Ethnic differences in pain coping: Factor structure of the coping strategies questionnaire and coping strategies questionnaire-revised

Ethnic Differences in Pain Coping: Factor Structure of the Coping Strategies Questionnaire and Coping Strategies Questionnaire-Revised Barbara A. Hastie,* Joseph L. Riley III,* and Roger B. Fillingim*,† Abstract: Coping has been examined extensively in the pain literature, although coping instruments have been typically validated in clinical populations with little ethnic diversity. This study examined the factor structure of the Coping Strategies Questionnaire (CSQ) and the CSQ-Revised (CSQ-R) in 650 healthy male and female African American (44%) and white (56%) subjects and explored associations of coping to health and pain-related measures. Factor analyses revealed 6 components for each ethnic group, accounting for comparable amounts of variance and resembling previously reported CSQ subscales. Internal consistency for both ethnic groups was acceptable (0.72-0.91). There were significant main effects for ethnicity on 4 of the CSQ-R scales (P < .05). No ethnic differences in pain or health variables emerged, although when split into high-pain versus minimal-pain groups, differences were revealed on catastrophizing. Results indicate that the factor structure of the CSQ-R in healthy adults is similar to clinical populations and is comparable across African American and white subjects. Group differences on CSQ-R scales suggest potentially important ethnic influences on pain coping. These findings support the use of the CSQ-R to assess coping in African Americans and in healthy young adults. Additional clinical research is needed to determine the practical importance of group differences in pain coping. Perspective: Coping has been examined extensively in the pain literature, although coping instruments typically have been validated in clinical populations with little ethnic diversity. This study examines the factor structure of the CSQ-Revised in an ethnically diverse population and supports the use of the CSQ-R to assess coping in African Americans and in healthy young adults. © 2004 by the American Pain Society Key words: CSQ, CSQ-Revised, pain coping, ethnic differences.

O

ver the past 2 decades, the importance of coping as a determinant of adjustment to chronic pain has been widely investigated.10,19,26,33,35-40,54,61-66,77-79 Rosenstiel and Keefe64 were among the first to address the issue of coping in the pain literature with their development of the Coping Strategies Questionnaire (CSQ). In addition to the CSQ, among the earliest instruments to assess active and passive coping strategies in a pain population was the Vanderbilt Pain Inventory,8 which addressed more of the functional limitations associated with pain and coping. Later, the Chronic Pain Coping Inventory was developed primarily to measure pain-coping strategies either encouraged or discouraged in multidisciplinary treatment.34 As such, the Chronic Pain Coping Inventory was intended to Received December 9, 2003; Revised March 23, 2004; Accepted May 13, 2004. From the *University of Florida College of Dentistry, Division of Public Health Services and Research, Gainesville, Florida, and the †Malcom Randall VA Medical Center, Gainesville, Florida. This work was supported by National Institutes of Health grant NS42754. Address reprint requests to Barbara A. Hastie, PhD, University of Florida College of Dentistry, Division of Public Health Services and Research, 1600 SW Archer Rd, HSC D8-37, PO Box 100404, Gainesville, FL 32608. E-mail: [email protected] 1526-5900/$30.00 © 2004 by the American Pain Society doi:10.1016/j.jpain.2004.05.004

304

be differentiated from other measures of coping in that it was explicitly designed for chronic pain populations. Subsequent instruments were developed and used to assess specific coping styles, such as catastrophizing.72,73,78 Among the instruments used to measure coping with pain, the CSQ has consistently emerged as the most widely used among clinicians and researchers. First normed on a population with chronic low back pain64 but with limited available demographic information, specifically ethnicity, the CSQ has been validated in various patient populations, including those with arthritic pain, fibromyalgia, joint replacement, sickle cell pain, juvenile arthritis pain, and multiple other conditions.2,24-27,37-40,42,49,66 Investigators also have demonstrated the utility of the CSQ and specific scales in predicting pain-related disability, perceived control over and adaptation to pain, treatment outcome, and depression.14,32,39,40,49,75,78 The CSQ also has been translated into different languages and used in other countries.9,20,31,70 It was originally constructed as a 48item self-report questionnaire that was intended to measure the extent to which patients with pain used 6 different cognitive coping techniques classified as Diverting Attention, Reinterpreting Pain Sensations,

The Journal of Pain, Vol 5, No 6 (August), 2004: pp 304-316

ORIGINAL REPORT/Hastie et al Coping Self-Statements, Ignoring Sensations, PrayingHoping, and Catastrophizing, along with 2 activityfocused factors, including Increasing Activity Level and Increasing Pain Behaviors. However, because of the low internal consistency of the Pain Behaviors scale, it was deleted from the tool, and ultimately one scale, Increasing Behavioral Activities, was incorporated into the CSQ as the measure of behaviorally related coping.64,79 Multiple investigations using the CSQ across various clinical pain populations have consistently identified the same 6 factors that represent cognitive coping, along with the one activity-focused factor.26,36-40,42 However, subsequent studies have found varied results in the number of stable factors.43,61,63,74 In recent years, investigators obtained a more stable factor structure by eliminating individual items that had inadequate or redundant factor loadings. This resulted in a revised version of the instrument, the CSQ-revised (CSQ-R), which has been shortened from 48 to 27 items.61 The CSQ-R has not been widely used, despite its compelling strength.61-63 It should be noted that the CSQ-R uses the identical items as the original CSQ, except for those determined to reduce the strength of the instrument. More recently, Harland and Georgieff29 conducted an item-level investigation of the original CSQ factor structure, and their findings corroborated those of previous researchers who shared concerns about the stability of the factor structure of the full CSQ. In particular, Harland and Georgieff29 found cross-loadings of several items that seemed to indicate inaccurate measurement of certain constructs, and thus they recommended removal of those items from the tool. Doing so resulted in omission of 23 items but low reliability coefficients for factors 5 and 6. Ultimately, a 4-factor solution with a total of 24 items was devised and called the CSQ-24. It has yet to be used or tested against the previous revised instrument, the CSQ-R, as proposed and validated by Riley and Robinson.61,62 Nonetheless, given the extensive use of the CSQ, as well as the concerns and apparent variability of its factor structure in different populations, it is important to test the factor structure of the newer version, the CSQ-R, and to compare it against the original instrument. Notwithstanding the disparate views regarding the factor structure of the CSQ, what has not been contested in the literature is the importance of the instrument in measuring coping strategies that ostensibly reflect internal resources. The utility of the CSQ, and especially the CSQ-R, is its ability to assess various cognitive coping factors derived from a rationally constructed pool of strategies reported by patients experiencing pain and crossvalidated by pain clinicians and pain psychologists.61,64 It is important to consider whether the coping styles represented by the CSQ factors are a result of a chronic pain syndrome and thus a significant component of chronic medical conditions or whether the CSQ factors maintain their valence in healthy populations and thus represent inherent coping styles predating any type of medical or pain condition. In early literature of the CSQ, healthy samples were compared with chronic pain samples.44-46

305 However, subsequent literature of the CSQ has predominantly studied chronic pain populations, very few investigations have reported the CSQ factor structure and coping styles across races, and no study has used the CSQ-R in this regard. Because the few studies involving ethnic differences primarily used samples of white subjects with limited numbers of undifferentiated ethnic groups, it might be misguided and perhaps harmful if one were to extrapolate such information and findings and apply them across all ethnic groups. Consequently, investigation into understanding ethnic differences lags substantially behind other areas of pain research, and this paucity extends to studies validating and comparing assessment instruments, such as the CSQ and CSQ-R. Although ethnicity,16-18,28,47,56,67,81 as well as sex,16,21,67 are important predictors of pain-related symptomatology and pain coping, whether the factor structure of the CSQ-R is consistent across healthy ethnic groups has not been established. It is important to assess healthy individuals because it lends insight into coping strategies that are not confounded by strong influences and nuances of chronic conditions, and such study might shed light on the underlying coping techniques inherent to one ethnic group or communal across healthy individuals. Importantly, the factor structure of the CSQ-R has not been determined in these populations or compared across ethnic groups. Thus, the primary aims of this investigation were to first examine the factor structure of the CSQ and CSQ-R in a large sample of healthy young adults and to extend additional analysis specifically to the CSQ-R. Therefore, this study sought to conduct an exploratory factor analysis (FA) of the original CSQ to determine the optimal number of factors underlying the CSQ in a biracial healthy sample. Second, a separate exploratory FA was conducted by using the CSQ-R to determine whether it would be more parsimonious than the full CSQ and to ascertain whether the previous findings suggesting a more stable factor structure for the CSQ-R could be replicated. Given the anticipated enhanced utility of the CSQ-R over that of the full CSQ, additional analyses included examination of ethnic differences in pain coping across various outcome and general health variables.

Materials and Methods Participants The participants included 650 undergraduate psychology students at the University of Alabama-Birmingham, 56% of whom were white (n ⫽ 363) and 44% of whom were African American (n ⫽ 287), who participated for course credit. The mean age of the sample was 21 years (SD 4.31; range, 17-46 years), with women representing 64% (n ⫽ 415) of the sample, and men comprising 36% (n ⫽ 235). The majority of the participants were single/ never married (90%, n ⫽ 584), and the average current annual household income was $10,000 (n ⫽ 240), with 48% (n ⫽ 312) reporting an income of less than $20,000. Given the nature of the sample, these household income

306 Table 1.

Ethnic Differences in Pain Coping

Demographic, Health History, and Pain Information for African American and White Subjects VARIABLES

Demographic variables Sex (% female) Age (y) Income (⬍$20,000 annually) Marital status (% unmarried) Health history and pain Overall perceived health Total health care use Total pain episodes Total pain sites Average Severity†

AFRICAN AMERICAN SUBJECTS, N ⫽ 287 (44%)* 75.3% (n ⫽ 216) 20.27 (3.87) 30.5% (n ⫽ 180) 96.5% (n ⫽ 273) 23.71 (3.75) 4.37 (8.24) 4.68 (6.96) 1.58 (1.26) 39.42 (23.65)

WHITE SUBJECTS, ⫽ 363 (56%)*

N

P

54.8% (n ⫽ 199) 21.26 (4.59) 22.3% (n ⫽ 132) 87.4% (n ⫽ 311)

⬍.0001 .003 ⬍.0001 ⬍.0001

23.87 (3.71) 5.90 (9.89) 5.65 (7.57) 1.53 (1.08) 38.43 (22.48)

VALUE

.594 .036 .094 .610 .622

Note: Values are presented as means (SD) where noted. *Total sample ⫽ 650 participants. † Total Severity from all pain episodes divided by total number of pain sites.

data reflect a student population that worked part time, worked limited hours, or were unemployed. Demographic information by ethnic group is shown in Table 1. Exclusion criteria included any chronic pain condition or systemic medical condition. Although the sample was free of chronic pain or mitigating health conditions, participants were asked to report any pain episodes they had experienced over the previous month, and they indicated the site or sites, frequency, and average severity (from 0-100) of each pain episode. All procedures were approved by the Human Subjects Committee at the University of Alabama-Birmingham. Written and verbal informed consent was obtained from each participant.

Measures CSQ The CSQ is a widely used instrument to assess coping techniques used by individuals with chronic pain.64 It is a 48-item self-report tool that assesses 6 cognitive (Catastrophizing, Diverting Attention, Ignoring Sensations, Coping Self-Statements, Reinterpreting Pain Sensations, Praying-Hoping) and 1 behavioral (Increasing Behavioral Activities) coping techniques. Each domain is comprised of 6 items, and participants rate the frequency of their use of specific coping strategies on a 7-point Likert scale from 0 (ie, “Never do that”) to 6 (ie, “always do that”). The CSQ also includes two 1-item scales that assess participants’ subjective ability to control or decrease their pain, or their “perceived coping effectiveness.” Using a similar 7-point Likert scale, participants rate from 0 to 6, with 0 signifying “no control/no ability” to decrease pain, and 6 signifying “complete control” or “complete ability” to decrease pain. Notably, these 2 single-item scales are not included in the 7 original subscales of the CSQ.

CSQ-R The CSQ-R consists of 27 items from the original CSQ, measuring 6 dimensions of coping techniques. It has the original domains of the CSQ, except for the Increasing

Behavioral Activities scale, which is deleted from the CSQ-R. Only one item from the original Increasing Behavioral Activities scale is included in the CSQ-R, question 45, and it typically loads on the Diverting Attention scale. The CSQ-R has shown robust psychometric properties, namely a sounder factor structure, but it has had limited exposure in patient populations because of its recent development.61-63

General Health Questionnaire The General History Questionnaire (GHQ) was developed from previous survey studies of pain,44,71 and it has been used in recent investigations of pain in general populations.16,21 The GHQ acquires demographic information, such as ethnicity, sex, age, marital status, educational level, and income, and also obtains important pain and health-related information. The GHQ assessed health factors and recent pain experiences, including type of pain, number of location of painful sites, and pain severity. Participants indicated whether they experienced any of the following types of pain within the past month: headache, back pain, muscle pain, joint pain, stomach pain, dental pain, and premenstrual or menstrual pain. Notably, the latter 2 types of pain were not included in the overall rating of pain experiences in this study to avoid any overrepresentation of sex-related pain. For each type of pain reported, the participant indicated the number of episodes in the past month and the average severity from 0 (“no pain”) to 100 (“worst pain imaginable”). The number of pain sites and the number of painful episodes were determined, and average severity was obtained by calculating the mean severity score across all painful episodes. Other pain-related information acquired from the GHQ included family history of pain, frequency of missed work or school caused by illness, and prescription and nonprescription medications consumed in a 1-month period. A Health Care Use summary score was computed from subjects’ indications of the number of times they engaged in health care use, such as the number of health

ORIGINAL REPORT/Hastie et al care visits and the use of prescription and nonprescription medication (excluding oral contraceptives). Lastly, participants were asked to rate their perceived health on a scale from 1 to 7 across several dimensions, including overall health, the frequency of aches and pains, how bothered they were by aches and pains, and how often they visited a health care professional or used medication compared with other individuals in their age group. The Overall Perceived Health summary score was ascertained by totaling these 5 categories, and scores ranged from 5 to 35, with higher scores indicating better overall perceived health. The GHQ and Overall Perceived Health scores were developed in a laboratory setting within the context of experimental pain testing. The dimensions within the scales are based on experimental observations of issues salient to self-perception of health.

Data Analysis As part of the first goal of this study and in an effort to test the factor structure of the full CSQ in this sample, an exploratory FA was performed by using principal components analysis (PCA). PCA was chosen over principal axis factoring or other factoring techniques specifically because PCA takes into account all common and unique variance, thus accounting for the total variance in the variables, whereas principal axis factoring assesses only common variance. Moreover, the PCA technique was used because it was consistent with the early validation studies of the CSQ.26,63,64,74 Varimax rotation was selected to maximize the variance of squared factor loadings of a factor on all the variables in the factor matrix.57 Arguably, an oblique rotation might reveal specific correlations between factors that could then be subjected to additional analysis. However, the larger aim of replication took precedence in selecting the method for this current study. Thus, although there has not been a uniform approach on the type of FA or rotation used in the previous CSQ studies, most of the major investigations on the CSQ used a PCA method with varimax rotation. Importantly, because this study sought to examine the CSQ-R in greater detail, it was important to replicate the technique of Robinson et al,63 and thus the PCA with varimax rotation was used consistently throughout the present analyses. Two criteria were used to determine whether CSQ individual items loaded on one of the derived scales consistent with previous factor analytic studies of the CSQ,43,61,63,74,79 such that (1) the item loaded at or above 0.500 and (2) the difference in magnitude between the highest and next highest factor loadings for that item had to exceed 0.200. No specific number of factors was determined a priori, and the data were not forced to fit any specific limit of iterations. Factors were selected by their eigenvalues, with values greater than 1 required for selection.57 Factor scale scores were calculated by summing the scores on the CSQ scales that loaded on each of the extracted factors, and these identified factors were then subjected to a second-order FA.

307 An initial PCA was conducted for ethnicity on the full CSQ, which is consistent with the first aim of this study. In an effort to specifically examine the CSQ-R, a second PCA was performed on the revised instrument. Third, in an effort to further validate the findings of the factor structure of the CSQ-R, a comparative FA was conducted on a separate sample of healthy adults. Fourth, previous literature has demonstrated a passive versus active coping style evidenced by factor scales on the CSQ through a second-order FA.12,49,52,69 To further test the CSQ-R for active and passive coping domains, a second-order FA was conducted of the 6 components that emerged from the initial PCA of the individual items on the CSQ-R. Lastly, these factors were then subjected to outcome analysis on several pain and coping variables. Descriptive statistics are reported as means ⫾ SD unless otherwise indicated. Between-group significance on continuous variables was determined by means of analysis of variance, and ␹2 analyses were used for categorical data with the SPSS 11.5 statistical package. Significance was set at the .05 level. Analysis of covariance was used to examine potential mediators of group differences. Associations between continuous variables were determined by using Pearson correlations.

Results Characteristics of the Sample: Demographic and General Health Variables African American and white subjects did not differ on measures of overall perceived health, total pain episodes, total pain sites, and average severity. However, they did differ on the scale of total Health Care Use, such that white subjects reported higher Health Care Use (F(1,648) ⫽ 4.438, P ⬍ .05) than African American subjects (Table 1). In addition, there were differences in age, sex, and income, with white subjects being older and reporting higher incomes and women being overrepresented among both African American and white subjects (Table 1). It should be noted that although there were significant differences in age, the practical importance of this difference is minimal because the degree of separation was less than 2 years.

Factor Analysis and Comparisons for African American and White Subjects in the Original CSQ For African American subjects, the PCA on the original CSQ revealed 10 factors with eigenvalues of more than 1.0, explaining 64.84% of the variance. For white subjects, a 9-factor solution emerged, accounting for 63.86% of the variance. For both African American and white subjects, 7 of the components resembled the previously reported factors of the CSQ: Catastrophizing, Ignoring Sensations, Diverting Attention, Reinterpreting Pain Sensations, Praying-Hoping, Coping Self-Statements, and Increasing Behavioral Activities. Item loadings for most of the scales were similar across ethnic groups.

308

Ethnic Differences in Pain Coping

Item Number (Factor Loadings), Eigenvalues, Percentage, and Cummulative Variance for Both Ethnic Groups on Original CSQ

Table 2.

IS*

CAT

DA*

RPS

CSS*

1 (0.677) 11 (0.513) 18 (0.716) 34 (0.703) 46 (0.702)

23 (0.553) 26 (0.753) 35 (0.525) 36 (0.599) 37 (0.718)

2.10 4.99 46.01

1.74 4.14 50.15

1.44 3.43 53.58

1.42 3.37 56.95

1.16 2.77 59.72

1.09 2.60 62.32

DA*

CSS

RPS*

PH*

IBA*

Q10/DA

Q7/IBA

3 (0.705) 30 (0.777) 31 (0.759) 43 (0.813) 44 (0.533)† 45 (0.577)† 3.16 7.53 42.52

6 (0.723) 8 (0.718) 23 (0.694) 26 (0.653) 36 (0.518) 37 (0.625) 2.29 5.46 47.99

1 (0.698) 11 (0.520) 18 (0.846) 34 (0.829) 46 (0.792)

African American subjects (n ⫽ 287) 20 (0.737) 5 (0.724) 3 (0.554) 22 (0.591) 12 (0.741) 30 (0.841) 24 (0.758) 14 (0.656) 31 (0.865) 27 (0.681) 28 (0.587) 43 (0.781) 35 (0.505) 38 (0.788) 40 (0.700) 42 (0.731) 44 (0.538)† EV 9.99 4.72 2.51 PV 23.80 11.24 5.98 CV 23.80 35.04 41.02 CAT

IS*

White subjects (n ⫽ 363) 5 (0.708) 20 (0.703) 12 (0.743) 24 (0.810) 14 (0.707) 27 (0.761) 28 (0.744) 35 (0.637) 38 (0.783) 40 (0.791) 42 (0.762) EV 8.54 6.16 PV 20.34 14.66 CV 20.34 35.00

1.80 4.28 52.27

PH*

IBA*

17 (0.875) 2 (0.786) 32 (0.870) 39 (0.565) 41 (0.782) 47 (0.530)

CSS2

6 (0.736)† 8 (0.692)†

17 (0.885) 2 (0.761) 10 (0.627)† 32 (0.846) 39 (0.664) 41 (0.859) 47 (0.662)

1.42 3.37 55.64

1.31 3.12 58.76

1.10 2.63 61.39

PH2

DA1/RPS2

21 (0.527)† DA10 (0.676)† 25 (0.766)† RPS11 (0.528)† RPS13 (0.631)†

1.06 2.52 64.84

7 (0.638)†

1.04 2.47 63.86

Abbreviations: IS, Ignoring Sensations; CAT, Catastrophizing; DA, Diverting Attention; RPS, Reinterpreting Pain Sensations; CSS, Coping Self-Statements; PH, Praying-Hoping; IBA, Increasing Behavioral Activities; CSS2, 2-item scale comprised of questions traditionally on CSS (questions 6 and 8); PH2, 2-item scale comprised of items traditionally on PH (questions 21 and 25); DA1/RPS2, 1-item from DA (question 10), 2 items from RPS (questions 11 and 13); EV, eigenvalue; PV, percent variance; CV, cumulative variance; Q10, 1-item scale comprised of CSQ question 10 originally on DA scale; Q7, 1-item scale comprised of CSQ question 7 from the IBA scale. *Scales that have missing items from original CSQ because of insufficient factor loadings (⬍.500). † Items that originally loaded on a different scale or original CSQ.

However, individual items on several of the factors did not achieve a significant loading (at the .500) level and therefore were not included in the factor. Also, the factor structure, comprised of 10 factors for African American subjects and 9 factors for white subjects, differed from the previously reported 7-factor solution. Specifically, for white subjects, the Ignoring Sensations scale is missing question 22. Diverting Attention is missing questions 10 and 13, and questions 44 and 45 load on that factor, but they are originally from the Increasing Behavioral Activities factor. Question 4 from Reinterpreting Pain Sensations did not achieve sufficient loading, and question 14 did not achieve the cutoff on the PrayingHoping factor. Increasing Behavioral Activities factor for white subjects was lacking questions 7, 44, and 45 (the latter 2 items were subsumed under Diverting Attention). Factors 8 and 9 had only one item of sufficient loading (questions 10 and 7, respectively). African American subjects had a comparable number of items that did not load sufficiently on the original factors, loaded on other factors, or had shared loading, including the following: questions 44 and 45 were originally intended for Increasing Behavioral Activities but question 44 loaded on Ignoring Sensations instead and question 45 did not load sufficiently on any scale; Diverting Attention lacked questions 10 and 13; RPS was missing question 4; and

Increasing Behavioral Activities did not have question 7. Praying-Hoping for African American subjects was the most notable in that it was missing 3 of the 6 items, questions 14, 21, and 25. African American subjects also had 3 additional factors, namely (1) CSS2, which was 2 items from the Coping Self-Statements factors, questions 6 and 8; (2) items 21 and 25; and (3) 1 item from Diverting Attention (question 10) and 2 items from Reinterpreting Pain Sensations (questions 11 and 13). The item loadings that correspond to the factors of the original CSQ appear in Table 2.

Factor Analysis and Comparisons for African American and White Subjects on the CSQ-R In the second FA, the 27 items of the CSQ-R were analyzed with PCA with varimax rotation. For both ethnic groups, identical components emerged that resembled the 6 major scales of the CSQ-R: Catastrophizing, Ignoring Sensations, Diverting Attention, Reinterpreting Pain Sensations, Praying-Hoping, and Coping Self-Statements. For African American subjects, the 6 factors accounted for 65.00% of the variance and 67.98% of the variance in white subjects. In contrast to the FA with the full CSQ, the factor loadings appeared more stable and

ORIGINAL REPORT/Hastie et al

309

Item Number (Factor Loadings), Eigenvalues, Percentage, and Cummulative Variance for Both Ethnic Groups on CSQ-R

Table 3.

AFRICAN AMERICAN

EV PV CV

SUBJECTS (N

⫽ 287)

IS

DA

CAT

RPS

PH

CSS

20 (0.628) 24 (0.804) 27 (0.701) 35 (0.708) 40 (0.786)

3 (0.660) 30 (0.834) 31 (0.872) 43 (0.841) 45 (0.580)

1 (0.675) 18 (0.782) 34 (0.771) 46 (0.717)

17 (0.876) 32 (0.862) 41 (0.812)

6 (0.781) 8 (0.622) 23 (0.633) 37 (0.638)

6.616 12.87 12.87

4.110 12.75 25.62

5 (0.726) 12 (0.748) 14 (0.647) 28 (0.642) 38 (0.786) 42 (0.736) 2.289 12.26 37.88

1.855 10.67 48.54

1.494 8.88 57.42

1.186 7.59 65.00

Abbreviations: IS, Ignoring Sensations; DA, Diverting Attention; CAT, Catastrophizing; RPS, Reinterpreting Pain Sensations; PH, Praying-Hoping; CSS, Coping SelfStatements; EV, eigenvalue; PV, percentage variance; CV, cumulative variance. Note: Increasing Behavioral Activities scale is deleted from the CSQ-R; 1-item, question 45, loads on DA. *Item no. 37 in the white sample has shared loading on IS and CSS; it was originally intended only for CSS.

much stronger in the CSQ-R, wherein most loadings ranged from 0.600 to 0.899. There were only 4 items with factor loadings of less than 0.600, ranging from 0.500 to 0.580. This confirmed the hypothesis that the CSQ-R would have a more robust factor structure and be more parsimonious. The specific factor loadings and eigenvalues of the CSQ-R for both ethnic groups appear in Table 3.

Validation of Factor Analysis of the CSQR in a Separate Healthy Sample An FA was conducted on a second sample of healthy young adults (n ⫽ 198) to further validate the factor structure found on the CSQ-R in this first sample. This second sample consisted primarily of white subjects (n ⫽ 140, 70.7%), and the remaining 29.1% of the sample consisted of mixed ethnicity, including African American (n ⫽ 15, 7.5%), Asian American–Pacific Islander (n ⫽ 15, 7.5%), Hispanic (n ⫽ 24, 12.1%), and “other” (n ⫽ 4, 2.0%). The mean age, education, and income were similar to the primary sample for this study. This validation FA, using identical techniques of PCA with varimax rotation as in the initial FA with the CSQ-R, yielded the same 6 factors with a comparable percentage of variance (68.02%). Item loadings were virtually identical with the single exception of CSQ-R question 37, which loaded on Ignoring Sensations (0.698), whereas in the primary sample it loaded on Coping Self-Statements (0.638 for African American subjects and .591 for white subjects). These data appear in Table 4.

Second-order Factor Analysis of the Extracted Components on CSQ-R for African American and White subjects In an effort to determine second-order coping factors, an additional FA of the 6 extracted components from the CSQ-R for both ethnic groups revealed 2 primary components. From the particular factor loadings, it was surmised that component I represented active coping, and

component II was comprised of items traditionally reported as passive coping, generally a negative, maladaptive style. Notably, the scales that comprised the 2 factors were virtually identical, with the notable exception of the Diverting Attention scale, which loaded on component I for African American subjects and on component II for white subjects. Previous findings with the CSQ revealed that the Diverting Attention scale loaded on component I as opposed to component II, as it did in the African American portion of this sample.26,27,36 The factor loadings for these extracted scales by ethnic group are included in Table 5.

Internal Consistency of Extracted Factors To determine internal consistency for the derived factors for both ethnic groups, coefficient ␣ was calculated, and the values are shown in Table 6. Acceptable internal consistency scores were considered at an ␣ value of greater than .80.13,57 Virtually all scales showed acceptable internal consistency, with ␣ values ranging from .82 to .91, with the exception of Coping Self-Statements, which showed marginally acceptable consistency for both ethnic groups (␣ range was .72 for African American subjects and .79 for white subjects).

Ethnic Differences on CSQ-R Scales Initial covariance analysis controlling for sex revealed significant differences between African American and white subjects on Catastrophizing, Diverting Attention, Ignoring Sensations, and Praying-Hoping. When age and sex were both considered covariates, significant differences were revealed on every CSQ-R scale as follows: Catastrophizing (F(1,645) ⫽ 20.129, P ⬍ .0001); Coping Self-Statements (F(1,645) ⫽ 7.933, P ⫽ .005); Diverting Attention (F(1,645) ⫽ 7.761, P ⫽ .005); Ignoring Sensations (F(1,645) ⫽ 16.056, P ⬍ .0001); Reinterpreting Pain Sensations (F(1,645) ⫽ 4.098, P ⫽ .043); and Praying-Hoping (F(1,645) ⫽ 119.301, P ⬍ .0001). Notably, the largest

310 Table 3.

Ethnic Differences in Pain Coping

Continued WHITE

SUBJECTS (N

⫽ 363)

CAT

IS

DA

RPS

PH

CSS

5 (0.725) 12 (0.761) 14 (0.701) 28 (0.742) 38 (0.789) 42 (0.763) 5.517 13.48 13.48

20 (0.725) 24 (0.835) 27 (0.777) 35 (0.656) 37 (0.500)* 40 (0.812) 5.289 13.46 26.94

3 (0.737) 30 (0.808) 31 (0.802) 43 (0.838) 45 (0.683)

1 (0.694) 18 (0.864) 34 (0.867) 46 (0.809)

17 (0.899) 32 (0.857) 41 (0.862)

6 (0.765) 8 (0.790) 23 (0.686) 37 (0.591)

2.688 12.30 39.24

2.040 10.70 49.93

1.586 9.20 59.14

1.236 8.84 67.98

difference emerged for the Praying-Hoping scale. Means and scale differences appear in Table 7.

Coping and Pain The association between pain coping and reported pain across ethnic groups was examined. Because this was a healthy sample, there was a skewed distribution on pain scores with limited variability across measures, which would attenuate any bivariate correlation. Therefore, we divided the sample into 2 groups on the basis of their reported number of pain episodes. Those subjects reporting one or fewer pain episodes in the previous month were classified as the minimal-pain group (n ⫽ 225), and those subjects reporting 4 or more pain episodes were classified as the high-pain group (n ⫽ 273). The only CSQ-R scale on which the pain groups differed was Catastrophizing (F(1,497) ⫽ 6.414, P ⬍ .05).

Discussion This study demonstrates that the factor structure of the CSQ-R is comparable across African American and white samples and seems to be more parsimonious than the CSQ in healthy young adult samples. Moreover, we found a similar factor structure in our pain-free sample that has been reported in patients with chronic pain.61,63 Internal consistencies and factor loadings for the 6 main factors were generally acceptable and comparable to prior research, noting that in the CSQ-R the Increasing Behavioral Activities scale is eliminated because of unacceptable factor structure and factor-loading complications.26,27,36,43,44,63 To further validate these findings, a second confirmatory FA was conducted on a sample of 198 healthy participants with similar demographic composition, although the majority was white with varied ethnic distribution. Nonetheless, as in the primary FA of the CSQ-R, the confirmatory FA found the same 6 factors accounting for 68.02% of the variance. These results suggest a robust factor structure of the CSQ-R across and

within healthy young adult African American and white subjects. Moreover, although previous factor analytic studies of the CSQ have used subscale summary scores, a limited number, including the study at hand, conducted item level FA. This latter technique has 2 advantages. It averts the data from being subject to instability of the subscales, and it allows for item composition of each subscale to be evaluated. An important point to consider is that researchers assert the value of previous exploratory FA on the CSQ, although they had only marginal sample sizes when evaluating the ratio of subjects to number of items (ranging on average from 3.7:1 to 2.6:1 subjects to item).63 A strength of the current study is the sample size of 650 subjects, which yielded a ratio of 13.54 for the CSQ and 24.07 for the CSQ-R, thus providing a more favorable subject-to-variable ratio and presumably a stronger and more stable factor structure. These techniques fortify the strength of the present findings in terms of highlighting specific differences between the ethnic groups and the scales and factors on the CSQ-R factor loadings. Consistent with much of the early literature on coping, the extracted components of this study were then subjected to a second-order FA to reveal passive and active coping styles.26,27,52,64 The second-order FA was similar across ethnic groups, except that the Diverting Attention scale loaded on different components for African American and white subjects. The Diverting Attention scale loaded on active coping for African American subjects (0.664) but on passive coping for white subjects (0.659). Notably, the Diverting Attention scale has been shown as an active coping factor,26,27,36,69 and thus for African Americans, these findings are consistent with previous literature. However, for white subjects, the Diverting Attention loaded on the same second-order factor as other passive coping strategies, which include Catastrophizing and Praying-Hoping. However, the loading of Diverting Attention on factor II (passive coping) for white subjects was not overwhelmingly convincing because the same

ORIGINAL REPORT/Hastie et al

311

Table 4. Item Number (Factor Loadings), Eigenvalues, Percentage, and Cummulative Variance for Validation Factor Analysis of CSQ-R on a Separate Sample of Healthy Subjects

EV PV CV

IS

DA

RPS

CAT

PH

CSS

20 (0.722) 24 (0.836) 27 (0.647) 35 (0.793) 37 (0.698)* 40 (0.804) 5.65 20.92 20.92

3 (0.622) 30 (0.817) 31 (0.847) 43 (0.851) 45 (0.686)

1 (0.807) 18 (0.870) 34 (0.873) 46 (0.893)

17 (0.934) 32 (0.913) 41 (0.893)

6 (0.794) 8 (0.790) 23 (0.571)

4.89 18.14 39.06

2.24 8.31 47.37

3 (0.625) 12 (0.706) 14 (0.671) 28 (0.527) 38 (0.790) 42 (0.815) 2.15 7.97 55.34

1.90 7.04 62.38

1.52 5.64 68.02

Abbreviations: IS, Ignoring Sensations; DA, Diverting Attention; RPS, Reinterpreting Pain Sensations; CAT, Catastrophizing; PH, Praying-Hoping; CSS ⫽ Coping Self-Statements; EV, Eigenvalue; PV, Percentage Variance; CV, Cummulative Variance. Note: Sample size is 198. Ethnic composition in as follows: white subjects, n ⫽ 140; African American subjects, n ⫽ 15; Asian subjects, n ⫽ 15; Hispanic subjects, n ⫽ 24; “other,” n ⫽ 4. *Item no. 37 typically loads on CSS factor but reaches significant loading (⬎.500) on IS in this sample.

item cross-loaded on factor I (active coping) at 0.401, whereas conversely for African Americans, it had a shared loading at 0.384 on factor II. It might be that in this group of young healthy adults, the Diverting Attention items on the CSQ-R might be interpreted as reflecting a passive method of coping with day-to-day aches and pains to a greater degree in white subjects than in African American subjects. Further speculation regarding this finding should await replication in another sample. The reasons for the observed ethnic differences in pain coping in this sample are not known, and these findings need to be confirmed in other age groups and ethnically diverse samples to further characterize coping differences. It is possible that the differences might reflect a reporting bias, such that African American participants might be more willing to acknowledge the use of these coping strategies. Nevertheless, it is important to highlight the similarity in coping style that the African American subjects demonstrated with the style reported in earlier studies, and this strengthens the finding that the CSQ-R is useful for assessing pain coping in African American young adults. Ethnic differences on several pain-coping scales also emerged, with African American subjects reporting higher levels of Catastrophizing and Praying-Hoping,

whereas white subjects reported higher levels of Ignoring Pain Sensations, Diverting Attention, and Coping Self-Statements. These findings are consistent with previous research in clinical populations demonstrating ethnic differences in pain coping.35,36,73 Our findings extend these results by demonstrating that ethnic differences in pain coping are present, even in a pain-free sample of young adults, suggesting that ethnic differences in pain coping within clinical samples are not the result of prolonged exposure to chronic pain but might be evident even in the absence of chronic pain. Thus, the ethnic differences in coping in pain populations might possibly reflect an exacerbation of inherent styles of managing stressors, such as pain. Given that ethnic differences in pain severity and pain-related symptomatology have been increasingly reported in recent years,5,16-18,28,47,50,51,56,67,81 the present findings suggest the potential importance of pain coping in contributing to these ethnic differences in pain-related adjustment. This study adds to the growing body of literature on ethnic differences in pain, including psychological adjustment and coping, with this evidence that the CSQ-R is a fairly reliable and valid instrument to assess coping strategies. In addition, the benefits of the CSQ-R over the CSQ include its decreased burden on participants and

Component Matrix of Second-order Factor Analysis of CSQ-R Extracted Components for Both Ethnic Groups: Identification of Active and Passive Scales

Table 5.

CSQ-R

FACTORS

Catastrophizing Ignoring Sensations Diverting Attention Reinterpreting Pain Sensations Praying-Hoping Coping Self-Statements

COMPONENT I: ACTIVE

COPING

COMPONENT II: PASSIVE

COPING

AA

W

AA

W

⫺0.079 0.818 0.664 0.735 0.154 0.743

⫺0.132 0.801 0.401 0.563 0.015 0.830

0.818 ⫺0.278 0.384 0.177 0.677 0.025

0.732 ⫺0.359 0.659 0.245 0.737 0.047

Abbreviations: AA, African American subjects (n ⫽ 287); W, white subjects (n ⫽ 363).

312

Ethnic Differences in Pain Coping

Scales of Internal Consistency of CSQ-R (␣ Coefficient) for African American and White Subjects Table 6.

␣ COEFFICIENT FOR AFRICAN ␣ COEFFICIENT AMERICAN FOR WHITE CSQ-R

SCALE

Catastrophizing Coping Self-Statements Diverting Attention Ignoring Sensations Praying-Hoping Reinterpreting Pain Sensations

SUBJECTS

SUBJECTS

0.82 0.72 0.86 0.85 0.85 0.83

0.85 0.79 0.86 0.86 0.91 0.84

patients, with fewer items and reduced administration time. Moreover, the present findings reveal that the CSQ-R had greater factor stability and accounted for more variance than the full CSQ. This further fortifies the benefits of the revised version of the CSQ, which also appears to be reliable and useful in ethnic groups. Despite robust ethnic differences on CSQ-R scales, the only CSQ-R scale that was associated with recent pain episodes was Catastrophizing, such that individuals who reported a high number of pain episodes had higher Catastrophizing scores than those reporting little or no pain. This is consistent with a substantial body of clinical and experimental research associating Catastrophizing with increased clinical pain and psychological distress24,25,32,33,37,38,48,72,73,78 and greater experimental pain sensitivity.17,23,67 This association between Catastrophizing and pain was similar across both ethnic groups. Thus it seems plausible that the higher levels of Catastrophizing among African American participants might predispose these subgroups to increased clinical pain and poorer pain-related adjustment, especially within clinical samples. Again, it is important to highlight that this was a young and healthy sample, and the fact that Catastrophizing was such a salient coping strategy might speak to the relevance of targeting such a coping style at the outset of an injury or pain condition. Moreover, it might also explain why Catastrophizing seems to become a predominant coping theme in many pain populations. For instance, if it is already entrenched in one’s coping repertoire in a healthy sample, additional stress, such as chronic pain, would merely enhance the expres-

Table 7.

sion of such an inherent strategy. Other coping strategies were not associated with high or minimal pain in the present study, and further investigation is needed to determine whether their utility differs across ethnicity. Notably, the greatest difference between the ethnic groups on any one CSQ-R factor was on Praying-Hoping. The Praying-Hoping factor, as assessed with the CSQ, has previously been considered a passive and maladaptive coping strategy; however, it seems plausible that this might be an adaptive coping strategy for some individuals in certain circumstances. Indeed, Turner and Clancey77 reported that increased use of praying and hoping was related to decreases in self-report of pain intensity. Additionally, other researchers found that Praying-Hoping was the coping strategy most reported in a sample of patients with chronic pain.3,30 It is noteworthy that in the present sample, the questions that consistently loaded across groups also might reflect an active expression of faith-based activity (eg, “I pray to God it won’t last long.” “I pray for the pain to stop.” “I rely in my faith in God.”), whereas the 3 items that did not load sufficiently for either group might be more reflective of passive coping through hypothetical statements in future unknowns, such as the following: question 15, “I know someday someone will be here to help me and it will go away for awhile”; question 21, “I try to think years ahead, what everything will be like after I’ve gotten rid of the pain”; and question 25, “I have faith in doctors that someday there will be a cure for my pain.” Arguably, the mere acts of praying and hoping might not represent an active participation in managing, coping, or overcoming the challenge of pain, and thus it has been traditionally construed as a passive approach. However, what has not been addressed in the literature is the role of social learning and environmental influences that might shed light on this strategy, perhaps as a style adopted through social learning or ethnic influences and not as convincingly maladaptive as once believed. Previous researchers have suggested that coping, social learning, and attitudes might play a valuable yet fairly unstudied role in ethnic differences in health conditions, particularly pain.4,7,22,23,53 Coping is intricately related to social learning. There is a plethora of literature enumerating sex and ethnic differences in social learning, adjustment, and coping.1,4,22,23,68,76 In fact, the sociocul-

Ethnic Differences on CSQ-R Scales AFRICAN AMERICAN ⫽ 286), MEANS (SD)

WHITE SUBJECTS (N ⫽ 363), MEAN (SD)

F VALUE (1,645)

1.43 (1.26) 2.40 (1.52) 2.80 (1.55) 1.09 (1.32) 4.70 (1.55) 3.89 (1.33)

0.932 (1.03) 3.01 (1.45) 2.42 (1.44) 0.952 (1.20) 2.95 (2.00) 3.67 (1.41)

20.129 16.056 7.761 4.098 119.301 7.933

SUBJECTS (N

CSQ-R

FACTORS

Catastrophizing Ignoring Sensations Diverting Attention Reinterpreting Pain Sensations Praying-Hoping Coping Self-Statements

P

VALUE

⬍0.0001 ⬍0.0001 0.005 0.043 ⬍0.0001 0.005

ORIGINAL REPORT/Hastie et al tural viewpoint of coping, espoused primarily by cultural anthropologists and by psychologists in recent years, asserts that coping behavior virtually always occurs in a social context and is both affected by the context and contributes to its change. In other words, coping is not individualistic but is intricately entwined in the influences of one’s ethnocultural environment and subcultural context, and that is where one learns the foundations for coping.7,22,23 Indeed, in the pain literature there has been recognition of this social concept of coping, and it has been exemplified through the development of a spouse-related assessment instrument and the multiple studies on caregivers. However, there are a few researchers who have specifically addressed the issue of differences in pain coping and the influence of environment and social cues across races and ethnicity.35,36,51,53,56,81 It might be that in this sample, African American subjects have been more socially trained to use coping skills that would be termed passive and maladaptive, such as, in the scales representing Catastrophizing and Praying-Hoping.15,80 Yet there might be other reasons for these differences. Notably, these coping styles might be indicative of geographic influence and might be further strengthened by cultural influences. Whereas the southern region of the United States is known for the strong influence of religion and spirituality, the African American’s tendency to rely more on praying and hoping for coping might not necessarily be construed as a negative coping strategy, despite the assertions of many who study the CSQ. In other words, “active” praying-hoping actually might be a culturally developed coping mechanism that might be adaptive for the African American community, particularly in the South. Regardless of geographic influence, the cultural influence of African American subjects might explain some of the tendency to use more of the praying-hoping strategies. In fact, the findings of this study are consistent with previous investigations that found African American subjects to use more prayinghoping compared with white and Hispanic subjects.15,30,60 Even in a nonethnically diverse study, researchers reported that increased use of praying and hoping were related to decreases in self-report of pain intensity,77 and there is a new field emerging that asserts the influence of spirituality in medicine and its positive effects on recovery and treatment outcome.3,6,15,58,59 Yet other researchers reported that the amount of variance explained by the Praying-Hoping subscale was fairly low across a number of earlier studies in pain populations, and they suggested that such associations might have been spurious.79 Conversely, Haythornthwaite et al30 reported that Praying-Hoping was the coping strategy most reported. Correspondingly, the Praying-Hoping scale on the CSQ-R seemed to be quite meaningful for this present sample, and it was particularly noteworthy for African American subjects who most strongly endorsed its items. Moreover, in the recent literature, Folkman, one of the leading researchers in coping, found that goal-directed,

313 problem-focused coping and spiritual beliefs were associated with positive psychological states.22,23 In addition, there is a plethora of literature supporting the benefits of praying and other spiritual practices as positive actions for coping with inordinate stress.3,6,41,58,59 In the context of pain research and practice, what has been traditionally considered a negative coping strategy in the pain literature might actually represent an adaptive coping technique for African American subjects being confronted with the external threat of pain. However, such a notion has yet to be investigated in depth or in ethnically diverse groups. Thus, the findings of this healthy sample of African American subjects using the technique that loaded on the Praying-Hoping factor and further loading on the passive dimension might reflect more of a cultural influence than a maladaptive coping strategy. Consequently, the use of items evoking what has been deemed negative might artifactually induce spurious differences among people of different cultures, namely African American subjects or those with strong beliefs, especially if their social support or culture is rooted in those beliefs. Additionally, whereas Novy et al56 revealed that higher levels of education predicted lower levels of Praying-Hoping and Catastrophizing, this current study does not support that trend. Conversely, this study’s sample consisted of college-educated individuals who fairly consistently endorsed use of such coping strategies, and this was especially prevalent in African American subjects. Most, but not all, previous studies in ethnic differences report that African American subjects use Praying-Hoping more than white subjects, and this study parallels the findings of difference; in fact, this sample not only revealed a statistically significant difference, but it was the largest difference found. With regard to other forms of social and cultural learning, given the evidence that African American subjects receive less attention and treatment to pain conditions, including postoperative pain, cancer pain, and pain related to AIDS and sickle cell disease,11,26,27,55,68 it might be that African American subjects have been socialized to react, respond, and relay their feelings about pain in much more expressive and seemingly maladaptive ways to receive adequate and equitable treatment as white subjects. That might be true in a clinical population, but this sample was relatively young, healthy, and free of pain. Nevertheless, the findings in this present study suggest that response to the health care system, threats against health (eg, pain), and reaction and adjustment to pain might be deeply embedded in cultural, ethnic, and social learning, and those are important issues for future investigation in understanding ethnic differences in pain. The fact that this was a healthy sample and that the African American subjects had similar responses as those with premorbid health conditions suggests that many of the coping techniques might predate the influence of pain or other external health threats. In other words, the coping styles exhibited in this healthy sample suggest that the responses and techniques might be inculcated in one’s cognitive and emotional composition well before a

314

Ethnic Differences in Pain Coping

chronic medical condition subjects the person to prolonged stress and threat and might not be exclusively a reflection of the medical condition but rather an attribute of ethnic influences and responses to societal biases.68,76 Despite the robust findings of the factor structure of the CSQ-R and notable main effects on the CSQ-R in this sample, this study is not without limitations. First, the use of a sample of healthy young adults has disadvantages because the generalizability of results to clinical populations is questionable, and the ability to detect associations between coping and pain-related symptoms is compromised. Also, this sample was comprised of undergraduate students, which also limits generalizability to populations with wider ranges of economic and social backgrounds, particularly because education typically plays a role in socioeconomic differences in ethnic groups.65,68 Another limitation is statistical in nature; that is, there has not been a uniform use of the type of factor rotation on previous FA of the CSQ. Moreover, there has been a difference between item-level FA and scale-level analysis. Yet most of the exploratory item-level FAs on the full CSQ, as well as the newer CSQ-R, used the PCA.26,27,63,64,74 However, those studies varied by the rotation method used. For example, an early validation study of the original CSQ used an oblique (ie, Oblimin) rotation technique,64 whereas the present study used the varimax rotation, which is consistent with other investigations on CSQ-R.63 Other investigators used different extraction techniques, including maximum likelihood extraction43 and the least-squares method79; they also used the oblique Oblimin rotation. However, the varimax rotation produces more orthogonal factors, sometimes considered purer factors, although it might

also inadvertently reduce intercorrelations that could prove important in shared factor loadings. In fact, such issues were considered in the decision regarding extraction and rotation techniques for this study. Although the original CSQ study by Rosentiel and Keefe64 used a PCA with Oblique rotation, this current study aimed to replicate the findings of the CSQ-R, and thus it was prudent to use the technique of Robinson et al63 in their original application of the CSQ-R, a PCA with varimax rotation. Thus differences in identified factor structures across previous studies might be due to the differences in factor analytic techniques used. However, it is difficult to speculate to what extent, if any, the different factor structures and loadings were due to statistical FA methods used. Because the samples were quite different in several of the studies, there might have been other influences that account for the differences other than purely analytic technique. These limitations notwithstanding, this study provides important information concerning the validity of the CSQ-R across the ethnic groups of African American and white subjects. Moreover, consistent ethnic differences in self-reported pain coping emerged in this healthy population, and these differences in coping might have important implications for understanding ethnic differences in the experience of clinical pain. Further investigation is needed to elucidate explanations for these differences and to determine whether the effectiveness of various coping strategies differs across ethnic groups.

References

for the assessment of active and passive coping strategies in chronic pain patients. Pain 31(1):53-64, 1987

1. Aldwin C: Stress, Coping, and Development: An Integrative Perspective. New York, Guilford, 1994

9. Burckhardt CS, Henriksson C: The Coping Strategies Questionnaire-Swedish version: evidence of reliability and validity in patients with fibromyalgia. Scand J Behav Ther 30(3): 97-107, 2001

2. Anie KA, Steptoe A, Bevan DH: Sickle cell disease: pain, coping and quality of life in a study of adults in the UK. Br J Health Psychol 7:331-344, 2002 3. Ashby JS, Lenhart RS: Prayer as a coping strategy for chronic pain patients. Rehab Psychol 39(3):205-209, 1994 4. Bates MS: Ethnicity and pain: a biocultural model. Soc Sci Med 24:47-50, 1987

Acknowledgments This material is the result of work supported with resources and the use of facilities at the Malcom Randall VA Medical Center, Gainesville, Florida.

10. Carmody TP: Psychosocial subgroups, coping, and chronic low back pain. J Clin Psychol Med 8(3):137-148, 2001 11. Cleeland CS, Gonin R, Baez L, Loehrer P, Pandya KJ: Pain and treatment of pain in minority patients with cancer. Ann Intern Med 127:813-816, 1997

5. Bates MS, Edwards WT: Ethnic variations in the chronic pain experience. Ethn Dis 2(1):63-83, 1992

12. Covic T, Adamson B, Howe G, Spencer D: The role of passive coping and helplessness in rheumatoid arthritis depression and pain. J Appl Health Behav 4(1-2):31-35, 2002

6. Benson H: Timeless Healing: The Power and Biology of Belief. New York, Scribner, 1996

13. Cronbach LJ: Essentials of psychological testing, 3rd ed. New York, Harper & Row, 1970

7. Berry JW, Dasen PR, Saraswathi TS: Handbook of Crosscultural Psychology. Vol 2. Basic Processes and Human Development. Boston: Allyn & Bacon

14. Dozois DJA, Dobson KS, Wong M, Hughes D: Predictive utility of the CSQ in low back pain: individual and composite measures. Pain 66(2-3):171-180, 1996

8. Brown GK, Nicassio PM: Development of a questionnaire

15. Dunn KS, Horgas AL: Religious and nonreligious coping

ORIGINAL REPORT/Hastie et al

315

in older adults experiencing chronic pain. Pain Manage Nurs 5(1):19-28, 2004

arthritis and rheumatic conditions. Curr Opin Rheumatol 11: 98-103, 1999

16. Edwards RR, Doleys DM, Fillingim RB, Lowery D: Ethnic differences in pain tolerance: clinical implications in a chronic pain population. Psychosom Med 63:316-323, 2001

36. Jordan MS, Lumley MA, Leisen JCC: The relationships of cognitive coping and pain control beliefs to pain adjustment among African American and Caucasian women with rheumatoid arthritis. Arthritis Care Res 11(2):80-88, 1998

17. Edwards RR, Fillingim RB: Ethnic differences in thermal pain responses. Psychosom Med 61:346-354, 1999 18. Edwards CL, Fillingim RB, Keefe FJ: Race, ethnicity and pain. Pain 94:113-137, 2001 19. Endler NS, Coarace KM, Summerfeldt LJ, Johnson JM, Rothbart P: Coping with chronic pain. Pers Indiv Diff 34:323346, 2003 20. Estlander AM, Haerkaepaeae KL: Relationships between coping strategies, disability, and pain levels in patients with chronic low back pain. Scand J Behav Ther 18(2):59-69, 1989 21. Fillingim RB, Wilkinson CS, Powell T: Self-reported abuse history and pain complaints among healthy young adults. Clin J Pain 15:85-91, 1999 22. Folkman S, Lazarus RS, Gruen RJ, DeLongis A: Appraisal, coping, health status, and psychological symptoms. J Pers Soc Psych 50:571-579, 1986 23. Folkman S, Moskowitz JT: Positive affect and the other side of coping. Am Psychol 55(6):647-654, 2000

37. Keefe FJ, Brown GK, Wallston KA, Caldwell DS: Coping with rheumatoid arthritis pain: catastrophizing as a maladaptive strategy. Pain 37(1):51-56, 1989 38. Keefe FJ, Caldwell DS, Queen K, Gil KM, Martinez S, Crisson JE, Ogden W, Nunley J: Osteoarthritis knee pain: a behavioral analysis. Pain 28:309-321, 1987 39. Keefe FJ, Crisson J, Urban BJ, Williams DA: Analyzing chronic low back pain: the relative contribution of pain coping strategies. Pain 40:293-301, 1990 40. Keefe FJ, Williams DA: A comparison of coping strategies in chronic pain patients in difference age groups. J Gerontol B Psychol Sci Soc Sci 45(4):P161-P165, 1990 41. Koenig HG. Psychoneuroimmunology and the faith factor. J Gend Specif Med 3:37-44, 2000. 42. Kuile MM, Spinhoven P, Linssen ACG, van Houwelingen HC: Cognitive coping and appraisal processes in the treatment of headaches. Pain 64:257-264, 1995

24. Geisser ME, Robinson ME, Henson CD: The coping strategies questionnaire and chronic pain adjustment: a conceptual and empirical reanalysis. Clin J Pain 10:98-106, 1994

43. Lawson KC, Reesor KA, Keefe FJ, Turner JA: Dimensions of pain-related cognitive coping: cross-validation of the factor structure of the Coping Strategies Questionnaire. Pain 43(2):194-204, 1990

25. Geisser ME, Robinson ME, Keefe FJ, Weiner ML: Catastrophizing, depression and the sensory, affective and evaluative aspects of chronic pain. Pain 59:79-83, 1994

44. Lefebvre JC, Lester N, Keefe FJ: Pain in young adults: II. The use and perceived effectiveness of pain coping strategies. Clin J Pain 11(1):36-44, 1995

26. Gil KM, Abrams MR, Phillips G, Keefe FJ: Sickle cell pain: relation of coping strategies to adjustment. J Consult Clin Psychol 57(6):725-731, 1989

45. Lester N, Lefebvre JC, Keefe FJ: Pain in young adults: I. Relationship to gender and family pain history. Clin J Pain 10(4):282-289, 1996

27. Gil KM, Wilson JJ, Edens JL: The stability of pain coping strategies in young children, adolescents, and adults with sickle cell disease over an 18-month period. Clin J Pain 13(2): 110-115, 1997

46. Lester N, Lefebvre JC, Keefe FJ: Pain in young adults: III. Relationships of three pain-coping measures to pain and activity interferences. Clin J Pain 12(4):291-300, 1996

28. Greenwald HP: Interethnic differences in pain perception. Pain 44:157-163, 1991 29. Harland NJ, Georgieff K: Development of the coping strategies questionnaire-24, a clinically utilitarian version of the coping strategies questionnaire. Rehab Psychol 48(4): 296-300, 2003 30. Haythornthwaite JA, Menefee LA, Heinberg LJ, Clark MR: Pain coping strategies predict perceived control over pain. Pain 77:33-39, 1998 31. Jensen I, Linton SJ: Coping Strategies Questionnaire (CSQ): reliability of the Swedish version of the CSQ. Scand J Behav Ther 22(304):139-145, 1993 32. Jensen MP, Keefe FJ, Lefebvre JC, Romano JM, Turner JA: One and two-item measures of pain beliefs and coping strategies. Pain 104:453-469, 2003 33. Jensen MP, Turner JA, Romano JM, Karoly P: Coping with chronic pain: a critical review of the literature. Pain 47(3): 249-283, 1991 34. Jensen MP, Turner JA, Romano JM, Strom SE: The Chronic Pain Coping Inventory: development and preliminary validation. Pain 60:203-216, 1995 35. Jordan JM: Effects of race and ethnicity on outcomes in

47. Lipton JA, Marbach JJ: Ethnicity and the pain experience. Soc Sci Med 19:1279-1298, 1984 48. Main CJ, Wadell G: A Comparison of cognitive measures in low back pain: statistical structure and clinical validity at initial assessment. Pain 46:287-298, 1991 49. Martin MY, Bradley LA, Alexander RW, Alarcon GS, Triana-Alexander M, Aaron LA, Alberts KR: Coping strategies predict disability in patients with primary fibromyalgia. Pain 68:45-53, 1996 50. McCracken LM, Eccleston C: Coping or acceptance: what to do about chronic pain? Pain 105(1-2):197-204, 2003 51. McCracken LM, Matthews AK, Tang TS, Cuba SL: A comparison of blacks and whites seeking treatment for chronic pain. Clin J Pain 17:249-255, 2001 52. McCrae JD, Lumley MA: Health status in sickle cell disease: examining the roles of pain coping strategies, somatic awareness, and negative affectivity. J Behav Med 21(1):3555, 1998 53. Moore R, Brodsgaard I: Cross-cultural investigations in pain. in Crombie IK (ed): Epidemiology of Pain. Seattle, WA, IASP Press, 1999, p. 53-80 54. Morley S, Eccelston C, Williams A: Systematic review and meta-analysis of randomized clinical trials of cognitive be-

316 haviour therapy and behaviour therapy for chronic pain in adults, excluding headache. Pain 80:1-13, 1999 55. Ng B, Dimsdale JE, Shragg GP, Deutsch R: Ethnic differences in analgesic consumption for postoperative pain. Psychsom Med 58:125-129, 1996

Ethnic Differences in Pain Coping 68. Smedley BD, Stith AY, Nelson AR (eds): Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC, The National Academies Press, 2003 69. Snow-Turk AL, Norris MP, Tan G: Active and passive coping strategies in chronic pain patients. Pain 64:455-462, 1996

56. Novy DM, Nelson DV, Hetzel RD, Squitieru P, Kennington M: Coping with chronic pain: sources of intrinsic and contextual variability. J Behav Med 21(1):19-34, 1998

70. Spinhiven P, Ter Kuile MN, Linssen AC, Gazendam B: Pain coping strategies in a Dutch population of chronic low back pain patients. Pain 37:77-83, 1989

57. Nunnally JC, Bernstein IH: Psychometric Theory, 3rd ed. New York: McGraw-Hill, 1994. p. 248-292

71. Sternbach RA: Survey of pain in the United States: the Nuprin pain report. Clin J Pain 2:49-53, 1986

58. Pargament KI: The Psychology of Religion and Coping. New York, Guilford, 1997

72. Sullivan MJL, Bishop SR, Pivik J: The pain catastrophizing scale: development and validation. Pychol Assess 7:524-532, 1995

59. Pargament KI, Kennell J, Hathaway W, Grevengoed N, Newman J, Jones W: Religion and the problem-solving process: three styles of coping. J Sci Study Religion 27:90-104, 1988 60. Plesh O, Crawford PB, Gansky SA: Chronic pain in a biracial population of young women. Pain 99:515-523, 2002 61. Riley JL 3rd, Robinson ME: CSQ: Five factors or fiction? Clin J Pain 13:156-162, 1997 62. Riley JL, Robinson ME, Geisser ME: Empirical subgroups of the coping strategies questionnaire-revised: a multisample study. Clin J Pain 15(2):111-116, 1999 63. Robinson ME, Riley JL 3rd, Myers CD, Sadler IJ, Kvaal SA, Geisser ME, Keefe FJ: The coping strategies questionnaire: a large sample, item level factor analysis. Clin J Pain 13:43-49, 1997

73. Sullivan MJL, Thorn B, Haythornthwaite JA, Keefe F, Martin M, Bardley LA, Lefebvre JC: Theoretical perspectives on the relation between catastrophizing and pain. Clin J Pain 17:52-64, 2001 74. Swartzman LC, Gwadry FG, Shapiro AP, Teasell RW: The factor structure of the coping strategies questionnaire. Pain 57(3):311-316, 1994 75. Tan G, Jensen MP, Robinson-Whelen S, Thornby JI, Monga TN: Coping with chronic pain: a comparison of two measures. Pain 90:127-133, 2001 76. Todd KH: Pain assessment and ethnicity. Ann Emerg Med 27:421-3, 1996 77. Turner JA, Clancey S: Strategies for coping with chronic low back pain: relationship to pain and disability. Pain 24(3): 355-364, 1986

64. Rosenstiel AK, Keefe FJ: The use of coping strategies in chronic low back pain patients: relationship to patient characteristics and current adjustment. Pain 17(1):33-44, 1983

78. Turner JA, Jensen MP, Romano JM: Do beliefs, coping, and catastrophizing independently predict functioning in patients with chronic pain? Pain 85:115-125, 2000

65. Roth RS, Geisser ME: Educational achievement and chronic pain disability: mediating role of pain-related cognitions. Clin J Pain 18:286-296, 2002

79. Tuttle DH, Shutty MS, DeGood DE: Empirical dimensions of coping pain patients: a factorial analysis. Rehab Psychol 36(3):179-188, 1991

66. Schanberg LE, Lefebvre JC, Keefe FJ, Kredich DW, Gil KM: Pain coping and the pain experience in children with juvenile chronic arthritis. Pain 73(2):181-189, 1997

80. Vrana SR, Rollock D: The role of ethnicity, gender, and emotional content, and contextual differences in physiological, expressive, and self-reported emotional responses to imagery. Cognit Emotion 16(1):165-192, 2002

67. Sheffield D, Biles PL, Orom H, Maixner W, Sheps DS: Race and sex differences in cutaneous pain perception. Pyschosom Med 62(4):517-523, 2000

81. Zatzick DF, Dimsdale JE: Cultural variations in response to painful stimuli. Psychosom Med 52:544-557, 1990