Recognising ethnocultural diversity in chronic pain assessment: validation of the Pictorial Representation of Illness and Self Measure (PRISM) for use with culturally diverse communities.

BACKGROUND: A comprehensive and accurate assessment of pain is critical for successful pain management. However, there is a lack of reliable and valid assessment tools for exploring multidimensional aspects of the chronic pain experience in culturally and linguistically diverse communities. This study investigates the reliability and validity of the Pictorial Representation of Illness and Self Measure + (PRISM+) for evaluating pain-related suffering and the sociocultural context of chronic pain within culturally and linguistically diverse patient cohorts. METHOD: Three prospective validation studies are reported for three culturally and linguistically diverse communities. Two hundred and fifty-one patients with chronic pain who self-identified as Assyrian (n = 85), Arabic (n = 83) or Vietnamese (n = 83) completed a PRISM+ assessment, alongside a battery of standardised pain assessments. To evaluate construct validity, the position of the 'pain' disk placement was correlated with the Brief Pain Inventory (BPI), Depression Anxiety and Stress Scale (DASS), and the Short-Form 36 Health Survey (SF-36). For content validity, thematic analysis of patient narratives accompanying each disk placement was conducted. Test-retest reliability of repeated 'pain' and five additional disks (PRISM+) values was analysed using intra-class correlation coefficients. RESULTS: The PRISM pain assessment demonstrated moderate to good test-retest reliability for Arabic (ICC 0.76; 95% CI 0.65-0.84), Assyrian (ICC 0.65; 95% CI 0.50-0.76) and Vietnamese (ICC 0.82; 95% CI 0.73-0.88) patients. Moderate correlations between the PRISM 'pain' disk and sub-scores for the BPI, DASS and SF-36 were found (p < 0.001). Patient interpretations of the 'pain' disk aligned with accepted definitions of suffering, supporting content validity for PRISM. For the additional disks (PRISM+), moderate to good test-retest reliability (ICC 0.67-0.88) was observed and qualitative analysis highlighted each disk reflected social and cultural values. CONCLUSION: The PRISM demonstrates acceptable psychometric properties for measuring pain-related suffering for participants with chronic pain across three culturally and linguistically diverse communities. The use of additional disks (PRISM+) presents a reliable and valid option for exploring social and cultural dimensions of chronic pain in clinical encounters.

The Intersections of Chronic Noncancer Pain: Culturally Diverse Perspectives on Disease Burden.

OBJECTIVE: This study highlights the burden of chronic non-cancer-related pain from the perspectives of three culturally and linguistically diverse communities, using an intersectionality analysis. Specifically, we identify how multiple social identities intersect to account for the unequal distribution of the burden of chronic pain. DESIGN AND METHODS: Six focus groups of 41 culturally and linguistically diverse participants (Mandaean, Assyrian, and Vietnamese) living with chronic noncancer pain were conducted in South-West Sydney, Australia, between February and July 2015. Data were analyzed using inductive and intersectional methodology. RESULTS: The interaction between a patient with chronic pain from a culturally and linguistically diverse background and the health system is influenced by four identified social identities that interact to create relative positions of disadvantage for the patient within the health system and with health care providers. The social identities identified were ethnoculture, social class, migration status, and gender. CONCLUSIONS: Health care providers must consider how the intersectionality of social identities related to ethnoculture, social class, migration status, and gender can factor into the creation and maintenance of chronic pain disparities. A greater, more thoughtful incorporation of intersectionality in chronic pain research and clinical practice will ensure that pain management approaches are designed and applied in a way that reflects the social context of affected communities and individuals from those communities.

Integrating culturally informed approaches into physiotherapy assessment and treatment of chronic pain: a pilot randomised controlled trial.

OBJECTIVE: To evaluate patient engagement with, and the feasibility of, a novel, culturally adapted physiotherapy pain management approach. DESIGN: A participant-blinded and assessor-blinded pilot randomised controlled trial. SETTING: Outpatient physiotherapy departments at two public hospitals and one district pain clinic. PARTICIPANTS: Adults (n=48) with chronic musculoskeletal pain (daily pain >3 months), who self-identified as Mandaean, Assyrian or Vietnamese, were randomised to one of two physiotherapy treatment conditions. INTERVENTIONS: 24 participants underwent combined group and individualised treatment described as 'culturally adapted physiotherapy', while 24 underwent evidence-informed 'usual physiotherapy care'. Both treatment arms consisted of up to 10 sessions over a 3-month period. OUTCOME MEASURES: Patient engagement was measured via participant attendance, adherence and satisfaction data. Secondary outcomes included clinical measures of pain severity, interference and suffering, physical function and negative emotional state. RESULTS: 96% of participants undergoing culturally adapted physiotherapy completed treatment, compared with 58% of the usual physiotherapy group. For the culturally adapted group attendance (87%±18%) and adherence (68%±32%) were higher relative to usual care (68%±32% and 55%±43%). Satisfaction was similar for the culturally adapted (82.7%±13.4%) and usual care (79.3±17.3) groups. For secondary outcomes, a significant between-group effect for pain-related suffering in favour of the culturally adapted group was observed with a medium effect size (partial η2 0.086, mean 3.56, 95% CI 0.11 to 7), while results for pain severity, interference, physical function and negative emotional state were similar. CONCLUSIONS: Aligning treatment with the beliefs and values of culturally and linguistically diverse communities enhances patient engagement with physiotherapy. These results support the feasibility of a larger, multisite trial to determine if improved engagement with culturally adapted physiotherapy translates to improved clinical outcomes. TRIAL REGISTRATION NUMBER: ACTRN12616000857404; Pre-results.

An exploration of the experience of pain among culturally diverse migrant communities.

Objective. To explore the ethnocultural influences on the chronic pain experience in three culturally and linguistically diverse communities in Australia. Methods. Six focus groups were conducted with 34 women and 7 men (ages 36-74 years) who self-identified as Mandaean, Assyrian or Vietnamese. A purposive sample of community-dwelling adults living with chronic pain (daily pain >3 months) was recruited from community organizations. Participants were asked broadly about the meanings of chronic pain, acceptance, ethnocultural community expectations and approaches to pain management. A standardized interview collected sociodemographic and symptom data for descriptive purposes. Results. Inductive thematic analysis yielded a multidimensional web of themes interrelated with the pain experience. Themes of ethnocultural identity and migrant status were intertwined in the unique explanatory model of pain communicated for each community. The explanatory model for conceptualizing pain, namely biopsychosocial, biomedical or a traditional Eastern model, framed participants' approaches to health seeking and pain management. Conclusions. Chronic pain is theoretically conceptualized and experienced in diverse ways by migrant communities. Knowledge of cultural beliefs and values, alongside migration circumstances, may help providers deliver health care that is culturally responsive and thereby improve outcomes for migrant communities with chronic pain.

Integrating culturally informed approaches into the physiotherapy assessment and treatment of chronic pain: protocol for a pilot randomised controlled trial.

INTRODUCTION: There is strong evidence that biopsychosocial approaches are efficacious in the management of chronic pain. However, implementation of these approaches in clinical practice is known not to account for the beliefs and values of culturally and linguistically diverse (CALD) patients. This limitation in translation of research contributes to the disparities in outcomes for CALD patients with chronic pain adding to the socioeconomic burden of this prevalent condition. Cultural adaptation of chronic pain assessment and management is urgently required. Thus, the aim of this pilot randomised controlled trial (RCT) is to determine the feasibility, participant acceptance with and clinical effectiveness of a culturally adapted physiotherapy assessment and treatment approach when contrasted with 'usual evidence based physiotherapy care' for three CALD communities. METHODS AND ANALYSIS: Using a participant-blinded and assessor-blinded randomised controlled pilot design, patients with chronic pain who self-identify as Assyrian, Mandaean or Vietnamese will be randomised to either 'culturally adapted physiotherapy assessment and treatment' or 'evidence informed usual physiotherapy care'. We will recruit 16 participants from each ethnocultural community that will give a total of 24 participants in each treatment arm. Both groups will receive physiotherapy treatment for up to 10 sessions over 3 months. Outcomes including feasibility data, acceptance with the culturally adapted intervention, functional and pain-related measures will be collected at baseline and 3 months by a blinded assessor. Analysis will be descriptive for feasibility outcomes, while measures for clinical effectiveness will be explored using independent samples t-tests and repeated measures analysis of variance. This analysis will inform sample size estimates while also allowing for identification of revisions in the protocol or intervention prior to a larger scale RCT. ETHICS AND DISSEMINATION: This trial has full ethical approval (HREC/16/LPOOL/194). The results from this pilot RCT will be presented at scientific meetings and published in peer-reviewed journals. TRIAL REGISTRATION NUMBER: ACTRN12616000857404.