African Americans' Perceptions of Pain and Pain Management: A Systematic Review.

PURPOSE: The purpose of this systematic review is to explore the perceptions of acute, persistent, and disease-specific pain and treatment options held by adult African Americans. Underassessment and undermanagement of pain in African Americans has been well documented; however, the cultural continuum of pain perceptions and their influence on pain assessment and management has not been synthesized. DESIGN: Electronic database searches of the Cumulative Index for Nursing and Allied Health Literature and PubMed, Web-based searches of the pain-specific journals plus a manual search of reference lists identified 41 relevant articles addressing perceptions of pain and/or pain management. FINDINGS: Analysis of the literature revealed six themes: (a) meaning of pain, (b) description of pain, (c) coping with pain, (d) impact of pain, (e) patient-provider relationship, and (f) treatment approaches. CONCLUSION: These findings warrant further research and indicate the need for more precise evaluation of pain in African Americans, highlighting an imperative to incorporate cultural patterns into pain management practice and education.

Qualitative cross-cultural exploration of breast symptoms and impacts associated with hormonal treatments for menopausal symptoms to inform the development of new patient-reported measurement tools.

To explore cross-cultural experiences of women taking estrogen plus progestin therapies (EPT) and develop a symptom-based electronic diary and impact questionnaire for EPT-related breast symptoms. (1) Concept elicitation interviews were conducted with women in the US (n=14), Italy (n=15), Mexico (n=15) and China (n=15) to explore breast symptoms associated with EPT. Patients completed the Breast Sensitivity Questionnaire (BSQ) to evaluate understanding and comprehensiveness. (2) Based on concept elicitation, a 6-item eDiary (Breast Pain/Tenderness Daily Diary - BPT-DD) was generated and the BSQ modified forming the 18-item Breast Sensations Impact Questionnaire (BSIQ). (3) The measures were pilot-tested and then cognitively debriefed with US women receiving EPT. All qualitative data was subject to thematic analysis. Concept elicitation identified breast pain/tenderness, swollen breasts and sensitivity to contact as important symptoms, impacting women's emotional well-being, relationships with family/friends, social life, sleep, ability to move freely, contact, clothing and sexual activity. Experiences were relatively consistent across the country samples. Based on pilot testing and cognitive debriefing, the BPT-DD was reduced to 4 items (and renamed the Breast Pain Daily Diary - BP-DD) and the BSIQ was reduced to 13 items due to conceptual redundancy. Women taking EPT in the US, China, Mexico and Italy reported breast sensations that have a detrimental impact on quality of life. Two new measures were developed to assess the severity and impact of breast pain specific to EPT. This work highlights that EPT-related symptoms should be part of treatment decision-making, and treatments with less burdensome side effects are needed.

Preliminary psychometric properties of the Chinese version of the Chronic Pain Coping Inventory (ChCPCI) in a Hong Kong Chinese population.

UNLABELLED: The Chronic Pain Coping Inventory (CPCI) is a frequently used measure that assesses 8 categories of coping strategies that patients might use to cope with chronic pain. Despite its good psychometric properties and widespread use, the instrument has not been tested for its applicability and validity in non-Western populations, such as among Chinese. This study evaluated the reliability and validity of a Chinese translation of the 42-item CPCI (ChCPCI-42) in a sample of Chinese patients with chronic pain (n = 208). In addition to the ChCPCI-42, the patients were administered the Chronic Pain Grade (CPG) questionnaire, the Pain Catastrophizing Scale (PCS), the Centre for Epidemiological Studies-Depression Scale (CES-D), and questions assessing sociodemographic characteristics. Results of confirmatory factor analyses revealed that of the ChCPCI-42 8 scales, 6 demonstrated acceptable-to-good data-model fit (CFI >or= 0.90) and 2 demonstrated medium fit (CFI >or= 0.85). The 8 scales demonstrated adequate to good internal consistency (Cronbach alpha, 0.69 to 0.79) and correlated with CES-D, PCS, pain intensity, and disability in expected directions. Results of hierarchical multiple regression analyses showed that the ChCPCI-42 scales predicted concurrent depression (F (8,177) = 3.07, P < .01) and pain disability (F (1, 179) = 4.35, P < .001) scores, the Task Persistence scale being the strongest unique predictor among the 8 scales. The findings support the factorial validity and reliability of a 42-item CPCI that can be used among Chinese patients with chronic pain. PERSPECTIVE: The report outlines the first validation of the CPCI for use in Hong Kong Chinese. This makes available a suitable instrument for chronic pain research in the Southern Chinese population and will help to elucidate similarities and differences in pain coping between Chinese and other ethnic groups.

Associations between race and ethnicity and treatment for chronic pain in the VA.

UNLABELLED: The purpose of this study was to identify racial and ethnic differences in patient-reported rates of treatment for chronic pain and ratings of pain-treatment effectiveness among veterans treated in Veterans Affairs (VA) facilities. This was a cross-sectional analysis of data from 255,522 veterans who participated in the VA Survey of the Healthcare Experiences of Patients (SHEP) in Fiscal Year 2005. Measures included demographics, the Veterans Rand Health Survey-12, a single item inquiring if the patient received treatment for chronic pain in the VA within the prior 12 months, and a single item asking the patient to rate the effectiveness of chronic pain care. In a logistic model adjusting for demographics, pain interference, and mental health status, male and female veterans who were Hispanic (OR 1.39 [95%CI 1.26-1.53] and OR 1.57 [1.02-2.43], respectively) or non Hispanic black (OR 1.43 [1.33-1.54] and OR 1.35 [1.02-1.78], respectively) were more likely to report receiving treatment for chronic pain in the prior 12 months compared to non Hispanic white veterans. Among veterans who reported receiving treatment for chronic pain, non Hispanic black men were less likely to rate pain-treatment effectiveness as very good or excellent, compared to non Hispanic white men (OR .809 [.720-.910]). PERSPECTIVE: In our study, Hispanic and non Hispanic black veterans reported receiving chronic pain treatment more frequently than white veterans. Among veterans reporting pain treatment, non Hispanic black men were somewhat less likely to report receiving highly effective treatment than white men. Further research is needed to understand the reasons for these differences and their potential clinical implications.

A cross-cultural study of pain intensity in Egyptian and Dutch women with rheumatoid arthritis.

UNLABELLED: It has been suggested that patients from Mediterranean cultures tend to report more intense pain than their Northern or Western European counterparts in comparable medical conditions. However, empirical data to support this hypothesis are limited. The goals of the present study were to examine differences in pain intensity reports between Dutch and Egyptian women with rheumatoid arthritis (RA) and to examine the influence of possible confounding variables using multivariate analyses. We performed a cross-sectional study in 30 Dutch and 42 Egyptian women with comparable RA, matched for age and disease duration. Pain intensity was measured on a 100-mm graphic rating scale. Additionally, we assessed physical function, radiographic joint damage, progression of RA, disease activity, number of swollen and tender joints, medication, rheumatoid factor, and socioeconomic variables. The progression of RA and radiographic damage were not significantly different between Egyptian and Dutch patients. However, the Egyptian population reported significantly worse pain and physical function and demonstrated higher disease activity. Multiple linear regression analysis showed that the country of residence and the number of tender and swollen joints were significant independent determinants of pain reports. The results provide some support for the idea that there are ethnocultural differences in pain reports between Egyptian and Dutch women with RA, although the mechanisms underlying these differences remain unclear. PERSPECTIVE: This article shows that after controlling for differences in demographic, socioeconomic, and clinical variables, Egyptian women with RA reported more pain than Dutch women with RA. Clinicians and investigators should recognize that cultural or ethnic factors may play an important role in patients' pain reports.

Cancer pain management among underserved minority outpatients: perceived needs and barriers to optimal control.

BACKGROUND: Minority patients with cancer are at risk for undertreatment of cancer-related pain. Most studies of patient-related barriers to pain control have surveyed primarily non-Hispanic Caucasian patients. The purpose of the current study was to explore barriers to optimal pain management among African-American and Hispanic patients with cancer through the use of structured patient interviews. Structured interviews allowed the authors to probe for previously unidentified barriers to pain management in these populations. METHODS: Thirty-one socioeconomically disadvantaged minority patients with cancer (14 African-American patients and 17 Hispanic patients) who had cancer-related pain completed structured interviews that assessed three main content areas: information and communication regarding cancer pain, treatment of cancer pain, and the meaning of cancer pain. RESULTS: The African-American and Hispanic patients reported severe pain and many concerns about pain management. The majority of patients in both ethnic groups expressed a belief in stoicism and concerns about possible addiction to opioid medications and the development of tolerance. The patients described their physicians as the most frequent and trusted source of information about cancer pain. However, patients also reported difficulties with communication and a reluctance to complain of pain. CONCLUSIONS: The reported barriers to pain management indicate that socioeconomically disadvantaged African-American and Hispanic patients can benefit from educational interventions on cancer pain that dispel myths about opioids and teach patients to communicate assertively about their pain with their physicians and nurses.

The lens model: assessment of cancer pain in a Chinese context.

Obtaining a result closest to patients' reports about pain is crucial in pain management. The literature in the West supports the view that there are cultural differences in perception, interpretation, and expression of pain. However, there has been minimal review in Chinese communities. Therefore, the concepts of cancer pain among Chinese patients with cancer were explored by data source triangulation. There were 33 informants: 18 adult Chinese patients with cancer who were in pain, 7 physicians, and 8 nurses. The interview dialogue was transcribed into written Chinese, followed by coding and categorization. There were no predetermined themes for categorization. The dialogue was coded according to the contextual meaning. The nature and number of categories depended entirely on the coding. Five dimensions were identified: functional, pharmacologic, pain belief and meanings, psychosocial, and emotional. With reference to the five dimensions, a lens model was constructed to explain the cancer pain experience in a Chinese context. In the lens model, two lenses were used to illustrate the relations of the dimensions and cancer pain experience in the Chinese context. The pain experience was named as total pain intensity. The functional, pharmacologic, psychosocial, and emotional dimensions were the independent variables. The pain beliefs and meanings dimension was the mediating variable, and the dependent variable was the total pain intensity in the assessment of cancer pain.

An ethnographic study of factors influencing cancer pain management in South Africa.

Although the knowledge exists to relieve cancer pain, inadequate pain relief persists as an international health problem. The World Health Organization has recommended a threefold strategy to improve cancer pain management: health policy, drug availability, and education. Yet major barriers to effective cancer pain management exist in every country of the world. Effective strategies to improve pain management must be based on an understanding of the issues in individual countries. This report evaluates cultural and other factors influencing cancer pain management in the Republic of South Africa. This ethnographic field study included multiple methods of data collection: analysis of documents, participant observation, focused interviews, and in-depth interviews of informants (n = 33) who represented multiple stakeholders in a variety of settings. Cultural beliefs and practices form the context for understanding cancer pain and how it is managed. Cultural variability exists regarding cancer as a disease, pain expectations, pain tolerance, pain expression, and health care practices. Key factors that influence how pain is managed included standards, knowledge, resources, communication and the patient-provider relationship, and teamwork and professional relationships. The existence of these factors promotes effective pain management, whereas their absence creates a barrier to achieving this aim.

Concerns and misconceptions about pain among Hong Kong Chinese patients with cancer.

It is estimated that approximately 50% of patients with cancer experience pain, and this percentage increases to 80% in patients with terminal cancer. Misconceptions and concerns of patients with cancer regarding the use of opioid analgesics have been identified as one of the major barriers to achieving optimal pain control. Misconceptions and concerns regarding addiction and tolerance to opioid analgesics and patients' desire to be "good" have been reported in the United States. The aim of this survey was to determine if similar misconceptions and concerns exist in Hong Kong Chinese patients with cancer. The results indicate that Hong Kong Chinese patients have the same concerns regarding the use of opioid analgesics. The respondents' fatalistic beliefs are a major hindrance to optimizing pain control, with 79% indicating that pain is an inevitable aspect of hospitalization because they believe that cancer pain cannot be relieved by medications. Fear of addiction was a major concern for 52% of the respondents, and about the same number of respondents believed that opioid analgesics should be administered only as a last resort. Regarding a desire to be "good," more patients reported that they would prefer to disturb nurses rather than physicians. It is desirable that culturally specific education programs be provided to dispel patient misconceptions and concerns regarding the use of opioid analgesics.