Even though the assessment and treatment of pain is a universally important health care issue, modern medicine still has no accurate way of measuring it. Patients are often asked to rate their pain on a scale from 1- 10: mild (1-4), moderate (5-6), and severe (7-10). Sometimes smiling and frowning faces are used as visual aids to help both doctor and patient convey what the numbers signify. Cultural differences in response to pain compound the inherent challenges of communication. Although nearly all people experience pain sensations similarly, studies show there are important differences in the way people express their pain and expect others to respond to their discomfort. There are also culturally-based attitudes about using pain medication. An understanding of the impact of culture on the pain experience is important in assuring effective and culturally-sensitive patient care.
Pain Response & Culture
It is well established that pain is a highly complex phenomenon that involves biological, psychological, and social variables.1 Patients’ culturally-based responses to pain are often divided into two categories: stoic and emotive. Stoic patients are less expressive of their pain and tend to “grin and bear it.” They tend to withdraw socially. Emotive patients are more likely to verbalize their expressions of pain, prefer to have people around and expect others to react to their pain so as to validate their discomfort. We can make the broad generalization that expressive patients often come from Hispanic, Middle Eastern, and Mediterranean backgrounds, while stoic patients often come from Northern European and Asian backgrounds. If we use such broad generalizations to help understand human behavior, however, we must always keep in mind that while culture is a framework that directs human behavior, not everyone in every culture conforms to a set of expected behaviors or beliefs. Rigid use of generalizations leads to cultural stereotyping which in turn can lead to serious inaccuracies. Any individual’s experience of pain will manifest itself in emotional and behavioral responses particular to his or her culture, personal history, and unique perceptions.
American Culture & Pain Response
For western health care professionals it is important to understand how our own culture affects the attitudes we may hold about pain. Only through this self-awareness can we establish a basis for comparison that allows us to see where our attitudes and beliefs are likely to collide with those of patients who come
from very different cultures. We are apt to believe that our reaction to pain is “normal” and anything substantially different is “abnormal”. For example, a doctor or nurse raised in a family that encouraged stoicism may not know how to react to a patient who responds to pain with loud verbal complaints and may even discount such “overly expressive” reactions. There is a long tradition of stoicism in European American culture; generations of children, especially boys, would be admonished for crying like babies but applauded for keeping a stiff upper lip. In general, people made as little fuss as possible over injuries and illness. Naturally, children socialized in this way will grow up to be “easy patients” who behave in ways consistent with the values of the western medical system. On the other hand, there are cultures where a child’s crying immediately elicits the greatest sympathy, concern, and aid. In such cultures, children’s’ health is fretted over constantly – even a sneeze can be seen as illness. This predisposes children to become more anxious about their health in general, and as adults, they may need greater reassurance from caregivers even in the face of minor symptoms. In general, when people are ill they revert to childhood behavior. If complaining brought them attention as children, they will likely complain out of habit as adults – even if the desired results are not forthcoming from the caregivers around them.
Asian Culture & Stoicism
Patients from Asian cultures may often exemplify stoicism in the face of pain, which relates directly to strong cultural values about self-conduct. Behaving in a dignified manner is considered very important, and a person who is assertive or complains openly is considered to have poor social skills. This behavior might be tolerated in very small children, but not in adolescents and adults. In traditional Asian cultures, preserving harmony in interactions with others is very important, so an individual should never draw attention to himself, especially in negative ways. Though an individual may feel sadness or pain, it is not customary to make this obvious. On a related note, some Asian patients will be socialized to observe status differences between people and will avoid making demands of health care professionals for this reason. Asian societies have traditionally emphasized status differences between people based on variables such as age, sex, education, and occupation. A doctor or nurse will most surely be seen as a person of high status, not to be questioned or bothered with complaints about discomfort.
Putting Pain Into Words
The limitations of language to convey experience – even between people who speak the same language – are extremely obvious when we can’t explain something as important as the intensity of pain we feel or the unrelenting worry and frustration pain sometimes causes. To further complicate communications, not all cultures describe pain in the same way. Words such as “sharp,” “throbbing,” “stabbing,” or “aching” make sense to most people in the U.S., but in many tribal cultures stories or symbols are essential in relating one’s worldview, so very different words are used to describe pain. Clinicians might be baffled by patients explaining their pain in terms of natural symbols like lightning, trees with deep spreading roots, spider webs, or the tones of drums and flutes.2 In cultures where evil spirits are believed to cause illness and pain, patients may talk about their suffering as punishment. Indeed, some patients will need help in understanding how to talk about pain in ways western doctors and nurses can interpret. Through careful listening and probing health care professionals will uncover what is really happening with each patient’s pain. Keep in mind that referencing pain measurement tools that rely on numbers or any kind of linear format, such as a row of faces, won’t work equally well across cultures. People in some cultures attach great superstition to particular numbers, and smiling does not suggest feeling good in all cultures. In fact, in some Asian cultures, people tend to smile when they are embarrassed or angry.
Religious and Spiritual Aspects of Pain
In many cultures around the world where belief in fate and karma are strong, people often believe illness and injury are caused by a higher power. In many cases, the acceptance of pain is important in demonstrating a person’s religious faith. In one case, a Nigerian refugee to the U. S. suffered a severe knee injury and underwent arthro-miscroscopic surgery. His American nurse waited for him to request pain medication, but he never did. Being Muslim, he offered his pain to Allah in thanks for the good fortune of being allowed the special surgery.3 In a similar case, a Filipino patient hospitalized for shoulder surgery admitted to his nurse that he was in severe pain. However, he wasn’t taking his pain medication because he believed it was God’s will that he had such pain, and God would give him the strength to bear it.4 A similar stoicism in the face of pain may be common among Buddhists who believe acceptance of suffering leads to spiritual growth. Among some Native Americans, the blessing of medications by a tribal medicine man puts a patient more at peace with the creator which in turn makes the medicine “stronger”.
Cultural Perceptions of Pain Treatments
A tendency to discount immediately the sort of cultural practices and beliefs mentioned above can be countered by invoking the placebo effect, which is well-documented. There is also its opposite – the “nocebo effect” where a person who disbelieves in a treatment experiences a worsening of symptoms due to pessimism about getting well. What motivates people’s reactions to placebos is interesting in how it parallels different cultural perceptions and expectations around medicines in general. Are shots more effective than pills? Does a bigger pill work better than a smaller one? Is bitter medicine stronger and more effective than medicine that tastes good? Answers to questions like these are indeed often dependent upon cultural background. In some cultures, people believe that the more intrusive a procedure is, the better it is for them. So, an intravenous pain medication would be preferred to narcotic analgesic tablets even if the tablets were highly effective. In some countries, injections are very common; so a Cambodian patient, for example, might believe that without an injection, treatment is inadequate. A Filipino or East Indian patient might reject pain medications altogether out of fear of harmful effects, including addiction. Clearly, it is important to explain the rationale behind use of pain medication to all patients, and to ask patients from different cultural backgrounds which type of medication is preferred in their culture. Also, how do they feel about taking pain medications personally? Since cultural and/or religious reasons may inhibit someone from asking for pain medication, it is often necessary for doctors and nurses to anticipate a patient’s pain needs and to initiate important discussions.
Conclusion
Part of understanding our own culturally-based attitudes about pain includes gaining awareness of the things we take for granted. We have come to expect pain management as part of proper treatment in the U.S., but in many countries pain medications aren’t readily available or affordable. Or, their use may be stigmatized – as being self-indulgent, addictive, etc. An appreciation of the influence of culture on affective responses to pain and expectations for pain treatment is critical to culturally responsive management of people in pain. The role of the health care provider is to help patients advocate for what feels appropriate for them within their cultural context. r
References
1. Michelle A. Fortier, M.,Cynthia T. Anderson, C. and Kain, Z. Ethnicity Matters in the Assessment and Treatment of Children’s Pain PEDIATRICS Vol. 124 No. 1 July 2009, p. 378
2. Burhansstipanov L. Lessons Learned from Native American Cancer Prevention, Control and Supportive Care Projects. Asian American and Pacific Islander Journal of Health. Summer- Autumn 1998: vol. 6. No. 2. pp. 91-99.3,4 Geri-Ann 3,4. Galanti, Caring for Patients from Different Cultures (Philadelphia: University of Philadelphia Press, 1997 p. 35
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‘Cultural Aspects of Pain Management’ by Marcia Carteret. Copyright © 2011. All rights reserved.
