The Intersection of Pain and Culture ____________________________________________________________
sitivity and tolerance, and some groups will define a stimulus as “painful” while others will not [85]. Interpretations of Meaning When an event is perceived as distressing, the individual will then attribute meaning to the symptom. Two types of attribu- tions can be made: attributions of social significance or causal attributions. A social significance attribution involves an individual attaching a positive or negative social significance to the event. For example, a patient might believe that pain is reflective of a personal failure or character flaw [85]. Causal attribution involves attempting to determine the source(s) of a symptom or event (e.g., physical, psychologic/ emotional, or environmental factors) [86]. The method of help seeking is often partially influenced by causal attribution. For example, if pain is perceived to be emotionally rooted, then the individual might seek mental health or counseling services. In a study of 1,570 adults in Hong Kong, 25% attributed chronic pain to excessive physical work and self-treated with rest [147]. In Chinese cultures, pain may be attributed to an imbalance of yin and yang, with help then sought through acupuncture or herbal medications [5]. In cultures that believe pain is the result of spiritual unrest or imbalance (e.g., Hmong, Native American), patients may seek help from a traditional healer, shaman, or spiritual advisor [59; 72]. Some racial/ethnic minority patients (e.g., Navajo Indians) may be reluctant to seek help in places where people have died, including hospitals [66]. Social Context Dynamics Finally, an individual’s social, economic, and familial environ- ment will affect help seeking. The availability of resources (e.g., social network system, community, neighborhood, workplace, institutional organizations) will influence the type and extent of help available. In addition, social rules of exchange (e.g., who can partake in the resources, under what circumstances, and when they should be reciprocated) may also affect help seeking. Collectivistic cultures are more likely to provide assistance to members in their group, and it is expected that the individual will rely first on his or her family before seeking outside help [85]. Meanwhile, individualistic cultures expect that individu- als will first attempt to address and resolve the problem alone. After having taxed internal and external resources, they will then seek outside help [85]. FACTORS THAT CONTRIBUTE TO RACIAL AND ETHNIC DISPARITIES IN PAIN MANAGEMENT It is clear that health disparities exist among racial and ethnic minority groups, and this is true for pain management services and medications. A large-scale national study in the United States found racial differences in the prescription of analgesics for patients with migraine, low back pain, and bone fractures [87]. Specifically, African Americans were less likely to be pre-
scribed analgesics for their pain compared with their White counterparts. Racial minority patients are also more likely to experience longer wait times for medication compared with White patients [16]. In a 2023 study, Black patients with severe pain were less likely to receive analgesics compared with their White counterparts [202]. In a 2019 large-scale survey, African American patients were 6% and 7% less likely to receive opioids for abdominal pain and back pain, respectively, compared with White patients [172]. Hispanics were 6% and 14.8% less likely to be given opi- oids for abdominal and back pain, respectively, compared with White patients [172]. Analysis of a national dataset found that African Americans were less likely to be prescribed opioids for back pain and abdominal pain compared with non-Hispanic White Americans [148]. The authors speculate that racial biases may influence prescribing behaviors. An examination of Medicaid patients who received epidural analgesia during vaginal childbirth also found statistically significant racial/ ethnic differences [88]. In this study, 59.6% of the White patients received epidural analgesia, compared with 49.5% of African Americans, 48.2% of Asians, and 35.2% of Hispan- ics. Even after the researchers controlled for age, urban/rural residence, and the availability of anesthesiologists, race and ethnicity still predicted epidural analgesia prescribing trends [88]. In a systematic study about postoperative pain manage- ment, researchers found that African Americans reported more severe postoperative pain than their White counterparts, but White patients were more likely to be prescribed opioids for pain management [203]. In a meta-analysis of ethnicity and pain management, research- ers found that professionals under-rated ethnic minority patients’ levels of pain and were less likely to indicate their pain scores on their charts compared with their White counterparts [89]. In addition, African American and Hispanic patients were less likely to have been given analgesics than White patients. The result is that many patients feel their pain symptoms are minimized or that they are suspected of drug seeking [204]. Many factors contribute to these racial disparities. One factor may revolve around practitioners’ underlying biases, stereo- types, and mistaken assumptions, also referred to as implicit bias. For example, some practitioners may falsely attribute some level of innate “toughness” to African American patients based on the groups’ history of overcoming oppression and trauma [173]. Others may have an explicit or implicit belief that minor- ity patients are more likely to misuse prescribed opioids [174]. Studies have not definitively isolated the factors that contribute to these disparities. One of the challenges in understand- ing health disparities, and particularly pain management disparities, is the fact that racial and ethnic minority groups are heterogeneous [90; 125]. Recent immigrants from Japan, for example, are going to be very different from native-born Japanese who have resided in the United States for genera- tions [90]. However, researchers have often combined these groups, as challenges in recruitment yield small sample sizes
65
MDIL1526
Powered by FlippingBook