Pilot Study of Relationships Among Pain Characteristics
Mood Disturbances, and Acculturation in a Community
Sample of Chinese-American Patients With Cancer
Edrington, J., Sun, A., Wong, C., Dodd, M., Padilla, G., Paul, S., & Miaskowski, C.
This study is a pilot study to determine how level of acculturation and mood affect the intensity and functional aspects of pain in Chinese-American cancer patients. The purpose of the study is to determine if the pain perception of Chinese-American cancer patients is consistent with some past research on other ethnic groups (particularly Hispanic and African-Americans) that find that the level of acculturation is negatively related to the patients' self-reported pain intensity and the relief from pain associated with cancer. The researchers use the definition of acculturation as the process by which immigrants take on or embrace values, beliefs, customs, norms, and the lifestyle of the mainstream culture. Thus the Americanized the group is the more pain they report, a bit of biased statement. The researchers imply that there may be a reason for differing cultural perceptions of pain and noted that some previous research has hypothesized reasons as to why there might be differences in Chinese-Americans and most of these reasons are based on religious beliefs. The researchers wanted to determine if Chinese-Americans demonstrate the same results regarding cancer pain as other researched ethnic groups and imply that this can help understand and lead to better pain management in these groups.
A small group of Chinese-American cancer patients were recruited (see below for more). Main findings indicated that the level of pain intensity was negatively related to years of education and acculturation, and positively related to interference in activities. Most reported negative pain management scores. Overall comparisons with pain intensity with Caucasian samples indicate higher levels of perceived pain in Chinese-Americans, and with Hispanic and African-Americans.
The study uses a number of self-report measures are used to quantify pain perception, mood, perceived level of daily performance, pain management, and acculturation. The researchers take great care in making sure that the measures are culturally appropriate for the target population and can be readily understood by them even using a committee method of Chinese to making sure that the instruments are appropriate for the sample. The researchers also went as far to partner with local Chinese organizations such as the Chinese Community Health Resource Center to further make sure that there was a sense of trust between the participants and the researchers. The lengths the researchers go to make sure the measures are not contaminated by language or cultural barriers and to gain the trust of the subjects are quite extraordinary. Also such care and sensitivity is needed in such a study to avoid experimenter bias regarding the interpretation of the measures and bias in treatment and understanding the sample. In preparing the measures to be as objective and as acculturated as possible the researchers followed a sound protocol; however, the use of visual analog scales might have just as easily reduced the potential for some of these confounds (Gregory, 2011).
Seventy-six cancer patients were screened and 50 of those met the criteria for the study. The study is primarily quantitative in nature, which is consistent with its goals. The statistics are descriptive in nature, using measures of central tendency to describe the overall group performance on measures and correlations to compare the variables of interest. For a study that is descriptive and does not attempt to make a lot of inferences the protocol followed is acceptable, especially given the large number of variables and limitations of the measures. However, the study does attempt to go beyond the descriptive aspect and a better path to follow might have been a regression analyses common to similar types of studies used to predict what independent or subject variable best explains on outcome or dependent variable (see below). In that respect this study does not follow what we would expect from a study seeking to answer why questions as well as describing some phenomena.
There are some inferences made in this study that might be followed up a bit more clearly. For instance, the nature of the self-report data is descriptive as far as the pain aspect goes; however, if indeed we suspect acculturation is playing a role in the perception of pain in the sample (which is not born out fully in the findings by the way as education level was also related to pain) then in an ideal study more information should have been gathered about the participants' views on what it means to have cancer as well as their expectations of pain relief and pain in general. Could it be that certain groups (ethnic, religious, etc.) have different expectations concerning pain or cancer than do others? If so, this would lead to totally different self-reports of pain intensity and pain management in these groups. For example, in a well-cited study not cited by the authors Bates, Edward, and Anderson (1993) found that locus of control (the perception that you can or cannot control your circumstances) accounted for the much of the differences in different ethnic groups' reports of pain intensity (ethnic group is a predictor of an a general external or internal locus of control). Expectations and the perception of pain are highly interrelated (Koyama, McHaffie, Laurienti, & Coghill, 2005). So in terms of the analysis there is a huge missing piece to the puzzle that are researchers are attempting to solve. Moreover, in the discussion section the authors report that the pain intensity scores are consistent with those reported by cancer patients in Taiwan. But we also learn that the level of education was negatively related to pain perception. Thus, can we bolster the notion that acculturation plays a role in the pain intensity scores of these participants given that information? To me it seems that the patients are being consistent with their background. Other studies report that different ethnic groups differ on their reports of pain intensity regardless of the ailment and this is related to the locus of control issue. So how is acculturation related to locus of control?
The finding in this study that pain intensity was negatively related to education has not been a consistent finding. The variables of locus of control, education, and ethnicity may all have some reciprocal relationships that are not well-defined. Perhaps those having more acceptance of traditional American values acquire a sense of personal control over their lives. Perhaps more highly educated people do as well. The other issue of course was mentioned by the authors in their introduction, and that was religious and philosophical beliefs of the nature of pain. The authors report reasons based on differing religious philosophies as to why Chinese might report high perceptions of pain intensity in cancer. This study did not compare differing religious beliefs to pain intensity, but that might have also shed some light on the findings. Moreover, how do American Buddhists, Taoists, etc. differ from others in their reports of pain? A comparison might easily be made with the current sample to some Americans sharing similar religious convictions, especially in CA where this study was performed. This study may have also been more effective if it investigated these relationships via multivariate analysis such as regression or another analysis as opposed to simple descriptive statistics (Gregory, 2011).
The obvious problem with the study is that all cancers are lumped into a single study and this becomes a major confound because reports of cancer pain vary depending on type and location of the cancer (Ngamkham, Holden, & Wilkie, 2011). We would also expect expectations to play a role here. The researchers could have limited their initial study to a particular type of cancer and then later branched out to differing types of cancer to see if the…