Chronic pain is one of the most common and costly health conditions worldwide.1 A single solution to this problem has not yet been identified, perhaps due to the complex ways that biological, psychological, and social factors interact to contribute to and maintain this problem. Culture is one such factor.

Culture refers to the goals, beliefs, and traditions relating to an individual's racial, religious, and social group, which are socially transmitted and acquired. The most common proxy measures of culture used in pain research are ethnicity/race and country of origin. However, it is challenging to assess culture as distinct from other social factors. For example, socioeconomic status, a non-culture social variable, is often associated with both country of origin and race/ethnicity.

Evidence supports the idea that culture can influence many pain-related factors, including but not limited to, how an individual communicates pain, an individual's emotional responses to someone else's pain (empathy), pain intensity and tolerance, beliefs about and coping with pain, and pain catastrophizing. All of these can play key roles in the onset and maintenance of chronic pain states. However, in this editorial, we will focus on three primary pain-related domains: pain communication, beliefs, and coping.

How different people communicate about pain is influenced by their culture. For example, in some Asian cultures, there is a tendency to avoid talking about one's own pain. Moreover, when Asian's do communicate about pain, they are less direct when communicating with non-Asians than when communicating with someone from the same ethnicity.2,3 This has important implication in the management of chronic pain in the Asian individuals, especially when treated by a non-Asian clinician speaking a different language.

Culture can also influence pain beliefs. For example, educated individuals who have access to (often inaccurate) healthcare information on the internet may believe that the cause of their low back pain is a “disc bulge”, even though research indicates that disc budges tend to resolve on their own4 and 50% of asymptomatic individuals aged 40 years without low back pain has a disc buldge.5 Individuals who have such a belief may restrict their activities when they experience pain, so as not to make the so-called disc bulge worse. On the other hand, many individuals in rural Nepal did not report having low back pain when we surveyed for musculoskeletal pain prevalence, because they believed that their low back pain is related to “normal” aging processes. As the result, Nepalese in rural communities tend to continue to carry on with their normal activity of daily living without complaints or requests for medical examinations or imaging.

How people cope with their pain can also have a significant impact on chronic pain. Passive coping responses such as rest and use of appliances are not usually recommended and may further cause harm, while active coping such as appropriate physical activity tend to be effective.6 Similarly, a general sense of external locus of control (i.e., believing that physicians or traditional healers are responsible for the treatment or even “cure” of pain) can be detrimental to pain management, whereas, a general sense of internal locus of control (i.e., believing that it is up to the individual to manage pain) tends to be associated with better long-term adjustment.7 Whether or not an individual chooses to use active versus passive coping or has a general internal versus external locus of control can be influenced by that individual's culture.

Knowledge of a patient's culture may provide valuable information regarding likely beliefs about the cause(s) of and coping mechanisms for pain, both of which will inform the management and or prognosis. Clinicians should therefore be aware of how culture affects these variables. Use of a patient-centered approach when performing the evaluation may be particularly useful for assessing the patient's beliefs about pain and how they cope with it in the context of that patient's culture. Similarly, culture may influence the acceptability and appropriateness of treatments designed to impact cognitive and behavioral changes; as a result, treatments that have been developed by clinicians in one culture may not necessarily be relevant or effective in another culture; such treatments may need to be adapted in order to maximize their efficacy when used to treat patients in a new culture.8

Culture is an important social domain that clinicians should consider in the treatment of chronic pain. Given these cultural effects, it is important to adapt biopsychosocial assessments and treatments to a culture before using it in clinical practice. Future research on cultural comparison between pain-related factors including pain communication, beliefs, and coping can provide significant insight in management of pain across different cultures.

International Association for the Study of Pain for providing Developing Countries Collaborative Research Grant to MPJ and SS. SS is supported by University of Otago Doctoral Scholarship.

The authors have no conflicts of interest to report.