Introduction: Chronic pain is a major source of suffering and is a leading reason for many patients to consult health care personnel. It interferes with, and disrupts, activities of daily living and may be accompanied by distress. Irrespective of its etiology or classification, health care professionals require a good understanding of chronic pain in order to provide appropriate treatment and care.

Methods: A cross-sectional study was conducted involving a sample of 80 participants obtained by using a convenience sampling method. Data were obtained by completing a questionnaire entitled “Knowledge and attitude survey towards pain” and analyzed by using descriptive statistics, chi-square, Pearson correlation coefficient and cross tabulation using SPSS.

Results:  Overall knowledge was inadequate. More than two thirds of participants obtained a score below 50%. There was also negative attitude, almost 51% of the participants have negative attitude to pain management. Higher level of knowledge was associated with medical profession, highest of qualification and training on pain management.

Conclusion: The knowledge and attitudes of this sample of health care professionals regarding the management of chronic pain was inadequate to provide appropriate quality care for patients presenting with chronic pain conditions. This study identified the need for appropriate training for all health care professionals in order to assure adequate knowledge and skills to manage chronic pain using a multidisciplinary approach.

Keywords: Chronic pain, knowledge and attitude, healthcare providers, outpatients

CHUB, Centre Hospitalier Universitaire de Butare; OPD, Outpatient Department; IASP, International Association for the study of Pain

None.

Chronic pain is defined by the International Association for the study of Pain (IASP) as pain which persists more than three months.¹ There are numerous types of chronic pain including cancer pain, postsurgical and posttraumatic pain, neuropathic pain, headache and or facial pain, visceral pain and musculoskeletal pain.² Numerous mechanisms are involved at several stages from transduction and transmission through to modulation and perception.³

Chronic pain is a major source of suffering and one of the most common reasons to consult health care personnel. It interferes with daily living and is often accompanied by significant distress.¹ Irrespective of etiology or classification, chronic pain requires good understanding of interdisciplinary management approaches by health care providers in order to provide appropriate care.² Studies conducted in high- or low-resource countries among different health provider disciplines showed inadequate knowledge and  negative attitudes  toward management of chronic pain which may affect the quality of care provided to the patient.^4-9

Pain medicine in Rwanda is still inadequate and needs to develop. There is a paucity of data on knowledge and attitudes regarding chronic pain management in Rwandan health care professionals. A study conducted in Rwanda to evaluate knowledge and attitudes regarding acute pain management among nurses found adequate knowledge.^10,11

The current study was done in order to assess knowledge and attitudes among physicians and non-physician health professionals regarding chronic pain as it has been found that a multidisciplinary pain approach is the most effective.¹²

Objectives

The primary objective was to evaluate the level of knowledge and attitude of physicians and non-physician health professionals to chronic pain management. The second end point was to identify factors associated to the level of knowledge.

Before starting the study, it was approved by CHUB ethics committee with the following reference number: RC/UTHB/053/2018. All participants signed informed consent prior to participation and they were granted to withdraw from the study at any time. Confidentiality of the data and the responses was ensured by anonymity and keeping the questionnaire safely in a closed cupboard.

Study design

A cross sectional study was conducted among healthcare providers which included nurses, physicians and allied health professionals (Physiotherapists, non-physician Psychologists, social workers, mental health professionals that works in outpatient departments at CHUB in Rwanda. Data were collected during one month from January to February, 2020.

Recruitment of participants

A convenience sampling method was used among healthcare providers working at outpatient departments (OPD) at CHUB to get a sample size of 80 participants.  This sampling method was used because of the small number of staffs who work in these departments. 

Instrument and its validity and reliability

The instrument for this survey is the combination of two different instruments and it has three sections. Section one included demographic characteristics. Section two focused on knowledge which include sixteen questions regarding the pharmacology of pain, pain physiology and pain management developed by Betty Ferrell and Margo McCaffery.¹³ Its validity was determined by an expert group in pain. Internal consistency reliability was established (alpha r>.70). Section three was composed of the Nurses’ Attitude Survey tool of twenty-four items which included items on misconceptions regarding pharmacological and non-pharmacological management of pain, the use of opioids and goals of pain assessment developed by M. Elisabetta Zanolin,et al.¹⁴ This tool used Likert scales to assess attitudes regarding pain management. Responses went from strongly disagree to strongly agree and it was analyzed psychometrically in three phases. Its reliability was established by calculating Cronbach’s alpha (r=0.72). The validity also was ensured by confirmatory factor analysis which proved a very good construct validity.

The total tool validity and reliability was ensured. The content validity based on high level of evidence literature review, current pain management standard and through the review of Expert in Pain management. Reliability was ensured through test retest method which showed high reliability coefficient of (r=0.89,p=0.00) and internal consistence  reliability ( Cronbach’s Alpha =0.86).¹⁵

Data collection

The primary investigator approached the healthcare providers in their respective departments during their free time and explained the purpose of the study to them. After getting informed consent to participate in the study and sign it for those who accepted to participate, instructions and other relevant information regarding how to complete the questionnaire were provided. As the primary end point of this study was to determine the level of knowledge about chronic pain, the primary investigator supervised the participants while they were completing the survey in order to avoid discussion between them or searching on the internet or other sources of information. Following completion, all distributed questionnaires were collected and kept by the primary investigator in a locked drawer in order to protect the participants’ privacy. Anonymity was ensured by avoiding their names to questionnaire. 

Data analysis

Data were coded and entered in SPSS version 23 IBM for analysis. Descriptive statistics were used to describe frequency distribution of demographic characteristics. Inferential statistics (One-way ANOVA with Post Hoc Test were used to determine the associations between outcome variables and selected independent variables and the P value less than 0.05 was considered to be significant.

A total of 80 participants which included nursing staff, physicians and allied health professionals participated in the study. The majority of participants were nurses 47(58.75%). There were 21 physicians (26.25%) and 12 allied health professionals (15%). Forty-eight participants (57.5%) were advanced diploma holders, 11 (13.75%) had master’s degrees and 23(28.75%) had bachelor’s degrees. Forty-three (53.75%) of participants had worked in the health care field for six to fifteen (6-15) years. One quarter 20(25%) were trained in pain management (Table 1).

Knowledge regarding chronic pain among the participants

More than fifty percent 48(60%) of participants answered correctly that the most accurate and reliable judge of the intensity of the cancer patient’s pain is patient self-report. Around three quarters 59(73.75%) answered incorrectly that when a post-op patient request additional medication should not due to decreased levels of analgesic in the blood (Table 2).

Graph 1. Frequency distribution of overall knowledge marks over sixteen

This graph indicates that the majority of participants had below 8/16. The minimum mark obtained is 2/16 and the maximum obtained is 12/16 while the mode is 6/16.

Attitude distribution towards chronic pain among the participants

Almost 51% of the participants have negative attitude to pain management while almost 49 have positive attitude to pain management.

Although the majority of participants have negative attitude some positive attitude also was observed at higher level.90% of participants agreed that continuous assessment of pain and medication effectiveness is necessary for good pain management. 76.25% of participants agreed that the patient should be maintained in a pain free state. Higher negative attitudes compared to the mean were observed where 77.5% of participants disagreed that PRN schedule is not preferred for continuous pain and 80% who agreed that cutaneous stimulation or other none pharmacological management are effective for mild pain only (Table 3).

Association of knowledge and social demographic characteristics

One-way ANOVA with Post Hoc Tests between level of knowledge and demographic characteristics found statistically significant relationship between the level of knowledge and medical profession, highest qualification level and training on pain management with respective P values {(0.031), (0.001), and (0.000)}.

The results of this study demonstrated that there is no adequate knowledge about pain management in all participants and no positive attitudes only among health care professionals. The results showed that more than two third of participants, 58 of 80 had below 50% on general knowledge about pain management. This is consistent with the knowledge gaps identified in a previous systematic review of 36 articles from high income countries and low-income countries like Rwanda. In addition to this review the medical professional showed higher level of knowledge compared to the nurses which similar also to the presented study.⁷ This similarity may be justified by the majority of nurses with limited qualification to advanced diploma .The present findings are also consistent with a previous study conducted in five countries namely Australia, Canada, Japan, Spain and the United States to assess nurses’ knowledge about chronic pain from cancer which was also found to be inadequate.⁸ As the present study showed low knowledge among nurses when compared to medical professional, it may justify the similarly of inadequacy for that study conducted among nurses of five countries. The finding of this study are contrary to other studies done in Rwanda, Ethiopia and Zimbabwe to assess the knowledge and attitudes regarding acute pain which demonstrated adequate knowledge.^10,11,16,17 This difference may due to the fact that in nursing school ,the acute pain is much taught as sign and symptom which should managed while chronic pain is  less taught nor taught.

The study conducted in Taiwan and another done in Sudan among to assess pediatric residents and physicians’ knowledge and attitudes toward the management of chronic cancer pain showed inadequate knowledge and negative attitudes.^5,18 This is inadequacy like presented study but it is unexpected because those studies were done among medical profession who showed the higher level in the presented study. These surprising results may due to different tool used for surveys. It is contrary to the study done in Ethiopian nursing staff which found adequate knowledge and negative attitude.²⁰ This differences may be due to difference in training and cultural. The results also included a statistically significant relationship between the level of knowledge and medical profession, highest level of qualification and training in pain management with respective P-values {(0.031),(0.001),(0.000)}.This is in contrast to the study conducted in Zimbabwe which showed that the level of knowledge is associated to the experience and age of the professional.¹⁷ This discrepancies may be due to exposure on the patients with chronic pain which is different. The present findings are similar to the study conducted in Ethiopia which revealed that education level, training and reading articles were statistically significantly associated with the level of knowledge.²⁰ This may be justified by the fact of getting  the opportunity  to be taught chronic pain management. The presented study did not find a significant association between knowledge and the area of practice but the studies done in Greece and Jordan found a significant association between the knowledge and the area of practice.²¹ This may due to the staff nurses rotation in different area which hinder them to master one area of practice.

This study demonstrated inadequate knowledge regarding the management of chronic pain in a group of health care professionals at CHUB in Rwanda. Greater knowledge was associated with medical profession, highest level of qualification and training on pain management. Therefore, further training and upgrading to highest level are needed for all health care professionals since an interdisciplinary approach is needed for the best management of chronic pain.   In spite of poor knowledge this study found generally positive attitudes towards patients with chronic pain

Dr Angela Enright, OC, MBBCh, FRCPC for her time to reviewing the article
Durieux, Marcel E., MD, PhD, Professor Emeritus Anesthesiology, Global Health and Clinical Research for his review of the article
Dr Joel Parlow, Professor, Department of Anesthesiology and Perioperative Medicine, and Department of Biomedical and Molecular Sciences, Queen's University for his work reviewing the article
Prof Mary Lynch, Professor Department of Anesthesia, Pain Management & Perioperative Medicine, Department of Pharmacology, Department of Psychiatry for her time reviewing the article

No conflict of interest for this article.

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