Comparative Study of Patients With Chronic Pain India United States

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Volume: 1Issue: 3Year: 1992Pages: 278-291Journal Title: Clinical nursing research.Article Author: Kodiath,Article Tit le: A Comparative Study of Patients withChronic Pain in India and the United StatesNotice: This material may be protected by CopyrighLaw (Title 17 U.S. Code)ChargeMaxcost: 25.001FM

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Table of Contents /Index---


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Pain Is the mostfrequently reported symptom In the health care Industry today.Chronic pain In the United States costs millions of dollars annually, and Itsjfnanclallmpact ts mounting. For Individuals living In the United States. chronicpain affects nearly al l normal activities and often leaves the personfeellnghelpless and hopeless. Literature supports the Idea that chronic paln does nothave the same debilitating effect In the Eastern cultures as It does In the Westerncultures. Therefore. clients from both a Western and Eastern culture werestudied. This qualitative research. based on grounded theory. sampled 20persons from India and 20 from the United States. Focused. open-ended Interviews were used as the major mannerofgathering data. Although the conditionofchronic pain was the same or each culture. there were slgnljfcantdYJerencesregarding the phenomenon ofchronic paln. Thts research Indicates the needforhealth professionals to assess. Implement a plan of care for. and evaluatepatients suffering and need or Improved quality of ife rather than ocusing onlYon the elimination ofpain.

A Comparative Study ofPatients With Chronic Pain

in India and the United StatesMARY F. KODIATH

Veterans Admlntstratlon Medical Center; San DiegoALEX KODIATH

Samtupan. Poway. CA

Chronic pain has become one of the most prevalent. difficult.and expensive elements of today's health care tn the UnitedStates (Follick. Ahern. & Aberger, 1985). An estimated 50Authors' Note r . . . . . . _d edto Mary F - ...,.1-"'U ence and requests for reprints should be addresStstratto M odtath. Director. Chronic Low Back Pain Cllnlc. Veterans Adminn edtcal Center. 3350 La JoUa VIllage Drtve. San Diego. CA 92161.

~ ~ ~ ~ ~ E A R C H . Vol. 1 No.3, August 1992 278-291~ ~ r '- J.R;i l _ ons._ Inc..278


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Kodiath, Kodiath I PATIENTS WITH CHRONIC PAIN 279

million Americans are partially or totally disabled by chronicpain. This number translates into annual projected costs thatexceed $4 billion in health services, drugs, compensation payments, and lost workdays (Slater & Good, 1991).Nurses and other health care professionals caring for patients with chronic benign pain often complain of a sense of: f a i l u r e ~ in relieving the pain and express great frustration thatnothing can be done for these patients." Commonly, thereason for this sense ofMfailure" is that nurses and others focusonly on either eliminating or relieving the patients' pain andsuffering.

Most of the research regarding chronic benignPatn has beendone with patients from Western countries. Very little researchis documented regarding patients with chronic pain in Easterncountries such as Japan, China, and India. Under questioninghealth professionals from these countries noted that the problems and experiences of patients with chronic pain in theUnited States seemed to be very different from the experiencesof patients in Eastern countries.The purpose of the present research using the groundedtheory methodology was to develop a theory that explainedbasic patterns common to patients from the United States andIndia who experience chronic pain. An assumption underlyingthe method of grounded theory is that all groups share aspecific social psychological Mproblem." The fundamental problem is resolved by means of a social psychological process!Hutchinson. 1986). The specific social psychological problemfor this study was chronic benign pain

STATEMENT OF THE ISSUETh Ived patients withe focus of this comparative study invo pain (a)Chrontc benign pain Chronic benign pain is defined as ths (b )that . I ger than 6 man is prolonged and usually lasting on that is non-\Vith a cause that may or may not be known. ( ~ t does notresponsive to physical-surgical treatment. ( ~ I n t e n s i t y . andSUbside once injury heals. (e) with mild to c C a f f e r y 1982).

(I) that is not life threatening (Fordyce. 1976; . ts nniDons ofToday. chronic pain in the United States c: t tng (lamb &dollars annually, and its financial inlpact is mo

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Barbart, 1978). For indMduals living in the United States,chronic pain affects nearly all normal activities of dally life(Sternbach, 1987). Although the pain is termed benign, i t canhave devastating effects on a person's morale. Chronic painappears to destroy an individual's coping abilities, renderingthe person both helpless and hopeless, and, at times, evenabandoned (Lamb & Barbart, 1978). Patients do not die as aresult ofchronic pain, but they may wish they would, especiallyi f no relief is in sight.Western authors, including Evely (1967), Kennedy (1972).and John of the Cross (1987), have indicated in their writingsthat being human may be painful. Eighteenth- and 19th-century theologians considered one's humanness to be a stgnof weakness and people were subject to failure and imperfec-tion. Consequently, this imperfection was perceived as thecause of suffering. There are indications that some schools ofthought in Western culture consider physical pain to be theresult of sin or immorality (Rahner, 1967).

In opposition to this view, Indian philosophers have per-ceived pain quite differently. From an Indian philosophicalapproach, i t is a sign of low character to allow oneself to bedistracted by pain or hardship (Tiwari, 1986). For an Indianpain is often seen as suffering or Vedhana. A person is not ofthe true Indian spirit i f he or she concentrates on suffering orpain. An Indian may inltlally focus on the cause of the pain andthen begin to address how he or she needs to deal with i t(Tlwart, 1986). The Indian believes that there are greaterpurposes in pain and suffering that confer meantng, value, andjustification on life activities. Spirituality within the Indianculture Is a strong force that gives pain a constructive purpose(Radhakrishnan, 1952).Nurses in the United States who care for patients withchronic pain are very famJJtar With the feelings ofhopelessnessand failure frequently expressed by these patients. The nursescontinue to search for more therapeutic measures to assistth: ktients experiencing chronic benign pain.dia there are very few nurses per patient compared tothe United States. and most serve in acute care facilities.Consequently. Indian nurses educated to care for outpatientpatients With chro b r ch nic entgn pain were not available. This esear therefore. Will have more relevance for nurses in the


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United States. Increased understanding of the chronic benignpain experience may assist nurses in changing their therapeutic focus from the symptoms of pain to the meaning of pain forthe patient. .

METHODGrounded-theory methodology was used to generate a theory explaining the basic social psychological process for persons from both India and the United States who were experiencing chronic benign pain. Forty patient participants, men

and women, 20 from India and 20 from the United States, 25to ~ 1 years of age, and who were experiencing chronic benignPatn agreed to participate in the study .For several hours per day, observations along with formaland informal interviews were completed in southern India andthe United States. In each country, interviews were conducted

~ an outpatient clinic setting (see Table 1). During the intervtews, abbreViated notes were written along with several key .sentences that highlighted the major topics covered.Additional data were obtained from interviews with familymembers, friends, physicians, and chart notes . Experiences,ob_servations, personal thoughts, and ideas about this methodand theory made up the field notes. These notes were usuallyWritten after seeing the patient and then expanded later thatday. Left-hand margins of the field notes allowed for substantial coding that began during the data collection process.Through time, effort, and understanding of the data, thesubstantive codes were collapsed into larger categories.The third and highest level of codes, specifically theoreticalconstructs, was derived from theoretical and clinlcal knowle_dge (Chenitz & Swanson, 1986). Creating meaning was ess : -tially accomplished by conceptualizing the relationship -tw earch phenomenaeen the three levels of coding. In this res that developed as the basic psychological process w ~ e d ~scribed as well as the consequences of the phenomena o eacculture. For the purpose of his study. only the major : o : ~enon that developed regarding each culture along consequences were discussed (see Table 2>

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' 282 CLINICAL NURSING RESEARCH I August 1992Table 1Interview Questions1. How would you describe your pain?2. What have you done to relieve your pain?3. What is the history of your pain?4. How have medical doctors and/or nurses helped you to experience more

pain reltef?5. Do you have a story or a symbolic sign that helps to explain your pain?6. Is there anyone you can identify with when you are in pain?7. How has the pain affected your life?8. Is there anything you would ltke to try that you have not already tried to

relteve your pain?

Finally, the grounding process was completed by validatingthe theory against the data (Chenitz & Swanson, 1986; StraUSS &Corbin, 1990). Separate content analysis was completed byeach researcher for both populations and major findings wereagreed on. Throughout the data-gathering process and theanalysis, multiple international professionals who workedwithpatients experiencing chronic benign pain were consulted toensure validity.

GAINING ENTRYThe qualitative research was conducted during 1986 and

1987 at two sites: an outpatient clinic in southern Californiaand an outpatient clinic in southern India. In California. entryas a researcherwas gained through approval of the appropriatecommittees for the protection of human subjects. One Investi-gator was employed as the director of the chronic outpatientback pain clinic and had insider information.

In southern India the research was carried out in the Stateof Kerala. One of the investigators was born and raised in Indiaand provided considerable insider information.

DESCRIPTION OF THE SETTINGSw Both settings for this study were outpatient clinics, but they

ere very different in their respective descriptions.


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Table 2A Comparison of the Phenomena andConsequences of Indians and Americans With Chronic Palna..' Indian phenomenon American phenomenon

Searching for a cure

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Finding meaning In painIndian consequences

Became more revered by theirfamilyWere more respected by family

and friendsDeveloped closer bonds withfamily and friends

American consequencesFelt relationships with family and

friends were deteriorating

Felt isolated

Believed spiritual transformation Found little hope in Uvingwould resultIdentified with a religious leaderWere satisfied with theirprofessional careFelt peaceful

Continued daily activitiesFunctioned productively

Continued to search for professionalopinions

Felt victimizedFelt fearful of the futureHad difficulty working and continuingactivities of daily Uvlng

Used herbal medicines Tried expensive pain remediesa. Chronic pain (same for both Indians and Americans) is defined as pain : ~lasts longer than 6 months, with a cause that may or may o t ~ ~ ~ ~ o n c eIs nonresponsive to phys!cal-surgtcal treaiment. that did ~ ' : : c ~ e r y 1982).injury heals, and of mild to severe Intensity (Fordyce. 1976 ;

OUTPATIENT CLINIC IN THE UNITED STATES ed Stat s was locatedThe outpatient pain clinic in the Unit e d i ~ center. Theon the second floor in the east wing of a m desk twou ' table. one c me office consisted of four chairs. one tablewtthacbair.bookshelves, one computer located on a Iar:ee separate wallsand a Video camera and television. On ch as the spine,there were pictures of the human n a t o m y . ~ exercise bikernuscies, and joints. There also was a statio


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284 CLINICAL NURSING RESEARCH I August 1992

in one corner of the room and two blue mats leaning againstthe wall behind the video camera. The color of the room was adull peach. The clinic space was very quiet; the only externalnoise was the medical center loudspeaker that broadcastedoccasional announcements. The space in the clinic office appeared large but crowded.OUTPATIENT CLINIC IN INDIA

The clinic in India was located on the first floor of a largemedical setting. I t had a moderate amount of daylight that waspartially blocked by one large room divider and one small tablewith two chairs. A distinct medicinal odor was evident throughout both the building and the clinic space. No external clothingdifferentiated the doctors or staff from the patients. The voicesof children at play and the footsteps of people passing by couldfrequently be heard inside the clinic. The atmosphere appearedvery active but reserved.

ANALYSIS OF DATAData were analyzed using the methods outlined by strauss

and Corbin (1990). First, transcriptions of the intervieW andobservations were read and carefully examined for emergingcategories and phenomena. This process of naming the phenomenon through close examination of the data is called opencoding (Strauss & Corbin, 1990). Initially the coding processwas directed toward the discovery of the basic social psychologtcal process. The investigators then illuminated the maintheme Within the setting and explicated the data through severalphases of coding using the constant comparative method-During open coding, a number of phrases and codes began toemerge. The American patients were feeling distressed. looking

~ r more, and remained unsatisfied. The Indians were feelingeeper_respect, greater purification, closer bonds, and peace.shiDunng the next phase of analy'Sis, axial coding. relation-b ps between some of these categories became evident. Foroth the Indians and the Americans the condition of chronicpatndwas s i m i l a r ~ However, two completely different phenom-ena eveloped (see Table 2}.


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PHENOMENA AND CONSEQUENCESAmong Americans, the phenomenon included searching orlooking for a cure for their pain. The phenomenon that devel

oped for the Indians was finding meaning in their pain.The different consequences of each phenomenon are identified in the following sections.

Consequences for Indians: They felt respected and at peace. They were satisfied with the pain relief they felt. They discovered herbal ointments to be more effectiVe thananalgesic medication. They remained very involved socially. w:ere employed, and func

tioned with productivity.Consequences for Americans: They continued to search endlessly for a cure. They felt angry, lonely, and cheated. They spent a large amount of money looking for a cure. They often lost their jobs and reduced both their social andfamily involvements.

It became evident that the core category for the Indians wasfinding meaning In pain, whereas searching for the way toeliminate pain (a cure-all) was of primary importance for theAtnertcans (see Table 2).The most common response among the Americans wasSlntilar to that of one of the participants. Louise stated, "Theonly thing that gets me up in the morning Is the hope thatsomeday 111 be pain free." The Americans experienced consid;erable emotional, physical, and social distress during ~ tPresent. They did not look forward to the future unlesPromised a pain-free or close to pain-free experience. thThe Indian patients typically stated words similar t ~ in=! ) ( p r e s s e d by Elizabeth, "We all have pain at some ~ c u l t ylife and it is just natural." The Indian patients a . was notdating the onset of pain because the exper i ence := presentunusual for them. They were able to carryon v;: families were atasks in life despite the presence ofpatn. The ttentsgreat source of strength and support to these pa

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ll . 288 CLINICAL NURSING RESEARCH I August 1992'

The two stages of the psychological process were the samefor all the patients (Figure 1). Stage 1 was identified as lookingfor pain relifj. Every patient sought relief from his or herchronic benign pain. The patients from the United Stateslooked for this relieffrom multiple professional sources, includ-ing medical doctors, chiropractors, acupuncturists, physicaltherapists, and/or massage therapists. They also spent largesums of money on pain-relieving devices, such as transcuta-neous stimulators, vibrators, special chairs and beds, backbraces, and supports. Basically, Americans believed there wasa medication such as a narcotic that would relieve their pain.However, physicianswere not willing to provide i t for them. Thiscreated considerable anxiety and anger for these patients.

Indian patients reported that the best pain relief was fromherbal medicines. Occasionally they received analgesics ormild narcotics from their physician, but they always returnedto the herbal medicines because of the improved pain relief.

Stage 2 was classified asjlnding little or no lasting pain relief.All the patients experienced Stage 2. No matter what was usedto relieve pain, none of the methods, devices, or medicationscompletely eradicated the chronic benign pain.There were four phases of the basic psychological process(Figure 1). The first phase was questioning. All the patientsquestioned why they were experiencing this constant pain. Thepatients from the United States spent more time and energythinking and talking about their pain. Although the Indianpatients did not like the pain, they viewed i t as a naturalphenomenon of being human. Therefore, i t created much lessanxiety and almost no anger.The second phase was searching. Every patient searched forPain relief, but the Americans spent much more time, money.and energy in the quest of a cure. The Indian patients spentvery little time, money. or enermr and used family remediesalong 'th 1 E>J

eli wt ong Indian traditions such as special herbs for painr ef Th b e Indian patients did not need to continue the searchhcause they felt satisf ied even i f the pain relief was mild ands ort term.n.::: d Phase was different for each group of participants.g s Phase. the consequences of the phenomena be-camevery pronounced. The Indian patients were able to receiVe


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Kodlath, Kodlath I PATIENTS WITH CHRONIC PAIN 289

increased family support. Their social and interpersonal livesbecame more enriched because of their beliefs about pain andthe wisdom that was added to their lives. Indians valued thepurification process in their spiritual lives throughout thissuffering. They commonly experienced an increase in love andrespect and seldom decreased their activities of either daily .living or employment. This phase was labeled integrating.The American patients experienced disintegration of thepersonal, psychological, and social aspects of their lives. Theyhad very limited understanding of how the pain in their backaffected mood or behavior. These patients felt that i f thesymptom of pain was relieved then they would be cured. ThisPhase for the Americans was called separating.The fourth phase was identified as surrendering. The~ e r t c a n s ' sense of surrendering was voiced by Jane who said,Nothing has worked. I've used up al l my money. fve triedeverything and this pain continues. It's hopeless. I give up."Americans surrendered themselves to hopelessness and fail-ure. The patients from India experienced a spiritual surrenderto a higher power of good who cared for them and would helpthem to become purified by this experience.

IMPLICATIONS FOR PRACTICEThe most important finding of this research Is that therneantng of pain (or lack of meaning) for an individual affectsthe degree of human suffering experienced by that person.

r evidenced by the American responses, Americans report. Significantly more human suffering as a result of h r o n i c ~than did the Indian patients. There is a direct connectiforbetween the degree of suffering and the meaning of pain'each patient fFrankJ (lg77) states that i t is the s p e c i f i c ~ = ~ ~ :Person's life at any given moment that makes J.ifi pablef It is also when persons are confronted with an mes;:te thatunavoidable situation or whenever one hasu l : ~ t a : e ; deepestcannot be changed, that persons can suffering (Frankl. .r n ~ and their personal meanJng of c pain to be

.'r 19n l. The Americans perceived the fate of chronl. .\! '

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KodJath, KodJath I PATIENTS WITii CHRONIC PAIN 291Fordyce, W. E. (1976). Behavioural methods ln chronic pain and Ulness. St.

Lows: C. V. Mosby.Frankl, V. (1977). Man's searchjor meaning. New York: Pocket Books.Hutchinson, S. ( 1986). Chemically dependent nurses: The trajectory toward

self-annihtlation. Nursing Research, 35(4), 196-201.John of the Cross. Saint. (1987). John of the cross: Selected wrttlngs (KieranKavanaugh, Ed.). New York: Pauiist.Kennedy. E. C. ( 1972). The pain of being human. Chicago: Thomas Moore.Klerkegaard, S. (1980). The sickness unto death: A Christian psychologicalexposltlonfor upbutldlng and awakening. Princeton, NJ: Princeton University Press.Lamb, S., & Barbart, N. (1978). Neurosurgical approaches to the management

of chronic pain syndromes. Orthopaedic Nursing, 6(1), 23-29.McCaffery, M. (1982). Nursing management of the patient wlthpaln. Pblladelphia: J. B. Lippincott.Radhakrtsbnan, S. (1952). Contemporary Indian phtlasOPhY London: G. Allen.Rahner, K. (1967). On the theology of death (C. H. Henkey, Trans.). New York:Herder & Herder.Slater, M., & Good, A. (1991). Behavioral management of chroalc pain. Holistic

Nurstng. 6(1). 65-74.Sternbach, R. (1987). Mastering pain. New York: Ballantine.Strauss. A & Corbin, J. (1990). Bastes ofqualitative research. NewburY Park.CA: Sage.Tiwart, K. (Ed.). (1986). Suffering: Indian perspectives. Mylapore, MadraS: Sbrl

Jatnendra.

Mary F. Kodtath Is director of the Chronic Low Back Pain Clinic al:::;:Veterans Admlnlstra tlon Medical Center in San Dtega. CA- Alex KDdIs president of Samarpan. Poway. CA-

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