To help clinicians and policymakers understand and solve these problems, some researchers — such as Dr. Ivan Lin, a physiotherapist and researcher at the University of Western Australia — are investigating the cultural and social factors that influence various indigenous cultures' perception of pain.
In our previous post, we explored a little bit about the misconception that indigenous people do not get back pain often. I interviewed Dr. Lin, who had co-written two research papers that challenge the common misconception of back pain prevalence among Indigenous Australians.
But where did the belief that Indigenous Australians are less susceptible to LBP come from? What are some of the reasons that justify this belief?
Dr. Ivan Lin: In the Australian context there have been several studies that concluded LBP, and other painful conditions, had less impact on Indigenous Australians. This seems to match a common clinical belief, that the pain experience is different for Aboriginal people. Pain is always an individual experience, but to generalise that Aboriginal Australians are less susceptible to LBP is wrong and challenged by research that colleagues and I have been involved with.
There are several possible reasons for this perception. We know that Aboriginal people are less likely to attend a clinic or health service for many painful conditions. This could lead practitioners to conclude that LBP and other painful conditions are less of a problem. However there are a number of other possible reasons including a lack of trust of practitioners/services, financial and geographical barriers, and a lack of care that is culturally secure, just to name a few.
In the research context, most research that has reported that LBP is less of an issue for Aboriginal people has been from the perspective of researchers who for the most part have been non-Aboriginal. It is questionable whether the perspective of Aboriginal people has been considered, and therefore we are relying on what the researcher interprets through their understanding or ‘lens’. Differences in the way pain is expressed or communicated may be missed or misinterpreted by non-Aboriginal researchers. Therefore, some research that has concluded that “Aboriginal people are less susceptible to LBP” might be more accurately described as “Aboriginal people seem less susceptible to expressing their LBP in a way that is familiar to me and that I am comfortable recognising”.
Has there been previous studies that are similar to your research?
Dr. Lin: Other studies have looked at pain, including LBP, amongst Aboriginal people, so in that sense our research is not unique. Where the research of our team is perhaps different is that we are a cross-cultural and cross-disciplinary collaboration – between Aboriginal and non-Aboriginal researchers with professional backgrounds in physical therapy, public health medicine, pain medicine, education, and the arts.
During my PhD, I was also fortunate to work with an anthropologist who had worked for many years in remote communities. Our work has an explicit focus on cultural security, meaning that the way we go about our work and our understanding of the topic incorporates an Aboriginal cultural viewpoint. As a non-Aboriginal researcher, there is no way I could work effectively or with understanding in this area without the collaboration and support of knowledgeable Aboriginal colleagues. This possibly make the work of our collaboration unique, however, we would be very pleased to hear from other teams who are working in this area.
“The rewarding thing for me personally is that it benefits people I see in the clinic every session I am there, as I apply what I learn every time I see someone.”
Dr. Lin: I have two roles, as a physical therapist in an Aboriginal Community Controlled Health service, and an academic in a university rural health centre. I am interested in musculoskeletal pain and in my clinical practice I predominantly see Aboriginal people with musculoskeletal pain. There seemed to be a mismatch in between what I was seeing in clinical practice with what the research was saying. I was fortunate to have two very supportive workplaces and so I was able to begin to look at this in more detail through research.
In 2005, this led to embarking on a part-time PhD through Curtin University, Perth, Western Australia, which is about 4.5 hours from where I live. Throughout this journey I was also fortunate to have fantastic research support from supervisors, professors Peter O’Sullivan, Juli Coffin, Leon Straker, Donna Mak and Sandy Toussaint, the organisations for which I work, and from community people who were involved in the project. Post-PhD I’ve continued this work with a number of people who have been involved from the start and others who also think it is important. The rewarding thing for me personally is that it benefits people I see in the clinic every session I am there, as I apply what I learn every time I see someone.
Dr. Lin: In the paper, we discuss the impacts of CLBP (chronic low back pain) on daily life activities, emotional, and cultural well-being of Aboriginal men and women in rural and remote areas of Western Australia. In this study, we were looking at the impacts of CLBP and not whether or not they preceded or arose as a result of CLBP. We know that emotional factors such as pre-existing psychological distress increases the risk of developing an episode of LBP, can arise as a result of LBP, or prolong an episode of LBP. It is likely that this was the case with the emotional impacts we found in this study, however this wasn’t what we were investigating.
In another paper we suggest that disabling CLBP may be iatrogenic. This is because Aboriginal men and women who we interviewed had a number of misperceptions about the nature/cause of their pain. In many cases, these misperceptions originated from contact with health practitioners. These misperceptions, or maladaptive beliefs about pain (e.g. ‘I’ll end up in a wheelchair’, ‘my back is stuffed’), can be disabling because they increase fear and maladaptive coping. These beliefs can result in poorer outcome for Aboriginal people with LBP.
“Good quality clinical care is about providing care that is ‘scientifically’ sound and also meets the individual and cultural needs of the individual patient.
What questions should future research investigate and why?
Dr. Lin: There’s not one single question for future research. We believe that the issue of disparities in care is important and are continuing work that is investigating and aiming to improve the quality of health care Aboriginal people with musculoskeletal pain receive. Good quality clinical care is about providing care that is ‘scientifically’ sound and also meets the individual and cultural needs of the individual patient. Currently, a lot of healthcare [professionals] don't do this, and so this is what we would like to positively influence in our work.
This is something that is well known, complex, and cuts across all aspects of health including pain. Although the link between the disadvantages described above is well established, what to do about it is less well known. It is a large, complicated, and important area of research.
At the end of the day, aside from learning how socio-cultural factors can influence how certain populations perceive pain, I learned the proper way to address Indigenous Australians.