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Differences in Pain Coping Between Black and White Americans: A Meta-Analysis

Published:January 12, 2016DOI:https://doi.org/10.1016/j.jpain.2015.12.017

      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 Relevant studies were identified using electronic databases, an ancestry search, and by contacting authors for unpublished data.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.

      IOM. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, D.C., National Academies Press, 2011

      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.
      • Breitbart W.
      • Rosenfeld B.D.
      • Passik S.D.
      • McDonald M.V.
      • Thaler H.
      • Portenoy R.K.
      The undertreatment of pain in ambulatory AIDS patients.
      • Creamer P.
      • Lethbridge-Cejku M.
      • Hochberg M.C.
      Determinants of pain severity in knee osteoarthritis: Effect of demographic and psychosocial variables using 3 pain measures.
      • Faucett J.
      • Gordon N.
      • Levine J.
      Differences in postoperative pain severity among four ethnic groups.
      • Selim A.J.
      • Fincke G.
      • Ren X.S.
      • Deyo R.A.
      • Lee A.
      • Skinner D.
      • Kazis L.
      Racial differences in the use of lumbar spine radiographs: Results from the Veterans Health Study.
      • Sherwood M.B.
      • Garcia-Siekavizza A.
      • Meltzer M.I.
      • Hebert A.Y.
      • Burns A.F.
      • McGorray S.
      Glaucoma's impact on quality of life and its relation to clinical indicators: A pilot study.
      • White S.F.
      • Asher M.A.
      • Lai S.M.
      • Burton D.C.
      Patients' perceptions of overall function, pain, and appearance after primary posterior instrumentation and fusion for idiopathic scoliosis.
      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.
      • Campbell C.M.
      • Edwards R.R.
      • Fillingim R.B.
      Ethnic differences in responses to multiple experimental pain stimuli.
      • Chapman W.P.
      • Jones C.M.
      Variations in cutaneous and visceral pain sensitivity in normal subjects.
      • Edwards R.R.
      • Fillingim R.B.
      Ethnic differences in thermal pain responses.
      • Edwards C.L.
      • Fillingim R.B.
      • Keefe F.
      Race, ethnicity and pain.
      • Rahim-Williams F.B.
      • Riley III, J.L.
      • Herrera D.
      • Campbell C.M.
      • Hastie B.A.
      • Fillingim R.B.
      Ethnic identity predicts experimental pain sensitivity in African Americans and Hispanics.
      • Sheffield D.
      • Biles P.L.
      • Orom H.
      • Maixner W.
      • Sheps D.S.
      Race and sex differences in cutaneous pain perception.
      • Walsh N.E.
      • Schoenfeld L.
      • Ramamurthy S.
      • Hoffman J.
      Normative model for cold pressor test.
      • Woodrow K.M.
      • Friedman G.D.
      • Siegelaub A.B.
      • Collen M.F.
      Pain tolerance: Differences according to age, sex and race.
      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.

      Lazarus RS, Folkman S: Stress, Appraisal and Coping. New York, NY, Springer Publishing Company, 1984

      Differences in coping strategy use are associated with differences in pain intensity, adjustment to chronic pain, and psychological and physical functioning.
      • Jensen M.P.
      • Karoly P.
      Control beliefs, coping efforts, and adjustment to chronic pain.
      • Jensen M.P.
      • Turner J.A.
      • Romano J.M.
      Self-efficacy and outcome expectancies: Relationship to chronic pain coping strategies and adjustment.
      • Keefe F.J.
      • Williams D.A.
      A comparison of coping strategies in chronic pain patients in different age groups.
      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.
      • Rosenstiel A.K.
      • Keefe F.J.
      The use of coping strategies in chronic low back pain patients: relationship to patient characteristics and current adjustment.
      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.
      • Brown G.K.
      • Nicassio P.M.
      Development of a questionnaire for the assessment of active and passive coping strategies in chronic pain patients.
      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.
      • Brown G.K.
      • Nicassio P.M.
      • Wallston K.A.
      Pain coping strategies and depression in rheumatoid arthritis.
      • Holmes J.A.
      • Stevenson C.A.
      Differential effects of avoidant and attentional coping strategies on adaptation to chronic and recent-onset pain.
      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.
      • Brown G.K.
      • Nicassio P.M.
      Development of a questionnaire for the assessment of active and passive coping strategies in chronic pain patients.
      • Kraaimaat F.W.
      • Evers A.W.
      Pain-coping strategies in chronic pain patients: psychometric characteristics of the pain-coping inventory (PCI).
      • Snow-Turek A.L.
      • Norris M.P.
      • Tan G.
      Active and passive coping strategies in chronic pain patients.
      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.
      • Folkman S.
      • Lazarus R.S.
      An analysis of coping in a middle-aged community sample.
      There is some evidence suggesting emotion-focused coping is associated with worse pain and functioning in individuals with chronic pain.
      • Allen K.D.
      • Oddone E.Z.
      • Coffman C.J.
      • Keefe F.J.
      • Lindquist J.H.
      • Bosworth H.B.
      Racial differences in osteoarthritis pain and function: Potential explanatory factors.
      • Brown G.K.
      • Nicassio P.M.
      • Wallston K.A.
      Pain coping strategies and depression in rheumatoid arthritis.
      • Evers A.W.
      • Kraaimaat F.W.
      • Geenen R.
      • Bijlsma J.W.
      Psychosocial predictors of functional change in recently diagnosed rheumatoid arthritis patients.
      • Gil K.M.
      • Abrams M.R.
      • Phillips G.
      • Keefe F.J.
      Sickle cell disease pain: Relation of coping strategies to adjustment.
      In a topical review, Edwards and colleagues
      • Edwards C.L.
      • Fillingim R.B.
      • Keefe F.
      Race, ethnicity and pain.
      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,
      • Jordan M.S.
      • Lumley M.A.
      • Leisen C.C.
      The relationships of cognitive coping and pain control beliefs to pain and adjustment among African-American and Caucasian women with rheumatoid arthritis.
      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 al
      • Forsythe L.P.
      • Thorn B.
      • Day M.
      • Shelby G.
      Race and sex differences in primary appraisals, catastrophizing, and experimental pain outcomes.
      and McIlvane
      • McIlvane J.M.
      Disentangling the effects of race and SES on arthritis-related symptoms, coping, and well-being in African American and White women.
      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.
      • Cole L.J.
      • Farrell M.J.
      • Gibson S.J.
      • Egan G.F.
      Age-related differences in pain sensitivity and regional brain activity evoked by noxious pressure.
      • McIlvane J.M.
      Disentangling the effects of race and SES on arthritis-related symptoms, coping, and well-being in African American and White women.
      • Riley III, J.L.
      • Robinson M.E.
      • Wise E.A.
      • Myers C.D.
      • Fillingim R.B.
      Sex differences in the perception of noxious experimental stimuli: A meta-analysis.
      • Woodrow K.M.
      • Friedman G.D.
      • Siegelaub A.B.
      • Collen M.F.
      Pain tolerance: Differences according to age, sex and race.
      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,
      • Edwards C.L.
      • Fillingim R.B.
      • Keefe F.
      Race, ethnicity and pain.
      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
      PainCopingRace
      NociceptionCSQAfrican American
      CatastrophizingBlack
      Chronic Pain Coping InventoryEthnicity
      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
      • Moher D.
      • Liberati A.
      • Tetzlaff J.
      • Altman D.G.
      The PRISMA Group: Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.
      is included in Fig 1.
      Figure thumbnail gr1
      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.
      • Allen K.D.
      • Oddone E.Z.
      • Coffman C.J.
      • Keefe F.J.
      • Lindquist J.H.
      • Bosworth H.B.
      Racial differences in osteoarthritis pain and function: Potential explanatory factors.
      • Brown G.K.
      • Nicassio P.M.
      Development of a questionnaire for the assessment of active and passive coping strategies in chronic pain patients.
      • Brown G.K.
      • Nicassio P.M.
      • Wallston K.A.
      Pain coping strategies and depression in rheumatoid arthritis.
      • Evers A.W.
      • Kraaimaat F.W.
      • Geenen R.
      • Bijlsma J.W.
      Psychosocial predictors of functional change in recently diagnosed rheumatoid arthritis patients.
      • Gil K.M.
      • Abrams M.R.
      • Phillips G.
      • Keefe F.J.
      Sickle cell disease pain: Relation of coping strategies to adjustment.
      • Kraaimaat F.W.
      • Evers A.W.
      Pain-coping strategies in chronic pain patients: psychometric characteristics of the pain-coping inventory (PCI).
      • Rosenstiel A.K.
      • Keefe F.J.
      The use of coping strategies in chronic low back pain patients: relationship to patient characteristics and current adjustment.
      • Snow-Turek A.L.
      • Norris M.P.
      • Tan G.
      Active and passive coping strategies in chronic pain patients.
      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.
      • Lipsey M.W.
      • Wilson D.B.
      Practical Meta-Analysis.
      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.
      • Lipsey M.W.
      • Wilson D.B.
      Practical Meta-Analysis.
      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.
      • Higgins J.
      • Thompson S.G.
      • Deeks J.J.
      • Altman D.G.
      Measuring inconsistency in meta-analyses.
      To examine potential publication bias, the Orwin failsafe N (FSN) was calculated.
      • Orwin R.
      A fail-safe N for effect size in meta-analysis.
      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.
      • Lipsey M.W.
      • Wilson D.B.
      Practical Meta-Analysis.
      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 BehaviorActive Versus PassiveProblem- Versus Emotion-Focused
      CognitiveBehavioralActivePassiveProblem-FocusedEmotion-Focused
      CatastrophizingAsking for assistanceCoping self statementsCatastrophizingAsking for assistanceCatastrophizing
      Coping self StatementsDepending on othersDiverting attentionDepending on othersDepending on othersCoping self statements
      Diverting attentionExercise and stretchingExercise and stretchingHoping/prayingDiverting attentionHoping/praying
      Hoping/prayingFunctioning despite painFunctioning despite painPassive techniquesExercise and stretchingReinterpreting pain
      Ignoring painGuardingIgnoring painRestricting functioningFunctioning despite painSeeking support
      Reinterpreting painIncreasing behavioral activityIncreasing behavioral activityRetreatingGuardingTransformation
      TransformationReducing demandsReinterpreting painUsing medicationIncreasing behavioral activityWishful thinking
      Wishful thinkingRestricting functioningSelf-careWishful thinkingReducing demandsWorrying
      WorryingRetreatingTask persistenceWorryingRelaxation
      Seeking supportTransformationRestricting functioning
      Self-careRetreating
      Standard health careSelf-care
      Task persistenceStandard health care
      Using medicationTask 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.

      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
      StudySample Size (Black Participants), nMean Age, YearsPercent Female SexSampleCoping Questionnaire
      Allen et al
      • Allen K.D.
      • Oddone E.Z.
      • Coffman C.J.
      • Keefe F.J.
      • Lindquist J.H.
      • Bosworth H.B.
      Racial differences in osteoarthritis pain and function: Potential explanatory factors.
      491 (221)60.126.74ClinicalSNDCI adapted for pain
      Campbell et al
      • Campbell C.M.
      • Edwards R.R.
      • Fillingim R.B.
      Ethnic differences in responses to multiple experimental pain stimuli.
      120 (62)21.0757.69NonclinicalCSQ
      Cano et al
      • Cano A.
      • Mayo A.
      • Ventimiglia M.
      Coping, pain severity, interference, and disability: The potential mediating and moderating roles of race and education.
      105 (43)53.6459ClinicalCSQ-Revised
      Chibnall and Tait
      • Chibnall J.T.
      • Tait R.C.
      Confirmatory factor analysis of the Pain Catastrophizing Scale in African American and Caucasian Workers' Compensation claimants with low back injuries.
      1475 (580)N/A37.7Clinical-low back injuryPCS
      Cruz-Almeida et al
      • Cruz-Almeida Y.
      • Riley III, J.L.
      • Fillingim R.B.
      Experimental pain phenotype profiles in a racially and ethnically diverse sample of healthy adults.
      194 (95)24.3448.15NonclinicalPCS
      Dun et al
      • Dunn K.S.
      • Horgas A.L.
      Religious and nonreligious coping in older adults experiencing chronic pain.
      197 (38)76.3677NonclinicalModified version of the CSQ; modified version of the Religious Problem-Solving Scale
      Edwards et al
      • Edwards R.R.
      • Moric M.
      • Husfeldt B.
      • Buvanendran A.
      • Ivankovich O.
      Ethnic similarities and differences in the chronic pain experience: A comparison of African American, Hispanic, and white patients.
      194 (97)45.752.6ClinicalCSQ
      Fabian et al
      • Fabian L.A.
      • McGuire L.
      • Goodin B.R.
      • Edwards R.R.
      Ethnicity, catastrophizing, and qualities of the pain experience.
      37 (11)21.561.29NonclinicalPCS
      Forsythe et al
      • Forsythe L.P.
      • Thorn B.
      • Day M.
      • Shelby G.
      Race and sex differences in primary appraisals, catastrophizing, and experimental pain outcomes.
      155 (60)19.4753.5NonclinicalPCS
      Golightly et al
      • Golightly Y.M.
      • Allen K.D.
      • Stechuchak K.M.
      • Coffman C.J.
      • Keefe F.J.
      Associations of coping strategies with diary based pain variables among Caucasian and African American patients with osteoarthritis.
      153 (59)61.851.6Clinical-arthritisSNDCI adapted for pain; CSQ
      Goodin et al
      • Goodin B.R.
      • Fillingim R.B.
      • Machala S.
      • McGuire L.
      • Buenaver L.F.
      • Campbell C.M.
      • Smith M.T.
      Subjective sleep quality and ethnicity are interactively related to standard and situation-specific measures of pain catastrophizing.
      114 (28)19.950NonclinicalPCS
      Goodin et al (unpublished)114 (28)19.950NonclinicalCSQ
      Hastie et al
      • Hastie B.A.
      • Riley III, J.L.
      • Fillingim R.B.
      Ethnic differences in pain coping: Factor structure of the Coping Strategies Questionnaire and Coping Strategies Questionnaire-Revised.
      650 (287)2164NonclinicalCSQ-Revised
      Hastie et al
      • Hastie B.A.
      • Riley J.L.
      • Fillingim R.B.
      Ethnic differences and responses to pain in healthy young adults.
      372 (185)24.6358.2NonclinicalList of pain reducing behaviors
      Jones et al
      • Jones A.C.
      • Kwoh C.K.
      • Groeneveld P.W.
      • Mor M.
      • Geng M.
      • Ibrahim S.A.
      Investigating racial differences in coping with chronic osteoarthritis pain.
      939 (459)59.353.2Clinical-arthritisCSQ
      Jordan et al
      • Jordan M.S.
      • Lumley M.A.
      • Leisen C.C.
      The relationships of cognitive coping and pain control beliefs to pain and adjustment among African-American and Caucasian women with rheumatoid arthritis.
      100 (48)54.72100Clinical-arthritisCSQ
      McIlvane
      • McIlvane J.M.
      Disentangling the effects of race and SES on arthritis-related symptoms, coping, and well-being in African American and White women.
      175 (77)66.74100Clinical-unspecifiedVMPCI; Emotional Approach Coping Scale; catastrophizing subscale of the CSQ; 2 religious items from the SNDCI
      Ruehlman et al
      • Ruehlman L.S.
      • Karoly P.
      • Newton C.
      Comparing the experiential and psychosocial dimensions of chronic pain in African Americans and Caucasians: Findings from a national community sample.
      428 (214)53.558.4Clinical -unspecifiedProfile of Chronic Pain: Screen and Extended Assessment
      Tan et al
      • Tan G.
      • Jensen M.P.
      • Thornby J.
      • Andersonm K.O.
      Ethnicity, control appraisal, coping, and adjustment to chronic pain among black and white Americans.
      479 (127)51.29.6Clinical -unspecifiedCSQ
      Abbreviations: SNDCI, Stone and Neale Daily Coping Inventory; VMPCI, Vanderbilt Multidimensional Pain Coping Inventory.
      Table 4Study Effect Sizes
      StudyStudy SMD95% CIEffect
      Allen et al
      • Allen K.D.
      • Oddone E.Z.
      • Coffman C.J.
      • Keefe F.J.
      • Lindquist J.H.
      • Bosworth H.B.
      Racial differences in osteoarthritis pain and function: Potential explanatory factors.
      .26.17 to .34B > W
      Campbell et al
      • Campbell C.M.
      • Edwards R.R.
      • Fillingim R.B.
      Ethnic differences in responses to multiple experimental pain stimuli.
      .62−.24 to 1.47B = W
      Cano et al
      • Cano A.
      • Mayo A.
      • Ventimiglia M.
      Coping, pain severity, interference, and disability: The potential mediating and moderating roles of race and education.
      .38−.16 to .93B = W
      Chibnall and Tait
      • Chibnall J.T.
      • Tait R.C.
      Confirmatory factor analysis of the Pain Catastrophizing Scale in African American and Caucasian Workers' Compensation claimants with low back injuries.
      .28.14 to .35B > W
      Cruz-Almeida et al
      • Cruz-Almeida Y.
      • Riley III, J.L.
      • Fillingim R.B.
      Experimental pain phenotype profiles in a racially and ethnically diverse sample of healthy adults.
      .17−.11 to .45B = W
      Dunn et al
      • Dunn K.S.
      • Horgas A.L.
      Religious and nonreligious coping in older adults experiencing chronic pain.
      .22.12 to .31B > W
      Edwards et al
      • Edwards R.R.
      • Moric M.
      • Husfeldt B.
      • Buvanendran A.
      • Ivankovich O.
      Ethnic similarities and differences in the chronic pain experience: A comparison of African American, Hispanic, and white patients.
      .10−.10 to .31B = W
      Fabian et al
      • Fabian L.A.
      • McGuire L.
      • Goodin B.R.
      • Edwards R.R.
      Ethnicity, catastrophizing, and qualities of the pain experience.
      .89.14 to 1.64B > W
      Forsythe et al
      • Forsythe L.P.
      • Thorn B.
      • Day M.
      • Shelby G.
      Race and sex differences in primary appraisals, catastrophizing, and experimental pain outcomes.
      .68.34 to 1.01B > W
      Golightly et al
      • Golightly Y.M.
      • Allen K.D.
      • Stechuchak K.M.
      • Coffman C.J.
      • Keefe F.J.
      Associations of coping strategies with diary based pain variables among Caucasian and African American patients with osteoarthritis.
      .33.14 to .53B > W
      Goodin et al
      • Goodin B.R.
      • Fillingim R.B.
      • Machala S.
      • McGuire L.
      • Buenaver L.F.
      • Campbell C.M.
      • Smith M.T.
      Subjective sleep quality and ethnicity are interactively related to standard and situation-specific measures of pain catastrophizing.
      .70−1.20 to 1.60B = W
      Goodin et al (unpublished).47.29 to .64B > W
      Hastie et al
      • Hastie B.A.
      • Riley III, J.L.
      • Fillingim R.B.
      Ethnic differences in pain coping: Factor structure of the Coping Strategies Questionnaire and Coping Strategies Questionnaire-Revised.
      .26−.11 to .62B = W
      Hastie et al
      • Hastie B.A.
      • Riley J.L.
      • Fillingim R.B.
      Ethnic differences and responses to pain in healthy young adults.
      .17−.02 to .36B = W
      Jones et al
      • Jones A.C.
      • Kwoh C.K.
      • Groeneveld P.W.
      • Mor M.
      • Geng M.
      • Ibrahim S.A.
      Investigating racial differences in coping with chronic osteoarthritis pain.
      .07.03 to .11B > W
      Jordan et al
      • Jordan M.S.
      • Lumley M.A.
      • Leisen C.C.
      The relationships of cognitive coping and pain control beliefs to pain and adjustment among African-American and Caucasian women with rheumatoid arthritis.
      .06−.52 to .64B = W
      McIlvane
      • McIlvane J.M.
      Disentangling the effects of race and SES on arthritis-related symptoms, coping, and well-being in African American and White women.
      .18.05 to .31B > W
      Ruehlman et al
      • Ruehlman L.S.
      • Karoly P.
      • Newton C.
      Comparing the experiential and psychosocial dimensions of chronic pain in African Americans and Caucasians: Findings from a national community sample.
      .10−.18 to .38B = W
      Tan et al
      • Tan G.
      • Jensen M.P.
      • Thornby J.
      • Andersonm K.O.
      Ethnicity, control appraisal, coping, and adjustment to chronic pain among black and white Americans.
      .12.02 to .21B > 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.
      • Orwin R.
      A fail-safe N for effect size in meta-analysis.
      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 StrategykNEffectSMD95% CIZI2FSN
      Overall196,489B > W.25.17 to .326.35*46.8629
      Hoping/praying123,595B > W.70.48 to .926.34*88.8972
      Catastrophizing175,307B > W.40.26 to .535.81*79.5851
      Diverting attention112,781B > W.20.13 to .275.32*011
      Coping self-statements113,384B = W.08−.01 to .171.834.970
      Reinterpreting pain112,956B > W.10.03 to .182.8†00
      Ignoring pain sensations103,209B = W−.09−.26 to .08−1.0781.050
      Increasing behavioral activity51,729B = W.00−.11 to .11−.0234.780
      Exercising and stretching2679B > W.33.01 to .652.02†85.167
      Task persistence2910W > B−.28−.41 to −.14−3.99*04
      Guarding2679B = W.28−.04 to .601.7280.994
      Relaxation2679B = W.23−.04 to .501.6846.243
      Seeking social support31,029B = W.23−.04 to .511.6647.924
      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
      VariableR2βZ
      Overall
       Age.18−.42−1.58
       % Female sex.03.16.72
      Hoping/praying
       Age.16−.40−1.13
       % Female sex.22.471.75
      Catastrophizing
       Age.41−.64−3.14*
       % Female sex.01.10.47
      Diverting attention
       Age.01−.11−.23
       % Female sex.29.541.62
      Coping self-statements
       Age.23.481.07
       % Female sex.00.02.08
      Reinterpreting pain
       Age.02.13.21
       % Female sex.17.411.05
      Ignoring
       Age.01−.10−.19
       % Female sex.25−.50−1.84
      Increasing behavioral activity
       Age1.00−1.00−1.80
       % Female sex.01−.09.17
      Exercising and stretching
       Age.07−.26−.41
       % Female sex.91.962.48*
      *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 StrategykEffectSMD95% CIZ
      Active12B = W.03−.34 to .10.95
      Passive18B > W.53.39 to .687.28*
      Problem-focused12B > W.14.07 to .213.86*
      Emotion-focused18B > W.32.22 to .406.70*
      Cognitive17B > W.29.20 to .386.19*
      Behavioral8B = W.05−.03 to .121.30
      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
      • Geisser M.
      • Robinson M.
      • Riley J.
      Pain beliefs, coping, and adjustment to chronic pain: Let's focus more on the negative.
      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.
      • Chatters L.
      • Taylor R.
      • Bullard K.
      • Jackson J.
      Race and ethnic differences in religious involvement: African Americans, Caribbean Blacks, and non-Hispanic Whites.
      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.
      • Ashby J.
      • Lenhart R.
      Prayer as a coping strategy for chronic pain patients.
      • Mercado A.
      • Carroll L.
      • Cassidy D.
      • Cote P.
      Passive coping is a risk factor for disabling neck or low back pain.
      Previous research suggests that passive coping and avoidance are related to worse pain and functioning and to increased rates of disability.
      • Beckham J.
      • Keefe F.
      • Caldwell D.
      • Roodman A.
      Pain coping strategies in rheumatoid arthritis: Relationships to pain, disability, depressions, and daily hassles.
      • Brown G.K.
      • Nicassio P.M.
      Development of a questionnaire for the assessment of active and passive coping strategies in chronic pain patients.
      • Mercado A.
      • Carroll L.
      • Cassidy D.
      • Cote P.
      Passive coping is a risk factor for disabling neck or low back pain.
      • Parker J.
      • Smarr K.
      • Buescher K.
      • Phillips L.
      • Frank R.
      • Beck N.
      • Anderson S.
      • Walker E.
      Pain control and rational thinking.
      • Vlaeyen J.
      • Linton S.
      Fear-avoidance and its consequences in chronic musculoskeletal pain: A state of the art.
      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 Scale
      • Bade M.
      • Cook S.
      Functions of Christian prayer in the coping process.
      or the Multidimensional Prayer Inventory,
      • Laird S.
      • Snyder C.
      • Rapoff M.
      • Green S.
      Measuring private prayer: Development validation and clinical application of the Multidimensional Prayer Inventory.
      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.
      • Abramson L.Y.
      • Garber J.
      • Seligman M.E.
      Learned helplessness in humans: An attributional analysis, in: Human Helplessness: Theory and Applications.
      Studies indicate that black individuals are at increased risk for disparate pain care.
      • Green C.R.
      • Anderson K.O.
      • Baker T.A.
      • Campbell L.C.
      • Decker S.
      • Fillingim R.B.
      • Kaloukalani D.A.
      • Lasch K.E.
      • Myers C.
      • Tait R.C.
      The unequal burden of pain: Confronting racial and ethnic disparities in pain.
      • Mayberry R.M.
      • Mili F.
      • Ofili E.
      Racial and ethnic differences in access to medical care.
      • Tait R.C.
      • Chibnall J.T.
      Work injury management of refractory low back pain: Relations with ethnicity, legal representation and diagnosis.
      • Tait R.C.
      • Chibnall J.T.
      Attitude profiles and clinical status in patients with chronic pain.
      • Virnig B.A.
      • Lurie N.
      • Huang Z.
      • Musgrave D.
      • McBean A.M.
      • Dowd B.
      Racial variation in quality of care among Medicare+ Choice enrollees.
      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.
      • Sullivan M.J.
      • Adams H.
      • Sullivan M.E.
      Communicative dimensions of pain catastrophizing: Social cueing effects on pain behaviour and coping.
      • Sullivan M.J.
      • Bishop S.R.
      • Pivik J.
      The pain catastrophizing scale: Development and validation.
      • Sullivan M.J.
      • Martel M.O.
      • Tripp D.
      • Savard A.
      • Crombez G.
      The relation between catastrophizing and the communication of pain experience.
      The communal model of coping is consistent with the collectivistic orientation that is characteristic of many black cultures,
      • Coon H.M.
      • Kemmelmeier M.
      Cultural orientations in the United States: (Re)examining differences among ethnic groups.
      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 tolerance
      • Forsythe L.P.
      • Thorn B.
      • Day M.
      • Shelby G.
      Race and sex differences in primary appraisals, catastrophizing, and experimental pain outcomes.
      • Meints S.M.
      • Hirsh A.T.
      In vivo praying and catastrophizing mediate the race differences in experimental pain sensitivity.
      —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,
      • Arntz A.
      • De Jong P.
      Anxiety, attention and pain.
      • Jensen M.P.
      • Karoly P.
      Control beliefs, coping efforts, and adjustment to chronic pain.
      • Kleiber C.
      • Harper D.C.
      Effects of distraction on children's pain and distress during medical procedures: A meta-analysis.
      • Snijders T.J.
      • Ramsey N.F.
      • Koerselman F.
      • van Gijn J.
      Attentional modulation fails to attenuate the subjective pain experience in chronic, unexplained pain.
      whereas other studies suggest these strategies are associated with increased pain and dysfunction.
      • Keefe F.J.
      • Lefebvre J.C.
      • Egert J.R.
      • Affleck G.
      • Sullivan M.J.
      • Caldwell D.S.
      The relationship of gender to pain, pain behavior, and disability in osteoarthritis patients: The role of catastrophizing.
      • Keefe F.J.
      • Williams D.A.
      A comparison of coping strategies in chronic pain patients in different age groups.
      • Rosenstiel A.K.
      • Keefe F.J.
      The use of coping strategies in chronic low back pain patients: relationship to patient characteristics and current adjustment.
      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,
      • Snijders T.J.
      • Ramsey N.F.
      • Koerselman F.
      • van Gijn J.
      Attentional modulation fails to attenuate the subjective pain experience in chronic, unexplained pain.
      the duration of pain,
      • McCaul K.D.
      • Haugtvedt C.
      Attention, distraction, and cold-pressor pain.
      • Mullen B.
      • Suls J.
      The effectiveness of attention and rejection as coping styles: A meta-analysis of temporal differences.
      • Suls J.
      • Fletcher B.
      The relative efficacy of avoidant and nonavoidant coping strategies: A meta-analysis.
      and the level of pain catastrophizing.
      • Campbell C.M.
      • Witmer K.
      • Simango M.
      • Carteret A.
      • Loggia M.L.
      • Campbell J.N.
      • Haythornthwaite J.A.
      • Edwards R.R.
      Catastrophizing delays the analgesic effect of distraction.
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      • Campbell C.
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      • Greenbaum S.
      • Wasan A.D.
      • Borsook D.
      • Jamison R.N.
      • Edwards R.R.
      Distraction analgesia in chronic pain patients: The impact of catastrophizing.
      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.
      • George S.Z.
      • Dannecker E.A.
      • Robinson M.E.
      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.
      • Hirsh A.T.
      • George S.Z.
      • Bialosky J.E.
      • Robinson M.E.
      Fear of pain, pain catastrophizing, and acute pain perception: Relative prediction and timing of assessment.
      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.
      • Moore H.
      • Stewart I.
      • Barnes-Holmes D.
      • Barnes-Holmes Y.
      • McGuire B.E.
      Comparison of acceptance and distraction strategies in coping with experimentally induced pain.
      There is a growing evidence base for the effectiveness of acceptance approaches. Mindfulness-Based Stress Reduction

      Kabat-Zinn J: Mindfulness-based stress reduction (MBSR). Constructivism in the Human Sciences. 8:73-107, 2003

      has yielded significant improvements in pain intensity and functional limitations for individuals with arthritis as well as neck and back pain.
      • Rosenzweig S.
      • Greeson J.M.
      • Reibel D.K.
      • Green J.S.
      • Jasser S.A.
      • Beasley D.
      Mindfulness-based stress reduction for chronic pain conditions: Variation in treatment outcomes and role of home meditation practice.
      Likewise, Acceptance and Commitment Therapy
      • Hayes S.C.
      • Strosahl K.D.
      • Wilson K.G.
      Acceptance and Commitment Therapy: An Experiential Approach to Behavior Change.
      has been shown to improve pain interference, depression, and pain-related anxiety in individuals with chronic pain.
      • Wetherell J.L.
      • Afari N.
      • Rutledge T.
      • Sorrell J.T.
      • Stoddard J.A.
      • Petkus A.J.
      • Solomon B.C.
      • Lehman D.H.
      • Liu L.
      • Lang A.J.
      • Atkinson J.H.
      A randomized controlled trial of acceptance and commitment therapy and cognitive-behavioral therapy for chronic pain.
      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.
      • Dutton M.A.
      • Bermudez D.
      • Matas A.
      • Majid H.
      • Myers N.L.
      Mindfulness-based stress reduction for low-income, predominantly African American women with PTSD and a history of intimate partner violence.
      • Schuster K.
      Effect of mindfulness meditation on A1c levels in African Americans females with type 2 diabetes.
      • Zhang H.
      • Emory E.K.
      A mindfulness-based intervention for pregnant African-American women.
      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,
      • Jensen M.P.
      • Turner J.A.
      • Romano J.M.
      • Strom S.E.
      The Chronic Pain Coping Inventory: Development and preliminary validation.
      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.
      • Romano J.M.
      • Jensen M.P.
      • Turner J.A.
      The Chronic Pain Coping Inventory-42: Reliability and validity.
      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.
      • Broman C.L.
      • Mavaddat R.
      • Hsu S.Y.
      The experience and consequences of perceived racial discrimination: A study of African Americans.
      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).
      • Chapman P.
      • Mullis R.
      Racial differences in adolescent coping and self-esteem.
      • Kohn-Wood L.P.
      • Hammond W.P.
      • Haynes T.F.
      • Ferguson K.K.
      • Jackson B.A.
      Coping styles, depressive symptoms and race during the transition to adulthood.
      • Lunsford S.L.
      • Simpson K.S.
      • Chavin K.D.
      • Hildebrand L.G.
      • Miles L.G.
      • Shilling L.M.
      • Smalls G.R.
      • Baliga P.K.
      Racial differences in coping with the need for kidney transplantation and willingness to ask for live organ donation.
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      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.
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      Race differences in coping strategies may also relate to race differences in pain that have been documented in numerous experimental and clinical studies.
      • Green C.R.
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      • Tait R.C.
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      Because passive coping is related to greater pain,
      • Brown G.K.
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      Development of a questionnaire for the assessment of active and passive coping strategies in chronic pain patients.
      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.
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      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.
      • Jensen M.P.
      • Turner J.A.
      • Romano J.M.
      • Karoly P.
      Coping with chronic pain: A critical review of the literature.
      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 colleagues
      • Robbins J.A.
      • Qi L.
      • Garcia L.
      • Younger J.W.
      • Seldin M.F.
      Relationship of pain and ancestry in African American women.
      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.

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