____________________________________________________________ The Intersection of Pain and Culture
that make it difficult for statistical analyses to be meaningful. The literature has identified a variety of reasons for these disparities stemming from several factors [91]. BARRIERS RELATED TO WESTERN BIOMEDICAL CULTURE Western biomedical culture emphasizes a clear dichotomy between the mind and the body as well as what is observable (objective) and what is not (subjective) [92]. Pain is not easily measured, making its assessment and treatment a challenge in Western medicine [92]. In addition, many healthcare professionals may not be adequately trained to incorporate spirituality in the management and treatment of pain for patients who desire to incorporate a more holistic approach [93]. The Western American medical paradigm also leans toward cure rather than care [92]. Patients who present with symptoms that lead to a diagnosis for which there is a clear pathway of interventions and treatment are “favored.” Fur- thermore, in terms of pharmacologic pain management, the Western biomedical model has stigmatized addiction, result- ing in stigmatization of patients who seek pain management medications [205]. Because of the subjective nature of pain, healthcare professionals must often make clinical decisions in the face of a lack of absolute, clear physical evidence [94]. This is complicated by the fact that, in the biomedical model, the relationship between the practitioner and the patient positions the practitioner as the expert, with authority and power, and the patient as subordinate [205]. SOCIETAL AND INSTITUTIONAL BARRIERS Societal and institutional barriers include racism, discrimina- tion, poverty, lack of health insurance, and deleterious environ- mental factors in communities [7]. For example, groups that have historically (or currently) been victims of institutional racism and discrimination are more likely to delay seeking help for pain [89]. For example, some studies indicate that African American men may experience higher levels of pain intensity in part due to their experiences with different forms of racial discrimination [16]. Even today, racial and ethnic minority patients are more likely to be placed in a negative valenced relationship [94]. In the context of pain management, healthcare providers are more likely to discount the pain due to the negative valenced relationship triggered by racism and discrimination [94]. It has been shown that physicians tend to have less involved communication and less participatory interactions with racial minority patients and low-income patients [92]. In one study, when Hispanic patients visited physicians for back pain, their encounters were 1.6 minutes shorter compared with non- Hispanic White patient visits [172]. In addition, the stereotype that certain racial minority groups come from chaotic and dis- organized families and environments increases the likelihood of healthcare professionals labeling them as “difficult.” Just as healthcare professionals may have preconceived notions about patients, patients may have pre-existing assumptions about the
provider. For example, one study of Native American patients found that the participants tended to feel that healthcare professionals were not interested in hearing about their pain experience and did not have confidence that they would be helped [72]. Thus, a cycle of myths and stereotypes continues. One oft-cited study found that three-quarters of pharmacies located in areas of New York City with a high proportion of racial and ethnic minority residents did not stock adequate supplies of opioid analgesics [95]. One study found that only 25% of pharmacies in a predominately racial/ethnic-minority neighborhood were well supplied with opioids, compared with 72% in predominantly White neighborhoods [163]. Some pharmacists attributed the low supply to lower demand, but others cited factors related to racism and discrimination. In addition, pharmacies in areas with high concentrations of racial minorities are more concerned with burglaries, addi- tional regulations, and penalties imposed by state and federal drug-enforcement agencies than pharmacies in predominantly White neighborhoods [95].
HEALTHCARE PROFESSIONAL-RELATED BARRIERS
Healthcare professional barriers may include professionals’ beliefs about appropriate pain management; lack of training and knowledge about the intersection of pain and culture, race, and ethnicity; lack of culturally sensitive assessment for pain; and expectations about racial and ethnic minority pain patients based on stereotypes [96]. For example, the belief that African Americans’ skin is thicker than White skin and therefore experiences less pain is a common myth [175]. Con- sequently, practitioners may underestimate and minimize racial minority patients’ pain experiences. There is also a phenomenon of fundamental pain bias, mean- ing one’s own pain reports are viewed as more accurate and objectively communicated; conversely, individuals tend to believe that others exaggerate their pain. When there is racial/ ethnic discordance between the practitioner and patient, the practitioner is more likely to consider reports of pain as exagger- ated [206]. In a qualitative study, Native American individuals described their complaints of pain being dismissed, receiving inadequate care, and neglected aftercare [149]. Practitioners may also have implicit or explicit biases about individuals from lower socioeconomic backgrounds. These patients are often viewed as being less competent, unable to control medication use, and less compliant with medical regimens [207]. Studies have also shown that the language and race/ethnicity of the healthcare professional influences pain management. For example, the ratings of pain tend to be comparable when the patient and healthcare provider speak the same language. When there is a native language, pain ratings tend to diverge. When literacy and language barriers are eliminated, assessment and treatment improves and racial and ethnic minority patients with pain fare better [146]. In addition, healthcare professionals’ level of empathy appears to
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