Setting Clinical Pain Research Priorities in Low- and Middle-Income Settings

Setting Clinical Pain Research Priorities in Low- and Middle-Income Settings

Authors: 

• Mulugeta Bayisa Chala, PT, PhD, Lawson Research Institute, St. Joseph’s Health Care London, London, ON, Canada 
• Sintayehu Daba Wami, PhD Candidate, Queen’s University, School of Rehabilitation Therapy, Kingston, ON, Canada 
• Shehnaz Fatima Lakha, PhD, Wellness and Health Enhancement Engineering Lab, University of Toronto Pain and Wellness Centre, Toronto, ON, Canada
• Peter Kamerman, PhD, Brain Function Research Group, University of the Witwatersrand, South Africa
• Sudha Bechan, FCA, Inkosi Albert Luthuli Central Hospital, University of KwaZulu-Natal
• Jordi Miró, PhD, Department of Psychology, Universitat Rovira i Virgili, Spain
• Elizabeth Ogboli Nwasor, MBBS, Department of Anaesthesia, Ahmadu Bello University Teaching Hospital, Zaria, Kaduna State, Nigeria
• Gauhar Afshan, MBBS, FCPS, Endowed Professor of Anaesthesia & Pain Medicine. The Aga Khan University, Karachi. Pakistan

Introduction

Pain is a leading cause of disability worldwide, with its burden rising disproportionately in low- and middle-income countries (LMICs)^1-3 and among people living in low- and middle-income settings within high-income countries⁴. Socioeconomic, cultural, and health system challenges in these settings exacerbate untreated pain, reducing quality of life and economic productivity⁵. Despite this, pain often receives minimal attention and is poorly managed, leading to further incapacity, morbidity, and poor quality of life⁶. In low-resource settings, evidence-based and knowledge-driven effective pain management strategies are largely absent due to minimal investment in pain research^{7, 8}. Furthermore, there are significant gaps in the scope and focus of existing pain research conducted to inform contextually relevant care strategies. This Fact Sheet focuses on key challenges and priority areas to guide clinical pain research priorities in low- and middle-income settings, supporting IASP’s 2025 Global Year About Pain Management, Research and Education in Low- and Middle-Income Settings. 

Challenges of Conducting Clinical Pain Research in Low- and Middle-Income Settings 

Clinical pain research in low- and middle-income settings faces significant challenges, including limited funding, insufficient human capital, inadequate infrastructure, limited knowledge of research methodology, unsupportive work environments for conducting research, and lack of tools and data^9-11. Cultural stigma around pain, communication barriers, low literacy, participant retention issues, and cross-cultural and language differences further hinder research efforts^{12, 13}. Additionally, competing health priorities, such as infectious diseases and maternal and neonatal health, often divert attention from pain research¹⁴. The absence of robust policy support and socioeconomic inequalities further impede the inclusion of diverse populations and the development of sustainable pain research initiatives.

Priority Areas and Key Considerations for Clinical Pain Research in Low- and Middle-Income Settings 

There is a knowledge gap in our understanding of pain and its link to disability in low- and middle-income countries due to the lack of robust research on the topic¹⁵. Bridging this gap requires a comprehensive understanding of the burden and barriers to pain management and the development of cost-effective, culturally appropriate interventions. In addition, incorporating equity, diversity, inclusion, and other considerations, including patient and caregiver involvement in pain research, would help reduce these disparities. Closing these knowledge gaps is critical to advancing equitable pain care and improving health outcomes in under-resourced settings. 

The following outlines priority areas, considerations, and opportunities to advance clinical pain research and improve pain management in low- and middle-income settings: 

Understand the Burden of Pain

• Develop standardized research methodologies (e.g., protocols), tools (e.g., survey questionnaires), and outcome measures in local languages suitable to cultural needs. 
• Conduct epidemiological studies to determine the prevalence and impact of chronic pain conditions, thus forming the base from which further pain research and management agendas can be developed. 
• Prioritize research that considers the unique economic costs (e.g., medical costs, productivity losses), epidemiological transitions, and projected trends of painful conditions.

Develop and Evaluate Pain Management Strategies

• Focus on translational pain research and embedded research to impact clinical practice. 
• Develop and evaluate context-specific (e.g., local priority populations, groups such as older adults) pain management intervention strategies to local cultural, social, and economic contexts. The involvement of people living with pain in the development and evaluation process is crucial to improve the uptake and sustainability of newly developed interventions. 
• Develop and evaluate the effectiveness of various interdisciplinary rehabilitation programs (e.g.,   cognitive behavioral therapy interventions, physical therapy, occupational therapy), self-management strategies and toolkits, and supportive/palliative care, including spiritual and cultural practices, to improve the quality of life of people living with painful conditions. 

Address Barriers to Pain Care 

• Identify and develop processes to mitigate hindrances to effective pain care, such as inadequate infrastructure, access to medication and therapeutics, cultural and systemic factors, and healthcare personnel challenges.

Address the Training Needs of Pain Researchers to Conduct High-Quality Research

• Improve the capacity of pain researchers by developing locally relevant research training programs. The training programs should include skills such as (1) problem identification, (2) formulation of high-quality and priority research questions, (3) critical appraisal of published articles, (4) planning and conducting of impactful research, (5) implementation and dissemination of research findings, and (6) advocacy for pain research and education in the local context. 
• Encourage local, regional, and international collaboration and networks to share resources, expertise, and best practices. Existing examples include the In-ChildPain research network on chronic pain in childhood (www.neuron-eranet.eu/projects/INCHILDPAIN). 
• Foster research partnerships with people living with pain, community members, healthcare providers, and policymakers. 

Leverage Technology and Innovation

• Develop new and tailor existing digital treatments and mobile health platforms to improve pain assessment and care delivery in remote and underserved areas. Create pain registries specific to the local context to collect and share data among researchers and other users.

Policy and Advocacy 

There are several opportunities for policy advocacy to advance and sustain clinical pain research in low- and middle-income settings. Specific areas include: 

• Advocate for allocation of resources by governmental and non-governmental agencies to conduct pain research. 
• Encourage citizen science initiatives, including citizen panels or councils, in setting clinical pain research priorities and processes (e.g., identify and prioritize research questions). This not only increases public awareness of pain research but also provides alternatives to difficulties in securing pain research funding in LMICs ¹⁶.
• Promote the inclusion of diverse interest holder groups, including people living with pain, in research priority settings. 
• Promote adaptation of existing methodological approaches to suit local pain research needs. 
• Push for greater global representation of pain researchers from low- and middle-income countries. There are several challenges faced by researchers from LMICs to publish their research. However, research from these settings will benefit global health¹¹.
• Promote innovative and culturally relevant approaches for disseminating and translating knowledge locally. 
• Support policies that foster interdisciplinary collaboration in pain research. 

Conclusion and Call to Action 

Closing gaps in clinical pain research in low- and middle-income settings demands actionable strategies, including robust policy support, increased funding, mentorship, and training. Collaboration, capacity building, and fostering research with social impact are essential. Leveraging technological advances, such as telehealth and digital health platforms, can drive sustainable and scalable pain management solutions. Furthermore, embedding research findings into healthcare policies and practices will improve outcomes, guide resource allocation, and inspire innovation.

References 

1. Cross M, Ong KL, Culbreth GT, Steinmetz JD, Cousin E, Lenox H, Kopec JA, Haile LM, Brooks PM, Kopansky-Giles DR, Dreinhoefer KE, Betteridge N, Abbasian M, Abbasifard M, Abedi A, Aboye MB, Aravkin AY, Artaman A, Banach M, Bensenor IM, Bhagavathula AS, Bhat AN, Bitaraf S, Buchbinder R, Burkart K, Chu DT, Chung SC, Dadras O, Dai X, Das S, Dhingra S, Do TC, Edinur HA, Fatehizadeh A, Fetensa G, Freitas M, Ganesan B, Gholami A, Gill TK, Golechha M, Goleij P, Hafezi-Nejad N, Hamidi S, Hay SI, Hundessa S, Iso H, Jayaram S, Kadashetti V, Karaye IM, Khan EA, Khan MA, Khatatbeh MM, Kiadaliri A, Kim MS, Kolahi AA, Krishan K, Kumar N, Le TTT, Lim SS, Lobo SW, Majeed A, Malik AA, Mesregah MK, Mestrovic T, Mirrakhimov EM, Mishra M, Misra AK, Moberg ME, Mohamed NS, Mohan S, Mokdad AH, Momenzadeh K, Moni MA, Moradi Y, Mougin V, Mukhopadhyay S, Murray CJL, Narasimha Swamy S, Nguyen VT, Niazi RK, Owolabi MO, Padubidri JR, Patel J, Pawar S, Pedersini P, Rafferty Q, Rahman M, Rashidi MM, Rawaf S, Saad AMA, Sahebkar A, Saheb Sharif-Askari F, Saleh MMK, Schumacher AE, Seylani A, Singh P, Smith AE, Solanki R, Solomon Y, Tan KK, Tat NY, Tibebu NSS, You Y, Zheng P, Zitoun OA, Vos T, March LM, Woolf AD. Global, regional, and national burden of gout, 1990–2020, and projections to 2050: a systematic analysis of the Global Burden of Disease Study 2021. Lancet Rheumatol 2024;6:e507–e517. doi: 10.1016/S2665-9913(24)00117-6.
2. Ferreira ML, De Luca K, Haile LM, Steinmetz JD, Culbreth GT, Cross M, Kopec JA, Ferreira PH, Blyth FM, Buchbinder R, Hartvigsen J, Wu AM, Safiri S, Woolf AD, Collins GS, Ong KL, Vollset SE, Smith AE, Cruz JA, Fukutaki KG, Abate SM, Abbasifard M, Abbasi-Kangevari M, Abbasi-Kangevari Z, Abdelalim A, Abedi A, Abidi H, Adnani QES, Ahmadi A, Akinyemi RO, Alamer AT, Alem AZ, Alimohamadi Y, Alshehri MA, Alshehri MM, Alzahrani H, Amini S, Amiri S, Amu H, Andrei CL, Andrei T, Antony B, Arabloo J, Arulappan J, Arumugam A, Ashraf T, Athari SS, Awoke N, Azadnajafabad S, Bärnighausen TW, Barrero LH, Barrow A, Barzegar A, Bearne LM, Bensenor IM, Berhie AY, Bhandari BB, Bhojaraja VS, Bijani A, Bodicha BBA, Bolla SR, Brazo-Sayavera J, Briggs AM, Cao C, Charalampous P, Chattu VK, Cicuttini FM, Clarsen B, Cuschieri S, Dadras O, Dai X, Dandona L, Dandona R, Dehghan A, Demie TGG, Denova-Gutiérrez E, Dewan SMR, Dharmaratne SD, Dhimal ML, Dhimal M, Diaz D, Didehdar M, Digesa LE, Diress M, Do HT, Doan LP, Ekholuenetale M, Elhadi M, Eskandarieh S, Faghani S, Fares J, Fatehizadeh A, Fetensa G, Filip I, Fischer F, Franklin RC, Ganesan B, Gemeda BNB, Getachew ME, Ghashghaee A, Gill TK, Golechha M, Goleij P, Gupta B, Hafezi-Nejad N, Haj-Mirzaian A, Hamal PK, Hanif A, Harlianto NI, Hasani H, Hay SI, Hebert JJ, Heidari G, Heidari M, Heidari-Soureshjani R, Hlongwa MM, Hosseini MS, Hsiao AK, Iavicoli I, Ibitoye SE, Ilic IM, Ilic MD, Islam SMS, Janodia MD, Jha RP, Jindal HA, Jonas JB, Kabito GG, Kandel H, Kaur RJ, Keshri VR, Khader YS, Khan EA, Khan MJ, Khan MAB, Kashani HRK, Khubchandani J, Kim YJ, Kisa A, Klugarová J, Kolahi AA, Koohestani HR, Koyanagi A, Kumar GA, Kumar N, Lallukka T, Lasrado S, Lee WC, Lee YH, Mahmoodpoor A, Malagón-Rojas JN, Malekpour MR, Malekzadeh R, Malih N, Mehndiratta MM, Nasab EM, Menezes RG, Mentis AFA, Mesregah MK, Miller TR, Mirza-Aghazadeh-Attari M, Mobarakabadi M, Mohammad Y, Mohammadi E, Mohammed S, Mokdad AH, Momtazmanesh S, Monasta L, Moni MA, Mostafavi E, Murray CJL, Nair TS, Nazari J, Nejadghaderi SA, Neupane S, Kandel SN, Nguyen CT, Nowroozi A, Okati-Aliabad H, Omer E, Oulhaj A, Owolabi MO, Panda-Jonas S, Pandey A, Park EK, Pawar S, Pedersini P, Pereira J, Peres MFP, Petcu IR, Pourahmadi M, Radfar A, Rahimi-Dehgolan S, Rahimi-Movaghar V, Rahman M, Rahmani AM, Rajai N, Rao CR, Rashedi V, Rashidi MM, Ratan ZA, Rawaf DL, Rawaf S, Renzaho AMN, Rezaei N, Rezaei Z, Roever L, De Andrade Ruela G, Saddik B, Sahebkar A, Salehi S, Sanmarchi F, Sepanlou SG, Shahabi S, Shahrokhi S, Shaker E, Shamsi MB, Shannawaz M, Sharma S, Shaygan M, Sheikhi RA, Shetty JK, Shiri R, Shivalli S, Shobeiri P, Sibhat MM, Singh A, Singh JA, Slater H, Solmi M, Somayaji R, Tan KK, Thapar R, Tohidast SA, Tahbaz SV, Valizadeh R, Vasankari TJ, Venketasubramanian N, Vlassov V, Vo B, Wang YP, Wiangkham T, Yadav L, Yadollahpour A, Jabbari SHY, Yang L, Yazdanpanah F, Yonemoto N, Younis MZ, Zare I, Zarrintan A, Zoladl M, Vos T, March LM. Global, regional, and national burden of low back pain, 1990–2020, its attributable risk factors, and projections to 2050: a systematic analysis of the Global Burden of Disease Study 2021. Lancet Rheumatol 2023;5:e316–e329. doi: 10.1016/S2665-9913(23)00098-X.
3. Jatuworapruk K. Gout prevalence is rising in low-income and middle-income countries: are we ready? Lancet Rheumatol 2024;6:e494–e495. doi: 10.1016/S2665-9913(24)00134-6.
4. Rice AS, Smith BH, Blyth FM. Pain and the global burden of disease. Pain 2016;157(4):791-796. doi: 10.1097/j.pain.0000000000000454
5. Fatoye F, Gebrye T, Mbada CE, Useh U. Clinical and economic burden of low back pain in low- and middle-income countries: a systematic review. BMJ Open 2023;13:e064119. doi: 10.1136/BMJOPEN-2022-064119.
6. Walters JL, Jackson T, Byrne D, McQueen K. Postsurgical pain in low- and middle-income countries. BJA: British Journal of Anaesthesia 2016;116:153–155. doi: 10.1093/BJA/AEV449.
7. Goucke CR, Chaudakshetrin P. Pain: a neglected problem in the low-resource setting. Anesthesia & Analgesia 2018;126(4):1283-1286. doi: 10.1213/ANE.0000000000002736
8. Sharma S, Pathak A, Parker R, Costa LOP, Ghai B, Igwesi-Chidobe C, Janwantanakul P, de Jesus-Moraleida FR, Chala MB, Pourahmadi M, Briggs AM, Gorgon E, Ardern CL, Khan KM, McAuley JH, Alghwiri AA, Aoko OA, Badamasi HS, Calvache JA, Cardosa MS, Ganesh S, Gashaw M, Ghiringhelli J, Gigena S, Hasan ATMT, Haq SA, Jacob ENW, van Rensburg DCJ, Kossi O, Liu C, Malani R, Mason BJN, Najem C, Nava-Bringas TI, Nduwimana I, Perera R, Perveen W, Pierobon A, Pinto E, Pinto RZ, Purwanto F, Rahimi MD, Reis FJJ, Siddiq AB, Shrestha D, Tamang M, Vasanthan LT, Viljoen C. How Low Back Pain is Managed—A Mixed-Methods Study in 32 Countries. Part 2 of Low Back Pain in Low- and Middle-Income Countries Series. Journal of Orthopaedic and Sports Physical Therapy 2024;54:560–572. doi: 10.2519/JOSPT.2024.12406/ASSET/IMAGES/LARGE/JOSPT-12406-FIG002.JPEG.
9. Opportunities and Challenges of Conducting Clinical Research in Low- and Middle-Income Countries (LMICs) – Your Say. n.d. Available: https://yoursay.plos.org/2023/06/opportunities-and-challenges-of-conducting-clinical-research-in-low-and-middle-income-countries-lmics/. Accessed 27 Jan 2025.
10. Yenet A, Nibret G, Tegegne BA. Challenges to the Availability and Affordability of Essential Medicines in African Countries: A Scoping Review. Clinicoecon Outcomes Res 2023;15:443. doi: 10.2147/CEOR.S413546.
11. Sharma S, Verhagen AP, Elkins M, Brismée J-M, Fulk GD, Taradaj J, Steen L, Jette A, Moore A, Stewart A, Hoogenboom BJ, Söderlund A, Harms M, Pinto RZ. Research from low-income and middle-income countries will benefit global health and the physiotherapy profession, but it requires support. Journal of physiotherapy 2024;70(1):1-4. doi: 10.1016/j.jphys.2023.08.013
12. Global Inequities in Pain Treatment: How Future Research Can Address This Better – International Association for the Study of Pain (IASP). n.d. Available: https://www.iasp-pain.org/resources/fact-sheets/global-inequities-in-pain-treatment-how-future-research-can-address-this-better/. Accessed 27 Jan 2025.
13. Miller ET, Abu-Alhaija DM. Cultural Influences on Pain Perception and Management. Pain Management Nursing 2019;20:183–184. doi: 10.1016/j.pmn.2019.04.006
14. Briggs AM, Jordan JE, Sharma S, Young JJ, Chua J, Foster HE, Haq SA, Huckel Schneider C, Jain A, Joshipura M, Kalla AA, Kopansky-Giles D, March L, Reis FJJ, Reyes KA V., Soriano ER, Slater H. Context and priorities for health systems strengthening for pain and disability in low- and middle-income countries: a secondary qualitative study and content analysis of health policies. Health Policy Plan 2023;38:129–149. doi: 10.1093/HEAPOL/CZAC061
15. Matula ST, Polomano RC, Irving SY. The state of the science in paediatric pain management practices in low‐middle income countries: An integrative review. International Journal of Nursing Practice 2018;24(6):e12695. doi: 10.1111/ijn.12695
16. Gristwood A. Public participation in science: How citizen science initiatives in healthcare and the environment are opening up new directions in research. EMBO Rep 2019;20(8):e48797. doi: 10.15252/embr.201948797

 Reviewers 

1. Saurab Sharma, PhD, Royal North Shore Hospital, Sydney, Australia
2. Amanda C de C Williams, PhD, University College London, UK