Cultural Competence and Palliative Care Quality: An Assessment of Social Work Counsellors in Port Harcourt, Nigeria

Cultural competence is therefore increasingly recognized as an important dimension of quality healthcare delivery. It refers broadly to the capacity of professionals and organizations to understand, respect, communicate effectively with, and respond appropriately to the cultural beliefs, values, practices, and needs of individuals from diverse backgrounds. In healthcare practice, cultural competence involves more than knowledge of cultural traditions; it includes cultural awareness, cultural knowledge, cultural skills, cultural encounters, and cultural desire. These dimensions enable practitioners to avoid cultural assumptions and stereotypes while developing care interventions that are responsive to the individual circumstances of patients and their families. In palliative care, cultural competence is especially relevant because decisions concerning disclosure of illness, pain management, family authority, spiritual practices, advance care planning, and end-of-life decisions may differ substantially across cultural groups.

The role of social work counsellors in palliative care is particularly significant because palliative care involves complex psychosocial, emotional, family, and social challenges that extend beyond clinical treatment. Social work professionals assist patients and families in coping with the emotional consequences of serious illness, facilitate communication among family members and healthcare professionals, provide counselling, advocate for patient rights, connect families with social and financial resources, and support individuals through bereavement and end-of-life transitions. A recent systematic review of palliative social work competencies identified ethics, coordination, assessment, resource allocation, and education as core competencies required by social workers. The review further emphasized the role of social workers as interdisciplinary coordinators, communication facilitators, educators, and advocates who address psychosocial and environmental challenges within complex care systems (Zhang et al., 2025).

The importance of cultural competence becomes even more pronounced in multicultural societies such as Nigeria. Nigeria is characterized by considerable ethnic, linguistic, religious, and cultural diversity, with different communities maintaining distinct beliefs and practices concerning health, illness, suffering, death, dying, and bereavement. Within this context, palliative care providers may encounter patients and families whose cultural beliefs influence their willingness to accept palliative care, communicate openly about terminal illness, use opioid analgesics, involve family members in decision-making, or engage in discussions about death and dying. The WHO identifies cultural and social beliefs about death and dying, limited public awareness, and misconceptions about palliative care as important barriers to the development and utilization of palliative care services.

The Nigerian palliative care environment has also been characterized by challenges related to inadequate awareness, limited specialist services, financial constraints, workforce shortages, and institutional barriers. A study examining organizational culture surrounding palliative care in Nigeria found that cross-departmental collaboration, financial support, and continuity of care were important factors influencing the provision and utilization of palliative care. The study suggested that improvements in referral practices, telemedicine, and welfare support systems could contribute to strengthening palliative care delivery in Nigeria (Agom et al., 2020). These challenges demonstrate that the quality of palliative care depends not only on the clinical competencies of healthcare providers but also on the ability of professionals to navigate social, cultural, institutional, and economic barriers affecting patients and their families.

Recent evidence further underscores the need to strengthen palliative care competencies among healthcare professionals in Nigeria. A 2026 mixed-methods assessment of healthcare professionals' palliative care knowledge and attitudes in Nigeria highlighted continuing gaps in palliative care knowledge and attitudes among healthcare providers. This evidence suggests that strengthening professional education and competencies is essential for improving the availability and quality of palliative care services in the Nigerian healthcare system. Port Harcourt provides an important context for examining cultural competence and palliative care quality. As a major urban centre in Rivers State and a culturally diverse city with substantial healthcare activity, Port Harcourt serves patients from different ethnic, religious, linguistic, and socioeconomic backgrounds. Social work counsellors working within hospitals, hospices, specialist healthcare facilities, and community-based services may therefore encounter patients whose cultural beliefs and family structures influence their experiences of serious illness and end-of-life care. For example, cultural expectations regarding family authority, disclosure of terminal diagnoses, traditional healing practices, religious interpretations of suffering, and decision-making at the end of life may affect the delivery and reception of palliative care. Social work counsellors who possess strong cultural competence may be better positioned to identify these factors, facilitate culturally appropriate communication, mediate conflicts between patients, families, and healthcare teams, and support care plans that respect patients' values while maintaining professional and ethical standards.

The relationship between cultural competence and palliative care quality is therefore an important area of investigation. While culturally responsive practice may enhance communication, trust, patient satisfaction, family participation, adherence to care plans, and emotional support, inadequate cultural competence may contribute to misunderstanding, mistrust, communication breakdown, delayed referrals, conflicts over treatment decisions, and dissatisfaction with care. In palliative care, where communication and psychosocial support are central to the patient's experience, the ability of social work counsellors to understand and navigate cultural differences may have direct implications for the quality of services provided. Despite the growing recognition of cultural competence in healthcare, there remains a need for more empirical research examining its relationship with palliative care quality in Nigeria, particularly from the perspective of social work professionals. Existing Nigerian studies have examined broader challenges affecting palliative care provision and utilization, while international literature has increasingly explored the competencies required of palliative social workers. However, limited attention has been given specifically to how cultural competence among social work counsellors influences the quality of palliative care within the Nigerian urban healthcare context. This gap is particularly relevant in culturally diverse settings such as Port Harcourt, where social workers interact with patients and families from varied cultural backgrounds.

It is against this background that this study examines cultural competence and palliative care quality: An Assessment of Social Work Counsellors in Port Harcourt. The study seeks to contribute to the growing body of knowledge on culturally responsive palliative care by examining the extent to which social work counsellors' cultural awareness, cultural knowledge, cultural skills, cultural encounters, and cultural sensitivity relate to the quality of palliative care services. The findings are expected to provide useful evidence for social work education, professional training, healthcare policy, and the development of culturally responsive palliative care practices in Port Harcourt and Nigeria more broadly.

Literature Review

Cultural Competence and Quality of Palliative Care

Empirical research has increasingly established that cultural competence is an important component of quality palliative care because patients and families interpret illness, suffering, death, dying, pain, and bereavement through culturally influenced beliefs and values. The evidence suggests that culturally responsive care may improve communication, trust, patient and family engagement, satisfaction, and the overall experience of care. However, empirical evidence specifically examining cultural competence among social work counsellors in palliative care remains relatively limited, particularly in Nigeria. The available studies therefore provide indirect and contextual evidence that supports the need for the present investigation.

Agom et al. (2020) explored the organizational culture surrounding the provision and utilization of palliative care in Nigeria using an interpretive descriptive qualitative design. The study examined the experiences and perceptions of healthcare professionals and other stakeholders involved in palliative care delivery. Findings revealed that palliative care provision was affected by inadequate resources, limited funding, weak coordination, and insufficient awareness. The study also highlighted the importance of culturally sensitive approaches in improving patients' and families' acceptance and utilization of palliative services. The authors emphasized the need for collaboration, education, and contextually appropriate models of care. The study is relevant to the present research because it demonstrates that the organizational and cultural context in which palliative care is delivered can influence service quality. However, its focus was on organizational culture and palliative care systems rather than specifically measuring the cultural competence of social work counsellors.

Knowledge and Perception of Healthcare Providers towards Palliative Care in Rivers State

A cross-sectional study conducted among healthcare providers in Rivers State examined their knowledge and perceptions of palliative care. The study involved 114 participants, including doctors, nurses, pharmacists, social workers, and students, and used a structured self-administered questionnaire. The findings indicated varying levels of awareness and knowledge of palliative care among healthcare providers and highlighted the importance of professional education in improving palliative care delivery. The inclusion of social workers in the study is particularly relevant to the present investigation because it demonstrates that social work professionals are part of the multidisciplinary palliative care workforce in Rivers State. However, the study primarily examined knowledge and perception of palliative care rather than cultural competence or the relationship between cultural competence and care quality.

Agom et al. (2022) investigated the challenges of palliative care in Nigeria from the perspectives of healthcare professionals. The researchers used a qualitative approach involving healthcare professionals who had participated in palliative care training. Findings revealed that healthcare professionals faced several challenges, including inadequate resources, limited palliative care training, insufficient institutional support, and difficulties associated with communicating with patients and families about end-of-life issues. The study further demonstrated that cultural beliefs and patient receptivity can influence the delivery of palliative care. The findings suggest that professional competence should include not only technical knowledge but also the ability to communicate effectively and sensitively with patients and families whose cultural beliefs may differ from those of healthcare professionals. The study is relevant to the present research because social work counsellors frequently serve as communication facilitators and advocates between patients, families, and healthcare teams.

Yao et al. (2025) conducted a systematic review to identify the core competencies required by social workers providing palliative care. The review examined 19 high-quality studies published in English and Chinese and identified five major competency domains: Ethics, Coordination, Assessment, Resource Allocation, and Education (E-CARE). The findings emphasized that palliative social workers perform complex roles that require them to assess psychosocial needs, coordinate multidisciplinary services, allocate resources, educate patients and families, and address ethical issues. Although cultural competence was not treated as an independent outcome variable, the competencies identified in the review have important cultural dimensions because effective assessment, communication, education, coordination, and ethical practice require sensitivity to patients' cultural values and family structures. The study provides strong conceptual and empirical support for examining cultural competence among social work counsellors as a potential determinant of palliative care quality. However, because the study was a systematic review rather than an empirical investigation conducted in Nigeria, its findings may not fully reflect the cultural and institutional realities of palliative care practice in Port Harcourt.

Folorunso et al. (2026) conducted a mixed-methods assessment of palliative care knowledge and attitudes among healthcare professionals in Nigeria. The quantitative component involved 117 healthcare professionals from 26 hospitals across five geopolitical zones, while qualitative focus group discussions were used to explore professional experiences and challenges. The study found that although healthcare professionals generally understood the broad goals of palliative care, significant gaps remained in practical knowledge and professional preparedness. More than half of participants had received some form of palliative care training, while many expressed the need for additional training in pain management, end-of-life communication, ethics, and decision-making. Participants also identified patient and caregiver receptivity, opioid stigma, and systemic barriers as important challenges affecting palliative care delivery. The study concluded that improved professional training, communication skills, community education, and contextually appropriate protocols are necessary for strengthening palliative care in Nigeria. The findings are particularly relevant to the present study because cultural competence may influence how social work counsellors communicate about death and dying, negotiate family expectations, and respond to culturally shaped beliefs about serious illness.

The State of Palliative Care in Nigeria: Scoping Review (2026)

A recent scoping review of palliative care in Nigeria examined 59 studies selected from more than 6,000 identified records. The review found that most Nigerian research has focused on knowledge, attitudes, and practices related to palliative care, while relatively few studies have evaluated actual implementation, intervention effectiveness, or quality improvement. The review also reported generally low awareness of palliative care among patients and caregivers, although stakeholders expressed interest in expanded education, improved infrastructure, and culturally appropriate models of service delivery. Importantly, the review identified cultural norms as influential in end-of-life communication and highlighted inadequate education, delayed referrals, limited opioid availability, weak policy support, and insufficient professional validation as continuing barriers to high-quality palliative care. These findings strongly support the relevance of cultural competence as an area of investigation because culturally appropriate delivery was identified as an important element in improving palliative care acceptance and quality in Nigeria. However, the review did not specifically assess cultural competence among social work counsellors or examine its statistical relationship with palliative care quality.

International Evidence on Cultural Competence and Palliative Care

International empirical literature has similarly emphasized the importance of culturally responsive palliative care. Studies conducted across multicultural healthcare environments have demonstrated that patients and families may differ significantly in their expectations concerning disclosure of terminal diagnoses, family involvement in decision-making, spiritual practices, pain expression, use of analgesics, and preferred place of care. These differences create a need for professionals to possess cultural awareness, knowledge, communication skills, and the ability to negotiate culturally sensitive care plans. Cultural competence therefore contributes to person-centred care by allowing practitioners to identify culturally specific needs and avoid assumptions that may negatively affect patient-provider relationships.

Within palliative social work specifically, the systematic review by Yao et al. (2025) provides evidence that social workers require broad competencies extending beyond conventional counselling. The emphasis on assessment, coordination, ethics, education, and resource allocation demonstrates that social workers operate at the intersection of patients, families, healthcare professionals, and social institutions. In culturally diverse settings, these responsibilities necessarily require sensitivity to cultural differences and the ability to integrate cultural considerations into psychosocial assessments and care planning.

Synthesis of Empirical Evidence

The empirical evidence reviewed demonstrates a consistent relationship between professional competence, culturally responsive practice, and the quality of palliative care. Nigerian studies indicate that palliative care delivery is constrained by limited knowledge, inadequate professional training, weak institutional support, resource shortages, and cultural barriers. Evidence from Rivers State further confirms the need to improve healthcare professionals' understanding and perceptions of palliative care. More recent Nigerian evidence indicates that healthcare professionals require additional training in communication, pain management, ethical decision-making, and end-of-life care.

The literature also reveals that the quality of palliative care is multidimensional. It involves not only clinical effectiveness but also communication, emotional support, psychosocial care, respect for individual preferences, family engagement, ethical decision-making, coordination of services, and culturally appropriate care. Social work counsellors occupy an important position in this process because they frequently address the social and psychological dimensions of serious illness and facilitate communication between patients, families, and multidisciplinary healthcare teams.

However, a significant research gap remains. Much of the Nigerian literature focuses on general palliative care knowledge, attitudes, organizational barriers, and healthcare professional experiences. Few studies have directly examined cultural competence as a measurable predictor or correlate of palliative care quality, and there is particularly limited empirical evidence focusing specifically on social work counsellors. Furthermore, little research has examined this relationship within Port Harcourt, a culturally diverse urban environment in which social work professionals may encounter patients from different ethnic, religious, linguistic, and socioeconomic backgrounds.

Therefore, the present study, "Cultural Competence and Palliative Care Quality: An Assessment of Social Work Counsellors in Port Harcourt," seeks to fill this gap by empirically examining whether and to what extent cultural awareness, cultural knowledge, cultural skills, cultural encounters, and cultural sensitivity among social work counsellors are associated with the quality of palliative care they provide. The study is expected to contribute context-specific evidence that can support social work education, professional development, culturally responsive practice, and the improvement of palliative care services in Port Harcourt and Nigeria more broadly.

Methodology

Research Design

This study adopted a correlational research design to examine cultural competence as correlate on the quality of palliative care among social work counsellors in Port Harcourt. Correlational research design is appropriate because it enables the researcher to collect data from respondents at a single point in time and assess the relationship between psychological characteristics and professional outcomes within a defined population (Creswell & Creswell, 2023). The design is particularly suitable for investigating the relationships between variables, such as cultural competence (independent variable) and quality of palliative care delivery (dependent variable), without manipulating the study variables (Saunders et al., 2019). The study employed a quantitative research approach because it allows for objective measurement of cultural competence and palliative care quality using standardized instruments and statistical analysis techniques (Sekaran & Bougie, 2020). The quantitative approach will enable the researcher to determine the extent to which cultural competence predicts variations in the quality of palliative care provided by social work counsellors in healthcare institutions within Port Harcourt.

Study Area

The study was conducted in Port Harcourt, Rivers State, Nigeria. Port Harcourt is the capital city of Rivers State and one of the major healthcare and administrative centres in the Niger Delta region of Nigeria. The city hosts several tertiary and secondary healthcare institutions that provide specialized medical services, including oncology care, chronic disease management, and palliative care services for patients with life-limiting illnesses (Federal Ministry of Health, 2021).

Healthcare facilities within Port Harcourt provide care for patients experiencing conditions such as cancer, cardiovascular diseases, renal failure, HIV/AIDS, and other chronic illnesses requiring comprehensive palliative support (World Health Organization [WHO], 2020). The increasing burden of chronic and terminal illnesses in Nigeria has created greater demand for multidisciplinary palliative care teams, including social work counsellors who provide psychosocial interventions, emotional support, and family counselling (Connor & Bermedo, 2020). The setting is therefore considered appropriate for examining how cultural competence influences the quality of palliative care practice among social work professionals.

Population of the Study

The population of the study comprises social work counsellors providing psychosocial and supportive services within healthcare institutions offering palliative care services in Port Harcourt, Rivers State. The target population includes professional social workers involved in patient counselling, psychosocial assessment, grief support, family intervention, discharge planning, and coordination of palliative care services. Social work counsellors are selected as the study population because they experience substantial emotional demands arising from continuous interactions with patients facing life-threatening illnesses, death, bereavement, and complex family challenges (National Association of Social Workers [NASW], 2020). Their professional responsibilities require cultural competence to maintain effective therapeutic relationships and deliver patient-centered care (Brown et al., 2023).

Sample Size Determination

The sample size of 127 was determined using an appropriate statistical formula for estimating sample size in a correlational study. Where the population size is known, the Taro Yamane (1967) formula will be applied:

Where:

•              n = required sample size

•              N = total population size

•              e = level of precision (0.05)

The formula ensures that the sample selected is statistically adequate and representative of the study population while minimizing sampling error (Yamane, 1967). An additional percentage was added to the calculated sample size to compensate for possible non-response or incomplete questionnaire returns (Sekaran & Bougie, 2020).

Sampling Technique

A purposive sampling technique was employed to select participants who meet the inclusion criteria for the study. Purposive sampling is appropriate because the study requires respondents with specific professional experiences related to palliative care practice and psychosocial counselling (Creswell & Creswell, 2023).

Participants was selected based on the following inclusion criteria:

   i     Registered social work professionals or counsellors working in healthcare settings.

 ii     Professionals with direct involvement in palliative care or end-of-life support.

 iii     Individuals with at least six months of professional experience in healthcare counselling.

 iv     Participants willing to provide informed consent.

Social work professionals who are not directly involved in patient counselling or palliative care activities was excluded from the study.

Instruments for Data Collection

Data was collected using a structured questionnaire consisting of three sections:

Section A: Demographic Information

This section will collect information on participants' demographic characteristics, including: age, gender, educational qualification, years of professional experience, type of healthcare facility and professional designation

Section B: Cultural Competence Scale (CCS)

Cultural Competence was measured using the CCS. The questionnaire was designed to measure the influence of cultural competence on social work counselors, particularly in the context of palliative care and its perceived impact on practice. Responses will be collected using a four-point likert scale. The scale consists of 10 items assessing cultural sensitivity, competence and its impact on social work counsellors’ practice. It is rated on a four-point Likert scale ranging from:

1 = Very Low Extent, 2 = Low Extent, 3 = High Extent, 4 = Very High Extent

Scores expected from this section ranges from 1-40, with lower scores indicating low level cultural competence, and higher scores indicating high level cultural competence. Specifically, scores from 0-10 indicate low not culturally competent, scores from 11-20 indicate small level cultural competence, scores from 21-30 indicate moderate cultural competence and scores from 31-40 indicate high level cultural competence.

Section C: Quality of Palliative Care Measurement

Quality of palliative care will be assessed using a validated palliative care quality assessment instrument focusing on domains such as:

•              Patient-centred care

•              Communication effectiveness

•              Psychosocial support

•              Family involvement

•              Continuity of care

•              Professional responsiveness

The instrument will assess the extent to which social work counsellors provide effective and compassionate palliative care services.

Validity of the Instrument

The validity of the research instrument was established through expert review and content validation. The questionnaire was examined by experts in social work, psychology, healthcare management, and palliative care to ensure that the items adequately measure cultural competence and quality of palliative care delivery (Polit & Beck, 2021). Content validity involved assessing the relevance, clarity, adequacy, and appropriateness of questionnaire items in relation to the study objectives. Feedback obtained from experts guided the modification and refinement of the instrument before final administration.

Reliability of the Instrument

The reliability of the instrument was determined through a pilot study conducted among social work professionals outside the study area but with similar characteristics to the target population. Internal consistency reliability was assessed using Cronbach's alpha coefficient.

A Cronbach's alpha value of 0.70 or above was considered acceptable, indicating adequate reliability of the instrument (Pallant, 2020). The reliability analysis confirmed whether the questionnaire items consistently measures cultural competence and quality of palliative care.

Method of Data Collection

Data collection involved direct administration of structured questionnaires to eligible social work counsellors in selected healthcare institutions in Port Harcourt. Before data collection, permission was obtained from relevant healthcare authorities, and participants was informed about the purpose, procedures, and voluntary nature of participation. Participants was assured of confidentiality and anonymity, and informed consent was obtained before questionnaire administration. Completed questionnaires were retrieved immediately and within an agreed period to improve response rates.

Method of Data Analysis

Data collected was coded and analyzed using the Statistical Package for Social Sciences (SPSS) software. Research Questions were answered using simple linear regression and Hypotheses was tested using Analysis of Variance.

 Results and Discussion

Table 1 revealed the simple Regression Analysis of the relationship between cultural competence and the quality of palliative care of social works counsellors in Port Harcourt. The research aimed to explore how cultural competence relates to the quality of palliative care provided by social work counsellors in Port Harcourt. To analyze this relationship, a simple regression analysis was conducted, revealing a weak connection between cultural competence and the quality of palliative care. The correlation coefficient (R) between cultural competence and the quality of palliative care is .024, indicating a very weak positive relationship. This means that although cultural competence may contribute to the quality of palliative care, its impact is minimal. The R Square value, which stands at .001, demonstrates that cultural competence explains only 0.1% of the variance in the quality of palliative care. This suggests that cultural competence has an almost negligible influence on improving care outcomes in this context. The adjusted R Square, at .009, further confirms that even after accounting for adjustments to the model, cultural competence remains an insignificant factor.

Table 1: Outcome of the Simple Regression Analysis

Table 4.2 sought to determine if cultural competence has a significant impact on the quality of palliative care provided by social work counsellors in Port Harcourt. The regression analysis revealed that the unstandardized coefficient for cultural competence was 0.023, which indicates a very minor potential increase in the quality of palliative care per unit increase in cultural competence. The standardized coefficient (Beta) of 0.024 further underscores the minimal impact. The t-statistic of 0.243 and the p-value of 0.808 both suggest that this coefficient is not significant as p>0.05, leading to the conclusion that cultural competence does not significantly relate to the quality of palliative care provided by social work counsellors in Port Harcourt.