This study is the first, to our knowledge, to describe the barriers to cancer pain management and to determine the predictors of these barriers in a community sample of Chinese American patients. As shown in , the mean barrier score in this sample was equivalent to that reported by a Taiwanese sample of cancer patients11
but higher than that reported by a sample of White American cancer patients.8
In fact, the Chinese American cancer patients had a total BQ mean score that was 31% higher than that of the White American cancer patients. This difference equates with a moderate to large effect size (i.e., d=0.72)47
and suggests a clinically significant difference in barrier scores between the two groups of patients.48, 49
Comparison of the Rankings (Highest to lowest) of Subscale and Total Barriers Questionnaire Scores Among Three Studies
In this study, the four barriers with the highest mean scores were: concerns about developing tolerance to the pain medication; concerns about taking the pain medication on an ATC versus on an as needed basis (i.e., PRN); concerns about cancer pain being an indicator of disease progression; and concerns about the development of addiction. The ranking of these four barriers is consistent with previous studies of Taiwanese cancer patients.9, 11
In contrast, the barriers with the highest mean scores in a study of White American cancer patients were concerns about: disease progression; side effects of the pain medicine; addiction; and being viewed as a good patient.8
It is interesting to note that for both the Chinese American and Taiwanese cancer patients concerns about the development of tolerance was the highest ranking barrier while it ranked seventh in the study of White American cancer patients. This finding suggests that the Chinese Americans in this study perceived similar barriers to cancer pain management as patients in Asia and is consistent with the strong Asian identification in this sample. However, these discrepancies could be explained by differences in the clinical characteristics of the samples. In the study by Ward and colleagues,8
patients were terminally ill, while in this study and in those in Taiwan,11
the Chinese patients were undergoing active not palliative treatment. Additional research is needed to determine if barriers to cancer pain management change across the disease trajectory within and across ethnic groups.
Although one study found that older Taiwanese patients and patients with less education reported higher barriers to cancer pain management,9
these relationships were not supported in the current investigation. The differences between the two studies may be explained by the fact that the Chinese Americans in this study were older and better educated (mean age = 62.5 ± 11.6 years; only 18% of the patients had less than a high school education) than the patients in Taiwan (mean age = 47 ± 15.3 years; 31% of the patients had less than a high school education).
In this study, women reported higher religious fatalism scores (i.e., pain comes from God) and men reported higher levels of concern about their pain distracting their physician from treating their disease. These findings are not consistent with previous reports that evaluated for gender differences in barriers to pain management.6, 9, 50
In two of these studies,6, 50
male patients reported higher fatalism scores (i.e., pain is an inevitable part of cancer) than female patients. However, in both of these studies the “religious fatalism” subscale was not included in the BQ. In addition, while Lin and Ward 9
reported that women were more concerned about the development of tolerance than men, this association was not found in the current study. The reasons for the inconsistencies in gender differences among the studies are not readily apparent and warrant further investigation.
The barrier scores reported by the Chinese Americans in this study were relatively high and may indicate reluctance on the part of these patients to report their pain to clinicians and to adhere to their analgesic regimen.9
It should be noted that approximately 60% of the patients in this study, based on their PMI scores, were not receiving adequate treatment for their cancer pain. In addition, patients with lower PMI scores reported higher scores on the “fatalism” and the “distract MD” subscales, which is consistent with findings from a previous study.9
Furthermore, in this study, three of the four barriers with the highest scores were concerns related to analgesic use (i.e., tolerance, time for dosage, and addiction) while the barriers in a study of White American cancer patients were evenly divided between concerns about analgesic use (i.e., side effects, addiction) and perceived barriers that hindered patients’ communication with their health care provider about their pain (i.e., desire to be viewed a good patient, disease progression).8
Previous research showed that concerns about analgesic use can contribute to poor adherence with an analgesic regimen.51
This study is the first to evaluate the relationship between mood disturbance and barriers to cancer pain management in Chinese American cancer patients. While the mean anxiety and depression scores in this sample did not reach the cut off score of 11 for the HADS, higher anxiety and depression scores were associated with higher tolerance and religious fatalism subscale scores. Because of the relatively small sample size, these findings need to be confirmed in future studies.
This study also is the first to examine the relationship between Chinese Americans’ acculturation level and perceived barriers to cancer pain management. Patients with lower acculturation levels reported significantly higher tolerance, fatalism, and disease progression subscale scores (r=0.380, P=<0.01; r=−0.291, P=<0.05; r=−0.377, P<0.01), respectively). It should be noted that even though the Chinese Americans in this study had lived in the U.S. for a relatively long period of time (i.e., mean 18 ± 10 years; 35% of the sample lived in the U.S. for over 10 years), their acculturation scores suggested that they retained a strong Chinese or Asian identification. Future studies need to examine the relationships between barriers to cancer pain management and acculturation in samples of Chinese Americans with a broader range of acculturation scores.
In terms of the predictors of barriers to cancer pain management, even with the relatively small sample size, 21.3% of the variance in the total BQ score was explained by more years of education, lower level of acculturation, less than adequate analgesic prescription, and higher levels of depression. Patients’ level of acculturation and depression were the strongest predictors in the regression model. While these findings warrant replication, clinicians may be able to use these characteristics to identify Chinese Americans who have greater concerns about cancer pain management and who warrant additional interventions to improve the management of their cancer pain.
It should be noted that while language could have been a potential a barrier to patient recruitment, the use of trained trilingual translators and the establishment of collaborations with the Chinese American community facilitated the recruitment of a sufficient number of patients to begin to explore Chinese American patients’ perceived barriers to cancer pain management. Researchers who want to conduct studies with Chinese Americans need to pay careful attention to these methodologic issues and spend the time forming partnerships with the key stakeholders in the Chinese American community.
Several limitations of this study should be noted. The relatively small sample size and the homogeneity of the sample in terms of acculturation level limit the generalizability of the study findings. In addition, because of the relatively small sample and the characteristics of the patients, the findings from this exploratory study need to be interpreted with caution and warrant replication in larger and more heterogeneous samples of Chinese Americans, particularly in terms of their acculturation levels. Finally, because all of the patients were from a community setting in a large urban area, these findings cannot be generalized to hospitalized patients or to patients in more rural areas.
Despite these limitations, the findings from this study suggest that Chinese American patients experience barriers to cancer pain management that are more similar to those reported by Taiwanese cancer patients than to White American cancer patients. Additional research is warranted to explore the relationships between patient education level, socioeconomic status, acculturation level and health beliefs and various aspects of cancer pain management. These findings can be used to design and test culturally and linguistically appropriate pain management programs for Chinese American patients and family members. Additional research is warranted to determine which educational strategies are most effective for reducing barriers to cancer pain management in Chinese American patients. This research will require continued collaboration with members of the Chinese community to insure its success.