Chronic pain represents a common public health concern worldwide. It is a complex phenomenon, owing to the interaction of different factors, including biological, physiological, psychological, environmental, and social variables. Some groups, such as women and immigrants, are particularly vulnerable. However, little is known about how Chinese women in Italy live with and face chronic pain. The present study aimed at filling this knowledge gap by examining the burden of chronic pain in Chinese immigrants in Italy in terms of acculturation processes, perceived control over disease, social networks, and coping strategies. A qualitative approach was used, performing a thematic field analysis. We interviewed 82 Chinese women from different Italian towns (Genoa, Milan, Turin, Bologna, Florence, and Prato) in depth. The sense of belonging to the host culture was strong in our sample. However, this did not simply reflect or translate into a linear engagement with medical systems, as health care pathways were more complex and dual (both Chinese and Western). Chinese women who felt deeply rooted in the Italian environment did not discontinue the use of traditional Chinese medicine. Chronic pain extensively and adversely affected daily life, particularly interfering with work. Coping strategies were mainly adaptive behaviors, being problem focused or maladaptive, relying upon “cope and avoid” mechanisms. Chinese women preferred to use traditional Chinese remedies rather than conventional medicine, while using the Italian system in emergencies. Perceived control over chronic pain was usually external. Finally, Chinese women with chronic pain benefit from social networks and support, which were mainly composed of Chinese peers. In conclusion, our findings underline the tremendous burden of chronic pain affecting all aspects of Chinese women’s lives. Health care workers and providers should be aware of the complexity of chronic pain Therefore, a holistic approach, involving different stakeholders, should be adopted when managing chronic pain and approaching immigrant patients.
Keywords: chronic pain, Chinese immigrants, qualitative research, thematic field analysis
According to the International Association for the Study of Pain (IASP), pain is defined as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage”.1 This definition summarizes both the mental and physical components of the pain, emphasizing that pain is a multidimensional experience and is not limited to a feeling or sensation in a single or multiple parts of the body. There is currently no universal consensus about the definition of chronic pain: some authors define it as a form of pain lasting longer than 3 months, whereas others adopt other duration criteria (6 or even 12 months).2 Chronic pain undoubtedly represents a common public health concern worldwide, constituting “a burden to individuals and a challenge to society”.3 It is a complex phenomenon, owing to the interaction of different factors, including biological, physiological, psychological, environmental, and social variables, and thus, it requires a multidisciplinary approach. Inspired by the biopsychosocial model introduced by Engel in 1977, which tried to overcome the drawbacks and limitations of the dualistic biomedical model, Loeser4 and Waddell5 both established modified versions of the biopsychosocial model adapted to the context of pain. Pain becomes a multidimensional concept (nociception, pain, suffering, and pain behavior) arising from multiple etiological factors and complex interactions.6
The prevalence of chronic pain is highly variable and ranges from 10% to 64%, depending on the studied population, the study design, and the clinical criteria used.7,8 Chronic pain imposes a tremendous burden, both in terms of costs and quality of life, affecting and deeply involving not only the patient but also their family, caregivers, and peers in general. Living with chronic pain implies facing and coping with serious challenges, as it seriously interferes with normal physical, social, and physiological functions and with daily work activities.9
Various psychosocial variables have been shown to be associated with chronic pain experience and perception: female sex,10 low socioeconomic status, low educational level, lack of personal and social support, family history of chronic pain, cultural and ethnic identity,11 and immigrant status.10,12,13
Bates et al14,15 have particularly explored the topic of ethnic identity in pain perception and experience, using both quantitative and qualitative approaches, and have identified that subjects from New England and Puerto Rico experienced chronic pain differently.
The extant literature shows that the prevalence of chronic pain is higher among immigrants than among the native population of a country, even though not all authors agree with this view, claiming that the so-called Mediterranean syndrome is a myth lacking solid evidence.16 However, a recently published Danish investigation, the Danish Health Study, found that individuals with a non-western background had a significantly higher risk of reporting chronic pain than those with a Danish background.17 The Zurich Study, an investigation carried out in Switzerland, found high levels of pain intensity, depression, anxiety, and catastrophizing at baseline in a group with an immigration background compared with a group without this background.18 A study carried out in the USA showed a link between acculturation and chronic pain among Latino Americans.19 In a study carried out in Sweden, immigrant status was statistically associated with chronic pain behavior, with an odds ratio of 1.83.12
Therefore, immigrant women represent a particularly vulnerable group.9 In such groups, coping strategies play a major role in reducing the burden of anxiety and depression related to the immigration background and new context, as shown in some studies. Cultural self-efficacy was shown to act as a mediator in mitigating altered mental health in a sample of Chinese immigrants,20 as well as social support.21 Social capital (in Chinese guanxi) is particularly valuable in Chinese communities.22
In this study, we chose to focus on Chinese women in Italy, as they represent a particular group of immigrants who, differently from others, do not use the local health care systems, but prefer to use traditional Chinese medical systems.23 The Chinese population in Italy numbers about 270,000 (5.3% of the entire population of immigrants) and 49.0% of them are women.24 It is a population that is not adequately covered by the extant literature. For example, in various surveys performed by Naga, an important Italian voluntary association that offers free medical care to immigrants, Chinese communities are underrepresented, as such research tends to include subjects who trust Western medicine.25,26 Very little is known about how Chinese women in Italy live with and face chronic pain. The present pilot research was aimed at starting to fill this gap of knowledge.
In particular, our study aimed to examine the burden of chronic pain in Chinese immigrants in Italy in terms of their acculturation processes, perceived control over disease (locus of control, self-efficacy), social networks, and coping strategies. The following research questions were investigated:
- How do acculturation strategies affect the orientation and adoption of healthy behaviors and lifestyles? How does the acculturation level influence the choice of managing the disease27 and, in particular, treating the chronic pain?
- How does perception of control over disease (internal versus external locus of control, self-efficacy) influence the adoption of healthy behaviors and the use of traditional versus conventional medicine in migrant communities?28
- Does the level of contact that the subject has with the country of origin and their interactions with the host community influence the adoption of new beliefs and new behaviors in terms of health and disease? Or does it allow the maintenance of originally learned and acquired concepts and health strategies?
- Are coping strategies for chronic pain in a migrant community culturally influenced?29