University of Ghana http://ugspace.ug.edu.gh SCHOOL OF PUBLIC HEALTH COLLEGE OF HEALTH SCIENCES UNIVERSITY OF GHANA, LEGON PATIENT SATISFACTION WITH PAIN MANAGEMENT AFTER CAESAREAN SECTION DELIVERY IN THE GREATER ACCRA REGIONAL HOSPITAL BY ANDRIANA WILHEMINA PARKER ADAMS (10807149) THIS DISSERTATION IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR THE AWARD OF MASTER OF PUBLIC HEALTH (MPH) OCTOBER 2020 University of Ghana http://ugspace.ug.edu.gh DECLARATION I, ANDRIANA WILHEMINA PARKER ADAMS, do hereby declare that apart from all the references that have been duly acknowledged, this dissertation is my own work and is the result of my effort under able supervision. I take full responsibility for this work. th 17 September, 2021 ………………………………………… ..……………………… Dr Andriana Wilhemina Parker Adams Date (Student) th 17 September, 2021 ………………………………………… …………………………… Prof Alfred Edwin Yawson Date (Academic Supervisor) i University of Ghana http://ugspace.ug.edu.gh DEDICATION This project is dedicated to my parents and fiancé who stood by me and urged me on to push through to the summit, never relenting. ii University of Ghana http://ugspace.ug.edu.gh ACKNOWLEDGEMENT I am indebted to God for His abundant grace and strength that have seen me through a successful completion of my dissertation. Special thanks go to my able supervisor, Prof Alfred Yawson, for his guidance, motivation and support even during my lowest points in the school year, when I thought I could not carry on. To my family, thank you for never giving up on me and supporting my every dream and making sure I have an incredible foundation. I am more than grateful. I would like to also thank Dr Adom Manu, whose constant encouragement and confidence in me encouraged me during the entire school year. To my fiancé, it has been a tough year and you have been my backbone through it all, never giving up on my vision or me. Thank you. iii University of Ghana http://ugspace.ug.edu.gh ABSTRACT Introduction: Post-caesarean section pain when not managed properly can put mothers through a period of depression affecting mother-to-child bonding. The Greater Accra Regional Hospital (GARH), a tertiary health care facility in Accra, recorded caesarean delivery as the major birthing method, with an estimated 54% caesarean births as against 44.4% of spontaneous vaginal deliveries and 1.6% of vacuum and assisted deliveries in 2019. Despite these high numbers of caesarean births, there is no relevant information on patient satisfaction with pain management after Caesarean Sections. Objective: The purpose of the study was to assess patient satisfaction with pain management after caesarean section delivery in GARH. Methods: A facility-based cross-sectional study design was used in this study to randomly sample 154 women who delivered at the GARH by caesarean section within the month of September 2020, at least 7 days post the caesarean section. An interviewer - administered structured questionnaire was used to elicit responses on satisfaction with pain management as well as individual factors, clinical/drug related factors and health provider factors from respondents via phone interviews. Data was analysed in STATA v.16 using chi square and multiple logistic regression with statistical significance set at p < 0.05. Results: The proportion of respondents satisfied with pain management after caesarean section delivery at the GARH was 51.3%. Respondents who had tertiary education (aOR = 20.17; 95% CI = 1.35 – 301.83; p = 0.030), respondents who felt 10% - 50% of pain post caesarean section delivery, (aOR = 911.49; 95% CI = 1.93 – 431062.30; p = 0.030) and respondents who felt 60% - 100% pain relief post caesarean section delivery (aOR = 35.17; 95% CI = 6.83 – 181.09; p < 0.001) were more likely to be satisfied with post caesarean section pain management offered at the GARH. iv University of Ghana http://ugspace.ug.edu.gh Conclusion: More than half of the respondents were satisfied with their pain management after Caesarean delivery. Tertiary education, low level of pain felt after the surgery as well as level of pain relief felt post CS were significantly associated with patient’s satisfaction with pain management after Caesarean section delivery. Pain management post CS at the GARH should be revised to improve patient satisfaction. v University of Ghana http://ugspace.ug.edu.gh TABLE OF CONTENTS DECLARATION ........................................................................................................................ i DEDICATION ........................................................................................................................... ii ACKNOWLEDGEMENT ........................................................................................................iii ABSTRACT .............................................................................................................................. iv TABLE OF CONTENTS .......................................................................................................... vi LIST OF FIGURES .................................................................................................................. ix LIST OF TABLES ..................................................................................................................... x CHAPTER ONE ........................................................................................................................ 1 1.0 INTRODUCTION ............................................................................................................1 1.1 Background of Study ....................................................................................................1 1.2 Statement of the Problem .............................................................................................2 1.3 Research Questions.......................................................................................................3 1.4 Objectives of the study .................................................................................................3 1.5 Justification ...................................................................................................................3 1.6 Conceptual Framework .................................................................................................5 CHAPTER TWO ....................................................................................................................... 7 2.0 LITERATURE REVIEW .................................................................................................7 2.1 Introduction ..................................................................................................................7 2.2 Factors Associated with Patient Satisfaction with Pain Management ........................10 2.2.1 Socio-demographic Factors .....................................................................................10 2.2.2 Type of Analgesia/Anaesthesia used .......................................................................12 2.2.3 Preoperative Mental Preparation .............................................................................13 2.2.4 Indication for Caesarean Section .............................................................................13 2.2.5 Social Support..........................................................................................................14 2.2.6 Mother Child Bonding .............................................................................................14 2.2.7 Neonatal Outcomes ..................................................................................................15 2.2.8 History of Caesarean Section ..................................................................................15 2.3 Summary .....................................................................................................................16 CHAPTER THREE ................................................................................................................. 17 3.0 METHODOLOGY .........................................................................................................17 3.1 Introduction ................................................................................................................17 3.2. Study Design..............................................................................................................17 3.3 Study Location ............................................................................................................17 vi University of Ghana http://ugspace.ug.edu.gh 3.4 Study Population.........................................................................................................18 3.6 Sample Size Calculation .............................................................................................19 3.7 Sampling Method .......................................................................................................19 3.8 Data Collection Tools and Methods ...........................................................................20 3.9 Study Variables...........................................................................................................21 3.10 Quality control ..........................................................................................................22 3.11 Data Analysis ............................................................................................................23 3.12 Ethical Consideration ...............................................................................................23 CHAPTER FOUR .................................................................................................................... 25 4.0 RESULTS.......................................................................................................................25 4.1 Socio-demographic characteristics of respondents.....................................................25 4.2 Satisfaction with pain management after caesarean section delivery .........................26 4.3 Individual factors associated with pain management post caesarean section delivery ..........................................................................................................................................26 4.4 Drug related factors associated with pain management post caesarean section delivery .............................................................................................................................27 4.5 Pain related factors associated with pain management post caesarean section delivery ..........................................................................................................................................29 4.6 Health provider factors associated with pain management post caesarean section delivery .............................................................................................................................31 4.7 Factors associated with pain management post caesarean section delivery ...............31 CHAPTER FIVE ..................................................................................................................... 37 5.0 DISCUSSION ................................................................................................................37 5.1 Introduction ................................................................................................................37 5.2 Level of patient satisfaction with pain management post Caesarean section delivery. ..........................................................................................................................................37 5.3 Sociodemographic factors associated with patient satisfaction with pain management after caesarean section. .....................................................................................................38 5.3 Health provider factors associated with pain management satisfaction after Caesarean sections. ............................................................................................................................39 5.4 Strengths and Limitations of the study .......................................................................40 CHAPTER SIX ........................................................................................................................ 41 6.0 CONCLUSIONS AND RECOMMENDATIONS ........................................................41 6.1 Conclusions ................................................................................................................41 6.2 Recommendation ........................................................................................................41 REFERENCES ........................................................................................................................ 42 APPENDICES ......................................................................................................................... 50 vii University of Ghana http://ugspace.ug.edu.gh APPENDIX I: PARTICIPANTS INFORMATION SHEET ................................................... 50 APPENDIX II: CONSENT FORM FOR STUDY PARTICIPANTS ..................................... 54 APPENDIX III (QUESTIONNAIRE) ..................................................................................... 56 APPENDIX IV .................................................................................................................60 Budget and Justification ...................................................................................................60 viii University of Ghana http://ugspace.ug.edu.gh LIST OF FIGURES Figure 1: Conceptual Framework of Factors associated with Post Caesarean Section Management. .............................................................................................................................. 5 Figure 2: Location of Greater Accra Regional Hospital (Source: Google maps) .................... 18 ix University of Ghana http://ugspace.ug.edu.gh LIST OF TABLES Table 1: Dependent Variable ................................................................................................... 21 Table 2: Independent Variables ............................................................................................... 21 Table 3: Socio-demographic characteristics of respondents (n = 154) ................................... 25 Table 4: Individual factors associated with pain management post caesarean section delivery .................................................................................................................................................. 26 Table 5: Drug related factors associated with pain management post caesarean section delivery .................................................................................................................................... 27 Table 6: Pain related factors associated with pain management post caesarean section delivery .................................................................................................................................... 29 Table 7: Health provider factors associated with pain management post caesarean section delivery .................................................................................................................................... 31 Table 8: Factors associated with pain management post caesarean section delivery ............. 35 x University of Ghana http://ugspace.ug.edu.gh CHAPTER ONE 1.0 INTRODUCTION 1.1 Background of Study In the United States, pain is recognized as a public health problem that has physical, emotional, and societal impacts (Institute of Medicine, 2011). It affects 50 million adults with an estimated 19.6 million of these people experiencing severe chronic pain that interferes with day to day living and work activities (Dahlhamer et al., 2016), causing an estimated loss of between 560 and 635 billion dollars yearly (Gaskin et al., 2012). Pain is an unpleasant and subjective sensory experience associated with an actual or potential damage to tissue (International Association for the Study of Pain, 2018). Pain may be intentional or unintentional, acute or chronic causing fear, panic, (Malek, et al., 2017) delayed recovery and even death. Acute pain can cause fear and panic, resentment and attaching a negative perception to healthcare workers (Malek, et al., 2017). When sub optimally managed, pain can begin a cascade of morbidities that would unduly delay the recovery of the patient and mar their experience of surgeries (Barash, et al., 2009). Caesarean sections are one of the commonest and important surgeries performed when vaginal birth may pose health risk to the mother or baby in cases of prolonged labour, foetal distress and abnormal presentation of baby (World Health Organisation, 2015). Caesarean sections like other forms of surgery are means of causing intentional but beneficial tissue damage to patient accompanied with pain, which requires management in the form of anaesthesia during surgery or analgesia after surgery. Caesarean pain when not managed properly can put mothers into a period of depression affecting mother child bonding and a delay in recovery and return to normal day-to-day activities. According to Vermelis et al. (2010), 6-18% of new mothers who have undergone caesarean sections experience persistent 1 University of Ghana http://ugspace.ug.edu.gh postoperative pain demanding urgent and appropriate management that will decrease postoperative pain considerably (Schug et al., 2015). Severe postoperative pain may be associated with a delay in ambulation after surgery and increase in pulmonary complications like development of pneumonia (Malek, et al., 2017). Studies have shown that a good number of patients are unsatisfied with pain management methods administered hence it is important to assess patient satisfaction with the pain management provided. 1.2 Statement of the Problem Studies over the years and around the globe have emphasised the need for effective pain management especially in new mothers who have undergone caesarean section. Pain associated with this kind of surgery if not properly handled has been shown to affect mother child bonding, early introduction of breastmilk postpartum and a factor for maternal morbidity and mortality. It also affects timely recovery increasing dependency on family and delaying the mother’s return to work (Jasim et al., 2017). Mothers found in developing countries are the most disadvantaged due to the numerous challenges faced by the healthcare delivery system running from shortage of drugs, high patient to health worker ratio, inadequate space and bedding, faulty appliances, debt and bureaucracy (Pheage, 2017). Caesarean section rates in Africa varies from 1.4% to 51.8% showing that the African continent is quickly catching up with this type of delivery (Prah et al., 2017). The Ghanaian story is not very different with the Ghana Health Service (2015) recording 13% of which majority occurs in the urban areas particularly in the Greater Accra region. The Greater Accra Regional Hospital, a referral centre in Accra records caesarean delivery as the major birthing method used with an estimated 54% caesarean births as against 44.4% of spontaneous vaginal deliveries and 1.6% of vacuum and assisted deliveries (Greater Accra Regional Hospital Annual Report, 2019). Despite these high numbers of caesarean births, studies have not been done to ascertain patient satisfaction with pain management after the procedure hence the 2 University of Ghana http://ugspace.ug.edu.gh need to do so. This present aim to assess patient satisfaction with pain management after caesarean section delivery in the Greater Accra regional Hospital. 1.3 Research Questions 1. What is the level of patient satisfaction with pain management post Caesarean section delivery? 2. What are the sociodemographic factors associated with patient satisfaction with pain management after Caesarean section? 3. What are the health provider factors associated with pain management satisfaction after Caesarean sections? 1.4 Objectives of the study 1.4.1 General Objective To assess patient satisfaction and factors that affect patient satisfaction with pain management after caesarean section delivery in the Greater Accra Regional Hospital 1.4.2 Specific Objectives The specific objectives of this study are to: 1. Assess the level of patient satisfaction with pain management post Caesarean section delivery. 2. Determine the sociodemographic factors associated with patient satisfaction with pain management after Caesarean section. 3. Identify the health provider factors associated with pain management satisfaction after Caesarean sections. 1.5 Justification Rates of caesarean section keeps rising in Ghana, Africa and the world as a whole. Despite the many concerns raised with this procedure, many mothers are electively opting for 3 University of Ghana http://ugspace.ug.edu.gh caesarean sections. Despite the rise in numbers, much attention has not been paid to the level of pain mothers experience post caesarean section and their satisfaction with pain management. Inadequate pain management has numerous effects on both mother and child and even the general economy including poor mother child bonding, prolonged maternal recovery leading to extended sick leaves and reduction in productivity. Information on the current prevalence of caesarean section, level of pain experienced by mothers and their satisfaction with pan management is unavailable making it difficult to assess factors and finding subsequent solutions suitable to enhance patient satisfaction. This study when conducted will provide information on the current prevalence and factors associated with patient satisfaction with pain management among women who have undergone caesarean section. Findings from this study will also serve as a guide to stakeholders and policy makers on decisions pertaining to pain management after caesarean section and add to literature in Ghana. 4 University of Ghana http://ugspace.ug.edu.gh 1.6 Conceptual Framework INDIVIDUAL FACTORS Maternal Age PHARMACOLOGICAL FACTORS Marital Status HEALTH Type of Anaesthesia/ PROVIDER Employment Status Analgesia FACTORS Income Dosage Preoperative Body Mass Index Mental Preparation Frequency of Religion Administration Attitude of Health Workers Educational level Parity Gravidity Previous Caesarean Section Satisfaction with Pain Management Post Caesarean Section PSYCHOLOGICAL FACTORS Social Support Mother Child Bonding Neonatal Outcomes Figure 1: Conceptual Framework of Factors associated with Post Caesarean Section Management. Source: Researcher’s own construct 5 University of Ghana http://ugspace.ug.edu.gh 1.6.1 Narrative of Conceptual framework A number of factors ranging from the individual, clinical and drug factors and health provider factors can influence patient satisfaction with pain management after caesarean sections. Individual factors such as age, marital status, employment status, religion, educational level may vary the satisfaction that a woman has with post-caesarean pain management. In that, educational level of a woman may increase the possibility of reading and understanding medication leaflet that help them appreciate therapeutic changes that come with taking medication, hence influencing their satisfaction. Older women may have increased parity or gravidity with a possibility of having had a previous caesarean section hence they cope better with pain management as compared to younger women who may have lower odds of parity, gravidity and history of previous caesarean section. Religion may provide a spiritual opiate increasing a woman’s odds of being satisfied with pain management. The clinical condition that warrants a caesarean section may be accompanied by severe pain influencing a woman’s appreciation of the pain treatment given to her by health care providers. Different analgesia and anaesthesia with varying routes of administration may influence a woman’s satisfaction with post-operative pain management. The dose of pain medication and frequency of administration provide pain relief which influences a woman’s satisfaction with post- operative experience of pain management. Women who are well oriented about caesarean section and what to expect before surgery, augment their preoperative mentality, which may help them cope with pain thereby influencing their satisfaction with pain management. Attitude of health personnel and patients’ perception of how friendly they are may influence patient satisfaction with pain management after a caesarean section. 6 University of Ghana http://ugspace.ug.edu.gh CHAPTER TWO 2.0 LITERATURE REVIEW 2.1 Introduction Pain is an uncomfortable feeling that can occur in a steady, throbbing, stabbing, aching, pinching, or debilitating manner serving as a nuisance. Pain can either be a symptom of a condition or bring about other physical symptoms such as nausea, dizziness, weakness or drowsiness. Sweiboda et al. (2013) in a review paper also describes pain as a rather unpleasant, subjective, sensory, emotional and protective mechanism to which the body responds to harmful stimulus. The feeling of pain is caused by a complex irritation of pain receptors found in the skin, joints and many internal organs, which are sensitive to mechanical, thermal or chemical stimuli. The experience of pain depends on the strength of the stimulus, individual susceptibility and resistance to pain. Once receptors in a body part sense a harmful stimulus it is processed into an electrical signal conducted by nerve fibres into the spinal cord and then to the brain at which point we perceive pain. Pain can also be acute or chronic where acute pain is usually severe and short-lived, and is often a signal that the human body has been injured while chronic pain is long lived, could either be mild or severe and is often the result of a disease that may require constant treatment. Pain assessment is the clinician’s judgment of an individual’s pain situation by observing the type, significance and context of the individual’s pain experience (Penrose, 2019). The Farlex Medical Dictionary (2009) also defines pain assessment as the determination of the character, duration, intensity, and location of a patient's pain, including its effects on his or her ability to function. In pain assessment, documentation is important to help improve pain management. To assess pain, categories of the Numerical Rating Scales (NRS), Visual Analog Scales (VAS) or the Categorical Scales are used. 7 University of Ghana http://ugspace.ug.edu.gh Numerical rating scales include the various quantitative scales that use numbers or numerical values to rate pain on a single 11‐point numeric scale starting at 0 and ending at 10 where 0 denotes no pain and 10 denotes worst possible pain even in cases of rheumatic pain (Hawker et al., 2011). In using the Visual analog scales, the clinician would ask the patient to mark a place on a 10 centimetre scale of 0 – 10 that aligns with their level of pain, where 0 denotes no pain and 10 denotes worst pain useful in tracking pain progression. It is also useful in comparing pain between patients with a similar condition while been used to evaluate mood, appetite, asthma, dyspepsia, and ambulation (Delgado et al., 2018). Categorical scales are rather qualitative with a 4 -5 response category requiring that the patient uses words and sometimes numbers, colours, or relative location (Jacques, 2020) to tell how much pain he or she is experiencing. Response category include 0 = none, 1= mild, 2= moderate, 3= severe, 4= extreme (Averbuch & Katzper, 2004). Pain management, also referred to as pain medicine, pain control or algiatry is a branch of medicine that uses an interdisciplinary approach for easing pain and improving the quality of life of those living with chronic pain (Hardy, 1997). Shiel (2018) also describes pain management as a process of providing medical care that alleviates or reduces pain. Pain can be treated with drugs such as analgesics, including opiates, NSAIDS and other narcotics, anxiolytic or sometimes be resolved quickly when the underlying causative factor has been identified and treated. Analgesics such as acetaminophen and aspirin can be used for managing or treating mild to moderate pain while opiates and other narcotics may be used alone or in addition with other analgesics such as steroids or nonsteroidal anti-inflammatory drugs (NSAID) to lessen inflammatory pain. Narcotics may also be used with antidepressants to affect the brain's perception of pain. Usually, for postoperative caesarean pain, standard oral and parenteral analgesics may be used. Parenteral or oral opioids are reserved for treating 8 University of Ghana http://ugspace.ug.edu.gh breakthrough pain when a combination of neuraxial opioids and non-opioid adjuncts becomes inadequate (American College of Obstetricians and Gynaecologists, 2018). Patient satisfaction with pain management is complex interaction of factors including appropriate ongoing assessment, specialised but interdisciplinary and collaborative care planning that includes patient input, safe, cost effective and efficient treatment that is culturally and developmentally appropriate (Gordon et al., 2010). According to Farooq and colleagues (2016), patient satisfaction with post-operative pain management depends on the expectations of the patient, intensity of pain experienced, promptness of acute pain service response, effectiveness of treatment and the attitude of healthcare professionals. Ineffective pain management whether in the acute or chronic state can result in anger, depression, confusion, mood swings or irritability possibly affecting the day to day activities of an individual (Dueñas et al., 2016). According to the American College of Obstetricians and Gynaecologists (2018), it is important that clinicians focus on optimizing function, quality of life, and productivity while minimizing risks for drug misuse and harm. The Revised American Pain Society Patient Outcome Questionnaire (APS-POQ-R) is an important tool for assessing patient satisfaction with pain management by gaging the quality of pain management provided. The APS-POQ-R measures six aspects of quality including pain severity and relief, impact of pain on activity, sleep, and negative emotions, side effects of treatment, helpfulness of information about pain treatment, ability to participate in pain treatment decisions and the use of non-pharmacological strategies (Gordon et al., 2010). These six aspects help the clinician to identify the level of patient satisfaction in a reliable and valid manner because the assessment is done is a direct feedback from the patient. It is however important to note that effective pain management does not mean total eradication of all pain. 9 University of Ghana http://ugspace.ug.edu.gh Even though there are advances in terms of analgesia, patients who undergo Caesarean sections experience very high levels of pain relative to other surgical patients, possibly due to the restrictions in recommendations of analgesics for nursing mothers. (Gerbershagen et al., 2013) 2.2 Factors Associated with Patient Satisfaction with Pain Management Factors associated with patient satisfaction with pain management can be categorised under socio-demographic factors and health provider factors. 2.2.1 Socio-demographic Factors 2.2.1.1 Age A study conducted to determine the relationship between severe and enduring pain and patient satisfaction with pain management post-surgery revealed that majority of patients who were least satisfied with pain management were younger adults having an average age of 54 years. They stated that younger patients reported higher levels of pain and often requested more pain medication compared to older adults with an average age of 61 years (Tocher et al., 2012). Another study reported that younger patients are who have undergone mastectomy, or hernia operations were more likely to develop chronic postoperative pain hence they were more likely to be dissatisfied with pain management compared to older patients (Macrae, 2008). Studies by McNeil et al. (1998) also noted that younger patients were more likely to want more pain medication compared to older patients. Previous studies argue that this may be because of the lower levels of postoperative pain experience by older patients (Melzack et al. 1987) suggesting that pain scales may be unreliable with older people and that analgesic effect is increased in older people (Gagliese & Katz, 2003). However, some studies found no association between the two variables (Zalon 1989; Duggleby & Lander 1994). 10 University of Ghana http://ugspace.ug.edu.gh 2.2.1.2 Marital Status Jasim et al. (2017) in their study on factors affecting post caesarean pain intensity among four hundred women in the Northern Peninsular of Malaysia revealed a significant relationship between marital status and post caesarean pain. A retrospective chart review of records from this study showed that 97.3% were married, 1.8% were single and 1% were widowed. Being single showed significant statistical relationship with post caesarean pain. Women who were single were 11.6 times more likely to experience post caesarean pain. A cross sectional analysis of data on 1062 women from a prospective longitudinal study in Brazil studied the relationship between marital status and post caesarean pain. Among the 1062 women, post caesarean pain was more prevalent among women with partners. Women with partners recorded 86.2% compared to 13.8% for women without partners (Borges et al., 2017). 2.2.1.3 Educational Level A study in Tanzania (Masigati & Chilonga, 2014) on postoperative pain management outcomes among adults treated at a tertiary hospital reported educational status as a factor in patient satisfaction in pain management. In another study done, statistical analysis was based on total satisfaction with pain management with yes or no. For those with secondary education and higher, 42.9% answered yes and 57.1% answered no while 22% answered yes and 78% answered no for those with primary education. They concluded that the proportion of patients satisfied with pain management was increasing with the increase in patient’s level of education, which was statistically significant. Borges and colleagues (2017) also reported on educational level as a factor in pain management. This supports evidence by Masigati & Chilonga, (2014) that patient satisfaction with pain management increases with increasing level of education. 11 University of Ghana http://ugspace.ug.edu.gh 2.2.1.4 Occupation From a Tanzanian study (Masigati & Chilonga, 2014), majority of study participants (54.8%) were business owners or engaged in subsistence farming, 29.8% worked for other people while 15.4% were unemployed. This study found no significant relationship between occupation and pain management. 2.2.1.5 Religion A study in the Asante Akyem North District of Ghana on the assessment of post-operative pain management at Agogo Presbyterian Hospital, studied religion as a sociodemographic factor. According to the study, 87% of participants were Christian while 13% were of Islamic faith. This study did not report on any statistical association between religion and patient satisfaction with pain management (Ofori, 2016). From Afaya and colleagues (2020), Christianity represented the majority with 91% while Muslims represented 9% of the study sample. Again, they did not state any statistically significant association. Past literature talks about the use of the spirituality and religion as complementary pain strategies. Literature reports the use of prayer as a response to pain rather than medication because prayer provides the feeling of comfort and strength. In some cultures, spirituality and religiosity encourages mothers to experience pain and decline the use pain medications that may be available for use in the health facility. Pain was noted to help people discern more meaning into life, its purpose and death and also renew one’s spiritual dedication (Dezutter et al., 2011; Bussing et al., 2009). 2.2.2 Type of Analgesia/Anaesthesia used According to Kintu et al. (2019), during the assessment and management of postoperative caesarean pain, intramuscular diclofenac was the most prescribed analgesic followed by 12 University of Ghana http://ugspace.ug.edu.gh tramadol and pethidine, 4% of the participants received intrathecal morphine as part of the spinal anaesthetic while none of them received intravenous or intramuscular morphine. 2.2.3 Preoperative Mental Preparation Mental preparation is important in performing a surgical procedure, where the patient is educated on the condition, pros and cons of the chosen surgical procedure and allowed to give consent for the procedure to be done if conscious. In unconscious patients, a family member is made to go through the process (WHO, 2009). A previous study on the effect of preoperative factors on patient satisfaction with postoperative pain management (Neimi- Murola et al., 2007) among 102 participants revealed that eighty percent of the patients were satisfied with the pain management administered and their satisfaction correlated significantly with preoperative information received. Another study aimed at investigating whether preoperative anxiety in 85 women undergoing elective caesarean section predicts postoperative maternal satisfaction with the process, perceptions of recovery, analgesic use or length of hospital stay. Maternal satisfaction with pain management and perceptions of recovery were assessed around the third postoperative day where preoperative anxiety scores were comparable with those of general surgical or medical patients. Analysis showed that postoperative maternal satisfaction with pain management was higher among women who were given preoperative information from the anaesthetist (Hobson et al., 2006). 2.2.4 Indication for Caesarean Section Kintu et al. (2019) reported on the role of medical indication for caesarean section and patient satisfaction with pain management among 333 women. Among these mothers who reported yes for certain indications; foetal distress was 10%, 27% for obstructed labour, 37% for previous caesarean section scar, 7% for big baby and another 7% for prolonged labour. Kumar et al. (2014) also reported on indications for caesarean section stating that out of 175 women, 5 had breech presentation, 21 had failed induction, 19 were cases of cephalopelvic 13 University of Ghana http://ugspace.ug.edu.gh disproportion, 73 fetal distresses, 6 mothers requested the procedure while 17 had oligohydramnios, and 9 had issues with previous caesarean section scars. 25 others in the study suffered other complications, not particularly stated, which may include direct or indirect maternal causes such as hypertension and its related complications in pregnancy, diabetes and its complications as well as maternal Sickle Cell Disease. 2.2.5 Social Support Hobson and colleagues (2006) also studied the association between postoperative satisfaction in pain management with social support. According to reports from the study, 52% of patients agreed that perceived emotional support from partners was a key factor in postoperative maternal satisfaction especially among women with high levels of anxiety. Kumar et al. (2014) studied the effect of psychosocial support given to the patient during emergency caesarean section in South India among 175 new mothers. Most patient (93.1%) reported that they were comfortable with the people around them while the remainder were not. Among patients who were anxious 91.4% were made comfortable by people coming around them before they entered the operation theatre. They concluded that patients who had psychosocial support expressed higher satisfaction with postoperative pain management. 2.2.6 Mother Child Bonding Seeing, hearing baby cry and early introduction of breast feeding are important elements in mother child bonding. In most settings, babies are shown to their mothers immediately after the delivery unless the babies have complications needing immediate care. The WHO (2020) recommends immediate introduction of child to breastmilk within an hour of birth. According to Karlstrom et al. (2010) post caesarean pain that is well managed facilitates mother-to-child bonding, more effective infant care, improved breastfeeding, limits the stay of the infant and the mother in the hospital and also reduce expenditure (Jikijela et al., 2018). In South Africa, mother who had undergone caesarean section and were satisfied with pain management were 14 University of Ghana http://ugspace.ug.edu.gh able to bond and enjoyed bonding with their babies while those who were dissatisfied with the pain management expressed the need to get better before bonding with their babies (Jikijela et al., 2018). 2.2.7 Neonatal Outcomes Neonatal outcome was highlighted by Kimani (2012) to have a strong influence on maternal satisfaction with pain management. Mothers were categorised as satisfied or unsatisfied based on whether their babies were in nursery, were alive and well or were dead. Among mothers who had their babies in nursery, 97.8% were satisfied while 2.2% were unsatisfied. Ninety six percent of mothers who had their babies alive and well were satisfied while 4% were dissatisfied and 71.4% of mothers whose babies died were satisfied while 28.6% were dissatisfied. Mothers whose neonates died were 6.8 times more likely to be dissatisfied compared to mothers whose neonates were alive and well. 2.2.8 History of Caesarean Section Kimani (2012) studied previous history of caesarean section in relation to patient satisfaction with pain management. Among mothers who have never had a caesarean surgery, 3% were not satisfied while 97% were satisfied. Those who had one previous caesarean section, 9.6% were dissatisfied while 90.4% were satisfied whereas among those who had two previous surgeries, 2.2% were not satisfied while 97.8% were satisfied. These differences were however not statistically significant. Mothers who had three or four previous surgeries were 100% satisfied with pain management. A study in Sweden by Niklasson et al (2015) on maternal wellbeing post caesarean section revealed that out of 253 women, 125 had a previous caesarean section. Analysis showed that women undergoing caesarean section for the first time had a significantly higher risk for persistent pain and poor satisfaction with pain management while those expecting a child for the first time also had a higher tendency to feel pain. 15 University of Ghana http://ugspace.ug.edu.gh 2.3 Summary Pain is a somatic stimulant that can almost never be described objectively. For that reason, pain is what an individual says the pain is in their opinion. Several factors affect the pain threshold of an individual, and how they react to pain generally. It may be observed that the age of an individual may affect the way they perceive pain and even communicate their pain. Having a substantial social support may also influence the level of pain and the support may even help to alleviate the pain in some instances. That notwithstanding, the type of analgesic given for the pain, coupled with the pre-operative mental preparation may have an effect on the perception of pain and even with the feeling of satisfaction with pain management. 16 University of Ghana http://ugspace.ug.edu.gh CHAPTER THREE 3.0 METHODOLOGY 3.1 Introduction This chapter presents methods and procedures that were employed in conducting this study. 3.2. Study Design This study used a facility – based cross-sectional design with a quantitative approach. This was used to determine factors associated with patient satisfaction with post caesarean section pain management to measure both exposure and outcome simultaneously. 3.3 Study Location The Greater Accra Regional Hospital (formerly known as Ridge Hospital) is located at North Ridge, Accra, Ghana. The hospital was built in 1929 to provide healthcare for British nationals during the pre-colonial era. Currently it has been rebuilt into an ultra-modern facility with a 470-bed capacity. This is aimed at improving quality and expanding access to health care delivery. The hospital has a state of the art maternity unit with an average annual attendance of 17820. The maternity unit has a total of 40 beds, divided into postnatal wards, a labour ward and a theatre complex. In a day, an average of ten surgeries are done in theatre. Aside the in-patient aspect, the Maternity unit runs an outpatient antenatal clinic that see patients on weekdays at the Antenatal Clinic. The Obstetrics theatre manages an average of 335 caesarean sections per month in the GARH, as stated by the GARH 2019 yearly review. These patients go through the theatre and subsequently to the theatre recovery ward for further management. 17 University of Ghana http://ugspace.ug.edu.gh Figure 2: Location of Greater Accra Regional Hospital (Source: Google maps) 3.4 Study Population The study population was women who delivered by caesarean section at the Greater Accra Regional Hospital during the month of September, 2020. 3.5.1. Inclusion Criteria: 1. Women who had delivered at least 7 days post caesarean section at the time of the study. 2. Women aged 18 years and above. 3. Participants who consented to participate in the study. 3.5.2. Exclusion Criteria 1. Women who were too ill to partake in the study. 2. Women who opted out of the study. 18 University of Ghana http://ugspace.ug.edu.gh 3.6 Sample Size Calculation The sample size was calculated using the Cochran’s formula. No = minimum sample size z = standard normal deviate (1.96) p = proportion of patients satisfied with pain management = 89.7% (Subramanian et al, 2014) q = 10.3% e = degree of precision, set at 5% = 0.05 No= No = 141 This number was increased to 155 to make up for possible 10% non-response rate. 3.7 Sampling Method A systematic random sampling method was employed to enroll participants for this study. The changes book from the theatre recovery ward of women who delivered by CS in the month of September was used. From the changes book, women who delivered by CS were numbered in order of first to come from theatre. The total number of women who delivered by CS in the month of September (354) was divided by the sample size (155) to achieve a sampling interval, k= (354/155) = 2.3. The first participant was randomly selected in the first 2 set of women who had a CS and process repeated throughout rest of the women according to the numbers given to them to achieve the sample for the study. 19 University of Ghana http://ugspace.ug.edu.gh The women were contacted via phone calls to get consent and to answer interviewer- administered questionnaires. Any enrolled participant who refused to participate was dropped and the next woman in the numerical order approached to replace her as a participant. 3.8 Data Collection Tools and Methods A well-structured questionnaire was used to elicit responses from participants. The questionnaire had three sections. The first part of the questionnaire focused on the individual characteristics of participants. The other sections elicited information on Clinical/ drug- related factors and Health provider factors among respondents. Before administration of questionnaires, the aim of the study was explained to all respondents to ensure there was full comprehension and to rule out any form of ambiguity. The principal investigator with the help of three trained research assistants then administered the questionnaires. The contact numbers of the participants were obtained from the theatre recovery book, where patients put down their contact details on admission to the theatre for surgery. The participants were called with a newly registered phone number whose sole purpose was for the study. The call logs were immediately deleted at the end of each day to ensure participant phone numbers remained confidential and not in any way mishandled. The questionnaire were administered in English Language for literate women, and verbally translated into Twi/ Ga/ Ewe for the non-English literate women. Each phone call took approximately 16 minutes. With each phone call, the Principal Investigator had an introductory message where the purpose of the study was communicated and consent sought. The research assistants then endorsed the Statement of the Witness. Following that, the PI administer the questionnaire in whichever language the participant was comfortable with. 20 University of Ghana http://ugspace.ug.edu.gh 3.9 Study Variables 3.9.1 Dependent Variables Table 1: Dependent Variable Dependent Description Operational Definition Scale of Variable Measurement Satisfaction with Satisfied or not Self-reported satisfaction Nominal post CS pain satisfied pain treatment while in management (dichotomised from the hospital after your Satisfied vs. not a composite score Caesarean section. satisfied ranging from 0 to 10) on the revised APS-POQ 3.9.2 Independent variables Table 2: Independent Variables Independent Operational Type of Variable Scale of Variable Description Measureme nt Individual Factors Maternal age Mothers age in Numerical ratio completed years continuous Gravidity Total number of times Numerical ratio mother has been pregnant discrete Parity Total number of Numerical ratio children born a mother discrete has given birth to Occupation employment status of a Binary Nominal: mother Employed Unemployed Religion Christian, Muslim or Categorical Nominal: Traditionalist Christian Muslim Traditionalist Educational level Highest educational Categorical Ordinal: attainment of the No education mother Primary JHs/MSLC SHS Tertiary 21 University of Ghana http://ugspace.ug.edu.gh Income Amount a mother earns Numerical ratio monthly from continuous employment Body Mass Index Weight (kg)/ height Numerical ratio (m2) continuous (BMI) Previous CS Any history of Binary Nominal Caesarian section yes no Clinical/Drug Factors Indication for CS Clinical condition/ Categorical diagnosis that warranted a caesarean section Type of pain Diclofenac Categorical medication Paracetamol Pethidine Route of Suppository Categorical administration of Intravenous pain medication Oral Frequency of pain Daily Categorical medication Twice daily Three times daily Four times daily 3.10 Quality control Quality control measures were employed to ensure sanity as the data included a two-day training of research assistants on data collection methods for quantitative study, ethics of research, data entry and data validation. Pretesting of the data collection tool (structured questionnaire) was done. All anomalies, questions with ambiguity and typographical errors were edited and corrected before the actual data collection. After data collection, the data was sorted, coded and entered into Microsoft excel 2016. Accuracy of the entered data was checked, and the clean database was then converted into Stata version 16.0 file (Stata Corporation, Texas, USA) before the analysis. 22 University of Ghana http://ugspace.ug.edu.gh 3.11 Data Analysis Collected data was coded and entered into Microsoft Excel, and subsequently migrated into Stata (version 16.0) software for statistical analysis. Frequency distribution was done to compute demographic data. Tests of association on factors predicting satisfaction with post CS pain management was done using Chi Square and simple logistic regressions. The association between satisfaction with post CS pain management and each independent variable was analyzed using multiple logistic regression analysis with statistical significance set at p-values ≤ 0.05. This was done by first running a bivariate analysis (Chi Square/simple logistic regression) between satisfaction with post CS pain management and all the independent variables selecting those with p-values ≤ 0.05. These were then fitted in a final multiple logistic regression model to assess the strength of association looking at Adjusted Odds Ratio (AOR) with 95% confidence interval (CI). 3.12 Ethical Consideration Ethical Clearance: This was sought from Ghana Health Service Ethics Review Committee and approval given before the start of the study. Reference number as follows: GHS-ERC 037/08/20. Permission: Permission was granted after being sought from the Greater Accra Regional Health Directorate and the authorities of the Greater Accra Regional Hospital. Informed Consent: Verbal consent was sought from eligible participants after explaining the benefits and risks involved in participation. The initials of the participants were be filled on the consent form after due consent had been obtained during the phone call. Voluntary participation/withdrawal: Participants were made to understand that, participation was purely voluntary hence those who wished to opt out were at liberty to do so and this did not affect them in any way. 23 University of Ghana http://ugspace.ug.edu.gh Data storage/Security: All questionnaires completed were stored in a briefcase with a lock code, known only by the PI. Only the unique generated code of the participants were used on the questionnaire for confidentiality. Compensation: There was no compensation for participants in this study. Confidentiality: The questionnaires were administered at a time convenient for the participant to ensure privacy. In ensuring anonymity, participants were only identified with codes and numbers. No information regarding participants’ name or any other information that traced the data collected to the participants was taken. Participant information was entered and kept on a computer with a secured password. Filled questionnaires were kept under lock and key, with only the principal investigator having access. Cost: The study cost participants nothing except their precious time that was spent answering the questionnaires. Benefits: Participants may benefit from this study indirectly when findings are disseminated to inform practice among health professionals regarding pain management among post- caesarean patients. Risks: This study came with no risk that bordered on physical damage to the participant except the minimal risk of having to share information on health condition which may have seemed personal. Conflict of Interest: There was no conflict of interest. 24 University of Ghana http://ugspace.ug.edu.gh CHAPTER FOUR 4.0 RESULTS 4.1 Socio-demographic characteristics of respondents The descriptive statistics of respondents is shown below in table 4.1. The mean age of respondents was 30.9 years ± 5.1 SD. Majority of the respondents 115(74.7%) were married. Majority of the respondents 149 (94.2%) had had some form of formal education. Sixty of the participants, representing thirty nine percent (39.0%) of respondents were self-employed. Most of the respondents 119(77.3%) were Christians. The median number of times respondents had been pregnant (gravidity) and the median number of children they have given birth to (parity) was two (2). Table 3: Socio-demographic characteristics of respondents (n = 154) Variables Frequency Percent (%) Age in years (M ± SD) 30.9 ± 5.1 Marital status Unmarried 39 25 .3 Married 115 74.7 Educational level Junior High School 43 27 .9 Senior High School 56 36.4 Tertiary 46 29.9 No formal education 9 5.8 Occupation Unemployed 4 3 27 .9 Self employed 60 39.0 Salary worker 51 33.1 Religion Christian 11 9 77 .3 Muslim 35 22.7 25 University of Ghana http://ugspace.ug.edu.gh 4.2 Satisfaction with pain management after caesarean section delivery The proportion of respondents satisfied with pain management after caesarean section delivery was 51.3% (percentage = 51.3%; 95% CI = 43.1% - 59.4%). 4.3 Individual factors associated with pain management post caesarean section delivery Table 4.3 shows the results of the bivariate analysis i.e. Chi Square/Fischer’s exact test (marital status, educational level, religion, employment status, previous caesarean section, condition of baby from last caesarean section) and a two-sample t-test (age, gravidity, parity). The individual factors which showed significant association with pain management after caesarean section delivery are as follows; age (p = 0.009), educational level (p = 0.009) and employment status (p = 0.003). Table 4: Individual factors associated with pain management post caesarean section delivery 2 Variables Satisfaction χ Satisfied Dissatisfied (n = 79) (n = 75) p-value Age in years 31.9 ± 5.2 29.8 ± 4.8 0.009* Marital status 0.2 65 Unmarried 17(4 3.6) 22(5 6.4) Married 62(53.9) 53(46.1) E ducational level + 0.0 09* No formal education 4(44 .4) 5(55 .6) Junior high school 17(39.5) 26(60.5) Senior high school 25(44.6) 31(55.4) Tertiary 33(71.7) 13(28.3) Religion 0.2 56 Christian 64(5 3.8) 55(4 6.2) Muslim 15(42.9) 20(57.1) Gravidity 2.5 ± 1.3 2.5 ± 1.2 0.9 93 Parity 1.9 ± 0.9 2.0 ± 1.1 0.6 44 26 University of Ghana http://ugspace.ug.edu.gh Employment status 0.003* Unemployed 16(3 7.2) 27(6 2.8) Self employed 27(45.0) 33(55.0) Salary worker 36(70.6) 15(29.4) Previous caesarean section 0.5 49 Yes 31(4 8.4) 33(5 1.6) No 48(53.3) 42(46.7) C ondition of baby from last caesarean section 0.863 Baby alive and well 28(4 9.1) 29(5 0.9) Baby alive and ill 1(50.0) 1(50.0) Dead baby 3(60.0) 2(40.0) + (fisher’s exact) *(statistically significant, p≤0.05) t-test 4.4 Drug related factors associated with pain management post caesarean section delivery The type of medication (p = 0.001), route of administration of pain medication (p = 0.012), frequency of pain drug administration (p = 0.003), nausea (p < 0.001), drowsiness (p = 0.015), and dizziness (p = 0.024) are the drug related factors associated with pain management as shown in table 4.4. Table 5: Drug related factors associated with pain management post caesarean section delivery Total 2 Variables (n%) Satisfaction χ Satisfied Dissatisfied (n = 79) (n = 75) p-value Type of anaesthesia 0.163 General anaesthesia 10(6 .5) 3(30 .0) 7(70 .0) Spinal anaesthesia 144(93.5) 76(52.8) 68(47.2) Route of administration of anaesthesia 0.163 Intravenous 10(6 .5) 3(30 .0) 7(70 .0) Intrathecal 144(93.5) 76(52.8) 68(47.2) Type of pain medication 0.00 1* Diclofenac 30(1 9.5) 17(5 6.7) 13(4 3.3) 27 University of Ghana http://ugspace.ug.edu.gh Paracetamol 54(35.1) 22(40.7) 32(59.3) Diclofenac and paracetamol 15(9.7) 14(93.3) 1(6.7) Diclofenac and pethidine 18(11.7) 12(66.7) 6(33.3) Pethidine and paracetamol 33(21.4) 11(33.3) 22(66.7) Diclofenac, pethidine and morphine 4(2.6) 3(75.0) 1(25.0) Route of administration of pain + medication 0.012* Intravenous 29(1 8.8) 11(3 7.9) 18(6 2.1) Intramuscular 6(3.9) 2(33.3) 4(66.7) Rectal 50(32.5) 28(56.0) 22(44.0) Intramuscular and intravenous 18(11.7) 5(27.8) 13(72.2) Intramuscular and rectal 26(16.9) 13(50.0) 13(50.0) Intravenous and rectal 21(13.6) 17(80.9) 4(19.1) Intramuscular, intravenous and rectal 4(2.6) 3(75.0) 1(25.0) Frequency of pain drug administration 0.003* Twice daily 36(2 3.4) 25(6 9.4) 11(3 0.6) Thrice daily 94(61.0) 38(40.4) 56(59.6) Four times daily' 24(15.6) 16(66.7) 8(33.3) Nausea 0.00 0* No 101(6 5.6) 63(6 2.4) 38(3 7.6) Yes 53(34.4) 16(30.2) 37(69.8) D rowsiness 0.01 5* No 116(7 5.3) 66(5 6.9) 50(4 3.1) Yes 53(34.4) 13(34.2) 25(65.8) Itching 0.0 56 No 84(5 4.6) 49(5 8.3) 35(4 1.7) Yes 70(45.4) 30(42.9) 40(57.1) D izziness 0.02 4* No 117(7 6.0) 66(5 6.4) 51(4 3.6) Yes 37(24.0) 13(35.1) 24(64.9) + (fisher’s exact) *(statistically significant, p≤0.05) 28 University of Ghana http://ugspace.ug.edu.gh 4.5 Pain related factors associated with pain management post caesarean section delivery The table shows the pain related factors associated with pain management. These factors include; least pain experienced in the first 24 hours (p < 0.001), worst pain experienced in the first 24 hours (p < 0.001) and severity of pain in the first 24 hours (p < 0.001). Table 6: Pain related factors associated with pain management post caesarean section delivery Total 2 Variables (n%) Satisfaction χ Satisfied Dissatisfied (n = 79) (n = 75) p-value L east pain experienced in the first 24 hours 0.000* No pain 79(51.3) 57(72.2) 22(27.8) 1 to 5 72(46.8) 20(27.8) 52(72.2) 6 to 10 2(1.9) 2(66.7) 1(33.3) Worst pain experienced in the first 24 hours 0.000* No pain 79(51.3) 57(72.2) 22(27.8) 1 to 5 57(37.0) 15(26.3) 42(73.7) 6 to 10 18(11.7) 7(38.9) 11(61.1) Severity of pain in the first 24 hours 0.000* No pain 19(12.3) 12(63.2) 7(36.8) 10% - 50% pain score 128(83.1) 66(51.6) 62(48.4) 60% - 100% pain score 7(4.6) 1(14.3) 6(85.7) Activities in bed such as turning, sitting up, + repositioning 0.675 Did not interfere 149(96.8) 77(51.7) 72(48.3) Interfered 5(3.3) 2(40.0) 3(60.0) A ctivities out of bed such as walking, sitting in a chair, + standing at the sink 0.525 29 University of Ghana http://ugspace.ug.edu.gh Did not interfere 149(96.8) 76(51.0) 73(49.0) Interfered 5(3.3) 3(60.0) 2(40.0) + Falling asleep 1.000 Did not interfere 150(97.4) 77(51.3) 73(48.7) Interfered 4(2.6) 2(50.0) 2(50.0) + Staying asleep 1.000 Did not interfere 152(98.7) 78(51.3) 74(48.7) Interfered 2(1.3) 1(50.0) 1(50.0) + Anxiety 0.613 Did not interfere 151(98.1) 78(51.7) 73(48.3) Interfered 3(1.9) 1(33.3) 2(66.7) + Depression 1.000 Did not interfere 151(98.1) 77(51.0) 74(49.0) Interfered 3(1.9) 2(66.7) 1(33.3) + Frightened 1.000 Did not interfere 151(98.1) 77(51.0) 74(49.0) Interfered 3(1.9) 2(66.7) 1(33.3) + Helpless 0.487 Did not interfere 153(99.4) 79(51.6) 74(48.4) Interfered 1(0.6) 0(0.0) 1(100.0) + (fisher’s exact) *(statistically significant, p≤0.05) 30 University of Ghana http://ugspace.ug.edu.gh 4.6 Health provider factors associated with pain management post caesarean section delivery The pain relief felt in the first 24 hours (p < 0.001), information on pain treatment options (p = 0.001) and overall mental preparedness (p = 0.006) are the health provider factors associated with pain management. Table 7: Health provider factors associated with pain management post caesarean section delivery Total 2 Variables (n%) Satisfaction χ Satisfied Dissatisfied (n = 79) (n = 75) p-value Pain relief felt in the first 24 hours 0.000* No relief 0(0 .0) 0(0 .0) 0(0 .0) 10% - 50% 113(73.4) 43(38.1) 70(61.9) 60% - 100% 41(26.6) 36(87.8) 5(12.2) Participation in decisions about pain management 0.079 No 127(8 2.5) 61(4 8.0) 66(5 2.0) Yes 27(17.5) 18(66.7) 9(33.3) Information on pain treatment options 0.001* Yes 56(3 6.4) 19(3 3.9) 37(6 6.1) No 98(63.6) 60(61.2) 38(38.8) U sage of non-medicine methods 0.346 Yes 70(4 5.5) 33(4 7.1) 37(5 2.9) No 84(54.5) 46(54.8) 38(45.2) Overall mental preparedness 0.00 6* Inadequate mental preparedness 16(10.4) 3(18.8) 13(81.2) Adequate mental preparedness 138(89.6) 76(55.1) 62(44.9) + (fisher’s exact) *(statistically significant, p≤0.05) 4.7 Factors associated with pain management post caesarean section delivery The crude-odds ratios and adjusted odds ratios of factors associated with pain management post caesarean section delivery is shown below in table 4.7. A one year increase in age significantly increased the odds of respondents being satisfied with pain management post 31 University of Ghana http://ugspace.ug.edu.gh caesarean section delivery by 9% (cOR = 1.09; 95% CI = 1.02 – 1.17; p = 0.011). However, after adjusting for all other variables (educational level, employment status, type of pain medication, route of administration of pain medication, frequency of pain drug administration, nausea, drowsiness, dizziness, least pain experienced in the first 24 hours, worst pain experienced in the first 24 hours, severity of pain in the first 24 hours, pain relief received in the first 24 hours, information on pain treatment options, overall mental preparedness) this association was found not to be significant. The variable group “educational level” was found not to be significant after a simple logistic regression. However, after adjusting for all other variables, respondents who had tertiary education had significantly 20.17 times the odds of being satisfied with pain management post caesarean section delivery as compared to those with no formal education (aOR = 20.17; 95% CI = 1.35 – 301.83; p = 0.030). Salaried workers also had significantly 4.05 times the odds of being satisfied with pain management post caesarean section delivery as compared to those who were unemployed (cOR = 4.05; 95% CI = 1.71 – 9.60; p = 0.001) but this association was found not to be significant after adjusting for all other variables. The odds of being satisfied with pain management post caesarean section delivery was increased significantly by nearly 11 fold among respondents who took diclofenac and paracetamol as compared to those who took only diclofenac (cOR = 10.71; 95% CI = 1.24 – 92.22; p = 0.031). This association was found not to be significant after adjusting for all other variables. Those whose pain medication was administered intravenously and rectally had significantly increased odds of being satisfied with pain management after caesarean delivery by nearly 7 fold as compared to those whose pain medication was administered only intravenously (cOR 32 University of Ghana http://ugspace.ug.edu.gh = 6.95; 95% CI = 1.85 – 26.09; p = 0.004). However, after adjusting for all other variables this association was found not to be significant. Respondents who took pain medication thrice daily had significantly 71% reduction in their odds of being satisfied with pain management post caesarean section delivery as compared to those who took pain medication twice daily (cOR = 0.29; 95% CI = 0.13 – 0.68; p = 0.004). After adjusting for all other variables, this association was found not to be significant. Respondents who were nauseous after taking pain medication had a 74% significant reduction in their odds of being satisfied with pain management post caesarean section delivery as compared to those who were not nauseous after taking pain medication (cOR = 0.26; 95% CI = 0.13 – 0.53; p < 0.001). The odds of being satisfied with pain management post caesarean section delivery was significantly reduced by 61% among respondents who felt drowsy after taking pain medication as compared to those who did not feel drowsy after taking pain medication (cOR = 0.39; 95% CI = 0.18 – 0.85; p = 0.017). There was no significant association found after adjusting for all other variables. After caesarean section delivery, the odds of respondents being satisfied with pain management post caesarean section delivery was significantly reduced by 58% among respondents who felt dizzy after taking pain medication as compared to those who did not feel dizzy (cOR = 0.42; 95% CI = 0.19 – 0.90; p = 0.026). This association was found not to be significant after adjusting for all other variables. Respondents who felt no pain in the first 24 hours on the “worst pain scale” had significantly 4.07 times the odds of being satisfied with pain management post caesarean section delivery as compared to those who indicated 6 – 10 as their worst pain felt in the first 24 hours (cOR = 33 University of Ghana http://ugspace.ug.edu.gh 4.07; 95% CI = 1.39 – 11.84; p = 0.010). However, this association was found not to be significant after adjusting for all other variables. On the severity of pain scale, respondents who indicated that they felt “no pain” in the first 24 hours scale had a 10.29 significant increase in their odds of being satisfied with pain management post caesarean section delivery as compared to those who felt 60% - 100% of pain (cOR = 10.29; 95% CI = 1.02 – 103.95; p = 0.0048). However, after adjusting for all other variables, respondents who felt 10% - 50% of pain post caesarean section delivery had significantly 911.49 times the odds of satisfaction with pain management as compared to those who felt 60% - 100% of pain post caesarean section delivery (aOR = 911.49; 95% CI = 1.93 – 431062.30; p = 0.030). Respondents who felt 60% - 100% pain relief post caesarean section delivery had significantly 11.72 times the odds of being satisfied with pain management as compared to those who felt 10% - 50% pain relief post caesarean section delivery (cOR =11.72; 95% CI = 4.27 – 32.17; p < 0.001). After adjusting for all other variables, this association was found to be statistically significant (aOR = 35.17; 95% CI = 6.83 – 181.09; p < 0.001). The odds of satisfaction with pain management post caesarean section delivery was increased significantly by 3 fold among respondents who had no information on pain treatment options as compared to those who had information on pain treatment options (cOR = 3.07; 95% CI = 1.55 – 6.11; p = 0.001). After adjusting for all other variables, this association was found not to be significant. Respondents who were adequately prepared mentally, had significantly 5.31 times the odds of satisfaction with pain management post caesarean section delivery as compared to those who were inadequately prepared mentally (cOR = 3.07; 95% CI = 1.55 – 6.11; p = 0.001). This association was found not to be significant after adjusting for all other variables. 34 University of Ghana http://ugspace.ug.edu.gh Table 8: Factors associated with pain management post caesarean section delivery Variables cOR(95% CI) p-value aOR(95% CI) p-value Age in years 1.09(1.02 - 1.17) 0.011* 1.04(0.92 - 1.18) 0.502 Educational level No formal education 1.0 0 1.0 0 Junior high school 0.82(0.19 - 3.48) 0.7 85 2.11(0.19 - 22.96) 0.5 41 Senior high school 1.01(0.24 - 4.16) 0.991 4.59(0.37 - 56.59) 0.233 Tertiary 3.17(0.73 - 13.71) 0.122 20.17(1.35 - 301.83) 0.030* Employment status Unemployed 1.0 0 1.0 0 Self employed 1.38(0.62 - 3.07) 0.4 30 0.68(0.17 - 2.75) 0.5 88 Salary worker 4.05(1.71 - 9.60) 0.001* 0.83(0.16 - 4.22) 0.821 Type of pain medication Diclofenac 1.0 0 1.0 0 Paracetamol 0.53(0.21 -1.29) 0.1 63 0.53(0.02 - 14.32) 0.7 04 Diclofenac, paracetamol 10.71(1.24 - 92.22) 0.031* 17.79(0.16 - 1945.39) 0.229 Diclofenac, pethidine 1.53(0.45 - 5.17) 0.494 6.71(0.15 - 296.72) 0.325 Pethidine, paracetamol 0.38(0.14 - 1.06) 0.065 1.72(0.02 - 134.29) 0.807 Diclofenac, pethidine, morphine 2.29(0.21 - 24.68) 0.493 0.13(0.002 - 11.43) 0.375 Route of administration of pain medication Intravenous 1.0 0 1.0 0 Intramuscular 0.82(0.13 - 5.23) 0.8 32 1.98(0.07 - 57.19) 0.6 91 Rectal 2.08(0.82 - 5.31) 0.124 0.67(0.08 - 5.47) 0.708 Intramuscular and intravenous 0.63(0.18 - 2.25) 0.477 0.07(0.001 - 3.52) 0.184 Intramuscular and rectal 1.64(0.56 - 4.79) 0.369 0.19(0.004 - 8.56) 0.390 Intravenous and rectal 6.95(1.85 - 26.09) 0.004* 1.08(0.09 - 12.61) 0.954 Intramuscular, intravenous and rectal 4.91(0.45 - 53.27) 0.191 1 Frequency of pain drug administration Twice daily 1.0 0 1.0 0 Thrice daily 0.29(0.13 - 0.68) 0.00 4* 0.68(0.03 - 14.19) 0.8 01 Four times daily' 0.88(0.29 - 2.66) 0.821 2.50(0.14 - 45.38) 0.535 Nausea No 1.0 0 1.0 0 Yes 0.26(0.13 - 0.53) 0.00 0* 1.08(0.22 - 5.37) 0.9 23 35 University of Ghana http://ugspace.ug.edu.gh Drowsiness No 1.0 0 1.0 0 Yes 0.39(0.18 - 0.85) 0.01 7* 0.49(0.02 - 9.97) 0.6 42 Dizziness No 1.0 0 1.0 0 Yes 0.42(0.19 - 0.90) 0.02 6* 12.28(0.35 - 437.07) 0.1 69 Least pain experienced in the first 24 hours 6 to 10 1.0 0 1.0 0 No pain 1.29(0.11 - 15.02) 0.8 36 0.12(0.001 - 23.48) 0.4 31 1 to 5 0.19(0.02 - 2.24) 0.188 0.07(0.0003 - 15.27) 0.328 Worst pain experienced in the first 24 hours 6 to 10 1.0 0 1.0 0 No pain 4.07(1.39 - 11.84) 0.01 0* 1 1 to 5 0.56(0.18 - 1.71) 0.310 0.13(0.01 - 2.49) 0.1 78 Severity of pain in the first 24 hours 60% - 100% 1.0 0 1.0 0 No pain 10.29(1.02 - 103.95) 0.04 8* 88.04(0.23 - 33124.62) 0.1 39 911.49(1.93 - 10% - 50% 6.39(0.75 - 54.57) 0.090 431062.30) 0.030* Pain relief received in the first 24 hours 10% - 50% 1.0 0 1.0 0 60% - 100% 11.72(4.27 - 32.17) 0.00 0* 35.17(6.83 - 181.09) 0.00 0* Information on pain treatment options Yes 1.0 0 1.0 0 No 3.07(1.55 - 6.11) 0.00 1* 3.77(0.78 - 18.16) 0.0 98 Overall mental preparedness Inadequate mental preparedness 1.00 1.00 Adequate mental preparedness 5.31(1.45 - 19.48) 0.012* 1.15(0.09 - 15.32) 0.914 36 University of Ghana http://ugspace.ug.edu.gh CHAPTER FIVE 5.0 DISCUSSION 5.1 Introduction Patient satisfaction with pain management is a very essential tool for evaluating quality care delivery. It is a very subjective symptom and as such, pain is what a patient says it is, nothing more or less. Most of the respondents in the study were able to rate their pain using a Numerical Rating Scale as well as their satisfaction with pain management. According to Dueñas et al., (2016), acute pain may affect a person’s mood as much as cause anger, depression and anxiety among others. 5.2 Level of patient satisfaction with pain management post Caesarean section delivery. Patient satisfaction is a rather subjective perception based on a person’s past experiences and expectation of future experiences. For some reason, it is easy to assume that effective pain management would translate into patient satisfaction with pain relief. However, according to Farooq et al., (2016) a study showed that patients may end up being highly satisfied with their pain management even if they reported high levels of pain during their hospital admission. Slightly more than half of the respondents (51.3%) were satisfied with their pain management during their stay in the hospital. This finding is consistent with the results of similar studies done which reported that 52.2% (Mitsuru, et al., 2018) were satisfied with pain management. However, according to another study, 68% of their respondents were satisfied with pain management after Caesarean delivery (Kintu, et al., 2019). This was relatively higher than the other studies reviewed. These are however much lower than a previous study done by Dharmalingam & Ahmad, 2013, who reported respondents having 97% satisfaction with pain relief after Caesarean delivery. This disparity may due to the different evaluation methods used. 37 University of Ghana http://ugspace.ug.edu.gh However, the low proportion of respondents being satisfied with their pain management. Inadequate pain relief may lead to restricted physical activity and this makes mothers prone to developing thromboembolic complications after surgery (Chan et al., 2018). 5.3 Sociodemographic factors associated with patient satisfaction with pain management after caesarean section. Even though Jasmin et al. (2017) reported in a previous study that there was a significant relationship between marital status and post Caesarean pain, this study did not show any significant relationship between marital status and post Caesarean pain. The variable group “educational level” was found not to be significant after a simple logistic regression. However, after adjusting for all other variables, respondents who had tertiary education had significantly 20.17 times the odds of being satisfied with pain management post caesarean section delivery as compared to those with no formal education. This finding is in concordance with a study done by Masigati & Chilonga, (2014) who found that patient satisfaction with pain management increases with an increasing level of education. We were unable to determine why this association was realized. Salaried workers also had significantly 4.05 times the odds of being satisfied with pain management post caesarean section delivery as compared to those who were unemployed but this association was found not to be significant after adjusting for all other variables. Similarly, Afaya et al. (2020) found no statistically significant relationship between occupation and satisfaction with pain management. Even though a one-year increase in age in our study significantly increased the odds of respondents being satisfied with pain management post caesarean section delivery, there was no significant association after adjusting for all other variables. The likelihood that younger 38 University of Ghana http://ugspace.ug.edu.gh aged respondents experienced more severe pain and were more dissatisfied with their pain management is in concordance with other studies previously done. From our study, it was realized that a vast majority of the respondents were religious, most of them being Christians. However, apart from their religiosity causing them to use prayer as a complementary pain strategy, there was no significant association between religion and satisfaction with pain management. Ofori et al. (2016) also reported that there was no significant association between religion and satisfaction in pain management in a similar study done. 5.3 Health provider factors associated with pain management satisfaction after Caesarean sections. Combination of Diclofenac and Paracetamol as analgesic therapy after surgery was found to be associated with a high likelihood of being satisfied with pain management after surgery. The pain relief felt in the first 24 hours, having information on pain treatment options and an overall mental preparedness were the health provider factors associated with pain management. The study revealed that respondents who indicated that they felt “no pain” in the first 24 hours were more likely to be satisfied with pain management post caesarean section delivery as compared to those who felt 60% - 100% pain relief. Also, respondents who felt 60% - 100% pain relief post caesarean section delivery were more satisfied with pain management as compared to those who felt 10% - 50% pain relief post caesarean section delivery. Neimi-Murola et al., (2007), emphasised that patients were satisfied with pain management and their satisfaction positively correlated with preoperative information received. We found in our study that respondents who were adequately prepared mentally, more likely to be satisfied with pain management post caesarean section delivery as compared to those who 39 University of Ghana http://ugspace.ug.edu.gh were inadequately prepared mentally. This is in concordance with the study done by Neimi- Murola et al., (2007). Overall, the above were the factors that were associated with satisfaction with pain management after Caesarean delivery among the respondents. 5.4 Strengths and Limitations of the study The study employed a cross sectional study design which was useful in measuring patients’ satisfaction to post caesarean section pain management as well as factors that were associated with patients’ satisfaction. The t test and logistic regression employed in analysis were robust making the empirical evidence found in this study statistically sound. However, it is impossible to generalise the study to other parts of Ghana or Ghana as a whole since the study was conducted at the Greater Accra Regional Hospital. Factors found to be associated with patients’ satisfaction cannot be considered as causal due to the selected study design. 40 University of Ghana http://ugspace.ug.edu.gh CHAPTER SIX 6.0 CONCLUSIONS AND RECOMMENDATIONS 6.1 Conclusions At the end of the study, it was realised that, Nearly half of respondents were satisfied with pain management after caesarean section delivery (51.3%). Respondents who had tertiary education were more likely satisfied with pain management post caesarean section delivery as compared those with no formal education. Respondents who felt 10% - 50% of pain post caesarean section delivery were more likely to be satisfied with pain management as compared to those who felt 60% - 100% of pain post caesarean section delivery. Respondents who felt 60% - 100% pain relief post caesarean section delivery were more likely to be satisfied with pain management as compared to those who felt 10% - 50% pain relief post caesarean section delivery. 6.2 Recommendation Further qualitative studies on patient satisfaction with pain management should be done to determine factors that affect satisfaction as well as how much can be done to reduce the pain felt by patients after surgery. 41 University of Ghana http://ugspace.ug.edu.gh REFERENCES Afaya, A., Dzomeku, A.M., Baku, E.A., Afaya, R.A, Ofori, M., Agyeibi, F., Boateng, F., Gamor, O.R., Gyasi-Kwofie E., and Nyaledzigbor, P.P.M. (2020). BMC Pregnancy and Childbirth 20, Article number: 8 (2020). https://doi.org/10.1186/s12884-01926984 American College of Obstetricians and Gynaecologists (2018). Postpartum Pain Management. ACOG Clinical Number 742. 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PhD Thesis, New York University, New York, NY. 49 University of Ghana http://ugspace.ug.edu.gh APPENDICES APPENDIX I: PARTICIPANTS INFORMATION SHEET This information sheet is to inform the participants about the research for them to make an informed decision of whether to participate in the study or not. It also outlines the nature of the research, what the research involves, risks, benefits and compensation. Title of Study: Patient Satisfaction with Pain Management after Caesarean Section Delivery in the Greater Accra Regional Hospital. Introduction: The principal investigator (PI) is Andriana Wilhelmina Parker Adams, a Master of Public Health (MPH) student of the School of Public Health of the College of Health Sciences, University of Ghana. My email address is andrico2009@yahoo.com. My telephone number is 0553304143. Background and Purpose of Research: I am carrying out a research on the topic: “Patient Satisfaction with Pain Management after Caesarean Section Delivery in the Greater Accra Regional Hospital”. Nature of Research: The research is a cross-sectional study with a quantitative approach. My interest is in finding out Patient Satisfaction with Pain Management after Caesarean Section Delivery in the Greater Accra Regional Hospital. It would be conducted among women who have undergone caesarean section at the Greater Accra Regional Hospital. 50 University of Ghana http://ugspace.ug.edu.gh Data Storage/ Security: Questionnaires would be filled using codes generated for each participant. Completed questionnaires would be kept in a secured briefcase where I am the only one with access. Data would be entered and kept on a computer with a password privy to only me. Conflict of Interest: I have no conflict of interest in this study. PARTICIPANTS INVOLVEMENT Duration/ what is involved: A structured questionnaire will be used to elicit information from the study participants after the aim of the study has been explained to them and they are interested in participating. The questionnaire would be administered in English Language for literate respondents and translated into Twi or Ga for non-English literate respondents. This will last for 20 minutes. Potential Risks: This research poses no risk or physical harm to the participant except the minimal risk of having to share information which may seem personal. Benefits: Participants would have the opportunity to gain some knowledge and awareness on patient satisfaction with pain management after caesarean section delivery since each participant would be educated after data collection. 51 University of Ghana http://ugspace.ug.edu.gh Cost: There would be no cost incurred by participants for taking part of the study except their time. Compensation: There would not be any compensation for participating in the study. Confidentiality: In ensuring anonymity, participants would only be identified with codes and numbers. No information regarding participants name or any other information that traces the data collected to the participants will be taken. Filled questionnaires would be kept under lock and key, with only the principal investigator having access. Voluntary participation/ withdrawal: Participation in the study is voluntary and not compulsory. Participants have the right to decide whether or not they want to be part of the study. You can also withdraw your consent at any time of the study. Outcome and feedback: Findings of the study will be shared with the selected hospital which may improve health service delivery at the hospital. Feedback to participants: A report will be presented to various stakeholders such as the Ghana Health Service, Greater Accra Regional Hospital to formulate policies on pain management and maternal health related issues. The report will be published in a journal. 52 University of Ghana http://ugspace.ug.edu.gh Funding information: This study is funded by the Principal Investigator. Sharing of Participants Information/Data: Participant information or data will be kept by me. Filled questionnaires will be kept under lock and key, with only the principal investigator having access. It will not be shared with anyone else. Provision of Information and Consent for participants: A copy of the information sheet and consent form will be given to you to sign or thumb-print before participation in the study Who to Contact for Further Clarification/Questions: If there are any clarifications or concerns you want addressed concerning this research, please contact Andriana at the School of Public Health on telephone number 0553304143. You can also contact me by e-mail andrico2009@yahoo.com. For further clarification on ethical issues kindly contact the Ghana Health Service Ethics Review Committee Administrator, Nana Abena Apatu on phone number 0503539896. 53 University of Ghana http://ugspace.ug.edu.gh APPENDIX II: CONSENT FORM FOR STUDY PARTICIPANTS STUDY TITLE: PATIENT SATISFACTION WITH PAIN MANAGEMENT AFTER CAESAREAN SECTION DELIVERY IN THE GREATER ACCRA REGIONAL HOSPITAL. PARTICIPANTS’ STATEMENT I acknowledge that I have heard or have had the purpose and contents of the Participants’ Information Sheet read and satisfactorily explained to me in a language I understand (English Twi Ga ). I fully understand the contents and any potential implications as well as my right to change my mind (i.e. withdraw from the research) even after I have signed this form. I voluntarily agree to be part of this research. Initials of Participant………………………….. Date: ………………………………. INTERPRETERS’ STATEMENT I interpreted the purpose and contents of the Participants’ Information Sheet to the forenamed participant to the best of my ability in the (English [ ] Twi [ ] Ga [ ] ) language to his proper understanding. All questions, appropriate clarifications sort by the participant and answers were also duly interpreted to his/her satisfaction. Name of Interpreter……………………………………………………. Signature of Interpreter……………………… Date: ………………… Contact Details: ……………………………… 54 University of Ghana http://ugspace.ug.edu.gh STATEMENT OF WITNESS: I was present when the purpose and contents of the Participant Information Sheet was read and explained satisfactorily to the participant in the language he/she understood (English [ ] Twi [ ] Ga [ ]) I confirm that he/she was given the opportunity to ask questions/seek clarifications and same were duly answered to his/her satisfaction before voluntarily agreeing to be part of the research. Name: ……………………………………………………….. Signature…………………………... OR Thumb Print ………............................ Date: …………………………… INVESTIGATOR STATEMENT AND SIGNATURE: I certify that the participant has been given ample time to understand and learn about the study. All questions and clarifications raised by the participant have been duly addressed. Researcher’s Name ………………………………………….. Signature …………………………… Date……………………………………… 55 University of Ghana http://ugspace.ug.edu.gh APPENDIX III (QUESTIONNAIRE) QUESTIONNAIRE ON PATIENT SATISFACTION WITH PAIN MANAGEMENT AFTER CAESAREAN SECTION DELIVERY IN THE GREATER ACCRA REGIONAL HOSPITAL This is a research on the Patient Satisfaction with Pain Management after Caesarean Section Delivery in the Greater Accra Regional Hospital. The study is trying to find out how satisfied you were with pain treatment when your Caesarean section at the Greater Accra Regional Hospital. Kindly share your unique experiences to aid this study by responding to the following questions. QUESTIONS CODING CATEGORIES SKIP CODES TO 1. INDIVIDUAL FACTORS a age . Age (State your last birthday …………………………………….. age) Marital status mstat Educational Level educ Occupation occp How much do you earn monthly from the job you do? ………………………………………… Income Religion religion Body Mass Index bmi Weight………………………. Height……………………….. Body Mass Index How old was your last pregnancy? ……………………………………. How many times have you gravidit been pregnant? …………………………………… y How many children have you parity given birth to? …………………………………… Previous Caesarean Section Yes……………………………1 prev_c_s No……………………………..2 ection If yes in () above, how many times? Please State………………………… Indication for Caesarean 1. Fetal Distress [ ] 56 University of Ghana http://ugspace.ug.edu.gh Section (Tick as many as 2. Obstructed /Prolonged Labour [ ] apply) 3. Previous Caesarean Section Scar [ ] 4. Macrosomia/Big Baby [ ] 5. Breech Presentation [ ] 6. Failed induction [ ] 7. Cephalopelvic Disproportion [ ] 8. Oligohydramnios [ ] 9. Upon request [ ] 10. Others [ ] (Please State)…………………… How is the baby from your 1. Baby Alive and well [ ] last Caesarean section? 2. Baby Alive and ill [ ] 3. Dead baby 2. DRUG RELATED FACTORS g Type of pain medication 1. Diclofenac 2. Paracetamol 3. Pethidine Route of administration of 1. Suppository 2. Intravenous pain medication 3. Oral 4. Intramuscular Frequency pain drug 1. Daily 2. Twice daily administration 3. Three times daily 1. Yes [ ] 2. No [ ] PRE-OPERATIVE MENTAL PREPARATION I was well educated about my 1. Strongly disagree [ ] condition and the need for 2. Disagree [ ] caesarean section 3. Agree [ ] 4. Strongly agree [ ] I was well informed about the 1. Strongly disagree [ ] complications of caesarean 2. Disagree [ ] section 3. Agree [ ] 4. Strongly disagree [ ] My fears and anxiety about 1. Strongly disagree [ ] caesarean section were 2. Disagree [ ] allayed before the surgery 3. Agree [ ] 4. Strongly agree [ ] I was given the opportunity to 1. Strongly disagree [ ] consent for the procedure be 2. Disagree [ ] done 3. Agree [ ] 4. Strongly agree [ ] I was well informed about the 1. Strongly disagree [ ] benefits of caesarean section 2. Disagree [ ] 3. Agree [ ] 4. Strongly Agree [ ] 57 University of Ghana http://ugspace.ug.edu.gh APS REVISED PATIENT OUTCOME QUESTIONNAIRE PSYCHOMETRICS The following questions are about pain you experienced during The first 24 hours in the hospital or after your operation. 1. On this scale, please indicate the least pain you had in the first 24 hours: 0 1 2 3 4 5 6 7 8 9 10 no worst pain pain possible 2. On this scale, please indicate the worst pain you had in the first 24 hours: 0 1 2 3 4 5 6 7 8 9 10 no worst pain pain possible 3. How often were you in severe pain in the first 24 hours? Please circle your best estimate of the percentage of time you experienced severe pain: 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Never in Always in severe pain severe pain 4. Circle the one number below that best describes how much pain interfered or prevented you from: a. Doing activities in bed such as turning, sitting up, repositioning. 0 1 2 3 4 5 6 7 8 9 10 Does not Completely Interfere interferes b. Doing activities out of bed such as walking, sitting in a chair, standing at the sink. 0 1 2 3 4 5 6 7 8 9 10 Does not Completely Interfere interferes c. Falling asleep 0 1 2 3 4 5 6 7 8 9 10 Does not Completely Interfere interferes d. Staying asleep 0 1 2 3 4 5 6 7 8 9 10 Does not Completely Interfere interferes 5. Pain can affect our mood and emotions. On this scale, please circle the one number that best shows how much the pain caused you to feel: e. Anxious 0 1 2 3 4 5 6 7 8 9 10 Does not Completely Interfere interferes f. Depression 0 1 2 3 4 5 6 7 8 9 10 Does not Completely 58 University of Ghana http://ugspace.ug.edu.gh Interfere interferes g. Frightened 0 1 2 3 4 5 6 7 8 9 10 Does not Completely Interfere interferes h. Helpless 0 1 2 3 4 5 6 7 8 9 10 Does not Completely Interfere interferes 6. Have you had any of the following side effects? Please circle “0” if no; if yes, please circle the one number that best shows the severity of each: a. Nausea 0 1 2 3 4 5 6 7 8 9 10 None Severe b. Drowsiness 0 1 2 3 4 5 6 7 8 9 10 None Severe c. Itching 0 1 2 3 4 5 6 7 8 9 10 None Severe d. Dizziness 0 1 2 3 4 5 6 7 8 9 10 None Severe 7. In the first 24 hours, how much pain relief did you receive? Please circle one percentage that best shows how much relief received from all your pain 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% No Complete Relief 8. Were you allowed to participate in decisions about your pain treatment as much as you wanted to? 0 1 2 3 4 5 6 7 8 9 10 Not at all Very much so 9. Circle the one number that best shows how satisfied you are with the results of your pain treatment while in the hospital after your Caesarean section: 0 1 2 3 4 5 6 7 8 9 10 Extremely Dissatisfied Satisfied 10. Did you receive any information about your pain treatment options? 1. Yes [ ] 2. No [ ] a. if yes, please circle the number that shows how helpful the information was 0 1 2 3 4 5 6 7 8 9 10 Not at all Extremely helpful 11. Did you use any non-medicine methods to relieve your pain? 1. Yes [ ] 2. No [ ] If yes, check as many as apply: Cold pack [ ] Deep breathing [ ] Distraction( such watching TV, reading) [ ] Heat [ ] Massage [ ] Meditation [ ] Listening to music [ ] Prayer [ ] Relaxation [ ] Walking [ ] Imagery / Visualization [ ] Other (specify) ………………………………………………. 59 University of Ghana http://ugspace.ug.edu.gh APPENDIX IV Budget and Justification A total of 2,864.80 Ghana Cedi was used in conducting the study. The study was self- sponsored by the PI. Table 2 is the breakdown of the total for the study. An amount of GH¢ 50 was paid to the GHS-ERC. Two racks of A4 sheets was purchased for printing and photocopying of the questionnaires at a cost of GH¢ 50.00 and GH¢ 700. On the day of training the research assistants catered for at a cost of GH¢ 20 per head. The three research assistants were paid GH¢ 400 each at the end of data collection. Data entry cost an additional GHC 200.00. GH¢ 500 was paid as consultation to a biostatistician to help in data analysis. Table 3: Detailed Budget Unit Cost No Item Description Quantity (GhC) Total Cost 1 Ethical Clearance 1 50 50 2 A-4 sheet 2 25 50 3 Pre-Testing of Questionnaire 20 2 40 4 Printing of Questionnaire 4 2.5 10 Photocopying of Questionnaire, Consent 5 form and information sheets 350 2 700 6 Training of Research Assistants 3 20 60 Data Collection and Research Assistant 7 Per-diem and T&T 3 400 1200 8 Data Entry 1 200 200 9 Data Analysis 1 500 500 10 Dissemination of Findings 1 50 50 Total 2,860.00 60