The effect of palliative care education by peers on pain management in cancer
patients
El efecto de la educación en el cuidado paliativo por parejas
en el manejo del dolor en pacientes con cáncer
Mohammad Mojalli,
1
Zobide Rafat,
2a
Musa Sajjadi
3
Zahra Iman Panah
4
Gonabad University of Medical Sciences, Irán
1234
Orcid ID: https://orcid.org/0000-0002-3317-7246
1
Orcid ID: https://orcid.org/0000-0001-7115-4232
2
Orcid ID: https://orcid.org/0000-0003-0975-1655
3
Orcid ID: https://orcid.org/0000-0001-5535-4859
4
Recibido: 7 de mayo de 2019 Aceptado: 27 de setiembre de 2019
Abstract
The number of cancer patients is on the rise. Palliative care has an important role in improving the
quality of life of these patients. Regarding the role of peers, this study aimed to evaluate the effect
of peer care education by peers on pain management in cancer patients. In this clinical trial, 64
patients with cancer were selected as available, divided into control and intervention groups. The
control group received usual educations and the intervention group received education package
with pain management content by interested, educated and qualified peers in terms of education.
The research instrument was pain management questionnaires that were filled before and 3 and 6
weeks after the intervention. Data were analyzed by SPSS software at the significant level of 0.05.
The findings showed that the two groups were not significantly different in terms of age, sex, type
of cancer, type of treatment, family history, occupation and education and were homogenous. The
findings showed that pain management (from 11.78 to 22.59) was significantly different in the
intervention group before and three and six weeks after the intervention (P <0.001). The effect of
intervention of palliative care education by peers has increased the level of pain management
among cancer patients. The findings of this study showed that palliative care education by peers
affects the level of pain management in cancer patients. Getting help from interested and educated
peers in pain management education for cancer patients is recommended.
a
Correspondencia al autor:
E-mail: zobide_rafar@yahoo.com
ISSN 2312-4253(impresa)
ISSN 2078-4015(en línea)
89
Apuntes Universitarios, 2020: 10(1), Enero-Marzo
ISSN: 2304-0335 DOI: https://doi.org/10.17162/au.v10i1.420
apuntesuniversitarios.upeu.edu.pe
Keywords: Cancer, Palliative Care, Pain Management, Peer Education
Resumen
El número de pacientes con cáncer está en aumento. Los cuidados paliativos tienen un papel
importante en la mejora de la calidad de vida de estos pacientes. Con respecto al papel de los pares,
este estudio tuvo como objetivo evaluar el efecto de la educación de cuidado de pares por parte de
los pares en el manejo del dolor en pacientes con cáncer. En este ensayo clínico, 64 pacientes con
cáncer fueron seleccionados como disponibles, divididos en grupos de control e intervención. El
grupo de control recibió educación habitual y el grupo de intervención recibió un paquete
educativo con contenido de manejo del dolor por parte de pares interesados, educados y calificados
en términos de educación. El instrumento de investigación consistió en cuestionarios de manejo
del dolor que se completaron antes y 3 y 6 semanas después de la intervención. Los datos fueron
analizados por el software SPSS en el nivel significativo de 0.05. Los resultados mostraron que
los dos grupos no eran significativamente diferentes en términos de edad, sexo, tipo de cáncer, tipo
de tratamiento, antecedentes familiares, ocupación y educación, y eran homogéneos. Los
resultados mostraron que el manejo del dolor (de 11.78 a 22.59) fue significativamente diferente
en el grupo de intervención antes y tres y seis semanas después de la intervención (P <0.001). El
efecto de la intervención de educación en cuidados paliativos por parte de los compañeros ha
aumentado el nivel de manejo del dolor entre los pacientes con cáncer. Los hallazgos de este
estudio mostraron que la educación en cuidados paliativos por parte de los compañeros afecta el
nivel de manejo del dolor en pacientes con cáncer. Se recomienda obtener ayuda de colegas
interesados y educados en educación sobre el manejo del dolor para pacientes con cáncer.
Palabras clave: cáncer, cuidados paliativos, manejo del dolor, educación de pares
Introduction
Cancer is one of the most important causes of death in the world. According to the latest
World Health Organization (WHO) report in 2018, nearly 18.1 million people worldwide have
experienced cancer (Ferlay et al, 2018,). This disease has been recognized as a growing problem
in the Middle East (Daher, 2011). It is the third cause of death in Iran after heart disease and traffic
accidents. According to the latest statistics, the annual incidence of cancer in Iran is about 107 per
100,000 people (more than 80,000 considering a population of 75 million in Iran; Mansori et al,
2018). The World Health Organization (WHO) predicts that the incidence of cancer in Iran will
rise to 85653 in total population in 2020 and the death toll from cancer will rise to 62897 (World
Health Organization, 2011).
Cancer is often associated with pain, and pain is experienced in approximately 50-70% of
patients (Wiese et al., 2010). Pain occurs in cancer patients following a primary tumor, tumor
metastasis, radiation therapy, chemotherapy or surgery (Modesto et al, 2011). Pain is a stressful
Revista de Investigación Apuntes Universitarios
2020: 10(1), 88 - 100
ISSN 2312-4253(impresa)
ISSN 2078-4015(en línea)
90
event that can affect a patient's lifestyle, satisfaction, and comfort and cause suffering, loss of
control, fatigue and impairment of quality of life, sexual activity, personal relationships, meaning
of life, individual performance, sleep and daily activities (Sun et al., 2007; Paice y Ferrell, 2011).
It is therefore essential to identify and alleviate cancer pain in its early stages (World Health
Organization, 2010).
Methods of pain alleviation are very diverse (Dy et al., 2008). Pain control is performed in
both pharmacological and non-pharmacological ways (Golianu et al., 2007). Despite the
availability of painkillers and guidelines developed for effective pain relief, cancer pains have
remained still untreated (Koller et al., 2012). Drugs that are weaker are less likely to control pain
and stronger drugs have side effects such as drowsiness, nausea and constipation (Gutgsell et al.,
2013).
Palliative care is one of the important components of cancer treatment. Palliative care is an
approach that improves the quality of life for patients and families when confronted with life-
threatening diseases (World Health Organization, 2011). The main purpose of this type of care is
to pay attention to the needs of patients in physical, psychological and social dimensions (Farbicka
y Nowicki, 2012).
Palliative care is an approach that deals with early detection and complete evaluation, and
treatment of pain and other physical, psychological and spiritual problems (Medical Services
Commission, 2011). Patients want their pain to be effectively controlled and to have control over
their lives (Gutgsell et al., 2013). One of the most common barriers to pain control is inadequate
pain assessment and inadequate awareness of pain management (Oldenmenger et al., 2011). Lack
of awareness and misconceptions about the self-management of the pain and the difficulties that
may arise in implementing this procedure make the effects of this method not be seen in cancer
patients (Shojae y Mousavi, 2000). Therefore, one of the most important palliative care approaches
for patients with cancer is education (Bakitas et al., 2009).
One of the types of patient education that has emerged as a flexible educational model is
peer-based education (Secomb, 2008). This type of education has a great effect on facilitating and
promoting health and creating an environment for learning (Webel et al., 2010). In this approach,
adequate education and information on disease, control and care by informed and involved
individuals in the disease as a peer group is provided and, given the similar characteristics of the
members, a simple and secure learning environment is created and individuals share their own
Revista de Investigación Apuntes Universitarios
2020: 10(1), 88 - 100
ISSN 2312-4253(impresa)
ISSN 2078-4015(en línea)
91
experiences about the disease that they are jointly suffering from (Keller et al., 2011; Price y
Knibbs, 2009). Peer education is a form of exchange of information, attitude and behavior by those
who are not professionally educated but have shared experiences (Cartagena et al, 2006). In this
case, people will more easily accept information from their peers and share their secrets with them
(Van Rompay et al., 2008).
The positive effect of this educational approach has been confirmed in some studies.
Dehqan showed a positive effect of peer-based education on depression in MS patients (Dehghani
et al., 2013). Taleghani (2012) and Varaei (2013) have also shown the positive effects of this
approach on the quality of life of patients with cancer and anxiety and self-efficacy, respectively,
in surgical candidates.
According to what was said, pain management of cancer patients is of particular
importance and can play an important role in improving the quality of care for these patients. At
present, this is not very much considered in the care of patients, and some of the methods used in
this area, although effective, can have some side effects. As the role of nursing in palliative care is
high and education is the most important component of palliative care. And given the lack of
organized groups in Iran (Taleghani et al., 2008), the cultural, economic difference, and level of
patient awareness and the increasing number of patients and the limitation of the time for
physicians to educate and get patients affected by those who have experienced the disease; the
researcher aimed to discuss problems and solutions of pain by forming peer groups that have
experienced the problem and investigate the effect of palliative care education by peers on pain
management in cancer patients.
Materials and methodology
After obtaining permission from the Ethics Committee of Gonabad University of Medical
Sciences (IR.GMU.REC.1395.126) and registering in the Iranian Clinical Trial Registration
Center (IRCT20170723035250N1), library studies and the search for new sources to determine
educational content began. For sampling according to inclusion criteria, 64 patients with cancer
who referred to Imam Ali (AS) hospital in Bojnourd in 2017 were included in the study through
available sampling method and were randomly divided into control and intervention groups:
Inclusion criteria include: age of 18 to 55 years old, confirmation of cancer diagnosis according to
specialist's opinion, being able to speak and understand Persian, not having stage 3 and 4 of cancer,
Revista de Investigación Apuntes Universitarios
2020: 10(1), 88 - 100
ISSN 2312-4253(impresa)
ISSN 2078-4015(en línea)
92
passing one year since the diagnosis of cancer. Exclusion criteria included: patient's unwillingness
to continue research, patient's death, absence in the peer-based group discussion more than one
session. Sample size was determined using the results of similar research (Bennett et al., 2009).
The researcher first completed the demographic questionnaire and then the knowledge
and attitude questionnaires. In the peer group selection, 4 cancer patients with characteristics such
as good social interactions, better adaptation to the disease, and better pain control with physician
approval, having a history of at least one year of disease, ability to manage sessions, having a
higher education than diploma, being interested in group leadership, were selected by researcher
studies with the help of a psychologist and a physician to train patients in the experimental group.
Then, 4 2-hour educational sessions were held by the researcher and psychologist for the peer
group in order to prepare them to train the experimental group patients, in which the peer group
patients shared their experiences regarding strategies used to reduce pain that the researcher
corrected or supplemented all of the above based on scientific books. In this way, the peer group
was prepared and approved by the physician in order to train.
After completion of the peer group education sessions, the patients in the experimental
group were divided into 8-person groups and each of the 4 patients in the peer group was assigned
to one group for education. The way of implementing the educational program was the same for
all groups, then three sessions of education were held in the experimental group in collaboration
with the patients in the peer group. Content of education sessions included: Cancer education,
Cancer pain, Pharmacological treatments for cancer-related pain, and Non-pharmacological pain
relief techniques. The researcher also participated in all sessions as an observer and responded to
patients' questions if needed. It should be noted that following the completion of the intervention,
an educational booklet was given to those in the control group, due to the ethics.
Research instruments
Data collection instruments included demographic questionnaire, pain management
questionnaires.
Demographic questionnaire
This form includes information such as age, sex, education, marital status, type of
diagnosis, stage of disease completed through information in the records or interview with the
patients.
Revista de Investigación Apuntes Universitarios
2020: 10(1), 88 - 100
ISSN 2312-4253(impresa)
ISSN 2078-4015(en línea)
93
Pain management questionnaire
It is a researcher-made questionnaire that is implemented as self-assessment, consisting of
11 items that describe patients' views on how to use pain management techniques as always (4) to
never (0). To evaluate the content validity of the instrument, the subject of pain and cancer was
given to several faculty members of Gonabad University of Medical Sciences who were expert in
the research, and following the applying of their corrective views, its content validity was
confirmed.
Reliability of pain management questionnaire
The questionnaire consists of 11 questions; its reliability was determined using SPSS
software. Value of Cronbach's alpha (0.933) was desirable.
Findings
Independent t-test showed no significant difference between the two groups in terms of
age, sex, education, type of cancer, type of treatment (Table 1). Therefore, the subjects were
homogeneous in this respect.
Table 1
Demographic characteristics of cancer patients in the intervention and control groups
P -value
Control
Group
Characteristics
0.66
12
18-30
Age (year)
10
31-42
7
43-54
3
55-66
0.614
(40.6)13
Female
Gender
(59.4)19
Male
0.871
(6.25)2
Illiterate
Education level
(12.5)4
Elementary
(21.87)7
Middle school
(46.87)15
Diploma
(12.5)4
University
0.749
(50%)16
Surgery
Type of treatment
(34.37)11
Chemotherapy
(12.5)4
Radiotherapy
(3.12)1
Others
0.998
(9.4)3
Bladder
Type of cancer
(12.5)4
Prostate
(21.9)7
Colon
(15.6)5
Breast
Revista de Investigación Apuntes Universitarios
2020: 10(1), 88 - 100
ISSN 2312-4253(impresa)
ISSN 2078-4015(en línea)
94
(3.1)1
Lung
(12.5)4
Ovary and uterus
(9.4)3
Blood
(15.6)5
Others
Table 2
Frequency distribution of mean and standard deviation of pain management in control and
intervention groups
P -value
Intervention
Control
Pain management
0.580
10.85±11.78
9.10±29.37
Before intervention
(mean±standard deviation)
.007
14.86±21.12
9.12±19.56
Three weeks after intervention
(mean±standard deviation)
0.0001≤
14.30±22.59
8.11±64.46
Six weeks after intervention
(mean±standard deviation)
The mean pain management of patients from pain management in intervention and control
groups were similar before education in terms of mean but they have a significant difference in
terms of significance.
Discussion
The results above showed that there was a statistically significant difference in mean pain
management between the two groups after the intervention. For example, in a study by Bennett et
al, entitled “How Patient-Based Educational Interventions Affect Cancer Pain Management”, this
review study found that education improves patients’ knowledge and attitude about pain
management and that it can improve the cancer pain management. The results of this research are
similar to those of the mentioned study. The purpose of this study was “to determine the effect of
peer education on quality of life of patients after breast resection surgery in women who referred
to cancer clinics affiliated to Shiraz University of Medical Sciences". They concluded that peer
education improves the quality of life of patients after breast resection surgery, which is consistent
with the present study.
On the other hand, the results of this study are in line with those of Dehghani et al., (2013).
The results of this study are consistent with the conceptualization and validation research in 2012.
2013 is in line. Likewise, in a study by Tammall et al., (2010), “Primary Palliative Care in Patients
with Metastatic Lung Cancer,” they examined the effects of primary palliative care on newly
diagnosed patients at the Massachusetts Hospital. In this study, patients with lung cancer were
Revista de Investigación Apuntes Universitarios
2020: 10(1), 88 - 100
ISSN 2312-4253(impresa)
ISSN 2078-4015(en línea)
95
randomly selected and studied. The study was performed in two groups: the first group received
palliative care and in addition they received standard cancer care while the second group received
only standard cancer care. Changes in quality of life were monitored over the next 12 weeks.
Anxiety and depression were also assessed. They found that the first group had a better quality of
life than the second group. In addition, those in palliative care showed less anxiety and depression
than the second group. On the other hand, the first group received less invasive treatment and the
mean survival was higher in the first group compared to the second group.
A study by Ghadiri et al., (2016) aimed to “determine the effect of peer-centered education
on the anxiety of family caregivers of patients undergoing coronary artery bypass graft surgery.”
The study was a clinical trial in Chamran hospital, Isfahan, Iran, in 2015. In this study, after
selecting and preparing the peer group, 50 family caregivers of patients undergoing coronary artery
bypass grafting were selected and randomly divided into control and experimental groups. Anxiety
of family caregivers was measured before and after the intervention by a standard Spielberger
questionnaire. In the experimental group, the subjects were trained in a maximum of 6 individuals
in two one-hour sessions, two consecutive days before surgery by the peer group. After the
intervention, the difference between the anxiety score in the two groups was significant (P <0.001)
and the anxiety level was decreased in the experimental group. But there was no significant
difference in anxiety score in control group patients (P = 0.28). Peer-based education program was
effective in reducing anxiety of family caregivers of patients undergoing coronary artery bypass
graft surgery.
Similarly, a study by Roston et al., (2012) entitled “Self-Control Pain, Increases Patients'
Awareness of Pain Management” was a clinical trial in Norway on cancer patients. In the
intervention and control groups, before intervention, 40.8% of the intervention group used pain
relief alone and 42.9% of the control group used oral and anal pain relief at least in both groups.
Control and intervention with 12.2% and 14.3%, respectively, besides oral and injectable
analgesics by non-prescription methods Weiyi used. 3 weeks after the intervention in the
intervention group the use of non-pharmacological methods along with oral and injectable
analgesics reached 20.4% and in the 6 weeks after the intervention it reached 22.4%. Along with
other methods, there was no change.
Revista de Investigación Apuntes Universitarios
2020: 10(1), 88 - 100
ISSN 2312-4253(impresa)
ISSN 2078-4015(en línea)
96
Conclusion
There are many pharmacological and non-pharmacological methods to relieve pain in
cancer patients that are not used for various reasons mentioned in the research (lack of sufficient
knowledge and awareness), through education of patients by peers, pain palliative care education
was performed in this study, patients' knowledge of pain management was increased, and patients
took action to relieve their pain using the educations they got, which improved the pain outcomes
among cancer patients.
Since peer-based palliative care education is one of the low-cost techniques, the training of
nurses, nursing students, patients, and peer groups can improve the quality of care for patients with
cancer pain. Therefore, it is suggested that educational managers and planners consider the use of
peer-based palliative care education in developing the education program of nurses and caregivers
for cancer patients and train nurses working in the clinic to do this so that nurses, in turn, strive for
patients and peer groups to improve the quality of care for cancer patients.
References
Bakitas, M., Lyons, K.D., Hegel, M.T., Balan, S., Brokaw, F.C. y Seville, J. (2009). Effects of a
palliative care intervention on clinical outcomes in patients with advanced cancer: The
Project ENABLE II randomized controlled trial. Jama 302(7), 741-9.
Bennett, M.I. Bagnall, A.M. Jose Clos, S. (2009) How effective are patient-based educational
interventions in the management of cancer pain? Systematic Review and Meta-Analysis.
Pain, 143, 192-199
Cartagena, R.G., Veugelersm P.J., Kipp, W., Magigav, K., Laing, L.M. (2006). Effectiveness of
an HIV prevention program for secondary school students in Mongolia. Journal of
Adolescent Health. 39(6), 925-29.
Daher, M. (2011). Opioids for cancer pain in the Middle Eastern countries: a physician point of
view. Journal of Pediatric Hematology/Oncology.
Dehghani, A., Hojati, H., Shamsizadeh, M. (2013). The effect of peer-led education on depression
of multiple sclerosis patients. Iranian Journal of Psychiatric Nursing. 1(1), 63-71.
Dy, S.M., Hughes, M., Weiss, C., y Sisson, S. (2008). Evaluation of a web-based palliative care
pain management module for housestaff. Journal of Pain and Symptom Management,
36(6), 596-603.
Revista de Investigación Apuntes Universitarios
2020: 10(1), 88 - 100
ISSN 2312-4253(impresa)
ISSN 2078-4015(en línea)
97
Farbicka, P., Nowicki, A. (2012). Selected aspects of palliative care and quality of life at the
terminal stage of neoplastic disease. Contemporary oncology, 16(6), 506.
Ferlay, J., Colombet , M., Soerjomataram, I., Mathers, C., Parkin, D.M., y Piñeros, M. (2018).
Estimating the global cancer incidence and mortality in 2018: GLOBOCAN Sources and
Methods. International Journal of Cancer, Oct 23.
Ghadiri, E., Shahriari, M., Maghsoudi, J. (2016). The effects of peer-led education on anxiety of
the family caregivers of patients undergoing coronary artery bypass surgery (CABG) in
Shahid Chamran center Isfahan University of Medical Sciences. Iranian Journal of
Psychiatric Nursing, Jul 10;4(2):50–6. Retrieved from: http://dx.doi.org/10.21859/ijpn-
04026
Golianu, B., Krane, E., Seybold, J., Almgren, C., Anand, K.J. (2007). Non-pharmacological
techniques for pain management in neonates. InSeminars in Perinatology, 31(5), 318-322.
Gutgsell, K.J., Schluchter, M., Margevicius, S., DeGolia, P.A., McLaughlin, B., y Harris, M.
(2013). Music therapy reduces pain in palliative care patients: a randomized controlled
trial. Journal of Pain and Symptom Management, 45(5), 822-31.
Harif, F., Abshorshori, N., Tahmasebi, S., Hazrati, M., Zare N., y Masoumi, S. (2010). The effect
of peer-led education on the life quality of mastectomy patients referred to breast cancer-
clinics in Shiraz, Iran 2009. Health and Quality of Life Outcomes, Jul.
Keller, R., Frank-Bader, M., Beltran, K., Ascalon, M., Bowar-Ferres, S.L. (2011). Peer education:
an innovative approach for integrating standards into practice. Journal of Nursing Care
Quality, 26(2), 120-7.
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(2):264-84.
Mansori, K., Mosavi-Jarrahi, A., Motlagh, A.G., Solaymani-Dodaran, M., Salehi, M., Delavari, A.
(2018). Exploring Spatial Patterns of Colorectal Cancer in Tehran City, Iran. Asian Pacific
Journal of cancer prevention, 19(4):1099.
Medical Services Commission. (2011) Palliative care for the patient with incurable cancer or
advanced disease. Part 2: pain and symptom management. Victoria, BC: British Columbia
Medical Services Commission.
Modesto-Lowe, V., Girard, L., Chaplin, M. (2011). Cancer pain in the opioid-addicted patient: can
we treat it right? Journal of Opioid Management, 8(3):167-75.
Oldenmenger, W.H., Smitt, P.A., van Montfort, C.A., Pleun, J., van der Rijt, C.C. (2011). A
combined pain consultation and pain education program decreases average and current pain
Revista de Investigación Apuntes Universitarios
2020: 10(1), 88 - 100
ISSN 2312-4253(impresa)
ISSN 2078-4015(en línea)
98
and decreases interference in daily life by pain in oncology outpatients: a randomized
controlled trial. Pain, 152(11):2632-9.
Paice, J.A., Ferrell, B. (2011) The management of cancer pain. CA: a cancer journal for clinicians.
1;61(3):157-82.
Price, N, Knibbs, S. (2009). How effective is peer education in addressing young people’s sexual
and reproductive health needs in developing countries? Children & Society, 23(4), 291-
302.
Rustøen, T., Valeberg, B.T., Kolstad, E., Wist, E., Paul, S. y Miaskowski, C. (2012). The PRO-
SELF© Pain Control Program improves Patients' Knowledge of Cancer Pain Management.
Journal of Pain and Symptom Management, 44(3): 321-30.
Secomb, J. A (2008). Systematic Review of Peer Teaching and Learning in Clinical Education.
Journal of Clinical Nursing, 17(6), 703-16.
Shojae Zadeh, D, Mousavi, S.M.H. (2000). Models of studying behavior in health education. 1st
ed. Tehran: Iran Ministry of Health; p. 18 (en idioma persa).
Sun, V.C., Borneman, T., Ferrell, B., Piper, B., Koczywas, M., Choi, K. (2007). Overcoming
barriers to cancer pain management: an institutional change model. Journal of pain and
symptom management, 34(4):359-69.
Taleghani, F., Babazadeh, S., Mosavi, S., Tavazohi, H. (2012). The effects of peer support group
on promoting quality of life in patients with breast cancer. Iranian journal of nursing and
midwifery research, 17(2).
Taleghani, F., Yekta, Z.P, Nasrabadi, A.N, Käppeli, S. (2008). Adjustment process in Iranian
women with breast cancer. Cancer Nursing, 31(3), 32-41.
Temel, J.S., Greer, J.A., Muzikansky, A., Gallagher, E.R., Admane, S., Jackson, V.A., Dahlin,
C.M., Blinderman, C.D., Jacobsen, J., Pirl, W.F. y Billings, J.A. (2010). Early palliative
care for patients with metastatic non–small-cell lung cancer. New England Journal of
Medicine, 363(8): 733-42.
Van Rompay, K.K., Madhivanan, P., Rafiq, M., Krupp, K., Chakrapani, V. y Selvam, D. (2008)
Empowering the people: Development of an HIV peer education model for low literacy
rural communities in India. Human Resources for Health, 6(1):6.
Varaei, S., Cheraghi, M.A., Seyedfatemi, N., Talebi, M., Bahrani, N., Dehghani, A. (2013). Effect
of peer education on anxiety in patients candidated for coronary artery bypass graft surgery:
a randomized control trial. Journal of Nursing Education, 2(3), 28-37.
Revista de Investigación Apuntes Universitarios
2020: 10(1), 88 - 100
ISSN 2312-4253(impresa)
ISSN 2078-4015(en línea)
99
Webel, A.R., Okonsky, J., Trompeta, J., Holzemer, W.L. (2010). A systematic review of the
effectiveness of peer-based interventions on health-related behaviors in adults. American
Journal of Public Health, 100(2), 247-53.
Wiese, C.H., Löffler, E.K., Vormelker, J., Meyer, N., Taghavi, M. y Strumpf, M. (2010). Cancer
pain therapy in palliative care patients: knowledge of prehospital emergency physicians in
training. Prospective Questionnaire-based Investigation. Schmerz (Berlin, Germany),
24(5), 508-16.
World Health Organization (2011) WHO Definition of Palliative Care. Available at
http://www.who.int/cancer/palliative/definition/en. [Accessed at: June 2013].
World Health Organization (2007). Access to Controlled Medications Programme: Framework.
Geneva, Switzerland: World Health Organization; Available at:
http://www.who.int/medicines/areas/quality_safety/Framework_ACMP_withcover.pdf.
Accessed at: November 2, 2010.
Revista de Investigación Apuntes Universitarios
2020: 10(1), 88 - 100
ISSN 2312-4253(impresa)
ISSN 2078-4015(en línea)
100