© U.S. Cancer Pain Relief Committee, 2002 0885-3924/02/$–see front matter Published by Elsevier, New York, New York PII S0885-3924(02)00509-2
Vol. 24 No. 4 October 2002 Journal of Pain and Symptom Management 415
Original Article
Relationship Between Pain-Specific Beliefs
and Adherence to Analgesic Regimens in
Taiwanese Cancer Patients:
A Preliminary Study
Yeur-Hur Lai, RN, PhD, Francis J. Keefe, PhD, Wei-Zen Sun, MD, PhD, Lee-Yuan Tsai, RN, MSN, Ping-Ling Cheng, MPH, PhD,
Jeng-Fong Chiou, MD, and Ling-Ling Wei, RN, MS
College of Nursing (Y.-H.L., P.-L.C., L.-L.W.), Taipei Medical University, Taipei, Taiwan; Duke University Medical Center (F.J.K.), Durham, North Carolina, USA;
Anesthesiology Department (W.-Z.S.), National Taiwan University Hospital, Taipei, Taiwan; Department of Nursing (L.-Y.T.), Makay Memorial Hospital, Taipei, Taiwan;
and Department of Radiation Oncology (J.-F.C.), Taipei Medical University Hospital, Taipei, Taiwan
Abstract
This pilot cross-sectional study aimed to 1) explore pain beliefs and adherence to prescribed analgesics in Taiwanese cancer patients, and 2) examine how selected pain beliefs, pain sensory characteristics, and demographic factors predict analgesic adherence. Pain beliefs were measured by the Chinese version of Pain and Opioid Analgesic Beliefs Scale—Cancer (POABS-CA) and the Survey of Pain Attitudes (SOPA). Analgesic adherence was measured by patient self-report of all prescribed pain medicine taken during the previous 7 days. Only 66.5% of hospitalized cancer patients with pain (n 194) adhered to their analgesic regimen. Overall, patients had relatively high mean scores in beliefs about disability, medications, negative effects, and pain endurance, and low scores in control and emotion beliefs. Medication and control beliefs significantly predicted analgesic adherence. Patients with higher medication beliefs and lower control beliefs were more likely to be adherent. Findings support the importance of selected pain beliefs in patients’ adherence to analgesics, suggesting that pain beliefs be assessed and integrated into pain management and patient education to enhance adherence. J Pain Symptom Manage 2002;24:415–423. © U.S. Cancer Pain Relief Committee, 2002.
Key Words
Cancer pain, beliefs, analgesics, adherence
Introduction
Cancer has been the leading cause of death in Taiwan since 1982,1 and pain is the major
problem experienced by these patients. More than 30% of newly diagnosed cancer patients and 40% of advanced cancer patients in Tai-wan have been estimated to suffer from pain.2,3
Address reprint requests to: Yeur-Hur Lai, RN, PhD, Col-lege of Nursing, Taipei Medical University, #250 Wu-Hsing Street, Taipei 110, Taiwan.
416 Lai et al. Vol. 24 No. 4 October 2002
Because pharmacological agents are consid-ered a cornerstone of cancer pain manage-ment, patients’ adherence (commonly known as compliance) to prescribed analgesics has been recognized as the key to successful cancer pain control. The high prevalence of cancer pain in Taiwan may reflect questionable adher-ence to prescribed analgesics among cancer patients.
Despite the importance of adhering to pre-scribed pain medicine or treatment in pain control, however, this issue has not received sufficient attention4 and only a few studies
have examined related problems, such as gesic non-adherence or hesitation to take anal-gesics in cancer patients with pain.5–8 There is
even less information regarding the status of adherence to prescribed analgesics in cancer patients in Taiwan. Studying analgesic adher-ence and related factors in cancer patients with pain is important to help health care profes-sionals better understand these phenomena and lead to more effective cancer pain control in Taiwan.
Various theories of health psychology per-taining to psychological stress and coping,9
theory of reasoned action,10 and a
cognitive-behavioral pain model11 have proposed that a
person’s belief system crucially influences his/ her behaviors. Belief has been proposed to be one of the key factors contributing to medica-tion adherence.12–14 According to the
cogni-tive-behavioral pain theory,11 the framework
on which this study is based, pain beliefs repre-sent a patient’s thoughts (cognition) about pain, and pain belief system reflects a person’s ap-praisal of a pain experience.11,15 Empirical
stud-ies have found that selective pain beliefs influ-ence a person’s reaction to, coping with, or adjustment to pain.16–21 However, relatively
lit-tle attention has been addressed to the influ-ence of pain belief systems on cancer patients’
adherence to prescribed analgesics. In the present study, therefore, pain beliefs com-monly found in cancer patients were analyzed: beliefs related to the use of pain medication (medication belief) or its adverse effects (nega-tive effect belief), beliefs related to the cultural value of pain reactions (pain endurance be-lief), and beliefs reflecting patients’ overall pain experiences (control, disability, and emo-tion beliefs). Please refer to Table 1 for a sum-mary of these terms.
Beliefs directly related to pain medications and side effects have been associated with the sequential use of pain medication. When pa-tients believe medication is appropriate or nec-essary for dealing with pain or medical prob-lems (medication belief), they tend to use more medication18 or medical services,19
ex-press their pain, seek help,22 and adhere better
to a medication regimen.23 They also use less
active pain coping.22 When patients are more
concerned about the adverse effects of analge-sics (negative effect belief), they tend to be more hesitant to report pain and use analge-sics.8,24–26
Pain beliefs related to social–cultural or eth-nic values also influence how patients deal with
pain27,28 and take analgesics. Belief that one
should endure pain (pain endurance belief) has been found in cultures where stoicism is highly valued29 or where expression of feelings
is not encouraged.30 This belief may lead
pa-tients to avoid medication entirely, or limit the frequency or reduce the dose of medica-tion.29,31
Beliefs related to patients’ overall percep-tions about their pain experiences, such as control beliefs (belief that one can control his/her pain), disability beliefs (belief that one becomes disabled by pain), and emotion be-liefs (belief that pain is related to one’s emo-tional status), have been found to be associated
Table 1
Abbreviations and Definitions of Adherence and Belief Variables
Abbreviation Definition
Adherence Regularly taking all pain medications as prescribed by a physician Negative effect belief Belief that opioids have negative effects on the body
Pain endurance belief Belief that one should endure as much pain as possible Control belief Belief that one can control his/her pain
Disability belief Belief that one becomes disabled by pain
Medication belief Belief that medication is best or necessary for dealing with pain Emotion belief Belief that pain is related to one’s emotional status
Vol. 24 No. 4 October 2002 Pain Beliefs and Analgesic Adherence 417
with patients’ subsequent pain coping. For ex-ample, control beliefs have been found to be correlated positively to patients’ use of relax-ation and exercise, 18 ignoring pain,32 active
pain coping,22 and negatively correlated to
help-seeking and passive pain coping.22
Disabil-ity beliefs have been positively related to pa-tients’ use of rest,18 pain behaviors,20
expres-sion of pain, help-seeking and passive pain coping,22 and negatively correlated to use of
exercise18 and active pain coping.22 Emotion
beliefs have been positively related to the use of help-seeking, expression of pain, and passive pain coping.22 The relationship between these
beliefs and analgesic adherence, however, re-mains unclear due to a paucity of empirical data and should be further examined.
Additionally, sensory characteristics of pain and demographic factors might also be related to selected pain beliefs and analgesic adher-ence due to the multidimensional features of pain phenomena.33 For example, sex, age, and
education have been found to be associated with medication use in chronically ill patients34–36
and in patients with cancer pain.25,26,37 The
re-lationship of these factors to adherence is un-clear and needs to be further examined.
Although limited research in Taiwan25,26,37
has found that cancer patients and their family caregivers’ concerns about analgesics were re-lated to their reluctance to report pain and hesitancy to take or administer analgesics, these studies have not directly examined patients’ adherence status. Furthermore, previous stud-ies did not simultaneously examine how differ-ent kinds of pain beliefs (other than concerns or beliefs regarding analgesics), pain charac-teristics, and demographic factors together in-fluence cancer patients’ analgesic adherence. The specific aims of the study, therefore, were to 1) examine the current status of pain be-liefs, analgesic adherence, and the characteris-tics of adherent and non-adherent groups of Taiwanese cancer patients with pain; and 2) identify factors that could predict adherence to analgesics.
Methods
Subjects and Setting
Data were collected from the oncology inpa-tient wards of four teaching hospitals in Taipei.
Eligible subjects were 1) adult cancer patients aware of their diagnosis and with cancer-related pain during current week; and 2) alert and oriented patients, who were able to sign the consent form. Patients who had had sur-gery within a month of data collection were ex-cluded.
Measures
Analgesic Adherence. Although drug level monitoring has been recognized as the most accurate method for assessing adherence,38 it
was difficult to apply this method to cancer pa-tients of the current study because of the com-plicated medications prescribed, the limited availability and expense of the measures,38,39
custody of specimens, and complexity of inter-preting laboratory data.39 In the current study,
therefore, adherence was measured by patient self-report of prescribed pain medications taken during the previous seven days. Analge-sic adherence was defined as “regularly taking all pain medications as prescribed by the physi-cian.” A one-item self-report questionnaire with five options was developed. The five anal-gesic-taking options included: 1) regularly took all pain medications, 2) regularly took some prescribed pain medications, 3) took all pre-scribed pain medications after an increase in pain, 4) took some medications after an in-crease in pain, and 5) did not take prescribed pain medication most of the time. If a patient took all prescribed pain medication regularly, he/she would be further categorized as adher-ent. All others were categorized as non-adher-ent.
The validity and reliability of adherence self-report measures can be enhanced by decreas-ing pressure on patients, such by questiondecreas-ing them in a sensitive, non-threatening way and assuring them of confidentiality.40 These
strate-gies were applied in this study by asking pa-tients, “In general, how did you take your pain medicine during the last seven days?” and as-suring them about confidentiality. In addition, patients were re-tested over a 48-hour interval to confirm the consistency of their reports. A 0.93 test–retest coefficient was found.
Pain Beliefs. Six pain beliefs were measured by subscales selected from Pain and Opioid An-algesic Beliefs Scale—Cancer (POABS-CA)41
418 Lai et al. Vol. 24 No. 4 October 2002
and Survey of Pain Attitude (SOPA).18,19 The
POABS-CA, based on Agency for Health Care Policy and Research (AHCPR)42 cancer pain
guidelines and culturally related pain beliefs observed in clinical settings, was designed to measure negative effect beliefs about opioids (belief that opioids will have negative effects on the body) and pain endurance beliefs (be-lief that one should endure as much pain as possible). The POABS-CA is an 10-item Likert-type scale with a 0–4 scoring system, where 0 in-dicates “strongly disagree” and 4 represents “strongly agree.” The higher the score on the POABS-CA, the more negative effect beliefs and endurance beliefs the patient has about cancer pain and opioids. Promising psycho-metric properties of the POABS-CA included satisfactory content validity, clear two-factor structure, internal consistency reliability (Cron-bach’s alpha .84) and a stable 48-hour inter-val test–retest reliability (r .94).41 In the
present study, subscales that measured nega-tive effect and pain endurance beliefs showed acceptable internal consistency (0.74 and 0.80, respectively).
Four other pain beliefs (control, emotional, medication, and disability beliefs) were mea-sured by the Survey of Pain Attitude (SOPA).19
The SOPA is a Likert-type scale ranging from 0–4, where 0 indicates “this is very untrue for me” and 4 represents “this is very true for me.” The SOPA has been shown to have satisfactory psychometrics when measured in chronic pain patients.18 Permission to use and translate the
SOPA to a Chinese version was received from Dr. Jensen (personal communication). The SOPA was translated and back-translated be-tween English and Chinese based on principles of instrument translation across different lan-guages.43 The SOPA has been demonstrated in
pilot testing to have satisfactory psychometric properties.21 In the current study, the internal
consistency reliabilities of the four belief sub-scales (control, emotional, medication, and disability beliefs) were 0.81, 0.78, 0.70, and 0.75, respectively. Control belief was negatively correlated to disability belief and medication belief (r 0.56, P 0.0001; 0.40, P
0.0001, respectively). Disability belief was posi-tively correlated to medication belief (r 0.40,
P 0.0001). These correlations lend further support for the proposed construct relation-ship among the SOPA subscales.
Pain Sensory Characteristics. Average pain intensity, worst pain intensity (during the pre-vious seven days), and pain duration were as-sessed. Pain intensity was measured on a 0–10 Numerical Rating Scale (NRS), where 0 indi-cates “no pain at all” and 10 represents “the worst pain I can imagine.” Pain duration was determined by asking patients, “How many months have you had this pain?”
Demographic Factors. A background infor-mation form was used to collect demographic data. Among these factors, age, sex, and educa-tion were chosen as variables to be further ex-amined in predicting analgesic adherence.
Data Analysis
Descriptive statistical analysis was used to an-alyze adherence rate, the distribution of non-adherent patterns, and means for each pain belief. For descriptive purposes, bivariate Pear-son’s correlations were used to analyze rela-tionships between pain beliefs and all other pain sensory and demographic variables. The
t-test or Chi-Square test was used to compare differences between adherent and non-adher-ent groups in the six pain beliefs, pain inten-sity, duration, age, years of education, and sex. A stepwise logistic regression was further used to determine the best predictors of analgesic adherence.
Results
Subject Characteristics
A convenience sample of 194 subjects, re-cruited from four teaching hospitals in Taipei, included 119 men (61.3%) and 75 women (38.7%). Among these subjects, 88.7% were married, with ages from 18–82 years (M 57; SD 13.8). Education levels ranged from no formal education (10.3%) to college or higher (41.3%), with a mean of 8.9 years (SD 5.0). Participant diagnoses included lung cancer (31.4%), primary liver cancer (13.9%), breast cancer (7.2%), gastric cancer (6.2%), colon and rectum cancer (6.2%), gynecological can-cer (5.6%) and all others, with the majority in stage IV (70.6%). Patients experienced 3.72 months of pain (SD 4.11), with an average intensity of 3.49 (SD 1.77), and pain
inten-Vol. 24 No. 4 October 2002 Pain Beliefs and Analgesic Adherence 419
sity bursts up to 7.26 (SD 2.39) during the previous seven days.
Characteristics of Adherent and Non-Adherent Groups
Only two-thirds of participants (66.5%) fully adhered to prescribed analgesics. Among the four non-adherent patterns (Table 2), the larg-est subgroup was “did not take pain medica-tion most of the time” (n 27).
In general, patients in this study had rela-tively high scores in medication beliefs (M 2.74, SD 0.55), pain endurance beliefs (M 2.59, SD 0.77), disability beliefs (M 2.56, SD 0.55), and negative effects beliefs (M 2.45, SD 0.42). These patients, however, per-ceived themselves as having relatively little con-trol of their pain (M 1.52, SD 0.48), and did not think of their pain as emotion related (M 1.83, SD 0.58).
Patients in the adherent group had signifi-cantly higher medication and disability beliefs, lower control beliefs and longer duration of pain, and were older and less educated than those in the non-adherent group (Table 3).
There were no differences in pain endur-ance beliefs, negative effect beliefs, and pain intensity scores between the two groups. Relationships Among Pain Beliefs, Pain Sensory Characteristics, and Demographic Factors
For descriptive purposes, relationships among pain beliefs, pain sensory characteristics, and demographic factors were examined by Pear-son’s correlation and t-test. The results (Table 4) show that the worst pain intensity and aver-age pain intensity all correlated positively to disability and medication beliefs and corre-lated negatively to control beliefs. Patients with higher worst pain intensity were likely to have lower pain endurance beliefs. Older people had higher negative effective beliefs, pain
en-durance beliefs, and medication beliefs and lower control beliefs than those who were younger. Patients with higher education had higher control and emotion beliefs but lower pain endurance beliefs than those less edu-cated. Men had significantly higher medica-tion beliefs than women; the respective means were 2.81 (SD 0.51) and 2.62 (SD 0.60) (t 2.28, d.f. 192, P 0.02).
Factors Predicting Analgesic Adherence
Control and medication beliefs were the only two variables that could significantly pre-dict cancer patients’ analgesic adherence, when analyzed by a stepwise logistic regression. The higher a patient’s control belief, the less likely he/she was to adhere to prescribed analgesics (odds ratio 0.393, P 0.0001). In contrast, the higher a patient’s medication belief, the more likely he/she was to adhere to the pre-scribed pain medicine (odds ratio 2.153, P
0.02). None of the pain sensory and demo-graphic factors, however, could significantly predict analgesic adherence except possibly pain duration, which approached significance (P 0.09).
Discussion
The major purpose of this study was to ex-amine the relationship between pain beliefs and adherence in Taiwanese cancer patients with pain. The results revealed that only 66.5% of these patients adhered to prescribed analge-sics, which is similar to other studies6,7 that
re-ported adherence ranging from 60–72%. At-tention should be drawn, however, to the fact that all our subjects were hospitalized patients and were expected to take analgesics as sched-uled. The problem of non-adherence is likely to be worse in cancer patients at home without 24-hour professional care. The unsatisfactory adherence rate in this study strongly suggests
Table 2
Distribution of Analgesic-Taking Patterns (n 194)
Analgesic-Taking Patterns Frequency Percentage
Regularly took all pain medication (Adherence) 129 66.5
Regularly took some pain medication 5 2.6
Took all pain medication after an increase in pain 19 9.8
Took some pain medication after an increase in pain 14 7.2
420 Lai et al. Vol. 24 No. 4 October 2002
that more attention should be focused on this problem to increase the effectiveness of using pain medicine.
Pain beliefs represent patients’ own concep-tualization of their pain experience.44 This
study shows, however, a negative pain experi-ence in those patients having relatively high scores in disability beliefs, but low scores in control beliefs. Regarding analgesics, patients believed medication was the best way to deal with cancer pain, but they also strongly be-lieved that analgesics caused negative effects and that adults should endure as much pain as possible. Their concerns about the negative ef-fects of analgesics and beliefs about enduring pain were similar to findings on “patients’ bar-riers to pain control.”8,25,26
The current study, however, found no differ-ences between adherent and non-adherent groups in negative effect and pain endurance beliefs, which is inconsistent with previous findings.25,26 In other studies, patients’
hesi-tancy to use analgesics was associated with their concern about using analgesics. This inconsis-tency might be due to different measures of analgesic-taking behaviors. In Lin and Ward’s25
and Lin’s26 studies, patients reported their
hes-itancy to take analgesics in the previous month.25,26 Because this measure did not ask
whether or not patients actually took analge-sics as prescribed, it might therefore assess both patient intention and analgesic-taking behavior. In the current study, patients’ self-reported analgesic-taking status was measured. The inconsistency could be explained by pro-posed differences between intentions and be-havior.10,45 In brief, the influence of pain
be-liefs on individuals’ intention to adhere and adherent behaviors might not have the same mechanism. A lack of difference in negative ef-fect and pain endurance beliefs in the current study might, however, mean that these two be-liefs reflect similar concerns and phenomena among all cancer patients with pain.
Table 3
Characteristic Differences Between Adherent and Non-Adherent Groups Pain Beliefs Adherence Mean (SD) Non-adherence Mean (SD) t P Medication belief 2.84 (0.49) 2.54 (0.61) 3.54 0.0006 Disability belief 2.66 (0.48) 2.35 (0.64) 3.40 0.0010 Control belief 1.43 (0.44) 1.71 (0.52) 4.01 0.0001
Negative effect belief 2.45 (0.39) 2.44 (0.47) 0.05 nsa
Pain endurance belief 2.53 (0.76) 2.72 (0.76) 1.64 ns
Emotion belief 1.84 (0.56) 1.82 (0.62) 0.14 ns
Pain intensity at worst 7.45 (2.25) 6.88 (2.61) 1.58 ns
Pain intensity in average 3.53 (1.73) 3.42 (1.84) 0.41 ns
Pain duration 4.17 (4.54) 2.84 (2.91) 2.47 0.0001
Years of education 8.36 (5.03) 10.05 (4.85) 2.22 0.03
Age 58.54 (13.46) 53.98 (14.15) 2.19 0.03
aNot significant.
Table 4
Correlations: Pain Beliefs versus Pain Sensory and Demographic Factors
Variable Age Education (years) Average intensity Worst intensity Duration Control belief 0.18a 0.16a 0.39e 0.46e 0.10 Disability belief 0.06 0.12 0.33e 0.38e 0.06 Medication belief 0.15a 0.06 0.14a 0.35e 0.11 Emotion belief 0.06 0.24d 0.10 0.05 0.01
Endurance pain belief 0.21d 0.20b 0.08 0.22c 0.08
Negative effect belief 0.15a 0.07 0.05 0.02 0.04
aP 0.05. bP 0.01. cP 0.005. dP 0.001. eP 0.0005.
Vol. 24 No. 4 October 2002 Pain Beliefs and Analgesic Adherence 421
Analgesic adherence could be only predicted by higher medication beliefs and lower control beliefs. This result might best be understood in light of Claesson et al.’s definition46 of
adher-ence as “a positive act . . . because of a per-ceived benefit.” Because subjects in this study, on average, had the worst pain intensity up to 7.26 (SD 2.39), the necessity of analgesics is obvious. Higher medication beliefs reflect the perceived benefit of using medication among those patients who adhered well.
The fact that patients with lower control be-lief adhered better to prescribed analgesics might, however, be because they did not have any choice but to take analgesics as scheduled to get better pain control. This inference could be particularly true because control beliefs were negatively correlated to worst pain inten-sity, average pain intensity (Table 4), and dis-ability beliefs (r 0.40). Taken together, our results reflect a perceived benefit of using med-ication to control pain weighed against beliefs about the negative concerns of using analge-sics and the value of enduring pain. This find-ing is similar to Horne and Weinmans’ study,23
where adherence was best predicted by neces-sity/concern difference scores regarding treat-ment.
Caution should be exercised in applying the result of a negative relationship between con-trol beliefs and adherence. In order to main-tain effective pain control, the challenge to health care professionals is how to simulta-neously enhance patients’ sense of control over pain and strengthen accurate knowledge and concepts about taking analgesics as prescribed. Furthermore, patients with higher education or lower pain intensity had higher control be-liefs and they tended to be less adherent (Ta-ble 4). Health care professionals should be particularly aware of patients with these char-acteristics and emphasize the importance of adherence to them.
For example, clinicians can educate patients having high control beliefs by saying, “Some people take a very proactive position and feel they can do many things to control their pain. These other ways, such as relaxation, mild ex-ercise, and so forth, are very important and helpful for good pain management. However, research has shown that sometimes people who like to take charge of their health, or while their pain doesn’t bother them, may avoid
tak-ing or not take pain medicine. I’d like to em-phasize how important it is to regularly take your pain medicine. Taking pain medicine reg-ularly maintains a stable analgesic concentra-tion in your blood, which makes pain control more effective. If you stop taking pain medi-cine when you feel less pain, the pain could come back sooner. I’d like to encourage you to take your pain medicine, in addition to your own pain control methods, to manage the pain. Discuss your pain with your doctors or nurses, whether it gets worse or improves, to adjust your pain medicine. By combining regu-lar use of pain medicine with other strategies, you will feel even more in control of your pain, have less pain, and have better quality of life.”
Pain duration was the only sensory factor with the potential to predict analgesic adherence (P 0.09). Patients with longer pain duration tended to adhere better to prescribed analge-sics, in agreement with Hinkley and Jaremko,47
who found that longer pain duration predicted more frequent use of medical services. Al-though none of the pain sensory and demo-graphic factors significantly predicted adher-ence to analgesics, most of these factors were correlated to several pain beliefs (Table 4) and their influence on patient pain beliefs should not be neglected. In other words, pain beliefs might reflect a person’s final integration of re-lated demographic and pain sensory factors into their pain experience and thus influence analgesic adherence. A comprehensive clini-cal assessment, including pain beliefs and fac-tors related to pain beliefs, should be used to improve analgesic adherence.
While these results offer evidence for the in-fluence of selected pain beliefs on cancer pa-tients’ adherence to prescribed analgesics, sev-eral limitations still remain. Despite the many strategies used in our study to increase the ac-curacy of self-reported adherence, other meth-ods should be combined with self-report in fu-ture studies—for example, double checking analgesic-taking behavior with family mem-bers, checking patients’ knowledge about his/ her pain medicines, and having staff nurses count patient pill consumption. In addition, due to the preliminary nature of this study, other factors that could potentially influence adherence12 were not measured out of
con-cern for burdening cancer patients with a long questionnaire. Finally, although pain intensity
422 Lai et al. Vol. 24 No. 4 October 2002
and demographic factors were correlated to several pain beliefs in the current study, the mechanisms of building particular pain beliefs remain mostly unclear. Future research should further examine these factors, such as family influence,48 the relationship between patient
and therapist, side effects from analgesics, complexity of medication prescribed, knowl-edge about analgesics,13 and related pain
sen-sory characters and pain beliefs.
In conclusion, despite the limitations of this study, the results provide data about the cur-rent status of analgesic adherence and evi-dence of the influential role of selected pain beliefs, for example, medication and control beliefs in the current study, in cancer patients in Taiwan. The preliminary findings also sup-port and provide a challenge to develop and test the effects of cognitive-behavioral models, such as changing particular pain beliefs, to en-hance cancer patient adherence to pain medi-cation.
Acknowledgments
The authors would like to express their grati-tude to the patients who participated in the study and to Claire Baldwin for her English ed-iting of this manuscript. This study was par-tially supported by the National Science Coun-cil in Taiwan (NSC87-2314-B-038-019).
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