Posted: February 16th, 2022

The importance of cultural competence in pain and palliative care


Culture determines human behavior in many life decisions. Similarly, culture also determines how people perceive and manage pain. Over many years, medical practitioners have worked with the signs that they believe patients display for pain. Thus, many cultural aspects of communicating pain are not always captured by medical experts. There is a misconception that pain can only express through quiet endurance or verbal complaints, irrespective of culture (Orhan et al., 2018). The view contributes to improper pain management and cultural biases in healthcare settings. Some African cultural factors linked to pain include the cultural concept of suffering, pain language, social roles, traditional medicine and remedies, pain expression, perception, and expectations (Nortje & Albertyn, 2015). The challenges can lead to poor evaluation and measurement of pain. Further, medical practitioners’ judgments about pain, inability to discern cultural meanings of pain, the lack of ideas about verbal and non-verbal cues of pain impede pain management in healthcare settings. This paper addresses the sense of pain among African cultures and how the information is applicable in pain management. 

The Nguni and Sotho Practices 

Culture hampers the perception and management of pain in Africa. The failure to recognize how different groups of people link pain to suffering is a leading factor to misdiagnosis, cultural conflict, and inappropriate patient treatment plans. Traditional medicine in Africa is seen as a complementary and alternative form of medicine or pain management approach. For this reason, a significant majority of Africans believe that misfortunes, injuries, and diseases are caused by unpleasant ancestral spirits, witchcraft, and natural outcomes (Nortje & Albertyn, 2015). The Nguni culture of Southern Africa believes that pain may be caused by poor communication with ancestral spirits which reside among the living. The Sotho culture believes that pain results from the misfortunes and sickness brought about by an angered ancient spirit (Balimo). 

The varying perceptions of the Nguni and Sotho people of Southern Africa place more preference for traditional practices than Western medicine. The management of pain using conventional approaches is not readily accepted, especially in cultures where the ratio of traditional healers to patients is lower than that of medical doctors to patients. According to Nortje and Albertyn (2015), traditional remedies are preferred to modern medicine by 80% of the people living in sub-Saharan Africa. Hence, medical practitioners that use pain relievers, like morphine, may not receive a positive response from patients who believe that the cause of pain is not natural but spiritual. 

South African community members seek help from traditional healers faster than in healthcare facilities. People that opt for traditional medicine as a method of pain management cannot easily trust the efficacy of pain killers given to them by nurses in hospitals. Although Sotho members living in urban centers may seek consultation services from conventional doctors, they return to traditional healers in rural areas. Izimbiza (traditional remedy) is preferred for burns, toothache, hip pain, system cleaning, and inflammation of the glands (Nortje & Albertyn, 2015). Hence, some Africans may not use other non-traditional remedies for these common diseases in communities. 

Some folklores among African cultures influence the way people perceive pain and the modalities for pain management. The Setswana and the Sesotho view pain in emotional and physical forms. Among the latter, there is a belief that people should hide the pain. The folklore alludes that one should not openly express the pain in public. Thus, pain is seen as a weakness and hostile behavior among community members in such a culture. Other folklores also link pain to wickedness, and people in pain fear being negatively judged for doing unethical acts in society. While managing pain in modern healthcare settings, a medical practitioner should understand the culture of the patient (Orhan et al., 2018). Hence, addressing health concerns for some community members entail engaging clients beyond the expectations of unpleasant sounds of pain that a significant majority may not express. 

Although the Nguni and Sotho use traditional medicine to treat many illnesses, the practice is more pronounced among the latter. Healthcare access being an issue in many Southern Africa communities, the use of traditional medicine by the Nguni is mostly triggered by the poor access to modern medicine and the affordability of traditional remedies. 

Pain perception among African culture is also dependent on gender. All the sub-cultures in the Sotho group believe that men should not show the physical and emotional pain. Men expressing pain are considered weak and breaking the codes created by community elders against taboos. In contrast, ladies are allowed to express their pain or any displeasure to get help. In healthcare facilities, it is difficult to determine pain by the physical appearance of a man. The acceptance of pain by men of the Sotho culture could lead to poor disease prognosis and planning. Members of the Ghanaian culture describe pain as emotional or spiritual. People under the palliative care stage prefer to die at home under no medical support. Unlike Ghanaians, Kenyans avoid pain medicine but they also prefer to die at home when in the palliative care stage (Givler et al., 2021). Some patients also prefer to use alternative pain management options. 

There are misconceptions among many people the use of opioids in the palliative stage of disease are the same as euthanasia. Givler explains that some believe that such pain relievers are an indication of the near-death stages. The rejection of opioids as the primary pain management options compels many patients to seek alternative medications through acupuncture, herbs, coining, or moxibustion. 

Pain perception and management among Africans requires medical practitioners to understand perceptions of people concerning pain medication, preferred treatment options, and pain languages. The Sotho and Nguni have cultural codes that prevent men from expressing pain. The reliance on traditional medicine also creates the laxity to try modern treatment modalities. The massive preference by many people to avoid medication at the palliative is an indicator of how much African people are slow at accepting end-of care support, with the majority preferring to die at home.





Givler, A., Bhatt, H., & Maani-Fogelman, P. A. The importance of cultural competence in pain and palliative care. StatPearls. 

Nortjé, N., & Albertyn, R. (2015). The cultural language of pain: A South African study. South African Family Practice57(1), 24-27.

Orhan, C., Van Looveren, E., Cagnie, B., Mukhtar, N. B., Lenoir, D., & Meeus, M. (2018). Are pain beliefs, cognitions, and behaviors influenced by race, ethnicity, and culture in patients with chronic musculoskeletal pain: A systematic review. Pain Physician21(6), 541-558. 



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