Improving Pain Care for Culturally Diverse Populations in High-Income Countries

Improving Pain Care for Culturally Diverse Populations in High-Income Countries

Authors: 

• Chinonso Igwesi-Chidobe PhD^1,2
• Saurab Sharma PhD^3,4,5,6
• Ursula Wesselmann MD, PhD, DTM&H (Lond.)⁷

Introduction

Culturally diverse populations, in the context of this factsheet, refers to indigenous and aboriginal peoples, immigrant communities, refugee, and religious communities. Globally, there are more than 150 million international migrant workers whose major destinations are high-income countries in North America, northern, southern, and western Europe, and the Middle East.^1,2 Within this population are 11.5 million domestic workers, of which the majority are women.³ In the Asia Pacific region, two-thirds of all migration occurs intra-regionally and has been increasing steadily since the late 20^th century, reaching 65 million in 2019.^4,5

Care for culturally diverse populations, particularly in high-income countries, is crucial because they have a high burden of disease and experience the greatest health inequalities, including inaccessibility to treatment, unequal, culturally inappropriate, or ineffective treatments, and poor clinical outcomes.^6–11 The healthcare needs and well-being of migrant worker populations has remained a neglected public health concern, and few data exist regarding chronic pain in this group.^5,12 Care for culturally diverse populations must be specifically planned and implemented to achieve sustainable development goal 3 on “Good health and wellbeing for all.” 

Inequalities in chronic pain burden and chronic pain management are significant and particularly disproportionate for culturally diverse populations in high-income countries. For instance, in the United Kingdom (UK), Black people have the greatest burden of chronic pain in terms of prevalence, severity, and functional limitations.¹³ In the UK and United States of America (USA), Black patients are the most likely to report poor treatment experiences due to communication-related barriers, suboptimal treatment recommendations, and use of culturally insensitive tools/interventions.^14–17 For example, the perception that Black patients need less pain relief has particularly contributed to inequality in pain management for Black patients in high-income countries.^18–21 Compared to non-Indigenous people, Indigenous people around the world have higher prevalence of disabling pain conditions (e.g., low back pain), that impact well-being and cultural identity, and can be iatrogenic.^22,23 Despite this, they face barriers to accessing Western health services due to cultural insecurities, lack of awareness of availability of services, racism, and discrimination, among others. The result is a lack of trust and miscommunication with healthcare providers, contributing to poor clinical outcomes.²³ 

Current challenges to the care of culturally diverse populations in high-income countries are explored and potential solutions are proffered below. 

Current Challenges 

Communication and Cultural Barriers

Communication barriers affect care for culturally diverse people as language differences often exist between culturally diverse patients and healthcare providers. Healthcare providers’ inability to fully understand the pain experiences of these patients leads to suboptimal and low-value care.²⁴ 

Culturally specific pain expressions that are important for patients may be dismissed, leading to dissatisfaction with care. In the Igbo culture of Nigeria, there is no direct word for depression, and people with chronic low back pain often use the word “tiredness” to explain their depression, which may influence coping strategies.^25–30 In Korean culture, the use of somatic words to explain emotional states triggers more sympathy compared with using emotional words, which suggests some cultural influence of somatisation.^31,32  

The irrelevance of many assessment tools for culturally diverse patients may impact care. For instance, numerical pain rating scales lack utility among Nepali-speaking people, among whom verbal and faces as rating options are preferred.³³ Similarly, the visual analogue scale has limited clinical utility among rural Nigerian patients with chronic low back pain.^25,34 Religious, spiritual, traditional and cultural healing practices may conflict with Western medical approaches.³⁵ Family involvement in clinical decision-making is common in many non-Western cultures, which could hinder modern medical management and ultimately treatment adherence and self-management. 

Structural Problems 

Limited cultural competency of health care professionals negatively affects the relevance and quality of pain management services for culturally diverse populations.^36,37 There are often too few clinicians from culturally diverse backgrounds in many high-income countries who understand the cultural contexts of culturally diverse communities. Another major problem is the lack of inclusion of culturally diverse populations in clinical research and trials in high income countries; therefore, current evidence hardly apply to these individuals.³⁸ This leaves clinicians with a limited understanding of intervention suitability, acceptability, effectiveness, and safety in this population, leading to suboptimal treatment and reduced or delayed access to novel interventions.  

The Way Forward

Mandatory Cultural Competency Training 

Mandatory cultural competency for all pain clinicians on effective assessment and management of culturally diverse populations is necessary.³⁹ Some countries like New Zealand and Australia require cultural competency training as a requirement for obtaining and maintaining health professional license. Training needs to develop cross-cultural communication skills, effective integration of medical interpreters in clinical consultations, and understanding of the cultural variations in pain expression and coping mechanisms among culturally diverse populations, while acknowledging individual differences within cultures. This can lead to improved communication, trust, treatment adherence, and clinical outcomes. We suggest a systematic, practical, and experiential assessment of cultural competency training, the impact of which can be investigated in prospective studies, rather than a tick-box exercise where clinicians, for instance, complete multiple-choice questions in order to be licensed.  

Developing Workforce by Training Culturally Diverse Clinicians

Increasing the number of culturally diverse clinicians who speak the language of their patients and understand their cultural contexts can improve therapeutic alliance and treatment outcomes for culturally diverse populations.³⁹ Racial and ethnic concordance between patients and pain clinicians improves communication and health outcomes. 

Community Engagement to Ensure Appropriateness of Care for Culturally Diverse People

Clinicians and researchers need to use culturally appropriate, reliable, and valid outcome measures in clinical practice.^40,41 Faces Rating Scales and Verbal Rating Scales tend to be preferred and are associated with fewer errors than Numerical Rating Scales and Visual Analog Scales in some non-western cultures, particularly in older adults and those with limited education.^25,33 Education can be acceptable and effective when co-developed with culturally diverse communities, as the messages will be relevant and relatable.⁴² Effective and safe traditional therapeutic practices can be incorporated into pain management services to enhance cultural sensitivity.^27,28 

Policy Considerations

Supporting equitable, high-value, culturally-sensitive clinical care at national and institutional levels and discouraging non-evidence-based, low-value care is critical to improve care for culturally diverse communities. Co-development of pain educational resources in multiple languages to promote deeper understanding of pain and self-management among culturally diverse communities can empower them and help improve pain self-management. Inclusion of research agendas on culturally diverse populations in funding schemes should be a priority to improve care for these populations. Critical research questions could be cultural adaptation of patient-reported outcome measures, co-design and testing of culturally-appropriate pain interventions that acknowledge evidence, theory and context.^43,44

Conclusion

Comprehensive, evidence-based, multifaceted, and multilevel approaches that involve policy makers, health professionals, researchers, healthcare systems, and communities are required to improve the care for culturally diverse populations in high-income countries. This is not a unidirectional approach, but a logical and necessary pathway for different cultures to learn from each other by recognizing and respecting diverse ways of experiencing, expressing, and managing pain.

References

1. Hargreaves S, Rustage K, Nellums LB, et al. Occupational health outcomes among international migrant workers: a systematic review and meta-analysis. Lancet Glob Heal. 2019;7(7):e872-e882.
2. International Labour Organisation. ILO Global Estimates on Migrant Workers.; 2015. Available at: https://www.ilo.org/sites/default/files/wcmsp5/groups/public/@dgreports/@dcomm/documents/publication/wcms_436343.pdf. Accessed 6 June 2025.
3. World Health Organisation. Women on the Move: Migration, Care Work and Health.; 2017. Available at: https://www.who.int/publications/i/item/9789241513142. Accessed 6 June 2025.
4. Economic and Social Commission for Asia and the Pacific. Asia-Pacific Migration Report 2020: Assessing Implementation of the Global Compact for Migration.; 2020. Available at: https://www.unescap.org/resources/asia-pacific-migration-report-2020. Accessed 6 June 2025.
5. Chan J, Dominguez G, Hua A, Garabiles M, Latkin CA, Hall BJ. The social determinants of migrant domestic worker (MDW) health and well-being in the Western Pacific Region: A Scoping Review. PLOS Glob Public Heal. 2024;4(3):e0002628. https://doi.org/10.1371/journal.pgph.0002628
6. MacKinnon NJ, Emery V, Waller J, et al. Mapping health disparities in 11 high-income nations. JAMA Netw open. 2023;6(7):e2322310-e2322310. https://doi.org/10.1001/jamanetworkopen.2023.22310
7. Marcus K, Balasubramanian M, Short S, Sohn W. Culturally and linguistically diverse (CALD): terminology and standards in reducing healthcare inequalities. Aust N Z J Public Health. 2022;46(1):7-9. https://doi.org/10.1111/1753-6405.13190
8. Khatri RB, Assefa Y. Access to health services among culturally and linguistically diverse populations in the Australian universal health care system: issues and challenges. BMC Public Health. 2022;22(1):880. https://doi.org/10.1186/s12889-022-13256-z
9. Hernández A, Ruano AL, Marchal B, San Sebastián M, Flores W. Engaging with complexity to improve the health of indigenous people: a call for the use of systems thinking to tackle health inequity. Int J Equity Health. 2017;16:1-5. https://doi.org/10.1186/s12939-017-0521-2
10. Macgregor C, Walumbe J, Tulle E, Seenan C, Blane DN. Intersectionality as a theoretical framework for researching health inequities in chronic pain. Br J Pain. 2023;17(5):479-490. https://doi.org/10.1177/20494637231188583
11. Eikemo TA, Bambra C, Huijts T, Fitzgerald R. The first pan-European sociological health inequalities survey of the general population: the European Social Survey rotating module on the social determinants of health. Eur Sociol Rev. 2017;33(1):137-153. https://doi.org/10.1093/esr/jcw019
12. Urrego-Parra HN, Rodriguez-Guerrero LA, Pastells-Peiro R, et al. The health of migrant agricultural Workers in Europe: a scoping review. J Immigr Minor Heal. 2022;24(6):1580-1589. https://doi.org/10.1007/s10903-022-01330-y
13. England PH. Chronic Pain in Adults 2017: Health Survey for England. Published online 2020. Available at: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/940858/Chronic_Pain_Report.pdf. Accessed 6 June 2025.
14. Meints SM, Cortes A, Morais CA, Edwards RR. Racial and ethnic differences in the experience and treatment of noncancer pain. Pain Manag. 2019;9(3):317-334. https://doi.org/10.2217/pmt-2018-0030
15. Bazargan M, Loeza M, Ekwegh T, et al. Multi-Dimensional Impact of Chronic Low Back Pain among Underserved African American and Latino Older Adults. Int J Environ Res Public Health. 2021;18(14):7246. https://doi.org/10.3390/ijerph18147246
16. Burton AE, Shaw RL. Pain management programmes for non‐English‐speaking black and minority ethnic groups with long‐term or chronic pain. Musculoskeletal Care. 2015;13(4):187-203. https://doi.org/10.1002/msc.1099
17. Robinson-Lane SG, Booker SQ. Culturally responsive pain management for Black older adults. J Gerontol Nurs. 2017;43(8):33-41. https://doi.org/10.3928/00989134-20170224-03
18. Hoffman KM, Trawalter S, Axt JR, Oliver MN. Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Proc Natl Acad Sci. 2016;113(16):4296-4301. https://doi.org/10.1073/pnas.1516047113
19. Schoenthaler A, Williams N. Looking Beneath the Surface: Racial Bias in the Treatment and Management of Pain. JAMA Netw Open. 2022;5(6):e2216281-e2216281. https://doi.org/10.1001/jamanetworkopen.2022.16281
20. Akinlade O. Taking black pain seriously. N Engl J Med. 2020;383(10):e68. https://doi.org/10.1056/nejmpv2024759
21. Strand NH, Mariano ER, Goree JH, et al. Racism in pain medicine: we can and should do more. In: Mayo Clinic Proceedings. Vol 96. Elsevier; 2021:1394-1400. https://doi.org/10.1016/j.mayocp.2021.02.030
22. Lin IB, O’Sullivan PB, Coffin JA, Mak DB, Toussaint S, Straker LM. Disabling chronic low back pain as an iatrogenic disorder: a qualitative study in Aboriginal Australians. BMJ Open. 2013;3(4):e002654. https://doi.org/10.1136/bmjopen-2013-002654
23. Struyf N, Vanwing T, Jacquet W, Ho-A-Tham N, Dankaerts W. What do we know about Indigenous Peoples with low back pain around the world? A topical review. Scand J Pain. 2024;24(1):20230114. https://doi.org/10.1515/sjpain-2023-0114
24. Okolo CA, Babawarun O, Olorunsogo TO. Cross-cultural perspectives on pain: a comprehensive review of anthropological research. Int J Appl Res Soc Sci. 2024;6(3):303-315. https://doi.org/10.51594/ijarss.v6i3.888
25. Igwesi-Chidobe CN, Kitchen S, Sorinola IO, Godfrey EL. “A life of living death”: the experiences of people living with chronic low back pain in rural Nigeria. Disabil Rehabil. 2017;39(8). https://doi.org/10.3109/09638288.2016.1161844
26. Igwesi-Chidobe CN, Sorinola IO, Kitchen S, Godfrey EL. Unconventional Practitioners’ Causal Beliefs and Treatment Strategies for Chronic Low Back Pain in Rural Nigeria. Heal Serv Insights. 2018;11. https://doi.org/10.1177/1178632918808783
27. Igwesi-Chidobe CN, Nkhata LA, Ozumba B. The coping strategies employed by individuals with chronic low back pain: secondary qualitative analysis of data from diverse adult populations in two sub-Saharan African countries. Front Rehabil Sci. 2024;5:1442789. https://doi.org/10.3389/fresc.2024.1442789
28. Igwesi-Chidobe CN, Nkhata LA. Adaptive coping strategies for rehabilitation of people with non-specific chronic lower back pain or non-specific chronic neck pain. Front Rehabil Sci. 2025;6:1551777. https://doi.org/10.3389/fresc.2025.1551777
29. Igwesi-Chidobe CN, Sorinola IO, Godfrey EL. Only two subscales of the Coping Strategies Questionnaire are culturally relevant for people with chronic low back pain in Nigerian Igbo populations: a cross-cultural adaptation and validation study. J Patient-Reported Outcomes. 2021;5:1-16. https://doi.org/10.1186/s41687-021-00367-1
30. Igwesi-Chidobe CN, Muomah RC, Sorinola IO, Godfrey EL. Detecting anxiety and depression among people with limited literacy living with chronic low back pain in Nigeria: adaptation and validation of the hospital anxiety and depression scale. Arch Public Heal. 2021;79(1):72. https://doi.org/10.1186/s13690-021-00586-4
31. Choi E, Chentsova-Dutton Y, Parrott WG. The effectiveness of somatization in communicating distress in Korean and American cultural contexts. Front Psychol. 2016;7:383. https://doi.org/10.3389/fpsyg.2016.00383
32. Ma-Kellams C. Cross-cultural differences in somatic awareness and interoceptive accuracy: a review of the literature and directions for future research. Front Psychol. 2014;5:1379. https://doi.org/10.3389/fpsyg.2014.01379
33. Pathak A, Sharma S, Jensen MP. The utility and validity of pain intensity rating scales for use in developing countries. Pain reports. 2018;3(5). https://doi.org/10.1097/pr9.0000000000000672
34. Igwesi-Chidobe CN, Coker B, Onwasigwe CN, Sorinola IO, Godfrey EL. Biopsychosocial factors associated with chronic low back pain disability in rural Nigeria: A population-based cross-sectional study. BMJ Glob Heal. 2017;2(3). https://doi.org/10.1136/bmjgh-2017-000284
35. Sharma S, Pathak A, Parker R, et al. 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. J Orthop Sport Phys Ther. 2024;54(8):560-572. https://doi.org/10.2519/jospt.2024.12406
36. Shepherd SM, Willis-Esqueda C, Newton D, Sivasubramaniam D, Paradies Y. The challenge of cultural competence in the workplace: perspectives of healthcare providers. BMC Health Serv Res. 2019;19:1-11. https://doi.org/10.1186/s12913-019-3959-7
37. Flynn PM, Betancourt H, Emerson ND, Nunez EI, Nance CM. Health professional cultural competence reduces the psychological and behavioral impact of negative healthcare encounters. Cultur Divers Ethnic Minor Psychol. 2020;26(3):271. https://doi.org/10.1037/cdp0000295
38. Henley P, Martins T, Zamani R. Assessing ethnic minority representation in fibromyalgia clinical trials: a systematic review of recruitment demographics. Int J Environ Res Public Health. 2023;20(24):7185. https://doi.org/10.3390/ijerph20247185
39. Nair L, Adetayo OA. Cultural competence and ethnic diversity in healthcare. Plast Reconstr Surgery–Global Open. 2019;7(5):e2219. https://doi.org/10.1097/gox.0000000000002219
40. Lor M, Hammes AM, Arcia A. Development of a culturally appropriate faces pain intensity scale for Hmong patients. Pain Med. 2024;25(1):89-92. https://doi.org/10.1093/pm/pnad109
41. Igwesi-Chidobe CN, Kitchen S, Sorinola IO, Godfrey EL. World Health Organisation Disability Assessment Schedule (WHODAS 2.0): development and validation of the Nigerian Igbo version in patients with chronic low back pain. BMC Musculoskelet Disord. 2020 Nov 17;21(1):755. https://doi.org/10.1186/s12891-020-03763-8
42. Sharma S, Jensen MP, Moseley GL, Abbott JH. Results of a feasibility randomised clinical trial on pain education for low back pain in Nepal: the Pain Education in Nepal-Low Back Pain (PEN-LBP) feasibility trial. BMJ Open. 2019;9(3):e026874. https://doi.org/10.1136/bmjopen-2018-026874
43. Igwesi-Chidobe CN, Sorinola IO, Godfrey EL. Igbo Brief Illness Perceptions Questionnaire: A Cross-cultural adaptation and validation study in Nigerian Populations with Chronic Low Back Pain. J Back Musculoskelet Rehabil. 2021;34(3):399-411. https://doi.org/10.3233/bmr-191687
44. Igwesi-Chidobe CN, Kitchen S, Sorinola IO, Godfrey EL. Evidence, theory and context: Using intervention mapping in the development of a community-based self-management program for chronic low back pain in a rural African primary care setting-the good back program. BMC Public Health. 2020;20(1). https://doi.org/10.1186/s12889-020-8392-7

Author Affiliations:

¹ School of Allied Health Professions and Midwifery, Faculty of Health Studies, University of Bradford, Bradford, United Kingdom. 

² Global Population Health (GPH) Research Group, University of Nigeria, Nsukka, Nigeria.

³ Pain Management and Research Centre, Royal North Shore Hospital, Northern Sydney Local Health District, Sydney, NSW 2065, Australia

⁴ Pain Management Research Institute, Kolling Institute, Faculty of Medicine and Health, The University of Sydney and Northern Sydney Local Health District, Sydney, NSW, Australia.

⁵ School of Health Sciences, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia.

⁶ Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, Australia.

⁷ Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA.