Niger J Paed 2015; 42 (1): 28 – 33

ORIGINAL

Ughasoro MD

Management of childhood pain

Udem ND

and healthcare providers’

Ibeneme CA

Uzochukwu BSC

willingness to use topical

Onwujekwe OE

anaesthetic cream for minor

procedural pain in Nigeria

DOI:http://dx.doi.org/10.4314/njp.v42i1,7

Accepted: 17th October 2014

Abstract: Objective: To deter-

the pain. Only one respondent

mine providers’ willingness to use

(1%) knew about TAC, but none

Ughasoro MD

(

)

(WTU) topical anaesthetic cream

had used it before. Over 94% of

Department of Paediatrics,

(TAC) to alleviate childhood pain.

the respondents were WTU TAC.

Uzochukwu BSC

This information will be useful

The mean maximum preferred

Department of Community Medicine,

for successful implementation of

waiting time was 37.03 minutes.

and Department of Health

TAC in Nigeria.

Many (68.8%) were concerned

Administration and Management,

Subjects and Methods: The study

about the prolonged waiting time

was undertaken in hospitals in

required and 19.8% and 12.5%

Onwujekwe OE

southeast Nigeria.

Interviewer-

with its availability and afforda-

Department of Pharmacology and

administered questionnaire was

bility respectively. In linear multi-

Therapeutics, University of Nigeria

used to collect information: on the

variate analyses, WTU was not

Enugu Campus, Enugu, Nigeria.

providers’ preferred waiting time

statistically associated with desig-

Udem ND

and their WTU TAC. Likert scale

nation, age, average weekly proce-

Department of Pharmacy,

was used to assess the providers’

dure and scale-rating of the child-

University of Nigeria Teaching

level of uneasiness when perform-

hood pain ( p > 0.05).

Hospital, Ituku/Ozalla, Enugu, Nigeria.

ing painful procedures and their

Conclusion: The WTU TAC was

WTU the TAC. Multiple regres-

high, but the mean time willing to

Ibeneme CA

sion analyses were performed to

wait was lesser than mean recom-

Department of Paediatrics,

measure the relationship of WTU

mended time of 45 minutes. If this

Federal Medical Centre, Umuahia,

with the different independent

latter limitation is circumvented, it

Abia State, Nigeria.

variables, after creating a binary

may aid implementing the use of

option for some variables.

TAC in routine pediatric care.

Results: Providers surveyed were

232. Majority (94.8%) wanted the

Key words: Nigeria; Willingness

pain alleviated and 87.9% had

to

Use;

Topical

Anaesthetic

made some attempts to alleviate

Cream; Providers.

Introduction

providers handling their children should live up to their

responsibility of effective management of the pain their

children suffer . Although most mothers in a study by

4

Painful procedures are experienced by millions of chil-

dren worldwide . In the developed countries, it is a com-

1

Parvez et al were unaware that TAC can be used to alle-

mon practice to use topical anaesthetic cream (TAC) to

viate pain, but they were confident that their healthcare

alleviate pain amongst children attended to in health

providers’ practice was in the best interest of their chil-

dren . These caregivers were willing to comply with any

5

facilities . But the situation is different for children in

2

middle and low income countries, where pain have gone

management plan without any doubt on the complete-

ness of such treatment plan .With regards to manage-

5

on unattended.

ment of childhood pain, most healthcare providers prac-

According to the framework developed by the World

ticing in resource poor countries have continued to fail

Health Organization for the assessment of performance

in this aspect, essentially due to the limited option avail-

of health system, quality of health, fair-financing, and

able to choose from with regards to management of

responsiveness are the main components . Amongst

3

childhood pain. Those that have attempted to do so re-

these three goals, the latter has continually been over-

lied on the use of less effective non-pharmacologic

looked. It is one of the expectations of mothers that the

strategies, such as distraction or pacifying.

29

In the recent past years, many new introduction that can

viders that participated in the study were randomly se-

achieve anaesthesia of skin principally by applying a

lected from the list. The sample size of 220was calcu-

topical anaesthetics have been introduced. The common-

lated using Epi Info version 7 software. Based on using

est among them is the Eutectic Mixture of Local Anaes-

the power of 80%, 95% confidence level and the pilot

thetic (EMLA), which is suitable for usage in both

survey that suggested a prevalence of 50% of the health

adults and children, with proven safety and efficacy .

6

care providers perform any of the stated painful proce-

The EMLA cream contains 5% pure mixture of two

dures.

anaesthetics, lidocaine 2.5% and prilocaine 2.5%. When

applied on the skin, it achieves anaesthetic on the por-

Data collection

tion of the skin applied to in about 30 minutes

7,8

and it is

widely used in developed countries. This has been found

A pre-tested semi-structured interviewer administered

to be effective.

questionnaire was used to obtain data from providers

over a period of four months, from February to May

Despite increasing evidence on the efficacy of TAC in

2013. Data was collected about the providers’ demo-

reduction of pain associated with minor procedures,

9,10

graphic characteristics, years of practice, and number of

and its safety, its knowledge, as well as its usage in

11

painful procedures performed in a week. The respon-

most sub-Saharan countries such as Nigeria was poor.

dents were requested to subjectively rate their assess-

These gaps in both knowledge and practice need to be

ment of: the children’s painful experiences, and their

obliterated. Since reduction in the incidence of pain chil-

own feeling of uneasiness. Also data was collected on

dren suffer from planned procedures, will both improve

their attitudes on need to alleviate needle stick associ-

the report of illness by children, and also reduce the

ated pain, their pain control strategies, knowledge of

anxiety healthcare providers suffer when discharging

TAC, and their suggested time of action of the topical

their duties.

cream. They were then informed about the recom-

In order to ensure a successful and adept introduction of

mended time range of 30 – 60 minutes required for the

TAC in paediatric practice in these areas, there is need

cream to achieve local analgesia. They were asked to

to determine what providers feel about the pain children

state the maximum time they can afford to wait between

experience and their willingness to use the topical

application of the cream and performing the procedure.

cream. This study was conducted to assess health care

After their knowledge of the time requirement, their

providers’ willingness to use (WTU) TAC for minor

willingness to use TAC was re-evaluated as well as their

painful procedures on children in Nigeria. Such data will

willingness to recommend the topical cream. TheLikert

be helpful in the design of an appropriate health policy

scale was used to evaluate their assessment of the pain

with regards to childhood palliative care in Nigeria.

experienced by these children, unease while performing

painful procedures and their level of willingness to use

the cream. The 5-point Likert scale was used to grade

the level of pain experienced by these children into 5

Materials and Methods

=“very severe pain”, 4 = “severe pain”, 3 =“moderate

Study sites

pain”, 2 =“mild pain”, and 1 =“no pain”. The 4-point

Likert scale was used to grade the uneasiness into; 4

The study took place in the University of Nigeria Teach-

=“always”, 3 = “usually”, 2 =“sometimes” and 1=

ing Hospital (UNTH) Enugu, Enugu State and Federal

“never”. The 5-point Likert scale was used for their

Medical Centre, Umuahia (FMCU) also referred to as

willingness to use topical anesthetic cream into 1=

Queen Elizabeth Specialist Hospital (QEH), Abia State.

“strongly not willing”, 2 = “not willing”, 3= “don’t

The Departments of Paediatrics of the two hospitals are

know”, 4 = “willing” and 5 =“strongly willing”. The

well developed and have healthcare providers of all cad-

open-ended questions were on their pain management

res. In both UNTH and QEH, pediatric related health

strategies, reasons for rejecting TAC, and their com-

care services are available throughout the week. Chil-

ments on the topical cream.

dren seen at clinics that require venipuncture for blood

for laboratory investigations are often attended to at the

Data analysis

clinic areas by intern doctors or at the laboratory by

phlebotomist/laboratory technicians. Those that are to

The data was analyzed using SPSS version 20. The

receive intramuscular injections are attended to by the

mean WTU was computed. In addition, the link of elic-

nurse either in the clinic or in the wards.

ited WTU with different cadre of health care providers

was examined. All the qualitative variables has option of

Study design and sampling

“yes” or “no”, which was entered as “1” for “yes” and

“0’ for ‘no”. The questionnaires were reviewed; the-

This study was a cross-sectional study of the healthcare

matic responses given to different qualitative open-

providers who carry out any of these procedures: intra-

ended questions were obtained, and entered as a binary

venous cannula insertion, venipuncture for blood sam-

response “1” if such response was given by a respondent

ple, and any other form of therapeutic needle skin pierc-

and “0” if no such response was given.” The unease

ing procedures like intramuscular injections at least once

variable was collapsed into a binary scale of “yes” or

in a week. The identified providers were assigned num-

“no”. (Yesunease: “always’ and “usually”; not unease:

bers and the number was use to comply a list. The pro-

“never” and “sometimes”).The 5-Likert scale for pain

30

was collapsed into binary variables (painful: “very se-

Table 1: Demographic characteristics of the respondents and

vere pain” “severe pain”, and “moderate pain”; not pain-

their disposition towards alleviation of pain.

ful: “mild pain” and “no pain”). A binary variable was

Characteristics

Years

N= 232 (%)

obtained from their responses to the willingness to use

Cadre

TAC by grouping “strongly not willing” and “not will-

Doctors

96 (41.4)

Nurses

96 (41.4)

ing” as unwilling; and “willing” and “strongly willing”

Laboratory Scientists/Technician

40 (17.2)

as willing. In overall, the average score for the LIkert

Age: Mean (SD)

scale scores for rating of pains, level of uneasiness, and

20 – 29

35.96 (9.82)

WTU TAC were obtained. Multivariate logistic regres-

30 - 39

68 (29.3)

40 – 49

92 (39.6)

sion analyses were performed to measure the effect:

≥ 50

44 (19.0)

years of practice, perceived degree or severity of pain

Years Practicing:

28 (12.1)

experienced by the children, degree of uneasiness, aver-

Mean (SD)

10.92 (10.51)

age number of painful procedures performed weekly,

Median

6.5

Mode

1

and their cadre: doctor, nurse and laboratory technician/

Range

1-34

phlebotomist, as a health care provider on WTU TAC.

Procedures performed* (n=262)

Intramuscular injection

164 (31.3)

Ethics

Venipuncture

152 (29.0)

Intravenous cannula insertion

140 (26.7)

Immunization

68 (13.0)

The study received ethical approval from the Ethical

Committee of University of Nigeria Teaching Hospital,

*Some respondents gave more than one options.

Enugu. Informed written consent was collected from all

the respondents.

Table 2: Modes of pain control by providers, their knowledge

and willingness to use topical anaesthetic cream.

Characteristics

N = 232 (%)

Results

What was done to alleviate the pain?

Respondents’ demographic characteristics

Counseling

96 (41.2)

Petting

86 (37.3)

Cause distraction

78 (33.3)

Table 1 shows that out of 232 respondents, 41.4%

Use only prominent vein

42 (17.6)

(96/232) were doctors, 41.4% (96/232) were nurses and

Massage the site

28 (11.9)

17.2% (40/232) were laboratory scientists/technicians.

Use small needle

19 (7.9)

The mean year of practice was 10.9 years. On average,

Analgesic (Acetaminophen)

10 (3.9)

Allow to breastfeed

4 (2.0)

46.3 painful procedures were carried out by the provid-

Puncture very fast

4 (2.0)

ers weekly. About 91% (212) felt that the children ex-

Do you know about any Topical Anaesthetic cream?

1 (1.0)

perienced pain during the procedure. Majority (82.7%)

( Yes )

of the respondents accepted to feeling uneasy while per-

Will you be willing to Use Topical Anaesthetic cream?

220 (94.8)

( Yes )

forming painful procedure.94.8% (220) were of the

Will you be willing to use Topical Anaesthetic Cream?

172 (78.3)

opinion that pain should be alleviated, while 87.9 (204)

( Before being informed that average time of action is 45

had made attempt in the past to alleviate such pain. The

minutes ). [n= 220] ( Yes )

mean perceived pain experienced by these children was

Are you still willing to use Topical anaesthetic cream?

124 (64.6)

( After being informed that average time of action is 45

2.9. Intramuscular injection (IM), venipuncture, and

minutes ). [n=192] ( Yes )

intravenous cannula insertion were the main procedures

Doctors (43/124)

43 (34.7)

performed. Majority was of the opinion that pain should

Nurses (57/124)

57(46.0)

be alleviated; likewise, most did adopt some manoeuver

Laboratory Scientists/Technicians (24/124)

24(19.3)

to alleviate the pain.

Table 3 shows that the most common reasons given by

respondents that stated negative willingness to use TAC

Table 2 shows that amongst the things done by the re-

were: time wasting, and the pain experienced is mild.

spondents to alleviate the pains, counseling, petting, and

The major comments made by the respondents

distraction were the commonest. Only one (1/232) of the

were:”there is need to reduce the time of onset of ac-

respondents knew about TAC. Majority of the respon-

tion”, “the cream should be made availability”, and “the

dents stated positive willingness to use the TAC.

cream should be made affordability”.

Amongst those that showed Willingness to Use (WTU)

the TAC, 78.3% (n= 220) ranked their level of willing-

Table 4 shows the regression analysis using the WTU

ness high. The knowledge of the waiting time of 45 min-

TAC of the respondents as the dependent variable, that

utes did not cause much change to their willingness to

different cadre of health care provider, age and presence

use TAC.

of uneasiness had negative coefficients. All the inde-

pendent variables: cadre of profession, age, years of

The mean waiting time suggested by the respondents

practice, average weekly procedures, perception of

was 5.1 minutes. With knowledge of the waiting time of

childhood pain, presence of uneasiness, were not statisti-

45 minutes and 60 minutes, 58.6% (112/192) and 43.1%

cally significant ( P > 0.05).

(82/192) were willing to wait for 45 minutes and 60

minutes respectively. The mean time they were willing

to wait was 37.03 minutes.

31

Table 3: The respondents comment about topical anaesthetic

children warranting physical restraining

15

which these

cream

providers did not find too comfortable doing. Studies

Characteristics

N (%)

have shown both reduction in providers distress follow-

ing educational intervention , as well as reduction in the

16

Reasons for not wanting to use Topical anaesthetic

cream. [n = 28]*

duration taken to secure a venous access and increase in

Time wasting

18 (64.3)

Pain is not much

12 (42.9)

success rate amongst those that used TAC prior to the

minor painful procedures . This means that if the pain

17

Extra cost on patients

2 (7.1)

Suggestions made by the providers on Topical

experienced by these children is alleviated, the practice

anaesthetic cream. [n = 192]

of securing IV access or venipuncture for blood sample

Reduce the time of action.

132 (68.8)

Make topical cream available

38 (19.8)

for investigations will be more successful and cause

Make it affordable

24 (12.5)

minimal distress to the providers. This is further con-

Create awareness

18 (9.4)

firmed by the high attestation from the providers on the

It is not necessary

16 (8.3)

need to alleviate the pain as reported in this study. Inter-

Support its usage

12 (6.3)

Ensure sustainability

8 (4.2)

estingly, the quest for alleviation of the pain is within

reach. Studies have demonstrated that TAC can reduce

*Some gave more than one responses

the pain associated with intramuscular injection, intrave-

nous cannula insertion and venipuncture

18,19,20

.

Table 4: Ordinary regression analyses of WTU vs .

independent variables

The utilization of these TAC if introduced in this local-

Variables

Measurement

Coefficient.

P -value

ity will not be a problem, since majority of the provid-

Doctors

1= Doctor

-0.260

0.62

ers’ surveyed in this study showed high willingness to

0 = if otherwise

use it. This provider’s willingness to use together with

Nurses

1 = Nurse

-0.170

0.72

0 = if otherwise

the high parental/caregivers willingness to pay and stay

Laboratory Scientist

1 = Lab. Scien-

-0.042

1.00

for “painless” intravenous catheter placement that has

been reported by other studies, Walsh et al and

21

tist/Technician

0 = if otherwise

Ughasoro et al . In the study by Ughasoro et al in Nige-

22

Age (Child’s age in

(< 1 years and ≥

-0.622

0.54

years)

2 years).

ria, the caregivers’ willingness to pay for TAC was

high . This gave insight the value; pain relief, that par-

22

Years of Practice by the

( ≤ 5years and ≥

0.157

0.88

Provider.

6 years)

ents anticipated from the use of TAC on their children.

Average weekly painful

( ≤ 14 procedures

0.161

0.35

Nonetheless, one major obstacle to the smooth introduc-

procedures.

and ≥ 15 proce-

dures)

tion of a TAC in this locality is the lack of knowledge of

Perceived intensive of

(Painful and not

0.023

0.88

the existence of such medical innovation amongst health

pain

painful)

care providers. In this survey, only one provider; a doc-

Presence of uneasiness

(Unease and not

-0.036

0.82

tor, acknowledged knowing about any form of TAC.

unease)

What most do to alleviate pain is mainly cognitive, non-

P < 0.05

pharmacologic methods. This is similar to what Kozer et

al reported in their study .

9

The providers’ mean willingness to use TAC was

Discussion

slightly reduced after they were informed about the re-

quired time to achieve local anaesthetics compared to

Children that sought care from healthcare facilities have

their prior mean willingness to use, though the marginal

continued to experience painful procedures. Intramuscu-

difference was not much. One major shortcoming of

lar injection, venipuncture and intra venous cannula in-

TAC is the relatively prolonged time required for effec-

sertion were the commonest procedures. This is similar

tive anaesthesia to be achieved. Nonetheless, in spite of

to what Wong et al reported in their study . Apart from

12

the providers’ resentment towards the prolonged time

the pain of the illness that brought the child to the hospi-

requirement, 58.6% and 43.1% were still willing to wait

tal, the pain of IV cannula insertion, venipuncture and

for 45 minutes and 60 minutes respectively, with a mean

IM injection is the next . Interestingly, children that

13

of 37 minutes. But according to the study by Fein et

will undergo these minor painful procedures can be pre-

al which showed that nurses in emergency were able to

14

dicted according to Fein et al . Therefore, implementa-

14

predict children that will require IV insertion with rela-

tion of any prior measure that has the capacity of allevi-

tively impressive sensitivity of 72% and this was further

ating these pains is practicable.

improved when combined with a consideration of the

child’s recent medical history . Thus combination of

14

It was very insightful to find out that majority of the

both nursing prediction and the objective criteria upon

providers that perform these minor painful procedures

which their prediction was based upon will reduce both

felt some form of uneasiness, although the mean level of

time and product wastage. Therefore while research is

the uneasiness was relatively low.

Nonetheless, the

ongoing on how to reduce the time of onset of action of

finding of this uneasiness amongst providers is a possi-

TAC, judgment based on the power of prediction can be

ble indicator that they are concerned about the pain these

used to identify children that may require minor painful

children go through. It has been shown that performing

procedure and TAC applied way ahead of time. Interest-

these minor procedures on children are always go hand-

ingly, several advancements are available to shorten

in-hand with non-cooperation and restiveness from these

32

onset of skin anaesthesia to 5 minutes or less; iontopho-

pain experienced by these children. All but one of the

resis, ultrasonic pretreatment of skin and needle free jet

providers did not know about TAC, and though have not

injection of the local anaesthetics . Although these pro-

23

used it. There was high willingness to use TAC by pro-

tocols may not be easily applied in the sub-Saharan

viders, if made available. But majority suggested that

practices, but they offer hopes.

reduction in the time of action will improve its suitabil-

ity and applicability in healthcare services. Thus reduc-

The hypothetic nature of this study is one major limita-

tion of pain and distress in these children and anxiety in

tion. It would have been more appealing if objective the

the providers by the use of TAC will ensure immediate

providers’ willingness to use the TAC were also

procedural success and other long term benefits. There is

assessed after use of the TAC. Since what appears

need for policy makers to consider a reform that will

desirable ex-ante (hypothetical) may not be so ex-post. It

include the use of these agents during minor painful

is those who have used the product that will have a bet-

procedures especially in children.

ter understanding and more convinced in their decision.

Therefore, prior to wide introduction of the TAC in

Nigeria, an ex-post survey will be done. Therefore any

Authors’ Contribution

difference observed between the two studies (ex-ante

MDU conceptualized the study. MDU, BSU and OEO

and ex-post) will represent to a larger extent the real

designed the study. MDU, NDU and CAI participated in

value of the providers’ willingness to use the TAC.

data collection. BSU and OEO carried out the initial

Therefore the ex-ante study (this present study) repre-

data analyses. MDU drafted the initial manuscript. All

sents the opinion of providers’ naïve on use of TAC.

the authors reviewed the manuscript and approved the

final manuscript.

Conflict of interest: None

Funding: None

Conclusion

In contrast to previous belief that performance of painful

procedures does not affect providers, virtually all pro-

Acknowledgements

viders agreed to feel some form of uneasiness. They

rated the pain these children felt relatively high but only

A special thanks goes to all healthcare providers that

adopted non-pharmacologic strategies to deal with the

participated in this study.

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