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Psychometric Evaluation of the Pain Attitudes Questionnaire-Revised for People With Advanced Cancer

  • Kenneth Mah
    Affiliations
    Department of Supportive Care, Princess Margaret Cancer Centre, Toronto, Ontario, Canada

    Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada
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  • Kim T. Tran
    Affiliations
    Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada

    University College Dublin, Dublin, Ireland
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  • Lynn R. Gauthier
    Affiliations
    Department of Supportive Care, Princess Margaret Cancer Centre, Toronto, Ontario, Canada

    School of Kinesiology and Health Science, Faculty of Health, York University, Toronto, Ontario, Canada
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  • Gary Rodin
    Affiliations
    Department of Supportive Care, Princess Margaret Cancer Centre, Toronto, Ontario, Canada

    Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
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  • Camilla Zimmermann
    Affiliations
    Department of Supportive Care, Princess Margaret Cancer Centre, Toronto, Ontario, Canada

    Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
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  • David Warr
    Affiliations
    Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada

    Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
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  • S. Lawrence Librach
    Affiliations
    Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada

    Temmy Latner Centre for Palliative Care, Mount Sinai Hospital, Toronto, Ontario, Canada
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  • Malcolm Moore
    Affiliations
    British Columbia Cancer Agency, Vancouver, British Columbia, Canada
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  • Frances A. Shepherd
    Affiliations
    Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada

    Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
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  • Lucia Gagliese
    Correspondence
    Address reprint requests to Lucia Gagliese, PhD, School of Kinesiology and Health Science, York University, 367 Bethune, 4700 Keele St, Toronto, Ontario M3J 1P3, Canada.
    Affiliations
    Department of Supportive Care, Princess Margaret Cancer Centre, Toronto, Ontario, Canada

    Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada

    School of Kinesiology and Health Science, Faculty of Health, York University, Toronto, Ontario, Canada

    Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada

    Department of Anesthesia, Mount Sinai Hospital, Toronto, Ontario, Canada
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      Highlights

      • The Pain Attitudes Questionnaire-Revised is valid for use in advanced cancer.
      • Older patients were not more stoic or cautious than younger patients about pain.
      • Younger patients reported greater stoic-superiority than older patients.
      • Stoicism–pain correlations differed in direction between age groups.

      Abstract

      Pain-related stoicism and cautiousness are theorized to be more prevalent in older than younger patients and to lead to greater pain under-reporting and consequently inadequate pain management in older patients. The Pain Attitudes Questionnaire-Revised (PAQ-R), which measures 5 pain-related stoicism (fortitude, concealment, superiority) and cautiousness (self-doubt, reluctance) factors in chronic pain, can help test this hypothesis in advanced cancer but requires validation. We conducted a psychometric evaluation of the PAQ-R in 155 younger (younger than 60 years) and 114 older (aged 60 years and older) patients with advanced cancer. Participants showed disagreement with self-doubt items and floor effects with the subscale. Confirmatory factor analyses revealed good fit of the PAQ-R's 5 factors to younger and older groups' data but collinearity between fortitude and concealment. Multisample confirmatory factor analyses supported partial scalar invariance between age groups. Few hypothesized age-related differences were observed. Younger patients reported higher superiority scores than older patients. Whereas older patients showed greater fortitude and superiority with lower average pain intensity, younger patients showed greater concealment or fortitude with greater worst and average pain intensity. Furthermore, whereas older patients displayed greater superiority with lower interference in relations with others, younger patients displayed greater concealment and superiority with greater interference in walking ability and greater concealment and self-doubt with more interference in relations with others. Cross-validation of the PAQ-R's factor structure and identification of pathways to the factors and effect on pain-related outcomes using multivariate approaches are warranted.

      Perspective

      This article presents the psychometric properties of a measure of 2 particular pain-related attitudes. The measure can help clarify whether these attitudes adversely influence pain reporting in older patients with advanced cancer as hypothesized and, in turn, explain the inadequate pain management frequently reported with this clinical group.

      Key words

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      References

        • Abdulla A.
        • Adams N.
        • Bone M.
        • Elliott A.M.
        • Gaffin J.
        • Jones D.
        • Knaggs R.
        • Martin D.
        • Sampson L.
        • Schofield P.
        Guidance on the management of pain in older people.
        Age Ageing. 2013; 42: i1-i57
        • Anderson K.O.
        • Richman S.P.
        • Hurley J.
        • Palos G.
        • Valero V.
        • Mendoza T.R.
        • Gning I.
        • Cleeland C.S.
        Cancer pain management among underserved minority outpatients: Perceived needs and barriers to optimal control.
        Cancer. 2002; 94: 2295-2304
        • Baker F.
        • Haffer S.C.
        • Denniston M.
        Health-related quality of life of cancer and noncancer patients in Medicare managed care.
        Cancer. 2003; 97: 674-681
        • Bentler P.M.
        EQS 6 Structural Equations Program Manual.
        Multivariate Software, Inc, Encino2006
        • Byrne B.M.
        • Shavelson R.J.
        • Muthén B.
        Testing for the equivalence of factor covariance and mean structures: The issue of partial measurement invariance.
        Psychol Bull. 1989; 105: 456-466
        • Byrne B.M.
        • Stewart S.M.
        The MACS approach to testing for multigroup invariance of a second-order structure: A walk through the process.
        Struct Equation Model. 2006; 13: 287-321
        • Cagle J.G.
        • Zimmerman S.
        • Cohen L.W.
        • Porter L.S.
        • Hanson L.C.
        • Reed D.
        EMPOWER: An intervention to address barriers to pain management in hospice.
        J Pain Symptom Manage. 2015; 49: 1-12
        • Caltagirone C.
        • Spoletini I.
        • Gianni W.
        • Spalletta G.
        Inadequate pain relief and consequences in oncological elderly patients.
        Surg Oncol. 2010; 19: 178-183
        • Caraceni A.
        • Martini C.
        • Zecca E.
        • Portenoy R.K.
        • Ashby M.A.
        • Hawson G.
        • Jackson K.A.
        • Lickiss N.
        • Muirden N.
        • Pisasale M.
        • Moulin D.
        • Schulz V.N.
        • Rico Pazo M.A.
        • Serrano J.A.
        • Andersen H.
        • Henriksen H.T.
        • Mejholm I.
        • Sjogren P.
        • Heiskanen T.
        • Kalso E.
        • Pere P.
        • Poyhia R.
        • Vuorinen E.
        • Tigerstedt I.
        • Ruismaki P.
        • Bertolino M.
        • Larue F.
        • Ranchere J.Y.
        • Hege-Scheuing G.
        • Bowdler I.
        • Helbing F.
        • Kostner E.
        • Radbruch L.
        • Kastrinaki K.
        • Shah S.
        • Vijayaram S.
        • Sharma K.S.
        • Devi P.S.
        • Jain P.N.
        • Ramamani P.V.
        • Beny A.
        • Brunelli C.
        • Maltoni M.
        • Mercadante S.
        • Plancarte R.
        • Schug S.
        • Engstrand P.
        • Ovalle A.F.
        • Wang X.
        • Alves M.F.
        • Abrunhosa M.R.
        • Sun W.Z.
        • Zhang L.
        • Gazizov A.
        • Vaisman M.
        • Rudoy S.
        • Gomez Sancho M.
        • Vila P.
        • Trelis J.
        • Chaudakshetrin P.
        • Koh M.L.
        • Van Dongen R.T.
        • Vielvoye-Kerkmeer A.
        • Boswell M.V.
        • Elliott T.
        • Hargus E.
        • Lutz L.
        • Working Group of an IASP Task Force on Cancer Pain
        Breakthrough pain characteristics and syndromes in patients with cancer pain. An international survey.
        Palliat Med. 2004; 18: 177-183
        • Caraceni A.
        • Portenoy R.K.
        An international survey of cancer pain characteristics and syndromes. IASP Task Force on Cancer Pain. International Association for the Study of Pain.
        Pain. 1999; 82: 263-274
        • Cataldo J.K.
        • Paul S.
        • Cooper B.
        • Skerman H.
        • Alexander K.
        • Aouizerat B.
        • Blackman V.
        • Merriman J.
        • Dunn L.
        • Ritchie C.
        • Yates P.
        • Miaskowski C.
        Differences in the symptom experience of older versus younger oncology outpatients: A cross-sectional study.
        BMC Cancer. 2013; 13: 1-16
        • Cheung W.Y.
        • Le L.W.
        • Gagliese L.
        • Zimmermann C.
        Age and gender differences in symptom intensity and symptom clusters among patients with metastatic cancer.
        Support Care Cancer. 2010; 19: 417-423
        • Cleeland C.S.
        • Gonin R.
        • Hatfield A.K.
        • Edmonson J.H.
        • Blum R.H.
        • Stewart J.A.
        • Pandya K.J.
        Pain and its treatment in outpatients with metastatic cancer.
        N Engl J Med. 1994; 330: 592-596
        • Cleeland C.S.
        • Ryan K.M.
        Pain assessment: Global use of the Brief Pain Inventory.
        Ann Acad Med Singapore. 1994; 23: 129-138
        • Cornally N.
        • McCarthy G.
        Chronic pain: The help-seeking behavior, attitudes, and beliefs of older adults living in the community.
        Pain Manage Nurs. 2011; 12: 206-217
        • Davies A.
        • Zeppetella G.
        • Andersen S.
        • Damkier A.
        • Vejlgaard T.
        • Nauck F.
        • Radbruch L.
        • Sjolund K.F.
        • Stenberg M.
        • Buchanan A.
        Multi-centre European study of breakthrough cancer pain: Pain characteristics and patient perceptions of current and potential management strategies.
        Eur J Pain. 2011; 15: 756-763
        • Deshields T.L.
        • Tait R.C.
        • Manwaring J.
        • Trinkaus K.M.
        • Naughton M.
        • Hawkins J.
        • Jeffe D.B.
        The Cancer Pain Inventory: Preliminary development and validation.
        Psychooncology. 2010; 19: 684-692
        • Dunham M.
        • Collins K.
        • Allmark P.
        Older people’s cancer pain experience: Preliminary findings from a qualitative study.
        BMJ Support Palliat Care. 2014; 4: A41
        • Ellis J.
        • Lin J.
        • Walsh A.
        • Lo C.
        • Shepherd F.A.
        • Moore M.
        • Li M.
        • Gagliese L.
        • Zimmermann C.
        • Rodin G.
        Predictors of referral for specialized psychosocial oncology care in patients with metastatic cancer: The contributions of age, distress, and marital status.
        J Clin Oncol. 2009; 27: 699-705
        • Emanuel E.J.
        • Wendler D.
        • Grady C.
        What makes clinical research ethical?.
        JAMA. 2000; 283: 2701-2711
        • Fainsinger R.L.
        • Fairchild A.
        • Nekolaichuk C.
        • Lawlor P.
        • Lowe S.
        • Hanson J.
        Is pain intensity a predictor of the complexity of cancer pain management?.
        J Clin Oncol. 2009; 27: 585-590
        • Flora D.B.
        • Curran P.J.
        An empirical evaluation of alternative methods of estimation for confirmatory factor analysis with ordinal data.
        Psychol Methods. 2004; 9: 466-491
        • Gagliese L.
        Pain and aging: The emergence of a new subfield of pain research.
        J Pain. 2009; 10: 343-353
        • Gagliese L.
        • Jovellanos M.
        • Zimmermann C.
        • Shobbrook C.
        • Warr D.
        • Rodin G.
        Age-related patterns in adaptation to cancer pain: A mixed-method study.
        Pain Med. 2009; 10: 1050-1061
        • Gammons V.
        • Caswell G.
        Older people and barriers to self-reporting of chronic pain.
        Br J Nurs. 2014; 23: 274-278
        • Gauthier L.R.
        • Gagliese L.
        Assessment of pain in older persons.
        in: Turk D.C. Melzack R. Handbook of Pain Assessment. Guilford Press, New York2011: 242-259
        • Gauthier L.R.
        • Rodin G.
        • Zimmermann C.
        • Warr D.
        • Librach S.L.
        • Moore M.
        • Shepherd F.A.
        • Gagliese L.
        The communal coping model and cancer pain: The roles of catastrophizing and attachment style.
        J Pain. 2012; 13: 1258-1268
        • Gauthier L.R.
        • Rodin G.
        • Zimmermann C.
        • Warr D.
        • Moore M.
        • Shepherd F.
        • Gagliese L.
        Acceptance of pain: A study in patients with advanced cancer.
        Pain. 2009; 143: 147-154
        • Gauthier L.R.
        • Young A.
        • Dworkin R.H.
        • Rodin G.
        • Zimmerman C.
        • Warr D.
        • Librach L.
        • Moore M.
        • Shepherd F.A.
        • Riddell R.P.
        • Macpherson A.
        • Melzack R.
        • Gagliese L.
        Validation of the Short-Form McGill Pain Questionnaire-2 in younger and older people with cancer pain.
        J Pain. 2014; 15: 756-770
        • Gibson S.J.
        • Helme R.D.
        Age-related differences in pain perception and report.
        Clin Geriatr Med. 2001; 17: 433-456
        • Green C.R.
        • Hart-Johnson T.
        Cancer pain: An age-based analysis.
        Pain Med. 2010; 11: 1525-1536
        • Helme R.D.
        • Gibson S.J.
        Pain in older people.
        in: Crombie I.K. Epidemiology of Pain. IASP Press, Seattle1999: 103-112
        • Hooper D.
        • Coughlan J.
        • Mullen M.
        Structural equation modelling: Guidelines for determining model fit.
        Electron J Business Res Methods. 2008; 6: 53-60
        • Hsieh A.Y.
        • Tripp D.A.
        • Ji L.J.
        • Sullivan M.J.
        Comparisons of catastrophizing, pain attitudes, and cold-pressor pain experience between Chinese and European Canadian young adults.
        J Pain. 2010; 11: 1187-1194
        • Im E.O.
        • Lee S.H.
        • Liu Y.
        • Lim H.J.
        • Guevara E.
        • Chee W.
        A national online forum on ethnic differences in cancer pain experience.
        Nurs Res. 2009; 58: 86-94
        • Jensen M.P.
        The validity and reliability of pain measures in adults with cancer.
        J Pain. 2003; 4: 2-21
        • Katzman R.
        • Brown T.
        • Fuld P.
        • Peck A.
        • Schechter R.
        • Schimmel H.
        Validation of a short Orientation-Memory-Concentration Test of cognitive impairment.
        Am J Psychiatry. 1983; 140: 734-739
        • Lapane K.L.
        • Quilliam B.J.
        • Benson C.
        • Chow W.
        • Kim M.
        One, two, or three? Constructs of the Brief Pain Inventory among patients with non-cancer pain in the outpatient setting.
        J Pain Symptom Manage. 2014; 47: 325-333
        • Lautenschlager G.J.
        • Meade A.W.
        AlphaTest: A Windows program for tests of hypotheses about coefficient alpha.
        Appl Psychol Meas. 2008; 32: 502-503
      1. Lenhard W, Lenhard A: Testing the Significance of Correlations: 1. Comparison of Correlations from Independent Samples. Available at: http://www.psychometrica.de/correlation.html. Accessed February 26, 2016

        • Li C.H.
        Confirmatory factor analysis with ordinal data: Comparing robust maximum likelihood and diagonally weighted least squares.
        Behav Res Methods. 2016; 48: 936-949
        • MacCallum R.C.
        • Widaman K.F.
        • Zhang S.
        • Hong S.
        Sample size in factor analysis.
        Psychol Methods. 1999; 4: 84-99
        • Meghani S.H.
        • Houldin A.D.
        The meanings of and attitudes about cancer pain among African Americans.
        Oncol Nurs Forum. 2007; 34: 1179-1186
        • Molton I.R.
        • Terrill A.L.
        Overview of persistent pain in older adults.
        Am Psychol. 2014; 69: 197-207
        • Muthén L.K.
        • Muthén B.O.
        Mplus User’s Guide.
        7th ed. Muthén & Muthén, Los Angeles1998-2015
        • Nunnelly J.C.
        Psychometric Theory.
        2nd ed. McGraw-Hill, New York1978
        • Oosterman J.M.
        • Brazil I.A.
        Tools that should be considered in pain assessment: Cognitive factors, emotion, and personality.
        in: Pickering G. Gibson S. Pain, Emotion and Cognition. Cham, Springer International, Switzerland2015: 83-100
        • Sass D.A.
        Testing measurement invariance and comparing latent factor means within a confirmatory factor analysis framework.
        J Psychoeduc Assess. 2011; 29: 347-363
        • Serlin R.C.
        • Mendoza T.R.
        • Nakamura Y.
        • Eduards K.R.
        • Cleeland C.S.
        When is cancer pain mild, moderate or severe? Grading pain severity by its interference with function.
        Pain. 1995; 61: 277-284
        • Stapleton S.
        • Pattison N.
        The lived experience of men with advanced cancer in relation to their perceptions of masculinity: A qualitative phenomenological study.
        J Clin Nurs. 2015; 24: 1069-1078
      2. Canadian Cancer Society's Advisory Committee on Cancer Statistics: Canadian Cancer Statistics 2015. Toronto, Ontario, Canadian Cancer Society, 2015

        • Tabachnick B.G.
        • Fidell L.S.
        Using Multivariate Statistics.
        5th ed. Pearson Education, Boston2007
        • Tan G.
        • Jensen M.P.
        • Thornby J.I.
        • Shanti B.F.
        Validation of the Brief Pain Inventory for chronic nonmalignant pain.
        J Pain. 2004; 5: 133-137
        • Terwee C.B.
        • Bot S.D.
        • de Boer M.R.
        • van der Windt D.A.
        • Knol D.L.
        • Dekker J.
        • Bouter L.M.
        • de Vet H.C.
        Quality criteria were proposed for measurement properties of health status questionnaires.
        J Clin Epidemiol. 2007; 60: 34-42
        • Thomason T.E.
        • McCune J.S.
        • Bernard S.A.
        • Winer E.P.
        • Tremont S.
        • Lindley C.M.
        Cancer pain survey: Patient-centered issues in control.
        J Pain Symptom Manage. 1998; 15: 275-284
        • Tittle M.B.
        • McMillan S.C.
        • Hagan S.
        Validating the brief pain inventory for use with surgical patients with cancer.
        Oncol Nurs Forum. 2002; 30: 325-330
        • Turk D.C.
        • Sist T.C.
        • Okifuji A.
        • Miner M.F.
        • Florio G.
        • Harrison P.
        • Massey J.
        • Lema M.L.
        • Zevon M.A.
        Adaptation to metastatic cancer pain, regional/local cancer pain and non-cancer pain: Role of psychological and behavioral factors.
        Pain. 1998; 74: 247-256
        • Wolf E.J.
        • Harrington K.M.
        • Clark S.L.
        • Miller M.W.
        Sample size requirements for structural equation models: An evaluation of power, bias, and solution propriety.
        Educ Psychol Meas. 2013; 76: 913-934
        • Wool M.S.
        • Mor V.
        A multidimensional model for understanding cancer pain.
        Cancer Invest. 2005; 23: 727-734
        • Wu A.D.
        • Li Z.
        • Zumbo B.D.
        Decoding the meaning of factorial invariance and updating the practice of multi-group confirmatory factor analysis: A demonstration with TIMSS data.
        Pract Assess Res Eval. 2007; 12: 1-26
        • Yates P.M.
        • Edwards H.E.
        • Nash R.E.
        • Walsh A.M.
        • Fentiman B.J.
        • Skerman H.M.
        • Najman J.M.
        Barriers to effective cancer pain management survey hospitalized cx pts Australia.
        J Pain Symptom Manage. 2002; 23: 393-405
        • Yennurajalingam S.
        • Braiteh F.
        • Bruera E.
        Pain and terminal delirium research in the elderly.
        Clin Geriatr Med. 2005; 21: 93-119
        • Yennurajalingam S.
        • Kang J.H.
        • Hui D.
        • Kang D.H.
        • Kim S.H.
        • Bruera E.
        Clinical response to an outpatient palliative care consultation in patients with advanced cancer and cancer pain.
        J Pain Symptom Manage. 2012; 44: 340-350
        • Yong H.H.
        Can attitudes of stoicism and cautiousness explain observed age-related variation in levels of self-rated pain, mood disturbance and functional interference in chronic pain patients?.
        Eur J Pain. 2006; 10: 399-407
        • Yong H.H.
        • Bell R.
        • Workman B.
        • Gibson S.J.
        Psychometric properties of the Pain Attitudes Questionnaire (revised) in adult patients with chronic pain.
        Pain. 2003; 104: 673-681
        • Yong H.H.
        • Gibson S.J.
        • Horne D.J.
        • Elme R.D.
        Development of a pain attitudes questionnaire to assess stoicisim and cautiousness for possible age differences.
        J Gerontol B Psychol Sci Soc Sci. 2001; 56B: P279-P284
        • Zheng Z.
        • Gibson S.J.
        • Helme R.D.
        • McMeeken J.M.
        The effect of local anaesthetic on age-related capsaicin-induced mechanical hyperalgesia - A randomised, controlled study.
        Pain. 2009; 144: 101-109