Sociology Mind
2011. Vol.1, No.4, 156-163
Copyright © 2011 SciRes. DOI:10.4236/sm.2011.14020
Ethnicity and Fatigue: Expressions of Distress,
Causal Attributions and Coping
Kamaldeep S. Bhui1*, Sokratis Dinos1, Marie- La ur e Morelli 1,
Bernadette Khoshaba2, James Nazroo3, Simon Wessely4, Peter D. White1
1Centre for Psychiatry, Barts and the London School of Medicine and Dentistry,
Queen Mary University of London, London, UK;
2Faculty of Public Health and Policy, Department of Health Services Research and Policy,
London School of Hygiene & Tropical Medicine, London, UK:
3School of Social Sciences, University of Manchester, Manchester, UK;
4Department of Psychological Medicine and Psychiatry, Institute of Psychiatry,
King’s College, London, UK.
Received June 25th, 2011; revised August 3rd, 2011; accepted September 11th, 2011.
This paper reports on an MRC funded study of chronic fatigue and ethnicity. The purpose of the qualitative
component was to compare expressions of fatigue, illness attribution, coping styles and help seeking behaviour
across ethnic groups. The study used secondary analysis of qualitative data that were collected as part of the
Ethnic Minority Psychiatric Illness Rates in the Community (EMPIRIC) study. The charts of the qualitative data
used in the original study and the original transcripts were used to identify reports of fatigue and related symp-
toms that included feeling tired, exhausted, shattered, lack of energy, lack of sleep, insomnia and impaired con-
centration. We described symptoms by ethnic group, and examined whether ethnicity influenced illness attribu-
tions, coping strategies and help seeking behaviour. Fatigue related symptoms were common and encountered in
all the ethnic groups studied, and descriptions of fatigue, illness attribution and help seeking, on the whole, did
not vary between ethnic groups. The paper sets out the subtle differences between ethnic groups, and considers
the use of secondary qualitative data analysis in research. Fatigue was more common among women; coping in-
cluded self-help, and seeking help from social and counselling services. Religion was used as a coping mecha-
nism mainly amongst the Pak i st an i, Indian and Bangladeshi ethnic g roups.
Keywords: Fatigue, Ethnicity, Secondary Analysis, Qualitative
Introduction
Fatigue is one of the most common and disabling symptoms
encountered in medical practice and in the population (Skapi-
nakis, et al., 2003; Williamson et al., 2005). The population
prevalence of fatigue may be as high as 30% (Reyes-Gibby, et
al., 2003). Fatigue is a feature of numerous medical and psy-
chiatric illnesses (Addington, et al., 2001) but nevertheless
remains poorly understood (Mears et al., 2004). It is a subjec-
tive symptom that encompasses emotional, cognitive and
physical components (Kralik, et al., 2005), and is difficult to
define and measure (Chalder, et al., 1993).
Of the few epidemiological studies that have explored the
relationship between ethnicity and fatigue (Song, et al., 2002),
most find no ethnic differences in prevalence (Dinos et al.,
2009). However, ethnicity has been shown to moderate fatigue
severity and coping strategies (Dinos, et al., 2009). For example,
population-based studies have found that African Americans
reported greater levels of fatigue and particularly physical, as
opposed to mental, fatigue (Reyes-Gibby, et al., 2003; Bardwell,
et al., 2006; Thomas, et al., 2006). A study of fatigue in pri-
mary care across 14 countries also showed that subjects from
low income countries were more likely to present to their doc-
tors with fatigue (Skapinakis, et al., 2003). Fatigue may there-
fore be socially stratified, and be an expression of social dis-
tress and poverty in low income countries; it may also be a
easily noticed and communicated symptom of physical illness,
irrespective of culture and language; fatigue expressions are
commonplace, and do not require a sophisticated vocabulary
that perhaps is demanded of psychological experiences. Social
and cultural factors may influence the course of an illness
(Njoku, et al., 2005); a study in the US showed that African
Americans were more likely to cope with fatigue by turning to
religion compared with European Americans; denial as a form
of coping was more prevalent among Hispanic Americans
(Nkoju, et al, 2005). There is insufficient research on how peo-
ple experience and talk about fatigue, and how they cope with it,
especially when it is not obviously related to a physical illness
(Karasz & Mckinley, 2007). These research questions becom-
ing especially pertinent for ethnically diverse populations who
are sometimes reported to make use of physical idioms of dis-
tress as well as suffering higher rates of some physical illnesses,
making reports of fatigue commonplace. Some assert that
physical complaints can mask emotional distress, or in a psy-
choanalytic sense can represent the distress (converted into
physical illness) such that it need not be felt; physical accom-
paniments of emotional distress are actually common in all
societies, but the emphasis of such complaints by ethnic mi-
norities, and those of poor socio-economic backgrounds has
also led to suggestions that psychosomatic complaints are
forms of social protest and re-positioning in the real world us-
ing the idiom of physical illness (Kirmayer & Young, 1998). In
relation to fatigue specifically, less is known or researched
about its cultural origins or correlates, and how it may represent
somatic distress amongst groups of poorer social status (some
ethnic groups). Is fatigue readily recruited because it is com-

K. S. BHUI ET AL. 157
mon place and can easily be made use of without immediate
sanctions that the sick role might otherwise impose if a more
severe illness were diagnosed or suspected.
Given the lack of research on expressions of distress, attribu-
tions and coping with fatigue, qualitative methods can be a
good place to begin to explore whether illness behaviour for
fatigue is patterned by ethnic and cultural influences. Qualita-
tive methods can demonstrate subtle variations in expressions
of fatigue and coping, and can be useful for investigating what
underlies quantitative patterning by demographic variables
(O'Connor & Nazroo, 2002b). Existing research suggests that in
high income countries ethnic minorities may not seek help for
fatigue. (Dinos, et al., 2009) .If there are cultural differences in
expressions of fatigue, and in causal attributions and coping,
these might explain the previous research showing ethnic mi-
norities do not present to specialist services for fatigue.
Therefore, this study aimed to investigate ethnic and cultural
influences on fatigue expressions, causal attribution and coping
behaviours among the five main ethnic minority groups in
England (Bangladeshi, Black Caribbean, Indian, Irish and Paki-
stani) and among a white British comparison group. These eth-
nic categories are used in research and national survey work
including the national census. They clearly aim to group indi-
viduals by a common ancestral origin and migration history,
linking this with race and cultural factors. Notions of ethnicity
are clearly contested as categories, given there is so much vari-
ability of demographic and cultural characteristics within one
ethnic group. Nonetheless, ethnic group patterns for illness
prevalence and aetiologies are the first stage of investigating
what explains these variations: demographic, cultural, socio-
economic, neurophysiological or environmental factors. Fur-
thermore, ethnic patterns often reflect cultural patterning for
recent migrants, and where cultural integration is limited.
We were particularly interested to see if expressions of fa-
tigue were culturally informed, whether there were patterns
common to an ethnic group, and if some groups reported
greater physical (as opposed to mental) fatigue (Thomas, et al.,
2006). We were also interested to investigate individual and
ethnic group differences in causal attributions and coping be-
haviours for fatigue. The research made use of an innovative
method called “secondary analysis of qualitative data”. The
study also demonstrates how this method makes efficient and
cost-effective use of existing data sets, to ask specific questions,
and how it yields valuable new knowledge. We also highlight
the strengths and weaknesses of this method to guide other
researchers.
Methods
Sample
The Ethnic Minority Psychiatric Illness Rates in the Com-
munity (EMPIRIC) survey, commissioned by the Department
of Health, consisted of two components: a larger, quantitative
survey representative of the ethnic populations in the UK,
which investigated ethnic differences in mental illness rates
(Sproston & Nazroo, 2002), and a qualitative study of a sub-
sample of respondents investigating cultural and ethnic differ-
ences in contexts and experiences of mental illness (O'Connor
& Nazroo, 2002b). The quantitative survey included a total of
4281 participants between the ages of 16 and 74. A sub-sample
of 116 respondents who had experienced any form of difficulty
or mental distress (a lay notion of this rather than a clinically
diagnosed psychiatric disorder) was interviewed for the qualita-
tive follow-up study. Respondents were also selected on the
basis of a range of characteristics including ethnic group, main
language spoken, migration history, age and gender, and the
presence and absence of a common mental disorder (anxiety
and depression).
Interviews
The original interviews were all in-depth, interactive and
were conducted in respondents’ homes. They lasted between
half an hour and two hours. A topic guide was used to allow the
interviewer to cover key themes and direct an interview that
focused on the context of participants’ lives, and how this had
shaped their experience of mental distress. Key themes in-
cluded 1) a general introduction, 2) current circumstances, from
housing and employment to religion and ethnicity, 3) percep-
tion of difficulty and distress, 4) personal experiences of mental
distress and 5) coping mechanisms and 6) use of support ser-
vices. All interviews were recorded and transcribed verbatim. A
total of 34 interviews were conducted in languages other than
English, mostly in the Bangladeshi group; these were translated
and transcribed by the interviewer to minimise any loss of con-
text. Full details of the study design and original analyses can
be found in the original report (O'Connor & Nazroo, 2002b).
Analysis
In this study, we undertook secondary analysis of qualitative
data collected as part of the EMPIRIC study. This is an innova-
tive method that makes efficient use of existing data, and is not
as well known about as secondary quantitative data analysis
(Corti & Thompson, 2004; Corti & Bishop, 2005). The sample
used in the present study was selected for inclusion if, in the
original charts developed from the transcripts of the original
interviews, subjects had expressed fatigue in the widest sense –
using various terms, analogies, idioms and symptoms. The
transcripts of those identified to have fatigue, and the charts
from the original study, were subjected to framework content
analysis, defined as any “technique for making inferences by
objectively and systematically identifying specified characteris-
tics of messages” (Bryman, 2004). The analysis in this paper
followed the stages used in the original study (O'Connor &
Nazroo, 2002b). The first stage of analysis involved familiari-
sation with the transcribed data and identification of emerging
issues to inform the development of a thematic framework. The
analysis consisted of thematic analysis and constant comparison
across subjects, groups of subjects, and those of different ages,
genders, and ethnic groups. This comprised an extracting data
and constructing a series of thematic matrices or charts, con-
taining the strongly emergent topic headings, in which data
from each case was summarised. The charts were stored in
spreadsheet format in Microsoft Excel. The charts and then the
transcripts were analysed by two researchers, and later a third
to resolve any inconsistency.
The research team included investigators who were new to
this data, to ensure a critical and unbiased perspective in analy-
sis, as well as senior researchers who were part of the original
research team and so they were aware of the field methods,
analytic methods, pilot work and the strengths and weaknesses
of the original study. This was important in order not to de-
mand too much analysis beyond that which the data might
credibly support. The thematic charts allowed for the full range
of views and experiences to be compared and contrasted both
across and within cases and for patterns and themes to be iden-
tified and explored. The final stage involved classificatory and
interpretative analysis of the charted data in order to identify

K. S. BHUI ET AL.
158
patterns and explanations. The methods are consistent with a
special use of secondary analysis where the aim is to pursue a
new conceptual focus and on a subset of the original data
(Heaton, 1998).
Results
Forty-six transcripts (of 116) were found to contain refer-
ences to fatigue (see Tables 1, 2 for sample characteristics).
These references included expressing fatigue (both directly and
through analogies), reporting physical symptoms of fatigue,
commenting on sleep or energy, and describing a loss of moti-
vation and function.
Fatigue was often accompanied by self-reports of both
physical and psychological illnesses in the sample (Table 3)
such as diabetes, asthma, hypertension, etc. There were no ob-
vious patterns in self-reports of physical ill-health by gender or
ethnicity. Depression was reported across the ethnic groups,
both in the past and present tenses. Depression was reported by
a higher number of Black Caribbean, Indian and Irish females
than males in their respective ethnic groups; altogether 25 indi-
viduals (54%) reported having suffered from depression.
Table 1.
Fatigue reported by respondents in the EMPIRIC study by ethnic group
and gender.
Ethnic Group Total N (fe-
male:male) Fatigue reported (n; (n/N as %)).
Female Male Total
Bangladeshi 18 (9:9) 4 3 7 (39%)
Black Caribbean 20 (11:9) 6 3 9 (45%)
Indian 19 (12:7) 6 3 9 (47%)
Irish 21 (13:8) 6 2 8 (38%)
Pakistani 19 (11:8) 3 2 5 (26%)
White British 19 (11:8) 4 4 8 (42%)
Total 11 6 (67:49) 29 17 46 (40%)
Table 2.
Age and migration by ethnic group of 46 respondents reporting fatigue symptoms.
Ethnic Gro u p
Age Bangladeshi Black Carib- bean Indian Irish Pakistani White British
25 - 30 1 2 1 1 0 1
31 - 35 1 3 0 2 0 2
36 - 40 2 2 4 0 1 1
41 - 45 2 1 2 3 4 2
46 - 50 1 1 2 2 0 2
Migration Number of respondents reporting fatigue/ number of respo ndents in EMPIRIC study
Born in UK or moved
prior to age 11 3/6 8/15 5/10 8/16 0/9 8/19
Moved to UK a t age 11
or later 4/12 1/6 4/9 0/5 5/10 0/0
Table 3.
Depression & Physical Illness: Ethnicity in respondents r ep o rt i n g f a ti gue.
Ethnicity
(number of respondents ) Depression Depression + Physical Illness Physical Illness o nly Neither
Indian (9) 2 2 3 2
Pakistani (5) 0 4 1 0
Bangladeshi (7) 1 2 1 3
Black Ca rib bean (9) 6 1 2 0
White British (8) 1 1 3 3
Irish (8) 2 3 1 2

K. S. BHUI ET AL. 159
Expressions of fatigue
Overall there was little patterning of the expressions of fa-
tigue by ethnic group. Fatigue was conveyed using a variety of
terms, analogies, idioms and symptoms, and these are described
in detail below. Respondents from all the ethnic groups
(Excepting Black Caribbean) used various metaphors for
their fatigue such as comparing oneself to an old person, refer-
ring to oneself as a “broken stick” and feeling “continually
hungover”. For example, two respondents compared their fa-
tigue to falling into a “trance” or “spell”:
“I fall into a spell…it’s like when people like yourselves here
are talking to me and I just float off. I go into another world.”
(Male, 44, Bangladeshi, migrated to GB aged 24, interviewed
in Bengali)
“I was lethargic and… I can remember I used to go into sort
of trances, you know, for long periods of time.”
(Male, 44, Irish, born in GB)
Sleep disturbance
Individuals expressed their fatigue by referring to sleep
problems, and this was found in all ethnic groups. Respondents
spoke of “broken” and “affected” sleep, “sleeplessness”, “in-
somnia” and the inability to “switch off”. One respondent ex-
plained how tired she was by saying that she fell asleep as soon
as she went to bed, while another described spending his days
“battling against sleep”. A few respondents also expressed their
desire for sleep as means of communicating their fatigue. They
used phrases such as “I could just sleep forever at the moment”
and “I just wanted to sleep”. One individual remembered:
“not wanting to wake up, just feeling kind of tired and want-
ing to sleep…what I wanted to do was stay in bed all day”
(Male, 36, Indian, born in GB)
Somatic symptoms
Respondents frequently gave examples of their physical
limitations when describing their fatigue such as finding it “dif-
ficult to get out of bed”, having a “limited body” or having to
“sit and veg in front of the telly”. Respondents sometimes
quantified their fatigue by relating it to specific tasks that they
felt unable to carry out. For example, they described being “too
tired to go out” or being too tired to “keep fit”.
Only Pakistani and Bangladeshi groups used idioms of bod-
ily “weakness” to express their fatigue. One Pakistani respon-
dent, who was interviewed in English, referred several times to
feeling generally “weak” due to his diabetes, explaining that
when his sugar levels dropped he became “weaker”. A Bangla-
deshi respondent described how his “body gets really weak”
when he is stressed. Another Bangladeshi respondent linked
feeling “weak” directly to her lack of sleep, adding weight to
the notion that this term could be used interchangeably with
“tired” for these respondents:
“I am becoming weak day by day…[I] don’t get enough
sleep…I feel sleepy throughout the day”.
(Female, 44, Bangladeshi, migrated to GB aged 2, inter-
viewed in Bengal i )
People from Indian, Pakistani and Bangladeshi backgrounds
also tended to qualify their feelings of fatigue by describing an
accompanying physical symptom or feeling. For example, a
Pakistani woman explained that when she gets “really tired”
her “body starts to hurt” and she gets “headaches too” and a
Bangladeshi woman explained that her “eyelids are so heavy”.
Low or no energy
It was only ethnic minority groups that discussed their fa-
tigue in terms of lack of energy. In particular, four respondents
made references to “energy” in talking about their fatigue. An
Irish respondent described how his lack of sleep meant that he
was “just not feeling as energetic as one might”, while a Black
Caribbean woman with a history of depression spoke of having
“no energy” and wanting to sit around, smoke and drink coffee.
Another Black Caribbean respondent remarked: “I’ve got no
energy…it’s like I [have] no life to move.” Finally, an Indian
respondent explained that he had become tired because he was
using his energy “stressfully”.
Loss of motivation and “function”
Respondents from Black Caribbean, Irish and White British
background alluded to a loss of motivation. In particular, 15
respondents mentioned a loss of motivation and/or function, of
which only one was Indian. Black Caribbean, Irish and White
British respondents often used the expression “can’t be both-
ered” to convey this loss of motivation. These same ethnic
groups also reported losing the ability to “function”. A Black
Caribbean respondent also described this lost ability to function
when she was depressed:
“It took over my life. I couldn’t do nothing, couldn’t even get
in the bath… just used baby wipes, wasn’t doing housework,
house got really filthy”
(Female, 34, Black Caribbean, born in GB)
Causal Attributions for Fatigue
Respondents outlined a range of circumstances and experi-
ences that they felt to be the ‘cause’ of their fatigue. A single
cause was rarely given; rather, individuals saw their fatigue as
having several origins.
Mental distress and depression
In each ethnic group some respondents attributed their fa-
tigue to mental distress and depression.
Some individuals attributed their tiredness directly to depres-
sion, saying that it made them “slow”, “lethargic”, and “tired
physically”.
“If I get depressed then I just go into a hole…[I] lock myself
away…not wanting to wake up, just feeling and wanting to
sleep”
(Male, 36, Indian, born in GB)
Other respondents described an indirect link between fatigue
and depression, most commonly through insomnia. Interest-
ingly, it was often the fatigue and the difficulty sleeping that
spurred these respondents to seek help, rather than the cognitive
symptoms of depression. Respondents also alluded to their loss
of motivation when they were depressed:
“I was so depressed [I] didn’t want to go outside, [I] just
wanted to stay at home”
(Female, 40, Pakistani, migrated to GB aged 26, interviewed
in Urdu)
Work-related stress
Working long hours, having trouble at work, disliking one’s
job and increased workload were all linked to fatigue across the
ethnic groups. One Indian respondent attributed her fatigue to
taking on a new job where there was a backlog of work to take
care of. Two White British respondents spoke in very similar
terms of the effects of increased “stress” at work on their sleep.
Work, gender, family
Black Caribbean and Indian female respondents alone attrib-
uted their fatigue to the pressures of combining work with a
family. For example, a Black Caribbean respondent with three
young children spoke of her constant fatigue due to combining
full time work with looking after her young children. An Indian
respondent described a similar, busy schedule and complained
of never finding the time to sit down due to working all day and

K. S. BHUI ET AL.
160
then taking care of her family in the evenings. This same re-
spondent asked rhetorically “Why did God give so much work
to women? Less responsibility on men, for all women it’s like
this?” A Pakistani respondent whose husband had recently suf-
fered a heart attack also complained of feeling “shattered” due
to having to work all day and then look after both children and
home without her husband’s help.
Three South Asian women attributed their fatigue directly to
looking after the home and “family responsibilities”, without
implicating employed work. These responsibilities included
housework, laundry, cooking, shopping, going to the post office,
getting children ready and looking after visitors. Interestingly,
all three women were also full-time carers for their sick hus-
bands: “I look after my sick husband completely…everything I
do for him”. These women also complained of very busy
schedules—“when will I work? I am too busy with my family
responsibilities”—and attributed feeling tired to having so
many responsibilities.
Injury, illness and medication
Individuals across the ethnic groups attributed their fatigue to
an injury or a health-related problem such as childhood menin-
gitis, fibromyalgia, irritable bowel syndrome (IBS) and diabetes.
Two Irish and one Black Caribbean respondent attributed their
fatigue to the effects of medication for psychotic depression,
epilepsy and depression, respectively.
Relationship problems
Four female respondents attributed their insomnia to troubles
with their ex-partners. Interestingly, all four women described a
fear of staying at home alone as a consequence of their trou-
blesome relationships, and linked this fear to their insomnia.
“[I] felt insecure even about staying at home. Frightened
that someone would come and do something to us. Couldn’t get
to sleep at night because I was frightened”
(Female, 40, Pakistani, moved to GB aged 26, interviewed in
Urdu)
Racism
Over half (18/30) of the non-White respondents in this study
had experienced racial discrimination, both interpersonal and
institutional, at some point in their lives. These experiences of
racism were often related to bullying and victimisation as a
child and later at work:
“You can’t just suddenly forget about it, it got stuck into my
brain, his face and his behaviour, everything like a photo-
graphic memory keep coming and going, it was like it kept
playing to my mind”
(Male, 30, Bangladeshi, moved to GB age 21, interviewed in
English and Bengali)
“Somebody just made up their mind they didn’t want me
there and went out of their way to make it really difficult”
(Female, 29, Indian, born in GB)
One respondent spoke about institutional racism in particular
and suggested that he was worn by racism. In particular, the
participant reported that he finds institutional racism:
“…worse than being abused on the streets, it’s actually very,
very tiring”
(Male, 36, Indian, born in GB)
Coping Behaviours for Fatigue
Respondents outlined the resources they used to help them
cope with their fatigue itself, which ranged from visiting their
doctors to developing a positive outlook on life. The vast ma-
jority described how they had coped with what they saw as the
source of their fatigue.
Use of health services
Respondents from all of the ethnic groups reported visiting
their GP specifically, though not always exclusively, for their
fatigue. They often sought help for insomnia and six respon-
dents reported being prescribed sleeping tablets. Seeking
medical help for fatigue wa s especially common in the Indian
group.
Black Caribbean and Irish respondents were more likely to
use other formal support services including counsellors, psy-
chotherapists and voluntary groups. These services were widely
called upon to assist a wide range of problems, from depression
to discrimination in the workplace and troublesome relation-
ships, although respondents reported both positive and negative
experiences of these services.
Not Seeking Help
The vast majority of respondents who reported fatigue did
not mention seeking support specifically for their fatigue. This
may be because they saw fatigue as part of a larger problem,
and that they developed coping strategies for these other prob-
lems (see above). However, two other factors may have con-
tributed to not seeking help. Some individuals did not perceive
fatigue as a medical problem and normalised it by saying that
this “sort of frustration prevail[s] in everyone’s life”, or that
they expected other people in their position to feel tired too.
Some respondents were also cynical about service provision
because of bad or ineffective past experiences and respondents
across the ethnic groups were sceptical about professionals
empathising with them, commenting that “they’re not in your
shoes”, “they’re not experiencing what you’re experiencing”
and “they don’t understand the real situation”.
Support from family and friends
Family and friends were frequently seen as an important
source of support for respondents across the ethnic groups. For
example, a Pakistani respondent explained how she and her
husband would come back from work and “just talk to each
other…just to talk, just to take out everything”. A Black Carib-
bean respondent who suffered from severe depression ex-
plained how her foster children were key to her recovery, “be-
cause I always felt they had no-one except for me…I had to be
there for them”.
Keeping busy
Respondents described coping with fatigue by engaging in
many different activities, including watching television, going
outside for a walk, hill walking, exercise, artwork, drinking and
reading. There was recurring mention of “keeping busy”.
“The journey itself helped me to concentrate…I realise now
that…the travelling, even though it was making me tired, I was
actually focused”
(Male, 26, Black Caribbean, born in GB)
Religion
South Asian respondents were more likely to refer to religion
as a coping mechanism than the other ethnic groups. A Bang-
ladeshi respondent was asked how she coped with everyday
worries, and she replied “I surrender everything to God. He is
the boss”. Similarly, other respondents described believing that
their future was “in God’s hands”, and that “everything will be
taken care of by him”. An Indian respondent described how
religion had helped him during stressful times because he had
prayed more often: “when something goes wrong you start
praying and of course it helps”. An Irish respondent echoed this
by likening praying to a “mini counselling session”.
Outlook and personal resources
Some respondents kept a positive outlook on life and were
stoic about their difficulties, using phrases such as “I have to go
on”. Others described putting things into perspective and ac-

K. S. BHUI ET AL. 161
cepting difficulties, saying “you have to accept it sometimes” or
“I just let it go”. A few respondents recalled “keeping things
back” and “locking [their] problems in a cupboard” to help
them cope. Denial was also noted, mostly where respondents
‘normalised’ their difficulties. Some individuals adopted a phi-
losophical approach. For example, a Bangladeshi respondent
explained that her children were a source of inner strength for
her when she was exhausted, as she regained her inner happi-
ness when she saw their faces.
Discussion
Expressions of Fati gue
Fatigue was conveyed using a variety of terms, analogies,
idioms and symptoms and there were many similarities between
the groups. In particular, respondents from all the ethnic groups
described their fatigue by giving examples of their physical
limitations and qualified their fatigue by referencing their sleep.
This is curious given the attention given to differences in the
presentation of physical complaints in different ethnic groups.
The studies that find these differences tend to reflect profes-
sional judgements rather than the experience-near complaints in
the language of the subject. It may be that at the individual
level of analysis that makes use of lay terms, more similarities
are seen; and that it is only at a level of professionalised lan-
guage or diagnostic process that differences between ethnic
groups emerge, not as there are true differences but because the
observer makes sense of the observed symptoms and com-
plaints, but only recognising them if they match medical
nosology; ethnic minorities may not be as familiar with medical
language or popular psychology. This might relate to education,
or true differences in explanatory models for illness and distress
that makes use of culturally and religiously influenced beliefs
about health and well-being.
However, there were also some differences. Although the
term “tired” was used by all the ethnic groups, with respon-
dents using phrases such as “I feel tired” and “my whole body is
tired”, only Pakistani and Bangladeshi informants reported
feeling “weak” and expressed their fatigue in terms of bodily
“weakness”. They were also more likely to report an accompa-
nying physical symptom or sensation in relation to their fatigue.
These results suggest that expressions of fatigue were linguisti-
cally or culturally influenced rather than being “culture-bound”
(Kleinman, 1987). Previous research suggests that ethnic mi-
nority groups are more likely to report physical than mental
fatigue (Jason, et al., 1999; Thomas, et al., 2006). Although
physical fatigue is reported with greater frequency from ethnic
minority groups than the British white group, no ethnic differ-
ences were found in reports to mental fatigue. However, there
was a tendency to emphasise systemic weakness with greater
frequency in some minority ethnic groups perhaps reflecting
traditional South Asian humoural concepts associated with
depleted or weakened blood (Karasz & Mckinley, 2007). Black
Caribbean, Irish and White British respondents were more
likely to describe a loss of motivation and “function”. This
ranged from the inability to go to work to feeling unable to do
“anything” such as having a bath and doing housework. Thus
different expressions for fatigue may make this more difficult
to recognise in some individuals, but want explains previous
findings that ethnic minorities do not seek help from health care
services.
Causal Attribution and C oping
Explaining no ethnic differences
Everyday stressors such as work featured heavily in the dis-
courses of causality in all the ethnic groups, both directly—due
to their wearying effects—and indirectly, through their impact
on stress ‘levels’ and, consequently, on sleep. Inter-group dif-
ferences were mostly seen among female respondents who
attributed their fatigue to work, family, the home or a combina-
tion of these. It seems that diverse attributions and coping styles
for fatigue may well explain not seeking help. Illness attribution
can have a considerable impact on the experience of illness
(Torres-Harding, et al., 2002; Karasz & Mckinley, 2007). Most
respondents were most likely to attribute their fatigue to psy-
chosocial causes, including depression and mental distress,
work-related stress and relationship problems. This is in keep-
ing with other studies that have found low levels of health at-
tributions for fatigue in the community (Pawlikowska, et al.,
1994). Indeed only a small number of respondents (n = 7) at-
tributed their fatigue to a physical cause such as ill health or
injury, either wholly or in part. So the attributions may be
similar across ethnic groups, but again perhaps it is coping and
help seeking, and subsequent professional recognition and la-
belling, that differ across ethnic groups.
Explaining some ethnic differences
Some notable differences in both attributions and coping that
were related to ethnicity and gender were found. For example,
Black Caribbean and Indian women were more likely to attrib-
ute their fatigue to the difficult task of combining family life
with paid employment. Furthermore, South Asian women
tended to attribute their fatigue to a host of “family responsi-
bilities” that were strongly associated with traditional female
roles. These responsibilities included looking after their (sick)
husbands, doing the housework, getting their children ready and
looking after visitors. Black Caribbean, Irish and White British
respondents were more likely to attribute their fatigue directly
to their children.
Racism was also reported as a cause of fatigue in Bangla-
deshi and Indian respondents. Thomas, et al. (2006) found that
individuals who reported more racial discrimination experi-
enced greater fatigue and had less stage four sleep. A well
documented finding is that racism can be an important risk
factor for poor health. For example, hypertension, poorer
self-rated health status and common mental disorders are all
associated with self-reported experiences of racism and unfair
treatment (Schulz & Israel, 2000; Karlsen & Nazroo, 2002;
Bhui, et al., 2005).
So both gender roles and experiences of racism may differ
across ethnic groups and could explain different attributions,
coping styles, and therefore, help seeking. Indeed, many re-
spondents did not seek health care support for fatigue, either
because their attributions were not health related, or they per-
ceived health care professionals to be unhelpful. Normalised
attributions of fatigue without explaining their condition as
illness may explain poorer help seeking, or service uptake, or
that there are miscommunications in medical consultations that
overlook fatigue symptoms (Luthra & Wessely, 2004). The
social and normalising attributions, especially if expressed
alongside symptoms, may explain this tendency of doctors to
not to refer to specialist medical care.
Religious coping was quite common, but only in ethnic mi-
nority groups. This is a finding that was also reported in the
EMPIRIC study, which found that the Bangladeshi and Carib-
bean groups made more references to their religious beliefs in

K. S. BHUI ET AL.
162
response to mental distress (O'Connor & Nazroo, 2002a). The
results in this study showed that religion as a coping mecha-
nism featured heavily amongst the Pakistani, Indian and Bang-
ladeshi ethnic groups within the sample. Therefore, religious
coping may be used for all forms of distress and worry rather
than being a specific way of coping with fatigue.
Depression and Fatigue
Depression and mental distress were frequently cited as
causes of fatigue in our sample. This was not surprising in a
context where respondents were selected for interview only
after showing some indication of mental distress or some diffi-
culty. However, the attributions of a causal relationship oper-
ated in the opposite direction too, with a number of respondents
ascribing their depression to fatigue. Studies in both primary
and secondary care repeatedly find high levels of co-morbidity
between depression and fatigue (Williamson, et al., 2005). It
has been suggested that “fatigue is neither purely predictive
nor a consequence of psychiatric disturbance” and that it
probably represents an “aetiologically heterogeneous” condi-
tion (Addington, et al., 2001). In the absence of a past history of
depression, it is possible that some respondents did not recog-
nise, understand or experience the cognitive aspects of their
depression. If this is the case, and fatigue is a core symptom of
depression (WHO, 2004) (Williamson, et al., 2005), fatigue is
likely to be given greater diagnostic significance by doctors,
Therefore, knowledge and understanding of the range of idioms
used to express fatigue in different ethnic groups has important
implications for detection, intervention and recovery.
Limitations and methodological innovation
The approach to secondary qualitative data analysis depends
on the quality of the original data, and an understanding by
researchers of the risks of decontextualised data collected with
another purpose in mind. Although fatigue was expressed by
nearly half the EMPIRIC qualitative sample, and many of the
original research questions contributed valuable detail to the
context of respondents’ experience of fatigue, the original in-
terview was not focussed on fatigue. Interviewers were not
encouraged to probe deeper if respondents reported fatigue, and
questions designed to elicit respondents’ views on attribution
and coping may have reflected their experience of mental dis-
tress, rather than fatigue per se, although the data does not in-
dicate this to be a problem. Furthermore, respondents may have
experienced fatigue without the subject arising during the inter-
view.
Our results cannot be statistically generalised to the wider
ethnic minority populations, but, given the sample used in the
study is purposively drawn to represent key components of the
referent populations, the conclusions drawn can be applied to
the broader population. However, we are able to assert with
confidence the key findings, especially that mental distress and
social distress are proposed to be related to fatigue; a strength
of our work is that the researchers were experienced in working
with the EMPIRIC data and used transparent methods. This
approach permitted the research team to critically review the
analysis and to ensure that the findings were not a function of
the de-contextualisation of the data.
Conclusion
More research is needed into the effects of medical illness
and social adversity, for example, discrimination on fatigue,
functioning and depressive illness (Bhui, et al., 2005). The
moderating effect of socio-economic status on other minority
ethnic groups should also be investigated, as well as other co-
variates such as sleep and pain (Reyes-Gibby, et al., 2003).
Acknowledgements
This work was supported by the Medical Research Council
in the UK (grant G0500978 to KSB in 2006).
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