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

Sammanfattning: Illness, disease, sickness. Clinical factors, concepts of pain and sick leave patterns amongimmigrants in primary health care. Effects of different therapeutic approaches Monica Löfvander The outer framework for this thesis is the high rate of disability pensions amongsome immigrant groups in Sweden. The general aim for the research has been to understandthe phenomena of illness, disease and sickness certification in immigrants from aprimary care perspective and to test the effects on well-being and sickness certificationof different therapeutic approaches. The research has been done step-wise and hasmainly been of an inductive character. The first project is a descriptive - intervention study of sickness, disease andpsychosocial patterns in 105 consecutive, first-time health service visitors of Greekand Swedish origin with a ten year follow-up. In the second project, concepts ofbackache were explored in 15 consecutive Greek patients on long-term sick leave and21 healthy members of a Greek cultural association. The third project, comprising92 persons aged 25-45 years, consists of explorative studies of clinical factors,psychosocial stressors, sick leave patterns with a three year follow-up and conceptsof pain in the framework of a rehabilitation programme with two randomised treatmentgroups. 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 stressorsand social functioning. Global ratings of work incapacity were made jointly by theresearchers. Self-rated work ability and ratings of pain behaviour were includedin 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 psychosocialstressors. Counselling sessions with a Greek psychotherapist were generally not acceptedby the Greeks. Regarding work incapacitating diseases, the Greeks had chronic painand depression and the Swedes had other psychiatric disorders or chronic pain. Inspite of small differences in work incapacity between the ethnic groups, the Greekswere more often on long-term sick leave, a difference that increased over a ten yearperiod. In the second project, the concepts about backache among the Greek interviewees werefound to centre around the idea of a deteriorating disorder as the cause of persistentpain; a disorder inevitably leading to invalidity if the sufferer should deliberatelyaggravate the pain. The pain was also linked to much worrying, often shared by thewhole family. Chronic, benign pain, depressive disorders, pain anxiety, psychosocial stressorsand subjective work incapacity were also common among the immigrants in the thirdproject. In addition to physiotherapy and doctors' reassurance about the benignityof the pain, interviews and dialogue sessions about pain were included in one ofthe randomised groups. The interviews revealed two patterns of pain concepts. Oneconsisted of notions about a deteriorating disease along with worries for futuredisability; the other of vague ideas, concentrating on the immediacy of pain. Afterthe programme, pain anxiety and depressive symptoms had decreased, and self-ratedwork ability had increased significantly more among the interviewees than in thecontrol group. Self-rated work ability was a good predictor for returning to workand for staying at work the following years. In summary, pain anxiety was at the core of the illness, disease and sickness patternsof the immigrants in the research projects. Pain interviews and dialogue sessionsabout pain may reduce pain anxiety and depressive mood, increase self-rated workability, and increase the prospects of successful rehabilitation back to work. Key words: Immigrants, general practice, psykosocial stress, chronic pain, concepts,cross-cultural psychiatry, cognitive, sick leave, language, depression, social adjustment,psychosomatic disorders, qualitative research. Monica Löfvander ISBN 91-628-2662-X