Coping, Pain Severity, Interference, and Disability: The Potential Mediating and Moderating Roles of Race and Education

Researchers have called attention to racial disparities in pain care and compensation.4-6,12,30,32In addition, there are race differences in clinical and experimental pain with African-Americans reporting more clinical pain, lower pain thresholds for ischemic and cold pressor pain, higher pain-related disability, and higher pain unpleasantness than Caucasians.4,5,8,12,13,33,34,40,41 Other research groups have not found race differences in pain severity.9,21 Although such research may enhance treatment and prevention with diverse groups, it is essential to also examine variables that might moderate racial group differences in the pain experience. For instance, race differences in coping and educational background might explain group differences in pain and disability. The purpose of the current study is to examine race and education as variables that play a significant role in the relationship between coping and pain. According to Lazarus and Folkman,29 coping is a consequence of individuals’ appraisals of events. The use of particular coping strategies is based on judgments of pain as a threat as well as perceived ability to cope with pain, suggesting that certain types of coping are related to pain ratings. Indeed, greater pain control beliefs and ignoring pain are inversely related with poorer pain outcomes, including pain, distress, and disability, whereas prayer and hoping and diverting attention are positively correlated with these poorer outcomes.9,21,28,43 Pain coping can affect long-term functional disability and pain,1,10 and changes in coping are related to improvements in psychological and physical functioning.20,22-24 Researchers have demonstrated race differences in some pain coping strategies. African-Americans report using prayer and hoping more than Caucasians to cope with pain.7,9,21 African-American pain patients also report lower perceived control over pain, more external pain-coping strategies, and a stronger belief that others should be solicitous when they experience pain.41 In a study of rheumatoid arthritis (RA), African-Americans were more likely to divert attention away from pain whereas Caucasians were more likely to ignore the pain and use coping self-statements.21 However, few published studies have focused on racial group differences in the relationship between pain coping and pain variables. Jordan et al21 found that prayer and hoping was positively correlated with inactivity in African-American but not Caucasian participants. In contrast, reinterpreting pain sensations was positively correlated with pain severity in African-American participants whereas this coping strategy was negatively correlated with pain severity in Caucasian participants. While identifying race differences in coping, pain, and the correlation between coping and pain has added to our knowledge of disparities in pain, it is also important to consider other demographic characteristics that might account for or interact with racial group differences. In doing so, researchers may avoid the danger of overinter-preting racial group differences.16,31 Educational attainment is one such demographic factor, especially because many pain-coping strategies (eg, distraction, reinterpretation) rely on cognitive skills that might be enhanced by education. In the pain field, low levels of education are associated with maladaptive pain beliefs and coping strategies.38 Further examination of racial group and educational differences may provide valuable information to inform treatment and research on racial disparities and pain coping. In the current study, we examined race differences in the pain experience. First, we expected that African-American participants would report significantly more pain severity, interference, and disability than Caucasian participants. In addition, racial group differences in some coping strategies (eg, prayer and hoping, distraction, reinterpretation) were expected. Second, we expected that education would mediate these racial group differences. Third, it was hypothesized that education and race would moderate the relationship between pain coping and the pain variables.