Barriers to pain management among adolescents with cancer

Testing a Combined Cognitive Bias Hypothesis of Pain and Pain-related Worry in Young People

Cognitive factors are thought to contribute and maintain pain experiences in young people. However, most of these factors have been assessed in isolation. Considering more than 1 cognitive factor could increase explanatory power and identify multiple targets for intervention. Here, we tested a Combined Cognitive Bias Hypothesis (CCBH) that suggests information-processing factors associate with each other and exert either additive and/or interactive influences on pain outcomes. We conducted secondary analysis of data from 243 adolescents aged 16 to 19 years, who had completed a task measuring pain-related attention control impairments (emotion-priming visual search task) and a task measuring biased interpretations towards threatening cues (Adolescent Interpretation of Bodily Threat task). These young people also completed measures of recent pain experiences and pain catastrophizing, which served as primary and secondary outcomes, respectively. Regression analyses revealed that difficulties with attention control (following presentation of pain-related stimuli) and tendencies to endorse threatening interpretations of ambiguous situations had significant additive effects on both pain outcomes. However, correlations between these factors were non-significant. They also did not interact to influence pain outcomes. These findings require replication in broader age ranges and clinical samples but potentially suggest that, measuring multiple cognitive factors increases explanatory power of youth pain outcomes. PERSPECTIVE: Weak attention control following exposure to pain cues and tendencies to endorse threat interpretations, uniquely and additively associate with self-reported pain experiences and pain catastrophizing in community youth. Measuring several cognitive factors simultaneously could improve our ability to explain pain outcomes in adolescent populations.

Parental Experiences of Adolescent Cancer-Related Pain: A Qualitative Study

Objective

Despite advancing medical treatments, pain remains a significant outcome of adolescent cancer, as both a problematic and distressing symptom. With adolescents spending substantial periods of time at home during cancer treatment, parents perceive themselves as central to the experience and management of adolescents’ pain. The present study aimed to explore parental experiences of adolescent cancer-related pain during, and recently after, completing cancer treatment.

Methods

We interviewed 21 parents of adolescents (aged 12–18 years) with cancer, recruited through a hospital in South West England. Interviews were analyzed using reflexive inductive thematic analysis.

Results

Two themes were generated. The first theme, “Parental perceptions of being at the heart of pain management,” focused on the role of parents in adolescents’ pain journeys, and the vast knowledge they gained. The second, “Adapting and readjusting expectations,” captured parents’ journeys in learning to adjust their lives according to adolescents’ pain and difficulties they faced throughout this process.

Conclusions

Findings highlighted parents’ crucial role throughout adolescents’ pain experiences; learning how to manage adolescents’ pain, and supporting them with the detrimental impact on their lives. The findings emphasize the importance of a multidisciplinary approach to supporting families to manage pain. They also indicate a need for targeted research studies investigating parental experiences of adolescent cancer-related pain. This will help professionals understand how best to support parents and adolescents throughout the cancer journey and ultimately improve the physical and psychological outcomes of young people in the longer term.

Normalization of Symptoms in Advanced Child Cancer: The PediQUEST-Response Case Study

CONTEXT

Children, adolescents and young adults with cancer continue to experience significant symptom suffering throughout their illness.

OBJECTIVES

To identify barriers to effective symptom management in pediatric advanced cancer.

METHODS

Using a qualitative multiple case study we refined the Pediatric Quality of Life and Evaluation of Symptoms Technology Response to the Pediatric Oncology Symptom Experience (PediQUEST Response), a pediatric palliative care (PPC) intervention. Twenty-three children aged ≥2 years old with advanced cancer, their parents and primary and PPC clinicians were enrolled. Children and parents reported symptoms weekly over 4-months using the Memorial Symptom Assessment Scale (MSAS) administered by an electronic system (PediQUEST). When symptom distress episodes (SDEs) were reported (MSAS symptom score ≥33) we studied symptom management processes using interviews of family members/clinicians, and chart abstractions. Data were coded and analyzed using grounded theory and NVivo software.

RESULTS

Children reported 308 SDEs within 193 surveys and parents 529 SDEs in 165 surveys administered. We conducted 85 and 88 interviews with families and clinicians respectively. While we confirmed the presence of known barriers, we identified a prominent theme, that symptoms were "normalized." Patients, parents, and all clinicians, including PPC specialists, got accustomed to high symptom burden and lacked expectations that distress could be alleviated. We defined "normalization of symptoms," as the process by which symptom related suffering is appraised as unavoidable.

CONCLUSION

Normalization of symptoms is a pervasive barrier enacted by all involved in caring for children with advanced cancer. Strategies to overcome normalization are critical to ease child distress.

A Person-Centered Approach to Symptom Assessment and Management for Children and Adolescents Receiving Cancer Treatment

OBJECTIVES

Discuss the clinical assessment and management of symptoms for children and adolescents receiving treatment for cancer with attention to a person-centered approach to care.

DATA SOURCES

Review of currently published literature and guidelines pertaining to symptom assessment and management for children and adolescents receiving treatment for cancer.

CONCLUSION

Symptoms such as pain, nausea, and fatigue are commonly reported by children and adolescents receiving cancer treatment and are associated with greater symptom burden. Symptom assessment should be tailored to the child or adolescent and include the child's or adolescent's preference for reporting symptoms and attention to the symptoms that are of greatest priority. Evidence-based guidelines for the management of symptoms, including pain and nausea, are available to guide symptom management interventions and should be tailored to provide person-centered care.

IMPLICATIONS FOR NURSING PRACTICE

Nurses can lead efforts through clinical practice and research initiatives to advance person-centered symptom care for children and adolescents with cancer on a global level. Priorities for future work to advance person-centered symptom assessment and management include (1) identification of best practices for symptom assessment, (2) attention to social determinants of health and their subsequent influence on symptom outcomes, (3) compilation of evidence for management of less commonly reported symptoms, and (4) implementation of published clinical guidelines for symptom management in practice settings.

Validation of the Adolescent Barriers Questionnaire for use in Brazilian adolescents with cancer

OBJECTIVE

To translate, culturally adapt, and evaluate the psychometric properties of Adolescent Barriers Questionnaire for use in Brazilian adolescents with cancer aged 12 to 18 years, based on the original American Adolescent Barriers Questionnaire which was designed to measure the extent to which adolescents with cancer have concerns about reporting pain and using analgesics.

METHODS

The study analyzed the psychometric properties reliability (internal consistency and test-retest) and validity (known groups and convergent) of Adolescent Barriers Questionnaire in adolescents between 12 and 18 years of age with a diagnosis of cancer who were using or who had used analgesic medication (opioid or not) in a pediatric public health institution. It was estimated 64 adolescents as sample size and the research was conclude with 48.

RESULTS

Results of pre-test suggest good understanding (content validity index >0.9). The internal consistency value Cronbach's α was 88%. The convergent validity values ranged between -0.400 and -0.450. Analysis of known groups showed that the instrument discriminated groups of patients with solid vs. hematologic tumors. The intraclass correlation coefficient obtained after retest was 0.863.

CONCLUSION

After the process of translations, validations and analysis of psychometric properties, the Brazilian Portuguese version of Adolescent Barriers Questionnaire could be considered culturally adapted, valid, and reliable for the Brazilian adolescent population with cancer aged 12 to 18 years and it can be useful in practical clinic, offering the health professionals the opportunity to understand which barriers the adolescent with cancer can encounter and offer, thus, all the support to overcome them.

Pain Squad+ smartphone app to support real-time pain treatment for adolescents with cancer: protocol for a randomised controlled trial

INTRODUCTION

Pain negatively affects the health-related quality of life (HRQL) of adolescents with cancer. The Pain Squad+ smartphone-based application (app), has been developed to provide adolescents with real-time pain self-management support. The app uses a validated pain assessment and personalised pain treatment advice with centralised decision support via a registered nurse to enable real-time pain treatment in all settings. The algorithm informing pain treatment advice is evidence-based and expert-vetted. This trial will longitudinally evaluate the impact of Pain Squad+, with or without the addition of nurse support, on adolescent health and cost outcomes.

METHODS AND ANALYSIS

This will be a pragmatic, multicentre, waitlist controlled, 3-arm parallel-group superiority randomised trial with 1:1:1 allocation enrolling 74 adolescents with cancer per arm from nine cancer centres. Participants will be 12 to 18 years, English-speaking and with ≥3/10 pain. Exclusion criteria are significant comorbidities, end-of-life status or enrolment in a concurrent pain study. The primary aim is to determine the effect of Pain Squad+, with and without nurse support, on pain intensity in adolescents with cancer, when compared with a waitlist control group. The secondary aims are to determine the immediate and sustained effect over time of using Pain Squad+, with and without nurse support, as per prospective outcome measurements of pain interference, HRQL, pain self-efficacy and cost. Linear mixed models with baseline scores as a covariate will be used. Qualitative interviews with adolescents from all trial arms will be conducted and analysed.

ETHICS AND DISSEMINATION

This trial is approved by the Hospital for Sick Children Research Ethics Board. Results will provide data to guide adolescents with cancer and healthcare teams in treating pain. Dissemination will occur through partnerships with stakeholder groups, scientific meetings, publications, mass media releases and consumer detailing.

TRIAL REGISTRATION NUMBER

NCT03632343 (ClinicalTrials.gov).

Pain and its Impact on the Functional Ability in Children Treated at the Children's Cancer Center of Lebanon

PURPOSE

The purpose of this study was to describe the characteristics of pain in children under treatment at the Children Cancer Centre of Lebanon at the American University of Beirut Medical Centre. Design and Methods A cross-sectional correlational survey was used. The Adolescent Pediatric Pain Tool and the Functional Disability Inventory were used to examine the characteristics of pain experienced in a consecutive sample of children treated at the CCCL and its impact on their functional abilities.

RESULTS

The mean age of the 62 participants was 12.3 (SD 2.9). The overall mean pain intensity rating for the sample was 5.06 (SD 1.87) on a 10 cm Word Graphic Rating Scale. More than one-half of the children in the sample (57.4%) reported having pain "sometimes" with a median duration of two hours per pain episode. The most frequently reported locations of pain were the forehead, the abdomen, and the lower back. For the most part, the children used sensory words to describe their pain experience. The children reported moderate levels of functional disability (mean FDI score 25.04, SD 13.81). Multivariable linear regression analysis identified frequency, duration, location, use of affective descriptors, and treatments as statistically significant predictors of pain intensity.

CONCLUSION

Regrettably, the findings reported attest once again to unrelieved pain in a pediatric oncology population.

PRACTICE IMPLICATIONS

Policy makers can contribute to pain control by introducing legislation and national policies to ensure adequate pain management for children with cancer in Lebanon.

Opioid utilization among pediatric patients treated for newly diagnosed acute myeloid leukemia

Purpose

A cohort of pediatric patients with AML treated at hospitals contributing to the Pediatric Health Information System was used to evaluate differences in opioid utilization by sex, age, race, and insurance.

Methods

Billing data were used to compute the prevalence of opioid exposure and to quantify rates of utilization among those exposed to opioids as days of use per 1000 inpatient days. Multivariable regressions were used to compare opioid prevalence, and rates of utilization among those exposed.

Results

On average across courses, 95.2% of patients were exposed to analgesics, 84.7% were exposed to non-opioid analgesics and 77.7% were exposed to opioids. The proportion of opioid-exposed patients increased with age, but did not differ by gender, race, or insurance status. Analyses limited to patients exposed to opioids revealed modest differences in days of opioid use among female patients (adjusted rate ratio (aRR) = 1.19, 95% CI: 1.11, 1.28), patients <1 year (aRR = 1.37, 95% CI: 1.21, 1.55) or ≥10 years of age (aRR = 1.63, 95% CI: 1.46, 1.82), whereas Asian patients received fewer days of opioids compared with white patients (aRR = 0.76, 95% CI: 0.61, 0.95). There was moderate hospital-level variability in both the prevalence of opioid utilization overall and preference for specific opioid medications. There was greater inconsistency in practice concerning choices for supplemental and alternative opioids than in first-line opioid utilization.

Conclusion

Additional work is needed to discern whether observed differences in opioid utilization by age and race reflect a difference in treatment or a difference in the experience of pain. Future studies should also explore the factors which guide decisions on opioid selections in an attempt to explain the variability across institutions.

Development of a mHealth Real-Time Pain Self-Management App for Adolescents With Cancer: An Iterative Usability Testing Study [Formula: see text]

PURPOSE

A user-centered design approach was used to refine the mHealth Pain Squad+ real-time pain self-management app for adolescents with cancer for its usability (defined as being easy to use, easy to understand, efficient to complete, and acceptable).

METHOD

Three iterative usability testing cycles involving adolescent observation and interview were used to achieve this objective. During each cycle, adolescents used the app while "thinking aloud" about issues encountered. Observed difficulties and errors were recorded and a semistructured interview about the experience was conducted. Using a qualitative conventional content analysis approach, themes related to app usability were identified.

RESULTS

Participants required an average of 4.3 minutes to complete the pain assessment component of Pain Squad+. Overall, the app was acceptable. Problematic issues related to software malfunction, interface design flaws, and confusing text. Software revisions were made to address each issue.

CONCLUSION

The multifaceted usability approach used provided insight into how a real-time app can be made acceptable to adolescents with cancer and succeeded in developing a Pain Squad+ app that is fit for future effectiveness testing.

Construct validity and reliability of a real-time multidimensional smartphone app to assess pain in children and adolescents with cancer

We evaluated the construct validity (including responsiveness), reliability, and feasibility of the Pain Squad multidimensional smartphone-based pain assessment application (app) in children and adolescents with cancer, using 2 descriptive studies with repeated measures. Participants (8-18 years) undergoing cancer treatment were drawn from 4 pediatric cancer centers. In study 1, 92 participants self-reported their level of pain twice daily for 2 weeks using the Pain Squad app to assess app construct validity and reliability. In study 2, 14 participants recorded their level of pain twice a day for 1 week before and 2 weeks after cancer-related surgery to determine app responsiveness. Participants in both studies completed multiple measures to determine the construct validity and feasibility of the Pain Squad app. Correlations between average weekly pain ratings on the Pain Squad app and recalled least, average, and worst weekly pain were moderate to high (0.43-0.68). Correlations with health-related quality of life and pain coping (measured with PedsQL Inventory 4.0, PedsQL Cancer Module, and Pain Coping Questionnaire) were -0.46 to 0.29. The app showed excellent internal consistency (α = 0.96). Pain ratings changed because of surgery with large effect sizes between baseline and the first week postsurgery (>0.85) and small effect sizes between baseline and the second week postsurgery (0.13-0.32). These findings provide evidence of the construct validity, reliability, and feasibility of the Pain Squad app in children and adolescents with cancer. Use of real-time data capture approaches should be considered in future studies of childhood cancer pain. A video accompanying this abstract is available online as Supplemental Digital Content at http://links.lww.com/PAIN/A169.

[Cancer pain management: Systematic review and critical appraisal of clinical practice guidelines]

OBJECTIVE

Although several clinical practice guidelines have been developed in the last decades, cancer pain management is still deficient. The purpose of this work was to carry out a comprehensive and systematic literature review of current clinical practice guidelines on cancer pain management, and critically appraise their methodology and content in order to evaluate their quality and validity to cope with this public health issue.

MATERIALS AND METHODS

A systematic review was performed in the main databases, using English, French and Spanish as languages, from 2008 to 2013. Reporting and methodological quality was rated with the Appraisal of Guidelines, Research and Evaluation II (AGREE-II) tool, including an inter-rater reliability analysis. Guideline recommendations were extracted and classified into several categories and levels of evidence, aiming to analyse guidelines variability and evidence-based content comprehensiveness.

RESULTS

Six guidelines were included. A wide variability was found in both reporting and methodological quality of guidelines, as well as in the content and the level of evidence of their recommendations. The Scottish Intercollegiate Guidelines Network guideline was the best rated using AGREE-II, while the Sociedad Española de Oncología Médica guideline was the worst rated. The Ministry of Health Malaysia guideline was the most comprehensive, and the Scottish Intercollegiate Guidelines Network guideline was the second one.

CONCLUSIONS

The current guidelines on cancer pain management have limited quality and content. We recommend Ministry of Health Malaysia and Scottish Intercollegiate Guidelines Network guidelines, whilst Sociedad Española de Oncología Médica guideline still needs to improve.

Development of the Adolescent Cancer Suffering Scale

BACKGROUND

While mortality due to pediatric cancer has decreased, suffering has increased due to complex and lengthy treatments. Cancer in adolescence has repercussions on personal and physical development. Although suffering can impede recovery, there is no validated scale in French or English to measure suffering in adolescents with cancer.

OBJECTIVE

To develop an objective scale to measure suffering in adolescents with cancer.

METHODS

A methodological design for instrument development was used. Following a MEDLINE search, semistructured interviews were conducted with adolescents 12 to 19 years of age who had undergone four to six weeks of cancer treatment, and with a multidisciplinary cohort of health care professionals. Adolescents with advanced terminal cancer or cognitive impairment were excluded. Enrollment proceeded from the hematology-oncology department⁄clinic in Montreal, Quebec, from December 2011 to March 2012. Content validity was assessed by five health care professionals and four adolescents with cancer.

RESULTS

Interviews with 19 adolescents and 16 health care professionals identified six realms of suffering: physical, psychological, spiritual, social, cognitive and global. Through iterative feedback, the Adolescent Cancer Suffering Scale (ACSS) was developed, comprising 41 questions on a four-point Likert scale and one open-ended question. Content validity was 0.98, and inter-rater agreement among professionals was 88% for relevance and 86% for clarity. Adolescents considered the scale to be representative of their suffering.

CONCLUSIONS

The ACSS is the first questionnaire to measure suffering in adolescents with cancer. In future research, the questionnaire should be validated extensively and interventions developed. Once validated, the ACSS will contribute to promote a holistic approach to health with appropriate intervention or referral.

Oncologic pain relief: strategies told by adolescents with cancer

In view of the negative impact of pain on the quality of life of cancer patients, identifying and stimulating the use of effective strategies to minimize these painful feelings is highly relevant for care. The aim of this study was to identify painful experiences of adolescents with cancer and to get to know their strategies for pain relief. This is an exploratory research, using qualitative data analysis. Semistructured interviews were held with nine adolescents with cancer, who reported on acute, recurring and chronic, physical and emotional painful experiences. To relieve these pains, they described pharmacological and non-pharmacological strategies, including: distraction, presence of relatives, bed positioning, cooperation to accomplish procedures and keeping up positive thinking. Therefore, it is essential for health professionals to know available evidence for pain relief and to develop skills to articulate this knowledge with their professional experience and with the patients' own strategies.

The Impact of a National Guideline on the Management of Cancer Pain on the Practice of Pain Assessment and Registration

The Dutch clinical practice guideline on the diagnosis and management of pain in patients with cancer was published in 2008 and intensively promoted to healthcare professionals who see patients with cancer. One of the most important recommendations is the systematic registering of the pain and its intensity. To evaluate in which degree this part of the practice guideline is implemented, we analyzed the medical records of patients attending the outpatient oncological clinic in an academic hospital, a large teaching hospital, and 4 smaller peripheral hospitals. None of the participating hospitals assessed pain by a standardized scale. Reference to pain in the medical record happened more frequently in the academic hospital than in the other hospitals. The frequency of recording pain in the medical record in the academic hospital was much higher in this study than the one previously reported, whereas the findings in the other hospitals were comparable. There may be several reasons for the difference in reporting rate of pain in patients with cancer. Our findings indicate that the clinical practice guideline with regard to pain registration is poorly implemented in oncology outpatient clinics. More efforts should be made to generate the awareness for the need of pain registration.

Rasch Analysis of the Arabic Language Version of the Functional Disability Inventory

It is important for the responsive and effective treatment of pediatric cancer patients that functional disability is successfully measured, but no measures of functional disability have been validated for use with Arabic-speaking children and adolescents. The purpose of this study was to examine the psychometric characteristics of the first Arabic translation of the Functional Disability Inventory (FDI). A methodological study limited to the secondary analysis of functional disability data on 62 pediatric patients in Lebanon using the rating scale model and WINSTEPS Rasch analysis software was used. Disordered responses to 4 FDI times suggest that the Arabic translation of the rating scale categories might need revision or supplementation with a visual analogue scale. The dimensionality of the FDI needs further exploration because principal component analyses of residuals suggested the presence of secondary and possibly higher order dimensions. Additional FDI items are needed to improve targeting if low levels of functional disability are demonstrated to be clinically important for patient assessment and pain management. The FDI-A is suitable for clinical assessment and for monitoring the outcomes of pain management in Lebanese pediatric cancer patients. Our findings support the construct validity of the FDI-A and acceptable reliability for the 15-item scale, Cronbach α .93 and .85 for 4 of the item subsets we examined. Rating scale categories and the dimensionality of the FDI-A require further examination. The clinical relevance of distinctions between levels of functional disability in children and adolescents with cancer pain remains to be established.

Nursing care for adolescents and young adults with cancer: literature review

Cancer patients belonging to the adolescent and young adult (AYA) age group have unique and very specific needs, which require special attention from the caring staff. The difficulty in maintaining the personal and professional development at this age is both natural and normal. Adding to this, coping with a life-threatening disease turns this stage in life into a period with many dilemmas and challenges of quite a complex nature. AYA patients have to deal with issues above and beyond the disease itself, which create a very complex coping picture. On top of that, prognosis for this age group has not improved in recent years, unlike the situation in other age groups like children and adults. The literature on this subject is extensive and comprehensive. However, most of the papers on this subject are very specific and narrow in their approach, each dealing with a specific topic. In this article, we bring together many different papers which make a wide and comprehensive picture of the subject of AYAs coping with cancer, coupled with recommendations for the caring staff. In this review we focus on the various aspects of the disease and treatments in AYAs, based on the conceptual model of quality of life proposed by Ferrell and colleagues [Cancer Nurs 1992;15:153-160; Cancer Nurs 1992;15:247-253], including physical, social, emotional and spiritual aspects. From the psychological standpoint, most of the papers discuss the negative aspects; however, in this article we try to include some articles from the positive psychology school of thought. From our findings it is apparent that there is an opportunity and need to further explore research in this regard. It is apparent that taking a unique approach to AYA cancer patients is needed in order to deal with the unique needs of this age group. This article aims at putting a framework around this issue, with actionable recommendations for the caring staff.

A pilot exploration of symptom trajectories in adolescents with cancer during chemotherapy

BACKGROUND

Chemotherapy is frequently administered in repetitive cycles. Adolescents with cancer have multiple symptoms related to chemotherapy, but knowledge of symptom trajectories across a cycle is limited. Examining trajectories over a cycle may reveal key periods to manage symptoms.

OBJECTIVES

The aims of this pilot were to describe the trajectory of symptoms (pain, sleep, appetite, nausea, fatigue) and biological and behavioral variables (anxiety, stress, hematologic function) across 1 cycle and examine relationships between variables.

METHODS

Nine adolescents with cancer within 6 months of diagnosis participated. Data were collected by surveys, chart review, and biologic measures on days 1 and 2 of the cycle, 1 week later (nadir), and day 1 of the following cycle. To evaluate the trajectory, a simple random-effects repeated-measures analysis was computed.

RESULTS

The significant trajectories were fatigue (P = .003), difficulty sleeping (P = .032), and nausea (P = .04). Most of the adolescents reported some anticipatory anxiety about receiving chemotherapy. Significant correlations between symptoms and biobehavioral variables included anticipatory anxiety and nausea (r = .86, P = .003), trait anxiety and fatigue (r = -0.82, P < .001), and stress and pain (r = 0.78, P = .039).

CONCLUSIONS

Multiple symptoms were experienced across the cycle. Three symptoms displayed significant trajectories indicating that patterns of symptoms may be anticipated.

IMPLICATIONS FOR PRACTICE

Pilot findings suggest that monitoring symptoms, stress, and anxiety across a cycle is important, not only during chemotherapy administration, but also prior to being admitted for chemotherapy.

Unmet Support Service Needs and Health-Related Quality of Life among Adolescents and Young Adults with Cancer: The AYA HOPE Study

INTRODUCTION

Cancer for adolescents and young adults (AYA) differs from younger and older patients; AYA face medical challenges while navigating social and developmental transitions. Research suggests that these patients are under or inadequately served by current support services, which may affect health-related quality of life (HRQOL).

METHODS

We examined unmet service needs and HRQOL in the National Cancer Institute's Adolescent and Young Adult Health Outcomes and Patient Experience (AYA HOPE) study, a population-based cohort (n = 484), age 15-39, diagnosed with cancer 6-14 months prior, in 2007-2009. Unmet service needs were psychosocial, physical, spiritual, and financial services where respondents endorsed that they needed, but did not receive, a listed service. Linear regression models tested associations between any or specific unmet service needs and HRQOL, adjusting for demographic, medical, and health insurance variables.

RESULTS

Over one-third of respondents reported at least one unmet service need. The most common were financial (16%), mental health (15%), and support group (14%) services. Adjusted models showed that having any unmet service need was associated with worse overall HRQOL, fatigue, physical, emotional, social, and school/work functioning, and mental health (p's < 0.0001). Specific unmet services were related to particular outcomes [e.g., needing pain management was associated with worse overall HRQOL, physical and social functioning (p's < 0.001)]. Needing mental health services had the strongest associations with worse HRQOL outcomes; needing physical/occupational therapy was most consistently associated with poorer functioning across domains.

DISCUSSION

Unmet service needs in AYAs recently diagnosed with cancer are associated with worse HRQOL. Research should examine developmentally appropriate, relevant practices to improve access to services demonstrated to adversely impact HRQOL, particularly physical therapy and mental health services.

Development and testing of a multidimensional iPhone pain assessment application for adolescents with cancer

Background

Pain is one of the most common and distressing symptoms reported by adolescents with cancer. Despite advancements in pain assessment and management research, pain due to cancer and/or its treatments continues to be poorly managed. Our research group has developed a native iPhone application (app) called Pain Squad to tackle the problem of poorly managed pain in the adolescent with cancer group. The app functions as an electronic pain diary and is unique in its ability to collect data on pain intensity, duration, location, and the impact pain has on an adolescent’s life (ie, relationships, school work, sleep, mood). It also evaluates medications and other physical and psychological pain management strategies used. Users are prompted twice daily at configurable times to complete 20 questions characterizing their pain and the app transmits results to a database for aggregate reporting through a Web interface. Each diary entry represents a pain case filed by an adolescent with cancer and a reward system (ie, moving up through law-enforcement team ranks, built-in videotaped acknowledgements from fictitious officers) encourages consistent use of the diary.

Objective

Our objective was to design, develop, and test the usability, feasibility, compliance, and satisfaction of a game-based smartphone pain assessment tool for adolescents with cancer.

Methods

We used both low- and high-fidelity qualitative usability testing with qualitative semi-structured, audio-taped interviews and iterative cycles to design and refine the iPhone based Pain Squad app. Qualitative thematic analysis of interviews using constant comparative methodology captured emergent themes related to app usability. Content validity was assessed using question importance-rating surveys completed by participants. Compliance and satisfaction data were collected following a 2-week feasibility trial where users were alarmed to record their pain twice daily on the app.

Results

Thematic analysis of usability interviews showed the app to be appealing overall to adolescents. Analyses of both low- and high-fidelity testing resulted in minor revisions to the app to refine the theme and improve its usability. Adolescents resoundingly endorsed the game-based nature of the app and its virtual reward system. The importance of app pain diary questions was established by content validity analysis. Compliance with the app, assessed during feasibility testing, was high (mean 81%, SD 22%) and adolescents from this phase of the study found the app likeable, easy to use, and not bothersome to complete.

Conclusions

A multifaceted usability approach demonstrated how the Pain Squad app could be made more appealing to children and adolescents with cancer. The game-based nature and built-in reward system of the app was appealing to adolescents and may have resulted in the high compliance rates and satisfaction ratings observed during clinical feasibility testing.

Attitudes of Hungarian adults toward use of opioids in pain management

Introduction: Though the most effective pain medication is already available in Western countries, cancer pain is often undertreated. The primary causes of this phenomenon are the fears of opioids, which haven’t been explored systematically in Hungary. Aims: Exploration of the attitudes toward opioids among healthy Hungarian adults. Methods: The participants (88/143 male/female, 29.47 ± 11.05 years) were asked to complete story of a patient who was suggested to accept opioid therapy. The stories were rated by independent raters on Likert-scales to access the strength of attitudes toward pain medication [1]. Results: Only an average 29.6% of the stories expressed positive attitudes, but varied fears (of addiction: 20.9%, nearing death: 10.5%, the inattention of the doctor: 4.7%), and hopes connected to alternative therapies (4.7%) emerged, too. Conclusions: The compliance of the patient and his/her family members is a very important factor of effective medical treatment, therefore individual attitudes must be considered. Orv. Hetil., 2013, 154, 455–463.

Knowledge and attitudes regarding neonatal pain among nursing staff of pediatric department: an Indian experience

Neonates receiving care in intensive care units are highly likely to experience pain due to investigations and/or treatments carried out by the health care providers. Neonates are a vulnerable population because they are unable to vocalize their pain. Unaddressed and mismanaged pain can not only affect the child's comfort, but also may alter the development and cognitive abilities of the child in a later part of his/her life. Therefore it is entirely the caregiver's responsibility to accurately assess and manage neonatal pain. We assessed and compared the knowledge and attitudes regarding neonatal pain among the nurses posted in the various units of a pediatric department [pediatric ward, pediatric intensive care unit (PICU) and neonatal intensive care unit (NICU)]. An appropriately modified Knowledge and Attitudes Survey Regarding Pain questionnaire was consensually validated, pretested, and then administered to the nursing staff of the pediatric department at a department at a hospital in Gujarat. Data were entered in Epi-Info and analyzed with the use of SPSS 14.0. The questionnaire was administered to 41 nurses working in the Department of Pediatrics, and the response rate was 97.5%. Mean age of the nurses in the study sample was 25.75 years (SD 5.513). The mean total score of the participants was 8.75 out of 17 (SD 2.549), which was unsatisfactory. The mean correct answer rate was 49.67% among the staff of NICU and 48.67% among the pediatric ward and PICU staff. The attitudes among the nurses were assessed. It was concluded that the nurses lack knowledge and that their attitudes also were hindering pain management. One of the barriers identified by the nurses was that physicians do not prescribe analgesics for managing neonatal pain. So not only the nursing staff, but all of the caregivers involved in neonatal care may be lacking in knowledge and hold perceptions and attitudes that hamper neonatal pain management.

Pediatric pain management education in medical students: impact of a web-based module

OBJECTIVE

Reports from the Institute of Medicine and American Medical Association's Pain and Palliative Medicine Specialty Section Council emphasize the need for pain management education in medical schools, yet training in pediatric pain management (PPM) is limited. In this pilot program, we evaluated the effectiveness of a web-based PPM module on knowledge, confidence, attitudes, and self-reported skills in medical students.

METHODS

Third- and fourth-year medical students (n = 291) completed the module and a knowledge test. Of these students, 53 completed a pre- and postsurvey of confidence, attitudes, and self-reported skills and module evaluation.

RESULTS

For the 291 students, knowledge scores increased significantly by 21.8 points (95% confidence interval [CI] = 19.7-23.8; p<0.001). The majority of scores on the survey items significantly increased postmodule, including: increase in confidence in assessing pain in pediatric patients (6% to 25%; p = 0.004), increase in responses of "strongly disagree" or "disagree" to the belief that opioids will delay diagnosis (62% to 85%; p = 0.005), and increase in responses of "frequently" or "very frequently" to "how often do you use behavioral instruments to assess pain severity?" (35% to 57%; p = 0.008). The majority reported they intend to make changes in behavior or practice (71%), and would recommend the module to fellow students (88%).

CONCLUSION

This pilot program supports the effectiveness of a web-based module in improving knowledge, confidence, attitudes, and self-reported skills in PPM. Evaluation responses indicate high-quality content. Further evaluation for sustained impact is warranted.