Pain can be further categorized as acute (sudden and usually short-lived) or chronic (lasting three months or longer). Acute pain is the most common reason for emergency department visits [7]. High-impact chronic pain is pain that is chronic (i.e., experienced more often than not during the past three months) and that limits work and activities [156]. The temporal label to the term "chronic pain" has resulted in some controversy. Some maintain that this definition does not provide a comprehensive picture of the situation and the underlying dynamics, which involve a range of biological, psychological, social, and cultural factors [180]. The term can also lead to tension between providers and patients, with the provider at times assuming the patient is exaggerating or seeking a sick role [180]. It is important to remember that pain is not necessarily pathologic. Pain is the body's way of alerting that something is wrong and help is needed. When viewed in this way, pain facilitates healing [28].

Unfortunately, chronic pain is a common problem. Globally, it is estimated that 20% of adults experience pain, and every year, 1 in 10 adults are diagnosed with chronic pain [8]. On a worldwide basis, there are 1.9 billion individuals who experience recurrent, tension-based headaches—the most common type of chronic pain [18]. A 2023 study estimated that 21% of adults have chronic pain and 8% have high-impact chronic pain [156]. New cases of chronic pain among U.S. adults occur more often than other common conditions, including diabetes, hypertension, and depression [156]. This finding is consistent with previous findings that an estimated 20.4% of American adults report experiencing chronic pain in the past three months [19]. In the United States, the most common types of chronic pain are back pain (affecting 10.1% of adults), lower extremity pain (4.1%), upper extremity pain (4.1%), and headache (3.5%) [9,181].

Women in the United States are more likely than men to experience headaches, abdominal pain, and chronic widespread pain. Women are also more likely to report higher pain intensity than men, and young girls are more likely to experience pain in multiple areas compared with boys [27]. Reports of chronic pain differ among racial and ethnic minority groups. In one study, Asian Americans had the lowest prevalence of pain (2.4%), while Native Americans had the highest (11.1%) [182]. By comparison, the prevalence of pain is 6.8% for White Americans, 7.6% for Black Americans, and 5% for Hispanic Americans. Roughly 23.5% of non-Hispanic White adults have chronic pain, compared with 6.8% Asian adults and 19.3% African Americans [19]. In one survey, Mexican Americans and African Americans had lower rates of back pain, leg and feet pain, and arm and hand pain compared to their white counterparts [9].

According to U.S. Census data, the minority population is growing each year. By 2060, the minority population is expected to increase to 241 million, with the Hispanic population growing by 142%, the Asian population by 116%, and the African American population by 50% [14]. Hawaii, New Mexico, California, the District of Columbia, and Texas are regions in the United States that consist of a "majority-minority," meaning that more than half of the areas' populations consist of individuals who are racial/ethnic minorities [15]. With the increase of immigration and the slower birth rate in white families, it is anticipated that the United States is rapidly moving toward becoming a majority minority [15]. As of 2022, 63.7 million people in the United States identified as Hispanic, and they are the largest racial/ethnic minority group [185]. The Hispanic or Latino population is expected to increase from 19.1% in 2022 to 26.9% by 2060 [186].

Culture refers to the values and knowledge of groups in a society; it consists of approved behaviors, norms of conduct, and value systems [33,34]. Culture involves attitudes and beliefs that are passed from generation to generation within a group; it is continually evolving and fluid [157]. These patterns include language, religious beliefs, institutions, artistic expressions, ways of thinking, and patterns of social and interpersonal relations [35]. Culture can also represent worldviews—encompassing assumptions and perceptions about the world and how it works [36]. Understanding culture helps to elucidate why groups of people act and respond to the environment as they do [37].

On the other hand, historically, race has been linked to biology. In this traditional definition, race was partially defined by physical markers, such as skin or hair color [38]. It does not refer to cultural institutions or patterns, but it is generally used as a mechanism for classification, and social meanings are ascribed to these classifications. Historically, the census in the United States defined race according to ancestry and blood quantum; today, it is based on self-classification. Further, in modern society, race is viewed as socially constructed without a true biological basis [193]. Racial characteristics are also assigned differential power and privilege, lending to different statuses among groups [40]. It is important to recognize that, for individuals, racial categorization is based on self-identification due to adherence to cultural norms, language, religion, and geography as well as physical appearance [193]. All this lends to the complexity and dynamic nature of the definition [193].

Ethnicity is also a complex phenomenon and has been defined in many different ways. Four components of ethnicity have been identified [41]:

For healthcare providers, cultural awareness involves four components [44]:

The complexities of culture, race, and ethnicity and how they influence the meanings, definitions, and expression of pain are not completely understood. Studies have not delineated a clear model or pathway, but there is consensus that pain is more than just a biologic or physiologic response; there appears to be an interplay of biologic, social, psychologic, and environment factors. From a biopsychosocial perspective, how individuals react to a pain stimulus may be influenced by how they were socialized within their familial and cultural background [47]. Alternatively, gate control theory has been used to explain the link between culture and pain. According to this theory, pain is not merely a physiologic response to tissue damage; rather, reactions to pain are based on expectations and perceptions stored in one's memory [2,122,124,126,128,129,130]. Biologically, pain is moderated by a gating mechanism whereby cells block pain in the nervous system. Messages are sent to the brain to "open" or "close" these blocking mechanisms, and cultural memories can affect whether the pain impulses reach the brain [2].

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.

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].

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].

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].

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].

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].

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].

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].

The numerical rating scale was translated (and back-translated) into Swahili for use in Kenya and pilot tested with 15 individuals 8 to 69 years of age. In general, the participants understood what the progression of the numbers conveyed and thought the scale was easy to understand, with good face validity [106]. However, some studies have shown that linear numerical scales are conceptualized differently based on a group's cultural norms. For example, one study found that Native American patients selected a number on the rating scale not to reflect their pain but because it had symbolic and sacred connotations to them [93,107]. Language is another consideration. The number four is nearly homophonous with the Mandarin word for "death," and therefore, some Chinese patients will be less likely to select this number on the pain rating scale.

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]:

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]: