Managing Pain in People with Cancer—a Systematic Reviewof the Attitudes and Knowledge of Professionals, Patients,Caregivers and Public

Salim M. Makhlouf1 & Simon Pini1 & Shenaz Ahmed1& Michael I. Bennett1

# The Author(s) 2019

AbstractCancer pain is a common symptom experienced by patients, caused either by the disease or its treatment. Morphine remains themost effective and recommended treatment for cancer pain. However, cancer patients still do not receive appropriate managementfor their pain, and under-treatment is common. Lack of knowledge and negative attitudes towards cancer pain and analgesia amongprofessionals, patients and family caregivers are reported as one of the most common barriers to effective cancer pain management(CPM). To systematically review research on the nature and impact of attitudes and knowledge towards CPM, a systematicliterature search of 6 databases (the Cochrane library, MEDLINE, PsycINFO, CINAHL, Web of Science and EMBASE) wasundertaken in July 2018. Additionally, hand-searching of Google, Google Scholar and reference lists was conducted. The inclusioncriteria were adult (18–65 years of age), studies which included attitudes and knowledge towards CPM, studies written in English,published literature only and cross-sectional design. Included studies were critically appraised by two researchers independentlyusing the Joanna Briggs Institute Analytical Cross Sectional Studies Assessment (JBI-ACSSA). A total of 36 studies met theinclusion criteria. The main finding was that among professionals, patients, caregivers and the public there were similar attitudinalbarriers to effective CPM. Themost commonly cited barriers were fear of drug addiction, tolerance of medication and side effects ofopioids. We also found differences between professional groups (physicians versus nurses) and between different countries basedon their potential exposure to palliative care training and services. There are still barriers to effective CPM, which might result inunrelieved cancer pain. Therefore, more educational programmes and training for professionals on CPM are needed. Furthermore,patients, caregivers, and the public need more general awareness and adequate level of knowledge about CPM.

Keywords Cancerpainmanagement .Attitudesandknowledge .Professionals .Patients .Caregivers .Public .Systematic review

Introduction

Cancer has become the most common cause of death world-wide [7, 86]. It has been estimated that by 2030, there will beabout 21.4 million new cancer cases annually, and approxi-mately 13.3 million cancer patients expected to be die fromthe disease [31]. Pain related to cancer is a common problem

that can occur among patients who are having active cancertreatment [47].This can be a result of some complicationsfollowing treatment of cancer, which can be physical or psy-chological symptoms [21, 73]. The prevalence of cancer paincan be associated with the stage of disease and the location ofcancer [36, 41]. According to a recent meta-analysis, pain wasreported by more than 50% of cancer patients who receivedanti-cancer treatment and about 66% of patients with ad-vanced andmetastatic cancer [26]. Several attempts have beenmade to establish effective CPM. One of the most importantattempts is the Banalgesic ladder,^ established by the WorldHealth Organisation (WHO), to manage cancer pain in adultpatients [91]. Morphine remains the most effective and rec-ommended treatment for CPM [99, 103]. Despite the improv-ing quality of pharmacological options for pain management,several studies have revealed that patients at different stages oftheir disease still do not receive appropriate CPM [3, 18, 25,37, 52, 92]. Lack of knowledge and negative attitudes towards

Electronic supplementary material The online version of this article(https://doi.org/10.1007/s13187-019-01548-9) contains supplementarymaterial, which is available to authorized users.

* Salim M. Makhloufumsmam@leeds.ac.uk

1 Academic Unit of Palliative Care, Leeds Institute of Health Sciences,School of Medicine, University of Leeds, Level 10 WorsleyBuilding, Clarendon Way, Leeds LS2 9NL, UK

https://doi.org/10.1007/s13187-019-01548-9

Published online: 22 May 2019

Journal of Cancer Education (2020) 35:214–240

CPM among professionals [1, 18, 80, 82, 93], cancer patients[61] and family caregivers [79] were reported by recent re-views and studies as one of the most common barriers toeffective CPM.

Numerous studies conducted worldwide have assessed in-dependently either professionals’, patients’, caregivers’, or thepublics’ attitudes and knowledge towards CPM. However,synthesis of these results has not yet been undertaken.Conducting such a review is important as it is now wellestablished from a variety of studies that many common bar-riers delay the delivery of effective CPM to patients; this couldbe caused by professionals [9, 11, 18, 24, 46, 80, 83, 84],cancer patients [57], caregivers [95] and the general public[51], which is likely to result in inadequate CPM. Thus, theaim of this systematic review is to determine the nature andimpact of attitudes and knowledge towards CPM.

Methods

Protocol and Registration

The preferred reporting items for systematic reviews andmeta-analysis (PRISMA) statement has been used as a guide-line for reporting the findings in this systematic review [53,63, 85]. The protocol for this review was registered withPROSPERO; the registration number is CRD42018117625.

Adapting PICO into PCO for This Current SystematicReview

The types of studies, participants and interventions, as well asthe types of outcome measures (PICO) will be modified toPCO (population, context and outcome) as there are no inter-ventions or comparisons needed. [78, 89]. For more details,see Table 1.

Eligibility Criteria: Population, Context and Outcome

The inclusion and exclusion criteria are listed in Table 2

Search Strategy for Identification of Studies

In this systematic review, we searched 6 electronic databases(the Cochrane library, MEDLINE, PsycINFO, CINAHL,Webof Science and EMBASE) in July 2018. Additionally, hand-searching of Google, Google Scholar and reference lists wasconducted. The search terms were based on population, con-texts (context pain, context opioids and context cancer) andoutcome [16]. To identify publications for inclusion in thepresent systematic review, the keywords employed were asshown in Table 3. For more information regarding searchstrategy, see Appendix 5.

Data Extraction

The data extraction form was developed and piloted indepen-dently by two reviewers (SM & SP). A third reviewer (MB)was involved to reconcile any disagreements. Using data ex-traction forms can potentially reduce bias and improve valid-ity and reliability [17]. In this review, the data extraction formwas adapted from Centre for Reviews and Dissemination,University of York [17] (see Appendix 1). The extraction ofdata from the included studies was based on the names ofauthors, year, country of publication, design of study, theaim of study, sample size, the setting of study, mean age, sexratio, type of measurements, type of sample, type of cancer,main findings and the quality of study as outlined in Table 4.

Quality Assessment of the Included Studies

The reason for using a critical appraisal process for theincluded studies was that studies can be published withvariable levels of methodological rigour and thereforetheir results could be unreliable [15]. It has been stronglyrecommended that the assessment of quality should bedone separately by at least two reviewers [56, 64, 72,90]. Accordingly, all 36 included studies have been criti-cally apprised by two researchers (SM & SP) indepen-dently using the Joanna Briggs Institute Analytical CrossSectional Studies Assessment (JBI-ACSSA) (seeAppendix 2). To reconcile any differences, a third review-er (MB) was involved. The JBI-ACSSA tool was chosenas it is appropriate for the study design of included quan-titative studies [64, 90]. The assigning score for the qual-ity of the data was performed as 1 point for each applica-ble item with a score of 7 as the maximum score [74]. Anoverall score was calculated for each included study andthe rating of quality was judged as good (6/7 and 7/7), fair(3/7 to 5/7) or poor (< 3/7) [35] (see Appendix 3). Noscore was below 3/7, so no study was excluded basedon the quality assessment only.

Table 1 Example of systematic review: PICO modified to PCO(population, context and outcome)

Population Professionals, adult cancer patients,family caregivers of patients withcancer and general public aged18 to 65) years old

Context Caner pain and opioids

Outcome Attitudes and knowledge

Adapted from Butler et al. [15]

J Canc Educ (2020) 35:214–240 215

Results

Information Sources and Study Selection

The total number of studies identified by 6 electronic data-bases (the Cochrane library, MEDLINE, PsycINFO,CINAHL, Web of Science and EMBASE) was 6830 articles(see Appendix 5). In addition, 17 studies were identified byhand-searching (including Google, Google Scholar andchecking the reference lists). Among these 6847 studies,5650 articles were included after the duplicate studies wereremoved. Among the 5650 included studies, 5523 studieswere excluded after the title and abstract of each study werecarefully reviewed. The total number of full-text articles

assessed for eligibility was 133. A further 97 studies wereexcluded and all full references of these excluded articlesand the reasons for exclusion are listed in Appendix 4.Consequently, a total number of 36 studies were included inthis review as illustrated in Fig. 1.

Characteristics of Included Studies

The 36 studies included in this review used a cross-sectionaldesign, employing various questionnaires, to assess knowl-edge of and attitudes towards CPM. The studies were basedin 18 countries. The characteristics of included studies areillustrated in Table 4.

Table 2 Summary of inclusionand exclusion criteria Inclusion criteria Exclusion criteria

• Adult(18–65 years of age)

• Studies written in English

• Cancer pain

• Studies include attitudes andknowledge towards cancerpain and opioid

• Published literature only

• Cross-sectional design

• Children and adolescents(< 18 years of age)

• Studies not in English

• Pain related to non-malignant disease

• Barriers not related to attitudes and knowledge

• Unpublished research

Table 3 Example of PCO search terms

Population Context pain Context opioids Context cancer Outcome

adults* exp PAIN/ exp Analgesics/ Cancer* Attitude*

exp Pain management/ exp morphine/ tumor* Knowledge*

pain* exp narcotics/ carcinoma* View*

Management* management*, morphine* leuk?emia* opinion*

Buprenorphine* metasta* concern*

codeine* malignan* belief*

opium* lymphoma* feeling*

diamorphine* melanoma* idea*

opioid* oncolog* perception*

Dihydrocodeine* exp neoplasms/ perspective*

opiate* experience*

alfentanil* perceive*

fentanyl* standpoint*

oxycodone* expectation*

hydromorphone* preference*

need*

satisfaction*

interaction*

Adapted from Butler et al. [15]

J Canc Educ (2020) 35:214–240216

Overall Results of Included Studies

Patients’ Knowledge and Attitudes Towards CPM

The results from the majority of studies with cancer patientsreported that the mean scores on patient’s knowledge andattitudes towards CPM were low, indicating poor understand-ing or negative attitudes towards CPM [19, 20, 57, 77]. Forexample, a recent study conducted in China by Lou and Shang[57] reported through the Barriers Questionnaire-Taiwan(BQT; ranged from 0 to 5) that patients had negative attitudestowards CPM in six areas (scores ≥ 2.5), Btolerance^ (3.83 ±0.96), Buse of analgesics as needed (p.r.n.)^ (3.73 ± 1.01),Baddiction^ (3.44 ± 1.05), Bdisease progression^ (3.28 ±1.26), Bdistraction of physicians^ (3.16 ± 1.07) and Bsideeffects^ (2.99 ± 0.68), which can lead to attitudinal barrierstowards effective CPM [2]. Another example [20] is that more

than 50% of Turkish patients refused to receive strong opioids,such as morphine, and 36.8% of them preferred another (non-opioid) medication for managing their cancer pain.

Professionals’ Knowledge and Attitudes Towards CPM

Several studies showed that physicians had better knowl-edge and attitudes towards CPM compared with nurses[22, 32, 44, 45]. For instance, it has been reported thatphysicians who work at oncology units had higher under-standing and knowledge about CPM than nurses. Themean scores on the KAS (range 0–39) for physicianswas 24.3 (62.3%) compared with 20.08 (51.5%) fornurses (p < 0.001) [22]. The outcomes also showed thatoncologists recorded higher knowledge of CPM than sur-geons (p < 0.001) [33]. An interesting finding, which wasreported by McCaffery and Ferrell [59], is that Canadian

Screen

ing

Eligibility

Records after duplicates removed

(n = 5650)

Full-text articles assessed for

eligibility

(n= 133)

Full-text articles excluded,

with reasons (n= 97).

Not related to attitudes or

knowledge (n= 42).

Not related to cancer pain or

opioid (n= 35).

Not published in English (n=

6).

Not include adults (n= 5).

Not cross-sectional design

(n= 5).

Same data were used in

another study (n=2).

“Letter to the editor” (n=1).

Full-text article not found (n=

1).

Inclu

ded

Records screened based on

title and abstract

(n= 5650)

Records identified through 6 electronic

databases searching

(n= 6830)

Studies included in this

review

(n= 36)

Records excluded

(n= 5523)

noitacifitnedI

Additional records identified through

hand searching

(n= 17)

Fig. 1 PRISMA diagram forstrategy of the study selection.Adapted from Moher et al. [62]

J Canc Educ (2020) 35:214–240 217

Table4

The

characteristicsof

36included

studies

Author(s),

year,and

country

Study

design

Studyaim

Samplesize

Studysetting

Meanage

Sex

ratio

Measurements

Type

ofsample

Type

ofcancer

Mainfinding

Quality

scoring

Breuer

etal.,

(2011),

New

York,

USA

Cross-sectional

method

Toevaluatethe

attitudes,knowledgeand

practices

ofUSmedical

oncologiststhatarerelatedto

managem

ento

fcancerpain

482oncologists

The

American

Medical

Association’s

PhysicianMasterFile

56years(range

51–61years).

Male80%,

female

20%

Not

stated

USmedical

oncologists

N/A

The

mostimportantb

arriersto

CPM

werepoor

assessment

(median,6;

IQR,4

to7)

and

patient

reluctance

totake

opioids(m

edian,6;

IQR,5

to7)

orreportpain

(median,6;

IQR,4

to7).O

therbarriers

included

physicianreluctance

toprescribeopioids(m

edian,

5;IQ

R,3

to7)

andperceived

excessiveregulation(m

edian,

4;IQ

R,2

to7).Inresponse

totwovignettesdescribing

challengingclinicalscenarios,

60%

and87%,respectively,

endorsed

treatm

entd

ecisions

thatwould

beconsidered

unacceptableby

pain

specialists.F

requentreferrals

topain

orpalliativecare

specialistswerereported

byonly

14%

and16%,

respectively.

6/7

Bernardi

etal.,

(2007),

Italy

Cross-sectional

method

Toobtaininform

ationaboutthe

know

ledgeandattitudes

ofItalianoncology

nurses

concerning

CPM

andto

determ

inethepredictorsof

nurses’PM

know

ledge

287nurses

Oncologywards

inthe

north,centreand

southof

Italy

35(22–56)

Male (19.2%

),female

(78.7%

)

theNurses’

Knowledgeand

AttitudesSu

rvey

Regarding

(NKARSP

)

Oncologynurses

N/A

Amongthe39

questions

exam

ined,the

meanscorefor

correctly

answ

ered

itemswas

21.4(55%

correctanswer).

Amongthe39

items

surveyed,23received

less

than

60%

ofthecorrect

answ

errate.F

urtheranalysis

ofitemsshow

edthatmore

than

50%

ofoncology

nurses

underestim

ated

thepain

ofpatientsandthey

didnottreat

itin

acorrectw

ayandthey

hadan

incorrect

self-evaluationabouttheirPM

know

ledge.90.2%

ofrespondentsdidnotk

nowthe

correctp

ercentageof

patients

who

overreporttheirpain.

6/7

Colak

etal.,

(2014),

Turkey

Cross-sectional

method

Tosurvey

theattitudes

ofcancer

patientstowards

morphine

useforCPM

inaMMCand

identifythefactorsinfluence

patientdecisionsto

accept

orrefuse

morphineforCPM

488

cancerpatients

with

pain

Three

differentE

ducation

andTraining

Hospitals(ETH)

locatedin

3citiesof

CentralAnatolia:

Ankara,Konya

and

Kayseri;n

amely

Diskapi

Yildirim

54(range:18–87)

years

Fem

ale301,

male187

Not

stated

Patientwith

cancer

Breast2

17,

colorectal97,

gastric63

and

lung

37patients

About

50%

ofcancerpatients

refusedto

usemorphineand

36.8%

ofthem

preferanother

drug

dueto

fearof

addiction.

Reservationof

morphinefor

laterin

theirdiseasewas

the

case

for22.4%

ofthepatients

who

refusedmorphineuse.

Whereas,13.7%

ofcancer

6/7

J Canc Educ (2020) 35:214–240218

Tab

le4

(contin

ued)

Author(s),

year,and

country

Study

design

Studyaim

Samplesize

Studysetting

Meanage

Sex

ratio

Measurements

Type

ofsample

Type

ofcancer

Mainfinding

Quality

scoring

BeyazitETH,K

ayseri

ETHandKonya

patientsreused

morphineand

9.7%

ofthem

preferred

anothermedicationas

aresult

ofreligious

reasons.Both

beforeandafterthe

descriptiononly

12%

ofthe

patient

reported

they

would

notu

semorphineeven

ifit

was

recommended.

Cohen etal.,

(2005),

Israel

Descriptive

cross--

sectional

method

Toexplorecancerpain

experience,including

know

ledgeandattitudes

towards

painandpain

control

39cancerpatients

with

pain

Radiationdepartmentand

outpatient

centreof

alargeacadem

icmedicalinstitutionin

Israel

73.2(range

65–88;

SD=5.4)

years

Male(48.7),

female

(51.3)

PatientPain

Questionnaire

Knowledge

Subscale(PPQK)

Cancerpatient

Lung12%,breast

33.3%,colon

7.7%

,other

30.8%

Overhalf(56.7%

)reported

severeworstpain

andhad

negativepain

managem

ent

indexes(56.4%

).know

ledge

andattitudestowards

painand

pain

controlw

erepoor

(54.55%).

7/7

Daraw

adet

al.,

(2017),

Jordan

Descriptive

cross-sectional

method

Tocomparephysicians’and

nurses’know

ledgeand

attitudes

towards

cancerpain

managem

ent(CPM)and

describe

theirperceived

barriersto

CPM

atcancer

units

207participants

(72

physicians

and

135nurses)

Oncologyunits

from

the

military,educational,

oncology

centreand

publicsectorsin

Jordan

Nurses:28.1,

physicians

30.5

Nurses(M

54.8%;F

45.2%);

physi-

cians(M

61.1%;F

38.9%)

The

Knowledgeand

AttitudesSu

rvey

Regarding

Pain

(KAS)

72physicians

and135

nurses

N/A

Findings

revealed

thatboth

physicians

andnurses

hadfair

know

ledgeandattitudes

towards

CPM

.Physicianshad

significantly

higher

know

ledgeandbetter

attitudes

than

nurses

(62.3%

vs.51.5%

,respectively).

Physicians

were

know

ledgeableabout

medicationforP

Mandopioid

addictionbuth

adnegative

attitudes

towards

CPM

.Nurses’know

ledgewasbetter

inregard

ofCPM

guidelines,

whilethey

hadpoor

know

ledgeabout

pharmacologicalPM

and

opioid

addiction.Ph

ysicians

andnurses

perceived

know

ledgedeficit,lack

ofPM

,opioidunavailabilityand

lack

ofpsychological

interventions

asthemost

common

barriersto

CPM

.

5/7

Eftekhar

etal.,

(2007),

Iran

Cross-sectional

method

Toevaluateknow

ledgeaboutand

attitudes

towards

cancerpain

andits

managem

entinIranian

physicians

with

patient

care

responsibilities

55 physicians

insix

university

hospitals

Physicians

(haematologists,

oncologists,surgeons,

internists,

gynaecologists,

radiotherapists)in

six

university

hospitalsin

Tehran

37(ranged

28–65)

years.

54.6%

male

re-

sponders

Not

stated

Physicians

N/A

Physicians

recognised

the

importance

ofPM

priority

(76%

)andabouto

nehalfof

thephysicians

acknow

ledged

theproblemofinadequatePM

intheirsettings.Inadequate

staffknow

ledgeof

PMas

barriersto

good

PM.N

ocorrelationwas

found

betweenwhatp

hysicians

4/7

J Canc Educ (2020) 35:214–240 219

Tab

le4

(contin

ued)

Author(s),

year,and

country

Study

design

Studyaim

Samplesize

Studysetting

Meanage

Sex

ratio

Measurements

Type

ofsample

Type

ofcancer

Mainfinding

Quality

scoring

thinkthey

know

andwhat

they

know

aboutcancerpain

andits

managem

ent.

Elliottetal.,

(1996),

USA

Cross-sectional

method

The

studyreported

here

investigated

therelationship

betweenspecificknow

ledge

andattitudes

(cognitive

factors)andpatients’and

family

mem

bers’reportsof

pain

dueto

cancer

244participants,

122cancer

patientsand

122family

mem

bers

MCPP

communities,

medicalserviceareas

64yearsfor

cancer

patientsand

60yearsfor

family

mem

bers

Cancer

patients

53%

female;

family

mem

bers

62%

female

Not

stated

Cancerpatients

andfamily

mem

ber

N/A

Patients’andtheirfamilies’

reportsof

patient

pain

and

performance

status

were

highly

correlated,although

family

mem

bersconsistently

reported

morepain

and

disability.Using

regression

analysis,cognitivefactors

werestrongly

relatedto

family

reportsof

patients’

pain

(R2=0.27),but

contributedlittle

toexplaining

pain

reported

bypatients

them

selves

(R2=0.06).

Improved

understandingof

patients’pain

assessments

dependson

further

investigationof

other

cognitive

factorsandof

sensoryandaffectivefactors.

Assessm

entofp

ainforfam

ilymem

bersaresignificantly

relatedto

appropriate

know

ledgeandattitudes.

6/7

Elliottetal.,

(1995),

USA

Cross-sectional

method

Todeterm

ineknow

ledgeand

attitudes

aboutC

PMam

ong

physicians

insixMinnesota

communitiesandtodeterm

ine

thephysician-relatedbarriers

tooptim

alCPM

145physicians

The

MinnesotaCancer

Pain

Project(M

CPP

)Not

stated

Male89.7%,

female

10.3%

Cross-sectional

telephonesurvey,

thephysician

survey

instrument

Physicians

N/A

Significantk

nowledgedeficits

wereidentifiedin

nine

of14

CPM

principles,but

inappropriateattitudes

were

foundin

only

twoof

nine

CPM

concepts.M

edical

specially

hadthestrongest

influenceon

know

ledgeand

attitudes,w

ithprim

arycare

physicians

having

significantly

betteroutcom

esthan

surgeons

ormedical

subspecialists.

7/7

Elliottand

Elliott,

(1992),

Stateof

Minnes-

ota,

USA

Cross-sectional

method

Toexploretheprevalence

among

practicingphysicians

of12

proposed

myths

ormisconceptions

aboutthe

use

ofmorphinein

CPM

150physicians

Directp

atient

carein

Duluth,Minnesota.

47differentm

edical

schoolslocatedin

31states,C

anada,and

England.

OlderMDs,

N=41,

middle-aged

MDs

N=53,youn-

gerMDs

N=56

Itisnot

stated.

PhysicianCancerPain

Attitude

Questionnaire

Physicians

N/A

Manyphysicians

misunderstood

conceptsof

morphine

tolerance,both

toanalgesia

(51%

)andto

side

effects

(39%

).Manywereunaw

are

oftheuseof

adjuvant

analgesics

(29%

),efficacy

oforalmorphine(27%

)and

non-existent

risk

ofaddiction

inCPM

(20%

).

7/7

554participants:

43.4

years

Not

stated

N/A

6/7

J Canc Educ (2020) 35:214–240220

Tab

le4

(contin

ued)

Author(s),

year,and

country

Study

design

Studyaim

Samplesize

Studysetting

Meanage

Sex

ratio

Measurements

Type

ofsample

Type

ofcancer

Mainfinding

Quality

scoring

Furstenberg

etal.,

(1998),

Stateof

New

Ham

ps-

hire,

USA

Cross-sectional

method

Evaluatetheknow

ledgeand

attitudes

ofallthree

typesof

providersdirectly

involved

incaring

forCPs

andidentify

areaswheredeficiencies

exist

inorderto

targetfuture

educationalefforts

appropriately

188physicians,

118

pharmacists

and248

nurses.

Researchand

Development

Com

mittee

ofthe

New

Ham

pshireState

CancerPain

Initiative

basedon

areview

ofquestionnairesused

insimilarstudies.

Male44%,

female

56%

Physicians,

pharmacists,

nurses

The

results

aregenerally

consistent

with

results

from

otherstudiesof

physicians,

nurses

andpharmacistsin

term

sof

know

ledgeof

and

attitudes

towards

CPM

,perceivedbarriersto

effective

CPM

andlack

oftraining

inCPM

.Incontrastto

some

earlierstudies,however,

providersin

thissamplewere

notconcerned

aboutaddictio

nam

ongCPs.K

nowledge

deficitswerefoundacross

providers.Thisnegative

findingisconsistentwith

data

from

anumberof

recent

studiesandsuggeststhat

someprogresshasbeen

made

inallaying

providerconcerns

inthisarea.

Gallagher

etal.,

(2004),

British

Colum

bia

Survey

Toacquirecurrentd

ataon

physicianknow

ledgeand

attitudes

towards

CPM

asan

educationaln

eeds

assessment

fortheUBCDivisionof

PalliativeCare.Alsotosolicit

physicians’opinions

about

theTPP

’spossibleeffecton

CPprescribing

4618

physicians

Palliativecareatthe

University

ofBritish

Colum

bia,theBCCancer

Agencyandthe

College

ofPh

ysicians

/Surgeonsof

BC.

Not

stated

Male (67.9%

),female

(27.9%

)

Not

stated

BritishColum

bia

physicians

N/A

The

results

show

12.0%

ofMDs

agreed

atknow

ledgequestion

thatanyPt

givenopioidsfor

CPM

isata25%

ormorerisk

foraddiction.The

highest

percento

f80.6%

disagreed

thatmorphineforCPM

shortens

lifebutm

akespeople

morecomfortable.T

hequestio

nsmostfrequently

answ

ered

incorrectly

(orby

Bdonotk

now^)

werethose

aboutequi-analgesicdosing

(68%

)andadequate

breakthrough

dosing

(45%

),revealingknow

ledge

deficiencies

thatwould

significantly

impaira

physician’sability

tomanage

CP.The

resultshow

sthat

therewerehigh

scores

inthe

attitudequestions

butlarger

deficitsin

know

ledgeabout

CPM

.

6/7

Geret

al.,

(2000),

Taiwan

Cross-sectional

method

Toexam

inetheattitudes

ofMDs

regardingtheoptim

aluseof

analgesics

forCPM

,to

evaluatetheirknow

ledgeand

attitudes

towards

opioid

prescribingandto

204physicians

with

cancer

patient

care

Twomedicalcentres,

Kaohsiung

Veterans

GeneralHospital

(KSV

GH)and

Tri-Service

General

36.4

years

Males (95%

)and

females

(5%)

Not

stated

Physicians

N/A

The

mostimportantb

arriersto

optim

alCPM

identifiedby

physicians

them

selves

were

physician-relatedproblems,

such

asinadequateguidance

from

apain

specialist,

6/7

J Canc Educ (2020) 35:214–240 221

Tab

le4

(contin

ued)

Author(s),

year,and

country

Study

design

Studyaim

Samplesize

Studysetting

Meanage

Sex

ratio

Measurements

Type

ofsample

Type

ofcancer

Mainfinding

Quality

scoring

comprehendtheirperceptions

ofthebarriersto

optim

alCPM

Hospital(TSG

H),in

Taiwan

inadequateknow

ledgeof

CPM

andinadequatepain

assessment.The

results

ofhis

studysuggestthatactive

analgesiceducation

programmes

areurgently

needed

inTaiwan.

Hollen

etal.,

(2000),

South

Central

State,

USA

Cross-sectional

method

Toidentifyknow

ledgestrengths

andweaknessesand

misperceptions

aboutC

PMbetweentwogroups

ofreg

nurses

indifferentsetting

64hospiceand

hospital

oncology

unit

nurses

7adulth

ospitalo

ncology

units

and11

hospices

inaSo

uthCentral

State

45(10.54)for

hospice

nurses

and40

(9.32)

for

hospital

nurses

Itisnot

stated.

North

CarolinaCancer

Pain

Initiative

(NCCPI)survey

Hospice

(n=30)

andhospital

(n=34)nurses.

N/A

Hospice

nurses

(X=24.71,

SD=2.27)scored

significantly

higheron

the

totalk

nowledgetestthan

the

hospitalo

ncologynurses

(X=20.76,SD

=3.77;t

[61]

=5.09,p

=0.0001).Hospice

nurses

also

scored

significantly

higherthan

hospitaln

urseson

opioid

subscale(t[62]

=5.52,

p=0.0001)andscheduling

subscale(t[63]

=3.77,

p=0.0004).Regarding

attitudes,hospice

nurses

also

hadsignificantly

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

Jhoet

al.,

(2014),

Korea

Cross-sectional

method

Toevaluateknow

ledge,practices

andperceivedbarriers

regardingCPM

among

physicians

andnurses

inKorea

333physicians

andnurses

11hospitals(6

publicand

5privatehospitals)

across

Korea

33.2

yearsfor

physicians

and

29.0

yearsfor

nurses

Physician,

61.5%

male,

38.5%

female.

nurses,

0%for

maleand

100%

female

Not

stated

Physicians

(n=149)

and

nurses

(n=284).

N/A

Nursesperformed

pain

assessmentand

documentationmore

regularlythan

physicians

did.

Although

physicians

had

betterknow

ledgeof

PMthan

didnurses,bothgroups

lacked

know

ledgeregarding

theside

effectsand

pharmacologyof

opioids.

Physicians

working

inthe

palliativecarewardand

nurses

who

hadreceived

PM

educationobtained

higher

scores

onknow

ledge.

Physicians

perceivedpatients’

reluctance

totake

opioidsas

abarrierto

pain

control,more

sothan

didnurses,w

hile

nurses

perceivedpatients’

tendency

tounder-reportof

painas

abarrier,moreso

than

did.

6/7

7Not

stated

Not

stated

N/A

6/7

J Canc Educ (2020) 35:214–240222

Tab

le4

(contin

ued)

Author(s),

year,and

country

Study

design

Studyaim

Samplesize

Studysetting

Meanage

Sex

ratio

Measurements

Type

ofsample

Type

ofcancer

Mainfinding

Quality

scoring

Jeon

etal.,

(2007),

Korea

Cross-sectional

method

Toassessclinicians’practicesand

attitudes

aboutC

PMandto

identifyperceivedconcerns

aboutand

barriersto

pain

controlinurban

cancer-treatmentsettings

inKorea

250physicians

andnurses

hospitalsin

Korea

Male107

(42.8%

),female

143

(57.2)

Physicians

and

nurses

The

resultshow

sthatbothgroups

identified90.6%

concerned

thatdifficulty

incontrolling

strong

side

effectsas

the

biggestp

otentialb

arrierto

good

pain

control.Also,they

identifiedinadequate

assessmento

fpainandpain

managem

entw

ith78.5%

asthesecond

biggestp

otential

barrierto

good

pain

control.

64.5%

ofboth

groups

stated

inadequatestaffk

nowledgeof

PM.

Kassa

and

Kassa,

(2014),

Ethiopia

Cross-sectional

method

Toassess

theattitude,practiceof

nurses’andbarriersregarding

CPM

atselected

health

institutions

offering

cancer

treatm

entinAddisAbaba

city,Ethiopia,2013

82nurses

1publicand4private

healthinstitutions

that

providecancer

treatm

entinAddis

Ababa,the

capitalcity

ofEthiopia

42years

Male18

(22%

),female

64 (78%

).

Nurses’Knowledge

andAttitudes

Survey

Regarding

Pain

(NKARSP

)

Nurses

N/A

Morethan

half,53.7%

,ofthe

nurses

have

anegative

attitudetowards

CPM

.Similarly65.9%

ofnurses’

hadpoor

CPM

practice.Lack

ofcoursesrelatedto

pain

intheundergraduateclasses,

lack

ofcontinuing

training,

patient

andworkoverload,

roleconfusion,lack

ofmotivationincludingsalary

weretheidentifiedbarriersfor

adequatepain

managem

ent.

Monthly

incomeof

greater

than

1500

Ethiopian

Birr

(ETB)werefoundto

beassociated

with

attitude

towards

cancerpain

managem

ent(CPM)

(AOR=0.16,95%

CI=

0.03–0.78).

6/7

Kaki, (2011),

Saudi

Arabia

Cross-sectional

method

Toassess

thefinaly

earmedical

students’know

ledge,beliefs

andattitudetowards

cancer

pain,and

theneed

fora

form

alpain

curriculum

inmedical

schools

325thesixthyear

medical

students

KingAbdul-A

ziz

University

Hospital,Jeddah,

Kingdom

ofSaudi

Arabia

23years(42.9%

)Males (n=15-

8)and

females

(n=16-

7)

Not

stated

Sixthyearmedical

students

N/A

54%

oftherespondentsbelieved

that<40%

ofCPs

suffered

from

pain.46%

ofthem

considered

CPuntreatable,

while41.6%

considered

pain

aminor

problem

and58.6%

considered

therisk

ofaddictionishigh

with

legitim

ateopioids’

prescription.Thereare23.1%

ofstudentsbelievedthat

patientsarepoor

judges

oftheirpain,68%

ofthem

limitedopioidsprescriptionto

patientswith

poor

prognosis

and77.1%

believedthatdrug

4/7

J Canc Educ (2020) 35:214–240 223

Tab

le4

(contin

ued)

Author(s),

year,and

country

Study

design

Studyaim

Samplesize

Studysetting

Meanage

Sex

ratio

Measurements

Type

ofsample

Type

ofcancer

Mainfinding

Quality

scoring

toleranceor

psychological

dependence,ratherthan

advanced

stages’canceristhe

causeof

increasing

analgesic

doses.The

students’

know

ledgeon

thecauses

ofCP,pain

clinicruleandpain

inclusionin

themedical

curriculum

was

poor.

Kim

etal.,

(2011),

South

Korea

Cross-sectional

method

Toevaluateyoung

Koreanphysicians’attitude

towards

theusageof

analgesics

forCPM

andtheir

optim

alknow

ledgeof

opioid

prescriptionAlsowantedto

find

outthe

realfactorsthat

affecttheattitudeand

know

ledgeof

doctors.

1204

physicians

NationalC

ancerCentre,

Goyang-Si,

Gyeonggi-do,S

outh

Korea

29.9±

2.2years

Male100%

Not

stated

Internalmedicine

andfamily

medicine

doctors,

surgeons,

anaesthesiolog-

ists,

paediatricians

andgeneral

physicians

Gastric,lung,liver

andcolorectal

malignancies

formales

and

gastric,breast,

colon,rectum

,uterinecervix,

lung

and

thyroidgland

malignancies

forfemales

Alargesampleof

physicians

show

edanegativeattitude

andinadequateknow

ledge

status

aboutC

PM.T

hedegree

ofattitudeandknow

ledge

status

was

differentastheir

specialties

andpersonal

experiences.The

factorsthat

affected

doctors’attitudeand

know

ledgewere:(1)medical

specialty,(2)

pasthistoryof

usingpracticalpain

assessmenttool,(3)

self-perceptionof

know

ledge

status

aboutP

M,(4)

experience

ofprescribing

opioids,and(5)experience

ofeducationforCPM

.Although

manyphysicians

hada

passiveattitudein

prescribing

analgesics,theyarewillingly

open

touseopioidsforCPM

inthefuture.T

hemost

importantp

erceived

barriers

tooptim

alCPM

werethefear

forrisk

oftolerance,drug

addiction,side

effectsof

opioidsandknow

ledgedeficit

abouto

pioid.

7/7

Lou

and

Shang,

(2017),

China

Descriptive

cross--

sectional

method

Toinvestigatepatients’attitudes

towards

cancerpain

managem

entand

analysethe

factorsinfluencingthese

attitudes

726cancer

patientsand

their

caregivers

The

oncology

department

of7hospitalsin

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%

,caregive-

rs,m

ale

45.73%

;female

54.27

Pain

Managem

ent

Barriers

Questionnaire-Tai-

wan

Form

(BQT),andPain

Knowledge

Questionnaire

Cancerpatients

(n=363)

and

theircaregivers

(n=363)

Lung,oral,

nasopharyngeal,

oesophageal,

gastrointestinal,

breast,liver,

pancreatic,

lymphom

a,kidney,ureter,

bladder,

ovarian,and

uterine

The

averagescoreof

attitudes

towards

CPM

forCPs

and

caregiversthroughtheBQT

subscalescoreranged

from

0to

5were2.96

±0.49

and

3.03

±0.49,respectively.The

dimension

scores

forCPs

and

CGsindicatedgood

attitudes

inthreeareas(scores<2.5),

Bdesireto

begood^(2.22),

(2.38),Bfatalism^(2.08),

(2.31)

andBreligious

fatalism^(1.86),(2.02),and

7/7

J Canc Educ (2020) 35:214–240224

Tab

le4

(contin

ued)

Author(s),

year,and

country

Study

design

Studyaim

Samplesize

Studysetting

Meanage

Sex

ratio

Measurements

Type

ofsample

Type

ofcancer

Mainfinding

Quality

scoring

poor

attitudes

insixareas

(scores≥2.5),Btolerance^

(3.83),(3.74),Buse

ofanalgesics

asneeded

(p.r.n.)^

(3.73),(3.51),Baddiction^

(3.44),(3.43),Bdisease

progression^

(3.28),(3.27),

Bdistractionof

physicians^

(3.16),(3.01),andBside

effects^

(2.99),(3.22).Tw

ofactorswereenteredinto

the

regression

equation:

the

caregivers’attitudes

towards

CPM

andthepatients’pain

know

ledge.These

twofactors

explained23.2%

ofthetotal

variance

inthepatients’

averagescores

fortheir

attitudes

towards

CPM

.Larue

etal.,

(1999),

France

Cross-sectional

method,

mixed

method

Toassess

theevolutionof

the

know

ledgeandattitudes

oftheFrench

populationwith

respecttopain

managem

ent

andmorphineuse

2007

general

population:

1001

general

populationin

1990

and

1006

general

populationin

1996

Telephonesurveysby

professional

interviewers,and

structured

questionnaires

35–44years,

168/1001

(17%

)in1990

and201/1006

(20%

)in

1996

Male 470/100-

1(47%

)in

1990

and

474/100-

6(47%

)in

1996.

Not

stated

Generalpopulation

inFrance

Not

stated

The

respondents’aw

arenessof

theoccurrence

ofpain

inthe

course

ofcancerim

proved:

65%

(656

of1006)thought

thatpainisrareatearlystages

ofcancerin

1996,com

pared

with

49%

(490

of1001)in

1990;8

4%(845

of1006)

thoughtthatpainisfrequentat

advanced

stages

ofcancer,

comparedwith

72%

(724

of1001)in

1990.P

roportionof

peoplewho

werenotafraidof

becomingaddicted

tomorphineifprescribed

for

pain

reliefincreasedfrom

26%

(263

of1001)in1990

to69%

(699

of1006)in

1996.

How

ever,the

proportionof

respondentswho

agreed

that

morphinecanbe

prescribed

toCPs

increasedonly

slightly,

from

79%

(790

of1001)to

83%

(833

of1006)forCPs.

The

results

show

that58%

(558

of968)

ofthe1996

generalpublic

believedthat

theirknow

ledgeregarding

CPM

hadim

proved

overthe

past5years.

6/7

Larue

etal.,

(1995),

Cross-sectional

method

Toassessphysicians’estim

atesof

theprevalence

ofpain

among

900physicians

<35

(21.3%

)for

ONCsand

Fem

ale

Not

stated

N/A

Although

85%

ofprim

arycare

physicians

and93%

of4/7

J Canc Educ (2020) 35:214–240 225

Tab

le4

(contin

ued)

Author(s),

year,and

country

Study

design

Studyaim

Samplesize

Studysetting

Meanage

Sex

ratio

Measurements

Type

ofsample

Type

ofcancer

Mainfinding

Quality

scoring

France

patientswith

cancer,their

practicein

prescribing

analgesics,theirtraining

inCPM

andthequality

ofcare

received

bycancerpatientsin

theirow

npracticeandin

France

Telephoneby

professional

interviewers

(25.0%

)for

PCPs.>

45(36.3%

)for

ONCsand

(27.0%

)for

PCPs

oncolo-

gists

(36.3%

)and

female

prim

ary

care

physi-

cian

(17.0%

)

Oncologistsand

prim

arycare

physicians

medicaloncologistsexpress

satisfactionwith

theirow

nability

toCPM

,76%

ofprim

arycarephysicians

and

50%

ofmedicaloncologists

reportbeingreluctantto

prescribemorphineforCPM.

Bothgroups

citedfearof

side

effectsas

theirmainreason

tohesitateto

prescribe

morphine.Concernsaboutthe

risk

oftolerance(oddsratio

[OR],1.15–2.52),perceptions

thatothereffectivedrugsare

available(O

R,1.11–2.41),

perceptions

thatmorphinehas

apoor

imagein

public

opinion(O

R,0.96–2.07),and

theconstraintsof

prescription

form

s(O

R,1.12–2.26)

contributesignificantly

tophysicians’infrequent

prescriptionof

morphine,as

arebeingfemale(O

R,

1.01–2.03)

andbeingan

older

oncologist(O

R,1.09–2.51).

Lin

etal.,

(2000),

Taiwan

Cross-sectional

method

Toexam

ineattitudes

held

byTaiwanesefamily

caregivers

ofhospicein-patientswith

cancerthatserveas

barriersto

CPM

;todeterm

inetherela-

tionshipof

attitudinalbarriers

tofamily

caregiverhesitancy

toreportpain

andto

adminis-

teranalgesics;and

todeter-

minetherelationshipof

atti-

tudinalb

arriersto

theade-

quacyof

opioid

used

bythe

patient

160palliative

carepatients

andfamily

caregivers

Inpatient

palliativecare

units

oftwomedical

centresin

Taipeiarea

ofTaiwan

Patients

(59.63

±13.-

76);family

caregivers

(43.21±

12.88)

Patients,

male

(47%

);female

(53%

)and

family caregive-

rs,m

ale

(27%

);female

(73%

)

The

Barriers

Questionnaire–T

ai-

wan

(BQT)form

,ademographic

questionnaire,and

theBriefPain

Inventory(BPI)

Chinese

version

Palliativecare

patients

(n=80)and

caregivers

(n=80)

Lung(23%

),colorectal

(16%

),breast

(13%

),liver

(9%),gastric

(7%),oral(6%),

cervical(6%),

andvarious

othertypes

(20%

)

The

five

mean±SD

ofBQT

subscalescoreranged

from

0to

5am

onghospicefamily

caregiverswith

thehighest

scores

weredisease

progression(3.82),

side-effects(3.29),p.r.n.

(3.01),tolerance

(2.96),and

addiction(2.67),indicating

thattheseconcerns

are

moderatelyto

strongly

held

bycaregivers.T

woattitudinal

barriers,‘Constipationfrom

pain

medicineisreally

upsetting’and‘Painmedicine

will

causeharm

tokidneys’

wereendorsed

by100%

ofcaregivers.12of

the80

caregivers(15%

)reported

theirhesitationto

reportpain

inthepastmonth.T

hose

caregiverswho

hadexpressed

hesitancyto

reportpain

re-

corded

significantly

higher

scores

onthefearof

addiction

7/7

J Canc Educ (2020) 35:214–240226

Tab

le4

(contin

ued)

Author(s),

year,and

country

Study

design

Studyaim

Samplesize

Studysetting

Meanage

Sex

ratio

Measurements

Type

ofsample

Type

ofcancer

Mainfinding

Quality

scoring

barrierthan

thosewho

hadno

hesitancy.24

ofthecaregivers

(30%

)reported

thatthey

had

hesitatedto

administer

analgesics

totheirpatientsin

thepastmonth.T

hose

caregiverswho

expressed

hesitancyin

administering

analgesics

recorded

significantly

higherscores

onthebarrieritemsincluding

fearof

addiction,side-effects

andtolerance,as

wellasthe

totalB

QTscore,than

those

who

hadno

hesitancyin

ad-

ministering

analgesics

inthe

pastmonth.O

lderand

less-educatedcaregivers

scored

significantly

higheron

theBOTthan

didtheir

younger,moreeducated

counterparts.83%

ofthese

patientswereclassified

asusingadequatemedication

and17%

asbeing

under-medicated.

Levin

etal.,

(1985),

Wiscon-

sin,USA

Cross-sectional

method,

mixed

method

Toprovideobjectiveinform

ation

aboutthe

public’sattitudes

towards

PMandthepossible

effectsof

such

beliefson

avarietyof

factors,including

delayinseekingtreatm

entand

avoidanceof

analgesic

medications

496general

public

The

Wisconsin

Survey

ResearchLaboratory

Not

stated

Fem

ale

(57%

),male

(43%

)

Not

stated

Adultlaypublic

Not

stated

The

resultfrom

the472

respondentswho

hadnotbeen

diagnosedwith

cancer:15%

ofthem

agreed

orstrongly

agreed

thatifthey

hadcancer

theirfearof

thediseasewould

makethem

seekingmedical

care.9%

ofthesampleagreed

orstrongly

agreed

their

concernaboutC

Pwould

lead

toavoidanceof

medicalcare,

whereas

18%

indicatedthey

would

avoidseekingcareas

ofconcerns

aboutp

ain

associated

with

cancer

treatm

ent.62%

associated

the

onseto

fpain

with

disease

progression,and57%

thought

CPs

usually

dieapainful

death.50%

ofrespondents

hadsignificantconcerns

abouta

varietyof

consequences

oftaking

opioidsincludeconfusingor

4/7

J Canc Educ (2020) 35:214–240 227

Tab

le4

(contin

ued)

Author(s),

year,and

country

Study

design

Studyaim

Samplesize

Studysetting

Meanage

Sex

ratio

Measurements

Type

ofsample

Type

ofcancer

Mainfinding

Quality

scoring

disoriented,toleranceand

addiction.

McC

affery

and

Ferrell,

(1995),

Australi-

a, Canada,

Japan,

Spain,

andthe

USA

Cross-sectional

method

Toaddressnurses’know

ledge

andattitudes

aboutp

atients’

reportsof

pain,prevalenceof

cancerpain,preferred

routeof

administrationforanalgesics,

preferredchoice

ofopioid

analgesic,initiationof

treatm

ent,dosing

schedule,

andknow

ledgerelatedto

addictionanduseof

placebos.

1428 in

ternational

nurses

from

5countries

Pain

programmes

inWestern,E

astern,

Midwestern,&

southern,stsin

the

USA

,Pain

programmes

inAustralia,pain

programmes

inCanada,palliative

carein

Japan,and

from

nurses

had

lectures

InSp

ain

Not

stated

Not

stated

Not

stated

Nursesin

5countries

N/A

Prevalence

ofpain:h

igher%

from

nurses

inSp

an94.8%

andlower%

was

only49%

ofnurses

inJapan.

Over-reportingof

pain:

Nursesfrom

Japanreported

anextrem

elyhigh

degree

ofmisconception,with

28.9%

responding

that80–100%

ofCPs

overreporttheirpain.

Incidenceof

addiction:

Roughly

20–30%

ofnurses

from

each

countryreported

thelikelihoodof

addictionas

5%.T

he%

was

even

higher

of50.9%

Japanese

and

Spanishnurses

54.7%.

Initiationof

opioids:

Canadiannurses

reported

the

highestcorrectresponse

with

93.2%,w

hilewas

only51.2%

inJapanese

nurses.

Appropriateuseofanalgesics:

widespreadmisconceptions

inthisarea,w

ithonly

51.2%

ofnurses

from

Spainand61.6%

ofJapancomparedto

71.5%

ofCanadianand66.3%

American

nurses

who

selected

morphineforCPM

.Reasonof

pt.request↑↑

dose

ofopioids:Pt.w

asexp.↑↑

pain,w

ere94.7%

inCanada,

whereas,only57.8%

was

ofSp

anishnurses.

Determinationof

pain

intensity:P

t.isbestjudgeof

pain,95.8%

ofCanadian

nurses,w

hileonly

71.6%

ofJapanese

nurses.

3/7

O’Brien

etal.,

(1996),

North

Carolina,

USA

Cross-sectional

method

340registered

nurses

The

North

Carolina,

hospitalsettings

52years(range

21–73years).

Male3%

,female

97%.

The

North

Carolina

CancerPain

Initiative(N

CCPI)

survey

was

adapted

from

theWisconsin

CPI

RegisteredNurses

N/A

Knowledgescores

forthethree

subscalerevealed

that

nurses

who

hadworkedwith

CPs

weremoreknow

ledgeable

than

thosewho

didnotw

ork

with

CPs.Th

etotal

know

ledgescorefornurses

caring

forCPswas

18.47and

15.88fornurses

notcaring

7/7

J Canc Educ (2020) 35:214–240228

Tab

le4

(contin

ued)

Author(s),

year,and

country

Study

design

Studyaim

Samplesize

Studysetting

Meanage

Sex

ratio

Measurements

Type

ofsample

Type

ofcancer

Mainfinding

Quality

scoring

forCPs(t=−6.19,

p<0.001).A

ttitude

towards

PM

was

fornurses

caring

for

CPstheaveragewas

3.52.A

liberal

attitudewas

reported

moreoftenby

nurses

caring

foroneor

moreCPs

(X2=3.9,df

=1,p<0.02).

Riddelland

Fitch,

(1997),

Canada

Descriptive

correlational

study

Toexam

inepatients’know

ledge

ofandattitudes

towards

cancerpain

managem

entand

toidentify,from

patients’

perspectives,factors

contributingto

effectiveand

ineffectivepain

relief

42patients

Oncologyfacilityat

teaching

hospital

58.5

years

Fem

ale28

(67%

),male14

(33%

)

Amodifiedversionof

thePatient

Pain

Questionnaire

(PPQ

)

Cancerpatients

Head/neck,breast,

haem

atologic,

female

reproductive

system

,lung,

gastrointestinal,

male

reproductive

The

results

inthisstudyshow

edthatmanypatientslacked

know

ledgeof

theprincipals

involved

ineffectiveCPM

andhadunrealistic

concerns

abouttakingpain

medications.S

ignificant

negativerelationships

were

foundbetweenpain

intensity

ratingandfactorssuch

aspatients’know

ledgeof

PM,

theirlevelo

fsatisfactionwith

pain

reliefandtheir

perceptionof

thegoalof

PM.

Patientsidentifiedanumber

ofim

pedimentsto

effective

painrelief,includingconcerns

aboutaddictionandvarious

side

effectsto

pain

medications.

5/7

Shahriary

etal.,

(2015),

Iran

Cross-sectional

method

Todeterm

inethebaselinelevelof

know

ledgeandattitudes

ofoncology

nurses

regarding

CPM

58cancernurses

Shahid

Sadoughi

hospital,oncology

units,Y

azd,Iran

33.5(range

25–48)

years

100% fe

male

NursesKnowledgeand

AttitudesSu

rvey

Regarding

Pain

(NKAS)

tool

Oncologynurses

N/A

The

averagecorrectresponserate

foroncology

nurses

was

66.6%,ranging

from

12.1to

94.8%.T

henurses

mean

scoreon

theknow

ledgeand

attitudes

survey

regardingPM

was

28.5%.R

esultsrevealed

thatthemeanpercentage

scoreoverallw

as65.7%.

Only8.6%

ofnurse

participantsobtained

apassingscoreof

75%

orgreater.Widespread

know

ledgedeficitsandpoor

attitudes

werenotedin

this

study,particularly

regard

pharmacologicalPM

.

5/7

Shahnazi

etal.,

(2012),

Iran

Cross-sectional

method

Toobtaininform

ationaboutthe

know

ledgeandattitudes

ofnurses

concerning

CPM

with

theusehealth

beliefmodel

(HBM)as

fram

ework

98nurses

Alzahraeducational

hospitalin

Isfahan,Iran

38.7

±7.04

years

Male18

(18.4),

female

80(81.6)

Self-adm

inquestionnaire

designed

onthe

basisof

health

beliefmodel

(HBM)

Nurses

N/A

From

the10

CPknow

ledgeand

attitudequestions

assessed,

themeannumberof

correctly

answ

ered

questionwere61.2

(SD=16.5)and63

(SD=11)

with

arangeof

30–100

and

6/7

J Canc Educ (2020) 35:214–240 229

Tab

le4

(contin

ued)

Author(s),

year,and

country

Study

design

Studyaim

Samplesize

Studysetting

Meanage

Sex

ratio

Measurements

Type

ofsample

Type

ofcancer

Mainfinding

Quality

scoring

35–95,respectively.There

was

adirectcorrelation

betweenknow

ledgeand

attitudeof

nurses

with

health

beliefmodel(H

BM)

constructsexcept

for

perceivedbarriersand

perceivedthreat.A

mongthe

HBM

constructs,the

highest

scorewas

relatedto

self-efficacywith

meanscore

of87.2(SD=16.4).

Srisaw

ang

etal.,

(2013),

Thailand

Cross-sectional

method

Toassess

theknow

ledgeand

attitudes

physicians

and

policymakers/regulatorshave

regardinguseof

opioidsfor

CPM

.Barriersto

opioid

availabilitywerealso

studied

266physicians

andpolicy

makers/-

regulators

300hospitalsin

Thailand

From

36to

45physicians

(29.2%

),policymakers

(27.7).

Physicians,

male126

(57.5%

),female

93 (42.5%

);policy

makers,

male19

(40.4%

),female

28 (59.5).

Not

stated

Physicians

(n=219)

and

policy

makers/-

regulators

(n=47).

N/A

Ofthephysicians,62.1%

had

inadequateknow

ledgeand

33.8%

hadnegativeattitudes.

Physicians

who

didnotk

now

theWHOthree-step

ladder

weremorelikelyto

have

less

know

ledgethan

thosehaving

used

theWHOthree-step

ladder(O

R=13.0,

p<0.001).P

olicy

makers/regulatorsalso

had

inadequateknow

ledge

(74.5%

)andnegative

attitudes

(66.0%

).Po

licy

makers/regulatorswho

never

hadCPM

training

werelikely

tohave

morenegative

attitudes

than

thosehaving

hadtraining

within

less

than

oneyear(O

R=35.0,

p=0.005).L

ackof

training

opportunities

andperiodic

shortagesof

opioidswerethe

greatestbarriersto

opioid

availabilityforp

hysiciansand

policymakers/regulators,

respectively.

6/7

Utneet

al.,

(2018),

Norway

Cross-sectional

method

Tosurvey

know

ledgeand

attitudes

topainandPM

amongcancercarenurses,

andtoexploreanyassociation

betweenvariousdemographic

variablesandknow

ledgelevel

312cancernurses

Forum

forCancer

Nursing

45years

Fem

ale

(98.4),

male

(1.6)

Nurses’Knowledge

andAttitudes

Survey

Regarding

Pain

(NKAS)

Norwegian

oncology

nurses

N/A

Norwegiannurses

hadamean

NKAStotalscorewas

31points(75%

),indicatinga

relativelyhigh

levelo

fknow

ledgeandgood

attitudes

towards

pain

incancercare.

Significantassociations

were

foundbetweenNKAStotal

scoreandPM

course

(p=0.01)andworkplace

(p=0.04).Nursesin

cancer

carein

Norway

have

7/7

J Canc Educ (2020) 35:214–240230

Tab

le4

(contin

ued)

Author(s),

year,and

country

Study

design

Studyaim

Samplesize

Studysetting

Meanage

Sex

ratio

Measurements

Type

ofsample

Type

ofcancer

Mainfinding

Quality

scoring

relativelygood

pain

know

ledge.The

potentialfor

improvem

entisthegreatest

with

regard

topharmacology

andnurses’attitudes

tohow

patientsexpresspain.

Vallerand

etal.,

(2007),

Detroit,

Michiga-

n,the

USA

Descriptive

cross--

sectional

method

Todeterm

inepain

managem

ent

know

ledgeandexam

ine

concerns

aboutreportingpain

andusinganalgesics

ina

sampleof

prim

aryfamily

caregiversof

CPsreceiving

homecare

46prim

ary

caregivers

Hom

ecarepatientswith

cancer

55years(SD,

14.62years).

Fem

ale

67.4%

The

Barriers

Questionnaire,the

Family

Pain

Questionnaire

Prim

arycaregivers

N/A

The

meanforeachsubscaleofthe

BQof

caregiversexpressing

someagreem

ento

fconcerns

between1.05

and2.41.T

heconcerns

werebarriersto

reportingpain

andusing

analgesics,and

upto

15%

reported

having

strong

agreem

ent.The

areasof

greatestconcernwereabout

opioid

relatedside

effects

(2.41),fearsof

addiction

(2.35),the

beliefthatpain

meant

diseaseprogression

(2.28),and

tolerance(1.37).

Resultsshow

edthat

caregiverswith

higherPM

know

ledgehadsignificantly

fewerbarriersto

CPM

,supportingtheim

portance

ofincreasing

caregiver’s

know

ledgeof

CPM

.

7/7

Von

Roenn

etal.,

(1993),

USA

Cross-sectional

method

Todeterm

inetheam

ount

ofknow

ledgeaboutC

PM

amongphysicians

practicing

inECOG-affiliated

institutions

andto

determ

ine

themethods

ofpain

control

beingused

byphysicians

897physicians

The

Eastern

Cooperative

OncologyGroup

(ECOG).

Not

stated

Not

stated

Physiciancancerpain

questionnaire

Physicians

with

patient

care

(oncologists,

haem

atologists,

surgeons

and

radiation

therapists)

N/A

Concerningtheuseof

analgesics

forcancer

pain

intheUnited

States

(n=864),86%

ofthe

respondentsthoughtthatthe

majority

ofpatientswith

pain

areunder-medicated,

although

13%

thoughtthat

mostp

atientsreceive

adequatetreatm

entfor

pain.

Mosto

fthesample(67%

)thoughtthatatleast50%

ofthecancerpatientsthey

treat

hadpainatsomepointduring

theirillness.P

hysicians

estim

ated

thatalmostone

half

ofcancerpatients(48%

)had

pain

formorethan

1month.

7/7

Wellset

al.,

(2001),

Scotlan-

d,UK

Cross-sectional

method

Toassess

theknow

ledgeand

attitudes

ofnursingand

medicalstaffworking

ina

surgicalunit,

beforeandafter

working

with

anewly

establishedHospitalP

Cteam

101nursingand

medicalstaff

Asurgicalunit,

hospital

palliativecareteam

34years

Male22

(22%

)and

female

79(78%

)

Not

stated

Physicians

(n=22)and

nurses

(n=79)

N/A

Atbaseline,24%

ofstaffshow

edalack

ofknow

ledgeanda

negativeattitudetowards

the

risk

ofaddictiontomorphine.

Regarding

opioidtolerance,at

thefollow-uptim

epoint,only

4/7

J Canc Educ (2020) 35:214–240 231

Tab

le4

(contin

ued)

Author(s),

year,and

country

Study

design

Studyaim

Samplesize

Studysetting

Meanage

Sex

ratio

Measurements

Type

ofsample

Type

ofcancer

Mainfinding

Quality

scoring

14%

demonstratin

galack

ofknow

ledge.Atfollow-up,

34%

(com

paredwith

50%

atbaseline)still

believedthat

increaseddosesof

opioids

wereneeded

becauseopioids

becameineffectiveovertim

e.Although

25%

ofallstaffstill

lacked

know

ledgeaboutthe

risk

ofrespiratorydepression

atfollow-up,thiswas

asignificantimprovem

ento

nthe56%

who

demonstrateda

lack

ofknow

ledgeatbaseline.

Atb

aseline,afairly

high

proportionofstaffappearedto

believe

painwasalwaysapart

ofadvanced

cancer(38%

).Yanjun

etal.,

(2010),

China

Survey

Todeterm

inethedegree

ofphysicianknow

ledgeon

morphineuseandthefactors

thatim

pede

morphineusein

clinicalpracticein

China.

201physicians

4hospitalsin

China

Not

stated

Not

stated

Not

stated

Physicians

N/A

Physicians

who

reported

having

received

training

inCPM

and

drug

usedemonstrateda

significantly

highermean

scoreof

basicknow

ledge

comparedto

physicians

who

reported

noth

avingreceived

training

(9.31±2.88:8.23±2.70,

u=2.74,p

<0.001).T

hetop

threecitedim

pedimentsto

widespreadclinicaluseof

morphineforcancerpain

were:(1)lack

ofprofessional

know

ledgeandtraining

(57.2%

);(2)fearof

opioid

addiction(48.7%

);and(3)

physicians’personal

preferencesto

selectother

drugs(46.0%

).

6/7

Yildirim

etal.,

(2008),

Turkey

Cross-sectional

method

Toexam

ineinform

ationabout

theknow

ledgeandattitudes

ofTurkish

oncology

nurses

regardingCPM

68oncology

nurses

Oncology&

haem

atology

units

intwouniversityhospitals

locatedin

Izmir,

Turkey

From

21to

30years

Not

stated

Knowledgeand

AttitudesSu

rvey

Regarding

Pain

(NKASRP)

Oncologynurses

N/A

The

findings

show

edthatTurkish

oncology

nurses

have

insufficient

know

ledgeand

attitudes

aboutC

PMwhich

iswidelyrecommendedby

the

WHO.O

utof

the39

pain

questions

exam

ined,the

mean

scoreforcorrectly

answ

ered

itemswas

13.81(35.41%

correctanswerrate).

Com

paredwith

earlier

research

usingthesametool.

Only8.8%

ofoncology

7/7

J Canc Educ (2020) 35:214–240232

Tab

le4

(contin

ued)

Author(s),

year,and

country

Study

design

Studyaim

Samplesize

Studysetting

Meanage

Sex

ratio

Measurements

Type

ofsample

Type

ofcancer

Mainfinding

Quality

scoring

nurses

correctly

identifythat

less

than

1%of

patientswho

receiveopioidsfarpain

relief

will

developaddiction,and

91.2%

erroneouslybelieve

thataddictionwill

occurin

patients.Mostnurses(97.1%

)incorrectly

believedthatmore

patientsover-reporttheirpain.

Zhang etal.,

(2015),

China

Cross-sectional

method

Toevaluatephysicians’current

practice,attitudes

towards,

andknow

ledgeof

cancerpain

managem

entinChina

500physicians

11medicalfacilitiesin

China

<35–≥

35years

Male (n=212,

45.4%),

female

(n=255,

54.6%).

Not

stated

Physicians

(oncologists,

internists,

haem

atologists)

N/A

About

32.6%

ofphysicians

assessed

patients’pain

rarely,

and85.5%

neveror

occasionally

treatedpatients’

cancerpain

togetherwith

psychologists.Morethan

50%

ofphysicians

indicated

thatopioid

dose

titrationin

patientswith

poor

pain

controland

assessmento

fthe

causeandseverityof

pain

wereurgently

needed

know

ledgeforCPM

.Inadequateassessmentofpain

andPM

(63.0%

),patients’

reluctance

totake

opioids

(62.2%

),andinadequatestaff

know

ledgeof

PM

(61.4%

)werethethreemostfrequently

citedbarriersto

physicians’

CPM

.

4/7

J Canc Educ (2020) 35:214–240 233

and American nurses were more likely to use morphinefor CPM than nurses in Japan or Spain. For example,71.5% of Canadian nurses and 66.3% of nurses fromAmerica reported using morphine for managing cancerpain, compared with 61.6% of Japanese nurses and51.2% of nurses from Spain [59]. The results also re-vealed that there was a degree of misunderstanding re-garding opioid addiction by nurses between countries.For instance, the majority of nurses who answered therelevant questions correctly were from Canada and theUSA (51.3% and 43.4%), respectively, whereas, only14% of Spanish nurses and 17.2% of Japanese nursesresponded correctly [59]. Another interesting observationto emerge from the results was that there were geograph-ical variations within countries, for example, the nurseswho worked in the central region of Italy had lowest scoreof pain knowledge (47.9%; M = 18; n = 66) comparedwith those in the north (57.2%; M = 21; n = 149) and inthe south of Italy (56.9%; M = 23; n = 72) (p < 0.001) [11].

Family Caregivers’ Knowledge and Attitudes TowardsCPM

A study revealed that caregivers’ attitudes towards CPMand the patients’ pain knowledge explained 23.2% of thetotal variance in the patients’ average scores for their atti-tudes towards CPM when entered into a regression equa-tion [57]. This indicates that patients’ attitudes towardsCPM were influenced by their caregivers’ attitudes andthe patient’s pain knowledge [57]. The results from a studyconducted in Taiwan indicated that family caregivers heldsome moderate to strong concerns towards CPM. Theseconcerns were shown through the Barriers Questionnaire-Taiwan (BQT) survey (ranged 0–5) as follows: diseaseprogression (3.82), side effects (3.29), given as needed(p.r.n) (3.01), tolerance (2.96) and addiction (2.67) [55].The results also showed some family caregivers reportingtheir hesitation to administer opioids and to report pain totheir patients during the preceding month, because care-givers believed that opioids would cause constipation andharm to patients’ kidneys [55]. Surprisingly, there werealso similar concerns towards CPM by caregivers inChina, where these concerns were shown as higher or low-er in some dimensions; tolerance (3.74), given as needed(p.r.n) (3.51), addiction (3.43), disease progression (3.27)and side effects (3.22) [57]. However, these concerns werelower in the USA, indicating that caregivers in the USAmight have a good level of knowledge and positive atti-tudes towards CPM compared with caregivers in Taiwanand China. For example, the areas of concern for care-givers in the USA were about opioid-related side effects(2.41), fears of addiction (2.35), disease progression(2.28) and tolerance (1.37) [95].

General Public’s Knowledge and Attitudes TowardsCPM

The results from 472 general public respondents in the USAwho had not been diagnosed with cancer showed that 18%indicated they would avoid seeking care because of concernsabout pain associated with cancer treatment. Fifteen percent ofthe sample agreed or strongly agreed if they had cancer theirfear of the disease would make them seek medical care,whereas 9% of them agreed or strongly agreed their concernabout cancer pain would lead to avoidance of medical care[51]. The most common key concern among the general pub-lic in the USA that would affect them if they had cancer wasthe Bpotential for upset to their family ,̂ followed by concernabout the Bpossibility of dying of cancer .̂ Nearly 50% report-ed a significant concern about pain resulting from both thecancer and the process of its management [51]. The study alsoreported that 62% of the general public believed that pain isusually associated with disease progression, 57% thought thatcancer patients usually die with a painful death and 50% hadsignificant concerns about opioid side effects including con-fusion or disorientation, tolerance and opioid addiction [51].

Discussion

We aimed to systematically review research on the nature andimpact of attitudes and knowledge towards CPM. Overall, theresults of this review show that a majority of included studiesindicated similar attitudinal barriers to effective CPM sharedacross patients, caregivers, professionals and the public. Thebarriers most commonly cited by professionals [11, 22, 28, 44,48, 59, 98, 100], patients and their caregivers [20, 55, 57, 95]and the general public [51] were the fear of poor tolerance,side effects of opioids and drug addiction. However, the mostcommon barriers cited by professionals were contrary to othersimilar studies, which have suggested that the most importantbarriers were poor assessment of pain and its management,patient reluctance to take opioids and inadequate staff knowl-edge of CPM [14, 22, 27, 32, 34, 44, 45, 104]. Furthermore, aprevious systematic review by Jacobsen et al. [42] showedthat physicians from countries, such as some states in theUSA, Australia and Denmark were more often prescribingstrong opioids in efficient doses, as they were less concernedabout opioid addiction [42]. Nonetheless, their general find-ings were that physicians consistently reported being con-cerned about high doses of opioid and the fear of side effects,and these fears were common reasons for reluctance to pre-scribe adequate amounts of opioids for managing cancer pain[42]. It can thus be suggested that people from different coun-tries have different attitudes and knowledge towards CPM.

One interesting finding was that the results from the major-ity of studies with cancer patients showed low mean scores on

J Canc Educ (2020) 35:214–240234

patient’s knowledge and attitudes towards CPM [19, 20, 57,77]. This result may be explained by the fact that many pa-tients could be reluctant to report their pain to professionalsbecause they have a mistaken belief regarding opioid medica-tion [68]. This finding was also reported by a systematic ex-ploratory review by Jacobsen et al. [43]. Another importantfinding was that negative attitudes towards morphine wereshown by Turkish patients as they continued rejecting mor-phine for their cancer pain after sessions about opioids weregiven. The reasons for that were due to fear of addiction,religious reasons and cultural prohibitions [20, 58].Silbermann and Hassan [88] stated that patients’ response tocancer can differ based on the patients’ beliefs and culture. Ithas been argued that many patients and their family caregiversviewed opioid medications as a path to death; accordingly,opioid analgesics became their last choice [87]. Despite painbeing considered an individual experience, many patients areinfluenced by their culture, mainly when they are interpretingtheir pain or accepting the medication of CPM [5, 23, 65].Therefore, understanding patients’ culture and beliefs can pro-vide the professional with a consideration into how cancer isviewed by the patient [88]. However, professionals can also beinfluenced by their culture, as it has been reported that culturalbeliefs among professionals were one of the most obviouslyidentified barriers towards CPM [80].

Another interesting outcome was that several studiesshowed physicians had a better level of attitudes and knowl-edge towards CPM than nurses [22, 32, 44, 45]. There wasalso a difference between oncologists and surgeons regardingtheir level of knowledge about cancer pain and its manage-ment [33]. It seems possible that these results are due to workexperience and training in CPM, as many studies have shownthat working with cancer patients’ care and receiving trainingin CPM can improve professionals’ knowledge and attitudestowards CPM [29, 38, 40, 44, 50, 67, 94, 100].

Most notably, there was a variation between nurses fromdifferent countries regarding the level of knowledge and atti-tudes towards CPM [59]. As could be expected, the variationin knowledge about CPM among those nurses could indicatethat morphine is under-prescribed. This view was supportedby a systematic review by Oldenmenger et al. [68] who re-ported that the rates of adherence to opioids for CPM variedfrom 20 to 95%, with the majority of cancer patients takingtheir treatments only as needed.

The results also showed that some oncology nurses had anincorrect self-evaluation about their knowledge in CPM [11,102]. This finding is consistent with that of Omran et al. [70]who also found that Jordanian oncology and non-oncologynurses have a low level of knowledge about CPM. In contrastto earlier findings, several studies indicated that the oncologynurses and doctors achieved higher scores on the knowledgeand attitudes surveys (KAS) compared with general nursesand physicians [33, 44, 50, 84, 94]. These positive results

could be due to the work experience of professionals in cancerpain settings, as this was reported by McCaffery and Ferrell[59] who stated that nursing staff from countries such asCanada and the USA, which have the longest experience ofpalliative care units, showed a better level of attitudes andknowledge about CPM than nurses from countries (Japanand Spain) that had palliative care services more recently.

However, it seems that direct experience in oncology unitswithout education and training is not enough to increase pro-fessionals’ knowledge about CPM. This view was supportedby Bernardi et al. [11] who reported that the years of experi-ence of cancer nurses were not related to pain knowledgescores (p = 0.2). It is possible therefore that education inCPM is the key issue for improving the professionals’ levelof knowledge and attitudes towards CPM. A number of au-thors have considered the effects of educational interventionson professionals’ attitudes and knowledge towards CPM [4, 6,9, 12, 49, 70, 71]. According to previous systematic reviewsof educational interventions aimed to improve CPM in differ-ent settings, a significant effect was shown on pain scores,however, the quality of opioid prescription and interferencefrom pain in daily activities was not affected by the majority ofinterventions [4, 6, 8, 69].

As could be expected, lack of professional education andtraining in CPM could be one of the most important key bar-riers for physicians and nurses [34, 39]. Furthermore, this wasreported as the highest physician barrier to morphine usage inclinical practice [100]. Another argument was that profes-sionals with cancer patients’ care need professional teachingregarding CPM,which could aid patients in reporting pain andin effectively using the opioids that are prescribed to them [39,97]. It is also well documented that there is less than optimalpain management for patients with cancer as a result of a lackof professional healthcare education about CPM [18, 60].Numerous studies have showed that professionals who hadexperience in palliative care units, receiving training and highlevel of education in CPM obtained higher scores on theknowledge of cancer pain and its management [45, 49, 70,71, 94, 100].

Several studies have shown that caregivers had low level ofknowledge and attitudes towards CPM [55, 57, 95]. Thesenegative attitudes and inadequate knowledge by caregiverstowards opioids could result in attitudinal barriers towardseffective CPM [30, 54, 55]. Therefore, it has been argued thatit is important to increase caregivers’ ability to participate inCPM and enable them to assess pain and to help their patientstake adequate doses of opioids [101]. The correlation betweencaregivers’ attitudes and their patients’ pain knowledge to-wards CPM is interesting because patients’ attitudes towardsCPM were influenced by their caregivers’ attitudes and thepatient’s pain knowledge [57]. Therefore, caregivers shouldhave general awareness and adequate level of knowledgeabout CPM. It has been argued that caregivers with higher

J Canc Educ (2020) 35:214–240 235

pain management knowledge had significantly fewer barriersto CPM [95].

Results from a study on the general public showed thatmany people were concern about disease progression and be-lieved that pain was usually associated with this concern.However, some of the public had significant concerns aboutopioids side effects, tolerance and addiction [51]. Surprisingly,only two studies were found on the general public’s attitudesand knowledge towards CPM and both of articles were pub-lished before 2000, consequently updated studies about thisarea are needed.

Overall, the results of this review have found some evi-dence that there are negative attitudes and lack of knowledgetowards CPM among the four groups included in this review.These findings are consistent with those of recent studies andsystematic reviews [12, 13, 20, 26, 37, 79, 80, 96]. Thus, it canbe argued that due to these negative attitudes and lack ofknowledge towards CPM, the management of cancer painremains a major problem worldwide, especially in countrieswithin Europe, Africa and Asia [13, 26, 52, 75, 76, 81, 92].These could be due to lack of education and training aboutCPM among professionals and lack of general awareness andadequate level of knowledge about CPM among patients,caregivers and the public, as these were stated in all of theincluded studies. Therefore, healthcare professionalsexpressed a desire for additional education and training onCPM. A recent systematic review indicated that educationalprogrammes on CPM, including CPM topics in nursing cur-ricula, and training programmes on CPM are the most impor-tant factors for enhancing nurses’ knowledge and attitudestowards CPM [12]. It has also been argued that nurses whohad received educational programmes on CPM reported sig-nificantly higher mean of scores on knowledge about CPMthan those who did not have pain education (M = 22 versusM = 20; p = 0.02) [11].

Furthermore, patients, caregivers and the public need gener-al awareness and adequate level of knowledge about CPM. Asystematic review reported that providing educational sessionson CPM can improve caregivers’ knowledge and reduce theirattitudinal barriers towards CPM [62]. Regarding the generalpublic’s views, it is expected and inevitable that the generalpublic will know very little about CPM unless they have canceror someone close to them does. Thus, general awareness andadequate level of knowledge about CPM are needed.

Limitations

As only studies published in English were considered withinthe inclusion criteria, as well as just published studies, it ispossible that there are studies that have been published inother languages, also unpublished articles that could havebeen included in this review. Other limitations could be thateven though all included studies used the same design (cross-

sectional design), the questionnaires that were used to conductsurveys in this particular area were different and some studiesdid not state which questionnaire was used or failed to provideinformation regarding the validity of the tools. Therefore, itwas difficult to directly compare studies and the reliability ofthese included studies in this review could be compromised[74, 90]. In the quality analysis, 15 of the 36 included studieswere judged to be only fair quality (see Appendix 3). Thereason for a fair quality score instead of a good quality scoreis that these articles had some methodological limitations.However, almost two-thirds of the included studies, 25 outof the 36 (69.44%), were rated as of good quality. Includedstudies were from high and low income countries and thusdifferent healthcare systems and cultural beliefs across peopleform these countries could have affected their attitudes andknowledge towards CPM. Moreover, the possibility of biascould have happened during the reporting of outcomes.

Implications for Clinical Practice

Healthcare professionals should follow specific guidelines forCPM, which have been established by WHO [91] and NICE[10, 66]. Moreover, knowledge and attitudes of professionalsneed to be improved by intensive training on opioids andeducational interventions about cancer pain and its manage-ment in order to have effective CPM. Likewise, patients, care-givers and the public will need different approaches to im-prove general awareness and obtain an adequate level ofknowledge about CPM.

Implications for Research

All studies included in this review were quantitative studies.More in-depth understanding of the conceptions and attitudestowards CPM can be provided by qualitative studies [93].Additionally, qualitative methods could help to identify thefactors which can influence the professionals, cancer patients,caregivers and the general public’s attitudes and knowledgetowards CPM [93]. Furthermore, more updated studies withinCPM are needed to generate more contemporary data in thisarea.

Conclusions

This systematic review confirms that there are still barriers toeffective CPM by professionals, patients, caregivers and thegeneral publics’ lack of knowledge and/or poor attitudes to-wards CPM, which might result in unalleviated cancer pain.More detailed understanding of how these attitudes arise with-in different contexts and tailoring educational initiatives toaddress these are likely to have most impact on improvingCPM.

J Canc Educ (2020) 35:214–240236

Acknowledgments Sincere thanks to Sally Dalton for her advice asLibrary Research Support Advisor and to Dr. Aziza Al-Harbi for herencouragement.

Funding Information The authors acknowledge the Ministry ofEducation in Libya for funding this study.

Compliance with Ethical Standards

Conflict of Interest The authors declare that they have no conflicts ofinterest.

Open Access This article is distributed under the terms of the CreativeCommons At t r ibut ion 4 .0 In te rna t ional License (h t tp : / /creativecommons.org/licenses/by/4.0/), which permits unrestricted use,distribution, and reproduction in any medium, provided you giveappropriate credit to the original author(s) and the source, provide a linkto the Creative Commons license, and indicate if changes were made.

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