Acute pain following major surgery is known as postoperative pain (POP). This type of pain is typically caused by tissue damage sustained during surgical operations such as skin incisions, tissue dissections, manipulation, and traction [1]. POP may be the most typical side effect following surgery [2]. Such pain can have a detrimental impact on the patient’s Quality of Life [3]. If POP is not treated immediately, there is a higher chance of respiratory problems, anxiety, insomnia, atelectasis, and secretion retention [4]. Along with the potential for acute POP to turn into chronic pain, increased opioid consumption, dissatisfied patients, and higher medical costs, this pain may also alter the metabolism, leading to postoperative complications such as a longer hospital stay owing to delayed recovery and morbidity [5]. Patients and healthcare professionals may be burdened by these issues [6].

Moderate to severe POP is frequent in patients undergoing significant surgical procedures. According to research, an acute POP was present in almost 80% of patients undergoing major surgery [7]. According to another study, more than 40% of patients suffered moderate to severe acute post-operative pain and the percentage of patients who experienced this type of pain rose from 30% to more than 50% in the days following a major abdominal surgery [8]. Numerous studies have also revealed that, within 24 hours of surgery, 50% of patients suffered severe pain, and that, within a few days after the procedure, this pain may progressively worsen or disappear [9]. In Western countries, the incidence of moderate and severe POP varies (14% to 55%) among patients who underwent major surgery [10]. Whereas, such incidence is the highest (> 80%) among patients in low-and-middle-income countries [11].

Inadequate postoperative pain management (POPM) can cause anxiety, postpone ambulation after surgery, and expose patients to postoperative complications [12]. Patients who are unable to walk because they are afraid of POP may develop deep vein thrombosis, and those who have chest pain may have their cough reflex suppressed, resulting in lung infection [13]. A study discovered that moderate to severe POP was related to various post-surgical problems, all of which had a detrimental impact on effective POPM [14]. The results of POPM methods around the world are still unsatisfactory. For example, in Europe, more than 89% of patients had POP with inadequate POPM in the first several days after surgery [15].

Pain management has been designated as one of the most important human rights due to the high prevalence of POP and the global burden of such pain. As a result, there is an urgent need to strengthen POPM services [16]. This will result in better patient recovery and a reduction in risk factors and postoperative complications [17]. A survey done in the United States revealed that more than 80% of patients have POP, with more than half having insufficient POPM [18]. A prior study has shown that even after using POP-management medicines, up to 70% of patients still have insufficient POPM [19]. Major abdominal surgeries should ideally be followed by regular PM [20,21]. Consequently, the delivery of adequate POPM should be one of the top priorities for healthcare professionals [21].

Although there have been advances in POPM, acute POP continues to be a serious concern and difficulty for both patients and healthcare professionals, especially in low- and middle-income nations, such as Libya [22,23]. Many studies conducted in low- and middle-income countries found that acute pain following major surgery is frequently undertreated [24]. For example, a survey conducted in Nigeria discovered that more than 68% of patients had moderate to severe POP 24 hours after surgery and that patients had inadequate POPM [24]. Other studies from similar nations have similarly found, which are a high rate of POP with poor POPM [2]. Data on adequate POPM and identifying factors associated with poor POPM in low- and middle-income countries are still rare [25]. This is especially true in Libya, where such issues have not previously been assessed. As a result, this study aimed to measure patients’ POP in order to better understand their post-surgery status and to identify factors, which can influence POPM.

1. Participants and settings

A convenience sample of 105 eligible participants who underwent major abdominal surgery at a Tertiary hospital (Benghazi Medical Centre) in Eastern Libya was surveyed in a cross-sectional manner. Inclusion criteria were adult patients over 18. Patients eligible to participate had undergone abdominal operations, associated with POP based on their hospital records. Staff at this site (surgical practice manager and surgical nurse) screened patients’ records to identify if patients were meeting the eligibility criteria for this survey. Only participants who could give written or verbal consent to participate and without communication difficulties were included. Between February and April 2024, the intended adult volunteers aged 18 and above were recruited by survey coordinators (surgical physicians or nurses) after gaining ethical approval from the College of Medical Technology in Derna, Libya (CMTD 02-024), as well as permission from the relevant setting in Libya. The response rate was 70 percent. To reduce bias, all participants were recruited by survey coordinators, and surgical healthcare professionals (not senior or manager staff) from a tertiary hospital (Benghazi Medical Centre) in Eastern Libya. The author distributed questionnaires and information sheets via Dropbox to survey coordinators in surgical departments of a tertiary hospital (Benghazi Medical Centre) in Eastern Libya. To reduce potential bias, each survey organizer printed and distributed questionnaires and information sheets to all potential participants (100%), as instructed. After completing the questionnaires, the participants placed them in the secure boxes. The survey coordinators then scanned and uploaded all completed questionnaires to Dropbox, which they emailed to the author. After all, surveys were sent, each coordinator was advised to destroy electronic copies and shred paper copies securely. The study was reported in accordance with the STROBE checklist (Supplementary Materials) [26].

2. Survey instrument

The American Pain Society Patient Outcome Questionnaire-Revised (APS-POQ-R) is the most commonly utilised measure for assessing POPM quality [27]. Permission was obtained to use the APS-POQ-R in this survey. The scale consists of 23 multiple-choice questions, 18 of which are rated using a numerical rating scale (NRS) ranging from 0 to 10, and five subscales: pain severity and sleep interference, affective interference, interference with activity, side effects, and perception of pain care, which includes a degree of pain management, involvement in decision making, and satisfaction with pain care. The participants were then asked to score the usefulness of any pain-related information they had received using an NRS (range from 0 to 10). The application of non-pharmacological approaches and how often patients were encouraged to use them were also measured. This study’s data was collected using the APS-POQ-R (Arabic version). The survey items are scored on an 11-point Likert scale, indicating how much the participant agrees with the target statement. For example, ‘0’ signifies “not at all,” and ‘10’ means “very much so”. Furthermore, POP scores were measured using an NRS at 2, 12, and 24 hours. On the NRS scale, 0 = no pain, 1-3 = mild pain, 4-7 = moderate pain, and 8-10 = severe pain. In this investigation, an NRS greater than 3 indicated moderate to severe pain. At the same time, background information was gathered through the survey (Supplementary Materials).

Additionally, all analgesic medications administered for POP in the first 24 hours following surgeries were documented. All study-related measurements were performed by a trained researcher. The APS-POQ-R is a valid and reliable instrument that has been used in various research to assess the quality of POPM and POP-related parameters [28]. Hughes and Hazelwood found preliminary evidence of both the validity and reliability of the APS-POQ-R [28]. Such an instrument is a well-known questionnaire, having been validated and utilised in various studies as mentioned above in various languages, including Arabic [29].

The APS-POQ-R was translated into Arabic and checked using the back-translation method, and a linguistic specialist was engaged to ensure the accuracy of the translation. It is a well-known strategy that is commonly used for translating survey instruments [30]. It is advised that every instrument be tested before use in a study with a new target population [31]. As a result, a draft of this questionnaire was shared with experts, who provided important feedback. To ensure readability, an Arabic version of the APS-POQ-R was pilot-tested (with eight study participants) before being sent to the entire study population.

The researcher reported the psychometric properties for the Arabic version of the APS-POQ-R, using response data from the entire final sample size; n = 105 participants. It has been stated that determining the sample size is an important step that the researcher should carefully consider [32]. Thus, it can be challenging to identify the sample size owing to the lack of rules when using non-probability sampling techniques [33]. The Precision program’s power was used to calculate the sample size in this study ensuring that the survey could explore all of the study’s objectives [34]. As a result, 105 valid questionnaires were considered for statistical analysis in this study. Evidence advocated a sample size of 100 to 150, especially for instruments with an internal consistency of α = 0.60 or higher [35]. In the current investigation, the internal consistency reliability was determined for the total sample size (n = 105 participants). This study’s APS-POQ-R scales had a higher internal consistency reliability (α = 0.90) than indicated, indicating strong internal consistency. The test-retest reliability (r > 0.80) and internal consistency reliability (Cronbach’s Alpha) for the overall APS-POQ-R scales for participants was excellent (α = 0.90), and the Alpha for the three factors ranged from 0.75 - 0.85. Using a well-validated questionnaire, such as the APS-POQ-R, would increase internal validity (Supplementary Materials).

3. Statistical analysis

Descriptive statistics were utilised to evaluate demographic data such as age, gender, marital status, ASA score, educational level, type of operation, history of chronic pain, and POPM medicines. Categorical data were summarised as numbers (percentage), whereas continuous data were condensed into averages (standard deviation) and ranges. Multiple linear regression was used in inferential analyses to examine the connection between independent (cause) and dependent (outcome) variables [31]. Statistical significance was defined at a 2-sided P-value of < 0.05. The data was coded and analysed using the Statistical Package for Social Sciences (SPSS) version 26 software. The distribution of the collected data was investigated using the Kolmogorov-Smirnov test. Because this is an exploratory study, the researcher does not intend for readers to regard the data as definitive, hence no corrections/adjustments for repeated testing are made.

1. Sample characteristic

The average (mean) age of all responders was 31.1 years (SD = 1.03), with a range of 18 to 70 years old. Female participants outnumbered males (53.3%), and the majority of patients (41.0%) were between the ages of 18 and 30. There were more married participants (47.6%) than single (38.1%), nine divorced (8.6%), and just six widowed (5.7%). Participants were more likely to have a university education than those with a postgraduate degree (undergraduate: 50.5% vs. postgraduate degrees: 2.8%), while 18.1% had only a basic education. A small percentage of participants (19.1%) had finished grade 2 of the ASA score, whereas 80.9% obtained grade 1. There was more appendectomy (51.4%) patients than cholecystectomy (40.0%) or laparotomy (8.6%). Participants with a history of chronic pain (57.1%) outnumbered those without (42.9%). Only 9 patients (8.6%) received strong opioids (e.g., morphine or pethidine), while a few participants (19.0%) received weak-opioid medicines (e.g., codeine or tramadol), with the majority of patients (72.4%) receiving none. Table 1 shows participant characteristics.

Table 1 . Participants’ demographic characteristics.

Patients with abdominal surgery (n = 105)	Respondents
Gender; n (%)
Male	49 (46.7)
Female	56 (53.3)
Age (years); n (%)
18-30	43 (41.0)
31-40	25 (23.8)
41-50	15 (14.3)
51-60	12 (11.4)
61-70	8 (7.6)
> 70	2 (1.9)
Marital status; n (%)
Single	40 (38.1)
Married	50 (47.6)
Divorced	9 (8.6)
Widowed	6 (5.7)
Missing	0 (0.0)
Education; n (%)
Elementary	19 (18.1)
Intermediate	30 (28.6)
Undergraduate degree	53 (50.5)
Postgraduate degree	3 (2.8)
Annually salary; n (%)
Monthly salary (LYD)	48 (45.7)
On income	57 (54.3)
ASA score; n (%)
1	85 (80.9)
2	20 (19.1)
3	0 (0.0)
Type of surgery; n (%)
Appendectomy	54 (51.4)
Cholecystectomy	42 (40.0)
Laparotomy	9 (8.6)
History of chronic pain; n (%)
Yes	60 (57.1)
No	45 (42.9)
Medication for POPM; n (%)
None-opioids	76 (72.4)
Weak opioids	20 (19.0)
Strong opioids	9 (8.6)
Missing	0 (0.0)

ASA score: American Society of Anaesthesiologists; POPM: Post-Operative Pain Management; N: number; %: percentage; LYD: Libyan Dinar; >: greater than..

2. Barriers to adequate POPM

Participants’ demographic questionnaires were utilised to compare opioid usage for POPM among patients in three countries (Libya, Ethiopia, and Tanzania). This was done to see if Libyan patients had a different prevalence of opioid intake for POPM scores than Ethiopian and Tanzanian patients. Patients from three nations had significantly varying proportions of opioid analgesics (none-opioids, mild opioids, and strong opioids) prescribed for POPM in the first 24 hours after surgery. This study shows that Tanzanian patients (85.1%) and Ethiopian patients (12.7%) were prescribed stronger opioids for POPM than Libyan patients (8.6%).

In contrast, Libyan patients were prescribed non-opioids for POPM at a higher rate (72.4%) than Ethiopian (46%) or Tanzanian (1.9%) patients [2,25] (See Fig. 1 below).

Figure 1. Prescribed analgesics for POPM in the first 24 hours among patients from three countries (Libya, Ethiopia, and Tanzania).

3. Multiple regression for the mean APS-POQ-R

Multiple linear regression analysis was used to determine whether patients’ demographic variables (age, gender, marital status, ASA score, educational level, type of surgery, history of chronic pain, or POPM medication) were significantly associated with their mean overall APS-POQ-R scores (adjusted estimate). All of the assumptions had been met. The mean overall APS-POQ-R scores served as the dependent (outcome) variable, whereas age, gender, marital status, ASA score, educational level, type of surgery, history of chronic pain, and POPM medication were entered concurrently as independent (cause) factors. Multiple regression findings showed that the model explained 72% of the variance in the mean overall APS-POQ-R scores, with an R2 of 0.072.

The regression model strongly predicted the total mean of APS-POQ-R performance. However, only the kind of medication for POPM had a significant impact on the model (B = –0.0330, P < 0.05) (See Table 2). This finding indicates that the type of medication used for POPM has an inverse association since when pain medication (opioids) is reduced, pain scores rise. Table 2 shows the bootstrapped 95% confidence interval for the slope of the mean overall APS-POQ-R scores.

Table 2 . Summary of multiple linear regression findings between the mean overall APS-POQ-R scale and the socio-demographic.

Variables	Beta coefficients	R2	Coefficient (95% CI)	t-value	P-value
Constant		0.072	2.510, 5.778	5.072	0.000***
Age	0.142	0.072	–0.152, 0.404	0.907	0.368
Gender	0.179	0.072	–0.235, 0.974	1.222	0.227
Marital status	–0.242	0.072	–0.617, 0.018	–1.885	0.064
ASA score	–0.204	0.072	–1.165, 0.182	–1.459	0.150
Education	0.004	0.072	–0.286, 0.294	0.030	0.976
Type of surgery	–0.208	0.072	–1.075, 0.220	–1.320	0.192
History of CP	0.002	0.072	–0.598, 0.606	0.014	0.989
Drugs for POPM	–0.0330	0.072	–0.621, –0.040	–2.273	0.026**

POP: post-operative pain; P-value: the probability; CI: confidence interval; APS-POQ-R scores: the American Pain Society Patient Outcome Questionnaire; %: percentage; n: number; CP: chronic pain; POPM: postoperative pain management..

**P < 0.05; ***P < 0.001..

To the best of the researcher’s knowledge, this is the first study to assess patients’ POP in order to better understand their post-surgery status and identify factors that can negatively impact POPM. Many earlier studies demonstrated that pain, including POP, had a detrimental impact on the patient’s quality of life, particularly those who received inefficient POPM [3,36]. In the current study, the finding suggests that patients who have had abdominal procedures in Libya may face more challenges to effective POPM than patients in other countries, as there are very few Libyan patients who received strong opioids (morphine or pethidine) for POPM. Thus, Libyan patients may receive insufficient POPM compared to patients in other nations.

In this study, the most significant difference between participants (who had a history of chronic pain and those who did not) was that those with a history of chronic pain experienced higher levels of pain. This finding contradicts earlier findings [25]. These disparities in chronic pain scores could have an impact on POP. However, a history of chronic pain was found to have no effect on POP [25]. Similar to earlier studies, the findings of this study revealed that only 8.6% of Libyan patients received strong opioids to treat their POP [37]. This could imply that Libyan individuals who have undergone abdominal surgery suffer from POP with inadequate POPM.

Previous investigations conducted in Western countries found a low incidence of POP among patients [38]. This could be attributed to adequate POPM offered to patients in Western countries. Multiple linear regression analysis revealed that the type of POPM medication had a significant impact on the model (B = –0.0330, P < 0.05). This means that when there is a decrease in receiving pain medication (opioids), the pain score increases.

A systematic review found that the average incidence of moderate and severe POP in the first 24 hours postoperatively was 30% and 11%, respectively. The incidence of various pain intensities varied with the analgesic method. Patient-controlled analgesics and epidural analgesia were associated with a lower incidence than intramuscular analgesia [39]. The lower prevalence of POP in affluent nations could be attributed to sophisticated regional analgesic and pain regimens, which result in adequate POPM [38]. In the current study, such an analgesic approach, pain protocols, and opioid availability for POPM were not used, indicating that acute POP is not adequately treated in the country. Previous studies have identified a lack of regulations and guidelines for pain management as the most significant impediment to effective PM [40,41]. An earlier Libyan study discovered that a lack of opioid availability, pain policies, and pain management guidelines were all major impediments to effective pain relief [42]. This result could inform better pain management protocols and training for healthcare professionals, as such findings will provide insight into patients’ experiences of pain immediately after abdominal surgery and pave the way for adequate POPM, decreased hospital stays, and reduced cost of medical services. A previous Libyan study found that healthcare professionals perceived a lack of policies and guidelines, professional education, and training as barriers to pain management [42]. Consequently, professional education and training in pain management among healthcare professionals, addressing phobia and myths about opioid usage, and the benefits and complications of using opioids will likely result in reduced barriers to POPM in Libya.

Although there are several guidelines for enhancing the management of pain to manage acute POP, few patients in this study received opioids to control their POP, and non-opioid medications were typically administered to Libyan patients for POPM [43]. This was done without assessing their pain or enquiring about the efficacy of the prescribed drug. The findings are consistent with earlier studies [25]. Other studies in low- and middle-income nations, like ours, found that pain assessment was poor and that POP assessment and management were primarily based on healthcare professionals’ experience rather than worldwide POPM guidelines [11,25]. An earlier Libyan study discovered that most Libyan healthcare professionals relied on self-reporting and the patient’s facial expression to estimate pain [1,42]. It appears that an unprofessional assessment of POP may have a negative impact on POPM in Libya. According to previous studies, depending on patient self-reports or healthcare professional interpretations of patients’ facial expressions is a substantial barrier to the effective management of pain [44]. Due to a lack of pain rating scales and pain management guidelines for assessing and managing POP, patients’ pain may be underestimated and mistreated, resulting in poor POPM in Libya.

1. Study’s limitations

This study has some limitations, including that only patients who had undergone abdominal procedures in the Eastern part of Libya were polled. In contrast, patients in other Libyan regions (Northwestern and Western) who may have been in the same situation were omitted. As a result, the findings cannot be more broadly extrapolated to represent the sample group in issue. Another restriction could be the use of convenience sampling, which can result in sample bias and reduce the generalisability of the findings [31]. Another potential threat to external validity is the use of an Arabic non-validated questionnaire (APS-POQ-R). However, such a questionnaire (Arabic version of APS-POQ-R) has previously been validated and used in other investigations [29]. Finally, another restriction can be attributed to the analyses, which were designed to be exploratory and hypothesis-generating. As a result, no corrections (such as the Bonferroni correction) were applied, and the results were taken with caution.

2. Implications for practice and research

The cross-sectional approach adopted in this study allowed for knowledge of patients’ post-surgery state and the identification of POP-related factors that can have a detrimental effect on POPM in Libya. The findings of this study indicate that POPM is inadequate among Libyan patients, necessitating active coordination between hospital management, policymakers, and healthcare professionals to manage patients with acute POP. In the current study, it is unclear whether factors associated with POP and poor POPM influence Libyan patients’ views and knowledge regarding POP and its management. As a result, a longitudinal study is required to investigate the patient’s attitudes and knowledge about POP and opioids, as well as the contributions of these barriers connected to a lack of knowledge and unfavorable attitudes regarding POPM, including a follow-up study.

Although many patients with POP have a poor quality of life, which could be attributed to untreated POP, no published research has been conducted on the prevalence of POP and opioid intake for POPM in three different geographical regions of Libya (Eastern, North-western, and Western). As a result, it would be useful for future research on the prevalence of POP and opioid consumption for POPM in Libya’s three regions. The findings of these studies will have a significant impact on future POPM policy in Libya.

In conclusion, this survey shows that Libyan patients, who underwent abdominal surgeries, received inadequate POPM compared to patients in other countries, as view Libyan patients received opioids for POPM. Based on the results of this study, the author subscribes to the necessity for further implementation of POPM and teaching about POP and its management to both healthcare professionals and patients concerning acute POP in Libya.

The author acknowledges the hospital in Eastern Libya, which permitted us to recruit participants for this study and all patients, who participated in this study. Furthermore, to Ahmad Salam for his statistical insight.

All data have been collected via a questionnaire by SM. The findings were reviewed by SM, who is the corresponding author. SM. also analysed the data using descriptive statistics and inferential analyses. Data coding and analysis were checked independently author for validity (SM.), who was an experienced quantitative researcher. Furthermore, SM. analysed the data and wrote his interpretation of it in English. The researcher described and discussed detailed results with his colleagues to increase his results’ dependability. The author wrote the main manuscript text, and he and his colleagues reviewed the manuscript.

Data available on request from the author: the data that support the findings of this study are available from the corresponding author, upon reasonable request.

The study received ethical approval from the College of Medical Technology, Derna, Libya, and the relevant hospital setting in Libya.

The consent was verbally achieved and it was implied through the completion and return of the questionnaire. Therefore, completion of the questionnaire indicates informed consent.

No potential conflict of interest relevant to this article was reported.