week 4

Musculoskeletal Health Related to Mental Health in Developing Countries

Capstone Project Submitted to

Denver College of Nursing

Abstract

This Quality Improvement (QI) project will consist of researching the diagnosis of mental health conditions on individuals with a diagnosis of chronic pain as well. It will also consist of research on best practices for cross-cultural education. This project will be divided into two sections; Phase I and Phase II. Phase I will include a review of the literature, development of a power point presentation for students, and development of a psychosocial yoga graphic handout that Global Health Prospective (GHP) can take on medical mission trips abroad to teach individual yoga to assist in alleviating chronic pain and helping with the management of mental health disorders. The objective of this psychosocial yoga graphic handout is to see if alleviating chronic pain improves an individual's overall mental health status. Implementation will occur in Phase II.

Since this is a Quality Improvement project, the author will consult with GHP leadership to get approval for use. Once approved, the Global Health Program (GHP) students will participate as subjects in a cross over design Quality Improvement Project. First, as part of their own control group, they will take a pre-test before receiving a power-point lecture about best cross-cultural education methods, chronic pain, and mental health in developing countries. A post-test will be given. The GHP students will then cross over and be their own intervention group, where they participate in a simulation educational venue reinforcing the psychosocial Yoga Graphic handout and also appropriate stretches and exercises to use when teaching a patient. A second post-test will then be taken prior to embarking on a GHP Mission. Cognitive social learning will be used to teach this psychosocial yoga graphic handout in the environment in which the population lives. GHP staff will be able to evaluate the effectiveness of the psychosocial graphic handout by observing the students and population using a teach-back method and having patients demonstrate the skills they have learned. When the GHP students return from the mission, a third post-test will be administered. A statistician will be consulted.

Keywords: "demonstration, effectiveness, evaluate, objective, evaluating"

Table of Contents

Abstract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Chapter 1: INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Summary of Scholarly Work . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Problem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Intended Improvement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 11 Study Question . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Chapter 2: LITERATURE REVIEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Search Strategy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Literature Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Chapter 3: PROPOSED INTERVENTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Theoretical Framework . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23

Ethical considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Chapter 4: METRIC AND OUTCOMES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Metrics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Preliminary Recommendation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Potential Barriers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Use of Pre-Test/Post-Test Crossover Design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Chapter 5: DISCUSSION/CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Success . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Evaluation of Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Anticipated Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Recommendations for Further Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Appendix A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

Appendix B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Musculoskeletal Health Related to Mental Health in Developing Countries

Chapter 1: Introduction

Chronic pain is recognized as a major public health problem worldwide and can cause a significant economic and social burden on an individual. Not only does chronic pain affect an individual; it severely impacts their family and life. Chronic pain impacts both a patient's mental and physical health. Treating and diagnosing chronic pain can be difficult to do in a developing country, as pain is a subjective experience and there is no test to measure and locate it exactly. With that said, mental health resources are limited in developing countries as well, and can be difficult to diagnose and treat. It is the assumption that the results of this scholarly paper and proposal for a universal psychosocial yoga graphic handout for assisting in the treatment of chronic pain will help improve mental health. This paper will use the research found for best practices for cross-cultural education.

Summary of Scholarly Work

Chronic musculoskeletal pain is a common problem worldwide, being among the top ten most prevalent diseases (Sá et al., 2019). Musculoskeletal conditions include more than 150 different diagnoses that affect one's body (Briggs et al., 2018). Current reports on its prevalence in developing countries are diverse (Sá et al., 2019). Chronic musculoskeletal pain is mainly associated with headaches, migraines, lower back pain, and neck pain. Lower back pain and migraines ranked in the top five causes of people living with a disability in middle- and high-income countries (Sá et al., 2019). Maintaining musculoskeletal health is critical for normal human function, mobility, dexterity, and ability to work and participate in daily life (Briggs et al., 2018). With that said, musculoskeletal health and chronic pain often lead to a decline in one’s mental health (Briggs et al., 2018). More specifically, chronic pain and musculoskeletal pain are a common problem that has a profound impact on an individual’s life and society as a whole (Mills, Nicolson, & Smith, 2019).

Recent data shows that one in two adults in America lives with a musculoskeletal condition, and this is equal to the rate of cardiovascular and chronic respiratory disease, which cost the United States 213 billion dollars in 2011 (Briggs et al., 2018). There have been a relatively small number of studies done to assess the prevalence of chronic pain in developing countries. Sá et al., (2019) did twelve studies which included 29,902 individuals, and 7,263 individuals were identified to have chronic pain. Out of these studies, the percentage of individuals with chronic pain in developing countries ended up being 18%, according to the study (Sá et al., 2019). Being able to measure the prevalence of chronic pain in developing countries has clear advantages, as this provides supporting information for the guidance of healthcare, where there are limited resources.

Mental health is a leading cause of the global burden of disease, and the resources for mental health services in developing countries remain very limited (Gilbert, Patel, Farmer, & Lu, 2015). Mental health disorders account for about 8% of the global burden of diseases, affecting as many as 700 million people worldwide (Gilbert, Patel, Farmer, & Lu, 2015). It is common for a patient to feel sad or depressed after a big life change or if they are trying to manage a chronic condition like pain (National Institute of Mental Health, n.d).

Yifeng et al., (2020) did an investigation concerning mental and physical comorbidity with chronic back or neck pain in the Chinese population. The investigation assessed the prevalence of chronic neck and back pain with the onset of mental disorders. Chronic physical conditions were addressed by self-report. Mental disorders were assessed by the Composite International Diagnostic Interview (CIDI). Role disability during the past 30 days was assessed with the World Health Organization Disability Assessment Schedule. The 12-month prevalence of chronic back or neck pain was 10.8%. Most people with chronic back or neck pain reported at least one other comorbid condition, including other chronic pain conditions (53.4%), chronic physical conditions (37.9%), and mental disorders (23.9%) (Yifeng et al., 2020). It was found that there is a strong association between chronic back or neck pain and anxiety disorders. Chronic back or neck pain and physical-mental comorbidity is very common in China and chronic back or neck pain may increase the likelihood of other physical and mental diseases. This presents a great challenge for both clinical treatment and public health education (Yifeng et al., 2020).

Pharmacological and physical interventions are typically the first line of treatment for managing pain, however, in developing countries, this is not always an option. Psychosocial interventions have commonly been used in developed countries for treating pain. They have been incorporated alongside medical treatment and play a big role in helping patients adjust to the pain, cope with feelings of distress, sadness, or depression, and ensure adherence to medication (Portelli,2018). The most commonly used psychological interventions are behavioral treatments, cognitive therapies, cognitive behavior therapy, hypnosis, biofeedback, relationship and distraction, and emotional freedom techniques (Portelli, 2018). Using these techniques can help instill a sense of control and empowerment in a person, making them more likely to continue treatment (Portelli, 2018).

Problem

There are many barriers identified to the lack of treatment for chronic pain and mental health in developing countries. Kprinak (2015) notes that "According to the World Health Organization (WHO), mental health is a state of well-being in which every individual can realize his/her potential, and can cope with the normal stressors of life, work, and make a contribution to their family and community”. Mayo Clinic (2019) notes “Mental illness refers to a wide range of mental health disorders that affect mood, thinking, and behavior. Examples of mental illness include depression, anxiety disorders, schizophrenia, eating disorders, and addictive behaviors”. There is a large treatment gap for mental health care in low- and middle-income countries, where most people with a mental, neurological, and substance abuse diagnosis receive little or no care (Thornicroft & Sermrau, 2019). A countries’ healthcare system plays a crucial role in determining the countries are overstretched due to the higher burden of disease in their population and lower availability of human and financial resources (Thornicroft & Sermrau, 2019). Three-quarters of the global disease burden is due to mental health disorders, and 8.9% of the disease burden in low- and middle-income countries is due to mental health disorders (Thornicroft & Sermarau, 2019). An average of 1.9% of the healthcare budget in low- and middle-income countries is allocated to the treatment and prevention of mental health disorders (Thornicroft & Sermarau, 2019). Thornicroft & Sermarau (2019) stated "A large multi-country survey showed that 76%- 85% of people with a mental health disorder in low-income countries had not received treatment in the previous 12 months, this lack of treatment increases the rate of disability and suicide".

There has been a long-term disagreement on the exact causes of mental illness, which has led to a variety of treatments being used. There has been an increase in global health aid agencies to encourage and support national governments to move toward strengthening mental health care in developing countries (Kopinak, 2015). One organization that has recently been developed is called Emerald. Emerald is an international program that aims to improve mental health outcomes in six low -and -middle-income countries by generating evidence and capacity to enhance health system performance, thereby improving mental health services (Thornicroft & Sermarau, 2019). Emerald is working in Ethiopia, India, Nepal, Nigeria, South Africa, and Uganda. These countries all are facing mental health challenges, such as weak government, low resources, and poor information systems (Thornicroft & Sermarau, 2019). Some challenges Emerald is facing are inadequate resources, limited financing, poorly trained staff, lack of understanding about the education of mental health, low level of empowerment, and the marginalization of service users and caregivers (Thornicroft & Sermarau, 2019).

Not only are there challenges being faced with the treatment of mental illness, but there is also a stigma around it. Studies have suggested that developing countries exhibit a fear, shame, and stigma directed toward mental disorders (Seeman, Tang, Brown, & Ing, 2016). Shame and fear will lead to social distancing, which can result in isolation, lack of employment, avoidance of seeking help, poor adherence to treatment and poor health.

While mental health faces some significant barriers, we are also facing barriers regarding the treatment and diagnosis of chronic pain. Chronic pain is the leading cause of disability globally (Kohrt, Griffith, & Patel, 2018). In low- and middle-income countries people have greater exposure to road injuries, interpersonal and political violence, unregulated manual labor, and limited access to healthcare (Kohrt, Griffith, & Patel, 2018). Unfortunately, health care services to address pain are inadequate in low- and middle-income countries where the majority of people with chronic pain reside. However, improving access to medication is vital, and multidisciplinary, and multidimensional approaches demonstrate a better outcome (Kohrt, Griffith, & Patel, 2018). This is why it is important to consider the role of psychosocial interventions because psychological distress is one of the prime mediators for the relationship between chronic pain and disability (Kohrt, Griffith, & Patel, 2018).

Intended Improvement

This research study will evaluate the relationship of mental health in association with chronic musculoskeletal pain in developing countries. It will consist of two phases. Phase I is a proposal of a psychosocial yoga graphic handout that can be used to help with managing chronic musculoskeletal pain and mental health in developing countries. Phase I will also include the development of a power point presentation for students and faculty regarding best practices for cross cultural education, chronic pain, mental health, and development of a pre and post-test for students on the topic. Phase II is the implementation of the psychosocial yoga graphic handout. In phase II the students of GHP will receive a PowerPoint presentation, which will be about chronic pain, mental health, and treatment in developing countries. Students will also be given a pre-test before this presentation to determine their knowledge of these issues. Students will be trained on how to use the psychosocial yoga graphic handout on all future GHP trips, and this training will entail a simulation lab on how to properly perform these exercises and stretches.

On the trip, students will be expected to provide education to local patients on how to perform these exercises and be able to evaluate the effectiveness of the exercises. Students and faculty will be using a teach-back method with the developing countries’ population. Upon return, students will be given a post-test to evaluate their experience and determine if their knowledge base has grown based on their experience.

Through the review of the literature for this study, barriers to success will be identified as well as strategies recommended to overcome these barriers. During Phase II, training for students and faculty will be implemented. Both chronic pain and mental health education will be provided for faculty and students. Faculty and students should be aware of chronic pain and mental health and the prevalence within the culture they are traveling to. Requirements for this program and toll will include student evaluation, time requirements, and expectations will be set for students and faculty. During Phase II, this education will be implemented for all future occurring GHP trips. The effectiveness of knowledge gained from students will be evaluated after every trip.

Study Question:

1. What is the relationship between mental health and chronic pain in developing countries?

2. What is the relationship in pre-test/post-test scores between a traditional lecture vs. simulation venue of understanding basic Yoga Knowledge and Application by Global Health Students at Denver College of Nursing (DCN)?

3. What is the knowledge of faculty going on the mission with the GHP students regarding Yoga in relation to chronic pain and mental health?

Chapter 2: Literature Review

A literature review was conducted using the search terms of "mental health, developing countries, low-income countries, chronic pain, middle-income countries”, and “lower back pain". The publication date searched was from 2015 to 2020. The online databases used were Pubmed, Medline, and Google Scholar. Approximately 200 articles were located. Inclusion criteria were peer-reviewed, scholarly journals. The articles had to discuss chronic pain rates, mental health rates, correlation of mental health and chronic pain, treatment of chronic pain, or mental health. Twelve articles were chosen that met these criteria. See the reference list for the full citation of the scholarly articles utilized.

Most of the articles discussed the impact of chronic pain in developed and underdeveloped countries and their relationship to mental health. Chronic pain is the leading cause of years lived with disability globally (Kohrt, Griffith, & Patel, 2018). Populations in low- and middle-income countries have a higher rate of chronic pain due to greater exposure of road injuries, interpersonal and political violence, unregulated manual labor, and limited access to health care (Kohrt, Griffith, & Patel, 2018). Mental disorders are a leading cause of the global burden of disease (Gilbert, Patel, Farmer, & Lu, 2015). Mental health and substance use disorders account for approximately 8% of the global burden of disease, which accounts for about 700 million people worldwide (Gilbert, Patel, Farmer, & Lu, 2015). There are many barriers identified in the low treatment of chronic pain and mental health.

The main barriers are identified in the literature. Social factors such as poverty, urbanization, internal migration, and lifestyle changes all have an impact on mental and physical health. There are also demographic impacts such as age, sex, and family history that play a role. Developing countries also face the lack of available health care, the stigma behind mental health, poor governance, and greater exposure risk to hard physical labor and accidents. Not only are resources slim in developing countries, but cultural and religious attributes of illness and belief systems influence treatment behaviors and complicate access to services and outcomes for mental health (Rathod et al., 2017).

There is a significant treatment gap for mental health in developing countries, the majority of people with a mental health or substance abuse diagnosis receive little to no care (Thornicroft & Sermrau, 2019). A countries’ healthcare system plays a big role in the coverage their country provides for mental health and how effective it will be. More common than not, developing countries are overstretched due to the high burden of disease in their population and lower availability of human and financial resources (Thornicroft & Sermrau, 2019).

Not only does mental health face significant barriers, but there are also barriers to treatment and diagnosis of chronic pain. Chronic pain is the leading cause of disability globally (Kohrt, Griffith, & Patel, 2018). As mentioned above, in developing countries, people have greater exposure to road injuries, interpersonal and political violence, unregulated manual labor, and limited access to healthcare (Kohrt, Griffith, & Patel, 2018). In developing countries, health care services to address and treat pain are inadequate.

Kohrt, Griffith, & Patel (2018) discussed the relationship between chronic pain and mental health as a global problem. This author identifies that pain is the leading cause of disability globally. The review focuses on the burden of chronic pain in developing countries and why populations in developing countries are at a higher risk of developing chronic pain. The author talks about how using psychosocial interventions for the treatment of chronic pain should be used. Not only would psychosocial interventions help in the treatment of chronic pain, but also at improving one's mental health (Kohrt, Griffith, & Patel, 2018). Using psychosocial interventions would help with the burden of chronic pain, which will reduce the risk of over-utilization of opioid medications globally (Kohrt, Griffith, & Patel, 2018).

Yifeng et al., (2020) did an investigational study concerning mental and physical comorbidity in relation to chronic back or neck pain in the Chinese population. The investigation assessed the prevalence of chronic neck and back pain with the onset of mental disorders. Chronic physical conditions were addressed by self-report from patients (Yifeng et al., 2020). Mental disorders were assessed by the Composite International Diagnostic Interview (CIDI) (Yifeng et al., 2020). Role disability during the past 30 days was assessed with the World Health Organization Disability Assessment Schedule. The 12-month prevalence of chronic back or neck pain was 10.8%. Most people with chronic back or neck pain reported at least one other comorbid condition, including other chronic pain conditions (53.4%), chronic physical conditions (37.9%), and mental disorders (23.9%) (Yifeng et al., 2020). Yifeng et al., (2020) found that there is a strong association between chronic back or neck pain and anxiety disorders. Chronic back or neck pain and physical-mental comorbidity is very common in China and may increase the likelihood of other physical and mental diseases. This presents a great challenge for both clinical treatment and public health education (Yifeng et al., 2020). Ultimately, this study showed that the need for awareness and education around chronic pain and mental health conditions is needed in both developed and underdeveloped countries.

Seeman, Tang, Brown, & Ing (2016) proposed strategies for strengthening the mental health systems in developing countries that have arisen out of the work of the Emerald research program in in low- middle-income countries. This 5- year program was aimed to improve mental health outcomes in six developing countries in Africa and Asia. It helped with building capacity and generating evidence to enhance health system strengthening. The ultimate goal of this program was to assist in reducing the mental health treatment gap. Approximately 75% of people in developing countries do not receive any form of treatment or care for their mental health disorder, and approximately 95% receive inadequate? treatment in general (Seeman, Tang, Brown, & Ing, 2016). This study showed that there is a continued need for advocacy to enhance mental health services in developing countries.

Gilbert, Patel, Farmer, & Lu (2015) assessed the need for investment in global mental health. Mental illness and substance abuse account for approximately 8% of the global burden of disease, impacting as many as 700 million people worldwide. This study showed that mental health and substance abuse disorders are the third leading cause of disability, which is more than cardiovascular disease and cancer. The WHO reports that 75% of people with mental disorders live in low- or middle-income countries, and most don't have access to any kind of care, despite cost-effective pharmacological, psychological, and social interventions (Gilbert, Patel, Farmer, & Lu, 2015). This study reported that in 2011, on average, low-income countries devote 0.5% of their health budget to mental health (Gilbert, Patel, Farmer, & Lu, 2015). According to this study, a growing body of evidence shows that effective interventions could be integrated into the existing health systems in low-income countries to improve the mental health care (Gilbert, Patel, Farmer, & Lu, 2015).

Briggs et al., (2018) show the burden of musculoskeletal conditions globally. Musculoskeletal conditions include more than 150 different diagnoses that affect the locomotor system. These conditions are characterized by pain and reduced physical function, which can lead to a decrease in mental health. Musculoskeletal conditions account for the greatest number of persistent pains with all ages and geographies. Musculoskeletal health accounted for 61.4% of the global disability-adjusted life years (DALYs) in 2016, compared to 43.9% in 1990 (Briggs et al., 2018). The majority of this rise was witnessed in developing countries. This shift shows the importance of focusing on healthcare from curative to promotive, preventive, and rehabilitative health care in low- and middle-income countries. This study showed that musculoskeletal conditions were ranked second highest for years lived with a disability in 2016 (Briggs et al., 2018). Ultimately, there is likely an underestimate of the true burden of musculoskeletal health conditions. Most importantly, this study noted that it is important to address health concerns as a whole, this includes mind and body.

Koyanagi, Stubbs, & Vancampfort (2018) review the correlation of low physical activity across low- and middle-income countries, in a cross-sectional analysis of community-based data. Physical inactivity accounts for 5.5% of all avoidable global deaths (Koyanagi, Stubbs, & Vancampfort, 2018). This study utilized an International Physical Activity Questionnaire (IPAQ) and participants were split into those who do and do not comply with physical activity recommendations. The study found that physical co-morbidities might be direct barriers to physical activity or associations that might be mediated by feelings of depression, cognitive problems, and sleep/energy problems (Koyanagi, Stubbs, & Vancampfort, 2018). The data also showed that depression is an important factor that is negatively associated with physical activity participation amongst males 18-64 years of age (Koyanagi, Stubbs, & Vancampfort, 2018). However, being able to help people that suffer from depression become active is important because it has been demonstrated that physical activity can reduce symptoms of mild, moderate, and severe depression (Koyanagi, Stubbs, & Vancampfort, 2018).

Mills, Nicolson, & Smith (2019) did a review of chronic pain and its epidemiology and associated factors in population-based studies. Chronic pain is a complex and distressing problem that can have a significant impact on one's life. Chronic pain frequently occurs as a result of disease or an injury. Chronic pain is its condition with its medical definition. This study looked at the distribution and determinants of chronic pain and allowed understanding and treatment of the problem. The prevalence and incidence of chronic pain were looked at. The research suggested that chronic pain affects 13-50% of adults in the UK (Mills, Nicolson, & Smith, 2019). Out of this number, 10.4-14.3% were found to have moderate to severely disabling chronic pain (Mills, Nicolson, & Smith, 2019). This review looked at multiple factors that are associated with chronic pain, such as physical, psychological, and social. One specific area that was looked at was the link between chronic pain and mental health. Chronic pain is linked with depression, and the combination of these conditions can cluster in families. Depression, anxiety, and negative beliefs about pain are all related to developing chronic pain and worse outcomes from chronic pain. 20-50% of patients with chronic pain have co-morbid depression (Mills, Nicolson, & Smith, 2019). It is common for depression to go unrecognized, and untreated. Due to the bidirectional relationship between chronic pain and mental health, screening for mental health should be standard in patients with chronic pain.

Portelli (2018) reports that chronic pain has been identified as the most common somatic complaint that prompts people to seek medical care. Pain is an inevitable and universal human experience. Pain becomes problematic when it is enduring, persistent, and dominating, and can impair one’s quality of life (Portelli, 2018). Living with pain daily can be exhausting. Typically, pharmacological and physical interventions are the first line of treatment for pain. Corrective surgery, over the counter medications or prescription drugs, physical therapy, and massage are all options. Since symptoms of depression and anxiety often co-exist with chronic pain, psychotropic drugs are often prescribed. Being able to incorporate psychological interventions with medical treatments plays a crucial role in helping patients adjust to the pain, and cope with feelings of distress, sadness, or depression (Portelli, 2018). Psychological treatment is also effective in reducing fear and distress. Aside from reducing pain and distress, psychological interventions can instill a sense of control and empowerment in one's treatment.

Kamradt (2017) did a review on integrating yoga into psychotherapy and the ethics of moving from the mind to the mat. There has been recent qualitative and quantitative work supporting its use for a variety of medical and psychological disorders (Kamradt, 2017). Modern medical treatment highlights the importance of maintaining mental and physical well- being. This author states that it is becoming increasingly more relevant to understand how psychological treatment such as yoga may benefit individuals with mental health problems. Yoga has emerged as one of the most commonly used alternative medical treatments (Kamradt, 2017). The present research shows that yoga can ethically be used to meet individual client needs while alleviating psychopathological symptoms and promoting well-being. (Kamradt, 2017).

Schmid et al., (2019) did a pilot study to assess the benefits of 8 weeks of yoga in people with chronic pain. The participants of the study completed baseline assessments and were randomized to yoga or normal care. Yoga was offered twice a week for the 8 weeks. 83 people were recruited; 67 of them completed the study and were included in the analyses. The average age of the participants was 50.78 + 10.43 years, and most had pain greater than 10 years. There was a significant difference in body responsiveness and pain management scores between the two groups. The study showed that yoga was a feasible and positive influence on people with chronic pain.

Schuch et al., (2016) did a study on the effects of exercise on depression. A meta-analysis has demonstrated a range of effect sizes. Both inclusion criteria and heterogeneity may influence the effect sizes reported. Randomized controlled trials were identified from a recent Cochrane review and searches of major electronic databases from 01/2013 to 08/2015 (Schuch et al., 2016). A random-effects meta-analysis calculating the standardized mean difference, meta- regressions, trim and fill, and failsafe analyses was conducted. Twenty-five random control trials were included, comparing exercise versus control comparison groups, including 9 examining participants with depression. Overall, exercise had a significant effect on depression with a fail-safe number of 1,057 (Schuch et al., 2016).

Cramer, Klose, Brikhaus, Michalsen, & Dobos (2017) did three studies on 188 patients with chronic neck pain and comparing the treatment to yoga and normal care. Two studies had an overall low risk of bias, and one had a higher risk. The studies showed that yoga has short term effects on chronic neck pain, its related disability, and quality of life. This suggests that yoga is a good treatment option for managing chronic neck pain. Moreover, yoga is thought to help recognize and change habitual patterns of posture, lead to correction of body positions, and muscle tension (Cramer, Klose, Brinkhaus, Michalsen, & Dobos 2017).

Grovere & Grovere (2016) stated that with the rapid growth of minority populations within the United States and increase in global health care, there is a greater need to train healthcare providers to provide culturally competent care. There has been extensive research on cultural competence of healthcare providers, but no systematic review that focused on the effect of cultural training and patient satisfaction (Grovere & Grovere, 2016). Grovere & Grovere (2016) did a systematic review of literature to address how effective cultural training is in relation to patient satisfaction. It was found that cultural competence had a positive effect on patient satisfaction score (Grovere & Grovere, 2016).

Almutairi (2015) did a systematic review in May of 2014 on cultural and language differences being a barrier to quality healthcare in Saudi Arabia. There were six studies that showed the issues of healthcare workers concerning cultural diversity on the quality of patient care being provided. The results showed a lack of knowledge regarding Saudi Arabia (Almutairi, 2015). This study identified the issues of effective communication between patients and providers (Almutairi, 2015). Barriers in communication often cause unnecessary errors, excess pain, poor quality care, and even death (Almutairi, 2015). Almutairi (2015) determined that when a healthcare provider is knowledgeable of the culture in which they are teaching, this empowers them to provide better care and help avoid confusion.

Prosen (2015) stated that patients are entitled to culturally competent care. Nurses need to be prepared to recognize patients’ needs that derive from their culture (Prosen, 2015). Therefore, nursing curriculum needs to include cultural content and students need education to be culturally competent (Prosen, 2015). In nursing education, it is not standard to include a course directed at transcultural education (Prosen, 2015). The Faculty of Health Sciences of the University of Primorska, developed and introduced a transcultural nursing course into the program (Prosen, 2015). Prosen (2015) found that integration of cultural content into nursing curriculum is needed because the population’s diversity is increasing. Integrating cultural content into the nursing curriculum at The Faculty of health Sciences of the University of Primorska showed that it assists in preparing the nurses to be culturally competent. However, implementing this curriculum requires the commitment of faculty and support of the administration, as teaching transcultural nursing demands continuous self-assessment (Prosen, 2015).

MacLean, Kelly, Geddes, & Della (2018) did a quasi- experimental study to evaluate the effectiveness of information and interaction-based training to improve nursing communication skills with their patients. This study offered students the opportunity to use a teach-back method with simulated patients. MacLean, Kelly, Geddes, & Della (2018) confirmed that simulation provides an authentic clinical experience for nursing students. MacLean, Kelly, Geddes, & Della (2018) stated that using a teach-back method can be used to confirm a patient’s knowledge when teaching a patient or discharging them. This will allow the student or nurse to confirm that the patient understands what they have been taught.

The role of the nursing educator is to educate faculty and students on the cultural differences which GHP will be encountering. The nursing educator will teach faculty and students how to properly use the psychosocial handouts on the trips, while providing culturally competent care. The use of this tool in developing countries is supported by the literature.

Chapter 3: Proposed Interventions

The purpose of this crossover designed scholarly capstone Quality Improvement (QI) paper is to measure the knowledge gained about cross cultural education, chronic pain and mental health in developing countries by GHP students. There are two educational approaches: a traditional power-point presentation and a simulation teaching session. All GHP students will participate in these educational sessions to gain knowledge about the skills and research being taught.

The scholarly QI project consists of two phases. Phase I will occur before students go on their assigned GHP trip. This phase will include the development of the power point presentation on best practices for cross-cultural education, chronic pain and mental health for the students and faculty, development of the pre and post- test for students, and the development of the psychosocial yoga graphic handout that will be used on the GHP trip to provide education to the patient population being treated. Once the material has been developed, approval from GHP leadership will be required.

Phase II will occur after approval has been granted by GHP leadership to use the educational tools and psychosocial tool on GHP trips. Phase II involves the presentation of chronic pain and mental health using the power point presentation, giving students the pretest prior to the presentation and the posttest upon return from the GHP trip. The power point will include information on the problem, purpose, literature review, and methodology which involves the proposed intervention. Phase II will also consist of the implementation of the psychosocial yoga graphic handout on the GHP trip. This phase will also include a simulation, where students will learn how to use the psychosocial yoga graphic handout and perform the stretches/ exercises they will be teaching to patients.

The measurable intervention for this capstone scholarly paper is covering the topic of chronic pain in relation to mental health in a developing country and GHP students' knowledge about the topic. The pre and post-tests are being administered to evaluate the knowledge gained after the students implement the universal psychosocial yoga graphic handout for chronic pain and mental health. The universal psychosocial yoga graphic handout and assessments are available in Appendix A and Appendix B.

Ethical Considerations

For Phase I, there are no human subject consideration applications, and this Phase I will not be published. Phase II will involve collaboration with the GHP leadership which will have the final approval of the study and teaching tools that will be developed. This rationale is derived from Tappen (2016) who writes ethical considerations for the QI project usually do not require a formal rigorous application to the IRB since the study occurs in the workplace and will not be published. However, during Phase II, implementation, the author will have approval from the education leadership institutional hierarchy for the educational tool being used to make sure the risk to the participants is not greater than minimal and there is appropriate privacy protection for participants.

Summary

For Phase I of this Capstone Scholarly project the lecture and psychosocial yoga graphic handout will be developed and approval from GHP staff will be obtained. Implementation of the crossover design occurs whereby students serve as their own control and intervention group will occur during Phase II. The students will take a pre-test related to content that will later be provided by the power point and simulation education venues. Afterward, the students will participate in a power point presentation on the relationship between mental health and chronic disease and the psychosocial Yoga graphic handout. The first post-test follows. The GHP students will then cross over and be their own intervention group, taking part in the simulation venue which includes yoga stretching classes. A second post-test will then be administered. The pre and post- test can be found in Appendix A and Appendix B. This crossover design is to measure the knowledge gained by students from this educational handout PowerPoint presentation, and simulation educational venue. After the preparation, students will go on their GHP trip. Upon return, students will complete a second post-test to see how much they. The post- test will consist of the same questions at both times of testing. A statistician will be consulted.

Chapter 4: Metrics and Outcomes

Introduction

Phase I of this crossover design research study is describing the relationship between chronic pain and mental health in developing countries. This Phase will occur before the GHP students go on their assigned GHP trip. This phase includes the development of a PowerPoint presentation for students which can be used to orient GHP faculty regarding mental health and chronic pain and best cultural teaching practices. Phase I will also include the development of a pre- test/post-test that students will receive prior to and after their PowerPoint and simulation presentations and upon return from their GHP trip. Polit & Beck (2021) define Pretest as the collection of data prior to an experimental intervention, also called baseline data. Posttest is defined as the collection of data after introduction and intervention (Polit & Beck, 2021). The intervention in this research study is the education provided to the students prior to the GHP trip and the universal psychosocial yoga graphic handout that will be used on the GHP trips to provide education to the patient population being treated, which will be developed in Phase I. Once the educational tools and psychosocial graphic yoga handout have been developed, approval from GHP leadership will be required.

Phase II will consist of teaching nursing students and orienting/updating faculty about chronic pain and mental health in developing countries before their scheduled GHP trip. The learning objectives, topics to be taught regarding chronic pain and mental health, and criteria for implementation will be established in this Phase. The students will attend a one-day training covering chronic pain, mental health, and developing countries. The first part of the morning will consist of a pre-test regarding the students' knowledge about developing countries and mental health and chronic pain. The afternoon part will involve a power-point presentation on these topics and a simulation of the GHP psychosocial yoga graphic handout that will be getting used in developing countries while on GHP trips. A post-test will follow upon return from the mission.

Intervention

The study design to evaluate the effectiveness of the students’ learning regarding chronic pain and mental health will be a crossover design. The crossover design has a long history in the planning of scientific trials (Wellek & Blettner, 2012). Many clinical trials have used a crossover design. The essential feature distinguishing a crossover trial from a conventional parallel group is that each proband or patient serves as his or her own control (Wellek & Blettner, 2012).

It excludes the effect of individual variables like age, ability, and IQ, since the same individuals are participating in the study and simulation. This design requires a smaller sample size, making it quick and easy to implement (Oger, Ellis, Scibillia, Pammer, 2015).

There are limitations to this type of design as well. The issue of order in which education or treatment is provided can affect the outcome of the study (Wellek & Blettner, 2012). Not only does the way treatment or education is provided affect the study, but the issue of “carry over” between the education provided can affect the outcomes (Wellek & Blettner, 2012). So too much time or too little time between the education provided and implementation can affect the outcome.

Simulation as a teaching strategy has been shown to enhance the learning experience. It reinforces the principles of adult learning theory by allowing learners to build upon their knowledge and past experiences (Kapucu, 2017). High fidelity simulation offers the nurse educator realistic immersion in the teaching experience by capturing what happens in the clinical setting. It also provides a consistent experience rather than relying on the rapidly changing clinical situation. (Kapucu, 2017; Young & Shellenberger, 2012). Simulation can improve confidence and competence in performing clinical skills. Students using simulation reported improvement in their critical thinking skills, confidence in their technical skills, and helpfulness of the self-paced learning environment (Curl et al., 2016). Simulation is an effective method to teach students new skills. It allows students to test their skills in a safe learning environment (Kapucu, 2019; Kratzke & Bertolo, 2013).

Metrics

There are several positive expected outcomes for this proposed QI study. Faculty and students will be receptive to the training for both the educational piece regarding mental health and chronic pain, as well as the power point and simulation lab learning for the psychosocial yoga graphic handout. The educational information regarding mental health and chronic pain will also include a lesson about the culture in which the students will be visiting.

Preliminary Recommendation

The College does not have any formal training on any of these topics. It is an assumption of this author that the cultural teaching incorporated into the curriculum would be beneficial and increase the students’ and faculty's education regarding the country to be visited. The simulation will be evaluated at a higher level since it requires adult learning.

Potential Barriers

The barriers to this QI study may be that students and faculty are hesitant to participate in GHP trips due to the additional training required. It may be difficult to identify at-risk individuals in developing countries. Individuals in developing countries might be resistant to mental health education due to the stigma around mental health. Lastly, being able to re-evaluate the effectiveness of the psychosocial yoga graphic handout may be difficult due to a lack of time in the developing country.

Use of Pre-Test/Post-Test Crossover Design

The use of a pre and post- test crossover design (before and after), is a mixed design that can assist in analyzing differences between groups and changes over time (Polit & Beck, 2021). The use of pre and post-test can be effective in assisting in sample size selection for the students.

Chapter 5: Discussion and Conclusion

This Scholarly Capstone Quality Improvement paper has two Phases, in which the overall goal is to provide the best practices for cross- cultural education to reduce chronic pain and improve mental health in developing countries. The first Phase has six sections: 1) selection of a topic and purpose of the QI study, which relates to the benefits of a psychosocial tool that can be used in developing countries to improve mental health and assist with the treatment of chronic pain; 2) review of literature; 3) Proposed Interventions; 4) Proposed Metrics and Outcomes; 5) Discussion/ Implications; 6) Abstract. Since Phase II will involve the implementation of the psychosocial yoga graphic handout and education for students and faculty, the author offers hypothetical conclusions informed through literature that are related to this Discussion/ Implication/ Conclusion section.

The benefits of using a psychosocial yoga graphic handout to assist in the treatment and management of chronic pain and mental health are well documented in the literature. Incorporating a psychosocial yoga graphic handout can help patients adjust to the pain, cope with feelings of distress, sadness, or depression, and ensure adherence to medication (Portelli,2018). The most commonly used psychological interventions are behavioral treatments, cognitive therapies, cognitive behavior therapy, hypnosis, biofeedback, relationship and distraction, and emotional freedom techniques (Portelli, 2018). Using these techniques can help instill a sense of control and empowerment in a person, making them more likely to continue treatment (Portelli, 2018). Using this strategy proposed in Phase I, the author will be developing a PowerPoint presentation, pre and posttest, and psychosocial yoga graphic handout and obtaining approval from GHP leadership. The use of a one-day teaching course is proposed and evaluated for students using a pre and post-test for evaluation. The simulation will be used as a teaching strategy, as well as a power-point lecture and discussion.

Success

The development and implementation of a psychosocial yoga graphic handout in developing countries will be successful in helping control chronic pain and improving mental health. Individuals that use yoga as a treatment for chronic neck pain reported an improvement and usefulness as a treatment option (Cramer, Klose, Brinkhaus, Michalsen, & Dobos, 2017). Yoga has proven efficacy in treating major depression and provides an affordable, cost-effective treatment option (Prathikanti et al., 2017).

Patients that participated in the research study regarding chronic pain and mental health reported a reduction in chronic pain, improved quality of life, and a reduction in stress (Kamradt, 2017). There is research that shows that yoga is an effective method for reducing muscular tension, which precipitates pain and can have an important therapeutic implication for chronic pain and headaches (Kamradt, 2017). “Additionally, research shows that yoga’s potential for reducing stress related symptoms is so well established that the National Institute of Health recommends meditation over prescription drugs for a treatment of hypertension” (Kamradt, 2017). Patients that practice yoga on a regular basis were found to have lower levels of cortisol (Kamradt, 2017). Yoga also is shown to have benefits in treating anxiety, depression and acute mood disorders (Kamradt, 2017). Providers are able to teach yoga skills, such as deep breathing, and stretches that the client can safely use at home (Kamradt, 2017).

The inclusion of cultural competency education in the GHP program will add to the success of students on GHP trips. Nursing students need to be able to provide patient-centered care that is culturally competent, which allows nurses to recognize patient’s needs in their own cultural environment. Patients are entitled to culturally competent care (Prosen, 2015). The goal on GHP trips is to be able to provide culturally sensitive and congruent care to the patients and their families.

Cultural competency starts with the nursing educators (Gillson & Charian, 2019). Unfortunately, transcultural nursing education is not a standard in nursing programs. So, integration of culturally competent care and social determinants of health throughout the GHP curriculum is important. Implementation of transcultural education into nursing requires faculty that are passionate about diversity and commitment from faculty (Prosen, 2015). Having faculty that met these qualities were identified as strengths with success in transcultural education courses (Noone et al., 2016). Today diverse and culturally competent organization are becoming prized resources in health care systems, and setting the standard for excellence (Prosen, 2015).

Challenges

For faculty the main challenge is making sure to integrate how to provide culturally competent care into the GHP curriculum. Faculty can have a fear of stereotyping, when teaching about culturally competent care, which can have a negative effect on a student’s educational experience. Modification to course content by replacing less relevant content with cultural content will help equip students with cultural competencies in primary care and health promotion and prepare them for the GHP trip. Engaging students in experiential learning which promotes communication, active listening and reflection can aid in cultural competencies (Kapucu, 2019).

Students will be challenged by having to teach patients how to use the psychosocial yoga graphic handout in several different countries. Students will be teaching patients in a developing country these exercises and yoga moves without the ability to communicate or physically touch patients. Depending on the culture, physical touching may be offensive. In yoga it is common to use touch to help a patient be more comfortable in a pose, avoid injury, and move more deeply (Kamradt, 2017).

Evaluation of Intervention

The use of crossover design for students is useful to identify what students already know. It identifies gaps in knowledge. This type of design also provides information on the effectiveness of the teaching method and content. It can show if the content needs to be revised or be more challenging (Kuehn, 2019). This study design is effective for small sample sizes since it is not dependent on variables like age, ability, or IQ. The limitations of this design are threats to internal validity. This can be familiarity with the test itself or the role of technology, which can be used to learn something quickly (Spurlock, 2018).

The use of simulation enhances learning quickly, and builds on adult learning theory which includes the learner's knowledge and past experiences (Kapucu, 2019). Simulation is an effective method to increase cultural awareness, knowledge, and communication skills. The use of simulation enables the learner to examine their cultural attitudes, values, and beliefs (Kapucu, 2019). There are some challenges to using simulation--lack of familiarity with equipment, and pedagogy. Simulation can be time-consuming to implement. The fear of failure, looking incompetent in front of other students and faculty is another challenge (Simes et al., 2018).

Anticipated Outcomes

Based on the literature review and experience, the author’s hypothesis for Phase II implementation of the Quality Improvement is positive. The implementation of the psychosocial yoga graphic handout in developing countries will be a success for both faculty and students. The one-day class on chronic pain and mental health in Phase II will be successful in preparing students and faculty for the GHP trip. The lecture-style component for the students is more comfortable and the simulation experience will provide the hands-on experience needed for them to teach to individuals in developing countries.

Recommended for Further Study and Conclusion

It has been determined that psychosocial interventions can be used for the treatment of both mental health and chronic pain (Kohrt, Griffith, & Patel, 2018). Yoga specifically has a positive effect on chronic neck pain and improving one’s quality of life (Cramer, Klose, Brinkhaus, Michalsen, & Dobos, 2017). There is little research on use of psychosocial yoga graphic handout in developing countries, specifically yoga, as a treatment for chronic pain and mental health. More research is needed. Future research can focus on using psychosocial tools, primarily yoga, in developing countries for the treatment of mental health and chronic pain.

It is important to educate students and faculty to become culturally competent nurses. It is important to consider the addition of a Global Health course to the BSN curriculum in addition to the GHP program. The implementation of a Global Health course for GHP trips will help students become well rounded and gain cultural experience. Culturally competent nurses are able to provide quality effective care, which will reduce health disparities and accomplish health equity among populations (Registered Nursing Org, 2019). A critical ethical underpinning is that “Cultural competency is centered around respect and responsiveness” (Registered Nursing Org, 2019)

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