Knowledge, attitudes, and practices of Cameroonian physicians with regards to pain management at the emergency department: a multicenter cross-sectional study

Introduction: Pain is the most frequent presenting complaint in patients consulting or admitted to the emergency department (ED). Thus, its acute management is often done by physicians working in the ED. These practitioners are often general practitioners and not emergency medicine physicians in resource-poor settings. Hence, a mastery of pain management by these physicians may be important in relieving acute pain. We aimed to assess the knowledge, to determine the attitudes and practices of physicians in the management of pain in EDs of Cameroon. Methods: We carried out a prospective analytic cross-sectional study over four months in the year 2018. We enrolled all consenting physicians who were neither emergency medicine doctors nor anesthesiologists working at the EDs of five tertiary hospitals of Cameroon. Using a 30-item structured questionnaire, data on the knowledge, attitudes, and practices of pain management at the ED by these clinicians were studied. We used an externally validated score to assess the knowledge as either poor, insufficient, moderate or good. Results: A total of 58 physicians were included; 18 interns and 39 general practitioners. Their mean age was 28.6 ± 3 years and their average number of years of practice was 2.9 years. The level of knowledge was rated “poor” in 77.6% of physicians. Being a general practitioner was significantly associated with a poor level of knowledge (p=0.02; OR=5.1). We found a negative and significant correlation between knowledge and years of practice (p=0.04; r2= 0.06). More than three-quarter (82.8%) of participants used a pain scale to evaluate the severity of pain. The most used scale being the Visual Analog scale (56.9%). The most frequently used analgesic was paracetamol (98.3%), although only 3.5% of physicians correctly knew its half-life, delay of onset of action and duration of action. Conclusion: These findings suggest that physicians in EDs of Cameroon have poor

4 knowledge and suboptimal practices in pain management. General practice and a greater number of professional experience seemed to favour these attitudes. Overall, there is an urgent need for refresher courses in acute pain management for physicians working in these resource-limited EDs.

Background
Pain is the most common reason for consultation in the emergency department. Its global prevalence is 20% [1,2]. According to the International Association for the Study of Pain, pain is an unpleasant emotional experience in response to a real or potential tissue injury [3]. It is a multidimensional symptom involving sensory, emotional, cognitive and behavioral components [4]. Etiologies of pain are many and varied. They cause of pain depend on the type of pain, the location and the severity of the symptom. Hence, an adequate knowledge of the physiological and semiological bases of pain allows for a better diagnostic procedure and therefore an early and adequate aetiological and/or symptomatic management [4,5].
The emergency department (ED) of a health facility is often the first unit to encounter patients consulting for diverse forms of pains. Health professionals working in the ED, therefore, play a key role in the first-line management of pain. This initial management will, therefore, influence the subsequent medical and/or surgical treatment of the patient.
In order to improve the initial care of patients presenting with pain in the ED, we proposed this study to assess the level of knowledge, attitudes, and practices with regards to pain management in clinicians working in the EDs of major referral hospitals of Cameroon.

Study design, setting, participants and sampling
This was an analytic multicentre cross-sectional study carried out prospectively between June 1, 2018, to September 30, 2018. The study population consisted of all consecutive consenting physicians working at the ED of five tertiary hospitals in Yaounde, the political city of Cameroon. These five hospitals were the Yaoundé Gyneco-Obstetrics and Pediatrics Hospital (HGOPY), the Yaoundé General Hospital (HGY), the Yaoundé National Emergency Center (CURY), the Yaoundé University Hospital Center (CHUY) and Yaoundé Central Hospital (HCY). We excluded emergency medicine physicians and anesthetist physicians.

Data management and analysis
Data collection was conducted from physicians practicing in the five aforementioned EDs using a pre-established and pre-tested questionnaire (see attached data collection form).
This questionnaire consisted of 30 items. The variables studied were socio-demographic data, questions related to knowledge, attitudes, and practices of pain management.
Knowledge was scored out of 32 and ranked as in Table 1 [6]. The data were coded, entered and analyzed using SPSS software version 20.0. The mean, median, standard deviation and interquartile were used for the description of continuous variables.
Categorical variables were described in terms of frequency and percentage. The association between categorical variables was measured by the Chi-square and Fisher tests with odds ratios (OR) and logistic regression calculation. The association between two continuous variables was measured by the Pearson correlation test and materialized where appropriate by linear regression. Comparisons of continuous variables between the two groups were made by the Student t-test and the Mann-Withney U test when this was not the case. When necessary, covariate adjustment by covariance analysis (ANCOVA) was used. The threshold of significance has been set at 5%.

Socio-demographic characteristics
A total of 75 physicians were interviewed of whom 58 consented to participate in the 6 study. Hence, a response rate of 77.3%. The average age of participants was 28.6 ± 3 years and the average number of years of experience was 2.9 ± 2 years. The sex ratio was 1.14 in favor of men. Twenty-one (36.2%) of the participants practiced at the Yaoundé Central Hospital. More than half of the participants (67.2%) were general practitioners.

Knowledge of pain in emergencies
On average, the level of knowledge of the physicians was rated "poor", with a mean score of 11.8 ± 4.3 (range: 3 -24). This corresponded to 45 (77.6%) participants having a poor level of knowledge, 10 (17.2%) with an insufficient level of knowledge, and 3 (5.2%) has a moderate level of knowledge. No "good" level of knowledge was seen amongst the participants.
The highest percentage of the correct answer (93.1%) was obtained for the question regarding the types of analgesics used to treat pain. The lowest percentage (5.2%) was scored on the question regarding the number of types of pains. Residents and interns had significantly higher knowledge scores than general practitioners (p = 0.014). Being a general practitioner was significantly associated with poor knowledge (P = 0.02, OR = 5.1). The number of years of professional experience was significantly and negatively correlated with the level of knowledge (p = 0.04 r² = 0.06). The same was true for age (p = 0.02, r² = 0.08). Hence, the older the age of the clinician and the higher his or her number of years of professional experience, the worse was his or her level of knowledge regarding the management of pain in the ED.  (Table 3). Paracetamol was the preferred analgesic used. The reason given by 26.3% of participants was due to its effectiveness in pain relief. Of the 57 physicians who reported using paracetamol in the ED, only two

Discussion
The study's objectives were to assess the knowledge, to determine the attitudes and practices of physicians in the management of pain in EDs of Cameroon. We found that the level of knowledge was "poor" and significantly associated with being a general practitioner. Furthermore, there was a negative and significant correlation between knowledge and years of practice. More than three-quarter of participants used a pain scale to evaluate the severity of pain. The most used scale being the Visual Analog Scale. The most frequently used analgesic was paracetamol, although only 3.5% of physicians knew 8 its exact half-life, delay of onset of action and duration of action.
This study focused on clinicians working in the EDs of five major referral hospitals in Yaoundé with a good response rate (77.3%). However, this percentage is significantly lower than the 92% and 89.5% respectively found by Nasser et al [7] in Lebanon in 2016 and Subhashini et al [8] in India in 2008. This difference reflects the difficulty of clinicians, in our setting to undergo an assessment of their knowledge, attitudes, and practices in a domain. The mean age of participants was 28.6 ± 3 years, lower than the30.8 ± 5.7 years found in Iran [9]. This disparity may imply younger physicians practicing in the EDs of Cameroon compared to Iran.
The level of knowledge was averagely poor and lower than that found by Zanolin et al [10] in Italy and by Kheshti et al [9] in Iran. This low level of knowledge on pain management in comparison with that found in the literature could be explained by the lack of refresher courses on pain management undertaken by clinicians in Cameroon.
General practitioners had a statistically lower knowledge score than residents and interns.
The number of years of professional experience was significantly and negatively correlated with the knowledge score and therefore the percentage of correct answers. This is in contrast with previous reports c which showed inexperienced physicians to have a lower level of knowledge on pain management. More contradicting results were obtained in an Iranian study [9] which observed a positive and significant correlation between the number of years professional experience and the level of knowledge on pain management (p = 0.002, r = 0.03). The discrepancy between our finding and the aforementioned studies [7,9], may be explained by the absence of regular refresher courses organized in our resource-poor setting to form and update physicians on pain management in the ED.
We found that 82.8% of participants used a pain scale to evaluate pain intensity. The main scale used was the VAS (56.9%) probably explained by the simplicity in the clinical application of the VAS. By contrast, Nasser et al [7] found that the most used pain scale was the simple verbal scale (72.5%) and the VAS was used by only 29% of physicians. The most used analgesic was paracetamol, but its pharmacokinetics was mastered by only 3.5% of participants. Morphine was the least used analgesic (5/58). This could be explained by physicians' fear of its side effects, especially respiratory distress which can be fatal in some patients.
The results from the present study should be interpreted within the context of its