Pain management that is safe, effective, and compassionate is a critical topic in medicine, as is the disparities in pain care across cultural and ethnic landscapes. Despite concerted efforts to diminish health care disparities, these remain a challenge to equitable health care delivery 1. Retrospective cohort studies have long found that Hispanic and Black patients, for example, were considerably more likely than Caucasian patients to not receive similar analgesic treatments in the emergency department. This phenomenon is also seen in chronic, obstetric, and cancer pain care. Understanding the effect of culture on the perception and expression of pain is an important foundation for improving the quality of care.
Pain is a subjective experience that is cognitively appraised by the individual, and culture influences how pain is characterized, how it is expressed, and what approach should be used to best manage it. Since understanding the factors that mediate these differences is critical to eliminating disparities in pain management, the effect that culture and ethnic differences can have on both the self-perception and expression of pain needs to be continuously assessed.
With regard to pain practices, cultures have historically been categorized into either stoic or expressive cultures. Patients from stoic cultures have learned to suppress expressing their pain, while those from expressive cultures tend to express their pain more.
Many traditional Chinese cultures, for example, believe the notion that expression of pain outside of childhood is undignified, and that its overt expression reflects weak social skills.
African Americans have similarly been known to underreport pain across clinical settings. Many African cultures also tend to express pain less. Bedouin women, in particular, despite reporting high levels of pain and fear, tend to remain silent and expressionless when giving birth according to one study 2.
Across studies, Hispanics also tend to report acute pain with high expressivity but underreport chronic pain. Hispanic patients in America may recognize chronic pain as prevalent among their communities and accept these types of lingering pains as a normal part of aging, leaving them undertreated.
Conversely, traditional Muslim Middle Eastern cultures possess spiritual definitions for many ailments. These cultures tend to instill a strong belief in a greater meaning behind their suffering. Their expression of pain remains unobstructed by external pressures, thereby generally allowing for more effective diagnoses of underlying etiologies in clinical settings.
Differences with regard to pain treatment can also profoundly influence the treatment of pain across cultures. For example, views on utilization of opioids in pain management is considerably different in Muslim societies than in western cultures. Among most patients from Muslim cultures, there is an underlying fear that opioids will interfere with their sense of self, a fear which may extend to nonopioid pain management medications. Muslims might fear that pain medications will inhibit them from communicating with loved ones, or that such medications might violate their religious beliefs.
Multidisciplinary research needs to continue to investigate cross-cultural models of pain and treatment in order for beliefs and expectations about pain to best be harmonized with practical solutions and effective evidence-based pain management in the clinic 3.
Disparities in pain management emerge from a complex interplay between individual, health care provider, and health system characteristics . There is a clear need for cultural awareness in the context of pain management 4, and in order to optimize patient comfort and adequately address pain, health care providers should continue to consistently aspire towards cultural competency and cultural humility. Understanding the effect that culture can have on an individual’s pain is essential for designing appropriate treatment.
References
1. Cultural Perceptions of Pain – Why It Matters | Anesthesia Experts. Available at: https://anesthesiaexperts.com/uncategorized/cultural-perceptions-pain-matters/. (Accessed: 24th June 2023)
2. Harrison, A. Childbirth in Kuwait: The experiences of three groups of Arab mothers. J. Pain Symptom Manage. (1991). doi:10.1016/0885-3924(91)90002-L
3. Peacock, S. & Patel, S. Cultural Influences on Pain. Rev. Pain (2008). doi:10.1177/204946370800100203
4. Briggs, E. Cultural perspectives on pain management. J. Perioper. Pract. (2008). doi:10.1177/175045890801801101