Pain can be further categorized as acute (sudden and usually short-lived) or chronic (lasting three months or longer). Acute pain is the most common reason for emergency department visits [7].

Unfortunately, chronic pain is a common problem. Globally, it is estimated that 20% of adults experience pain, and every year, 1 in 10 adults are diagnosed with chronic pain [8]. On a worldwide basis, there are 1.9 billion individuals who experience recurrent, tension-based headaches—the most common type of chronic pain [18]. An estimated 20.4% of American adults report experiencing chronic pain in the past three months [19]. In the United States, the most common types of chronic pain are back pain (affecting 10.1% of adults), lower extremity pain (4.1%), upper extremity pain (4.1%), and headache (3.5%) [9]. Women in the United States are more likely than men to experience headaches, abdominal pain, and chronic widespread pain. Women are also more likely to report higher pain intensity than men, and young girls are more likely to experience pain in multiple areas compared with boys [27]. Reports of chronic pain differ among racial and ethnic minority groups. Roughly 23.5% of non-Hispanic White adults have chronic pain, compared with 6.8% Asian adults and 19.3% African Americans [19]. In one survey, Mexican Americans and African Americans had lower rates of back pain, leg and feet pain, and arm and hand pain compared to their white counterparts [9].

Pain can affect many aspects of a patient's life. More than 25% of adults with chronic pain indicate that their pain has had an adverse impact on their employment [10]. It is estimated that chronic pain results in costs of $635 billion annually, including more than $60 billion in lost productivity alone [11,32]. Direct healthcare costs are estimated to be up to $300 billion [30]. This is more than the costs of cancer, heart disease, and diabetes combined. Pain also affects the emotional and psychologic domains of an individual's life. Those who experience chronic pain are at increased risk for a variety of psychiatric problems, including substance abuse, depression, and anxiety. For example, patients with migraines are two to four times more likely to have depression than those without migraines [12]. Migraine also more than doubles the risk of anxiety disorder and agoraphobia or panic disorder and increases the likelihood of alcohol use disorder [13].

According to U.S. Census data, the minority population is growing each year. By 2060, the minority population is expected to increase to 241 million, with the Hispanic population growing by 142%, the Asian population by 116%, and the African American population by 50% [14]. Hawaii, New Mexico, California, the District of Columbia, and Texas are regions in the United States that consist of a "majority-minority," meaning that more than half of the areas' populations consist of individuals who are racial/ethnic minorities [15]. With the increase of immigration and the slower birth rate in white families, it is anticipated that the United States is rapidly moving toward becoming a majority minority [15]. As of 2017, 58.6 million people in the United States identified as Hispanic (the largest minority group), and Hispanic Americans accounted for more than half of the total growth in the country between 2016 and 2017 [132].

Culture refers to the values and knowledge of groups in a society; it consists of approved behaviors, norms of conduct, and value systems [33,34]. Culture involves attitudes and beliefs that are passed from generation to generation within a group; it is continually evolving and fluid [157]. These patterns include language, religious beliefs, institutions, artistic expressions, ways of thinking, and patterns of social and interpersonal relations [35]. Culture can also represent worldviews—encompassing assumptions and perceptions about the world and how it works [36]. Understanding culture helps to elucidate why groups of people act and respond to the environment as they do [37].

On the other hand, race is linked to biology. Race is partially defined by physical markers, such as skin or hair color [38]. It does not refer to cultural institutions or patterns, but it is generally utilized as a mechanism for classification. In modern history, skin color has been used to classify people and to imply that there are distinct biologic differences within populations [39]. Historically, the census in the United States defined race according to ancestry and blood quantum; today, it is based on self-classification. Racial characteristics are also assigned differential power and privilege, lending to different statuses among groups [40].

Ethnicity is also a complex phenomenon and has been defined in many different ways. Four components of ethnicity have been identified [41]:

Ethnicity may also be associated with persecution, both political and social. Ethnic unity may serve as a tool for social change and political reform [42]. Several famous ethnic movements took place in the 1960s, such as the unification of farm workers headed by César Chávez. Ethnicity has also been viewed as a return to traditions, characterized by a renewed interest in ethnic foods, traditional religious practices, native language, and folklore [42]. Finally, ethnicity is also acknowledged as being a symbolic token, a way for individuals to maintain a nostalgic connection to their homeland [42].

For healthcare providers, cultural awareness involves four components [44]:

The complexities of culture, race, and ethnicity and how they influence the meanings, definitions, and expression of pain are not completely understood. Studies have not delineated a clear model or pathway, but there is consensus that pain is more than just a biologic or physiologic response; there appears to be an interplay of biologic, social, psychologic, and environment factors. From a biopsychosocial perspective, how individuals react to a pain stimulus may be influenced by how they were socialized within their familial and cultural background [47]. Alternatively, gate control theory has been used to explain the link between culture and pain. According to this theory, pain is not merely a physiologic response to tissue damage; rather, reactions to pain are based on expectations and perceptions stored in one's memory [2,122,124,126,128,129,130]. Biologically, pain is moderated by a gating mechanism whereby cells block pain in the nervous system. Messages are sent to the brain to "open" or "close" these blocking mechanisms, and cultural memories can affect whether the pain impulses reach the brain [2].

The complexities of culture, race, and ethnicity and how they influence the meanings, definitions, and expression of pain are not completely understood. Studies have not delineated a clear model or pathway, but there is consensus that pain is more than just a biologic or physiologic response; there appears to be an interplay of biologic, social, psychologic, and environment factors. From a biopsychosocial perspective, how individuals react to a pain stimulus may be influenced by how they were socialized within their familial and cultural background [47]. Alternatively, gate control theory has been used to explain the link between culture and pain. According to this theory, pain is not merely a physiologic response to tissue damage; rather, reactions to pain are based on expectations and perceptions stored in one's memory [2,122,124,126,128,129,130]. Biologically, pain is moderated by a gating mechanism whereby cells block pain in the nervous system. Messages are sent to the brain to "open" or "close" these blocking mechanisms, and cultural memories can affect whether the pain impulses reach the brain [2].

There are two main aspects of pain experience: expectancy and acceptance [48]. Pain expectancy refers to an individual's expectation or anticipation of pain as inevitable and/or inescapable [48]. The inherent degree of pain expectancy will vary from individual to individual. Pain acceptance is an individual's attitude toward pain—the extent one is willing and able to handle and endure pain [48]. Cultural beliefs and norms can influence both pain expectancy and acceptance, as evidenced by studies illustrating differences in pain perception and tolerance in various racial/ethnical groups.

There are two main aspects of pain experience: expectancy and acceptance [48]. Pain expectancy refers to an individual's expectation or anticipation of pain as inevitable and/or inescapable [48]. The inherent degree of pain expectancy will vary from individual to individual. Pain acceptance is an individual's attitude toward pain—the extent one is willing and able to handle and endure pain [48]. Cultural beliefs and norms can influence both pain expectancy and acceptance, as evidenced by studies illustrating differences in pain perception and tolerance in various racial/ethnical groups.

The terms used to describe pain are also influenced by culture. Women tend to use more expressive language when communicating pain, tending to use words such as "throbbing," "sharp," and "stabbing" [161]. Men tend to use less expressive language, perhaps due to cultural norms supporting stoicism for men. For example, in a study with Somali women, the participants used the same word to describe a host of painful circumstances ranging from cuts and fevers to childbirth, because the Somali term xanuun means both pain and illness [52]. In another study, terms such as "pain," "ache," and "hurt" were used by Hispanics, Native Americans, African Americans, and whites to refer to painful events or conditions [53]. However, the terms conveyed a different level of pain severity and intensity depending on the race/ethnicity of the subject. In a study conducted to explore racial differences in descriptors employed by African American and white American patients who had experienced myocardial infarction, African Americans were more likely to use "atypical" descriptions for their pain, such as "sharp" or "miseries" [54,55]. One study found that older African Americans tended not to use the word "pain," as this term is reserved for severe discomfort, and instead used the terms "hurt" or "sore" [16]. More bothersome pain was described as "nagging" or "miserable." In a study of Cantonese Chinese individuals in Hong Kong, 597 different pain descriptor terms were distinguished [56]. In a study with participants from Cameroon, French-speaking females were more likely to use the word "crying" to connote an emotional state associated with the pain [162]. However, those who spoke Pidgin did not refer to pain physically (i.e., as a sickness) rather than an emotional state [162].

Some cultural groups have languages that are rooted in storytelling and symbols, and descriptions of pain in these groups may include vivid imagery. In a study with 10 Native Americans, the participants tended to use terminology rooted in nature to describe their pain [58]. Terms like "stretching," "throbbing," and "pulling" were common, and neuropathic pain was described as "hot lava," "freezing," "sparks," and "electric shocks." Some Native American participants employed the word "ache" even for extreme pain [163]. In a study of 101 Nepalese patients diagnosed with chronic musculoskeletal pain, 52% used metaphors (e.g., "like an infection," "like an ant bite," "like sleeping hands/feet") to describe the intensity or quality of their pain [139].

The underlying meanings of phrases are equally important. For example, descriptions of pain may be laced with underlying pride and achievement or fatalistic undertones. Some groups, including African Americans, Chinese, Koreans, and Mexican Americans, may view pain as an inevitable part of life, which can affect the way in which pain is experienced and described [59]. Other pain expressions may reflect idioms of distress, describing suffering in a cultural meaningful manner [164]. However, it is important not to stereotype and not to pathologize a group, as there is a tremendous amount of within-group diversity [60].

Individuals construct and attach different meanings to pain (referred to as pain cognitions). These meanings are linked to personal and/or cultural beliefs and norms and at times, religious or spiritual beliefs [165]. A common theme in many cultures is that pain is a part of the human experience [2]. In these cases, coping with pain with stoicism and a high degree of self-control is highly valued because it is part of learning key lessons in life [2]. In some cultures, children are told stories of heroes who meet challenges head on and who do not complain about their suffering [140]. The goal is to socialize children (and adults, by extension) to cope with life's challenges and pain with resiliency and stoicism. For these patients, complaints will be avoided; it is more important to be perceived as a "good patient" [141].

In a qualitative study, non-Hispanic White and Native American participants' terminologies to describe injury and the role of pain were explored [169]. Non-Hispanic White individuals were slightly more likely to use the word "pain" and believed that pain symptoms were an underlying manifestation of some illness or abnormality. Native American participants tended to ascribe pain to cultural and historical events. Native Americans were also more likely to view pain within the larger holistic context of the mind, body, emotions, and spirit [63]. As such, pain treatment should address each of these dimensions. In one study, individuals in rural Nepal reported the belief that pain is part of the aging process and is endured without the need to seek help [170].

Communication consists of verbal and nonverbal components, both of which are embedded within the culture of the parties disseminating and receiving the information. In the context of pain, the term "pain response" is used to refer to the verbal (e.g., wailing, verbal complaints about pain symptoms) and nonverbal (e.g., facial expressions, body gestures) expressions of pain [67]. In order to understand how culture influences the communication of and coping with pain, it is first important to understand the role of high- and low-context cultures within the larger perspective of communication styles.

Styles of communication can be classified on a continuum from high to low context [68]. High-context cultures rely on shared experience, implicit messages, nonverbal cues, and the relationship between the two parties to disseminate information [69]. Members of these cultural groups tend to listen with their eyes and focus on how something was said or conveyed [68,70]. On the other hand, low-context cultures rely on verbal communication, or what is explicitly stated in the conversation [69]. Consequently, low-context communicators listen with their ears and focus on what is being said [68,70]. Western culture, including the United States, can be classified as a low-context culture. On the other hand, groups from collectivistic cultures, such as Asian/Pacific Islanders, Hispanics, Native Americans, and African Americans, are considered high context [68]. Clearly, adherence to cultural values influences communication styles. Cross-cultural communication is by no means simple, and there is no set of rules by which to abide. Instead, promoting culturally sensitive communication is an art that requires practitioners to self-reflect, be self-aware, and be willing to learn. Therefore, as practitioners become skilled in noticing nonverbal behaviors and how they relate to their own behaviors and emotions, they will be more able to understand their own level of discomfort and comprehend behavior from a cultural perspective [70].

Styles of communication can be classified on a continuum from high to low context [68]. High-context cultures rely on shared experience, implicit messages, nonverbal cues, and the relationship between the two parties to disseminate information [69]. Members of these cultural groups tend to listen with their eyes and focus on how something was said or conveyed [68,70]. On the other hand, low-context cultures rely on verbal communication, or what is explicitly stated in the conversation [69]. Consequently, low-context communicators listen with their ears and focus on what is being said [68,70]. Western culture, including the United States, can be classified as a low-context culture. On the other hand, groups from collectivistic cultures, such as Asian/Pacific Islanders, Hispanics, Native Americans, and African Americans, are considered high context [68]. Clearly, adherence to cultural values influences communication styles. Cross-cultural communication is by no means simple, and there is no set of rules by which to abide. Instead, promoting culturally sensitive communication is an art that requires practitioners to self-reflect, be self-aware, and be willing to learn. Therefore, as practitioners become skilled in noticing nonverbal behaviors and how they relate to their own behaviors and emotions, they will be more able to understand their own level of discomfort and comprehend behavior from a cultural perspective [70].

Coping is defined as the use of behavioral and cognitive strategies to relieve the internal or external environmental stressors that stretch an individual's strengths and resources [74]. These strategies have been categorized as active or passive. Active coping strategies are characterized by directive problem-solving techniques, actively seeking social support, and employing reappraisal methods to reassess the situation. Meanwhile, passive coping strategies emphasize avoidance and utilizing techniques such as distancing, escaping, wishful thinking, and self-control [75]. In terms of coping or managing pain, individuals employing active coping strategies would attempt to stay busy, focus less on the pain, place their energies on another activity, and continue with normal activities of daily living [76]. Meanwhile, those in pain employing passive coping strategies may escape the pain by using wishful thinking, venting, or catastrophic thought patterns [76]. Some studies have found that active coping methods and positive reappraisals assist in improving well-being among individuals experiencing pain; those who use passive coping strategies such as wishful thinking and blaming oneself have poorer levels of well-being [77]. Catastrophizing is a coping method whereby one focuses on the pain stimulus, overstates the threat of the pain, and ultimately holds the belief that one cannot handle the pain [78]. Not surprisingly, this coping strategy is related to experiencing higher levels of pain, increased use of medication, and increased use of healthcare services across different age groups and different types of pain [78,79].

Certain cultures/ethnicities display a greater tendency for catastrophizing, which may be at least partially explained by a culture categorization of collectivistic or individualistic. Individualistic cultures place an emphasis on individuality and an internal locus of control, with challenges often attributed to modifiable environmental factors [80]. In general, white European and American cultures tend to be individualistic. Those from individualistic cultures are believed to be more likely to use active coping strategies in order to "manipulate" their environment to deal with pain and more likely to withdraw into themselves [52]. Collectivistic cultures emphasize the collective unit, interpersonal relationships, and the support system, and those from collectivistic cultures often display an external locus of control [81]. Many racial/minority groups are categorized as collectivistic cultures. In general, individuals from collectivistic cultures tend to rely more on passive coping strategies in order to reduce internal feelings of helplessness and stress [80]. A systematic review of Hispanic Americans found that this group tended to employ catastrophizing more than their non-Hispanic white counterparts [142]. African Americans also exhibit higher levels of catastrophizing and related increased pain sensitivity [82,145].

Saint Arnault proposed the Cultural Determinants of Help Seeking Model, which posits that there are three major dimensions that influence how assistance is sought: perceptions and labeling, interpretations of meaning, and social context dynamics [85].

When an event is perceived as distressing, the individual will then attribute meaning to the symptom. Two types of attributions can be made: attributions of social significance or causal attributions. A social significance attribution involves an individual attaching a positive or negative social significance to the event. For example, a patient might believe that pain is reflective of a personal failure or character flaw [85].

Causal attribution involves attempting to determine the source(s) of a symptom or event (e.g., physical, psychologic/emotional, or environmental factors) [86]. The method of help seeking is often partially influenced by causal attribution. For example, if pain is perceived to be emotionally rooted, then the individual might seek mental health or counseling services. In a study of 1,570 adults in Hong Kong, 25% attributed chronic pain to excessive physical work and self-treated with rest [147]. In Chinese cultures, pain may be attributed to an imbalance of yin and yang, with help then sought through acupuncture or herbal medications [5]. In cultures that believe pain is the result of spiritual unrest or imbalance (e.g., Hmong, Native American), patients may seek help from a traditional healer, shaman, or spiritual advisor [59,72]. Some racial/ethnic minority patients (e.g., Navajo Indians) may be reluctant to seek help in places where people have died, including hospitals [66].

Western biomedical culture emphasizes a clear dichotomy between the mind and the body as well as what is observable (objective) and what is not (subjective) [92]. Pain is not easily measured, making its assessment and treatment a challenge in Western medicine [92]. In addition, many healthcare professionals may not be adequately trained to incorporate spirituality in the management and treatment of pain for patients who desire to incorporate a more holistic approach [93]. The Western American medical paradigm also leans toward cure rather than care [92]. Patients who present with symptoms that lead to a diagnosis for which there is a clear pathway of interventions and treatment are "favored." Because of the subjective nature of pain, healthcare professionals must often make clinical decisions in the face of a lack of absolute, clear physical evidence [94].

Societal and institutional barriers include racism, discrimination, poverty, lack of health insurance, and deleterious environmental factors in communities [7]. For example, groups that have historically (or currently) been victims of institutional racism and discrimination are more likely to delay seeking help for pain [89]. For example, some studies indicate that African American men may experience higher levels of pain intensity in part due to their experiences with different forms of racial discrimination [16]. Even today, racial and ethnic minority patients are more likely to be placed in a negative valenced relationship [94]. In the context of pain management, healthcare providers are more likely to discount the pain due to the negative valenced relationship triggered by racism and discrimination [94].

Healthcare professional barriers may include professionals' beliefs about appropriate pain management; lack of training and knowledge about the intersection of pain and culture, race, and ethnicity; lack of culturally sensitive assessment for pain; and expectations about racial and ethnic minority pain patients based on stereotypes [96]. For example, the belief that African Americans' skin is thicker than White skin and therefore experiences less pain is a common myth [175]. Consequently, practitioners may underestimate and minimize racial minority patients' pain experiences. In a qualitative study, Native American individuals described their complaints of pain being dismissed, receiving inadequate care, and neglected aftercare [149].

The numerical rating scale was translated (and back-translated) into Swahili for use in Kenya and pilot tested with 15 individuals 8 to 69 years of age. In general, the participants understood what the progression of the numbers conveyed and thought the scale was easy to understand, with good face validity [106]. However, some studies have shown that linear numerical scales are conceptualized differently based on a group's cultural norms. For example, one study found that Native American patients selected a number on the rating scale not to reflect their pain but because it had symbolic and sacred connotations to them [93,107]. Language is another consideration. The number four is nearly homophonous with the Mandarin word for "death," and therefore, some Chinese patients will be less likely to select this number on the pain rating scale.

Education and empowerment work hand in hand. The Western biomedical culture often reduces pain to the physiologic symptoms and sensations, but pain is not merely about physiology, and focusing only on "curing" pain can result in patients forfeiting their sense of control and responsibility and becoming passive agents [117,118]. If patients are educated and empowered, they can become more resourceful in managing their pain and become active agents in their treatment [118]. In the context of pain treatment, the main components of empowerment are [118,127]:

Because pain is a multifaceted phenomenon, it is important for patients to consider pursuing an integrated system of care for their pain. This involves looking into the emotional and psychologic component of pain [117]. Mental health and social service providers can assist patients in identifying and discussing the meanings of their pain experience. Many racial and ethnic minority patients do not adhere to a dichotomy between the mind and body and may be more open to talking about pain's link to their emotions and life circumstances. A study conducted with patients at a pain center compared the attitudes of Puerto Rican patients with non-Hispanic white patients [45]. White patients disclosed feeling that their pain was being discounted or negated if their physicians asked psychosocial-related questions about the pain. In general, these patients wanted pharmacologic interventions and were upset by suggestions that their pain was potentially psychologically and/or emotionally rooted [45]. However, the Puerto Rican patients did not express any complaints when their physicians inquired about family, community, relationships, and other psychosocial factors that might be linked to their pain symptoms [45].

Cognitive-behavioral therapies have been widely employed for patients being treated for chronic pain. Alone, this type of therapy does not relieve pain symptoms [28]. Instead, techniques such as reframing, guided imagery, distraction, and identifying cognitive distortions such as catastrophizing and black-and-white thinking (i.e., all or nothing) can help patients understand how cognitions can influence pain and related behaviors [119]. The resultant improvements in coping can enhance quality of life [28]. There are four main goals when working from this paradigm [117]: