Patterns and Perceptions of Self-Management for Osteoarthritis Pain in African American Older Adults

Abstract

Objective

To explore and describe older African Americans’ patterns and perceptions of managing chronic osteoarthritis pain.

Methods

A convergent parallel mixed-methods design incorporating cross-sectional surveys and individual, semistructured interviews.

Setting

One hundred ten African Americans (≥50 years of age) with clinical osteoarthritis (OA) or provider-diagnosed OA from communities in northern Louisiana were enrolled.

Results

Although frequency varied depending on the severity of pain, older African Americans actively used an average of seven to eight self-management strategies over the course of a month to control pain. The average number of self-management strategies between high and low education and literacy groups was not statistically different, but higher-educated adults used approximately one additional strategy than those with high school or less. To achieve pain relief, African Americans relied on 10 self-management strategies that were inexpensive, easy to use and access, and generally perceived as helpful: over-the-counter (OTC) topicals, thermal modalities, land-based exercise, spiritual activities, OTC and prescribed analgesics, orthotic and assistive devices, joint injections, rest, and massage and vitamins.

Conclusions

This is one of the first studies to quantitatively and qualitatively investigate the self-management of chronic OA pain in an older African American population that happened to be a predominantly higher-educated and health-literate sample. Findings indicate that Southern-dwelling African Americans are highly engaged in a range of different self-management strategies, many of which are self-initiated. Although still an important component of chronic pain self-management, spirituality was used by less than half of African Americans, but use of oral nonsteroidal anti-inflammatory drugs and opioids was relatively high.

Introduction

Chronic pain is one of the most prevalent, costly, disabling, and understudied chronic conditions in older African Americans [1]. Among community-dwelling African Americans age 65 years and older, up to 78% suffer with chronic pain [2,3], and of these, 67% report arthritis as the major source of chronic pain [1]. Although osteoarthritic joint pain is a leading cause of chronic pain in older adults, older African Americans are disproportionately affected. The age-adjusted prevalence of severe, high-impact joint pain is 42% among non-Hispanic African Americans compared with 36% for Hispanics and 23% among non-Hispanic Whites [4]. In fact, a larger proportion of older African Americans (64.3%) reported chronic pain intensities in the moderate to severe range, in contrast to non-Hispanic Whites, Hispanics, and Afro-Caribbeans (35.6%, 54.5%, and 59.7%, respectively) [5]. Indeed, older African Americans with osteoarthritis (OA) experience more severe pain and disability, and every effort should be made to obtain sufficient pain relief. One way to do this is for older African Americans to consistently engage in self-management utilizing effective pain mitigation strategies.

As the United States faces a national opioid problem, federal and local initiatives to decrease the use of opioids are placing more emphasis on comprehensive care and self-management to achieve good pain control [6]. Pain self-management can describe a range of interventions and processes [7,8] that an individual actively engages in to minimize or eliminate the impact of pain on their daily physical, psychological, and social health [8,9,10]. In a broad sense, these methods include traditional or prescribed medical treatments (e.g., medications), complementary (e.g., topicals) and alternative (e.g., acupuncture) therapies, and coping strategies (e.g., prayer). A number of perceived and actual barriers to the use of nonpharmacological pain management [11] may play a part in African Americans engaging less optimally in OA self-management strategies and subsequently having greater pain ratings [12]. Specifically, well-documented disparities in access to and utilization of select complementary and alternative therapies—as well as mainstream treatments, such as prescribed medications and total joint replacements [13]—often lead older adults to adapt prescribed treatments based on their personal and financial ability, preferences, changing arthritis pain needs, and expectations for relief [14,15]. Nonetheless, there is a growing interest in complementary and alternative strategies across racial groups, particularly in African Americans [16]. Recent studies indicate that older African Americans with chronic pain conditions prefer and use more nonpharmacological strategies, including active (e.g., nonaquatic exercise and physical therapy) and passive strategies (e.g., prayer and meditation) [15,17]. This is significantly different than older, seminal quantitative studies, which consistently found that older African Americans primarily use passive strategies such as creams, prayer, and home remedies much more than other racial groups [12,18–22]. Thus, Silverman and colleagues [18] have noted a need for further research on the motivations that influence choice for OA self-care behaviors in African American and non-Hispanic White older adults.

The narrow focus on a static set of self-management modalities in many arthritis studies [14] substantially limits the evidence on utilization patterns, efficacy, and reason for use of traditional medical interventions, complementary and alternative strategies (including substances such as medical marijuana), and behavioral interventions in older African Americans with OA pain. [15,23]. Indeed, the self-management experience in older AAs has been largely explored from a quantitative standpoint, and the patients’ personal narratives remain absent. Therefore, mixed-methods research provides a rich medium for understanding what demographically diverse older African Americans do to manage pain and the context in which self-management is used to prevent the escalation of high-impact chronic pain. This is an essential step in achieving quality and equity in OA care, access to evidence-based arthritis interventions, and widespread promotion of self-management in older AAs [24]. Furthermore, identifying key patterns in self-management strategies can help providers individualize treatment plans, ensure safe self-management, and recommend strategies that are culturally congruent for enhanced patient compliance. Thus, the purpose of this study was to describe the patterns and perceptions of pain self-management strategies in a sample of community-living African American seniors. For the purposes of this study, self-management is broadly defined as the medical, complementary, alternative, and popular therapies adapted and used to manage OA pain.

Methods

A convergent parallel mixed-methods design (Figure 1 ) utilized convenience and snowball methods to recruit older African Americans from northeastern and northwestern Louisiana to complete cross-sectional in-person surveys (N = 110) and individual semistructured interviews (N = 18) from a purposive subset of the sample. Participants were recruited from community health fairs and events, churches, community senior centers, senior housing, and local Black Greek sororities and fraternities through flyers, study informational meetings, and word of mouth, and using e-mail listserves from the local National Association for the Advancement of Colored People chapter and alumni of Grambling State University (a Historically Black College and University).

Figure 1.

Convergent Parallel Mixed Methods Design.

Individuals were eligible to participate if they 1) met the OA criterion: a) having being told by a health care provider that they had OA or b) three of the following symptoms: stiffness, swelling, pain that gets better with rest and worse with activity and/or crepitus occurring in any major joint site; 2) had chronic pain for at least three months; 3) were aged 50 years or older; 4) identified as African American or Black; 5) resided in northern Louisiana; and 6) were without major cognitive impairment, as evidenced by a score ≥15 on the Animal Naming Test [25,26]. For the purposes of this study, African Americans were considered an older adult at age 50 years. Although 65 is the traditional age to describe an older adult, some chronic pain studies designate 50 or 55 years as the minimum age for “older” African Americans [17,27]. To reduce subject burden, the validated Animal Naming Test [25,26] was chosen as a brief (one-minute) assessment of cognitive impairment. Animal fluency is an established and reliable method to determine cognitive dysfunction in older African Americans [28]. No African American screened positive for possible major cognitive impairment in our study. Exclusion criteria were limited to a history of stroke or other neurological condition, lupus, sickle cell disease, institutionalization (e.g., nursing home, assisted living), and rheumatoid arthritis.

The University of Iowa Institutional Review Board approved the study, and informed consent was completed by the PI (i.e., SB). A $15 gift card to a local grocery store and educational resources on managing OA were provided to participants at the end of the study.

Measures

One hundred ten participants completed three closed- and open-ended surveys with the PI. These surveys provided information on participants’ demographics, health literacy, and pain self-management practices.

Participant Characteristics Questionnaire

The Participant Characteristics Questionnaire collected sociodemographic and health-related data. Data reported in this paper include age, gender, education level, income, and OA pain severity.

Health Literacy Questionnaires

We measured health literacy using two validated tools, the Rapid Estimate of Adult Literacy in Medicine–Short Form (REALM-SF) and the Single Item Literacy Screener (SILS). The REALM-SF is a two-minute health literacy test assessing word recognition of common health terms and has been validated in large ethnic minority and older adult populations [29]. Scores were derived as the number of words correctly pronounced (0–7).

SILS is a single question tool that asks, “How often do you need to have someone help you when you read instructions, pamphlets, or other written material from your doctor or pharmacy?” Possible responses include 1 = never, 2 = rarely, 3 = sometimes, 4 = often, and 5 = always. Scores of 2 or greater are considered positive and indicate patients who may need help with reading written health material [30].

Arthritis Pain Self-Management Inventory

This tool was developed by the PI combining elements of Davis and Atwood’s 16-item Pain Management Inventory [31] and Hampson et al.’s Summary of Arthritis Management Methods (SAMM) [32] with additional items added from the self-management literature. The Arthritis Pain Self-Management Inventory (APSI) assessed for 37 traditional and complementary/alternative strategies, and subjects reported on utilization (yes/no), frequency of use (every day, several days per week, once per week, once per month, and as needed), helpfulness (Likert scale: 0 = not at all helpful to 4 = extremely helpful), and reason for use (helps with pain, prescribed by provider or therapist, recommended by friend, or trying to see if it helps). A small pilot study with 10 African Americans (age 50 years and older) with and without OA pain provided preliminary support for face and content validity of the APSI. Based on comments received during the preliminary survey testing, questions were modified or eliminated to ensure clarity of language, ease of use, relevance, overall readability, and suitable completion time.

To elucidate the most comprehensive data about self-management strategies, we used a two-step approach. First, we posed an open-ended statement, “Over the past month (30 days), tell me how you’ve cared for your arthritis pain.” The specific self-management strategy and its frequency of use, helpfulness, and reason for use were recorded on the APSI. If a category was reported (e.g., “pain medication”), the interviewer asked for the specific medication category (e.g., opioid) and name (e.g., Lortab), and this was recorded on the APSI. Second, after the initial open-ended reporting, a list of all the APSI’s strategies was shown to participants to identify any other strategies not previously reported; any additional strategies reported were also recorded on the APSI. We also asked about perceptions of control with the question “Out of all the things you do to control pain, are they effective in controlling your pain?” Responses were coded as a categorical yes/no variable.

Qualitative Interviews

We used maximum variation sampling to select 18 demographically diverse men (N = 9) and women (N = 9) for qualitative interviews to understand better the full range of patterns employed by participants and their perceptions of the self-management process and strategies. To enhance individual heterogeneity, participants were stratified by pain severity (i.e., mild, moderate, and severe) and sex; then selection was varied according to education (less than high school, high school/trade, and college or higher) and age cohort (young-old [50–64], middle-old [65–79], and old-old [80 +]). Consistent with the overall sample, the majority of our interviewees had a high school diploma or college degree.

A semistructured interview guide gathered in-depth information about personal, cultural, and community-based self-management. Sample questions were 1) Tell me about how you care for your arthritis pain on a “typical day?”; “good day?”; “bad day?” 2) What do you to do keep arthritis pain from getting worse? 3) What things help you control your pain? 4) What are some things that Black people do to manage their arthritis pain? 5) How do you see spirituality, religion, and faith being related to pain or its management? All interviews were conducted by the PI in the participant’s home or a quiet public location such as a library. Interviews were audio-recorded and lasted between 40 and 90 minutes. Interviews ended with reflections by each participant and a summary by the PI.

Analysis Methods

Using SPSS 25.0 (IBM, Armonk, NY, USA), sample characteristics and self-management strategies were summarized using descriptive statistics. Seven respondents reported a frequency of once a week or monthly for several of the commonly employed self-management strategies; therefore, we combined once a week with several days a week and monthly with as needed for a total of three categories (every day, several days a week, and as needed). Regarding the helpfulness variable, the proportion of participants endorsing moderately and very helpful is reported. To quantitatively analyze the mean number of strategies by education and health literacy rate, we developed dichotomous groups for education (less than high school/GED and some college, or college degree), REALM-SF (0–6 words and 7 words), and SILS (never/rarely compared with sometimes, often, always). Independent t tests assessed for between-group differences in the average number of self-management strategies employed by participants as a function of their education and health literacy levels. Analysis of variance, with the Welch test, was used to compare mean self-management strategies of the mild, moderate, and severe pain groups. Significance was set at P ≤ 0.05.

Interviews were transcribed by professional transcriptionists; then the audio-to-transcription accuracy was verified by the PI, who is African American and familiar with the Southern dialect spoken by participants. Transcripts were imported to HyperRESEARCH qualitative management software. A qualitative descriptive (QD) approach guided our content analysis given its relevance for conducting mixed-methods studies with vulnerable populations to describe health disparities, support culturally appropriate and contextually rich research, and facilitate a needs assessment from the perspective of older African Americans [33–36].

Two researchers (i.e., SB and TTR) separately conducted line-by-line reading of five transcripts to identify and extract meaning units of text and preliminarily coded transcripts to identify major categories for the coding template. Discrepancies or disagreements were resolved through discussion until a consensus was reached. Once the coding template was stable and identified no new categories, we applied this final version to all transcripts, including the five preliminary transcripts. Then, we collaboratively sorted and grouped categories into meaningful clusters (i.e., self-management strategies for this paper). Through triangulation, qualitative data complemented our quantitative findings for a more complete understanding of personal self-management, including areas where data converged and diverged. Credibility of the data was enhanced through triangulation of data, whereas trustworthiness [37] and legitimation (i.e., validity, reliability, and objectivity) [38] were established through gaining trust of the participants and iterative engagement with the data, which occurred over a four-month period.

Results

Sample Characteristics

Sociodemographic data for 110 African Americans, who ranged in age from 50 to 94 years, are presented in Table 1. The sample was predominantly female 82%), and most participants (87%) rated their pain in the moderate to severe range and reported experiencing pain for >12 years. Sixty percent had received some college education or obtained a college degree. Characteristics of the qualitative participants, who were diverse in education and age, are presented in the Supplementary Data.

Table 1.

Sociodemographic and pain characteristics (N = 110)

Characteristic	No. (%)
Age, mean ± SD, y	68.4 ± 12.4
Sex
Female	90 (81.8)
Male	20 (18.2)
Income*
<Enough	14 (12.7)
= Just enough	71 (64.5)
≥ Enough	24 (21.8)
Employment
Yes	31 (28.2)
No (retired, disabled, other)	79 (71.8)
Education
≤ High school/GED	43 (39.1)
= Attended/graduated college	67 (60.9)
Health literacy: REALM-SF
0–6 words	49 (44.5)
7 words	61 (55.5)
Health literacy: SILS
Always, often, sometimes	18 (16.4)
Rarely and never	92 (83.6)
Perceived OA pain severity
Mild	25 (22.7)
Moderate	66 (60.0)
Severe	19 (17.3)

GED = General Educational Diploma; OA = osteoarthritis; REALM-SF = Rapid Estimate of Adult Literacy in Medicine–Short Form; SILS = Single Item Literacy Screener.

^*Missing, N=1

Overall Patterns of Self-Management Strategies

Both the qualitative and quantitative data show that African Americans engage in a variety of physical, spiritual, and pharmacological self-management and coping strategies simply “trying to get some control over the pain” (Participant 4). The APSI survey revealed 10 self-management strategies (Table 2) that participants commonly employed. From highest to lowest frequency, these included 1) over-the-counter (OTC) topicals, 2) thermal modalities, 3) exercise, 4) OTC medications, 5) spiritual practices, 6) prescribed medications, 7) assistive and orthotic devices, 8) joint injections, 9) rest, and 10) massage and vitamins. These strategies were primarily used to relieve pain, but several were also used for other reasons. For example, prescribed medications and vitamins were taken because their provider recommended them; exercise was also used for stiffness, and assistive and orthotic devices were used for stability.

Table 2.

Frequency and perceived helpfulness of commonly used pain self-management strategies (N = 110)

Rank	Behavior	Using, No. (%)	Frequency, No. (%)*			Helpfulness, No. (%)‡
			Every Day	Several Days/Week	As Needed
1	Topical: OTC
	Creams†	63 (57.3)	11 (17.5)	8 (12.7)	43 (68.3)	42 (66.7)
	Rubs	57 (51.8)	12 (21.4)	7 (12.5)	37 (66.1)	29 (50.9)
2	Thermal modalities
	Warm showers/baths†	62 (56.4)	24 (38.7)	23 (37.1)	14 (22.6)	55 (88.7)
	Warm/cool compress	47 (42.7)	6 (12.8)	6 (12.8)	35 (74.5)	37 (78.7)
3	Land-based exercise	58 (52.7)	18 (31.0)	32 (55.2)	8 (13.8)	48 (82.8)
4	Medications: OTC
	NSAIDs†	53 (48.2)	11 (20.8)	8 (15.1)	34 (64.2)	40 (75.5)
	Acetaminophen	38 (34.5)	2 (5.3)	4 (10.5)	32 (84.5)	22 (57.9)
5	Spiritual practices
	Prayer	46 (41.8)	35 (76.1)	5 (10.9)	6 (13.0)	44 (95.7)
	Church	26 (23.6)	0 (0)	25 (96.2)	1 (3.8)	25 (96.2)
6	Medications: prescribed
	NSAIDs†	36 (32.7)	24 (66.7)	2 (5.5)	9 (25.0)	21 (58.3)
	Opioids	33 (30.0)	18 (54.5)	2 (0.06)	13 (39.4)	24 (72.7)
7	Devices
	Orthotic†	36 (32.7)	7 (19.4)	9 (25.0)	18 (50.0)	27 (75.0)
	Assistive	35 (31.8)	17 (48.6)	4 (11.4)	14 (40.0)	26 (74.3)
8	Joint injections (steroid or hyaluronic acid)§	35 (31.8)	20 (57.1)	13 (37.1)	2 (5.7)	25 (71.4)
9	Rest†	24 (21.8)	8 (33.3)	6 (25.0)	9 (37.5)	17 (70.8)
10	Massage	21 (19.1)	1 (4.8)	4 (19.0)	16 (76.2)	18 (85.7)
	Vitamins†	21 (19.1)	16 (76.1)	1 (4.8)	3 (14.3)	5 (23.8)

NSAID = nonsteroidal anti-inflammatory drug; OTC = over the counter.

^*Percentage of users only.

^†Missing data at random on frequency: creams (N = 1, 1.6%); warm baths (N = 1, 1.6%); NSAIDs: prescribed (N = 1, 2.8%); orthotic device (N = 2, 5.6%); rest (N = 1, 4.2%); vitamins: never (N = 1, 4.8%).

^‡Percentage of users endorsing moderately helpful and very helpful.

^§Frequency categories for joint injections: every three to six months, yearly, and as needed.

From the 37 strategies assessed by the APSI, females used an average (SD) of 8.26 (3.73) strategies, whereas males, on average, used one less strategy (7.25 [3.73], P = 0.28). African Americans with severe pain used 9.58 (2.80) strategies, whereas those with moderate pain (7.86 [3.87]) and mild pain (7.48 [3.81]) used fewer strategies (P = 0.06). Although not significantly different, African American older adults with higher education and health literacy used an average of one more strategy than those with lower education and health literacy (Table 3).

Table 3.

Average self-management strategies by education and literacy level

Variable	No.	%	M	SD	PValue
Education					0.53
≤ High school/GED	43	39.1	7.79	3.80
= Attended/graduated college	67	60.9	8.25	3.71
Health literacy: REALM-SF					0.08
0–6 words	49	44.5	7.22	2.95
7 words	61	55.5	8.75	4.16
Health literacy: SILS					0.44
Sometimes, often, always	18	16.4	7.44	2.59
Never and rarely	92	83.6	8.19	3.92

GED = General Educational Development; REALM-SF = Rapid Estimate of Adult Literacy in Medicine–Short Form; SILS = Single Item Literacy Screener.

Despite describing their pain as moderate overall, the vast majority of participants (N = 93, 84.5%) reported that the various types of self-management strategies together were effective in controlling pain. Only 11 (10%) reported that self-management did not control pain, and six (5.5%) participants had missing data due to an unanswered question from time constraints. On average, African Americans with good pain control used 8.35 (3.8) strategies, whereas those with less-controlled pain used fewer strategies (6.36 [2.2]). African Americans who agreed that their self-management strategies controlled pain were more apt to use a combination of the 10 above-mentioned strategies, and participants summarized this process as “just trial and error” because it was hard “to pinpoint one strategy cause it all works together.”

Patterns and Perceptions of Specific Self-Management Strategies

The qualitative interviews provided additional context on the patterns and perceptions of the most commonly used strategies, and this section presents triangulated findings for OTC topicals, thermal modalities, exercise, spiritual practices, and medications (OTC and prescribed).

OTC Topicals

“A lot of [black] people…use different kinds of rubs and creams and even the pain relief patches, ointment” (Participant 14). Survey data supported this statement by showing that creams (thicker ointments) and rubs (thin liquids) were used by 57% and 52% of all African Americans, respectively. African American participants avoided using oral analgesic medications or visiting a health care provider as a first response to pain. Instead, they resorted to creams and muscle rubs that they grew up seeing family members use or that were recommended by family and friends. One older man in our study reported, “It’s like a lot of times I’m in pain, and it’s somethin’ out there could help me, like a rub—rather than havin’ to go to the doctor every time” (Participant 15). Many different types of creams (e.g., Bengay, IcyHot, Aspercreme, Two Old Goats) and rubs (e.g., various formulations of isopropyl rubbing alcohol, Watkins liniment) were used as needed, frequently at night and when the pain was becoming severe. On average, creams and rubs were rated as moderately helpful. These were massaged directly on the painful area and/or sometimes used conjointly with thermal modalities.

ThermalModalities

Fifty-six percent used warm baths/showers, whereas a lower proportion (43%) used warm/cool compresses. Although warm showers and baths were part of their daily hygiene, they specifically noted the therapeutic effects of the warmth/heat, often immersing themselves in water “as hot as they could stand.” Topicals were often used in conjunction with warm baths/showers to enhance the analgesic effect. In fact, a subanalysis detected that between 9% and 38% of African Americans were using thermal sensation creams and rubs (e.g., IcyHot, biofreeze, Vick’s salve), warm baths/showers, and massage in some combination (Figure 2). Many poured various types of rubbing alcohol, arthritis rubs, or Epsom salt into warm bath water for soaking to ease joint achiness and soreness or massaged a cream onto the affected area after bathing.

I walk, and then they say you can soak yourself in a tub or get in your tub and just run you some water and put some Epsom salt and stuff in your water. I have got in the tub and laid in there for a long time. (Participant 9)

Figure 2.

Distribution of combination self-management strategies. Results: warm baths and over-the-counter (OTC) rubs: N = 42; warm baths and OTC creams: N = 39; warm baths and massage: N = 15; OTC rubs and OTC creams: N = 36; OTC rubs and massage: N = 11; OTC creams and massage: N = 10.

A majority of older African Americans who reported taking warm baths/showers rated this strategy as moderately to very helpful in easing pain (89%). Fewer preferred cool compresses because in some cases this increased the stiffness and hurt. Thermal modalities were primarily used because they helped with pain, but African Americans were unsure “Which is better, an icepack or heat?” (Participant 6); thus, a recommendation from a health care provider or physical therapist also prompted a small proportion of participants to use thermal strategies.

Exercise

Over half of all participants (52%) reported engaging in exercise at least several days a week and rated exercise as moderately helpful. Exercise ranged from walking to chair and bed exercises.

OK, what I normally do, I get up in the morning, and to get my legs goin’…. I’ll do exercise.… Walkin’ is very good for me. Now that my daughter and I have gotten into this contest, we exercise in the evenin’. The exercisin’ is good for me in the mornin’, just the arthritis. (Participant 1)

Because OA is “always gonna be a constant thing,” the majority recognized that the “key is just to keep moving and…do some exercise. A person just need to stay active” (Participants 1 and 15) in order to experience the benefits of exercise in reducing pain and stiffness.

Your exercise is important, ‘cuz it keeps your joints movin’. It helps to relieve the pain. At least it does in me. A lot of people don’t do ‘em, and a lot of people don’t think they help. Well, if you do nothin’, it’s still gonna hurt. (Participant 13)

However, others were not motivated and believed that “if it [exercise] doesn’t seem to help any or if it causes me to ache more or something, I probably won’t fool with it” (Participant 18). Thus, pain was regularly cited as a deterrent, and participants noted the difficulty of exercising due to severe movement-evoked pain and instability of weight-bearing joints. Although they wanted to exercise, severe pain was disabling and interfered with their ability to carry out recommended exercises.

Say that people that has severe joint, like my knees are so severe, if I bend down, I cannot get up…. They say exercise. OK…when I get through exercisin’, I’m in pain. What am I supposed to do? What are the alternatives? I can’t walk from here to there. (Participant 11)

She did a little exercise with me and then give me a piece of paper talking about do these every day. If I could do that, I wouldn’t need to be there with you. I can’t do them on my own. I need somebody to help with these joints and muscles. (Participant 17)

SpiritualPractices

Prayer was used by 42% of African Americans surveyed in our study, with substantially fewer participants (23.6%) attending church. However, prayer and attending church were the only strategies rated by the highest proportion of participants as very helpful. Nearly all interview participants (83%, N = 15/18) spoke explicitly about prayer. Those who engaged in prayer strongly believed in the importance and power of prayer regardless of whether they considered themselves religious because “prayer help heal the pain” (Participant 16).

African Americans in our study viewed prayer as a way “for the Lord to help you be able to manage or deal with your pain” (Participant 14), and participants would ask God (or the Lord/Jesus) to 1) remove the pain, 2) ease the pain, 3) help them bear the pain, or 4) give them strength in their body. One woman explained:

I’d have to call out to Him in the middle of the night. When I’m layin’ there, my legs will be so bad, just before I had finally got the surgery. I said, “Lord, all I want, if you don’t take it away, just allow me to go to sleep. I didn’t even ask Him to take away the pain. I just wanted to go to sleep [laughter], and He would do that for me. I’m really dependent on that, on many a time, to bring me through whatever it was. (Participant 1)

The majority of participants (58.2%) had never considered using prayer as a direct strategy to control or reduce pain but did acknowledge that they prayed daily, but not specifically related to pain. Others used prayer to cope with pain. Of all the self-management strategies, prayer was the strategy most likely to be used on a daily basis (32%).

Medications

Analgesic medications were a temporary solution to “subdue the pain just for a moment because after that wear off, you gotta deal with your pain” (Participants 3, 8, and 11). From both surveys and qualitative interviews, older African Americans made clear their dislike of oral pain medications, particularly prescribed medications. Participants voiced a clear preference for using topical agents such as creams/rubs or OTC pain patches first. “I need to do something about it, to get some pain relief. The pain patches, not the one that’s prescribed by doctors, but over-the-counter pain patches. The next thing is to take an Aleve” (Participant 4). They often waited until the pain was severe/unbearable, and even then, they would limit the frequency and dose of both prescribed and OTC oral pain medications taken. For example, “If I’m hurting bad, I got somethin’ to do, that’s when I take a pain pill” (Participant 11) or “On a bad day, I have to stop and find something to take” (Participant 14).

A large proportion of older African Americans took OTC nonsteroidal anti-inflammatory drugs (NSAIDs; 48%), OTC acetaminophen (35%; i.e., Tylenol), and prescribed NSAIDs (33%). The most common OTC NSAID was Naproxen (Aleve), which was more often rated as moderately to very helpful than the most commonly prescribed NSAID (e.g., meloxicam). Some participants would substitute OTC medications when their prescribed medications were out or if they didn’t want to take “strong” pain medication: “But sometime instead of tryin’ to take pain pill, I’ll just take—I think they say I can take up to eight Aleves a day” (Participant 11). Most rated OTC NSAIDs as very helpful and OTC Tylenol and prescribed NSAIDs only as somewhat helpful or not helpful. “Sometimes I take them Tylenols. I take two of them to soothe the pain, and it’s just short relief. When pain relieves, oh, you feels so relaxing!” (Participant 8).

Thirty percent reported taking prescribed opioids. Despite being rated as moderately to very helpful, participants’ willingness to use opioids consistently was overshadowed by their concerns about addiction, dependence, and side effects on the kidneys and heart. For example, at the advice of their provider or due to personal concerns with adverse effects, a large subset (39.4%) took opioids as needed by reserving these medications for severe pain. This approach was problematic because “sometimes you don’t get it in your system, you never know it works” (Participant 8), and as a result, their pain escalates.

‘Cuz I’ma be honest. I’m not good at—I don’t take the medicine like they tell me I should take it. I don’t like pain meds. I just found out that I made things worse for myself, because I shoulda been takin’ it, and the pain wouldn’t be so bad. (Participant 13)

Finally, older African Americans were more adherent taking both prescribed NSAID and opioid medications every day after making lay evaluations of their effectiveness and safety.

Discussion

Our mixed-methods study revealed that African American seniors with predominantly moderate to severe pain 1) were actively engaged in numerous methods to control pain, regardless of education or literacy status, and these strategies together were perceived temporarily as effective in controlling their pain; 2) used spirituality less often than previously reported [5,14] but still strongly endorsed its helpfulness; and 3) used oral NSAID and opioid medications and joint injections at relatively high rates. These are important findings about OA pain self-management patterns and perceptions given that much of the chronic pain literature has reported on a singular group of older African Americans, primarily those with lower education and income [18,21,39]. Sixty percent of our sample had attended or graduated college, and thus, our results diverge from prior studies, both in terms of education and in the use of a wider range and greater number of pain self-management strategies employed (Supplementary Data). Specifically, our sample used on average seven to eight strategies, compared with other studies that report fewer self-management strategies (e.g., five or fewer) when compared with Hispanic, non-Hispanic White, and Chinese older adults [21,40–42]. Although recent reports show that having a college education predicted a higher number of complementary and alternative modalities used for arthritis [43], the average numbers of self-management strategies were not notably different between the education and literacy groups in our study.

African American older adults who used a greater number of strategies also reported better-controlled pain in this study. Although the number of strategies alone may not fully explain this difference, it is possible that older African Americans with better pain control can more easily engage in varied strategies, unlike those who experience higher and physically limiting pain. Specifically, we were surprised to find that over half of our participants (53%) were engaged in some form of regular exercise given earlier studies indicating that, independent of pain intensity, exercise utilization is lowest in African American older adults (e.g., 41%). Thus, the effects of exercise may contribute to better-controlled pain. Exercise is one of the core OA treatments [44,45], and studies show that exercise produces a significant effect in reducing pain and improving function [46,47]. We also discovered that many older African Americans tailored strategies by combining creams, thermal modalities (e.g., warm baths with Epsom salts or isopropyl rubs), and massage to increase their efficacy and obtain greater pain relief. Multiple mechanisms may play a role in explaining why these strategies were perceived as moderately to very helpful, including the type of active ingredient in the topicals, namely menthol, isopropyl alcohol, methyl salicylate, and lidocaine; the interactive effect of massaging creams and rubs on the joint; or intergenerational traditions and learned behaviors emphasizing the benefit of these complementary strategies.

One unexpected result is that less than half (42%) of African Americans in our study reported using prayer to manage pain; this finding stands in contrast to a well-established body of research [48]. These studies suggest that prayer and spiritual mechanisms are dominant self-management and coping strategies used by African Americans to manage chronic pain conditions such as OA [41,49,50] and cancer [51,52]. Perhaps having a higher education may reinforce the benefits of more tangible strategies over the psychological benefit of prayer. Therefore, prayer and “spiritual medicine” may be valuable and relevant for managing chronic pain in a proportion or specific subset of older African Americans [17,53].

Lastly, medications, although not a preferred strategy for many, was an essential component of self-management. Our findings confirm that African Americans are more likely to use nonopioid medications, particularly NSAIDs, for chronic pain [11,54], possibly related in part to provider caution and bias toward prescribing opioids in African Americans [11,55] and patient concerns about the safety of opioids [11,17]. Specifically, a large study with 400 African American older adults documented that 47% were taking pain medications for chronic pain, and NSAID use had the highest rate of 77% [54]. Of clinical importance is the high use of OTC NSAIDs in our study, which may pose significant overdose risks as well as higher risk of both gastrointestinal and cardiovascular adverse events. Acetaminophen rather than NSAIDs is recommended for mild OA pain in this population [56]. The safety of NSAIDs in older African Americans deserves further clinical trial investigation, patient education, and provider vigilance. Interestingly, OTC NSAIDs were viewed as more helpful than prescribed NSAIDs by our sample. One explanation for this finding may lie in the pharmacological mechanism of action and onset of action. Some studies suggest that inhibiting both Cox-1 and Cox-2 (i.e., nonselective Cox inhibitors such as OTC NSAIDs) produces a greater analgesic effect than Cox-1 inhibitors (i.e., Meloxicam) alone [57].

Compared with the 12% (N = 48/400) of older African Americans using opioids in Yazdenshenas et al.’s study [54], >30% of participants reported use of opioids. Concerns for using opioids are widely documented in older African Americans [15,17] and support our observations of two distinct groups of older African Americans: everyday users of opioids and pro re nata (PRN) users who reserve opioids for severe pain. Based on the patterns reported, when medications are taken, OTC NSAIDs take precedence over opioids, particularly in the PRN group. Similar patterns of opioid avoidance and substitution have been shown in other older African American populations [15].

Strengths and Limitations

The design of this study has several advantages, including its mixed-methodology design and ability to recruit higher-educated older African Americans from both urban and rural areas, a population not well represented in the literature. However, data for this descriptive study were obtained from a convenience sample using self-report measures, which introduces limitations and several sources of bias. In addition, the APSI is a new tool derived by combining elements of two validated tools with additional content from a review of the literature; the APSI has not been validated beyond face and content validity. OA was not verified through radiographic imaging or medical record documentation. The findings are limited to community-dwelling, noninstitutionalized older African Americans residing in a discrete geographic location (north-central/northwestern LA), and therefore should not be (overly) generalized to other populations of older African Americans. Our sample had, on average, a high education level, which could account for greater engagement in self-management strategies.

Lastly, because participants were asked about strategies used within the past month, recall bias is possible, but our participants could readily identify the strategies they used for pain. Although increasing the period for which participants must remember events decreases the accuracy of recall, it may also make the recall period more representative, especially when self-reporting symptoms, such as pain, which are highly variable from day to day. We must acknowledge the potential influence of social desirability on the high frequency of exercise reported in our study.

Conclusions

Our older African American study participants, regardless of education or health literacy level, used multiple strategies to control pain. This finding is encouraging because a combination of nonpharmacological and pharmacological strategies, rather than singular methods, is most effective for managing pain [58]. More importantly, our results show that there are specific trends in the experience of selecting and using a wide variety of self-management strategies. In conclusion, understanding the strategies most used, when they are used, and why they are used is essential to inform self-management interventions that are culturally familiar and efficacious in older African Americans, a population that is under-researched.

Supplementary Data

Supplementary data are available at Pain Medicine online.

Funding Statement: Staja Booker: Postdoctoral Fellow: NIA T32AG049673 (PI: Roger Fillingim, PhD); Predoctoral Fellow: NINR T32NR011147 (PIs: Keela Herr, PhD, RN, AGSF, FGSA, FAAN; Ann Marie McCarthy, PhD, RN, PNP, FNASN, FAAN).