Date Published: March 14, 2019
Publisher: Public Library of Science
Author(s): Million Tesfaye Eshete, Petra I. Baeumler, Matthias Siebeck, Markos Tesfaye, Dereje Wonde, Abraham Haileamlak, Girma G. Michael, Yemane Ayele, Dominik Irnich, Alexandra Sawyer.
Postoperative pain remains a challenge in the developed world, but the consequences of inadequately treated postoperative pain are particularly severe in low- and middle-income countries. Since 2011, reports have drawn attention to the poor quality of postoperative pain management in Ethiopia; however, our multicenter qualitative study was the first to attempt to understand the factors that are barriers to and facilitators of quality pain managment in the country. To this aim, the study explored the perspectives of patients, healthcare professionals, and hospital officials. We expected that the results of this study would inform strategies to improve the provision of quality pain management in Ethiopia and perhaps even in other low- and middle-income countries.
This study used a qualitative, descriptive approach in which nine healthcare professionals, nine patients, and six hospital officials (i.e. executives in a managerial or leadership position in administration, nursing, or education) participated in face-to-face, semi-structured interviews. Thematic data analysis was conducted, and patterns were explained with the help of a theoretical framework.
The barriers identified ranged from healthcare professionals’ lack of empathy to a positive social appraisal of patients’ ability to cope with pain. They also included a lack of emphasis on pain and its management during early medical education, together with the absence of available resources. Enhancing the ability of healthcare professionals to create favorable rapport with patients and increasing the cultural competence of professionals are essential ingredients of future pain education interventions.
Barriers to and facilitators of postoperative pain management do not exist independently but are reciprocally linked. This finding calls for holistic and inclusive interventions targeting healthcare professionals, patients, and hospital officials. The current situation is unlikely to improve if only healthcare professionals are educated about pain physiology, pharmacology, and management. Patients should also be educated, and the hospital environment should be modified to provide high-quality postoperative pain management.
The number of patients undergoing surgery is rising worldwide . However, pain treatment after surgical procedures remains unsatisfactory , and up to 40% of patients experience severe pain after surgery . Estimates of the proportion of patients who develop persistent postoperative pain vary from 5% up to 85% . Globally, about 22% of chronic pain is related to previous surgery, but this rate can be reduced by adequate postoperative pain management . Untreated postoperative pain has also been linked to extended hospital stays, atelectasis, respiratory infection, myocardial infarction [6,7], and even death . In the developed world, awareness of the impact of postoperative pain has grown, but endeavors to improve its management remain challenging . Patients in low- and middle-income countries (LMIC) are at greater risk of the severe consequences of untreated postoperative pain [7,9]. This is partly because pain management is not a priority in low-resource settings, where the health care systems are focused on achieving the United Nations Millennium Development Goals, such as eradicating poverty and reducing maternal and child death . Other reasons why health policy in LMIC pays little or no attention to postoperative pain management, despite its importance for the prevention of disability, remain unclear. To improve the care of surgical patients in LMIC, we have to explore barriers to and facilitators of quality pain management (QPM). Although it is difficult to define and measure the quality of pain management, QPM is defined as a characteristic that encompasses the structure, process, and outcomes of care . It has specific characteristics, including appropriate ongoing assessment (both before and after the administration of analgesics) and multidisciplinary, safe, efficacious, cost-effective, and culturally and developmentally appropriate care . Furthermore, experts around the world currently recommend the use of multimodal regimens in many situations, although the exact ingredients can vary, depending on the patient, setting, and surgical procedure .
The aim of this study was to explore the perspectives of post-surgical patients, HCPs, and hospital officials on the barriers to and facilitators of the effective delivery of QPM services. To our knowledge, this is the first multicenter study to qualitatively evaluate issues related to postoperative QPM in Ethiopia. This report provides unique information by incorporating the views of patients, HCPs, and hospital officials. Findings from such a variety of perspectives can inform the design and implementation of strategies to improve the delivery of QPM services to surgical patients. This is especially important in LMIC, where access to adequate treatment has been reported to be limited .
Our results might not be generalizable to all surgical patients in all parts of Ethiopia because we included only patients undergoing elective general, gynecologic, or orthopedic surgery. Furthermore, this was not a quantitative study, i.e. there were no specific power calculations or assessments of statistical significance or effect size. Cultural, religious, and contextual differences in multi-ethnic countries such as Ethiopia could influence the results. Moreover, the validity might have been compromised because the interview transcripts were not shown to the participants. Although we used the reciprocal determinism theory to explain the reciprocal influence of the environment and personal factors on the HCPs’ practice of pain management, we did not specifically examine the individual constructs of SCT and did not measure the HCPs’ performance. The fact that the patient interviews were short (mean duration: 15 minutes) potentially limits the richness of the data and depth of the analysis. All patients preferred the bedside for the interview and the presence of other patients in the wards might have affected their response. However, patients were very comfortable throughout the interview and which might neutralize the possible bias. By using purposive and maximum variation sampling to include a diverse group of participants, however, we may have counteracted this limitation, as indicated by the fact that our findings are in line with previous reports [45,47]. Nevertheless, we cannot guarantee that by using these sampling techniques we included a wide enough variety of people to obtain information on all relevant barriers to and facilitators of QPM, i.e. to reach data saturation. Despite these limitations, to our knowledge the qualitative work presented here was the first multi-center study to obtain perspectives on pain management in Ethiopia from various groups. To date, only a few qualitative studies have used reciprocal determinism to explain barriers to and facilitators of QPM in the surgical patients.
This study illustrates the barriers to and facilitators of postoperative pain management from the perspective of Ethiopian patients, HCPs, and hospital officials. The findings provide probably the first qualitative insight into the factors that affect the management of postoperative pain in Ethiopia. Participants in this study believed that QPM is difficult under the current conditions, as a result of the above-mentioned barriers. From the perspective of the reciprocal determinism theory, the HCPs’ current poor provision of QPM is in part related to the HCPs themselves, i.e. to personal factors that are a result of poor training during their medical education and while working. In addition, patients’ attitudes and the lack of political will to make changes to the health care system (i.e. failure to make resources available and establish guidelines and lack of leaders’ insight that pain management is a priority compared with other “diseases”) have contributed to creating an environment in which HCPs continue to practice the way they have been practicing in the past. These findings call for holistic and inclusive interventions that target HCPs, patients, and hospital officials. The current situation is unlikely to improve if interventions educate only HCPs about pain physiology, pharmacology, and management and do not include the other stakeholders. To achieve high-quality postoperative pain management, we also have to educate patients and modify the environment.