore, the findings represented
here relate to a single follow-­up timepoint. Additional
monitoring and educational sessions will be needed to
confirm the sustainability of identified improvements
over time. Nevertheless, our unique training experience
will be essential for building knowledge and expertise
related to pediatric palliative care globally and to inform
future educational initiatives.
The EPEC-­Pediatrics Eurasia course demonstrated that
regional adaptation of the EPEC-­Pediatrics curriculum to
a virtual asynchronous/synchronous platform delivered
bilingually with local facilitators is feasible and effective.
We plan to repeat this course annually with improvements
from participant feedback. This successful experience can
be leveraged to address learning gaps in PPC globally and
overcome challenges arising from physical distance, lan-
guage barriers, and the ongoing pandemic. Additionally,
this feasible and effective educational strategy can inform
the development of future curricula to improve provider
knowledge globally.
DISCLAIMER
This work including the preparation and facilitation of the
educational conference as well as the preparation of the
manuscript occurred prior to February 24, 2022.
AUTHOR CONTRIBUTIONS
MJM, BE, TY, AA, and JNB developed the idea. MJM,
BE, TY, AA, and JNB verified the data. MJM, BE, TY,
HW, RR, and MD did the data analysis. MJM drafted
the manuscript and prepared tables and figures. All the
authors contributed to the interpretation of findings,
editing of the article, and approved the final submitted
version. All the authors had full access to all study data
and accept responsibility for the decision to submit for
publication.
ACKNOWLEDGMENTS
We greatly appreciate the dedicated efforts of our Russian
interpreters for their assistance in delivering this course.
FUNDING INFORMATION
This project was supported by the American Lebanese
Syrian Associated Charities (ALSAC).
CONFLICT OF INTEREST
The authors declared that they have no conflict of interest.
DATA AVAILABILITY STATEMENT
Data are available upon reasonable request from the
authors.
|
20457634, 2023, 3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/cam4.5213 by Cochrane Colombia, Wiley Online Library on [21/06/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
   3667
ORCID
Michael J. McNeil https://orcid.
org/0000-0001-8817-1995
Huiqi Wang https://orcid.org/0000-0002-7599-7349
Volha Mishkova https://orcid.org/0000-0001-6566-3137
Narine Movsisyan https://orcid.
org/0000-0002-0258-9002
Ximena Garcia Quintero https://orcid.
org/0000-0003-1416-544X
Daniel Moreira https://orcid.org/0000-0003-4082-156X
Asya Agulnik https://orcid.org/0000-0001-8932-8181
REFERENCES
1. WHO Definition of Palliative Care/WHO Definition of Palliative
Care for Children. World Health Organization; 2002 http://
www.who.int/cance​r/palli​ative/​defin​ition/​en/. Accessed 21
July 2021.
2. World Health Organization. Integrating Palliative Care and
Symptom Relief into Paediatrics: A WHO Guide for Health Care
Planners. World Health Organization; 2018.
3. Resolution WHA67.19. Strengthening of Palliative Care as
a Component of Comprehensive Care Throughout the Life
Course. In Proceedings of the Sixty-­ seventh World Health
Assembly, Geneva, Switzerland, 19–­24 May 2014. World Health
Organization; 2014. http://apps.who.int/gb/ebwha/​pdf_files/​
WHA67/​A67_R19-­en.pdf Accessed 21 July 2021.
4. Knapp C, Woodworth L, Wright M, et al. Paediatric palliative
care provision around the world: A systematic review. Pediatr
Blood Cancer. 2011;57:361-­368.
5. Connor SR, Sepulveda Bermedo MC. Global Atlas of Palliative
Care at the end of Life. 2nd ed. Worldwide Palliative Care
Alliance; 2020.
6. Connor SR, Downing J, Marston J. Estimating the global need
for palliative care for children: A cross sectional analysis. J Pain
Symptom Manage. 2017;53(2):171-­177.
7. Knaul FM, Farmer PE, Krakauer EL, et al. Alleviating the ac-
cess abyss in palliative care and pain relief—­an imperative
of universal health coverage: the lancet commission report.
Lancet. 2018;391:1391-­1454.
8. Wolfe J, Grier HE, Klar N, et al. Symptoms and suffer-
ing at the end of life in children with cancer. N Engl J Med.
2000;342:326-­333.
9. Wolfe J, Hammel JF, Edwards KE, et al. Easing of suffering in
children with cancer at the end of life: Is care changing? J Clin
Oncol. 2008;26:1717-­1723.
10. Feudtner C, Kang TI, Hexem KR, et al. Pediatric palliative care
patients: A prospective multicenter cohort study. Pediatrics.
2011;127:1094-­1101.
11. Friedrichsdorf SJ, Postier A, Dreyfus J, Osenga K, Sencer S,
Wolfe J. Improved quality of life at end of life related to home-­
based palliative care in children with cancer. J Palliat Med.
2015;18:143-­150.
12. Rosenberg AR, Orellana L, Ullrich C, et al. Quality of life in
children with advanced cancer: A report from the PediQUEST
study. J Pain Symptom Manage. 2016;52:243-­253.
13. Groh G, Borasio GD, Nickolay C, Bender HU, von Luttichau I,
Fuhrer M. Specialized pediatric palliative home care: A pro-
spective evaluation. J Palliat Med. 2013;16:1588-­1594.
 |
3668   
14. Groh G, Vyhnalek B, Feddersen B, Fuhrer M, Borasio GD.
Effectiveness of a specialized outpatient palliative care ser-
vice as experienced by patients and caregivers. J Palliat Med.
2013;16:848-­856.
15. Vollenbroich R, Duroux A, Grasser M, Brandstatter M, Borasio
GD, Fuhrer M. Effectiveness of a pediatric palliative home care
team as experienced by parents and health care professionals.
J Palliat Med. 2012;15:294-­300.
16. Friedrichsdorf SJ. Contemporary pediatric palliative care:
Myths and barriers to integration into clinical care. Curr Pediatr
Rev. 2017;13:8-­12.
17. Szymczak JE, Schall T, Hill DL, et al. Pediatric oncology
Providers' perceptions of a palliative care service: The influ-
ence of emotional esteem and emotional labor. J Pain Symptom
Manage. 2018;55:1260-­1268.
18. Himelstein BP, Kane RJ. Appendix G: Education in pediatric
palliative care. In: Field MJ, Behrman RJ, eds. When Children
Die: Improving Palliative and End-­ of-­
Life Care for Children
and Their Families. Institute of Medicine (US) Committee on
Palliative and End-­of-­Life Care for Children and Their Families.
National Academies Press (US); 2003.
19. Friedrichsdorf SJ, Remke S, Hauser J, et al. Development of a
pediatric palliative care curriculum and dissemination model:
Education in palliative and end-­of-­life care (EPEC) pediatrics.
J Pain Symptom Manage. 2019;58(4):707-­720.e3.
20. Widger K, Friedrichsdorf S, Wolfe J, et al. Protocol: Evaluating
the impact of a nation-­wide train-­the-­trainer educational initia-
tive to enhance the quality of palliative care for children with
cancer. BMC Palliat Care. 2016 Jan;27(15):12.
21. Widger K, Wolfe J, Friedrichsdorf S, et al. National Impact of
the EPEC-­pediatrics enhanced train-­the-­trainer model for de-
livering education on pediatric palliative care. J Palliat Med.
2018;21(9):1249-­1256.
22. Postier AC, Wolfe J, Hauser J, et al. Education in palliative and
end-­of-­life care-­pediatrics: Curriculum use and dissemination.
J Pain Symptom Manage. 2022;63(3):349-­358.
23. Hauser JM, Preodor M, Roman E, Jarvis DM, Emanuel L. The
evolution and dissemination of the education in palliative and
end-­of-­life care program. J Palliat Med. 2015;18:765-­770.
24. University N. EPEC Core Curriculum 2018. Northwestern
University; 2021. http://bioet​hics.north​weste​rn.edu/progr​ams/
epec/curri​cula/index.html (Accessed 21 July 2021)
25. St. Jude Global Eurasian Regional Program. St. Jude Global; 2021.
https://www.stjude.org/globa​l/regio​ns.html#:~:text=The%20
Eur​asian​%20Reg​ional​%20Pro​gram%2C%20or,Oncol​ogist​s%20
(Mosco​w%2C%20Rus​sia). Accessed December 14, 2021.
26. Kogan S EY, Yakimkova T, Mishkova V, Sagoyan G, Ehrlich
B, Arakelyan T, Boranbaeva R, Borisevich M, Batmunkh T,
Delgertsetseg C, Ibragimova S, Ismail-­ zade R, Manzhuova
L, Mindruta-­ Stratan R, Proleskovskaya I, Raciborska A,
Rustamova K, Samaganova B, Tamamyan G, Umarova M, Ritter
J, Lam C, Agulnik A, Kirgizov K. Mapping of resources and pri-
orities for pediatric hematology/oncology in 11 Eurasian coun-
tries: Report from Eurasian Alliance in Pediatric Oncology.
International Society of Paediatric Oncology 52nd Congress
October, 2021.
27. Agulnik A MM, Yakimkova T, Ehrlich B, Mishkova V, Williams
K, Bezler Z, Kumirova E, Movsisyan N, Madni A, Chatman G,
Nunez P, Sonnenfelt J, Baizakova B, Borisevich M, Erimbetova
20457634, 2023, 3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/cam4.5213 by Cochrane Colombia, Wiley Online Library on [21/06/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
MCNEIL et al.
I, Golban R, Kirby B, Sakhar N, Volkova A, Baker JN. Regional
Adaptation of Education in Pediatric Palliative Care: EPEC-­P
Eurasia. International Society of Paediatric Oncology 52nd
Congress October, 2021.
28. Ehrlich BS, Movsisyan N, Batmunkh T, et al. A multicountry as-
sessment in Eurasia: Alignment of physician perspectives on pal-
liative care integration in pediatric oncology with World Health
Organization guidelines. Cancer. 2020;126(16):3777-­3787.
29. Ehrlich BS, Movsisyan N, Batmunkh T, et al. Assessing
Doctors' attitudes on palliative treatment (ADAPT) re-
search group. Barriers to the early integration of palliative
care in pediatric oncology in 11 Eurasian countries. Cancer.
2020;126(22):4984-­4993.
30. Cure4Kids. https://www.cure4​kids.org/. Accessed November
17, 2021.
31. Zoom Video Communications Inc. https://zoom.us/en-­us/
trust/​legal​-­compl​iance.html. Accessed December 4, 2021.
32. World Health Organization. Global Initiative for Childhood
Cancer. World Health Organization; 2020. https://www.who.
int/publi​ c atio​ n s/m/item/globa​ l -­i niti​ a tive​ - ­f or-­c hild​ h ood-­
cancer. Accessed December 14, 2021.
33. Salkind NJ. Encyclopedia of Research Design. Vol 1-­0. SAGE
Publications, Inc.; 2010.
34. Wild D, Grove A, Martin M, et al. Principles of good practice
for the translation and cultural adaptation process for patient-­
reported outcomes (PRO) measures: Report of the ISPOR task
force for translation and cultural adaptation. Value Health.
2005;8(2):94-­104.
35. Qualtrics [computer program]. Version 2019. Qualtrics; 2005.
36. SAS Institute Inc. SAS/STAT® 13.1 User's Guide. SAS Institute
Inc.; 2013.
37. Kaye EC, Weaver MS, DeWitt LH, et al. AAHPM research
committee. The impact of specialty palliative Care in Pediatric
Oncology: A systematic review. J Pain Symptom Manage. 2021
May;61(5):1060-­1079.e2.
38. Green SB, Markaki A. Interprofessional palliative care educa-
tion for pediatric oncology clinicians: An evidence-­based prac-
tice review. BMC Res Notes. 2018;11(1):797.
39. Brian JW. The need for increased access to pediatric hos-
pice and palliative care. Dimens Crit Care Nurs. 2011;30(5):​
231-­235.
40. Alharbi J, Jackson D, Usher K. The potential for COVID-­19 to
contribute to compassion fatigue in critical care nurses. J Clin
Nurs. 2020;29(15–­16):2762-­2764. doi:10.1111/jocn.15314 Epub
2020 May 18. PMID: 32344460; PMCID: PMC7267232.
41. Morgantini LA, Naha U, Wang H, et al. Factors contribut-
ing to healthcare professional burnout during the COVID-­19
pandemic: A rapid turnaround global survey. PLoS One.
2020;15(9):e0238217. doi:10.1371/journal.pone.0238217 PMID:
32881887; PMCID: PMC7470306.
42. Graetz D, Agulnik A, Ranadive R, et al. Global effect of the
COVID-­ 19 pandemic on paediatric cancer care: A cross-­
sectional study. Lancet Child Adolesc Health. 2021;5(5):332-­340.
43. Goodyear HM, Hatton S, Cuddeford L, Wallis M, Kruse S,
Blackwell N. Developing an e-­learning module in paediatric
palliative care. Arch Dis Child. 2011;96:A79-­A80.
44. Daniels A, Downing J. Increasing access to children's palliative
care education through e-­learning: a review of the ICPCN expe-
rience. Int J Palliat Nurs. 2018;24(7):351-­358.
 |

20457634, 2023, 3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/cam4.5213 by Cochrane Colombia, Wiley Online Library on [21/06/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
MCNEIL et al.    3669

45. Vallée A, Blacher J, Cariou A, Sorbets E. Blended learning com-

pared to traditional learning in medical education: Systematic
SUPPORTING INFORMATION
review and meta-­analysis. J Med Internet Res. 2020;22:e16504. Additional supporting information can be found online in
46. Mauco KL, Scott RE, Mars M. Validation of an e-­health read- the Supporting Information section at the end of this article.
iness assessment framework for developing countries. BMC
Health Serv Res. 2020;20:575.
47. Caniza MA, Homsi M, Gonzalez M, et al. Development, imple- How to cite this article: McNeil MJ, Ehrlich B,
mentation, and outcomes of a global infectious disease training
Yakimkova T, et al. Regional adaptation of the
course. J Med Educ Curric Dev. 2021;8:23821205211015290.
48. Moreira DC, Gajjar A, Patay Z, et al. Creation of a successful
education in palliative and end-­of-­life Care Pediatrics
multidisciplinary course in pediatric neuro-­ oncology with (EPEC-­Pediatrics) curriculum in Eurasia. Cancer
a systematic approach to curriculum development. Cancer. Med. 2023;12:3657-3669. doi: 10.1002/cam4.5213
2021;127(7):1126-­1133.