____________________________________________________________ The Intersection of Pain and Culture
a return to traditions, characterized by a renewed interest in ethnic foods, traditional religious practices, native language, and folklore [42]. Finally, ethnicity is also acknowledged as being a symbolic token, a way for individuals to maintain a nostalgic connection to their homeland [42]. Cultural competence exists on both the individual level (practi- tioner’s self-awareness) and the practitioner-patient relationship level. On an individual level, cultural competence training might focus on the expectations, preferences, and desires of culturally diverse patients or it might focus on practitioners’ worldviews and experiences [43]. To focus only on the indi- vidual (or micro) level neglects the macro, community, and organizational levels. Cultural competent pain management requires an understanding of the complex interplay of social and cultural factors on individuals’ perceptions, behaviors, and access to resources related to pain and pain management on micro, messo, and macro levels [157]. More extensive cultural competence training would help practitioners to see how social, economic, and political forces influence the patient-provider relationship and patients’ access to resources [43; 123]. For healthcare providers, cultural awareness involves four components [44]: • Ability to identify key cultural values of the patient • Understanding of how cultural values influence a patient and his/her environment • Skills to apply and implement services that are congruent with the patient’s value systems • Acknowledgement that awareness is a continual journey to learn about different cultural value systems and beliefs and apply them to Western intervention models Practitioners working with patients experiencing pain should be aware of the patient’s cultural value and belief systems and how they impact their pain experience and also how their own cultural background and professional culture/system affects how they view pain. Furthermore, culture can influence access to and utilization of pain management services and medica- tions and provider communication [136; 157]. For the most part, practitioners are trained and socialized from a biomedical tradition [45]. Practitioners should reflect on their own experi- ences and the values and beliefs they attribute to pain [46]. Furthermore, it is important to exhibit cultural humility by forfeiting the role of expert and learning and understanding the lived experiences of patients living in pain [158]. Take a moment to consider the following self-reflective ques- tions [46]. Pain Experiences in Childhood • When you were a child, how did those who cared for you react when you were in pain? • How did they expect you to behave when you had a minor injury?
• How did they encourage you to cope when you had severe pain? • How did they encourage you to behave during an injection or procedure? • When those who cared for you as a child were in pain, how did they react? • What words did they use to describe the pain?
• How did they cope with their pain? • Do you tend to follow their example?
Pain Experiences in Adulthood • What painful experiences have you had as an adult (e.g., childbirth, fracture)? • How did you express (or not express) your pain? • Did the pain cause you fear? What were you afraid of? • How did you cope with the pain? • How did you want others to react while you were in pain? Pain Experiences by Patients • Have you ever felt uncomfortable with the way a patient was reacting (or not reacting) to pain? • What did the patient do that concerned you? • Why did you feel that way? • Do you make value judgments about patients in pain who: – Behave more stoically or expressively than you would in a similar situation? – Ask for pain medication frequently or not often enough? – Choose treatments you do not believe are effective or with which you are unfamiliar? – Belong to a cultural group (e.g., ethnic, linguistic, religious, socioeconomic) different from your own? • Do you tend to feel certain reactions to, descriptions of, or treatments for pain are “right” or “wrong?” What about these reactions makes them seem right or wrong?
CULTURAL DEFINITIONS AND EXPRESSION OF PAIN
The complexities of culture, race, and ethnicity and how they influence the meanings, definitions, and expression of pain are not completely understood. Studies have not delineated a clear model or pathway, but there is consensus that pain is more than just a biologic or physiologic response; there appears to be an interplay of biologic, social, psychologic, and environment factors. From a biopsychosocial perspective, how individuals react to a pain stimulus may be influenced by how they were socialized within their familial and cultural background [47].
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