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Chronic pain management by ethnically and racially diverse older adults: pharmacological and nonpharmacological pain therapies

Practice Points

Juyoung Park*1, Karen Manotas2 & Nancy Hooyman3 „„ Ethnically and racially diverse older adults showed different approaches to management of chronic pain. „„ Reported pain treatment strategies included: pain medications; nonpharmacological management;

surgery; or both types (e.g., surgery and exercise, medications and physical therapy). „„ Non-Hispanic whites had typically been prescribed pain medication and other pain procedures by pain

specialists. They tended to use prescribed pain medications, as well as over-the-counter medications and pain procedures (e.g., cortisone shots and epidural steroid injections) prescribed by pain specialists. „„ African–American, Afro–Caribbean, and Hispanic/Latino older adults were more likely than non-Hispanic

whites to use an over-the-counter pain medication and less likely to visit healthcare professionals for pain procedures (e.g., epidurals) or take prescribed pain medications. „„ Exercise was the nonpharmacological treatment most frequently used by all four racial/ethnic groups. „„ Non-Hispanic whites often used physical interventions as nonpharmacological pain management, such

as acupuncture, massage, water exercise and chiropractic treatment. „„ African–Americans, Hispanics and Afro–Caribbeans used, as nonpharmacological pain management,

home remedies (e.g., cream and over-the-counter ointment), culturally based treatments (e.g., herbal tea, Mauve/Malva leaves, piper peltatum leaves and avocado leaves) and psychological therapies (e.g., prayer, distraction, relaxation, meditation and support groups) to manage chronic pain. „„ Race or ethnicity is not the only factor that influences preference for pain management. Such preference

is complex and multifactorial, including the factors of immigration and socioeconomic status (e.g., education and income). „„ Simply showing an interest in pain management by asking specific questions associated with

their current pain therapy can be the first step toward an integrative use of culturally appropriate interventions.

Florida Atlantic University School of Social Work, 777 Glades Road, Boca Raton, FL 33431, USA University of Utah, School of Medicine, UT, USA 3 University of Washington, School of Social Work, WA, USA *Author for correspondence: Tel.: +1 561 297 4537; Fax: +1 561 297 2866; [email protected] 1 2

10.2217/PMT.13.48 © 2013 Future Medicine Ltd

Pain Manage. (2013) 3(6), 435–454

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RESEARCH ARTICLE  Park, Manotas & Hooyman SUMMARY Aims: Exploration of racial and ethnic group differences in noncancer chronic pain management in older adults. Participants & methods: Qualitative data, which were collected in semistructured face-to-face interviews with 44 racially and ethnically diverse community-dwelling older adults (ten African–Americans, ten Hispanics, 12 Afro– Caribbeans and 12 non-Hispanic whites), were analyzed using constant comparative analysis. Results: The three racial and ethnic minority groups were more likely to use culturally based treatments (e.g., herbal tea and avocado leaves), home remedies and folk medicine, and/or psychological therapies (e.g., distraction and relaxation) than non-Hispanic whites to manage chronic pain. African–Americans relied on religious coping methods. Non-Hispanic whites were more likely to use physical interventions such as massage and chiropractic treatment. Conclusion: Study findings suggest differences by ethnicity in preferred pain ­interventions for an older adult population. By 2030, shifting demographics will result in a tripling of the population of older adults (defined as age 65 years or older) to 72.1 million [101]. Racial and ethnic minority older adults (defined as those age 65 years or older who are not categorized as non-Hispanic white [1,102]) are one of the fastest-growing age subgroups in the USA [2]. They are projected to increase from 14.1% of the US population in 2020 to 18.3% by 2050 [103], representing 24% of all older adults by 2020 [104]. Race includes several dimensions, including physical characteristics (e.g., skin color and hair texture), culture (e.g., belief systems, attitudes, and group behavioral norms and expectations), and self-identity [3], whereas ethnicity as a social construct is defined as “groups of people on the basis of characteristics such as shared culture, language, beliefs, behaviors, history and experience” [4]. The 1997 Office of Management and Budget (OMB) revised minimum standards for maintaining, collecting and presenting data on race and ethnicity [5]. There were five minimum categories of race: American–Indian or Alaska native, Asian, black or African–American, native Hawaiian or other Pacific Islander, and white. There were two categories for ethnicity: Hispanic or Latino and not Hispanic or Latino [5]. In spite of the categories on race and ethnicity designated by the OMB [5], ethnic and racial categories are often inadequately described in pain literature and both terms are frequently used interchangeably without clear definitions [4,6]. For instance, non-Hispanic white refers to a participant’s race and ethnicity based on the categories illustrated by the OMB in 1997. Owing to the complicated and multifaceted characteristics of race and ethnicity, the terms race and ethnicity were used in the current study, as in racial and ethnic minority older adults. The four groups (non-Hispanic white, Hispanic,

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African–American, and Afro–Caribbean) recruited in the study designated both racial and ethnic categories. Afro–Caribbean usually refers to people with African ancestral origins who migrated via the Caribbean islands, typically from Jamaica, Haiti, the Republic of Trinidad and Tobago or the Dominican Republic [7]. Afro–Caribbean people have cultural values that are different from those of other African populations in terms of language, diet, customs, belief and migration history [7]. African–Americans are defined as persons of African ancestral origins who self-identify or are identified by others as African–American. Although most African– Americans in the USA came from sub-Saharan Africa, the term is not applied to Africans from northern African c­ ountries, such as Morocco [7]. The term Hispanic refers to persons from Spain and Spanish-speaking Latin Americans (except Brazilians, who speak Portuguese), while the term Latino excludes persons from Spain but includes both Spanish-speaking and Portuguese-speaking Latin Americans [102]. Most are of Mexican, Puerto Rican, Cuban, Central or South American or other Spanish culture or origin [5]. Non-Hispanic whites (or whites, not Hispanic or Latino) are people in the USA who are of the white race and are not of Hispanic or Latino origin/ethnicity. A person with origins from Europe, north Africa or the Middle East are included in this group [5]. Older adults are more likely than younger age groups to be diagnosed with pain-related disorders such as musculoskeletal disorders (e.g., osteo­arthritis, osteoporosis and back problems) and neuropathic disorders (e.g., peripheral neuro­pathy) [8]. Older adults use a variety of methods to manage chronic pain. Pain management often includes: pharmacological therapies (prescribed and over-the-counter [OTC] medications); nonpharmacological therapies

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Chronic pain management by ethnically & racially diverse older adults  (e.g., complementary alternative medicineyoga, exercise, physical therapy, meditation, natural products, dietary supplements and herbal medicine); and surgery (e.g., knee or hip replacement) [9]. The relationship between race/ethnicity and chronic pain and chronic pain management is more complex for racial and ethnic minority elders than for white elders [10]. As empirical evidence supports the presence of racial and ethnic disparities in access to pain treatment in general [11], it is assumed that ethnicity/race could influence the selection of pain therapies. In Lavin and Park’s systematic review, most studies reported that ethnic and racial older adult groups were less likely to receive prescribed medication and surgery and more likely to use folk medicines (e.g., herbal tea, copper bracelets and moxa) or home remedies (cream or heating/ ice pack) owing to their generally not being prescribed treatments that are often prescribed for white patients [9]. African–Americans, Asian– Americans and Hispanics were reported to be less likely than non-Hispanic whites to use the services of a pain clinic and to receive pharmacological pain therapy (including opioid analgesics), more likely to leave pain untreated and more likely to use nonpharmacological pain therapies [11–13]. Rausch et al. identified that the most commonly used nonpharmacological pain therapies were spiritual healing/prayer (62%), exercise (20%), music (18%), chiropractic treatment (16%), and meditation (13%) [14]. One survey showed that whites were more likely to visit nonpharmacological providers (e.g., acupuncturists, chiropractors and massage therapists) and older African–Americans were more likely than nonHispanic whites to use movement/exercise and rely on home care remedies [15]. Hispanics have been reported to prefer dietary supplements for arthritis treatments, while whites tended to use chiropractic treatment and massage for pain treatment [16]. However, some studies found no significant differences in nonpharmacological pain therapy by ethnicity [17,18]. Many studies on pain disparities were complicated by the interchangeable use of the terms race and ethnicity, which were not defined. As less is known about whether ethnicity influences selection of pain therapies, qualitative research is the first step for identifying a range of pain management variables and their contextual meanings [19]. The current study explored the

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types of chronic pain therapies, both pharmaco­ logical and nonpharmacological, used by four racially and ethnically diverse groups of older adults to determine whether race/ethnicity may influence choice of chronic pain therapies. Participants & methods „„ Study design & procedure

Qualitative methods with semistructured interviews were utilized to explore participants’ experiences with chronic pain management. In the literature, older adults are defined as adults age 65 years or older; however, older adults in this paper were defined as those more than 60 years old in order to capture various age level of older adults, including the baby boom generation. The aging population in south Florida (USA) is diverse, with substantial populations of Hispanics/Latinos, African–Americans and Afro–Caribbeans, as well as non-Hispanic whites. However, Asians and native Americans were not included in the Healthy Aging Research Initiative (HARI) registry due to an extremely small proportion of those groups in south Florida. For the current study, the term ethnic minority elders refers to people age 60 years or older from four racial/ethnic groups. In-depth semistructured interviews were conducted with 44 participants (12 non-Hispanic whites, ten African–Americans, ten Hispanics and 12 Afro–Caribbeans). HARI members consented to be contacted by researchers or research assistants (RA) for research projects at the participating university. The information about participants’ ethnic identity was obtained from the HARI registry and confirmed by the participant during the telephone screening. Although we did not consider immigrant status among inclusion criteria, all of the Afro–Caribbean and Hispanic participants were immigrants. Before the interview, each participant was given a definition of chronic pain (“Chronic pain means pain that lasts for 3 months or longer and may interfere with your daily activities” [20]) and was provided demographic information (Table 1) and the frequency of pain therapies reported by participants (Table 2). The main interview questions were: “What have you done so far (or what did you do in the past) to try to manage your chronic pain?”; “What did you find to be particularly helpful in managing your chronic pain?” and “Were there any methods that you tried that did not work or help at all? If so, what were these methods?”

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RESEARCH ARTICLE  Park, Manotas & Hooyman Table 1. Demographic characteristics of the participants (n = 44). Characteristic and category

n

%

9 35

20.5 79.5

12 10 10 12

27.3 22.7 22.7 27.3

3 1 1 2 1 1 1

30.0 10.0 10.0 20.0 10.0 10.0 10.0

1 6 3 2

8.3 50.0 25.0 16.7

Gender† Male Female Ethnicity Non-Hispanic white African–American Hispanic/Latino Afro–Caribbean Country of origin Hispanic/Latino Cuba Dominican Republic Colombia Puerto Rico Spain Bolivia Nicaragua Afro–Caribbean Haiti Jamaica Bahamas Republic of Trinidad & Tobago Education (by ethnic group) Less than high school Non-Hispanic white Hispanic African–American Afro–Caribbean High school graduate Non-Hispanic white Hispanic African–American Afro–Caribbean Some college Non-Hispanic white Hispanic African–American Afro–Caribbean College graduate Non-Hispanic white Hispanic African–American Afro–Caribbean

7 0 3 1 3 7 2 1 1 3 6 1 0 4 1 11 3 3 2 3

0.0‡ 37.5§ 10.0¶ 25.0# 18.2‡ 12.5§ 10.0¶ 25.0# 9.1‡ 0.0§ 40.0¶ 8.3# 27.3‡ 37.5§ 20.0¶ 25.0#

Age (years): mean = 70.32; standard deviation = 6.83. Percentage of the non-Hispanic white group. Percentage of the Hispanic group. ¶ Percentage of the African–American group. # Percentage of the Afro–Caribbean group. † ‡

§

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Table 1. Demographic characteristics of the participants (n = 44) (cont.). Characteristic and category

n

%

10 5 1 2 2 3

45.5‡ 12.5§ 20.0¶ 16.7#

Education (by ethnic group) (cont.) Graduate degree (Master, PhD, MD, among others) Non-Hispanic white Hispanic African–American Afro–Caribbean Missing Household income Less than US$10,000 Non-Hispanic white Hispanic African–American Afro–Caribbean US$10,000–19,999 Non-Hispanic white Hispanic African–American Afro–Caribbean US$20,000–34,999 Non-Hispanic white Hispanic African–American Afro–Caribbean US$35,000–49,999 Non-Hispanic white Hispanic African–American Afro–Caribbean US$50,000–99,000 Non-Hispanic white Hispanic African–American Afro–Caribbean US$100,000 or more Non-Hispanic white Hispanic African–American Afro–Caribbean Declined to answer Non-Hispanic white Hispanic African–American Afro–Caribbean Missing

5 0 4 0 1 8 0 2 4 2 8 3 0 3 2 4 1 1 0 2 12 4 1 3 4 2 2 0 0 0 2 1 0 0 1 3

0.0‡ 50.0§ 0.0¶ 8.3# 0.0‡ 25.0§ 40.0¶ 16.7# 27.3‡ 0.0§ 30.0¶ 16.7# 9.1‡ 12.5§ 0.0¶ 16.7# 36.4‡ 12.5§ 30.0¶ 33.3# 18.1‡ 0.0§ 0.0¶ 0.0# 9.1‡ 0.0§ 0.0¶ 8.3# 6.8

Age (years): mean = 70.32; standard deviation = 6.83. Percentage of the non-Hispanic white group. Percentage of the Hispanic group. ¶ Percentage of the African–American group. # Percentage of the Afro–Caribbean group. † ‡

§

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RESEARCH ARTICLE  Park, Manotas & Hooyman Table 1. Demographic characteristics of the participants (n = 44) (cont.). Characteristic and category

n

%

7 25 8 4

15.9 56.8 18.2 9.1

40 3 1

90.9 6.8 2.3

Religion Catholic Protestant Jewish No formal religion Duration of chronic pain >3 years 1–3 years 3–6 months Age (years): mean = 70.32; standard deviation = 6.83. Percentage of the non-Hispanic white group. § Percentage of the Hispanic group. ¶ Percentage of the African–American group. # Percentage of the Afro–Caribbean group. † ‡

The procedures were approved by the Institutional Review Board of the participating university. The participants were recruited from Palm Beach and Broward counties in south Florida from those who had received services at senior centers and other aging-related services listed in the HARI registry at the participating university. Older adults in the HARI registry who ­self-identified as one of the four targeted racial/ ethnic groups were contacted for the telephone screening; three screening questions were administered by telephone to check eligibility. Each interview was conducted in the participant’s home or in an office of the Memory and Wellness Center at the participating university, depending on the participant’s preference. The two RAs received rigorous training and were monitored by the principal investigator in observing practice sessions and conducting interviews, including how to probe participants’ answers. A standard script including open-ended questions was used in each interview, which lasted 40–60 min. Spanish-speaking participants were interviewed in Spanish by the bilingual RA. With each participant’s permission, interviews were audio tape recorded and transcribed. Interviews conducted in Spanish were transcribed in Spanish and then translated to English by the bilingual RA. After the interview, each participant received a US$20 gift card. The study’s inclusion criteria were: 60 years or older; self-identified as non-Hispanic white, Hispanic/Latino, African–American or Afro–Caribbean, regardless of immigration status; reported chronic noncancer pain that had persisted for at least 3 months; pain that limited daily activities or functional ability; and a pain level of at least 4 on a 10-point scale (0 = no pain

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to 10 = excruciating pain). Exclusion criteria were: possible cognitive impairment determined by a score of less than 23 on the Mini-Mental State Exam­ination (MMSE) [21]; and primary language other than English or Spanish (Afro–Caribbeans who spoke only Creole were excluded). „„ Data analysis

Analysis proceeded using a grounded theory methodology of constant comparative analysis of individual interviews to identify similarities and differences within and across interviews [22]. The two researchers independently reviewed each transcript line by line to identify themes related to chronic pain management [23]. Each researcher copied and pasted each coded segment into a separate document to form a list of initial categories [24]. Each meaningful statement and phrase were identified and grouped into categories of pain therapies based on similarities and differences in pain management across ethnic groups. Categories were clustered into themes related to the interview questions. The data were systematically coded and analyzed for themes. The transcripts, coding sequences and final categories were reviewed by the other investigator to establish the identified themes. In order to identify the ethnic group differences in preferences for pain treatment, quantitative data show the frequencies of types of pharmacological (Table 3) and nonpharmacological pain therapies (Table 4) reported by the participants. Results „„ Sample characteristics

Sample characteristics are displayed in Table 1. The mean age of the 44 participants was

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Chronic pain management by ethnically & racially diverse older adults  70.3 years (standard deviation = 6.83), range: 60–92 years. Hispanics and Afro–Caribbeans were immigrants (see Table  1 for country of origin). The majority of the participants were women (79.5%; n = 35) and the ethnic groups were almost evenly distributed (Table 1). A third of the participants were either widowed (32%; n = 14) or divorced (32%; n = 14). The highest level of education is displayed across racial and ethnic groups (Table 1); 45.5% (n = 5) of the non-Hispanic participants had earned a graduate degree and 27.3% (n = 3) had earned a college degree. In comparison, 37.5% (n = 3) of the Hispanic participants and 25% (n = 3) of the Afro–Caribbean participants had not earned a high school diploma. Household income level is displayed by racial and ethnic group; 50% of the Hispanic participants earned less than US$10,000 and 40% of the African–American participants earned US$10,000 –19,000; 18.1% of the non-Hispanic participants earned US$10,000 or more. A majority (82.9%; n = 34) reported having had chronic pain for more than 3 years. Regarding pain intensity (“Please rate your pain that best describes your pain at its worst in the last week”; 0 = does not interfere to 10 = completely interferes), 27% (n = 11) reported the worst pain level as 9 and 19.5% (n = 8) reported an average pain level of 8 (“Please rate your pain by circling the one number that best describes your pain on the average”). Regarding type of pain therapies, participants reported having used: pain medication (e.g., prescribed and OTC medications); nonpharmacological management (e.g., acupuncture, exercise, relaxation, physical therapy, chiropractic treatment, praying, spiritual belief, relaxation); surgery; or both types (e.g., surgery and exercise, medications and physical therapy; Table 1). Of the participants who were currently taking pain medication (82%; n = 36), 86% (n = 31) of these reported that they were receiving enough medication(s) to manage chronic pain. In terms of nonpharmacological pain therapies, the majority (93.2%; n = 41) were currently using nonpharmacological pain therapies, either from professionals (e.g., acupuncture) or by self-management (e.g., stretching and water exercise). Of the 41 participants who used nonpharmacological pain therapies, some participants used more than one therapy; the most frequently reported types were exercise, including walking and stretches (97.6%; n = 40); prayer (spiritual direction: 53.7%; n = 22); massage

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therapy (36.6%; n = 15); relaxation (34.1%; n = 14); meditation (31.7%; n = 13); and water exercise (26.8; n = 11; Table 2). Those who were not currently using these therapies reported that they had used them previously but had stopped for a variety of reasons (e.g., “not effective”, “exercises did nothing but cause me more problems”, “I didn’t have the money”, “my depression paralyzes me”). The participants reported a variety of factors involved in their pain ­treatment decisions, as described below. Table 2. Pain therapies reported by participants. Type and category

n

%

3 1 1 4 3 4 2 1

7.3 2.4 2.4 9.8 7.3 9.8 4.9 2.4

14 13 11 11 3

34.1 31.7 26.8 26.8 9.8

40 22 15 14 13 11 6 4 6 3 3 3 3 2 2 2 2 1 16

97.6 53.7 36.6 34.1 31.7 26.8 13.6 9.8 13.6 7.3 7.3 7.3 7.3 4.9 4.9 4.9 4.9 2.4 39.0

Medications (n = 41) Prescribed medications Vicodin Celecoxib Meperidine Oxycodone Oxycodone with acetaminophen Tramadol Hydrocone Morphine Over-the-counter medications Acetaminophen (Tylenol®) Ibuprofen Naproxen (Aleve®) Aspirin Pain procedures (cortisone shot, epidural steroid injection) Nonpharmacological pain therapies (n = 41) Exercise Prayer (spiritual direction) Massage therapy Relaxation Meditation Water exercise Physical therapy Acupuncture Yoga Transcutaneous electrical nerve stimulation Pain support group Aromatherapy Tai-chi Pain support group Music therapy Homeotherapy Aromatherapy Cognitive–behavioral therapy Home remedies/folk medicine

Some participants were taking more than one medication or more than one nonpharmacological pain therapy.

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RESEARCH ARTICLE  Park, Manotas & Hooyman Table 3. Pharmacological pain therapies reported by ethnic groups (n = 41). Therapy and ethnic group

n

%

11 8 10 12

91.7 80.0 100.0 100.0

2 0 1 0

18.0 0.0 10.0 0.0

1 0 0 0

9.0 0.0 0.0 0.0

1 0 0 0

9.0 0.0 0.0 0.0

2 1 1 0

18.0 12.5 10.0 0.0

2 0 1 0

18.0 0.0 10.0 0.0

3 1 0 0

27.3 12.5 0.0 0.0

2 0 0 0

18.0 0.0 0.0 0.0

1 0 0 0

9.0 0.0 0.0 0.0

3 3

27.2 37.5

Pharmacological pain therapies White Hispanic African–American Afro–Caribbean Vicodin White Hispanic African–American Afro–Caribbean Celecoxib White Hispanic African–American Afro–Caribbean Meperidine White Hispanic African–American Afro–Caribbean Oxycodone White Hispanic African–American Afro–Caribbean Oxycodone with acetaminophen White Hispanic African–American Afro–Caribbean Tramadol White Hispanic African–American Afro–Caribbean Hydrocone White Hispanic African–American Afro–Caribbean Morphine White Hispanic African–American Afro–Caribbean Acetaminophen (Tylenol®) White Hispanic

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Table 3. Pharmacological pain therapies reported by ethnic groups (n = 41) (cont.). Therapy and ethnic group

n

%

4 4

40.0 33.3

4 4 1 4

36.4 50.0 10.0 33.3

2 0 3 6

18.2 0.0 30.0 50.0

0 2 5 4

0.0 25.0 50.0 33.3

Acetaminophen (Tylenol®) (cont.) African–American Afro–Caribbean Ibuprofen White Hispanic African–American Afro–Caribbean Naproxen (Aleve®) White Hispanic African–American Afro–Caribbean Aspirin White Hispanic African–American Afro–Caribbean

Pain procedures (cortisone shot, epidural steroid injection) White Hispanic African–American Afro–Caribbean

3 0 0 0

Pharmacological pain therapies The non-Hispanic white participants had typically been prescribed pain medication and other pain procedures by pain specialists. They tended to use prescribed pain medications and pain procedures (cortisone shot, epidural steroid injection) prescribed by pain specialists, as well as OTC medications. “This psychopharmacologist was fabulous … There’s a medication called Cymbalta … it is a fabulous pain reducer … he (psychopharmacologist) started very slowly and he got me off of Effexor and now all I take is Cymbalta. They found the dose that I am fine with and I really feel good. I still have pain, but nothing like I had before” (non-Hispanic white woman, 63 years). African–American, Afro–Caribbean and Hispanic/Latino older adults were more likely to use an OTC pain medication (e.g., acetaminophen [Tylenol®]) and less likely to visit healthcare professionals for pain procedures (e.g., epidural); thus, they were less likely than non-Hispanic whites to take prescribed pain medication. One Afro–Caribbean woman (75 years old) did not take cortisone pills prescribed by the doctor;

instead, she took OTC medications recommended by her son. “I had some cortisone pills too but I don’t take it, it is too strong so I don’t take it, yeah, I don’t take that cortisone … My son said, ‘Mother, why you don’t take something for your pain? Why are you bearing your pain like that when there is something remedy that you can take?’ He said, ‘Mother, Aleve is very good, Tylenol is good but Aleve is much better.’ So I say, OK, I am going to go and get two Aleve … I take two and it helps a little and I say, Oh, after all, why suffer so much when there is something that can help me a little bit? So that’s how I do but I say, Thank God, right now I am doing a lot, lot better.” One Afro–Caribbean woman took OTC medication in order to resume exercise. “The exercise could probably alleviate it somewhat but I don’t think it would alleviate it as much as … what I think the exercise does is just keep it from, in terms of a different word which I am not sure to use, is to keep it from corroding, put it that way, because with the naproxen, then I am still able to do the exercise, I am still able to move my hand. If I don’t take the naproxen, I can’t lift my hand. I do this just right here every day, then

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27.3 0.0 0.0 0.0

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RESEARCH ARTICLE  Park, Manotas & Hooyman Table 4. Nonpharmacological pain therapies reported by ethnic groups (n = 41). Therapy and ethnic group

n

%

11 8 10 12

91.7 80.0 100.0 100.0

11 8 9 12

100.0 100.0 90.0 100.0

1 4 9 8

9.1 50.0 90.0 66.7

5 3 4 3

45.4 37.5 40.0 25.0

0 4 4 6

0.0 50.0 40.0 50.0

0 3 6 4

0.0 37.5 60.0 33.3

4 0 6 1

36.4 0.0 60.0 8.3

1 1 2 2

9.1 12.5 20.0 16.7

2 1 2 1

18.2 12.5 20.0 8.3

1 2

9.1 25.0

Nonpharmacological pain therapies White Hispanic African–American Afro–Caribbean Exercise White Hispanic African–American Afro–Caribbean Prayer (spiritual direction) White Hispanic African–American Afro–Caribbean Massage therapy White Hispanic African–American Afro–Caribbean Relaxation White Hispanic African–American Afro–Caribbean Meditation White Hispanic African–American Afro–Caribbean Water exercise White Hispanic African–American Afro–Caribbean Physical therapy White Hispanic African–American Afro–Caribbean Yoga White Hispanic African–American Afro–Caribbean Acupuncture White Hispanic

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Table 4. Nonpharmacological pain therapies reported by ethnic groups (n = 41) (cont.). Therapy and ethnic group

n

%

1 0

10.0 0.0

1 0 1 1

9.1 0.0 10.0 8.3

1 2 0 0

9.0 25.0 0.0 0.0

1 0 1 0

9.1 0.0 10.0 0.0

1 0 1 0

9.1 0.0 10.0 0.0

1 0 0 1

9.1 0.0 0.0 8.3

1 0 1 1

9.1 0.0 10.0 8.3

1 0 0 0

9.1 0.0 0.0 0.0

2 1 1 0

18.2 12.5 12.0 0.0

0 4 5 7

0.0 40.0 50.0 58.3

Acupuncture (cont.) African–American Afro–Caribbean Transcutaneous electrical nerve stimulation White Hispanic African–American Afro–Caribbean Tai-chi White Hispanic African–American Afro–Caribbean Pain support group White Hispanic African–American Afro–Caribbean Music therapy White Hispanic African–American Afro–Caribbean Homeotherapy White Hispanic African–American Afro–Caribbean Aromatherapy White Hispanic African–American Afro–Caribbean Cognitive–behavioral therapy White Hispanic African–American Afro–Caribbean Acupuncture White Hispanic African–American Afro–Caribbean Home remedies/folk medicine White Hispanic African–American Afro–Caribbean

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RESEARCH ARTICLE  Park, Manotas & Hooyman I think I corrode my shoulder, my joints, all of my ligaments, where they get tight and therefore I cannot do this at all. With the naproxen I can do this so I am not feeling the pain. The problem is probably still there but because I think I am exercising it. I can do that with naproxen without any effort … I would say that, if I could, if I would go and do the pulls every day, even after I take the pain medication but without the pain medication it’s an effort, it’s trying to be a giant without the pain medication but I am not a giant. I am a weakling, so I need to take the pain medication. That’s how I probably would feel” (Afro–Caribbean woman, 67 years). Although most of the participants from the three racial and ethnic groups were less likely to visit a doctor or take prescribed medication and more likely to take OTC medication, there were exceptions. A 63-year-old Hispanic woman relied on a doctor and took prescribed medication. However, when a doctor was not available, she had to take OTC medication. “I will only take it (prescribed pain medication) when the pain is severe and she (doctor) is not available to give me treatment, then I will take two Advils. Although I know I should take Tylenol instead because of my high blood pressure, Tylenol doesn’t sit well in my stomach like Advil.” Some racial and ethnic minority groups do not take any medication to relieve pain. For example, a Jamaican woman did not rely on pharmacological pain therapy but followed Jamaican culture and customs. Jamaicans do not receive conventional treatments and do not go to doctors. “Our culture, you don’t go to the doctor unless it is something you can’t fix. You gotta be in dire straits to actually go to the doctor. There are people in Jamaica who have never been to a doctor and they are living to 100 and something and never gone to a doctor, never” (Afro–Caribbean woman, 75 years). Although many participants were still taking medications for pain, the majority reported being hesitant to take pain medication for various reasons. First, pain medication did not relieve the pain. “They gave me a morphine patch. So of course you start with the lowest dose. It worked for a while and I still had pain … I want to get off of the meds, they are not helping me” (­non-Hispanic white woman, 63 years). Second, some participants were afraid of side effects and an increasing tolerance level. “I don’t like to take pain medication during the day because it makes me sleepy and I cannot

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drive well while on the medication” (Hispanic man, 69 years). Although most non-Hispanic whites were more likely than the other three groups to take prescribed medication, some did not want to take strong pain medication due to possible adverse events associated with the medications. “I do not want to take no more morphine, I am worried about my liver, I am worried about everything else, even though I went for check ups and everything came back OK. I said that I can’t live like this, I have to find another way. So over a 9-month period of time I was weaned off slowly. But I was so used to having pain that I still get through my day in about the same way when I was on the meds and I had already, no more gardening, certain things, and I felt better because those meds were making me feel worse than anything. They were playing with my head and giving me side effects. I stopped the profuse sweating, except when I am having a flush or something which is normal. And I feel emotionally better” (non-Hispanic white woman, 63 years). Third, some participants reported fear of building tolerance and addiction to medications. “I was afraid of becoming addicted; that was my greatest fear. Also, I realized that the medication was only masking the pain” (African–American, 71 years). “If I take it (pain medication) all now for the pain that I can tolerate, then if I get into a crisis or I have a bad flare, which I have with Lupus and I’ve taken everything every day, then when I really need some relief, it won’t give you as much relief. That’s my own opinion there, I don’t know if that’s so. But I know if people are junkies, the more they take, the more it takes to get high. So if I take pain pills for a three or a four (pain level), when I get that six or the seven, I am in trouble. So that’s why I really try not to take it.” (African–American, 60 years). “I don’t like to swallow pills, I don’t want to get addicted. Especially strong medicine. They had me on Darvocet … That was strong and that used to take my pain away but it started irritating my stomach, so I stopped. I haven’t ordered any more, so I depend on the transcutaneous electrical nerve stimulation (TENS) unit” (Afro–Caribbean woman, 82 years). “There’s some medication that gives you a false sense of being well so what you do is you do things that you wouldn’t do if you had pain and when you do those things, it makes you worse. You

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Chronic pain management by ethnically & racially diverse older adults  hurt yourself, not knowing that you’re hurting yourself because you don’t have the pain to show you. Pain can be your friend” (African–American woman, 62 years). Surgical treatment Non-Hispanic whites often selected surgery to manage chronic pain, based on the physician’s recommendations. “The more I moved around, it got better and it kept going that way until about 12 years ago I decided to have surgery because there was no choice” (non-Hispanic white man, 84 years). Some participants experienced pain relief from surgery. “It was to recuperate my knee after the surgery and be able to walk again and return to my regular function” (Hispanic woman, 70 years). By contrast, other participants reported that surgery did not relieve pain. “I had the surgery, which I guess really hasn’t helped at all. Supposedly, through x-rays and postsurgical MRI the discs are now not compressed any more … The surgery has not relieved the pain” (non-Hispanic white woman, 84 years). One Hispanic woman shared the pain episode that she had experienced after surgery: “I had to go in for a second operation in my hip and the operation did not go well at all this time. I remember screaming from the pain afterwards. It was so horrible. Till today, the effects of that surgery bother me. So afterwards, I switched doctors again and this one has definitely helped me a lot more. I’ve been getting better, but the pains are still deathly” (Hispanic woman, 69 years). Unlike the non-Hispanic whites who selected surgery as a treatment option, the Hispanic participants did not comply with physician recommendations for surgery due to fear of pain after surgery. “The orthopedic doctor told me that the cartilage in my knees has been worn down and the only solution was to get surgery but I am too scared to get it done. I have a terrible fear of surgery” (Hispanic woman, 64 years). Nonpharmacological pain therapies Table  2 illustrates the nonpharmacological pain therapies used by participants. The most frequently used therapies were exercise and prayer. Racially and ethnically diverse participants showed different approaches to managing chronic pain. Non-Hispanic whites often used physical interventions such as exercise, water exercise, acupuncture, massage and chiro­practic

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treatment. By contrast, African–Americans, Hispanics and Afro–Caribbeans reported using home remedies (cream and OTC ointment), culturally based treatments (e.g., herbal tea, Mauve/Malva leaves, piper peltatum leaves and avocado leaves) and psychological therapies (e.g., prayer, distraction, relaxation, meditation and support groups) to manage chronic pain. In particular, African–Americans relied heavily on religious coping methods (prayer, God as ‘healer,’ attending services regularly or maintaining the ­religion’s practice in daily life or Bible study). „„ Physical interventions: body-based

& mind–body-based therapies

The participants used physical interventions, including exercise, water exercise, acupuncture, yoga, massage, chiropractic treatment and taichi. In particular, yoga, acupuncture and tai-chi are mind–body practices that focus on the interaction among brain, mind and body with the intent to use the mind capacity to impact p­hysical functions and improve overall health [25]. First, exercise helped these older adults to manage pain. Regardless of ethnic group, the majority of the participants had been doing exercise or had tried exercise in the past. They understood that exercise provides benefits in managing chronic pain. “It helps strengthen the muscles and when your muscles are stronger, you manage your pain better … the exercise helps me if I sleep” (Afro–Caribbean woman, 75 years). “When I walk on the treadmill only, I notice the pain does not come as strongly as usual. So I’ll say that this the exercise has helped” (Hispanic woman, 70 years). One participant reported that he would continue to exercise even though it is difficult. “If you stagnate moving, your muscles are going to tighten up and everything and then you are going to be harder to start again. Even if I miss 1 or 2 days, when I go, it’s a little harder to get going but I get going. But if I would not do it for 2 months or so, I think it would be very difficult” (non-Hispanic white man, 84 years). Non-Hispanic whites and Hispanics were doing individual exercise rather than in a group. “I now walk 2 miles every day, a minimum of 3 days a week and … I go walking and I have slight pain and I live with it” (non-Hispanic white man, 84 years). In contrast, the African–Americans exercised as a group in a faith-based community setting. “They have exercise classes here at our church for the seniors and they pay for a personal

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RESEARCH ARTICLE  Park, Manotas & Hooyman trainer to work with them. It’s like 30 or 40 of them and they are all together. So that makes it very good. So I think that’s a good thing, that makes it easier for people that they are comfortable doing stuff with” (African–American woman, 60 years). One participant reported that she was afraid of having to take narcotics for pain and used this fear as motivation to prevent it getting worse by staying consistent with her exercise routine. “I tried keeping a set routine because I don’t want to slip in having to take narcotics … I don’t want to take no narcotic medicine so I keep that focus and that’s my goal” (­African–American woman, 70 years). Participants also described that physical movement, including exercise and walking, loosened joints so they could function well. “Trying to keep moving, I think that’s been most helpful. The more I move, the less stiffness and pain I have. Keeping active has been the best for me” (African–American woman, 60 years). Some reported that, even if exercise was initially painful, it did not cause severe pain when done continuously. “When sometimes I am walking and my knee locks in place, I can feel that the pain is going to begin. When that happens, I make sure to be strict about doing the exercises each day. It helps the pain not come on too strongly” (Hispanic woman, 68 years). Some participants reported that pain was worse during and/or immediately after exercise. “I’m not doing the aerobic exercises any more because I noticed that my pain would come worse after doing them” (Hispanic woman, 70 years). Second, water exercise relieves pain but also produces side effects. One African–American woman described how water exercise relieved her chronic pain. “When I get in that pool, I exercise. Water aerobics helps me a lot and it helps me to lose the weight, too” (African–American woman, 70 years). However, another African–American woman stopped water exercise because of her medical conditions. “For my legs and things, especially for the veins and stuff, I tried to do water aerobics … I was going to a gym where I walked in water to try to exercise the legs but the bladder had gotten so bad I had to stop from that to do other things. I had a prolapsed bladder and they didn’t want me to get back in the water because they didn’t want me to get a really bad infection” (African–American woman, 71 years).

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Third, acupuncture seems to be effective but pain persists. Some of the participants had tried acupuncture for managing chronic pain and preferred it to medication. “I just recently tried acupuncture. I think that gets to more of the underlying cause, so I think that seems more effective than medicine” (non-Hispanic white woman, 67 years). “I went to a Chinese man for a period of time for acupuncture in my back. This helped alleviate my pain greatly. I was able to be more active and do more activities” (Hispanic woman, 64 years). One African–American woman (69 years) reported that acupuncture seemed to be effective in reducing pain but that the pain nevertheless persisted. “I have been taking acupuncture for 3 weeks now and it really helped me, so the pain has diminished some what but it’s still there.” However, one African–American participant said that she could not afford it due to limited insurance coverage for treatments. “Most insurance will not take care of acupuncture. You have to pay out of your pocket for that. I haven’t been able to find anyone who includes acupuncture as a part of the practice that would be covered by the insurance that I have” (African–American woman, 71 years). By contrast, some participants reported that acupuncture had been ineffective in pain management and had produced negative side effects. One Hispanic participant stopped acupuncture treatment because she experienced too much pain from the treatments due to needles. “I tried it once and I felt so much pain from it that I never did it again … I think it was because the knee pain combined with my fibromyalgia had me extremely sensitive and so I could not resist even the acupuncture” (Hispanic woman, 70 years). “I had a lady that was a doctor in China, so I would say she was trained in it and she was over here as an acupuncturist, which is totally different from being a doctor, but she tried it. It did not work. The Veterans Administration Medical Center also has a chiropractor and he tries acupuncture. He tried it on me and it did not work” (non-Hispanic white man, 65 years). Fourth, participants reported different reactions to massage. Some Hispanic and non-Hispanic white women had reported that massage was effective for certain areas of the body. “I am a real advocate of massage, especially massage for back and neck problems. I feel like it’s the muscles tightening up and if you go to a good masseuse” (non-Hispanic white woman, 67 years).

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Chronic pain management by ethnically & racially diverse older adults  One Hispanic woman reported side effects from massage. “He gave me very strong massage, which frightened me because I was in so much pain that night that I had to take Tylenol to go to bed” (Hispanic woman, 76 years). Fifth, there were safety issues related to yoga. Yoga, as a mind–body practice, had been used by some participants. However, some reported being afraid of yoga due to safety issues (e.g., balance problems, fall and injury), which limited their ability to participate in yoga practice [26]. “I’ve tried yoga but I find it … if they put you down on the floor, you can’t get up from the floor. That’s the worst thing with older people, they cannot get up, especially when they fall” (non-Hispanic white woman, 92 years). “I think I stretched too much and I left there almost limping. I didn’t want anyone to know I was in pain. I don’t try to do all that stretching on my hips any more because that makes pain” (African–American woman, 61 years). Sixth, participants showed different responses to chiropractic treatment across ethnic groups. Some participants had used chiropractic treatment. “The chiropractor I go to bought some kind of a vertebrate stretching machine that targets only the bad vertebrae and they can calibrate this thing to where it doesn’t stretch your whole spine, just the one vertebra, and maybe a little bit the one above and below it … The only reason I can walk today is because I’ve been to the ­chiropractor” (non-Hispanic white man, 65 years). On the other hand, one participant stopped chiropractic treatment because she did not like sound of cracking her neck. “I paid the rest of the money but I am not coming back here no more because I said, ‘You like to crack my neck too much.’ I am not coming back here no more. That scares me, every time I hear that crack” (African–American woman, 61 years). Seventh, tai-chi provided positive energy and calming but did not relieve pain. Only a few non-Hispanic white and Hispanic participants had tried tai-chi. “There are some that are light but others that I cannot do and miss doing, which I like doing because it brings me much positive energy” (Hispanic woman, 63 years). “I’ve tried tai-chi, standing basically in one spot, doing all your exercise in one spot and for an hour, that’s tiring” (non-Hispanic white woman, 92 years). “The pain calmed down a bit. It did not cure or get rid of my pain but did calm it a bit” (Hispanic woman, 73 years).

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„„ Herbal medicines & other natural products

A majority of the Afro–Caribbean and Hispanic participants had used herbal medicine and other natural products for pain management. By taking these products, they felt relaxed and had less pain and, as a consequence, were able to sleep. “I tried to drink herbal teas such as ‘sleepy time’ tea (chamomile) and all that did was put me to sleep. Although I feel the pain less while asleep” (Hispanic woman, 70 years). One participant used enemas with herbal mixture and water. “I used to use Mauve/Malva leaves. I used to boil them in water and while still hot, I’d apply them to the affected area. I would bathe in the water I boiled them in. I also used to drink a tea made from calendula plant” (Hispanic woman, 68 years). “One was rosemary, another was horse tail herb … they would give me a jar with all the herbs already mixed together. I would have to boil the herbs and strain them out to use the water for the enema. I used this treatment for 1 month. It would give me great relief ” (Hispanic woman, 60 years). One Afro–Caribbean woman mixed garlic with various oils and put them on the pain area. “I use this garlic oil, the coconut oil, and the burned garlic. You can mix it up with the oil and rub so you have this on this side and you have on the knee and leave it on it and then the heat will penetrate through and draw the pain and you can do it in the elbow here, too” (Afro–Caribbean woman, 70 years). Some Hispanic and Afro–Caribbeans used herbs and plants grown in their own countries, although it was difficult to find them in the USA. “(Calendula plant and mauve leaves) helped alleviate my pain. I used to use both in Colombia but I haven’t been able to find either one here in the USA. So when I go to Colombia, I bring some back” (Hispanic woman, 68 years). A woman from the Republic of Trinidad and Tobago purchased bark from an ethnic store instead of bringing it from her country. “People would always take a bit of bark; in the country we call it sercie; it’s a bitter tea … Not only is it good for pain, they say it’s good for cleansing your system as well. You really have to go to the West Indian stores to get this” (Afro–Caribbean woman, 67 years). „„ Psychological treatments

Some participants had tried psychological treatments, including spirituality (praying), distraction, meditation and pain support groups,

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RESEARCH ARTICLE  Park, Manotas & Hooyman sometimes in addition to physical therapies and medications to manage chronic pain. First, African–Americans relied on spiritual treatment. Compared to non-Hispanic whites the three ethnic groups used spiritual treatments. In particular, the African–Americans relied heavily on religious coping methods (prayer, God as healer). “I am praying to God that Jesus will take that pain away from me little bit by little bit. When I do hard work, it develops a little bit so I take an arthritis pill that I bought OTC. I don’t have to take it every day” (African–American woman, 61 years). One participant said that she prayed while walking to relieve pain. “I may use it when I have those cramps. You’ve got to get up, if you can, and walk and rub it and rub it and pray and pray. Eventually, it goes away” (African–American woman, 70 years). Another said that praying relieves pain. “I always say that maybe sometimes faith and believing in something is what cures because, when you have faith in something and you pray in the name of God to help you, it works. Because sometimes when I walk with this hip problem, I even feel like my bones are breaking. I couldn’t hardly walk and I would pray to God to help me and meanwhile find myself massaging the area with the ointment and thanks to God, I am able to walk almost 2 miles” (Hispanic woman, 76 years). Second, distraction helped to manage chronic pain. One participant distracted herself by doing other things as well as taking medication. “When I distract myself while doing things and speaking to others, it helps me not to feel my pain as much” (Hispanic woman, 76 years). “I take my pain medication and distract myself by reading or doing a crossword puzzle. This way I try to distract my mind from the pain and I concentrate on something else. Time passes and I don’t think about the pain” (Hispanic woman, 71 years). An African–American went outside and focused on other activities to distract herself from pain. “Someone who stays by themselves and who don’t venture out would just stay in the house and dwell on their pain. But if you go outside, you drive to the store or you come to some place where you meet other people, it takes your mind off it. It exposes you to other things so you don’t just sit there and wallow in depression and think about all this pain that you have” (African–American woman, 71 years). Third, relaxation helps older adults to deal with pain. Most African–Americans and Afro–Caribbeans used relaxation with medication

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to get rid of tension and relieve pain. “If I relax and take it easy sometimes and use something to rub … it eases the pain” (Afro–Caribbean woman, 75 years). “I know how to deal with it so when I feel like it’s staying … I go take a pain pill and I stop whatever I am doing and just relax” (African– American woman, 61 years). “Try to go to sleep, just relax, relax. That would be my most of dealing with it” (African–American woman, 70 years). „„ Home remedies/folk medicine

Some participants used home remedies such as ice/cold showers and heating pads, herbal tea, burned garlic and alcohol. “I am using ice, cold shower, and the pool for the charley horses and the heating pad, the chair and bed with the heat and the TENS machine for the pain and the exercises in and outside of the pool” (African–American woman, 62 years). “The icy hot takes your mind off your pain because it’s burning you and cold at the same time” (­A frican–American woman, 60 years). “(Rubbing) alcohol is very good. My mother thought alcohol was a cure-all. She rubbed my back with alcohol” (Afro–Caribbean woman, 75 years). “You put it on your temple and use a wet cloth with hot water. Then you add vinegar and alcohol and you put it on there and you relax and it kind of soothes the ‘fleming’” (African–American woman, 72 years). One Afro–Caribbean woman used a cream called ‘spirit of turpentine’. “I think that’s the name of it, Aspercreme. They are all creams that I can put on an old family remedy, it’s called spirit of turpentine. It’s kind of hard to find spirit of turpentine. It’s just an old Bahamian remedy that you could use. Take a Q-tip and just put it on your joints and it relieves the pain” (Afro–Caribbean woman, 72 years). „„ Unique ways to manage chronic pain

Some Afro–Caribbeans used unusual methods of self-management of pain. First, urinating. One Afro–Caribbean woman urinated in the morning to relieve pain. “One of the best ways that I manage this pain is, first thing in the morning when I urinate, I get relief. It’s very strange but while I am urinating, I can feel the misery leaving the right leg. And if I am sleeping at night, once I have to get up and urinate, and that’s usually about once, maybe twice during the night, I cannot get my legs in a comfortable position until I get up and urinate. I have to hobble to the bathroom but then after I

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Chronic pain management by ethnically & racially diverse older adults  hobble to the bathroom and do what I go in there for, I can get right back in bed and go back to sleep. But my legs, it’s like my leg, my knees and my legs are controlling me now as far as pain is concerned” (Afro–Caribbean woman, 69 years). Second, cold iron. An Afro–Caribbean woman used a cold iron to manage chronic pain. “I was having real bad (pain), I used to use a cold iron, because the iron was the closest thing to me one day and it was cold and I just started pressing on my body and I found that it helped. I just ironed it out because that was the closest thing to me. So then I started doing the ice and that helps. Then when it is so much pain and it’s more than one little spot, then the shower” (Afro–Caribbean woman, 62 years). Discussion Based on this exploratory study’s findings, ethnicity and race appear to influence choice of pain therapies. However, ethnicity is not the only factor that influences preference for pain management. As noted previously, in racially and ethnically diverse older adults, preference for managing pain is complex and multifactorial, with socioeconomic status a primary factor influencing the selection of treatment options. However, socioeconomic factors (household income and education level) were also divided by racial and ethnic groups; non-Hispanic whites appeared to have higher socioeconomic status than members of the three racial/ethnic minority groups. Although some participants in the minority groups preferred to receive prescribed medications and pain procedures provided by pain specialists, they were more likely to use alternative treatments (e.g., OTC medications and exercise) because treatments that are normally prescribed for white patients were not available to them due to diverse barriers such as lack of health insurance, limited funds for services at pain clinics and treatments by specialists, and transportation. Across the four racial and ethnic groups, the majority of participants took an active role in managing their chronic pain by selecting types of pharmacological and nonpharmacological pain therapies. Most reported that they used prescribed or OTC medications to relieve pain, even though they were hesitant to take medication due to fear of side effects, addiction or building tolerance. Regarding racial and ethnic differences in types of pain medications, nonHispanic whites tended to use prescribed pain medications and other procedures recommended

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by pain specialists or other healthcare providers. African–American, Afro–Caribbean and Hispanic/Latino older adults were more likely to rely on OTC pain medications that can be easily purchased without a prescription and less likely to visit healthcare professionals. This may lead to under-reporting of chronic pain in racial and ethnic minorities and may contribute to pain management disparities by ethnicity [27]. As found in previous studies [28], older racial and ethnic minorities, particularly Hispanics, followed doctors’ recommendations of knee surgery or joint replacement as a treatment, although they were afraid of the surgery. On the other hand, Hispanic participants in the current study did not choose surgery recommended by their physician due to fears about pain after surgery. Rather, they used racially and ethnically based treatments that were prevalent in their home country, such as herbal medicine and other natural products. Hispanic participants appeared to prefer these alternative treatments rather than surgery. Participants who used nonpharmacological pain therapies stated that the treatments were (with the exception of yoga and aerobic exercise) safer than conventional therapies (e.g., medications and knee/hip surgery) prescribed by physicians. Exercise was commonly used by all three racial and ethnic groups. A previous study reported that, excluding prayer, most ethnic minorities were less likely than non-Hispanic whites to use nonpharmacological pain therapies [29]. However, the current study showed an opposite pattern: not only did the three racial and ethnic minority groups use these therapies (home remedies, folk/herbal medicine, relaxation and religious coping methods), but they were even more likely to use them than nonHispanic whites, who preferred massage and physical therapy. Religious coping mechanisms were used predominately by African–Americans, a finding similar to that reported in other studies [30–32]. Attitudes regarding prayer differed, with ­African–Americans more likely to perceive prayer as helpful and to have relied on God as healer to manage chronic pain. Afro–Caribbeans or Hispanics were more likely to maintain traditional or culturally based methods and folk remedies that had been used in the home country. Home remedies included herbal medicine and ointment or cream, as well as unusual methods (e.g., using a cold iron and urinating). Use of herbal preparations and other therapies by these groups may be supported by a tradition of self-management

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RESEARCH ARTICLE  Park, Manotas & Hooyman practices, easy access to natural products from the home country and the ­traditionally lower cost of gathered herbs. Since Afro–Caribbeans and Hispanics in this study were immigrants (e.g., Jamaica, Haiti, Bahamas, Cuba, Colombia and Dominican Republic), their preferences for pain therapies may differ from those who were born in the USA. Immigration status may affect interpretation of the results because immigrants’ and first-generation’s cultural beliefs and practices differ from those of US-born ethnic groups. In addition, due to immigration status, some of these groups were not eligible to receive Medicare or gain access to medical services unless they had private insurance. It is also plausible that different types of pain therapies could be influenced by socioeconomic and immigration status. For example, previous pain studies [27,33] have indicated that ethnic and racial minority groups were less likely to receive adequate pain treatment and specialty medical care, including pain procedures, even though socioeconomic status was controlled for. The current study has several limitations. First, the majority of the non-Hispanic whites were recruited in locations that were higher in socioeconomic status than those where racially and ethnically minority groups were recruited. The participants were recruited in Palm Beach and Broward Counties in south Florida. However, due to the limited project budget, we recruited participants whose homes were less than 35 miles from the university. Second, persons whose primary language was other than English or Spanish (Afro–Caribbeans who spoke only Creole) were excluded, which could affect the representativeness of the sample. Third, immigrant status among Hispanics and Afro–Caribbeans may affect interpretation of preference of pain therapies in these groups, since they may differ from preferences of those born in the USA. Fourth, self-reported data from interviews may be unreliable if participants’ memory is impaired, which influences validity. Fourth, the interviews were long, which may intensify fatigue and distraction associated with chronic pain. However, the participants were allowed a break during the interview or to withdraw at any time. The study results have implications for healthcare providers and researchers. Providers may play a significant role in guiding older adults to manage pain effectively. In particular, since Afro–Caribbeans and Hispanics often

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practice culturally based treatments/folk medicine and self-management, healthcare providers should be informed about such culturally sensitive interventions and may incorporate them in their treatment plans. Simply showing an interest in pain management techniques by asking specific questions (e.g., how often the patient applies boiled Mauve leaves to the knee, how often the patient drinks a tea made from calendula plan, or how yoga helped the patient to manage osteoarthritis) can be the first step toward an integrative use of culturally ­appropriate interventions. The results identified methodological challenges that should be considered in future studies. As few evidence-based studies with rigorous research designs have been conducted on pain management by racially and ethnically diverse older adults, more research is needed to provide evidence of effectiveness of pain i­nterventions in this population [27]. Conclusion Racially and ethnically diverse older adults utilized different approaches to mange chronic pain. They were more likely to use ­self-management for chronic pain rather than medical/specialty services or reliance on a medical doctor’s treatments and advice. As a pharmacological approach, they used OTC medications instead of prescribed drugs to manage pain. Non­pharmacological pain therapies included psychological interventions, home remedies and culturally based treatments. However, these findings on chronic pain management in racially and ethnically diverse older adults are limited. Until more conclusive study results are established, healthcare providers should be aware of other possible factors, including socioeconomic status, that may influence the preference for pain treatment in racially and ethnically diverse older adults. Acknowledgements The authors acknowledge Joseph Ouslander of the College of Medicine and Ruth Tappen of the College of Nursing, Florida Atlantic University, for helping the corresponding author to gain access to the Healthy Aging Research Initia­ tive (HARI) registry and for providing support and ­guidance in completing the project.

Financial & competing interests disclosure This project was funded by the John A Hartford Foundation, Hartford Geriatric Social Work Faculty Scholars Program.

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Chronic pain management by ethnically & racially diverse older adults  The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed. No writing assistance was utilized in the production of this manuscript.

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Ethical conduct of research The authors state that they have obtained appropriate insti­ tutional review board approval or have followed the princi­ ples outlined in the Declaration of Helsinki for all human or animal experimental investigations. In addition, for investi­gations involving human subjects, informed consent has been obtained from the participants involved.

n n

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