Backache in Greek Immigrants to Sweden

http://tps.sagepub.com

Transcultural Psychiatry

DOI: 10.1177/136346159603300304 1996; 33; 319 TRANSCULT PSYCHIATRY

Monica B. Lfvander and Anna-Karin Furhoff Backache in Greek Immigrants to Sweden: A Cultural Interpretative Approach

http://tps.sagepub.com/cgi/content/abstract/33/3/319 The online version of this article can be found at:

Published by:

http://www.sagepublications.com

can be found at:Transcultural Psychiatry Additional services and information for

http://tps.sagepub.com/cgi/alerts Email Alerts:

http://tps.sagepub.com/subscriptions Subscriptions:

http://www.sagepub.com/journalsReprints.navReprints:

http://www.sagepub.co.uk/journalsPermissions.navPermissions:

http://tps.sagepub.com/cgi/content/refs/33/3/319 Citations

by HILDA VILA on September 27, 2009 http://tps.sagepub.comDownloaded from

http://tps.sagepub.com/cgi/alertshttp://tps.sagepub.com/subscriptionshttp://www.sagepub.com/journalsReprints.navhttp://www.sagepub.co.uk/journalsPermissions.navhttp://tps.sagepub.com/cgi/content/refs/33/3/319http://tps.sagepub.com

319

Backache in Greek Immigrants to Sweden:A Cultural Interpretative Approach

MONICA B. LFVANDER & ANNA-KARIN FURHOFF

Scandinavian medical methods for treating musculoskeletalpain have often proved unsuccessful with immigrant patients.This study examined the perception and meanings of backpain among Greek immigrants to Sweden to identify possiblecauses of this poor outcome. Fifteen Greek immigrant patientson long-term sick-leave because of backache and 21 strategi-cally selected members of a Greek cultural association inStockholm, Sweden, not on sick-leave received semi-structuredinterviews about backache. In addition to a content analysis, acultural approach was used in the interpretation of the mate-rial. On the whole, pain was considered as somethingdangerous, inevitably leading to permanent disability if the suf-ferer should deliberately aggravate the pain. Persistent pain wasalso linked to the tendency to worry and obsess in a way thatwould eventually make one ill. There was little confidence indoctors examinations and physiotherapy. The study providesa possible explanation as to why Scandinavian medical treat-ment of backache is less successful in this immigrant group.

INTRODUCTION

In Sweden, as in most industrialized nations, there is a high prevalenceof work disability due to musculoskeletal pain. This prevalence appearsto be even higher among certain immigrant groups (Donovan,dEspaignet, Merton &von Ommeren, 1992; Sundquist, 1994). Unsuc-cessful rehabilitation programmes for immigrants have been reportedfrom many countries (Grunfeld & Noreik, 1991; Holtedahl, 1991; Keel& Calanchini, 1989; Lee, Chow, Lieh-Mak & Chan, 1989; Parker, 1977).The poor outcome of these programmes has been attributed to the

prolonged duration of pain prior to treatment and/or to psychosocialcauses including migrant status and ongoing litigation.

Back pain is among the most common forms of musculoskeletalpain and is often frustrating and difficult to manage for patients andphysicians alike. Many patients are partially incapacitated or unable to



320

work. In societies, like Sweden, where work, self-reliance, will powerand personal achievement are central values, an inability to workbecause of pain, especially of undocumented origin, evokes mistrustand anger (Spitzer, Le Blanc & Dupuis, 1987).

Cultural background influences how people perceive and respondto pain; how pain is communicated; where and when it is translatedfrom private experience to public expression; and, help-seeking(Helman, 1990a; Wolff & Langley, 1977; Zborowski,1952; Zola, 1966).Cultural and individual factors contribute to a persons interpretationof the significance of pain, whether it is normal and thus accepted as apart of life, or abnormal and hence unacceptable (Helman,1990a). Thecause of pain is also an object of evaluation. Is it caused by natural orsupernatural forces, by events in the social world, or is it due to theindividuals own actions? Is it potentially under ones own control?(Helman, 1990b).

In a previous study, it was noted that, compared to Swedish patients,Greek patients kept still or moved very slowly when suffering from pain(Lofvander & Papastavrou, 1990; 1993). Physiotherapy or psychosocialcounselling was of no use in the rehabilitation efforts. The pain behav-iour was, in most cases, distinct from depressive symptomatology andalso from the concept of&dquo;nevra&dquo; pain (L6fvander & Papastavrou,1990,1993). Greek patients did not seem to adapt to the limitations of pain,and refused to participate in the abundant opportunities offered inSweden for job retraining, and school programmes or in restructuringthe work place (L6fvander & Papastavrou, 1990,1993).

Greek immigrants to Sweden form a relatively homogenous group.They arrived in the 60s and 70s to earn a living. The vast majority grewup in poorly developed rural areas in the northern and western partsof Greece and few completed their basic schooling. In Sweden, theylive in the larger cities where they work mostly in the service sector,notably in cleaning offices. Unemployment among immigrants, includ-ing the Greeks, was almost non-existent ( 1 %) at the time of the study.The annual income was generally good and so was housing andopportunities for special educational programmes for immigrants.Children live in their parents home until the age of 30 and, in manycases, even after they get married. When they leave home, they settle inthe vicinity. Even amongst the second generation, the first language is



321

usually Greek. The connections with Greece are close and most of theGreeks in Sweden go &dquo;home&dquo; every summer for holidays.

The present research concerns the possibility that discrepancies inthe meaning and treatment of backache between the Swedish medicaltradition and the conceptions of backache among Greek immigrantsin Stockholm, Sweden, also contribute to poor treatment outcome andchronicity. The first aim of this study was to find out if there were anypotential links between the way Greek patients think about their painand their clinically observed pain behaviour. Secondly, we wanted toinvestigate prevailing attitudes among Greek non-patients. Backachewas chosen as the focus for the study since it is the most common paincomplaint in this group.

METHOD

The study involved two series of subjects, patients and controls. Dur-ing a six week period, we asked all Greek immigrant patients at thehealth centre, who were on sick-leave or had a disability pensionbecause of back pain, for permission to be interviewed. Patients withserious concurrent diseases were excluded. To ascertain prevailing atti-tudes among Greek immigrants not on sick-leave, contact wasestablished with a Greek cultural association in Stockholm. Subjectswere selected to represent diversity in age (16-65 years), sex, educa-tion, occupation and length of time in Sweden.

Most interviews took place in the homes of the interviewees andwere conducted in Swedish; a professional Greek interpreter was avail-able for those who so desired. A set of open-ended questions devisedfor primary care research, was used to explore informants concepts ofpain (Helman, 1990c). The interview also collected sociodemographicbackground information.

The study was approved by the local ethical committee at SachsChildrens Hospital, Stockholm. All interviewees gave their informedconsent to participate in the study. All interviews were conducted bythe same researcher (ML). The average interview lasted 60-90 minutes.Each interview was tape-recorded and transcribed for later analysis.Answers to questions were categorized and interpreted in relation tothe social and cultural context of the respondents, with emphasis onthe internal logic and coherence of accounts of backache (Kvale,1991 ).



322

RESULTS

All eligible patients consented to take part in the study. Amongst thecontrols, two persons did not want to be interviewed. In total, 15

patients and 21 controls were interviewed (Table 1). Nine of theinformants were less than 30 years old. It was not possible to find anyfemale controls older than 50 years, as all eligible women of that agewere either on sick-leave or had a disability pension.

Table 1. General characteristics of the participants in the study

All patients and 17/21 controls were married. Five of the controlswere born in Sweden or had arrived before the age of seven. These arereferred to as &dquo;second generation: Almost all patients had worked infactories in the past and were now working as cleaners. The controlswere younger than the patients, better educated and had more skilledjobs (Table 1). Many of the controls worked at second jobs as cleaners,a business which is profitable in Stockholm. Although some had lim-ited knowledge of the language, all but seven participants preferred tospeak Swedish.

Despite differences in sex, age, education and duration of back-pain, pain concepts converged on a specific pattern with no consistent



323

differences in the meaning of the symptom between patients and con-trols. There was a tendency for younger informants to rely more on activemeasures like physiotherapy and to relate the cause of pain to &dquo;stress.&dquo;Two case histories illustrate concepts common to most interviews:

Case 1. Patient

A.K., a 46 year old man, was born in a village in northern Greece.At the age of 21, he came to Sweden to earn his living. His painbegan after four years of working as a cleaner. As a result, he trainedas a bus driver and, after some years, as a driver of undergroundtrains. The back pain recurred some years later and has continuedever since. He doesnt know where the pain comes from: &dquo;I cantunderstand why it comes...it might be sciatica, maybe my back isworn out and the nerves come between the bones and cut them. Idont know. I havent worked so bloody hard, but I think my back istired. Or something has gone wrong. The pain keeps comingback- that means something is really wrong with me. Its just thatthe doctors havent found out what it is yet. He gets relief from painby resting and from warmth and massage. He is afraid of movingor even doing a little housework, because then the pain startsimmediately.&dquo; He feels that working when in pain is very dangerousfor the body. As for the future, he thinks he will deteriorate andbecome paralyzed or perhaps psychiatrically ill, as well. He just can-not imagine being able to go back to work in the future. &dquo;Its bad forthe family that I cant help my wife and our economy is not as goodas it used to be...but thats the way it is:

Case 2. Control

S.L., a 40 year old man, grew up in a village in the northwest ofGreece. He spent six years at school. After school, he trained to bean electrician. Due to lack of employment in Greece, he moved toSweden at the age of 27. In Sweden, he first worked as a cleaner fornine years. After that, he trained as a chef and is presently workingin a restaurant. He lives in a flat with his wife and three children.Now and then he has pain, mostly in the upper part of his back andin one or both legs. He has consulted the GP several times but hebelieves the examinations were too brief, and he is disappointedsince he was not given any explanation for his pain. The pain usu-ally disappears quickly, so he seldom has to take sick leave. Heconsiders the cause of the pain to be only coincidental or due tostress at work. He avoids thinking about pain because if he starts tothink, this leads to worries which would make him ill. However, he



324

is concerned about his wife, aged 29, who has more or less constantpain in her back as well as in other parts of her body. This beganwhen she was pregnant with her first child. The doctors told herthe pain would disappear when the baby was born but, instead, itgot worse and she now has persistent pain. Both S.L. and his wifeare convinced that her pain will never end and fear that she mightend up like a friend of theirs who also had constant back pain. Thedoctors told this friend that nothing was wrong with her back butnow she goes around on crutches. His wife gets no relief from medi-cation or physiotherapy. He thinks his wifes pain could be causedby her work load as a cleaner combined with the cold weather. Thecouple are not worried about their economy and both want to workhard for the sake of their children. However, his wife doesnt con-sider it possible that she will ever be able to work outside the homeagain.

CORE CONTENT OF THE INTERVIEWS

What has happened?-Symptom Labelling. All interviewees, exceptone male control, had experienced pain. The main difference betweenthe patients and the controls was in how often they experienced pain.All the patients had pain almost all the time, often varying accordingto the weather. Two were free of pain during the night-time. Nearlytwo-thirds of the controls (13/21) had occasional pain. Four of thesewere on 50% sick-leave or had been certified sick for a short period(

325

ache was thus considered a serious and abnormal symptom, a symp-tom one must pay attention to and do something about. The persistent,but not necessarily intense, backache was considered a &dquo;sick&dquo; pain (e.g.,&dquo;As soon as I move, start walking, there is pain. Im afraid!&dquo;) whileoccasional pain was &dquo;normal (&dquo;It is normal to have a little pain whileyou work.&dquo;).

Why does it hurt?-The meaning of the symptom For most inform-ants (30/36), continuing pain was considered to be part of an ongoingdestructive process. Frequently occurring expressions were &dquo;the bonesin the spine are gnawing at each other; &dquo;the bones are melting down&dquo;or &dquo;(what) has tilted and cant be corrected&dquo; ( 19/36). Other commonremarks were: &dquo;the back-bones are constantly growing&dquo; or &dquo;the pain isspreading around&dquo; (I1/36), or simply, &dquo;there is something dangerousgoing on&dquo; (2/36). The only exceptions to this pattern were two inter-viewees who had not thought much about their own pain, but had vividideas about their relatives pain, and two male controls who consid-ered the cause to be muscle strain.

Why have you got this pain?-Illness causation. The supposed under-lying cause of pain was work of all kinds, but especially cleaning (30/36). Cleaning was worse than work in factories, for example, becausecleaning offices involves a lot of bending to pick up papers or to emptythe waste paper baskets. When speaking of this, a female patient, 45years old, made this association: &dquo;Many of the villagers back home (inGreece) have backache, because they bend their backs in the tobaccofields.&dquo;

Some interviewees (10/36), most of them women, believed that per-sonal factors, like worries about the future and their children, couldalso cause pain. Five of them also mentioned that the cleaning compa-nies had increased the cleaners workload. A total of five, especiallythose who did not think they had worked hard, believed that coldweather could also have contributed to their backache. Three of theolder interviewees had the same thoughts about their childrens back-ache. The two men mentioned above, who thought that they hadmuscle strain, considered their back pain to be their own fault as theyhad not been careful enough.



326

y now?-Help-seeking pattern. A common opinion (29/36) wasthat one could wait a week or two to see if the pain went away. If itdidnt, then one should see a doctor. The longer one waited, the worsethe pain would get and it would spread to, and ruin, the arms and legs.Interviewees frequently considered the doctors explanations insuffi-cient and, especially among the controls, distrusted doctorsexplanation entirely (9/21). They suspected that the doctors did notcarry out extensive enough examinations to find out what was wrong,or perhaps they did not want to tell the truth.

What will happen to you in thefuture?- The course of the illness. Themost common thought was that the pain would probably spread fromthe back to all over the body (24/36) and many patients (9115), as wellas many of the young controls (6/21 ), were convinced that their activelife would soon be over. A commonly occurring thought was that theywould be confined to a wheelchair in five to ten years time. Three ofthe middle-aged interviewees thought that they would be dead fromthe pain in a year or two.

Pain associated feelings were fear, worry and sadness about the lossof function. Thoughts and worries about the pain were further con-sidered to make a person &dquo;mad&dquo; or &dquo;melancholic.&dquo; Nine informantswere sure melancholy would make future life unbearable, and threeyoung controls stated that it was best never to think about the pain,because if one did, it would certainly make that person crazy. Notably,the informants usually explicitly separated feelings about pain fromsocial or family conflicts.

Only eleven informants, five of whom were teenagers or in theirtwenties, thought that they would be able to work for the next ten years.None of the patients or the controls, irrespective of age or education,thought that they would be able to work until retirement at 65. Thereason given was that if one had pain, it was almost always necessaryto stop working before that age, otherwise the pain certainly wouldruin the rest of ones life. One middle aged man among the controlsdeeply regretted not having given up work years ago.

What are the likely effects on your fiamily and economy? All inform-ants stated that their thoughts and fears about pain were shared by allthe members of the family and, consequently, the family as a unit wouldsuffer. Only five informants worried about their financial situation. All



327

informants pointed out that health is more important than money.Many of the older participants also stressed the fact that they hadalways been poor. One-third of informants, the women in particular,expressed great faith in their children and emphasized the importanceof keeping the family together. All second generation interviewees werealso very eager to help their parents.

What can be done to cure or to relieve the pa in?-Strategies for treat-ing the pain. Rest and massage were clearly stated as the treatments ofchoice (28/36); a few informants (8/36) believed that activity, e.g.,walks or active exercises, could relieve the pain. There was minimalconfidence in medication. Only five of the controls and two among thepatients relied on analgesics. Nor was there much confidence in physi-otherapy or in other pain relieving therapies such as transcutaneousnerve stimulation or acupuncture due to frequent adverse effects suchas dizziness, nausea or increased pain (14/36). A few patients evenstated that everything made the pain worse. One man and one womanprayed for help each night.

DISCUSSION

Since the early 1980s, an extremely high prevalence of long-term sick-leave and disability pension among young Greek immigrants in Swedenhas been noted. According to recent official statistics, only a few abovethe age of fifty are not on long-term sick-leave (Sundquist, 1994).

The striking finding in this study was the great consistency of thenotions concerning backache among all interviewees, both patientsand controls, regardless of differences in age, sex, education or occu-pation and independent of whether they were on sick-leave or not.Continuing pain was regarded as being due to a deteriorating, spread-ing or growing process in the back with disastrous consequences forthe sufferers future health and function. This process was almost

unanimously thought to be worsened by any physical activity increas-ing pain. Persistent pain was also linked to thoughts and worries aboutillness, as well as, mourning over loss of function. These thoughts wereconsidered to be able to obsess a person and eventually make him ill.This somatopsychic process resembles the concern among Greekimmigrants in Montreal that worry and melancholy will lead to mad-ness, as reported by Lock (1990) and Dunk (1989).



328

Migration from one culture to another is a stressful experience. InNorth America, immigrants from poor countries not uncommonly livedisrupted family lives and feel nostalgia, hopelessness or helplessnessdue to unemployment and poor finances, discrimination and poorhousing (Dunk, 1989; Dunkas &Nikelly, 1972; Lock, 1990). In Sweden,the socioeconomic situation for immigrants is considerably better. Allthe same, the stress of migration and social difficulties could be a causeof the Greek immigrants illness-behaviour.

Somatization is the presentation of unpleasant emotional states ina language of distress of mainly physical symptoms (Kirmayer, 1989).In the USA, somatization is reported more commonly among blue-collar workers (Kleinman & Good, 1985). However, in this and ourprevious studies concerning Greek immigrants, we had no impressionthat Greek immigrants backaches should be viewed as a somatizationdisorder. Anxiety caused by somatic illness was often observed as aseparate phenomenon (L6fvander & Papastavrou, 1990, 1993). Asrelated above, there may be gender differences, since worries over chil-dren were sometimes reported as an additional cause of backache. Suchdescriptions resemble the kind of backache associated with &dquo;nevrca&dquo;(Dunk, 1989; Lock, 1990).

The phenomenon of disabling backache in immigrants from south-ern Europe is known as the &dquo;Mediterranean back&dquo; (Keel & Calanchini,1989; Parker, 1977; Rubenstein, 1982). This syndrome has mostly beenattributed to socio-economic factors or to litigation. However, wefound no indication in the present material that malingering or com-pensation claims were the main etiology. Instead, the great consistencyin the conception of pain among the Greek immigrants interviewed inthe present study points to the possibility that cultural factors play animportant role in the development of disabling backache. Greek fam-ily structure may contribute to the consistency and intensity of culturalillness beliefs. Strong family bonds are a cornerstone of Greek life allover the world (Bottomley, 1976; du Boulay,1974b). In this family sys-tem, informal consultations tend to be extensive (Bottomley, 1976). Inthis way, ideas about illnesses are preserved. The tight family bondsalso may facilitate the maintenance of sick-roles (Bottomley, 1976). Aswell, the family system ensures the economic survival of all membersof the family which could explain the lack of worry about their finan-cial future shown by both patients and controls in the study.



329

In ancient Greece, pathology was considered to be due to an imbal-ance of mind and body according to the humoral tradition. Incontemporary rural Greece, men (especially young, unmarried men)(ta pallikaria), should ideally be tall, slender, vigorous, brave and with-out any physical deformities. A woman should never be ill. Health, i.e.freedom from ill-health, is regarded as extremely important (Campbell,1964). Given the emphasis on health as a perfect balance, and the ruralarchetype of the faultless physical body, even small indications of pos-sible disturbances, such as pain and the side-effects of physiotherapy,may be regarded as a threat.

To blame work as the source of pain is an example of the externali-zation of the etiology of an illness, which assigns causality to forces orindividuals outside oneself (Clark, 1989). There are parallels to thebelief in the evil eye (Gr. Matiasma) (Tripp-Reimer, 1983). Interest-ingly, there was a small shift towards more internal etiologic agents inthe younger interviewees notions of the cause of back pain illustratedby their mention of &dquo;stress: However small, this shift in notions mightdemonstrate that culturally patterned ideas are subjected to constanttransformations (du Boulay,1974a).

In Sweden, backache, especially long-term backache, is not consid-ered a serious symptom and is seldom the cause for further examinationor sickness certification (Spitzer, Le Blanc & Dupuis, 1987). The treat-ment of choice for backache in Sweden is physiotherapy where thepatients active participation in physical exercises is often required, atherapy that may be painful in the beginning. These conceptions standin contrast to the Greek interviewees ideas of the meaning of back-ache, their distrust in medications and physiotherapy and perhaps totheir view of doctors as an Asclepian or magic healer of disorders(Marketos, Diamandopoulos, Bartsocas, Poulakou-Rebelakou &Koutras,1996).

Similar disparities between Western medical practice and immi-grant patients beliefs could be part of the explanation of thenon-response to treatment for other immigrant groups as well: a dis-crepancy that may be maintained by strong reliance on the family forwelfare and support (Grunfeld & Noreik,1991; Holtedahl, 1991; Keel& Calanchini, 1989; Kinebanian & Stomph, 1992; Lee et al, 1989;Lbfvander & Papastavrou, 1993; Parker, 1977).



330

Although exploratory, this study has important limitations. The waypeople present their symptoms varies not only with the individual butalso with social and cultural factors including the interview context. Inthis study, both patients and controls knew the profession of the inter-viewer. However, the shift in location, from the surgery to theinterviewees home, resulted in a shift in the balance of power in favourof the informant. It also facilitated the necessary shift of the interview-ers perspective, from a doctor to that of an observer and investigator.

Due to a sometimes limited knowledge of Swedish, the answersgiven by the informants could not always be elaborated. However,descriptions of symptoms and illnesses were generally explicit and col-ourful. When an interpreter was used, the content of the accounts ofpain did not differ from that in the other interviews, which suggeststhat the language barrier did not constrain the stories to any consider-able extent.

Although our sample was small, and we cannot exclude the possi-bility that there may be other concepts regarding pain in this group ofimmigrants, the uniformity of response suggests our results are repre-sentative. While some Swedish patients or those from other immigrantgroups may have ideas similar to those presented here, there is noindication, either in the literature or in our own experience as clini-cians, that such concepts are as consistent or as disabling as thosereported by our informants.

In conclusion, the cause of medically unexplained disabling back-ache in working-class immigrants with poor education need not besomaticised psychosocial distress. On the contrary, these intervieweesexpressed marked anxiety about the meaning of backache and this anxi-ety could well be the reason that their pain behaviour involvedrestriction of activity (Kirmayer, 1989). Considering the disabling courseof benign pain in some cultural groups, these considerations seem to beas important as any treatment of more well-defined disease entities.Whether greater clinical attention to the dimensions of symptom mean-

ing and illness behaviour discussed in the article will also lead toimproved treatment compliance and better outcomes in the case of thetreatment of backache among Greek immigrants, remains to be investi-gated.



331

REFERENCES

BOTTOMLEY, G. (1976). Rural Greeks and illness: An anthropologists viewpoint.Medical Journal of Australia, 1, 798-800.

CAMPBELL, J.K. (1964). The values of prestige. In Honour, family and patronage.A study of institutions and moral values in a Greek mountain community,(pp. 263-321). Oxford: Clarendon Press.

CLARK, M.H. (1989). Nevra in a Greek village: Idiom, metaphor, symptom ordisorder? Health Care Women International, 10(2-3),195-218.

DONOVAN, J., DESPAIGNET, E., MERTON, C., & VON OMMEREN, M. (Eds.) (1992).Differences in levels and types of disabilities. In Immigrants in Australia: Ahealth profile, (pp. 214-224). Canberra: AGPS, Ethnic Health Series no. 1.

DU BOULAY, J. (1974a). Past and present. In Portrait of a Greek mountain village,(pp. 233-258). Oxford: Clarendon Press.

DU BOULAY, J. (1974b). The House. In Portrait of a Greek mountain village, (pp.1-69). Oxford: Clarendon Press.

DUNK, P. (1989). Greek women and broken nerves in Montreal. MedicalAnthropology, 11 (1), 29-45.

DUNKAS, N. & NIKELLY, A. (1972). The Persephone syndrome: A study ofconflict in the adaptive process of married Greek immigrant females inthe USA. Social Psychiatry, 7, 211-216.

GRUNFELD, B. & NOREIK, K. (1991). Uforepensjonering blant innvandrare i Oslo(Disability pension among immigrants in Oslo). Tidsskrifft for den NorskeLaegefrening, 9,1147-1150. (In Norwegian with English summary).

HELMAN, C. (1990a). Pain and culture. In C. Helman (Ed.), Culture, health andillness, Second edition, (pp. 158-169). Bristol: Wright.

HELMAN, C. (1990b). Doctor-patient interactions. In C. Helman (Ed.),Culture, health and illness, Second edition, (pp. 86-126). Bristol: Wright.

HELMAN, C. (1990c). Clinical questionnaires. In C. Helman (Ed.), Culture,health and illness, Second edition, (pp. 288-289). Bristol: Wright.

HOLTEDAHL, R. (1991). Innvandrere i en attfringsavdeling. Tidsskrifft for denNorske Laegefrening, 9, 1085-1087. (In Norwegian with English summary).

KEEL, P. & CALANCHINI, C. (1989). Chronische Ruckenschmerzen beiGastarbeitern aus Mittelmeerlndern im Vergleich zu Immigranten ausMitteleuropa: Demographische und Psychosociale Aspekte. SchweizischeMedicinische Wochenschrift, 1, 22-31. (In German with English summary).

KINEBANIAN, A. & STOMPH, M. (1992). Cross-cultural occupational therapy: Acritical reflection. American Journal of Occupational Therapy, 8, 751-757.

KIRMAYER, L. (1989). Cultural variations in the response to psychiatric disor-ders and emotional distress. Social Sciences and Medicine, 3, 327-339.

KLEINMAN,A. & GOOD, B. (Eds.) (1985). Culture and depression. (pp.429-490).Berkeley: University of California Press.



332

KVALE, S. (1991). To validate is to question. In S. Kvale (Ed.), Issues of validityin qualitative research, (pp. 73-92). Lund: Studentlitteratur.

LEE, P.W., CHOW, S.P., LIEH-MAK, F. & CHAN, K.C. (1989). Psychosocial factorsinfluencing outcome in patients with low-back pain. Spine, 8, 838-843.

LOCK, M. (1990). On being ethnic: The politics of identity breaking andmaking in Canada, or, nevra on Sunday. Culture, Medicine & Psychiatry,14(2), 237-254.

LFVANDER, M. & PAPASTAVROU, D. (1990). Clinical factors, sick-leave patternsand psychosocial stressors in a group of Swedish and Greek patients.Scandinavian Journal of Social Medicine, 2, 133-138.

LFVANDER, M. & PAPASTAVROU, D. (1993). Cross-cultural psychiatric Assess-ment in Greek and Swedish patients. Nordic Journal of Psychiatry, 47,179-183.

MARKETOS, S.G., DIAMANDOPOULOS,A.A., BARTSOCAS, C.S., POULAKOU-REBELAKOU,E. & KOUTRAS, D.A. (1996). The Hippocratic oath. Lancet, 347, 101-102.

PARKER, N. (1977). Accident litigants with neurotic symptoms. MedicalJournal of Australaa, 10, 318-322.

RUBENSTEIN, A. (1982). The Mediterranean back and other stereotypes: Areview of the Australian literature dealing with industrial back injuries.Australian Journal of Social Issues, 4, 295-303.

SPITZER, W.O., LE BLANC, F.E. & DUPUIS, M. (1987). Scientific approach to theassessment and management of activity-related spinal disorders. Reportof the Quebec task force on spinal disorders. Spine, 7, Suppl.1.

SUNDQUIST, J. (1994). Migration and health: Epidemiological studies in Swedishprimary health care, (pp. 9-47). Lund: Dissertation.

TRIPP-REIMER, T. (1983). Retention of a folk-healing practice (matiasma)among four generations of urban Greek immigrants. Nursing Research,32(2),97-101.

WOLFF, B.B. & LANGLEY, S. (1977). Cultural factors and the response to pain. InD. Landy (Ed.), Disease and healing, (pp. 313-319). New York : MacMillan.

ZBOROWSKI, M. (1952). Cultural components in responses to pain. Journal ofSocial Issues, 8, 6-30.

ZOLA, I.K. (1966). Culture and symptoms: An analysis of patients presentingcomplaints. American Sociology Review, 31,615-630.



Backache in Greek Immigrants to Sweden

Documents

greek immigrants

introductionin sweden

musculoskeletal pain

theprolonged duration

persistent pain wasalso

annakarin furhoff backache

hilda vila

patients andphysicians