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Volume: 1
Issue: 3
Year: 1992
Pages: 278-291
Journal Title: Clinical nursing research.
Article Author: Kodiath,
Article Title: A Comparative Study of Patients with
Chronic Pain in India and the United States
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Table of Contents /Index
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Pain Is the mostfrequently reported symptom In the health care Industry today.
Chronic pain In the United States costs millions of dollars annually, and Its
jfnanclallmpact ts mounting. For Individuals living In the United States. chronic
pain affects nearly all normal activities and often leaves the personfeellng
helpless and hopeless. Literature supports the Idea that chronic paln does not
have the same debilitating effect In the Eastern cultures as It does In the Western
cultures. Therefore. clients from both a Western and Eastern culture were
studied. This qualitative research. based on grounded theory. sampled 20
persons from India and 20 from the United States. Focused. open-ended Inter-
views were used as the major manner of gathering data. Although the condition
of chronic pain was the same for each culture. there were slgnljfcant dYJerences
regarding the phenomenon of chronic paln. Thts research Indicates the need for
health professionals to assess. Implement a plan of care for. and evaluate
patients suffering and need for Improved quality of life rather than focusing onlY
on the elimination of pain.
A Comparative Study of
Patients With Chronic Pain
in India and the United States
MARY F. KODIATH
Veterans Admlntstratlon Medical Center; San Diego
ALEX KODIATH
Samtupan. Poway. CA
Chronic pain has become one of the most prevalent. difficult.
and expensive elements of today's health care tn the United
States (Follick. Ahern. & Aberger, 1985). An estimated 50
Authors' Note r......_d ed
to Mary F - ....,.1-"'U ence and requests for reprints should be addresS
tstratto M Kodtath. Director. Chronic Low Back Pain Cllnlc. Veterans Admin
n edtcal Center. 3350 La JoUa VIllage Drtve. San Diego. CA 92161.
~ ~ ~ ~ ~ E A R C H . Vol. 1 No.3, August 1992 278-291
~ ~ r '- J.R;il __ ons._ Inc..
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Kodiath, Kodiath I PATIENTS WITH CHRONIC PAIN 279
million Americans are partially or totally disabled by chronic
pain. This number translates into annual projected costs that
exceed $4 billion in health services, drugs, compensation pay-
ments, and lost workdays (Slater & Good, 1991).
Nurses and other health care professionals caring for pa-
tients with chronic benign pain often complain of a sense of
in relieving the pain and express great frustration that
nothing can be done for these patients." Commonly, the
reason for this sense ofMfailure" is that nurses and others focus
only on either eliminating or relieving the patients' pain and
suffering.
Most of the research regarding chronic benign Patn has been
done with patients from Western countries. Very little research
is documented regarding patients with chronic pain in Eastern
countries such as Japan, China, and India. Under questioning
health professionals from these countries noted that the prob-
lems and experiences of patients with chronic pain in the
United States seemed to be very different from the experiences
of patients in Eastern countries.
The purpose of the present research using the grounded-
theory methodology was to develop a theory that explained
basic patterns common to patients from the United States and
India who experience chronic pain. An assumption underlying
the method of grounded theory is that all groups share a
specific social psychological Mproblem." The fundamental prob-
lem is resolved by means of a social psychological process
!Hutchinson. 1986). The specific social psychological problem
for this study was chronic benign pain .
STATEMENT OF THE ISSUE
Th Ived patients with
e focus of this comparative study invo pain (a)
Chrontc benign pain Chronic benign pain is defined as ths (b)
that
. I ger than 6 man
is prolonged and usually lasting on that is non-
\Vith a cause that may or may not be known. does not
responsive to physical-surgical treatment. and
SUbside once injury heals. (e) with mild to 1982).
(I) that is not life threatening (Fordyce.
1976
; . ts nniDons of
Today. chronic pain in the United States c:ttng (lamb &
dollars annually, and its financial inlpact is mo
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Barbart, 1978). For indMduals living in the United States,
chronic pain affects nearly all normal activities of dally life
(Sternbach, 1987). Although the pain is termed benign, it can
have devastating effects on a person's morale. Chronic pain
appears to destroy an individual's coping abilities, rendering
the person both helpless and hopeless, and, at times, even
abandoned (Lamb & Barbart, 1978). Patients do not die as a
result of chronic pain, but they may wish they would, especially
if no relief is in sight.
Western authors, including Evely (1967), Kennedy (1972).
and John of the Cross ( 1987), have indicated in their writings
that being human may be painful. Eighteenth- and 19th-
century theologians considered one's humanness to be a stgn
of weakness and people were subject to failure and imperfec-
tion. Consequently, this imperfection was perceived as the
cause of suffering. There are indications that some schools of
thought in Western culture consider physical pain to be the
result of sin or immorality (Rahner, 1967).

In opposition to this view, Indian philosophers have per-
ceived pain quite differently. From an Indian philosophical
approach, it is a sign of low character to allow oneself to be
distracted by pain or hardship (Tiwari, 1986). For an Indian
pain is often seen as suffering or Vedhana. A person is not of
the true Indian spirit if he or she concentrates on suffering or
pain. An Indian may inltlally focus on the cause of the pain and
then begin to address how he or she needs to deal with it
(Tlwart, 1986). The Indian believes that there are greater
purposes in pain and suffering that confer meantng, value, and
justification on life activities. Spirituality within the Indian
culture Is a strong force that gives pain a constructive purpose
(Radhakrishnan, 1952).
Nurses in the United States who care for patients with
chronic pain are very famJJtar With the feelings of hopelessness
and failure frequently expressed by these patients. The nurses
continue to search for more therapeutic measures to assist
th: ktients experiencing chronic benign pain.
dia there are very few nurses per patient compared to
the United States. and most serve in acute care facilities.
Consequently. Indian nurses educated to care for outpatient
patients With chro b
r ch nic entgn pain were not available. This
esear therefore. Will have more relevance for nurses in the
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Kodiath, Kodiath I PATIENTS WITH CHRONIC PAIN 281
United States. Increased understanding of the chronic benign
pain experience may assist nurses in changing their therapeu-
tic focus from the symptoms of pain to the meaning of pain for
the patient. .
METHOD
Grounded-theory methodology was used to generate a the-
ory explaining the basic social psychological process for per-
sons from both India and the United States who were experi-
encing chronic benign pain. Forty patient participants, men
and women, 20 from India and 20 from the United States, 25
to years of age, and who were experiencing chronic benign
Patn agreed to participate in the study ..
For several hours per day, observations along with formal
and informal interviews were completed in southern India and
the United States. In each country, interviews were conducted

an outpatient clinic setting (see Table 1). During the inter-

vtews, abbreViated notes were written along with several key .
sentences that highlighted the major topics covered.
Additional data were obtained from interviews with family
members, friends, physicians, and chart notes .. Experiences,
ob_servations, personal thoughts, and ideas about this method
and theory made up the field notes. These notes were usually
Written after seeing the patient and then expanded later that
day. Left-hand margins of the field notes allowed for substan-
tial coding that began during the data collection process.
Through time, effort, and understanding of the data, the
substantive codes were collapsed into larger categories.
The third and highest level of codes, specifically theoretical
constructs, was derived from theoretical and clinlcal knowl-
e_dge (Chenitz & Swanson, 1986). Creating meaning was ess:-
tially accomplished by conceptualizing the relationship -
tw earch phenomena
een the three levels of coding. In this res
that developed as the basic psychological process
scribed as well as the consequences of the phenomena o eac
culture. For the purpose of this study. only the major
enon that developed regarding each culture along
consequences were discussed (see Table
2
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282 CLINICAL NURSING RESEARCH I August 1992
Table 1
Interview Questions
1. How would you describe your pain?
2. What have you done to relieve your pain?
3. What is the history of your pain?
4. How have medical doctors and/or nurses helped you to experience more
pain reltef?
5. Do you have a story or a symbolic sign that helps to explain your pain?
6. Is there anyone you can identify with when you are in pain?
7. How has the pain affected your life?
8. Is there anything you would ltke to try that you have not already tried to
relteve your pain?
Finally, the grounding process was completed by validating
the theory against the data (Chenitz & Swanson, 1986; StraUSS &
Corbin, 1990). Separate content analysis was completed by
each researcher for both populations and major findings were
agreed on. Throughout the data-gathering process and the
analysis, multiple international professionals who worked with
patients experiencing chronic benign pain were consulted to
ensure validity.
GAINING ENTRY
The qualitative research was conducted during 1986 and
1987 at two sites: an outpatient clinic in southern California
and an outpatient clinic in southern India. In California. entry
as a researcher was gained through approval of the appropriate
committees for the protection of human subjects. One Investi-
gator was employed as the director of the chronic outpatient
back pain clinic and had insider information.
In southern India the research was carried out in the State
of Kerala. One of the investigators was born and raised in India
and provided considerable insider information.
DESCRIPTION OF THE SETTINGS
w Both settings for this study were outpatient clinics, but they
ere very different in their respective descriptions.
IJ ;'''' rmrrn
I . . . . . . KOOiath, Kodtath I PATIENffl MTH :HROMC PMN
283
Table 2
A Comparison of the Phenomena and
Consequences of Indians and Americans With Chronic Palna
..
' Indian phenomenon
American phenomenon
Searching for a cure
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Finding meaning In pain
Indian consequences
Became more revered by their
family
Were more respected by family
and friends
Developed closer bonds with
family and friends
American consequences
Felt relationships with family and
friends were deteriorating
Felt isolated
Believed spiritual transformation Found little hope in Uving
would result
Identified with a religious leader
Were satisfied with their
professional care
Felt peaceful
Continued daily activities
Functioned productively
Continued to search for professional
opinions
Felt victimized
Felt fearful of the future
Had difficulty working and continuing
activities of daily Uvlng
Used herbal medicines Tried expensive pain remedies
a. Chronic pain (same for both Indians and Americans) is defined as pain
lasts longer than 6 months, with a cause that may or may
Is nonresponsive to phys!cal-surgtcal treaiment. that did 1982).
injury heals, and of mild to severe Intensity (Fordyce. 19
76
;
OUTPATIENT CLINIC IN THE UNITED STATES
ed Stat s was located
The outpatient pain clinic in the Unit center. The
on the second floor in the east wing of a m desk two
u ' table. one
c me office consisted of four chairs. one tablewtthacbair.
bookshelves, one computer located on a Iar:ee separate walls
and a Video camera and television. On ch as the spine,
there were pictures of the human exercise bike
rnuscies, and joints. There also was a statio
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284 CLINICAL NURSING RESEARCH I August 1992
in one corner of the room and two blue mats leaning against
the wall behind the video camera. The color of the room was a
dull peach. The clinic space was very quiet; the only external
noise was the medical center loudspeaker that broadcasted
occasional announcements. The space in the clinic office ap
peared large but crowded.
OUTPATIENT CLINIC IN INDIA
The clinic in India was located on the first floor of a large
medical setting. It had a moderate amount of daylight that was
partially blocked by one large room divider and one small table
with two chairs. A distinct medicinal odor was evident through
out both the building and the clinic space. No external clothing
differentiated the doctors or staff from the patients. The voices
of children at play and the footsteps of people passing by could
frequently be heard inside the clinic. The atmosphere appeared
very active but reserved.
ANALYSIS OF DATA
Data were analyzed using the methods outlined by strauss
and Corbin (1990). First, transcriptions of the intervieW and
observations were read and carefully examined for emerging
categories and phenomena. This process of naming the phe
nomenon through close examination of the data is called open
coding (Strauss & Corbin, 1990). Initially the coding process
was directed toward the discovery of the basic social psycho
logtcal process. The investigators then illuminated the main
theme Within the setting and explicated the data through several
phases of coding using the constant comparative method-
During open coding, a number of phrases and codes began to
emerge. The American patients were feeling distressed. looking
more, and remained unsatisfied. The Indians were feeling
eeper_ respect, greater purification, closer bonds, and peace.
shiDunng the next phase of analy'Sis, axial coding. relation-
b ps between some of these categories became evident. For
oth the Indians and the Americans the condition of chronic
patndwas However, two completely different phenom-
ena eveloped (see Table 2} .
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Kodiath, Kodiath I PATIENTS WITH CHRONIC PAIN 285
PHENOMENA AND CONSEQUENCES
Among Americans, the phenomenon included searching or
looking for a cure for their pain. The phenomenon that devel-
oped for the Indians was finding meaning in their pain.
The different consequences of each phenomenon are identi-
fied in the following sections.
Consequences for Indians:
They felt respected and at peace.
They were satisfied with the pain relief they felt.
They discovered herbal ointments to be more effectiVe than
analgesic medication.
They remained very involved socially. w:ere employed, and func-
tioned with productivity.
Consequences for Americans:
They continued to search endlessly for a cure.
They felt angry, lonely, and cheated.
They spent a large amount of money looking for a cure.
They often lost their jobs and reduced both their social and
family involvements.
It became evident that the core category for the Indians was
finding meaning In pain, whereas searching for the way to
eliminate pain (a cure-all) was of primary importance for the
Atnertcans (see Table 2).
The most common response among the Americans was
Slntilar to that of one of the participants. Louise stated, "The
only thing that gets me up in the morning Is the hope that
someday 111 be pain free." The Americans experienced consid;
erable emotional, physical, and social distress during
Present. They did not look forward to the future unles
Promised a pain-free or close to pain-free experience. th
The Indian patients typically stated words similar in =
by Elizabeth, "We all have pain at some
life and it is just natural." The Indian patients was not
dating the onset of pain because the experience:= present
unusual for them. They were able to carry on v;: families were a
tasks in life despite the presence of patn. The ttents
great source of strength and support to these pa
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286 CLINICAL NURSING RESEARCH I August 1992
For the Americans, as pain increased, there was a definite
pattern of decreased communication among friends, family.
and society. However, the Indians verbalized a pattern of
openness. For the Indians, pain was not a barrier between
family and friends. Gita stated, "My family knows when I am
in pain. They take turns in the evening rubbing my arms and
back with herbal ointment that my mother used to use."
Respect and worthiness were communicated to Indian patients
by family, friends, and society as a result of their pain experi-
ence. Generally, the Americans felt "out of step" with family.
friends, and society as a result of chronic pain. They experi-
enced a decreased coherence in life events after the onset of
pain. Often, the American patients felt as if they were slowly
losing control. Fred stated, "My wife and I used to go biking.
camping, and partying but now all I find myself doing is staying
at home trying to find a comfortable position either in my chair
or in bed." Events no longer had significant meaning because
the primary focus was ridding themselves of pain.
The Indian patients, on the other hand, saw pain as a natural
part oflife and viewed it as an ebb and flow in life's experiences.
Pain was both a process of purification and a stage of maturity
and growth. Philomena stated, "When I have pain I know that
is similar to having good days and bad days. We all have a little
bit of both."
SUBSTANTIVE THEORY
The substantive theory derived from the data consisted of
the folloWing: (a) the basic psychological problem that was
articulated both by the Indians and Americans and (b) the basic
social psychological process that illuminated the main theme
of the actors in the setting and explicated the data. The stages
and phases clearly describe the basic social psychological
process for each group of patients studied.
According to the analysis, the basic social psychological
for all the patients was chronic benign pain (Figure 1).
1
social psychological process for the patients from
meantng in their pain. For the patients from
. tes the process was searching for a cure (Figure 1).
.............. "{
.. ,
Chronic benign
-1
pain
'
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naslc Social
Psychological
Problem
'
.......
---
Finding meaning
In pain
(Indians)
Searching for a
cure
(Americans)
Basic Psychological
Process
.. -..--....---- --.
-----
Stages
1. Looking for
pain relief
-
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2. Finding no
I
pain relief
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Ffoure 1. The Sub1tuntlue Theorv-M'\Ior Theoretlcul Constructs
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'""'' '"""''
.;;;,:;;.&[;.- .:>."'"''. "-' .
., __ ...
.-.. .-.,.,,, .,._,..,.,,,,,.,.
'"-'"' '
-- -- --- -- --
,. ,..,... ""''"'."--'<-
............ ...............
Phases
(Indians)
Questioning
Searching
Integrating
Surrendering
(Americans)
Questioning
Searching
Separating
Surrendering
rw
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'
The two stages of the psychological process were the same
for all the patients (Figure 1). Stage 1 was identified as looking
for pain relifj. Every patient sought relief from his or her
chronic benign pain. The patients from the United States
looked for this relief from multiple professional sources, includ-
ing medical doctors, chiropractors, acupuncturists, physical
therapists, and/or massage therapists. They also spent large
sums of money on pain-relieving devices, such as transcuta-
neous stimulators, vibrators, special chairs and beds, back
braces, and supports. Basically, Americans believed there was
a medication such as a narcotic that would relieve their pain.
However, physicians were not willing to provide it for them. This
created considerable anxiety and anger for these patients.
Indian patients reported that the best pain relief was from
herbal medicines. Occasionally they received analgesics or
mild narcotics from their physician, but they always returned
to the herbal medicines because of the improved pain relief.
Stage 2 was classified asjlnding little or no lasting pain relief.
All the patients experienced Stage 2. No matter what was used
to relieve pain, none of the methods, devices, or medications
completely eradicated the chronic benign pain.
There were four phases of the basic psychological process
(Figure 1). The first phase was questioning. All the patients
questioned why they were experiencing this constant pain. The
patients from the United States spent more time and energy
thinking and talking about their pain. Although the Indian
patients did not like the pain, they viewed it as a natural
phenomenon of being human. Therefore, it created much less
anxiety and almost no anger.
The second phase was searching. Every patient searched for
Pain relief, but the Americans spent much more time, money.
and energy in the quest of a cure. The Indian patients spent
very little time, money. or enermr and used family remedies
along 'th 1 E>J
eli
wt ong Indian traditions such as special herbs for pain
r ef Th
b e Indian patients did not need to continue the search
h
ecause they felt satisfied even if the pain relief was mild and
s ort term.
n.::: d Phase was different for each group of participants.
g s Phase. the consequences of the phenomena be-
came very pronounced. The Indian patients were able to receiVe
Kodlath, Kodlath I PATIENTS WITH CHRONIC PAIN 289
increased family support. Their social and interpersonal lives
became more enriched because of their beliefs about pain and
the wisdom that was added to their lives. Indians valued the
purification process in their spiritual lives throughout this
suffering. They commonly experienced an increase in love and
respect and seldom decreased their activities of either daily .
living or employment. This phase was labeled integrating.
The American patients experienced disintegration of the
personal, psychological, and social aspects of their lives. They
had very limited understanding of how the pain in their back
affected mood or behavior. These patients felt that if the
symptom of pain was relieved then they would be cured. This
Phase for the Americans was called separating.
The fourth phase was identified as surrendering. The
sense of surrendering was voiced by Jane who said,
Nothing has worked. I've used up all my money. fve tried
everything and this pain continues. It's hopeless. I give up."
Americans surrendered themselves to hopelessness and fail-
ure. The patients from India experienced a spiritual surrender
to a higher power of good who cared for them and would help
them to become purified by this experience.
IMPLICATIONS FOR PRACTICE
The most important finding of this research Is that the
rneantng of pain (or lack of meaning) for an individual affects
the degree of human suffering experienced by that person.
r evidenced by the American responses, Americans report
. Significantly more human suffering as a result of
than did the Indian patients. There is a direct connectifor
between the degree of suffering and the meaning of pain
'
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each patient f
FrankJ (lg77) states that it is the
Person's life at any given moment that makes J.ifi pable
f It is also when persons are confronted with an mes;:te that
unavoidable situation or whenever one has deepest
cannot be changed, that persons can suffering (Frankl. .
and their personal meanJng of c pain to be
.
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290 CLINICAL NURSING RESEARCH./ August 1992
something that Wa.s unchangeable and at the same time found
no meaning in their pain, except that they and/or the medical
system had failed.
For nurses and other health care professionals who care for
patients with chronic pain, it is essential to assess the degree
of suffering experienced by each patient as a result of this pain.
The most difficult task for nurses and other health care pro-
fessionals is to help patients find some meaning in their pain
and, most important, meaning in their suffering.
CONCLUSION
This research generates the following questions that require
more study: Does finding meaning in a painful experience
always generate a sense of peacefulness? How does finding or
not finding meaning in pain affect patients who experience
chronic malignant pain? What are the findings if this study is
to be replicated using other Western and Eastern cultures?
If health professionals continue to focus on eUmlnatlng pain
when caring for patients with chronic benign pain, then they
will probably feel as helpless and hopeless as the patients.
However, if nurses and others are sincerely interested in
assisting patients to increase their quality of life, then it is
imperative that these professionals understand the patients'
suffering and help them to find meaning that will be liberating.
Finally, if a nurse assists even one more patient to experience
a sense of freedom from the bonds of chronic benign pain and
function With more productivity in society, then this study has
resulted in a significant contribution for the researchers.
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KodJath, KodJath I PATIENTS WITii CHRONIC PAIN 291
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Mary F. Kodtath Is director of the Chronic Low Back Pain Clinic al:::;:
Veterans Admlnlstratlon Medical Center in San Dtega. CA- Alex KDd
Is president of Samarpan. Poway. CA-
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