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Rheumatology Advance Access originally published online on March 31, 2007
Rheumatology 2007 46(6):1009-1014; doi:10.1093/rheumatology/kem037
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© The Author 2007. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org

Acculturation and the prevalence of pain amongst South Asian minority ethnic groups in the UK

B. Palmer, G. Macfarlane1, C. Afzal, A. Esmail2, A. Silman and M. Lunt

ARC Epidemiology Unit, Manchester University Medical School, Manchester, 1Aberdeen Pain Research Collaboration (Epidemiology Group), School of Medicine, University of Aberdeen and 2Department of Primary Care, Manchester University Medical School, Manchester, UK

Correspondence to: A. Silman, ARC Epidemiology Unit, Manchester University Medical School, Oxford Road, Manchester M13 9PT UK. E-mail: a.silman{at}manchester.ac.uk


   Abstract
Top
 Abstract
Introduction
 Subjects and methods
 Results
 Discussion
 Supplementary data
 Acknowledgements
 References
 
Background. Musculoskeletal pain is reported more commonly by South Asians in the UK than by white Europeans. This may result from a variety of factors, including cultural differences, and thus we investigated the extent to which differences in the prevalence of pain within the South Asian population could be explained by differences in acculturation (the extent to which immigrants take on the culture of their host population).

Methods. Nine hundred and thirty-three Europeans and 1914 South Asian (1165 Indian, 401 Pakistani and 348 Bangladeshi) subjects were recruited from the age–sex registers of 13 general practices in areas with high densities of South Asian populations (Bolton, Oldham, Ashton-under-Lyne and Birmingham). A 28-item acculturation scale was developed, based, on aspects including use of language, clothing style, and use of own-culture media. Principle component analysis generated a score (range 0–100), which was validated against constructs expected to relate to acculturation, such as years of full time education and time spent in the UK. The presence of widespread pain was assessed by the answer to the question ‘Have you suffered from pain all over the body in the past month?’

Results. Widespread pain was more common in all three South Asian ethnic groups than in the white Europeans [odds ratio (OR) = 3.7, 95% confidence interval (CI) 2.9–4.9], with this increase ranging from 2.7 to 5.8 in the different South Asian subgroups. There was a similar increase in consultation rates for pain. Within the South Asians, pooling all three groups, there was a strong negative association between acculturation score and widespread pain, which remained after adjusting for age and sex: [OR (95% CI) per standard deviation decrease in acculturation score –1.2 (1.0–1.3)]. Adjusting for acculturation accounted for some, but not all, of the differences between the ethnic groups in the prevalence of widespread pain: OR 2.0 (95% CI 1.4–3.0).

Conclusions. Widespread pain is more commonly reported in South Asians though there are interesting differences within the South Asian community. Lower acculturation has a strong influence on the reporting of pain, but cannot explain all of the difference between South Asian and European populations.

KEY WORDS: acculturation, questionnaire development, prevalence, South Asian, ethnic, widespread pain, population-based, cross-sectional


   Introduction
Top
 Abstract
 Introduction
Subjects and methods
 Results
 Discussion
 Supplementary data
 Acknowledgements
 References
 
There are frequent anecdotal reports suggesting inter-ethnic differences in the experience of musculoskeletal pain. Such observations are supported from the results of a population-based study that reported a higher prevalence of pain in ‘most joints’ amongst South Asians compared with Europeans in the UK. This increase was considerably greater for widespread pain than any individual site of joint pain [1]. Possible reasons for variations in prevalence include differences in the presumed underlying disorder or in pain reporting and associated health seeking behaviour. Indeed the latter does vary across cultures and societies [2].

Widespread pain is considered as one of the somatizing group of disorders, which are predominantly ‘unexplained’ and such syndromes are strongly associated with abnormal illness behaviour and high rates of consultation [3]. Specifically, the association between psychosocial factors and musculoskeletal pain has been shown to be greater where the pain is widespread as opposed to regional (where pain origin is more likely to be ‘explained’) [4]. Thus, any ethnic differences in widespread pain prevalence may be a result of psychosocial or cultural differences, although a range of other factors, including genetic predisposition and the physical or social environment, may be important.

One approach to exploring the relative contribution of these different factors in explaining ethnic differences in pain is to investigate the role of acculturation. The process of acculturation may be defined as that through which members of one culture may acquire the norms and values of another (host) culture [5]. Acculturation has been identified as a factor in explaining excess poor health experienced by ethnic minorities in North America [6–8] though the extent to which experiences from the minority ethnic groups in that geographical area can be extrapolated more widely is limited.

Minority ethnic groups of South Asian origin, specifically Indians, Pakistanis and Bangladeshis, constitute the largest ethnic minority population in the UK, but both within and between these communities there are large differences in the level of acculturation. To date, there has been very little work focused on the role of cultural factors in explaining differences in chronic syndromes such as musculoskeletal pain in South Asians; reflecting, in part, the lack of a validated scale for assessing acculturation in this group.

The present study had three main aims. Firstly, we wished to develop an instrument that could be used to measure levels of acculturation in UK South Asians. Secondly, we wished to confirm previous observations of differences in widespread pain prevalence both between South Asians and Europeans and for the first time to investigate possible differences in prevalence between the three main South Asian groups. Finally, we wished to explore the contribution of acculturation to explaining differences in pain reporting both within and between these three groups.


   Subjects and methods
Top
 Abstract
 Introduction
 Subjects and methods
Results
 Discussion
 Supplementary data
 Acknowledgements
 References
 
Overview of study design
The first stage involved the development and piloting of a questionnaire-based acculturation scale using South Asian volunteers. Secondly, the psychometric properties of the acculturation scale were assessed and an appropriate scoring system derived from a sample of respondents to a population-based cross-sectional survey of South Asian (including those of Indian, Pakistani and Bangladeshi origin) and European populations. Specifically the construct validity of these acculturation scores were assessed in relation to attributes such as duration of residence in the UK. Data were collected to assess the prevalence in widespread pain in the three South Asian and between European groups. Finally, the association between the derived acculturation scores and the prevalence of pain was assessed.

Development of acculturation scale
A questionnaire was developed covering several items of acculturation considered appropriate for use in UK South Asians, based on a literature review, existing acculturation scales (developed in other countries and for different ethnic groups) and discussion groups with community link-workers from Indian, Pakistani and Bangladeshi backgrounds. The aim was to ensure the appropriateness of the questions being posed and to ensure that they covered all relevant areas of interest (face and content validity). The questionnaire was then pre-piloted in various groups of South Asians including students, hospital clinic attenders and local ethnic leaders. Questions that were ambiguous, incompletely answered or did not distinguish between groups were dropped.

The scale was designed to reflect the language, religious beliefs and traditions of culture and lifestyle distinctive to South Asians from the Indian subcontinent. Eight distinct domains were identified, covering both behaviour and beliefs (the final questionnaire is provided in Appendix 1; supplementary data are available at Rheumatology online). The domains were:

  1. Language. Language was assessed at two levels. First, the relative use of English and traditional South Asian languages, both at home and outside the home, and secondly, proficiency of the use of English as a language (i.e. the ability to understand, speak, read and write English).
  2. Religion. Two questions enquired about religious belief and practices.
  3. Alienation and belonging. Two questions related to whether the respondent saw the UK as their ‘home’ and whether they felt a part of British society.
  4. Traditions/celebrations. Two questions related to observance and participation in important traditional South Asian cultural festivals.
  5. Customs. Enquiry was made about the respondent's fear of loss of cultural identity for themselves and their family.
  6. Media. Three questions enquired about the respondent's media preference (South Asian or English) regarding television, radio and newspapers.
  7. Clothing. Two questions enquired about the respondent's clothing preference (traditional South Asian or Western) at home and outside the home environment.
  8. Living conditions. One question enquired about living with family or extended family.
The study questionnaire was translated and back-translated into the main South Asian languages (Gujarati, Bengali, Urdu and Punjabi).

Selection of population samples
For the subsequent investigation, population samples were selected. The population sampling frames were derived from the age–sex registers of 13 general practices in areas with high densities of South Asian populations across the three target groups, based on the UK 2001 Census. Ten general practices in the North West towns of Bolton, Oldham and Ashton-under-Lyne and three from the West Midlands city of Birmingham participated. All registered patients, both European and Asian, from the 13 study practices aged 18–75 were eligible for inclusion in the study. All those with Asian-sounding surnames (used only as a first screen to identify South Asians) and a random sample of Europeans were selected for study, a total of 7668 subjects.

Questionnaire
A questionnaire was then developed that incorporated the following items. First, individuals were asked to self-identify their ethnic group using categories from the 2001 UK census. Secondly, questions were asked about place of birth, religion and main language. If not born in UK, length of time spent in UK was sought, and the number of years of education. Thirdly, the questionnaire included the acculturation items described above. Finally, a number of questions aimed to determine the prevalence and severity of widespread pain, the cardinal feature of the fibromyalgia syndrome [9]. Questions therefore asked about the presence of pain lasting at least 24 h in the previous 1 month. Widespread pain was additionally defined by a positive answer to pain ‘all over the body’. Two indicators of pain severity were also assessed: (i) if the pain had led to primary care consultation and (ii) severity of pain was measured using a numerical rating score (NRS) with scale 0–10.

Each subject was mailed an English language version of the questionnaire. A note in each of the appropriate South Asian languages (Urdu, Punjabi, Bengali and Gujarati) offered a version of the same questionnaire in any of those languages, if requested by mail or telephone. Following the initial mailing, non-responders at 2 weeks were sent a postcard reminder, followed by a repeat questionnaire at 4 weeks if there was still no reply. If this second questionnaire was not returned, a contact visit by a link worker (usually of the same ethnic group) was made to offer assistance in completing the questionnaire.

Analysis
Derivation of acculturation scales
The questionnaire included the items shown in Appendix 1 (supplementary data are available at Rheumatology Online). For each item a subject scored 0 or 1, with 1 being the more accultured response. A principal component analysis was undertaken (Appendix 2; supplementary data are available at Rheumatology Online) from which three distinct subscales were derived: (i) behaviours suggesting greater acculturation in the host community (including use of the English language, and wearing western style clothing), (ii) attitudes indicative of greater or lesser acculturation (such as feelings of acceptance, fears of discrimination and concerns regarding loss of cultural identity) and (iii) behaviours associated with the society of origin (including use of Asian media, and non-use of the English language). All three subscales were transformed to a 0–100 scale, with a higher score representing greater levels of acculturation. The reliability coefficients (Cronbach's {alpha}) for the three scales formed were 0.93, 0.75 and 0.72.

Assessment of construct validity of the acculturation scales
To examine the construct validity of the questionnaire it was hypothesized that certain key demographic variables would be associated with increased acculturation. The demographic variables used to test the construct validity of the acculturation scale were: younger age, male gender, whether born in UK, increased length of time spent in UK (as an absolute value and as a proportion of lifetime), and increased years of education (categorized as none, 1–7 years, 8–12 years, or more than 12 years). The association of each of the above constructs with the principal component scores was assessed using linear regression. In order to test whether the associations between predictors and the acculturation score were the same in the three ethnic groups (Indians, Pakistanis and Bangladeshis) interaction terms were added to the linear regression model. A multivariate model was built up including all significant predictors and interactions. Using this model, the differences in acculturation between the three ethnic groups were assessed, adjusting for differences between the groups in the demographic predictors of acculturation.

Ethnicity was defined in two ways. First, this was based on the subjects’ self-reports as being Indian, Pakistani, Bangladeshi or European. Secondly, a cluster analysis was undertaken based on the following variables reported in the questionnaire: command and use of South Asian languages, religious affiliation and place of birth of subject, parents and grandparents. This analysis identified seven statistically distinct subgroups which were homogeneous in terms of languages spoken, regional lineage and migratory patterns. These groups were then mapped to the self-reported ethnicities (Table 1). In order to ensure homogeneous groups with respect to both characteristics and self-perception of ethnicity, any subject whose assignment was discordant with the variables analysed was excluded.


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  		TABLE 1. South Asian subgroups identified by cluster analysis

 
Pain prevalences and consultation rates were compared across the subgroups using logistic regression, with the European group as the reference. The odds ratios (ORs) for each ethnic group were adjusted for age (using age bands 18–24, 25–34, 35–44, 45–54, 55–64 and 65–75 years). Pain-related severity NRSs were analysed by comparing inter-ethnic group medians and interquartile ranges (IQRs) and tested for statistical significance using the rank sum test. Acculturation scores were compared across South Asian subgroups. Finally, associations between widespread pain reporting and levels of acculturation within South Asians are expressed as age- and gender-adjusted ORs per standard deviation increase in score, with their 95% CIs.


   Results
Top
 Abstract
 Introduction
 Subjects and methods
 Results
Discussion
 Supplementary data
 Acknowledgements
 References
 
Response rates
The study questionnaire was mailed to 7668 individuals. There were several inaccuracies in the address lists as determined by post office returns, notification of deaths and subjects missing from local electoral registers. We therefore estimated that 1774 questionnaires had not been received. Of the 5894 successfully delivered questionnaires, following concerted efforts made to contact initial non-responders outlined earlier, 2998 (51%) were completed and returned. As the final ethnicity was determined from the responses to the questionnaire, it was not possible to compare ethnic specific response rates, although the responses from those with and without Asian-sounding surnames were broadly similar. From the responders, 1949 participants considered themselves to be South Asian and 933 to be European. As described earlier, South Asian subjects were excluded if their answers did not map to their self-report. From this analysis, 35 subjects were so excluded leaving 1914.

The demographic characteristics of the eight ethnic groups (Europeans and seven South Asian subgroups) are shown in Table 2. The largest South Asian groups were Indian Gujarati, Indian Punjabi, Pakistani Urdu and Bengali speaking Bangladeshi. There were large differences in the age and gender distribution of the respondents by ethnic group reflecting the demographic construction of the UK population, though in part this may reflect differences in the age- and gender-specific response rates. All subsequent analyses were therefore adjusted for age and gender.


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  		TABLE 2. Demographic characteristics by ethnic group

 
Construct validity of acculturation scores
The results of the univariate linear regression of acculturation scores on the hypothesized predictors are given in Table 3, pooled across the ethnic groups. The scores are expressed as the change in acculturation score per one-unit increase in the value of each predictor. A negative score means that an increase in that variable is associated with a decrease in acculturation.


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  		TABLE 3. Association between derived acculturation scores and constructs tested

 
The first behavioural component (see earlier text) correlated strongly with the hypothesized predictors: thus, those who had spent more time in the UK and those with more education tended to be more accultured. The second component of attitudes did not correlate with any of the predictors except gender and age which interestingly acted in the opposite direction compared with the first component. The third component of behaviour (mainly language use, see above) correlated to the predictors in a similar way to the first component, but the associations were generally less strong.

The distribution of the acculturation scores between the Asian subgroups is shown in Table 4. The scores show considerable variation, even between subgroups originating form the same country.


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  		TABLE 4. Acculturation scores by ethnic group

 
Prevalence of pain
The crude pain prevalence results are shown in Table 5. The crude prevalence of widespread pain was greater in all seven South Asian subgroups (pooled prevalence across all subgroups 21%) than in Europeans (9%). Amongst the South Asian subgroups the prevalence amongst Sylhetis (those speaking Sylheti alone) (11%) was significantly lower than amongst other minority ethnic groups (range 16–23%), although after adjusting for age and gender the difference was no longer significant. The excess of widespread pain amongst South Asian ethnic subgroups was evident across age groups and in both genders (data not shown). After adjusting for age and gender, the excess widespread pain prevalence in South Asians was even greater [OR 3.7, 95% CI 2.9–4.9]. The OR compared with Europeans ranged from 2.7 in Sylhetis to 5.8 in Bengali/Sylhetis (those speaking both languages), with the Indian and Pakistani subgroups having intermediate ORs from 3.4 to 4.2 (Table 5). Consultation rates were higher across all South Asian subgroups, with ORs ranging from 2.4 in Sylhetis to 5.7 in Bengali/Sylhetis. The medians and IQRs of the NRS for widespread pain severity were identical between Europeans and South Asians (median 7, IQR 5–8). Within South Asian subgroups, median severity scores ranged from 5 (IQR 4–7) in Gujarati Africans to 8 (IQR 6–9) in Gujaratis (P = 0.0007).


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  		TABLE 5. Prevalence of widespread pain by ethnic group

 
Finally, the associations between the derived acculturation scores and widespread pain were assessed (Table 6). Combining together the South Asian study population, a decrease in behaviour acculturation score was significantly associated with an increased probability of reporting widespread pain in the past month, with an OR of 1.17 per standard deviation decrease (95% CI 1.03–1.33). The association between low acculturation scores and increased risk of pain was also observed for chronic pain (lasting more than 3 months), pain leading to GP consultation and interference with daily and work activities (Table 6). Similarly, low acculturation in terms of attitudes was found to be associated with widespread pain in the past month, as well as several other measures of widespread pain. After adjusting for both acculturation scores, the OR for South Asians decreased from 3.7 to 2.0 (95% CI 1.4–3.0). No associations were found between the language acculturation component and widespread pain.


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  		TABLE 6. Age/gender-adjusted associations between acculturation component scores and widespread pain prevalence in South Asians

 

   Discussion
Top
 Abstract
 Introduction
 Subjects and methods
 Results
 Discussion
Supplementary data
 Acknowledgements
 References
 
In summary, age and gender-adjusted widespread pain prevalence in South Asians is almost 4-fold that in Europeans. However, there is also a pronounced variation in reporting of widespread pain between groups of South Asians formed along linguistic, religious and geographical lines. These inter-ethnic differences extend to GP consultation. The degree of acculturation had an important influence on the likelihood of reporting pain: the greater the degree of acculturation, the lower the prevalence of pain. These findings may provide some insight into understanding of the mechanism by which there may be increased widespread pain prevalence in South Asians.

In order to investigate this topic we needed to develop an acculturation scale: prior to the current study there was no such instrument available for use in South Asians. The scale was assessed for internal consistency, validity, comprehension and reliability and performed well, and was completed by the overwhelming majority of South Asian respondents. The scale correlated with key constructs of acculturation including levels of education, time in the UK, age, generational status, sex and ethnic group. These measures of construct validity of the acculturation behavioural scale were demonstrated for all South Asian groups.

Language usage was a major marker of acculturation. In other populations, language usage and familiarity with the language of the host culture have been shown to be the most important measures of acculturation [10–12] and have been used as proxy measures for acculturation [11–12]. However, they cannot replace the formal measure of acculturation. Previous attempts at measuring acculturation have been restrictive in their content, choosing focus on certain aspects of acculturation while ignoring others [12] or combining language and ethnic identification [13]. Many previous studies [14] have been limited to students from university settings and consequently are not representative of the vast majority of immigrants. Other studies have tended to aggregate culturally or linguistically different individuals into one category, e.g. viewing all Asians as a culturally homogeneous group [15].

Interestingly, the principal component analysis suggested three distinct dimensions of acculturation were being captured by the items on the questionnaire: behavioural traits related to the host culture, attitude traits and behavioural traits related to the culture of origin. We therefore created subscales of acculturation in our study corresponding to these three dimensions, instead of awarding one composite score for acculturation.

The attitude scale seemed to be measuring something that was not related to the pre hoc defined constructs of acculturation. Thus, feelings of belonging and anxiety about being part of a minority did not change with increasing residence in the UK. By contrast, however, these aspects were as strongly associated with the reporting of pain as host-related behaviours.

The samples in the current study were selected to represent the three largest South Asian groups in the UK. However, caution should be exercised in generalising these findings to ethnic minorities outside those studied. Subjects were largely recruited from socio-economically deprived areas, which may have implications for the external validity of the results, as widespread pain has been linked to social deprivation [16, 17]. Furthermore, the association between ethnicity and widespread pain may be confounded by further factors that have not been addressed in this study, such as psychological distress, adverse work-related psychosocial factors and attitudes to health and illness behaviour.

The self-reporting of pain itself may be culturally determined and does not necessarily represent any difference in the occurrence of pathological processes leading to pain. We chose to use the phenotype of a positive answer to ‘pain all over’ as this has been shown in previous population studies, in Europeans, to be closely related to psychosocial factors. It is unfeasible to ‘validate’ pain reporting within a population, especially one with significant cultural diversity. By undertaking subgroup analyses on those with severe and those with consulting pain, we attempted to reduce the heterogeneity of the outcome measure. Ultimately a study such as this can only conclude about the subjective reporting of pain.

We attempted to maximize participation in this population-based study by using general practice registers as a sampling frame, offering questionnaire translations in various languages and making considerable efforts to chase up non-responders through repeat questionnaires and link worker visits. Despite strenuous attempts to maximize participation, there was a relatively poor response rate, which might have lead to levels of non-response bias both in the reporting of pain and its association with the acculturation scale scores, as these may have differed between responders and non-responders. The nature of the study meant that accurate ethnic assignment could only be made following participation, which hinders attempts to assess the levels of any such bias. As a crude indicator, we assessed the level of pain in subjects who answered without a reminder and those who required further follow-up (reluctant responders). These data (not shown) do not suggest any differential non-response bias, between the groups in relation to pain.

The results of this study are consistent with those from other work in this area. Allison et al. [1], in a study from Greater Manchester, found increased risks of ‘pain in most joints’ in South Asians compared with the local white population, with ORs ranging from 3.4 in Bangladeshis to 5.1 in Pakistanis. A survey in Glasgow found a greater prevalence of musculoskeletal pain reporting in South Asian women than the general population (35% vs 26%), although the reverse was found for South Asian men [18]. Increased general practice attendance in adult Asians compared with Europeans has been reported previously [19, 20]. The present study has shown that such disproportionate health-seeking behaviour persists when musculoskeletal symptoms are considered in isolation. Furthermore, the prevalence of pain syndromes has been shown to be greater in specific subgroups within the UK's South Asian population.

The mechanisms underlying the excess widespread pain prevalence in South Asians are unclear, although some possible explanations have been proposed. There may exist a pain threshold disparity between ethnic groups. There is some evidence for this from experimental studies though some studies have reported no such differences [21, 22]. Levels of psychological distress may be greater in South Asians, specifically those less acculturated to their new environment. This hypothesis warrants further investigation. However, Rogers and Allison [23] report an apparent lack of demarcation in South Asians between body pain and personal concerns, which other ethnic groups may describe as ‘depression’. Furthermore, they note that while Europeans and Afro-Caribbeans assign pain to specific joints, South Asians tend to demonstrate a heightened sense of ‘soma’, and describe pain radiating through the whole body. An excess of widespread pain may occur if there were communication barriers between European doctors and patients from ethnic minorities and if this subsequently affected their treatment plan. In this study, however, many of the GPs involved were themselves of South Asian origin. Finally, there may be more biological explanations; predominant amongst these is the possibility of ‘subclinical’ osteomalacia. We have recently showed in a population of young South Asian females that there is a high prevalence of Vitamin D deficiency, which was associated with widespread pain reporting in that group [24], though the numbers studied precluded a more definitive answer. Vitamin D intake or serum data were not available in the current cohort.

In summary, this study has confirmed an excess prevalence of widespread pain in South Asians living in the UK. It has extended knowledge by demonstrating that this excess prevalence varies in magnitude between population groups of South Asian origin. Furthermore, this study has demonstrated that the excess is principally related to those whose culture reflects their South Asian origin rather than their host country (the UK). Future work could usefully determine the role of specific cultural factors in relation to excess musculoskeletal symptoms.


   Supplementary data
Top
 Abstract
 Introduction
 Subjects and methods
 Results
 Discussion
 Supplementary data
Acknowledgements
 References
 
Supplementary data are available at Rheumatology Online.


   Acknowledgements
Top
 Abstract
 Introduction
 Subjects and methods
 Results
 Discussion
 Supplementary data
 Acknowledgements
References
 
This work was funded by the United Kingdom's Arthritis Research Campaign. We acknowledge the willing support of all the primary care physicians who permitted access to their patient populations and to the link workers and other members of the minority ethnic communities surveyed in this report for much advice, assistance and guidance.

The authors have declared no conflicts of interest.


   References
Top
 Abstract
 Introduction
 Subjects and methods
 Results
 Discussion
 Supplementary data
 Acknowledgements
 References
 

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Submitted 3 October 2006; revised version accepted 24 January 2007.
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