The Intersection of Pain and Culture ____________________________________________________________
CLOSED-ENDED QUESTION PAIN RATING SCALES Pain rating scales can be categorized as either unidimensional or multidimensional. As the term indicates, unidimensional scales assign a number to a single dimension of a concept. For example, a unidimensional scale might measure pain intensity. Typically, these scales are easy to administer and cost and time effective [100]. Examples of unidimensional pain scales include a numerical pain rating scale, a visual analog scale, and a verbal descriptor scale. All these pain-rating scales are self-reports from the patient, which is the most reliable regardless of age, communication, or any other factor [150]. Unidimensional Pain Scales Unidimensional pain scales measure the patient’s self-reported pain intensity [150]. The numerical pain rating scale is a self- report scale whereby the practitioner asks the patient to rate their pain on a scale of 1 to 10 or 1 to 100 (from least to most severe) [100]. Some patients, particularly those with lower English proficiency, may have difficulty using numerical rat- ings to convey changes in pain quality and intensity over time [158]. Choosing a favorite number or a sacred or meaningful number is common in some groups [163]. With the visual analog scale, the patient is asked to mark her or his current level of pain on a horizontal line, where one end of the continuum is anchored with “no pain” and the other end is anchored with “extreme pain” [100]. It has been argued that this scale is more sensitive than the numerical pain rating scale [100]. Finally, a verbal descriptor scale asks the patient to consider his or her level of pain, and it consists of several numerically ranked adjectives or verbal descriptors. For example, 0 means “no pain,” 1 is “mild,” 2 is “moderate,” 3 is “severe,” and 4 is “unbearable” [101]. The problem with the verbal descriptor scale is that because pain is subjective, the descriptors may only be an artificial assessment of the patient’s perceived pain. For example, the term “severe” and “unbearable” may have different connotations for each indi- vidual [101]. A review of articles written on these three scales concluded that they all have good validity and reliability and are practical for clinical purposes [102]. Generally, patients appear to have more challenges in understanding the visual analogue scale than the verbal descriptor or numeric rating scales. The numerical rating scale has good sensitivity and appears to be the easiest to use and comprehend [102]. The most popular unidimension pain scales are the numeric rating scale, the visual analog scale, and the verbal rating/descriptor scale [150]. Multidimensional Pain Scales Multidimensional scales for pain assess for more than one attribute or dimension of pain [101]. Examples of multidi- mensional scales for pain include (but are not limited to) the McGill Pain Questionnaire, the Brief Pain Inventory, the Dartmouth Pain Questionnaire, and the West Haven-Yale Mul- tidimensional Pain Inventory. The McGill Pain Questionnaire is one of the most popular multidimensional measures of the sensory, affective, and evaluative dimensions of pain, assessing
increase when the patient and healthcare professional share the same skin color or are of the same ethnic group [97; 131]. PATIENT-RELATED BARRIERS Patient barriers to effective pain management include fear and anxiety about substance misuse and addiction, cultural values such as fatalism (i.e., pain is inevitable), and ideas about being a good patient [91]. Cultural values about pain coping, definitions, expression, and experience may also be patient- related barriers. For example, those with a fatalistic perspective of pain are often stoic. A qualitative study of Somali women found that the participants felt wailing or crying about one’s pain was a sign of weakness [52]. Similarly, Hispanics and African Americans are more likely to embrace the importance of being stoic and are less likely to ask for pain medication [89]. Sometimes, stoicism is tied to historical experiences with oppression and trauma. In a 2015 study, Aboriginal people in two rural communities indicated that mistrust of Western medicine kept them from expressing their pain [176]. Studies also show that Hispanic and African American patients with cancer tend to under-report their pain for fear of being labeled as complainers or of distracting their physicians treating their illness [98]. Some patients will not ask questions for fear that would be viewed challenging an authority figure [143]. Some ethnic/racial minority patients disclose that they avoid pain medications because they overestimate the risk dependence [99; 141; 143]. CULTURALLY SENSITIVE ASSESSMENT OF PAIN It is important to remember that assessment is an ongoing process. Practitioners may use closed-ended and open-ended assessment questions to evaluate the patient’s level of pain. A combination of closed- and open-ended assessment questions is recommended, as they both have their merits and limitations.
According to the Institute for Clinical Systems Improvement, the use of pain scales has been part of pain treatment for many years and has become standard practice. Pain scales should be posted for the patient to understand what the scale
means. Clinicians can reassure patients by explaining that two people may have a different score for the same type of pain. (https://www.icsi.org/guideline/pain. Last accessed September 27, 2024.) Level of Evidence : Expert Opinion/Consensus Statement
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