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| Journal of the New Zealand Medical Association,
21-January-2011, Vol 124 No 1328
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Understanding the role of culture in pain: Māori
practitioner perspectives relating to the experience of pain
Jane E Magnusson, Joyce A Fennell
It is widely accepted that pain is a multidimensional
experience as it includes sensory, emotional, motivational, and social
factors.1,2 An aspect of the social factor
which can impact the experience of pain is culture as a person’s culture
can play an essential role in how they perceive and respond to
pain.3,4 While there has been interest in the
role of cultural diversity within healthcare settings over the years, there is
also growing interest in understanding the influence of race and ethnicity on
the experience of pain.5,6
Culture represents a significant force in shaping the
values, beliefs, norms and practices of individuals including the way the person
reacts to pain.7 Early studies looking at pain
and culture have described how ethnic norms for pain behaviour can influence
pain perception, interpretation and response.8
In addition to influencing the experience of pain, culture can influence the
assessment and management of pain.7,8
As culture can influence the perception and experience of
pain, and hence the reporting and potentially the treatment of pain, it is
important to be aware of cultural differences when working with patients from
different ethnic backgrounds.
Māori perspectives of painAccording to Durie’s Māori model of health,
te whare tapa wha,9,10 the dimensions
of health include a spiritual aspect (te taha wairua), mental and emotional
aspects (te taha hinengaro), family and community aspects (te taha whānau)
and a physical aspect (te taha tinana). This is a holistic model with health
dimensions represented by four supporting walls of a house.
The integrity of all four dimensions is required for a sound
whole. This viewpoint is consistent with the widely accepted biopsychosocial
view of health and wellness as well as with the multidimensional nature of the
pain experience in that the different aspects of the person and their pain need
to be taken into consideration when assessing and treating their pain.
As little has been published regarding Māori
perspectives on pain it is not clear if the current measures and approaches to
pain assessment and management are appropriate for this cultural group. A better
understanding of Māori perspectives pertaining to the experience of pain
would guide assessment and treatment approaches for this cultural group. By
taking into account the distinct elements of the Māori culture with regard
to the experience of pain, the present study was designed to be in accordance
with the Treaty of Waitangi by holding to the principles of partnership,
participation, and protection.
As a first step to understanding the Māori perspective
of pain, we sought the views of Kaumātua (tribal leaders/elders) and
Māori healthcare providers to gain insight into how pain is perceived and
expressed within the Māori culture. Kaumātua are regarded as the
tribal experts on most matters, and therefore
represent an essential source of information on the suitability of items for a
culturally appropriate pain measure for Māori.
MethodsAn important aspect of this research involved cultural
consultation. Guidance from our cultural advisors and kaumātua was sought
regarding Māori tikanga (customs and protocol) including issues such as
language, protocol including rituals of encounter, perspectives on health, and
assessing pain in Māori.
Qualitative interviews regarding Māori perspectives on painTo investigate the experience of pain within the
Māori culture, an in-depth ‘semi-structured’ interview format
was employed as it has been shown to be useful in advancing cultural
understandings of health among indigenous communities, including
Māori.10-13
The interviews sought to gain insight into how pain was
perceived and expressed by those Māori with whom kaumātua and
Māori healthcare providers had health-related interactions. Approval for
this research was obtained from the University of Auckland Human Participants
Ethics Committee.
Interview proceduresA purposeful sampling technique was used to recruit
participants as it selects the most appropriate group (i.e. those involved with
the topic) to provide ‘information-rich’ data on the phenomenon
under study.14,15 For this study participants
were recruited through our cultural advisors’ iwi (tribe) and their
Māori healthcare networks. Participants were kaumātua and Māori
healthcare providers who worked in a health-related role with Māori clients
(e.g. hospitals, mental health settings and private clinics).
To take part in this study, participants were asked if
they would be willing to be interviewed to explore the experience of pain within
the Māori culture. On the advice of the cultural advisor, and at the
request of the elders, group-format interviews were offered to kaumātua.
The group-format was viewed as a cultural preference by some as it is commonly
used on the marae (meeting house) and it provides opportunities for verification
or disputation of views presented.
A semi-structured interview-guide was used to ensure
that the range of topics relevant to the study objectives was covered in each
interview. The interview-guide aided in framing questions to elicit the
participants’ observations and experiences with Māori patients’
perceptions and beliefs pertaining to pain. Participants were asked to comment
on the manner and format of assessing pain with Māori including whether
English or te reo would be recommended. Interviews were on average 60 minutes
long.
It should be noted that the type of interview
conducted, group or individual, did not appear to negatively influence
participation or discussion as individuals were able to choose which environment
they were most comfortable taking part in. All participants consented to
audio-recording of the interview.
Data analysis of qualitative interviewAudio recordings of the interviews were transcribed
verbatim and the written transcripts constituted the raw data for qualitative
analysis. Transcripts were analysed using purposeful constant comparative
methodology.16 Comparisons of data collected
from the groups were made using ‘data triangulation’, a form of
convergent validation employed in qualitative
research.17 The written transcripts were
compared with the audio-recordings and notes taken at the time of the
interviews. In some instances, verification of wording was obtained from a
Māori advisor to ensure accuracy of transcription.
The constant comparative method (CCM) of qualitative
data analysis16 was used. Accordingly three
stages of comparison were conducted when generating analytical themes:
In the
process of ‘open coding’, every passage of the interview was studied
to determine the underlying intent or theme. Comparison of the codes used
throughout a single interview determined the consistency of a theme. Judgment
about saliency of themes was based upon either frequency of occurrence, emphasis
of phrasing, or word choice.
The aim of the comparisons of the interviews within the
same group (e.g. text of one kaumātua compared to that of another
kaumātua) was to determine whether the content or themes were similar among
groups, and between groups (e.g. between kaumātua and Māori healthcare
providers) to determine the saliency of themes.
ResultsInterview participant demographic characteristicsOf the 33 participants 23 (70%) were female and 10 (30%)
were male. As expected, the kaumātua group was older (median age 72 years)
than the Māori healthcare provider group (median age 38 years). The
majority of kaumātua (65%) were fluent in te reo Māori, whereas the
majority of Māori healthcare providers (86%) indicated basic te reo
Māori competency. The demographic characteristics of the participants are
presented in Table 1.
Table 1. Demographic characteristics of
interview participants
Twenty kaumātua were interviewed in a group format. Six
kaumātua and seven Māori healthcare providers were interviewed
individually. All participants indentified themselves as being involved in a
health-related role with Māori (see Table 2 for the categories participants
chose to describe themselves). Additionally, all of the kaumātua (100%)
were actively involved in their local marae and most (96%) were regular
participants at the Kaumātua Advisory Group.
Table 2. Categories of interview
participants
Results of interviewsSeveral themes emerged from the interviews, with the same
themes emerging from analysis of interviews from both the kaumātua and
Māori healthcare providers’ interviews. Themes included: experiences
of pain, pain as multidimensional, pain as a private experience, spiritual
dimension, coping strategies including the complex role of whānau, and
specific recommendations for assessment and treatment of pain.
Experiences of painWhen asked to describe pain issues and the experience of
pain (e.g. key issues for Māori, pain behaviours observed with Māori
patients, how Māori cope with/manage pain), both groups recounted
experiences of supporting or caring for people with pain. Most kaumātua,
unlike most of the Māori healthcare providers, also described pain they had
experienced themselves, and consequently they mentioned more personal coping
strategies.
This difference in reporting is likely an artifact of the
older age of the kaumātua group. Some healthcare providers prefaced their
answer with a caveat that their opinion was influenced by clinical experience
predominantly with Māori individuals experiencing either severe pain or who
were not coping with their pain.
In describing pain and the pain experience, a number of
descriptors were used to convey location (e.g. “back pain”,
“leg pain”), emotion (e.g. “joyous pain”, “dreaded
pain”), possession (e.g. “my pain”, “his pain”),
temporal qualities (e.g. “continuous pain”, “lingering
pain”), intensity (e.g. “a lot of pain”, “greatest
pain”), and some less specific qualifiers (e.g. “another
pain”, “that same pain”).
Table 3 provides a sample of the descriptors used by the
participants during the interviews.
Table 3. Pain descriptors used by interview
participants
Pain as a multidimensional human experienceParticipants described mamae (i.e. Māori word for pain)
in terms of being a complex multidimensional experience. Reference was made to
the te whare tapa wha model of
health12,13 in explaining the dimensions of
pain. Differentiations between acute pain and chronic pain, as well as between
physical pain and emotional or spiritual pain were made. Pain was frequently
described in relation to an accompanying disease or medical condition (e.g.
arthritis pain, cancer pain) and was personified as a demon (ngangana) preying
upon the person’s life force.
With regard to the experience of pain, the universality of
this experience was summed up by one of the kaumātua who stated:
“What do you mean Māori pain? I’ve never heard of cultural
pain. I thought pain was a human experience.” Similarly, a Māori
healthcare provider commented that “I have worked with a number of
Māori patients, and their whānau who have experienced pain, I can
think of a group of words which are very much the common parlance, burning,
stabbing, tearing, ripping, aching, and the pain might have a quality of being
intermittent, pervasive, fluctuating or consistent in intensity, or building
over certain periods, alleviated by some things and exacerbated by other things,
and I can’t really think of anything particularly unusual that would
differentiate Māori patients from non-Māori patients in the language
that they used, and the English words that they’ve used.”
Pain is privateA common theme which emerged was that Māori were
private people, who did not readily talk about their health worries. There were
multiple descriptions of Māori enduring and or ignoring pain, with both
positive and negative connotations. Pain and other health worries were regarded
as private and only spoken of with close whānau. For some Maori there was
shame (whakamā) associated with speaking of pain with outsiders.
The reasons given for the reluctance to disclose thoughts
and feelings about pain were diverse. In some instances non-disclosure was seen
as a positive coping strategy. Alternatively, ignoring pain was listed as a
concern when it caused a delay in health-seeking behaviour. Explanations for
delayed health-seeking behaviour included childhood memories and family stories
of culturally insensitive healthcare, of perceived medical mismanagement, and of
not wanting to be a burden. One kaumātua reported that seeing the negative
consequences of such health-seeking delay was the impetus for becoming actively
involved in health advocacy in the local community.
Another consequence of this reticence to talk openly about
pain was the difficulty in having open debate among the community on certain
sensitive topics such as euthanasia which was raised in the context of
intractable pain in terminal illness. Fundamental to discussions about matters
such as death, and indeed for any aspect of life according to the Māori
interviewed, was the spiritual dimension.
Generational as well as gender differences in expression of
pain were reported. Among the kaumātua, there was recognition that a
pattern of ignoring pain was less useful with advancing age. Elderly Māori
were reportedly less likely to report pain or to seek medical attention for
their pain. Additionally, males were reportedly less responsive to symptoms such
as pain than females.
Role of whānau (extended family)All participants had provided care or support for Māori
experiencing pain. Most participants described personal experiences of providing
whānau support for close family members (e.g. spouse, sibling, cousin,
niece, nephew, or grandparent) through the final stages of terminal illness
involving intractable pain. Several participants recounted filling this role on
two or three occasions. In addition to the importance of caring for their unwell
whānau member, the importance of looking after the carer(s) was
raised.
Regarding the role of whānau in relation to pain, a
variety of important issues were raised. The dynamic tension of having
whānau support on the one hand and of being overwhelmed with the number of
visitors on the other was presented.
Another issue was the tension between the desire to be
private and not burden others with one’s pain or health worries (i.e. not
call on whānau support) versus the value of whānau support. Most
participants commented on the importance of providing whānau support, but
expressed reticence in notifying whānau when unwell.
An interesting interpretation presented was that this
behaviour (i.e. of not accessing whānau support or of feeling guilty about
seeking whānau support) was regarded as selfish. It was recommended that
responsibility to whānau could be viewed as motivation for adherence to
treatment recommendations including pain management.
There was also recognition of the disparity between the
‘ideal’ availability of whānau to provide support and the
‘real’ experience of complex family situations where actual support
was not so readily available with family members living considerable distances
away (including overseas).
Whānau as advocateSeveral of the participants described the role of
whānau as health advocate and asserted its importance for those elderly
Māori who were reluctant to disclose their health worries in doctor-patient
interactions as these settings were often found to be inhospitable or
insensitive of cultural practices. The role of the health advocate was to
negotiate these health encounters on behalf of individuals from their
whānau or hapu (wider community) who were experiencing pain. It was
acknowledged that those members of the community who had family members with
medical training were at an advantage in negotiating such encounters.
Participants’ recommendationsPain measure—The possibility of
developing a pain measure incorporating Māori perspectives was discussed
and endorsed by kaumātua and Māori healthcare workers. To improve the
appropriateness and usefulness of such a measure, the following recommendations
were made:
With regard to
whether such a pain measure should be in English and/or te reo participants
commented that the majority of New Zealand Māori were not fluent in te reo
Māori, but were fluent in English and would therefore not find a te reo
Māori version helpful. However, it was suggested that incorporating
Māori words on charts visible in treatment could be beneficial.
Emphasis was placed on the quality of the healthcare
relationship (i.e. culturally appropriate rituals of encounter). Other
recommendations from participants were for auditing current practices of pain
management within health services to ensure the general standard of practice was
at a high standard and to provide standardised pain management training to all
medical personnel.
Trust is earned—Enhancement of
Māori health in relation to the quality of the relationship between the
healthcare provider and the Māori client was discussed. It was suggested
that this needs to be a negotiated encounter with rapport and trust earned
through awareness of, and adherence to, cultural practices.
Recommendations for culturally-appropriate practice, which
would be applicable for any health encounter not just for pain management,
included:
DiscussionThe findings of this study illustrate that, as with many
cultures, Māori perceive pain as a multidimensional experience impacting
them physically, psychologically, socially and spiritually. These findings are
consistent with those found in many other cultures, suggesting that assessing
and treating pain from a multidimensional perspective would be appropriate
within the Māori culture and that consideration of Māori langue and
cultural concepts (e.g. inclusion of whānau, developing trust in healthcare
relationships, using the te whare tapa wha model) would be valuable in the
assessment and treatment of Māori clients.
The presence of pain, its significance, cause, and purpose
have been the basis of speculation and study in cultures over time. Cultural
groups have sought meanings for pain and have incorporated their
conceptualisation of pain within their language and discourse. As stated by
Morris18 “Pain is as elemental as fire or
ice. Like love, it belongs to the most basic human experiences that make us who
we are.” As exemplified by comments in this study’s interviews, pain
is a universal human experience.
While findings from qualitative studies cannot be
generalised beyond the study sample, they provide useful insight into the nature
of the topic under investigation. In this instance Māori perspectives of
pain generated from this study’s interviews with Kaumātua and
Māori healthcare providers reflect themes consistent within the greater
body of literature. For example, the finding of the multidimensional experience
of pain is consistent with previous studies exploring the applicability of the
McGill Pain Questionnaire for use in other languages and cultures, in that the
dimensions of human pain, independent of the language used, can best be
described as encompassing a range of sensory-discriminative,
cognitive-evaluative, and motivational-affective
dimensions.1,19
Similarly, the role of whānau described in this study
aligns with the body of research on the important role the family plays in the
health of its members, an area which has gained prominence within pain research
in terms of the role of the family in the onset and maintenance of
pain.20-23 With regard to pain treatments, the
efficacy of partner-guided or family-guided pain management protocols have been
demonstrated for chronic pain due to
arthritis22and
cancer.23
In a recent overview of research on psychological aspects of
persistent pain, Keefe et al.23 regarded the
social dimension as a relatively untapped area of research, and recommended more
research examining how psychological factors relate to the broader social
context of persistent pain.
The importance of spirituality in the conceptualisation of
health and pain as found in this study was consistent with a growing body of
literature on the relationship between spiritual commitments and health
outcomes. In an article on the impact of spirituality on quality of life,
Baker24 described how spirituality as a
variable in scientific study had evolved over the years, and cited research
guides for the inclusion of spirituality within health research. Additionally,
several articles in the Journal of the American Medical Association
highlighted the role of the spiritual dimension in healthcare, providing
evidence of its inclusion in medical training and providing guidelines for
incorporating spiritual dimensions within an initial intake
interview.25-29
Koenig26 recommended
acknowledging spirituality within health not for the purpose of addressing
spiritual issues, but rather to identify how patients cope with their illness or
pain, the types of support systems available to them in the community, and any
strongly held beliefs which might influence medical care.
Within the context of pain,
Morris28 contended that religious discussions
of pain and suffering provide a reference to the importance of the meaning of
the suffering, an emphasis on the spiritual dimension of human experiences, and
an acknowledgement that suffering is more than just a private matter but
involves others in a sociocultural context.
In a recent review of spirituality in health literature,
Unruh, Versnel and Kerr29 found diverse
definitions of spirituality which they categorised as sacred (construed in
relation to a higher being), secular (without reference to a higher being), or
religious (participation with an identifiable group of people that is organised
around a spiritual goal). Unruh et al.29
recommended clearly separating the spirituality construct from related
psychological constructs, and respecting the spiritual views of a client
(whether secular, sacred, or religious), while providing healthcare in a manner
which does not violate the client’s spiritual needs.
Conclusion—Clearly pain is a
multidimensional and universal experience and while this means there is a
commonality between cultures with regard to the experience of pain, it is
valuable to understand a culture’s perceptions and experiences regarding
pain before assessing and treating it.
Our findings demonstrate that while commonly used and widely
accepted approaches to the assessment and treatment of pain are appropriate to
use when working with Māori pain patients, it would be beneficial to
include the additional items/approaches indicated by the participants in this
study (e.g. role of whānau, trust between client and provider) when working
with Māori pain patients in order to improve understanding and treatment of
their pain.
The findings from this study therefore provide a useful
framework for exploring Māori perceptions of pain within a Māori pain
population which could be explored in future research.
Competing interests: None.
Author information: Jane E Magnusson,
Senior Lecturer, Department of Sport and Exercise Science, University of
Auckland; Joyce A Fennell, Health Psychologist, Respiratory Services, Auckland
District Health Board, Auckland
Acknowledgements: While bicultural research
can be difficult, we are grateful for the cooperation and support from our
cultural advisors as well as the kaumātua and Māori healthcare
providers who took part in this study.
Correspondence: Dr Jane E Magnusson,
Department of Sport and Exercise Science, University of Auckland, Private Bag
92019, Auckland, New Zealand. Fax: +64 (0)9 3737043; email: j.magnusson@auckland.ac.nz
References:
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