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Keywords:

  • Native Americans;
  • joint pain;
  • self-care;
  • education;
  • health beliefs;
  • coping

Abstract

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. SUBJECTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES

Objective

To describe beliefs and self-care strategies of American Indians with chronic arthritis joint pain.

Method

In-depth interviews were conducted with a convenience sample of urban-dwelling American Indians (n = 56) concerning self-care and beliefs about arthritis; objective measures of arthritis disease activity were obtained through standardized interview protocols.

Results

Joint pain was not generally assumed to be arthritis nor directly related to aging. Belief that chronic pain affecting multiple joints was a serious and unexpected condition oriented American Indians' decisions to seek medical attention. However, verbal communications about pain may be subtle or under emphasized. Few coping strategies were used to control either chronic or episodic pain.

Conclusions

Chronic arthritis pain may not be optimally managed in this population. Cultural assessment should recognize that American Indian patients may understate serious symptoms. Community educational interventions should target this population to enhance self-care, pain management, and communication of arthritis symptoms to physicians.


INTRODUCTION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. SUBJECTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES

American Indians are a culturally heterogeneous population composed of over 300 nations, tribes, rancherias, and bands. Limited archaeological evidence suggests that rheumatoid arthritis may be a disease of New World origin (1). Research conducted in selected reservation communities across the US found that certain autoimmune rheumatic diseases are more prevalent among American Indians than either non-Indians or Alaskan Natives and that this difference is most likely genetic in origin (2). American Indian populations have been reported to have a higher prevalence of inflammatory arthritides, including rheumatoid arthritis (3–6), systemic lupus erythematosus (3, 7, 8), and scleroderma (9). In a recent national study, American Indians reported significantly more frequent pain experiences than other Americans (10), and arthritis was the greatest predictor of that pain (11).

Cultural interpretations can affect treatment decisions and self-care of chronic disease in contemporary American Indian populations. For instance, Tlingit Indians who have been diagnosed with an inflammatory arthritis may understate their level of disability as a culturally appropriate response to inquiry about functional impairment (12). Members of the Canadian First Nations generally delayed their entry into the healthcare system until more severe symptoms manifested (13). Other coping behaviors for dealing with arthritis are not documented for Native Americans. This report, therefore, is the first to describe beliefs about chronic joint pain, the interaction of personal experiences and beliefs, and the manner in which beliefs affect self-care strategies and other health-seeking behaviors. Recommendations are given to improve management of chronic arthritis pain in American Indian patients.

SUBJECTS AND METHODS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. SUBJECTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES

Study sample.

The study was conducted in Los Angeles and northern Orange counties in southern California. Arthritis/rheumatism had been previously found to be a leading health problem for American Indians living in the study area (14). This region has the highest population density of urban-dwelling American Indians in the US and no reservations are located in the study area. As many as 200 American Indian tribes and Alaskan Native and villages may be represented in this population according to the Los Angeles City/County Native American Indian Commission. The majority are affiliated with cultural groups from the historic Oklahoma Indian territories (e.g., Choctaw), the Southwest (e.g., Navajo), and the Northern Plains (e.g., Sioux) (15–17). In comparison, relatively few indigenous California peoples live in the study area. This pan-Indian community is defined by interaction, rather than geography, and participation in American Indian community activities is an important marker of ethnic identity (17).

Convenience sampling was used as the most appropriate methodology for a community-based psychosocial study of urban American Indians (18). This strategy has been demonstrated to reflect the general American Indian population in this region (19). Study participants were recruited by local American Indian organizations (i.e., a multipurpose community organization and several churches). These agencies are Indian-operated and serve a pan-tribal clientele from which study participants were recruited. Subject recruitment criteria were 1) recognition as an American Indian by the community, and 2) currently experiencing any type of joint pain.

Interview procedure.

Persons who were identified as potential participants were contacted and, with the subject's permission, audiotaped interviews were conducted by American Indian interviewers. Bilingual interviews and translations were performed as needed. Research staff trained the interviewers and monitored their performance throughout the data collection period.

Structured in-depth interviews were conducted with a cross-sectional convenience sample of American Indian subjects experiencing chronic joint pain, plus a smaller similar sample of subjects not experiencing joint pain on the day of the interview. The interview included both open-ended and closed-ended questions and could be completed in about 45 minutes. Open-ended questions were designed to elicit 1) experiential descriptions of joint pain and the impact of chronic pain on usual activities, 2) meanings and beliefs associated with this type of pain, 3) preferred coping strategies, and 4) medical experiences. Objective information about joint disease was elicited through responses to standardized instruments, including a connective tissue disease screening questionnaire (20), the Health Assessment Questionnaire disability section (HAQ), mannequin-assisted self-reported tender and swollen joint counts (21), and a pain visual analog scale (VAS). Both open-ended and closed-ended questions, as well as visual analog scales, were pretested in focus groups convened at 2 American Indian community centers.

If potential respondents were not experiencing joint pain on the day of the interview, the protocol was to conduct a brief interview on beliefs and meanings associated with arthritis. The questions were identical to those sections of the longer interview form.

Quantitative and qualitative analyses.

The analysis compared responses of study participants according to 4 disease categories: inflammatory arthritis, noninflammatory arthritis, localized musculoskeletal pain syndrome, and no current joint pain problems. Assignment to a likely disease category was made by a clinical rheumatologist based on participant responses to the connective tissue disease screening questionnaire, the pattern of joint involvement on the mannequin-assisted self-reported tender and swollen joint counts, and self-reported use of prescribed or over-the-counter medications. The diagnoses likely to be identified in the inflammatory arthritis category were rheumatoid arthritis, lupus, seronegative spondylarthropathy, scleroderma, and Sjögren's syndrome; diagnoses in the noninflammatory arthritis category were generalized and localized osteoarthritis; and diagnoses in the localized musculoskeletal pain syndrome category were tendinitis, bursitis, and localized myofascial pain syndromes.

Quantifiable responses from the voice recordings, note-based documents, and transcripts were entered into Microsoft Excel database files (Microsoft Corporation; Seattle, WA). These responses included qualitative data that were amenable to coding, scaling, and statistical analyses, such as the use of prescription or over-the-counter medications, the duration in years of joint pain, and the self-reported pain ratings. Quantitative data were exported to a SPSS database (Statistical Package for the Social Sciences, 1999, Chicago, IL) for descriptive, parametric, and nonparametric analyses. Qualitative text data were also managed using Microsoft Excel to facilitate sorting and comparisons by disease classification, beliefs, and experiences. In an iterative process, textual responses were analyzed to establish domains of belief, and responses were coded for further analyses. Inter-rater reliability was set to 95% and greater disagreement required re-analysis of the coding system and additional training. Two coders working independently generally achieved 98% agreement, and a third coder resolved any disagreements.

RESULTS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. SUBJECTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES

Sample.

In-depth, face-to-face interviews were conducted with 56 American Indians, ranging in age from 23–90 years (mean 54.9 ± 16.1 years). The sample consisted of persons classified with inflammatory arthritis (n = 12), noninflammatory arthritis (n = 24), localized musculoskeletal pain syndrome (n = 9) (Table 1), and an additional group who were experiencing no current joint pain problems (n = 11). The majority of sample respondents were women and that proportion varied by disease category: 92% in the inflammatory arthritis group, 79% in the noninflammatory arthritis group, and 44% in the localized musculoskeletal pain group. The sample represented 30 tribal affiliations and, consistent with other studies, the majority were affiliated with tribes from the Southwest, Oklahoma historic Indian territories, and Northern Plains; few indigenous California tribes were represented. All respondents spoke English, and 2 respondents preferred to conduct parts of the interview discussions in both English and Navajo.

Table 1. Sample characteristics: self report of disease activity*
 Inflammatory arthritis (n = 12)Non-inflammatory arthritis (n = 24)Musculoskeletal pain syndrome (n = 9)ANOVA
MeanSDMeanSDMeanSDF-testP
  • *

    Means in same row with different subscripts differ in Tukey honestly significant difference comparison at: a versus b, P < 0.001; b versus c, P < 0.02; d versus e, P < 0.05. ANOVA = analysis of variance; HAQ = Health Assessment Questionnaire.

  • Assumptions for ANOVA were not met; nonparametric Kruskal-Wallis test results are reported.

  • Assumptions for ANOVA were met using log-transformed tender joint counts; results of ANOVA are for transformed data; means and SD are reported for non-transformed data.

Swollen joints (Range 0–48)10.9a(11.7)1.4b(2.0)0.0b(0.0)14.550.001
Tender joints (Range 0–50)17.8a(11.9)4.4b(4.1)1.3c(0.9)25.830.000
HAQ disability (Range 0–3)0.958d(0.758)0.464(0.511)0.347e(0.548)3.600.036
Highest current pain rating (Range 0–10)6.7(2.6)5.6(2.5)4.7(2.6)1.380.265
Age, years54.0(14.6)59.4(13.8)46.7(19.4)2.360.107
Chronic pain duration, years9.6(7.0)10.4(8.6)4.3(3.7)0.720.931

Symptoms and disease activity.

In general the group classified as having inflammatory arthritis had more severe symptoms than the other 2 groups (Table 1). The inflammatory arthritis group had an average of 11 swollen joints, significantly more than in the noninflammatory and the musculoskeletal groups, (Kruskal-Wallis non-parametric test = 14.55, degrees of freedom = 2, P = 0.001). The total number of each respondent's tender joints were log-transformed to meet assumptions of analysis-of-variance, which showed significant differences between groups, (F[2,42] = 25.8, P < 0.001). As expected, the inflammatory arthritis group had significantly more tender or painful joints than the other 2 groups, Tukey's honestly significant difference (HSD) post-hoc tests P < 0.001; and the noninflammatory arthritis group had more tender joints than the musculoskeletal group, P = 0.024.

The inflammatory arthritis group also reported a significantly higher level of disability (HAQ) than the musculoskeletal pain group but not the noninflammatory arthritis group. Although the inflammatory arthritis group reported the highest mean pain rating, there were no statistically significant differences among the groups in reported pain. However, pain was correlated with HAQ scores (Pearson's r = 0.703, P < 0.001). For all 3 groups, mild to moderate pain was associated with less disability (HAQ scores of <1.0), while severe to worst pain was associated with greater disability and reduced functional independence (HAQ scores of >1.0).

Beliefs.

Arthritis was perceived as an illness affecting Indians and non-Indians alike and characterized by pain, suffering, decreased function, and crippling deformities. Arthritis was not considered to be a disease that was unique or more prevalent among Indian peoples. Respondents' beliefs about what happens to people with arthritis were related to their own illness experiences. Those with inflammatory arthritis were more likely to describe the functional impact of arthritis (63%) than the painful aspects (38%), while those with noninflammatory arthritis were more likely to focus on pain and suffering (69%) than on functional disability (30%). Those with localized musculoskeletal pain syndrome or with no joint pain problems were equally divided in their opinions that arthritis results in either pain or disability. Beliefs about the causes of arthritis were elicited in responses to open-ended questions. The cause of arthritis was attributed to heredity, illness, injury that resulted from hard or repetitive work, or environmental factors. Most (82%) of the total sample, including all subjects classified with inflammatory arthritis, believed that arthritis was not directly related to aging. Some persons elaborated that although “aches and pains” might be age-related, pain was not normal at any age and that “aging doesn't hurt.”

Self-care.

Respondents' self-care strategies to cope with chronic joint pain became increasingly less aggressive with duration of arthritis pain. Their self-care methods varied by disease category, as would be expected (Table 2). Although respondents had experienced joint pain for years, they still recalled their first efforts to alleviate that pain. Those classified with inflammatory arthritis joint pain recalled using over-the-counter pain relievers and rubs but also remembered that these brought no relief. In contrast, half of the respondents with noninflammatory arthritis obtained pain relief, generally from a combination of over-the-counter pain relievers, rubs, heat, massage, exercise, or use of a device such as a cane or brace. Alternative nutritional supplements were rarely tried and multiple preparations were combined (i.e., methylsulfonylmethane, dehydroepiandrosterone, and Vitamin E; vinegar with honey; and alfalfa tea). Respondents deemed these remedies to be ineffective in relieving their initial noninflammatory arthritis joint pain (although some found MSM to be helpful for chronic pain). “Indian tea,” an all-purpose tonic was also tried initially by subjects classified with any type of joint disease, but this remedy also brought no pain relief.

Table 2. Self-care for chronic joint pain
Self-care strategyInflammatory arthritisNon-inflammatory arthritisLocalized musculoskeletal pain syndrome
  • * OTC = over-the-counter; VAS = visual analog scale;

  • In descending order of frequency

  • Number who ever sought care from a physician for joint pain, excluding one respondent with scheduled appointment for care of joint pain.

Self-care for first pain, (effectiveness rating)OTC pain reliever (ineffective) Rubs (ineffective)Combination OTC pain reliever, rubs, heat, massage, exercise and/or mobility aid (50% effective)OTC pain reliever, heat or exercise (effective)
Traditional: Indian tea (ineffective)Nutritional supplements (ineffective)Rub or ice (ineffective)
 Traditional: Indian tea (ineffective)Traditional: Indian tea (ineffective)
Consult physician (n = 31)   
 No (%) seeking care10 (83)18 (75)3 (33)
 Age, years (mean, SD)56.2 (14.2)60.5 (14.4)50.6 (24.1)
 Swollen joints, no. (mean, SD)10.9 (11.8)1.3 (2.0)0
 Tender joints, no. (mean, SD)16.1 (10.7)4.8 (4.4)1.7 (0.6)
 Years in pain9.4 (6.2)11.4 (8.8)5.4 (4.5)
 Pain VAS 1–10 (mean, SD)6.4 (2.8)6.1 (2.2)6.2 (3.6)
Self-care for daily chronic painEndure painEndure painExercise
Ignore painOTC pain relieverEndure, ignore or rest
OTC pain relieverExercise 
Prescription drugPrescription drug, heat or rest 
Self-care for episodic intense painOTC pain relieverOTC pain relieverOTC pain reliever
HeatEndure or ignoreEndure
ExerciseHeatHeat

Pain relief strategies were not pursued as aggressively when joint pain became chronic. The most common strategy used to cope with chronic joint pain on a day-to-day basis was to endure the discomfort by using various distraction strategies, including meditative thoughts, prayer, deep breathing, visualization, humor, reducing stress, maintaining positive mood and attitude, and focusing on activities or other interests. A similar and frequently mentioned coping strategy was to “ignore the pain” or “let it hurt” rather than allow pain to interfere with activities. Pain relief was not the first response to chronic inflammatory arthritis joint pain although analgesics were ranked as the most frequent response for chronic pain of noninflammatory arthritis or localized musculoskeletal pain syndrome. In contrast, intense episodic pain was most likely to be treated with an over-the-counter pain reliever for all types of joint pain. Although most people felt that they could influence their own pain, there was an inverse relationship between pain intensity and belief that one could influence pain.

Knowledge of traditional practices did not imply use of these modalities. About one-third of respondents were familiar with indigenous remedies for joint pain but only “Indian tea” was actually used by these respondents as a traditional remedy. Familiarity with traditional treatments was unrelated to tribal affiliation, although practices varied somewhat by cultural group. Traditional treatments described for joint pain were poultices, rubs, teas, snake venom, and heat, including steam infused with herbs and hot mineral water baths. Respondents did not relate tub-baths for heat, or over-the-counter commercial products for rubs to traditional practices. The only traditional type of care considered appropriate and effective, based on respondents' experiences, was seeking treatment from a traditional healer as well as from a medical doctor.

These management strategies were based on personal experience, advice of family and friends, and exposure to print and broadcast media reports on health. Few (13%) attributed their self-care methods to recommendations by a health care provider or educator. These recommendations were limited to use of prescribed or over-the-counter analgesics, advice to endure painful symptoms, and recommendations to exercise that did not necessarily include joint protection instructions. However, American Indians were receptive to learning more about arthritis self-care modalities. With only one exception, all respondents were interested in attending an arthritis self-help class. Although most respondents thought that convenience would be the most important factor facilitating their participation, 11% would prefer to attend classes only with other Indian people.

Seeking medical care.

Initially, most did not assume that their joint pain was caused by arthritis. Interviews indicated that respondents tended to refer to their joint pain as “arthritis” only after a physician had diagnosed the illness. Others, who suspected that they might have arthritis, also consulted a physician once they experienced pain in more than 1 joint. Overall, 70% of those with pain discussed symptoms of joint pain with a doctor. Of those who sought medical care for joint pain, most chose their primary care provider. Only 5 physician referrals and 3 patient self-referrals were made to rheumatologists.

With only one exception, all respondents who were classified with inflammatory arthritis sought medical attention at some time (Table 2) or were scheduled to see a doctor to discuss joint pain. Three-quarters of the group that was classified as having noninflammatory arthritis had also sought medical care and these respondents continued to experience more intense symptoms of pain (mean VAS score of 6.1 ± 2.2 versus 3.5 ± 3.0), and had more tender joints (mean 4.9 ± 4.4 versus 2.8 ± 2.9) in comparison with those classified with noninflammatory arthritis who had never sought medical care for joint pain. One-third of the group classified as having localized musculoskeletal pain syndrome consulted a medical doctor, and this subgroup experienced more intense symptoms of pain (mean VAS score of 6.2 ± 3.6 versus 2.4 ± 2.1) than the remaining two-thirds of this group who did see a doctor.

Although most respondents did consult a physician about their symptoms, their level of pain or dysfunction might not be presented at first onset of symptoms or might be revealed in a subtle, guarded manner. In response to the open-ended question on what they “would like doctors to know about treating American Indian patients,” respondents openly commented on the cultural practice of minimizing pain complaints. They noted that American Indians generally do not readily ask for help, discuss pain, or disclose the intensity of a painful episode. Typical statements included: “We don't feel comfortable talking about ourselves and usually don't let people know our pain.” “Indians are independent, shy, and won't ask for help.” “Indians don't complain of aches and pain.” “If someone says it hurts a little, [they are] probably underplaying the level of pain.” “A Native American who suffers from pain is a very needy patient.” One respondent delineated the key to a productive clinical physician-patient relationship as, “Doctors need to be aggressive but friendly to dig out problems.” If a pain complaint, once divulged to a physician, is not addressed, the complaint will not be voiced again “unless they are really bad off.”

Seeking healthcare did not necessarily lead to prescribed pharmacotherapies for the management of disease activity or education about pain control through localized specific therapies. Table 3 displays current daily medication of patients classified with inflammatory and noninflammatory arthritis. Half of those classified with inflammatory arthritis received medication prescriptions from their physicians, although if respondents discontinued medication because of side effects, they did not report pursuing additional alternate therapies with their physicians. Only 2 of the 12 subjects classified with inflammatory arthritis were using disease-modifying antirheumatic drug therapy. All other drug therapies were prescribed as analgesics to alleviate joint pain. Respondents understood that these products provided symptomatic relief only and did not expect these therapies to improve the underlying illness. Over-the-counter nonsteroidal antiinflammatory drugs (NSAIDs) were used in subtherapeutic doses for chronic arthritis pain. Two-way analysis of variance tested the relationship between diagnosis (inflammatory or noninflammatory arthritis) and receiving prescription drug therapy (yes/no) on measures of symptom severity. The significant interaction between diagnosis and prescription medication revealed that subjects with inflammatory arthritis who received prescribed pharmacotherapy reported significantly more swollen joints (mean = 16.5), and tender joints (mean = 21.7) than subjects with inflammatory arthritis who only took over-the-counter pain relievers or no medication (mean = 5.3 swollen and 7.8 tender joints). For those with noninflammatory arthritis, prescribed drug therapies were not associated with self-reported pain, number of swollen or tender joints, or disability.

Table 3. Self-report of arthritis disease activity measures and daily medication use among American Indians who consulted a physician
 Inflammatory arthritisNon-inflammatory arthritisANOVA
Prescribed medicine (n = 6)OTC analgesic or none (n = 4)Prescribed medicine (n = 5)OTC analgesic or none (n = 13)
meanSDmeanSDmeanSDmeanSDF-testP
  • * OTC = over the counter; ANOVA = analysis of variance; HAQ = Health Assessment Questionnaire.

  • Interaction results for arthritis group by medication use.

Swollen joints (Range 0–48)16.5(12.3)2.5(3.0)1.4(1.3)1.3(2.3)7.38.012
Tender joints (Range 0–50)21.7(10.1)7.8(3.8)6.8(5.4)4.2(4.0)5.12.033
HAQ disability (Range 0–3)1.06(0.79)0.91(1.01)0.53(0.47)0.60(0.58)0.16.691
Highest current pain rating (Range 0–10)7.0(2.6)5.4(3.1)6.5(2.4)5.9(2.2)0.26.617

DISCUSSION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. SUBJECTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES

The limitations of this study are typical of a single-site qualitative study. The sample size is small, consistent with the methodology, and the present study is not intended as an epidemiologic study. Further research would be needed to establish the distribution of knowledge, attitudes, beliefs, and self-care preferences in this population. However, this study establishes the domains and range of responses that would be relevant to a forced-choice survey appropriate for a larger study. Health information was collected exclusively from self-reports without concurrent clinical examination or review of patient medical records. It was not possible to confirm respondents' arthritis diagnoses, prescribed pharmacologic therapies, or physician's assessments. Nor was it possible to confirm whether respondents had discussed side effects or discontinuation of medication with their physicians.

Despite the likelihood of New World origin for rheumatoid arthritis, there was no attribution of any type of joint pain as uniquely indigenous. American Indians did not use the term “arthritis” as a synonym for joint pain; instead, they reported arthritis only when a community physician had made a formal medical diagnosis. Most respondents considered arthritis to be an illness that is not directly related to the normal aging process. The belief that chronic polyarticular joint pain was a serious health condition oriented American Indians' decisions to seek medical attention. The experience of living with arthritis resulted in different appraisals of the long-term impact, depending on the type of arthritis: decreasing functional abilities were viewed as the long-term impact among those having inflammatory arthritis, while increasing pain and suffering were the impacts expected among those having noninflammatory arthritis. These quality of life issues mirror the long-term concerns of First Nations peoples who had been diagnosed respectively with inflammatory or noninflammatory arthritis (13).

Most American Indians eventually sought medical attention for chronic joint pain. However, the severity and impact of chronic arthritis appeared to be under-recognized and therefore not optimally treated in a multidisciplinary fashion. Those with the most severe symptoms of inflammatory arthritis were likely to receive pharmacotherapies; however, severity of symptoms did not predict pharmacotherapy for noninflammatory arthritis in this population. Healthcare providers also recommended few options to treat or reduce localized pain. NSAIDs were commonly used in subtherapeutic doses for daily and/or intense joint pain episodes in people with chronic arthritis. Even a decade after onset, these persons continue to experience moderate pain on a regular basis. Although drug therapies should be the first line strategy for pain flares of inflammatory arthritis, this was the least frequently used option. Instead, American Indians most frequently endured the discomfort of their chronic pain and episodic flares. Nevertheless, this community was overwhelmingly interested in an arthritis self-help class to learn more about the condition and alternatives for managing chronic arthritis.

We explored the concept of coping strategies using open-ended questions rather than limiting the responses to items of the Cognitive Strategy Question (22) or the Vanderbilt Pain Management Index (VPMI) (23). Our open-ended questions on “coping with pain” were interpreted by all participants as queries about self-management. Typically, American Indian respondents choose management behaviors designated as active strategies on the VPMI (e.g., ignoring pain, distracting attention from pain, exercise) that have been associated with better pain control, better function, and less depression than those using passive strategies (e.g., taking medication) (23, 24). In the present sample, neither cognitive nor behavioral pain relief strategies were associated with pain intensity, the total number of swollen joints, total number of tender joints, or total number of years of chronic joint pain. However, American Indians who chose to endure painful symptoms were significantly older (mean age = 62.0 years) than persons who used pain control (mean age = 55 years) or who ignored their pain (mean age = 43 years, F[2,33] = 3.50, P = 0.042). Negative thoughts and catastrophizing, which have been associated with poor psychological outcomes (25–27) and greater physical disability (28), were generally absent in the narrative responses during in-depth interviews with the current sample. These findings underscore the cultural value of embracing and adapting to present circumstances but highlight the subtlety that might be expected in communications related to pain.

American Indian patients may not emphasize their pain complaints. Because this population describes pain in a subtle manner, verbal descriptions of mild symptoms might, in fact, reflect symptoms of a more serious nature, such as an inflammatory arthritis like RA. Therefore, the act of seeking medical attention for joint pain should suggest to primary care physicians that an American Indian patient is likely to need further evaluation of his/her joint pain or arthritis in order to arrive at an appropriate assessment and successful treatment approach. Additionally, since these patients are interested in more information about self-care, they would benefit from education on proper use of analgesics and localized therapies to reduce pain, as well as joint protection instructions for exercise.

American Indians in this study made a clear distinction between chronic pain and the expected aches and pains that result from living a full and active life. They did not consider chronic joint pain to be normal at any age. As a result, most American Indians consulted physicians after the nature of pain had become chronic in multiple joints and self-care options had failed. Nevertheless, chronic joint pain was generally under-treated in this population. In conducting a cultural assessment, clinicians should be aware that American Indian patients do not emphasize pain symptoms and that cultural appropriate expressions of painful symptoms are subtle. Their requests for medical care for chronic joint pain should be taken seriously, and they should be evaluated fully and appropriately treated, or referred to a rheumatologist for arthritis care. American Indian patients may appear stoic, enduring or ignoring pain, but many would welcome information about arthritis, disease management, and effective pain relief strategies. Future community health programs should target educational programs, such as the Arthritis Self-Help Course, to urban American Indian populations to enhance self-care options and to reduce painful symptoms.

REFERENCES

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. SUBJECTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES
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