Asians are one of the largest groups of immigrants in developed countries; for example, about 1 in 20 of the US population are Asians (United States Census Bureau, 2017). Yet, Asian immigrants (AIs) are heavily underrepresented in pain research studies (Institute of Medicine Committee on Advancing Pain Research, Care, & Education, 2011; Janevic, McLaughlin, Heapy, Thacker, & Piette, 2017). In effect, there is lack of clear understanding as to how AIs manage their pain. When this is not well-explicated, assumptions are made among AIs and pain-related healthcare decisions are done based on the general population irrespective of cultural differences. Synthesizing current literature allows for greater understanding that can provide relevant research directions and assist in improving pain management among AIs.
Purpose: This integrative review provided an understanding on how AIs manage their chronic pain. AIs are defined in this review as those with citizenship at birth in Asian countries and then immigrated or became citizens in their new countries of residence.
Methods: Whittemore and Knafl’s (2005) methodology was used for this integrative review to enhance rigor and reduce bias. A systematic literature search was performed by 3 collaborative researchers in nursing and anthropology using multiple databases: Cochrane, EBSCO, ProQuest, PubMed, Scopus, ScienceDirect, and Web of Science. Search words were: Asian, Asian American, Asian immigrant, pain, and pain management, in various combinations. After data evaluation, 15 studies were found to meet the inclusion criteria (written in English, included AIs, and addressed pain management). Data were consequently analyzed based on Whittemore and Knafl strategies (data reduction, display, comparison, and conclusion drawing with verification); consensus was reached by the 3 researchers on emerging themes. Further, recommendations for rating scientific evidence were used based on Melnyk and Fineout-Overholt (2015) and the Agency for Healthcare Research and Quality (2002). Guidelines for Preferred Reporting Items for Systematic Reviews and Meta-analysis (Moher, Liberati, Tetzlaff, & Altman, 2009) were also followed for reporting this review.
Results: Study designs for the 15 studies included in this review were: 1 mixed methods, 7 quantitative (2 randomized controlled trials and 5 descriptive), and 7 qualitative (1 grounded theory and 6 descriptive). All participants (7 to 2095 sample sizes) were adults; majority were Chinese Americans. Twelve studies were conducted in the US, and the rest were in Australia, Canada, and UK. Six of the 15 studies were done within the past 5 years. The overall theme that emerged based on data analyses was directed on how resilience enhanced effective self-management (SM) among AIs in chronic pain.
Resilience in chronic pain is described as having minimal burden and dysfunction despite the pain (Karoly & Ruehlman, 2006) operationalized through acceptance, positive affect, and adaptive pain beliefs (Alschuler, Kratz, & Ehde, 2016). AIs demonstrated resilience as they reconstructed the meaning of pain and accepted this as a natural part of aging. They exerted control over their own pain managing this effectively with SM and high tolerance. Their social expectations and cultural beliefs prompted their resilience as they continued to live their lives in the face of chronic pain. However, this resilience existed in a continuum where the positive end is effective SM and the negative end reflects mental distress when pain is continually self-managed despite the need for medical treatment for severe, persistent pain.
SM refers to taking responsibility for one’s care, operationalized through medical, role, and emotional management (Lorig, Sobel, Ritter, Laurent, & Hobbs, 2001). The practice of SM is deeply rooted among AIs allowing for their effective pain management. In medical management, there is strong preference for use of traditional Eastern medicine with significant relief. SM programs incorporating Tai-Chi engaged AIs in pain management. Ethnic healers were sought for common pain problems and analgesics, especially opioids, were minimally used. In role management, AIs were less likely to report pain, took control without complaint, and believed in a higher power to help address pain. In emotional management however, the choice to endure and manage one’s own pain contributed to anxiety and depression.
Implications: Despite the magnitude of pain studies existing in the literature, most of the studies included in this review were older than 5 years indicating that current data are lacking among AIs in the pain literature. This emphasizes the need for increased representation and engagement of AIs in pain studies and health policies to minimize pain care disparities.
Future research directions are clear with global implications since most of the studies in this review were conducted in the US, majority were on Chinese Americans despite possible subgroup differences within AIs, and there is lack of pediatric AI studies. The mediating and moderating roles of resilience in SM of chronic pain among AIs also need to be explicated. Further, it may be worthwhile to investigate resilience interventions and initiatives to increase resilience for improving SM of chronic pain in the general population considering the impact of resilience among AIs. Despite the high global statistics of chronic pain, prevalence among AIs is less compared to other races. For example, depending on location, (e.g., head, neck, back), chronic pain impacts 10-19.5% of Asian adults in the US, 16-28.8% among Whites, and 15-26.2% among Blacks (Blackwell & Villarroel, 2018). The lower numbers among AIs may be attributed to how they manage their pain.
In pain education and clinical practice among healthcare providers, cultural competence, avoiding stereotypes, and facilitating communication with AIs are crucial to limit underreporting of pain. Assessing that their resilience is not preventing them from much needed pain management and evaluating their mental health in cases of unnecessary endurance to severe and persistent pain can minimize underdiagnosis and undertreatment. Pain-related culturally-appropriate activities are also important in engaging AIs who are highly influenced by their culture when managing their pain.
Conclusion: Findings from this review emphasize the significance of culture in health (Napier et al., 2014) with collaborative perspectives from nursing and anthropology toward improving global pain care and outcomes. Understanding how AIs manage their pain are important toward facilitating adequate pain management and minimizing inequity.
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