IJE Advance Access originally published online on July 19, 2008
International Journal of Epidemiology 2008 37(5):1189-1191; doi:10.1093/ije/dyn143
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Commentary: Culture and pain in the work place: the domain of occupational epidemiology?
Corresponding author. Department of Health Sciences, University of York, 1st Floor Seebohm Rowntree Building, Heslington, York YO10 5DD, UK. E-mail: ja14{at}york.ac.uk
Accepted 19 June 2008
Madan and colleagues1 test the hypothesis that cultural factors have an important influence on common musculo-skeletal symptoms. They do so by comparing the prevalence of musculo-skeletal pain in three different anatomical sites (back, neck and arm) in groups of workers carrying out similar occupational physical activities in different ‘cultural’ settings. Six ‘cultural groups’, who were largely male, were compared: Indian manual workers; UK manual workers of Indian subcontinental origin; white UK manual workers; Indian office workers; UK office workers of Indian subcontinental origin and white UK office workers.
If we agree with Bhopal2 who purports that the central question in ‘cross-cultural’ epidemiology is: why is a disease more (or less) common in one ethnic group of people than another? Then we would hope the paper would help us to understand better the ‘causes’ of disease or, in this case, an explanation for the differential patterns of symptom reporting observed across cultural groups.
The authors offer a cultural explanation for their findings—and as defined by social epidemiology—‘culture’ is typically conceptualized and operationalized in relation to health-related beliefs and practices.3 Medical sociologists and anthropologists have long since provided insights into the potential cultural aspects of pain, reminding us that physical experiences, including perceptions of pain and responses to pain take place within a socio-cultural context. Classic studies, such as that by Zola, compared the nature of presenting complaints between Italian-Americans and Irish-Americans living in Boston in the mid-1960s. His finding that the Italian response to symptoms was typified by ‘over-expressiveness’ compared with the ‘playing down’ of symptoms by the Irish group, neatly demonstrated one example of the cultural impact of symptom presentation.4 Despite some criticism about over generalizing cultural values, the study remains heavily cited and still commonly appears on undergraduate medical school curricula. So, might we explain the findings presented by Madan et al. in this way?
The particularly interesting finding stemming from the research is that (with the odd exception) it is the Indian manual workers who report less pain, in each of the anatomical sites, when compared with each of the other occupational groups. What might be the possible cultural interpretations of this and more specifically, what might be different about the health beliefs and expectations among this group of workers that would lead them to report less pain? The authors hint at the possibility that the differing prevalence of musculo-skeletal pain stems from differing lay knowledge of occupational hazards across the groups. Those workers who have been exposed to information relating to the potential risks of certain occupational activities are in turn more likely to develop those symptoms. Indeed, medical sociologist have stressed that the process of interpretation of problematic symptoms, is done within a framework of lay health knowledge.5 This approach, however, struggles to place ‘lay’ interpretations within a wider structural and cultural context, as commentators have argued it does not fully acknowledge the relationship between structure and agency.6 Consequently, an alternative explanation could be that for Indian manual workers pain is a common feature of normal everyday life. Disclosing such pain may be seen as a threat to self-identity, ability to work and potentially having serious socio-economic consequences. However, explanations of this type do have inherent difficulties—such broad reaching statements about culture, whatever form they take, may justifiably be criticized for providing crude explanations that only serve to stereotype. A topic that has attracted much attention among those working in the field of ethnicity and health.7
For cultural explanations for differences between such groups as studied in this research to have any merit, two key assumptions must be met: first, that each group shares some common cultural values and norms and in particular (given the context of comparing symptoms), share health beliefs and expectations; and second, there is some inherent logic in the process of comparison.
Taking each of these in turn. First, are the Indian manual workers likely to be an homogenous enough cultural group to share similar health beliefs? What is it these workers have in common? Sharing a similar occupation background, which might explain the differences in their responses, when compared with Indian non-manual workers? Or having a similar, broadly defined, national or ethnic identity, which can serve as a point of comparison? Since most of the White manual worker group and White office worker groups generally had similar hazard ratios for pain, when compared with the Indian manual group, are we suggesting that the ‘White’ group as a whole are more likely to share similar health beliefs than their Indian counterparts? Likewise, since in the majority of cases UK office workers labelled as Indian subcontinent and White UK office workers shared similar hazard ratios for pain at each site across the different time points, should we conclude they share similar cultural values?
Second, responding to such questions raises a more general tension in how comparative methods are used in social epidemiology and the difficulties in offering interpretations from cross-cultural research. What is it in terms of ‘exposure’ that we are seeking to compare? In practical terms, is comparing a group of Indian workers, living in Mumbai, with a broader Indian subcontinental group living in the UK group appropriate? Many people of Indian origin living in the UK, for example, originate from provinces (such as Gujart, Punjab and Kashmir) other than the one in which Mumbai is located (Maharashtra). Given the considerable diversity in Indian regions, are we really comparing like with like? There are then broader problems of how we come to define and report ethnicity in research.8 A phrase such as Indian subcontinent, which is used in the article, usually includes India, Pakistan and Bangladesh. Is there sufficient cultural similarity within such groups to regard them as an appropriate point of comparison between the UK and India. The authors—to their credit—do attempt to avoid the tendency to overemphasise the ‘inherent’ qualities possessed by different ethnic groups, often found in similar work, by conceptualizing ethnic origin in relation to some idea of socio-economic position and this is a particular strength of the article. Yet, this raises another question about the extent to which notions of social stratification can be compared across countries with different social, economic and political histories.
In developing comparison methodologies, however, perhaps the real issue is how we imagine ‘culture’.9 This article uses general definitions of ethnic origin as a proxy for culture. There is little wrong in this per se as it overcomes the problem of how one can conceptualize, what is essentially a process, in terms of a variable, which can be measured and used to attribute associations. How else could we do such research? Broad comparisons can also be helpful in generating further hypothesis. This article demonstrates the value of this and it provides useful insights into how different ethnic groups respond to ‘occupational pain’.
On the other hand, such approaches can sometimes seem to oversimplify a multi-facetted process, in which a dialogue between heritage, ethnicity, language, history, religion and politics in addition to age, gender and social class, comes to define a person's cultural identity. This process may be further complicated by the process of migration, in which people have to sustain and often re-invent their sense of who they are and then relate this to ideas about health and illness. This is how studies using broad cultural comparisons can become problematic as we are not really sure what we are trying to explore and explain.10 Questioning the relationships between the process of interpretation and how comparison groups become defined and operationalized would enable researchers—as part of a broader process of reflexive engagement—to offer explanations, which take account the subtle nuances of how culture is understood.
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1 Madan I, Reading I, Palmer KT, Cultural Coggon D. differences in musculoskeletal symptoms and disability. In: Int J Epidemiol. (2008) 37:1181–89.
2 Bhopal R. Glossary of terms relating to ethnicity and race: for reflection and debate. J Epidemiol Community Health (2004) 58:441–45.
3 Krieger N. A glossary for social epidemiology. J Epidemiol Community Health (2001) 55:693–700.
4 Zola IK. Culture and symptoms – an analysis of patient's presenting complaints. Am Sociol Rev (1966) 31:615–30.[CrossRef][Web of Science][Medline]
5 Dingwall R. Aspects of Illness. (1976) London: Martin Robertson.
6 Calnan MC, Wainwright D, O’Neill C, Winterbottom A, Watkins C. Illness action rediscovered: a case study of upper limb pain. Sociol Health Illn (2007) 29:321–46.[Web of Science][Medline]
7 Ahmad WIU, Bradby H. Locating ethnicity and health: exploring concepts and contexts. Sociol Health Illn (2007) 29:793–811.
8 Bradby H. Describing ethnicity in health research. Ethn Health (2003) 8:5–14.[CrossRef][Web of Science][Medline]
9 Ahmad WIU. The trouble with culture. In: Research cultural differences in Health.—Kelleher D, Hillier S, eds. London: Routledge.
10 Karslen S, Nazroo J. Defining and measuring ethnicity and ‘race’: theoretical and conceptual issues for health and social care research. In: Health and Social Research in Multi-ethnic societies.—Nazroo J, ed. London: Routledge.
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