Table 4.
The characteristics of 36 included studies
| Author (s), year, and country | Study design | Study aim | Sample size | Study setting | Mean age | Sex ratio | Measurements | Type of sample | Type of cancer | Main finding | Quality scoring |
|---|---|---|---|---|---|---|---|---|---|---|---|
| Breuer et al., (2011), New York, USA | Cross-sectional method | To evaluate the attitudes, knowledge and practices of US medical oncologists that are related to management of cancer pain | 482 oncologists | The American Medical Association’s Physician Master File | 56 years (range 51–61 years). | Male 80%, female 20% | Not stated | US medical oncologists | N/A | The most important barriers to CPM were poor assessment (median, 6; IQR, 4 to 7) and patient reluctance to take opioids (median, 6; IQR, 5 to 7) or report pain (median, 6; IQR, 4 to 7). Other barriers included physician reluctance to prescribe opioids (median, 5; IQR, 3 to 7) and perceived excessive regulation (median, 4; IQR, 2 to 7). In response to two vignettes describing challenging clinical scenarios, 60% and 87%, respectively, endorsed treatment decisions that would be considered unacceptable by pain specialists. Frequent referrals to pain or palliative care specialists were reported by only 14% and 16%, respectively. | 6/7 |
| Bernardi et al., (2007), Italy | Cross-sectional method | To obtain information about the knowledge and attitudes of Italian oncology nurses concerning CPM and to determine the predictors of nurses’ PM knowledge | 287 nurses |
Oncology wards in the north, centre and south of Italy |
35 (22–56) | Male (19.2%), female (78.7%) |
the Nurses’ Knowledge and Attitudes Survey Regarding (NKARSP) |
Oncology nurses | N/A | Among the 39 questions examined, the mean score for correctly answered items was 21.4 (55% correct answer). Among the 39 items surveyed, 23 received less than 60% of the correct answer rate. Further analysis of items showed that more than 50% of oncology nurses underestimated the pain of patients and they did not treat it in a correct way and they had an incorrect self-evaluation about their PM knowledge. 90.2% of respondents did not know the correct percentage of patients who over report their pain. | 6/7 |
| Colak et al., (2014), Turkey | Cross-sectional method | To survey the attitudes of cancer patients towards morphine use for CPM in a MMC and identify the factors influence patient decisions to accept or refuse morphine for CPM |
488 cancer patients with pain |
Three different Education and Training Hospitals (ETH) located in 3 cities of Central Anatolia: Ankara, Konya and Kayseri; namely Diskapi Yildirim Beyazit ETH, Kayseri ETH and Konya | 54 (range: 18–87) years |
Female 301, male 187 |
Not stated | Patient with cancer |
Breast 217, colorectal 97, gastric 63 and lung 37 patients |
About 50% of cancer patients refused to use morphine and 36.8% of them prefer another drug due to fear of addiction. Reservation of morphine for later in their disease was the case for 22.4% of the patients who refused morphine use. Whereas, 13.7% of cancer patients reused morphine and 9.7% of them preferred another medication as a result of religious reasons. Both before and after the description only 12% of the patient reported they would not use morphine even if it was recommended. | 6/7 |
| Cohen et al., (2005), Israel | Descriptive cross-sectional method | To explore cancer pain experience, including knowledge and attitudes towards pain and pain control | 39 cancer patients with pain | Radiation department and outpatient centre of a large academic medical institution in Israel | 73.2 (range 65–88; SD = 5.4) years | Male (48.7), female (51.3) | Patient Pain Questionnaire Knowledge Subscale (PPQK) | Cancer patient | Lung 12%, breast 33.3%, colon 7.7%, other 30.8% | Over half (56.7%) reported severe worst pain and had negative pain management indexes (56.4%). knowledge and attitudes towards pain and pain control were poor (54.55%). | 7/7 |
| Darawad et al., (2017), Jordan |
Descriptive cross-sectional method |
To compare physicians’ and nurses’ knowledge and attitudes towards cancer pain management (CPM) and describe their perceived barriers to CPM at cancer units |
207 participants (72 physicians and 135 nurses) |
Oncology units from the military, educational, oncology centre and public sectors in Jordan | Nurses:28.1, physicians 30.5 | Nurses (M 54.8%; F 45.2%); physicians (M 61.1%; F 38.9%) |
The Knowledge and Attitudes Survey Regarding Pain (KAS) |
72 physicians and135 nurses | N/A | Findings revealed that both physicians and nurses had fair knowledge and attitudes towards CPM. Physicians had significantly higher knowledge and better attitudes than nurses (62.3% vs. 51.5%, respectively). Physicians were knowledgeable about medication for PM and opioid addiction but had negative attitudes towards CPM. Nurses’ knowledge was better in regard of CPM guidelines, while they had poor knowledge about pharmacological PM and opioid addiction. Physicians and nurses perceived knowledge deficit, lack of PM, opioid unavailability and lack of psychological interventions as the most common barriers to CPM. | 5/7 |
| Eftekhar et al., (2007), Iran | Cross-sectional method | To evaluate knowledge about and attitudes towards cancer pain and its management in Iranian physicians with patient care responsibilities |
55 physicians in six university hospitals |
Physicians (haematologists, oncologists, surgeons, internists, gynaecologists, radiotherapists) in six university hospitals in Tehran | 37 (ranged 28–65) years. | 54.6% male responders | Not stated | Physicians | N/A | Physicians recognised the importance of PM priority (76%) and about one half of the physicians acknowledged the problem of inadequate PM in their settings. Inadequate staff knowledge of PM as barriers to good PM. No correlation was found between what physicians think they know and what they know about cancer pain and its management. | 4/7 |
| Elliott et al., (1996), USA | Cross-sectional method | The study reported here investigated the relationship between specific knowledge and attitudes (cognitive factors) and patients’ and family members’ reports of pain due to cancer | 244 participants, 122 cancer patients and 122 family members | MCPP communities, medical service areas | 64 years for cancer patients and 60 years for family members | Cancer patients 53% female; family members 62% female | Not stated | Cancer patients and family member | N/A | Patients’ and their families’ reports of patient pain and performance status were highly correlated, although family members consistently reported more pain and disability. Using regression analysis, cognitive factors were strongly related to family reports of patients’ pain (R2 = 0.27), but contributed little to explaining pain reported by patients themselves (R2 = 0.06). Improved understanding of patients’ pain assessments depends on further investigation of other cognitive factors and of sensory and affective factors. Assessment of pain for family members are significantly related to appropriate knowledge and attitudes. | 6/7 |
| Elliott et al., (1995), USA | Cross-sectional method | To determine knowledge and attitudes about CPM among physicians in six Minnesota communities and to determine the physician-related barriers to optimal CPM | 145 physicians | The Minnesota Cancer Pain Project (MCPP) | Not stated | Male 89.7%, female 10.3% | Cross-sectional telephone survey, the physician survey instrument | Physicians | N/A | Significant knowledge deficits were identified in nine of 14 CPM principles, but inappropriate attitudes were found in only two of nine CPM concepts. Medical specially had the strongest influence on knowledge and attitudes, with primary care physicians having significantly better outcomes than surgeons or medical subspecialists. | 7/7 |
| Elliott and Elliott, (1992), State of Minnesota, USA | Cross-sectional method | To explore the prevalence among practicing physicians of 12 proposed myths or misconceptions about the use of morphine in CPM | 150 physicians | Direct patient care in Duluth, Minnesota. 47 different medical schools located in 31 states, Canada, and England. | Older MDs, N = 41, middle-aged MDs N = 53,younger MDs N = 56 | It is not stated. | Physician Cancer Pain Attitude Questionnaire | Physicians | N/A | Many physicians misunderstood concepts of morphine tolerance, both to analgesia (51%) and to side effects (39%). Many were unaware of the use of adjuvant analgesics (29%), efficacy of oral morphine (27%) and non-existent risk of addiction in CPM (20%). | 7/7 |
| Furstenberg et al., (1998), State of New Hampshire, USA | Cross-sectional method | Evaluate the knowledge and attitudes of all three types of providers directly involved in caring for CPs and identify areas where deficiencies exist in order to target future educational efforts appropriately |
554 participants: 188 physicians, 118 pharmacists and 248 nurses. |
Research and Development Committee of the New Hampshire State Cancer Pain Initiative based on a review of questionnaires used in similar studies. | 43.4 years | Male 44%, female 56% | Not stated | Physicians, pharmacists, nurses | N/A | The results are generally consistent with results from other studies of physicians, nurses and pharmacists in terms of knowledge of and attitudes towards CPM, perceived barriers to effective CPM and lack of training in CPM. In contrast to some earlier studies, however, providers in this sample were not concerned about addiction among CPs. Knowledge deficits were found across providers. This negative finding is consistent with data from a number of recent studies and suggests that some progress has been made in allaying provider concerns in this area. | 6/7 |
|
Gallagher et al., (2004), British Columbia |
Survey | To acquire current data on physician knowledge and attitudes towards CPM as an educational needs assessment for the UBC Division of Palliative Care. Also to solicit physicians’ opinions about the TPP’s possible effect on CP prescribing | 4618 physicians |
Palliative care at the University of British Columbia, the BC Cancer Agency and the College of Physicians /Surgeons of BC. |
Not stated | Male (67.9%), female (27.9%) | Not stated |
British Columbia physicians |
N/A | The results show 12.0% of MDs agreed at knowledge question that any Pt given opioids for CPM is at a 25% or more risk for addiction. The highest percent of 80.6% disagreed that morphine for CPM shortens life but makes people more comfortable. The questions most frequently answered incorrectly (or by “do not know”) were those about equi-analgesic dosing (68%) and adequate breakthrough dosing (45%), revealing knowledge deficiencies that would significantly impair a physician’s ability to manage CP. The result shows that there were high scores in the attitude questions but larger deficits in knowledge about CPM. | 6/7 |
| Ger et al., (2000), Taiwan | Cross-sectional method | To examine the attitudes of MDs regarding the optimal use of analgesics for CPM, to evaluate their knowledge and attitudes towards opioid prescribing and to comprehend their perceptions of the barriers to optimal CPM | 204 physicians with cancer patient care |
Two medical centres, Kaohsiung Veterans General Hospital (KSVGH) and Tri-Service General Hospital (TSGH), in Taiwan |
36.4 years | Males (95%) and females (5%) | Not stated | Physicians | N/A | The most important barriers to optimal CPM identified by physicians themselves were physician-related problems, such as inadequate guidance from a pain specialist, inadequate knowledge of CPM and inadequate pain assessment. The results of his study suggest that active analgesic education programmes are urgently needed in Taiwan. | 6/7 |
| Hollen et al., (2000), South Central State, USA | Cross-sectional method | To identify knowledge strengths and weaknesses and misperceptions about CPM between two groups of reg nurses in different setting | 64 hospice and hospital oncology unit nurses | 7 adult hospital oncology units and 11 hospices in a South Central State | 45 (10.54) for hospice nurses and 40 (9.32) for hospital nurses | It is not stated. | North Carolina Cancer Pain Initiative (NCCPI) survey | Hospice (n = 30) and hospital (n = 34) nurses. | N/A | Hospice nurses (X = 24.71, SD = 2.27) scored significantly higher on the total knowledge test than the hospital oncology nurses (X = 20.76, SD = 3.77; t [61] = 5.09, p = 0.0001). Hospice nurses also scored significantly higher than hospital nurses on opioid subscale (t [62] = 5.52, p = 0.0001) and scheduling subscale (t [63] = 3.77, p = 0.0004). Regarding attitudes, hospice nurses also had significantly higher liberalness score (X = 18.31, SD = 1.79) than hospital nurses (X = 16.94, SD = 2.32; t [62] = 2.58, p = 0.0122). | 5/7 |
| Jho et al., (2014), Korea | Cross-sectional method | To evaluate knowledge, practices and perceived barriers regarding CPM among physicians and nurses in Korea | 333 physicians and nurses | 11 hospitals (6 public and 5 private hospitals) across Korea | 33.2 years for physicians and 29.0 years for nurses | Physician, 61.5% male, 38.5% female. nurses, 0% for male and 100% female | Not stated | Physicians (n = 149) and nurses (n = 284). | N/A | Nurses performed pain assessment and documentation more regularly than physicians did. Although physicians had better knowledge of PM than did nurses, both groups lacked knowledge regarding the side effects and pharmacology of opioids. Physicians working in the palliative care ward and nurses who had received PM education obtained higher scores on knowledge. Physicians perceived patients’ reluctance to take opioids as a barrier to pain control, more so than did nurses, while nurses perceived patients’ tendency to under-report of pain as a barrier, more so than did. | 6/7 |
| Jeon et al., (2007), Korea | Cross-sectional method | To assess clinicians’ practices and attitudes about CPM and to identify perceived concerns about and barriers to pain control in urban cancer-treatment settings in Korea | 250 physicians and nurses |
7 hospitals in Korea |
Not stated | Male 107 (42.8%), female 143 (57.2) | Not stated | Physicians and nurses | N/A | The result shows that both groups identified 90.6% concerned that difficulty in controlling strong side effects as the biggest potential barrier to good pain control. Also, they identified inadequate assessment of pain and pain management with 78.5% as the second biggest potential barrier to good pain control. 64.5% of both groups stated inadequate staff knowledge of PM. | 6/7 |
| Kassa and Kassa, (2014), Ethiopia | Cross-sectional method | To assess the attitude, practice of nurses’ and barriers regarding CPM at selected health institutions offering cancer treatment in Addis Ababa city,Ethiopia, 2013 | 82 nurses | 1 public and 4 private health institutions that provide cancer treatment in Addis Ababa, the capital city of Ethiopia | 42 years | Male 18 (22%), female 64 (78%). |
Nurses’ Knowledge and Attitudes Survey Regarding Pain (NKARSP) |
Nurses | N/A | More than half, 53.7%, of the nurses have a negative attitude towards CPM. Similarly 65.9% of nurses’ had poor CPM practice. Lack of courses related to pain in the under graduate classes, lack of continuing training, patient and work overload, role confusion, lack of motivation including salary were the identified barriers for adequate pain management. Monthly income of greater than 1500 Ethiopian Birr (ETB) were found to be associated with attitude towards cancer pain management (CPM) (AOR = 0.16, 95% CI = 0.03–0.78). | 6/7 |
| Kaki, (2011), Saudi Arabia | Cross-sectional method | To assess the final year medical students’ knowledge, beliefs and attitude towards cancer pain, and the need for a formal pain curriculum in medical schools | 325 the sixth year medical students |
King Abdul-Aziz University Hospital, Jeddah, Kingdom of Saudi Arabia |
23 years (42.9%) | Males (n = 158) and females (n = 167) | Not stated | Sixth year medical students | N/A | 54% of the respondents believed that < 40% of CPs suffered from pain. 46% of them considered CP untreatable, while 41.6% considered pain a minor problem and 58.6% considered the risk of addiction is high with legitimate opioids’ prescription. There are 23.1% of students believed that patients are poor judges of their pain, 68% of them limited opioids prescription to patients with poor prognosis and 77.1% believed that drug tolerance or psychological dependence, rather than advanced stages’ cancer is the cause of increasing analgesic doses. The students’ knowledge on the causes of CP, pain clinic rule and pain inclusion in the medical curriculum was poor. | 4/7 |
| Kim et al., (2011), South Korea | Cross-sectional method |
To evaluate young Korean physicians’ attitude towards the usage of analgesics for CPM and their optimal knowledge of opioid prescription Also wanted to find out the real factors that affect the attitude and knowledge of doctors. |
1204 physicians | National Cancer Centre, Goyang-Si, Gyeonggi-do, South Korea | 29.9± 2.2 years | Male 100% | Not stated | Internal medicine and family medicine doctors, surgeons, anaesthesiologists, paediatricians and general physicians | Gastric, lung, liver and colorectal malignancies for males and gastric, breast, colon, rectum, uterine cervix, lung and thyroid gland malignancies for females | A large sample of physicians showed a negative attitude and inadequate knowledge status about CPM. The degree of attitude and knowledge status was different as their specialties and personal experiences. The factors that affected doctors’ attitude and knowledge were: (1) medical specialty, (2) past history of using practical pain assessment tool, (3) self-perception of knowledge status about PM, (4) experience of prescribing opioids, and (5) experience of education for CPM. Although many physicians had a passive attitude in prescribing analgesics, they are willingly open to use opioids for CPM in the future. The most important perceived barriers to optimal CPM were the fear for risk of tolerance, drug addiction, side effects of opioids and knowledge deficit about opioid. | 7/7 |
| Lou and Shang, (2017), China | Descriptive cross-sectional method | To investigate patients’ attitudes towards cancer pain management and analyse the factors influencing these attitudes | 726 cancer patients and their caregivers | The oncology department of 7 hospitals in Beijing, China | Patients: 54.39± 12.72 (range, 18–88) years, caregivers 46.07 ± 13.26 (range, 18–76) years | Patients: male 52.34%, female 47.66%, caregivers, male 45.73%; female 54.27 |
Pain Management Barriers Questionnaire-Taiwan Form (BQT), and Pain Knowledge Questionnaire |
Cancer patients (n = 363) and their caregivers (n = 363) | Lung, oral, nasopharyngeal, oesophageal, gastrointestinal, breast, liver, pancreatic, lymphoma, kidney, ureter, bladder, ovarian, and uterine | The average score of attitudes towards CPM for CPs and caregivers through the BQT subscale score ranged from 0 to 5 were 2.96 ± 0.49 and 3.03 ± 0.49, respectively. The dimension scores for CPs and CGs indicated good attitudes in three areas (scores < 2.5), “desire to be good” (2.22), (2.38), “fatalism” (2.08), (2.31) and “religious fatalism” (1.86), (2.02), and poor attitudes in six areas (scores ≥ 2.5), “tolerance” (3.83), (3.74), “use of analgesics as needed (p.r.n.)” (3.73), (3.51), “addiction” (3.44), (3.43), “disease progression” (3.28), (3.27), “distraction of physicians” (3.16), (3.01), and “side effects” (2.99), (3.22). Two factors were entered into the regression equation: the caregivers’ attitudes towards CPM and the patients’ pain knowledge. These two factors explained 23.2% of the total variance in the patients’ average scores for their attitudes towards CPM. | 7/7 |
| Larue et al., (1999), France | Cross-sectional method, mixed method | To assess the evolution of the knowledge and attitudes of the French population with respect to pain management and morphine use | 2007 general population: 1001 general population in 1990 and 1006 general population in 1996 | Telephone surveys by professional interviewers, and structured questionnaires |
35–44 years, 168/1001 (17%) in 1990 and 201/1006 (20%) in 1996 |
Male 470/1001 (47%) in 1990 and 474/1006 (47%) in 1996. | Not stated | General population in France | Not stated | The respondents’ awareness of the occurrence of pain in the course of cancer improved: 65% (656 of 1006) thought that pain is rare at early stages of cancer in 1996, compared with 49% (490 of 1001) in 1990; 84% (845 of 1006) thought that pain is frequent at advanced stages of cancer, compared with 72% (724 of 1001) in 1990. Proportion of people who were not afraid of becoming addicted to morphine if prescribed for pain relief increased from 26% (263 of 1001) in 1990 to 69% (699 of 1006) in 1996. However, the proportion of respondents who agreed that morphine can be prescribed to CPs increased only slightly, from 79% (790 of 1001) to 83% (833 of 1006) for CPs. The results show that 58% (558 of 968) of the 1996 general public believed that their knowledge regarding CPM had improved over the past 5 years. | 6/7 |
| Larue et al., (1995), France | Cross-sectional method | To assess physicians’ estimates of the prevalence of pain among patients with cancer, their practice in prescribing analgesics, their training in CPM and the quality of care received by cancer patients in their own practice and in France | 900 physicians | Telephone by professional interviewers | < 35 (21.3%) for ONCs and (25.0%) for PCPs. > 45 (36.3%) for ONCs and (27.0%) for PCPs | Female oncologists (36.3%) and female primary care physician (17.0%) | Not stated | Oncologists and primary care physicians | N/A | Although 85% of primary care physicians and 93% of medical oncologists express satisfaction with their own ability to CPM, 76% of primary care physicians and 50% of medical oncologists report being reluctant to prescribe morphine for CPM. Both groups cited fear of side effects as their main reason to hesitate to prescribe morphine. Concerns about the risk of tolerance (odds ratio [OR], 1.15–2.52), perceptions that other effective drugs are available (OR, 1.11–2.41), perceptions that morphine has a poor image in public opinion (OR, 0.96–2.07), and the constraints of prescription forms (OR, 1.12–2.26) contribute significantly to physicians’ infrequent prescription of morphine, as are being female (OR, 1.01–2.03) and being an older oncologist (OR, 1.09–2.51). | 4/7 |
| Lin et al., (2000), Taiwan | Cross-sectional method | To examine attitudes held by Taiwanese family caregivers of hospice in-patients with cancer that serve as barriers to CPM; to determine the relationship of attitudinal barriers to family caregiver hesitancy to report pain and to administer analgesics; and to determine the relationship of attitudinal barriers to the adequacy of opioid used by the patient | 160 palliative care patients and family caregivers | Inpatient palliative care units of two medical centres in Taipei area of Taiwan | Patients (59.63 ± 13.76); family caregivers (43.21± 12.88) |
Patients, male (47%); female (53%) and family caregivers, male (27%); female (73%) |
The Barriers Questionnaire–Taiwan (BQT) form, a demographic questionnaire, and the Brief Pain Inventory (BPI) Chinese version | Palliative care patients (n = 80) and caregivers (n = 80) | Lung (23%), colorectal (16%), breast (13%), liver (9%), gastric (7%), oral (6%), cervical (6%), and various other types (20%) | The five mean ± SD of BQT subscale score ranged from 0 to 5 among hospice family caregivers with the highest scores were disease progression (3.82), side-effects (3.29), p.r.n. (3.01), tolerance (2.96), and addiction (2.67), indicating that these concerns are moderately to strongly held by caregivers. Two attitudinal barriers, ‘Constipation from pain medicine is really upsetting’ and ‘Pain medicine will cause harm to kidneys’ were endorsed by 100% of caregivers. 12 of the 80 caregivers (15%) reported their hesitation to report pain in the past month. Those caregivers who had expressed hesitancy to report pain recorded significantly higher scores on the fear of addiction barrier than those who had no hesitancy. 24 of the caregivers (30%) reported that they had hesitated to administer analgesics to their patients in the past month. Those caregivers who expressed hesitancy in administering analgesics recorded significantly higher scores on the barrier items including fear of addiction, side-effects and tolerance, as well as the total BQT score, than those who had no hesitancy in administering analgesics in the past month. Older and less-educated caregivers scored significantly higher on the BOT than did their younger, more educated counterparts. 83% of these patients were classified as using adequate medication and 17% as being under-medicated. | 7/7 |
| Levin et al., (1985), Wisconsin, USA | Cross-sectional method, mixed method | To provide objective information about the public’s attitudes towards PM and the possible effects of such beliefs on a variety of factors, including delay in seeking treatment and avoidance of analgesic medications | 496 general public | The Wisconsin Survey Research Laboratory | Not stated | Female (57%), male (43%) | Not stated | Adult lay public | Not stated | The result from the 472 respondents who had not been diagnosed with cancer: 15% of them agreed or strongly agreed that if they had cancer their fear of the disease would make them seeking medical care. 9% of the sample agreed or strongly agreed their concern about CP would lead to avoidance of medical care, whereas 18% indicated they would avoid seeking care as of concerns about pain associated with cancer treatment. 62% associated the onset of pain with disease progression, and 57% thought CPs usually die a painful death. 50% of respondents had significant concerns about a variety of consequences of taking opioids include confusing or disoriented, tolerance and addiction. | 4/7 |
| McCaffery and Ferrell, (1995), Australia, Canada, Japan, Spain, and the USA | Cross-sectional method | To address nurses’ knowledge and attitudes about patients’ reports of pain, prevalence of cancer pain, preferred route of administration for analgesics, preferred choice of opioid analgesic, initiation of treatment, dosing schedule, and knowledge related to addiction and use of placebos. | 1428 international nurses from 5 countries | Pain programmes in Western, Eastern, Midwestern, & southern, sts in the USA, Pain programmes in Australia, pain programmes in Canada, palliative care in Japan, and from nurses had lectures In Spain | Not stated | Not stated | Not stated | Nurses in 5 countries | N/A | Prevalence of pain: higher % from nurses in Span 94.8% and lower % was only 49% of nurses in Japan. Over-reporting of pain: Nurses from Japan reported an extremely high degree of misconception, with 28.9% responding that 80–100% of CPs over report their pain. Incidence of addiction: Roughly 20–30% of nurses from each country reported the likelihood of addiction as 5%. The % was even higher of 50.9% Japanese and Spanish nurses 54.7%. Initiation of opioids: Canadian nurses reported the highest correct response with 93.2%, while was only 51.2% in Japanese nurses. Appropriate use of analgesics: widespread misconceptions in this area, with only 51.2% of nurses from Spain and 61.6% of Japan compared to 71.5% of Canadian and 66.3% American nurses who selected morphine for CPM. Reason of pt. request ↑↑ dose of opioids: Pt. was exp. ↑↑ pain, were 94.7% in Canada, whereas, only 57.8% was of Spanish nurses. Determination of pain intensity: Pt. is best judge of pain, 95.8% of Canadian nurses, while only 71.6% of Japanese nurses. | 3/7 |
| O’Brien et al., (1996), North Carolina, USA | Cross-sectional method | 340 registered nurses | The North Carolina, hospital settings | 52 years (range 21–73 years). | Male 3%, female 97%. | The North Carolina Cancer Pain Initiative (NCCPI) survey was adapted from the Wisconsin CPI | Registered Nurses | N/A | Knowledge scores for the three subscale revealed that nurses who had worked with CPs were more knowledgeable than those who did not work with CPs. The total knowledge score for nurses caring for CPs was 18.47 and 15.88 for nurses not caring for CPs (t = − 6.19, p < 0.001). Attitude towards PM was for nurses caring for CPs the average was 3.52. A liberal attitude was reported more often by nurses caring for one or more CPs (X2 = 3.9, df = 1, p < 0.02). | 7/7 | |
| Riddell and Fitch, (1997), Canada | Descriptive correlational study | To examine patients’ knowledge of and attitudes towards cancer pain management and to identify, from patients’ perspectives, factors contributing to effective and ineffective pain relief | 42 patients | Oncology facility at teaching hospital | 58.5 years | Female 28 (67%), male 14 (33%) | A modified version of the Patient Pain Questionnaire (PPQ) | Cancer patients | Head/neck, breast, haematologic, female reproductive system, lung, gastrointestinal, male reproductive | The results in this study showed that many patients lacked knowledge of the principals involved in effective CPM and had unrealistic concerns about taking pain medications. Significant negative relationships were found between pain intensity rating and factors such as patients’ knowledge of PM, their level of satisfaction with pain relief and their perception of the goal of PM. Patients identified a number of impediments to effective pain relief, including concerns about addiction and various side effects to pain medications. | 5/7 |
| Shahriary et al., (2015), Iran | Cross-sectional method | To determine the baseline level of knowledge and attitudes of oncology nurses regarding CPM | 58 cancer nurses | Shahid Sadoughi hospital, oncology units, Yazd, Iran | 33.5 (range 25–48) years | 100% female | Nurses Knowledge and Attitudes Survey Regarding Pain (NKAS) tool | Oncology nurses | N/A | The average correct response rate for oncology nurses was 66.6%, ranging from 12.1 to 94.8%. The nurses mean score on the knowledge and attitudes survey regarding PM was 28.5%. Results revealed that the mean percentage score overall was 65.7%. Only 8.6% of nurse participants obtained a passing score of 75% or greater. Widespread knowledge deficits and poor attitudes were noted in this study, particularly regard pharmacological PM. | 5/7 |
| Shahnazi et al., (2012), Iran | Cross- sectional method | To obtain information about the knowledge and attitudes of nurses concerning CPM with the use health belief model (HBM) as framework | 98 nurses |
Alzahra educational hospital in Isfahan, Iran |
38.7 ± 7.04 years | Male 18 (18.4), female 80 (81.6) | Self-admin questionnaire designed on the basis of health belief model (HBM) | Nurses | N/A | From the 10 CP knowledge and attitude questions assessed, the mean number of correctly answered question were 61.2 (SD = 16.5) and 63 (SD = 11) with a range of 30–100 and 35–95, respectively. There was a direct correlation between knowledge and attitude of nurses with health belief model (HBM) constructs except for perceived barriers and perceived threat. Among the HBM constructs, the highest score was related to self-efficacy with mean score of 87.2 (SD = 16.4). | 6/7 |
| Srisawang et al., (2013), Thailand | Cross-sectional method | To assess the knowledge and attitudes physicians and policy makers/regulators have regarding use of opioids for CPM. Barriers to opioid availability were also studied | 266 physicians and policy makers/regulators | 300 hospitals in Thailand | From 36 to 45 physicians (29.2%), policy makers (27.7). | Physicians, male 126 (57.5%), female 93 (42.5%); policy makers, male 19 (40.4%), female 28 (59.5). | Not stated | Physicians (n = 219) and policy makers/regulators (n = 47). | N/A | Of the physicians, 62.1% had inadequate knowledge and 33.8% had negative attitudes. Physicians who did not know the WHO three-step ladder were more likely to have less knowledge than those having used the WHO three-step ladder (OR = 13.0, p < 0.001). Policy makers/regulators also had inadequate knowledge (74.5%) and negative attitudes (66.0%). Policy makers/ regulators who never had CPM training were likely to have more negative attitudes than those having had training within less than one year (OR = 35.0, p = 0.005). Lack of training opportunities and periodic shortages of opioids were the greatest barriers to opioid availability for physicians and policy makers/ regulators, respectively. | 6/7 |
| Utne et al., (2018), Norway | Cross-sectional method | To survey knowledge and attitudes to pain and PM among cancer care nurses, and to explore any association between various demographic variables and knowledge level | 312 cancer nurses | Forum for Cancer Nursing | 45 years | Female (98.4), male (1.6) | Nurses’ Knowledge and Attitudes Survey Regarding Pain (NKAS) | Norwegian oncology nurses | N/A | Norwegian nurses had a mean NKAS total score was 31 points (75%), indicating a relatively high level of knowledge and good attitudes towards pain in cancer care. Significant associations were found between NKAS total score and PM course (p = 0.01) and workplace (p = 0.04). Nurses in cancer care in Norway have relatively good pain knowledge. The potential for improvement is the greatest with regard to pharmacology and nurses’ attitudes to how patients express pain. | 7/7 |
| Vallerand et al., (2007), Detroit, Michigan, the USA | Descriptive cross-sectional method | To determine pain management knowledge and examine concerns about reporting pain and using analgesics in a sample of primary family caregivers of CPs receiving homecare | 46 primary caregivers | Homecare patients with cancer | 55 years (SD, 14.62 years). | Female 67.4% | The Barriers Questionnaire, the Family Pain Questionnaire | Primary caregivers | N/A | The mean for each subscale of the BQ of caregivers expressing some agreement of concerns between 1.05 and 2.41. The concerns were barriers to reporting pain and using analgesics, and up to 15% reported having strong agreement. The areas of greatest concern were about opioid related side effects (2.41), fears of addiction (2.35), the belief that pain meant disease progression (2.28), and tolerance (1.37). Results showed that caregivers with higher PM knowledge had significantly fewer barriers to CPM, supporting the importance of increasing caregiver’s knowledge of CPM. | 7/7 |
| Von Roenn et al., (1993), USA | Cross-sectional method | To determine the amount of knowledge about CPM among physicians practicing in ECOG-affiliated institutions and to determine the methods of pain control being used by physicians | 897 physicians | The Eastern Cooperative Oncology Group (ECOG). | Not stated | Not stated |
Physician cancer pain questionnaire |
Physicians with patient care (oncologists, haematologists, surgeons and radiation therapists) | N/A | Concerning the use of analgesics for cancer pain in the United States (n = 864), 86% of the respondents thought that the majority of patients with pain are under-medicated, although 13% thought that most patients receive adequate treatment for pain. Most of the sample (67%) thought that at least 50% of the cancer patients they treat had pain at some point during their illness. Physicians estimated that almost one half of cancer patients (48%) had pain for more than 1 month. | 7/7 |
| Wells et al., (2001), Scotland, UK | Cross-sectional method | To assess the knowledge and attitudes of nursing and medical staff working in a surgical unit, before and after working with a newly established Hospital PC team | 101 nursing and medical staff | A surgical unit, hospital palliative care team | 34 years | Male 22 (22%) and female 79 (78%) | Not stated | Physicians (n = 22) and nurses (n = 79) | N/A | At baseline, 24% of staff showed a lack of knowledge and a negative attitude towards the risk of addiction to morphine. Regarding opioid tolerance, at the follow-up time point, only 14% demonstrating a lack of knowledge. At follow-up, 34% (compared with 50% at baseline) still believed that increased doses of opioids were needed because opioids became ineffective over time. Although 25% of all staff still lacked knowledge about the risk of respiratory depression at follow-up, this was a significant improvement on the 56% who demonstrated a lack of knowledge at baseline. At baseline, a fairly high proportion of staff appeared to believe pain was always a part of advanced cancer (38%). | 4/7 |
| Yanjun et al., (2010), China | Survey | To determine the degree of physician knowledge on morphine use and the factors that impede morphine use in clinical practice in China. | 201 physicians | 4 hospitals in China | Not stated | Not stated | Not stated | Physicians | N/A | Physicians who reported having received training in CPM and drug use demonstrated a significantly higher mean score of basic knowledge compared to physicians who reported not having received training (9.31 ± 2.88:8.23 ± 2.70, u = 2.74,p < 0.001). The top three cited impediments to widespread clinical use of morphine for cancer pain were: (1) lack of professional knowledge and training (57.2%); (2) fear of opioid addiction (48.7%); and (3) physicians’ personal preferences to select other drugs (46.0%). | 6/7 |
| Yildirim et al., (2008), Turkey | Cross-sectional method | To examine information about the knowledge and attitudes of Turkish oncology nurses regarding CPM | 68 oncology nurses |
Oncology& haematology units in two university hospitals located in Izmir, Turkey |
From 21 to 30 years | Not stated |
Knowledge and Attitudes Survey Regarding Pain (NKASRP) |
Oncology nurses | N/A | The findings showed that Turkish oncology nurses have insufficient knowledge and attitudes about CPM which is widely recommended by the WHO. Out of the 39 pain questions examined, the mean score for correctly answered items was 13.81 (35.41% correct answer rate). Compared with earlier research using the same tool. Only 8.8% of oncology nurses correctly identify that less than 1% of patients who receive opioids far pain relief will develop addiction, and 91.2% erroneously believe that addiction will occur in patients. Most nurses (97.1%) incorrectly believed that more patients over-report their pain. | 7/7 |
| Zhang et al., (2015), China | Cross-sectional method | To evaluate physicians’ current practice, attitudes towards, and knowledge of cancer pain management in China | 500 physicians | 11 medical facilities in China | < 35–≥ 35 years | Male (n = 212, 45.4%), female (n = 255, 54.6%). | Not stated |
Physicians (oncologists, internists, haematologists) |
N/A | About 32.6% of physicians assessed patients’ pain rarely, and 85.5% never or occasionally treated patients’ cancer pain together with psychologists. More than 50% of physicians indicated that opioid dose titration in patients with poor pain control and assessment of the cause and severity of pain were urgently needed knowledge for CPM. Inadequate assessment of pain and PM (63.0%), patients’ reluctance to take opioids (62.2%), and inadequate staff knowledge of PM (61.4%) were the three most frequently cited barriers to physicians’ CPM. | 4/7 |