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Psychosomatic Medicine 68:136-142 (2006)
© 2006 American Psychosomatic Society

ORIGINAL ARTICLES

The Association Between Somatization and Perceived Ability: Roles in Dysmenorrhea Among Israeli Arab Adolescents

Sari Goldstein-Ferber, PhD and Michal Granot, DSc

From the Faculty of Social Welfare and Health Studies, University of Haifa, Haifa, Israel.

Address correspondence and reprint requests to Sari Goldstein-Ferber, PhD, Department of Nursing, Faculty of Social Welfare and Health Studies, University of Haifa, Haifa, Israel. E-mail: sarig{at}research.haifa.ac.il


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 NOTES
 REFERENCES
 
Objective: The aim of this study was to investigate whether somatization and attitudes toward menstruation predict the incidence of pain intensity and dysmenorrhea among Israeli Arab adolescent females.

Methods: Participants were 160 Israeli Arab adolescents, including 50 Muslims, 50 Christians, and 60 Druze. A 20-item questionnaire was used to assess attitudes regarding menstruation. The short version of the Brief Symptom Inventory was used to measure the level of somatization.

Results: Factor analysis of the Attitudes Toward Menstruation Instrument revealed two significant composites: perceived ability and impurity during menstruation. High levels of somatization predicted pain intensity and low levels of perceived ability predicted the prevalence of dysmenorrhea. Although the Israeli Muslim adolescents revealed higher levels of somatization as compared with their Christian and Druze counterparts and the Druze revealed the lowest levels of perceived ability compared with the other subgroups, no significant role for ethnicity and impurity was found. No differences were found between groups in scores of menstrual pain and prevalence of dysmenorrhea. Higher levels of somatization and lower levels of perceived ability, as well as a greater portion of Muslim and Druze and higher levels of religiosity, were found among rural residents.

Conclusions: The role of cultural variables and personality traits in the complexity of dysmenorrhea as a socio-bio-psychological phenomenon is proposed in light of contemporary interactive models. It is suggested that within the Israeli Arab minorities the impact of cultural background on health affects more the perceptual and cognitive levels and are not generalized to overt behavior and morbidity such as dysmenorrhea.

Key Words: dysmenorrhea • somatization • adolescence

Abbreviations: VAS = visual analog scale; ATMI = Attitudes Toward Menstruation Instrument


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
METHODS
 RESULTS
 DISCUSSION
 NOTES
 REFERENCES
 
As part of many adolescence changes, experiences and challenges, menstruation onset, menarche, is a very significant event. Dysmenorrhea, or menstrual pain, is defined as chronic pelvic pain that occurs in about 15% to 70% of young women (1–2). Wood et al. (3) found that dysmenorrhea is most common between the ages of 15 and 19 and that 82% of the women in this age group experience such pain. This pain gradually increases from the age of 15 and then begins to decline by the age of 20 and following parity (4,5). There are two types of dysmenorrhea: primary versus secondary dysmenorrhea. This article focused on primary dysmenorrhea which in contrast to secondary dysmenorrhea, affects most women throughout the menstrual years and declines gradually with every live birth and is the leading cause of school and work absence in this age group (6).

Several etiological theories have been proposed as possible explanations of dysmenorrhea. The first group of theories represents the underlying physiological mechanism of menstrual pain, according to which the role of prostaglandins has been suggested (6,7). Primary dysmenorrhea is related to myometrial contractions induced by prostaglandins originating in secretory endometrium, which results in uterine ischemia and pain (8,9). In addition to the physiological perspective, various psychological theories have also been proposed, emphasizing the role of personality factors and attitudes toward menstruation (10). In line with this approach, Koff and Rierdan (11) found that negative attitudes toward menstruation are associated with dysmenorrhea. Regarding the role of personality traits in dysmenorrhea, there are conflicting results. Several researchers reported that dysmenorrheic women tend to be more preoccupied with bodily sensations, tend to express greater negative attitudes toward illness, and have more negative affect toward menstruation than do nondysmenorrheic women (12–17). In contrast, others did not find any personality differences in dysmenorrheic women as compared with nondysmenorrheic subjects (18–19).

Contemporary interactive models combine physiological and affective factors together with cognitive variables. According to these models, stress and negative emotional arousal may exacerbate menstrual pain, either by affecting physiological processes or by decreasing the woman’s perceived ability to cope with the pain once it is experienced, thus suggesting reciprocal effects between physiological factors and emotional-cognitive factors (10,20–22). One can assume that the affective facet in the above-mentioned models corresponds with previously designated categories of personality factors and that the cognitive aspects are considered as attitudes or "health beliefs." This is in accordance with current views in the psychology of illness and health (e.g., 23).

One of the personality factors outlined in contemporary interactive models is that of somatization. This psychological trait, which is also termed as bodily concerns (17), relates to patients who complain about symptoms that have no medical basis and who may use physical complaints to elicit care (24–25). The broad category of somatization includes the somatoform disorders that encompass pain disorders (24) and is found to be strongly associated with chronic pain syndromes and dysmenorrhea (26–27). Thus, beyond the role played by negative attitudes, somatization may further contribute to the perceived intensity of menstrual pain and development of dysmenorrhea among adolescents.

This study was based on contemporary interactive models to evaluate the role of both affective components and attitudes toward menstruation among Arab adolescents living in Israel. Although culturally based attitudes toward menstruation were considered in the interactive models, there is debate regarding the effect of socialization processes on attitude development regarding menstruation. One large multi-country study identified different patterns of beliefs and preferences regarding menstruation that were distributed as a function of cultural background. Data in this multi-country study were obtained from a WHO non-nationally representative sample of 5322 parous women from 14 cultural groups between 1973 to 1980 and a subsample of 500 women with detailed daily diaries from 10 countries (Egypt, India, Indonesia, Jamaica, Korea, Mexico, Pakistan, Philippines, UK, and Yugoslavia). According to the results, beliefs such as bathing behavior during menstruation, fertility and femininity issues, interpretations and implications of menstruation, and beliefs about not washing hair or body during menstruation explained more than 53% of the estimated variance. The authors concluded that beliefs, which reflect socialization according to demographic variables, appear to affect choice of contraceptive methods and family size which exemplify the complexity of socialization effects on female identity and her perceived attitudes toward menstruation and fertility issues in general (28). In contrast, Sigmon et al. (17) and others did not find an effect of sex role socialization or other cultural attitudes on menstrual symptoms.

Arabs constitute the largest minority group in Israel, comprising 20% of the total population. About 80% of the Arabs are Muslims, and the rest are Christians and Druze. In a patriarchal society, menstruation, pregnancy and birth are considered as major events in the female developmental process (29–31). According to this cultural perspective, menstruation represents the girl’s entrance to her expected social role as a mature woman. From the time of menarche, her family may impose stricter rules on her regarding social behavior.

While menstruation may involve positive changes in the social role of the Israeli Arab girl, it may also lead to a conflict in attitudes regarding menstruation that may be expressed by negativity and the development of dysmenorrhea. Evidence showing that there is an alteration in the regular daily activity of Arab women during menstruation (32–35) may reflect such an attitude conflict (11). Given the unique patterns of each subgroup of the Israeli Arab population, the present study aims to explore the roles of attitude and personality variables associated with menstruation among these three subgroups of Israeli Arab adolescents.

This study aimed to explore primary dysmenorrhea only in young Israeli Arab adolescents. The uniqueness of this study lies mainly in the psychosocial focus on dysmenorrhea and the investigation of this phenomenon from a cultural and psychological perspective. Also, the contribution of this study to the body of knowledge lies in the expansion of the research on dysmenorrhea, usually examined mainly from the angles of pain and gynecology, to the examination of somatization in order to consider the psychosomatic aspects of the phenomenon as they correspond with cultural alignment and personality attitudes.

In light of the above, the aims of this study were twofold: (a) to characterize dysmenorrhea in three subgroups of Israeli Arab adolescents (Muslims, Christians, and Druze), and (b) to evaluate the role of both somatization and attitudes toward menstruation in these ethnic groups. We hypothesized that somatization will predict menstrual pain and that attitudes toward menstruation will predict dysmenorrhea. We also hypothesized that differences will be found between the three ethnic groups in the prevalence of dysmenorrhea and we had a two-sided hypothesis for each ethnic group.


   METHODS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
RESULTS
 DISCUSSION
 NOTES
 REFERENCES
 
Sample
The sample consisted of 160 nonmarried Israeli Arab adolescents from three subgroups: Muslims (n = 50), Christians (n = 50), and Druze (n = 60). All participants were high school students in grades 10 to 11 who were attending public schools comprised of both boys and girls. Mean age of the girls in the total sample was 15.7 ± 0.8, with no significant differences found between subgroups. As for residence, 107 reported living in Arab villages and 53 in towns. In general, most of the subjects were from medium-low socioeconomic status. There were no differences in characteristics of menstruation. The number of children in the family ranged from 1 to 8 (mean 4.6 ± 2.1), with no significant differences found between subgroups. The refusal rate was very low and only two subjects refused to fill-in the questionnaires.

Instruments
Characteristics of Menstruation and Dysmenorrhea
The characteristics of menstruation were assessed by collecting data regarding the age at first menstruation, the duration of menstrual bleeding, whether pain is experienced during the first 1 to 2 days of menstruation, and the level of menstrual pain intensity as measured by visual analog scale (VAS) with the regular medical ruler tool (36). Participants were also asked to rate on a 5-point scale: 1) whether there was a change in their regular functioning due to menstrual pain (ranging from 1 = no change to 5 = a drastic reduction in regular behavior), and 2) whether they used analgesia to reduce the intensity of their menstrual pain. The presence of dysmenorrhea was defined by a response to the first question that was greater than two and/or a positive response to the second question.

Attitudes Toward Menstruation Instrument (ATMI)
A 20-item questionnaire was used to assess attitudes regarding menstruation. The questionnaire was created in Hebrew and translated to Arabic. The subjects filled in the Arabic version. The Arabic version was achieved using back-and-forth translation and dual-language speakers check ups on a different subjects pool with acceptable to high internal consistency ({alpha} ranging from 0.65 to 0.7). Subjects were asked to rate their level of agreement with each item on a 5-point scale ranging from 1 = do not agree at all to 5 = very much agree. Factor analysis with orthogonal Varimax rotation was conducted to define the different domains of the questionnaire (see Table 1). The two different factors were revealed including items that significantly contributed to the variance above the cutoff point of 33.9.


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  		TABLE 1. Factor Analysis of ATMI With Varimax Rotation

 

Impurity
This domain included six items that assessed the degree to which women perceived menstruation as an impure event. Five of them turned out to contribute a significant portion of variance. For example: "I believe that the menstrual blood is different compared with other sources of bleeding;" "I think that it is forbidden by God to have sex during menstruation;" "I believe that women during menstruation are impure." (Cronbach {alpha} = 0.69).

Perceived Ability
This factor included eight items that evaluated the perceived extent to which the women subjectively perceive her ability to cope and maintain regular functioning during menstruation. For example: "I think that women cannot function regularly during menstruation;" "Women who complain about menstrual pain use this argument as an excuse to avoid functioning;" and "I expect the family to reduce my obligations during menstruation." (Cronbach {alpha} = 0.70). Note that accepted measures of disability/reduced functioning during menstruation were used to identify dysmenorrheic women, while assessments of subjective perceptions of ability were used to assess perceived ability and predict the prevalence of dysmenorrhea.

Somatization
The level of somatization was assessed by the short version of the Brief Symptom Inventory (BSI), representing one factor in the Symptom Check List (SCL-90) (37–38). This multidimensional screening instrument is a self-report of psychological distress and multiple aspects of psychopathology and is often included in the evaluation of pain patients (32). The 13-item questionnaire rates the frequency of complaints or symptoms in different areas of the body, including chest pain, headache, low back pain, vomiting, dizziness, flushes, or numbness. The internal consistency reliability coefficient (Cronbach {alpha}) of the short version was 0.78 (39).

Procedure
Data were collected using self-report questionnaires that were completed during a class at school. The study was approved by each high school principal, who introduced the study to the pupils and requested that they sign letters of informed consent. Two female Israeli Arab students from the School of Nursing at the University of Haifa provided instructions about the questionnaires, with a special emphasis on their confidentiality and anonymity. The students collected the completed questionnaires, and none of the teachers or school staff had access to the content of the data.

Data Analysis
Factor analysis was used to define the two composites of the ATMI. Cronbach {alpha} was applied to assess the internal consistency. All variables (attitudes toward menstruation (ATMI), somatization level, and demographic data) were compared between the three ethnicity groups (Muslims, Christians, and Druze). Nonparametric Kruskal-Wallis test for ranks was used to compare dysmenorrheic to nondysmenorrheic women on the measure of somatization. Linear regression was conducted to predict menstrual pain intensity. In addition, a logistic regression model was applied to predict dysmenorrhea.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
DISCUSSION
 NOTES
 REFERENCES
 
Characteristics of menstruation
Mean age at first menstruation was 12.8 ± 0.7, with a range from 11 to 15 years old (F(2,157) = 2.17, p > .05). The mean number of bleeding days was 3.2 ± 2.1, with no significant differences between groups (F(2,157) = 2.42, p > .05). In the entire sample, most subjects (n = 129) reported having painful menstruation to some degree, with 99 describing the pain as moderately intense (n = 42) and the remaining 57 as severely intense. The mean VAS scores of menstrual pain intensity was 4.8 ± 2.7. No significant difference was found in the level of pain intensity between groups (Christians = 5.4 ± 2.3, Muslims = 4.9 ± 2.6, and Druze = 4.3 ± 0.4 (F(2,131) = 1.75, p > .05). While 68 subjects were assessed as having dysmenorrhea (45%), no difference in the prevalence of dysmenorrhea was revealed between groups ({chi}2 (2) = 1.102, p > .05). The Muslim group revealed higher levels of somatization (16.2 ± 9.5) as compared with the Christians (11.1 ± 5.1) and the Druze groups (11.6 ± 7.3) (F(2,154) = 7.11, p = .001). The Druze group reveled the lowest levels of perceived ability compared with the Muslim and Christian groups (Druze = 22.31 ± 5.108; Muslim = 25.59 ± 5.78; Christian = 29.97 ± 4.22; F(2,1) = 28.629, p < .0001). No differences were found in prevalence of dysmenorrhea and pain intensity between rural and urban areas of residency ({chi}2 (1) = 0.58, p > .05, t (132) = –1.43, p < .05). However, compared with urban areas, in rural areas the Israeli Arab adolescents revealed higher levels of somatization (13.79 ± 8.71 versus 11.07 ± 5.23, t (155) = 2.08, p < .05) and lower levels of perceived ability (24.2 ± 5.83 versus 29.09 ± 4.77). More Druze and Muslim Israeli Arab adolescents reported living in rural areas compared with the Christian subpopulation ({chi}2 (2) = 131.019, 45 of 50 Muslim and 60 of 60 Druze compared with 2 of 50 Christian Arabs Israeli girls lived in rural areas). Likewise, the Christian group revealed different trends than the other two groups by reporting lower levels of religiosity compared with the other two groups ({chi}2 (2) = 29.91, 49 of 50 Muslim and 56 of 60 Druze compared with 29 of 50 Christian Israeli Arabs reported on maintaining religious beliefs and style of life).

Comparison Between Dysmenorrheic and Nondysmenorrheic Adolescents
No difference in the level of somatization was found between dysmenorrheic (mean = 13.16 ± 7.1, range 1 through 39) and nondysmenorrheic subjects (mean = 13.24 ± 7.5, range 3 through 40, F(2,126) = 0.951, p > .05). However, an interesting finding was that when the questions assessing pain symptoms alone were included, the dysmenorrheic women reported higher scores of pain symptoms (Z = 4.4293, p = .035). No differences were noted when questions regarding the nonpain symptoms alone were analyzed.

Prediction of Menstrual Pain Intensity and Dysmenorrhea
Linear regression analysis revealed that the level of somatization and perceived ability significantly predicted the intensity of menstrual pain. No significant role was found for ethnicity or impurity (see Table 2).


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  		TABLE 2. Linear Regression for the Prediction of Menstrual Pain Intensity

 

The logistic regression analysis that was conducted to predict dysmenorrhea showed that lower perceived ability during menstruation is associated with higher prevalence of dysmenorrhea (see Table 3). No significant role was found for ethnicity or impurity (see Table 2).


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  		TABLE 3. Logistic Regression for the Prediction of Dysmenorrhea (Muslim and Druze Adolescents Were Separately Compared to the Christian Adolescents)

 


   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
NOTES
 REFERENCES
 
This study focused on the characteristics of menstruation and dysmenorrhea among three ethnic sub-groups of Israeli Arab adolescents. The results showed an association between dysmenorrhea and negative attitudes toward functioning, as expressed by the lower level of perceived ability during menstruation in all three ethnic groups. In addition, high levels of somatization and lower levels of perceived ability were associated with greater intensity of menstrual pain, regardless of ethnic group. Thus, the somatization scores were not necessarily associated with dysmenorrhea, but with greater pain intensity. This clearly implies that dysmenorrhea should be considered as a behavioral manifestation of pain perception and not a direct result of pain intensity. Moreover, Druze Arab adolescents showed the lowest level of perceived ability and the Muslim Arab adolescents showed the highest levels of somatization suggesting that these two subpopulations in Israel are more at-risk than the Christian subgroup.

An accepted concept proposed by Bandura (40), which is known as self-efficacy, relates perceived competence and behavior such that lack of self-efficacy results in reduced effective behavior. Efficacy beliefs are context-specific evaluations and are formed through mastery experiences, observations of others, social-verbal persuasion, and interpretations of physiological and emotional states. Self-efficacy is a cognitive construct implicating one’s self-perception about one’s performance ability (41). In other words, self-efficacy develops through the process of socialization similarly to the development of attitudes and characterizes the individual’s sense of his/her performance ability as subjectively perceived. This possibly was correspondingly expressed by the subjective phenomenon investigated by the ATMI in the current research.

Another concept which may be valuable to expand the understanding of the phenomenon revealed by the ATMI is Rotter’s concept of locus of control (42). Rotter hypothesized that individuals differ on their type of expectations for reinforcement and may be classified either as Internals who expect an internal reinforcement from within themselves or Externals who expect a reward from the outside on a particular action. Rotter hypothesized that internals will engage more frequently in action taking than externals and was able to show that such individuals present more political involvement (43–44). According to the original concept, locus of control is developed through socialization and in close relation to cultural impacts and may be related to performance techniques such as planning, coping, persistence of action and analysis of situation (43) thus densely associated with self-efficacy. We suggest that locus of control may be the general construct to describe activity, ability and functioning in many areas of the individual’s life while self-efficacy may represent the available resources of the individual on a particular issue. In the case of the ATMI, it is possible that it measures the available cognitive and emotional internal resources of the individual as subjectively perceived and felt by her in the case of menstruation but also may be linked to a more general attitude such as locus of control.

Although self-efficacy and locus of control per se were not assessed in this research, it may be that attitudes regarding regular functioning, as reflected by the level of perceived ability, express the extent of self-efficacy during menstruation through decreased prevalence of dysmenorrhea and as a part of a more general approach toward expected reinforcements.

Our findings show that somatization predicts the intensity of menstrual pain, in accordance with previous suggestions that somatization enhances the perception of a variety of noxious stimuli (45). As such, somatization may be regarded as a personality trait, a view supported by Granot et al., report of higher pain perception in response to experimental painful stimuli directed to a nongynecological site in women with primary dysmenorrhea (46). There are also other reports of greater pain response to uterine cervical laser therapy (47) and higher scores of labor pain (48) in dysmenorrheic women. Furthermore, higher incidences of various other pain syndromes have been reported in dysmenorrheic women (49–50). This raises the possibility that dysmenorrhea is not just a syndrome of painful uterine contractions, but rather represents an enhanced pain perception related to somatization. Our findings show the interactive roles of both attitudes, such as perceived ability, and personality traits, such as somatization. Therefore, the suggested interactive models proposed earlier gain further support.

Interestingly, the Muslim adolescents exhibited higher degrees of somatization, which may suggest that the cultural factor had a unique effect on the menstrual experience in this group. This is in accordance with other reports showing a higher incidence of somatization within Muslim as compared with Christian communities (51–52) and is in line with the fact that the female identity in Muslim communities is predominantly affected by their role in the family (53). Further studies are needed in order to elucidate the nature of how cultural variables, such as the role of women in the family, are associated with somatization among Muslim adolescents.

Although somatization differed between groups, the frequency of dysmenorrhea and the level of pain intensity did not. These findings regarding the prevalence of dysmenorrhea and reported menstrual pain intensity are akin to other reports from both Western and non-Western societies (54–56). The greater somatization symptomatology among Israeli Muslim suggests that the transition from traditional society to modern life which is apparent among Israeli Arabs nowadays including the changes in women’s social role and familial duties, is demanding and costly for the Muslim Israeli adolescents compared with the adolescents from among the Christian minority which is more easily affiliated with modern and Western values. The differences between the Muslim girls who revealed higher levels of somatization and the Druze who revealed the lowest levels of perceived ability may be related to the current developments in the transition process toward more modern views, attitudes, perspectives and style of life. While the Muslim minority is actively undergoing such psychological and sociological transforming changes, the Druze are more tied to their religion as yet and are only initiating such assimilation processes and implementation of foreign concepts beyond their tradition in their society. As such the Druze may be protected from generalizing their low perceived ability during menstruation, which may be related to the traditional women role during menstruation in this subgroup, into a more larger frame of symptomatology such as somatization. The Muslim girls may show a more generalizing response due to the more stressful condition inherent in processes of active social assimilation and change. As the specific mechanisms in which the socialization processes and culture affect attitudes toward menstruation and menstrual pain are still puzzling researchers in this field (17,28), future study should use cross-cultural designs in order to expand our understanding of the contribution of cultural attitudes and personality variables to the development of dysmenorrhea. However, in light of the conflict in the research reports (e.g., 17,28) this study supports the view that socialization and cultural effects may be involved in dysmenorrhea through their impact on personality traits.

The limitations of the current study lie mainly in the absence of a Jewish control group from the majority of the population in Israel. However, all three major minorities in Israel were represented in this study. Other limitations may be the lack of individual data on the SES measure and the inclusion of a general characteristic of SES only, since SES might be related to myths and health beliefs. However, we measured the level of religiosity as a self-report variable which may be more closely associated with myths and health beliefs than SES and we found that the two sub-populations who revealed at-risk potential in somatization and perceived ability, the Muslim and the Druze, also reported significant more religious beliefs and style of life. Interestingly, the same subpopulations, the Muslim and Druze Israeli Arab adolescents, reported living more in rural than urban areas. Correspondingly, rural more than urban areas were associated with lower perceived ability during menstruation and higher levels of somatization. Differences in prevalence of dysmenorrhea between rural and urban area were not found probably due to a possible greater impact of simply being a part of an ethnic minority in light of cultural dominancy of the western and Jewish cultures in Israel. The result that Israeli Muslim and Druze seem to be more at risk of somatization and perceived ability compared with the Israeli Arab Christian minority shows the impact of culture on pain perception. However, the impact of ethnicity within three Arab minorities in Israel is shown to be restricted to the perceptual level of pain experience (somatization) and the cognitive level of available attitudes (perceived ability) rather than appearing in overt behavior and morbidity such as dysmenorrhea.

It seems that at least in Israel, the transition from traditional to modern life, which is more apparent in urban areas, is associated with less symptomatology of the Israeli Arab women. This transition may be responsible for changing the locus of control from traditional beliefs only and God (Allah) to internal responsibilities, action taking and more social involvement. There are contradicting results on the compared levels of self-efficacy and locus of control between rural and urban areas in different countries (57–61). As the concepts self-efficacy and locus of control represent mainly the impact of socialization on perceived ability and action or coping, it is not surprising that the differences on those measures between rural and urban areas are dependent on the cultural background and environment of the subjects, thus revealing differences in results between different regions on the globe.

In sum, the results of the present study reveal the complexity of dysmenorrhea as a socio-bio-psychological phenomenon and demonstrate that the characteristics of dysmenorrhea in Israeli Arab adolescents are only partially culturally based. There may be genetic neural sensitivities and individual personality traits, which may be interacting with the cultural impact. This may imply the importance of education and clinical support that takes into consideration the role of culture. Among the clinical implications of this study is the possibility to use the Attitudes Toward Menstruation Instrument to detect at-risk populations especially among minorities in other cultural backgrounds. Examples for clinical interventions may be verbal psychotherapeutic reflections and ventilation as well as cognitive imaginative methods to reduce pain. However, when these carried out among minorities they should include traditional contents as well as respect of and honor to differences in life conceptualization, basic individual values, age and sex roles.


   NOTES
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 NOTES
REFERENCES
 

Received for publication October 31, 2004; revision received September 18, 2005.

DOI:10.1097/01.psy.0000197644.95292.00


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 NOTES
 REFERENCES
 

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