Pain management in indigenous and tribal peoples: a scoping review protocol

Abstract

Introduction

Effective and culturally safe pain management can facilitate analgesia and improve the quality of life. Individualised, multimodal and multidisciplinary approaches are highly recommended. There exist gaps in the knowledge on pain management, in terms of the assessment and/or treatment, in indigenous peoples and the currently available information is scattered in the literature. A scoping review will provide an overview or evidence map on the variety of approaches used in different cultures, in different parts of the world.

Methods and analysis

The search strategy comprises three stages. The first stage identified the MeSH terms and keywords in PubMed. The second stage will consist of a search of MEDLINE, EMBASE, LILACS, CINAHL, Web of Science, APA PsycNet and Scopus, followed by a search in Google and Google Scholar, GreyGuide, ProQuest Dissertations and Theses, Theses Canada Portal (Library and Archives Canada), TROVE (National Library of Australia), Aboriginal and Torres Strait Islander Health Bibliography, and Cybertesis. The papers will be screened, selected and extracted independently by two researchers. Descriptive data analysis will be performed, and the results will be presented using a narrative summary, graphs, tables and figures.

Ethics and dissemination

This review does not require ethical approval, as data from the literature available in databases will be collected and analysed. The protocol was registered at the Open Science Framework. The data on pain assessment and treatment in indigenous peoples will be presented through a narrative summary, figures, charts and tables. Results will be submitted to an open-access journal for publication and will be disseminated through scientific events, scientific meetings, public events and conversation circles with indigenous peoples.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• This protocol will ensure clarity, transparency and integrity in the research report, therefore, details of the conduct of the study will be presented in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews flow chart.

• The stakeholders and indigenous health professionals and non-indigenous health professionals will be consulted throughout the study.

• The search strategy was developed under the guidance of a librarian and nurse with experience in database searches and research with indigenous peoples, ensuring the suitability of the search strategies for each database and a comprehensive search strategy.

• A limitation is that only pain assessment and treatment will be mapped. Other dimensions of pain management, such as education and rehabilitation, will not be mapped.

Introduction

There is no dissociation between pain and cultural belonging.^1–3 Pain may have a deeper meaning among indigenous peoples that goes beyond biomedical definitions.^{4 5} In addition to the neurophysiological aspects, trauma, suffering, depression, each individual’s personal history and cultural background interfere with the perception of pain and the need for effective treatment.^3–5

From an anthropological perspective, it is not possible to understand the manner in which people react to pain without understanding their culture, that is, ‘the web of meanings and the lenses through which these people understand, explain, and interpret the world’.² In addition to the neurophysiological aspect, each individual’s personal history and cultural background interfere with the perception of pain and the need for effective treatment.³

Currently, pain can be classified according to various parameters of pain experience, such as location in the body (low back pain, pelvic pain), severity (no pain, moderate or worst possible pain), duration (acute or chronic), etymology (somatogenic or psychogenic) or body system involved (myofascial, rheumatic, causal, neurological or vascular).⁶ Identifying pain and proposing proper management is a complex and challenging task. There is no clear definition of pain management, which is complex and includes broad concepts such as its measurement, assessment, treatment, education and rehabilitation.^{7 8} However, irrespective of any established definition, the goal of pain management is to help and support people living with pain in order to relieve suffering and improve the quality of life.^{9 10} It should adopt an individualised patient-centred, multimodal and multidisciplinary approach.¹¹

Many methods are used for measuring pain, and the available instruments can be one-dimensional or multidimensional; the former being used to quantify only one dimension of the painful experience, often intensity and the latter to measure different dimensions such as sensory-discriminative, affective-motivational and cognitive-evaluative dimensions. Different approaches can be used to manage acute or chronic pain at different levels of healthcare, including one or different therapeutic modalities (such as pharmacological and non-pharmacological, holistic, or spiritual) and involving professionals from different areas of knowledge (multidisciplinary/interdisciplinary).^{8 11}

In pain management, the biopsychosocial approach is desirable and highly recommended, as it considers multiple aspects involving causes, effects and different treatment strategies according to the individual and subjective nature of the painful experience, culture and life history of each patient.^{7 8 11} In the meantime, it is important to accurately assess and manage the patient’s pain and recognise the various factors that can affect the painful experience, such as cultural norms, beliefs, environmental circumstances, and emotional and cognitive status.7 8 11 12

Although knowledge of pain management has advanced, prejudice and discrimination against people or populations by healthcare professionals can compromise healthcare, especially assessment and treatment decisions.¹³ Therefore, it is essential to focus on the care of indigenous people with pain to ensure that the process does not become fragmented, culturally inadequate and unsafe, thereby failing to meet the unique and specific needs of these people.^{14 15}

It is estimated that 476 million individuals worldwide belong to indigenous peoples, which corresponds to 6.2% of the world’s population.¹⁶ There are more than 5000 indigenous peoples, each with its own sociocultural specificities and own way of viewing and relating to the world.^{16 17}

Indigenous peoples share a similar history of colonisation, discrimination and marginalisation, subjugation, expropriation to different degrees, and different health and disease experiences that have caused, and still continue to cause, serious inequalities and oppression, thereby affecting their health and well-being.^{7 18 19} Healthcare services do not always consider the experiences of indigenous peoples; although there is evidence that chronic pain may be caused by trauma and violence,8 11 20 21 pain management is rarely planned on the basis of the health, equity, history of colonisation, subjugation and resistance to subjugation of these peoples,^{8 11 14} with considerations of social issues and disparities.^{22 23}

It is evident that there are gaps in the knowledge on pain management in culturally diverse contexts, especially concerning indigenous peoples, which makes it necessary to conduct studies to review this topic for directing future research and health policies that guide the quality of care, and ensure that it is culturally adequate and safe to the person experiencing pain.¹² Thus, an initial search was conducted for studies focusing on pain management in indigenous peoples using the PuBMed, Cochrane Database of Systematic Reviews and JBI Evidence Synthesis, and although sufficient evidence^24–27 exists to ensure a successful scoping review, no scoping or systematic review on the topic with indigenous peoples was identified.

A scoping review methodology was chosen rather than a systematic review to review the literature on pain management in indigenous peoples, in terms of the assessment and/or treatment, as it can provide an overview or evidence map on the variety of approaches used in different cultures, in different parts of the world, thus exposing existing inadequacies, gaps and necessary future research, as well as reporting and discussing these concepts in a global context.

Therefore, the objective of this study is to map the literature on pain management (assessment and/or treatment) in indigenous and tribal peoples across different cultures in a global context.

Review questions

The guiding research questions are defined using the mnemonic structure Population, Concept and Context:

• What approaches are used for pain management (assessment or treatment) in indigenous and tribal peoples and what are their characteristics?

• What pharmacological and non-pharmacological therapies and measuring instruments are used in pain management?

• Which professionals are involved in the healthcare of indigenous patients with pain, and in what contexts do they work?

• What are the gaps reported by the authors about pain management in indigenous and tribal peoples, and what are the recommendations for future research?

Methods and analysis

Type of knowledge synthesis

The proposed scoping review will be conducted according to the JBI methodology for scoping reviews.²⁸ The protocol was registered at the Open Science Framework (https://osf.io/q9jw4).

Patient and public involvement

The review is the first stage of a larger research programme, an ethnographic study of pain management in indigenous peoples of Brazil, whose objective is to analyse pain management (assessment and treatment) in indigenous people of the Xavante ethnic groups. This study was reviewed and approved by the National Research Ethics Committee (Document number: 5.634.023). Stakeholders were involved in defining the objective and research questions through informal conversations and talking circles with indigenous peoples. They were invited to speak freely about pain management (their own knowledge) and what they consider to be important factors for assessment and treatment. The conversations took place through meetings with indigenous midwives, indigenous health agents, indigenous health professionals and informal conversations with indigenous patients (in the waiting room of the indigenous health clinic).

The results will be presented and discussed with stakeholders through talking circles, respecting the way indigenous peoples prefer to report their opinion. Stakeholder perspectives are important to understand the inseparability of cultural aspects and pain management. The perspectives of indigenous peoples are important sources of knowledge, not only for researchers, but also for other professionals who participate in pain management.

Inclusion criteria

This scoping review will consider peer-reviewed journal articles qualitative, quantitative or mixed-methods on indigenous and tribal peoples from different countries that addressed pain management. Systematic reviews and meta-syntheses will not be included, but the reference list will be searched for additional sources. Opinion texts and articles, technical or research reports, dissertations and theses, conference proceedings and articles, government documents (national or international), and organisational websites can also be included in this scoping review.

Participants

This review will consider sources of evidence that include pain management (assessment and/or treatment) in indigenous peoples (irrespective of geographic location, age, sex, year of publication, type or location of pain). There is no universally accepted definition of ‘indigenous peoples’, but international treaties,^{16 17} have emphasised the importance of identifying these peoples via objective and subjective criteria such as self-identification and group recognition (acceptance).^{16 17} Thus, in accordance with the recommendations of the United Nations,¹⁷ we will use the word ‘indigenous’ to identify these peoples in this study. Studies that include both indigenous and non-indigenous peoples will be considered if it is possible to extract data related to indigenous peoples (eg, in qualitative studies).

Concept

This review will analyse studies on pain management (assessment and/or treatment) in indigenous and tribal peoples, regardless of type, duration or location of pain. However, pain is multidimensional and may have deeper meaning among indigenous peoples, so we will consider all types of pain (in addition to biomedical definitions) in this review.⁴ The concept of interest is pain management, understood as an interdisciplinary or multidisciplinary strategy for assessing and treating people with acute or chronic pain, individualised patient-centred, focusing on their well-being, to alleviate pain, while also considering factors that modulate the painful experience, such as biological, sociocultural, environmental, behavioural, psychological and spiritual factors.

Regarding pain management, the concepts to be examined will include (1) assessment and/or treatment of the painful experience, (2) the methods/ instruments used for measuring or the assessment of pain, (3) the treatment modalities, pharmacological or non-pharmacological, used in western medicine or traditional treatments and (4) approaches used in pain management (individualised and patient-centred, multimodal or unimodal, interdisciplinary/multidisciplinary).

Context

The protocol will involve different indigenous and tribal cultures in different health systems at all levels of healthcare without geographic limitations.

Search strategy

The search strategy will be conducted in three stages,^{28 29} with no restrictions on the year of publication or language. A preliminary search was conducted in MEDLINE (via National Library of Medicine) and CINAHL (via EBSCO) to identify articles on the subject. The text words contained in the titles and abstracts of relevant articles and the index terms used to describe the articles were used to develop a comprehensive search strategy for each included database. The search strategy was developed under the guidance of a librarian and nurse with expertise in database searches. A comprehensive search strategy for MEDLINE (via National Library of Medicine) is included in table 1.

Table 1.

Search strategy for MEDLINE (via the National Library of Medicine)

Search December 12, 2022	Query	Records retrieved
#1 Time: 18:12:04	“Indigenous Peoples”[All Fields] OR “Alaskan Natives”[All Fields] OR (“inuits”[MeSH Terms] OR “inuits”[All Fields] OR “inuit”[All Fields] OR “indians south american”[All Fields] OR “indians north american”[All Fields] OR “Alaskan Natives”[All Fields] OR “American Natives”[All Fields] OR “Indigenous Canadians”[All Fields] OR “Alaskan Natives”[MeSH Terms] OR (“indigen*“[All Fields] OR “aborigin*“[All Fields] OR “Aboriginal Population”[All Fields] OR “Aboriginal Australians”[All Fields] OR “first nation”[All Fields] OR “First Nation Peoples”[All Fields] OR “tribal people”[All Fields] OR (“maoris”[All Fields] OR “oceanic ancestry group”[MeSH Terms] OR (“oceanic”[All Fields] AND “ancestry”[All Fields] AND “group”[All Fields)) OR “oceanic ancestry group”[All Fields] OR “maori”[All Fields] OR “Alaska Natives”[All Fields] OR “Alaska Indigenous Peoples”[All Fields] OR “Indigenous Alaskans”[All Fields] OR “Indigenous People of Alaska”[All Fields] OR “Native Alaskans”[All Fields]	82 144
#2 Time: 18:13:21	“pain”[MeSH Terms] OR “pain”[All Fields] OR “Pain Management”[All Fields] OR “Pain Measurement”[All Fields] OR “Pain Managements”[All Fields] OR “Pain Assessment”[All Fields] OR “Pain Treatment”[All Fields]	978 989
#3 Time: 18:14:17	#1 AND #2 (“Indigenous Peoples”[All Fields] OR “Alaskan Natives”[All Fields] OR (“inuits”[MeSH Terms] OR “inuits”[All Fields] OR “inuit”[All Fields] OR “indians south american”[All Fields] OR “indians north american”[All Fields] OR “Alaskan Natives”[All Fields] OR “American Natives”[All Fields] OR “Indigenous Canadians”[All Fields] OR “Alaskan Natives”[MeSH Terms] OR (“indigen*“[All Fields] OR “aborigin*“[All Fields] OR “Aboriginal Population”[All Fields] OR “Aboriginal Australians”[All Fields] OR “first nation”[All Fields] OR “First Nation Peoples”[All Fields] OR “tribal people”[All Fields] OR (“maoris”[All Fields] OR “oceanic ancestry group”[MeSH Terms] OR (“oceanic”[All Fields] AND “ancestry”[All Fields] AND “group”[All Fields] OR “oceanic ancestry group”[All Fields] OR “maori”[All Fields] OR “Alaska Natives”[All Fields] OR “Alaska Indigenous Peoples”[All Fields] OR “Indigenous Alaskans”[All Fields] OR “Indigenous People of Alaska”[All Fields] OR “Native Alaskans”[All Fields] AND (“pain”[MeSH Terms] OR “pain”[All Fields] OR “Pain Management”[All Fields] OR “Pain Measurement”[All Fields] OR “Pain Managements”[All Fields] OR “Pain Assessment”[All Fields] OR “Pain Treatment”[All Fields]	1053

A comprehensive search strategy for all databases and sites is available in online supplemental file 1. The search strategy, including all identified keywords and index terms, will be tailored for each included database and/or information source. The list of references of all included evidence sources will be screened for additional studies. Grey literature sources will be included.

The databases that will be searched include MEDLINE (via National Library of Medicine), EMBASE (via Elsevier), LILACS, CINAHL (via EBSCO), Web of Science - Main Collection (via Clarivate Analytics), PsycINFO (via APA) and Scopus (via Elsevier). The Boolean operators ‘AND’ and ‘OR’ will be combined with controlled and uncontrolled search terms. No filters will be used initially. These databases are selected as they provide a wide range of studies within the scope of the study. The authors of the studies will be contacted for further information if needed.

Grey literature sources that will be searched include consensus, public policies and official document recommendations, Google, and Google Scholar, GreyGuide, ProQuest Dissertations and Theses, Theses Canada Portal (Library and Archives Canada), TROVE (National Library of Australia), Aboriginal and Torres Strait Islander Health Bibliography, Cybertesis, and other national and international websites of governmental and non-governmental institutions.

The keywords “pain”, “management pain”, “indigenous”, “indigenous people” will be used in the grey literature search. Other words will be used (eg, “aboriginal”, “Inuits”, “alaska natives”, “Metis”, “Saami”, “Maori” and “Ainu”, “indigenous peoples of the north”, “arctic indigenous”, “indigenous nationalities”, “scheduled tribes”, “hill tribes”, “tribal peoples”, “hunters and collectors”, “shepherds”), if necessary. For Google and Google Scholar search we will use an advanced search strategy, the first 100 results of each included search term will be explored.³⁰

Selection of studies/sources of evidence

After a systematic search of the databases, all identified records will be uploaded, grouped and managed in Rayyan (Qatar Computing Research Institute, Doha, Qatar). The titles and abstracts will be assessed by two independent reviewers according to the inclusion criteria for the review. In case of disagreements not resolved by consensus, a third reviewer will participate in the decision-making.

We will pilot our selection process. The pilot test will be conducted in accordance with the structure proposed by JBI,²⁸ especially the selection of a random sample of 25 titles/abstracts. Two reviewers independently will screen the sample using the eligibility criteria and definitions/preparation document. The research team will subsequently discuss the discrepancies and modify the eligibility criteria and definitions/preparation document. The team starts screening only after reaching an agreement of 75% (or more).

Potentially relevant sources will be retrieved in full. The full text of selected articles will be assessed in detail with respect to the inclusion criteria by two or more independent reviewers. Reasons for excluding full-text evidence sources that do not meet the inclusion criteria will be recorded and reported in the scoping review. Two reviewers will also screen the grey literature, using an analogous approach. Any disagreement between reviewers at each stage of the screening process will be resolved by discussion between them or with an additional reviewer. The results of the search and the study inclusion process will be reported in full in the final scoping review and presented in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews flow chart (online supplemental file 2).³⁰

Data extraction

The relevant data will be extracted using an extraction form. The draft extraction form is provided in box 1. Two reviewers will extract the data independently. The data extracted will include specific information to respond to each of the objectives of the scoping review.

Box 1. Data extraction form.

Scientific articles and/or Grey literature.

Citation details: (eg, author/s, date, title, journal, volume, issue, pages).

Source of information (MEDLINE/Embase/Scopus or Grey Literature—specify source organisation).

Type of study (scientific articles): (qualitative, quantitative, or mixed approach, systematic reviews, pilot study, literature review).

Country or/and continent: country or continent where the study was conducted.

Identification of indigenous and tribal peoples: for example: study participant province/territory of habitation or indigenous status of study population (Sami/or Métis/or Inuit/or Ainu).

Participants (details, eg, age/sex and number).

Pain: (beyond biomedical definitions, all types of pain will be considered).

Eligibility criteria

Details/results extracted from sources of evidence.

Pain management—approaches used:

For example: how is pain management conducted—individualised and patient-centred approach; multimodal or unimodal approach; multidisciplinary, interdisciplinary or disciplinary approach; based on a biopsychosocial or biopsychospiritual model of care).

Assessment/treatment:

For example: how is pain assessed and/or treated?—the instruments used (one-dimensional instruments or multidimensional instruments); how indigenous peoples express their pain; treatment modalities, pharmacological or non-pharmacological (traditional indigenous treatment; restorative therapies; behavioural health approaches; complementary and integrative health).

Professionals involved in the care of indigenous patients with pain:

For example: doctor, nurse, psychologist, physiotherapist, midwife, traditional healer; allopathic practitioners; herbalist; spiritual healer; elder.

Gaps and future direction or limitation or challenges:

What are the limitations or challenges for pain management in indigenous and tribal peoples? What are the gaps reported by the authors about pain management in indigenous and tribal peoples? What are the recommendations for future research?

All reviewers will independently screen three publications before starting the data extraction process by analysing the title, abstract and full text to test and refine the data extraction form, to increase consistency among reviewers and avoid data extraction bias.²⁸ The reviewers will discuss the results and continuously update the form, and the changes will be documented in the final scoping review report. Any disagreement between reviewers will be resolved by consensus between them or a third reviewer. The authors of the respective papers can be contacted to request for missing or additional data, when necessary.

Data analysis and presentation

The findings can be presented in several formats according to the complexity and extent of the data, such as graphs, tables or figures.²⁸ Tables will be used to summarise the characteristics of the articles, such as year of publication, country of origin, methods and objectives. A descriptive analysis will be used to describe the results in segments.²⁸ The results (narrative summary) will be divided according to the type of evidence, for example, a narrative summary will highlight different approaches used in pain management (assessment and/or treatment) in indigenous and tribal peoples. Pharmacological and non-pharmacological therapies, instruments used to measure pain, professionals involved in pain management, the gaps that exist in the literature and the implications for further research for pain management. The narrative summary will be discussed and reviewed by all authors.

Ethics and dissemination

This review does not require ethical approval, as data from the literature available in databases will be collected and analysed. The data will be presented through a narrative summary of the assessment and treatment of pain in indigenous peoples. Results will be submitted to an open-access journal for publication. Furthermore, the data will be disseminated through presentations at scientific and non-scientific events, for example, at conferences/workshops in the indigenous and non-indigenous communities. Results will be disseminated to relevant audiences and the scientific community, including indigenous and tribal peoples, indigenous and non-indigenous health professionals, and researchers.

Ethics statements

Patient consent for publication

Not applicable.