Improving pain assessment, management, and research in low-income countries: An example of Nepal

Pain is a global public health problem resulting from complex interactions of multiple biopsychosocial factors. Most published pain research comes from developed countries using samples from western countries; developing countries continue to face challenges in conducting high-quality pain research. This thesis illustrates a systematic approach to planning a pain research programme in a (resource-limited) country, using my country of Nepal as an example. It also demonstrates ways to overcome preliminary barriers to conducting high-quality pain research in developing countries. This thesis has 10 chapters and includes ten manuscripts published in international peer-reviewed journals. Chapter 1 is a general introduction providing an overview of pain and includes the aims of the thesis. Chapter 2 is a scoping review of published pain research conducted in Nepal (last search updated in November 2018) with an aim to describe the findings from this research, identify research gaps, and inform pain research priorities. This chapter also informed the need for Chapters 5 through 9. Chapter 3 is a systematic review aiming to explore between-country and -language differences in chronic pain beliefs, coping, and catastrophizing. Chapter 4 prepares the readers for the four chapters that follow (Chapter 5 – 8) that describe the translation, cross-cultural adaptation, and validation of five patient-reported outcome measures (PROMs) that assesses four domains into Nepalese that can be used in future pain research in Nepal. These domains were identified as important domains to measure in individuals with pain in Nepal based on the recommendations of the core outcome sets of several pain conditions. Instruments translated to assess these domains were the Numerical Pain Rating Scale (NPRS), the Patient-Specific Functional Scale (PSFS), the Pain Catastrophizing Scale (PCS), the Connor Davidson Resilience Scale (CDRISC), and the Global Rating of Change (GRoC). Chapter 9 describes the development of pain education materials in Nepali and the results of a feasibility clinical trial that aimed to explore if conducting a high-quality clinical trial is feasible in the Nepalese healthcare system. The final chapter, Chapter 10 is a general discussion of the thesis with implications of the studies on pain policy, future research, and clinical practice in Nepal, as well as the overall significance, recommendations, strengths, and limitations of the work presented. In summary, the current thesis identified two important knowledge gaps in the current pain literature in Nepal: (1) the general unavailability of PROMs that are in the Nepali language and that could be used to assess pain and other important pain-related domains significant to advancing scientific knowledge and (2) the biopsychosocial management of pain in Nepal. The research reported here addressed these knowledge gaps by translating and cross-culturally adapting and validating 5 PROMs that can be used in the assessment of pain conditions, and developing a credible and acceptable pain education programme in Nepali. Moreover, the systematic review found important country and language effects on the beliefs people have and the response they engage in to cope with pain, suggesting that these factors may be considered when developing treatments for and adapting treatments to individuals living in a specific country or speaking a specific language. Finally, the results indicate that a definitive high-quality clinical trial to investigate the effectiveness of the pain education programme is feasible and warranted in Nepal

Early post-stroke cognitive impairment and in-hospital predicting factors among stroke survivors in Ethiopia

BackgroundIn low-and middle-income countries, post-stroke cognitive impairment (PSCI) is the least investigated stroke complication that clinically is given little attention. Finding patients who are at high risk of having cognitive problems after a stroke could allow targeted follow-up and help with prognosis discussions, which would then contribute to improved treatment outcomes. The main aim of this study was to determine the incidence and predictors of PSCI among stroke survivors in Northwest Ethiopia.MethodsThe study was a multicenter prospective cohort study. The study participants were 403 stroke survivors who were alive on follow-up after 3 months of stroke onset at the neurology department of three hospitals in Northwest Ethiopia. To investigate the link between the outcome and the explanatory variables, analyses of bivariable and logistic multivariable regression were performed. A value of p of 0.05 or less was regarded as statistically significant, and data were presented as odds ratios and 95% confidence intervals.ResultsThe mean age of the participants was 61.3 years (SD = 0.7), 56% were females, the mean time from symptom onset to hospital arrival was 46 h (SD = 3.32), and the mean National Institute of Health Stroke Scale (NIHSS) score at admission was 14.79 (SD = 0.25). PSCI was observed in 122 patients (30.3%) after 90 days of stroke onset, that is, 83 (20.6%) of female and 39 (9.7%) of male stroke survivors. The result of multivariable logistic regression analysis revealed PSCI was independently associated with age (adjusted OR = 1.04, 95% CI = 1.061–1.981), women (AOR = 1.390, 95% CI = 1.221–2.690), admission modified Rankin scale (mRS) (AOR = 1.629, 95% CI = 1.381–2.037), moderate Glasgow coma scale (GCS) score (AOR = 1.149, 95% CI = 1.402–3.281), and poor GCS score (AOR = 1.632, 95% CI = 1.610–4.361) and stage one (AOR = 1.428, 95% CI = 1.198–2.922) and stage two hypertension (AOR = 1.255, 95% CI = 1.107–2.609).ConclusionNearly one-third of stroke survivors developed PSCI. Moreover, further research is needed with a larger sample size, showing a time trend and longer follow-up duration

Pain-related beliefs, coping, and function: an observational study on the moderating influence of country of origin

Chronic pain is a multidimensional experience and pain treatments targeting psychosocial factors reduce pain and improve function. These treatments often overlook the sociocultural factors that influence pain and the psychological factors associated with function in people with chronic pain. Although preliminary findings suggest that cultural background may influence pain and function via their effects on beliefs and coping, no previous study has directly tested if the country of origin moderates the associations between these psychological factors and pain and function. This study sought to address this knowledge gap. Five hundred sixty-one adults with chronic pain, born and living in the USA (n = 273) or Portugal (n = 288), completed measures of pain, function, pain-related beliefs, and coping. Between-country similarities were found in the endorsement of beliefs related to disability, pain control, and emotion, and in asking for assistance, task persistence, and coping self-statement responses. Portuguese participants reported greater endorsement of harm, medication, solicitude, and medical cure beliefs, more frequent use of relaxation and support seeking, and less frequent use of guarding, resting, and exercising/stretching. In both countries, disability and harm beliefs and guarding responses were associated with worse outcomes; pain control and task persistence were associated with better outcomes. Six country-related small effect-size moderation effects emerged, such that task persistence and guarding are stronger predictors of pain and function in adults from the USA, but pain control, disability, emotion, and medication beliefs are more important in adults from Portugal. Some modifications may be needed when adapting multidisciplinary treatments from one country to another. Perspective: This article examines the similarities and differences in beliefs and coping endorsed by adults with chronic pain from 2 countries, and the potential moderation effects of country on the associations between these variables and pain and function. The findings suggest that some modifications may be needed when culturally customizing psychological pain treatments.info:eu-repo/semantics/acceptedVersio

Translation and cross-cultural adaptation of Nepali versions of the patient-reported outcomes measurement information system (PROMIS®) pain intensity, pain interference, pain behavior, depression, and sleep disturbance short forms in chronic musculoskeletal pain

Purpose: The Patient-Reported Outcomes Meaurement Information System (PROMIS®) measures have been translated into many languages and have been shown to have strong measurement properties across a wide range of clinical conditions. However, Nepali translations of the PROMIS short forms are not yet available. The aim of this study was to translate and cross-culturally adapt the PROMIS Pain Intensity, Pain Interference, Pain Behavior, Depression, and Sleep Disturbance short forms into Nepali. Methods: We used the Functional Assessment of Chronic Illness Therapy (FACIT) translation methodology, which incorporated two forward translations, synthesis of the translations, a back-translation, and three independent reviews, harmonization, cognitive debriefing, revisions, and proof reading. The translation and review teams were fluent in Nepali and English and represented five different countries and four continents. We evaluated the short forms for comprehensibility and relevance (two key aspects of the content validity of an instrument), conducting cognitive debriefing with six adults with chronic musculoskeletal pain, in compliance with recommendations by the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN). The final version was proofread by two native Nepali speakers before and three new proofreaders after cognitive debriefing. Results: All five short forms were successfully translated and cross-culturally adapted into Nepali while maintaining equivalence to the source. Conclusions: The translation and review team, along with a sample from the target population with chronic musculoskeletal pain and the proofreaders considered all five PROMIS short forms relevant and comprehensible. An important next step is to evaluate the measurement properties of these instruments

Cross-sectional study examining the epidemiology of chronic pain in Nepal

Abstract. Introduction:. The World Health Organization recognizes chronic pain as a global public health concern; however, there is a bias towards research conducted in relatively affluent nations. There is a dearth of large-scale epidemiological studies in Nepal using rigorously validated, cross-culturally adapted instruments. Objectives:. The aim of this study was to examine the prevalence of both chronic pain and chronic pain of predominantly neuropathic origin and their associations with a range of sociodemographic and psychosocial characteristics. Methods:. We conducted a cross-sectional study of adults (≥18 years) in all households in Ranipani, Baluwa Village Development Committee, Nepal. All adults (n = 887) were approached, and those consenting, who met the inclusion criteria (n = 520, 58.6%), participated. Questionnaires validated in Nepali were used to examine several constructs: demographics; chronic pain; neuropathic pain; pain catastrophizing; resilience, pain intensity; pain interference; sleep disturbance; and depression. Results:. The point prevalence of chronic pain was 53.3% (n = 277). The point prevalence of chronic pain of predominantly neuropathic origin was 12.7% (n = 66). Chronic pain was associated with female gender, older age, and manual labour occupations. Using standardized scoring techniques, compared with available population estimates from other countries, those with chronic pain were associated with lower pain intensity and resilience scores and higher pain catastrophizing, pain interference, and depression scores. Conclusion:. These findings are broadly comparable to epidemiological studies from other countries, and these indicate areas for targeting interventions (eg, occupational and mental health). For comparison, more data are needed, from larger population samples in this region

The role of perfectionistic self-presentation in pediatric pain

This study sought to better understand the associations between perfectionistic self-presentation and measures of pain intensity, pain catastrophizing, pain interference, and fatigue in children and adolescents with pain. In the study, 218 adolescents responded to measures of perfectionistic self-presentation (i.e., perfectionistic self-promotion, nondisplay of imperfection and nondisclosure of imperfection), pain intensity, pain catastrophizing, pain interference, and fatigue. Four hierarchical regression analyses and three mediation analyses were conducted. Our results showed that perfectionistic self-promotion was significantly and independently associated with pain intensity and that nondisplay of imperfection was significantly and independently associated with pain catastrophizing, pain interference, and fatigue. Nondisclosure of imperfection was not significantly associated with any criterion variable. Pain catastrophizing mediated the association between both perfectionistic self-presentation and nondisplay imperfection and pain interference but not between nondisclosure of imperfection and pain interference. The findings provide new information about the role of perfectionistic self-presentation in children and adolescents' experience of pain. These findings, if replicated, support perfectionism as a potential target of pain treatment in young people.Fundação para a Ciência e Tecnologia - FCTinfo:eu-repo/semantics/publishedVersio

Development of recommendations for a minimum dataset for Identifying Social factors that Stratify Health Opportunities and Outcomes (ISSHOOs) in pain research

There is increasing recognition of the need for researchers to collect and report data that can illuminate health inequities. In pain research, routinely collecting equity-relevant data has the potential to inform about the generalisability of findings; whether the intervention has differential effects across strata of society; or it could be used to guide population targeting for clinical studies. Developing clarity and consensus on what data should be collected and how to collect it is required to prompt researchers to further consider equity issues in the planning, conduct, interpretation, and reporting of research. The overarching aim of the 'Identifying Social Factors that Stratify Health Opportunities and Outcomes' (ISSHOOs) in pain research project is to provide researchers in the pain field with recommendations to guide the routine collection of equity-relevant data. The design of this project is consistent with the methods outlined in the 'Guidance for Developers of Health Research Reporting Guidelines' and involves 4 stages: (i) Scoping review; (ii) Delphi Study; (iii) Consensus Meeting; and (iv) Focus Groups. This stakeholder-engaged project will produce a minimum dataset that has global, expert consensus. Results will be disseminated along with explanation and elaboration as a crucial step towards facilitating future action to address avoidable disparities in pain outcomes. </p

Does religiosity/spirituality play a role in function, pain-related beliefs, and coping in patients with Chronic Pain? A Systematic Review

This systematic review examined the extent to which measures of religiosity/spirituality (R/S): (1) are associated with pain, function, pain-related beliefs (beliefs), coping responses, and catastrophizing in people with chronic pain; and (2) moderate the association between beliefs, coping and catastrophizing, and pain and function. Experimental and observational studies examining at least one of these research questions in adults with chronic pain were eligible. Two reviewers independently performed eligibility screening, data extraction, and quality assessment. Twenty studies were included. Most studies focused on the association between R/S and pain or function. When significant associations emerged, those between R/S and psychological function were weak to strong and positive; those between religious/spiritual well-being and pain and physical dysfunction were negative, but weak. Few studies examined the associations between R/S and beliefs/coping/catastrophizing; none examined the moderation role of R/S. The findings suggest that R/S is associated with pain and psychological function in people with chronic pain, and that viewing oneself as being "spiritual," regardless of religion, may contribute to positive psychological adjustment. More research is needed to determine the reliability of this finding. PROSPERO registry CRD42018088803.Fundação para a Ciência e Tecnologia - FCTinfo:eu-repo/semantics/publishedVersio

Implementation of Best-Evidence Osteoarthritis Care: Perspectives on Challenges for, and Opportunities From, Low and Middle-Income Countries

The “Joint Effort Initiative” (JEI) is an international consortium of clinicians, researchers, and consumers under the auspices of the Osteoarthritis Research Society International (OARSI). The JEI was formed with a vision to improve the implementation of coordinated programs of best evidence osteoarthritis care globally. To better understand some of the issues around osteoarthritis care in low- and middle-income countries (LMICs), the JEI invited clinician researcher representatives from South Africa, Brazil, and Nepal to discuss their perspectives on challenges and opportunities to implementing best-evidence osteoarthritis care at the OARSI World Pre-Congress Workshop. We summarize and discuss the main themes of the presentations in this paper. The challenges to implementing evidence-based osteoarthritis care identified in LMICs include health inequities, unaffordability of osteoarthritis management and the failure to recognize osteoarthritis as an important disease. Fragmented healthcare services and a lack of health professional knowledge and skills are also important factors affecting osteoarthritis care in LMICs. We discuss considerations for developing strategies to improve osteoarthritis care in LMICs. Existing opportunities may be leveraged to facilitate the implementation of best-evidence osteoarthritis care. We also discuss strategies to support the implementation, such as the provision of high-quality healthcare professional and consumer education, and systemic healthcare reforms