Let’s visit the women in the busy labor and delivery room of a large county hospital located in a culturally diverse area. Each woman is reacting to her labor pains in different ways. A Mexican woman, delivering her third child, clutches the nurse’s hand, crying, “My God, it hurts so bad!” Across the ward, a Chinese woman in the middle of labor with her first child lies quietly, stoically bearing her discomfort without requesting any analgesia. In another room, a Russian woman insists that unless the nurses give her something for pain, she will report them to the authorities. Finally, an African-American woman is protesting loudly that something must be wrong with her delivery. Are these women experiencing different labor pains or is only the degree and manner in which they express their pain different? Is cultural background a factor in their pain expressions?

Although individual differences do affect the manner in which pain is tolerated and expressed, cultural conditioning seems to play its own important role. People’s cultural backgrounds can affect their display of pain as well as caregivers’ assessment and management of it. And to be more effective in practice, caregivers need to be sensitive to similarities and differences in their own and their patients’ beliefs and practices associated with the experience of pain.^1,2

Some Background Definitions

A variety of terms define the experience of pain. Pain threshold is the point at which a stimulus is perceived as pain. In laboratory studies, pain thresholds tend to be similar, but not much is known about variation across cultural groups. Pain tolerance is the amount of pain a person will withstand before outwardly responding to it. There is variation in individual pain tolerance. It is influenced by cultural perceptions, expectations, role behavior, and physical and mental health. However, external environmental factors can modify both pain threshold and tolerance. For example, a football player may not immediately notice a painful injury in the heat of competition. He may also tolerate more pain while engaged in a game than he might in a quiet room by himself.

People manifest discomfort through pain behaviors, which can be physiological (sweating, increased blood pressure), affective (depression, anxiety), or behavioral. Behavioral manifestations or pain expressions emerge through facial expressions (grimacing), vocalizations (groaning), verbalizations (complaints, expressions of anger), body actions (shifting positions, thrashing), and behaviors that attempt to alleviate pain (warm baths, pain medicine). Pain expressions vary among individuals as well as cultural groups.³

Individual and Group Differences in Pain

Both social and individual physiological factors seem to influence the experience of pain. One popular biocultural model postulates that the neurophysiological systems of people, regardless of ethnic group, are basically alike so that we generally perceive pain alike.³ However, more recent thinking holds that there are innate differences in internal physiological mechanisms that modulate pain. People experience pain differently even within the same cultural group by having more or less of a modulating substance, such as level of endorphins, within their physiological system.⁴ This could explain why the response to pain differs not only among people from different backgrounds, but even among those from the same ethnic group. Increasing evidence suggests that exposure to pain can sensitize the basic mechanisms that set the pain process. These factors may play a role in how patients experience, tolerate, and express their pain on an individual level.⁵

However, attitudes about pain learned in the social context of family and community also affect peoples’ pain experience. Adults convey cultural meanings about pain to developing children, and these learned values affect how children respond to painful stimuli.^1,6 For example, children in ethnic groups where parents tend to make a big fuss over them when they fall are more likely to focus on and magnify the painful stimuli of a scraped knee. On the other hand, the children of parents in another ethnic group who typically minimize or distract them from painful experiences will tend to interpret painful stimuli as less important, respond less overtly to discomfort, and perhaps experience it as less severe. These children may even repress the memory of painful experiences. These ethnic values related to pain are transmitted from one generation to another with other cultural norms and standards. Repetition of such experiences affects how a pain sensation is defined and experienced in a particular ethnic group. In some cultures, elders give children much concern and sympathy for complaints and painful experiences; in others, children receive less protection and instead, absorb a message to expect some pain and distress and not to react to it with a lot of emotion. These culturally based cognitive patterns, in turn, affect the physical and psychological mechanisms of pain perception. Pain is a subjective physical, psychological, and spiritual experience that can be modified by neurochemistry, cognition, and sensory factors.⁷ In addition to physiological factors, cultural conditioning also modifies pain.

Research supports an association between culture and pain responses, beliefs, and behaviors. For example, after subjecting 108 women of different ethnicities to the same pain stimulus by immersing an extremity in cold water, investigators found that white non-Hispanics showed greater pain tolerance than African-Americans. Regardless of ethnicity, study participants’ tolerance to pain increased when they believed their experimenter was friendly. This perception of friendliness was linked to whether a subject shared the same race and culture with the experimenter.⁸

Cultural Influences on Healthcare Professionals’ Response to and Management of Pain

Culture not only affects patients’ expressions of pain, but influences the way healthcare professionals respond to and manage that pain. In fact, the values of caregivers in their professional groups may come into play. For instance, caregivers value self-control and the ability to work well in stressful situations. They often expect patients to fall in line with similar ways of dealing with pain; that is, to be uncomplaining, calm, and objective.^2,3

On the whole, clinicians tend to underevaluate patients’ pain, attributing pain behavior to mental or psychological distress, rather than actual physical pain.⁷ However, apparently caregivers can also respond to the pain of their patients based on ethnicity. One study of 4,000 nurses from 13 countries found that a diverse ethnic group believed that Jewish and Hispanic patients were suffering more than Anglo-Saxon or Germanic ones. For example, nurses of northern European background (especially those from England, the U.S., and Belgium, where people tend to believe in being more constrained and “keeping a stiff upper lip”) inferred the least patient suffering. On the other hand, nurses of African, and southern and eastern European backgrounds (cultures usually portrayed as more expressive and emotional) inferred the highest patient suffering.⁹

Another study that compared the responses of Sri Lankan nurses and patients with nurses from the United Kingdom reported that whereas the U.K. nurses believed the patient determines his or her own level of pain, the Sri Lankan nurses were much less likely to accept the patient’s report of pain because they believed they were better qualified to determine the existence and nature of pain than the patient.² The researchers attributed these differences to the nurses’ cultural beliefs about pain as well as knowledge about pain assessment.¹⁰

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Subjective and Objective Assessment of Pain¹⁵

Intensity	Quality
Slight	Burning (hot)
Mild	Sharp (piercing)
Moderate	Aching (dull)
Severe	Penetrating (radiating)
Unbearable	Nagging (agonizing)
	Cramping (gnawing)
	Throbbing (pulsing)
	Tingling  (stinging)

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There is evidence that the cultural backgrounds of caregivers affect how they evaluate and assess patients’ pain, which has important implications for the diversity of today’s U.S. healthcare environment. For example, what if clinicians from one ethnic background were to apply their own cultural programming to patients from another culture to assess less pain or distress than they were actually experiencing? The patients could be labeled as complainers, with their expressions of distress ignored. Their unmet needs and expectations could cause them to perceive care as unsympathetic and inadequate. Conversely, if clinicians from other cultures were to assess more pain in patients from different backgrounds than they actually had, they might administer too much medication or make their patients anxious with an exaggerated sense of concern.

Pain behavior is a two-way communication. The attitudes and behaviors a caregiver uses to respond to a patient’s pain can affect the person’s experience of pain. Conversely, a caregiver is also influenced by the patient’s pain expressions. For example, if a caregiver feels disdain for the way a patient from a different cultural background expresses pain, the resulting attitudes can affect how that patient’s pain will be managed. If the patient senses unfriendliness or a critical attitude from the caregiver, the pain may be exacerbated and more difficult to bear. Ultimately, however, patients are the authorities on their own pain, and their expression of that pain should not influence the caregiver’s treatment of the pain.

Another Look at Culturally Based Pain Behavior

Let’s go back to the delivery room for another look at the patients. Can we assume the silence of the Chinese woman or her failure to request medication indicates she experiences less pain than the Hispanic or the African-American women? For an answer to that question, we might consider two components of pain — private and public. Private pain, or the original sensation, is an involuntary sensation a person experiences. Public pain is a voluntary reaction to the sensation that aims at communicating and relieving the discomfort.¹¹

To know whether a person is experiencing pain, he or she must verbally or nonverbally signal it to another, transforming the private experience into a public one. In some groups, such as Hispanic, Jewish, and Iranian cultures, the expression of pain is allowed and even rewarded with sympathy, attention, and comforting behaviors. On the other hand, in societies that value stoicism and fortitude, such as the “stiff upper lips” of Anglo-Saxons or the belief in Asian, American Indian, and Germanic cultures that an overt display of pain is shameful, private pain is never made public. Taking this into account, it is clear that the absence of pain behavior does not necessarily mean that a patient is not experiencing private pain and vice versa. Each culture has expectations and a level of acceptance of pain as part of life. In many cultures, women accept the pain of labor and birth, whereas current trends in the U.S. demonstrate that women do not accept the pain of childbirth and, in fact, expect relief through analgesia as the norm.

The expression of pain does not necessarily indicate an inability to tolerate it. There can be differences between expressed levels of pain and the belief that pain should be controlled through pain management. One study, for example, showed that Mexican women have a great tendency to self-report pain (as opposed to Mexican men, who are expected to remain stoic). At the same time, Mexicans have also been shown to have a higher tolerance of pain than many other cultural groups, possibly because they view pain as a natural part of the human condition and therefore expect to have to deal with it.¹² On the other hand, in both Hispanic and Jewish cultures, it is perfectly acceptable for women to moan, groan, and cry during childbirth. These behaviors do not necessarily carry a plea that the women from these groups wish or expect someone to give them medication or do anything extraordinary to alleviate their pain. Often it is in an effort to “share” their experience of pain in the belief that the very act of crying out, will, like the Lamaze form of breathing, help the women cope with and feel a sense of control over their discomfort.

Relying on patients’ self report about pain is one of the most important ways caregivers can help transcend cultural barriers related to understanding it. When patients communicate through the use of an objective scale that measures perceived pain, their private pain is made public in a less culturally biased way. Pain rating scales are the acceptable way for us to gauge patients’ pain and use data for adequate intervention.

The patient’s self reporting of pain (as part of the assessment/reassessment process) and using a pain rating scale to determine the patient’s level of pain are also regulatory requirements mandated by the Joint Commission on Accreditation of Healthcare Organizations. The JCAHO standard states that patients have a right to pain management, the rationale being that pain has adverse physical and psychological effects that delay a patient’s ability to progress as rapidly as possible to a state of wellness. To address this issue, JCAHO expects hospitals to assess each patient for pain and reassess routinely or after pain intervention, educate appropriate clinical staff about assessing and managing pain, and educate patients and families about their role in managing pain and the limitations and adverse effects of pain interventions.¹³

Nursing and OT staff can optimize patient care when they work collaboratively to manage patient pain. Patient pain levels are best managed when nursing and therapy staff work closely together; for example, letting the nursing staff know 20 minutes before therapy will begin so that pain medication can be delivered beforehand. Pain is of interest to OTs because it can interfere with purposeful activity, the ability to learn new skills or, ultimately, to be successful in therapy.¹⁴ Furthermore, OTs can moderate the experience of pain by engaging the client in meaningful activities, thereby activating both mental and physiological mechanisms known to reduce attention to pain. While OTs do not treat pain directly, they do plan treatment to optimize performance and promote success in occupations. OTs begin treatment session by evaluating both the quality (subjective nature) and the functional limitations (objective nature) of pain.¹⁴ Common foods that trigger pain, including caffeine, refined sugar, and cheese, can be evaluated for during initial evaluation.¹⁵

One study advises the first rule a caregiver should follow when approaching a patient in pain is to avoid cultural stereotyping. Although caregivers should learn as much as they can about the cultural beliefs of the patient populations they serve, they shouldn’t make assumptions based upon this information, because many inter- and extracultural beliefs and responses to pain are unique to each patient. The researcher suggests the following questions for conducting an accurate cultural assessment of each individual patient’s beliefs about pain:

• What do you call your pain? What name do you give it?
• Why do you think you have this pain?
• What does your pain mean for your body?
• How severe is it? Will it last a long or short time?
• Do you have any fears about your pain?
• If so, what do you fear most about your pain?
• What kind of treatment do you think you should receive? What are the most important results you hope to receive from the treatment?
• What cultural remedies have you tried to help you with your pain?
• Have you seen a traditional healer for your pain? Do you want to?
• Who, if anyone, in your family do you talk to about your pain? What do they know? What do you want them to know?
• Do you have family and friends who help you because of your pain? Who helps you?

While we should never undervalue patients’ experience of pain, we shouldn’t overestimate their ability to modulate the pain either.¹⁴ Guy McCormack, OT, PhD, chair of the Department of Occupational Therapy and Occupational Science in the MU School of Health Professions, who has pioneered using techniques to reduce pain, uses several noninvasive techniques to direct attention to activities other than pain. Pulling in techniques from many cultures, he advocates a holistic approach to pain reduction.

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Holistic Approaches to Pain Reduction

• Apply deep pressure to surrounding tissue following principles from shiatsu and acupressure.
• Massage, myofascial therapy, cranial sacral, and therapeutic touch
• Visualization and therapeutic relaxation
• Deep breathing
• Singing (loudly and in tempo of the pain)
• Listening to music
• Exercises to increase circulation and decrease muscle tension such as qi gong, tai chi and yoga
• Increasing natural warmth through sauna and hot baths (if not contraindicated)
• Increasing cooling by brisk walks in cool morning air
  (if not contraindicated)

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Cultural Influence on Patient Pain Control Beliefs

Cultural learning molds both the patient’s pain behavior and the caregiver’s interpretation and response to it. Clinicians’ personal interpretation of pain should not influence the treatment response to the patient’s self-reported pain level. However, research reveals that patients’ behaviors may influence caregivers’ assessment or sometimes, lack of adequate assessment.

Culture also influences patients’ and caregivers’ views on pain management. When the pain responses of a group of English- (both white and black), Korean-, and Spanish-speaking patients with cancer were compared, the Koreans reported higher levels of pain, but had less of a belief than other groups that their pain should be controlled through pain management by caregivers.¹⁷ There were no differences among the other patients’ perceived level of pain. In the Hispanic patients, feelings of psychological distress and reported physical pain were not connected to each other. Oddly enough, although Mexican women are often reputed to cry out in pain more than members of other cultural groups, studies have reported that self-control is important in Mexican culture. In this case, crying out is considered an acceptable response to pain and not a loss of self-control.

Interconnecting factors complicate pain behavior and pain management. They involve both patients’ and caregivers’ cultural learning about the expression of pain and expectations of pain relief, patients’ ability to articulate the degree and location of pain, and the caregivers’ culturally and professionally learned attitudes about pain management. There are several ways, as a caregiver, to enhance your understanding of cultural influences on patients’ pain behavior and your response to them.

1. Become more acutely aware of your own cultural programming and never underestimate pain. Cultural blindness — ethnocentrism — is the assumption that one’s cultural beliefs are the only correct ones and are superior to those of others. This usually involves a tendency toward judging others based on similarity to or difference from one’s own cultural view.¹⁸ And this is surprisingly common. We may not even be aware of how our views affect our behavior toward patients from other cultures. To become more aware of your personal cultural perspective, list and analyze the acceptable ways in which members of your own culture display pain. What are their beliefs about open display, such as moaning or crying out? Are members of your culture expected to “grin and bear it”? What are the accepted beliefs about pain management? Should a person “tough it out” or should pain be avoided as much as possible? Try to become aware of how these cultural practices influence your responses to the expressions of pain by patients who have different cultural orientations.

2. Be aware of how personal stereotypes surrounding patients’ ethnicity or education can influence your evaluation of the degree to which patients are suffering stress or pain. Although cultural tendencies do influence how patients express pain, be careful not to stereotype patients based on ethnicity or educational background. In general, better-educated patients from higher socioeconomic levels may be able to articulate their pain more clearly than those less educated or from lower socioeconomic backgrounds. However, an inability to articulate the presence, type, and location of pain does not mean that pain is absent. And behaviors thought to be common to ethnic groups may not hold true, especially when patients are faced with chronic, relentless pain. Nevertheless, knowledge of specific cultural beliefs and practices of the patients to whom you give care will help you assess their pain more accurately.¹⁹

3. Don’t label patients who demonstrate what you interpret as an exaggerated response to pain as “complainers.” Remember that some patients may come from cultures in which pain, when shared, is believed to bring relief or from cultures in which the ill are supposed to voice their pain if they are truly ill. Take the time to ascertain whether patients are merely trying to relieve pain or whether they are communicating a request for intervention. Respond to patients in a manner that is appropriate to their cultures, even if they may be inappropriate to your own.

4. If patients have illnesses or conditions that are normally accompanied by sufficient pain to require medication, don’t simply ask patients if they would like some medical relief. Administer it, unless the patient expressly opposes it. This advice is especially true when the patient comes from a culture that teaches that a person should suffer pain in silence. Explain to patients that, as caregivers, we have found that good pain control tends to hasten healing and prevent complications. Current healthcare standards recommend that pain should be controlled or alleviated whenever possible.³

Explaining these things to patients gives them the opportunity to understand the professional standards on pain management and accept or reject these according to their own cultural beliefs.

5. Remember that caregivers commonly underevaluate pain. The information presented here has shown how easy it is for caregivers to underevaluate pain for all patients, regardless of ethnicity, and thus limit analgesics in an attempt to relieve, rather than dispel, patient pain. Instead of relying on our own possibly culturally biased indicators of pain, such as the presence of grimacing, we need to use more objective, evidence-based measures. The currently accepted practice standard is to rely on patients’ self-reports as the most reliable indicators of the presence and intensity of pain. Using patient self-reports, such as analogue scales, moves the assessment of pain away from the clinician’s subjective view, which may be highly colored by cultural and professional conditioning, to a more objective stance.¹⁷ Believing what the patient says will lead to more effective evaluation and treatment of pain. Caregivers should also avoid undervaluing the impact of pain and overvaluing concern about the “over-use” or adverse effects of pain medications. Both of these issues are implicated in the decision to reduce rather than eliminate pain.

6. You need to initiate questioning patients about the presence of pain and encourage them to talk about their pain, their attitude toward pain control, and their beliefs about the use of analgesics. Some patients underreport pain or are afraid to discuss pain with caregivers for fear of addiction to drugs or criticism by caregivers whom they view as authority figures. They may also be afraid to admit to pain for fear that the discomfort is indicative of a worsening of their condition. Take the time to ask not only about the level of pain, but to find out whether, in their culture, moaning or crying is appropriate, and what caregivers are expected to do about it. Remember that Western medical care has a culture of its own;20 entering a healthcare facility for treatment can be a scary experience, especially for those unfamiliar with its customs and procedures. The environment may seem strange and impersonal, especially when patients don’t speak English. Caregivers who take an extra few moments to establish a trusting relationship by asking patients about their pain and expectations about how it should be managed show respect and will be more effective in managing patients’ pain. Warmth and respect are characteristics understood by patients from all cultural backgrounds.² Finally, obtain the patient self-reported pain score and conduct a cultural pain interview, and then gauge treatment based on those reports.¹⁶