Illness, disease, sickness : clinical factors, concepts of pain and sick leave patterns among immigrants in primary health care : effects of different therapeutic approaches

Abstract

The outer framework for this thesis is the high rate of disability pensions among some immigrant groups in Sweden. The general aim for the research has been to understand the phenomena of illness, disease and sickness certification in immigrants from a primary care perspective and to test the effects on well-being and sickness certification of different therapeutic approaches. The research has been done step-wise and has mainly been of an inductive character.

The first project is a descriptive, intervention study of sickness, disease and psychosocial patterns in 105 consecutive, first-time health service visitors of Greek and Swedish origin with a ten year follow-up. In the second project, concepts of backache were explored in 15 consecutive Greek patients on long-term sick leave and 21 healthy members of a Greek cultural association. The third project, comprising 92 persons aged 25-45 years, consists of explorative studies of clinical factors, psychosocial stressors, sick leave patterns with a three year follow-up and concepts of pain in the framework of a rehabilitation programme with two randomised treatment groups.

Psychiatric ratings were performed according to the CPRS (first project) and DSM-III-R (third project). Criteria from the DSM-III were used for assessing psychosocial stressors and social functioning. Global ratings of work incapacity were made jointly by the researchers. Self-rated work ability and ratings of pain behaviour were included in the third project. Concepts of pain were explored in thematic interviews.

In the first project, a majority had pain complaints. In contrast to the Swedes, the Greeks exhibited a passive pain behaviour. Half the Greeks, but only few Swedes, had a mostly mild depressive/dysphoric illness often associated with psychosocial stressors. Counselling sessions with a Greek psychotherapist were generally not accepted by the Greeks. Regarding work incapacitating diseases, the Greeks had chronic pain and depression and the Swedes had other psychiatric disorders or chronic pain. In spite of small differences in work incapacity between the ethnic groups, the Greeks were more often on long-term sick leave, a difference that increased over a ten year period.

In the second project, the concepts about backache among the Greek interviewees were found to centre around the idea of a deteriorating disorder as the cause of persistent pain; a disorder inevitably leading to invalidity if the sufferer should deliberately aggravate the pain. The pain was also linked to much worrying, often shared by the whole family.

Chronic, benign pain, depressive disorders, pain anxiety, psychosocial stressors and subjective work incapacity were also common among the immigrants in the third project. In addition to physiotherapy and doctors' reassurance about the benignity of the pain, interviews and dialogue sessions about pain were included in one of the randomised groups. The interviews revealed two patterns of pain concepts. One consisted of notions about a deteriorating disease along with worries for future disability; the other of vague ideas, concentrating on the immediacy of pain. After the programme, pain anxiety and depressive symptoms had decreased, and self-rated work ability had increased significantly more among the interviewees than in the control group. Self-rated work ability was a good predictor for returning to work and for staying at work the following years.

In summary, pain anxiety was at the core of the illness, disease and sickness patterns of the immigrants in the research projects. Pain interviews and dialogue sessions about pain may reduce pain anxiety and depressive mood, increase self-rated work ability, and increase the prospects of successful rehabilitation back to work.