Pain in Indigenous Peoples from Colonized Countries

Pain in Indigenous Peoples from Colonized Countries

Authors: 

• Brooke Conley: The University of Melbourne, Physiotherapy Department, Melbourne, Vic, Australia
• Ivan Lin: Western Australian Centre for Rural Health, University of Western Australia, Geraldton, WA, Australia and Geraldton Regional Aboriginal Medical Service, Geraldton, WA, Australia
• Jane Linton: University Centre for Rural Health, School of Health Sciences, The University of Sydney, Sydney, NSW, Australia
• Cheryl Davies: Tū Kotahi Māori Asthma and Research Trust, Wellington, New Zealand 
• Eva Morunga: Te Toka Tumai, Te Whatu Ora, Auckland and Department of Psychological Medicine, University of Auckland, Auckland, New Zealand
• Debbie Bean: Centre for Person Centred Research, Auckland University of Technology, Auckland, New Zealand
• Angela Upsdell: Department of Medicine, Ōtākou Whakaihu Waka ki Pōneke | University of Otago Wellington, New Zealand.
• Lívia Gaspar Fernandes: Rehabilitation Teaching and Research Unit (RTRU), Department of Medicine, Ōtākou Whakaihu Waka ki Pōneke | University of Otago Wellington, New Zealand.
• Hemakumar Devan: Rehabilitation Teaching and Research Unit (RTRU), Department of Medicine, Ōtākou Whakaihu Waka ki Pōneke | University of Otago Wellington, New Zealand.
• Ellie White: Department of Physiotherapy | The University of Melbourne, Victoria, Australia.
• Blayne Arnold: School of Health Sciences and Social Work, Griffith University, Queensland, Australia
• Jenny Setchell: School of Health and Rehabilitation Sciences, The University of Queensland, Australia
• Ben Darlow: Department of Primary Health Care and General Practice, Ōtākou Whakaihu Waka ki Pōneke | University of Otago Wellington, New Zealand.
• Allyson Jones: Department of Physical Therapy, University of Alberta, Edmonton, Canada
• Katrina Pōtiki Bryant: Ōtākou Whakaihu Waka/ University of Otago School of Physiotherapy, New Zealand.

This fact sheet was developed from the collective efforts of Indigenous and non-Indigenous clinicians and researchers from Australia, Aotearoa New Zealand, and Canada, including authors from the “Moving Forward Together” series, the first editorial series for musculoskeletal pain amongst Indigenous peoples, which will be published in the Journal of Sports and Physical Therapy in 2025.  

Background

2025 is the IASP’s global year for pain management, research and education in low- and middle-income settings, including populations disproportionately impacted by pain within high-income countries. This fact sheet looks at pain care amongst Indigenous peoples in the colonized, high-income countries of Australia, Canada, and Aotearoa New Zealand. These countries share related histories of British colonization; although they are high-income countries with attendant social and health advantages such as universal healthcare, Indigenous peoples within these countries do not all share these benefits and there are inequities in pain care. 

Colonization and Its Impacts 

Disparities in the prevalence and burden of pain between Indigenous and non-Indigenous peoples (for example see ^[9]) originates from and is the ongoing consequence of colonization. Colonization, in which genocide, slavery, stealing of lands, spread of disease, displacement, oppression, assimilation, child removal and deliberate attempts to eradicate language, social, cultural, and spiritual practices occurred, and still occur, alongside harm to ecological systems and Country ^[12]. The sequelae includes historical, collective, and intergenerational trauma, racism, and marginalization of Indigenous peoples ^[13]. These can have a profound impact on pain, in which pain is experienced not only individually, but within broader relationships to family, land, spirit, and Community ^[6].

Many Indigenous people have withstood and continue to flourish despite colonization. For thousands of years, Indigenous peoples have cared for pain conditions with, for example,  traditional medicines, movement practices, ceremony, and lifestyle practices. Indigenous holistic understandings about wellbeing and pain pre-date the “biopsychosocial model of pain.” Some guiding values of Indigenous approaches to pain and healing (examples from Aotearoa New Zealand – see also glossary) include:

• Whakapapa (genealogy/kinship and connection): Pain and healing are understood within the interconnectedness of whānau (family), ancestors, and future generations. In many traditions, kinship extends beyond the human world to include plants, animals, past ancestors /spirits.
• Holistic models of health including Wairuatanga (spirituality – often missed in Western models): Spiritual wellbeing is central to health. Practices such as karakia (prayer), wānanga (collective learning), ceremony, waiata (song) and connection to wairua (spirit) are key to support healing.
• Whanaungatanga (fostering mutually respectful relationships): Building and maintaining deep, respectful relationships is vital in supporting healing and shared decision-making. Deep listening, trust, shared understanding, and reciprocity are essential in clinical and community contexts.
• Rangatiratanga (self-determination and sovereignty): Indigenous people should lead their own healing journeys and have autonomy over how care is designed and delivered. Leadership in health care needs to ensure that services reflect Indigenous priorities, values, and knowledge.
• Mātauranga (knowledge sovereignty): Indigenous knowledge systems need to be valued alongside clinical knowledge. Healing practices may include traditional medicine, physical therapies (mirimiri), storytelling (yarning), and other oral traditions.

Long-established Indigenous philosophies and approaches to pain care and wellbeing have not been valued by contemporary mainstream pain management services (the last 100-200 years), which were primarily established to meet the needs of non-Indigenous people. These services are often considered inaccessible and culturally unsafe by Indigenous peoples, further reinforcing inequities in health care. 

Building on the collective values and resilience of Indigenous peoples, and utilizing strengths-based approaches (recognising and working with the the inherent resilience, resources, and cultural strengths of Indigenous peoples), there are numerous considerations and opportunities for pain advocates, researchers, educators and clinicians to contribute to greater wellbeing of Indigenous peoples at the societal, health systems/services, and clinician level, aiming to achieve fair and equitable pain outcomes.

Societal 

Pain clinicians and policy makers should be aware of the upstream determinants of Indigenous health that also impact on pain. A key determinant is the relationship between non-Indigenous and Indigenous peoples. Considerations include:

• Are there formal agreements between Indigenous and non-Indigenous peoples? An example is the Te Tiriti o Waitangi (Treaty of Waitangi) in Aotearoa New Zealand ^[10].  
• What truth-telling and reconciliation activities have been undertaken, e.g., ^[12], and whether these have been enacted successfully? 
• What Indigenous self-determination and Indigenous leadership exists within societal, political, and health contexts (such as Indigenous Community Controlled Health Care Organisations, e.g., ^[11])? 
• Is there adequate funding for Indigenous-led, implementation-oriented pain research that fosters innovation and drives health care improvement?  

Pain societies/organizations should support efforts to promote Indigenous self-determination. This includes providing resources for Indigenous-led pain care and research. Strengthened relationships between Indigenous and non-Indigenous peoples, communities, and organizations that contribute to the allyship are needed to achieve equity in pain services.

Health Systems/Services

Health systems and pain management services can support pain management for Indigenous people by:

• Supporting and learning from strengths-based, Indigenous-led models of pain care that integrate Indigenous concepts of wellbeing and culture into the way services are routinely provided. This could include traditional medicines, movement practices, ceremony, lifestyles, breathing, meditation, spiritual practices, and philosophies to manage pain. Examples are a Māori-led community-based pain management program that incorporates Rongoā Māori – Māori traditional treatment in Aotearoa New Zealand ^[4]; an arthritis service embedded within an urban Aboriginal primary health care service in Calgary, Canada ^[1]; and culturally appropriate arthritis information resources co-developed with Aboriginal Communities that integrated Clinical Practice Guideline recommendations and the needs and wants of Aboriginal people living with arthritis ^[3]. 
• Developing pain services within Indigenous Community Controlled Health Care Organizations. In settings with non-Indigenous controlled health care (i.e., mainstream services), engage Indigenous stakeholders in the development and overseeing of pain services.
• Employing Indigenous staff at multiple levels (e.g., managerial, clinical, support, and administrative). Most pain professions are not ethnically or culturally representative of the populations they serve, and there are not enough Indigenous pain clinicians. Educational institutions require policies/programs to recruit and support Indigenous peoples in the pain health professions so that the Indigenous pain workforce reflects population demography and health needs (for example, see: Te Kauae Parāoa: Division of Health Sciences Policy on Admissions at the University of Otago ^[14]).
• Addressing (or countering) health system/service barriers for Indigenous peoples by adopting culturally safe, relational, and antiracist pain care approaches. Key considerations include ensuring a well-supported Indigenous health workforce (as above), improving communication, strengthening relationships between health services and Indigenous Communities, health systems that understand and are able to respond to Indigenous peoples’ cultural knowledge, beliefs and values, recognizing racism as a determinant of health, and skills-based cross-cultural and anti-racism training ^{[2; 5]}.
• Recognizing limitations in commonly used pain measurement tools for Indigenous people ^[7].

Clinicians  

Indigenous and non-Indigenous clinicians can enhance outcomes for Indigenous people with pain by developing their knowledge, skills, and practices. Key considerations for clinicians are: 

• Develop person/family/Community-centered skills in pain care, including clinical communication skills such as including deep listening, narrative/storytelling, and explaining pain using culturally appropriate methods. Examples include Clinical Yarning from Australia ^[8] and the Hui process from Aotearoa New Zealand ^[15].
• For non-Indigenous clinicians especially, undertake training in cultural responsibility, safety, security, or related concepts. Training should begin with critical self-reflection and an understanding of one’s own cultural perspective and internal biases, and then understanding local Indigenous ways of knowing, being, and doing. Incorporate Indigenous cultural knowledge into practice, e.g., appropriate decision making that may involve family members, using local words/phrases if suitable.  
• Value strong and trusting relationships with Indigenous people and Community. 
• Trusting relationships between patients and clinicians should be a primary goal of practice. 
• For non-Indigenous pain clinicians, strive to be an ally and advocate, recognizing that allyship is a critical lifelong practice and process rather than an outcome or identity, and involves non-Indigenous and Indigenous peoples acting together to improve pain outcomes. This involves recognizing and calling out racism within and beyond the workplace. Mutually supportive relationships between non-Indigenous and Indigenous colleagues that recognize the added potential burden of cultural/colonial load for Indigenous staff are critical. 

Conclusion 

Indigenous-led solutions at societal, health system/service, and service delivery levels can foster fair and equitable outcomes for Indigenous people living with pain and improve pain care for all people. 

References 

1. Barnabe C, Lockerbie S, Erasmus E, Crowshoe L. Facilitated access to an integrated model of care for arthritis in an urban Aboriginal population. Can Fam Physician 2017;63(9):699. https://www.cfp.ca/content/63/9/699.long 
2. Chakanyuka C, Bacsu J-DR, DesRoches A, Dame J, Carrier L, Symenuk P, O’Connell ME, Crowshoe L, Walker J, Bourque Bearskin L. Indigenous-specific cultural safety within health and dementia care: A scoping review of reviews. Soc Sci Med 2022;293:114658. https://doi.org/10.1016/j.socscimed.2021.114658 
3. Conley B, Linton J, Bullen J, Lin I, Toovey R, Persaud J, O’Brien P, Prehn R, Bromley J, Gregory N, Pickett T, Papertalk L, Green C, Flanagan W, Bunzli S. Integrating evidence from lived experience of Aboriginal people and clinical practice guidelines to develop arthritis educational resources: a mixed-methods study. Lancet Rheumatol 2025;7(2):e94-e107. https://doi.org/10.1016/s2665-9913(24)00233-9 
4. Davies C, Devan H, Reid S, Haribhai-Thompson J, Hempel D, Te Aho-White IJ, Te Morenga L. “When you’re in pain you do go into your shell” A community-based pain management programme co-designed with Māori whānau to address inequities to pain management–A qualitative case study. J Pain 2024:104760. https://doi.org/10.1016/j.jpain.2024.104760 
5. De Zilva S, Walker T, Palermo C, Brimblecombe J. Culturally safe health care practice for Indigenous Peoples in Australia: A systematic meta-ethnographic review. J Health Serv Res Policy 2022;27(1):74-84. https://doi.org/10.1177/13558196211041835 
6. Fernandes LG, Davies C, Jaye C, Hay-Smith J, Devan H. “We do not stop being Indigenous when we are in pain”: An integrative review of the lived experiences of chronic pain among Indigenous peoples. Soc Sci Med 2025:117991. https://doi.org/10.1016/j.socscimed.2025.117991 
7. Hoeta TJ, Baxter GD, Bryant KAP, Mani R. Māori pain experiences and culturally valid pain assessment tools for Māori: a systematic narrative review. NZ J Phys 2020;48(1):37-50. https://doi.org/10.15619/NZJP/48.1.05 
8. Lin I, Green C, Bessarab D. ‘Yarn with me’: applying clinical yarning to improve clinician–patient communication in Aboriginal health care. Aust J Prim Health 2016;22(5):377-382. https://doi.org/10.1071/py16051 
9. Lin IB, Bunzli S, Mak DB, Green C, Goucke R, Coffin J, O’Sullivan PB. Unmet Needs of Aboriginal Australians With Musculoskeletal Pain: A Mixed‐Method Systematic Review. Arthritis Care Res 2018;70(9):1335-1347. https://doi.org/10.1002/acr.23493 
10. Manatu Hauora – Ministry of Health. Te Tiriti o Waitangi framework. In: TKoA-NZ Government editor. Wellington, Aotearoa New Zealand, 2024.
11. NACCHO. National Aboriginal Community Controlled Health Organisation, Vol. 2009. Canberra: National Aboriginal Community Controlled Health Organisation, 2008.
12. National centre for truth and reconciliation. Truth and reconciliation commission, Vol. 2019. Winnipeg: University of Manitoba, 2019.
13. Paradies Y. Colonisation, racism and indigenous health. J. Popul. Res.2016;33(1):83-96. https://link.springer.com/article/10.1007/s12546-016-9159-y 
14. University of Otago: Otakou Whakaihu Waka. Te Kauae Parāoa: Division of Health Sciences Policy on Admissions. Available at: https://www.otago.ac.nz/oms/education/te-kauae-paraoa. Accessed 8 August 2025.
15. Lacey C, Huria T, Beckert L, Gilles M, Pitama S. The Hui Process: a framework to enhance the doctor-patient relationship with Maori. NZ Med J 2011;124:1347.

Glossary:

*Although understanding specific Indigenous concepts and values is facilitated by translating words from Indigenous languages and dialects into English, we acknowledge that meaning making is informed by worldviews and encompasses concept and practice.

Māori terms/concepts: 

• Karakia: prayer
• Mātauranga: knowledge systems
• Mirimiri: a traditional Māori healing approach often described as massage or bodywork
• Rangatiratanga: self-determination
• Waiata: songs and performance
• Wairua: spirit
• Wairuatanga: spirituality
• Wānanga: learning space, collective learning 
• Whakapapa: genealogy and kinship
• Whānau: extended family and family network
• Whanaungatanga: connections and relationships

Aboriginal and Torres Strait Islander terms/concepts: 

Yarning: informal conversational and storytelling approach.

Country: place of ancestral lands, where someone belongs, deeply intertwined with identity, culture and spirituality.

Community: refers to interrelatedness, family ties, belonging and shared experience as Aboriginal and Torres Strait Islander people, as well as relationships to Country and kin. People can belong to more than one Community e.g. where people are from, the Community in a specific location, or place of work.