Table Of ContentStriving to maintain well-being:
Self-management of chronic pain by elderly
people living in rural communities
in North-East Thailand
Ladawan Panpanit
Doctor of Philosophy
Victoria University
2012
Striving to maintain well-being:
Self-management of chronic pain by elderly
people living in rural communities
in North-East Thailand
Ladawan Panpanit
st
BSc Nursing (1 class Hons, Khon Kaen Thailand),
Master of Nursing (Newcastle)
A thesis submitted in fulfilment of the requirements
for the degree of Doctor of Philosophy in the
School of Nursing and Midwifery,
Faculty of Health,
Engineering, and Science,
Victoria University,
Melbourne.
July 2011
I hereby certify that the work embodied in this thesis is the result of original
research and has not been submitted for a higher degree to any other university
or institution.
(Signed) ……………………………………………………………….
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ACKNOWLEDGEMENTS
This PhD thesis is dedicated to the many people who give me encouragement and
support. I am indebted to them, without their unflagging support, this thesis would not
have been completed.
I would like to thank my parents, brothers and all friends and colleagues who always
understood, supported and encouraged me during this long journey.
I extend my deep appreciation to Professor Dr.Terence McCann, my Principal
Supervisor, for generously and continuously giving me his time and expertise to
complete the thesis. I thank my former Acting Supervisor, Professor Dr. Helen Baker,
for her kind suggestions about my study while my Principal Supervisor was on
sabbatical leave. I thank my Associate Supervisor, Associate Professor Dr. Mary
Carolan, for her thoughtful guidance to improve my work. I also Dr. Joan Deegan, for
her detailed advice on my initial analysis. I am grateful to my field supervisor,
Associate Professor Dr. Wanapa Srithanyarat for her support, especially during the
field part of my study.
I am thankful to the Learning support staff of Victoria University, especially Angela
Rojter, Carol Marshall, and Petre Santry, who assisted me with my language
difficulties from having English as a second language. Also, Eileen Clark, who helped
me edit my work. Special thanks to Graham and Merle Van Cooten, who are not only
my English teachers, but helped me with the study from the translation of interview
data onwards. They also supported me as their ‘daughter,’ and inspired me to
persevere.
My thanks to the School of Nursing and Office of Graduate Research, Victoria
University for providing me with workshops, seminars, and conferences to build up
skills related to my study; and funding me, in part, for data collection, editing thesis,
and conference attendances outside the university. Special thanks to librarian, Jenny
Cameron, who assisted me with EndNote queries.
Many thanks to my work place, the Department of Gerontological Nursing, Faculty of
Nursing, Khon Kaen University, and my scholarship provider, Endeavour Postgraduate
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Awards, for making my dream to pursue PhD study become a reality. I could not have
achieved my dream without permission to take study leave and without sponsor
support from the scholarship and constant support through case managers, especially
Jose Paulino, Heath Fisher, and Anneliese Elmendorp.
My thanks to all who supported me during my field work, especially Miss Tippavon
Sopavonnakul and Mrs. Kanchana Sunthorn as well as their families, health centre
staff, village health volunteers, formal leaders of the villages, who facilitated the
recruitment process and data collection. Finally, my special thanks to all the elderly
participants and their family members for their time and experiences they shared with
me.
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ABSTRACT
Chronic pain is a common problem among elderly people. Proper self-management of
chronic pain is crucial in promoting general well-being; however, elderly people who
live in Thai rural communities have limited access to self-management resources.
Understanding the way these people self-manage chronic pain within their life context
will provide guidance on how to support them to achieve effective self-management,
which in turn, enhances their well-being.
The broad aim of the study was to describe and understand the ways in which elderly
people, aged 60 years or over, who lived in rural communities in north-east Thailand,
self-managed their chronic pain. The specific objectives were to: examine the
strategies that they used to self-manage their chronic pain; identify the factors that
moderated the way they self-managed their chronic pain; develop a substantive theory
that explained the experience of self-managing chronic pain; and evaluate the
developed theory within the context of current literature in the area.
Participants were 32 elderly people (six males and 26 females), aged 60 years or over
who had suffered pain for at least six months. The setting for the study was three
villages in three provinces in the north-east region of Thailand. Strauss and Corbin’s
(Corbin & Strauss, 2008; Strauss & Corbin, 1990, 1998) approach to grounded theory
was used to inform data collection and analysis, incorporating interviews, observations
and a questionnaire.
The findings showed that chronic pain had a major impact on the daily life of
participants. They experienced challenges in simultaneously dealing with pain and
meeting the requirements of their daily lives. A substantive theory, Striving to
maintain well-being: adapting to chronic pain, was generated from the study. It is this
process that the elderly people used to self-manage their chronic pain. The persistence
of pain necessitated adaptation in their lives in order to preserve an acceptable level of
well-being, similar to health-illness transition espoused by Meleis (2010). The theory
comprises three transitional phases: undergoing wellness–illness change, coming to
terms with chronic pain, and modulating autonomous–dependent pain management.
Three categories overarched by the core process are Making sense of pain, Seeking the
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most suitable treatment, and Integrating treatment into everyday life. The ways the
elderly participants comprehended their chronic pain situation, sought and identified
the most suitable pain treatment, and integrated it into their lives, were shaped by their
cultural beliefs, accumulated life experiences, and access to health information and
services.
Overall, the study findings suggested several strategies to promote elderly people’s
self-management of pain and to prevent undesirable outcomes. In particular, the
findings have implications for improving the distribution of health information,
providing greater access to health care, and making pain treatment more affordable and
acceptable. Facilitation of integration of pain treatment into their re-defined lives was
also recommended.
Keywords: Self-management, chronic pain, elderly people, rural, north-east Thailand.
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KEY TO TRANSCRIPTS
Categories Italics are used for all category names
Direct quotations Regular font style is used to present direct quotations from the
literature
Examplars Regular font style is used for all exemplars from participants’
interviews
Pseudonyms Pseudonyms are used when referring to all names, including
study participants, villages, and other names that appear in
exemplars
I: 14 I = interview
14 = interview number
O: 5 O = observation
5 = observation number
[ square brackets] Comments to provide explanation or clarity added by the
researcher
… Part of a sentence is omitted
…. Words omitted from more than one consecutive sentence
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TABLE OF CONTENTS
ACKNOWLEDGEMENTS ..................................................................................... ..iii
ABSTRACTS .............................................................................................................. .v
KEY TO TRANSCRIPTS ........................................................................................ .vii
TABLE OF CONTENTS ........................................................................................ .viii
LIST OF TABLES ................................................................................................. .xviii
LIST OF FIGURES ................................................................................................. .xix
PART I .............................................................................................................. 1
CHAPTER ONE: INTRODUCTION ........................................................................ 2
1.1 Introduction .......................................................................................................... 2
1.2 Background .......................................................................................................... 2
1.3 Justification for the study of self-management of chronic pain ........................... 3
1.4 Research question ................................................................................................ 5
1.5 Aims of the study ................................................................................................ .5
1.6 Definition of terms ............................................................................................... 6
1.7 Structure of the thesis ........................................................................................... 7
CHAPTER TWO: LITERATURE REVIEW .......................................................... 9
2.1 Introduction .......................................................................................................... 9
2.2 Thailand and Thai elderly .................................................................................... 9
2.2.1 Distribution of Thai and Thai elderly population .......................................... 9
2.2.2 Socio-economic background ......................................................................... 9
2.2.3 Thai health care system ............................................................................... 12
2.2.4 Health care and welfare services for Thai elderly ....................................... 14
2.3 Chronic pain ....................................................................................................... 16
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2.3.1 Definition .................................................................................................... 16
2.3.2 Prevalence of chronic pain ......................................................................... 17
2.3.3 Prevalence of chronic pain in elderly people .............................................. 17
2.3.4 Factors contributing to chronic pain ............................................................ 18
2.3.5 Effects of chronic pain on well-being ......................................................... 21
2.3.6 Management of chronic pain ....................................................................... 23
2.4 self-management ................................................................................................ 28
2.4.1 Definition of self-management .................................................................... 28
2.4.2 Skills necessary for self-management ......................................................... 29
2.4.3 Self-management of chronic illness ............................................................ 30
2.4.4 Strategies for self-management of chronic symptoms and related
factors .......................................................................................................... 31
2.4.5 Self-management of chronic pain................................................................ 32
2.4.5.1 Self-management of chronic pain in elderly people ............................ 33
2.4.5.2 Self-management of chronic illness and chronic pain in Thai
elderly people ...................................................................................... 34
2.5 Summary ............................................................................................................ 37
CHAPTER THREE: METHODOLOGY ............................................................... 39
3.1 Introduction ........................................................................................................ 39
3.2 Tenets of qualitative research ............................................................................ 39
3.2.1 Ontology and qualitative research ............................................................... 39
3.2.2 Epistemology and qualitative research ........................................................ 40
3.2.3 Methodology and qualitative research ........................................................ 40
3.3 Symbolic interactionism as a framework for grounded theory .......................... 43
3.4 Grounded theory ................................................................................................ 45
3.4.1 The nature of grounded theory .................................................................... 46
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