Being admitted to hospital is supposed to bring relief. But for thousands of patients across Africa, hospital care comes with another burden: severe pain. A landmark study led by the University of Cape Town (UCT) found that two-thirds of adults admitted to hospitals across Africa experienced pain, while one in seven suffered severe pain. The study was funded by the National Institute for Health and Care Research Global Health Group in Perioperative and Critical Care.
A study of 19 438 patients in 180 hospitals across 22 African countries found that 67.9% of patients reported some level of pain, while 14.4% rated their worst pain during the previous 24 hours at seven or more out of 10 – the study’s definition of severe pain.
The findings suggest that acute pain is not a marginal problem confined to a handful of patients. It is widespread across African hospitals and remains an under-addressed global health problem. The study is one of the largest yet to examine the burden of acute pain in African hospitals.
Pain was particularly common among patients admitted following trauma, where 84.1% experienced pain and 20.3% reported severe pain.
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Patients in surgical wards were also more likely to experience pain than those in medical wards. Severe pain was reported by 16.2% of patients in surgical wards, compared with 11.1% in medical wards. High-care units recorded a prevalence of severe pain of 19.3%.
The researchers found no meaningful overall difference in pain severity between men and women.
Concerns
The relationship between pain and survival was a concern to the researchers. After taking other factors into account, increasing pain severity was associated with a greater likelihood of dying in hospital within seven days. Patients with severe pain had 27% greater odds of dying within seven days than those without severe pain.
The study did not collect information about which pain medication or other treatments patients received. It therefore cannot determine whether particular approaches to pain relief reduced pain or influenced patients’ chances of survival.
“Further studies are needed to determine whether pain is a warning sign, a contributor to poor clinical outcomes.”
“We stress that this does not mean severe pain causes death,” said Dr Gillian Bedwell, a postdoctoral research fellow in UCT’s African Pain Research Initiative (APRI), who led the new study, published in PAIN. The APRI is based in the Department of Anaesthesia and Perioperative Medicine and the Neuroscience Institute.
Because the study was observational, it cannot establish cause and effect. Severe pain could instead be a sign of an underlying condition that makes a patient more vulnerable to dying. “Further studies are needed to determine whether pain is a warning sign, a contributor to poor clinical outcomes, or both,” said Dr Bedwell.
Significance of findings
For Bedwell, the findings expose an important blind spot in healthcare. “Africa has historically had little large-scale data on pain among hospitalised patients. Previous international estimates have largely come from high-income countries, leaving a major gap in understanding what patients experience in African hospitals.”
The study suggests the burden of pain is surprisingly similar to that of high-income countries despite vast differences in healthcare resources.
According to Bedwell, the significance of these findings extends beyond pain itself. “Acute pain in hospital is sometimes viewed primarily as a symptom to be endured while the underlying illness or injury is treated. But poorly managed acute pain can have broader consequences for patients, their families and health systems.”
“Recognising and managing pain effectively should be a fundamental part of providing high-quality hospital care.”
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In addition to causing substantial distress, Bedwell said that poorly managed acute pain can interfere with sleep, movement and rehabilitation, and has been associated with delayed recovery and other clinical complications. Its effects, she said, may also extend beyond the hospital stay, contributing to delayed return to normal activities and work, greater demands on caregivers, and increased healthcare use and costs.
“Recognising and managing pain effectively should be a fundamental part of providing high-quality hospital care,” said Bedwell. “The next step for this work is to better understand how acute pain is currently assessed and managed in African hospitals, what prevents patients from receiving effective pain relief and which strategies could improve care.”
APRI and the African Perioperative Research Group are now developing a programme of research to address these important questions across African hospitals.
