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

Abstract

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.