Healthcare Workers' Knowledge Attitude and Practice in Management of Pain During Acute Pain Crisis in Children With Sickle Cell Disease in Homabay County Teaching and Referral Hospital-mixed Methods Study

Abstract

Background: Sickle cell disease has contributed significantly to mortality rate in children; pain is a regular problem during painful crises. Studies have shown that it is the most common cause for admission in children with sickle cell disease. Pain has significant physiological effects on the body during a painful crisis, and severe painful crises are associated with severe disease complications. There is minimal evidence on the level of knowledge among health care workers regarding pain assessment, use of pain scales/tools, and treatment. Some existing evidence suggests that healthcare workers (HCWs) have misconceptions about opioid use to manage pain. Study Objective: To assess knowledge, attitude, and practice of health care workers, regarding assessment and treatment of acute pain crisis in children with sickle cell disease in Homabay County Hospital. Study design and setting: Two-phase study – phase A, observational cross-sectional design, and phase B, a retrospective abstraction of medical records. Data collection methods were concurrent mixed method in phase A where quantitative followed by qualitative data collection (FGDs and KII) was done. Phase B - quantitative data abstracted from medical records. It was conducted in Homabay County Teaching and Referral Hospital (Homabay CH) a county referral hospital in Western Kenya. Study Methods: Phase A: pretested questionnaire was administered to HCWs. The study used both knowledge and attitude (K&A) questionnaire (Appendix II). Two FGDS conducted one for clinicians and one for nurses, KII done with four Hcws. The study included HCWs in the paediatrics and medical ward attending to children hospitalized with acute pain crisis (n = 50).Inclusion criteria mentioned HCWs in paediatrics and medical wards, pharmacists and pharmaceutical technologists working in main pharmacy. Exclusion criteria HCWs with less than 6 months of experience and pharmacist/pharmaceutical technologist not working in the main pharmacy. 16 Phase B: Retrospective evaluation of pain management in children over preceding two years by reviewing medical records. This was done by use of a structured audit tool (Appendix I). To abstract data from patient files and treatment sheets retrospectively. The study population comprises of children diagnosed with and hospitalized with acute pain crisis in the paediatrics ward and medical ward of HCTRH (N=67). Inclusion criteria Children and adolescents with a diagnosis of aged 6 months to 18 years old hospitalized with acute pain crisis from March 2018 to March 2020 with available medical records. Exclusion criteria children with a diagnosis of SCD hospitalized with other complications, outside the study period, children with missing medical record. Data Analysis Phase A: One point was awarded for each correct/appropriate answer and zero for incorrect/unclear response. Total scores were therefore analysed for each HCW, and HCWs who score between 80-100% were considered to have good knowledge, between 60-79% were regarded as a medium/moderate, while those below 60% were deemed to have poor knowledge. This was applied to knowledge on pain assessment, and on treatment of pain. To explore challenges that HCWs face in implementing optimal pain management for children presenting with acute pain crisis, the study collected qualitative data guided by FGDS and KII. This data was analysed using inductive thematic analysis with the help of NVivo software. Phase B: For each analgesics that was given morphine, tramadol, ibuprofen, and paracetamol, dosage, route, duration and any inconsistency that occurred in administration was analysed and based on WHO analgesic ladder NSAIDS/paracetamol for mild pain, weak opioid for mild to moderate pain, strong opioid for moderate to severe pain it was decided if it was optimal or suboptimal practice. Results: Phase A - We enrolled 50 HCWs, 42 % male and 58% female, by cadre nurses 48%, clinical officers 46% and doctors 6%.70 % of the participants were aged between 21-30 years. Diploma holders 78% and degree being the highest level of education at 22%. By department 56 % medicine department and 44% paediatrics department. 17 HCWs knowledge regarding pain assessment during acute pain crisis was good as Majority of clinicians 58% and nurses 54% had a good score. Regarding knowledge on pain treatment during acute pain crisis HCWS had a fair knowledge, 88% of nurses had a fair score while 54% of clinician had a fair score. HCWs had a negative attitude on opiate use for treatment of pain in children experiencing an acute painful crisis, specifically fear of side effects such as addiction, respiratory distress, difficulty in weaning off morphine and constipation. Challenges that were facing HWCs included opiate drug stock outs, difficulty in accessing morphine when it was available due to administrative barriers, and inadequate pre-service training regarding management of painful SCD crisis. Phase B - We retrieved files for 67 children for phase B to assess pain practices for children treated for SCD acute pain crisis at the hospital during the preceding two years. HCWs practice was found to be suboptimal no assessment of pain was documented and 60% of children were started on morphine (strong opioid) as initial analgesic weak opioid was not used and NSAID was used as an escalation or combination analgesic rather than initial analgesic. Conclusions Health care workers had good knowledge regarding pain assessment during acute painful crisis. HCW's knowledge on pharmacological pain treatment was fair for both the nurses and clinicians, as the majority had a moderate score. Healthcare workers’ had a fearful attitude towards use of opiate analgesics during acute pain crisis. Health care workers' practice regarding pharmacologic treatment of acute pain crisis management was suboptimal, despite having good knowledge on treatment. Challenges that HCWs face during acute pain crisis management are stock outs and limited access to stronger analgesics, and inadequate pre service training in management of acute pain crisis.