Shakila Mohmand,1 ND, and Sumar Chams,2 BSc
ABSTRACT
Cultural competency within health care helps eliminate racial and ethnic health disparities. When assessing and treating patients with chronic pain, practitioners should feel confident in using information regarding a patient’s individual cultural beliefs due to their significant impact on the pain experience. Culture impacts perception, outlook, and communication of pain, as well as coping mechanisms. These are aspects of subjective history that influence important decisions regarding the management of chronic pain. Becoming more aware of what to look for and which questions to ask can allow naturopathic doctors and other health-care providers to continue improving therapeutic relationships and patient outcomes.
Key Words Cultural competency, pain management, naturopathic medicine, integrative health, holistic medicine, interdisciplinary care, health care, health intake, health-care practitioners
Chronic pain is a condition with various etiologies and is experienced differently by each individual.1 When people live with chronic pain, the pain experience often becomes a part of their identity. Therefore, to understand the pain experience, we must take into consideration all the dimensions of pain, not only the physical.2 Addressing thoughts, emotions, and behaviours related to the pain is just as important in achieving optimal outcomes as looking after the physical component. Certain social conditions and cultural norms can either assist with the management of pain or act as barriers.1 Being aware of these gives practitioners an advantage when it comes to treating patients.
It is becoming increasingly clear how important access to culturally competent health care is. Cultural competency in health care reflects the ability of health-care providers to successfully provide care which meets the unique social and cultural needs of diverse patient populations, thereby improving quality of care and health outcomes.1 Cultural competency training is essential to help eliminate health disparities and ensure patient safety, because failure to address culture can lead to diagnostic errors and treatment interactions.3 Patient engagement and collaboration are also impacted because cultural competency increases understanding of what the patient is experiencing and leads to increased trust within the doctor–patient relationship.3 Recognizing that individual values and behaviour surrounding health care are shaped by cultural, social, and other individual factors is an important part of cultural competence.1 Integrating these factors into health-care delivery and providing high quality, individualized care regardless of differences in cultural background is what forms the basis for a culturally competent health-care system.1 Developing cultural competence requires more than merely discussing a set of skills and knowledge in a classroom setting. An overall approach to health care that incorporates concepts of cultural humility, questioning of one’s biases, respecting differences and addresses cultural values in health promotion tools, results in culturally competent care that can make a significant impact.1
With its patient-centred and holistic approach, naturopathic medicine has the ability to elevate cultural competence within the health-care system. Naturopathic doctors are able to spend time with patients and gain a deep understanding of their condition and experience.4 Through the therapeutic order, a guide to how naturopathic principles can be used effectively, naturopathic doctors aim to establish the foundations for optimal health. In order to do so, the barriers to healing must be removed. This involves addressing lifestyle aspects, such as diet, activity, stress management, rest, and socioeconomic stressors.5 Culture can impact these determinants of health but is less often taken into consideration.
Chronic pain is a growing public health concern leading to increased medical costs and loss of productivity.6 It can have a significant impact on daily activities and is often associated with medication dependence, anxiety, depression, and overall poor quality of life.6 This is likely to become an even more significant issue, based on the knowledge that chronic pain conditions are often closely correlated with stress, which, in the current pandemic context, has been at an all-time high for many people.7
Chronic pain is a biopsychosocial condition, meaning that social, emotional, and cultural factors play a role in shaping the pain experience and a patient’s attitudes and behaviours towards it.2 Across cultures, the chronic pain experience differs in terms of communication, perception, and coping.8 Due to the intricate ways in which biopsychosocial factors influence pain, treatment must be highly personalized to fit the needs and lifestyle of each patient.2 Appreciating the role that culture plays in patients’ health helps practitioners recommend treatments that are consistent with the patient’s cultural worldview.8
Communication of pain differs across cultures, and research has shown that health-care professionals are more likely to be responsive to pain communication coming from people who belong to the same culture, and are less attuned to that of other cultures.9 Since providers rely on subjective reports to determine pain response, an accurate assessment of the severity or impact of pain will require consideration of possible cultural influences.10 For some patients, the chronic pain experience becomes a prominent part of their life, whereas others will choose to avoid talking about it even if they are experiencing high levels of pain.10 Due to this varying pain response, culture can impact health-seeking behaviours and acceptance of interventions.11
The way in which pain is expressed, either directly or indirectly, is also influenced by the cultural background of the patient.10 Cultural responses to pain can range from expressive to stoic.10 Some cultures believe they should endure pain quietly and serve as a role model to others; therefore, they may be more likely to express pain through non-verbal cues.10 Building awareness of verbal and nonverbal cues, such as tone, silence, eye contact, and body language, will help practitioners identify and understand these cues in practice.9 Cultural differences in pain response can also lead to either over- or underestimation of pain tolerance in certain populations.10 A decreased pain expression may be viewed as an absence of pain, leading to under-treatment, which is detrimental to patient care.10 It is also important to note that language barriers may come into play when it comes to describing pain. Being clear with explanations and providing examples of types of pain during the patient encounter can help overcome this.10 Using medical interpreters or technology can also help optimize patient communication in the case of language barriers.12 Cultural interpreters are preferred, as they are trained to provide clear translations and pick up on cultural nuances. If unavailable, professional virtual language services can be used as an alternative.12
Health professionals need to acknowledge that the meaning of pain often differs between cultures. Cognitive, emotional, and biological factors significantly affect perception of pain and can impact the trajectory of a patient’s improvement.2 Therefore, understanding how an individual patient feels about pain is as important as the fact that they have pain.8 For example, some cultures may believe pain is a sign of progress towards recovery, whereas others may believe it is a test of faith.9 Some patients are so accustomed to pain that they don’t ever expect to see a full recovery.9 Therefore, pain beliefs can impact a patient’s ability to be proactive about addressing their pain. It is important to assess stages of change and understand at which level the patient is situated in terms of outlook and motivation for change.9
Views on appropriate coping responses differ across cultures, and this will significantly impact treatment outcomes.11 Some cultures promote activity as a means of coping with pain; others promote rest.2 Education regarding appropriate levels of rest versus activity is therefore paramount because this is a situation where assumptions could lead to less than favourable outcomes.2
Locus of control also differs between cultures.11 External locus of control tends to result in less favourable outcomes, while internal locus of control is related to preferable outcomes.11 Assessing locus of control will open up opportunities for cognitive behavioural interventions that can lead to positive change overall.11
Various tools exist to assist practitioners in facilitating clear communication with and understanding of patients across cultures. The LEARN model is a framework generated to support cross-cultural communication and can be used as a general guideline for patient interactions.12 The acronym LEARN stands for the following:
Listen: Assess each patient’s understanding of their health condition including causes, potential treatments, and expectations.
Explain: Convey your own perceptions of the condition while being mindful of the patient’s perspective.
Acknowledge: Be respectful when discussing differences between views. Point out areas of agreement as well as differences, and determine obstacles to care.
Recommend: Develop a treatment plan.
Negotiate: Ensure that the plan is culturally appropriate and fits with the patient’s perceptions of healing.12
To ensure that all aspects of the patient’s health history are taken into consideration, it is important to assess the patient’s understanding of pain and the beliefs surrounding it.9 This can be achieved by using specific and directed questions which will influence important decisions regarding the management of chronic pain. Asking the patient what they believe is the cause of their pain is important because this will also help determine whether the patient can identify any potential barriers to their health. To determine how the pain is impacting their life, it is important to ask this directly, as well as determine which emotions the pain brings up for them and whether they have any coping mechanisms to deal with the pain. Asking the patient’s opinion regarding what healing looks like for them, the type of treatment they believe is best suited for them, and their expectations regarding treatment outcomes will also increase compliance. With these types of open-ended questions, practitioners are more likely to gain an in-depth knowledge of the patient experience, which will aid in providing more culturally competent care.
Culturally competent care recognizes that treatments developed for one culture may not be relevant or effective in another culture.2 This is especially important when recommendations are related to cognitive and behavioural changes.2 In the case of chronic pain management, it is essential to discuss lifestyle modifications surrounding diet and exercise. In order to ensure patient compliance, clinicians need to be aware of appropriate treatments and adapt them to make culturally relevant suggestions. For example, asking a patient to remove a staple from their cultural diet will likely lead to poor adherence and is not a long-term solution unless the patient makes that decision on their own. Patients can be supported by directing them to culturally relevant resources which can help them make the most beneficial and long-lasting changes. This type of culturally informed evaluation of patients strengthens doctor–patient relationships and leads to better health outcomes.10
Practitioners who are aware of diverse cultural backgrounds as well as the values of current medical models are more prepared to offer culturally appropriate treatment plans.12 Being aware of personal biases can prevent ethnocentrism, which, left unaddressed, can hinder appropriate care.12 Overall, developing a deeper understanding of the role of culture in the experience of pain can help providers tailor treatments to better match the worldview of their patients.8 This can be supported using tools such as the LEARN model as well as a more in-depth culturally oriented health assessment during medical encounters.
1 Independent Scholar, Ottawa, ON, Canada
2 Independent Scholar, London, ON, Canada.
Not applicable.
We have read and understood the CAND Journal’s policy on conflicts of interest disclosure and declare that we have none.
This research did not receive external funding.
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Correspondence to: Shakila Mohmand. E-mail: sue.mohmand@gmail.com
To cite: Mohmand S, Chams S. Cultural considerations in the management of chronic pain. CAND Journal. 2021;28(4):11-13. https://doi.org/10.54434/candj.93
Received: 11 September 2021; Accepted: 7 October 2021; Published: 15 December 2021
© 2021 Canadian Association of Naturopathic Doctors. For permissions, please contact candj@cand.ca.
CAND Journal | Volume 28, No. 4, December 2021