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Pain Management and Its Possible Implementation Research in North

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Advances in Medicine
Volume 2020, Article ID 5317352, 8 pages
https://doi.org/10.1155/2020/5317352

Research Article
Pain Management and Its Possible Implementation Research in
North Ethiopia: A before and after Study

Mengistu Hagazi Tequare ,1 James John Huntzicker,2 Hagos Gidey Mhretu,3

Yibrah Berhe Zelelew,3 Hiluf Ebuy Abraha,4 Mehari Abrha Tsegay,3
Kesatea Gebrewahd Gebretensaye,3 Daniel Gebre Tesfay,4 Julio Gonzalez Sotomayor,2
Rahel Nardos,2 Mary Beth Yosses,2 Joshua Edwin Cobbs,2 Jennifer Pui Ling Schmidt,2
Wendy Weisman,2 and Leslie K. Breitner5
1
Mekelle University, College of Health Sciences, School of Public Health, Mek’ele, Ethiopia
2
Oregon Health and Science University, Portland, OR, USA
3
Mekelle University, College of Health Sciences, School of Medicine, Mek’ele, Ethiopia
4
Mekelle University, Ayder Comprehensive Specialized Hospital, Mek’ele, Ethiopia
5
McGill University, Desautels Faculty of Management, Montreal, Canada

Correspondence should be addressed to Mengistu Hagazi Tequare; mengistu.hagazi@mu.edu.et

Received 6 January 2020; Revised 22 April 2020; Accepted 2 May 2020; Published 2 June 2020

Academic Editor: Monica Rocco

Copyright © 2020 Mengistu Hagazi Tequare et al. This is an open access article distributed under the Creative Commons
Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is
properly cited.
Background. Though there is an effective intervention, pain after surgical intervention is undermanaged worldwide. A systematic
implementation is required to increase the utilization of available evidence-based intervention to manage the inevitable pain after
surgery. The aim of this research project is to develop a scalable model for managing pain after cesarean section by implementing
the World Health Organization’s (WHO) pain management guidelines through a combination of implementation research and
quality improvement methods. Methods. We implemented the World Health Organization (WHO) pain management guidelines
using effective implementation strategies. First, we conducted a formative qualitative exploration to identify enablers and
obstacles. In addition, we took base-line assessment on pain management implementation process and outcome using a checklist
prepared from the guideline and an adapted American Pain Outcome assessment tool version 2010, respectively. Then, we
integrated the guidelines into the existing practice by using collaborative iterative learning strategy. We analyzed the data by
Statistical Packages for Social Sciences (SPSS) version 21. We compared the before and after data using chi-squared and Fischer’s
exact test. A change in any measurement was considered as significant at p value 0.05. Result. We collected data from 106 mothers
before and 110 mothers after intervention implementation. We successfully integrated pain as a fifth vital sign in more than 87%
(p value <0.001) of patient, and fidelity was approximately 59% (p value <0.001). In addition, we significantly improved pain
outcome measures after the implementation of the intervention. Conclusion and Recommendations. A systematic approach to
implement pain management guidelines was successful. We recommend the ward sustain these gains and that hospital, the region,
and the nation to replicate the success.

1. Introduction varying degrees in low- and high-income countries across

the globe [6–12]. A study conducted in the United States
There are continuing advancements in multimodal analgesia reported that 80% of patients who underwent surgery ex-
techniques to prevent and control pain after surgical in- perienced pain after surgery, of which 86% had moderate,
terventions [1–6]. Though solutions are available, patients severe, and extreme pain [7]. Another study from China
undergoing surgery still suffer from postoperative pain of revealed that around 85% patients complained of pain after
2 Advances in Medicine

surgery [8]. In addition, a study conducted in one Ethiopian 2.3. Sample Size. We took samples of mothers who under-
Tertiary care hospital found more than 91% patients who went caesarean Section 3 weeks before and 3 weeks after the
had a surgical intervention experienced pain [11]. A similar implementation. We employed consecutive sampling tech-
study in another tertiary care hospital of Ethiopia also nique. Patients who were unwilling to participate, uncon-
showed 78% of postoperative patients suffering from pain scious during data collection, unable to clearly communicate
ranging from moderate to severe intensity [12]. ideas, and known psychiatric illness were excluded. Before the
Poorly managed postoperative pain may result in the intervention, we found 106 mothers underwent caesarean
development of chronic postoperative pain, impaired section and 110 mothers after intervention.
function, and delayed recovery from surgery. In addition, it
could cause depression, mood alterations, sleep disorders,
2.4. Procedures. We collected four categories of variables:
inability to focus, abnormal appetite, poor hygiene, and
sociodemographic, clinical, pain management process, and
prolonged opioid use. As a result, poor postoperative pain
pain outcome variables. For the first three, we prepared a
management increases the medical costs to the patient and
piloted data extraction sheet and collected the data from
the health system [13–16].
patients’ medical record. For the outcome variables, we
Pain after surgery is mostly predictable [17]. Different
adapted the American Pain Society Pain Outcome Ques-
factors could predict pain of post operation: preoperative
tionnaire (APS-POQ-R) version 2010 [32] contextually by
state anxiety, level of preoperative pain, preoperative in-
piloting it in 5 patients, which is around 5% of the prestudy
formation, age, gender, type of surgery, incision size, eth-
sample size. The reason why we are using this tool is because
nicity, and education [18–21].
many studies used it as an outcome pain measurement tool
There are barriers that hinder utilization of the well-
[11, 33]. The APS-POQ-R was translated into local languages
known practice. Attitude and aptitude (knowledge and skill)
(Tigrigna and Amharic) before starting data collection.
of practicing professionals, low leadership focus, drug
Furthermore, we changed the 11-level pain scoring scale into
regulatory and legislative rules, inadequate resource-like
four-level scoring scale (no pain, mild pain, moderate pain,
staffing, equipment, and financial constraints in low-income
and severe pain) after testing in five patients for easy un-
nations are among the barriers for implementation [22, 23].
derstanding. The pain outcome data were collected by
Evidence shows different approaches at different hier-
interviewing patients approximately 24 hours after they
archies to overcome the barriers of pain management.
underwent surgery.
Making pain management a priority, modifying policies for
drug supply management and prescription pattern, collab-
oration among multidisciplinary professionals, job training 2.5. Intervention Core Components. The intervention is the
for the health practitioners, improvement of pain man- WHO pain management guidelines. The implementation of
agement education in under and postgraduate curriculum, effective pharmacologic pain management will involve the
identifying a working list of drugs for pain and quality inclusion of pain assessment as a fifth vital sign and pro-
improvement approaches are among well-recognized vision of pharmacologic solutions (Figure 1).
strategies [13, 22–30]. The core components are as follows:
The aim of this research project is to develop a scalable
(i) Inclusion of pain as a fifth vital sign—the frequency
model for managing pain after caesarean section by
of pain recorded as a fifth vital sign should be equal
implementing the World Health Organization’s (WHO)
to the frequency of the four other vital signs
pain management guidelines through a combination of
implementation research and quality improvement (ii) Drug treatment based on the protocolas shown in
methods. Figure 1

2. Materials and Methods 2.6. Implementation Strategies. We used the following

strategies to implement the intervention based on recom-
2.1. Design. We employed a before and after intervention mendations from the literature [34] and our qualitative
study design to implement effective pain management formative research:
protocol. In addition, we utilized iterative collaborative
(1) Develop stakeholder interrelationships
quality improvement methods to integrate the new protocol
with the existing system. (2) Train and educate stakeholders
(3) Change infrastructure
(4) Use evaluative and iterative strategies
2.2. Study Area and Period. The study was conducted in the
Ayder Comprehensive Specialized Hospital labor ward,
north Ethiopia, from January to July 2018. The ward has 18 2.7. Develop Stakeholder Interrelationships (Teams). To ef-
postoperative beds, 11 obstetrician/gynecologists, 50 mid- fectively implement our strategy, we formed two teams:
wives, and 7 interns. The total number of caesarean sections research team and quality improvement team. Both teams
conducted in 2017/2018 (one Ethiopian Fiscal year) was performed their roles independently without the knowledge
1490. Within the study period, there were a total of 800 what the other team was doing. The principal investigator
caesarean section procedures conducted [31]. coordinated the overall project for the project so that the
Advances in Medicine 3

Pain persisting Strong opioid 2.10. Data Analysis. The data were entered into Microsoft
or increasing +/– nonopioid Excel version 2010. Then, it was transferred into Statistical
Pain persisting +/– adjuvants Packages for Social Sciences version 21 for analysis. We
or increasing Weak opioid
+/– nonopioid Step 3 cleaned, coded, and checked for accuracy before analysis.
severe pain
+/– adjuvants Following this, we compared sociodemographic and clinical
Step 2 characteristics of patients and process and outcome variables
Nonopioid
+/– adjuvants
moderate pain of the pain management before and after our intervention.
Step 1
We used chi-squared tests for those which fulfil the as-
mild pain sumptions and Fischer’s exact test for cells containing less
than 5 expected values. p value less than or equals to 0.05 was
Figure 1: A pocket guide of pain management in Africa (source: taken as a statistically significant change.
beating pain) [22].

project would go smoothly and that the activities in the 3. Results

proper sequence. 3.1. Implementation Process and Strategies. We used four
implementation strategies in our implementation process:
2.7.1. Role of Research Team. The role of the research team (1) Develop stakeholder interrelationships: we formed
was to collect baseline and end-line data, enter, clean, an- two teams, research team and quality improvement
alyze, and report. This team was led by the principal team.
investigator.
(2) Train and educate stakeholders: we trained 50
midwives, 24 interns, and 7 residents
2.7.2. Role of the Quality Improvement Team: Iterative (3) Change infrastructure: we changed vital sign sheet,
Strategy. The quality improvement team prepared the training list, and evaluation criteria
postcaesarean section pain management protocol; prepared
(4) Use evaluative and iterative strategies
necessary resources, like drugs and vital sign sheets; and
provided training and orientation for all midwives, medical We used model for improvement for continuous pain
residents, and interns about the protocol before imple- management process and outcome improvement. We took
mentation. Furthermore, the team trained the newly in- baseline data for three key performance indicators (pro-
coming residents, interns, and midwives during portion of patients’ pain included as a fifth vital sign,
implementation. proportion of patients correctly treated, and proportion of
The other role of this team was collecting data daily from postcaesarean section mothers satisfied by pain manage-
all postoperative mothers on three core measures: inclusion ment) for 18 days. Then, we started implementing the
of pain as a fifth vital sign, correct drug treatment, and protocol, collected data daily, gave feedback, and followed
mothers’ satisfaction on pain management. The principal this for 37 days. A total of 683 patient interactions were
investigator followed the process closely daily and provided made to collect data for 55 data points for the whole im-
necessary feedback and learned from actual practice. We provement process.
used model for improvement [35] for iterative learning. In
addition, learning from each change ideas developed to
integrate pain management into the existing system, and 3.2. Pain Management Process and Outcome Improvement
sketching the information collected in run charts for deci-
3.2.1. Pain Management Process Improvement. We imple-
sion-making [36] was one of the major roles of the team. The
mented pain management protocol for postcaesarean sec-
main change ideas developed were training staff on the
tion mothers for six months, and we approached 106 and
protocol and revising vital sign sheet to include pain.
110 mothers before and after the intervention, respectively.
The participation rate in both situations was 100%. The pain
2.8. Train and Educate Stakeholders. After preparation of the management process was significantly improved: the in-
pain management protocol, members of the team trained the clusion of pain as a fifth vital sign was improved from none
midwives, interns, and residents. These are frontline workers to 87.30% and correct pharmacologic treatment (fidelity) of
who are directly involved in the patient care. pain as the protocol was improved from 25.5% to 59.1%
(Table 1).
2.9. Change Infrastructure. We added pain as a vital sign in
the vital sign sheet and pain in the training/orientation list 3.2.2. Pain Management Outcome Improvement. Pain out-
for midwives and medical students. In addition, we added come was significantly improved after implementation of the
pain management in the evaluation criteria for students and pain management protocol in all parameters when com-
midwives. pared with the condition before intervention (Table 2). In a
In summary, through the full participation of the staff four-level Likert scale, the least pain patients experienced
working in the area, we included pain as a fifth vital sign within 24 hours after surgery; patients reported “moderate”
using iterative multidisciplinary learning. pain reduced from 20.8% to 0.9%. In addition, patients
4 Advances in Medicine

Table 1: Process variables of postcaesarean section mothers before and performance management systems, and using iterative
and after implementation of pain management protocol, ACSH, quality improvement methods.
north Ethiopia, Jan–June 2108. We started the improvement process by forming two
Before After teams. Those teams were informed about the criticality of the
Characteristics intervention intervention p value pain management problem and the aim of the overall
N (106) % N (110) % project. This is in line with Kotter’s model for managing
Pain as fifth vital sign
change [38]. Kotter describes eight consecutive phases to
Yes 0 0.0 96 87.3 happen to bring about a change. The first and second are
<0.001 creating a sense of urgency and bringing people together to
No 106 100.0 14 12.7
Correct treatment have a shared understanding, respectively.
Yes 27 25.5 65 59.1 In implementing a new intervention, the first process
<0.001 that should happen is creating awareness about the inter-
No 79 74.5 45 39.9
vention. According to Roger’s diffusion of innovation, the
decision to adopt a new thing starts by knowing its existence
experienced worst pain reported “severe” reduced from and its function and the innovation decision process con-
52.8% to 17.3% and the amount of time patients spent in tinues based on the effect of the knowledge [39]. Based on
severe pain reported as “always” and “around half” reduced this principle, the implementation team in this study con-
from 16.0% to 0.9% and from 61.3% to 34.5%, respectively. ducted training for the staff on the pain management
Restriction of activities and interruption of normal life protocol. The training was done by themselves to increase
due to pain was also significantly improved. Proportion of ownership.
patients reporting severe and moderate restriction in bed The training was followed by implementation. The
reduced from 23.6% to 3.6% and from 60.4% to 38.2%, implementation team had to change some infrastructure,
respectively. In addition, proportion of patients reporting like recording [37]. We inserted the change into the existing
severe restriction when moving out of bed reduced 49.1% to record sheet to avoid additional burden to the staff. Every
18.2%. Moreover, proportion of patients reporting moderate change was done by the full participation and ownership of
interference in falling asleep reduced from 45.3% to 3.6% the implementing team. Real change not only happens in the
and interference in staying asleep reduced from 30.2% to real work but also in those who do the job and do the change
1.8%. and people own what they create [40]. This helps innovations
The effect of pain on mood and emotions of patients was to be easily adopted and sustained. Furthermore, we used the
also significantly improved. Proportion of patients reporting principles of Edgar Schein about process consulting. Schein
moderate anxiety due to pain reduced from 72.6% to 9.1%. advises to help people help themselves and help them release
Patients reported mild and no for depression, frightening their potential to understand their own problems and solve
and helplessness before and after the intervention. No pa- their problems themselves, not prescribing solutions [41].
tient reported moderate or severe in both times. But, three of Henry Mintzberg strengthens this by arguing that a strategy
them were improved significantly from mild to no. in health care should come/comes from the frontline staff
Drug side effects showed slight change before and after [42].
the implementation. From four parameters, only drowsiness The iterative quality improvement strategy helped us
showed significant improvement. Proportion of patients repeatedly test and learn and finally integrate our inter-
reported moderate drowsiness reduced from 2.8% to 0.9%. vention to the existing system of care. We tested it in small
Nausea/vomiting, itching, and dizziness showed no signif- scale and learned the constraints on a focused manner. We
icant change. could learn more in small scale and were able to predict to
Pain relief and patients’ satisfaction showed significant full scale later. These types of strategies are effective ways for
improvement after the intervention. Proportion of patients adaptations of evidence-based medicine nowadays [23, 37].
whose pain relieved completely before and after the inter- After and during the implementation of all these
vention improved from 3.8% to 23.6% and most relief strategies, we could see a significant change in the process
improved from 26.4% to 60.0%. In addition, proportion of and outcome metrics of pain management after caesarean
patients participated in their pain treatment as much as they section. This may be due to our intervention.
wanted increased 30.2% to 80.9%. Finally, the proportion of
patients who were satisfied by the pain management made to
them improved from 34.0% to 80.9%. 4.2. Pain Management Process and Outcome. There was a
significant improvement of pain management process and
4. Discussion outcome after the implementation of this study. The im-
provement could be attributed to this study. Pain as a vital
4.1. Implementation Strategies. We used proven imple- sign was included in majority of the patients (Table 1), but it
mentation strategies [37] to integrate pain management was not 100%. This may be due to a difference in patient
protocol in the daily routine practice in ACSH labor ward. characteristics. Some patients had a different vital sign sheet,
The strategies are as follows: building change coalition, and this might have contributed to this gap. Even though
training the staff with the intervention components (in- there was a significant improvement in the correct treatment
cluding the coalition members), changing some recording of pain based on the WHO ladder (the protocol) [22], there
Advances in Medicine 5

Table 2: Outcome variables of pain management implementation for postcaesarean section patients in ACSH, north Ethiopia, Jan–June
2018.
Before After
Characteristics intervention intervention p value
N (106) % N (110) %
Least pain experienced within 24 hours
Moderate 22 20.8 1 0.9
Mild 80 75.5 91 82.7 <0.001
No 4 3.8 18 16.4
Worst pain experienced within 24 hours
Severe 56 52.8 19 17.3
Moderate 46 43.4 75 68.2 <0.001
Mild 4 3.8 16 14.5
Amount of time spent in severe pain within 24 hours
Always 17 16.0 1 0.9
Around half 65 61.3 38 34.5 <0.001
Some of it 24 22.6 71 64.5
Restricting activities in bed
Severe 25 23.6 4 3.6
Moderate 64 60.4 42 38.2 <0.001
Mild 17 16.0 64 58.2
Restricting activities out of bed
Severe 52 49.1 20 18.2
Moderate 44 41.5 75 68.2 <0.001
Mild 10 9.4 15 13.6
Interferes falling asleep
Moderate 48 45.3 4 3.6
Mild 52 49.1 97 88.2 <0.001
No 6 5.7 9 8.2
Interferes staying asleep
Moderate 32 30.2 2 1.8
Mild 60 56.6 91 82.7 <0.001
No 14 13.2 17 15.5
How much the pain makes you feel anxious
Moderate 77 72.6 10 9.1
Mild 23 21.7 78 70.9 <0.001
No pain 6 5.7 22 20.0
How much the pain feel you depressed
Mild 78 73.6 30 27.3
<0.001
No 28 26.4 80 72.7
How much the pain makes you feel frightened
Mild 46 43.4 2 1.8
<0.001
No 60 56.6 108 98.2
How much the pain makes you feel helpless
Mild 21 19.8 0 0.0
<0.001∗
No 85 80.2 110 100
Severity of nausea/vomiting
Mild 42 39.6 36 32.7
0.323
No 64 60.4 74 67.3
Drowsiness
Moderate 3 2.8 1 0.9
Mild 27 25.5 12 10.9 0.01
No 76 71.7 97 88.2
Itching
Moderate 56 52.8 10 9.1
Mild 23 21.7 78 70.9 0.543
No pain 6 5.7 22 20.0
6 Advances in Medicine

Table 2: Continued.
Before After
Characteristics intervention intervention p value
N (106) % N (110) %
Dizziness
Mild 15 14.2 18 16.4
0.863
No 91 85.8 92 83.6
How much pain relief was receives in 24 hours
All 4 3.8 26 23.6
Around half 28 26.4 66 60.0 <0.001
Some 74 69.8 18 16.4
Were you allowed to participate in pain treatment as much as you wanted?
Yes 32 30.2 89 80.9
<0.001
No 74 69.8 21 19.1
Are you satisfied with the result of your pain treatment?
Yes 36 34.0 89 80.9
<0.001
No 70 66.0 21 19.1
∗
� Fischer’s exact test used.

remains a huge gap between the recommended treatment patients in their own pain management by active inquisition.
and the practice. Finally, the study improved patients’ participation the pain
Pain management outcome, as measured from the pa- management significantly. The overall satisfaction of pa-
tients’ reports, has significantly been improved. Pain ex- tients in the pain management process changed significantly,
perience within 24 hours after surgery was improved after showing strong possible relationship with participation in
the study (Table 2). Majority of the patients experiencing the implementation of the new pain management protocol.
least pain after the study shifted to mild and no pain. In
addition, the worst pain experienced within 24 hours after 5. Conclusion
surgery also changed from severe to moderate and mild pain.
Our result is far better than other studies conducted in China We implemented an effective pharmacologic pain man-
and Ethiopia [11, 43], showing most patient experiencing agement protocol in an Ethiopian Tertiary Care Hospital
moderate to severe pain after surgery. This difference could labor ward for postcaesarean section patients successfully.
be due to our intervention. In fact, before our pain im- Taking pain as a fifth vital sign was successfully integrated
provement, 96.2% of patients experienced moderate and into the existing system. Consequently, pain outcome ex-
severe pain, which is similar to the result of the above- perienced by postcaesarean section patients after imple-
mentioned study in Ethiopia. The pain significantly de- mentation of pain management protocol was significantly
creased after intervention in our study (85.5%) improved when compared with the baseline information.
Mood or emotional alterations due to severity of pain
(anxiety, depression, frightening, and helplessness) have Abbreviations
been significantly improved after our intervention. Majority
of the patients were experiencing moderate anxiety before APS-POQ- American Pain Society Pain Outcome
our study and more than 90% felt mild or no anxiety after R: Questionnaire
our intervention. ACSH: Ayder Comprehensive Specialized Hospital
The interruption of function or limitation of activities WHO: World Health Organization.
(movement in the bed, moving out of bed, falling asleep, and
staying asleep) due to pain of patients after surgery has Data Availability
significantly been improved after our intervention.
However, there was no significant difference in side Data used to support the findings of this study are available
effects (nausea/vomiting, dizziness, itching, and drowsiness) from the corresponding author upon reasonable request.
of pain drugs except for drowsiness, which showed a sig-
nificant change. The result is acceptable. Because we did not Ethical Approval
do anything to affect drug side effects and also, we did not We secured ethical clearance from the Mekelle University
add a new drug into the care. The only significant change Institutional review board. Then, permission was found
seen is drowsiness, and this may be due to opioid intro- from the chief clinical director of the hospital.
duction of the regimen.
The amount of pain relief with the pain care improved
significantly. Furthermore, participation of patients on their
Consent
own care is one of the parameters of patient-centered care Informed consent was requested from the patients who
[44]. In our study, we tried to improve the participation of provided the data during data collection.
Advances in Medicine 7

Conflicts of Interest patients in an Ethiopian hospital,” PLoS One, vol. 9, no. 7,

Article ID e102835, 2014.
The authors declare that they have no conflicts of interest. [12] W. S. Admassu, A. G. Hailekiros, and Z. D. Abdissa, “Severity
and risk factors of post-operative pain in university of Gondar
hospital, northeast Ethiopa,” Journal of Anesthesia & Clinical
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MT conceptualized the study, oversaw all aspects of how the N. Vadivelu, “Availability and utilization of opioids for pain
study was carried out, and wrote significant portions of the management: global issues,” The Ochsner Journal, vol. 14,
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dents, and midwives for their irreplaceable contributions
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