Irena Veljanova

Are multidisciplinary interventions multicultural? : a topical review of the pain literature as it relates to culturally diverse patient groups

Worldwide, societies are becoming increasingly culturally diverse. International migration continues to rise, influenced by political, economic, and socioenvironmental factors and is now a structural feature of almost all contemporary nations. Cultural diversity was recognised by the United Nations Educational Scientific and Cultural Organisation (UNESCO) as a key global concern at the start of the 21st century. The changing demographics and economics of a multicultural world, and the health disparities for some culturally diverse communities, provide significant challenges for health care systems internationally. Cross-cultural investigations demonstrate that definitions, descriptions, and perceptions of pain and pain control are culturally specific. Experimental pain investigations demonstrate significant differences in pain tolerances and thresholds according to ethnicity. The way in which pain is experienced is powerfully influenced by culturally based attitudes, beliefs, and values. Beliefs and values mediate emotional responses to pain disorders and pain coping strategies, such as stoicism, spiritual coping, hypervigilance, and catastrophising. Unravelling and understanding the multiple and fluid dimensions that construct the pain experience is fundamental to reducing suffering and ensuring equitable pain management.

Culturally informed practice and physiotherapy

Australia is culturally diverse, with more than half (52.2%) of the population born overseas or having at least one parent born overseas.[6_TD

Lifestyle science: Self-healing, co-production and DIY

DIFF] Since 2005, migration has been the main driver of Australia’s population growth, contributing approximately 60% of overall growth. While historically the bulk of Australia’s overseasborn population comprised migrants from Anglo-Celtic descent, the dismantling of the White Australia Policy four decades ago heralded a new era of more inclusive migration policies. This saw a sustained rise in the proportion of migrants to Australia from non-English speaking countries. The combination of Indigenous populations and the long history of immigration has created a culturally rich and diverse Australia. The growth in migrants and refugees, many of whom have been displaced due to conflict and persecution, has fuelled debate about the preparedness of plural societies like Australia for the challenges associated with such cultural diversity. One challenge is health system responsiveness; specifically, health systems must be responsive to the social, economic and cultural factors underpinning disparities in health for patients from culturally and linguistically diverse backgrounds. With international migration continuing to rise, it is timely to consider whether Australian health professionals, including physiotherapists, are equipped to deliver culturally responsive healthcare. Culturally responsive healthcare, an extension of patient-centred care, ensures that attention is given to social and cultural factors during therapeutic encounters by exploring the beliefs and values that underpin the illness experience.[2_TD

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

DIFF] A number of terms have been used, often interchangeably, to describe culturally responsive healthcare or practice, such as cultural competency and cultural safety. Broadly, these terms describe the attributes required by health professionals to engage effectively with health consumers from culturally diverse communities. Our national physiotherapy competency standards cite cultural competence, cultural responsiveness and cultural safety in four of seven requirements for physiotherapists. Further, accreditation standards for physiotherapy entry-level programs require teaching of skills necessary for culturally responsive physiotherapy practice. Thus, [8_TD

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

DIFF]the profession clearly recognises the importance of culturally responsive practice. However, given that cultural responsiveness is not a static competence to be achieved once, but a continually evolving process, it is reasonable to question whether we are delivering culturally responsive care. If not, where do physiotherapists receive guidance regarding how to implement practices responsive to the changing demographics of the Australian population?

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

2 Volume 22, Issue 1, March 2013 H SR Self healing, co-produced care and doit-yourself healing (DIY) care are becoming increasingly pervasive aspects of how people manage their health and illness. A large part is played in this by alternative forums of social engagement such as provided by open source technology where contemporary individuals negotiate and share their everyday care experiences. This intensifying negotiation of experience is conceptualised by Fuller as manifesting an ‘anti-establishment science movement’ which tacitly challenges the ‘scientifi c expert’ and the ‘knowledgeable doctor’ – the agents and experts who for decades have controlled evidence and knowledge in the domain of care and healing (Fuller, 2010). True, the evidence-base of medicine has continued to expand over the last several decades in an effort to consolidate the scientifi c grounding of traditional biomedicine. As Lynch notes, ‘Expertise can be hard-won, and expert advice can be a valuable and reliable guide to action. As educated people, we know and live this as a fact of daily life’ (Lynch, 2007, p. 17). Lynch continues by articulating an increasingly common social concern: ‘Expertise becomes a problem when it, and the grounds for it, are reifi ed and exaggerated beyond all proportion and circumstance’ (Lynch, 2007, p. 17). Indeed, the emphasis on evidence can be interpreted as not simply furnishing the consumer with more equitable and certain choice options, but as also reinforcing science’s claim to be the exclusive arbiter of what is authoritative knowledge. Henderson and Petersen already addressed this problem when they observed that consumerism in health care is ‘often presented in terms of personal empowerment and freedom of choice’ (Henderson & Petersen, 2002, pp. 2–4). As Annemarie Mol has since shown in her book The logic of care (Mol, 2008), choice does not operate transparently in the context of patients’ diffi cult decisions around treatment, uncertainty about their recovery, and changes in their understanding about treatment and healing. Consumerism in effect is contingent on the pro-active agency of the neo-liberal and wellinformed health consumer, and rejects the passive, under-informed patient cared for by the welfare state. It has thus been argued that consumerism offers ‘[an] imagined consumer autonomy’ where people are expected to consume ‘the commodity of “good health” (goods, services, knowledge) without challenging the monopoly of the commodity producers; that is, the biomedical industries’ (Veljanova, 2011, p. 120). Keying into the new consumerism and its emphasis on rational, science-based choice, evidence-based medicine seeks to ensure that clinical practice decisions are no longer contingent on clinicians’ personal opinion and individual experience (Sackett & Rosenberg, 1995). Not surprisingly, evidence-based medicine’s aim has since run up against a number of problems. First, much of medicine has never been and can never be fully evidence-based (Jorm, 2012). This ‘limitation’ does not just arise because scientifi c trials are simply not possible in many domains of medicine, but also because imposing trials on medical domains might necessitate subjecting patients to unethical practices. Even more troubling of course is that several trials, of those conducted in the same domain, produce confl icting results (for example, the use or not of beta-blockers following surgical procedures). EDITORIAL

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

Abstract 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.

Raising awareness, improving victim safety: Exploring the efficacy of proactive domestic and family violence prevention measures

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.

Raising awareness, improving victim safety: Exploring the efficacy of DFV proactive prevention measures

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.