Barriers and facilitators to postoperative pain management in Rwanda from the perspective of health care providers: A contextualization of the theory of planned behavior

Aims: Identify opportunities to improve knowledge translation for post-operative pain management in Rwanda by exploring clinician and environmental factors affecting this practice. Methods: The theory of planned behavior (TPB) guided development of a questionnaire to measure intent to assess and treat postoperative pain. Focus groups and individual interviews were used to contextualize the final questionnaire and generate questions related to pain management practice. Health care providers from two Rwandan teaching hospitals involved in postoperative pain management completed the TPB questionnaire in May 2015. TPB subscale scores were analyzed to identify demographic and practice characteristics associated with intention to treat pain. The general linear model was used to test effect of attitudes, subjective norms, and perceived control on behavioral intent to treat pain. Results: Forty-six percent of participants (N = 131) had training in acute pain management, 56% used a pain protocol, and 74% used pain scales. Tramadol (78%), morphine (79%), and paracetamol (75%) were used most often to treat pain. Drug availability was the most frequently reported barrier to treating pain. Though intention to treat pain was high, only attitudes and perceived control about assessing pain were associated with intention to treat pain. The theme of fear of the adverse effects of pain medications was consistent across focus groups and interviews in both sites. Conclusions: System and knowledge barriers exist: interventions to address these barriers may lead to improved postoperative pain care. Further validation of the TPB questionnaire is required to address cultural and language factors specific to the Rwandan context.