Researchers led by Adam T. Hirsh of the School of Science at Indiana University-Purdue University Indianapolis report that black and white Americans cope with pain differently and that blacks employ pain coping strategies more frequently than whites. The IUPUI review and analysis of 19 studies is the first to examine the entire published literature and quantify the relationship between race and the use of pain-coping strategies.
"Coping" is broadly defined as the use of behavioral and cognitive techniques to manage stress. Pain coping is the specific application of these techniques for pain management.
Hirsh, an assistant professor of psychology, and graduate students Samantha M. Meints and Megan M. Miller conducted the evidence-based review and analysis of clinical and experimental studies that included a total of 2,719 black and 3,770 white adults. "Differences in Pain Coping between Black and White Americans: A Meta-analysis" is published online in advance of print in The Journal of Pain.
Blacks were significantly more likely to use praying and hoping as pain-coping strategies than whites. Blacks were also more likely than whites to think about their pain in a catastrophic manner.
"Our findings suggest that blacks frequently use coping strategies that are associated with worse pain and functioning," said Hirsh, a clinical health psychologist. "They view themselves as helpless in the face of pain. They see the pain as magnified -- the worst pain ever. They ruminate, think about the pain all the time, and it occupies a lot of their mind space.
"This catastrophic manner of coping is frequently labeled by health providers as a negative or maladaptive approach to pain and has been associated with poor functioning," Hirsh continued. "But it may also be a potent communication strategy -- it tells others in a culture with a strong communal component that the person is really suffering and needs help. Thus, it may be helpful in some ways, such as eliciting support from other people, and unhelpful in other ways. In future studies, we will give this more nuanced investigation."
Ignoring pain rather than allowing it to interfere with the task at hand, known as task persistence, was the only coping strategy employed by whites more than blacks.
Numerous investigations have found that differences in coping strategies are associated with differences in pain intensity, adjustment to chronic pain, and psychological and physical functioning. For example, several of the studies reviewed by the IUPUI researchers found that ignoring strategies are associated with less pain, whereas praying and hoping and catastrophizing are associated with higher pain levels.
Blacks report higher levels of pain than whites for a number of conditions including AIDS, glaucoma, arthritis, post-operative pain and lower-back pain.
Blacks also experience greater pain in both clinical and experimental studies. Blacks report less-effective pain care, are unable to return to work for a longer time and have worse functional outcomes. These race differences may be partly due to differences in pain-related coping, according to Hirsh.
Chronic pain is a leading cause of work disability and costs the United States more than $600 billion annually in medical treatment and lost productivity, according to the Institute of Medicine report "Relieving Pain in America."
Understanding how different racial groups cope with pain may inform chronic pain care and support individually tailored treatment.
"How people think about their pain matters," said Hirsh. "For example, religion can be used as a passive coping strategy -- asking a higher authority to take the pain away -- or as an active coping strategy -- asking to be given strength to manage pain. Why do black and white Americans differ in the coping strategies they use for pain? Because we are talking about coping, a cognitive and emotional and behavioral approach to pain, we think these differences are largely driven by cultural differences. We will be looking into why and how that occurs in future research.
"Clinicians see patients who are becoming more and more diverse over time," he continued. "It behooves us to ask about these things and to make good use of what the patient tells us. This study speaks to the need to provide such patient-centered and culturally sensitive medical care."
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