Linking the Malawian Diaspora to the Development of Malawi”
Malawi
Malawi (/məˈlɔːwi,məˈlɑːwi/; Chichewa pronunciation:[maláβi]; Tumbuka: Malaŵi), officially the Republic of Malawi and formerly known as Nyasaland, is a landlocked country in Southeastern Africa. It is bordered by Zambia to the west, Tanzania to the north and northeast, and Mozambique to the east, south and southwest. Malawi spans over 118,484 km2 (45,747 sq mi) and has an estimated population of 19,431,566 (as of January 2021). Malawi’s capital and largest city is Lilongwe. Its second-largest is Blantyre, its third-largest is Mzuzu and its fourth-largest is its former capital, Zomba.
Local resident Dr. John E. Fleming has spent much of his life working to bring visibility to American history — in particular, African American history — via his five decades as a historian who has helped establish museums throughout the U.S.
Now, after retiring from his most recent position as director of the National Museum of African American Music, Fleming’s focus has turned inward to his own personal history; his memoir,“Mission to Malawi,” was published this spring.
The book details Fleming’s service in the early years of the Peace Corps— during which he was the only Black American in his cohort — against the backdrop of the U.S. Civil Rights Movement. It also provides a snapshot of Malawi, an African nation that, at the time of Fleming’s service there, was newly independent, but still influenced heavily by colonial rule and racism.
Weaving together those two concurrent histories from Fleming’s point of view, “Mission to Malawi” serves as the remembrance of a young man’s deepening understanding of the need for social change through a global lens, and how it ultimately affected the course of his life.
Fleming spoke with the News recently about writing the memoir, which spans the years 1967 to 1969. With the events depicted in “Mission to Malawi” having taken place nearly 60 years ago, Fleming acknowledged that the book’s completion would have been more difficult had he not been a prolific letter-writer during those years. As he explains in the book’s preface: “I was a voracious writer because I wanted my family and friends to write to me, as it was my only form of communication.”
Likewise, he said he was lucky that those to whom he wrote then — including his mother, and future wife, Barbara Fleming —were diligent at saving his letters.
“It’s really sort of funny; as a historian, you’d think you’d remember historical facts as they happened — and it turned out that wasn’t exactly true,” he said.
Fleming wrote the first draft of the memoir without the aid of letters, and later, organized the letters chronologically and read them. The letters allowed him to revise his first draft and improve upon his memory.
“I was very fortunate to be able to find those letters. … The first draft is quite different from what the final manuscript turned out to be,” he said.
Though he said the letters he’d written in his youth didn’t deviate wildly from his own memory, they did contain vital insight into what he felt from day to day, as well as his perspective on his experiences then compared to his perspective now.
In particular, he pointed to his time at Berea College in Kentucky, where he studied before joining the Peace Corps. As Fleming’s book describes, Berea had initially been an integrated college, but was segregated in 1904 by state law until 1954. Fleming came to the college as one of only a few Black students in 1962; by the time he graduated, Berea was still struggling to “find its place in this new desegregated society,” he wrote.
“My experience [at Berea] was, at best, neutral, and at worst, negative,” Fleming told the News. “But I’ve been on the board at Berea now for almost 18 years, and my perspective has changed dramatically. I think that influenced the way I wrote about being a student at Berea, and it turned out a lot more positive than I would have anticipated.”
In the same vein, Fleming’s memoir goes on to detail his Peace Corps training in Alabama and in England as an agricultural volunteer to Malawi. Fleming writes that he learned he was nearly “de-selected” for Peace Corps service — that is, he almost didn’t “make the cut.” He writes that his close call came because his experiences with racist white people caused him to have “strong feelings against those who wanted to keep Black people in their place.”
“It never occurred to me that my attitude and behavior toward whites would reflect on the assessment of my fitness to be a Peace Corps volunteer who represented this country,” he writes early in the book. In a later chapter, he adds: “The Peace Corps blamed me rather than the society that had permanently injured me.”
The bulk of “Mission to Malawi” is dedicated to Fleming’s time in the country in which he served, as well as his visits to other African countries. Hepresents his memoir chronologically in four chapters, each of which is broken into smaller, subtitled sections, giving the work an episodic rhythm.
Humor, heartbreak and the humdrum of daily life come to the page as Fleming describes his first grudging taste of pan-fried grasshoppers; his disappointment that his then-girlfriend, Barbara, would not join him in Malawi; and the “culture shock” of learning how to keep a schedule in a country where work was traditionally not dictated by the hands of a clock.
Winding through these episodes, Fleming writes about how his perspective on the foundational racism of the United States was deepened by both his experiences in Malawi and news of the ongoing fight for civil rights at home. After learning of the murder of Martin Luther King Jr. in 1968, he writes that he turned the lens of his grief toward his own work with the Peace Corps. At the time, he believed he had been “too silent and had acquiesced too often” when he encountered racism in Malawi, where Black people constituted the majority, but whites were “in control.”
“If I said that I loved Malawians, then I had to prove it by words and deeds,” he writes. “I knew that the changes I experienced with the death of Dr. King would be reflected in my relationships with white folks in Malawi.”
As readers of “Mission to Malawi” will discover, Fleming held true to that revelation, forming close relationships with Malawians and advocating for their agency in their own society and government. Before leaving Malawi, he made sure that his own post was not filled by another Peace Corps volunteer or European expatriate, but by an African diploma student.
He returned to the U.S. galvanized to continue working for social change. He soon took a job with Pride Inc., a Washington D.C.-based organization that, as Fleming writes, was “dedicated to working with the hardcore unemployed and unemployable, especially Black men.” He later earned his Ph.D. at Howard University, and went on to serve as director of many museums, including the National Underground Railroad Freedom Center and the National Afro-American Museum and Cultural Center in nearby Wilberforce.
Fleming said his time in the Peace Corps heavily shaped his life; much of his work in Malawi required him to learn through experience or teach himself new skills, and to build relationships across cultural divides.
“I’ve encouraged people who know me to read the book, and said, ‘This will give you a perspective on who I am, and how I developed over the years,’” Fleming said.
Despite his experiences with systemic racism and prejudice in the Peace Corps, as outlined in the book, Fleming said he believes his two years in Malawi were some of the most important in his life.
“I ran into some negative experiences, but by the time my term in the Peace Corps was up, the negative had turned into positive,” Fleming said. “What I truly believe about the Peace Corps experience is that it is beneficial to our life today.”
Ever the museum expert, Fleming mentioned the Museum of the Peace Corps Experience, which is currently being developed in Washington D.C.
“When we talk about why we should have a Museum of the Peace Corps Experience, it’s not just to recount the stories that volunteers had,” he said. “It is to show the impact of individuals on foreign communities, and that we can learn from our experiences, bring those experiences back to the U.S. and bring about social change in this country.”
“Mission to Malawi” is available for purchase via Amazon, and to borrow from the YS Community Library.
Christy Davis Jackson transitioned over the Thanksgiving Holiday after facing a series of medical-related ailments.
Ms. JAckson was the beloved wife of AME Bishop Reginald T. Jackson; mother to Seth Joshua; step mother to Regina Victoria; former Supervisor of the Sixth Episcopal District of the African Methodist Episcopal Church (AME); a dear friend to so many across the states of Georgia, New Jersey, and Ohio; and a national figure in the fight for equity, civil rights, and equal rights.
Ms. Jackson worked tirelessly to forge partnerships among the public, private and faith sectors, and to help government reach its potential as a force for policies that improve people’s lives.
In her early professional career, she served as the legal counsel and Chief of Staff for State Senator Wynona M. Lipman, who was the first African American woman elected to the state Senate in New Jersey. She went on to serve various organizations and institutions throughout the Garden State, including as Senator Frank Lautenberg’s State Director and Chair of Jon Corzine’s senatorial campaign. She continued her professional career developing education, workforce and economic development, and health polices as the Founder of City Strategy Group and a Principal at BusDev Solutions.
From 2012 to 2016, she served with her husband in the AME’s 20th Episcopal District, which includes Malawi, Zimbabwe, the northern portion of Mozambique, Tanzania, and Uganda.
In 2016, Ms. Jackson relocated to Georgia to once again work alongside her husband as Supervisor for the Sixth Episcopal District (AME). In that role, she led the statewide organizational and operational activities for the AMEs and its 534 churches across the state, directed the Women’s Missionary Society in the state of Georgia, fought to strengthen the voice of women within the Church, and served as advisor and strategist to her husband.
This August, Bishop Jackson and Supervisor Jackson were chosen to lead the Second Episcopal District, which includes the District of Columbia, Maryland, Virginia, and North Carolina.
Bishop Jackson, Regina, and Seth would like to thank the outpouring of love, prayers, and support shared over the last few hours. At this time, funeral arrangements have not been finalized. Thank you.
Among Peace Corps volunteers, we often say our service is “the toughest job you’ll ever love.” At 18, however, I couldn’t grasp this sentiment; I was too focused on escaping my responsibilities to understand the profound journey ahead. It was the summer before my senior year of college, and I felt the pressure to go to law school — a goal I had pursued my whole life. Having graduated high school with an associate degree through dual enrollment and spent just two years “finding myself” at college, I knew I wasn’t ready for that next chapter. Then I discovered the Peace Corps and immediately knew I would serve.
In hindsight, I was naive and overzealous; the possibility of rejection didn’t even cross my mind. When I told my parents about my application, they were skeptical. Both had served in the U.S. Navy, so they understood life in resource-limited places. My family, Haitian immigrants, questioned why I would abandon a life they had worked so hard to build in a country full of comfort and security that had been generations in the making. Admittedly, I hadn’t thought through the practicalities of living in one of the poorest countries in the world, but that was probably fortunate. Otherwise, I might have missed out on the best experience of my life.
It didn’t take long for me to understand what “the toughest job you’ll ever love” truly meant. I lived each day at the edge of my comfort zone, facing challenges I had never anticipated. As the first volunteer in my community, I felt the weight of expectations. For the first time, I had to defend my Americanness as a Black American in Malawi, Africa, while also taking on the role of a teacher responsible for my students’ education in a large class with limited resources. I struggled with the extroverted nature of my new community, feeling the spotlight on me constantly, and I often felt overwhelmed, as I hadn’t yet learned how to laugh at myself. This was my first “real” job, and I was living alone, far from family and familiar comforts. These challenges sometimes brought me to tears, but they also made me acutely aware of my own growth.
A turning point came when my Muslim community invited me to my first funeral. It was a humbling moment that made me realize I was squandering the privilege of this unique opportunity. I resolved to fully embrace my service, understanding that time was fleeting — “The days are long, but the weeks are short,” as we like to say. I began to let go of my frustrations, focusing instead on the connections and experiences right outside my door.
One memorable experience occurred during the rainy season eight months into service when my roof began to leak. Frustrated and slightly cranky, I vented to my principal through tears. That same day, I walked into class feeling defeated after grading essays and struggling to engage over 100 ninth graders in a cramped room with too few books. Remembering how I learned grammar through catchy jingles and knowing Malawians loved to sing, I wrote the lyrics on the board, hoping my chalk would hold out. When I turned around, I faced a mix of confusion and amusement, but I sang the jingle in call-and-response anyway. Soon, they joined in, and by the end of class, we were all laughing. Hearing them sing as they left gave me a sense of accomplishment like no other.
When I came home from school, I was still riding high on my first “teacher win” only to find a community member repairing my roof. Embarrassed remembering my earlier complaints, I learned a valuable lesson about gratitude and community. My Peace Corps experience became a defining chapter in my life, teaching me resilience, connection and the profound joy of service. I believe it has made me a better person. For the first time, I felt truly present in my own life because of service. I now have greater confidence in both my professional abilities and my personal identity. This experience has sparked a desire in me to explore more of the world and its rich diversity, and the realization that I may not even be a footnote in the book of life excites me.
Today, I’m in my final year of law school at UF and the university’s Peace Corps recruiter. If you want to learn more, visit me in the International Center or email peacecorps@ufic.ufl.edu.
Dani Arnwine is a UF law school student and Peace Corps recruiter.
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“The Kenyan political thinker who was unafraid to confront contentious issues.” “The African political scientist who sparked controversy.” This was how The Guardian and The Times of London respectively described Ali Mazrui shortly after his death in October 2014. That Mazrui thrived on controversy is widely known.
The image of Mazrui portrayed by Malawian scholar Paul Zeleza in his intervention at the Ali Mazrui 10th anniversary virtual webinar last month is, however, quite different. Just as Nelson Mandela and Martin Luther King Jr. have often been shorn of their radicalism in much of contemporary analyses, Zeleza’s Mazrui seems to be ideologically compatible with an eclectic motley crew of diverse scholars, revealing a cardboard cutout of the Kenyan scholar.
Precisely because Zeleza is a widely respected academic and administrator whose work could have a great impact, particularly on younger scholars, we wish to challenge the portrayal of the Kenyan academic in his 18-page essay “The Enduring Legacy of Ali Mazrui: Commemorating an Intellectual Griot.”
Zeleza purports to discuss comparatively Mazrui’s scholarship and that of 28 other thinkers: his predecessors, contemporaries, and successors. The task could not be nobler, but Zeleza unfortunately largely fails to achieve his stated goals of placing the Kenyan intellectual within the context of his ancestral and contemporary influences.
We might classify Zeleza’s sins into two parts: sins of commission and sins of omission. Sins of commission are largely misinterpretations or distortions of what Mazrui has written, while sins of omission are fundamental facts that are overlooked.
Sins of commission Zeleza correctly notes that: “Mazrui’s most well-known concept of the Triple Heritage (was) articulated in his book and television series The Africans: A Triple Heritage (1986).” Mazrui, however, never critiqued the imposition of Western liberalism on African societies resulting in a scepticism of Western-style democracy, as Zeleza claims in seeking to align the Kenyan’s views to those of Nigerian scholar Claude Ake.
Mazrui’s position was more nuanced. While he was strongly anti-colonialist, he was only mildly anti-capitalist. He genuinely believed that capitalism was the mother of both imperialism (of which he disapproved) and liberal democracy (which he admired in theory, but felt was hypocritically practiced by Western nations particularly in their support of foreign autocrats and maltreatment of black minorities at home).
Zeleza suggests that Mazrui’s advocacy of Pan-Africanism was consistent with that of individuals like America’s W.E.B. Du Bois and Ghana’s Kwame Nkrumah. Zeleza could have further clarified the different shades of meaning in which the term is understood, as well as how Mazrui’s own thinking of the concept evolved, by drawing on the Kenyan’s rich typology of Pan-Africanism elaborated in detail in his seminal 1977 book, Africa’s International Relations: The Diplomacy of Dependency and Change.
Zeleza links Nkrumah’s ideas on Pan-Africanism and neo-colonialism to Mazrui’s, but fails to interrogate the Kenyan scholar’s most contentious debate which was centred around Nkrumah. Mazrui’s most influential article “Nkrumah: The Leninist Czar?” published in 1966 shortly after Nkrumah’s fall from power, depicted the Ghanaian leader as a “Leninist Czar”: a royalist revolutionary who had helped pioneer one-party rule in Africa and ruled in a monarchical fashion that lost the organisational effectiveness of a Leninist party structure. Mazrui was widely vilified by leftists and Pan-Africanists for what many felt, at the time, was a treacherous pro-imperialist critique of an African liberation icon.
Zeleza also highlights Wole Soyinka sharing Mazrui’s beliefs on the importance of African intellectual and cultural autonomy, without noting the fundamental differences between the two scholars evident in their ferocious debate of 1991/1992 in which Soyinka accused Mazrui of an Islamophilic slant in his 1986 nine-part documentary The Africans, berating the Kenyan scholar for underplaying the damage of the Arab slave trade on Africa, and for trivialising and misrepresenting African indigenous cultures.
Among Mazrui’s intellectual successors named by Zeleza are such eccentric choices as Ghana’s George Ayitteh, African-American Henry Louis Gates Jr. and Cameroon’s Achille Mbembe. Ayitteh is a conservative scholar who disproportionately focuses attention on African tyrants and domestic deficiencies and thus blames Africa for its own failures. Mazrui, in stark contrast, consistently blamed historical and contemporary external forces for most of Africa’s problems, without ignoring domestic autocracy.
In 2000, Mazrui scathingly critiqued Gates’s six-part documentary Wonders of the African World for: portraying ancient Egyptians as racist; ignoring Swahili experts; overplaying Muslim atrocities in Zanzibar; and under-playing Jewish commercial involvement in the Transatlantic slave trade. Cameroon’s Achille Mbembe was described by Malawian scholar, Thandika Mkandawire, as representing “an obscurantist anti-‘victimology’ discourse”, and has more recently acted as an academic ambassador for French president Emmanuel Macron’s neo-colonial efforts in Africa: a far cry from Mazrui’s dyed-in-the-wool Pan-Africanism.
Sins of omission In terms of Mazrui’s contemporary influences, Zeleza lists writers like Nigeria’s Chinua Achebe, Kenya’s Ngugi wa Thiong’o, and Ghana’s Ayi Kwei Armah, but fails to note Nigeria’s greatest poet, Christopher Okigbo, on whom Mazrui wrote his only novel: The Trial of Christoher Okigbo, in 1971.
Mazrui’s focus on literature also tended to be a global and not just a continental one that sought to use authors like Shakespeare, Milton, and Kipling to illuminate the African condition.
Among Mazrui’s closest intellectual collaborators within his peers were Nigeria’s Ade Ajayi and Jamaica’s Dudley Thompson with whom he campaigned relentlessly on the issue of reparations to Global Africa for the European-led Transatlantic slave trade and colonialism. All three Pan-African intellectuals also served on the Organisation of African Unity’s Group of Eminent Persons established in 1992.
Zeleza mentions none of this. Furthermore, some of the political figures he identifies like Amilcar Cabral were not as central to Mazrui’s scholarship as Tanzania’s Julius Nyerere, Uganda’s Milton Obote and Idi Amin, Egypt’s Gamal Abdel Nasser, Libya’s Muammar Qaddafi, and later, South Africa’s Nelson Mandela and America’s Barack Obama, none of whom are mentioned. Zeleza has thus omitted individuals who would have to form an integral part of any serious discussion of Mazrui’s scholarship. Zeleza’s list appears arbitrary, and even he himself concedes that it is based on “impressionistic selectivity” (apparently because it is no easy task to capture in a short essay the essence of Mazrui’s intellectual output of 58 books and 679 academic articles). Many of these scholars and statesmen, we think, are perhaps those that Zeleza himself admires. They are not the ones that were major influences on, and disciples of, Mazrui.
Zeleza then outlines 10 of Mazrui’s most important ideas, but fails to mention perhaps his most influential: Pax Africana. This was a concept that the Kenyan told us he was most proud to have coined. The idea is developed in Mazrui’s very first 1967 book Towards A Pax Africana: A Study of Ideology and Ambition in which he argued for Africa to craft its own self-pacification mechanisms in order to avoid pernicious interventions by external actors. This study remains a foundational text of Africa’s International Relations and Conflict Resolution, but somehow does not make it into Zeleza’s top ten.
Some of the comprehensive work in the rich treasure of Mazruiana that would also have been helpful for Zeleza to have mentioned is Mazrui’s 2014 African Thought in Comparative Perspective, and in reference to his discussion on Mazrui’s contributions to feminist thought, the late Kenyan scholar’s 2014 The Politics of Gender and the Culture of Sexuality.
But what should not be overlooked is who else is missing from Zeleza’s account: the Ali Mazrui we know who loved to argue, generate controversy, and stimulate ideas. Where is the Mazrui who made a name for himself by challenging conventional wisdom?
Where is the Mazrui who once said “my life itself is one long debate”? The Mazrui we knew was also different from Zeleza’s Mazrui in another sense. The Kenyan intellectual was a storyteller, the master of paradox, the master comparativist, the master of metaphor, the master verbal gymnast, a master jargon-buster, a master inventor of words, and a master classifier. This “Multiple Mazrui” is mostly missing from Zeleza’s interesting essay.
In short, Zeleza’s interpretation of the “enduring legacy” of Mazrui vastly overplays the connections between Mazrui’s scholarship and that of his predecessors, contemporaries, and successors. The Kenyan had noted in 1991: “My own worldview does not fit into any particular …school. That is why I am attacked from (all directions.)”
In the Hereafter which he dubbed “After Africa”, Mazrui himself would be unlikely to recognise Zeleza’s reinvention and caricature of Africa’s most eloquent griot and the Black Atlantic’s Master Essayist.
Professor Adebajo is a Senior Research Fellow at the University of Pretoria’s Centre for the Advancement of Scholarship; and Dr Adem is a Research Fellow at JICA Ogata Research Institute for Peace and Development in Tokyo, Japan. Dr Adem is also Ali Mazrui’s intellectual biographer.
Chronic pain affects approximately 35% of older adults and is a leading cause of disability, but rates of pain double to 60–75% for older adults in underserved communities.1–8 Quantitative studies have demonstrated that chronic pain interferes with work, social relationships, and activities of daily living.1,9 Chronic pain also markedly impacts psychological functioning, with high rates of depression and anxiety, which can in turn cyclically exacerbate pain intensity and interference.10 Healthcare staff often have difficulty fully addressing the needs of patients with chronic pain, especially in under-resourced community clinics, where many underserved and historically marginalized patients receive their care.11 Considering the perspectives of medical staff and older adult patients with chronic pain is crucial for developing treatments that fully meet the needs of patients in the context of the limited resources of community clinics.
There has been a recent push to understand how contextual factors intersect to impact health conditions, such as chronic pain, especially for individuals from underserved communities whose health is often affected by communal and structural factors outside of their immediate control.12 In particular, the socioecological model (SEM) provides a framework through which to comprehensively view the interplay of factors that impact and are impacted by pain at four levels of analysis: individual, interpersonal, community, and societal.13–15 Individual factors include the cognitive, affective, and behavioral experience of chronic pain, including interference of pain in work, social, and emotional functioning. Interpersonal factors represent those between two individuals or within a single family (eg, relationship satisfaction, relationships with healthcare providers), while community factors include the social (eg, culture, religion) and physical (eg, city transportation) context that the individual lives in. The structural level describes broader societal factors (eg, discrimination, healthcare policy), which dictate an individual’s place in society and the resources they have access to. The SEM is thus a helpful tool for organizing our understanding of a population that moves beyond focusing solely on the individual. While our interventions are mostly centered on addressing individual factors, previous research suggests all four levels may be relevant for the experience of chronic pain. For example, at the individual level, some older adults display an acceptance of their pain experience and understanding that pain is sometimes a normal part of aging,16–18 while others experience increased depression and anxiety.10 These individual factors can be viewed in the context of interpersonal factors, including the dynamics of a family unit and the availability of social support.19 These in turn interact with broader cultural/community factors, such as language and ethnic cultural background, while societal factors (eg, discrimination) often exert stress on individuals that can exacerbate chronic pain.20
While quantitative findings have enabled a general evaluation of the contributors to and effects of pain, qualitative methods are particularly useful for elucidating the contextual factors highlighted in the socioecological model. Qualitative methods can help to expound not just individuals’ quantitative ratings of pain interference but also the detailed ways in which pain interferes in their lives, as well as the contribution of interpersonal relationships to their pain, including relationships with medical staff. In explaining the specific ways in which pain interferes in their lives, older adults express particular frustration with their loss of ability to perform activities of daily living and subsequent feelings of uselessness due to pain and age.16,21 This disrupted sense of self is paired with a sense of disconnect from others, and older adults report large impacts of pain on their relationships,22 including those with medical staff.17,23,24 Meanwhile, medical staff report understanding the difficulty of living with chronic pain25 while experiencing frustration with patients’ lack of willingness to acknowledge psychosocial contributors to pain.26 All told, patients often experience chronic pain as a disabling condition that takes away their sense of who they once were, while medical staff feel the burden of educating and connecting with patients whose needs they cannot always meet. However, much of this existing research was conducted with higher-SES populations, and there is an absence of qualitative information regarding the communal and societal contributors to pain from the patient and staff perspective.
These existing qualitative analyses of chronic pain in older adults provide a foundation of information about the individual perspectives of medical staff and patients with chronic pain. An unmet need remains using qualitative methods to synthesize these perspectives in the context of the larger communal, cultural, and societal influences on chronic pain.27,28 Further, given that most behavioral pain treatments were developed with higher SES populations in ethnically homogeneous trials,29 it is especially important to consider these broader levels of analysis when seeking to understand the factors that interact with chronic pain for older adult patients in underserved settings. In these populations, aging is accelerated by a range of life factors, including increased financial stress,30 and pain outcomes can be worse due to stressors, including class and ethnicity-based discrimination.31,32 While the socioecological model has been used to examine the experience of a range of health conditions and behaviors,33–35 it has yet to be used as a framework for the qualitative assessment of chronic pain for older adults in underserved communities. Such an analysis is essential for understanding the factors that impact and are impacted by chronic pain, including points of intervention across all socioecological levels of analysis. By understanding the comprehensive factors affecting the pain experience, we can better implement evidence-based pain management interventions in the community.
The present study aimed to elucidate individual, interpersonal, community, and societal factors associated with chronic pain from the perception of older adult patients and medical staff from a community health clinic, using qualitative analyses grounded in the socioecological model. Our primary research question centered on understanding the multi-layered factors influencing the pain experience in this clinic to inform future treatment development and implementation. We used thematic analysis to create a descriptive narrative of the experience of this patient population. This analysis will help to bridge the gap between patients and medical staff by identifying the commonalities and discrepancies between patient and staff perceptions of the factors that impact and are impacted by chronic pain for older adults in a community primary care setting. We also aim to broaden our understanding of the contextual circumstances that are often ignored in biomedically focused treatment planning.
Materials and Methods
Study Overview
We conducted 4 focus groups and 2 individual interviews with medical staff (n=25) and 3 focus groups and 7 individual interviews (n=18) with older adult patients (age 55+) with chronic pain at a primary care clinic in an economically and ethnically diverse community. Approximately half of patients in the clinic identify as Latino, Asian, Black, multiracial, and/or were born outside the United States. The purpose of these qualitative interviews was to understand the unique needs of diverse older adults with chronic pain in this clinic to inform the adaptation of a mind-body activity intervention, which was initially developed in a predominantly White, affluent sample. We followed the Criteria for Reporting Qualitative Research (COREQ)36 in acquiring, analyzing, and reporting on qualitative data for this study.
Participants
Clinic Staff
For the staff groups and interviews, we purposively sampled and conducted groups based on clinic role (eg, primary care physicians, nurse practitioners, administrative staff) to gather a range of staff perspectives. The medical director, administrative staff, and clinic “champions” assisted with recruitment following a similar sampling procedure in a prior treatment development study in rural and low-income settings.37 Participants did not have a prior relationship with the interviewers; however, they were made aware of the research purpose prior to participation.
Patients
We recruited older adults (55+) with chronic pain from a community health clinic using purposive sampling. Clinic champions and other clinic staff referred patients to the study. Staff who participated in the focus groups were encouraged to refer. Staff were encouraged to refer any patients with chronic pain who were 55 or older. Other participants self-referred through flyers posted in the clinic or through a clinic-wide platform for advertising research studies. The majority of patient participants were referred from providers (n=15) as opposed to flyer referrals (n=3). There were no prior relationships between the patients and the interviewers; patients were aware of the purposes of the research prior to participating. For both staff and patients, only those participating in the study were present in the qualitative assessments. Participant demographic characteristics are presented in Table 1. Patient participants were generally characteristic of those seen at the clinic, although we were unable to recruit patients from some immigrant communities due to language barriers (eg, Khmer and Arabic-speaking patients).
Table 1 Demographics for the Staff and Patient Qualitative Assessments, Mean (SD) and N (%)
Ethics Statement
The study was approved by the Massachusetts General Hospital Institutional Review Board (IRB), who determined that this qualitative study was exempt from written informed consent (protocol number: 2022P001691). The study complies with the Declaration of Helsinki guidelines for conducting research with human subjects. In accordance with IRB policies, participants reviewed a fact sheet, which included a statement that the deidentified results of the focus groups (for example, participant quotes) will be shared and published in relevant scholarly journals, and provided verbal consent to participate prior to data collection.
Procedure
We developed two semi-structured interview guides, one for staff and one for patients, using the socioecological model13–15 and prior chronic pain literature.38,39 The scripts began with general questions (eg, for patients: aspects of their personal background impact their pain), followed by questions probing at the environmental (eg, socioeconomic, employment, finances, caregiver roles), sociocultural (eg, culture, social support), behavioral (eg, behavioral changes due to pain), and medical factors (eg, managing pain and comorbidities) that impact and are impacted by pain. For the full interview guide, please see the supplemental material.
Two PhD-level clinical psychologists (female: KM, male: JG) and one master’s level research assistant trained by the clinical psychologists (one female: ME) conducted the focus groups and individual interviews either in person, using HIPAA-approved Zoom video calls, or through telephone audio calls. The PhD-level facilitators had backgrounds in chronic pain. All facilitators were cognizant of potential bias resulting from the discrepancy between their main work in an academic medical center to this community setting; probes were built into the interview guide to encourage facilitator openness to differences between the settings. One master’s level or bachelor’s level female trained research assistant (RA; ME, NL) took field notes during the interview that were then used in rapid data analysis (RDA).40 We used RDA to evaluate thematic saturation (ie, was consistent information obtained throughout assessments) in a timely manner to inform the additional qualitative assessments. RDA involved deductively mapping field notes and observations from the qualitative assessment onto a template summarizing the interview guide. RDA was conducted with the RA and the interviewer in the 24 hours after the qualitative assessment. RDA notes were consolidated into a matrix, which was consulted during the larger coding process, following established procedures.40 The matrix was created using a hybrid inductive-deductive manner by using the domains from the RDA template alongside pertinent information from the assessments. One row summarized the information reported in the present manuscript regarding the clinic population, while the other rows consisted of information related to pain treatment experiences and feedback on a proposed mind-body intervention.
The focus groups and interviews lasted between 30 and 60 minutes. Individual interviews were conducted with staff when there was a sole individual in a particular role (eg, clinic director, pain psychologist). Initially, we planned to conduct only focus groups for patient qualitative assessments but found this to be impractical due to scheduling conflicts (eg, numerous medical appointments) and other responsibilities (eg, caregiving) that made scheduling groups difficult for this patient population. We audio recorded, de-identified, and transcribed verbatim all interviews and focus groups. De-identified data was stored on a secure qualitative platform (Dedoose version 9.0.90), where it was coded. Neither data (ie, transcripts) nor results were returned to participants. There were no repeat interviews.
Data Analysis
We conducted a hybrid inductive-deductive thematic analysis of our transcripts, following the Framework Method.41 Step 1 was completed with the verbatim transcription of the interviews. Step 2 (familiarization with the qualitative data) was completed by the lead author (KM) and research assistant (NL), who conducted, reviewed transcripts, or were present for most interviews. In steps 3 (coding) and 4 (developing a working analytical framework), we (KM and JG) first developed two separate codebooks using a hybrid deductive-inductive approach. We pre-specified potential domains such as “individual factors” deductively based on the socioecological model. We used a deductive-inductive approach to specify potential parent and child codes such as “psychological factors (depression, anxiety, emotional distress)”, “resiliency factors”, or “health literacy” based on prior research in chronic pain and the socioecological model as well as information gathered from conducting the interviews and rapid data analysis.40 We allowed for themes to overlap. JG and KM met to review and integrate preliminary codes into a single codebook. Next, the larger team (AP – PhD-level male clinical psychologist, CR – PhD-level female clinical psychologist, JG, KM, and NL) each reviewed a transcript and the RDA matrix summarizing the RDA findings to inform edits to the codebook. Using this iteration of the codebook, ME and NL independently coded 20% of the transcripts. During this “first pass” of coding they continued to inductively revise parent and child codes as novel information emerged from the data (eg, merging the codes for immigration status and citizenship, addition of physical function into a code for other individual factors).
After the two RAs coded 20% of the transcripts, they then met with CR and AP to discuss novel codes that emerged during the initial coding process and to examine the concordance between the coders’ coded transcripts. To ensure strong consistency in the application of codes, the team resolved coding discrepancies via discussion informed by the codebook. The team then updated the codebook to include the new, inductively derived codes. In step 5 (applying the analytical framework), the RAs used the refined, hybrid deductive-inductive codebook to recode the 20% of transcripts they initially coded and to code the remaining 80%. CR met with the RAs regularly during the coding process to provide guidance and problem solve as needed.
In step 6 (charting data into the framework matrix), we first extracted the coded excerpts from Dedoose and compiled into an Excel document. In step 7 (interpreting the data), AP and KM then independently and systematically reviewed the excerpts by creating summary codes, which were compiled into suggested themes and subthemes. AP and KM then met to discuss the emergent patterns from the excerpts, and to finalize themes and subthemes.
Results
A summary of the findings and illustrative quotes is presented in Table 2.
Table 2 Socioecological Model Domains, Themes, and Illustrative Quotes
Individual Domain
At the individual level, we identified three themes: 1) Older adults with complex care needs. (Subthemes: 1a) Multimorbidity, 1b) Multiple life stressors, and 1c) Low health literacy); 2) Impact of pain (Subthemes: 2a) Physical functioning, 2b) Emotional functioning, 2c) Work participation and financial insecurity, 2d) Identity); and 3) Coping with pain (Subthemes 3a) Adaptive coping and 3b) Maladaptive coping).
Older Adults with Complex Care Needs
Multimorbidity
Medical staff described their older adult patients with chronic pain as often presenting with complex medical and mental health comorbidities. Older adults with chronic pain presented with a wide range of pain conditions, including arthritis, back pain, neck pain, irritable bowel syndrome, herniated discs, and neuropathy. Comorbidities included diabetes, sickle cell anemia, obesity, depression, anxiety, and bipolar disorder. Many patients reported previous falls and fear of falling again. There were also interactions between comorbidities, including an interplay between physical and mental health conditions.
Multiple Life Stressors
Staff and patients highlighted multiple stressors patients face that exacerbate pain, including financial concerns, grief, and trauma. Patients described multiple stressors co-existing and compounding each other to the extent that it was difficult to engage in stress management.
Low Health Literacy
Staff highlighted that many patients within the clinic have difficulty understanding medical concepts and had little knowledge of the medical system. They noted that some patients do not know the difference between the roles of different medical staff, and others do not have a primary care physician to help them navigate the healthcare system. Staff expressed that patients often lacked understanding of pain education and that providers struggle to have the resources in both time and training needed to address these deficits.
Impact of Pain
Patients and staff reported negative effects of pain on multiple types of functioning with interactions between physical functioning, emotional functioning, work participation and financial insecurity, and identity. Pain was noted to worsen patients’ mobility, which often led to difficulty with work, increased depression and anxiety, and feeling like they could not be the selves they once were.
Physical Functioning
Staff and patients described the patient population as one with many mobility difficulties resulting both from pain itself and fear of pain. They noted bidirectional relationships between the physical and emotional experience of pain. Some patients expressed the fear that physical movement would lead to an increase in pain, which led to greater sedentariness. Other patients described stopping activities that they used to enjoy because of the perception that the cost of completing them was too much.
Emotional Functioning
Both staff and patients discussed the negative impact of pain on emotional functioning. Patients particularly described fear of pain and increased emotional reactivity to pain, including irritability, anxiety, depression, and helplessness. For example, one patient noted the interaction between pain’s impacts on physical and emotional functioning by stating, “When you have pain, you are in such misery, you do not want to do anything.”
Work Participation and Financial Insecurity
Many patients reported that they had lost the ability to participate in work at their prior ability level due to pain; others reported being unable to work altogether and needing to rely on disability. This in turn led to feelings of financial insecurity, which interacted with impacts of pain on physical and emotional functioning.
Identity
Some patients expressed strong beliefs about the immense impact of pain on their lives across multiple domains, leading them to feel unlike the person they were before pain. Many expressed that they could not do the activities that used to be core to their sense of self and felt that they will always be limited in these ways because of their pain.
Coping with Pain
Adaptive Coping
Some patients described maintaining a resilient outlook characterized by acceptance of pain and willingness to engage in physical activity despite pain. Others reported finding creative ways to cope with pain and embracing identity changes in positive ways through the learning of new coping skills.
Maladaptive Coping
Some patients exhibited stoicism and expressed that they had been taught to push through pain, while others exhibited avoidance of activity due to fear of exacerbating pain. Additionally, staff expressed that some older adults in the clinic exhibited a maladaptive acceptance of pain, such that they did not seek treatment that could improve functioning.
Interpersonal Domain
At the interpersonal level, we identified the following themes: 1) Complex relationships with social supports and 2) Complex relationships with medical staff.
Complex Relationship with Social Supports
Both patients and staff shared that quality of social support was critical for coping with pain. Many patients perceived that social support and connection enable them to stay active despite pain, to cope emotionally with the effects of pain, and to reduce the intensity of pain. Still, others discussed their willingness to prioritize social connection despite pain. Both patients and staff also highlighted the important role that instrumental social support plays in coping with pain.
On the other hand, many discussed complexities and barriers to connecting with social supports. Many patients expressed that the pain experience is isolating, and often leads to losing social experiences and entire relationships due to mobility concerns. In addition to physical limitations, some patients described the negative impact of emotional reactivity, including irritability, shame, and guilt, on social relationships. Others noted that the experience of pain can strain their relationships, such as feeling invalidated. Both patients and staff discussed patients’ concerns about becoming a burden on their family, leading to withdrawal, so as to not ask too much of social supports.
Patients and staff also discussed that interpersonal responsibilities could lead to barriers to instrumental support, including assistance with transportation to medical appointments. Some patients, especially those from lower-income backgrounds, relied on their working children for transportation and had caregiving responsibilities that sometimes necessitated prioritizing others’ well-being over their own.
Patients and staff discussed how family dynamics can help patients cope with pain but also contribute to sedentariness over time. For example, social supports can remove the burden of physical activity away from older adult patients, but this can also decrease function long term.
Complex Relationships with Medical Staff
Patients and staff described the patient–staff relationship as being important but sometimes contentious. They described a disconnect between expectations of pain treatment from staff and patients, with patients being more solution-focused with greater expectations for pain management. Patients expressed concerns about invalidation and at times feeling misunderstood or abandoned by medical staff. Staff reported that the strongest relationships exist between patients and medical interpreters and that due to these trusting relationships, patients share more with interpreters than they do other staff.
Community Domain
At the community level, we identified two themes: 1) need for community resources and 2) need for culturally informed care.
Need for Community Resources
Nearly all patients and staff discussed a considerable need for community resources to facilitate or encourage older adults with chronic pain to walk. In particular, participants discussed the need for safe outdoor amenities and affordable indoor facilities to adapt to the local colder climate. They noted that while there were safe places to walk in the warmer months, the community lacked resources for encouraging physical activity in the colder months, especially with surfaces that were suitable for older adults with chronic pain.
Need for Culturally Informed Care
Staff discussed the need for tailored care at the clinic, including a need for chronic pain programming to be delivered in groups of older adults with similar culture and language to aid in establishing cohesion. Many shared how the large ethnolinguistic diversity of the clinic population can create challenges to providing equitable and culturally adapted pain treatment, especially given that there is no single majority ethnic population that the clinic serves.
Staff described difficulty bridging the cultural, linguistic, and generational divide between staff and patients, especially those who speak languages other than English. Staff and patients also discussed the importance of religious institutions and cultural values to some patients. They noted ways in which cultural factors impact pain treatment, including that there may be practices of families providing support at the expense of patient mobility and independence. They also discussed that a subset of the community clinic population encountered many traumas prior to emigrating to the United States, which thus requires trauma-informed care.
Societal Domain
At the societal level, we identified one theme: Socioeconomic and immigration status impacts the availability of resources for managing chronic pain.
Patients and staff reported a discrepancy between individuals with access to resources and those who depended on insufficient or unavailable government services, including foreign-born patients who lacked access to programming. Staff also noted that some patients were limited in the types of jobs they could work and were more likely to have labor jobs that increased their pain and necessitated greater demand for time-limited pain treatments. Socioeconomic status interacted with issues at other socioecological levels, including increasing stress and frustration and worsening multimorbidity, including through lack of access to healthy food.
Discussion
We conducted a qualitative analysis informed by the socioecological model of the individual, interpersonal, community, and societal factors associated with the experience of living with chronic pain as perceived by older adult patients and medical staff from an underserved community clinic. We aimed to understand the contextual factors influencing the pain experience in this population in order to inform treatment implementation. Patients and staff noted a high burden of pain on older adult patients combined with complexity in their relationships with their personal social support systems and their relationships with medical staff. Further, community resources were noted to be limited in comparison to the need for resource-intensive, culturally informed care. Societal factors, especially socioeconomic status, interacted with these factors to increase the negative impact of pain. Variability was noted as well, with some patients experiencing more resilience, support, and resources than others. There were interactions between the domains at all four levels of the socioecological model, suggesting that the standard approach for pain management to intervene only at the individual level is likely to be inadequate for patients in the community.
Regarding individual factors, staff and patients highlighted that older adults at the clinic had complex care needs, with many comorbidities and stressors. Some themes were similar to what has been reported in existing qualitative analyses of older adults with chronic pain, including the large impact of pain on functioning and sense of identity16,21 and the bidirectional relationships between physical and emotional functioning,10,28 which can create a spiral of increased disability and sedentariness over time. At the same time, staff noted greater complexity in this patient population compared to more affluent populations and a tendency for individual factors to compound each other in ways they may not for patients with greater access to resources and support. For example, staff noted that although older adult patients with chronic pain often present to the clinic with more psychiatric and medical comorbidities, they also often exhibit low health literacy that made it difficult for them to navigate the medical system to gain access to care for these conditions. Patients were also more likely to have financial stressors, including those resulting from the impact of pain on occupational functioning, which can then contribute to elevated emotional distress and worse pain.
In addition to interactions within factors at the individual level of the socioecological model, there were also interactions between individual, interpersonal, community, and societal factors. Patients and staff emphasized the importance of social support and connection to facilitate physical activity and emotional coping. Many patients noted that their support systems were crucial to living well despite pain. In contrast, many patients also endorsed feelings of isolation in association with their pain condition, including fewer social interactions and lost relationships. An individual’s emotional reactivity to pain could have strong effects on interpersonal functioning, including increased irritability, shame, and guilt, which could then worsen relationships in a bidirectional cycle. At the societal level, patients of lower SES endorsed more complex family dynamics and greater caregiving responsibilities that necessitated prioritizing others’ well-being over their own.
Across domains, an absence of resources commensurate with the needs of the population was noted. In keeping with prior qualitative research,17,23,24 staff noted being unable to meet the needs of patients’ treatment expectations with the resources at their disposal, and patients endorsed feeling at times invalidated and disconnected from their medical staff. At the community level, patients and staff noted a need for more community resources both physically and culturally, including resources to facilitate older adults’ engagement in safe physical activity. Of specific concern was a lack of indoor community spaces for exercise during the winter when the weather is unfavorable and hazardous for older adults. Further, given the ethnolinguistic diversity of the community, staff also identified a need for more programming to be delivered in patients’ languages and with staff from the same culture than was available based on existing clinic resources. At the societal level, the intersectionality between societal factors (eg, SES, immigration status) and individual factors was noted because lower SES patients can endorse greater pain severity (eg, from working labor-intensive jobs without access to options for alternative employment), more stressors and worse overall health (eg, more comorbidities, less access to healthy diet) and reduced access to resources for managing chronic pain. Foreign-born and older adult immigrant patients were found to be disadvantaged in their access to resources (eg, adult daycares) that could increase health and socialization, a key factor at the interpersonal level.
Existing pain management therapies typically intervene only at the individual level.29 Our findings suggest that the individual experience does not exist in a vacuum but rather is greatly intertwined with interpersonal, community, and societal factors. Thus, to implement evidence-based pain interventions for older adults in the community, we need to tailor them to consider all levels of the socioecological model. For example, to address the considerable multimorbidity that can result from a lifetime of higher stress and lower health literacy/access to care, it is important to include a medical check-in within the context of a pain intervention. Medical check-ins can be incorporated into shared medical visits,42 which also facilitate group cohesion to address the isolation at the interpersonal level and can reduce the need for as many trained staff that the community does not have in resource-strapped clinics.11
The present study has several limitations worth noting. In this initial qualitative analysis, we only interviewed English-speaking patients. Qualitative research targeting the needs and treatment experiences of linguistic minorities with chronic pain is needed. Additionally, while we were very successful with recruitment for the staff focus groups and interviews, recruiting patients was more difficult because of competing demands on patients’ resource-strapped time. Thus, it is likely we missed patient perspectives of those for whom life’s demands interfered, including many of the patients the staff discussed as having the most difficulty coping with chronic pain.
Conclusion
The present study provides important perspectives on the intersection between individual, interpersonal, community, and societal factors on the chronic pain experience for older adults in an underserved community clinic. Older adult patients and staff described considerable complexity among this patient population, with various stressors, comorbidities, interpersonal difficulties, and communal and societal factors impacting pain. Patients with more financial strain, less social support, more responsibilities, and cultural complexity tended to need more resources than they had available at the clinic. Older adults in underserved community clinics may be more likely to have broader community and societal factors that impact their already complex individual and interpersonal experience of their health, yet many interventions are developed to address factors at the individual level only. Our findings highlight the crucial need to develop pain management interventions to address the intersecting individual, interpersonal, community, and societal needs of older adults with chronic pain in the community.
Data Sharing Statement
Our qualitative study was not pre-registered. The analysis plan of this manuscript was not formally pre-registered. De-identified data from this study are available in the Vivli data repository. There is no analytic code associated with this qualitative study. The interview is available in the supplementary material for this manuscript.
Acknowledgments
Christine S Ritchie and Ana-Maria Vranceanu are co-senior authors for this study. This study was funded by the HEAL Initiative (https://heal.nih.gov/): Advancing Health Equity in Pain Management. We also thank those who provided meaningful contributions by way of thoughtful study participation.
Funding
This work was supported by the National Institute on Aging/National Institute of Neurological Disorders and Stroke [1R61AG08103402 to AMV and CR], the National Institute on Aging [3R61AG081034-01S1 to KM], and the National Center for Complementary and Integrative Health [K24AT011760 to AMV, K23AT012789-01 to KM, K23AT01065301A1 to JG, K23AT012363 to TP].
Disclosure
The authors report no conflicts of interest in this work.
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Greenwood, professor of classics and comparative literature at Harvard University, spoke about the history of classical naming of Black individuals pre and post-emancipation.
During the lecture, Greenwood spoke about her early life, which helped her relate cultural and colonial history in her studies.
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Greenwood was born in the Caribbean to a British father and Ugandan mother and grew up in East Africa. She would grow an interest in the classics in Malawi when living under the Banda dictatorship.
Greenwood would later move to the United States where she began teaching at Yale University. Here, Greenwood hoped to find a common place in a shared environment through researching the classics.
Her diverse heritage and time spent in multiple countries would give her a sense of classical identities.
Discussing her early life and inspirations, Greenwood then introduced what formed the majority of her lecture — her research of a man named Adrastus Hazzard.
As a new resident moving to Groton, Mass., Greenwood found records of a free Black farmer and later union soldier named Adrastus Hazzard.
Greenwood said she was struck by Hazzard’s classical name, and that three questions surfaced in her mind — “why the name Adrastus?” “which Adrastus in Greek Literature is this referencing?” and “might this name be linked to slavery and a more cynical etymology?”
Greenwood discussed how slave owners often gave their slaves classical names as a show of power and, for slaves brought to the United States through Africa, a form of cultural deletion. Names were often chosen sadistically, and the name “Adrastus” could have referred to a classical prince who could not run away or escape his fate, according to Greenwood.
Greenwood described her research into Hazzard’s military service, in which he likely met Charles Remond Douglass, the son of Frederick Douglass and the first black man from New York to enroll in the Union Army, in the 54th Massachusetts Volunteer Infantry regiment.
According to Greenwood, this regiment — historically known for being composed of African Americans — contained many names indicative of the classics.
According to Greenwood, Hazzard may have had ties to the Lew family, a prominent Black family who advocated for further freedoms and rights for African Americans. The Lew family had multiple members with the first name “Adrestus,” suggestive of where his first name might have appeared from.
Greenwood also spoke about the meaning entailed in the name of Hazzard.
According to her, it bears a different meaning than what slave owners may have assumed. On a greater scale, Hazzard’s story can represent how names can represent any number of things, whether they be the mockery of slave owners or the hope of Black families.
“The life of Adrestus suggests that old metaphors expire and new ones replace them,” Greenwood said.
The Badger Herald asked professor Greenwood how someone’s name relates to their identity alongside aspects such as one’s gender, ethnicity, or religious belief in the modern era.
There is and always has been a difference between intrinsic (self-given) and extrinsic (placed-on-a-person) identities, Greenwood said. Slave naming was an extrinsic identity that deterritorialized Black individuals and cut them off from kinship and language groups.
The concept of a “name” as an extrinsic identity can be subverted, however, if someone makes a conscious decision to retain it and tie it to a new identity it has the ability to shift from a characteristic prescribed to a person to that same characteristic being self-defined and is not confined to the names alone.
The journey of the name Adrastus Hazzard through the metamorphing political and social climates shows the broader use and purposes names are assigned and used throughout history and today.
Likewise, he said he was lucky that those to whom he wrote then — including his mother, and future wife, Barbara Fleming —were diligent at saving his letters.
