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Addressing the Challenge of Pain Education in Low-Resource Countries: Essential Pain Management in Papua New Guinea

Marun, Gertrude N. MMed (Anaesthesiology)*; Morriss, Wayne W. MBChB, FANZCA†,‡; Lim, Jessica S. BMed, FANZCA, MMed (PainMgmt)§; Morriss, Jacqueline L. NZRN, PGDipHealSc (Advanced Nursing); Goucke, C. Roger MBChB, FANZCA, FFPMANZCA

Author Information
doi: 10.1213/ANE.0000000000004742

Abstract

See Article, p 1605

Poorly treated pain is a global health care problem.1,2 It is estimated that 5.5 billion people (80% of the world’s population) do not have access to treatments for moderate to severe pain, with the majority of these people living in low- and middle-income countries (LMICs).3,4

Multiple reasons for inadequate pain management have been identified, including differing cultural attitudes toward pain, inadequate health care worker numbers, poor knowledge and attitudes among health care workers, and lack of access to appropriate treatments (including opioid analgesics).2 Pain management education is often inadequate,5,6 and it is likely that this contributes to poor pain management at the bedside as well as a lack of effective advocacy at higher levels.

The Essential Pain Management (EPM) educational program was developed in 2009 following a request from Papua New Guinea (PNG) clinicians for a course to address the challenge of pain management education in that country.7,8 This article outlines the development of EPM in PNG from 2010 to 2018.

PAPUA NEW GUINEA

PNG is a South-West Pacific nation comprising 600 islands with a population of more than 8 million people. Despite abundant natural resources, it is classified as a low human development country by the United Nations with a ranking of 153 of 188.9 It has a low per capita gross domestic product (US $2723 in 2018 compared to US $62,641 for the United States) and is classified as a lower middle-income country by the World Bank.10 PNG is one of the most culturally diverse nations in the world with more than 800 indigenous languages.11

The health care challenges facing PNG are considerable.12 More than 80% of the population lives in remote and rural areas that are often mountainous and geographically isolated from larger population centers. This contributes to late presentations with more advanced disease. In 2009, PNG had 326 doctors, 1622 nurses and midwives, 87 health extension officers (HEOs), and 1093 community health workers (CHWs).13 HEOs are nonphysicians who are able to prescribe and administer some medications as well as perform nursing roles, while CHWs have more limited training and scope of practice. Most doctors work in the capital, Port Moresby, and consequently, care in rural areas is usually provided by nonphysicians. Anesthesia services, including pain management, are currently provided by 22 anesthesiologists, 20 trainee anesthesiologists, and 85 nonphysician anesthesia providers (called anesthetic scientific officers or ASOs) (Dr Arvin Karu, Division of Anaesthesia and Intensive Care, Port Moresby General Hospital, Port Moresby, Papua New Guinea, personal communication, November 20, 2019).

There are very limited data on the burden of painful disease in PNG. Cancer is common, with oral, cervical, breast, and liver the most frequently diagnosed types.14 The incidence of acute pain secondary to trauma is high; causes include road traffic accidents, domestic violence, assault, tribal fighting, and self-harm.15 Pain relief for childbirth is usually not offered. The prevalence of chronic noncancer pain is likely to be similar to other LMICs and at least as high as the prevalence in high-income countries.16

RATIONALE AND STRUCTURE OF EPM

The aims of the EPM7,8,17 program are as follows:

  • To improve pain knowledge,
  • To teach a simple system for managing pain, and
  • To address local pain management barriers.

EPM is usually delivered as an interactive, multidisciplinary 1-day workshop comprising short interactive lectures, brainstorming sessions, and small group case discussions. There are typically 4–5 instructors and 20–25 participants. The standard 1-day program is shown in Supplemental Digital Content, Appendix 1, http://links.lww.com/AA/D48.

EPM uses the “RAT system” as a framework for managing different types of pain. RAT is a simple teaching tool that stands for Recognize, Assess, and Treat, and is analogous to the ABC approach used in trauma management. The classification of pain is simplified and participants are encouraged to consider nonpharmacological as well as pharmacological treatments. The small group case discussions are a vital part of the workshop because they allow participants to apply the RAT system to a range of clinical scenarios and formulate locally appropriate multidisciplinary management plans.

The EPM program emphasizes early handover to local health care workers, and a half-day workshop has been developed to specifically prepare local instructors to organize and teach the program (Supplemental Digital Content, Appendix 2, http://links.lww.com/AA/D48). Typically, a “one-half-one” approach is used over 3 days. On day 1, the standard 1-day workshop is delivered. On day 2, the instructor workshop is delivered and 10–15 instructors are trained. On day 3, the newly trained instructors deliver 2 concurrent standard 1-day workshops. Day 3 is a critical part of the process because it reinforces course knowledge and also allows the newly trained instructors to put their instructor training into immediate action.

In 2014, a condensed workshop called EPM Lite was developed. It can be delivered in 4–5 hours and is primarily designed for undergraduate medical and nursing students but can also be used for time-poor clinicians. EPM Lite has similar content to EPM but omits the sessions on barriers.

EPM WORKSHOPS IN PNG

The 1-day EPM workshop was piloted in Lae, PNG, in 2010. Lae is the second-largest city in the country, with a population of 100,000, and relatively good connections to the mountainous Highlands region. Angau Memorial Hospital in Lae was, at the time, the main cancer referral hospital for PNG.

The pilot workshop was followed by a 1-day workshop in the capital, Port Moresby. Port Moresby has a population of 360,000 and is the home of the country’s largest hospital, Port Moresby General Hospital, and the University of Papua New Guinea Medical School.

Between 2010 and 2018, in total, 42 one-day workshops were held in 12 locations across PNG (Table 1, Figure 1). A total of 783 health care workers attended the 1-day workshop and a range of health care cadres was represented (Table 2). During the same time period, 60 instructors were trained during 6 instructor workshops. Twenty-nine of the 42 one-day workshops (69%) were taught entirely by local instructors. Four EPM Lite workshops were held between 2016 and 2018, attended by 109 nursing and medical students.

Table 1. - EPM Workshops in PNG 2010–2018
Year EPM Workshops Instructor Workshops EPM Lite Workshops
Number of Workshops Number Trained Number of Workshops Number Trained Number of Workshops Number Trained
2010 7 131 1 7
2011 10 166 1 8
2012 6 115 0 0
2013 2 38 0 0
2014 3 56 1 7
2015 9 175 0 0
2016 3 67 1 13 1 42
2017a 0 0 0 0 0 0
2018 2 35 2 25 3 67
Totals 42 783 6 60 4 109
Abbreviations: EPM, Essential Pain Management; PNG, Papua New Guinea.
aNo workshops were conducted in 2017 due to lack of funding.

Table 2. - Roles of EPM Participants (n = 783)
Role Number
Nurse 372
Doctor 142
Community health worker 81
Anesthetic scientific officer 70
Health extension officer 50
Pharmacist 11
Physiotherapist 8
Dental officer/therapist 7
Other role 23
Not specified 19
Total 783
Abbreviation: EPM, Essential Pain Management.

Figure 1.
Figure 1.:
Delivery of EPM workshops in PNG 2010–2018. EPM indicates Essential Pain Management; PNG, Papua New Guinea.

Workshop costs included instructor travel and accommodation, printing of manuals, catering, and, in some locations, venue hire. Workshop participants were not given a per diem payment. The majority of funding was provided by the Australian and New Zealand College of Anaesthetists (ANZCA) with significant contributions by the Ronald Geoffrey Arnott Foundation, Australian Society of Anaesthetists, PNG Department of Health, and World Federation of Societies of Anaesthesiologists (WFSA).

PROGRAM EVALUATION

The Kirkpatrick model for evaluating training programs has been used for a variety of clinical programs, and we have found this structure useful during EPM development in PNG.18–21 The 4 Kirkpatrick levels are as follows:

  • Level 1: Reaction
  • Level 2: Learning
  • Level 3: Behavior
  • Level 4: Results

Levels 1 and 2 evaluations have been performed regularly since the inception of EPM. Levels 3 and 4 evaluations have proved much more challenging because of limited resources.

Level 1: Reaction

Participant feedback was collected at the end of all EPM workshops, and this has been important for assessing immediate reaction to the workshop as well as guiding improvements in course design and delivery. Initially, feedback was obtained using individual written forms that included Likert scales to assess participant satisfaction and potential changes in knowledge, attitudes, and skills. From 2016, we have used a technique where participants work together to write responses on a whiteboard to 3 questions: “What I learned,” “What I liked,” and “What to change about the workshop.” This has proved to be a very simple but effective method because it encourages group engagement and constructive suggestions, and the responses are easy to tally. Table 3 gives a summary of feedback obtained at the end of a workshop in Lae, PNG, in 2018.

Table 3. - Summary of Participant Feedback, Lae, July 2018
What I learned Use of the RAT system and WHO ladder
Nonpharmacological and pharmacological treatments
Different types of pain
Pain management barriers
Multidisciplinary management
What I liked RAT system
Case discussions
Use of local facilitators
What to change Nothing!
Need more workshops
Need to involve more nurses
Need an obstetric scenario
Abbreviations: RAT, Recognize, Assess, Treat; WHO, World Health Organization.

Feedback has led to improvements and alterations in program content and delivery such as involvement of a wider range of health care professionals (in particular pharmacists, rural CHWs, and ASOs), more regular workshops, provision of a soft copy of the workshop manual, the development of EPM Lite, and development of the EPM mobile application.

Level 2: Learning

The workshops have included a test at the beginning of the workshop and a second test at the end (preworkshop and postworkshop tests) to assess knowledge acquisition. The current tests have a multiple true-false (MTF) format (Table 4) and are mapped to specific learning objectives. Five 5-part MTF questions are used at the beginning of the workshop, and these questions are repeated at the end of the day along with an additional 5 matched 5-part questions.

Table 4. - Example of MTF Question Used in EPM
Question 1
A 52-y-old man caught his right hand in machinery at work 1 h ago. He has open fractures and is in severe pain. He will be going to theatre later.
a. T F The pain type is acute, nociceptive, noncancer pain.
b. T F An opioid is an appropriate pharmacological treatment.
c. T F If opioids are used for more than 48 h, there is a high risk of addiction.
d. T F Suitable nonpharmacological treatments include reassurance at the same time as medication is being given.
e. T F Analgesia should not be given until the surgeon has seen the patient.
Abbreviations: EPM, Essential Pain Management; MTF, multiple true-false.

In general, we have seen modest improvements between preworkshop and postworkshop scores. For example, in Madang, in July 2018, the mean preworkshop score was 65% and the mean postworkshop score was 77%. Questions relating to concerns about opioid side effects and addiction have often shown less improvement than questions mapped to other domains. To date, we have not evaluated knowledge retention after a fixed time, for example, 6 months or 1 year, but this is part of our plan for future course evaluation.

Levels 3 and 4: Behavior and Results

In July 2018, in an attempt to get some feedback on possible behavioral changes and impact on patient outcomes, we performed structured interviews on 20 health care workers who had previously attended an EPM workshop (between 2010 and 2017). The interviews were planned as an informal quality assurance activity rather than a rigorous qualitative study. They were conducted by 2 external EPM instructors (J.S.L. and J.L.M.) using a standardized set of questions that focused on clinical, educational, and other changes since attending the EPM workshop and ongoing barriers to effective pain management (Supplemental Digital Content, Appendix 3, http://links.lww.com/AA/D48). The interviewees came from a variety of backgrounds and included 11 nurses, 7 doctors (5 anesthesiologists, 2 obstetrician-gynecologists), 1 ASO, and 1 midwife. The interviews were recorded and transcribed, and the responses were grouped thematically by the interviewers. The themes and transcribed interviews were reviewed by the other authors to check for consistency and completeness. The following themes were identified:

  • Increased knowledge leading to change in clinical practice

Many patients come out of surgery and they yell and scream. I assess the patient and ask the anesthetist to intervene so we can give something to relieve the pain. Before we didn’t do that because we thought it was part of the surgery. (nurse)

It has greatly improved my practice especially recovery times for post-op patients. I get them to sit up and walk sooner than expected, most obviously because of the good pain management I learned from the workshop. (obstetrician-gynecologist)

Those of us who have attended the course are very vocal when we are dealing with patients especially in the theatre and when we see patients who are in pain. We don’t stop, we talk, if there is a need to give pain killer we go ahead and do it. (nurse)

  • Dissemination of education to other health workers

I think it has really significantly changed … our nurses so they are really concerned about pain in critically ill patients and even in the operating theaters now. Staff don’t seem happy if the patient is going out in pain. They will think of us to come and make sure there is adequate pain relief on board before the patient is transferred. (anesthesiologist)

I am working in the general hospital, whatever we are applying here should be applied in the rural health centers as well. Those that come in for delivery or have tears and all this - we can apply the same principles on what the staff are working on out there as well. (midwife)

The significant changes that I’ve seen in my ward especially after we educated our nurses on how to use the pain scale to improve the quality of treatment that we give to our patients. They assess their patient according to the pain scale system, so every time they do the observations they also include the pain to see whether the patient is comfortable. (nurse)

  • Increased use of multimodal analgesia

Initially when I started we would just give one or the other like just diclofenac or paracetamol but now after the EPM course, on the gynecological ward and even the post cesarean section patients, we give a combination of drugs and we understand better. Infusions for the opioids - morphine and pethidine have always been there - but adding things like one of them with PR paracetamol or diclofenac, that has been a new thing. (obstetrician-gynecologist)

Earlier on in the cancer ward and other general wards the staff were a bit reluctant to use morphine and they don’t use combined therapies like adding paracetamol to the opioids. They will just give pethidine on its own. But since the EPM, that practice has changed. Nowadays they’re using combined therapies even with pethidine. (anesthesiologist)

  • Use of the RAT system

I follow the RAT system to ensure you start simple then you make your way up to ensure you treat pain. Although I teach the students analgesics and the pharmacology, I still try to simplify the clinical management using the RAT system. (anesthesiologist)

The RAT. How to recognize, assess and treat. Well I think it’s a very simple concept I see that you can really pick it up the way it’s been taught in the course. (nurse)

PAIN MANAGEMENT BARRIERS

The 1-day EPM workshop includes group discussion and brainstorming on issues that prevent pain being managed as well as it could be (pain management barriers) and how these can be overcome. Participants are encouraged to find local solutions for local problems. EPM workshops in PNG have revealed common and consistent themes, including lack of education and training, inadequate numbers of health care workers, lack of medications, and low prioritization of pain management due to health worker and patient attitudes as well as cultural beliefs.

Ninety-three percent of participants at an EPM workshop in 2018 stated that they had not had specific formal undergraduate training in the multidisciplinary management of pain. As a result, none of these participants had felt confident in their ability to manage pain at the end of their training. Participants suggested incorporation of EPM training into the undergraduate medical and nursing programs, more regular EPM workshops for hospital staff, and the introduction of simple pain management protocols based on the EPM workshop and RAT system.

Participants have consistently identified a lack of medications or inconsistent supply as a major barrier. For this reason, pharmacists have also been encouraged to participate in the EPM workshops. Lack of access to opioids is a common issue and often compounded by exaggerated health care worker concerns about the harmful effects of opioids, for example, respiratory depression and addiction.

From a cultural point of view, pain in PNG is frequently seen as an inevitable part of life. For men, in particular, any demonstration of discomfort or pain is seen as sign of weakness. Many health care workers also see pain as an expected part of illness and surgery, and the need to manage pain is often not seen as a priority by these workers. These beliefs and the reasons for treating pain are discussed during the workshop.

A number of specific barriers were identified during the July 2018 interviews:

  • Lack of availability/inconsistent supply of analgesic medications

The difficult thing is when we don’t have the drugs. We usually run short of drugs so when someone is in pain we just comfort them. (nurse)

Where I’m working most of the time we don’t have those pain killers in the dispensary. Sometimes we run short of pain killers. That’s the barrier. (midwife)

We would really love to get the immediate release oral morphine but for some reason it is very difficult to get … I’ve tried to talk to the narcotics bureau because they control the drugs here, the opioids. That’s the police department, not department of health. That’s how difficult it is. (anesthesiologist)

  • Lack of knowledge among health workers

It would be great if everyone could go through the course, it doesn’t matter if you are a doctor or nurse. We have to know why we are doing this. Most doctors and nurses see the results, they don’t need to question it, they can see the results. It would be good to have lots of people involved especially the guys at the pharmacy. That’s the biggest barrier, changing that mindset. (obstetrician-gynecologist)

In the operating theatre we work closely with the anesthetist and it is ok, but in the wards for the post op care I would suggest our nurses need to be more knowledgeable. I think they are a bit scared to use the different pain relief drugs on one patient, maybe they lack the knowledge. They are aware but reluctant. They need to understand more on certain drugs so they feel competent to give it. (nurse)

The course is very important so we should educate everybody. (nurse)

  • Lack of staff

I think it’s knowledge and the other thing related to that is the issue of inadequate staffing in order to give adequate pain relief. These two often go together. (anesthesiologist)

  • Myths/culture

Some of the myths like in college we were taught not to give too much opioids, they might get addicted to the drug. So, it’s a big change from that point. And another barrier would be culture. Where we come from, especially males. Males when they are very strong, when they are in pain, they don’t actually say the word pain. It’s you who will have to approach them, ask how they feel. (nurse)

SUCCESSES AND CHALLENGES

The aims of the EPM program are to improve pain knowledge, to teach a simple system for managing pain, and to address local pain management barriers. During the first 8 years of EPM in PNG, we have had a number of successes but there are significant ongoing challenges.

In total, we have delivered 52 workshops (42 one-day, 6 instructor, 2 EPM Lite) to more than 900 participants. Feedback from participants has been positive, and pre- and posttest scores have shown modest improvements. The RAT system for managing pain appears to be an easily understood educational tool that can be easily applied to a range of clinical scenarios.

The EPM program emphasizes early handover to local instructors. This promotes local ownership and the development of local solutions to local problems, both educational and clinical. In our view, the fact that more than two-thirds of the workshops were taught entirely by local instructors is an important success.

PNG has very limited health care resources, including severe staff shortages, and the availability of resources for educational activities is also very limited. In this context, the relatively rapid local uptake and spread of EPM could be seen as evidence of the need for pain management education and the appeal of a simple and practical approach.

The multidisciplinary nature of the EPM program in PNG has been groundbreaking for some participants who are used to more formal educational programs that involve only 1 cadre of health care workers. Participants often contribute different but complementary viewpoints during the case discussions, for example, nurses are often much more aware of nonpharmacological treatment strategies than doctors. Discussions on barriers and solutions are often enlivened by input from a range of health care workers, for example, input by pharmacists on medication issues.

Similarly, the interactive teaching techniques used in EPM have been new for some health care workers. Lectures are designed to be short and interactive, there are usually high levels of engagement during small group case discussions, and the brainstorming sessions on barriers usually provoke good constructive debate.

Major challenges include a lack of funding, limited uptake at undergraduate level, the need more formal evaluation of clinical impact, and the requirement for an all-of-system approach to improve pain management in PNG.

External funding has been required for most EPM workshops in PNG. The costs are relatively low but include instructor travel and accommodation, catering, and printing. The National Department of Health and local hospitals/institutions have provided limited funding but greater commitment by the government and/or teaching institutions will be required if EPM is to become financially sustainable in PNG.

We have had limited success regarding introduction of EPM teaching into the undergraduate nursing and medical curricula. EPM Lite is now taught to medical students at Divine Word University in Madang and is part of the nursing curriculum in some institutions; however, we have been unable to establish regular EPM Lite workshops in the main nursing and medical schools in Port Moresby. We regard undergraduate teaching of EPM as an important first step in changing health care worker knowledge and attitudes.

Continuous program evaluation is a vital part of EPM. Level 1 and 2 evaluations are encouraging but more detailed evaluation of clinical impact is required. We would like to be able to collect patient-reported outcome measures (PROMs) such as patient satisfaction, pain intensity scores, and functional measures; however, analysis of these data is likely to be complex as PROMs reflect multifactorial influences on the patient’s journey through the health care system.22 Our recent survey provides some anecdotal evidence of behavioral change and possible improved patient outcomes, but properly designed and funded qualitative and/or quantitative research is required.

Finally, EPM aims to improve pain management knowledge and attitudes, but an all-of-system approach is needed to improve the overall provision of pain management. Knowing what is required is not the same as being able to provide what is required. Other issues, such as poor availability of analgesic medications (especially opioids) and workforce shortages, must also be addressed. It is our hope that EPM will continue to produce local champions who will advocate for and effect change in the PNG health care system.

EPM, PNG, AND THE WORLD

Since the pilot workshop in PNG in 2010, EPM has been taught in more than 60 countries worldwide (Figure 2; Supplemental Digital Content, Appendix 4, http://links.lww.com/AA/D48). Approximately 10,000 health care workers have attended the 1-day EPM workshop, although this number is likely to be an underestimate because of handover to local instructors and limited reporting of locally run workshops.

Figure 2.
Figure 2.:
Global delivery of EPM workshops 2010–2019. EPM indicates Essential Pain Management.

The EPM program has expanded more quickly than anticipated and this suggests that there is a need for simple and practical pain management education that can be readily adopted by local health care workers. Oversight of the EPM program was initially performed by an ANZCA committee but, in 2018, a memorandum of understanding was signed between ANZCA and the WFSA that sets out plans for further expansion and consolidation of the program. Our priorities for coming years include support for embedding EPM into health care systems and teaching programs, increased mentorship for instructors, assistance with overcoming local pain management barriers, and development of specific projects that will assess the impact of EPM education on patient outcomes. There has been a shift toward longer projects that focus on the development of the program in a specific country or part of a country where monitoring and evaluation are integral to the project and specifically funded.

Our experience with the development of EPM in PNG illustrates that local health care workers are enthusiastic about pain management education, and there are encouraging signs that EPM is changing behaviors and improving patient outcomes in PNG and other low-resource countries. We need to demonstrate this in the coming years and work with our colleagues to ensure that better knowledge translates into better outcomes for our patients.

ACKNOWLEDGMENTS

Tenkyu tru to our friends and colleagues in PNG, including Dr Harry Aigeeleng, Dr Nora Dai, Dr Pauline Wake, Dr Magea Pole, Claire Matainaho, and Sister Rahela Babona. Thanks also to Dr Michael O’Connor, Dr Linda Huggins, and many other EPM instructors worldwide who have contributed to the development of EPM. Special thanks to Kate Davis and Anthony Wall at the Australian and New Zealand College of Anaesthetists for their untiring administrative support.

DISCLOSURES

Name: Gertrude N. Marun, MMed (Anaesthesiology).

Contribution: This author coordinated EPM training in Papua New Guinea, assisted with workshop delivery, collected data, and helped draft and edit the manuscript.

Name: Wayne W. Morriss, MBChB, FANZCA.

Contribution: This author coauthored the EPM program, assisted with workshop delivery, and helped conceive, draft, and edit this manuscript.

Name: Jessica S. Lim, BMed, FANZCA, MMed (PainMgmt).

Contribution: This author assisted with workshop delivery, collected and analyzed data, and helped draft and edit the manuscript.

Name: Jacqueline L. Morriss, NZRN, PGDipHealSc (Advanced Nursing).

Contribution: This author assisted with workshop delivery, collected data, and helped draft and edit the manuscript.

Name: C. Roger Goucke, MBChB, FANZCA, FFPMANZCA.

Contribution: This author coauthored the EPM program, assisted with workshop delivery, and helped draft and edit this manuscript.

This manuscript was handled by: Angela Enright, MB, FRCPC.

FOOTNOTES

GLOSSARY

ANZCA = = Australian and New Zealand College of Anaesthetists

ASO = = anesthetic scientific officer

CHW = = community health worker

EPM = = Essential Pain Management

HEO = = health extension officer

LMICs = = low- and middle-income countries

MTF = = multiple true-false

PNG = = Papua New Guinea

PROM = = patient-reported outcome measure

RAT = = Recognize, Assess, and Treat

WHO = = World Health Organization

WFSA = = World Federation of Societies of Anaesthesiologists

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