Using nominal group technique to assess chronic pain, patients' perceived challenges and needs in a community health region

Using nominal group technique to assess chronicpain, patients’ perceived challenges and needsin a community health region

Anne Dewar RN BA MHP PhD,* Marc White PhD,� Santiago T. Posade MD�and Wilson Dillon MD FRCPC�*Assistant Professor, School of Nursing, University of British Columbia, Canada, �Candidate, Centre for the Study of Curriculumand Instruction, University of British Columbia and Executive Director, Physical Medicine Research Foundation, Vancouver,

Canada and �Physical Medicine Research Foundation, Vancouver, Canada

Correspondence

Dr Anne Dewar

T254-2211 Wesbrook Mall

Vancouver, BC V6T 2B5

Canada

E-mail: [email protected]

Accepted for publication

16 October 2002

Keywords: chronic pain, needsassessment, nominal group technique,

patient perspectives, patient–physician

interactions, PRECEDE–PROCEED

planning model

Abstract

Purpose The purpose of this study was to better understand the

experiences of people suffering from chronic pain in order to plan

client-centred educational interventions.

Methods People in the community with chronic pain were invited

via newspapers, newsletters and e-mail discussion lists to participate

in a needs assessment process and to attend an educational session at

a local community college. Using the nominal group technique,

which is a qualitative method of data gathering, 53 participants

reported their perceived challenges and needs in dealing with chronic

pain. Participants were randomly assigned to one of 10 groups

ranging from three to seven people. Responses were pooled to

develop an overall list of their major concerns and needs.

Results Issues were classified into six priority areas: medical and

treatments, problems with daily living, emotional distress, social

issues, sleep disturbances and financial issues. Participants indicated

they had difficulty finding accessible, effective and acceptable care.

Many participants perceived their family physician or other health-

care providers were not adequately meeting their health-care needs.

Specifically, sleep disorders; feeling of depression, irritability, worry

and anxiety were perceived as medical and treatment areas requiring

improvement. In addition, participants sought greater validation of

their lived experience of chronic pain.

Conclusion Participants perceived that their needs were not being

met adequately. There is a need for further study on physician–

patient communication and its impact on patient health status and

disability.

44 � Blackwell Publishing Ltd 2003 Health Expectations, 6, pp.44–52

Introduction

Since 1980 there has been a growing qualitative

andquantitative literature base about peoplewith

chronic pain, its prevalence, aetiology and man-

agement as well as a better understanding of some

of the challenges experienced by people with

chronic pain.1,2 Chronic pain can impact

employment, family relationships and overall

social functioning, and may exacerbate or lead to

depression, health concerns and withdrawal from

activities.3 Individuals with chronic pain have a

serious impactonhealth-care resourcesandhealth

utilization. Miller4 reported people with chronic

pain experience more disability days, spend more

time in hospital, have more frequent doctor visits

and have greater medication use. Based on the

1998–99 National Population Health Survey5

(NPHS) in Canada, 12.4% (3.47 million) of the

population aged 4 or older, excluding residents in

institutions, reported having chronic pain, 30%

reported their pain as mild, 55% as moderate and

15% reported their pain as severe. There were age

differences in severity with 8%of 15–24 year-olds

with chronic pain reporting it to be severe, by ages

45–64 the proportion was 20%.

The purpose of this study was to better

understand the experiences of people suffering

from chronic pain with the aim of exploring the

client-perceived needs and potential client-

identified solutions to inform the development

of interventions to assist them. To gather data,

people with chronic pain were invited to parti-

cipate in a needs assessment process and attend

an educational session introducing a chronic

disease self-management programme.

Need assessment methods are used by a vari-

ety of stakeholders to identify and examine

values and information for many purposes.6 The

PRECEDE–PROCEED* model is a systematic

framework developed by Green and Kreuter7 to

enhance the planning and implementation of

educational programmes in the health promo-

tion field. The model emphasizes a comprehen-

sive diagnosis of the nature of the problem, the

desired outcome, the context of the client and

the identification of potential barriers that could

interfere with producing the desired outcome.7

A first step of the diagnosis is concerned with an

analysis of social problems or quality-of-life

concerns.

In group interactions, power is not evenly

distributed, as the more vocal individuals often

influence the outcomes because of their ability to

express their concerns and opinions. One

method to systematically gather data and elicit

participation from all participants is the nominal

group technique (NGT).8,9 The NGT has been

used in several research studies to elicit concerns

of a particular population and to establish

priorities.10–13 As a qualitative approach, this

technique is driven by the opinions and needs of

the participants and not by the perceptions of

the researchers. The highly structured interactive

process allows much information to be elicited

in a short time period.

Methods

The stages of the NGT are (i) listing, (ii)

recording, (iii) collating and (iv) prioritizing.14

The purpose of the research was to develop an

understanding of the needs and requirements of

individuals with chronic pain and of the impact

of pain on their daily lives.

Procedures

Members of the target community were invited

to attend a needs assessment public forum at a

local community college. The forum was adver-

tised through newspaper advertising, internet

e-mail lists concerned with chronic pain and

arthritis, bulletin board postings at community

centres and the community college. The adver-

tisement indicated that individuals with chronic

pain were invited to participate in a research

forum designed to examine their needs. Included

*PRECEDE is an acronym for predisposing, reinforcing

and enabling constructs in educational diagnosis and

evaluation. PROCEED is an acronym for new elements

in planning, implementation and evaluation and stands

for policy, regulatory and organizational constructs in

educational and environmental development recognizing

that other institutional factors influence behavioural

change.

Nominal group technique to assess chronic pain, A Dewar et al.

� Blackwell Publishing Ltd 2003 Health Expectations, 6, pp.44–52

45

in the forum was an educational workshop on

strategies to manage pain. The workshop was

not part of the research process but was offered

as an encouragement to participate in the needs

assessment. The ethics committee of a partici-

pating university approved the research.

At registration, participants signed consent

forms and were given copies for their own

records. The population of 53 participants was

divided into 10 groups of three to seven people.

During the registration process, the participants

were randomly assigned to a focus group by

drawing a number between one and 10 from a

bag. Participants were given a demographic sur-

vey and a pain questionnaire to complete during

registration. Following an introduction about

the purpose and programme activities for the

half-day activity (2 h NGT, lunch, 1 h education

session), participants were directed to their des-

ignated work group area to meet their facilitator.

Each group was lead by a facilitator who had

received written information by mail about the

NGT process prior to attending the event. A

45-min briefing and role playing in the NGT

process with all of the facilitators was held 1 h

prior to the event. Two of the researchers, who

were also group facilitators, gave the briefing

sessions. The facilitators guided the participants

through the process. Each group was given two

questions to address separately. The first ques-

tion focused on their problems as individuals

with chronic pain, �What problems do you

experience when dealing with your chronic

pain?� The second question focused on what they

thought would be helpful to them, �What would

you like to see happen to better meet your needs

as a person in pain?� Each question was written

on a flip chart so that it would be visible to the

participants during the NGT.

The following four components of the NGT

were used in the assessment process:

1. Group members were asked to work alone

for 5 min and to generate their ideas or concerns

in writing. There was no discussion during this

stage.

2. Following the individual generation of

ideas, responses were elicited in a round-robin

fashion. The facilitator recorded the ideas or

recommendations of each group member in

short phrases on the flip chart. At this stage, if

any items were ambiguous they were clarified so

that every group member understood the

meaning of each item. The group facilitators

remained neutral and recorded the participants’

concerns as they were given.

3. The responses were now collated, clarified,

simplified and grouped logically.

4. Prioritizing involved voting on the priority

of the items. Group members were asked to

select from the list on the flip chart, the five items

they perceived to be most important to them

individually, and to record them. The group

priorities were then derived through ordering or

rating by each individual member. A final list of

items with the highest number of votes was

compiled. The remainder of the items was listed

in descending order.

Participants

The age of the participants ranged from 15 to

80 years and there were many females than males

in the group (see Table 1). The majority of the

participants (69%) reported that they had chro-

nic pain for more than 2 years. Twenty-two per

cent reported chronic pain for longer than 1 year

but <2 years. Two people reported chronic pain

<6 months. Thirteen participants (24.5%) were

either self-employed or employed, seven partici-

pants (13%) classified themselves as home-

makers, one individual was a student, and the

remainder of the participants, i.e. 24 participants

(45%) were unemployed or retired (see Table 2).

Table 1 Age and gender of participants

Age Males Females Both

Under 20 0 2 2

20–29 0 3 3

30–39 2 4 6

40–49 2 7 9

50–59 4 12 16

60–69 2 8 10

70–79 2 3 5

80–89 1 0 1

Total 13 40 53


Nominal group technique to assess chronic pain, A Dewar et al.46

Priorities

Each group listed their five top priorities (see

Table 3). The results were tabulated, resulting in

six top priorities among the 10 groups.

Data analysis

The data was examined for the top priorities of

each group. Four investigators (nursing profes-

sor, medical educator, family physician and

psychiatrist) independently developed a classifi-

cation system. Differences in classification were

discussed and through consensus, a standardized

classification system was used. Two investigators

reclassified individual and group responses and

differences were discussed with a third investi-

gator. The issues that were common to all par-

ticipants who participated in the 10 groups are

described in Table 3.

Findings

Medical and treatment issues

Many participants expressed concern about

their medical treatment. They indicated that

they had difficulty finding accessible, effective

and acceptable health-care. Skilled health pro-

fessionals, specialized medical pain management

specialists and disability services were not read-

ily available when the participants had acute

problems and at other times.

Several participants commented that they had

experienced unacceptable attitudes and behav-

iours from their physicians. These included

being dismissed, not being believed, receiving

insensitive treatment and insensitive comments.

Several participants commented their physicians

displayed a lack of compassion and under-

standing.

When [I’m] having a flare-up, I have a very hard

time getting help for pain. Doctors think it is �inyour head� and instead of getting pain medication,

I’m given antidepressants. Yes I am depressed but

it is the pain that causes the depression.

Some participants believed their medical practi-

tioners lacked knowledge about pain manage-

ment and consequently believed they had

prescribed improper treatment. One concern was

that a first diagnosis hampered subsequent diag-

noses, for example if a patients was diagnosed

with depression it was more difficult to get

treatment for pain. Treatment provided only

short-term relief, some prescribed exercise, and

activities increased pain, and sometimes partici-

pants felt like �guinea pigs� as various treatments

were tried. Participants identified that the side-

effects of drugs made some treatments unac-

ceptable and did not always provide relief. �I�mnot able to take strong medication due to my

allergy to codeine’. Another participant com-

mented, �The use of Tylenol #3� causes severe

constipation which is almost as bad as the

disease.�In response to their perceptions of treatment,

many participants felt they lacked knowledge

about managing their condition and about

making treatment decisions. Some indicated they

did not get clear information about medications,

were not aware of available services and felt a

need for supportive advocates. One participant

commented, �I am indecisive regarding available

treatments, trying to decide whether financial

Table 3 Top six priorities (sorted by frequency)

1 Medical and treatment issues 15 (30%)

2 Problems with activities of daily living 11 (22%)

3 Emotional distress 10 (20%)

4 Social issues 6 (12%)

5 Sleep disturbance 5 (10%)

6 Finance 3 (6%)

Table 2 Employment and disability status

Employment

status

Not receiving

disability

payments

Receiving

disability

payments Total

Homemaker 6 1 7

Self-employed 3 0 3

Employed 10 3 13

Unemployed 7 5 12

Retired 9 3 12

Student 1 0 1

No answer 5 0 5

Total 41 12 53


Nominal group technique to assess chronic pain, A Dewar et al. 47

outlay is worth the risks of not [trying anything]

especially with [having] a low income…�

Activities of daily living (mobility and physical

issues)

Pain is pervasive and affects almost all activities

of daily living. Difficulties were experienced in

finding physical comfort, dressing and undress-

ing, lifting, driving, doing housework and

other work and recreational activities. Lack of

mobility increased dependence on others, as one

participant wrote, �I can�t care for myself when

I’m in the worst condition’.

Pain on movement was a major concern for

some participants. Any activity, including get-

ting out of bed caused problems. Inability to

exercise meant gaining weight. Others noted the

progressive nature of their problems and the

difficulties in recovering. �My pain only frees me

about 2 days a month and at times it won�tstop’. Participants wrote that they had pain in

many body areas including back, neck, arms,

legs and even bowels. One participant wrote,

�Diarrhea, hemorrhoids, swollen skin tags,

fistulas are part of my day. What fun eh!�Of the physical problems, sleep disturbances

and fatigue were major problems. Chronic pain

in itself can be fatiguing and most participants

reported sleep problems. Poor sleep contributed

to fatigue and to depression. One participant

wrote, �Rheumatoid arthritis, pain all over [my]

body when the attack is on, pain in hands is

chronic but varies [in] intensity. This pain makes

sleep impossible some nights�.

Emotional distress

Psychological problems were a major area of

concern. Several emotional reactions were listed

such as anger, depression, anxiety, irritability,

upset feelings and limited patience. Mood swings

and negative feelings contributed to distur-

bances in relationships and created high levels of

stress.

Participants expressed frustration at many

situations such as not having answers to their

problems, or not knowing what caused their

pain. �I am frustrated with myself for not being

able to control my pain, and sad [because I]

don�t know what would help’. For many indi-

viduals the future was uncertain and they felt let

down when pain-relieving methods did not

work. Cognitive symptoms were also reported

including confusion, forgetfulness, decreased

ability to concentrate, problems making good

decisions due to sleeplessness and an inability to

focus on anything but pain. �Pain affects my

memory too, I could not do much about studies.

I read a lot for comfort but don�t remember

much’.

Social issues

Pain impacted on the participants’ social lives as

they experienced difficulties interacting with

family, friends and society. The lack of predict-

ability and ability to plan ahead affected many

aspects of life, �I cannot go out with my spouse

because of uncontrolled pain�. Participants

indicated that changes in lifestyle had dimin-

ished their quality of life. One participant com-

mented that being unable to work made him

more socially isolated and bored. �I feel less thanspecial as my closest friends and I enjoy many

activities and [I] cannot do these at present

because of pain and awkwardness. [My] self-

worth decreases.�Many people commented they had experi-

enced discrimination, and lack of support and

understanding about the impact of pain on their

lives. There were many comments about the

invisibility of chronic pain and the feeling of

being stigmatized. �The public have a hard time

believing in your pain, if they can�t see it, it doesnot exist’.

Participants felt powerless to influence some

factors in the social world that markedly affected

their lives. For example, if they were involved in

litigation, the process was time-consuming and

the paperwork was complex and there were few

services to assist them. For example, one young

woman said childcare was a problem for her,

and if she was suddenly taken ill there was no

one to help her. Age discrimination was also

mentioned, as there were services and some



group support for the older age groups but

nothing for young people. Other comments

included the lack of understanding from

employers and lack of work rehabilitation.

Financial issues

Costs of medication, therapy, equipment and

complementary ⁄alternative treatments were

financial burdens, especially if such treatments

did not result in improved health outcomes.

When you need certain exercise equipment or

instruction on how to get better, if you can’t pay

for it, you can’t have it. If you need a new bed, etc.

it is hard to get one. The process is so hard, you

feel like giving up.

There was interest in the complementary and

alternative medicine but some participants indi-

cated that their physicians hesitated to recom-

mend these as adjuncts or options. This was a

quandary for those participants who wanted to

try these alternatives but were unsure about their

effectiveness. For some participants, chronic

pain limited their ability to work, as one parti-

cipant commented, �I could not hold my job as a

nursing assistant [as this type of work was] very

heavy for my joints�.

Client-centred solutions

For the second question, the NGT was used to

ask the participants what would be helpful to

them as individuals in pain. Their requests for

assistance mirrored the descriptions of their

needs. Many indicated that improvements in

treatment, education and services, as well as

greater public awareness and financial support,

would lead to improvements in their quality of

life. Table 4 lists their solutions in order of

priority.

Improved treatment

The first identified priority was improved treat-

ment. Participants indicated they wanted access

to competent, knowledgeable physicians and for

those physicians to demonstrate compassion and

understanding. Some participants commented

they needed other health professionals such as

physiotherapists and occupational therapists to

be available as needed. A recurring theme is

reflected in the following quote �awareness that

the pain is real�. They also wanted effective

medications and �clearer information on medi-

cations and on their diagnoses�.

I feel I get passed from one doctor to another. The

[alternative] treatments for the knee were expensive

and worked not at all. The arthritis in the knee

developed after an ill-fitting air cast was applied

after original cast for broken fibula had been

removed. The tendonitis – no treatment received.

Bursitis – one cortisone treatment. Numbness in

left arm – my doctor said it was related to neck

problems and to ignore it. Which is ridiculous!

Education and services

The second priority was education. Participants

indicated they wanted to learn about pain and

how to manage it. Some participants wanted

information about exercises to lessen pain. Sev-

eral of the participants indicated they wanted

improvements in services including access to a

multidisciplinary pain centres so that there was a

more coordinated approach to their care. Access

to support groups was considered important for

themselves and their families. There were strong

indications that participants wanted to help

themselves and not depend upon health profes-

sionals. �Every health worker tells me what my

pain is and gives me bits of information that I

have not been able to amalgamate into a plan of

action�.

Public awareness

A major concern was feeling stigmatized. As

their disability was not visible they felt they were

not credible. Many requested improved public

Table 4 Client-centred solutions

1 Medical and treatment issues

2 Education

3 Public awareness

4 Financial needs



awareness and education at schools, community

settings, as well as more public forums to bring

greater awareness of chronic pain issues to the

community. One participant wrote, �people in

pain are physically challenged but not disabled�.

Financial support

Financial issues were a concern as for some

individuals pain limited their ability to be

employed. Participants wanted affordable treat-

ment, counselling and assistance in making

modifications to their homes. Some participants

suggested tax deductions for adjustments to their

homes and for essential equipment such as

wheelchairs. Re-training for work was identified

as a need along with supportive employers who

were willing to take people with disabilities.

Government subsidies could, according to the

participants, be offered as an incentive to

employers willing to hire people hindered by

chronic pain.

One participant noted, �Hell! Never realized

how many people must suffer so much and how

little is being done to help�. Another participant

remarked that the extent of their concerns

and the lack of solutions were so apparent, he

suggested legalized euthanasia.

Discussion

As noted by Charmaz15 qualitative analysis can

provide health-care workers with an under-

standing of their patients’ beliefs about and

views of their illness. Many people reported

they felt their physician and other health-care

providers offered little support, providing little

or no validation of their �pain� experience. Thislack of validation continued in their social life,

resulting in a greater challenge of having an

invisible impairment ⁄disability. The degree of

patients’ level of ongoing anxiety about the

future indicated a great need for realistic

patient reassurance. The perceptions of these

participants was that the impact of chronic

pain on their roles and relationships were not

adequately addressed in treatment plans, nor

was the impact on their social life, leisure

activities and hobbies outside the home man-

aged adequately, resulting in increased feelings

of isolation and alienation. Some problems

were specific to only a few individuals, but the

nominal process was helpful in uncovering

issues and situations that might not otherwise

be known such as problems experienced by the

younger sufferers.

Understanding patients’ attitudes is partic-

ularly important considering the findings of a

recent systematic review of the evidence for a

relationship between patient’s recovery expec-

tations and health outcomes.16 Mondloch

et al.16 concluded that physicians have a role in

assisting patients to set realistic and feasible

recovery goals, this may improve patients’

adherence to treatment protocols and foster

their motivation to work towards achieving

these goals. This calls for frank and supportive

dialogue between health-care providers and

patients.

In today’s health-care system the relationship

between health-care providers, primarily physi-

cians and patients is changing to become less

paternalistic and more of a partnership. For

example, models of collaboration are being

developed between physicians and the lay pub-

lic.17 These changes are considered to be bene-

ficial to both providers and care recipients,

provided the patient wants to be involved in

decision-making and is informed during the

process.

Some research has identified that patients

negotiate with their physicians, demanding and

receiving unnecessary treatments, such as anti-

biotics.18 However, the perceptions of the par-

ticipants in this study indicated that they felt

powerless in the health-care system and were not

able to receive the treatments they needed to

control their pain. Most voiced comments were

directed towards physicians probably because

they are the health-care providers they saw most

often. Previous research has identified that

physicians lack knowledge about pain and pain

management, are reluctant to prescribe opioids

and may hold negative views about patients in

chronic pain.19 Health-care providers need to

improve their knowledge of pain management to



assist this group and to be conscious of how

their attitudes may impact on this vulnerable

group. Patients’ perceptions of inadequate sup-

port could be addressed, in part, by strategies

that would empower them so that they can

negotiate the health-care system.

This research also identified that when

patients’ needs were not met by the traditional

health-care system, they wanted access to com-

plimentary and alternative therapies. Some

patients commented that their physicians were

hesitant to recommend alternatives. For the

well-researched therapies, this option is viable,

but for those therapies with minimal or no

validity this can be an additional source of

confusion, disappointment and an additional

expense many cannot afford. There is a growing

trend for patients to visit complimentary and

alternative therapists as well as to use compli-

mentary and alternative therapies.20,21 Physi-

cians need to assess their patients and provide

advice on recommended complimentary and

alternative therapies. Previous research identi-

fied that <40% of patients disclose their use

of complimentary and alternative therapies to

physicians.20 Eisenberg et al.20 calls for more

research into the effects of these therapies.

The results of this study also suggest that

access to pain clinics is a problem because of the

limited number of these services and geograph-

ical problems. Support services such as the self-

management programme for chronic pain as

described by Lorig et al.22 could provide know-

ledge and skills about pain management for these

patients. Chronic pain is an area that remains

quite resistant to improvements. Support needs

to be extended to permit patients to manage their

own pain as much as possible. Some success has

been achieved with chronic pain self-manage-

ment programmes located in the community.1

Further research is required regarding: (a) the

impact of physician–patient communication on

patient health status and pain; (b) the effective-

ness of multidisciplinary pain clinics; (c) evalu-

ation of prescribed treatment regimens; (d)

strategies to provide adequate psychological

support to address pragmatic issues of people

living with chronic pain and (e) the usefulness of

treatment plans in facilitating functional

improvements (such as ADL, and returning to

work).

Limitations

The generalizability of the findings is limited

because the population was a convenience sam-

ple of those with chronic pain who were aware

of the workshop and were able to attend. It is

not a substitute for representative sampling but

can serve as a means of developing questions for

more in-depth surveys. The NGT is helpful in

identifying and ranking patients problems and in

encouraging reticent individuals to speak during

group discussions, however, the NGT process

does not provide an opportunity for group dis-

cussion for more in-depth planning of identified

client-centred solutions.

Conclusion

The purpose of the study was to look at per-

ceived needs and potential client identified

solutions pertaining to a specific target group in

the community. The people participating repre-

sented part of the target population in the

region. Many participants perceived their family

physician or other health-care providers were

not adequately meeting their health-care needs.

Specifically, sleep disorders, feelings of depres-

sion, irritability, worry and anxiety were per-

ceived as medical and treatment areas requiring

improvement. In addition, participants sought

greater validation of their lived experience of

chronic pain. Alternative measures to improve

self-management and accessibility of treatment

especially during acute flare-ups were also indi-

cated. Evidence-based knowledge about treat-

ment efficacy is needed to benefit both patients

and physicians and strategies for effective dis-

semination are also required.

The problem of chronic pain remains challen-

ging for both patients and health-care profes-

sionals. Finding comprehensive andmultifocused

strategies are needed urgently to combat this

problem, not only from the economic perspective

but also for compassionate reasons.



References

1 LeFort SM, Gray-Donald K, Rowat KM, Jeans ME.

Randomized controlled trial of a community-based

psychoeducation program for the self-management

of chronic pain. Pain, 1998; 74: 297–306.

2 Jensen MP, Turner JA, Romano JM, Karoly P.

Coping with chronic pain: a critical review of the

literature. Pain, 1991; 47: 249–283.

3 Kelly P, Clifford P. Coping with chronic pain:

assessing narrative approaches. Social Work, 1997;

42: 266–277.

4 Millar JW. Chronic pain. Health Reports, 1996;

7: 47–53.

5 Stats Canada Vol 2001, No. 2. Health Indicators.

http://www.statcan.ca/english/freepub/82-221-XIE./

00601/high/sever.htm retrieved September 4, 2001�.

6 Sarvela PD, Huetteman JD, Bajracharya S. Needs

assessment for a University wellness center: a strategic

planning project. Health Values, 1990; 14: 24–32.

7 Green LW, Kreuter MW. Health Promotion Planning.

An Educational and Ecological Approach, 3rd edn.

Mountain View, CA: Mayfield Publications Co.,

1999.

8 Delbecq AL, Van de Ven AH. A group process model

for problem identification and program planning.

Journal of Applied Behavioral Science, 1971;

7: 466–492.

9 Delbecq AL. The nominal group as a technique for

understanding the qualitative dimensions of client

needs. In: Bell RA, Sundel M, Aponte JF, Murrell

SA, Lin E (eds) Assessing Health and Human Service

Needs. Concepts, Methods and Applications. New

York, NY: Human Sciences Press, 1983: 210–218.

10 Miller D, Shewchuk R, Elliot TR, Richards S.

Nominal group technique: a process of identifying

diabetes self-care issues among patients and

caregivers. Diabetes Educator, 2000: 26: 305–314.

11 Ginsburg KR, Menapace AS. Slap GB factors

affecting the decision to seek health care: the voice of

adolescents. Pediatrics, 1997; 100: 922–930.

12 Carney O, McIntosh J, Worth A. The use of the

nominal group technique in research with community

nurses. Journal of Advanced Nursing, 1995; 23: 1024–

1029.

13 Siegel LM, Attkisson CC, Carson LG. Need identi-

fication and program planning the community con-

text. In: Attkisson CC, Hargreaves WA, Horowizt

MJ, Sorensen JE (eds) Evaluation of Human Service

Programs. New York, NY: Academic Press, 1978:

215–251.

14 Green LW, Lewis FM. Measurement and Evaluation

in Health Education and Health Promotion. Palo Alto,

CA: Mayfield Publications Co., 1986.

15 Charmatz K. Discovering chronic illness: using

grounded theory. Social Science and Medicine, 1990;

30: 1161–1172.

16 Mondloch MV, Cole DC, Frank JW. Does how you

do depend on how you think you’ll do? A systematic

review of the evidence for a relation between patients’

recovery expectations and health outcomes. Cana-

dian Medical Association Journal, 2001; 165: 174–179.

17 Young A, Flower L. Patients as partners, patients as

problem-solvers. Health Communication, 2002; 14:

69–97.

18 Shapiro E. Injudicious antibiotic use: an unforeseen

consequence of the emphasis on patient satisfaction?

Clinical Therapy, 2002; 24: 197–204.

19 Weinstein SM, Laux LF, Thornby JI, Lorimor RJ,

Hill CS Jr, Thorpe DM, Merrill JM. Physicians’

attitudes toward pain and the use of opioid analge-

sics: results of a survey from the Texas Cancer Pain

Initiative. Southern Medical Journal, 2000; 93: 479–

487.

20 Eisenberg DM, Davis RB, Ettner SL, Appel S,

Wilkey S, Van Rompay MI, Kessler RC. Trends in

alternative medicine use in the United States, 1990–

1997. Journal of the American Medical Association,

1998; 280: 1569–1575.

21 Kessler RC, Davis RB, Foster DF, Van Rompay MI,

Walters EE, Wilkey SA, Kaptchuk TJ, Eisenber DM.

Long-term trends in the use of complementary

and alternative medical therapies in the United

States. Annals of Internal Medicine, 2001; 135:

262–268.

22 Lorig KR, Sobel DS, Stewart AL, Brown BW Jr,

Bandura A, Ritter P, Gonzalez VM, Laurent DD,

Holman HR. Evidence suggesting that a chronic

disease self-management program can improve

health status while reducing hospitalization: a rand-

omized trial. Medical Care, 1999; 37: 5–14.

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Using nominal group technique to assess chronic pain, patients' perceived challenges and needs in a community health region