Chronic pain: The prevalence of chronic pain in patients attending Soshanguve Community Health Centre

ABSTRACT

Introduction

Chronic pain is a costly and incapacitating condition, with a projected global prevalence of 20%. In South Africa, almost one in five adults experience chronic pain. The aim of this study was to assess the prevalence of chronic pain and the association between chronic pain intensity and the interference of pain with life domains in patients attending a primary health care center.

Methods

We conducted a cross-sectional quantitative study on a sample of 331 patients at Soshanguve Community Health Centre. The data were collected using the Wisconsin Brief Pain Questionnaire, a validated scale for measuring pain.

Results

The mean age of participants was 51.6 years (SD = ±15.15, range = 18–86). The median age was 48 years (interquartile range = 40–64). The prevalence of chronic pain was 21.5% (95% confidence interval [CI] 17.0–25.9). Approximately 58% of participants were female, and female patients were affected more frequently than male patients. Chronic pain was observed to be 11.1% more prevalent in females than in males. Chronic pain mildly impacted general activity in 33.8% of patients (95% CI 23.9–45.4), mood in 42.3% (95% CI 31.4–53.8), walking ability in 29.6% (95% CI 20.2–41.0), relationships in 47.9% (95% CI 36.7–59.3), sleep in 31.0% (95% CI 21.4–42.5), enjoyment of life in 39.4% (95% CI 28.9–51.1), and normal working ability in 25.3% (95% CI 16.7–36.6).

Conclusions

Findings from this study show that among patients who attended the primary health care clinic, chronic pain was highly prevalent and interfered with their life domains. The intensity of pain was high in a significant proportion of patients. These findings provide invaluable information needed for the improvement of resources at the primary care level to comprehensively evaluate pain in our communities.

Résumé

Introduction : La douleur chronique est une affection coûteuse et invalidante, dont la prévalence mondiale est estimée à 20 %. En Afrique du Sud, près d’un adulte sur cinq souffre de douleur chronique. Cette étude avait pour but d’évaluer la prévalence de la douleur chronique, de même que l’association entre l’intensité de la douleur chronique et l’interférence de la douleur avec différents domaines de la vie chez les patients fréquentant un centre de soins de santé primaires.

Méthodes : Nous avons mené une étude quantitative transversale portant sur un échantillon de 331 patients au Centre de santé communautaire de Soshanguve. Les données ont été recueillies à l’aide du Questionnaire concis sur la douleur du Wisconsin, une échelle validée pour mesurer la douleur.

Résultats : L’âge moyen des participants était de 51,6 ans (ÉT = ±15,15, plage = 18–86). L’âge médian était de 48 ans (intervalle interquartile = 40–64). La prévalence de la douleur chronique était de 21,5 % (intervalle de confiance à 95 % [IC] 17,0-25,9). Environ 58 % des participants étaient des femmes, et les patientes étaient affectées plus fréquemment que les patients de sexe masculin. La douleur chronique était 11,1% plus fréquente chez les femmes que chez les hommes. La douleur chronique a eu de légères répercussions sur l’activité générale chez 33,8 % des patients (IC à 95 % 23,9-45,4), l’humeur chez 42,3 % (IC à 95 % 31,4-53,8), la capacité de marcher chez 29,6 % (IC à 95 % 20,2-41,0), les relations chez 47,9 % (IC à 95 % 36,7-59,3), le sommeil chez 31,0 % (IC à 95 % 21,4-42,5), jouissance de la vie chez 39,4 % (IC à 95 % 28,9-51,1) et la capacité de travail normale chez 25,3 % d’entre eux (IC à 95 % 16,7-36,6).

Conclusions : Les résultats de cette étude montrent que parmi les patients qui ont fréquenté la clinique de soins de santé primaires, la douleur chronique était très répandue et interférait avec différents domaines de leur vie. L’intensité de la douleur était élevée chez une proportion significative de patients. Ces résultats fournissent des informations inestimables nécessaires à l’amélioration des ressources au niveau des soins primaires pour évaluer de manière exhaustive la douleur au sein de nos collectivités.

KEYWORDS:

• Chronic pain
• prevalence
• interference
• primary care

Introduction

Chronic pain is a significant public health challenge. It leads to profound alterations in individuals’ lives and is associated with detrimental effects on the affected individuals, their families, and the broader society. These effects extend to society at large, exacerbating the financial burden due to escalating health care utilization, cost of medications, decreased work productivity, absenteeism, and early retirement.¹ Over the years, researchers have increasingly recognized the importance of understanding the prevalence of chronic pain in different populations. South Africa, a country with a unique sociodemographic and health care setting, has gained attention as studies continue to shed light on the prevalence of chronic pain within its population.

Figure 1. CONSORT diagram of sampling for data collection.

Ongoing research within South Africa’s public health care system indicates high rates of chronic pain that impact an already overburdened health care system.^2,3 In South Africa, similar to the rest of the word, chronic pain affects one in five adults and has been noted to interfere with work, important social and recreational activities, and family relations.¹ In a study of 394 adult patients conducted in Transkei, South Africa, 43% of adults reported chronic pain, with a significant impact on their quality of life.¹ A larger study, based on 1066 adult patients, conducted at several primary health care clinics in southwest Tshwane, found that 41% patients had chronic pain; the patients also reported that the chronic pain impacted their quality of life and functioning.⁴ A severe impact was noted on sleep quality in 39.2% of patients, on walking ability in 37.4%, on routine housework in 33.8%, on mood in 20.1%, on interpersonal relationships in 15.3%, and on enjoyment of life in 16.3%.⁴ A study of 10,336 adults patients, which is a representative sample of the South African population, found that 18.3% patients had chronic pain.⁵ The differences in the prevalence rates between the study representative of a sample population of South Africa⁵ and the study conducted in small rural communities⁴ may be attributable to a nonrepresentative sample in the study with the smaller sample size. However, it is important to recognize that these differences may have resulted from biases due to other causes.

There has been a recent reengineering of primary health care (PHC) in South Africa, and the implications of the new vision for PHC reengineering regarding chronic pain are significant.⁶ The reengineering of PHC promotes data collection and research efforts to better understand the prevalence, impact, and management of chronic pain in South Africa. This can lead to evidence-based policies and interventions.

Given the reengineering of primary health care in South Africa, it is essential to explore the impact of medical conditions on specific communities to promote community health and decentralize health care services. Therefore, the aim of this study was to assess the prevalence of chronic pain and the association between chronic pain intensity and the interference of pain with life domains in patients attending the Soshanguve Community Health Centre (CHC). This will yield additional critical data for PHC reengineering and could lead to more effective and patient-centered approaches to addressing this prevalent health condition in rural communities.

Methods

Ethics Approval

Ethics approval was obtained from Sefako Makgatho University Research Ethics Committee (SMUREC/M/14/2020:PG) and the Tshwane Research Council (Clearance No. GP 202010 060). Those willing to participate were asked to give written informed consent.

Study Design

The study was a quantitative cross-sectional study conducted with patients attending chronic care at the CHC, Tshwane District. The CHC provides primary health care to the community and is managed by a primary health care team consisting of primary health care nurses, family physicians, and allied health care workers. The services provided include preventative medicine, women’s health and maternity services, mental health, infectious diseases, chronic adult medicine, child health, emergency medicine, and dispensing facility (pharmacy).

For the purpose of this study, chronic pain (specifically chronic non-cancer pain) was defined as any type of persistent or recurrent pain experienced for a minimum duration of 6 months on most days or every day as a standard criterion to differentiate chronic pain from acute pain. The International Association for the Study of Pain (IASP) defines “chronic pain” as “pain that persists or recurs for longer than 3 months.”⁶ In using this time frame, the study focused specifically on individuals experiencing prolonged pain that extended beyond the typical duration of acute pain, which is usually expected to resolve within a few weeks.

The purpose of using the 6-month duration for defining chronic pain in this study was to be able to specifically identify and examine the characteristics, impact, and management of chronic pain conditions. Chronic pain is often associated with complex and long-lasting effects on patients’ physical, psychological, and social well-being and may require different approaches to assessment and treatment compared to those for acute pain.

By employing the 6-month threshold, the study targeted a specific subgroup of patients experiencing ongoing pain, enabling a more in-depth investigation into the factors contributing to chronic pain development, its persistence, and potential interventions for long-term relief and management.

This criterion is consistent with the study conducted in South Africa with pain lasting 6 months or more with a prevalence of 41%.⁴ Breivik and colleagues reported prevalence rates in Europe ranging between 12% (Spain) and 30% (Norway).⁷ Two other studies were conducted in Brazil where the criterion for chronic pain was persistent pain for more than 6 months.^8,9

Study Population and Sampling

The study sample was recruited from among patients attending chronic care services at the CHC. Chronic care comprises two groups of patients, the first group being patients who visit the area to receive medication for their chronic conditions and the second group being patients who visit the CHC to consult a nurse or physician for their chronic illness.

The sample size was calculated using Cochran’s equation for calculating a sample size in cross-sectional studies together with a population correction to calculate sample size.¹⁰ This formula takes into account the desired level of confidence, the margin of error (or precision), and an estimate of the proportion or prevalence within the population. Using a population size of 3209 (based on the number of patients seen during a 3-month period at the CHC) and a precision of 0.05 (based on a 95% confidence interval, CI), the formula indicated that a sample of 344, rounded up to 345 participants with chronic pain, was needed for the results to be generalizable to the sampling frame of all patients seen during a 3-month period. Due to the implementation of COVID-19 restriction protocol period overlapping with the data collection period, the sample size attained was 331.

A simple random sampling technique was employed to choose patients for inclusion in the study. The process involved inviting the first patient in the queue to participate. Then, every third patient in the queue was approached, and their written informed consent was sought. If the initially selected patient declined participation, the subsequent patient in the queue was approached. Patients who expressed a willingness to participate underwent a screening process to assess the presence of chronic pain after informed consent was obtained.

Inclusion and Exclusion Criteria

Inclusion criteria included consenting patients 18 years and older being treated in the chronic care area of the CHC during the study period who had experienced pain for 6 months or more and had been taking analgesia for 6 months or more.

Exclusion criteria included patients referred from a different local clinic for further evaluation or use of resources, patients known to be on neuroleptic medication or who had been admitted within the past month as mental health care users, and patients with pain associated with cancer.

Data Collection Instrument

Demographic and Clinical Information

Data on baseline characteristics were collected, including sex, age, employment status, educational level, chronic disease present, and duration of chronic pain.

Pain Intensity and Interference

The Wisconsin Brief Pain Questionnaire (WBPQ) was employed as a comprehensive tool to assess pain intensity, the extent to which pain interfered with function, and the efficacy of analgesic medications used. Both the pain intensity and pain interference dimensions of the questionnaire were validated.^11,12 Trained fieldworkers conducted interviews using English, IsiZulu, and Setswana, 3 of the 11 official languages of South Africa, tailored to the interviewee’s choice. The questions were translated by native speakers of each language and subsequently reviewed by an unbiased translator. Any alternative translations were discussed and refined with the primary translator until a consensus was reached. Feedback from the fieldwork training led to minor adjustments in the translations, which were incorporated as needed. The WBPQ is validated in IsiZulu and Setswana, which are common languages in the study location.¹³

The WBPQ gathers data across three distinct clusters of information: site of pain and ratings of the intensity of the pain, treatment and analgesic relief of pain, and ratings on interference of chronic pain with the with life domains of patients.

Pain intensity, based on participants’ ratings of their worst pain in the last month, was scored from 1 to 3, with 1 being associated with mild pain (a rating of 1–3 on the WBPQ Pain Intensity subscale), 2 with moderate pain (4–7 on the WBPQ Pain Intensity subscale) and 3 with severe pain (8–10 on the WBPQ Pain Intensity subscale). Participants who reported having no pain were excluded from this analysis.

The degree of pain relief resulting from analgesic treatment was evaluated using a percentage scale, wherein 0% indicated no pain relief and 100% denoted complete pain relief. The extent to which pain interfered with various aspects of functionality, including mood, sleep, quality of life, interpersonal relationships, walking ability, and work performance, was assessed using a numerical scale ranging from 0 to 4, where 0 = no interference whatsoever, and 4 = significant interference.

The life domains affected were indicated by six components: sleep quality, walking ability, routine housework, mood, interpersonal relationships, and enjoyment of life. Participants described their experiences of the interference of pain with life domains using a score of 0 to 4, where 0 = no interference/impact at all, 1 = a little interference/impact, 2 = moderate interference/impact, 3 = considerable interference/impact, and 4 = extreme interference.¹⁴

Period

The data collection period was 3 months, from December 2020 to February 2021. All patients who reported experiencing pain for 6 months or longer and had been taking analgesia for 6 months or more were deemed to have chronic pain and were eligible for the study.

Data Analysis

The data collected were captured using Microsoft Excel before further analysis was done. To keep the participants anonymous, they were allocated a study number. The data were analyzed using SAS v14.2 analytics software.¹⁵

The analysis was done using means, standard deviations (SDs), or interquartile ranges (IQRs) for numeric data such as age. Percentages were used for categorical data (sex of the participants, educational status, and population group).

Charts and summary tables were used on descriptive data obtained about the intensity/severity of chronic pain, efficacy of treatment, and baseline characteristics. The interference/impact was reported as a percentage, using a 95% CI.

Fisher’s exact test was conducted to evaluate the relationship between pain intensity scores and sociodemographic characteristics. Fisher’s exact test was also used to evaluate the strength of the association between chronic pain intensity and pain interference on the various life domains. The dependent variable, severity of pain, was graded as 1–3 = mild, 4–6 = moderate, and 7–10 = severe.¹⁴

The percentage of pain relief obtained from medication was graded as poor (0–29%), moderate (30–69%), and good (70–100%).¹⁴ The chi-square test was used to assess the difference between sociodemographic groups with respect to the interference of chronic pain.

In measuring the association between chronic pain and the patients’ sociodemographic characteristics, a binary logistic regression analysis was used. Odds ratios (ORs) and their 95% CIs were calculated for the presence or absence of chronic pain. A P value < 0.05 was considered statistically significant. Sociodemographic variables assessed in the logistic regression model included age group in years (18–37, 38–53, 54–69, >70 [reference group]); gender (female, male [reference group]), employment (employed, self-employed, unemployed [reference group]), and level of education (no schooling, primary, secondary, tertiary [reference group]).

Results

Three hundred and forty-eight patients were invited to take part in the study. Seventeen patients were excluded from the study (1 did not meet the criteria and 16 declined participation during data collection). Figure 1 shows the CONSORT (Consolidated Standards of Reporting Trials) diagram of patient flow including recruitment and flow through the study.

Sociodemographic Characteristics of Participants

A total of 331 adult patients aged 18 years and older were eligible and consented to participate in the study, as summarized in Table 1. Patient age ranged from a minimum of 18 and to a maximum of 86 years, with a mean of 51.6 years (SD = ±15.15). The median age was 48 years (IQR = 40–64).

Table 1. Demographic characteristics of participants (N = 331).

Characteristic		Frequency, N	Frequency, % (95% CI)
Age, years	18–37	53	16.0 (12.1–20.0)
	38–53	143	43.2 (37.9–48.5)
	54–69	88	26.6 (21.8–31.3)
	70+ Mean (SD) Min/max	47 51.6 (15.15) 18/86	14.2 (10.4–18.0)
	IQR (lower/upper)	40/64
Sex	Female	191	57.7 (52.4–63.0)
	Male	140	42.3 (37.0–47.6)
Employment	Employed	88	26.6 (21.8–31.3)
	Self-employed	37	11.2 (7.8–14.6)
	Unemployed	206	62.2 (57.0–67.5)
Education	None	89	26.9 (22.1–31.7)
	Primary level	58	17.5 (13.4–21.6)
	Secondary level	135	40.8 (35.5–46.1)
	Tertiary level	49	14.8 (11.0–18.6)
Population group	African	330	99.7 (99.1–100.3)
	Colored	1	0.3 (−0.3–0.9)
Chronic illness	Multiple diseases	76	23.0 (18.4–27.5)
	Communicable	151	45.6 (40.3–51.0)
	Noncommunicable	104	31.4 (26.4–36.4)
Duration of chronic illness, years	Mean (SD)	8.4 (7.32)
	Min/max	0.5/40

Of the 331 patients, there were more female patients than males, 57.7% (95% CI 52.4–63.0) and 42.3% (95% CI 37.0–47.6), respectively. Most participants were between 38 and 56 years of age (43.2%, 95% CI 37.9–48.5). Unemployed participants comprised the largest group (62.2%, 95% CI 57.0–67.5).

A majority of participants had a secondary level of education (40.8%, 95% CI 35.5–46.1). Patients with communicable diseases represented the highest number of participants at 45.6% (95% CI 40.3–51.0). African patients represented 99.7% (95% CI 99.1–100.3) of participants.

Prevalence

Of the 331 participants, 71 adults were identified as reporting chronic pain, representing 21.5% (95% CI 17.0–25.9) of the sample. Chronic pain was prevalent in 22.5% of females and 20.0% of males.

Pain Duration

The highest pain duration among males, lasting between 6 months and 1 year, was 35.7%. In contrast, females had the highest pain duration, with more than 10 years, accounting for 42.9% of cases. Furthermore, for both males and females, a substantial proportion of individuals (>43.6%) experienced chronic pain persisting beyond 7 years Table 2.

Intensity of Chronic Pain

We analyzed the intensity of chronic pain, from mild to severe intensity in Table 3. The percentage of patients with mild chronic pain was 29.6%, 52.1% had moderate chronic pain, and 11% of patients had severe chronic pain.

Table 2. Prevalence of chronic pain grouped by duration and gender (N = 71).

Duration of pain	Gender		Whole group, % (95% CI)
	Male, % (95% CI)	Female, % (95% CI)
6–12 months	35.7 (18.0–53.5)	39.3 (24.7–53.9)	29.6 (19.0–40.2)
1–3 years	14.3 (1.3–27.2)	17.9 (6.4–29.3)	12.7 (4.9–20.4)
4–6 years	17.9 (3.7–32.0)	17.9 (6.4–29.3)	14.1 (6.0–22.2)
7–10 years	17.9 (3.7–32.0)	35.7 (21.4–50.0)	21.1 (11.6–30.6)
>10 years	14.3 (1.3–27.2)	42.9 (28.1–57.6)	22.5 (12.8–32.3)

Table 3. Intensity of pain versus chronic pain (N = 71).

Variable	Categories	Chronic pain, % (95% CI)
Intensity of pain	Mild 1–3	29.6 (19.0–40.2)
	Moderate 4–6	52.1 (40.5–63.7)
	Severe 7–10	11.3 (3.9–18.6)

The pain intensity of chronic pain according to gender is summarized from mild to severe intensity in Table 4. Women were more likely to be moderately impacted than men (women, 26.8%, 95% CI 16.5–37.1; men, 18.3%, 95% CI 9.3–27.3).

Table 4. Intensity of chronic pain according to gender (N = 71).

Pain intensity	Gender
	Female, % (95% CI)	Male, % (95% CI)
Mild 1–3	23.9 (14.0–33.9)	11.3 (3.9–18.6)
Moderate 4–6	26.8 (16.5–37.1)	18.3 (9.3–27.3)
Severe 7–10	5.6 (0.3–11.0)	4.2 (0.5–8.9)

Interference of Pain with Everyday Activities

Regarding the interference of chronic pain with daily activities, the following were evaluated: general activity, mood, walking ability, normal work (routine housework), interpersonal relationships, sleep quality, and enjoyment of life.

Participants reported that chronic pain adversely interfered in varying degrees from a value of 1 to 4 (Table 4). Chronic pain severely interfered (a score of 3–4), with mood in 14.1% (95% CI 14.1–22.2), relationships in 9.9% (95% CI 2.9–16.8), walking ability in 38.0% (95% CI 26.7–49.3), sleep in 25.4% (95% CI 15.2–35.5), normal working ability in 38.0% (95% CI 26.7–49.3), and enjoyment of life in 23.9% (95% CI 14.0–33.9) of participants.

Pain Relief

Figure 2 shows the pain relief from analgesia. A minority of patients were dissatisfied with their pain relief (1.4%, 95% CI 1.3–4.1). Most of the patients with chronic pain reported moderate (30%–69%) relief of pain (63.4%, 95% CI 52.2−74.6). The percentage of patients who reported their treatment as providing good pain relief (70%−100%) was 35.2% (95% CI 24.1–46.3).

Figure 2. Pain relief from analgesia.

Chronic Pain Prevalence and Multivariable Logistic Regression Model for Associations

Table 5 shows the adjusted odds ratios (AORs) and corresponding P values derived from the binary logistic regression model. The dependent variable was chronic pain (yes/no). The independent or predictor variables were age group in years (>70, reference group), gender (male, reference group), employment status (unemployed, reference group), and level of education (tertiary education, reference group). The prevalence of chronic pain among patients was higher in women (60.6%, 95% CI 48.9–71.1) compared to men (39.4%, 95% CI 28.9–51.1).

Table 5. Interference of chronic pain with everyday activities.

Interference with	Percentage of patients with chronic pain
	Score of 1–4, % (95% CI)	Score of 3–4, % (95% CI)
Mood	60.6 (49.2–71.9)	14.1 (6.0–22.2)
Relationships with other people	64.8 (53.7–75.9)	9.9 (2.9–16.8)
Walking ability	73.2 (62.9–83.5)	38.0 (26.7–49.3)
Sleeping disturbances and difficulty falling asleep	71.8 (61.4–82.3)	25.4 (15.2–35.5)
Difficulty with performing routine work	71.8 (61.4–82.3)	38.0 (26.7–49.3)
Enjoyment of life	64.8 (53.7–75.9)	23.9 (14.0–33.9)

Table 6. Chronic pain prevalence and multivariable logistic regression model for associations (N = 71).

Variable	Categories	Chronic pain, % (95% CI)	AOR (95% CI)	P value
Age, years	18–37	8.5 (3.9–17.2)	0.45 (0.13–1.54)	0.278
	38–53	28.2 (19.0–39.5)	0.48 (0.18–1.24)	0.177
	54–69	40.8 (30.2–52.5)	1.08 (0.48–2.42)	0.078
	≥70	22.5 (14.4–33.5)	1.00
Sex	Female	60.6 (48.9–71.1)	1.45 (0.80–2.65)	0.225
	Male	39.4 (28.9–51.1)	1.00
Employment	Employed	15.5 (8.9–25.6)	1.03 (0.44–2.41)	0.859
	Self-employed	5.6 (2.2–13.6)	0.90 (0.26–3.10)	0.44
	Unemployed	78.9 (68.0–86.8)	1.00
Education	None	53.5 (42.0–64.6)	3.92 (1.20–12.84)	0.001
	Primary	21.1 (13.2–32.0)	1.80 (0.49–6.67)	0.590
	Secondary	16.9 (9.9–27.3)	0.75 (0.23–2.46)	0.140
	Tertiary	8.5 (3.9–17.2)	1.00
Total		21.5 (17.0–25.9)

The binary regression analysis revealed that individuals with no schooling had a significantly higher likelihood of experiencing chronic pain (AOR = 3.92, 95% CI 1.2–12.84) as shown in Table 6. The statistical analysis using the Fisher’s exact test yielded a probability of 0.0071 (P < 0.05), indicating a statistically significant correlation.

Discussion

We found that chronic pain affected 21.5% (95% CI 17.0–25.9) of patients attending chronic care at the CHC. The national survey conducted in South Africa yielded a reported prevalence rate of 18%,⁵ which is almost one in five adults of a representative population sample. Research has shown that approximately 20% of adults in the United States have chronic pain, resulting in lower work productivity and fewer annual hours worked.¹⁶ Health economists from Johns Hopkins University estimated the annual cost of pain to be as high as $635 billion in 2010, which is more than the yearly costs for cancer, heart disease, and diabetes combined.¹⁷ In the European Union population, about 44% of those aged 55 years are affected by pain, interfering with their ability to carry out daily activities.¹⁸ Recent statistics show that one in five European adults experiences chronic pain.¹⁹ Research conducted by Fayaz et al.²⁰ suggested that chronic pain has a substantial impact on a significant proportion of the adult population in the UK, with estimated prevalence rates ranging from 13% to 50%. The results of the present study, showing that approximately one in five adult patients who visited the CHC reported chronic pain, are consistent with the prevalence rates from other countries around the world.

Among the participants included in the study, a notable majority of female individuals, accounting for 60.6% of the total, reported experiencing chronic pain (AOR = 1.45, 95% CI 0.80–2.65). In terms of pain intensity, the study observed that among respondents experiencing mild pain intensity, 23.9% were females, whereas only 11.3% were males. In the case of moderate pain intensity, 26.8% of females reported such pain compared to 18.3% of males. For severe pain intensity, 5.6% of females reported this level of pain, whereas 4.2% of males did. Women were more likely to have higher health care expenditure than men, with the level of expenditure increasing with age.¹⁶ This finding underscores the prominence of chronic pain among females within the studied population. This aligns with findings from other studies regarding chronic pain in females.^{2,4,5,14,18,21,22} Such significant sex differences could be accounted for by hormonal responses to pain; the psychosocial and cultural influence on pain perception, expression, and tolerance; and seeking medical treatment.^23,24 The findings derived from the present study place a significant emphasis on the necessity for further research endeavors centered on clinical pain. In particular, there is a compelling call for investigations that explore the intricate interplay between the gender construct and the myriad psychosocial and cultural factors that influence pain perception, expression, and tolerance. This avenue of research holds substantial promise for shedding light on the nuanced differences between females and males in how they perceive, communicate, and tolerate pain. Understanding the role that psychosocial and cultural influences play in shaping pain experiences is pivotal, because it provides a comprehensive framework for comprehending the underlying reasons behind gender-based distinctions in pain perception. Exploring how societal expectations, emotional responses, coping mechanisms, and cultural norms interact with gender to influence pain experiences is essential for crafting tailored pain management strategies. Addressing sex differences in the clinic will be a turning point in designing and developing optimized therapeutics and improving the efficacy of existing analgesic agents for treatment needs of males and females based on biological differences.²⁵

A lack of schooling was the only variable found to be a predictor of chronic pain (53.5%, 95% CI 42.0–64.6). This is similar to past studies where the likelihood of chronic pain was associated with lower education levels.^5,13,26 No other sociodemographic variable was significantly associated with chronic pain. This result was different from previous results concerning the association of chronic pain with other demographic variables such as employment status and sex.^{13,19,22,27–29} This lack of association with more variables, rather than one variable, may shed some light on chronic pain and its indiscriminate nature.

The results obtained show that chronic pain either mildly, moderately, or severely interfered with several domains of daily life. The most significant finding is that most patients with mild to moderate chronic pain were also mildly to moderately affected by pain in life domains.

In terms of the interference of chronic pain on sleep disturbance and difficulty falling asleep, the findings of this study shows that 71.8% of patients reported sleep problems, which is significantly higher than the 50% to 88% reported internationally.³⁰ This finding is similar to another South African study, which showed that 83.72% of patients reported sleep problems. Interestingly enough, most patients had mild interference on all six components that constituted quality of life.

Furthermore, only 63.4% of patients with chronic pain reported good pain relief from analgesia prescribed by the CHC. This may allude to the probable best approach for pain treatment, namely, to ensure that all patients are started on multimodal analgesia and supplemented with nonpharmacological management where necessary. Though there is good analgesic relief of chronic pain from the treatment, most patients’ lives are still adversely affected by chronic pain.^1,4 The pain intensity was mild for 52.1% of patients and severe for 11.3% of patients.

Limitations and Future Directions

Because the study only involved one CHC, the results cannot be generalized to other primary health care facilities. A multicenter study could have provided more data. The COVID-19 restriction protocol could have impacted the available pool of patients to obtain participants from.

Another limitation of this study is the recruitment approach, which exclusively focused on patients experiencing chronic pain and using medication. The exclusion of individuals with chronic pain who were not prescribed medication for a minimum of 6 months may result in an underestimation of the actual prevalence of chronic pain. This limitation arises from the study’s reliance on a sample population connected to pain medication usage, potentially overlooking a subset of patients with chronic pain who manage their condition through alternative means and are not reflected in the study’s findings.

An additional limitation of this study pertains to the definition of chronic pain as persisting beyond a 6-month duration, in contrast to the criterion set forth by the IASP, which defines chronic pain as lasting beyond 3 months. By adopting the 6-month threshold, the study inadvertently excluded individuals who experienced pain within the intermediate time frame of 3 to 6 months. This methodological choice could potentially lead to an underestimation of the true prevalence rate of individuals grappling with chronic pain within the specified 3- to 6-month time frame, because it deviates from the internationally recognized definition provided by IASP, thereby affecting the study’s comprehensive representation of the chronic pain population.

Although participants were asked whether they were taking medication under the pain relief question, a limitation of the study is that not all participants provided information about the specific pain medications they were taking, including the dosage. Though this limitation should be acknowledged, it is worth noting that pain intensity and pain interference, which are the primary areas of interest in this study, are influenced by a range of factors, including the type and dosage of pain medications.

Integrating the assessment of quality of life by community health workers of patients affected by chronic pain and links to support groups may be a next step in the near future. Another consideration would be advocacy for interdisciplinary management of these patients in facilities. Specific criteria are needed in primary health care settings to diagnose chronic pain, enabling consistency of data collection on chronic pain and possibly a detailed standardized guideline on comprehensive screening, assessment, and management of chronic pain at a primary level. Globally, a cohesive conclusion is needed for evidence-based, multidisciplinary approaches to pain management that incorporate patients’ perspectives.

Conclusion

A substantial portion of patients attending primary health care facilities experience chronic pain in their everyday lives. This study investigated the prevalence of chronic pain lasting at least 6 months in a sample of patients who visited the CHC to consult a nurse or physician about their chronic illness. Chronic pain is a significant problem among patients at primary health care clinics in Soshanguve. This study also found that the impact of chronic pain is greater in patients experiencing higher pain intensity and poor pain relief than in patients with chronic pain with a relatively lower intensity/severity and better pain relief.

The study aimed to enhance understanding of the prevalence of chronic pain, with the expectation that future follow-up inquiries will explore the ramifications of chronic pain across a spectrum of patient profiles. This can result in improvements of available resources at the PHC level and determining the long-term impact on cost and productivity in communities. Data are needed to enable district-level strategic planning. Chronic pain is multidimensional by nature, which makes effective management approaches challenging, especially in primary health care settings.

Ethical Approval Statement

Ethical approval was obtained from Sefako Makgatho University Research Ethics Committtee, SMUREC/M/14/2020:PG) and Tshwane Research Council, clearance number: GP 202010 060.

Author Contributions

All authors contributed substantially to the article. S.L.N.N. and T.P. were involved in the conception of the study. All authors were involved in the interpretation of the data. F.F.P. drafted the manuscript, and all authors revised it.

Acknowledgments

The authors are most grateful to all of the patients who agreed to participate in this study for their time and patience during the COVID-19 pandemic. The authors also are grateful to the interviewers Gontse Gift Mahlangu and Lahliwe Maria Thabathe for their commitment and dedication during the data collection. The authors thank statistician Professor H. Schoeman for his assistance. The study was conducted as part of the master of medicine in family medicine degree by F.F.P.

Disclosure Statement

The authors have no conflict of interest to report.

Supplementary Material

Supplemental data for this article can be accessed online at https://doi.org/10.17632/42dsgt398v.1.

Additional information

Funding

FFP was supported by the Discovery Foundation Scholarship [No. 045927].