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Taylor JL, Clair CA, Lee JW, Atkins S, Riser TJ, Szanton SL, McCoy MC, Thorpe RJ, Wang C, Gitlin LN. A protocol for a wait list control trial of an intervention to improve pain and depressive symptoms among middle-aged and older African American women. Contemp Clin Trials 2023; 132:107299. [PMID: 37478967 PMCID: PMC10527967 DOI: 10.1016/j.cct.2023.107299] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 07/09/2023] [Accepted: 07/15/2023] [Indexed: 07/23/2023]
Abstract
BACKGROUND Pain and depression frequently co-occur among older adults with comorbidities and can exacerbate one another. The intersection of race, gender and age puts older African American women at high risk of experiencing comorbid pain and depression. The purpose of this study is to test the feasibility and acceptability of a 12-week behavioral activation intervention called DAPPER (Depression and Pain Perseverance through Empowerment and Recovery) that uses non-pharmacological, tailored strategies to target pain and mood symptoms. We will measure pain intensity and depressive symptoms as outcomes, although we are not powered to test differences. METHODS We describe the protocol for this study that uses a randomized waitlist control design to examine acceptability and feasibility of an intervention. The study population is comprised of self-identified African American women, 50 years of age or older with chronic pain and who self-report of depressive symptoms. Participants must also be pre-frail or frail and have an ADL or IADL limitation. The intervention consists of eight 1-2-h visits with a nurse interventionist via in-person or virtual telecommunication methods and two visits for non-invasive specimen collection. The primary outcomes include goal attainment, pain and depressive symptoms. Secondary outcomes include stress, frailty, and communication with providers. Follow-up qualitative interviews are conducted with participants to assess intervention acceptability. DISCUSSION Findings from this pilot study will provide further evidence supporting the use of non-pharmacological techniques to intervene in the cycle of pain and depression among an at-risk sub-population.
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Affiliation(s)
| | - Catherine A Clair
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Ji Won Lee
- Johns Hopkins School of Nursing, Baltimore, MD, United States
| | - Shelbie Atkins
- Johns Hopkins School of Nursing, Baltimore, MD, United States
| | - Tiffany J Riser
- Johns Hopkins School of Nursing, Baltimore, MD, United States
| | - Sarah L Szanton
- Johns Hopkins School of Nursing, Baltimore, MD, United States; Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Megan C McCoy
- Northern Arizona University College of Social and Behavioral Sciences, Flagstaff, AZ, United States
| | - Roland J Thorpe
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Claire Wang
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Laura N Gitlin
- Drexel University College of Nursing and Health Professions, Philadelphia, PA, United States
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2
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Baker TA, Morales KH, Brooks AK, Clark J, Wakita A, Whitt-Glover MC, Yu YZ, Murray M, Hooker SP. A biopsychosocial approach assessing pain indicators among Black men. FRONTIERS IN PAIN RESEARCH 2023; 4:1060960. [PMID: 36860329 PMCID: PMC9968840 DOI: 10.3389/fpain.2023.1060960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 01/11/2023] [Indexed: 02/15/2023] Open
Abstract
Introduction The lack of empirical evidence documenting the pain experience of Black men may be the result of social messaging that men are to project strength and avoid any expression of emotion or vulnerability. This avoidant behavior however, often comes too late when illnesses/symptoms are more aggressive and/or diagnosed at a later stage. This highlights two key issues - the willingness to acknowledge pain and wanting to seek medical attention when experiencing pain. Methods To better understand the pain experience in diverse raced and gendered groups, this secondary data analysis aimed to determine the influence identified physical, psychosocial, and behavioral health indicators have in reporting pain among Black men. Data were taken from a baseline sample of 321 Black men, >40 years old, who participated in the randomized, controlled Active & Healthy Brotherhood (AHB) project. Statistical models were calculated to determine which indicators (somatization, depression, anxiety, demographics, medical illnesses) were associated with pain reports. Results Results showed that 22% of the men reported pain for more than 30 days, with more than half of the sample being married (54%), employed (53%), and earning an income above the federal poverty level (76%). Multivariate analyses showed that those reporting pain were more likely to be unemployed, earn less income, and reported more medical conditions and somatization tendencies (OR=3.28, 95% CI (1.33, 8.06) compared to those who did not report pain. Discussion Findings from this study indicate that efforts are needed to identify the unique pain experiences of Black men, while recognizing its impact on their identities as a man, a person of color, and someone living with pain. This allows for more comprehensive assessments, treatment plans, and prevention approaches that may have beneficial impacts throughout the life course.
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Affiliation(s)
- Tamara A. Baker
- Department of Psychiatry, University of North Carolina, School of Medicine, Chapel Hill, NC, United States,Correspondence: Tamara A. Baker
| | - Knashawn H. Morales
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, United States
| | - Amber K. Brooks
- Department of Anesthesiology, Wake Forest University School of Medicine, Winston salem, NC, United States
| | | | - Anna Wakita
- University of North Carolina, Gillings School of Global Public Health Chapel Hill, Chapel Hill, NC, United States
| | | | - Yelia Z. Yu
- Department of Psychiatry, University of North Carolina, School of Medicine, Chapel Hill, NC, United States
| | | | - Steven P. Hooker
- College of Health and Human Services, San Diego State University, San diego, CA, United States
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3
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Tanner JJ, Cardoso J, Terry EL, Booker SQ, Glover TL, Garvan C, Deshpande H, Deutsch G, Lai S, Staud R, Addison A, Redden D, Goodin BR, Price CC, Fillingim RB, Sibille KT. Chronic Pain Severity and Sociodemographics: An Evaluation of the Neurobiological Interface. THE JOURNAL OF PAIN 2022; 23:248-262. [PMID: 34425249 PMCID: PMC8828699 DOI: 10.1016/j.jpain.2021.07.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 07/19/2021] [Accepted: 07/27/2021] [Indexed: 02/03/2023]
Abstract
Chronic pain is variably associated with brain structure. Phenotyping based on pain severity may address inconsistencies. Sociodemographic groups also differ in the experience of chronic pain severity. Whether differences by chronic pain severity and/or sociodemographic groups are indicated in pain-related areas of the brain is unknown. Relations between 2 measures of chronic pain severity and brain structure via T1-weighted MRI were investigated and sociodemographic group differences explored. The observational study included 142 community-dwelling (68 non-Hispanic Black [NHB] and 74 non-Hispanic White [NHW]) adults with/at risk for knee osteoarthritis. Relationships between chronic pain severity, sociodemographic groups, and a priori selected brain structures (postcentral gyrus, insula, medial orbitofrontal, anterior cingulate, rostral middle frontal gyrus, hippocampus, amygdala, thalamus) were explored. Chronic pain severity associated with cortical thickness. NHB participants reported lower sociodemographic protective factors and greater clinical pain compared to NHWs who reported higher sociodemographic protective factors and lower clinical pain. Greater chronic pain severity was associated with smaller amygdala volumes in the NHB group and larger amygdala volumes in the NHW group. Brain structure by chronic pain stage differed between and within sociodemographic groups. Overall, chronic pain severity and sociodemographic factors are associated with pain-related brain structures. Our findings highlight the importance of further investigating social and environmental contributions in the experience of chronic pain to unravel the complex array of factors contributing to disparities. PERSPECTIVE: The study presents data demonstrating structural brain relationships with clinical pain severity, characteristic pain intensity and chronic pain stage, differ by sociodemographic groups. Findings yield insights into potential sources of previous inconsistent pain-brain relationships and highlights the need for future investigations to address social and environmental factors in chronic pain disparities research.
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Affiliation(s)
- Jared J Tanner
- Department of Clinical and Health Psychology, University of Florida, Gainesville, FL
| | - Josue Cardoso
- Department of Community Dentistry and Behavioral Science, University of Florida, Gainesville, FL,Pain Research and Intervention Center of Excellence, University of Florida, Gainesville, FL
| | - Ellen L Terry
- Pain Research and Intervention Center of Excellence, University of Florida, Gainesville, FL,Department of Behavioral Nursing Science, University of Florida, Gainesville, FL
| | - Staja Q Booker
- Pain Research and Intervention Center of Excellence, University of Florida, Gainesville, FL,Department of Behavioral Nursing Science, University of Florida, Gainesville, FL
| | - Toni L Glover
- School of Nursing, Oakland University, Rochester, MI
| | - Cynthia Garvan
- Department of Anesthesiology, University of Florida, Gainesville, FL
| | | | - Georg Deutsch
- Department of Radiology, University of Alabama at Birmingham, Birmingham, AL
| | - Song Lai
- Department of Radiation Oncology, University of Florida, Gainesville, FL
| | - Roland Staud
- Department of Medicine, University of Florida, Gainesville, FL
| | - Adrianna Addison
- Department of Psychology, University of Alabama at Birmingham, Birmingham, AL
| | - David Redden
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL,Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL
| | - Burel R Goodin
- Department of Psychology, University of Alabama at Birmingham, Birmingham, AL
| | - Catherine C Price
- Department of Clinical and Health Psychology, University of Florida, Gainesville, FL
| | - Roger B Fillingim
- Department of Community Dentistry and Behavioral Science, University of Florida, Gainesville, FL,Pain Research and Intervention Center of Excellence, University of Florida, Gainesville, FL
| | - Kimberly T Sibille
- Pain Research and Intervention Center of Excellence, University of Florida, Gainesville, FL,Department of Aging & Geriatric Research, University of Florida, Gainesville, FL
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4
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Aaron SP, Gazaway SB, Harrell ER, Elk R. Disparities and Racism Experienced Among Older African Americans Nearing End of Life. CURRENT GERIATRICS REPORTS 2021; 10:157-166. [PMID: 34956825 PMCID: PMC8685164 DOI: 10.1007/s13670-021-00366-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/02/2021] [Indexed: 11/23/2022]
Abstract
Purpose of Review The purpose of this review is to examine racism in healthcare as it relates to older African American adults. We focus on health disparities in old age and medical mismanagement throughout their lifespan. Recent Findings In the United States there have been extensive medical advances over the past several decades. Individuals are living longer, and illnesses that were deemed terminal in the past are now considered chronic illnesses. While most individuals living with chronic illness have experienced better quality of life, this is not the case for many African American older adults. Summary Older African American adults are less likely to have their chronic illness sufficiently managed and are more likely to die from chronic illnesses that are well controlled in Whites. African American older adults also continue to suffer from poorer healthcare outcomes throughout the lifespan to end-of-life.
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Affiliation(s)
- Siobhan P Aaron
- College of Nursing, University of Utah, 10 2000 E, Salt Lake City, UT 84112 U.S.A
| | - Shena B Gazaway
- School of Nursing, University of Alabama Birmingham, Birmingham, AL U.S.A
| | - Erin R Harrell
- Department of Psychology, University of Alabama, Tuscaloosa, AL U.S.A
| | - Ronit Elk
- Department of Medicine, University of Alabama Birmingham, Birmingham, AL U.S.A
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5
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Ji L, Qiao X, Jin Y, Si H, Liu X, Wang C. Functional disability mediates the relationship between pain and depression among community-dwelling older adults: Age and sex as moderators. Geriatr Nurs 2021; 42:137-144. [PMID: 33401094 DOI: 10.1016/j.gerinurse.2020.12.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 12/21/2020] [Accepted: 12/22/2020] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To examine the moderating effects of age and sex in the role of functional disability as a mediator between pain and depression. METHODS Participants were 1917 community-dwelling older adults from Jinan, China. Data were collected on pain intensity, functional disability in activities of daily living and instrumental activities of daily living, depressive symptoms and covariates. RESULTS Functional disability partially mediated the relationship between pain intensity and depressive symptoms (estimate = 0.015, SE = 0.007, 95% CI [0.004, 0.030]). Age and sex moderated both the direct and indirect effect of the mediation model. The mediating effect of functional disability was significant in the old-old men, young-old men, and young-old women, but not in the old-old women. CONCLUSIONS Interventions should target both pain and pain-related functional disability to improve their emotional well-being among community-dwelling older adults. Importantly, strategies should be tailored across different age and sex groups to improve their effectiveness.
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Affiliation(s)
- Lili Ji
- School of Nursing, Peking University, Beijing 100191, China
| | - Xiaoxia Qiao
- School of Nursing, Peking University, Beijing 100191, China
| | - Yaru Jin
- School of Nursing, Peking University, Beijing 100191, China
| | - Huaxin Si
- School of Nursing, Peking University, Beijing 100191, China
| | - Xinyi Liu
- School of Nursing, Shandong University, Jinan, China
| | - Cuili Wang
- School of Nursing, Peking University, Beijing 100191, China.
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6
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Taylor JL, Drazich BF, Roberts L, Okoye S, Rivers E, Wenzel J, Wright R, Beach MC, Szanton SL. Pain in low-income older women with disabilities: a qualitative descriptive study. J Women Aging 2020; 32:402-423. [PMID: 32475259 DOI: 10.1080/08952841.2020.1763895] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
The purpose of this qualitative study was to identify how low-income older women with disabilities perceive pain, pain management, and communication with healthcare providers. We interviewed 26 low-income women (average age 75 years; SD 7.0), eliciting the following overarching themes: "Invisibility of Pain: Unnoticed or Undetected," "Escalating Pain Leads to Help Seeking," "Communication with Healthcare Providers and Outcomes," "Pain Management Facilitates Function and Accomplishment," and "The Intersection of Pain, Disability, and Depressive Symptoms." Study findings support the ways in which behavior changes from pain can impede pain management.
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Affiliation(s)
- Janiece L Taylor
- School of Nursing, Johns Hopkins University , Baltimore, Maryland, USA
| | | | - Laken Roberts
- School of Nursing, Johns Hopkins University , Baltimore, Maryland, USA
| | - Safiyyah Okoye
- Bloomberg School of Public Health, Johns Hopkins University , Baltimore, Maryland, USA
| | - Emerald Rivers
- School of Nursing, Johns Hopkins University , Baltimore, Maryland, USA
| | - Jennifer Wenzel
- School of Nursing, Johns Hopkins University , Baltimore, Maryland, USA
| | - Rebecca Wright
- School of Nursing, Johns Hopkins University , Baltimore, Maryland, USA
| | | | - Sarah L Szanton
- School of Nursing, Johns Hopkins University , Baltimore, Maryland, USA.,Bloomberg School of Public Health, Johns Hopkins University , Baltimore, Maryland, USA
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7
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Booker S, Cardoso J, Cruz-Almeida Y, Sibille KT, Terry EL, Powell-Roach KL, Riley JL, Goodin BR, Bartley EJ, Addison AS, Staud R, Redden D, Bradley L, Fillingim RB. Movement-evoked pain, physical function, and perceived stress: An observational study of ethnic/racial differences in aging non-Hispanic Blacks and non-Hispanic Whites with knee osteoarthritis. Exp Gerontol 2019; 124:110622. [PMID: 31154005 PMCID: PMC6660381 DOI: 10.1016/j.exger.2019.05.011] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 05/23/2019] [Accepted: 05/24/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND Knee osteoarthritis (OA) is a pervasive musculoskeletal condition, often exacerbated by movement-evoked pain (MEP). Despite established research demonstrating significant racial differences in OA pain, few studies have investigated ethnic/racial group differences in MEP and lower extremity function and their association with psychosocial factors, such as perceived stress. Therefore, the primary aims were: (1) to identify ethnic/racial group differences in persons with or at risk for knee OA pain based on MEP, physical performance, and perceived stress measures, and (2) to determine if perceived stress explains the relationship between MEP and function in non-Hispanic Blacks (NHBs) and non-Hispanic Whites (NHWs). METHODS A total of 162 NHB and NHW community-dwelling older adults (50-78 years of age) were included in this analysis from the Understanding Pain and Limitations in Osteoarthritic Disease (UPLOAD) cross-sectional cohort study. Demographic, anthropometric, pain and functional parameters were assessed using a battery of validated instruments. Descriptive statistics, parametric, and multivariate analyses were conducted to determine ethnic/racial differences in perceived stress, MEP, and function. RESULTS Our results support the hypothesis that among persons with knee OA pain, NHBs have significantly greater MEP and lower functional level, despite similar levels of perceived stress. However, perceived stress was more strongly related to MEP in NHB compared to NHWs. Differences in function were limited to walking speed, where NHWs demonstrated faster gait speed. CONCLUSIONS Our cross-sectional study demonstrated important ethnic/racial differences in MEP and function. Also, perceived stress had a stronger effect on MEP in NHBs, suggesting that perceived stress may more strongly influence pain with physical movement among NHB adults. MEP may be a clinically important pain outcome to measure in persons with OA, and these data warrant future research on the impact of stress on pain and functional outcomes in older adults, particularly in NHBs.
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Affiliation(s)
- Staja Booker
- The University of Florida, Department of Community Dentistry and Behavioral Science, Gainesville, FL 32610, USA; The University of Florida, Pain Research and Intervention Center of Excellence, Gainesville, FL 32610, USA.
| | - Josue Cardoso
- The University of Florida, Department of Community Dentistry and Behavioral Science, Gainesville, FL 32610, USA; The University of Florida, Pain Research and Intervention Center of Excellence, Gainesville, FL 32610, USA
| | - Yenisel Cruz-Almeida
- The University of Florida, Pain Research and Intervention Center of Excellence, Gainesville, FL 32610, USA; The University of Florida, Department of Aging & Geriatric Research, College of Medicine, Gainesville, FL 32611, USA
| | - Kimberly T Sibille
- The University of Florida, Pain Research and Intervention Center of Excellence, Gainesville, FL 32610, USA; The University of Florida, Department of Aging & Geriatric Research, College of Medicine, Gainesville, FL 32611, USA
| | - Ellen L Terry
- The University of Florida, Department of Community Dentistry and Behavioral Science, Gainesville, FL 32610, USA; The University of Florida, Pain Research and Intervention Center of Excellence, Gainesville, FL 32610, USA
| | - Keesha L Powell-Roach
- The University of Florida, Department of Community Dentistry and Behavioral Science, Gainesville, FL 32610, USA; The University of Florida, Pain Research and Intervention Center of Excellence, Gainesville, FL 32610, USA
| | - Joseph L Riley
- The University of Florida, Department of Community Dentistry and Behavioral Science, Gainesville, FL 32610, USA; The University of Florida, Pain Research and Intervention Center of Excellence, Gainesville, FL 32610, USA
| | - Burel R Goodin
- University of Alabama at Birmingham, Department of Psychology, Birmingham, AL 35294, USA
| | - Emily J Bartley
- The University of Florida, Department of Community Dentistry and Behavioral Science, Gainesville, FL 32610, USA; The University of Florida, Pain Research and Intervention Center of Excellence, Gainesville, FL 32610, USA
| | | | - Roland Staud
- The University of Florida, Department of Medicine, Gainesville, FL 32608, USA
| | - David Redden
- University of Alabama at Birmingham, Department of Biostatistics, Birmingham, AL 35294, USA; University of Alabama at Birmingham, Department Medicine and Rheumatology, Birmingham, AL 35294, USA
| | - Laurence Bradley
- University of Alabama at Birmingham, Division of Clinical Immunology and Rheumatology, Birmingham, AL 35294, USA
| | - Roger B Fillingim
- The University of Florida, Department of Community Dentistry and Behavioral Science, Gainesville, FL 32610, USA; The University of Florida, Pain Research and Intervention Center of Excellence, Gainesville, FL 32610, USA
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8
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The Relationship Between Life Purpose With Depression and Disability in Acute Low Back Pain Patients. Orthop Nurs 2018; 37:287-291. [PMID: 30247411 DOI: 10.1097/nor.0000000000000480] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Life purpose in acute low back pain patients is not well described in published literature. METHODS/PURPOSE We used linear regression models to describe the relationship of life purpose with perceived functional disability and depression in persons with acute low back pain (N = 42) participating in a randomized clinical trial to prevent transition to chronic low back pain. RESULTS In our predominantly female sample (81.8%) with a mean age of 53 years (SD = 11.6 years), 52% worked full-time. Adjusting for age, gender, and working status, life purpose was a significant correlate of depression (p = .007). For every 10-unit increase in life purpose score, the estimated depression score decreased by almost 2.5 points. A significant relationship between life purpose and perceived functional disability was not identified. CONCLUSION Life purpose likely is a modifiable risk factor for depression in acute low back pain patients.
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9
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Walker Taylor JL, Campbell CM, Thorpe RJ, Whitfield KE, Nkimbeng M, Szanton SL. Pain, Racial Discrimination, and Depressive Symptoms among African American Women. Pain Manag Nurs 2018; 19:79-87. [PMID: 29422125 PMCID: PMC6053541 DOI: 10.1016/j.pmn.2017.11.008] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Revised: 11/13/2017] [Accepted: 11/16/2017] [Indexed: 11/30/2022]
Abstract
African American women with osteoarthritis (OA) are at high risk of experiencing pain. They report more pain than non-Hispanic White women and men of other racial/ethnic groups. This pain can limit independence and diminish their quality of life. Despite the detrimental effects that pain can have on older African American women with OA, there is a dearth of literature examining factors beyond the OA pathology that are associated with pain outcomes within this population. The purpose of this study was to examine the relationships between racial discrimination and depressive symptoms with pain intensity in African American women with OA. The sample comprised of 120 African American women, aged 50-80 years, with OA, from Texas and New Mexico. The women completed survey booklets to answer study questionnaires. We used multiple linear regression to test associations between racial discrimination, depressive symptoms, and pain intensity. We tested whether depressive symptoms mediated the relationship between racial discrimination and pain intensity by using bootstrapping. Results indicated that racial discrimination was significantly associated with pain intensity and that this relationship was mediated by depressive symptoms, even after controlling for body mass index, years of education, and length of time with OA. Both depressive symptoms and racial discrimination may be modifiable. If these modifiable factors are addressed in this population, there may be decreased pain in middle-aged and older African American women.
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Affiliation(s)
| | - Claudia M Campbell
- School of Medicine, Psychiatry and Behavioral Sciences, Johns Hopkins University, Baltimore, Maryland
| | - Roland J Thorpe
- Hopkins Center for Health Disparities Solutions, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Wayne State University, Detroit, Michigan
| | | | - Manka Nkimbeng
- School of Nursing, Johns Hopkins University, Baltimore, Maryland
| | - Sarah L Szanton
- School of Nursing, Johns Hopkins University, Baltimore, Maryland; Hopkins Center for Health Disparities Solutions, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Wayne State University, Detroit, Michigan
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