Christina Chrysohoou

Christodoulos Ioannis Skoumas

Demosthenes B Panagiotakos
email: d.b.panagiotakos@usa.net

Christos Pitsavos

Christodoulos Stefanadis

Five-year incidence of cardiovascular disease and its predictors in Greece: the ATTICA study

Keywords: cardiovascular, diet, education, epidemiology, hypercholesterolemia, incidence, inflammation

Five-year incidence of cardiovascular disease and its

predictors in Greece: the ATTICA study

Introduction

It is well known that cardiovascular disease (CVD) is the leading cause of death and disability in the developed world. The American Heart Association and the National Heart, Lung, and Blood Institute reports that the cost for CVD in 2006 was estimated to be about $400 billion. 1 Incidence of CVD varies from country to country, and culture to culture. For example, in a population-based Italian study, 2 the age-adjusted annual incidence of coronary heart disease (CHD) was about 3.7%, in a Japanese study the age-adjusted incidence of CHD increased from 0.4% during 1963 to 1970 to 1.5% during 1979 to 1986, and then was stable until 1994, [START_REF] Kitamura | Trends in the incidence of coronary heart disease and stroke and the prevalence of cardiovascular risk factors among Japanese men from 1963 to 1994[END_REF] while in the US, and according to the National Health and Nutrition Examination studies, the annual agestandardized CVD incidence rates decreased from 29.3% (1971-1982) to 22.5% (1982-1992). [START_REF] Ergin | Secular trends in cardiovascular disease mortality, incidence, and case fatality rates in adults in the United States[END_REF] It is important to mention that the aforementioned studies used similar criteria for defining CVD. According to the World Health Organization, unhealthy dietary habits, smoking and physical inactivity constitute the major, modifiable risk factors for the development of CVD, while increased arterial blood pressure, glucose and lipids levels, together with a low-grade inflammation process seem to promote the development of the disease. [START_REF]Diet, nutrition, and the prevention of chronic diseases[END_REF] Furthermore, the investigators of the INTERHEART study reported that abnormal lipids, smoking, hypertension, diabetes, abdominal obesity, psychosocial factors, consumption of fruits, vegetables, and alcohol, and regular physical activity were the most significant factors associated with the risk of myocardial infarction worldwide in both sexes, and at all ages in all regions. [START_REF] Yusuf | INTERHEART Study Investigators. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study[END_REF] Until now, the effect of various risk factors on CVD incidence in Greece has been mainly based on the findings from the Seven Countries study that started in the early 1960s. Given the lack of current data regarding the incidence of CVD in European, and especially south European, populations such as the Greek, the 5-year incidence of CVD (i.e. fatal or non-fatal acute coronary syndromes, stroke, or other CVD) and its determinants was investigated in a random sample of CVD-free adults.

Methods

Sampling procedure

The 'ATTICA' epidemiological study was carried out in the Attica area (including 78% urban and 22% rural regions) during 2001-2002. The sampling anticipated enrolling only one participant per household; it was random, multistage and based on the age (five strata) and sex (two strata) distribution of the Attica region (27 strata, census of 2001). At first, an invitation was sent to 4056 inhabitants from the above area, based on the census roll of each city. The invitation clarified that people with a history of CVD or living in institutions or having chronic viral infections should not participate in the sampling. Of the invited individuals, 3042 agreed to participate (75% participation rate); 1514 of the participants were men (18-87 years) and 1528 were women (18-89 years). All participants were interviewed by trained personnel (cardiologists, general practitioners, dieticians and nurses) who used a standard questionnaire. Exclusion of CVD was also performed through a detailed clinical evaluation by the study physicians, following standard criteria. The examination was performed in the individuals' homes. Further details about the aims, design and methods used in the ATTICA study may be found elsewhere in the literature. [START_REF] Pitsavos | Epidemiology of cardiovascular risk factors in Greece; aims, design and baseline characteristics of the ATTICA study[END_REF]

Baseline measurements

The baseline evaluation included information about: socio-demographic characteristics (age, sex, mean annual income and years of school), personal and family history of hypertension, hypercholesterolemia and diabetes, family history of CVD, dietary and other lifestyle habits (i.e. smoking status and physical activity). The evaluation of the nutritional habits was based on a validated semi-quantitative food-frequency questionnaire 8 : the EPIC-Greek questionnaire that was kindly provided by the Unit of Nutrition of Athens Medical School. All participants were asked to report the average intake (per week or day) of several food items that they consumed (during the last 12 months). Then, the frequency of consumption was quantified approximately in terms of the number of times a month a food was consumed. Any type of alcohol consump-tion was measured in wine glasses (100 ml) and quantified by ethanol intake (in g per day). Based on the nutritional information, a special Mediterranean diet score was applied (range 0-55) that evaluates adherence to the Mediterranean diet. [START_REF] Panagiotakos | Dietary patterns: a Mediterranean diet score and its relation to clinical and biological markers of cardiovascular disease risk[END_REF] Moreover, smokers were defined as those who were smoking at least one cigarette per day during the past year or had recently stopped smoking (during the past year); the rest of the participants were defined as non-smokers. Pack-years were calculated as cigarette packs per day smoked by years of smoking. For the ascertainment of physical activity status the International Physical Activity Questionnaire (IPAQ 10 ) was used as an index of weekly energy expenditure using frequency (times per week), duration (in minutes per time) and intensity of sports or other habits related to physical activity (in expended calories per time). Participants who did not report any physical activities were defined as physically inactive (sedentary lifestyle). Body mass index (BMI) was measured as weight (in kg) divided by standing height (m 2 ). Obesity was defined as a BMI greater than 29.9 kg/m 2 . Waist (in cm) and hip (in cm) circumferences were also measured. Arterial blood pressure (three recordings) was measured at the end of the physical examination with the individual in a sitting position. All participants rested for at least 30 minutes. Participants whose average blood pressure levels were greater or equal to 140/90 mmHg or were under antihypertensive medication were classified as having hypertension. Blood samples were collected from the antecubital vein between 8 and 10 am in a sitting position after 12 hours of fasting and alcohol abstinence. Total serum cholesterol, high-density lipoprotein (HDL)cholesterol, and triglycerides were measured using a chromatographic enzymic method in a Technicon automatic analyser RA-1000 (Dade Behring, Marburg, Germany). Hypercholesterolemia was defined as total cholesterol levels greater than 200 mg/dl or the use of lipid-lowering agents. HDL-cholesterol was determined after precipitation of the apolipoprotein B-containing lipoproteins with dextranmagnesium-chloride. Serum for the measurement of these lipids was harvested immediately after admission. Low-density lipoprotein (LDL)cholesterol was calculated using the Friedewald formula: (total cholesterol) -(HDL cholesterol) -1/5 (triglycerides) (only in people who had triglyceride levels lower than 250 mg/dl). The intra and interassay coefficients of variation of cholesterol levels did not exceed 9%, triglycerides 4% and HDL 4%. Blood glucose levels (mg/dl) were measured with a Beckman Glucose Analyzer (Beckman Instruments, Fullerton, CA, USA). Diabetes mellitus (type 2) was defined according to the American Diabetes Association diagnostic criteria (i.e. blood glucose levels greater than 125 mg/dl classified participants as having diabetes). C-reactive protein and serum amyloid A were assayed by particle-enhanced immunonephelometry.

The Greek translation of the 20-item self-report State-Trait Anxiety Inventory (STAI), state version, was used to evaluate levels of anxiety. 11, [START_REF] Fountoulakis | Reliability and psychometric properties of the Greek translation of the State-Trait Anxiety Inventory form Y: preliminary data[END_REF] Total scores were based on the summation of the values assigned to each response (range: 20-80). Additionally, the Greek version of the Zung Self-Rating Depression Scale (ZDRS) was used in this work. [START_REF] Zung | A self-rating depression scale[END_REF][START_REF] Zung | The role of rating scales in the identification and management of the depressed patient in the primary care setting[END_REF] The ZDRS is also a self-report test designed to quickly and easily quantify the presence and severity of depression.

Metabolic syndrome was defined by the recent NCEP ATP III criteria [START_REF] Grundy | Diagnosis and management of the metabolic syndrome. An American Heart Association/National Heart, Lung, and Blood Institute Scientific Statement[END_REF] if three or more of the following risk factors were present: waist circumference ≥ 102 cm for men or ≥ 88 cm for women; triglyceride level ≥ 150 mg/dl; HDL-cholesterol level < 40 mg/dl for men or < 50 mg/dl for women; blood pressure ≥ 130/85 mmHg; fasting glucose ≥ 100 mg/dl. Further details about the aims and procedures of the ATTICA epidemiological study may be found elsewhere. [START_REF] Pitsavos | Epidemiology of cardiovascular risk factors in Greece; aims, design and baseline characteristics of the ATTICA study[END_REF] Follow-up During 2006, the ATTICA study's investigators performed the 5-year follow-up. Of the 3042 initially enrolled participants, 2101 were found during the follow-up (69% participation rate). Of the individuals that were lost to follow-up (i.e. 941), 706 were not found because of missing or wrong addresses and telephone numbers that they had provided at the baseline examination and 235 because they denied being re-examined. No significant differences in the baseline characteristics were observed between those who participated to follow-up and those who did not participate regarding the distribution of age (45 ± 14 vs 45 ± 13 years, p = 0.78), sex (males 50% vs 50%, p = 0.99), years of school (12.1 ± 4 vs 12.0 ± 4, p = 0.67), presence of hypertension (30% vs 28%, p = 0.12), diabetes (7% vs 6%, p = 0.27), hypercholesterolemia (39% vs 33%, p = 0.10), obesity (19% vs 15%, p = 0.54), as well as anxiety (p = 0.20) and depression levels (p = 0.16). However, those who participated in the follow-up were less likely to be smokers at baseline compared with those who were lost (41% vs 49%, p < 0.001).

In order to participate in the follow-up all participants were appointed through telephone calls (80% of the participants) or face-to-face interviews when their telephone number was not available, and asked to provide all their medical records to the study's investigators. Afterwards, the investigators performed a detailed evaluation of the participants' medical records (i.e. in the 2101 individuals that were found to follow-up). The following informa-tion about participants was assessed: (a) vital status (death from any cause or due to CVD); (b) development of CHD (i.e. myocardial infarction, angina pectoris, other identified forms of ischemia -WHO-ICD coding 410-414.9, 427.2, 427.6-, heart failure of different types, and chronic arrhythmias -WHO-ICD coding 400.0-404.9, 427.0-427.5, 427.9-); (c) development of stroke (WHO-ICD coding 430-438); (d) development of hypertension, hypercholesterolemia and diabetes, as well as management of these conditions; (e) assessment of body weight and height; and (f) lifestyle habits, including physical activity and smoking status, as well as consumption of various food groups and beverages.

Statistical analysis

Incidence rates of CVD (CHD as defined above or stroke) were calculated as the ratio of new cases to the number of people who participated in the follow-up. Continuous variables are presented as mean values ± standard deviation, and categorical variables are presented as frequencies. Associations between categorical variables were tested using the chi-squared test. Comparisons of mean values of normally distributed variables between those who developed an event and the rest of the participants were performed using Student's t-test, after controlling for equality of variances using the Levene's test. For some continuous variables that were not normally distributed (i.e. C-reactive protein levels, years of school) the Mann-Whitney nonparametric test was applied to evaluate the differences in the distributions of the skewed variables between those who developed a CVD event and the rest of the participants.

The relative risks of developing a CVD event during the 5-year period, according to the participants' baseline characteristics, were estimated using Cox proportional hazards models. The time to a CVD event was recorded on an annual basis. A stepwise procedure was applied. We used 5% as the cut-off for the probability of entering a variable in the model and 10% as the cut-off for the probability of removing a variable from the model. Interactions between sex and other covariates were tested in all steps, and when significant they remained in the model. Moreover, known confounders were also included in the model. A pseudo R 2 (Negelkerke) was used to evaluate the explanatory ability of the predictive models.

To further explore which of the baseline measurements was the best predictor of CVD, discriminant analysis was performed using the area under the receiver operating characteristic curve (AUC; higher values of the AUC = better discriminating ability). Moreover, a cut-off point analysis using the ROC curve was used in order to determine the optimal values of the baseline continuous factors that predict the event with the highest accuracy.

All reported p-values are based on two-sided tests and compared to a significance level of 5%. SPSS version 14 (Statistical Package for Social Sciences, SPSS Inc, Chicago, IL, USA) software was used for all the statistical calculations.

Results

Regarding the vital status of the 2101 individuals that participated in the follow-up, 1012 men and 1035 women were found alive, while 32 (3.0%) men and 22 (2.1%) women died during the 5-year period.

The 5-year incidence of CVD was 108 (11.0%) cases in men and 62 (6.1%) cases in women (p for sex difference < 0.001, the overall 5-year CVD event rate was 8.5%); 32 of these events were fatal (21 men, the 5-year CVD death rate was 1.6%). Causes of death were: myocardial infarction (25 cases), stroke (six cases) and other CVD (one case). Thus, the annual incidence of CVD was calculated to be 220 new cases per 10,000 men and 122 new cases per 10,000 women participants. A strongly significant linear trend was observed between incidence of CVD and baseline age of the participants (p for trend < 0.001, Table 1). In particular, men who were aged between 65 and 75 years at baseline examination experienced about a 10 times higher risk of developing CVD compared with those who were between 35 and 45 years, while the aforementioned relative risk in older women was about 18 times higher compared with those who were between 35 and 45 years. Furthermore, the overall men-to-women incidence rate ratio was 1.8; however, a gradual change according to participants' age was observed. In particular, the mento-women ratio decreases consistently with age, starting from about 3:1 in younger people and became about 1:1 in those over 75 years (Table 1).

Demographic, clinical and behavioural characteristics of the participants by 5-year CVD status are presented in Table 2. Although, multiple comparisons are made in the presented results, and consequently the probability of false positives findings (i.e. p-value) increases dramatically, it is noticeable to mention that people who developed CVD were more likely to be older men, with increased blood lipids, systolic/diastolic blood pressure, glucose and C-reactive protein levels, as well as with lower adherence to the Mediterranean diet (i.e. lower diet score), but increased ethanol intake, body mass and waist-to-hip ratio, and lower education status, at baseline examination (all p-values < 0.009). Of the anthropometric indices waistto-hip ratio had the best discriminating ability (AUC = 0.68), followed by waist circumference (AUC = 0.62), BMI (AUC = 0.64) and hip circumference (AUC = 0.60). Moreover, from the baseline biochemical measurements, ROC analysis showed that triglycerides (AUC = 0.645) followed by blood glucose (AUC = 0.626), C-reactive protein (AUC = 0.591), HDL-cholesterol (AUC = 0.587), total cholesterol (AUC = 0.584), and LDLcholesterol (AUC = 0.569) were all significantly associated with the development of CVD (at p < 0.05). Additionally, cut-off point analysis based on the ROC curve showed that a waistto-hip ratio greater than 0.94/0.82 for men and women, respectively (sensitivity 62%/69%, specificity 60%/66%), triglycerides greater than 125 mg/dl (sensitivity 53%, specificity 70%) and C-reactive protein levels greater than 1.6 mg/l (sensitivity 65%, specificity 51%) were the optimal cut-off values of these markers that predict with the highest accuracy the outcome. When the level of 3 mg/l was used as the cut-off for C-reactive protein the sensitivity decreased to 22% and the specificity increased to 82%.

However, all the aforementioned comparisons are prone to residual confounding; therefore, a multiadjusted logistic regression analysis was performed. Based on this analysis, increased age (p < 0.001), waist-to-hip ratio (p = 0.003), C-reactive protein levels (p = 0.05), presence of hypertension (p = 0.05) and diabetes (p = 0.009) were the most significant baseline predictors of developing CVD within a 5-year period. No significant interactions were observed between the previous factors and sex of the participants on the development of CVD. Moreover, the aforementioned baseline predictors were then used as binary variables, based on the previous cut-offs (i.e. waist-to-hip ratio above 0.94/0.82, C-reactive protein above 1.6 mg/l). Then a cumulative score was calculated (range 0-4). According to this score people who had all four conditions (i.e. waist-to-hip ratio above 0.94/0.82, C-reactive protein above 1.6 mg/l, hypertension and diabetes) experienced a 4.6 higher risk (95%CI 1.47-14.5) of developing CVD, after adjusting for various potential confounders. Moreover, low education status was also a significant predictor of CVD (p = 0.033). It is of interest that although smoking habits and physical inactivity increased the risk of CVD (see initial model presented in Table 3), these factors did not reach significance (at p < 0.05). These associations were further explored; the age-sex adjusted odds ratio of smoking was 1.02 per 40 pack-years (p = 0.01); however, when hypertension, hypercholesterolemia and diabetes were entered in the model, this relationship becomes insignificant. Moreover, the age-sex adjusted odds ratio of physical inactivity was 2.38 (p = 0.001); however, when the waist-to-hip ratio and smoking habits were taken into account this relationship becomes insignificant.

The presence of the metabolic syndrome was then evaluated. After adjusting for age, sex, physical activity, smoking, and dietary habits, the presence of the metabolic syndrome was associated with a 2.09 times higher risk of developing a CVD event (95% CI 1.44-3.04). To test whether metabolic syndrome is a better predictor of future CVD events than the risk factors, we also estimated a model that contained age, sex, physical activity, smoking, dietary habits, and all the features of the syndrome. Based on the calculated pseudo R 2 statistics we observed that the two models had a similar explanatory ability (i.e. Negelkerke R 2 of the model that is based on the metabolic syndrome = 23.8% and Negelkerke R 2 of the model that is based on the individual components of the syndrome = 24.7%).

Regarding dietary habits, the Mediterranean diet score was inversely associated with the development of CVD (relative risk per 1 unit = 0.92; 95% CI 0.89-0.94, after adjustment for sex, physical activity status, smoking habits and other bio-clinical characteristics of the participants), but the relationship became insignificant when age was also included in the model. Thus, the analysis was repeated for different age groups. It was revealed that only in people aged between 35 and 65 years that greater adherence to a Mediterranean diet was inversely associated with CVD incidence (relative risk per 1 unit = 0.94; 95% CI 0.90-0.97, after several adjustments were made), while no significant associations were observed among younger or older adults (p for homogeneity between odds ratios < 0.001).

Discussion

In this work the 5-year incidence rate of CVD was evaluated in a population-based sample of men and women from the Attica region of Greece. Approximately 8.5% of those who participated in the followup of the ATTICA study developed a fatal or nonfatal CVD event within this period. The men-towomen ratio was almost 3:1 in younger adults and become close to 1:1 in older adults. The annual incidence rate was about 2.2% in men and 1.2% in women, which means that about 550,000 people developed CVD during the preceding 5 years. These figures underline the burden of CVD in a 'low-risk' population. Of the baseline factors that were evaluated in this report, increased waistto-hip ratio, the presence of hypertension and diabetes, and high C-reactive protein levels were the most significant bio-clinical predictors of CVD, while a low education level and lower adherence to the Mediterranean diet were also associated with increased CVD incidence rates. Furthermore, these findings reveal the importance of measuring the waist-to-hip ratio as the most significant anthropometric predictor of future CVD events, emphasize the need to focus the prevention strategies on low educated people, underline the significance of the inflammation process in predicting CVD and confirm the cardioprotective effects of adherence to a healthy dietary pattern, such as the Mediterranean diet.

One of the main findings of this work is the strong association of the waist-to-hip ratio with the incidence of CVD. Discriminant analysis revealed that the waist-to-hip ratio had the best discriminating ability of all the anthropometric measurements. Obesity, abnormal waist circumference or waistto-hip ratio have already been associated with the development of CHD and various metabolic disorders. [START_REF] Dalton | Waist circumference, waist-hip ratio and body mass index and their correlation with cardiovascular disease risk factors in Australian adults[END_REF][START_REF] Hu | Joint effects of physical activity, body mass index, waist circumference and waist-to-hip ratio with the risk of cardiovascular disease among middle-aged Finnish men and women[END_REF] Recently, the INTERHEART study [START_REF] Yusuf | INTERHEART Study Investigators. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study[END_REF] investigators, based on a large case-control study, reported that abdominal obesity was one of the most significant risk factors of CHD in both sexes and in all parts of the world. The previous reports, together with our findings, underline the relative importance of waist-to-hip ratio compared with BMI or waist circumference in the prediction of future CVD events.

Moreover, the metabolic syndrome was also related to CVD in our work, irrespective of various potential confounders. However, the value of the metabolic syndrome as a scientific concept remains controversial, since several investigators suggest that the presence of the syndrome alone cannot predict global CVD risk, better than individual risk factors, and especially abdominal obesity which is a marker of 'dysfunctional adipose tissue'. [START_REF] Despres | Abdominal obesity and metabolic syndrome[END_REF] We have also observed similar findings, since the model that contained metabolic syndrome did not show better explanatory ability compared with the model that contained the individual features of the syndrome. Low-grade systemic inflammation seems to participate in the pathobiology of obesity, insulin resistance, metabolic syndrome and CHD. [START_REF] Libby | Inflammation in atherosclerosis[END_REF][START_REF] Das | Obesity, metabolic syndrome X, and inflammation[END_REF][START_REF] Libby | Inflammation and atherothrombosis from population biology and bench research to clinical practice[END_REF][START_REF] Cushman | C-reactive protein and the 10-year incidence of coronary heart disease in older men and women: the cardiovascular health study[END_REF] Prospective cohort studies in healthy individuals revealed strong associations between elevated C-reactive protein levels and the risk of CVD events. Recently, Cushman et al., [START_REF] Cushman | C-reactive protein and the 10-year incidence of coronary heart disease in older men and women: the cardiovascular health study[END_REF] in a 10-year follow-up reported that the relative risk of CHD for C-reactive protein levels greater than 3 mg/l compared with lower than 1 mg/l was 1.45, adjusting for various potential confounders, while the population-attributable risk of the disease for elevated C-reactive protein levels was 11%. In this work, baseline levels of C-reactive protein predicted CVD with good accuracy, irrespective of age, sex, smoking and dietary habits, as well as various other potential confounders (Table 3). It is of interest that cut-off point analysis revealed that the crucial level of C-reactive protein that better discriminates CVD events was 1.6 mg/l, which is much lower than the usual cut-off (i.e. 3 mg/l). Despite which should be the optimal cut-off for C-reactive protein, the present study, together with other reports, strongly suggest that this inflammatory marker should be included in the predictive models of CVD.

Diabetes and hypertension together with hypercholesterolemia constitutes major clinical risk factors for the development of CVD. In this work, both hypertension and diabetes showed a strong positive association with the development of CVD; in particular, hypertension increased by 55% the risk for CVD, while diabetes twofold the aforementioned risk, independently of the various other characteristics of the participants (Table 3). Both conditions promote the development of the metabolic syndrome, which is a current threat for CVD mortality and morbidity. [START_REF] Grundy | Obesity, metabolic syndrome and cardiovascular disease[END_REF] Wilson et al., from the Framingham Heart Study, reported that the metabolic syndrome accounts for up to one-third of CVD in men over 8 years of follow-up. In particular, the metabolic syndrome's age-adjusted relative risk for CVD was found equal to 2.88 (95% CI 1.99-4.16) in men and equal to 2.25 (95% CI 1.31-3.88) in women. [START_REF] Wilson | Metabolic syndrome as a precursor of cardiovascular disease and type 2 diabetes mellitus[END_REF] In the present work, the metabolic syndrome was also strongly associated with the development of CVD within a 5-year period; specifically, the presence of the syndrome was associated with a 2.09-fold increase in the risk of a CVD event, irrespective of various potential confounders. Although hypercholesterolemia and hypertriglyceridemia showed a positive association with the development of CVD, this relationship did not reach significance when various characteristics of the participants were taken into account (Table 3). Probably, the presence of the waist-to-hip ratio together with hypertension and diabetes excluded these disorders from the final predictive model (Table 3).

Based on several observational studies, the socioeconomic status of people, as determined by occupation, education level and income, has been related to all-cause mortality and morbidity. [START_REF] Feldman | National trends in educational differentials in mortality[END_REF][START_REF] Lantz | Socioeconomic disparities in health change in a longitudinal study of US adults: the role of health-risk behaviours[END_REF][START_REF] Steptoe | The role of psychobiological pathways in socio-economic inequalities in cardiovascular disease risk[END_REF][START_REF] Marmot | Social/economic status and disease[END_REF] Moreover, at the beginning of the twentieth century results from epidemiologic studies suggested that CVD was originally more common in the upper socio-economic class than the lower or middle class (i.e. a 'disease of affluence'). 1 This hypothesis seems to fail nowadays. In our work, increased years of education was associated with a lower 5-year incidence of CVD in both sexes. It is of interest that the aforementioned association was independent of various clinical and lifestyle characteristics of the participants. Marmot and colleagues [START_REF] Marmot | Social/economic status and disease[END_REF] have suggested that some intermediate factors between social class and CVD risk factors, such as high consumption of saturated fat, refined sugar and fiber, and smoking behavior may be responsible for the observed differences regarding the prevalence and the incidence of the disease among social classes. Previous reports from the ATTICA study [START_REF] Panagiotakos | The association between educational status and risk factors related to cardiovascular disease in healthy individuals: The ATTICA study[END_REF] underlined that the inverse relationship observed between education status and prevalence of CVD risk factors was mainly explained by the adoption of an unhealthy lifestyle (including increased smoking habits, physical inactivity, obesity and non-compliance to medication) by individuals of low education. Nevertheless, the presented findings of the 5-year follow-up emphasize the need for special attention in people with a low education level in order to reduce the burden of CVD in the future.

An extensive body of scientific evidence relates diet and incidence of CVD. [START_REF]Diet, nutrition, and the prevention of chronic diseases[END_REF][START_REF] Keys | The diet and 15-year death rate in the Seven Countries Study[END_REF][START_REF] Trichopoulou | Adherence to a Mediterranean diet and survival in a Greek population[END_REF][START_REF] Panagiotakos | Status and management of hypertension, in Greece; the role of the adoption of Mediterranean diet: the ATTICA study[END_REF] There is also increasing scientific evidence that there are protective health effects from diets which are high in the consumption of fruits, vegetables, legumes, whole grains, and which also include fish, nuts, and lowfat dairy products. The traditional Mediterranean diet, whose principal source of fat is olive oil, encompasses these dietary characteristics. Since the early 1970s, many investigators have recognized the beneficial role of this diet on CVD, metabolic disorders and several types of cancer. [START_REF]Diet, nutrition, and the prevention of chronic diseases[END_REF][START_REF] Panagiotakos | Status and management of hypertension, in Greece; the role of the adoption of Mediterranean diet: the ATTICA study[END_REF] In the present work, greater adherence to the Mediterranean diet was associated with a lower 5-year CVD incidence, especially among middle-aged people. The previous relationship was independent from the potential confounding effect of various clinical and biochemical characteristics of the participants (Table 3). The lack of association in younger or older adults may be attributable to the fact that in people below 35 years of age there were very few cases of CVD, while in older adults the adherence to this traditional dietary pattern was high in most of the participants (as presented in previous reports from the ATTICA study [START_REF] Panagiotakos | Status and management of hypertension, in Greece; the role of the adoption of Mediterranean diet: the ATTICA study[END_REF] ). Finally, it should be mentioned that although smoking habits and physical inactivity increased the risk of CVD (see the initial model presented in Table 3), these factors did not reach statistical significance when the analysis was adjusted for various bio-clinical and other potential confounders. It seems that hypertension, hypercholesterolemia and diabetes masked the effect of smoking on CVD risk, while waist-to-hip ratio and smoking habits masked the effect of physical inactivity. Nevertheless, this insignificant effect should not underestimate its deleterious effect on the cardiovascular system as it has been shown in several other studies.

Limitations

The baseline evaluation was performed once, and may be prone to measurement error. Thus, the prevalence of various clinical risk factors or the levels of biological factors may have been overestimated. However, the applied methodology was similar to those of other prospective epidemiological studies in Europe and the USA, and therefore the results are comparable. Another limitation is that the dietary analysis for nutrient components (including electrolytes) was not completed, so the role of specific nutrients was not evaluated. Finally, telephone calls for the ascertainment of CVD are valid only when accurate medical records exist; thus, special attention was given to assess participants' medical files.

Conclusion

The present work evaluated factors associated with the development of CVD during a 5-year period in a Mediterranean population. Among several findings, multi-adjusted analysis revealed that waist circumference was the best anthropometric predictor for CVD events, a fact that may make the scientific community reconsider the role of BMI in cardiovascular risk evaluation. Moreover, low education level seems to predict CVD events; thus, people with a low social status are more likely to develop the disease, and therefore deserve more attention. Finally, adherence to the Mediterranean diet seems to be associated with a lower CVD event rate; although this is not entirely new, our finding is independent from various socio-demographic, clinical, inflammatory and other biochemical, as well as lifestyle characteristics of the participants.

Table 1

 1 Five-year incidence of CVD in men and women from the ATTICA study, by age group

	Age at baseline	Men (n a )	W o m e n ( n a )	Men-to-women incidence
				rate ratio
		5-year incidence of CVD
	< 35 years	2.5% (218)	0.0% (278)	>> 1
	35-45 years	3.4% (270)	1.5% (271)	2.26
	45-55 years	10.8% (309)	4.0% (254)	2.70
	55-65 years	21.0% (140)	12.5% (131)	1.68
	65-75 years	35.2% (51)	26.9% (78)	1.30
	75+ years	43.8% (24)	42.3% (23)	1.03
	Overall	11.0% (1012)	6.1% (1035)	1.80

a People who participated in the follow-up examination.

Table 2

 2 Characteristics of the ATTICA study's participants according to the 5-year incidence of CVD

		Baseline levels	Status at 5-year follow-up	p
			CVD event-free	CVD events
			(n = 1826)	(n = 170)
	Age, years	45 ± 14	44 ± 13	60 ± 13	< 0.001
	Male sex	50%	48%	64%	0.01
	Years of school	12 ± 4	12 ± 3	10 ± 4	< 0.001
	Smoking	43%	40%	30%	0.03
	Physical activity	40%	42%	40%	0.63
	Depression scale, ZDRS (20-8 0 )	3 5 ± 7	3 5 ± 7	3 5 ± 8	0 . 8 7
	Anxiety scale, STAI (20-80)	41 ± 11	40 ± 11	41 ± 8	0.93
	Mediterranean diet score (0-5 5 )	2 6 ± 7	2 6 ± 6	2 3 ± 7	0 . 0 0 1
	Ethanol intake, g/d	12.4 ± 116	8.8 ± 13	15.1 ± 21	0.009
	Systolic blood pressure, mmHg	123 ± 19	121 ± 17	134 ± 20	< 0.001
	Diastolic blood pressure, mmHg	80 ± 24	79 ± 21	83 ± 18	< 0.001
	Hypertension	30%	29%	58%	< 0.001
	Total cholesterol, mg/dl	194 ± 42	193 ± 41	206 ± 44	< 0.001
	Hypercholesterolemia	39%	39%	52%	0.001
	Fasting glucose, mg/dl	93 ± 25	91 ± 22	104 ± 31	< 0.001
	Diabetes	7%	5%	25%	< 0.001
	Family history of CHD	28%	28%	34%	0.33
	C-reactive protein, mg/l	1.93 ± 2.4	1.90 ± 2.3	2.42 ± 2.1	< 0.001
	Metabolic syndrome	20%	20%	42%	< 0.001
	Waist-to-hip ratio	0.86 ± 0.1	0.85 ± 0.1	0.92 ± 0.11	< 0.001
	Body mass index, kg/m 2	26 ± 5	26 ± 4	28 ± 5	0.001
	Obesity	18%	17%	30%	0.008
	Abnormal waist (> 102/95 cm, m/f)	52%	52%	68%	< 0.001

STAI, State-Trait Anxiety Inventory; ZDRS, Zung Self-Rating Depression Scale.

Table 3

 3 Results from stepwise multiple logistic regression analysis that evaluated socio-demographic, lifestyle, biological, and clinical baseline characteristics in relation to the 5-year incidence of hypercholesterolemia in the ATTICA study participants

	Odds ratio	95% confidence interval

Vascular Medicine 2008; 13: 113-121

Acknowledgements

The authors would like to thank the field investigators of the 'ATTICA' study: Yannis Skoumas, Natassa Katinioti, Labros Papadimitriou, Dina Masoura, Spiros Vellas and Yannis Lentzas for their assistance in the initial physical examination and follow-up evaluation, Efi Tsetsekou for her assistance in psychological evaluation. Also the technical team: Carmen Vassiliadou (genetic analysis), Manolis Kambaxis and Konstadina Palliou for the nutritional evaluation, Marina Toutouza-Giotsa, Constadina Tselika and Sia Poulopoulou for the biochemical evaluation and Maria Toutouza for the database management.

The ATTICA study is supported by research grants from the Hellenic Cardiological Society (HCS2002) and the Hellenic Atherosclerosis Society (HAS2003).


David Armstrong
email: david.armstrong@kcl.ac.uk

The myth of concordance: response to Stevenson and Scambler

Introduction

Stevenson and Scambler's article makes two major claims. The first is that the trust patients have in their doctors has declined in recent years; the second is that, in consequence, concordance, that assumes open communication between doctor and patient, is now becoming impossible to achieve. I will argue that the first claim is unproven (and unprovable) and that the second is correct, but not for the reasons the authors suggest.

Declining trust

The first two-thirds of the article argues that patients are growing less trusting of their doctors (and health care organizations) than in the past. The claim is made tentatively in the early pages -there is the 'possibility' of declining trust or there 'may' be a decline in trust -but soon crystallizes into more dogmatic statements such as 'The trust people instinctively invested in professional expertise has substantially diminished'. Yet only three pieces of evidence are used to support the claim: the first is a prediction (from one observer) that concerns about health plans in the US would spill over into attitudes towards personal trust between doctor and patient; the second is that there is an increase in litigation against doctors (does this indicate a decline in trust or easier recourse to legal redress?); and the third that there are increased challenges to medical experimentation. None of this evidence is very persuasive that trust in the patient's own doctor has declined. Even less convincing are the supportive comments from others who cling to this article of conventional wisdom. For example, surely the editor of the British Medical Journal should not be taken too literally when he announces with great rhetorical flourish that 'trust will never be the same again' following a report on the latest health care scandal. Did anyone's trust in their medical practitioner change the day after, I wonder?

The problem of course is that there can be no clinching evidence either way on the decline of trust in medicine since patients have not been systematically consulted on the question over the last century. Indeed, the very idea of eliciting patients' views is little over half a century old [START_REF] Armstrong | The patient's view[END_REF]. Yet even the limited evidence from these early studies does not support the idea of a golden age of trust that now is lost. In The Health of Regionsville [START_REF] Koos | The health of regionsville: what the people thought and did about it[END_REF], for example, a quarter of patients expressed dissatisfaction with their last consultation; and in Cartwright's 1967 study of patients and their doctors, less than a quarter of respondents ticked the option that their doctor 'puts (you) at ease, you can talk to him'. Further, only 17-41 percent of patients (depending on age) would be happy to discuss a personal problem with their doctor. And from the 1970s there is the dawning realization that perhaps 50 percent of patients were not taking their medication as advised (building on earlier work on the problem of 'defaulting' from treatment) [START_REF] Ley | Satisfaction, compliance and communication[END_REF]. Such survey findings are not sufficient to show conclusively that trust has not declined but they do imply that the opening argument of this article needs treating with considerable scepticism.

Yet whether or not there really has been a decline in trust seems less important than the conceptual muddle about the relationship of communication to trust, which forms the essential context for the later discussion of concordance. The key argument is taken from [START_REF] Gilson | Trust and the development of health care as a social institution[END_REF] who argued that 'trust, by keeping minds open to all evidence, secures communication and dialogue'. But, surely, trust is the complete antithesis of this. It is only when there is trust -in a brother, a friend, a child -that there is no need to 'keep minds open to all evidence' as there is no need for suspicion or doubt or need for vigilance for acts of betrayal. Equally, patients would surely have more intensive 'communication and dialogue' with doctors they did not trust than with ones they did ('Thank you doctor, as I trust you I'll just do what you advise'). So, does trust imply communication and dialogue, as argued here? Or should we be persuaded by Mechanic's claim (also endorsed here) that 'patient trust depends on the capacity of clinicians and health organizations to communicate effectively' (Mechanic, 1998: 299), that is, rather than trust securing communication it is good communication that engenders trust? Or maybe the authors want it both ways.

In summary, the article's opening claim seems empirically unsupported (and perhaps untestable) and the form of the relationship of trust with communication uncertain. Nonetheless, the argument of the article depends on such an (empirical) decline in trust and on the belief that declining trust compromises good communication. These assumptions underpin the final discussion on the form and limitations of concordance.

Concordance in context

The idea of concordance, as the authors point out, was first proposed by Marinker and several colleagues in 1997. Concordance involved 'an open health: 9(1) exchange of beliefs about medicine about which prescribing and medicinetaking decisions may then be based'. The authors express this ideal of an open exchange in Habermasian terms as 'communicative action' but then insist that as neither party is likely to be entirely open about their views (particularly in view of the supposed decline in trust) the result will, in fact, be 'systemically distorted communication'. A valid point for anyone persuaded that complete openness about views and agendas in consultations is highly unlikely -but who claimed that concordance was a form of communicative action in the first place? There is brief reference to Britten's support for concordance as a means of acknowledging patient autonomy, together with mention of Coulter's advocacy of partnership models in interaction between doctor and patients (though she makes no mention of concordance in her article). Otherwise there is no clear identification of who promotes concordance as this open ideal, even less who believes it to represent communicative action. The article's language is always suggestive: 'the concordance ideal may be presented in terms of the ideal of communicative action' or 'concordance may be interpreted as a call for communicative action' (my emphasis). Are we therefore to understand that it is the authors themselves who are making these presentations and interpretations (before debunking them)? Add to this the knowledge that these two authors figure prominently in the literature that promotes a Habermasian view of the consultation [START_REF] Barry | Patients' unvoiced agendas in general practice consultations: qualitative study[END_REF][START_REF] Scambler | System, lifeworld and doctor-patient interaction, issues of trust in a changing world[END_REF] and they seem to be going to curious lengths to attack themselves.

Part of the problem is that concordance is never placed in a wider context that would allow better understanding of its claims Thus concordance's emphasis on sharing views and negotiating (patients') behaviour places it firmly in the 'patient-centred' or 'shared decision-making' genre that emerged in the late 1970s and early 1980s. (Patient-centredness was adapted by Byrne and Long in 1976 from the concept of illness-centredness that had been developed by [START_REF] Balint | Treatment or diagnosis: a study of repeat prescriptions in general practice[END_REF] some years earlier.) The inventors and proponents of concordance promoted it as a means of establishing a therapeutic alliance between doctor and patient. This agenda reflected contemporary concerns to facilitate shared decision-making in the consultation as a counter to traditional medical dominance. Not only was medical dominance unsuited to a consumerist age in which patients' rights were stressed by political commentators and their autonomy by ethicists, but the old system was thought not to deliver effective health care. As noted, successive studies had shown the wide extent of the problem of noncompliance (recast more recently as non-adherence by psychologists anxious to switch the emphasis from patients' misbehaviour to patients making choices). The task was how to influence patient behaviour.

Shared decision-making had a number of advantages. Sharing decisions addressed the increasing need to recognize patients' rights and autonomy; they might solve the compliance problem as it would encourage patient commitment to a course of action; and in shifting some of the responsibility Armstrong: The Myth of Concordance for decisions from doctor to patient they might just relieve the doctor of some clinical, psychological and legal burdens. Concordance was simply one variant of this new approach to consultations. Not only was concordance involved with shared decision-making but also in the view that a shared decision secured the patient's subsequent behaviour: an agreement to take or not to take medication implied the patient would follow the agreed course of action (though again the empirical basis for this assumption is far from established).

In effect, the concept of concordance emerged at the confluence of a number of different streams of political and clinical events. Concordance gave patients shared decision-making and a consumer status in the doctor-patient relationship; as noted, concordance might even have persuaded the patient to take their medicines; and concordance had some advantages for the doctor both in terms of more rewarding consultations and decreased responsibility for taking on the burden of patients' illnesses. The concept of concordance was therefore an ideal solution to a number of late-20th-century clinical problems. This means it can be cast in either a positive or negative light, as either a liberating device (as in communicative action) that gives power to the patient or, more cynically, as yet another pernicious attempt by medicine to get the patient to behave according to the doctor's own wishes. The latter of course needs to conceal its purpose by masquerading as the former. So let us not get starry-eyed about concordance. The main goal of many (most?) of its proponents is to get patients to take their medicines as directed, or at least not waste them. Arguments in favour of concordance are consistently embedded in discussion of the compliance 'problem' (which is of course a problem for paternalistic medicine, not for patients who simply decide for themselves whether to take their medicine as directed or not). Look at the publications on the 'Medicines Partnership: from compliance to concordance' website (http://www.medicines-partnership.org) or note the telling title of a recent report from the UK House of Commons All-party Pharmacy Group, 'Concordance and wasted medicines'. Concordance is fast becoming the acceptable face of compliance: the goals remain the same but the technique is more subtle as patients are recruited to direct themselves in medicine-taking. Could this ever have been communicative action? To present a romantic and idealized view of the potential of concordance and then to claim this dream has gone because trust has gone is simply to create and then destroy a straw man. Concordance never could have been what these authors clearly wish it had been.

Author biography

DAVID ARMSTRONG is Reader in Sociology as applied to Medicine. He is the author of Political anatomy of the body: medical knowledge in Britain in the twentieth century (Cambridge, 1983) and A new history of identity: a sociology of medical knowledge (Palgrave, 2002).

Armstrong: The Myth of Concordance


Lecturer, Jane C Richardson
email: j.c.richardson@keele.ac.uk

Establishing the (extra)ordinary in chronic widespread pain

Keywords: chronic illness, chronic pain, in-depth interviews, legitimacy

Sufferers of chronic illness face delegitimation of their condition and threats to their identities. One way of establishing the legitimacy of their position is for sufferers of chronic illness to emphasize the 'ordinary' in their accounts. Sufferers of conditions which are chronic, invisible and contested, such as chronic widespread pain, have the same, and possibly greater, need to legitimize their condition and refute allegations of 'malingering' or psychological instability. The article uses interviews with women with chronic widespread pain to illustrate the ways in which the invisible, subjective and everyday nature of chronic pain leads to sufferers experiencing delegitimation of their condition. It suggests that the accounts of women suffering from chronic widespread pain are constructed to portray a positive identity in the face of this experience, particularly through the emphasis on the 'extraordinary'.

Introduction

The prevalence of chronic widespread pain, in which pain is experienced in multiple bodily areas 1 , has been estimated at between 4.7 percent and 11.2 percent by community-based surveys (for example, [START_REF] Croft | The prevalence of chronic widespread pain in the general population[END_REF][START_REF] Hunt | The prevalence and associated features of chronic widespread pain in the community using the 'Manchester' definition of chronic widespread pain[END_REF]. The research on which this article is based is part of a broader, ongoing project exploring the experiences of this group of people: the meanings they attribute to their pain; how they manage their everyday lives; how they make sense of their condition within the broader context of their lives; and the impact of pain on them and their families. This article will focus on how the accounts of women suffering from chronic widespread pain are constructed to portray a positive identity in the face of delegitimation.

The chronicity of an illness or a painful condition can affect the sufferer's experience [START_REF] Hilbert | The acultural dimensions of chronic pain: flawed reality construction and the problem of meaning[END_REF] to the extent that the assumption of a shared everyday world is 'deformed' [START_REF] Good | Medicine, rationality, and experience -an anthropological perspective[END_REF]. In conditions where symptoms are largely invisible, feelings of isolation can be compounded. Sociological studies of chronic illness and chronic pain have shown how sufferers face delegitimation -the systematic disconfirmation of one's illness perceptions [START_REF] Ware | Suffering and the social construction of illness: the Richardson: Establishing the (Extra)ordinary in Chronic Pain delegitimation of illness experience in chronic fatigue syndrome[END_REF] -by friends and family, and by the medical profession. In studies of fibromyalgia and chronic fatigue syndrome, for example, the invisible nature of the condition, the lack of 'objective' evidence of disease and the 'familiarity' of the symptoms of pain and fatigue are contributors to the perceived lack of credibility of sufferers [START_REF] Asbring | Women's experiences of stigma in relation to chronic fatigue syndrome and fibromyalgia[END_REF][START_REF] Henriksson | Living with continuous muscular pain -patient perspectives 2. Strategies for daily life[END_REF][START_REF] Soderberg | Struggling for dignity: The meaning of women's experiences of living with fibromyalgia[END_REF][START_REF] Ware | Suffering and the social construction of illness: the Richardson: Establishing the (Extra)ordinary in Chronic Pain delegitimation of illness experience in chronic fatigue syndrome[END_REF]. Sufferers of chronic back pain face similar threats to legitimacy, also linked to the invisible nature of their pain (see, for example, [START_REF] Osborn | The personal experience of chronic benign lower back pain: An interpretative phenomenological analysis[END_REF]Rhodes, Mc-Phillips-Tangum, Markham and Klenk, 1999), as do sufferers of RSI [START_REF] Reid | Pilgrimage of pain -the illness experiences of women with repetition strain injury and the search for credibility[END_REF].

In addition to the invisibility of chronic pain in the body of an individual, cultural constraints on the expression of pain mean that chronic pain may also be socially invisible [START_REF] Morris | The culture of pain[END_REF]. People experiencing chronic, invisible and contested conditions are caught in a double-bind, in that to express their pain (or fatigue) is the only way to attempt to have the condition taken seriously but the lack of accepted cultural ways of so doing [START_REF] Hilbert | The acultural dimensions of chronic pain: flawed reality construction and the problem of meaning[END_REF] may contribute to the experience of delegitimation, for example through accusations of 'whinging' or being perceived as psychologically unstable. Other identities may also be threatened by doubts about the existence of a chronic, invisible condition, for example, identity as a woman [START_REF] Johansson | The meanings of pain: an exploration of women's descriptions of symptoms[END_REF], a worker or a 'competent homemaker' [START_REF] Ewan | Falling out of culture': the effects of repetition strain injury on sufferers' roles and identity[END_REF].

Sufferers of chronic illnesses attempt to counter the process of delegitimation through attempting to 'maintain a sense of personal integrity, and reduce the threat to social status, in the face of radically altered circumstances' (Bury, 1991: 456). This may be achieved by asserting the physical, as opposed to psychological, origins of the illness (see, for example, [START_REF] Kugelmann | Complaining about chronic pain[END_REF]; by employing particular narrative strategies, in the case of back pain, 'to reduce the risk of being classed as "psychological" cases' (May, Rose and Johnstone, 2000: 225); by constructing accounts in which health: 9(1) personal responsibility for the pain is removed and sufferers present themselves as experts in their own pain (May et al., 2000); and by attempting to 'manage expression of feeling' in medical encounters [START_REF] Rhodes | The power of the visible: the meaning of diagnostic tests in chronic back pain[END_REF]. In addition, patients may attempt to find ways to maintain their previous identities or to assert new, positive identities in the face of disconfirmation (see, for example, [START_REF] Charmaz | Struggling for a self: identity levels of the chronically ill[END_REF][START_REF] Charmaz | Good days, bad days: The self in chronic illness and time[END_REF].

This article explores the use of 'extraordinary' stories by women with chronic widespread pain as one aspect of the process of establishing a positive identity in the face of delegitimation and threats to identity as family members and workers, in a cultural climate which is antipathetic to malingerers.

Methods

The sample

The sample was taken from responders to a survey carried out in New South Wales (NSW), Australia, in 1998 2 (see [START_REF] Blyth | Chronic pain in Australia: a prevalence study[END_REF], for full details) designed to assess the prevalence of chronic pain in the community. A sample was selected from those who reported experiencing any type of chronic pain (20% of females and 17.1% of males). To obtain a sample suffering from chronic widespread pain, on the basis of the available information, potential participants were selected if they reported pain in more than one body site and if they reported no clear reason or cause for their pain onset. The broader study, of which this research was part, uses the stricter Manchester criteria (see endnote 1) for definition of chronic widespread pain. The sample in the study being described here was selected pragmatically on the basis of available information. However, four out of the six participants did meet the stricter criteria.

Written invitations to participate in an interview were sent to five men and 24 women, of whom seven (one man and six women) agreed and were able to participate. This surprisingly low level of response may have been due to the hospital initially advising that participants preferred to be interviewed at the hospital, rather than in their homes. This factor, combined with the timing of the interviews during relatively cold weather, may account for the initial low level of response. I later found that people actually preferred to be interviewed in their homes, which increased the response rates. One participant was not suffering from chronic pain and was therefore excluded from analysis. Results reported here are therefore based on six interviews.

The interview

Interviews, lasting between one and two hours, were carried out (by JCR) with participants, in their homes or at Royal North Shore Hospital, Sydney, during July 2000. Written and verbal information about the study was given to all participants prior to obtaining written consent. Life-grids (Parry, Richardson: Establishing the (Extra)ordinary in Chronic Pain [START_REF] Parry | Life course data collection: Qualitative interviewing using the life grid[END_REF] were used to facilitate respondents' telling of the story of their pain and to encourage reflections on the areas of their life in which their condition is experienced. Participants' understanding of the condition and their beliefs about its cause were also explored, together with their ways of coping with the pain. The life-grids used were A3-sized printed grids, with rows showing the years of a respondent's life, and columns the different areas of their life, in this case 'family/personal', 'work/leisure', 'health/illness' and 'pain'. Details were filled in by the interviewer, in negotiation with the participant, as the participant talked. Lifegrids offer participants some degree of control over the structure of the interview and the order in which they deal with potentially sensitive topics [START_REF] Parry | Life course data collection: Qualitative interviewing using the life grid[END_REF]. This approach can provide a way to understand the social context in which illness is experienced and reported [START_REF] Murray | The storied nature of health and illness[END_REF][START_REF] Radley | Social realms and the qualities of illness experience[END_REF]; to explore identity (for example, [START_REF] Bendelow | Transcending the dualisms -towards a sociology of pain[END_REF][START_REF] Bury | Chronic illness as biographical disruption[END_REF]; and to look at the meaning people give to events [START_REF] Bendelow | Transcending the dualisms -towards a sociology of pain[END_REF][START_REF] Bury | Chronic illness as biographical disruption[END_REF][START_REF] Williams | The genesis of chronic illness: narrative reconstruction[END_REF].

Description of participants

Analysis

Interviews were transcribed fully and N5 (QSR, 2000) was used to manage the data. The transcripts were read in conjunction with completed life-grids in order to build up a picture of the participants' lives, before and since the onset of their pain. Issues identified are illustrated here with extracts from interviews.

Results

The women in the study described vividly the ways in which the chronicity of their pain had transformed their world into one in which pain had become a normal part of everyday life and previous 'normal' life could no longer be brought to mind. This transformation and the consequent social isolation is similar to that described by sufferers of chronic illness and chronic pain in other studies and will not therefore be dwelt on here. The first part of this section will therefore focus on the descriptions given by the participants in this study of their experiences of delegitimation, including the disbelief of friends and family, the perception of others that the condition is psychological or not real and the consequent threats to their identities. The second part will focus on the ways in which the women attempt to counter the processes of delegitimation.

'They're called bludgers 3 ': delegitimation of the pain

The embodied nature of the pain described by the women in this study leads to doubts about its very existence and consequent suggestions of malingering, as described below by Anne. This extract raises and illustrates a number of issues, including the doubting of the existence of pain because of its invisibility; the consequent threats to identity; and the dilemmas over communication of pain.

The perceived link between the visible and the real, both in clinical medicine and wider society, is acutely felt by sufferers of chronic pain Richardson: Establishing the (Extra)ordinary in Chronic Pain [START_REF] Good | Medicine, rationality, and experience -an anthropological perspective[END_REF]. Anne herself doubts the legitimacy of people saying they have backache, as did the RSI sufferers in Reid et al.'s study (1991: 608), making a distinction between 'liars' and 'genuine cases', and a 'vehement minority' in Rhodes et al.'s study (1999Rhodes et al.'s study ( : 1192) ) who suggested that 'other' patients faked back pain. As members of a society which shares a cultural understanding of pain, sufferers may be both the subjects of, and makers of, 'misguided inferences' about pain and its legitimacy [START_REF] Hilbert | The acultural dimensions of chronic pain: flawed reality construction and the problem of meaning[END_REF]. Anne's account also echoes the women in [START_REF] Hilbert | The acultural dimensions of chronic pain: flawed reality construction and the problem of meaning[END_REF] study who had considered having unnecessary surgery in order to have a scar to 'show'. The search for visible, bodily 'proof' of pain is also a search for a physical, and therefore not psychological, explanation of their condition. Having a physical 'marker' of pain opens up additional communication possibilities and allows sufferers access to a medical and hence more culturally acceptable discourse. Similarly, other chronic conditions are legitimated by the existence of a diagnostic label even though they may have the same invisibility as chronic pain. Friends and family would be unlikely to doubt the experience of someone diagnosed with multiple sclerosis or, as Anne points out, someone with a scar. The importance of being believed is emphasized by participants in other studies of chronic unexplained pain (for example [START_REF] Bendelow | The end of the road? Lay views on a painrelief clinic[END_REF][START_REF] Osborn | The personal experience of chronic benign lower back pain: An interpretative phenomenological analysis[END_REF][START_REF] Reid | Pilgrimage of pain -the illness experiences of women with repetition strain injury and the search for credibility[END_REF]. [START_REF] Honkasalo | Vicissitudes of pain and suffering: chronic pain and liminality[END_REF] refers to the 'double delegitimation' which occurs in chronic pain, due to the ambiguity inherent in chronic illness and the invisibility of chronic pain. In chronic pain this may be further exacerbated due to its unpredictable nature. This unpredictability may manifest itself in the body, whereby sufferers do not know from day-to-day where the pain will appear. Pain is also unpredictable over time, in that there may be 'good days' and 'bad days', or variation of pain levels within one day, although outwardly there is very little difference in a sufferer's appearance.

Not only does the invisibility of pain threaten a sufferer's identity as a credible person, it also threatens their identity as a worker, through accusations of attempting to 'bludge', or avoid responsibilities and be lazy. Additional threats may arise from suspicion from employers or colleagues that individuals are seeking compensation, a double accusation of attempting to avoid responsibilities and receive payment for it. Kathleen, for example, describes her employers watching how she 'bent and lifted'. She felt that her previous identity as a good worker was under threat and reasserts this through emphasizing her adherence to good lifting techniques. The negative media coverage of 'RSI' in Australia in the 1980s and the development of 'the 'blame-the-worker' explanation, or 'malingering' thesis' (Willis, 1994: 137) may have influenced the women's perceptions of how their employers and colleagues viewed their chronic pain.

Pretending to have a backache in order to avoid work -bludging -is not socially acceptable, but neither is talking, or 'whinging', about 'real' pain. For example, in the previous extract Anne explains that she does not talk about her pain because it is invisible and to talk about it risks being seen health: 9(1) as trying to avoid her responsibilities and being perceived as a 'whinger'. Chronic pain is essentially a private and unnoticed experience unless the sufferer decides to disclose it. It is also a social experience because of this 'choice' over whether or not to bring it into a social context [START_REF] Kotarba | Chronic pain: Its social dimensions[END_REF], although the pressures towards disclosure and concealment exist simultaneously and the decision is never final [START_REF] Hilbert | The acultural dimensions of chronic pain: flawed reality construction and the problem of meaning[END_REF][START_REF] Kugelmann | Complaining about chronic pain[END_REF]. This fear of being seen to be 'whinging', or complaining, occurs throughout the women's accounts, and in other studies of chronic unexplained pain, for example, Ewan et al.'s (1991) study of RSI. Despite their sense of isolation from the everyday world, the women in this study seem acutely aware of socially acceptable behaviour regarding talk about their chronic widespread pain, illustrated in the following extract:

We are friends now [at the pool], literally after all those years and we share health, but you don't make a thing about it: 'How's your knee today?' -'Oh, a bit bad'. Or I say to Susie, 'How's your back?' -'Oh not too bad. Are you alright for coffee next Friday?', or something, and she will say, 'Oh, lovely'. So some people -there is the other person who you can't get away from -you would swear they were the only ones who. . . . (Alice)

Alice suggests that there is a certain amount of pain that can be acceptably talked about, but this has strict limitations, even within the culture of the hydrotherapy pool, where everyone has some form of health problem. Alice feels, and possibly exerts, a strong social pressure not to talk about pain ('you don't make a thing about it') which she goes on to illustrate with examples of 'acceptable' pain conversations. Alice then contrasts this with the unacceptable behaviour of dominating conversations with pain talk. Contrasting oneself in this way with others who complain excessively about pain may be a way for women to distance themselves from what is seen as a predominantly female discourse of 'whining and complaining' [START_REF] Werner | I am not the kind of woman who complains of everything'. Illness stories on self and shame in women with chronic pain[END_REF].

The pressure not to talk about pain is not just felt from friends and family. Indeed, one suggested chronic pain management technique is 'to avoid talking about your pain as much as possible' (Nicholas, Molloy, Tonkin and Beeston, 2000: 182). This pressure may be exacerbated for women in cultures which admire the 'restitution narrative' [START_REF] Frank | The wounded storyteller[END_REF], in which people are ill, recover and 'return to normal', or in which certain illnesses are seen as discrediting and hence to be hidden (for example, breast cancer, see [START_REF] Broom | Reading breast cancer: reflections on a dangerous intersection[END_REF]) or stigmatizing (for example, CFS, see [START_REF] Asbring | Women's experiences of stigma in relation to chronic fatigue syndrome and fibromyalgia[END_REF]. Cultural perceptions that women have a greater resilience to pain on a 'day-to-day' basis lead to the idea that women's pain does not therefore need to be taken seriously [START_REF] Bendelow | Pain and gender[END_REF]. Women therefore face a dual dilemma that expression of their pain is necessary if they want it to be taken seriously but, at the same time, this remains socially undesirable.

One aspect of the decision about whether to disclose pain -to translate

Richardson: Establishing the (Extra)ordinary in Chronic Pain private pain into public pain -is the interpretation of the significance of the pain, for example, whether it is considered 'normal' or 'abnormal' [START_REF] Helman | Culture, health and illness[END_REF]. Again chronic pain presents a dilemma -it is not 'normal' to have pain which persists for a long time and which has no obvious cause, but this pain has become 'normal' for the person with it. Although the women in this study tended towards concealment of their pain, there are contexts in which they do talk about it, although these too are limited by fears of not being believed, or of being seen as a 'whinger'. Kathleen's description of her pain, for example, is couched in particular terms which reinforce culturally acceptable expressions and de-emphasize more problematic elements of discourse: Kathleen has had intermittent episodes of chronic pain for over 20 years and her extract exemplifies the continuing difficulties in the public expression of private feelings. While all the women described situations in which disclosure became necessary due to, for example, inability to continue in a job or a need to explain behaviour which was 'out of character' (such as being unable to have grandchildren sitting on a knee), they used strategies of controlled information release (as described in [START_REF] Asbring | Women's experiences of stigma in relation to chronic fatigue syndrome and fibromyalgia[END_REF]. In doing so they mitigated social stigma and maintained positive identities as far as possible within the cultural milieu in which they operated.

Extraordinary stories: legitimating chronic pain

The interview process brings something of a challenge to the sufferers of chronic widespread pain. It is a direct invitation to step outside of the boundaries of discourse they are familiar with. However, the interviewee may also want to maintain a cautious approach, and conditioned release of information, as in 'everyday' life. For example, an interview is a social situation in which the participant has to 'defend' themselves against the same potential accusations of malingering, whinging or psychological instability.

health: 9(1)

The interviewer is usually healthy, demonstrated by the fact of their carrying out their job and the participant may therefore feel the need to legitimate their position throughout the interview [START_REF] Radley | Accounts of health and illness: Dilemmas and representations[END_REF].

In the case of chronic illness one way of doing so is by construction of an ordinary identity, by making the extraordinary -the condition -ordinary, demonstrated through mention of 'things that healthy people do in the course of everyday life' (Radley, 1999: 24) or through accounts of ordinary events [START_REF] Dingwall | Aspects of illness[END_REF][START_REF] Radley | Accounts of health and illness: Dilemmas and representations[END_REF]. In the case of chronic widespread pain, I suggest that the participants in my study attempt to achieve this through emphasizing the extraordinary, the 'beyond everyday', in their accounts, in order to present the pain as physical, and not psychological, and to portray a positive identity. In the following section I present some examples of what I have termed 'extraordinary stories' and explore their function in the context of the interview.

In this extract Anne is giving an account of a visit to her general practitioner during which the GP gives her an injection in her heel. The words of Anne and her GP have been set out as a conversation to reflect the style in which Anne told the story, using direct reporting of the actual words used:

GP: This should be really hurting you, because these are really painful.

[Anne: I've had them all over the place in my hips. The one through your heel, because they have got to go up through the heel because it is very thick and hard to get through] GP: It is very painful. Anne's account can be interpreted as having a number of different functions. The account she gives is initially not about her chronic pain, but begins with a description of having an injection. Anne refers to the Richardson: Establishing the (Extra)ordinary in Chronic Pain temporary nature of the pain of the injection as a reason for not reacting in the way that her GP seems to expect, thus implying a distinction between this pain and her chronic pain and also between the pain and her pain behaviour. The GP, despite Anne's continued assertions that the injection is hurting, rejects her verbal reports and continues to look for physical evidence of pain. Through this continued resistance to exhibiting physical pain behaviour, Anne is presenting herself as having a high degree of selfcontrol. Other aspects of respondents' accounts reinforce this idea of the 'strong' and 'in control' self, epitomized by phrases such as, 'I've learned to live with it' (Kathleen) and, 'It is something that people can't really help you with -you have to do it for yourself' (Anne), exemplifying the coping strategy of 'mind over matter', often referred to by sufferers of chronic pain. Respondents reject any suggestion of a psychological origin for their pain and this particular coping strategy further emphasizes their control over their minds, hence strengthening claims for a physical origin to the pain.

A second purpose of Anne's account seems to be to demonstrate her high pain tolerance. She uses 'footing' [START_REF] Goffman | Forms of talk[END_REF] -the direct reporting of the doctor's words -to justify and lend weight to her claim. The conversation Anne reports in direct speech is quite long, providing an opportunity to display herself 'as possessing a rather acute and veridical recall of otherwise doubtful or questioned events' (Edwards and Potter, 1992: 37). In this case the doubtful event could be the attribution of her high pain tolerance, the pain itself, or even the sanity of the teller ('people are going to have me locked up'). In this last comment Anne seems to move towards a broader reflection on her chronic pain, the nature of acceptable pain behaviour and pain talk and the cultural limits placed on this behaviour. She describes to the GP (and to the interviewer) the difficulty of communicating chronic pain and of cultural expectations regarding this ('I don't know what you're expected to do . . .'), a dilemma encapsulated by Hilbert:

One cannot moan all the time; one cannot confide or expect deferential treatment all the time; one cannot quietly withdraw for the rest of one's life; one cannot conceal such an object of one's attention all the time. Thus, culture fails once again to tell sufferers how to handle pain. (1984: 370) Alice's story also illustrates the cultural constraints on pain behaviour and pain talk in the context of work: I loved my work [as a nurse] and I suppose I look back and I always had a bit of a backache, but there again we just got on with it, you see. We never complained. The only time I complained when I was training, I think, when I was just about to have a ruptured appendix on New Year's Eve in my second year of training, and it was just sort of got out in time, and it was New Year's Eve and you didn't complain unless you were going to be dying. It was gangrenous and what-have-you when they got to it, so I suppose I was lucky to health: 9(1) have made it in that regard. I was just explaining how things were; you didn't go round saying, 'Oh, my back aches', or, 'My knees are funny today, I don't think I can work', because that just wasn't on. (Alice)

The contextual and factual details of the story again serve to verify the story and suggest a 'sharp' mind, strengthening Alice's claim for a high degree of self-control and high pain tolerance. The stoicism expressed here, epitomized by her phrase 'you just got on with it', suggests a shared cultural belief of that time (the events she described occurred in 1945). Similarly the phrase 'that just wasn't on' is used to express what were culturally acceptable forms of pain talk. In expressing her stoicism and conformity to culturally acceptable pain behaviour Alice is also presenting herself as a good worker, albeit in the past, countering any potential accusations of malingering.

These two 'extraordinary' stories are not necessarily attempts to communicate the current experience of chronic widespread pain, but are participants' attempts to present themselves as being a particular type of person, and to establish a positive identity. An examination of the contexts in which other 'extraordinary' stories occurred can further illuminate the function of these claims.

Joan's account of her high pain tolerance/threshold (participants used the terms 'pain tolerance' and 'pain threshold' interchangeably) occurs as part of a description of her shoulder and spine pain. She uses similar devices to Anne to assert her high tolerance of pain, invoking the authority of health care professionals and, additionally, of medical technology to lend weight to her claims: I can't stand for very long because of it. It just starts to grab. I know I have a high tolerance, pain tolerance, because I have been told that a number of times. I brought one of those TENS machines and the lass at physio showed me how to use it. She said, 'Can you feel that?'. She was turning it up and I said, 'Yes, that's alright'. She turned it up a bit more and I said, 'That's alright'. And she said, 'You can't be' and I said, 'Well I am'. She said, 'You must have a high tolerance of pain'. I said, 'I think I've had so much that it sort of grows on you' . . . There have been nights I have just sat on the side of the bed and cried it has been so bad. (Joan)

The extraordinary story in this extract, told to demonstrate her high pain tolerance, follows Joan's statement of the physical effects of the pain and precedes her description of the consequences. By ascertaining her high degree of pain tolerance in the context of the physiotherapist's TENS machine, Joan establishes herself as a particular type of person -an 'extraordinary' person who can cope with high levels of pain. The audience then know that in order to make her cry, the pain must have been really serious. Her emphasis on the extraordinary is an attempt to communicate her experience of everyday chronic pain, in addition to presenting a positive identity as a person with a high pain threshold.

Richardson: Establishing the (Extra)ordinary in Chronic Pain

Presentation of a positive identity may also be achieved by using an extraordinary story to compare oneself with other people, as illustrated in Anne's extract: I have a very high tolerance of pain. I don't know how they judge it but the fellow that did my spine said, because they told me I would be like a zombie for a few days on [medication] and what-have-you. He told me I'm the only person that came out of having major spinal surgery with a smile on my face. And I said, 'My mother told me never to be rude to anyone'. And I always did what I was told, and I said, 'You know you can't inflict it on anyone else'. A friend had migraines and everyone suffers when she has migraines and that is why hopefully I never inflict it on anyone else. (Anne) Medical technology and health professionals' comments are again used to provide further validation to the story and to suggest that the surgeon might also have considered it 'extraordinary' for someone to emerge smiling from major surgery. Anne's account can also be seen as an extreme (or extraordinary) example of conformation to cultural expectations on women to hide negative emotions. Anne demonstrates her awareness of social expectations regarding pain behaviour and pain talk, through comparison with her friend who does not conform to these expectations. The comparison of the teller with 'others' is, as already suggested, a way of distancing oneself from the discourse of 'whining and complaining' and thus presenting a positive identity.

The 'work' done by women with chronic medically unexplained muscular pain in order to be perceived as credible patients in encounters with health care professionals is described by [START_REF] Werner | It is hard work behaving as a credible patient: encounters between women with chronic pain and their doctors[END_REF]. The women in their study employed strategies which would make their illness credible, present themselves as mentally stable, while simultaneously maintaining their self-esteem and dignity as women in a potentially discrediting encounter. This involved negotiating a balance between, for example, not looking 'too strong or too weak, too healthy or too sick, or too smart or disarranged' (p. 1414). Anne's accounts of the GP visit (previously) and surgery (above) and Joan's account of the physiotherapist's visit could also be seen in this way. They present themselves as strong and in control of their pain, while not denying its existence, and conforming to cultural constraints around expression of pain.

Demonstrating this awareness of the cultural constraints of talking about pain provides a further context in which the presentation of oneself as having a high pain threshold occurred. Although the interview invited the women to talk about their pain, they still felt a need to defend themselves against potential accusations of talking too much about pain, and to demonstrate their awareness of 'correct' behaviour. Kathleen, for example, commented that '[it] sounds dreadful, doesn't it, when you talk about pain?'. Alice's reflection, following, that she hadn't been 'a bad talker', occurred towards the end of quite a long interview: health: 9(1) I'm a very good listener, haven't been a bad talker either, not bad. I'm usually not, I'm more of a listener. Maybe I needed to get something off my chest. There are those people who corner you somewhere: 'No idea what I'm suffering, no idea. My hip, my legs, are driving me mad' . . . They are the people whose threshold -whose pain isn't really any worse that Jo Blow's, but they can't help it I suppose [. . .]. I consider that I've got a reasonably high threshold of pain, I think, and I know I have friends who think I don't do too badly. (Alice)

After having spent almost two hours talking about herself and her pain, Alice attempts to lessen the risk of being seen to be whinging, through emphasizing her identity as a listener and asserting her high pain tolerance. She also compares herself with other people with 'low pain thresholds', who do not have awareness of acceptable pain talk. Her phrase 'they can't help it' again suggests that she is someone with a high degree of self-control and invokes the 'mind over matter' strategy of dealing with pain.

A further function of the extraordinary stories is to attempt to maintain a previous positive identity which is under threat due to the chronic pain:

But I mean, I can remember crawling round the bedroom to make the bed. I'm not one for sitting down, I can't stand the mess. I'm not fanatical about housework by any means, but my husband would go to work. He'd say, 'Leave the dishes, I'll do them when I come home', but I would have to do it. It is silly things, you make things more difficult for yourself. (Anne)

Anne is presenting herself here as a 'good housewife' ('I can't stand the mess') despite her pain, and as a previously active person ('I'm not one for sitting down'). The RSI sufferers in Reid et al.'s (1991) study similarly described themselves as conscientious and previously hardworking, and demonstrated 'proof' of this in their accounts, in order to lessen the inference that they did not 'deserve' to have time off work. They want to perform their social roles, whether through paid work or housework, but only the seriousness of the pain prevents them from doing so. [START_REF] Horton-Salway | Narrative identities and the management of personal accountability in talk about ME: A discursive psychology approach to illness narrative[END_REF] suggests that one function of the emphasis on active lifestyles which occurs throughout narratives of various illnesses is that of asserting the physical, as opposed to the psychological, origins of the condition. Anne emphasizes that she is 'not fanatical about housework', countering any potential accusation that she might have brought it on herself (see [START_REF] Horton-Salway | Narrative identities and the management of personal accountability in talk about ME: A discursive psychology approach to illness narrative[END_REF] or any possible suggestions of psychological instability. In a further extract from Anne's account, below, the impression is conveyed that housework is not a choice but an ongoing responsibility, even if the pain means that paid work can no longer be performed (see [START_REF] Johansson | The meanings of pain: an exploration of women's descriptions of symptoms[END_REF]: doors and things. I was expert at sort of managing things, I used to have a little -what do you call them? -a shoulder bag type thing, I used to put in my cleaning, anything I wanted and hobble around with that, so you find ways of managing things. You don't have a choice, you just have to do it. (Anne) Despite her limitations, Anne is able to present a positive identity as an expert in 'managing' her condition and her responsibilities. She also presents an identity as alone but strong ('you had no-one'), despite some help from her husband and the presence of her mother. Stoicism in the face of hardship is a dominant theme throughout Anne's account, possibly reflecting broader popular ideas of the migrant experience. Anne's account also illustrates a particular dilemma for women with chronic widespread pain, in that in order to maintain a positive identity through continuation with traditional female tasks, women risk being seen as not really ill [START_REF] Johansson | The meanings of pain: an exploration of women's descriptions of symptoms[END_REF].

Discussion

The women in this study used 'extraordinary' stories as part of an attempt to portray positive identities in the face of delegitimation. They presented themselves as hard workers -and therefore not malingerers or compensation-seekers; as sane and in control -and therefore their condition could not be perceived as 'psychological'; as listeners -and therefore not whingers; as people who can cope with high levels of other kinds of painand therefore this pain must be real; and as people who know what the cultural expectations are regarding pain behaviour -and are therefore 'normal'. Their accounts also echo those of chronic illness sufferers who assert their normality through description of ordinary everyday activities. People with chronic pain are simultaneously presenting their 'ordinariness' and their 'extraordinariness'.

The stories told by the women could be interpreted simply as 'dramatizations' of symptoms, as suggested by Kleinman (1994: 181) in his description of Stella, who felt the validity of her experience challenged and hence, 'like most other chronic pain patients, feels pressed to dramatize her symptoms. Her pain is twelve out of ten.' Dramatizing pain in this way, to deal with potential invalidation, means that one might not be taken seriously. The alternative, to downplay the pain in an attempt to appear normal, means that the sufferer runs the risk of not being believed. However, the extraordinary stories that I have described were not told simply as descriptions of the experience of chronic pain itself, but as part of an attempt to overcome this dilemma, to present a particular identity, and through this, to legitimate the pain.

The stories were told to me as an interviewer and as a representative of a wider audience. My interpretation is that the stories were told in the knowledge that I would find them extraordinary, not that they were extraordinary to the chronic pain sufferer themselves, for whom such experiences had health: 9(1) become part of their 'ordinary' existence. The women conveyed the impression that the stories had been told previously, having been constructed for the purpose of countering accusations, for example, of malingering, in the workplace; to portray a positive identity, for example, at work or at home; or to present oneself as psychologically stable, in a medical setting. Different settings may evoke different presentations of self and the emphasis of the extraordinary stories could change according to the contexts, but with the aim of fulfilling the same purpose -of legitimating pain and person. [START_REF] Bury | The sociology of chronic illness: a review of research and prospects[END_REF] suggests that legitimization is problematic in conditions where symptoms occur in milder forms in the normal population. The everyday nature of the symptoms may exacerbate the disconfirming responses when sufferers attempt to communicate the nature of their distress. In chronic fatigue syndrome, for example, symptoms such as headache, fatigue and sore throat may be perceived as trivial, leading to further delegitimation of the condition [START_REF] Ware | Toward a model of social course in chronic illness: The example of chronic fatigue syndrome[END_REF]. In contested conditions which rely almost exclusively on patients' experience for communication, and in which symptoms are largely invisible, ordinary and everyday, extraordinary stories may therefore be told. People with other contested conditions, such as chronic fatigue syndrome, may have other 'extraordinary' stories to tell.

Chronic pain has, with a few notable exceptions, been subsumed under the study of chronic illness, yet there are key differences between the two. These differences may be related to the nature of chronic pain -it is invisible, subjective and everyday, and is not legitimated by a diagnostic label. Language and the ways that people have to express their experience may be influenced by the nature and characteristics of the condition. The way in which people present themselves, attempt to communicate their experience of pain and to legitimate their condition, for example, through the use of extraordinary stories, may also be different and therefore deserves attention. Exploring the function of such stories may also help health care professionals to understand the experiences of women with chronic widespread pain.

Notes

An earlier version of this article was presented at the 8th International Qualitative Health Research Conference, Banff, Canada, April 2002.

1. In the Manchester definition of chronic widespread pain (MacFarlane, Croft, Schollum andSilman, 1996: 1629) pain is considered to be present in a limb if at least two sections from four are indicated as painful. Pain is considered to be widespread if it occurs in the axial skeleton, above and below the waist and in contralateral limbs (e.g. lower back, plus left arm plus right leg). 2. Ethical approval for the study was given by the Human Research Ethics Committee, Northern Sydney Health (9606-093M). 3. A colloquial Australian/ New Zealand word meaning to evade responsibilities, to be idle or to 'cadge' (Macquarie Dictionary Online, 2002).

Richardson: Establishing the (Extra)ordinary in Chronic Pain

  [I'm on the bed gritting my teeth and waiting]. GP: This should be hurting you. Anne: It is. GP: Well you're not reacting. Anne: Well what do you want me to do -scream? I know it's only going to take a few seconds. GP: Well it should hurt you. Anne: It is hurting. GP: But you aren't reacting like it's hurting. Anne: I don't know what you're expected to do. If I walk around all day going, 'Ooh!, Aaaahh!', people are going to have me locked up. GP: It should be hurting you.

34 Table 1 Characteristics of participants

	health: 9(1)
	Name	Age at time	Work	Family status
	(pseudonym)	of interview
	Kathleen	51	Catering, now retired	Married
				Children and grandchildren
	Susannah	59	Nursing and office work,	Now single
			now has own counselling	Children and grandchildren
			business
	Anne	57	Office work, now works as Married
			bridal milliner	Children
				Grandchildren
	Alice	74	Nursing (home and	Single
			overseas) and occupational No children
			health, now retired	Lives in a self-care retirement
				village
	Elizabeth	75	Various jobs including	Single
			research and voluntary	No children
			work, now retired	Lives in nursing home
	Joan	88	Office work, now retired	Twice widowed
				Children and grandchildren
				Lives in 'granny flat' next to
				daughter's house
	Table 1 gives an outline of the characteristics of participants. Brief details
	are also given below in the context of interview extracts. All names are
	pseudonyms.

  Int: So, do you talk to people, your family and friends, about your pain on a day-to-day basis? Kathleen: No, no. I might when my shoulder plays up. I might say to my husband, 'My shoulder is aching again, my elbow is aching. I'll have to turn over'. But no, I don't.

Int: Can I ask why that is? Kathleen: I'm sure they don't want to hear me whinging. I just don't, because I can't see any point in it really.

Int: Mmmm. So do you think they know how you. . .? Kathleen: Well my children are married now, so they're not at home. But they are aware. When the grandchildren were small they said, no, Grandma couldn't pick them up, because of my back.

Well, with everything that I had, my mother lived here, but the rest of my family lived overseas, so it was just a matter of you had no-one, so you just had to get on with it. My husband helped as much as he could, but he had to go to work and, even when I had the plaster cast and when I was on crutches, you devise ways of getting the washing out to the clothes line and down steps and out of

To all the participants in the study who gave their time to be interviewed. To the Wellcome Trust who funded the research. To the West Midlands NHS(E) Primary and Community Care Research Initiative and the Primary Care Sciences Research Centre, Keele University, who funded sabbatical leave enabling the author to undertake this research. To the Rheumatology Department at Royal North Shore Hospital/University of Sydney where the author was a Visiting Research Fellow, particularly Lyn March.

Author biography

JANE C. RICHARDSON is a lecturer in the Primary Care Sciences Research Centre at Keele University. She is currently carrying out research on the experiences of people with chronic widespread pain in the United Kingdom and Australia. Her other research interests and publications are in the area of women's understanding of osteoporosis; developing research awareness among health care professionals; approaches to in-depth interviewing; and ethical issues in qualitative research.

health: 9(1)