Advancing drug availability-experiences from Africa

Quality of life assessments in a cohort of Mozambican children with sickle cell disease

Introduction

sickle cell disease (SCD) has significant pediatric morbidity and mortality in sub-Saharan Africa, where access to therapies such as hydroxyurea and opioids is often limited. Poor disease control and Pain management adversely affects the well-being and mental health of affected children. Questionnaires have been utilized in other regions to report the quality of life (QOL) in children with SCD, but assessments from Africa are lacking.

Methods

children age 2-14 years with SCD presenting for routine outpatient consultations at Hospital Central de Maputo from June-August 2017 were offered participation. After informed consent, the Pediatric QOL Inventory (PedsQL) SCD Module was administered to all caregivers and children > 5 years. Responses were scored from 0-100, with higher scores representing better QOL.

Results

a total of 14 children were included, with six (43%), four (29%), two (14%), and two (14%) from the age groups of 2-4, 5-7, 8-12, and 13-14 years, respectively. Mean overall patient QOL was 65.3 and 56.0 in child and caregiver respondents. In patients > 5 years, the difference in mean overall QOL for those on/not on hydroxyurea was 0.6 (66.5-64.9) in child respondents and 15.8 (68.4-52.6) in caregiver respondents. Domains related to worry/emotions and communication scored lower in QOL than Pain-related domains for both patient and caregiver respondents.

Conclusion

SCD has a negative impact on QOL as reported by this cohort of Mozambican pediatric patients and caregivers, with Pain being less of a concern than emotional and interpersonal issues. A comprehensive, child-focused care approach with robust psychosocial support is needed.

Palliative and end-of-life care in COVID-19 management in sub-Saharan Africa: a matter of concern

The COVID-19 pandemic has strained health care systems beyond capacity resulting in many people not having access to life-sustaining measures even in well-resourced countries. Palliative and end-of-life care are therefore essential to alleviate suffering and ensure a continuum of care for patients unlikely to survive. This is challenging in sub-Saharan Africa where lack of trained teams on basic palliative care and reduced access to opioids limit implementation of palliative and end-of-life care. At the same time, health care providers have to cope with local cultural conceptions of death and absence of advance care directives.

The Global Opioid Policy Initiative (GOPI) project to evaluate the availability and accessibility of opioids for the management of cancer pain in Africa, Asia, Latin America and the Caribbean, and the Middle East: introduction and methodology

Opioid analgesics are critical to the effective relief of cancer pain. Effective treatment is predicated on sound assessments, individually tailored analgesic therapy, and the availability and accessibility of the required medications. In some countries, pain relief is hampered by the lack of availability or barriers to the accessibility of opioid analgesics. As the follow-up to a successful project to evaluate the availability and accessibility of opioids and regulatory barriers in Europe, the European Society for Medical Oncology (ESMO) and the European Association for Palliative Care (EAPC) undertook to expand their research to those parts of the world where data were lacking regarding these aspects of care, in particular Africa, Asia, the Middle East, Latin America and the Caribbean, and the states of India. This project has been undertaken in collaboration with the Union for International Cancer Control (UICC), the Pain and Policy Studies Group (PPSG) of the University of Wisconsin, and the World Health Organization (WHO), together with a consortium of 17 international oncology and palliative care societies. This article describes the study methodology.

Formulary availability and regulatory barriers to accessibility of opioids for cancer pain in Africa: a report from the Global Opioid Policy Initiative (GOPI)

With nearly 1.1 billion inhabitants living in more than 50 countries, Africa is the world's poorest and most socioeconomically underdeveloped continent. Despite some advances for individual states, many African countries have very low opioid consumption and, overall, the continent has the lowest consumption per capita of any in the world. This article presents the findings of the first systematic study of the availability and accessibility of opioids for the management of cancer pain across the continent. Data are reported on the availability and accessibility of opioids for the management of cancer pain in 25 of 52 countries, with 744 million of the region's 1127 million people (66%) covered by the survey. Many countries had severely restricted formularies of opioids and only 15 of 25 had morphine available in oral IR, CR and injectable formulations. Even when opioids are on formulary they are often unavailable, and access is significantly impaired by widespread over-regulation that is pervasive across the region.

Pain Management for Persons Living With HIV Disease

Context:

Pain management (PM) has not been routinely incorporated into HIV/AIDS care and treatment in resource-constrained settings.

Objectives:

We describe training for multidisciplinary teams tasked with integrating care management into HIV clinics to address pain for persons living with HIV in Nigeria.

Methods:

Education on PM was provided to mixed-disciplinary teams including didactic and iterative sessions following home and hospital visits. Participants identified challenges and performed group problem solving.

Results:

HIV trainers identified barriers to introducing PM reflecting views of the patient, providers, culture, and the health environment. Implementation strategies included (1) building upon existing relationships; (2) preliminary advocacy; (3) attention to staff needs; and (4) structured data review.

Conclusion:

Implementing PM in Nigerian HIV clinics requires recognition of cultural beliefs.

Models of delivering palliative and end-of-life care in sub-Saharan Africa: a narrative review of the evidence

PURPOSE OF REVIEW

This narrative review examines evidence for models of palliative and end-of-life (eol) care delivery in sub-Saharan Africa (SSA) since 2010. It highlights recent developments, on-going challenges and innovative approaches used to address obstacles to increased access to care.

RECENT FINDINGS

Electronic databases were searched for the literature published in English during the period 2010-2012 around broad thematic areas of palliative and eol care delivery models in SSA. Literature showed increased palliative and eol care service development, underpinned by advocacy work undertaken by regional and national palliative care associations. Despite this increase, care provision remains inadequately integrated in national public health agendas and systems. Consequently, it continues to be heavily reliant upon nongovernmental, community-based and home-based care (HBC) models. Efforts are, however, underway to integrate palliative care into national health systems, which should increase access to care. National policies and government financing will be important to sustain this integration.

SUMMARY

Although community and HBC programs remain primary models of palliative and eol care delivery in SSA, there is an urgent need to develop a public health approach that integrates care into national health systems to increase accessibility.

Adequacy of opioid analgesic consumption at country, global, and regional levels in 2010, its relationship with development level, and changes compared with 2006

CONTEXT

In most countries, patients do not have adequate access to opioid analgesics because of barriers resulting from the abuse potential of these medicines.

OBJECTIVES

To provide an analysis for the adequacy of the consumption of opioid analgesics for countries and World Health Organization regions in 2010 as compared with 2006.

METHODS

We calculated the Adequacy of Consumption Measure using data for 2010 based on a method established by Seya et al. This method calculates the morbidity-corrected needs per capita for relevant strong opioid analgesics and the actual use for the top 20 Human Development Index countries. It determines the adequacy of the consumption for each country, World Health Organization region, and the world by comparing the actual consumption with the calculated need. Furthermore, the method allows us to calculate the number of people living in countries at various levels of adequacy. We compared our outcomes with data from Seya et al. for 2006.

RESULTS

Most people have no access to opioids for pain relief in case of need; 66% of the world population has virtually no consumption, 10% very low, 3% low, 4% moderate, and only 7.5% adequate. For 8.9%, no data are available. Between 2006 and 2010, 67 countries increased the adequacy of opioid consumption per capita. These changes are independent of countries' level of development.

CONCLUSION

The consumption of opioid analgesics remains inadequate in most of the world and, as a result, patients with moderate and severe pain do not receive the treatment they need. Governments, health organizations, and nongovernmental organizations must collaborate to address this situation, targeting their efforts at educational, cultural, health policy and regulatory levels.

Prevalence and correlates of pain and pain treatment in a western Kenya referral hospital

BACKGROUND

Pain is often inadequately evaluated and treated in sub-Saharan Africa (SSA).

OBJECTIVE

We sought to assess pain levels and pain treatment in 400 hospitalized patients at a national referral hospital in western Kenya, and to identify factors associated with pain and pain treatment.

DESIGN

Using face-validated Kiswahili versions of two single-item pain assessment tools, the Numerical Rating Scale (NRS) and the Faces Pain Scale-Revised (FPS-R), we determined patients' pain levels. Additional data collected included patient demographics, prescribed analgesics, and administered analgesics. We calculated mean pain ratings and pain management index (PMI) scores.

RESULTS

Averaged between the NRS and FPS-R, 80.5% of patients endorsed a nonzero level of pain and 30% of patients reported moderate to severe pain. Older patients, patients with HIV, and cancer patients had higher pain ratings. Sixty-six percent of patients had been prescribed analgesics at some point during their hospitalization, the majority of which were nonopioids. A majority of patients (66%) had undertreated pain (negative scores on the PMI).

CONCLUSION

This study shows that hospitalized patients in Kenya are experiencing pain and that this pain is often undertreated.

Assessment of the face validity of two pain scales in Kenya: a validation study using cognitive interviewing

BACKGROUND

Patients in sub-Saharan Africa commonly experience pain, which often is un-assessed and undertreated. One hindrance to routine pain assessment in these settings is the lack of a single-item pain rating scale validated for the particular context. The goal of this study was to examine the face validity and cultural acceptability of two single-item pain scales, the Numerical Rating Scale (NRS) and the Faces Pain Scale-Revised (FPS-R), in a population of patients on the medical, surgical, and pediatric wards of Moi Teaching and Referral Hospital in Kenya.

METHODS

Swahili versions of the NRS and FPS-R were developed by standard translation and back-translation. Cognitive interviews were performed with 15 patients at Moi Teaching and Referral Hospital in Eldoret, Kenya. Interview transcripts were analyzed on a question-by-question basis to identify major themes revealed through the cognitive interviewing process and to uncover any significant problems participants encountered with understanding and using the pain scales.

RESULTS

Cognitive interview analysis demonstrated that participants had good comprehension of both the NRS and the FPS-R and showed rational decision-making processes in choosing their responses. Participants felt that both scales were easy to use. The FPS-R was preferred almost unanimously to the NRS.

CONCLUSIONS

The face validity and acceptability of the Swahili versions of the NRS and FPS-R has been demonstrated for use in Kenyan patients. The broader application of these scales should be evaluated and may benefit patients who currently suffer from pain.