#77033: The Intersection of Pain and Culture

"African American" is a classification that serves as a descriptor; it has sociopolitical and self-identification ramifications. The U.S. Census Bureau defines African Americans or blacks as persons "having origins in any of the Black racial groups of Africa" [17].

According to the U.S. Census, African Americans number 49.6 million as of 2021 [31]. The state with the largest African American population, numbering at 3.9 million, is Texas [187]. By 2060, it is projected they will comprise 17.9% of the U.S. population [31]. In terms of a metropolitan city in the United States, New York City had the largest concentration of African Americans in 2022, numbering at 3.6 million [188]. This group tends to be young; in 2022, the median age of this population was 32.1 years, compared with a nation median age of 38 years [188]. In terms of educational attainment, 90.3% of those 25 years of age and older have a high school diploma or have completed college [31].

As of 2021, 24.0 million Americans identified as Asian [189]. California had the largest concentration of Asians (6.5 million) followed by New York (1.8 million) [57]. Between 2000 and 2019, Asians experienced the greatest growth (81%) compared with any other racial group [133]. Between 2016 and 2017, this group had the highest growth rate at 3.0% [132]. The Chinese group represents the largest Asian subgroup in the United States, and it is projected that this population will grow to 35.7 million between 2015 and 2040 [20,21]. In 2021, Chinese Americans numbered 5.2 million; this number does not include Taiwanese individuals [189]. They also have the highest educational attainment of any racial/ethnic group; 55.1% of Asian Americans 25 years of age and older have a bachelor's degree or higher [189].

"Asian" is a single term widely used to describe individuals who have kinship and identity ties to Asia, including the Far East, Southeast Asia, and the Indian subcontinent [22]. This encompasses countries such as China, Japan, Korea, Vietnam, Cambodia, Thailand, India, Pakistan, and the Philippines. Pacific Islander is often combined with Asian American in census data. The Pacific Islands include Hawaii, Guam, Samoa, Fiji, and many others [22]. There are more than 25 Asian/Pacific Islander groups, each with a different migration history and widely varying sociopolitical environments in their homelands [23].

Asian American groups have differing levels of acculturation, lengths of residency in the United States, languages, English-speaking proficiency, education attainment, socioeconomic statuses, and religions. For example, there are approximately 32 different languages spoken among Asian Americans, and within each Asian subgroup (e.g., Chinese), multiple dialects may be present [23,24]. The diversity of this group makes generalizations difficult.

The term "Hispanic" refers to individuals who self-identify as having origins in Spain or Spanish-speaking countries, such as Mexico, Guatemala, Peru, Ecuador, or the Dominican Republic [25]. Persons of Latin American descent or origin are considered Latino/a/x.

In 2022, there were 63.7 million Hispanics in the United States, which represents 19.1% of the U.S. population [185]. The majority of the Hispanic population in the United States (63.3%) identify themselves as being of Mexican descent [26]. Approximately 27% of the U.S. Hispanic population identify as Puerto Rican, Cuban, Salvadoran, Dominican, Guatemalan, Colombian, Honduran, Ecuadorian, or Peruvian [26].

By 2060, Hispanics are expected to represent 31% of the U.S. population [132]. In 2019, the three states with the largest Hispanic population also had the most growth: Texas, California, and Florida [154]. They are also a young group, with a median age 30.7 years in 2022 [185].

The Native American population is extremely diverse. According to the U.S. Census, the terms "Native American," "American Indian," or "Alaskan Native" refer to individuals who identify themselves with tribal attachment to indigenous groups of North and South America [29]. In the United States in 2023, there are 574 federally recognized tribal governments and 324 federally recognized reservations [190].

In 2022, it was reported that there were 7.3 million Native Americans in the United States, which is approximately 2% of the U.S. population [190]. By 2060, this number is projected to increase to 10.1 million, or 2.5% of the total population [135].

In general, this group is young, with a median age of 31 years, compared with the general median age of 37.9 years [155]. According to the 2020 U.S. Census, the top five states with the greatest number of residents identifying as Native American are Oklahoma, Arizona, California, New Mexico, and Texas [191]. In 2022, this group had the highest poverty rate (25%) of any racial/ethnic group in the United States, more than double the national poverty rate of 11.5% [192].

There are two main aspects of pain experience: expectancy and acceptance [48]. Pain expectancy refers to an individual's expectation or anticipation of pain as inevitable and/or inescapable [48]. The inherent degree of pain expectancy will vary from individual to individual. Pain acceptance is an individual's attitude toward pain—the extent one is willing and able to handle and endure pain [48]. Cultural beliefs and norms can influence both pain expectancy and acceptance, as evidenced by studies illustrating differences in pain perception and tolerance in various racial/ethnical groups.

In general, research indicates that African Americans tend to experience pain more intensely and tolerate pain less than their white counterparts [137]. In one study, African American college students rated thermal pain stimuli more unpleasant compared with their white counterparts, but the underlying mechanisms to explain these racial differences are unclear [49]. Another experimental study found that African American women were more sensitive to pain compared to their White counterparts [159]. Some studies have shown that, compared with children from other racial groups, African American children require higher doses of morphine to alleviate pain [137]. These differences may be due to genetic differences in CYP450 2D6 pathway, which is responsible for metabolizing opioids [137].

An experimental study was conducted to examine the extent to which ethnic identity predicts pain sensitivity to three different types of pain—thermal, cold, and ischemic—among African American, Hispanic, and non-Hispanic white adults [50]. The researchers found that African American and Hispanic participants demonstrated lower tolerance to cold and heat pain compared to their white counterparts. The researchers suggest that chronic stress, socialization in exhibiting pain, and acculturation could all play a role in explaining such ethnic differences [50].

In a study that compared pain levels of Latino and white adults, a pain stimulus was administered (i.e., a blood pressure cuff was inflated and held for three minutes). In general, Latinos reported greater pain compared to their white counterparts [138]. A separate study examined the role of acculturation on pain perception in a sample of undergraduate Asian American and white students [51]. Research participants were engaged in a cold pressor task (immersing their non-dominant hand in a cold-water bath for as long as tolerable) to trigger acute pain. Pain response was higher for first-generation Asian Americans, who removed their hands earlier than other study participants, demonstrating lower pain tolerance. This finding was replicated in a 2018 study that found higher levels of acculturation among Asian American participants correlated with greater heat pain tolerance [160]. Again, it was speculated that acculturative stress and chronic stress pertaining to immigration (including experiences with discrimination and racism) made this group more sensitive to pain [51]. This sensitivity could be triggered by physiologic exhaustion and reduced coping mechanisms resulting from such chronic stress [51].

Differences in pain acceptance or tolerance may also be explained by how likely individuals are to report pain. Some cultural groups may be less likely to disclose pain because they do not want pain medication or because they fear stigmatization [194]. Others adhere to a more holistic view of health, whereby pain is a symptom of an imbalance of physical, social, emotional, and spiritual factors. Differences can also be accounted for by implicit or explicit biases regarding some patient groups. For example, a study of medical students found that they attributed a perceived higher tolerance to pain among Black patients to less-sensitive nerve endings; some thought it was due to their thicker skin compared to White patients [195].

The terms used to describe pain are also influenced by culture. Women tend to use more expressive language when communicating pain, tending to use words such as "throbbing," "sharp," and "stabbing" [161]. Men tend to use less expressive language, perhaps due to cultural norms supporting stoicism for men. For example, in a study with Somali women, the participants used the same word to describe a host of painful circumstances ranging from cuts and fevers to childbirth, because the Somali term xanuun means both pain and illness [52]. In another study, terms such as "pain," "ache," and "hurt" were used by Hispanics, Native Americans, African Americans, and whites to refer to painful events or conditions [53]. However, the terms conveyed a different level of pain severity and intensity depending on the race/ethnicity of the subject. In a study conducted to explore racial differences in descriptors employed by African American and white American patients who had experienced myocardial infarction, African Americans were more likely to use "atypical" descriptions for their pain, such as "sharp" or "miseries" [54,55]. One study found that older African Americans tended not to use the word "pain," as this term is reserved for severe discomfort, and instead used the terms "hurt" or "sore" [16]. More bothersome pain was described as "nagging" or "miserable." Similarly, the Hmong language does not have a word for "pain," so they use the word "hurt" because it is the closest in translation [196]. In another study, healthcare practitioners reported that Hmong patients employed minimal or no descriptors or adjectives for their pain, making it difficult for practitioners to evaluate pain intensity [197].

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 storytelling 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," "throbbing," 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 underlying 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 manner [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].

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 verbalizing 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 American 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 food, their siblings, or banana stalk [196]. Native Americans were also more likely to view pain within the larger holistic context of the mind, body, emotions, and spirit [63]. As such, pain treatment should address each of these dimensions. In one study, individuals in rural Nepal reported the belief that pain is part of the aging process and is endured without the need to seek help [170].

In a study of black Caribbean and white patients being treated for cancer, the black Caribbean patients were more likely to attribute their cancer (and related pain) to a testing of their faith (i.e., loyalty to God) and to consider the diagnosis to be an opportunity to strengthen and confirm their religious beliefs [64]. Because the meanings of pain are interwoven with religion and spirituality, it is not surprising that pain is linked to past sins and immoral behaviors in many cultural groups. Similarly, some cultural groups attribute the cause of pain to mysticism or "the evil eye" [144]. Some patients may feel that their pain is a result of wrongdoing—a justifiable retribution [64,193]. In some religions, prayer and other religious rituals may be done as a means to cope and atone for sins [65]. Similarly, some cultures believe pain symptoms are the result of an imbalance or a lack of harmony and may seek traditional healers to restore order (e.g., by performing a ritual or ceremony) [66,194]. Overall, patients from Western societies tend to attribute pain to biological factors; other cultures are more likely to give a metaphysical explanation, including karma, evil, family wrongdoing, sin, and/or weakness. In these cultures, pain does not automatically mean that one should seek medical treatment. Instead, it may signify hardship and the need to build character and resilience [180].

Communication consists of verbal and nonverbal components, both of which are embedded within the culture of the parties disseminating and receiving the information. In the context of pain, the term "pain response" is used to refer to the verbal (e.g., wailing, verbal complaints about pain symptoms) and nonverbal (e.g., facial expressions, body gestures) expressions of pain [67]. In order to understand how culture influences the communication of and coping with pain, it is first important to understand the role of high- and low-context cultures within the larger perspective of communication styles.

Styles of communication can be classified on a continuum from high to low context [68]. High-context cultures rely on shared experience, implicit messages, nonverbal cues, and the relationship between the two parties to disseminate information [69]. Members of these cultural groups tend to listen with their eyes and focus on how something was said or conveyed [68,70]. On the other hand, low-context cultures rely on verbal communication, or what is explicitly stated in the conversation [69]. Consequently, low-context communicators listen with their ears and focus on what is being said [68,70]. Western culture, including the United States, can be classified as a low-context culture. On the other hand, groups from collectivistic cultures, such as Asian/Pacific Islanders, Hispanics, Native Americans, and African Americans, are considered high context [68]. Clearly, adherence to cultural values influences communication styles. Cross-cultural communication is by no means simple, and there is no set of rules by which to abide. Instead, promoting culturally sensitive communication is an art that requires practitioners to self-reflect, be self-aware, and be willing to learn. Therefore, as practitioners become skilled in noticing nonverbal behaviors and how they relate to their own behaviors and emotions, they will be more able to understand their own level of discomfort and comprehend behavior from a cultural perspective [70].

In-depth interviews with Somalian women living in Sweden revealed that their pain is often communicated through body language as opposed to explicit verbal expression [52]. Most of the women indicated that they had experienced pain symptoms for a long time before communicating them to others. To be extremely expressive with one's pain (e.g., loud crying, wailing) was also viewed as unacceptable [52]. Similarly, in a qualitative study with Chinese women, the participants believed that pain should be dealt with stoically [71]. A separate study found that Asian Indian students were less likely to find overt expressions of pain acceptable compared with their American-born Indian counterparts [67]. Native Americans prefer to "block" all discussion and thoughts of pain [72]. A key theme that emerged in a focus group study about the expression of pain among patients and families in Ethiopia was perceived bravehood for stoic responses [39]. Focus group participants discussed how hiding one's pain is a sign of strength; tolerating pain was considered brave [39]. In many indigenous groups, endurance of pain is seen as a rite of passage to maturity and signifies courage [199].

Conversely, some cultural groups may be more likely to directly express pain. Studies have observed greater willingness to overtly express pain in American society, with a greater tendency to seek help from pain professionals and prescribed analgesics [67,73].

Coping is defined as the use of behavioral and cognitive strategies to relieve the internal or external environmental stressors that stretch an individual's strengths and resources [74]. These strategies have been categorized as active or passive. Active coping strategies are characterized by directive problem-solving techniques, actively seeking social support, and employing reappraisal methods to reassess the situation. In a quantitative survey with 90 Filipino migrant workers, the use of diversion and cognitive coping skills helped control pain better than reinterpreting and catastrophizing [200]. Meanwhile, passive coping strategies emphasize avoidance and utilizing techniques such as distancing, escaping, wishful thinking, and self-control [75]. In terms of coping or managing pain, individuals employing active coping strategies would attempt to stay busy, focus less on the pain, place their energies on another activity, and continue with normal activities of daily living [76]. Meanwhile, those in pain employing passive coping strategies may escape the pain by using wishful thinking, venting, or catastrophic thought patterns [76]. Some studies have found that active coping methods and positive reappraisals assist in improving well-being among individuals experiencing pain; those who use passive coping strategies such as wishful thinking and blaming oneself have poorer levels of well-being [77]. Catastrophizing is a coping method whereby one focuses on the pain stimulus, overstates the threat of the pain, and ultimately holds the belief that one cannot handle the pain [78]. Not surprisingly, this coping strategy is related to experiencing higher levels of pain, increased use of medication, and increased use of healthcare services across different age groups and different types of pain [78,79].

Certain cultures/ethnicities display a greater tendency for catastrophizing, which may be at least partially explained by a culture categorization of collectivistic or individualistic. Individualistic cultures place an emphasis on individuality and an internal locus of control, with challenges often attributed to modifiable environmental factors [80]. In general, white European and American cultures tend to be individualistic. Those from individualistic cultures are believed to be more likely to use active coping strategies in order to "manipulate" their environment to deal with pain and more likely to withdraw into themselves [52]. Collectivistic cultures emphasize the collective unit, interpersonal relationships, and the support system, and those from collectivistic cultures often display an external locus of control [81]. Many racial/minority groups are categorized as collectivistic cultures. In general, individuals from collectivistic cultures tend to rely more on passive coping strategies in order to reduce internal feelings of helplessness and stress [80]. A systematic review of Hispanic Americans found that this group tended to employ catastrophizing more than their non-Hispanic white counterparts [142]. African Americans also exhibit higher levels of catastrophizing and related increased pain sensitivity [82,145]. Practitioners should be careful not to automatically label patients who catastrophize as "faking it" [201]. Nor should it be viewed as maladaptive behavior requiring intervention. Instead, for some patients, catastrophizing may be a coping strategy to ensure they receive medical or psychological assistance [201].

African Americans have also historically relied on religion and spirituality to cope with racism and discrimination, and this appears to also extend to other challenges, including pain [145]. In a study of 939 veterans with chronic arthritis pain, African Americans were more likely to view a prayer as a helpful method and to use prayer and hope to cope with pain compared with their white counterparts [74]. In a systematic review, African Americans employed coping strategies that included prayer, catastrophizing, hoping, distraction, and problem solving more frequently to deal with pain compared with White patients. White patients attempted to ignore the pain more often than African Americans [171].

Hispanic Americans also depend on religion for pain-coping. Among this population, talking to a priest or a pastor is viewed as part of pain management, and asking God to help alleviate pain is a coping mechanism for many Hispanics [142]. It is important to support patients' spiritual coping while also providing education on other pain management options (e.g., medication) [16].

The theme of self-control (a passive coping method) is also prevalent among many racial and ethnic minority groups. In a small study with 35 African American patients recruited from oncology clinics, participants stated that continually talking about pain would amplify it and make them feel even more helpless and out of control. Family and the community were identified as important, but constantly talking about pain with family members was believed to push them away [83].

The question of whether religious coping (e.g., praying, seeking comfort in faith) is an example of active or passive coping has been raised. A study of 200 Latino patients with arthritis pain found that there was a positive relationship between active coping and religious coping [76]. For these patients, use of religious coping was also associated with greater psychologic well-being and adjustment [76]. However, some argue that prayer, hope, and meditation are examples of passive coping and lead to poor adjustment to pain [146].

In a study of Native Americans' cancer pain experience, participants navigated a fine line between privacy and reliance on communal support [58]. By using traditional native ceremonies, rituals, and prayers, they bring together their tribal relations for healing, coping, and support. Yet participants expressed concern about safeguarding their privacy, as tribal communities are often closed systems.

Use of pain coping strategies is not static [157]. For immigrants, strategies can alter over time as they become familiar with cultural norms of the host country, Western biomedical interventions, and different self-management strategies. The key is for practitioners to avoid stereotyping and pathologizing patients' belief systems.

Help seeking consists of the ways (formal and informal) in which individuals request assistance due to distress [84]. Understanding individuals' patterns of help seeking allows for a greater appreciation of their attitudes toward pain and pain management. Asking for either formal or informal assistance implies different meanings in different cultures.

Saint Arnault proposed the Cultural Determinants of Help Seeking Model, which posits that there are three major dimensions that influence how assistance is sought: perceptions and labeling, interpretations of meaning, and social context dynamics [85].

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." Furthermore, in terms of pharmacologic pain management, the Western biomedical model has stigmatized addiction, resulting 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 include racism, discrimination, poverty, lack of health insurance, and deleterious environmental 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 disorganized 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, additional regulations, and penalties imposed by state and federal drug-enforcement agencies than pharmacies in predominantly white neighborhoods [95].

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]. Consequently, practitioners may underestimate and minimize racial minority patients' pain experiences.

There is also a phenomenon of fundamental pain bias, meaning 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 exaggerated [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 increase when the patient and healthcare professional share the same skin color or are of the same ethnic group [97,131].

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].

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].

Because pain is highly subjective, some argue that a numerical score calculated from pain instruments does not capture the underlying meanings and experiences of pain. Consequently, asking open-ended questions and paying close attention to both verbal and nonverbal cues are essential to understanding a patient's pain [71]. Experts recommend asking the following questions [116]:

In a qualitative study, practitioners encouraged their Hmong patients to use scenarios and images to describe their pain, as these patients had difficulty with numerical pain scores. The stories, metaphors, and imageries would often contain the elements found in quantitative pain instruments [196]. Focusing on physical cues, such as energy level, appetite, weight, and sleep, can be less stigmatizing [197]. The importance of rephrasing questions and breaking down questions into simpler terms were also identified [197]. Because many racial and ethnic minority patients value the role of stoicism, use of the term "pain" may not be conducive to engaging patients in conversations about their condition. The practitioner should first ask the patient which term she or he prefers to use to describe the pain [89]. Prompting with alternate terms (e.g., "nagging," "sore") may be helpful [16]. Asking about how a patient's pain affects their work in and/or outside the home on a daily basis can be helpful in understanding the patient's functioning, pain quality, pain intensity, and pain evolution [208]. Developing good rapport and trust can help overcome stoicism and allow practitioners to identify nonverbal pain indicators (e.g., tenseness, grimacing, flinching) [143; 197].

As trust between patients and providers develops, both will gradually let go of their own biases and cultural stereotypes [151]. Asking patients for their opinions and views and spending more time listening than talking will build trust. It is important to allow the patient to tell their pain story without interruption [177].

It is important to remember that patients are the experts on the pain they are experiencing. When patients tell their own narratives/stories, clinicians will have a better understanding of their meanings of pain, coping mechanisms, and impact of family and social support [151]. Patients should also be reassured that reporting pain is not complaining [16].

Education and empowerment work hand in hand. The Western biomedical culture often reduces pain to the physiologic symptoms and sensations, but pain is not merely about physiology, and focusing only on "curing" pain can result in patients forfeiting their sense of control and responsibility and becoming passive agents [117,118]. If patients are educated and empowered, they can become more resourceful in managing their pain and become active agents in their treatment [118,209]. In the context of pain treatment, the main components of empowerment are [118,127]:

Practitioners' conveyance of compassion is important because patients being treated for pain often fear that no one believes their pain is real.

When working with racial and ethnic minorities, it is crucial for practitioners to remember that the concept of individualism is more embraced by Western cultures that place more emphasis on the concept of autonomy. When it comes to pain management, empowering patients assumes that they have a level of responsibility to manage their pain. However, many cultures place more value on collectivism. In these cases, practitioners should explore the role of the family, community, and other support networks that may be involved in the patient's pain management [45].

The concept of continuing social roles and not taking time to rest despite pain may be more common among racial and ethnic minority groups [178]. Practitioners can include education on the importance of balancing rest and self-care along with the challenges of continuing with life roles [178].

Practitioners should also consider health literacy and English proficiency when working with immigrants and racial minorities [141]. Reader-friendly materials in a variety of languages are needed to disseminate pain information. Finally, it is important to keep in mind that racial/ethnic minority patients often have less access to research and news regarding new therapies, medications, and treatments to pain. Therefore, it is important to provide education and information [210].

Because pain is a multifaceted phenomenon, it is important for patients to consider pursuing an integrated system of care for their pain. This involves looking into the emotional and psychologic component of pain [117]. Mental health and social service providers can assist patients in identifying and discussing the meanings of their pain experience. Many racial and ethnic minority patients do not adhere to a dichotomy between the mind and body and may be more open to talking about pain's link to their emotions and life circumstances. A study conducted with patients at a pain center compared the attitudes of Puerto Rican patients with non-Hispanic white patients [45]. White patients disclosed feeling that their pain was being discounted or negated if their physicians asked psychosocial-related questions about the pain. In general, these patients wanted pharmacologic interventions and were upset by suggestions that their pain was potentially psychologically and/or emotionally rooted [45]. However, the Puerto Rican patients did not express any complaints when their physicians inquired about family, community, relationships, and other psychosocial factors that might be linked to their pain symptoms [45].

Cognitive-behavioral therapies have been widely employed for patients being treated for chronic pain. Alone, this type of therapy does not relieve pain symptoms [28]. Instead, techniques such as reframing, guided imagery, distraction, and identifying cognitive distortions such as catastrophizing and black-and-white thinking (i.e., all or nothing) can help patients understand how cognitions can influence pain and related behaviors [119,209]. For patients who tend to catastrophize, practitioners can provide education on the deleterious impact negative thoughts and emotions can have on experiences of pain. Relaxation techniques can also be included in patient education [201]. The resultant improvements in coping can enhance quality of life [28]. There are five main goals when working from this paradigm [117,209]:

Because religion and spirituality are central to the lives of many racial and ethnic minority patients, it is important to understand how they use religion and spirituality to understand and cope with their pain symptoms [120]. Practitioners may employ cognitive-behavioral techniques to help patients identify religious cognitive distortion. An example of a pain-related cognition is: "Pain is a symptom of guilt." A religious cognition might be: "God is good and fair. My pain is a symptom of my guilt from sin." This then yields a cognitive distortion: "My pain is a consequence of my sins, and I deserve it" [119]. Practitioners can teach patients to identify these types of cognitive distortions, challenge their validity, and identify problem-solving strategies, reframing, and positive reappraisals [119,209]. These patients should be encouraged to employ positive religious coping strategies such as prayer, meditation, and confession.

Practitioners should explore both traditional biomedical pain management interventions and non-traditional alternative remedies (as appropriate) when working with racial and ethnic minority patients. Complementary self-management approaches for pain can be generally classified as mind/body approaches or natural products [152]. Self-management is a common and primary method of managing pain among Asian immigrants. Use of exercise, traditional Chinese medicine, nutrition, and general physical activity are typical and perceived as culturally appropriate [178].

Mind/body approaches include meditation, yoga, acupuncture, and breathing techniques. Natural products include herbs, vitamins, and topical ointments [152]. Some patients may be more receptive to traditional healing methods (e.g., herbal remedies, traditional healers) [72].

In focus groups, Native American participants reported using a range of alternative therapies for pain, including acupuncture, massage, chiropractic treatment, and guided imagery [149].

Alternative remedies for pain can be classified into five different areas, and many can be used as adjuncts to conventional therapies [121,153]:

Some cultural groups subscribe to the hot/cold theory of disease, which argues that illnesses are the result of bodily imbalances and that foods and alternative medications are inherently "hot" or "cold." Pain is considered a "cold" disease, and some patients who adhere to traditional healing will take this into account when selecting and adhering to treatment approaches [142].