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Pain experience of cancer patients receiving care in a multidisciplinary pain management clinic

25 May 2023
Volume 32 · Issue 10



Few longitudinal studies have focused on patients' cancer pain experience when receiving care in a multidisciplinary pain management clinic (MPMC). This study aimed to evaluate the experiences of a cohort of cancer patients newly engaged in a MPMC.


This study was based on a longitudinal approach in which data were collected over a 6 months period at the King Hussein Cancer Centre in Jordan. The study adopted the Arabic version of the Brief Pain Inventory to identify the level and prevalence of cancer pain, and to identify the impact of receiving care at the MPMC on patients' pain experience. Data were collected over four time points, and the period between these points ranged from 2 to 3 weeks.


The majority of patients demonstrated improvement in their pain after receiving treatment at the MPMC, while a third still experienced severe pain. Significant improvement was reported at T1, and no further decline in pain was noted after this point. This indicates that exposure to the intervention provided by the MPMC generated, on average, an improvement in patients' pain experience.


The MPMC may be an effective pain management strategy in the treatment of cancer pain.

Pain has been described as ‘an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage’ (Raja et al, 2020). The prevalence of pain in cancer patients has been found to range from 24% to 60% in patients on active anticancer treatment, and 62% to 86% in patients with advanced cancer (van den Beuken-Van Everdingen et al, 2016). In fact, 30% to 50% of cancer patients will have some sort of pain (Cancer Research UK, 2020). Previous studies demonstrated that, despite huge efforts to improve pain management, 70% to 80% of patients were experiencing pain unnecessarily (Yau et al, 2017).

Pain in cancer patients is often called malignant pain, which arises as a result of the disease itself or is related to the treatment of cancer, including chemotherapy, radiotherapy, surgery and diagnostic procedures (Bond and Simpson, 2006). Generally, cancer pain is determined by the type of cancer, site of tumour, stage of disease and location of metastases (Jin et al, 2020).

The pain that is associated with cancer can be visceral, somatic and/or neuropathic in origin (Bond and Simpson, 2006). The pain related to cancer treatment can be chemotherapy-related, such as oral ulceration and caused by inflammation along the gastrointestinal route. Additional types of pain include neuropathic pain such as burning sensations, numbness and tingling (Colloca et al, 2017), radiotherapy-related pain, phantom pain and procedural pain (Bond and Simpson, 2006).

Cancer pain is not only a sensory experience; it is also physiological, physical, social and psychosocial (Ozen et al, 2020). Physically, patients are more likely to have fatigue, nausea and vomiting, and socially they may be unable to interact with others as pain limits their social activities (Ozen et al, 2020). Psychologically, patients may develop anger, anxiety and depression (Niedzwiedz et al, 2019).

Different approaches have been used to manage cancer pain such as pharmacological, educational, cognitive behavioural and complementary therapy approaches. Biological, psychological and social factors might also have an impact on the pain (Chou et al, 2020). So, there is a significant amount of variation in the effectiveness of pain treatments, depending on the condition or type of underlying pain being treated (Chou et al, 2020). The epidemiological effect of cancer pain worldwide, makes researchers receptive to any approaches available to decrease cancer pain (De Paolis et al, 2019). Cancer pain is multidimensional in nature, therefore researchers have used different types of interventions to control it (Prommer, 2015). Some of these interventions may have an indirect effect by improving patients' self-efficacy and increasing self-esteem that empowers patients to investigate the best ways to control their pain (Keefe et al, 2005). For example, social support, nutritional advice, exercises, complementary or cognitive interventions could all work as an adjuvant to pharmacological intervention (Loh and Musa, 2015). Cognitive behavioural therapy can improve patients' tolerance to pain by diverting attention away from pain as well as improving social, psychological and physiological aspects of life (Eccleston et al, 2013). Moreover, psychological interventions can be effective in addressing anxiety and depression, considered to be the main causes of feelings of hopelessness, sometimes leading to attempted suicide in cancer patients (Zaorsky et al, 2019).

In Jordan, the incidence of cancer is considered to be high relative to Jordan's total population, and it may be associated with dietary patterns (Harris et al, 2017), physical activity (Wu et al, 2013), and tobacco smoking (Dossus et al, 2014). This is the first study in Jordan that has produced important information concerning cancer patients receiving care in a multidisciplinary pain management clinic (MPMC). The majority of previous studies have focused solely on the chronic pain experience. In contrast, few studies have focused on cancer pain experience while receiving care at an MPMC. Therefore, this study could provide comprehensive understanding about the impact of a multidisciplinary approach to the cancer pain experience over time, and it will contribute to understanding the extent to which an MPMC can improve the experience of pain from cancer in patients in Jordan. Therefore, this study aimed to evaluate the experiences of a cohort of cancer patients newly engaged in an MPMC in Jordan.

Research questions

  • What are the levels of pain reported by cancer patients in an MPMC through different time periods?
  • Do the pain intensity measures (worst, average, least and current pain in last 24 hours) of cancer patients treated at a MPMC alter over time?



This study was based on a longitudinal approach in which data were collected over a period of 6 months.

Participants and setting

The study took place at the King Hussein Cancer Centre (KHCC) in Jordan. The MPMC was established as a part of the department of anaesthesiology at KHCC to help rid patients of pain caused by cancer and its related management. The work on the MPMC began in January 2005, and the clinic runs 6 days a week alongside 24-hour pain management consultations. Approximately 300 patients per month attend the MPMC, of whom 40 patients are new referrals.

Pain-management services at MPMC are co-ordinated by the pain management team, which comprises four anaesthesiologists and five senior nurses. Patients who are new to the pain clinic receive a general assessment by one of the four anaesthesiologists to identify the severity and type of pain. Moreover, patients will have a general assessment to identify whether pain is interfering with their quality of life. This involves an assessment of sleeping pattern, mood and activities of daily living. The period of time the patient has been in pain is also assessed to determine whether pain is chronic or acute, and an assessment is made of the frequency and severity of breakthrough pain. Patients are followed up by the physicians in the MPMC through routine appointment to assess the effectiveness of treatment and make adjustments as necessary. The doctors carry out regular assessments of all patients to investigate whether they need further action, such as a change in the type of analgesics or any treatment, such as psychotherapy or physiotherapy. The nurses' role includes undertaking a detailed pain assessment, contributing to decision-making on treatment plans, intervening using pharmacological and non-pharmacological methods, and evaluation of responses and drug adjustment. Patients are required to attend the pain clinic regularly to renew their medications, particularly opioids, as the prescribing period of opioids in Jordan is 10 days and 1 month for non-steroidal anti-inflammatory drugs (NSAIDs), anticonvulsants or antidepressants.

Patients also receive information about how opioids and other medications work and how to take them. Patient follow-up is carried out by pain nurses at a specified period after treatment using methods such as follow-up phone calls. During the call, feedback is obtained from the patient about the effectiveness of the care they have received and the patient is given the opportunity to ask any questions.

The inclusion criteria were: being Jordanian, an adult cancer patient, experiencing cancer pain, and new referrals to the MPMC. Participants also had to be able to read and to communicate.

Data collection

Patients were given information about the study at their first appointment. On arrival at the clinic, after staff completed the routine registration process, participants who were interested in the study were directed to a comfortable area to meet with the researchers and were provided with a description of the study. Participants who met the study inclusion criteria were given an information sheet and a consent form. This process of recruitment was followed over a period of 2 months until a consecutive sample of 58 participants was achieved.

Data were collected over four points of time, with the period between them ranging from 2 to 3 weeks. This was based on the schedule of routine appointments for patients. This amount of time would seem to be sufficient for participants to practise what they have learnt during the clinic appointment and put what they have learnt into practice. The time intervals are similar to those used in previous studies (Goytia et al, 2009). The Brief Pain Inventory (BPI) was completed at baseline (time point 0 or T0) before receiving any intervention at the MPMC to identify the baseline scores for pain intensity. Subsequently, the BPI was completed at T1, T2 and T3 before each visit as patients attended for follow-up appointments. Before each visit, participants were requested to arrive about 20 minutes early, before seeing the doctor. After registration, and through available nurses on the help desk, participants were requested to fill in the study questionnaire in a designated room in the MPMC, which had been allocated for the purpose. Throughout the period of data collection, participants were advised to ask if they had any query regarding their pain management.


The study adopted the Arabic version of the BPI to assess the prevalence of cancer pain, and to identify the impact of receiving care at the MPMC on patients' pain.

The BPI is a valid self-report measure to assess pain levels in the past 24 hours (Cleeland, 2009). It consists of two main subscales – a pain intensity scale and a pain interference scale. The pain intensity subscale consists of four items measuring the ‘worst’, ‘least’, ‘average’ and ’pain right now’ levels, while the pain interference subscale consists of seven items: pain interference with physical activities, mood, walking ability, relationship with others, work outside or housework, sleeping and enjoyment (Tan et al, 2004). Each item on both subscales is measured on a Likert scale, with scores ranging from 0 (no pain) to 10 (pain as bad as you could imagine). Similarly, on the pain interference scale, a 0 score indicates no pain interference at all and 10 indicates interference to a great extent (Cleeland, 2009).

The two subscales were constructed to measure two main dimensions – the sensory dimension of pain severity, and the reactive dimension, which refers to the interference of pain with daily life activities (Cleeland, 2009). Previous studies suggested that both scales had strong validity and consistency. Its reliability was confirmed and showed a Cronbach's alpha for the pain intensity scale of 0.85 and 0.88 for the interference scale (Tan et al, 2004).

The Pain Management Index (PMI) is a tool used to assess cancer pain management globally (Deandrea et al, 2008). The PMI measures the effectiveness of pain management by balancing the type of strongest analgesics used or prescribed with the patient's stated pain severity. Pain intensity and analgesic drug ratings range from 0 to 3, and the PMI is calculated by subtracting the latter from the former. Therefore, the PMI is negative when the score for pain intensity is higher than the score for analgesic drugs; this reflect insufficient pain management (Cleeland et al, 1994).

Data analysis

Based on the nature of the study design, and using the repeated measure analysis of variance (ANOVA) formula, the calculation of required sample size for this study showed that 50 subjects are sufficient to have a real difference within the group over an extended period. This number was selected to reach a statistical power of 0.80, with an alpha of 0.05.

Given the risk of attrition in follow-up studies, more than 50 patients were recruited, and the final sample consisted of 58 cancer patients.


A convenience sample of 73 Jordanian cancer patients over the age of 18 years initially agreed to participate in the study at the KHCC in Jordan. Of these, 58 completed data collection at all time points; this may have been due to natural attrition because of changes in the patients' clinical status. Some 39.7% of participants were between 20 and 40 years of age. Over half of the respondents were female (55.2%). Approximately half of the participants (51.7%) were unemployed (Table 1). The most common education level was undergraduate degree level (46.6%) while almost a third (31%) and nearly a quarter (22.4%) had completed primary and secondary education, respectively. The most common diagnoses were breast cancer (22.4%), leukaemia (22.4%), colon cancer (15.5%), bone cancer (10.3%) and cervical cancer (8.6%). Some 5.2% of the participants were receiving chemotherapy, and 3.4% were receiving radiotherapy; 20.7% had had previous surgery, while 58.6% were having some combination of chemotherapy, radiotherapy and surgery (Table 1).

Table 1. Demographical characteristics and medical history of participants (n=58)
Variables n %
Age group (years) 20−39 23 39.7
40−49 13 22.4
50−59 9 15.5
Over 60 13 22.4
Marital status Married 41 70.7
Single 11 19.0
Divorced 6 10.3
Employment Regular 13 22.4
Part time 8 13.8
Retired 7 12.1
Not working 30 51.7
Monthly income* $300−400 37 63.8
$400−500 8 13.8
$500−600 4 6.9
$700−800 3 5.2
$800< 6 10.3
Education Primary 18 31.0
Secondary 13 22.4
Undergraduate 27 46.6
Diagnosis Breast 13 22.4
Lung 4 6.9
Head and neck 3 5.2
Colon 9 15.5
Leukaemia 13 22.4
Bone cancer 6 10.3
Cervical cancer 5 8.6
Others 5 8.6
Treatment No treatment 7 12.1
Chemotherapy 3 5.2
Radiotherapy 2 3.4
Surgery 12 20.7
Chemotherapy, radiotherapy and surgery 11 19.0
Chemotherapy and radiotherapy 9 15.5
Chemotherapy and surgery 8 13.8
Radiotherapy and surgery 6 10.3
* In US dollars

Pain experienced during the course of study

Table 2 shows that the pain experience declined at all time points (T1, T2 and T3) compared with the pain experience at T0. The main decrease in total pain scores occurred between T0 and T1, with small fluctuations after that.

Table 2. Pain scores at each time point
Time period Mean Standard deviation
T0 25.0 8.34
T1 18.3 8.64
T2 19.1 10.2
T3 17.7 9.26

The total pain score can range from 0 to 40

A repeated ANOVA measure showed that there was a significant difference in the mean total pain score after T0; F (3, 55)=14.63, P<0.001. This indicates a significant decrease in total pain score between T0 and all other time points. Pairwise comparisons showed a significant decline in pain intensity between T0 and T1 (mean difference=6.67, P<0.001), T0 and T2 (mean difference=5.91, P<0.001), T0 and T3 (mean difference=7.29, P< 0.001), whereas there were no statistically significant differences in mean total pain scores between the time points T1, T2 and T3.

Pain intensity measures in the past 24 hours

Table 3 shows the mean scores of pain intensity measures (worst, average, least and current pain in the past 24 hours) of cancer patients treated at the MPMC. All scores declined between time T0 and all other time points.

Table 3. Mean scores and SD for pain intensity measures (worst, least, average and pain now) over different time periods
Pain intensity Time
T0 T1 T2 T3
mean SD mean SD mean SD mean SD
Worst pain 7.89 2.15 6.10 2.54 5.75 2.84 5.72 3.01
Least pain 4.89 3.11 3.39 2.39 3.81 2.69 3.34 2.56
Average pain 7.03 2.26 4.68 2.54 4.37 3.12 5.08 2.84
Pain now 5.20 2.89 4.17 2.69 4.37 3.12 3.58 2.44

Higher r mean indicates higher pain experience. Score can range from 0-10

A repeated ANOVA measure showed a statistically significant difference in the mean score for the four pain intensity measures over the time points T0-T3 (Table 4).

Table 4. Differences in pain intensity measures (worst, least, average and pain now) over different time periods
Pain intensity measure F P value
Worst pain 15.2 0.000*
Least pain 4.25 0.009*
Average pain 17.0 0.000*
Pain now 5.12 0.003*
* indicates significance

Pairwise comparisons showed that there was a significant difference in worst pain between T0 at all other time (Wilks' Lambda=0.55, F (3, 55) =15.2, P< 0.05) (Table 5). This pattern was similar for average pain, with a significant difference between T0 and all other time points, with a significant effect for time (Wilks' Lambda=0.52, F (3, 55) =17.0, P< 0.05). For least pain, the decline was only significant between T0 and both T1 and T3 (Wilks' Lambda=0.81, F (3, 55) =4.25, P< 0.05). No significant difference was identified between T0 and T2. The decline in pain now was only significant between T0 and T3 (Wilks' Lambda=0.78, F (3, 55) =5.1, P< 0.05). No significant difference in pain now scores was found between T0 and either T1 or T2. There were no significant differences in worst, least, average and pain now between time points T1, T2 and T3 (Table 5).

Table 5. Pair wise comparisons of pain intensity measures (worst, least, average and pain now) over different time periods
Pain intensity Time I Time J Mean difference (I-J) Standard error P value
Worst pain T0 T1 1.793* 0.356 0.000
T2 2.138* 0.368 0.000
T3 2.172* 0.393 0.000
Least pain T0 T1 1.500* 0.441 0.007
T2 1.086 0.433 0.090
T3 1.552* 0.505 0.019
Average pain T0 T1 2.345* 0.346 0.000
T2 1.862* 0.358 0.000
T3 1.948* 0.392 0.000
Pain now T0 T1 1.034 0.394 0.067
T2 0.828 0.469 0.497
T3 1.621* 0.432 0.002

The mean difference is significant at 0.05.


indicates significant difference

Least pain in the last 24 hours also showed a significant difference between T0 and both T1 and T3, with a significant effect for time Wilks' Lambda=0.81, F (3, 55) =4.25, P< 0.05). However, the difference was not statistically significant between T0 and T2. There was no statistical significant difference in the mean least pain score between T1, T2 or T3, (P>0.05). For pain now, the difference was significant only between T0 and T3 (Table 5). Generally, these results indicate an improvement in the overall pain experience between T0 and T1, with little further change over the course of the treatment.

Adequacy of pain management

At T0, almost two-thirds of the participants (63.8%) had a negative PMI score, indicating that they were not receiving adequate or appropriate pain medication for their worst pain (Table 6). However, an improvement in pain management was noticed at T1, T2 and T3 during the PMI as most patients were receiving appropriate pain medication, with a positive PMI. For instance, only one-third of participants (36.2%) were receiving adequate pain medication at T0 (+PMI). However, an improvement in pain management was shown at T1, as two-thirds (76.2%) were receiving adequate pain medication for their worst pain. Moreover, the improvement in pain management was continued at T2 and T3, as more than two-thirds of participants had an adequate level of pain management (77.5%) at T2 and (79.3%) at T3, respectively (Table 6).

Table 6. Pain Management Index scores over the study's time periods
Table head PMI F % n Cumulative %
T0 -3 2 3.4 37 63.8
-2 16 27.6
-1 19 32.8
0 14 24.1 21 36.2
1 5 8.6
2 1 1.7
3 1 1.7
Total 58 100 58 100
T1 -2 7 12.1 19 32.8
-1 12 20.7
0 20 34.5 39 76.2
1 16 27.5
2 3 5.2
Total 58 100 58 100
T2 1- 13 22.4 13 22.5
0 23 39.7 45 77.5
1 16 27.6
2 6 10.3
Total 58 100 58 100
T3 -2 3 5.2 12 20.7
-1 9 15.5
0 29 50.0 46 79.3
1 12 20.7
2 5 8.6
Total 58 100 58 100

PMI=Pain Management Index, F=frequency, N=number of participants who had positive or negative PMI

The PMI scores suggest a significant change in the adequacy of pain management after T0 (P<0.05). However, the adequacy of pain management did not change significantly for participants over the period of T1, T2 and T3 (P>0.05), and even at T3, 20.7% of patients still had a negative PMI.


Findings indicated a significant reduction in total pain intensity at T1 after exposure to the MPMC pharmacological and non-pharmacological interventions such as giving patients an explanation about opioids and other medications prescribed, changes in the type of analgesics or any treatment such as psychotherapy or physiotherapy. The major decrease in the level of pain experienced by patients was between T0 and T1. There was no further significant reduction in total pain over the rest of the follow-up period.

Looking at the subscales, there was a significant reduction in worst, average and least pain, but not ‘pain now’ after T0. This result is consistent with the findings of a previous study that found a beneficial effect of a multidisciplinary approach in cancer pain management (Reis-Pina et al, 2019). Moreover, this finding is similar to the previous findings of Jongen et al (2011), who found a significant difference in the proportions of patients with mild, moderate and severe pain at the start of consultation, at 48 hours and at discharge.

The change in pain experience is also illustrated by changes in the number of patients who reported pain at mild, moderate and severe intensity at T1; however, there were no significant changes in the number of patients who reported pain at mild, moderate and severe intensity between periods T1 and T2 or T2 and T3. Despite this initial significant decline, approximately one-third of participants reported a severe level of pain at the end of the follow-up, at T3. This may explain why the mean score of total pain experience remained constant. These findings are similar to a previous study, which found that patients rated their pain 5-6 and 7-10 at different points, which indicates severe pain. Also, it is consistent with a previous longitudinal study, which showed that 80% of patients experienced significant improvement in their pain experience and other symptoms at week 1 follow-up, while no significant differences were observed thereafter between different time points after T1 (Chang et al, 2006). These findings suggest that the interventions provided by the MPMC were able to alleviate cancer pain experience in two-thirds of the study population.

This study showed that the number of patients who used pain medication, particularly opioids and adjuvant medication, increased after T0. These results are consistent with previous studies, and show that patients were using pain medication at a more acceptable level than at baseline (Ward et al, 2000; Lovell et al, 2010). These consistencies in the findings of the current study and those from previous research suggests that the decrease in pain after T0 might be attributed to the more effective use of pain medication as well as to the more appropriate prescribing of pain medication. The evidence that supports the suggestion that the early reduction in pain experience was attributed to pain medication is that patients were receiving more appropriate pain medication after enrolment in the MPMC.

Participants in this study reported poor pain management at T0, as they were not receiving appropriate pain medication before being enrolled in the MPMC. This result is in line with the impact of pain medication on cancer pain experience as well as the increasing number of participants who were using opioids after T0. This leads to the conclusion that using pain medication was likely to be helpful in alleviating the pain experience. This study showed that the improvement in analgesic intake by patients was consistent with the adequacy of pain management. This finding is consistent with a previous study, which suggested that an improvement in pain intensity scores was attributable to changes in analgesic prescriptions, analgesics intake and in patients' perceptions of their pain experience (Miaskowski et al, 2004).

The MPMC-prescribed pain medications are based on World Health Organization (WHO)(2018) ladder guidelines. Therefore, results of the current study support the use of WHO guidelines, suggesting that applying these guidelines would improve cancer pain management in Jordan. This is consistent with the study of Meuser et al (2001), which stated that applying the WHO guidelines is effective in improving cancer pain.

Patients' experience of pain was significantly reduced during the course of receiving treatment in the MPMC. Two-thirds of participants reported improvement in their worst pain experience; one-third reported a substantial improvement, and approximately one-third reported better improvement. Thus, it can be concluded that the majority of patients with mild or moderate pain intensity reported a decline of more than 2 points, which is a substantial improvement in pain experience for those patients (Cepeda et al, 2003). In contrast, the change in pain intensity is not clinically significant for those with severe pain.

The improvement in pain intensity was noticed after two weeks of treatment (T1), while, no significant improvement occurred between T1, T2 and T3. Also, this study found that the majority of participants reported good pain relief; however, approximately one-third of the patients still experienced pain at a severe level. These findings suggest that multidisciplinary pain management programmes have a beneficial effect in alleviating the cancer pain experience for the majority of cancer patients. However, at some stage, some patients may experience an increase in their pain intensity.

Previous studies showed significant associations between stage and type of cancer and pain experience (Macfarlane et al, 2012). In the current study, patients had different types of diagnosis, location of metastasis as well as different stages of disease. Previous studies found that type of cancer and stage of disease was significantly associated with pain experience (Rustøen et al, 2003; Edrington et al, 2004). These reasons could explain why some of the study participants remained in pain. Due to KHCC restrictions, it was not possible to determine the stage of patients' disease in this study; consequently, the stage of disease may function as a confounding factor, affecting therapy effectiveness at MPMC.


The lack of a control group was one of the study's limitations. It is possible that additional confounding variables contributed to these results. Furthermore, the MPMC was used in only one Jordanian medical centre, it is difficult to generalise the findings to all Jordanian medical centres. However, the study demonstrated the effectiveness of the MPMC in reducing cancer patient pain and offered feedback on current practice in a unique cancer facility in Jordan.


The majority of patients demonstrated an improvement in their pain after receiving treatment and advice at the MPMC, while a third still experienced severe pain. The significant improvement reported by patients was at T1, with a significant decline in pain noted after this point. This indicates that exposure to the intervention provided by the MPMC generates, on average, an improvement in pain experience over the period of engagement in the pain management programme.


  • The use of pain management strategies has been shown to be effective in treating cancer pain, therefore the MPMC model should be implemented permanently in the authors' hospital and applied more widely in Jordan
  • To ensure the accessibility of opioids for cancer patients, it is critical to launch an urgent re-evaluation of the Jordanian healthcare system's legislation and procedures in relation to the opioid prescription policy. For example, in order to ensure safe and effective administration of opioid analgesics, it is necessary to facilitate systematic improvement involving a team specialising in pain control and the re-evaluation of regulations on opioid analgesics
  • Various initiatives, such as health education, workshops, and awareness campaigns about cancer pain management, are required for nursing and medical working both in cancer and other units.


  • Few longitudinal studies have focused on the cancer pain experience throughout the journey of receiving care at a multidisciplinary pain management clinic (MPMC)
  • In this study, the type of cancer and stage of disease were significantly associated with the experience of pain
  • The intervention provided by the MPMC was shown to lead to an improvement in patients' experience of pain over the period of engagement in the pain management programme
  • In Jordan, the incidence of cancer and cancer pain is considered to be high relative to the country's total population

CPD reflective questions

  • In your area of practice, how could health professionals be supported to improve their pain management practices?
  • What additional research could be conducted on this topic to improve pain management for patients with cancer
  • Consider how clinics such as the one described in this article could be implemented permanently and more widely across a country such as Jordan