Non-Scandinavian and Scandinavian women's expectations and experiences of acute pain

1. Introduction 

The perception of pain is a personal experience influenced by many factors, including ethnic and cultural issues. In Mark Zborowskis classic studies on pain (1962; 1969) he concluded that pain, like many other psychological phenomena, acquires specific social and cultural significance and thus reactions to it must be understood in light of this [1], [2]. Ethnic differences regarding pain have been studied from both a nursing perspective [3], [4], [5], [6], [7] as well as from a medical point of view [8], [9] Some studies have found no ethnic differences [10], [11], while others did find differences regarding pain management, but could not always relate them to ethnicity [12], [13]. However, Streltzer and Wade [13] demonstrated great differences according to ethnicity in post-operative analgesic distribution, suggesting that undertreatment of pain could be either a sign of ethnic differences or a cultural bias in pain treatment. This is in line with Todd et al., who observed the underestimation of pain in minorities by health care providers [10]. There is also evidence that assessment of pain by medical staff is influenced by the ethnic origin of the patient [10], [14], [15], [16], [17]. Therefore, although examining rather different populations, these studies reached similar conclusions—that ethnicity has a significant impact on both assessment and treatment of pain. In experimental laboratory studies, Zatzick and Dimsdale demonstrated greater pain sensitivity among African Americans compared to European Americans [18]. More current studies have suggested greater sensitivity to experimental heat pain among African Americans compared to whites, especially for measures of pain unpleasantness [19], [20]. Patients undergoing root canal therapy and/or tooth extraction have reported significant pain discomfort [21], and both Widstrom [23], [24] and Jamison [22] have suggested that the pain a person experiences when he or she has toothache could serve as an example of acute pain [22], [23], [24], [25].

The effects of background stress as well as coping strategies for acute pain perception have been described by Raak and Wahren and the emotive part of coping with background stress was suggested to be a variable when measuring emotional factors involved in pain perception [26]. Melzack also indicated that pain perception may be influenced by the stress response system, and the report of acute pain in medical procedures has been shown to be associated with emotional distress [27], [28]. Moreover, pain behaviour has been described to result from earlier pain experiences, fear and expectation of pain. Gedney et al. examined the expectation of pain in relation to root canal therapy (RCT) from both a sensory and an emotional perspective [29]. The emotional state, i.e., the expectation of unpleasantness in relation to RCT, was found to be of importance [29]. Watkins et al. demonstrated that Visual Analogue Scale (VAS) ratings of expected pain in endodontic treatment mostly exceeded ratings of experienced pain [30]. The present study was designed to elucidate the nature of ethnic differences in pain perception (i) by investigating the expectation and experience of acute pain and (ii) by examining the distribution of analgesics and the use of stress-coping styles in women born outside Scandinavia compared to Scandinavian women.

2. Materials and methods 

2.1. Subjects 

Sixty-seven adult women (mean age 42.2 years; range 19–84 years) were invited to participate in the study. Twenty-two women were immigrants born outside Scandinavia, and 45 were Scandinavian women. No participants reported histories of any condition known to influence pain perception, and all reported that they were in good health. All women were scheduled to undergo potentially painful dental treatment (root canal therapy and/or extraction), which might require analgesics. A further requirement was that all women should speak, read and understand Swedish. Exclusion criteria were analgesic treatment on the evening before or the day of examination/treatment. Subjects were recruited consecutively.

Of the 45 women born in a Scandinavian country, three were not included: two claimed lack of time and one had the treatment postponed. Of the 22 women born in a non-Scandinavian country, three were not included: two due to the cancellation of treatment, and one due to current analgesic treatment. A final total of 61 women (42 born in a Scandinavian country, age range 19–72; 19 born in a non-Scandinavian country, age range 21–84) participated in the study (Table 1). All subjects gave informed consent, and the ethics committee of the University of Linköping, Sweden, approved the study.

Table 1. Country of origin in the non-Scandinavian women (N=19)

	Country of origin	Number
	Bolivia	1
	Chile	1
	Italy	1
	Kosovo	1
	Sri Lanka	1
	Thailand	1
	Czech Republic	1
	Turkey	1
	Hungary	1
	India	2
	Lebanon	2
	Iraq	3
	Syria	3

3. Results 

The non-Scandinavian women rated their expected pain during dental treatment significantly higher than the Scandinavian women. Non-Scandinavian women (n=19) VAS-rated their expected dental treatment pain at M=46.1, S.D.=29.1, while the Scandinavian women (n=42) rated their expected dental treatment pain at M=26.3, S.D.=25.6 (p=0.012).

The non-Scandinavian women also experienced the dental treatment pain as significantly greater. The women born in non-Scandinavian countries rated their experienced pain at M=24.1, S.D. 21.5, while the Scandinavian women rated their experienced pain at M=11.9, S.D. 14.4 (p=0.015) (Table 2).

Table 2. Visual Analogue Scale (VAS) scored expected and experienced dental treatment pain in non-Scandinavian (n=19) and Scandinavian women (n=42) respectively

	VAS	Non-Scandinavian women		Scandinavian women		p-Values
		M	S.D.	M	S.D.
	Expected pain	46.7	29.1	26.3	25.6	0.012
	Perceived pain	24.1	21.5	11.9	14.4	0.015

No significant difference was found in administered analgesics between the two groups (Table 3).

Table 3. Distribution of local anaesthetic (in millilitres) during a painful dental treatment procedure in non-Scandinavian and Scandinavian women, respectively

	Anaesthetic (ml)	Non-Scandinavian women (n=19)	Scandinavian women (n=42)
	0	8	23
	0–1.8	9	15
	1.9–3.6	2	2
	>3.6	0	2

Comparing the use of stress-coping styles, no significant difference was found between women born outside a Scandinavian country and those born in a Scandinavian country. A non-significant tendency toward difference was found in the supportant coping style (Scandinavian women M=1.44, S.D. 1.2; non-Scandinavian women M=1.06, S.D. 0.72; p=0.057) (Table 4).

Table 4. Stress coping styles were measured on the JCS (Jalowiec Coping Scale) both in non-Scandinavian and Scandinavian women respectively. The styles assessed were confrontative, evasive, optimistic, fatalistic, emotive, palliative, supportant and self-reliant. The range of all items is 0–3, with 0 indicating “never used” and 3 indicating “often used”

	Coping styles	Non-Scandinavian women		Scandinavian women		p-Values
		M	S.D.	M	S.D.
	Confrontative	1.58	0.82	1.77	0.71	NS
	Evasive	1.41	0.61	1.35	0.52	NS
	Optimistic	2.02	0.66	2.01	0.62	NS
	Fatalistic	1.40	0.78	1.48	0.65	NS
	Emotive	1.26	0.64	1.28	0.60	NS
	Palliative	0.97	0.57	0.97	0.47	NS
	Supportant	1.06	0.72	1.44	0.66	NS
	Self-reliant	1.53	0.83	1.73	0.53	NS

The three most used stress-coping styles were similar in both groups of women, with the optimistic stress-coping style the most common, followed by the confrontative style, and thirdly the self-reliant stress-coping style. The least used stress-coping style in both groups was the palliative style.

4. Discussion 

The result of this study shows that non-Scandinavian women rate both expected pain as well as experienced pain significantly higher than Scandinavian women. Previous studies have shown that pain is more likely to be reported by those who are anxious about dental treatment [38], [39]. It might be that the non-Scandinavian women are more anxious about the dental treatment than the Scandinavian women. One explanation to this can be that Scandinavians are more comfortable in the dental treatment situation being brought up with Public dental service, and therefore used to regular visits to the dentist.

It is also known that oral and dental health is worse among immigrants, possibly due to less regular dental care before migration. Poor dental health might mean greater need for potentially painful dental treatments [40]. As a contrast, Scandinavian women could have relied on being given sufficient analgesics, and therefore not expecting pain.

Anderson showed that emergency dental patients in most cases requested information and psychological support as well as symptom relief [17]. Further, Lahti et al. [41] suggested that greater focus should be placed on the communication skills of dentists. One suggestion might be that structured preparatory information could reduce patients’ anxiety levels [41]. Assessment of patients’ pain experience and/or pain intensity level should also be in focus to a greater extent. This is in accordance with van Wijk, who stated that written information prior to treatment can alter the pain experience [42].

Fear, anxiety, and expectation of pain can be based on painful memories of dental treatment [29]. Rhudy and Meagher [43] investigated whether fear and anxiety influenced the experience of pain, based on the hypothesis that fear inhibits pain whereas anxiety enhances it. Their study showed that fear and anxiety had divergent effects on pain thresholds in people, with anxiety lowering pain thresholds [43]. Similarly, the findings in the current study could reflect a higher anticipation of pain in the non-Scandinavian women, thus generating a greater experienced pain rating. One suggestion might be that by controlling the pre-treatment level of anxiety, it would be possible to generate a positive experience of a painful, stressful situation and thus increase pain relief.

Coping styles and strategies have been suggested to moderate the relationship between ethnicity and pain, and have also been demonstrated to vary by culture [44], [45]. This is not confirmed by the present study, where no differences were found in the use of stress-coping styles between groups. A non-significant tendency towards more supportant coping style in the Scandinavian group could indicate that the immigrant women might require extra support in the clinical situation and that nurses should be aware of this need.

On pain treatment, Streltzer suggested that some cultural styles may be more susceptible to undertreatment of pain than others [13]. While individual factors are probably of greatest importance in the treatment of pain, cultural factors do contribute to differences or variability. Whether this reflects ethnic differences in analgesic requirements or is a demonstration of cultural bias in treatment could not be determined. In the present study, the amount of analgesics given did not differ between the groups, although the non-Scandinavian women both expected and experienced significantly more dental treatment pain. Several studies have indicated that physicians tend to prescribe less analgesic medication for African Americans than for whites [8], [9]. In the assessment of pain, there is evidence that staff are influenced by the ethnic origin of the patient [10], [16], [17], [46]. One explanation in the present study might be that the women undergoing dental treatment show similar pain behaviours, regardless of ethnic origin. Another explanation might be a lack of communicational skills in medical staff, which is in line with Lahti's (1996) findings [41].

The present study has a number of limitations: firstly, the heterogeneity of the sample; secondly, the small sample size. The representation of several cultures/nationalities in the present study could be regarded as both a limitation and a strength. Other studies on ethnicity and pain have examined selected ethnic groups, such as Hispanics, Black Americans, etc., making generalisation easier. On the other hand, this could be a strength since Sweden during the past few decades has developed into a multicultural society, therefore the present sample could be representative of the immigrant population in Sweden. Further limitations might be language barriers resulting in difficulties in completing questionnaires in Swedish, which also was noted by Dahlberg and Pendle [4]. This might contribute to the lack of differences in stress-coping styles, if the items in the JCS questionnaire were difficult to understand there is a possibility that the results are skewed.

Both expectation of pain and experience of pain are culturally conditioned. Differences between non-Scandinavian and Scandinavian women should lead to greater consideration of the differences in pain expression. This paper addresses cultural perspectives that should be considered when a patient is in pain and specifically when a patient is unable to explain the expectancy and experience of pain. Nurses in these situations must be aware of the need for appropriate assessment tools as well as of the need to be sensitive to variations in both verbal and non-verbal communication styles across cultures.

Conflict of interest 

There are no conflicts of interest.