Anesthesia & Clinical Research
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Healthcare providers knowledge, attitude, practice and associated factors towards pain management at Debremarkos referral hospital, Gojjam, Northwest Ethiopia

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Introduction

Pain is one of the most common health problems worldwide, particularly in resource limited settings. The International Association for the Study of Pain defines pain as “an unpleasant sensory and emotional experience associated with or resembling that associated with actual or potential tissue damage. The available evidence shows that pain is undertreated nearly in 50%-80% of patients due to various reasons. Poor pain management leads to an increase in the length of hospital stay of patients and perioperative complications, patient dissatisfaction with medical care and affects the quality of life of patients. Perioperative pain management can be affected by the knowledge, attitude and practice level of healthcare providers towards pain management. An adequate level of knowledge, attitude and practices are the most important aspects for effective perioperative patient assessment, communication with the clients and pain management. However, the knowledge, attitude and practice of pain management of healthcare providers can be affected the availability of analgesic drugs, refreshment courses, locally applicable hospital pain management guidelines and pain assessment tools. Moreover, good pain management practice can be affected by the level of training, work experience and the type of professional specialty. Perioperative pain remains undertreated both in the developing and developed worlds despite several efforts to improve it. The current study was designed to assess the knowledge, attitude and practice level of healthcare providers towards pain management at the university referral and teaching hospital of Northwest Ethiopia [1].

Materials and Methods

Study design

A cross-sectional study was conducted by using standardized structured self-administered questionnaire.

Source population

All clinical healthcare workers who are currently working at Debre Markos Referral Hospital.

Study population

Clinical healthcare workers who were involving in pain management at Debremarkos referral hospital [2].

Inclusion criteria

All selected clinical healthcare workers who were working at Debremarkos referral hospital and available during the data collection period were included.

Exclusion criteria

Healthcare workers who were not directly involved in clinical practice, who were in annual leave; seriously ill and maternal leave during data collection period were excluded.

Sample size determination

All participants (n=346) who were directly involved in clinical practice on pain management at Debremarkos Referral Hospital (DMRH) were participated in this study. The study was conducted from February 12- March 30, 2019. Paper based survey was conducted. The questionnaire was given to the participants at the respective departments and enough time was provided to complete the survey. The participants were selected by census method [3]. Twenty participants were on annual leave, 10 participants were on training and 5 participants were on maternity leave (Figure 1).

Data collection procedure

Figure 1: Showing the allocation of healthcare workers who were included in the study among the healthcare workers at Debremarkos Referral Hospital, Amhara regional state, Ethiopia 2019.

Pre-tested self-administered English version structured questionnaire was used. To ensure the validity and reliability of the questionnaire, the questionnaire was pre-tested on 5% of healthcare workers who were working in one none elected nearby hospital (Lumamie hospital). Training was provided for data collectors and supervisors regarding the objectives of the study, data collection method and the significance of the study [4]. During data collection, data collectors were supervised for any difficulties and direction and necessary correction provided. Collected questionnaires were checked for completeness.

Study variables

Dependent: Knowledge, attitudes and practice level (adequate/ inadequate).

Independent

Socio demography: Age, marital status, professions, level of education (qualification), monthly income, years of working experience, years of unit experience.

Knowledge: Source of information about pain assessment, responsible professional to assess pain, analgesic drugs for patients with renal and hepatic problem, knowledge about multimodal analgesia, routes of drug administration, factors to consider before analgesia administration, non-pharmacological methods to manage pain, advice for non-pharmacological pain management, vital sign of patient.

Attitude: Pain assessment tool, training on pain assessment tool, availability of local pain management guideline, managing pain effectively, factors to consider before analgesia administration, pain management in PNR base, nonpharmacological pain management, balanced analgesia, pain is a problem [5].

Practice: Pain management experience, use of age specific pain assessment tool, frequency of pain assessment tool use, use of pharmacological pain management, type of analgesic drugs for pain management, use of non-pharmacological pain management, type of non-pharmacological pain management method used, preparation for adverse effect management before analgesia administration, frequency of analgesia provision,

Administration related variables: Inefficient/lack of pain assessment too in the hospital, workload, inefficient/lack of drug at store, lack of short term trainings on pain assessment and management and pain in-service education.

HCWs factors: The numbers of patients who had been seen per day, attending seminars/ short or long term trainings, communication with staff and patients.

Operational definitions

Scoring of knowledge, attitude and practice questions: Eleven questions, with “Yes” (for correct answers) or “No” (for incorrect answers) response and choice, was prepared to assess the knowledge of respondents about pain management and those respondents who scored greater than or equal to 75% were considered Knowledgeable, if below this inadequate knowledge. Nine item questions were used to assess the participants’ attitude towards pain management and those who scored 75% and above were considered as having favorable attitude. To assess the practice of respondents’ ten questions were prepared and those who scored more than or equal to 75% of the questions were considered as good practice, if below this score poor practice [6].

Data processing and analysis: All collected questionnaires were rechecked for completeness and coded. Then these data were entered and cleaned using Epic data software, and exported to SPSS version 20 for analysis. Bivariate and multivariate logistic regression analyses were performed to determine the association between dependent and independent variables. The variables having p-value less than 0.2 from the bivariate analysis was fitted in to the multivariate logistic regression model. Ninety five percent confidence interval with odd ratio was computed and the variables having p-value less than 0.05 from the multivariate logistic regression analysis was considered as determinant factors for pain management. Additionally, descriptive statistics such as frequencies and cross tabulation were performed [7]. The results were presented using graphical presentation such as bar charts and pie charts, and tables.

Ethical clearance: Ethical clearance letter was obtained from the Ethical Review Committee of School of Medicine, Debremarkos University. Ethical clearance letter was also obtained from Debremarkos referral hospital. Written informed consent was obtained from the study participants prior to study commencement.

Results

Socio-demographic characteristics of the study participants

Out of 381 healthcare workers (HCWs), 346 were included in the study with a response rate of 90.8%. Thirty five HCWs were absent during data collection due to different reasons. The majority of HCWs (n=223, 64.5%) were males. The age of 59.8% of HCWs was in the range of 20-30, 32.9% in the range of 31-40 and 7.2% in the range of > 41 years old respectively. Additionally, regarding the educational status, 298 (86.1%) of the respondents were first degree holders. Moreover, the majority of the study participants were nurses 194 (56.1%) and most of the participants (n=150, 43.4%) were from the inpatient ward. Two hundred fifty two (72.8%) had less than or equal to three years ‘service. Furthermore, out of the total respondents, 197 (58.6%) of the participants earn a monthly income of less than the mean value (6455.56 Birr). (Figure 2).

Figure 2: Types of profession of HCWs who were working at Debremarkos referral hospital, 2019.

Knowledge of healthcare workers towards pain management

The majority (n=185, 53.3%) of study participants had inadequate knowledge about pain management (Figure 3). Medical doctors (94.5%, n=69/73) were the most knowledgeable professionals followed by anesthetist (92.8%, n=13/14) and lastly pharmacist (21.4%, n=6/28). Regarding to the source of information about pain assessment tool, only 105 (39.5%) of the respondents heard about pain assessment tool from formal education (like regular class, including seminars). Only 159 (45.8%)) of the healthcare workers correctly answered knowledge questions regarding basic pharmacology, which were the major drug groups for pain management for the inpatients who have renal and hepatic problem and previous history of allergy to local anesthetics (Figure 3).

Figure 3: Knowledge status of HCWs who were working at Debremarkos referral hospital, 2019.

Factors associated with the knowledge level of healthcare workers

The factors that were significantly associated (P<0.05) with knowledge from the multivariate logistic regression analysis were medical doctor, anesthetist, attending any seminar/symposium / short term training on pain management, workload, availability of local guideline , media which talks about pain assessment and pain management [8]. Medical doctors were 31.38 times more likely knowledgeable than nurses (AOR=31.38, CI=10.8-90.9). Additionally, those who heard on media about pain assessment and pain management were 3.6 times knowledgeable than their counterparts (AOR=3.6, CI=1.1-11.5). Moreover, those HCWs who had seen less than thirty five patients per day were 2 times more knowledgeable than those who had seen more than or equal to thirty five patients per day (AOR=2.04, CI=1.20-3.50). Participants who attended seminar/symposium/short term training on pain management were 2.37 times more knowledgeable than their counterparts (AOR=2.37, CI=1.11-5.10) [9].

Attitude of healthcare workers towards pain management

The majority of the respondents (n=177, 51.3%) had unfavorable attitude towards pain management. Anesthetists followed by medical doctors had the most positive attitude towards pain management compared to other professionals [10]. Two hundred ninety six (85.3%) strongly agreed that pain is a priority problem, whereas two hundred eighteen (71.5%) respondents were strongly agree that pain management in PRN bases is important.

Only 44.1% of the participants strongly agreed that considering the age, organ function, intensity of pain and weight of the patient is important during pain management.

Factors associated with the attitude level of healthcare workers

The variables that showed association from the bivariate logistic regression analysis were: availability of local guideline on pain management in the hospital, attending seminar/symposium / short term training on pain management and attending long term training on pain management [11]. However, long term training had significant association with positive attitude from the multivariate logistic regression analysis. Those who were attended long term training had 7.6 times more favorable attitude than their counterparts (AOR=7.6, CI=3.3-17.4) (Table 1).

Table 1: Multivariate logistic regression analysis of attitude and associated factors of healthcare workers towards pain management at Debremarkos referral hospital, 2019.

Practice status of healthcare workers towards pain management

Among all the respondents, 268 (77.5%) of them had poor pain management practice and only 78 (22.5%) had good practice. Two hundred forty six (71.1%) of the respondents didn’t prepare for the management of adverse effects before analgesic drug administration [12]. Surprisingly, only 100 (28.9%) of the respondents were prepared for the management of adverse effects before analgesic drug administration. Additionally, 217 (62.7%) of the respondents didn’t assess the patients after drug administration. Only 129 (37.3%) of the respondents assessed the patients after analgesic drug administration. All anesthetists and emergency surgeons had the poorest practice on pain management [13].

Factors associated with the practice of healthcare workers

The multivariate logistic regression analysis results showed that the availability of pain assessment tool, workload (numbers of patients treated per day), and information about pain management on media were significantly associated with the practice of HCWs. Those who had access for pain assessment tool in the institution were 11 times more practical on pain management than their counterparts (AOR=11.02, CI=2.82-43.00). Additionally, those who had seen less than thirty five patients per day were 12.50 times more skillful than those who had seen more than or equal to thirty five patients per day (AOR=12.50,CI=5.52-28.31). Moreover, participants who heard on media about pain management were 11.66 times more practical than their counter parts (AOR=11.661, CI=2.86-47.62).

Discussion

This study showed that the knowledge level of the majority of healthcare providers towards pain management was substandard. Of the participants, 46.5% of healthcare providers in the current study had adequate knowledge. This was similar with a study conducted in Iran, where the percentage of HCWs with adequate knowledge in their study was 43.1%. Additionally, the current finding was relatively similar with a study conducted in Kenya, where the reported percentage of HCWs with adequate knowledge in their study was 43% [14]. On the other hand, our finding was higher than Jordan study, where the overall percentage of HCWs with adequate knowledge was 28.7%. The difference between the present and Jordan study could be due to the difference in training, practice and socio-cultural context.

In this study, only 159 (45.8%)) of the healthcare workers are correctly answered knowledge questions regarding basic pharmacology, which were the major drug groups for pain management for the patients who have renal and hepatic problem and had also previous history of allergy to local anesthetics. The current finding was low compared to a study conducted in public hospitals in Mekelle City, Northeast Ethiopia, where the majority of healthcare workers have adequate knowledge about the principles of pharmacological and non-pharmacological pain managements (58.6%). The difference could be due the difference in the training and clinical practice on pain management.

In our study, medical doctor were the most knowledgeable with a total score of 94.2%. However, this finding was higher than a study conducted done in Jordan, where the medical doctors’ knowledge score level was 36.1%. The discrepancy might be due the difference on the availability of refreshing courses and training on pain management and as well as the availability of drugs for pain management [15].

In the present study, those who took short and long term training on pain assessment and management in the institution were 3.2 times more knowledgeable than their counterparts. On the other hand, lack of training is one of the main barriers for effective pain management. It was reported in Ugandan hospital study that lack of education on assessment tools and lack of familiarity with tools were the main barriers for pain management. Similarly, another study in Southeast Ethiopia showed that the barriers for pain management were lack of training on assessment tools, lack of availability of assessment tools, lack of familiarity with tools, lack of protocols and guidelines on pain management.

In the current study, only 48.7% of the participants had adequate positive attitude towards pain management. Our finding was low compared the study conducted in Zimbabwe, where the attitude level of nurses was 56%. This discrepancy could be to the difference in pain management facilities such as availability of drugs, training and courses. The majority of participants (n=218, 71.5%) strongly agreed that pain management should be as PRN bases. However, this is contradictory to the WHO pain management guideline, where it recommends that pain should be managed in standing (fixed dose) rather than giving analgesia as PRN base. Those who attended long term training had 7.6 times more favorable attitude towards pain management than their counterparts. It clear that refreshing courses and trainings are very vital to maintain positive attitude towards pain management [16].

In the current study, the majority of respondents, (n=268, 77.5%) had poor pain management practice. This finding was in line with the study conducted in Iran, where the practice of healthcare provider about pain management was insufficient. In the present study, 246 (71.1%) of the respondents didn’t prepare for the management of adverse effects before analgesic drug administration. Only 100 (28.9%) of the respondents were prepared for the management of adverse effects before analgesic drug administration. This could lead to an increase medication related adverse effects and poor treatment outcome.

In this study, those who had access to pain assessment tool in the institution were 14 times more practical on pain management than their counterparts. This implies that the lack or minimal use of tools among the HCWs at Debremarkos referral hospital could contribute to poor pain assessment and management practice. This finding was supported by a study conducted at Mulago hospital, Uganda, where the majority of the healthcare worker reported that lack of education on assessment tools and lack of familiarity with tools were the main barriers for pain management. A large numbers of participants (n=217, 62.7%) respondents didn’t assess the patient after the administration of analgesic drugs. Surprisingly, a small numbers of the respondents (37.3%) assessed the patient after pain medication administration. Lack of patient monitoring after drug administration can lead to an increase in medication related patient morbidity and patient dissatisfaction with the medical service.

In the current study, the availability of pain assessment tool and workload had strong association with pain management practice (P<0.001). With regard to workload, those who had seen <35 patients per day were 11.8 times more skillful or practical on pain management than those who had seen ≥ 35 patients per day. This shows that heavy workload limits the time given to the interaction between patients and professionals for adequate pain assessment and management. This finding was in accordance with the study conducted in Uganda, where pain assessment and management was affected negatively by heavy workload on the clinicians.

Conclusion

The majority of healthcare providers had a significant deficit on knowledge, attitude and practice of healthcare providers towards pain management. Profession (medical doctor and anesthetist), short term training, workload and the availability of local pain management guideline were associated with knowledge. Long term training was the only factor which was associated with positive attitude. Moreover, the availability of pain assessment tool and workload were associated with pain management practice. It is recommended that refreshing courses, seminars and short or long term training on pain assessment and management should be given to the HCWs. Moreover, training on the pharmacology of analgesic drugs, and patient evaluation or monitoring before and after analgesic drug administration, and as well as the management of adverse effects should be provided. Furthermore, locally applicable pain assessment tool and pain management guidelines should be developed at Debremarkos referral hospital.