____________________________________________________________ The Intersection of Pain and Culture
In a study of Cantonese Chinese individuals in Hong Kong, 597 different pain descriptor terms were distinguished [56]. In a study with participants from Cameroon, French-speaking females were more likely to use the word “crying” to connote an emotional state associated with the pain [162]. However, those who spoke Pidgin did not refer to pain physically (i.e., as a sickness) rather than an emotional state [162]. Some cultural groups have languages that are rooted in storytell- ing and symbols, and descriptions of pain in these groups may include vivid imagery. In a study with 10 Native Americans, the participants tended to use terminology rooted in nature to describe their pain [58]. Terms like “stretching,” “throb- bing,” and “pulling” were common, and neuropathic pain was described as “hot lava,” “freezing,” “sparks,” and “electric shocks.” Some Native American participants employed the word “ache” even for extreme pain [163]. In a study of 101 Nepalese patients diagnosed with chronic musculoskeletal pain, 52% used metaphors (e.g., “like an infection,” “like an ant bite,” “like sleeping hands/feet”) to describe the intensity or quality of their pain [139]. However, it is important for practitioners to avoid generalizing and applying an attribute for all groups or all members of a group. In some cases, age or generation might account for certain trends. For example, older Hmong patients were more likely to use storytelling compared with younger Hmong patients [196]. The underlying meanings of phrases are equally important. For example, descriptions of pain may be laced with underly- ing pride and achievement or fatalistic undertones. Some groups, including African Americans, Chinese, Koreans, and Mexican Americans, may view pain as an inevitable part of life, which can affect the way in which pain is experienced and described [59]. Other pain expressions may reflect idioms of distress, describing suffering in a cultural meaningful man- ner [164]. However, it is important not to stereotype and not to pathologize a group, as there is a tremendous amount of within-group diversity [60]. MEANINGS AND DEFINITIONS OF PAIN Individuals construct and attach different meanings to pain (referred to as pain cognitions). These meanings are linked to personal and/or cultural beliefs and norms and at times, religious or spiritual beliefs [165]. A common theme in many cultures is that pain is a part of the human experience [2]. In these cases, coping with pain with stoicism and a high degree of self-control is highly valued because it is part of learning key lessons in life [2]. In some cultures, children are told stories of heroes who meet challenges head on and who do not complain about their suffering [140]. The goal is to socialize children (and adults, by extension) to cope with life’s challenges and pain with resiliency and stoicism. For these patients, complaints will be avoided; it is more important to be perceived as a “good patient” [141].
In many Hispanic cultures, for example, life is believed to be full of trials that should be met and accepted with patience and without complaining [2]. Qualitative studies have found that Mexican Americans tend to believe that it is their duty (to God, their family, and community) to endure pain stoically [61; 62; 142]. The cultural value of machismo also has a functional role in health beliefs and behaviors. Part of machismo is the belief that men should be protectors and providers. Being in pain is viewed as contrary to these roles; therefore, being healthy is essential to fulfilling one’s role as a man [166]. This value has been linked to the stoicism and duty promoted in Aztec and Mayan cultures. For these individuals, pain is not just a physical experience but encompasses social, familial, interpersonal, and spiritual factors as well. Some patients may feel that pain is bestowed by God and/or is part of familial or societal obligations. By extension, they may consider caring for others in pain to be an important or even sacred duty [62]. In these cases, perceptions of pain are clearly linked to religious and spiritual views. Many Asian cultures also adhere to similar definitions and views about pain. For example, in Chinese culture, pain has three philosophical/religious foundations: Taoism, Buddhism, and Confucianism [5]. Taoism argues for harmony with the environment, whereby people live and adapt themselves to the order of nature [5; 167]. In terms of pain, Taoism argues that pain occurs if qi , the life energy, is blocked; resolution of pain requires the individual to restore harmony with the universe [5; 198]. In Chinese medicine, five elements play a role in health: water, fire, wood, metal, and earth. The goal is to keep all five elements in balance. Imbalances (e.g., dampness and cold) can affect the body and cause pain [168; 198]. Buddhism regards pain as a part of the human experience that must be experienced alone, with the knowledge that it is a temporary state. Finally, Confucianism focuses on adhering to a social order, in which loyalty to parents and family is paramount. According to this philosophy, pain is also a part of life and serves as a reminder of humanity [5; 167]. Knowledge of this background provides a frame of reference when working with Chinese patients and attempting to understand how they might construct meaning and what types of interventions may be most appropriate [5]. Many Chinese patients will avoid verbal- izing their pain or suppress moans of pain, because stoicism is a highly valued cultural virtue [143]. They may not report pain until it becomes unbearable. In a qualitative study, non-Hispanic White and Native Ameri- can participants’ terminologies to describe injury and the role of pain were explored [169]. Non-Hispanic White individuals were slightly more likely to use the word “pain” and believed that pain symptoms were an underlying manifestation of some illness or abnormality. Native American participants tended to ascribe pain to cultural and historical events. This is similar to a study of Hmong patients, in which some participants attributed the cause of their pain to their experiences during the Vietnam War, when they had to carry heavy baskets of
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