Influences of Culture on Pain Perception and Management

Cultural Influences on Pain Danielle Sorrentino-Brightman, Ed.D., MHA Charlotte County Medical Society 2023-2024

Overview The connection between pain and ethnicity is influenced by personal experiences, education, and cultural background.. Mistaken beliefs about pain and disability are not culturally specific obstacles to treatment seeking or compliance with treatment outcomes. A cultural group's expectations and acceptance of pain as a normal part of life will determine whether pain is seen as a clinical problem that requires a clinical solution. Based on the reviewed literature, it is evident that there are disparities in pain treatment that are influenced by an individual's ethnic background. Multidisciplinary research needs to investigate the models of pain and treatment in different cultural groups to allow us to understand how pain is presented and how beliefs and expectations about treatment can be married with practical solutions and effective evidence-based pain management.

Introduction As ethnic diversity increases, healthcare providers are faced with the challenge of meeting the needs of patients from different cultures and providing culturally relevant healthcare. Therefore, it is becoming increasingly important to understand how race and ethnicity influence pain management. Cross-cultural differences are evident in many aspects of human behavior, illness prevalence, and healthcare usage. Cultural factors play a significant role in shaping beliefs, behavior, perceptions, and emotions, all of which have important implications for health and healthcare. Culture influences illness behavior in several ways, including defining what is considered normal or abnormal, determining the cause of illness, influencing decision-making control in healthcare settings, and impacting health-seeking behavior.

LABORATORY PAIN STUDIES Studies conducted in laboratories have suggested that there may be differences in experimental pain sensitivity among different ethnic groups. However, some other research has questioned this finding. According to one study, African-Americans are more sensitive to experimental pain stimuli than non-Hispanic Caucasians. Another study focused on South Asian males and White British males and found that South Asian males had significantly lower thermal pain thresholds and experienced higher pain intensity than White males. It is important to note that these differences were only observed for thermal pain, and no differences were reported for cold pain threshold or heat unpleasantness. Studies have shown that there may be ethnic differences in acute clinical pain, such as post- operative pain, low back pain, and exercise-induced angina. African-American patients have reported greater pain intensity than Caucasians in some studies, but we should be cautious in interpreting these results as other studies have failed to find any ethnic differences in acute clinical pain. Additionally, some studies have found that when matching ethnic groups on certain confounding variables such as education, pain duration, and work status, the differences in pain- related consequences and emotional distress may be reduced. The race/ethnicity of the experimenter is rarely documented or controlled. Some studies have suggested that the experimenter's gender has been found to influence results. It could be that similar effects occur in the context of ethnic characteristics.

FACTORS INFLUENCING THE CLINICAL SITUATION Pain beliefs are brought to the clinical setting by both the clinician and the patient, and they can have a significant impact on the care provided. Misconceptions about the nature of pain and disability, reluctance to seek treatment, failure to comply with treatment, and unwillingness to accept responsibility for the treatment outcome are not specific to any culture or subculture, and they can all pose obstacles to effective pain management. Although pain is a private experience, it can be influenced by social, cultural, and psychological factors, which can determine whether private pain is expressed as pain behavior, the form this behavior takes, and the social context in which it occurs. The decision to express private pain as public pain behavior depends on how the pain is interpreted, such as whether it is considered "normal" or "abnormal," with the latter being more likely to be brought to the attention of others.

FACTORS INFLUENCING THE CLINICAL SITUATION CONT Every cultural and social group has its own unique way of expressing pain and distress. People who are ill or unhappy have specific, often standardized ways of communicating their suffering, both verbally and non-verbally. The form that this pain behavior takes is largely determined by culture, as is the response to this behavior. This depends on factors such as whether their culture values or disvalues the display of emotions, postural mobility, or verbal expression in response to pain or injury. Some cultural groups expect an extravagant display of emotion in the presence of pain, but others value stoicism, restraint, and playing down the pain. According to Zborowski, whether a cultural group considers pain as a normal part of life or a clinical problem that requires medical attention, determines their expectations and acceptance of it. This is evident from the observations made on Australian aborigines. Despite a significant number of men and women reporting back pain, they did not perceive it as a health issue and hence did not display pain behavior, report symptoms or seek medical treatment unless asked. Similarly, a study conducted in rural Nepal found that back pain was common, but people did not seek medical help even when facilities were available. In this case, the symptoms of back pain were not considered a medical issue but rather a part of the aging process.

FACTORS INFLUENCING THE CLINICAL SITUATION CONT According to the literature reviewed by Bonham, there are disparities in pain treatment based on the patient's race or ethnic background. The review found that Black and Hispanic patients were more likely to receive inadequate pain treatment across different types of healthcare facilities and treatment settings, including emergency rooms, community hospitals, and nursing homes. These disparities are believed to be caused by stereotyped perceptions of race and ethnicity, language barriers, socioeconomic status, doctor-patient communication, and clinical assessment of pain. According to Carey & Garrett, there are significant disparities in the way Black and White patients are treated for back pain. Despite recording worse disability and higher pain scores on a 10 point scale, Black patients are considered less likely to have disc disease and to have less pain than White patients by clinicians. Additionally, Black patients are less likely to receive radiographs or advanced imaging studies, even after controlling for income, education, insurance status and baseline severity scores of low back pain. Interestingly, the incidence of hospitalization and surgery for back pain is significantly lower in Black patients than in White patients.

IMPROVING THE SITUATION Davidhizar and Giger have suggested some practical solutions to reduce disparities in pain management. Although many pain assessment tools have been translated into different languages with varying levels of reliability and validity, it is crucial to use the appropriate cultural and linguistic tool. The basic pain assessment tool has limited usefulness and should be supplemented with reports from the patient and their families to ensure accurate pain information is obtained and culturally appropriate care is provided. It is crucial for healthcare professionals to understand both verbal and non-verbal expressions of pain to avoid misdiagnosing patients with both pain and a hysterical emotional disorder. Cultural responses to pain are often categorized as stoic or emotive, but it is important to investigate the reasons behind non-verbal behavior. Research has shown that healthcare professionals are more responsive to pain communication from patients of the same culture and less understanding of those from different cultures. Healthcare providers must recognize cultural differences in pain perception.

IMPROVING THE SITUATION CONT Healthcare providers should consider ethnic differences in drug metabolism, dosing requirements, therapeutic responses, and side effects when treating pain. It is crucial for health professionals to engage in personal reflexivity to enhance their self-awareness of values and beliefs. Reflexivity can help prevent ethnocentrism, which is the belief that one's culture is superior to others, and enable health professionals to recognize that personal biases can affect their responses to pain management.

CONCLUSION Policy documents emphasize the importance of valuing individuals and taking into account their views and experiences. However, there is a concern that ethnic minority communities may not receive the same level of treatment for painful conditions as the host nation. Studies have shown that people from ethnic groups are provided with less preventative healthcare, medication, and secondary referrals than host nationals. To address this issue, it is necessary to conduct multidisciplinary research that integrates basic clinical and health service research methodologies into practical interventions for ethnic and minority groups. This will help overcome the barriers that prevent them from accessing pain management.