Professional Documents
Culture Documents
No.
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2015
Original Article
Abstract
Context. Family caregivers play an increasingly critical role in cancer patients symptom management as the number of
cancer patients receiving home care grows. However, there is a lack of research measuring the impact of the family caregivers
hesitancy to use analgesics on analgesic adherence and the resulting influence on patient pain intensity.
Objectives. To examine whether family caregivers hesitancy to use analgesics is a mediator that influences patient
adherence and investigate how analgesic regimen adherence affects pain intensity.
Methods. This study used a cross-sectional and descriptive design. One hundred seventy-six patient-family caregiver dyads
(N 352) were recruited from one local hospital in southern Taiwan. Instruments included the Short Version of the Barriers
Questionnaire-Taiwan, the Morisky Medication Adherence Measure-Taiwan, the Brief Pain Inventory-Chinese, and
demographic and illness questionnaires. A one-way analysis of variance and post hoc comparisons were performed to assess
the influence of analgesic regimen adherence on pain intensity. Sobel tests were used to examine mediating effects.
Results. Family caregivers hesitancy to use analgesics was a significant mediator between patient barriers to use analgesics
and patient analgesic regimen adherence (P < 0.0001). Patients with low and moderate adherence levels reported
significantly higher levels of pain severity (F 3.83, P < 0.05).
Conclusion. This study showed that family caregivers hesitancy to use analgesics was a significant mediator associated with
their hesitancy to use analgesics and the patients analgesic adherence. It is important for health care providers to consider
family caregivers hesitancy to use analgesics when attempting to improve adherence to pain management regimens in clinical
practice. J Pain Symptom Manage 2015;-:-e-. 2015 American Academy of Hospice and Palliative Medicine. Published by Elsevier
Inc. All rights reserved.
Key Words
Cancer pain, family caregivers, hesitancy to use analgesics, analgesics adherence, pain management
Introduction
Insufficient pain control in cancer patients remains
a significant challenge.1e3 The effective management
of cancer pain relies mainly on adequate adherence
to analgesic regimens.4,5 The number of cancer patients receiving care at home in Taiwan and Western
countries is increasing rapidly because of limitations
in health insurance benefits.6,7 Therefore, family caregivers are now playing a more critical role in cancer
outpatients symptom management.7,8 Recent studies
have shown that family caregivers rising concerns
and hesitancy regarding the use of analgesics is significantly correlated with the effectiveness of pain management in cancer patients.9 Indeed, in clinical
Lee et al.
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Methods
A cross-sectional and descriptive design was used. A
convenience sample was recruited from an outpatient oncology clinic at a teaching hospital in Taiwan.
Inclusion criteria were as follows: 1) a pathological
diagnosis of cancer, 2) at least 20 years old, 3) could
communicate in Mandarin or Taiwanese, 4) experienced average pain >0 on the Brief Pain InventoryChinese version (BPI-C), 5) had been taking oral
analgesics for more than one week, and 6) lived
with the family. Patients were excluded if they were
cognitively impaired or only used fentanyl patches
as we could not calculate adherence.
Inclusion criteria for family caregivers were as follows: 1) at least 20 years old, 2) could communicate
in Mandarin or Taiwanese, 3) lived with the patient,
and 4) not foreign workers or certified care workers.
Instruments/Measures
A survey questionnaire including three instruments
and demographic and disease information sheets was
used in this study.
Short Version of the Barriers Questionnaire-Taiwan. The
original Barriers Questionnaire-Taiwan (BQT) was
translated and adapted from the Barriers Questionnaire by Lin and Ward26,27 and specifically modified
for Taiwanese cancer patients; it was used to measure
patients and families hesitancy toward analgesic use
in previous studies.11,28,29 The original BQT includes
nine subscales: 1) addiction, 2) disease progression,
3) pain tolerance, 4) fatalism, 5) religious fatalism,
6) p.r.n. (pro re nata or as needed), 7) concern
regarding side effects, 8) fear of distracting physicians,
and 9) a desire to be good.
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Ethical Considerations
Ethical approval for the study was granted by the
Human Subject Committee of a local hospital in
Procedure
Participants who met the inclusion criteria were
referred to the primary investigator (PI) by their physicians. The PI approached patient-family dyads to
explain the study and obtain informed consent. Data
collection was conducted in the outpatient department. Patients and caregivers completed questionnaires either before or after outpatient department
consultations in a separate room to avoid crosscontamination of responses. Patients filled out the
S-BQT, MMAM-T, and BPI-C questionnaires. Family
caregivers completed the S-BQT only. Demographic
and illness data were collected by the PI. If the patient
appeared distressed or verbalized any distress, the
interviewer ceased the interview until the patients
symptoms were relieved.
Statistical Analysis
Descriptive statistics were used to assess the distribution of patients and family caregivers demographic
data and family caregivers S-BQT scores. Associations
between patients and family caregivers S-BQT scores
and patients pain intensity and family caregivers
S-BQT scores were determined using Pearsons
product-moment correlation coefficient. One-way analyses of variance (ANOVAs) and post hoc comparisons
were performed to assess the effect of analgesic
regimen adherence on pain intensity. A regression
model, the Sobel test, was used to examine the mediating effects of family caregivers hesitancy to use analgesics. The Sobel test of mediating effects is an
extension of the four regression equations proposed
by Baron and Kenny35 and Preacher and Hayes.36
The mediation equation also controlled for covariates
in the equation.37 In this study, the Sobel tests were
performed using SAS, version 9.1 (SAS Institute,
Inc., Cary, NC) to assess the mediating role of caregivers hesitancy to use analgesics. Other statistical
procedures were performed using SPSS, version 18.0
(SPSS, Inc., Chicago, IL). The significance level was
set at 0.05; all P-values were two-tailed.
Results
Patients and family caregivers demographic and
disease information are presented in Table 1.
Lee et al.
Table 1
Demographic and Disease Information on Patients and
Their Family Caregivers (N 352)
Characteristics
Patients
(n 176)
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Table 2
S-BQT Scores of Patients and Their Family Caregivers
(N 352)
Family
Caregivers
(n 176)
Age, yrs
59.21 (SD 15.58) 44.98 (13.11)
Education, yrs
8.08 (SD 4.54) 10.93 (3.94)
Karnofsky Performance Status 82.65 (SD 12.63)
Score
Gender, n (%)
Female
70 (40)
86 (49)
Male
106 (60)
90 (51)
Marital status, n (%)
Married
144 (82)
130 (74)
Divorced/separated/widowed
32 (18)
46 (26)
Relationship to patient, n (%)
Spouse
85 (48)
Child
67 (38)
Parent
12 (7)
Sibling
5 (3)
Other
7 (4)
Diagnosis, n (%)
Nasopharyngeal cancer
37 (21)
Liver cancer
35 (20)
Breast cancer
33 (19)
Oral/buccal cancer
30 (17)
Lung cancer
9 (5)
Cervical cancer
9 (5)
Colorectal cancer
7 (4)
Various others
16 (9)
Metastasis, n (%)
Yes
132 (75)
No
44 (25)
Medication used, n (%)
Nonsteroidal anti123 (70)
inflammatory drug
Codeine/Tramadol/Utracet/
74 (42)
Depain-X
Morphine
46 (26)
Fentanyl
40 (23)
Adjuvant medication (e.g.,
55 (31)
steroid/tegretol
antidepressant)
Treatment status, n (%)
Only chemotherapy
30 (17)
Only radiotherapy
67 (39)
Chemotherapy with
23 (13)
radiotherapy
(chemoradiation therapy)
None
57 (32)
Pain scores
Worst
5.26 (SD 2.22)
Average
3.02 (SD 1.67)
Least
1.81 (SD 1.91)
Now
2.49 (SD 1.97)
Patients
S-BQT
S-BQT
P.r.n.
Tolerance
Addiction
Distract physicians
Religious fatalism
Side effects
Fatalism
Desire to be good
Family
Caregivers
S-BQT
Mean
SD
Mean
SD
1.87
2.71
2.61
2.41
2.05
1.64
1.61
0.94
0.70
.91
1.20
1.68
1.68
1.40
1.50
.83
.88
.99
1.97
2.66
2.62
2.35
1.94
1.92
1.29
1.14
1.05
.94
1.28
1.59
1.57
1.01
1.28
1.35
1.13
.92
27.99
0.000
Patient S-BQT
Family caregiver S-BQT
Mean pain
Worst pain
Patient
S-BQT
Family
Caregiver
Mean
Pain
Worst
Pain
1
0.525
0.269
0.294
d
1
0.311
0.279
d
d
d
d
d
1
1
0.907
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The Sobel tests showed that family caregivers hesitancy to use analgesics was a significant mediator
between patients analgesic regimen adherence and
barriers to analgesics use (P < 0.0001) (Table 4). An
explanation for this may be that family caregivers hesitancy to use analgesics is an underlying and important
factor that influences patients hesitancy to use analgesics, especially to predict poorer patient analgesic
regimen adherence.
Discussion
To our knowledge, this is the first study that examined the mechanism underlying family caregivers hesitancy to use analgesics with regard to patients
analgesics adherence. Our study has revealed that
family caregivers hesitancy to use analgesics was
moderately correlated with patients hesitancy to use
analgesics. Family caregivers hesitancy to use analgesics was a significant mediator between patients analgesic regimen adherence and reluctance to use
analgesics. In addition, patients with lower levels of
analgesic regimen adherence experienced more
intense pain.
Family caregivers and patients mean S-BQT scores
were correlated. Family caregivers mean S-BQT score
was 1.97 (SD .94), indicating that it may be quite
common for Taiwanese cancer patients family caregivers to experience a certain degree of hesitation
with respect to taking analgesics. In this study, the first
three barriers to analgesic use, according to score,
Table 4
Determining the Mediating Role of Family Caregiver Hesitancy to Use Analgesics on Patients Hesitancy to Use Analgesics
and Analgesic Adherence (N 352)
Standard b
Step
1. PS barriers (independent)
2. FC barriers (mediator) /
3. PS barriers (independent)
4. PS barriers (independent)
/ FC barriers (mediator)
adherence (dependent)
/ adherence (dependent)
/ adherence (dependent) with mediator
0.54
0.70
0.68
0.44
SE
0.07
0.09
0.10
0.11
P-value
0.000
0.000
0.000
0.000
Test Statistic
Mediation results
5.48
<0.0001
Standard b standardized beta coefficient; PS barriers patient S-BQT score; FC barriers family caregiver S-BQT Score; Adherence analgesics adherence.
P-value at 0.05 level.
Steps 1e4 controls: patient gender (men vs. women) and morphine used (yes vs. no).
Lee et al.
Table 5
Relationship of Analgesics Adherence, Pain Intensity
(N 352)
Mean (SD)
Adherence Level
a
Low adherence
Moderate adherenceb
High adherencec
n (%)
Mean Pain
78 (43)
91 (50)
13 (7)
2.92 (1.50)
2.73 (1.62)
1.60 (1.42)
3.83
<0.05
4.13
<0.05
Worst Pain
a
Low adherence
Moderate adherenceb
High adherencec
Scheffe post hoc:
a b
78 (43)
91 (50)
13 (7)
5.13 (2.26)
4.70 (2.39)
3.08 (2.39)
> c.
that tolerance could be overcome with dose adjustment. The notion of restricting analgesic use to an
as-needed basis to avoid a lack of available drugs in
the future often led family caregivers to encourage patients to endue the pain; this prevented patients from
using the analgesics as prescribed. These concerns
affected Taiwanese patients compliance behaviors
with respect to analgesics and caused them to experience more prolonged pain of greater intensity. The
concept of pain endurance and a lack of appreciation
of the possibility of dose adjustment have created significant obstacles to the use of analgesics for the people of Taiwan.
In this study, family caregivers hesitancy to use analgesics significantly predicted patients analgesic
regimen adherence (b 0.70, P < 0.0001) and was
a significant mediating factor affecting the concerns
and compliance behaviors of patients with respect to
analgesic use. One study showed that pain intensity
and interference were increased in patients with lower
levels of analgesic regimen adherence.41 Cancer patients analgesic regimen adherence is often inadequate, which has been shown to result in poor pain
management.4 A study of 92 cancer outpatients in
Taiwan found that 84.6% and 30.6% of patients
adhered to opioid regimens on an around-the-clock
and p.r.n. basis, respectively.18 Another large study in
the U.S. investigated oncology outpatients analgesic
regimen adherence and found that only 53% of
patients had complete compliance with physicians
prescriptions.42 In our study, 43%, 50%, and 7% of patients reported low (MMAM-T score: 0e1), moderate
(MMAM-T score: 2e3), and high (MMAM-T score: 4)
levels of analgesic regimen adherence, respectively.
This finding is very similar to that of a previous study
conducted in Taiwan.17
The promotion of cancer patients analgesic
regimen adherence is an important issue with respect
to improving their pain management. Family caregivers cannot be ignored in the promotion of patient
analgesic regimen compliance involving pain
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Conclusions
This study revealed that family caregivers hesitancy
to use analgesics is a mediator between patients hesitancy to using analgesics and their analgesics adherence. This study also demonstrated that patients with
lower levels of analgesic regimen adherence experienced more intense pain. Family caregivers are an
important part of cancer pain management and
should be part of all patient education. Therefore,
the impact of the family on the patients analgesic
regimen adherence and the quality of pain management should not be ignored.
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