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Vol. 54 No. 4 October 2017
Journal of Pain and Symptom Management 563
Brief Methodological Report
Iranian Brief Pain Inventory: Validation and Application in
Elderly People With Cancer Pain
Mahtab Alizadeh-Khoei, MPH, PhD, Farshad Sharifi, MD, MPH, PhD, Mohamad Esmaeil Akbari, MD,
Reza Fadayevatan, MD, MPH, PhD, and Marjan Haghi, MSN, PhD
Gerontology & Geriatric Department (M.A.-K.), Medical School, Tehran University of Medical Sciences, Tehran; Elderly Health Research
Center (M.A.-K., F.S.), Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran;
Department of Cancer Research Center and Medical School (M.E.A.), Shahid Beheshti University of Medical Sciences, Tehran; and
Gerontology Department (R.F., M.H.), University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
Abstract
Context. Cancer is a major health problem in the elderly, and pain is one of the most common symptoms among older
patients with cancer. Sufficient pain treatments depend on the accuracy of the pain assessment tool.
Objectives. This study aimed to assess the psychometric properties of the Iranian version of the Brief Pain Inventory
(BPI-IR) among elderly individuals with cancer.
Methods. This validation study was conducted with 368 people aged 60þ years old who were undergoing oncology
treatments. The BPI-IR was applied to the elderly participants through face-to-face interviews. Reliability of the BPI-IR was
evaluated using Cronbach’s alpha coefficient and intraclass correlation coefficient between test-retest scores. Criterion validity
was determined by calculating the Spearman’s correlation coefficient between scores on the BPI-IR and those on the SF-36
physical function, Activities of Daily Living, Instrumental Activities of Daily Living, Center for Epidemiological Studies
Depression, Patient Pain Questionnaire, and Symptom Distress Scale. Construct validity of the BPI-IR was evaluated using
exploratory factor analyses.
Results. Cronbach’s alpha coefficient was calculated to be 0.94, and the intraclass correlation coefficient between twice the
BPI-IR scores over two weeks obtained was 0.89. There were moderate-to-high correlations between the BPI-IR and the Patient
Pain Questionnaire (r ¼ 0.886), Symptom Distress Scale (r ¼ 0.492), SF-36 physical function (r ¼ 0.554), and Center for
Epidemiological Studies Depression (r ¼ 0.608). Two factors were extracted in exploratory factor analyses, and they explained
73.86% of total variance.
Conclusion. The BPI-IR is a reliable and valid tool for assessing pain among older adults with cancer. J Pain Symptom
Manage 2017;54:563e569. Ó 2017 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.
Key Words
Pain measurement, elderly, psychometrics, cancer, Brief Pain Inventory
Introduction
The incidence of cancer increases in the older
population as a vulnerable aged group.1 Elderly
patients diagnosed with cancer have many problems
like pain.2 Pain management in elderly patients with
cancer is one of the main concerns for clinicians.2,3
Cancer pain is underreported in elderly patients due
Address correspondence to: Mahtab Alizadeh-Khoei, MPH, PhD,
Gerontology & Geriatric Department, Medical School,
Tehran University of Medical Sciences, Engelab Street,
Ó 2017 American Academy of Hospice and Palliative Medicine.
Published by Elsevier Inc. All rights reserved.
to fear of cancer progression.4 It was estimated that
25%e40% of elderly individuals with cancer had daily
pain.4 Sufficient pain treatments depend on accurate
pain assessment tools.5 Self-reporting is a gold
standard method for pain assessment.6 The Brief
Pain Inventory (BPI) is short and easy to apply and
is the most useful multidimensional tool for pain
Poursina Avenue, Tehran, Iran. E-mail: [email protected]
yahoo.com
Accepted for publication: July 6, 2017.
0885-3924/$ - see front matter
http://dx.doi.org/10.1016/j.jpainsymman.2017.07.015
564
Alizadeh-Khoei et al.
assessment in patients with cancer.7,8 The BPI is a
numeric scale that has sensory and reactive dimensions to measure intensity of and interference in
pain to apply for both clinicians and researchers.7e9
It has been translated into different languages.7,9e22
One Iranian study reported good reliability of the
BPI among young and adult outpatients with any
kind of pain in a hospital clinic;23 however, a validated
Persian version of the BPI in elderly patients with
cancer has not been available until now. The purpose
of this study was to evaluate the psychometric properties in terms of construct and concurrent validity of
the Iranian BPI (BPI-IR) in older patients with cancer
pain and to evaluate the internal consistency and
test-retest stability.
Methods
Participants
In this cross-sectional validation study, older
participants were selected from a cancer clinic of
the Shohadaye Tajrish hospital, Tehran. Inclusion
criteria were age $60 years with pathological
diagnosis of cancer (primary or metastatic), start of
oncology treatments within the past two weeks
(among both inpatients and outpatients), presence
of cancer-related pain, lack of infection, presence
of any analgesic treatment, and experience of at least
one episode of pain during the last week. Older
patients who had undergone surgery within one
month before the interview, were completely
bedridden, had severe visual or hearing impairment,
had cognitive impairment measured by MinieMental
State Evaluation test (<24 score),24,25 and were
aphasic were excluded. After approval from the
hospital’s ethical committee board, participants
were selected by simple random sampling based on
medical record codes. Finally, 368 eligible older
adults agreed to participate and signed or fingerprinted the consent form.
Data Collection
This study was conducted from February of 2015 to
October of 2016. Participants completed the BPI-IR, a
modified version of the functional items of the ShortForm Health Survey (SF-36),26 Katz’s Activities of Daily
Living (ADL) scale,27 the Lawton Instrumental ADL
(IADL) Scale,28 the Center for Epidemiological
Studies Depression (CES-D) Scale,29 the Patient Pain
Questionnaire (PPQ) pain experience subscale,30
and two questions from the Symptom Distress Scale
(SDS).31 Meanwhile, demographic characteristics,
cancer location and stage, treatments, use of medications to relieve pain, and pain status were assessed.
Vol. 54 No. 4 October 2017
The BPI-IR asked older patients to rate their pain at
its worst in the past week on a scale from 0 to 10. Most
of the items were administered by elderly patients
themselves according to the user guides,32 although
the researchers were allowed to read the items for illiterate older participants and showing hand fingers
instead of the Numeric Rating Scale (NRS; 0e10). In
clinical trials, the NRS is more reliable in patients
with cancer due to ease of understanding and scoring,
especially in less-educated people.16,33
Measures
The original of BPI was translated into the Farsi
language in another study23 before being used in
the present study.
In the BPI, the NRS (0e10) is used for elderly
patients to rate their pain at the time of responding
to the questionnaire as worst, least, and average pain
for the last week.16 Eleven-point rating scales include
four questions on pain intensity with responses
ranging from 0 ¼ ‘‘No pain’’ to 10 ¼ ‘‘Pain as bad as
you can imagine.’’ The other seven NRS items related
to pain interference with function, rated from
0 ¼ ‘‘Does not interfere’’ to 10 ¼ ‘‘Interferes
completely,’’14,34 were general activity, mood, walking,
working, relationships, sleep, and life enjoyment.8 The
BPI has shown high reliability and validity in cancer
pain; Cronbach’s alphas are typically over 0.80.14,35
Patients’ health-related quality of life was assessed
using the SF-36, including eight domains.26 The Persian version of the SF-36 was validated for use with
an Iranian population (Cronbach’s alpha ¼ 0.65).36
In this study, nine items of the SF-36 were used as a
modified physical functioning subscale. These items
measured how cancer may affect vigorous functions,
such as climbing stairs, transferring in and out
of bed, running, lifting heavy objects, bending and
stooping, climbing one flight of stairs, and walking a
block unassisted.37
Katz’s ADL index summarizes overall performance
in six functions.27 The Iranian version of Katz’s ADL
is a reliable and valid tool for use with elderly patients
with cancer with Cronbach’s alpha of 0.923.37
The Lawton IADL scale measures more complex
activities than the basic ADL assessed by Katz
index.38,28 The Persian version of the Lawton IADL
scale has excellent reliability and validity among
people with dementia.39
The CES-D scale is commonly used to assess depressive symptoms in patients with cancer during the last
week.40 The Farsi version of the CES-D-10 was determined as valid and reliable among the Iranian elderly
population with Cronbach’s alpha of 0.85.41
The PPQ is a scale with 16 ordinal items that
measures the knowledge and experience of pain in
patients with cancer, and each subscale can be assessed
Vol. 54 No. 4 October 2017
Iranian Brief Pain Inventory
565
as a total score. The experience subscale has seven
items that measure pain relief, distress, and pain
control.30,42 Cronbach’s alpha for this subscale was
reported as 0.84.43
The SDS questionnaire has 13 items that measure 11
symptoms associated with cancer. Two items related to
pain were intensity and frequency of pain. Cronbach’s
alpha of the total scale was reported as 0.75.44
indicate good correlation between scores on the
questionnaires.
Exploratory factor analyses with varimax rotation at
eigenvalues $1 were used for extraction of factors in
the BPI. Percentage of variance was explained by
each factor, and factor loading was calculated for
each item.
Reliability
Results
Internal reliability and external reliability of the
BPI-IR were assessed using a questionnaire administrated two weeks after the first time of evaluation
and test-retest analysis.
Validity
Face validity of the BPI-IR was asked from 10 elderly
participants with normal cognition who had at least six
years of schooling through a four-point Likert questionnaire regarding items’ clarity and fluency with
0 ¼ the least and 3 ¼ maximum score. The
mean $2 for each item indicated clarity and fluency,
and face validity of the items was considered sufficient.
Content validity was assessed by a group of five
experts including an oncologist, nurses, an anesthesiologist, and a gerontologist who reviewed the BPI-IR
items’ relevance and coverage, scoring each item on
a four-point Likert scale. A score of 3 ¼ complete
relevancy and coverage, and a score of 0 ¼ the least.
If mean scores for each item were $2, the content
validity was considered sufficient.
For the factor model of the BPI, correlation of the
BPI was determined by two types of scales.12,14 Concurrent validity was evaluated by calculating the Spearman’s rank correlation coefficient in the pain
interference subscale by the physical functioning
subscale of the SF-36, ADL, IADL, and depression
tools. Pain severity was measured by a pain experience
subscale of the PPQ and pain-related questions in the
SDS tools. Construct validity was evaluated by exploratory factor analysis.
Statistical Analysis
Descriptive statistics were used for demographic,
cancer, and treatment data. For all tests, P < 0.05
was considered statistically significant.
Internal reliability and external reliability were
assessed by Cronbach’s alpha coefficient and intraclass
correlation coefficient (ICC) between test-retest
scores for pain severity and pain interference items.
Cronbach’s alpha coefficients $0.70 were considered
to have acceptable internal consistency. ICC for agreement between test-retest scores $0.80 was considered
to indicate very strong external reliability. Spearman’s
correlation coefficient $0.70 was considered to
The mean age of participants was 67.53 5.81 years,
and 36.7% were illiterate or unable to read and write
(Table 1). The top cancer diagnosed was gastrointestinal (30.1%). Elderly patients rated more interference
with enjoyment of life (Table 2).
Reliability
High Cronbach’s alpha for the pain severity (0.80)
and pain interference subscales (0.95) and the total
scale (0.94) demonstrated good internal consistency
(Table 3). All corrected item total correlations were
Table 1
Demographic and Disease-Related Characteristics
(N ¼ 368)
Variables
Age
60e69
70e79
#80
Marital status
Married
Single
Literacy
Literate
Illiterate (unable to read and write)
Cancer stage
1 or 2
3 or 4
Top five cancer types
Gastrointestinal
Prostate and bladder
Breast
Brain
Lung
Cancer treatments
Surgery
Radiotherapy
Chemotherapy
Surgery and chemotherapy
Surgery and radiotherapy
Radiotherapy and chemotherapy
Surgery and radiotherapy
and chemotherapy
Daily use of analgesics
Yes
Analgesics use in the past week
Yes
Pain location
Left upper side
Left lower side
Right upper side
Right lower side
% Male
% Female
58.8
36.7
4.5
74.3
22.9
2.8
93.7
6.3
50.3
49.7
86.8
13.2
76.5
23.5
53.8
46.2
44.4
55.6
19.0
15.7
0.0
5.1
5.7
11.1
1.3
17.1
4.6
1.0
15.0
23.2
10.5
5.9
6.8
5.9
32.7
19.0
25.1
9.5
6.1
9.5
8.4
22.3
58.8
65.2
88.7
91.6
35.3
23.1
31.2
10.4
35.0
22.0
34.5
8.5
566
Alizadeh-Khoei et al.
Vol. 54 No. 4 October 2017
Table 2
Descriptive Statistics Study Variables and Correlations With the BPI-IR (N ¼ 368)
Variables
Pain intensity
Pain worst
Pain least
Pain average
Pain now
Pain interference
General activity
Mood
Walking ability
Normal work
Relationship
Sleep
Enjoyment of life
SF-36 Physical Function
ADL
IADL
CES-D
PPQ
SDS
Mean
SD
6.76
1.30
4.83
2.17
2.415
1.970
1.983
2.378
3.32
2.91
3.35
3.59
3.29
2.98
3.90
33.55
6.98
8.76
20.95
26.52
3.5
2.848
2.908
3.001
2.919
2.707
2.730
2.981
8.20
2.45
3.89
6.24
12.88
2.19
Correlation With Pain Intensity
Correlation With Pain Interference
0.554a
0.228b
0.304b
0.608a
0.886a
0.492b
BPI-IR ¼ Iranian version of the Brief Pain Inventory; ADL ¼ Activities of Daily Living; IADL ¼ Instrumental Activities of Daily Living; CES-D ¼ Center for Epidemiological Studies Depression; PPQ ¼ Patient Pain Questionnaire; SDS ¼ Symptom Distress Scale.
a
P < 0.01.
b
P < 0.05.
more than 0.2,17 indicating that no item should be
revised or excluded. Regarding values of ‘‘alpha if
item deleted,’’ which were less than the subscale
alpha, it was not necessary to remove any items. The
ICC between test-retest obtained was 0.89, showing
acceptable stability in both pain intensity (0.91) and
pain interference (0.87).
Validity
Spearman’s correlation coefficient between the
BPI-IR pain interference subscale scores with ADL
and IADL was weak but statistically significant
(r ¼ 0.228, r ¼ 0.304, P < 0.05). The correlation
coefficient of the BPI-IR interference subscale was
moderate with the SF-36 physical function subscale
(r ¼ 0.554, P < 0.01) and high with the CES-D
(r ¼ 0.608). Generally, pain interference items were
correlated with the physical function and depression
(Table 2). Meanwhile, the BPI-IR intensity score had
high correlation with the pain experience subscale
of the PPQ (r ¼ 0.886, P < 0.01) and moderate correlation with the pain-related questions of the SDS
(r ¼ 0.492, P < 0.05).
The possibility to perform factor analyses was examined by the Kaiser-Meyer-Olkin measure of sampling
adequacy (0.91) and Bartlett’s test of sphericity
(c2 ¼ 3856.453, P < 0.05), which attained significance.
Based on the rule that meaningful factors should be
associated with eigenvalues greater than 1.0, a
two-factor solution is appropriate (Table 3). The
two-dimensional structure of the BPI-IR was
confirmed by scree plot (Fig. 1). In Table 3, pain interference items were highly correlated with Factor I, and
pain severity items had high correlation with Factor II.
Table 3
Validity and Reliability Analyses of the BPI-IR
Factor Loading
Variable
Pain severity
Pain worst
Pain least
Pain average
Pain now
Pain interference
General activity
Mood
Walking ability
Normal work
Relationship
Sleep
Enjoyment of life
Internal Consistency
Factor I
Factor II
Corrected Item Total Correlation
Alpha if Item Deleted
0.143
0.277
0.228
0.399
0.763
0.663
0.859
0.719
0.543
0.548
0.745
0.673
0.798
0.788
0.701
0.729
0.858
0.804
0.861
0.906
0.835
0.709
0.883
0.327
0.274
0.198
0.246
0.317
0.424
0.232
0.884
0.796
0.829
0.907
0.853
0.754
0.875
0.943
0.951
0.948
0.941
0.946
0.954
0.944
Cronbach’s Alpha
0.805
0.954
Vol. 54 No. 4 October 2017
Iranian Brief Pain Inventory
Fig. 1. Scree plot of the eigenvalues of BPI-IR factors.
BPI-IR ¼ Iranian version of the Brief Pain Inventory.
These two factors explained 73.86% total variance of
the BPI-IR while the first factor explained 47.58% variance, and second factor explained 26.28% (Table 4).
Discussion
We conclude that the BPI-IR is a valid and reliable
cancer pain assessment tool in Iranian elderly with
excellent internal consistency and external reliability.
The BPI-IR has two factors (pain severity and pain
interference). Acceptable criterion validity was
observed with a high correlation between the BPI-IR
score and other criteria: functional items of the
SF-36, Katz’s ADL scale, the Lawton IADL scale, the
CES-D, the PPQ pain experience subscale, and painrelated questions of the SDS.
Many studies conducted on the validity of the BPI in
different languages presented the BPI as a valid and
reliable scale to assess cancer pain.7,12,17 Supporting
the validity of the BPI-IR are the similarity of the factor
structure of the BPI-IR with other validated language
versions of the BPI7,8,12 and excellent internal consistency. Exploratory factor analysis indicates that the
BPI-IR is composed of two factors similar to the
original BPI8 and other language versions.11e14,16
Although much evidence found a two-factor structure
for the BPI, few studies exhibited a three-factor structure including pain severity, activity interference, and
mood interference.10,19,45 This difference may be
due to changes in the conceptual meaning of items
during translation.19
567
To our knowledge, there is no valid and reliable
version of the BPI for use with geriatric patients with
cancer. Mirzamani et al. found the Iranian version of
the BPI to be reliable with Cronbach’s alphas of 0.89
for the interference subscale and 0.88 for the severity
subscale in a hospital clinic;23 however, the study by
Mirzamani et al. was about any age group (until
70 years old) and any types of pain. Considering that
the BPI was initially developed to assess cancer
pain,8 being original pain research among Iranian
elderly with cancer is the strength of our study.
Despite these differences, both studies found the
Persian BPI to be a valid and reliable tool.
Measures of pain interference were correlated with
physical functioning, depression, and mood.9,33 Pain
interference especially is a predictor of patients’
quality of life.9 In a Portuguese study, patients with
more pain interference and higher levels of pain
intensity had worse physical functioning and more
depression.9
Older patients with cancer face functional limitations in ADL performance37,46 due to daily pain.4,47
The BPI-IR interference subscale is a measure to assess
the impact of pain on function.12 In this study, the BPI
was correlated with quality of life and performance status. Functional limitations were caused by pain effects
on quality of life in the Norwegian version of BPI.19
We observed pain interference to be more correlated
with the SF-36 physical function subscale, which was
similar to the finding of Greek15 and Malaysian17
studies. Pain interference was correlated with bodily
pain in the SF-36 in a German study.22
Severe pain in patients with cancer is more related
to depression.48e50 In the present study, correlation
between depression and the BPI-IR was assessed for
concurrent validity and showed a strong correlation
in the pain interference subscale. In a Korean study,
higher depression scores were observed in patients
with cancer with more pain.33
The original BPI can be used as a self-administered
questionnaire just for highly educated adult
patients,17,18 except in Vietnamese and Chinese
patients.13,51 For the BPI-IR among elderly illiterate
individuals, participants were asked by interviewers
by showing hand fingers as a symbol of numbers on
a 0e10 scale to describe pain severity. We used this
method, as with the NRS, due to simplicity46 and
better applicability among illiterate older participants.
Table 4
Eigenvalue of Components and Percentage of Variance Explained by Each Factor
Initial Eigenvalues
Rotation Sums of Squared Loadings
Component
Total
% of Variance
Cumulative %
Total
% of Variance
Cumulative %
1
2
6.769
1.356
61.538
12.326
61.538
73.864
5.234
2.891
47.580
26.284
47.580
73.864
568
Alizadeh-Khoei et al.
Regarding limitations, this used a cross-sectional
design that is not representative of the Iranian older
cancer population, although it should be pointed out
that this is the first study to look at the geriatric cancer
pain validity of the BPI. Furthermore, we did not use
the BPI for longitudinal evaluation and, therefore,
cannot offer conclusions about the sensitivity of the
BPI to changes in the analgesics. We also did not determine a cutoff point for the BPI-IR. Moreover, we did
not calculate the pain management index for our
patients as the adequacy of the analgesic therapy.8,17,23
Conclusions
Validity and reliability of the BPI-IR was comparable
to the original version for cancer pain in terms of
structure and psychometric properties. The BPI-IR
has two factors in which pain interference items could
measure cancer pain’s impact on elderly function.
Applying the BPI-IR is easy and brief to complete for
assessing pain severity and interference. It could also
reduce some of the typical communication barriers
in Iranian geriatric patients to pain management.
Disclosures and Acknowledgments
Tehran University of Medical Sciences funded this
study, and the authors declare no conflicts of interest.
The authors would like to thank the staff and patients
for participating and Dr. Bijan Kaboudi for statistical
support.
Ethical approval: This study was approved by the
ethics committee in the research department of
Tehran University of Medical Sciences (project number 90-04-27-15837) following the Helsinki declaration
and guidelines of the Iranian Ministry of Health and
Medical Education.
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