Highlights
- •We meta-analyzed differences in pain coping between white and black Americans.
- •Overall, black individuals use coping strategies more frequently.
- •Race differences in pain coping are largest for praying and catastrophizing.
- •Research is needed to better understand the influence of culture in this context.
Abstract
Compared with white individuals, black individuals experience greater pain across clinical and experimental modalities. These race differences may be due to differences in pain-related coping. Several studies examined the relationship between race and pain coping; however, no meta-analytic review has summarized this relationship or attempted to account for differences across studies. The goal of this meta-analytic review was to quantify race differences in the overall use of pain coping strategies as well as specific coping strategies. Relevant studies were identified using electronic databases, an ancestry search, and by contacting authors for unpublished data. Of 150 studies identified, 19 met inclusion criteria, resulting in 6,489 participants and 123 effect sizes. All of the included studies were conducted in the United States. Mean effect sizes were calculated using a random effects model. Compared with white individuals, black individuals used pain coping strategies more frequently overall (standardized mean difference [d] = .25, P < .01), with the largest differences observed for praying (d = .70) and catastrophizing (d = .40). White individuals engaged in task persistence more than black individuals (d = −.28). These results suggest that black individuals use coping strategies more frequently, specifically strategies associated with poorer pain outcomes. Future research should examine the extent to which the use of these strategies mediates race differences in the pain experience.
Perspective
Results of this meta-analysis examining race differences in pain-related coping indicate that, compared with white individuals, black individuals use coping strategies more frequently, specifically those involving praying and catastrophizing. These differences in coping may help to explain race differences in the pain experience.
Key words
Chronic pain affects approximately 100 million Americans and is associated with $635 billion in annual medical treatment and lost productivity.
44
Although differences in the pain experience have been documented across many racial and ethnic groups, most of the literature focuses on differences between black and white individuals. The current meta-analytic review reflects this focus by examining black and white differences in pain-related coping. Because racial terminology varies across studies (eg, black vs African American, white versus Caucasian), we will adopt the terms used in the source articles throughout this introduction.Compared with Caucasian, African American individuals report higher levels of pain for a number of conditions including AIDS, glaucoma, arthritis, postoperative pain, postspinal fusion pain, and low back pain.
7
, 20
, 29
, 80
, 82
, 98
Further, African American individuals show a lower pain tolerance and report higher pain intensity and unpleasantness than non-Hispanic white individuals during experimental pain tasks.11
, 15
, 24
, 25
, 71
, 81
, 96
, 100
Race differences in clinical and experimental pain may be due to psychosocial factors such as pain coping. Coping is broadly defined as the use of behavioral and cognitive techniques to manage stress.58
Differences in coping strategy use are associated with differences in pain intensity, adjustment to chronic pain, and psychological and physical functioning.45
, 46
, 53
For example, several studies found that ignoring strategies are associated with less pain, whereas praying and hoping and catastrophizing are associated with higher pain levels.Individual coping strategies may also be grouped into conceptual categories. The 3 most common categorizations will be discussed in this article. One conceptualization of pain coping differentiates cognitive from behavioral strategies. This conceptualization served as the basis for the Coping Strategies Questionnaire (CSQ), a widely used measure of 6 cognitive (diverting attention, reinterpreting pain, coping self-statements, ignoring pain, praying/hoping, and catastrophizing) and 2 behavioral (increasing activity level and increasing pain behaviors) coping strategies.
75
Another conceptualization of coping differentiates active from passive strategies. Active coping refers to strategies to control pain or to function despite pain by using one's own resources, and passive coping involves relinquishing control of pain to others.
9
Studies have linked active coping strategies to positive affect, better psychological adjustment, and decreased depression, and passive strategies are linked to poor outcomes such as increased pain and depression.10
, 43
The Vanderbilt Pain Management Inventory was designed to differentiate active and passive coping strategies. In addition, the strategies measured using the CSQ and Pain Coping Inventory can be classified into active and passive categories.9
, 56
, 84
Coping can also be classified into problem-focused versus emotion-focused strategies. Problem-focused approaches involve direct attempts to deal with pain, whereas emotion-focused approaches involve managing the emotional reactions to pain.
30
There is some evidence suggesting emotion-focused coping is associated with worse pain and functioning in individuals with chronic pain.2
, 10
, 27
, 34
In a topical review, Edwards and colleagues
25
discussed mechanisms of race and ethnic differences in pain, including differences in pain-related coping. Unfortunately, only 1 study had examined the relationship between race and pain coping at that time,50
preventing the authors from making strong conclusions. Since their review, a number of studies have examined the relationship between race and pain coping, with inconsistent results, perhaps because of differences in conceptualization of coping across studies. To date, however, no critical or meta-analytic reviews have summarized the relationship between race and pain coping or attempted to account for the differences observed across studies. Further, few studies (Forsythe et al31
and McIlvane63
are notable exceptions) have examined the interactions between race and other putatively important demographic variables, such as sex and age, which are known to be independently associated with pain.18
, 63
, 72
, 100
It is reasonable to speculate that the relationship between race and pain coping differs on the basis of sex and age.The Current Study
The goal of this meta-analytic review was to quantify race differences (black vs white) in the use of pain coping strategies to better understand one possible mechanism of race differences in the pain experience. Such an understanding may inform chronic pain care and support an individually tailored treatment approach. We had the following hypotheses: 1) black and white individuals would differ in their use of pain coping strategies overall, 2) consistent with the topical review by Edwards and colleagues,
25
black individuals would report using hoping/praying strategies more than white individuals, 3) race differences in coping would vary across different conceptualizations of coping, and 4) the relationship between race and coping would vary across age and sex.Methods
Search Methods
An exhaustive literature search of published studies was conducted using PubMed, PsychInfo, PsychArticles, Embase, Ovid, and Web of Science to find articles published through August 2014. Searches were defined by all possible keyword combinations of the terms for and variations of 1) pain, 2) coping, and 3) race. Additional search terms are presented in Table 1. Although different studies used different terms for race, for the sake of clarity, from this point forward we use “black” and “white,” which are the broadest terms for these racial groups. After the online search, an ancestry search was used by inspecting the reference sections of relevant articles and related reviews to identify additional studies that could be included. Authors of relevant studies were also contacted via email with a request for unpublished data and were given a 1-month time period in which to respond.
Table 1Alternative Search Terms
| Pain | Coping | Race |
|---|---|---|
| Nociception | CSQ | African American |
| Catastrophizing | Black | |
| Chronic Pain Coping Inventory | Ethnicity | |
| Coping self statements | ||
| Distraction | ||
| Diverting attention | ||
| Guarding | ||
| Hoping | ||
| Ignoring | ||
| PCS | ||
| Pain Coping Inventory | ||
| Pain Coping Questionnaire | ||
| Praying | ||
| Reinterpreting pain | ||
| Relaxation | ||
| Seeking social support | ||
| Stone and Neale Daily Coping Inventory | ||
| Transformation | ||
| Vanderbilt Multidimensional Pain Coping Inventory | ||
| Wishful Thinking |
Eligibility Criteria
Studies were included if they 1) used a self-reported measure of pain-related coping, 2) compared black and white participants, 3) used an adult sample (older than the age of 18), and 4) provided either an effect size representing the relationship between race and coping strategies or directly compared black and white participants on pain-related coping. Studies were excluded if they 1) measured nonspecific coping that is not pain-related (eg, coping with a chronic illness such as cancer), 2) used a sample of children, 3) grouped black participants with other nonwhite participants, or 4) were not available in English. Each abstract was reviewed by the first author (S.M.M.) to determine eligibility. If eligibility could not be determined from the abstract, the full article was examined. If published studies did not include data in a form that could be coded for the meta-analysis, authors were contacted via email and given a 1-month time period in which to respond and provide the necessary information. A study flowchart that uses the Preferred Reporting Items for Systematic Reviews and Meta-Analyses model
66
is included in Fig 1.
Figure 1PRISMA flow diagram of process of identification and screening of articles for inclusion. Abbreviations: PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses; ES, effect size.
Screening, Coding, and Requests for Missing Data
Each article was read and data were extracted and independently coded by 2 study authors (S.M.M. and M.M.M.) using a standardized coding form. Sample size, type of study, coping questionnaire used, and average effect sizes were coded for each study. The following sample characteristics were also coded to analyze potential moderator variables: mean age of the sample, sample age range, and percentage of the sample that was female. Additionally, the following key features of the study were coded: study design, statistic used, individual coping strategies used, and effect sizes for each individual coping strategy. Finally, the categories of each coping strategy (ie, active or passive, cognitive or behavioral, and problem- or emotion-focused) were coded as potential moderators by 2 study authors (S.M.M. and M.M.M.) according to categorization conventions used throughout the coping literature.
2
, 9
, 10
, 27
, 34
, 56
, 75
, 84
Any missing data were coded as such. There was good interrater reliability (K = .982) for the categorization coding, and any disagreements were resolved by mutual discussion and, if necessary, adjudication by the senior author (A.T.H.).Data Analytic Approach
The standardized mean difference (SMD; d) was computed as the effect size for each study and each coping strategy. Positive values for d indicated higher values for black participants, and negative values indicated higher values for white participants. SMDs were adjusted using the Hedge adjustment to correct for small sample sizes within studies. The Hedge adjusted mean differences were then weighted using the inverse variance weight for each study to account for differences in sample sizes across studies.
A random effects model was used to calculate SMDs. This model assumes that the true effect size varies from one study to the next, and that studies in this analysis represent a random sample of effect sizes that could have been observed. The random effects model allows for study results to be generalized to wider populations. This was appropriate for the current analyses because of the expected difference in population effect sizes across sample types and the diversity in coping measurement across studies.
For studies that reported multiple effect sizes, an average of the effect sizes (ie, the overall effect size) was computed. The effect sizes within each study measuring the same associations were averaged to avoid bias. These averaged effect sizes were used to calculate the SMD for each coping strategy. Effect sizes <.20 were considered small, effects sizes of .50 were considered medium, and effect sizes >.80 were considered large. Heterogeneity of the effect sizes was assessed using the I2 statistic. The I2 statistic ranges from 0 to 100%, with increasing values indicative of greater between-study variability.
41
To examine potential publication bias, the Orwin failsafe N (FSN) was calculated.
69
This statistic indicates the number of unpublished studies with an average effect size of 0 that would be needed to reduce the observed effect size to a negligible magnitude. For this meta-analysis, d = .10 was determined to be a negligible effect size.Moderator Analyses
To test the extent to which continuous variables moderated the effect of race on coping, we conducted weighted meta-regression analyses using a random effects model with method of moments estimation. The following continuous variables were examined as potential moderator variables: 1) age of the sample, and 2) percentage of the sample that is female.
To examine the extent to which race differences in coping varied across coping category, an average of the effect sizes for each categorization was computed for each study to avoid bias. These averaged effect sizes were used to calculate the SMD for each category of coping, and the effect sizes were then examined to determine the extent to which the race-coping relationship differed between categories of coping. The following categorical variables were examined as potential moderator variables: 1) cognitive versus behavioral coping strategies, 2) active versus passive coping strategies, and 3) problem- versus emotion-focused coping strategies. See Table 2 for categorizations.
Table 2Coping Categorization
| Cognitive Versus Behavior | Active Versus Passive | Problem- Versus Emotion-Focused | |||
|---|---|---|---|---|---|
| Cognitive | Behavioral | Active | Passive | Problem-Focused | Emotion-Focused |
| Catastrophizing | Asking for assistance | Coping self statements | Catastrophizing | Asking for assistance | Catastrophizing |
| Coping self Statements | Depending on others | Diverting attention | Depending on others | Depending on others | Coping self statements |
| Diverting attention | Exercise and stretching | Exercise and stretching | Hoping/praying | Diverting attention | Hoping/praying |
| Hoping/praying | Functioning despite pain | Functioning despite pain | Passive techniques | Exercise and stretching | Reinterpreting pain |
| Ignoring pain | Guarding | Ignoring pain | Restricting functioning | Functioning despite pain | Seeking support |
| Reinterpreting pain | Increasing behavioral activity | Increasing behavioral activity | Retreating | Guarding | Transformation |
| Transformation | Reducing demands | Reinterpreting pain | Using medication | Increasing behavioral activity | Wishful thinking |
| Wishful thinking | Restricting functioning | Self-care | Wishful thinking | Reducing demands | Worrying |
| Worrying | Retreating | Task persistence | Worrying | Relaxation | |
| Seeking support | Transformation | Restricting functioning | |||
| Self-care | Retreating | ||||
| Standard health care | Self-care | ||||
| Task persistence | Standard health care | ||||
| Using medication | Task persistence | ||||
| Using medication | |||||
Statistical Software
Meta-analyses, meta-regression analyses, and modified analyses of variance were conducted using IBM SPSS 22 and macros provided by Wilson.
99
Wilson DB: Meta-analysis macros for SAS, SPSS, and Stata. Available at: http://mason.gmu.edu/∼dwilsonb/ma.html. Accessed May 3, 2014
Results
Study Sample
One hundred thirty-three records were identified through the initial database search. An additional 16 references were identified through the ancestry search. Of the 16 authors contacted via email for additional data sets, 7 responded and 1 provided an additional unpublished data set. A total of 131 studies were excluded (see Fig 1 for a breakdown of the reasons for exclusion). Two studies did not report sufficient data to calculate effect sizes; however, authors for both studies provided the necessary data upon request, and thus these studies were included in the final sample.
A total of 123 effect sizes from 19 studies were included in this meta-analysis, with an average of 6.3 effect sizes per study (see Table 3, Table 4). These studies used the following self-report measures of coping: Stone and Neale Daily Coping Inventory adapted for pain, Pain Catastrophizing Scale (PCS), CSQ, CSQ-Revised (CSQ-R), Vanderbilt Multidimensional Pain Coping Inventory, Emotional Approach Coping Scale, and Profile of Chronic Pain: Screen and Extended Assessment. Modified versions of the CSQ, Religious Problem Solving Scale, and Stone and Neale Daily Coping Inventory were also used, and 1 study used a list of pain-reducing behaviors. Most studies used some form of the CSQ or CSQ-Revised (k = 10) or the PCS (k = 5). Although most studies used standard instructions for completing the coping questionnaires, a few studies used situation-specific (“in vivo”) instructions for the CSQ (k = 1) and PCS (k = 4).
Table 3Study Characteristics
| Study | Sample Size (Black Participants), n | Mean Age, Years | Percent Female Sex | Sample | Coping Questionnaire |
|---|---|---|---|---|---|
| Allen et al 2 | 491 (221) | 60.12 | 6.74 | Clinical | SNDCI adapted for pain |
| Campbell et al 11 | 120 (62) | 21.07 | 57.69 | Nonclinical | CSQ |
| Cano et al 13 | 105 (43) | 53.64 | 59 | Clinical | CSQ-Revised |
| Chibnall and Tait 17 | 1475 (580) | N/A | 37.7 | Clinical-low back injury | PCS |
| Cruz-Almeida et al 21 | 194 (95) | 24.34 | 48.15 | Nonclinical | PCS |
| Dun et al 22 | 197 (38) | 76.36 | 77 | Nonclinical | Modified version of the CSQ; modified version of the Religious Problem-Solving Scale |
| Edwards et al 26 | 194 (97) | 45.7 | 52.6 | Clinical | CSQ |
| Fabian et al 28 | 37 (11) | 21.5 | 61.29 | Nonclinical | PCS |
| Forsythe et al 31 | 155 (60) | 19.47 | 53.5 | Nonclinical | PCS |
| Golightly et al 35 | 153 (59) | 61.8 | 51.6 | Clinical-arthritis | SNDCI adapted for pain; CSQ |
| Goodin et al 36 | 114 (28) | 19.9 | 50 | Nonclinical | PCS |
| Goodin et al (unpublished) | 114 (28) | 19.9 | 50 | Nonclinical | CSQ |
| Hastie et al 39 | 650 (287) | 21 | 64 | Nonclinical | CSQ-Revised |
| Hastie et al 38 | 372 (185) | 24.63 | 58.2 | Nonclinical | List of pain reducing behaviors |
| Jones et al 49 | 939 (459) | 59.35 | 3.2 | Clinical-arthritis | CSQ |
| Jordan et al 50 | 100 (48) | 54.72 | 100 | Clinical-arthritis | CSQ |
| McIlvane 63 | 175 (77) | 66.74 | 100 | Clinical-unspecified | VMPCI; Emotional Approach Coping Scale; catastrophizing subscale of the CSQ; 2 religious items from the SNDCI |
| Ruehlman et al 77 | 428 (214) | 53.5 | 58.4 | Clinical -unspecified | Profile of Chronic Pain: Screen and Extended Assessment |
| Tan et al 91 | 479 (127) | 51.2 | 9.6 | Clinical -unspecified | CSQ |
Abbreviations: SNDCI, Stone and Neale Daily Coping Inventory; VMPCI, Vanderbilt Multidimensional Pain Coping Inventory.
Table 4Study Effect Sizes
| Study | Study SMD | 95% CI | Effect |
|---|---|---|---|
| Allen et al 2 | .26 | .17 to .34 | B > W |
| Campbell et al 11 | .62 | −.24 to 1.47 | B = W |
| Cano et al 13 | .38 | −.16 to .93 | B = W |
| Chibnall and Tait 17 | .28 | .14 to .35 | B > W |
| Cruz-Almeida et al 21 | .17 | −.11 to .45 | B = W |
| Dunn et al 22 | .22 | .12 to .31 | B > W |
| Edwards et al 26 | .10 | −.10 to .31 | B = W |
| Fabian et al 28 | .89 | .14 to 1.64 | B > W |
| Forsythe et al 31 | .68 | .34 to 1.01 | B > W |
| Golightly et al 35 | .33 | .14 to .53 | B > W |
| Goodin et al 36 | .70 | −1.20 to 1.60 | B = W |
| Goodin et al (unpublished) | .47 | .29 to .64 | B > W |
| Hastie et al 39 | .26 | −.11 to .62 | B = W |
| Hastie et al 38 | .17 | −.02 to .36 | B = W |
| Jones et al 49 | .07 | .03 to .11 | B > W |
| Jordan et al 50 | .06 | −.52 to .64 | B = W |
| McIlvane 63 | .18 | .05 to .31 | B > W |
| Ruehlman et al 77 | .10 | −.18 to .38 | B = W |
| Tan et al 91 | .12 | .02 to .21 | B > W |
Abbreviations: CI, confidence interval, B, black individuals; W, white individuals.
The overall sample size was 6,489 participants, including 2,719 black participants and 3,770 white participants. The mean sample size for included studies was 341.84 participants. The mean age for the samples was 42.4 years (95% confidence interval, 32.3–52.3). Fifty-eight percent of the samples had predominantly female participants (more than 50% female), and 79% of the samples had predominantly white participants (more than 50% white).
Relationship Between Race and Overall Coping Strategies
The SMD for the relationship between race and overall coping ranged from .06 to .89. Table 5 includes SMDs for overall coping and specific coping strategies as well as Orwin failsafe N for each SMD.
69
The SMD for the difference in overall coping between black and white participants was small but statistically significant (d = .25, z = 6.35, P < .01, FSN = 29), indicating that black participants scored higher on measures of pain coping overall than did white participants. The heterogeneity analysis showed that a moderate amount of the total variance (I2 = .47) was due to between-study variability.Table 5Summary of Effect Sizes for Pain Coping Strategies According to Categorization
| Coping Strategy | k | N | Effect | SMD | 95% CI | Z | I2 | FSN |
|---|---|---|---|---|---|---|---|---|
| Overall | 19 | 6,489 | B > W | .25 | .17 to .32 | 6.35* | 46.86 | 29 |
| Hoping/praying | 12 | 3,595 | B > W | .70 | .48 to .92 | 6.34* | 88.89 | 72 |
| Catastrophizing | 17 | 5,307 | B > W | .40 | .26 to .53 | 5.81* | 79.58 | 51 |
| Diverting attention | 11 | 2,781 | B > W | .20 | .13 to .27 | 5.32* | 0 | 11 |
| Coping self-statements | 11 | 3,384 | B = W | .08 | −.01 to .17 | 1.8 | 34.97 | 0 |
| Reinterpreting pain | 11 | 2,956 | B > W | .10 | .03 to .18 | 2.8† | 0 | 0 |
| Ignoring pain sensations | 10 | 3,209 | B = W | −.09 | −.26 to .08 | −1.07 | 81.05 | 0 |
| Increasing behavioral activity | 5 | 1,729 | B = W | .00 | −.11 to .11 | −.02 | 34.78 | 0 |
| Exercising and stretching | 2 | 679 | B > W | .33 | .01 to .65 | 2.02† | 85.16 | 7 |
| Task persistence | 2 | 910 | W > B | −.28 | −.41 to −.14 | −3.99* | 0 | 4 |
| Guarding | 2 | 679 | B = W | .28 | −.04 to .60 | 1.72 | 80.99 | 4 |
| Relaxation | 2 | 679 | B = W | .23 | −.04 to .50 | 1.68 | 46.24 | 3 |
| Seeking social support | 3 | 1,029 | B = W | .23 | −.04 to .51 | 1.66 | 47.92 | 4 |
Abbreviations: CI, confidence interval; B, black individuals; W, white individuals.
*P < .01.
†P < .05.
Relationship Between Race and Specific Coping Strategies
The race difference in use of hoping and praying was medium-to-large (d = .70, z = 6.34, P < .001, FSN = 72), indicating that black participants scored higher on measures of hoping and praying coping strategies than white participants. A considerable portion of variance in this effect (I2 = .89) was accounted for by between-study variability, suggesting that additional variables may moderate this relationship.
There was a small-to-medium effect of race on the use of catastrophizing (d = .40, z = 5.81, P < .001, FSN = 51), indicating that black individuals scored higher on measures of catastrophic thinking than white individuals. A substantial portion of this effect (I2 = .80) was accounted for by between-study variability, suggesting the presence of potential moderators of this effect.
The SMDs indicating race differences in the use of diverting attention (d = .20), reinterpreting pain (d = .10), and exercising and stretching (d = .33) were small but statistically significant, indicating that black individuals scored higher on measures of each of these strategies than white individuals (Table 5). The SMD for the race difference in the use of task persistence was also small but statistically significant (d = −.28), however it was in the opposite direction, such that white individuals scored higher on measures of this strategy than black individuals. The effect sizes for these coping strategies are consistent with their relatively small FSN values (all were ≤ 11; Table 5).
There were not significant differences in the use of coping self-statements, ignoring pain, increased behavioral activity, relaxation, and seeking social support.
Moderation
The mean age of the sample and percentage of the sample that was female were tested as continuous moderators of the relationship between race and overall coping, as well as race and specific coping strategies (Table 6). Although not a significant moderator for overall coping, age was a significant moderator of the relationship between race and catastrophizing, such that race differences in catastrophizing decreased as the sample age increased (β = −.64, P < .01). Sex was not a significant moderator for overall coping, however, it did moderate the relationship between race and exercising and stretching, such that samples including a higher percentage of females tended to demonstrate larger race differences in exercising and stretching (β = −.96, P = .01).
Table 6Continuous Moderator Analyses
| Variable | R2 | β | Z |
|---|---|---|---|
| Overall | |||
| Age | .18 | −.42 | −1.58 |
| % Female sex | .03 | .16 | .72 |
| Hoping/praying | |||
| Age | .16 | −.40 | −1.13 |
| % Female sex | .22 | .47 | 1.75 |
| Catastrophizing | |||
| Age | .41 | −.64 | −3.14* |
| % Female sex | .01 | .10 | .47 |
| Diverting attention | |||
| Age | .01 | −.11 | −.23 |
| % Female sex | .29 | .54 | 1.62 |
| Coping self-statements | |||
| Age | .23 | .48 | 1.07 |
| % Female sex | .00 | .02 | .08 |
| Reinterpreting pain | |||
| Age | .02 | .13 | .21 |
| % Female sex | .17 | .41 | 1.05 |
| Ignoring | |||
| Age | .01 | −.10 | −.19 |
| % Female sex | .25 | −.50 | −1.84 |
| Increasing behavioral activity | |||
| Age | 1.00 | −1.00 | −1.80 |
| % Female sex | .01 | −.09 | .17 |
| Exercising and stretching | |||
| Age | .07 | −.26 | −.41 |
| % Female sex | .91 | .96 | 2.48* |
*P < .05.
To examine the extent to which race differences in coping varied across coping category, 3 types of categorical moderators were examined: 1) active versus passive coping, 2) problem- versus emotion-focused coping, and 3) cognitive versus behavioral coping. There were notable differences in the effect sizes within each of the 3 coping categories. The SMD between race and coping was larger for passive (d = .53) versus active (d = .03), emotion-focused (d = .32) versus problem-focused (d = .14), and cognitive (d = .29) versus behavioral (d = .05) coping (Table 7).
Table 7Categorical Moderator Analyses
| Coping Strategy | k | Effect | SMD | 95% CI | Z |
|---|---|---|---|---|---|
| Active | 12 | B = W | .03 | −.34 to .10 | .95 |
| Passive | 18 | B > W | .53 | .39 to .68 | 7.28* |
| Problem-focused | 12 | B > W | .14 | .07 to .21 | 3.86* |
| Emotion-focused | 18 | B > W | .32 | .22 to .40 | 6.70* |
| Cognitive | 17 | B > W | .29 | .20 to .38 | 6.19* |
| Behavioral | 8 | B = W | .05 | −.03 to .12 | 1.30 |
Abbreviations: CI, confidence interval; B, black individuals; W, white individuals.
*P < .01.
Conclusions
The purpose of this meta-analytic review was to quantify the relationship between race and the use of pain coping strategies. Overall, black individuals reported using pain-coping strategies more frequently than white individuals. Specifically, black individuals engaged in hoping and praying, catastrophizing, diverting attention, and reinterpreting of pain sensations more frequently. Conversely, white individuals used task persistence more frequently. The magnitude of the observed race differences was larger for passive versus active strategies, emotion-focused versus problem-focused strategies, and cognitive versus behavioral strategies.
These findings suggest that black individuals use overall pain-related coping strategies more frequently than do white individuals. This effect was not only driven by significant differences in strategies such as hoping and praying, catastrophizing, and diverting attention, but also by smaller differences in most of the coping strategies assessed. In fact, white individuals only engaged in task persistence (significant difference) and ignoring strategies (nonsignificant difference) more frequently than did black individuals. Although it seems intuitive that having more tools in one's coping toolbox is preferable to having fewer, the current findings argue against such an assumption. Indeed, Geisser and colleagues
32
reported that maladaptive coping was a more important determinant of pain adjustment than was adaptive coping. Because black individuals use pain-coping strategies more frequently overall, they are also more likely to engage in maladaptive strategies more frequently, which may partly account for their increased pain and impairment compared with white individuals.Race differences were largest for hoping and praying strategies, with black individuals praying more frequently than white individuals in response to pain. This finding is consistent with the central role of the church in many black communities. Compared with white individual, black individuals attend church more, read religious materials more, listen to religious programs more, pray more, request prayer from others more, self-identify as more religious, and place higher importance on religion.
16
Thus, it is not surprising that black individuals pray more than white individuals in general as well as in response to pain.Exactly how these differences in hope and prayer are related to race differences in pain remains to be clarified. Hoping and praying, measured using the CSQ, is a passive coping strategy associated with avoidance.
4
, 65
Previous research suggests that passive coping and avoidance are related to worse pain and functioning and to increased rates of disability.6
, 9
, 65
, 70
, 95
Thus, the more frequent engagement in a passive type of prayer (eg, “I pray to God it won't last long”) for black individuals may reduce their ability to manage pain and may lead to poorer pain outcomes. Thus, this effect may not be driven by prayer, per se, but rather by the fact that many studies conceptualize and measure prayer as a passive strategy. Future studies should consider alternative measures of prayer, such as the Prayer Functions Scale5
or the Multidimensional Prayer Inventory,57
that more broadly conceptualize prayer beyond passive strategies to better understand its relationship to pain and its role as a mediator of race differences in pain.The race difference in catastrophizing was smaller than that for hoping and praying, however, the pattern was the same: black individuals catastrophize in response to pain more than white individuals. One speculative interpretation of these findings is that the catastrophizing response of black individuals is related to a more general sense of learned helplessness. The learned helplessness model posits that individuals who perceive that outcomes are uncontrollable suffer motivation, cognitive, and emotional deficits.
1
Studies indicate that black individuals are at increased risk for disparate pain care.37
, 61
, 89
, 90
, 94
As a result of this clinical discrimination, black patients might conclude that no matter what they do, their pain will not be adequately treated. Consequently, they may adopt a catastrophic style of thinking about pain, and white patients, who do not face such discrimination, continue to seek treatment or engage in new actions to reduce pain and improve function. Future research should examine perceptions of powerlessness and helplessness as potential mechanisms underlying the race differences in pain catastrophizing. Moreover, a closer examination of the individual facets of catastrophizing (ie, the Rumination, Magnification, and Helplessness subscales of the PCS) will provide a more nuanced understanding of catastrophizing in the context of race, pain, and discrimination.Catastrophizing may also function to solicit assistance or empathic responses from others, including family, friends, and medical providers. This interpretation is consistent with the communal model of coping, which posits that catastrophizing strategies are used to secure social or interpersonal resources, as well as induce others to alter their expectations, reduce performance demands, or manage interpersonal conflict.
85
, 86
, 87
The communal model of coping is consistent with the collectivistic orientation that is characteristic of many black cultures,19
wherein members place a higher importance on interpersonal than on intrapersonal outcomes. Consequently, although pain catastrophizing might lead to increased pain at the intrapersonal level—indeed, catastrophizing has been shown to mediate race differences in pain tolerance31
, 64
—it may also confer significant advantages at the interpersonal level. This communal coping model interpretation would also be consistent with findings that black individuals seek social support more than do white individuals. Although we found no significant race differences in seeking social support in the current study, because there were only 3 effect sizes included in our analysis, we cannot draw strong conclusions at this time. Future studies should further examine race differences in seeking social support as well as other factors that may be indicative of a communal model of coping.Results of this meta-analysis also indicated that black individuals attempt to divert attention away from pain and reinterpret pain sensations more than do white individuals. Evidence for the effectiveness of these coping strategies is mixed. Some results suggest that diverting and reinterpreting strategies confer benefit, particularly in the short term, by distracting individuals from painful sensations,
3
, 45
, 54
, 83
whereas other studies suggest these strategies are associated with increased pain and dysfunction.52
, 53
, 75
These inconsistent findings suggest that the effectiveness of attentional diversion strategies is moderated by other factors such as whether the individual has a clinical pain condition or is otherwise pain-free,83
the duration of pain,62
, 68
, 88
and the level of pain catastrophizing.12
, 78
In the context of chronic pain in particular, these latter results are consistent with conceptualizing attentional diversion strategies as avoidance techniques that may develop from a fear of pain. Indeed, fear of pain and the resulting avoidance of it have been linked to increased pain intensity, chronicity, and disability.33
, 42
The association between avoidance strategies and poor pain outcomes provides support for treatments that encourage acceptance rather than avoidance of pain, such as third-wave cognitive behavioral therapies. Indeed, attentional diversion strategies have been specifically contrasted with acceptance-based strategies.
67
There is a growing evidence base for the effectiveness of acceptance approaches. Mindfulness-Based Stress Reduction51
has yielded significant improvements in pain intensity and functional limitations for individuals with arthritis as well as neck and back pain.76
Likewise, Acceptance and Commitment Therapy40
has been shown to improve pain interference, depression, and pain-related anxiety in individuals with chronic pain.97
Although these treatment modalities have been shown to improve pain outcomes overall, few studies have specifically examined their efficacy for black individuals; of those that have, none were focused on pain.23
, 79
, 101
Future research should examine Acceptance and Commitment Therapy, Mindfulness-Based Stress Reduction, and other third-wave therapies in black individuals with chronic pain and compare the effectiveness of these treatments across racial groups.Task persistence was the one coping strategy endorsed by white individuals significantly more than black individuals. Task persistence, as measured using the Chronic Pain Coping Inventory,
48
involves continuing on with a task by ignoring painful sensations rather than allowing the pain to interfere with the task at hand. Task persistence has been associated with decreased pain, disability, and depression.74
Interestingly, a similar pattern (although it did not reach statistical significance) emerged for ignoring strategies, such that white individuals ignored pain sensations more than black individuals. Although ignoring pain and task persistence are often considered to be distinct strategies, there is overlap in their measurement; for example, the task persistence scale of the Chronic Pain Coping Inventory contains items related to ignoring pain sensations as well as continuing on with tasks. Because of this overlap, future research should examine the advantages and disadvantages—from statistical and conceptual points of view—of keeping these coping strategies separate versus combining them into a single strategy. The conceptualization and measurement of task persistence may need to be refined to exclude aspects of ignoring pain. Such a refinement might allow for a better understanding of the unique and combined effects of ignoring and persistence strategies on the pain experience for white and black individuals.Moderation analyses indicated that race differences for general and specific coping strategies were larger for some categorizations of coping. Most notably, race differences were larger for passive compared with active strategies. Effect sizes for hoping/praying and catastrophizing, both of which are passive strategies, were the largest across all of the strategies examined and may be driving the overall effect size for passive strategies.
Black individuals may be more prone to engage in passive coping for several reasons. Passive strategies may be more commonly modeled in black communities. Evidence suggests that black individuals have a more external locus of control orientation, have a lower overall sense of self-efficacy, and report greater feelings of helplessness.
8
Studies examining race differences for nonpain coping also reported that black individuals engaged in more passive strategies (ie, avoiding problems, hoping and praying, and denial).14
, 55
, 60
, 92
Because passive strategies are minimally effective for pain management, individuals who frequently use them might conclude that they have limited control over their pain. Such a belief is likely to lead to and/or reinforce a helplessness orientation toward pain. This recursive cycle of passive coping leading to perceptions of helplessness leading to passive coping may partly contribute to the poorer pain outcomes experienced by black patients.7
, 20
, 29
, 80
, 82
, 98
Race differences in coping strategies may also relate to race differences in pain that have been documented in numerous experimental and clinical studies.37
Because passive coping is related to greater pain,9
race differences in pain may be due, in part, to black individuals' greater inclination to engage in passive strategies as a whole. It is reasonable to speculate that the passive nature of these strategies—not the specific strategy itself—is what influences pain to the greatest extent. If so, perhaps investigations of coping should focus on this broader classification rather than examining individual coping strategies. Such a focus on active versus passive categories might confer advantages for conceptualization of pain coping, as well as its measurement.For the most part, sample age and sex did not moderate the race differences in pain coping, nor did sample type (clinical vs nonclinical), study design (experimental vs nonexperimental), and specific coping measure (results for these latter 3 analyses were not presented). Age was a significant moderator of the relationship between race and catastrophizing, such that race differences in catastrophizing decreased as the sample age increased. This could be related to the general decrease in catastrophizing that occurs with advancing age.
93
Additionally, race differences in exercising/stretching increased as the female sample percentage increased, however, there were only 2 studies that included this coping strategy, thus the reliability of this finding is uncertain. These 2 moderation results should be interpreted cautiously. Because demographic variables were reported inconsistently across studies, future work should examine the role of age and sex, as well as other demographic factors such as socioeconomic status, in the context of race differences in pain coping.There are several limitations of this meta-analysis. First, studies used a wide range of coping measures, which may have introduced heterogeneity across effect sizes. Although many strategies (eg, catastrophizing, praying, and diverting attention) were consistently included across studies and measures, some strategies (eg, seeking social support and task persistence) were unique to measures used less frequently, which may limit the generalizability of findings for these strategies. Additionally, many measures confound coping with other reactions to pain.
47
For example, catastrophizing can be considered a pain appraisal rather than (or in addition to) a coping response. Likewise, exercise and stretching may be classified as outcomes or adjustments to pain. It is beyond the scope of this meta-analysis to adjudicate these issues. We included these strategies in the current analyses because they are often conceptualized and measured as coping strategies in research and clinical settings. Nevertheless, research is needed to more clearly define and measure the related constructs of pain coping, appraisals, and outcomes, which will enhance our understanding of their relationships to the pain experience for all patients and for specific patient subgroups. Furthermore, higher levels of pain in black individuals may be confounded with the race differences observed in pain coping. It was beyond the scope of this meta-analysis to specifically examine this relationship, although our moderation analyses for sample type and study design (discussed, but not included in the results section) may inform future studies that specifically consider factors underlying race differences in pain coping. Finally, race differences in coping may be primarily driven by differences in culture, for which race serves as a frequently measured but imprecise proxy. Indeed, Robbins and colleagues73
suggest that genetically identified ancestral differences account for a small fraction of the variation in pain between white and black individuals. Unfortunately, we could not address the issue of culture in the current meta-analysis because of lack of data. Additionally, the studies examined in this meta-analysis included samples only from the United States. Our understanding of race and culture in the context of pain would benefit greatly from studies that directly measure specific cultural indicators within more diverse samples.This meta-analytic review, to our knowledge, is the first of its kind to quantify the relationship between race and the use of pain-coping strategies. Black individuals not only endorsed more frequent engagement in pain-coping strategies overall than white individuals but also more frequent use of specific strategies such as hoping and praying and catastrophizing. The largest of these race differences was found for passive coping strategies, which have been associated with poorer pain outcomes. Future research should examine race differences in intra- and interpersonal values and goals in the context of pain, which may lead to better understanding of race differences in pain coping and ultimately to improved culturally sensitive care for all patients in pain.
Acknowledgments
The authors thank Drs. Melissa Cyders and Catherine Mosher for their helpful comments on study methods and data analysis. We also thank Madison Stout and David Wuest for copyediting assistance.
References
- Learned helplessness in humans: An attributional analysis, in: Human Helplessness: Theory and Applications.Academic Press, New York, NY1980
- Racial differences in osteoarthritis pain and function: Potential explanatory factors.Osteoarthritis Cartilage. 2010; 18: 160-167
- Anxiety, attention and pain.J Psychosom Res. 1993; 37: 423-431
- Prayer as a coping strategy for chronic pain patients.Rehabil Psychol. 1994; 39: 205-209
- Functions of Christian prayer in the coping process.J Sci Study Relig. 2008; 47: 123-133
- Pain coping strategies in rheumatoid arthritis: Relationships to pain, disability, depressions, and daily hassles.Behav Ther. 1991; 22: 113-124
- The undertreatment of pain in ambulatory AIDS patients.Pain. 1996; 65: 243-249
- The experience and consequences of perceived racial discrimination: A study of African Americans.J Black Psychol. 2000; 26: 165-180
- Development of a questionnaire for the assessment of active and passive coping strategies in chronic pain patients.Pain. 1987; 31: 53-64
- Pain coping strategies and depression in rheumatoid arthritis.J Consult Clin Psychol. 1989; 57: 652
- Ethnic differences in responses to multiple experimental pain stimuli.Pain. 2005; 113: 20-26
- Catastrophizing delays the analgesic effect of distraction.Pain. 2010; 149: 202-207
- Coping, pain severity, interference, and disability: The potential mediating and moderating roles of race and education.Pain. 2006; 7: 459-468
- Racial differences in adolescent coping and self-esteem.J Genet Psychol. 2000; 161: 152-160
- Variations in cutaneous and visceral pain sensitivity in normal subjects.J Clin Invest. 1944; 23: 81
- Race and ethnic differences in religious involvement: African Americans, Caribbean Blacks, and non-Hispanic Whites.Ethn Racial Stud. 2009; 32: 1143-1163
- Confirmatory factor analysis of the Pain Catastrophizing Scale in African American and Caucasian Workers' Compensation claimants with low back injuries.Pain. 2005; 113: 369-375
- Age-related differences in pain sensitivity and regional brain activity evoked by noxious pressure.Neurobiol Aging. 2010; 31: 494-503
- Cultural orientations in the United States: (Re)examining differences among ethnic groups.J Cross Cult Psychol. 2001; 32: 348-364
- Determinants of pain severity in knee osteoarthritis: Effect of demographic and psychosocial variables using 3 pain measures.J Rheumatol. 1999; 26: 1785-1792
- Experimental pain phenotype profiles in a racially and ethnically diverse sample of healthy adults.Pain Med. 2013; 14: 1708-1718
- Religious and nonreligious coping in older adults experiencing chronic pain.Pain Manag Nurs. 2004; 5: 19-28
- Mindfulness-based stress reduction for low-income, predominantly African American women with PTSD and a history of intimate partner violence.Cogn Behav Pract. 2013; 20: 23-32
- Ethnic differences in thermal pain responses.Psychosom Med. 1999; 61: 346-354
- Race, ethnicity and pain.Pain. 2001; 94: 133-137
- Ethnic similarities and differences in the chronic pain experience: A comparison of African American, Hispanic, and white patients.Pain Med. 2005; 6: 88-98
- Psychosocial predictors of functional change in recently diagnosed rheumatoid arthritis patients.Behav Res Ther. 1998; 36: 179-193
- Ethnicity, catastrophizing, and qualities of the pain experience.Pain Med. 2011; 12: 314-321
- Differences in postoperative pain severity among four ethnic groups.J Pain Symptom Manage. 1994; 9: 383-389
- An analysis of coping in a middle-aged community sample.J Health Soc Behav. 1980; 21: 219-239
- Race and sex differences in primary appraisals, catastrophizing, and experimental pain outcomes.Pain. 2011; 12: 563-572
- Pain beliefs, coping, and adjustment to chronic pain: Let's focus more on the negative.Pain Forum. 1999; 8: 163-170
- Fear of pain, not pain catastrophizing, predicts acute pain intensity, but neither factor predicts tolerance or blood pressure reactivity: An experimental investigation in pain-free individuals.Eur J Pain. 2006; 10: 457
- Sickle cell disease pain: Relation of coping strategies to adjustment.J Consult Clin Psychol. 1989; 57: 725
- Associations of coping strategies with diary based pain variables among Caucasian and African American patients with osteoarthritis.Int J Behav Med. 2014; 4: 4
- Subjective sleep quality and ethnicity are interactively related to standard and situation-specific measures of pain catastrophizing.Pain Med. 2011; 12: 913-922
- The unequal burden of pain: Confronting racial and ethnic disparities in pain.Pain Med. 2003; 4: 277-294
- Ethnic differences and responses to pain in healthy young adults.Pain Med. 2005; 6: 61-71
- Ethnic differences in pain coping: Factor structure of the Coping Strategies Questionnaire and Coping Strategies Questionnaire-Revised.Pain. 2004; 5: 304-316
- Acceptance and Commitment Therapy: An Experiential Approach to Behavior Change.Guilford Press, New York, NY1999
- Measuring inconsistency in meta-analyses.BMJ. 2003; 327: 557-560
- Fear of pain, pain catastrophizing, and acute pain perception: Relative prediction and timing of assessment.Pain. 2008; 9: 806-812
- Differential effects of avoidant and attentional coping strategies on adaptation to chronic and recent-onset pain.Health Psychol. 1990; 9: 577
IOM. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, D.C., National Academies Press, 2011
- Control beliefs, coping efforts, and adjustment to chronic pain.J Consult Clin Psychol. 1991; 59: 431
- Self-efficacy and outcome expectancies: Relationship to chronic pain coping strategies and adjustment.Pain. 1991; 44: 263-269
- Coping with chronic pain: A critical review of the literature.Pain. 1991; 47: 249-283
- The Chronic Pain Coping Inventory: Development and preliminary validation.Pain. 1995; 60: 203-216
- Investigating racial differences in coping with chronic osteoarthritis pain.J Cross Cult Gerontol. 2008; 23: 339-347
- The relationships of cognitive coping and pain control beliefs to pain and adjustment among African-American and Caucasian women with rheumatoid arthritis.Arthritis Rheum. 1998; 11: 80-88
Kabat-Zinn J: Mindfulness-based stress reduction (MBSR). Constructivism in the Human Sciences. 8:73-107, 2003
- The relationship of gender to pain, pain behavior, and disability in osteoarthritis patients: The role of catastrophizing.Pain. 2000; 87: 325-334
- A comparison of coping strategies in chronic pain patients in different age groups.Gerontol. 1990; 45: 161-165
- Effects of distraction on children's pain and distress during medical procedures: A meta-analysis.Nurs Res. 1999; 48: 44-49
- Coping styles, depressive symptoms and race during the transition to adulthood.Religion Culture. 2012; 15: 363-372
- Pain-coping strategies in chronic pain patients: psychometric characteristics of the pain-coping inventory (PCI).Int J Behav Med. 2003; 10: 343-363
- Measuring private prayer: Development validation and clinical application of the Multidimensional Prayer Inventory.Int Psychol Relig. 2004; 14: 251-272
Lazarus RS, Folkman S: Stress, Appraisal and Coping. New York, NY, Springer Publishing Company, 1984
- Practical Meta-Analysis.Sage, Thousand Oaks, CA2001
- Racial differences in coping with the need for kidney transplantation and willingness to ask for live organ donation.Am J Kidney Dis. 2006; 47: 324-331
- Racial and ethnic differences in access to medical care.Med Care Res Rev. 2000; 57: 108-145
- Attention, distraction, and cold-pressor pain.J Pers Soc Psychol. 1982; 43: 154
- Disentangling the effects of race and SES on arthritis-related symptoms, coping, and well-being in African American and White women.Aging Ment Health. 2007; 11: 556-569
- In vivo praying and catastrophizing mediate the race differences in experimental pain sensitivity.J Pain. 2015; 16: 491-497
- Passive coping is a risk factor for disabling neck or low back pain.Pain. 2005; 117: 51-57
- The PRISMA Group: Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.PLoS Med. 2009; 6: e1000097
- Comparison of acceptance and distraction strategies in coping with experimentally induced pain.J Pain Res. 2015; 8: 139
- The effectiveness of attention and rejection as coping styles: A meta-analysis of temporal differences.J Psychosom Res. 1982; 26: 43-49
- A fail-safe N for effect size in meta-analysis.J Educ Stat. 1983; 8: 157-159
- Pain control and rational thinking.Arthritis Rheum. 1989; 32: 984-990
- Ethnic identity predicts experimental pain sensitivity in African Americans and Hispanics.Pain. 2007; 129: 177-184
- Sex differences in the perception of noxious experimental stimuli: A meta-analysis.Pain. 1998; 74: 181-187
- Relationship of pain and ancestry in African American women.Eur J Pain. 2015; 19: 601-610
- The Chronic Pain Coping Inventory-42: Reliability and validity.Pain. 2003; 104: 65-73
- The use of coping strategies in chronic low back pain patients: relationship to patient characteristics and current adjustment.Pain. 1983; 17: 33-44
- Mindfulness-based stress reduction for chronic pain conditions: Variation in treatment outcomes and role of home meditation practice.J Psychosom Res. 2010; 68: 29-36
- Comparing the experiential and psychosocial dimensions of chronic pain in African Americans and Caucasians: Findings from a national community sample.Pain Med. 2005; 6: 49-60
- Distraction analgesia in chronic pain patients: The impact of catastrophizing.Anesthesiology. 2014; 121: 1292-1301
- Effect of mindfulness meditation on A1c levels in African Americans females with type 2 diabetes.Dissertation Abstracts International. 2012; 72: 4308
- Racial differences in the use of lumbar spine radiographs: Results from the Veterans Health Study.Spine (Phila Pa 1976). 2001; 26: 1364-1369
- Race and sex differences in cutaneous pain perception.Psychosom Med. 2000; 62: 517-523
- Glaucoma's impact on quality of life and its relation to clinical indicators: A pilot study.Ophthalmology. 1998; 105: 561-566
- Attentional modulation fails to attenuate the subjective pain experience in chronic, unexplained pain.Eur J Pain. 2010; 14: 282
- Active and passive coping strategies in chronic pain patients.Pain. 1996; 64: 455-462
- Communicative dimensions of pain catastrophizing: Social cueing effects on pain behaviour and coping.Pain. 2004; 107: 220-226
- The pain catastrophizing scale: Development and validation.Psychol Assess. 1995; 7: 524
- The relation between catastrophizing and the communication of pain experience.Pain. 2006; 122: 282-288
- The relative efficacy of avoidant and nonavoidant coping strategies: A meta-analysis.Health Psychol. 1985; 4: 249-288
- Work injury management of refractory low back pain: Relations with ethnicity, legal representation and diagnosis.Pain. 2001; 91: 47-56
- Attitude profiles and clinical status in patients with chronic pain.Pain. 1998; 78: 49-57
- Ethnicity, control appraisal, coping, and adjustment to chronic pain among black and white Americans.Pain Med. 2005; 6: 18-28
- Race, social support, and coping strategies among HIV-positive gay and bisexual men.Cult Health Sex. 2006; 8: 235-249
- Pain-related catastrophizing: A daily process study.Pain. 2004; 110: 103-111
- Racial variation in quality of care among Medicare+ Choice enrollees.Health Aff (Millwood). 2002; 21: 224-230
- Fear-avoidance and its consequences in chronic musculoskeletal pain: A state of the art.Pain. 2000; 85: 317-332
- Normative model for cold pressor test.Am J Phys Med Rehabil. 1989; 68: 6-11
- A randomized controlled trial of acceptance and commitment therapy and cognitive-behavioral therapy for chronic pain.Pain. 2011; 152: 2098-2107
- Patients' perceptions of overall function, pain, and appearance after primary posterior instrumentation and fusion for idiopathic scoliosis.Spine (Phila Pa 1976). 1999; 24 (discussion 1699-1700): 1693-1699
Wilson DB: Meta-analysis macros for SAS, SPSS, and Stata. Available at: http://mason.gmu.edu/∼dwilsonb/ma.html. Accessed May 3, 2014
- Pain tolerance: Differences according to age, sex and race.Psychosom Med. 1972; 34: 548-556
- A mindfulness-based intervention for pregnant African-American women.Mindfulness. 2015; 6: 663-674
Article Info
Publication History
Published online: January 12, 2016
Footnotes
All authors have read and approved the manuscript, and all have contributed substantially to data analysis and manuscript preparation. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Preliminary results from this study were presented in a poster session at the 2015 meeting of the American Pain Society.
This work was supported by a grant from the National Institutes of Health awarded to A.T.H. ( R01MD008931 ).
The authors have no conflicts of interest to declare.
Identification
Copyright
© 2016 by the American Pain Society
00019-5&id=gr1.jpg){kind=link}