- Email: [email protected]
Ethnicity in the reported pain, emotional distress and requests of medical outpatients
Sec.Ser.Med. Vol. 18.No. 6.pp 487490. 1984 Printed in Great Britain. All rights reserved
0277-9536184 53.w+ 0 00 CopyrIght I( 19x4Perpmm Press Lrd
ETHNICITY IN THE REPORTED PAIN, DISTRESS AND REQUESTS OF MEDICAL CHERYL KOOPMAN’, ‘Harvard
SHERMAN EISENTHAL’t
Medical School and ZDepartments Massachusetts General Hospital
of Psychiatry Fruit Street,
EMOTIONAL OUTPATIENTS*
and JOHN D. STOECKLE’ and Medicine (Primary Care Boston. MA 02114, U.S.A.
Program),
Abstract-Relationships investigated. When
of patents’ ethnicity to their reported pain, emotional distress and requests were patients aged over 60 years were compared. Italian-Americans were found to more frequently report pain than were Anglo-Americans; however, this difference was not replicated in the younger patients of Italian and Anglo backgrounds. In addition to patients’ age, their sex also was found to mediate the relationship of ethnicity to the expression of pain. In particular, older female ItalianAmericans were likely to report pain while, in contrast, older male Anglo-Americans were not. Age and sex may be important mediators of ethnic differences because older and female patients may carry on ethnic traditions more than do younger and male patients. Ethnicity was not found to be significantly related to emotional distress and requests.
That ethnicity can influence patients’ expression of pain has been noted in classic studies by Zborowski [l] and Zola [2]. In 1952 Zborowski was the first to note ethnic differences in reports of pain, with patients of Italian and Jewish backgrounds expressing their pain more intensely than ‘Old Americans’ (of northern European descent) [l]. Some years later, in 1966, Zola observed that patients of an Italian ethnic background reported pain more frequently than did patients of Irish or Anglo-Saxon ethnic background
121.
Both studies contributed to physicians’ understanding of the meanings of pain to various patients, an understanding that plays an important role in the diagnostic and treatment process. Physicians’ responses to patients’ pain experiences are based largely on their judgements of patients’ reports, as no reliable physiological measure of pain has been found [3]. However, adequate interpretations of patient communications require understanding of patients’ statements within an ethnic cultural framework [4]_When physicians are inattentive to the influence of ethnicity on patients’ reports of pain, important diagnostic cues may be overlooked or misinterpreted [2]. OBJECTIVES
Whether these ethnic influences on communication still continue today as groups become more acculturated is not only a practical issue in patient care, but a theoretical one in general. We undertook a study to examine the relationships of patient’s ethnicity (Italian/Anglo) to patients’ reported pain, emotional distress and their requests for medical help. The four objectives of the study were, first, to determine whether similar ethnic differences to those found by Zola in the same clinic would still be present two decades later; second, to determine whether patients’ age and sex mediate the effect of ethnicity on their reports of pain; third, to examine ethnic *Supported by Grant MH-14246 from the National Institute of Mental Health. Public Health Service, U.S.A. +To whom all correspondence should be addressed. 487
influence on patients’ emotional distress and, fourth, on patients’ requests for medical aid. In the United States, enculturation and submersion of ethnic backgrounds occur to such an extent that it is valuable to replicate findings regarding ethnic differences over time. In the Boston area, where this study took place, ethnic identity seems to be stronger among older residents, many of whom have maintained strong ties to their ethnic community. Also, it has been observed that older persons are more likely to adhere to traditional ethnic biomedical beliefs, at least among Italian-Americans [5]. Hence, the relationship of ethnicity to patients’ reports of pain would be expected to be more evident in older patients. The patients’ sex was also expected to interact with ethnicity in patients’ reports of pain. This latter prediction was guided by the assumption that, in the United States, ethnic traditions are retained more by women than men. Women, more often than men, have had social roles that limit their occupational exposure to the mainstream culture; more confined to home and family, they perpetuate cultural traditions. Hence, women’s responses to pain, more than those of men, were expected to reflect their cultural background. Irrespective of ethnic background, the relation of age and sex to reported pain was also examined. Previous research suggests that age and sex are related to reports of pain tolerance when pain is experimentally induced [6,7], with females and older patients showing lower pain tolerances than do males and younger patients. However, since knowing the origin of pain, e.g. laboratory-induced, may considerably influence the experience of pain, it is not clear how generalizable such experimental pain responses are to those encountered in patients whose pain source and cause is often unknown [8]. Since Zborowski had already shown that the quality of emotional distress associated with pain varies with patients’ ethnic background [l], this study extended this observation by examining the influence of ethnicity on the expression of emotional distress per se, irrespective of the report of pain. The purpose of including emotional distress was to clarify the re-
$88
CHERYL KOOPMAN
iationships between ethnicity and dimensions of emotional expressiveness-distinguishing the expression of emotional distress from that accompanying physical discomfort. A final study objective was to investigate the communication of specific requests [9, lo] for medical aid by patients of Italian-American and AngloAmerican backgrounds, testing the hypothesis that ethnic background may be associated with this feature of the patient’s perspective. METHOD
Forty Italian-American patients and 44 AngloAmerican patients from two ambulatory medical practices at the Massachusetts General Hospital participated in the study. Fifty-two (62%) of the 84 patients in this study had appointments with three internists in a general medical practice providing primary care; the other 32 (38%) were seen by physicians at a walk-in screening clinic. All 84 patients were drawn from a larger research sample of 200 adult patients (100 from each setting) that also included patients of other ethnic backgrounds. No other ethnic groups were represented in large enough numbers within this sample to merit their inclusion in this study. No statistically significant differences were found between the Anglos and Italians within the 84 patient sample in age, sex, marital status, complaint or number of prior clinic visits. Patients who did not speak English or who were judged by physicians’ staff as too physically ill or emotionally distressed were not asked to participate in the study; however, this procedure did not result in any Italian-Americans being excluded from the study. Participation in the study was voluntary. In the larger study, 19 patients of undetermined ethnic backgrounds declined to participate. Patients waiting to see physicians were approached by a psychologist (CK) who requested their participation in “a study of clinical services in order to improve them”. They were informed that the focus of the research was “to better understand how patients see things, especially their problems”. Patients were also told that the information that they provided would be kept confidential and that there was no obligation to participate. This information was also printed on a consent form that was signed by each patient participating in the study. Each patient was individually interviewed by the psychologist prior to the patient’s visit with a physician. A printed interview guide was used to elicit and record verbatim the patient’s responses. To elicit the complaint, the patient was asked, “What troubles, problems, or difficulties do you feel you want help with today”. If the patient did not mention aches or pains in responding to this question, he or she asked, “Have you been having any pain?’ To elicit the request, the patient was asked, “How do you hope the clinic, doctor, or staff can be of help to you today?” At the conclusion of each interview, the patient was asked to describe the ethnic background (referring to the national origin of ancestors) of each of his or her parents. Only those patients who identified the ethnic background of at least one parent as Italian or English, Irish and/or Scottish (‘Anglo’) were included as subjects in this study.
et al.
Patients who identified the background of one parent as Italian and the other as Anglo were excluded. After all interviews .were completed. the written verbatim responses were content analyzed using a coding system that was tested for inter-rater reliability. The complaint data were coded for pain (e.g. “I have a headache”, “My back hurts”). Emotional distress was identified by a content analysis for complaint of dysphoric affect (e.g. “I feel depressed”. “I’ve been anxious”). Each request response was coded on three dimensions: first, its specificity, whether the patient described specifically how he or she hopes the physician will help, e.g. “I hope he will give me diet pills”; second, its focus (problem definition, treatment, relationship, or administration), the area in which the patient wants help, e.g. on what is wrong (problem definition) versus on what to do (treatment); and third, its form (somatic, directive, affective, cognitive or instrumental), which specifies what kind of action is desired, a somatic intervention (e.g. a drug prescription), and explanation, advice, etc. Coding differences were resolved by conference. Copies of the detailed coding system are available upon request. RESULTS
Chi-square analyses were used to determine statistical significance of the results.
the
Pain
As hypothesized, Italian-American patients were found to report pain significantly more frequently than did Anglo-American patients (;c* = 7.90, d.f. = 1, P ~0.01). Twenty-five (63%) of the Italian Americans reported pain, while only 13 (309,;) of the Anglo-Americans did so. The main effects of age and sex with reported pain were not statistically significant. However, age and sex were found to mediate the relationship of ethnicity to reported pain. We found that ethnicity interacted with age and sex (as shown in Fig. 1). For patients 60 years and older, pain was reported by a significantly higher proportion of Italian-Americans than of Anglo-Americans, but the relationship between ethnicity and report of pain was not statistically significant for patients under 60. Similarly, while significantly more ltalianAmerican than Anglo-American women reported pain, among men no significant difference was noted between the two ethnic groups. The finding of no overall ethnic difference in pain among males does
Fig. I. Percentages
of patients reporting pain within ethnic. age and sex subgroups.
Ethnicity
in pain,
emotional
distress
and requests
4XY
x2 = 9.08, d.f. = 1, P > 0.01) and with wanting directive forms of help for Italians, x = 4.91, d.f. = 1, P <0.05), and for Angles, x2=3.17, d.f. = 1. P < 0.08). DISCUSSION
v
Fig. 2. Percentages of patients expressing distress within ethnic. age and sex subgroups.
not tell the whole story. While young males were very similar in percentages reporting pain (4 of 9 Italians, 44% 6 of 14 Anglos, 43x), they were the only age-by-sex subgroups that did not manifest the pattern of ethnic differences. As a result, in the overall tabulation for males, the differences among older males reporting pain (4 of 8 Italians, 50%; 1 of 9 Anglos, 11%) were obscured. Older female ItalianAmerican patients were the most likely to report pain (13 of 16, 817;); whereas least likely were the older Anglo-American males, with only 11% (1 of 9) reporting it. Emotional distress Ethnicity was not found to be significantly associated with patients’ reported emotional distress. Approximately one-quarter of the patients in each ethnic group reported distress, and that emotional distress was not significantly associated with reports of pain, either overall or within each ethnic group. Age and sex did not show any statistically significant relationship to express emotional distress, although a statistical trend (P < 0.10) suggested that females more frequently communicated it (see Fig. 2). Requests Eighty percent of the Italian-American patients stated a specific request (32 of 40), as compared to 68% (30 of 44) of the Anglo-American patients, but this difference was not statistically significant. For both groups, the most frequently expressed requests focused on treatment and problem definition, with 51% (43 of 84) of all patients stating a treatment request and 44:; (37 of 84) stating a problem definition request. The most frequent forms of requests were somatic and cognitive, with 43% of all patients (36 of 84) stating a somatic request; 38% (32 of 84), a cognitive. Somatic forms of requests were those in which patients stated they wanted a medical procedure or intervention (e.g. requests for blood tests, medication). In cognitive forms of requests, patients stated a desire for information or explanation to aid in their understanding. For both ethnic groups. requests focusing on problem definition were significantly associated with wanting cognitive forms of help (Italian--%’ = 36.26; Anglo-x’ = 20.69, for both groups d.f. = I and P > 0.0001). Moreover, for both groups, requests focusing on treatment were associated with wanting somatic forms of help (Italian-_%’ = 12.79. d.f. = 1, P < 0.001; Anglo--
Zola’s 1960-1961 study reported that more Italian patients talked of pain than did Anglo patients, and this 1980-1981 study, using the same clinic setting and patient population, found that ethnicity continues to be a very significant factor in the report of pain, an indication of the remarkable potency and stability of this cultural influence. The present study also reports that the ethnic difference is mediated by age and sex, an observation not previously noted. These different patterns in the Italian-American and Anglo-American subgroups can be interpreted by separately analyzing the effects of age and sex within each ethnic group (as shown in Fig. 1). The effects of Italian ethnicity, which contains a tradition of expressing and dramatizing pain [2], may be accentuated in older females for two reasons: ( 1) their sex has social ‘permission’ to express pain; and (2) their sex and age are associated with greater socialization to carry on cultural traditions which, for their ethnic group, leads to a high readiness to report pain when seeking medical care. The effects of the Anglo ethnicity, which contains a tradition of inhibiting the expression of pain [1,2,12] may be accentuated in older males for two reasons: (1) their sex generally does not have social permission to express pain; and (2) their age is associated with greater socialization to carry on cultural traditions, which, for their ethnic group, leads to a readiness to inhibit the expression of pain when seeking medical care. Similarly, with current cultural trends promoting more open expression, younger male Anglos may not be so inhibited as older generations. Furthermore, as Zola [l l] has noted, increased formal education may be washing out ethnic differences. Looking next at emotional distress, it was not correlated with the reports of pain and was about one half its frequency, irrespective of ethnicity. This finding, contrary to other reports [l], supports the impression that the pain communication to the physician is aimed at focusing on the physical disorder, not the psychological reaction. In effect, pain reports are distinct, not simply one feature of a generalized emotional reaction. Italian-American patients may use pain reports to emphasize the immediacy of their ‘somatic’ problems or, as Zola has suggested [2], to dramatize their attitudes toward the ‘sick role’. Feelings of distress are converted to a somatic form. In effect, the psychological response to the illness experience is not what the patient wishes the physician to attend to. The fact that the Italian and Anglo subgroups were similar in emotional distress suggests that each group is coping by avoidance, the ItalianAmericans by focusing on the somatic and painful to legitimize being cared for, whereas the Anglos, by the very denial of painful feelings, do not acknowledge a need. Among the older patients, a puzzling age-sex interaction is worthy of further investigation. as older Italian males were much more emotionally expressive of distress than older Anglo males (38 vs
490
CHERYL KGGPMAN et al.
11x), while older Anglo females were more expressive than older Italian females (46-250;,). Over the full range of symptoms, including psychiatric, the patients’ request for an explanation of their symptoms is an area of contradiction in the literature. On one hand, the literature on the informative process in general medicine indicates that patients want to receive explanations from their doctors [13, 141though McIntosh’s study from a cancer ward reported that the majority of patients did not want to know their diagnosis [ 151. Zola observed that Italians in pain wanted symptom relief more than they wanted explanations [2]. The study data here do not support this aspect of Zola’s previous observations. Our finding is that Italian-Americans wanted both relief and an explanation as do their Anglo-American counterparts. This observation is consistent with the previous literature [ 13, 16, 171 that patients expect and derive satisfaction from receiving explanations, even though they may not request them. Implications
The results of this study suggest additional areas of research. Studies of clinical practice might usefully examine physicians’ understandings of ethnic differences and their diagnostic and treatment decisions in relation to these differences. For example, clinicians’ interpretations of patients’ reports of pain and their decisions for diagnostic tests could be examined to determine whether there are variations according to patients’ ethnicity, age and sex. Although many scholars have analyzed ethnicity in terms of common origin, as we have done, ethnicity is a complex concept that can also be analyzed in other ways [ 181. Future research on ethnic differences should include religious background and generation in the current country as well as national origin of ancestors so that the influence of these components of ethnicity can be distinguished. Other clinical implications concern the findings on emotional distress. The results suggest that physicians should distinguish patients’ expressions of emotional distress from their reports of pain. Since emotional distress was found to be less frequently mentioned and was found to be unrelated to report of pain, it may be necessary for physicians to probe specifically for indications of emotional distress in the presence of pain complaints. Finally, for those patients whose requests focus on problem definition, the results suggest that patients are especially concerned with receiving an explanation about what is wrong and its cause, a valid observation for both ethnic groups, and worth exploring in patients of other cultural backgrounds.
Acknowle~~emenu-The authors thank, Dr Richard Pingree and the staff of the Ambulatory Screening Clinic and Dr James Dineen and the staff of the Internal Medicine Associates for the cooperation in facilitating this study of
their patients. The authors also thank Dr Irving K. Zola. who made helpful suggestions for revising an earlier draft of this report. REFERENCES
1. Zborowski M. Cultural components pain. J. sot Issues. 8, 16, 1952.
in responses to
analysis of 2. Zola I. K. Culture and symptoms-an patients’ presenting complaints. Am. social. Rev. 31. 615, 1966. 3. Elton D., Burrows G. D. and Stanley G. V. Clinical measurement of pain. Med. 1. Ausr. 1, 109, 1979. 4. Weidman H. H. The transcultural view: Prerequisite to interethnic (intercultural) communication in medicine. Sot. Sci. Med. 13, 85, 1979. 5. Harwood A. (Ed.) Efhnicirv and Medical Care. Harvard University Press, ‘Cambridge, MA, I98 1. 6. Notermans S. L. H. and Tophoff M. M. W. A. Sex difference in pain tolerance and pain apperception. In Pain: Clinical and Experimental Perspectives (Edited by Weisenberg M.), p. III. C. V. Mosby Company, St Louis, 1975. 7. Woodrow K. M., Friedman G. D., Siegelaub A. B. and Collen M. F. Pain tolerance: differences according to age, sex and race. In Pain: Clinical and E_yperimental Perspectives (Edited by Weisenberg M.), p. 133. C. V. Mosby Company, St Louis, 1975. 8. Beecher N. K. The measurement of pain, prototype for Ithe quantitative study of subjective responses. Pharmac. Rev.‘%9, 60, 1956. _ 9 Lazare A.. Eisenthal S. and Wasserman L. The customer approach to patienthood. Archs gen. Psychiar. 32, 553, 1975.
IO. Lazare A., Eisenthal S., Frank A. and Stoeckle J. D. Studies on a negotiated approach to patienthood. Fogarty International Center Proceedings, p. 119. D.H.E.W., Washington, DC, 1976. 11 Zola I. K. Illness behavior of the working class: implications and recommendations. In Blue Collar World. Studies of the American Worker (Edited by Shostak A. and Gomberg W.), p. 350. Prentice-Hail, Englewood Cliffs, NJ, 1964. 12 Opler M. K. Culture and Mental Health. Macmillan, New York, 1959. I3 Bradley N. C. A. Expectations and experience of people who consult in a training practice. Jl R. Call. gen. Pracr. 31, 420, 1981.
14. Hayes-Bautista D. E. Chicano patients and medical practitioners: a sociology of knowledges paradigm of lav-wofessional interaction. Sot. Sci. Med. 12,83, 1978. 15. McIntosh J. Communication and Awareness in a Cancer Ward. Crown Helen, London, 1977. 16. Stiles W. P., Putnam S. M., Wolf M. H. and James S. A. Interaction exchange structure and patient satisfaction with medical interviews. Med. Care 17, 667. 1979. 17. Stoeckle J. D. and Barsky A. J. Attributions: uses of social science knowledge in the “doctoring” of primary care. In The Relevance of Social Science to Medicine (Edited by Kleinman A: and Eisenberg L.), p. 223. Reidel, Amsterdam, 1981. 18. Cohen A. Variables in ethnicity. In Erhnic Change (Edited by Keyes C. F.), p. 307. University of Washington Press, Seattle, 1981.
0277-9536184 53.w+ 0 00 CopyrIght I( 19x4Perpmm Press Lrd
ETHNICITY IN THE REPORTED PAIN, DISTRESS AND REQUESTS OF MEDICAL CHERYL KOOPMAN’, ‘Harvard
SHERMAN EISENTHAL’t
Medical School and ZDepartments Massachusetts General Hospital
of Psychiatry Fruit Street,
EMOTIONAL OUTPATIENTS*
and JOHN D. STOECKLE’ and Medicine (Primary Care Boston. MA 02114, U.S.A.
Program),
Abstract-Relationships investigated. When
of patents’ ethnicity to their reported pain, emotional distress and requests were patients aged over 60 years were compared. Italian-Americans were found to more frequently report pain than were Anglo-Americans; however, this difference was not replicated in the younger patients of Italian and Anglo backgrounds. In addition to patients’ age, their sex also was found to mediate the relationship of ethnicity to the expression of pain. In particular, older female ItalianAmericans were likely to report pain while, in contrast, older male Anglo-Americans were not. Age and sex may be important mediators of ethnic differences because older and female patients may carry on ethnic traditions more than do younger and male patients. Ethnicity was not found to be significantly related to emotional distress and requests.
That ethnicity can influence patients’ expression of pain has been noted in classic studies by Zborowski [l] and Zola [2]. In 1952 Zborowski was the first to note ethnic differences in reports of pain, with patients of Italian and Jewish backgrounds expressing their pain more intensely than ‘Old Americans’ (of northern European descent) [l]. Some years later, in 1966, Zola observed that patients of an Italian ethnic background reported pain more frequently than did patients of Irish or Anglo-Saxon ethnic background
121.
Both studies contributed to physicians’ understanding of the meanings of pain to various patients, an understanding that plays an important role in the diagnostic and treatment process. Physicians’ responses to patients’ pain experiences are based largely on their judgements of patients’ reports, as no reliable physiological measure of pain has been found [3]. However, adequate interpretations of patient communications require understanding of patients’ statements within an ethnic cultural framework [4]_When physicians are inattentive to the influence of ethnicity on patients’ reports of pain, important diagnostic cues may be overlooked or misinterpreted [2]. OBJECTIVES
Whether these ethnic influences on communication still continue today as groups become more acculturated is not only a practical issue in patient care, but a theoretical one in general. We undertook a study to examine the relationships of patient’s ethnicity (Italian/Anglo) to patients’ reported pain, emotional distress and their requests for medical help. The four objectives of the study were, first, to determine whether similar ethnic differences to those found by Zola in the same clinic would still be present two decades later; second, to determine whether patients’ age and sex mediate the effect of ethnicity on their reports of pain; third, to examine ethnic *Supported by Grant MH-14246 from the National Institute of Mental Health. Public Health Service, U.S.A. +To whom all correspondence should be addressed. 487
influence on patients’ emotional distress and, fourth, on patients’ requests for medical aid. In the United States, enculturation and submersion of ethnic backgrounds occur to such an extent that it is valuable to replicate findings regarding ethnic differences over time. In the Boston area, where this study took place, ethnic identity seems to be stronger among older residents, many of whom have maintained strong ties to their ethnic community. Also, it has been observed that older persons are more likely to adhere to traditional ethnic biomedical beliefs, at least among Italian-Americans [5]. Hence, the relationship of ethnicity to patients’ reports of pain would be expected to be more evident in older patients. The patients’ sex was also expected to interact with ethnicity in patients’ reports of pain. This latter prediction was guided by the assumption that, in the United States, ethnic traditions are retained more by women than men. Women, more often than men, have had social roles that limit their occupational exposure to the mainstream culture; more confined to home and family, they perpetuate cultural traditions. Hence, women’s responses to pain, more than those of men, were expected to reflect their cultural background. Irrespective of ethnic background, the relation of age and sex to reported pain was also examined. Previous research suggests that age and sex are related to reports of pain tolerance when pain is experimentally induced [6,7], with females and older patients showing lower pain tolerances than do males and younger patients. However, since knowing the origin of pain, e.g. laboratory-induced, may considerably influence the experience of pain, it is not clear how generalizable such experimental pain responses are to those encountered in patients whose pain source and cause is often unknown [8]. Since Zborowski had already shown that the quality of emotional distress associated with pain varies with patients’ ethnic background [l], this study extended this observation by examining the influence of ethnicity on the expression of emotional distress per se, irrespective of the report of pain. The purpose of including emotional distress was to clarify the re-
$88
CHERYL KOOPMAN
iationships between ethnicity and dimensions of emotional expressiveness-distinguishing the expression of emotional distress from that accompanying physical discomfort. A final study objective was to investigate the communication of specific requests [9, lo] for medical aid by patients of Italian-American and AngloAmerican backgrounds, testing the hypothesis that ethnic background may be associated with this feature of the patient’s perspective. METHOD
Forty Italian-American patients and 44 AngloAmerican patients from two ambulatory medical practices at the Massachusetts General Hospital participated in the study. Fifty-two (62%) of the 84 patients in this study had appointments with three internists in a general medical practice providing primary care; the other 32 (38%) were seen by physicians at a walk-in screening clinic. All 84 patients were drawn from a larger research sample of 200 adult patients (100 from each setting) that also included patients of other ethnic backgrounds. No other ethnic groups were represented in large enough numbers within this sample to merit their inclusion in this study. No statistically significant differences were found between the Anglos and Italians within the 84 patient sample in age, sex, marital status, complaint or number of prior clinic visits. Patients who did not speak English or who were judged by physicians’ staff as too physically ill or emotionally distressed were not asked to participate in the study; however, this procedure did not result in any Italian-Americans being excluded from the study. Participation in the study was voluntary. In the larger study, 19 patients of undetermined ethnic backgrounds declined to participate. Patients waiting to see physicians were approached by a psychologist (CK) who requested their participation in “a study of clinical services in order to improve them”. They were informed that the focus of the research was “to better understand how patients see things, especially their problems”. Patients were also told that the information that they provided would be kept confidential and that there was no obligation to participate. This information was also printed on a consent form that was signed by each patient participating in the study. Each patient was individually interviewed by the psychologist prior to the patient’s visit with a physician. A printed interview guide was used to elicit and record verbatim the patient’s responses. To elicit the complaint, the patient was asked, “What troubles, problems, or difficulties do you feel you want help with today”. If the patient did not mention aches or pains in responding to this question, he or she asked, “Have you been having any pain?’ To elicit the request, the patient was asked, “How do you hope the clinic, doctor, or staff can be of help to you today?” At the conclusion of each interview, the patient was asked to describe the ethnic background (referring to the national origin of ancestors) of each of his or her parents. Only those patients who identified the ethnic background of at least one parent as Italian or English, Irish and/or Scottish (‘Anglo’) were included as subjects in this study.
et al.
Patients who identified the background of one parent as Italian and the other as Anglo were excluded. After all interviews .were completed. the written verbatim responses were content analyzed using a coding system that was tested for inter-rater reliability. The complaint data were coded for pain (e.g. “I have a headache”, “My back hurts”). Emotional distress was identified by a content analysis for complaint of dysphoric affect (e.g. “I feel depressed”. “I’ve been anxious”). Each request response was coded on three dimensions: first, its specificity, whether the patient described specifically how he or she hopes the physician will help, e.g. “I hope he will give me diet pills”; second, its focus (problem definition, treatment, relationship, or administration), the area in which the patient wants help, e.g. on what is wrong (problem definition) versus on what to do (treatment); and third, its form (somatic, directive, affective, cognitive or instrumental), which specifies what kind of action is desired, a somatic intervention (e.g. a drug prescription), and explanation, advice, etc. Coding differences were resolved by conference. Copies of the detailed coding system are available upon request. RESULTS
Chi-square analyses were used to determine statistical significance of the results.
the
Pain
As hypothesized, Italian-American patients were found to report pain significantly more frequently than did Anglo-American patients (;c* = 7.90, d.f. = 1, P ~0.01). Twenty-five (63%) of the Italian Americans reported pain, while only 13 (309,;) of the Anglo-Americans did so. The main effects of age and sex with reported pain were not statistically significant. However, age and sex were found to mediate the relationship of ethnicity to reported pain. We found that ethnicity interacted with age and sex (as shown in Fig. 1). For patients 60 years and older, pain was reported by a significantly higher proportion of Italian-Americans than of Anglo-Americans, but the relationship between ethnicity and report of pain was not statistically significant for patients under 60. Similarly, while significantly more ltalianAmerican than Anglo-American women reported pain, among men no significant difference was noted between the two ethnic groups. The finding of no overall ethnic difference in pain among males does
Fig. I. Percentages
of patients reporting pain within ethnic. age and sex subgroups.
Ethnicity
in pain,
emotional
distress
and requests
4XY
x2 = 9.08, d.f. = 1, P > 0.01) and with wanting directive forms of help for Italians, x = 4.91, d.f. = 1, P <0.05), and for Angles, x2=3.17, d.f. = 1. P < 0.08). DISCUSSION
v
Fig. 2. Percentages of patients expressing distress within ethnic. age and sex subgroups.
not tell the whole story. While young males were very similar in percentages reporting pain (4 of 9 Italians, 44% 6 of 14 Anglos, 43x), they were the only age-by-sex subgroups that did not manifest the pattern of ethnic differences. As a result, in the overall tabulation for males, the differences among older males reporting pain (4 of 8 Italians, 50%; 1 of 9 Anglos, 11%) were obscured. Older female ItalianAmerican patients were the most likely to report pain (13 of 16, 817;); whereas least likely were the older Anglo-American males, with only 11% (1 of 9) reporting it. Emotional distress Ethnicity was not found to be significantly associated with patients’ reported emotional distress. Approximately one-quarter of the patients in each ethnic group reported distress, and that emotional distress was not significantly associated with reports of pain, either overall or within each ethnic group. Age and sex did not show any statistically significant relationship to express emotional distress, although a statistical trend (P < 0.10) suggested that females more frequently communicated it (see Fig. 2). Requests Eighty percent of the Italian-American patients stated a specific request (32 of 40), as compared to 68% (30 of 44) of the Anglo-American patients, but this difference was not statistically significant. For both groups, the most frequently expressed requests focused on treatment and problem definition, with 51% (43 of 84) of all patients stating a treatment request and 44:; (37 of 84) stating a problem definition request. The most frequent forms of requests were somatic and cognitive, with 43% of all patients (36 of 84) stating a somatic request; 38% (32 of 84), a cognitive. Somatic forms of requests were those in which patients stated they wanted a medical procedure or intervention (e.g. requests for blood tests, medication). In cognitive forms of requests, patients stated a desire for information or explanation to aid in their understanding. For both ethnic groups. requests focusing on problem definition were significantly associated with wanting cognitive forms of help (Italian--%’ = 36.26; Anglo-x’ = 20.69, for both groups d.f. = I and P > 0.0001). Moreover, for both groups, requests focusing on treatment were associated with wanting somatic forms of help (Italian-_%’ = 12.79. d.f. = 1, P < 0.001; Anglo--
Zola’s 1960-1961 study reported that more Italian patients talked of pain than did Anglo patients, and this 1980-1981 study, using the same clinic setting and patient population, found that ethnicity continues to be a very significant factor in the report of pain, an indication of the remarkable potency and stability of this cultural influence. The present study also reports that the ethnic difference is mediated by age and sex, an observation not previously noted. These different patterns in the Italian-American and Anglo-American subgroups can be interpreted by separately analyzing the effects of age and sex within each ethnic group (as shown in Fig. 1). The effects of Italian ethnicity, which contains a tradition of expressing and dramatizing pain [2], may be accentuated in older females for two reasons: ( 1) their sex has social ‘permission’ to express pain; and (2) their sex and age are associated with greater socialization to carry on cultural traditions which, for their ethnic group, leads to a high readiness to report pain when seeking medical care. The effects of the Anglo ethnicity, which contains a tradition of inhibiting the expression of pain [1,2,12] may be accentuated in older males for two reasons: (1) their sex generally does not have social permission to express pain; and (2) their age is associated with greater socialization to carry on cultural traditions, which, for their ethnic group, leads to a readiness to inhibit the expression of pain when seeking medical care. Similarly, with current cultural trends promoting more open expression, younger male Anglos may not be so inhibited as older generations. Furthermore, as Zola [l l] has noted, increased formal education may be washing out ethnic differences. Looking next at emotional distress, it was not correlated with the reports of pain and was about one half its frequency, irrespective of ethnicity. This finding, contrary to other reports [l], supports the impression that the pain communication to the physician is aimed at focusing on the physical disorder, not the psychological reaction. In effect, pain reports are distinct, not simply one feature of a generalized emotional reaction. Italian-American patients may use pain reports to emphasize the immediacy of their ‘somatic’ problems or, as Zola has suggested [2], to dramatize their attitudes toward the ‘sick role’. Feelings of distress are converted to a somatic form. In effect, the psychological response to the illness experience is not what the patient wishes the physician to attend to. The fact that the Italian and Anglo subgroups were similar in emotional distress suggests that each group is coping by avoidance, the ItalianAmericans by focusing on the somatic and painful to legitimize being cared for, whereas the Anglos, by the very denial of painful feelings, do not acknowledge a need. Among the older patients, a puzzling age-sex interaction is worthy of further investigation. as older Italian males were much more emotionally expressive of distress than older Anglo males (38 vs
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11x), while older Anglo females were more expressive than older Italian females (46-250;,). Over the full range of symptoms, including psychiatric, the patients’ request for an explanation of their symptoms is an area of contradiction in the literature. On one hand, the literature on the informative process in general medicine indicates that patients want to receive explanations from their doctors [13, 141though McIntosh’s study from a cancer ward reported that the majority of patients did not want to know their diagnosis [ 151. Zola observed that Italians in pain wanted symptom relief more than they wanted explanations [2]. The study data here do not support this aspect of Zola’s previous observations. Our finding is that Italian-Americans wanted both relief and an explanation as do their Anglo-American counterparts. This observation is consistent with the previous literature [ 13, 16, 171 that patients expect and derive satisfaction from receiving explanations, even though they may not request them. Implications
The results of this study suggest additional areas of research. Studies of clinical practice might usefully examine physicians’ understandings of ethnic differences and their diagnostic and treatment decisions in relation to these differences. For example, clinicians’ interpretations of patients’ reports of pain and their decisions for diagnostic tests could be examined to determine whether there are variations according to patients’ ethnicity, age and sex. Although many scholars have analyzed ethnicity in terms of common origin, as we have done, ethnicity is a complex concept that can also be analyzed in other ways [ 181. Future research on ethnic differences should include religious background and generation in the current country as well as national origin of ancestors so that the influence of these components of ethnicity can be distinguished. Other clinical implications concern the findings on emotional distress. The results suggest that physicians should distinguish patients’ expressions of emotional distress from their reports of pain. Since emotional distress was found to be less frequently mentioned and was found to be unrelated to report of pain, it may be necessary for physicians to probe specifically for indications of emotional distress in the presence of pain complaints. Finally, for those patients whose requests focus on problem definition, the results suggest that patients are especially concerned with receiving an explanation about what is wrong and its cause, a valid observation for both ethnic groups, and worth exploring in patients of other cultural backgrounds.
Acknowle~~emenu-The authors thank, Dr Richard Pingree and the staff of the Ambulatory Screening Clinic and Dr James Dineen and the staff of the Internal Medicine Associates for the cooperation in facilitating this study of
their patients. The authors also thank Dr Irving K. Zola. who made helpful suggestions for revising an earlier draft of this report. REFERENCES
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