Setting Priorities for African Postoperative Pain Research Through an International Delphi Process

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Perioperative pain management is essential for patients’ well-being and efficient health service delivery.1 Alleviating pain is not merely a matter of goodwill but also part of the duty to prevent harm and protect human rights.2 Biological, psychological, and social dimensions of the pain experience should be considered and understood to provide optimum pain management in the postoperative setting.3 However, in low- and middle-income countries (LMICs), a surgeon-led prescription of postoperative analgesia4 may not address the biopsychosocial dimension of pain and interdisciplinary and multimodal approaches. Despite the declarations that access to pain management is a fundamental human right5 and different initiatives, like the Pain-Free Hospital Initiative (PFHI) and pain as the fifth Vital Sign6 acute postoperative pain remains a challenge across the continent of Africa.4 The global prevalence of moderate-to-severe postoperative pain ranges between 50 and 80%.7 A meta-analysis of 27 studies involving 22,108 patients found that the average prevalence rates of moderate to severe postoperative pain were 31% and 58% 1 day and 1 to 2 weeks after discharge, respectively.8 In Africa, the prevalence of moderate-to-severe postoperative pain has been reported as high as 91.4–95%.4 On the other hand, it is now widely accepted that the severity of untreated postoperative pain is 1 of the most important predictors of prolonged postoperative pain and the development of chronic postsurgical pain.9 The burden of acute pain is compounded by undertreatment and disparity in the availability of analgesic treatments and multimodal analgesia practices.10,11 Significant barriers to effective pain treatment include, among others, the failure of many governments to put in place functioning drug supply systems, the failure to enact policies on pain treatment, poor training of health care workers, and the existence of unnecessarily restrictive drug control regulations.12,13 These barriers are unequally distributed between high-income and LMICs, with the most disadvantaged patients bearing the burden of this disparity.14 Except for a few institutional attempts,4 no comprehensive studies have been conducted to identify research priorities in Africa related to postoperative pain. Establishing key priorities for African postoperative pain research is a logical first step in addressing this issue. Therefore, we used a modified Delphi method to delineate the top 10 research priorities and the 3 principal strategies to address them. STUDY SETTING, EVIDENCE REVIEW, AND CONSENSUS PROCESS Health care providers in Africa who are actively engaged in perioperative pain management and research were invited as study participants inclusive of different educational backgrounds and areas of clinical expertise. We preferred a broad professional mix of experts instead of single-specialty experts. As part of the preparatory phases for the Delphi process, a literature review was conducted at the PubMed and Scopus databases and using the Google Scholar search engine. The search used key terms, and Medical Subject Headings (MeSH) terms (“Postoperative pain, “postsurgical pain,” “pain after surgery,” Africa, African regions). Boolean operators such as “AND” and “OR” were also used to identify the evidence gaps in the literature. The review substituted the open-ended round typically used in classical Delphi studies, thereby reducing participants’ attrition rates and response fatigue.15 After the literature review, the questions were thematized, and a survey template was prepared using Google Forms. A pilot test was subsequently conducted. Semistructured electronic Delphi questionnaires were used as they allowed flexibility and reach.16 Participants were instructed to select 10 statements from a list of 41 potential questions and select 3 strategies from lists of 7 possible options to address the established key priorities (see Supplemental Digital Content I, https://links.lww.com/AA/F419). Each selection was guided by criteria including problem severity, magnitude, feasibility, scientific, practical, and societal relevance, as well as community and government concern. Additionally, participants were invited to propose research questions or strategies beyond those listed in the questionnaire during the first-round survey. The commencement/intention of the research was circulated to different national anesthesia professional societies in Africa, as well as the African Society for Regional Anesthesia (AFSRA); hence, eighteen national leads were attained. The participants were briefed about the Delphi process and deliverables, and the survey template was evaluated and agreed on with minor modifications. The national leads used a multipronged approach of communication to recruit the maximum number of participants for the first-round survey (04/11/2023–21/01/2024); however, it had a limitation in determining the response rates. After the closure of the first-round survey, results were communicated to the participants by email, and a debriefing and consensus virtual meeting was conducted to reframe and decide on the number of questions to be included in the second-round survey. Based on the outcomes of this consensus, statements that achieved more than 25% agreement in the first round (n = 19) and additional statements introduced by participants (n = 7) were deemed eligible for inclusion in the second round. The first-round survey results and the second-round survey form were shared with all participants via email. The round was open from February 2, 2024, through April 20, 2024, and during that time 3 email reminders were sent. The participants reviewed the rating results from the previous round and had the option to modify or retain their initial responses. However, they were restricted to selecting only 10 statements from the list. On the conclusion of the second-round survey, the results were disseminated to the participants. Subsequently, a final virtual consensus meeting was convened to either finalize the top 10 priorities based on their magnitude and stability from the second-round survey results or to determine the necessity of a third-round survey. The participants ultimately agreed to establish the top 10 key priorities and strategies based on the second-round survey results, ordered by magnitude. Modification of the Delphi Technique Common modifications to the classical Delphi method include summarizing existing evidence, conducting in-person or virtual meetings that compromise anonymity, providing group-only vs individualized statistical reports, incorporating focus groups and other qualitative methods, utilizing online survey platforms and discussion forums, and adjusting items and rating criteria across different rounds.15,17 The classical Delphi method starts by identifying unanswered questions through participant input. To mitigate response fatigue, a comprehensive literature search was conducted, generating a long list of statements or questions. Participants prioritized by selecting 10 key priorities or suggesting additional priorities. In the second step, questions from the first-round survey were thematized, though the number of questions remained limited due to the extensive initial list. The third step, involving verification of uncertainties and evidence review, was omitted as the steering committee had already agreed on the long list based on the literature review. The fourth step involved interim prioritization for the second-round online survey. The participants held a virtual consensus meeting to determine the number of questions for this survey. Questions with at least 25% agreement were included, while those with less agreement were excluded (see Figure 1 and Supplemental Digital Content II, https://links.lww.com/AA/F420). Newly added questions from the first-round survey were also included. Based on the results of the second-round survey, a virtual consensus meeting was conve

Ce résumé expose les affirmations des auteurs. BNTIC ne l’interprète pas comme une validation indépendante des résultats.