Koller, A., Miaskowski, C., De Geest, S., Opitz, O., & Spichiger, E. (2012). A systematic evaluation of content, structure, and efficacy of interventions to improve patients' self-management of cancer pain. Journal of Pain and Symptom Management, 44, 264–284.

• Databases searched were MEDLINE, CINAHL, and the Cochrane Library (December 2007–November 2010).
• Authors used the same search terms as Bennett, Bagnall, and Jose Closs (2008), whose publication said that details of the search were available upon request.
• Studies were included if they
  • Were randomized controlled trials or controlled trials in which the control group received usual care or attention only.
  • Included adults with pain from active cancer and not pain from cancer treatment.
  • Used a patient-based educational intervention on an individual basis.
  • Assessed pain-related outcomes. 
• Studies were excluded if they used psychobehavioral methods in the intervention.

• The final number of studies included was 34.
• The sample range across studies included a total of 4,139 patients in 24 interventions. The number of patients in the 11 statistically significant studies was 1,041. The range of sample size was 30–1,256 patients.
• The range of mean patient age was 48–77 years.
• Of all patients, 57% were women and 43% were men.
• Cancer diagnoses in the sample were primarily lung, breast, prostate, gastrointestinal, gynecologic, hematologic, and head and neck cancers.
• The majority of studies (14) were conducted in the United States.

• Structural components of the intervention included the factors that follow.
  • How the intervention was delivered.
  • What materials were given to patients.
  • Receiver and provider of the intervention.
  • Whether interactions took place between providers and receivers.
  • Level of individualization (structured or tailored) for each patient.
  • Contact time between clinicians and patients or family caregivers.
  • Timing of the intervention
• The 16 content components of the intervention were divided into four categories:
  • Cognition.
  • Behavioral.
  • Goal setting.
  • Direct contact between research staff and clinicians.
• Authors found no apparent patterns, for any single component or any combination of components, with statistically significant and clinically meaningful effects. This may be due to the lack of homogeneity in study designs and the variability of the structure and content components.
• Other factors may play a role in an intervention's efficacy (e.g., provider’s empathy, setting of the intervention).
• Spending more time with patients did not always result in increased knowledge or changes in patients’ behaviors. Similarly, multiple interventions did not always result in increased knowledge or behavior changes.
• Optimal dose and timing of the intervention to improve cancer pain management are unknown.

Although the efficacy of various intervention components could not be clearly delineated, this systematic review provides an overview of the various structural and content components of intervention studies to improve cancer pain management and an evaluation of combinations of components.

• One limitation was the fact that authors included published studies only.
• The number of studies included was small, which may have led to overestimation of effect sizes.

Nurses need to be aware of the various structural and content components of interventions to support patients’ self-management of cancer pain. The interventions should be culturally appropriate and include written material; a face-to-face educational session of at least 15 minutes; and information about pain treatment, cognitive barriers to pain management, and implementation of self-management pain strategies.