الفهرس 
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Abstract
Breast cancer has become a public health problem worldwide. Most cases diagnosed in developing countries are in more advanced stages of the disease, which complicates treatment. Despite the development of different analgesics and updated pain guidelines, breast cancer pain remains undermanaged, and some patients with moderate to severe pain do not receive adequate pain treatment. The delay in diagnosis and inadequate pain management can be attributed to several barriers found during the search for health care such as age, gender, education, place of residence, ethnic group, working conditions, low financial status, and lack of health insurance. Given the multidimensional nature of cancer pain and the multifaceted barriers involved, effective pain control mandates multidisciplinary interventions from inter professional teams. Educational interventions for patients and health care professionals may improve the success of pain management.
The aim of the study was to identify barriers associated with pain management among advanced breast cancer patients.
Materials and method
Study design
A descriptive research design was utilized for the present study to collect data at the Chandaria Cancer and chronic Disease Center (CCCDC) at Moi Teaching and Referral Hospital Eldoret, Kenya.
Study subjects
A systematic random sample of 115 female patients diagnosed with stage III or stage IV Advanced Breast Cancer (ABC) from the CCCDC oncology outpatient clinic, who met the inclusion criteria of being an adult female patient aged from 21 -60 years and able to communicate verbally, diagnosed with histologically proven clinical stage III and/stage IV or inflammatory breast cancer, informed of their diagnosis of breast cancer and on ongoing treatment for stage III /stage IV of breast cancer (chemotherapy, radiation and post-surgical interventions). All the patients who gave consent to participate in the study were included.
Tools of the study
Two tools were used for data collection;
Tool 1: Structured Advanced Breast Cancer Pain Management Barriers Interview Schedule (ABCPMIS).
This tool was developed by the researcher based on relevant literature review to explore barriers associated with pain management among advanced breast cancer patients. It consisted of two parts:
Part 1: Bio socio demographic and clinical data.
a) Bio socio demographic characteristics
This part included statements regarding, residence, age, marital status, living arrangements, level of education, religion, occupation, health insurance, and income.
b) Patient’s clinical history data
This part had statements related to patients, stage of disease, current status of disease, previous and current treatment, presence of pain, date associated with the symptom occurrence/reason for seeking treatment, and pain rating.
Part 11: Pain Management Barriers Interview Schedule (PMBIS).
The PMIS was developed by the researcher based on relevant literature review to explore patient’s responses on barriers to pain management, which included 5 categories of barriers;
I. Health Care Professional Related Barriers; This part consisted a list of nine statements in relation to waiting list, pain assessment, management of pain, time taken to be reviewed by the medical professionals, talking about pain, endurance of pain, information on pain medication side effects, management of medication side effects, and consultation to supportive care by the medical professionals.
II. Patient Related Barriers; This part had ten patient related barriers such as financial, transport, locating the referral facility, reporting of pain, worries about pain, personal beliefs, long term use of opioids, information about pain medication, shame of being on treatment regularly, refusing to take opioids and time off work or school.
III. System barriers; This part elicited seven system barriers as regards to, availability of morphine, issuance of drugs in the pharmacy, pain medication prescriptions, accessibility of pain medications, being reviewed by different doctors, schedule visit and the nurse patient ratio.
IV. Medication barriers; This part had nine barriers on effect of prescribed dose, side effects, reporting of side effects and management of side effects, addiction and tolerance, attitude about opioids, alternative medicine and severity of pain.
V. Sociocultural barriers; This part included ten barriers: role of family, taking care of a sick family member, attitude of friends and family members, negative public image of morphine, seeking medical advice is against religion, society influence, traditional herbal medicine, previous experiences of friends and cultural beliefs to talk about pain.
Tool 11: Visual analog scale (VAS);
This is a standardized pain assessment tool in research and clinical practice and was used to measure pain intensity among advanced breast cancer patients. It is a single-item scale and using a ruler, the score was determined by measuring the distance on the 10-cm line between the “no pain” anchor and the patient’s mark, providing a range of scores from 0–10cm. Mild pain (1-3), moderate pain (4-7) and severe pain (5-10).
The selected female patients were interviewed individually during a regularly scheduled clinic visit. The interview took 30 - 45 minutes in the outpatient clinic. It was done on a face to face basis in an allocated room by the department to collect the necessary data using the Tool I.
Main results of the current study were as follows:
A total of 115 patients were interviewed of which 56.6% of the studied female patients were 40-50 years old, while 44.3% were married. More than one third (44.3%) had high school education.
More than two thirds of the patients (67%) presented with stage IV and regarding current status of disease 45.2% were under treatment, while 42.6% of them had recurrent breast cancer after surgical intervention but were under treatment.
More than half of the patients (58.3%), had surgery previously(mastectomy or breast conserving surgery), while 22.6% were on chemotherapy, and 17.4% had taken herbal medication for example tree barks of local confetti and the pepper-wood trees, the latter known as “Mkaa” in Kiswahili, least of them 1.7% having undergone radiotherapy.
Majority of the patients 84.8% were currently on chemotherapy.
Furthermore, majority of the patients (98.3%) were in pain, 60% sought medical advice, 41.7% visited the clinic immediately when in pain and 18.3% waited for the scheduled visit. According to the Visual Analogue Scale (VAS) approximately half of the patients (49.6%) reported severe pain and 47.8% moderate pain while 2.6% had mild pain.
A health care professional barrier mostly highlighted by less than three quarter of the patients at 70.4% was waiting list for scheduling consultation which always took a long time.
Patient related barriers commonly reported each at 91.3% were “worries of pain being a sign that the illness has gotten worse and long term use of pain medication”
The most prevalent system barriers (94.8%) was “review by different doctors”
For medication barriers majority of the patients 90.4% reported they were worried of getting addicted to pain medicine.
Sociocultural barriers most prevalent were “People around you believe if you have cancer you should not go for treatment” “Your community believe in traditional herbal medicine than seeking treatment” each at 96.6% respectively.
Patient related barriers and sociocultural barriers had the highest mean and standard deviation (67.1±10.9) and (67.1±9.7) respectively while medication barriers had the lowest mean 58.5±8.9.
There was statistical significant difference between level of barriers experienced and educational level where P=0.036 and sufficiency of monthly income where P=0.006.
Statistical significant difference existed between levels of barriers experienced and patients stage of disease, current status of disease, seeking medical advice when in pain and VAS where P<0.0006, P<0.0001, P=0.006, P<0.0001 respectively.
Significant statistical relationship between VAS levels of pain experienced and the patients’ stage of disease P<0.0001, current status of disease P=0.003, previous treatment P<0.0001 and seeking medical advice when in pain P<0.0001 respectively was also observed.
It can be concluded from the present study that
Women in Kenya face barriers in all periods of the course of care for breast cancer, highlighting the patient and sociocultural barriers, which were mentioned the highest number of times.
There is a high prevalence of breast cancer pain in advanced disease and also a high proportion of those in pain, getting inadequate pain management.
A statistical significant relationship between level of barriers experienced and educational level and sufficiency of monthly income existed.
Statistical significant difference also existed between levels of barriers experienced and patient’s current status of disease, seeking medical advice when in pain and VAS.
In addition significant statistical relationship between VAS levels of pain experienced and the patients’ stage of disease, current status of disease, previous treatment and seeking medical advice when in pain respectively was also observed.
Based on the results of the present study the following recommendations are suggested;
Regular breast cancer awareness campaigns to be conducted in all counties in Kenya, emphasizing the early symptoms and signs of breast cancer.
Presence of support groups comprising of breast cancer survivors may assist in reassuring newly diagnosed patients about the efficacy of conventional treatment, as fear of treatment, denial and negative attitude could be avoided through counseling.
Identifying the underlying cause of pain should be an integrated part of a patient’s pain assessment done by nurses.
A cooperative program whereby patients and nurses can discuss different opportunities for pain management may help. Such programs should focus on identifying the optimal regimen for each patient.
Future Recommended Researches
Further studies are needed to identify the factors contributing to such a high rate of inadequate pain management in advanced breast cancer patients.
Research is needed to examine the impact of doctor-patient communication on perceived barriers to pain management and health outcomes.
Identify factors contributing to delay in seeking medical care in breast cancer patients.