Library
APS Bulletin • Volume 17, Number 2, 2007
Research Update
Norman Harden, MD, Department Editor
Culture, Pain, and Pain Research
Jennifer Zinke, MS
Department editor’s note: Pain is a ubiquitous experience affecting an individual’s physical and psychological functioning. It is recognized as a multidimensional experience influenced by cultural conditioning, expectancies, and social contingencies (Turk & Melzack, 2001). Cultural learning has been acknowledged as an important influence on the verbal and behavioral expressions of pain (Melzack & Katz, 2001). Angel and Guarnaccia (1989) suggested that culture provides a distinct symbolic and linguistic system within which individuals label and express pain. This article reviews what the literature suggests about the effects of culture and ethnicity on pain, highlights the limits of current research in the area, and offers recommendations for future research efforts.
State of Cross-Cultural Literature
The role of culture on pain was introduced into the scientific literature by Mark Zborowski (1952), and has since been recognized as an important influence on an individual’s pain experience. In his seminal work, Zborowski proposed that people have certain beliefs about pain based on the cultures in which they were socialized. Three decades later Bates (1987) presented a biocultural model of pain that suggested that ethnic differences observed across samples were not necessarily due to inherent differences in nociceptive processing, but may be due to experience, attitudes, and cultural meaning of pain.
Since Zborowski, cross-cultural research in pain has suggested that there are differences across cultural groups in several areas. Crosscultural variation has been observed in clinical samples related to the report of pain intensity, interference with work, emotional distress and pain expressiveness, qualitative descriptors of pain, healthcare workers’ assessments of pain, differences in pain tolerances in laboratory settings, and coping styles. In a 2005 study, Edwards and colleagues suggested the importance of considering confounding factors such as education, work status, and pain duration, and including them in the statistical design. These factors as well as gender and age may help to explain differences observed among groups. In this study, they found no differences in qualitative pain descriptors, pain intensity, and physical and emotional functioning; instead they found differences related only to coping, specifically the use of prayer and hope. All other differences disappeared when controlling for the above-mentioned variables.
Of great concern, current research has suggested that racial and ethnic minorities are at risk for inadequate access to pain care, including pain assessment and treatment. For example, Hispanics have been identified as disproportionately at risk for injury and subsequent pain, yet there remains a paucity of research studying pain in this growing population. Nurse researchers have suggested the importance of developing more culturally inclusive research standards and increased funding sources to study this population.
Limitations of Current Pain Research
Some limitations of the literature include differences in the methodological parameters of the research, the overall lack of cross-cultural research, small sample sizes, and often a lack of specificity with regard to nationality or ethnic affiliation of research participants (e.g., Hispanic versus Mexican-American designation). Also, the quality of cross-cultural research in pain relies on the appropriateness and relative quality of standard assessment tools. Advanced statistical approaches, such as Item Response Theory, would help to further the understanding of the cross-cultural and cross-linguistic equivalences of pain assessment measures (Turk & Melzack, 2001). By enhancing the interpretive value of standard pain assessment instruments, service providers may gain a better understanding of their patients’ pain experience and the relative cultural underpinnings of pain and pain expression. This may improve assessment and treatment of minority consumers and enhance the interpretive value of research findings.
Suggestions for Future Research
Future research should include more culturally diverse groups. For those groups whose primary language is not English, it is important to provide linguistically appropriate measures that have been validated with that population. Unfortunately, few measures have been translated and validated for non-English speaking patients. For instance, with the influx of Hispanics in urban centers around the United States, and the propensity for work-related injury and subsequent pain, there remains little work dedicated to the validation and publication of Spanish language pain assessment measures to date.
Considering important variables such as age, gender, and education will offer more precision within the design, analysis, and interpretation of results. Moreover, using more culturally and linguistically sensitive recruitment methods in the early stages of research may help engage larger numbers of minorities in research.
In the event that differences are observed across culturally diverse groups, qualitative methods may aid in the interpretation of results within the framework of the culture. This can be accomplished by employing research personnel who understand the culture. Another useful approach may be to conduct literature reviews and book reviews on the culture of interest. An example of a review within nursing literature is an article written by A. M. Villarruel and B.O. Montellano (1992). These researchers conducted an ethnohistoric study to enhance the understanding of Mexican-American meanings, expressions, and care behaviors associated with pain.
An increase in funding is critical for increasing cross-cultural research, enhancing research design by including item-level analyses, considering confounding variables, increasing sample sizes, increasing the specificity with which we categorize culturally distinct groups, considering the linguistic component of self-report assessments, and using a sound basis for interpreting results that suggest cross-cultural variability in the experience and expression of pain. Continued research is needed to understand pain from diverse cultural perspectives. A better understanding of the cross-cultural experience of pain will enhance our assessment practices and treatment delivered to an increasingly diverse clientele presenting at pain clinics around the United States.
References
Angel, R. & Guarnaccia, P. J. (1989). Mind, body, and culture: Somatization among Hispanics. Social Science & Medicine, 28, 1229–1238.
Bates, M. S. (1987). Ethnicity and pain: A biocultural model. Social Science Medicine, 24 (1), 47–50.
Edwards, R. R., Moric, M., Husfeldt, B., Buvanendran, A., & Ivankovich, O. (2005). Ethnic similarities and differences in the chronic pain experience: A comparison of African American, Hispanic, and White patients. Pain Medicine, 6 (1), 88–98.
Melzack, R. & Katz, N. (2001). The McGill Pain Questionnaire: Appraisal and current status. In Turk, D. C. & Melzack, R. (Eds.), Handbook of Pain Assessment. New York: The Guilford Press.
Turk, D. C. & Melzack, R. (2001). Trends and future directions in human pain assessment. In Turk, D. C. & Melzack, R. (Eds.), Handbook of Pain Assessment. New York: The Guilford Press.
Villarruel, A. M. & Montellano, B. O. (1992). Culture and pain: A Mesoamerican perspective. Advances in Nursing Science, 15(1), 21–32.
Zborowski, M. (1952). Cultural components in responses to pain. Journal of Social Issues, 8, 16–30.
Jennifer Zinke, MS, is a doctoral candidate in the Clinical/Rehabilitation Psychology Program, Illinois Institute of Technology, and is a clinical psychology intern at the Jesse Brown VA Medical Center in Chicago.
