Beyond Symptom Reduction: A Qualitative Study of Refugees' Experiences of a Trauma‐Informed Community‐Based Pain Management Program

ABSTRACT

Background

Chronic pain is common among refugees, who have often experienced significant trauma and have needs distinct from those of the non‐refugee population. Pain programs do exist but little is known about how and in what ways they meet, or do not meet, refugees' needs. To that end, we sought to understand refugee experiences of a pain management program specifically designed for and with refugees, within a trauma‐informed, biopsychosocial framework.

Methods

Collaborating with a torture and trauma rehabilitative service, six focus groups and one interview were conducted with 31 refugees in a semi‐structured format. These were audio‐recorded, transcribed verbatim and analysed using reflexive thematic analysis.

Results

Five themes were generated capturing refugees' perspectives on the program, its content and format: (1) We learned to rethink pain as complex and not just physical; (2) Exercise does wonders for our pain and more; (3) We valued connecting with (our) people; (4) We found great value and meaning in the program and want it to continue; and (5) Our engagement with the program is impacted by broader life challenges. Social connection and reduced isolation were linked to the program's group format and culturally tailored activity design. Participants' emphasised understanding of the multidimensional nature of pain prompted new coping strategies they employed beyond the program, and they expressed a desire for the program to continue.

Conclusion

Our findings demonstrate the value of culturally responsive, group‐based approaches to pain management that include exercise, social and education components, but also highlight the complex challenges that refugees face beyond their pain experience.

Significance Statement

This study offers novel insights into how refugees experienced a pain management program. By demonstrating how elements such as exercise, social connection, cultural responsiveness and trauma‐informed approaches fostered engagement and reshaped participants' understanding and management of pain, it meaningfully informs a neglected area of pain research. The findings identify practical and methodological considerations for designing and delivering tailored group‐based pain programs for refugees, offering evidence to inform more equitable, responsive and culturally safe pain care.

1. Introduction

The number of refugees worldwide reached 43.7 million in 2024, doubling in a decade (UNHCR ^2024a). Refugees are driven from their countries by persecution, conflict, violence, and human rights violations. They comprise a highly heterogeneous population with diverse cultural backgrounds, languages and migration trajectories. Low and middle‐income countries host the majority of refugees; 29% end up in high‐income countries (UNHCR ^2024a). For example, Australia hosted approximately 35,000 refugees and Uganda 1.9 million as of mid‐2025, according to UNHCR (2025) estimates. High‐income host countries are in a position to adapt health services to more effectively address the unique health and welfare needs of refugees through culturally responsive and accessible care.

Chronic pain is common among refugees, with prevalence reaching 85% among refugee survivors of torture (Kaur et al. 2020; Musisi et al. ²⁰⁰⁰; Olsen et al. ²⁰⁰⁶; Şahin ¹⁹⁹⁸; Teodorescu et al. ²⁰¹⁵; Williams et al. ²⁰¹⁰). The biopsychosocial model of pain considers that contextual, psychological and social factors often contribute to a pain experience. Contemporary ideas also emphasise the protective value of pain (Moseley et al. 2025). That the onset of pain can occur during highly traumatic experiences points to the added relevance of pain's multifactorial nature to the refugee context. Additionally, systemic barriers to care, particularly culturally appropriate care, are common (Altun et al. 2023; Mangrio and Sjögren Forss ²⁰¹⁷; Yaru and Wau ²⁰²⁵). This gap in effective treatment reflects broader global inequities in the provision of pain care services, leading to significant disparities in pain‐related outcomes and overall well‐being for refugee populations (IASP ^2025a). Recognition of these inequalities reinforces the importance of the International Association for the Study of Pain's 2025 Global Year priorities (IASP ^2025b), which call for urgent action to improve pain care in low‐resource and marginalised settings, including among displaced and refugee communities.

Refugees are frequently underrepresented in the evidence base for chronic pain interventions (Altun et al. 2022). While generic guidance exists for delivering healthcare to underserved populations, there is currently no specific guidance on addressing refugees' pain care needs (Australian Commission on Safety and Quality in Healthcare ²⁰²¹; US Department of Health and Human Services ²⁰¹³; World Health Organisation ²⁰²²). Pain management approaches and programs designed for the general population are unlikely to account for the complex, multidimensional factors that influence refugees' pain and its impact (American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine ²⁰¹⁰; Corp et al. ²⁰²¹; Pillastrini et al. ²⁰¹²). Moreover, refugees' access to existing programs is often hindered by factors including inadequate accommodation for language needs and lack of culturally responsive and trauma‐informed care (Altun et al. 2023; Mangrio and Sjögren Forss ²⁰¹⁷; Yaru and Wau ²⁰²⁵). Tailored, evidence‐based recommendations are needed to ensure accessible, culturally appropriate and effective pain management for refugees (IASP ^2025c).

A deeper understanding of refugees' lived experience of pain programs is critical to identifying unmet needs and improving care (Altun et al. 2023; Brady et al. ²⁰¹⁷). This study explored the experiences of refugees participating in a trauma‐informed, biopsychosocial pain management program, examining what they valued most, how it impacted their understanding and management of pain, and how well it met their needs.

2. Methods

2.1. Design and Ethics

This study was of a qualitative design, utilising focus groups to explore the views, perceptions and experiences of refugees with chronic pain regarding a community‐based group pain management program. The protocol for the study was registered on Open Science Framework before data collection began (https://osf.io/kry5f). There were no deviations from protocol. Ethics approval was obtained from the University of South Australia Human Research Ethics Committee (Application ID: 206232).

2.2. The Multicultural Wellbeing Program

The Survivors of Torture and Trauma Assistance and Rehabilitative Service (STTARS) is a non‐government, not‐for‐profit organisation providing culturally sensitive and trauma‐informed services to torture and trauma survivors in South Australia since 1991 (see https://www.sttars.org.au/). One of their flagship programs is the Multicultural Wellbeing Program (MWP), a holistic community‐based trauma‐informed chronic pain management group program for refugees, funded by the Adelaide Primary Health Network (PHN). Focusing on pain science education (Moseley and Butler 2015) with learning objectives guided by non‐refugee consumer research (Leake et al. 2022), the program also incorporates movement and mindfulness (Supplementary File S1). This program was rolled out to address a recognised gap in chronic pain care, as hospitals and primary care services had often struggled to engage refugee participants in group‐based pain management interventions.

The MWP was trauma‐informed, i.e., the overarching principles of trauma‐informed care guided its design and delivery. This trauma‐informed approach recognised the pervasive effects of trauma and prioritised emotional, physical and cultural safety through practices emphasising predictability, choice, collaboration and strengths‐based, non‐pathologising language, while avoiding activities that could inadvertently retraumatise participants (Butler et al. 2011; Elliott et al. ²⁰⁰⁵). STTARS operationalised these principles through community consultation and co‐design, delivery in familiar community settings, advance review of activities with bicultural workers to ensure cultural sensitivity, and continuous interpreter support. Group norms were collaboratively established, potential triggers were acknowledged and participants were supported with emotional regulation strategies and opportunities to opt out of activities when needed. For example, hydrotherapy was offered with sensitivity to migration‐related trauma, including experiences of sea travel. While some participants accessed trauma‐focused psychological therapies through STTARS or external services (which involve structured interventions that directly address traumatic memories and related symptoms), the MWP itself did not involve trauma processing, but functioned as a trauma‐informed, culturally adapted pain education and self‐management intervention designed to maximise safety and engagement.

The MWP is currently delivered over 10 weeks, with weekly sessions lasting between 2 and 3 h. This duration creates space for activities such as games, food sharing, music and celebrations, which aim to foster social connection, strengthen trust and enhance engagement with the program content. Importantly, the program is not delivered in a highly clinical format but instead adopts a trauma‐informed and culturally responsive approach that emphasises collective healing. Recognising that many refugees have experienced collective trauma—where entire families and communities are deeply affected—the program purposefully integrates opportunities for communal activities, reflecting the belief that healing occurs when people connect, share and support one another. This approach prioritises creating a safe space for participants, both physically and emotionally, which is a key consideration for STTARS working with survivors of torture and trauma. The MWP is held in familiar locations, involves community leaders and incorporates culturally relevant food, music, dance and games.

Each iteration of the MWP is co‐developed with specific refugee cultural groups through consultation with community leaders and members, alongside individual pre‐program assessments to understand each participant's pain experience, incorporating their preferences, values, and activity recommendations into the program structure and delivery. The programs are led by STTARS staff with qualifications in health and social sciences, all of whom have specific training in pain education. Crucially, the content is tailored to the cultural and religious backgrounds and literacy and numeracy levels of participants and utilises interpreters also familiar with modern pain concepts. Strategies such as storytelling, metaphors, and culturally relevant examples are used to make the material relatable and accessible (See Supplementary File S2).

All participants of the MWP had access to the full range of services offered by STTARS, which included individual and family counselling, therapeutic groups, caseworkers to address practical needs, a refugee mental health clinic and many more (see https://sttars.org.au). For example, throughout the sessions and during pre‐ and post‐group assessments, any participants who described symptoms consistent with post‐traumatic stress or other trauma‐related difficulties were offered referrals to individual counselling or trauma‐focused psychological support within STTARS. Where other unmet needs were identified, participants were referred to other STTARS or external services as required, such as general practitioners and other medical services, advocacy programs, financial counselling, non‐trauma‐specific mental health services and domestic violence support. Thus, the MWP was embedded within a broader package of care by STTARS in which participants could receive trauma‐focused treatment and holistic psychosocial support alongside the pain program.

2.3. Participants and Recruitment

Refugees in Adelaide, Australia, with a lived experience of chronic pain who had been involved in the group pain management program, the STTARS MWP, within the preceding 12 months were involved in this study. All refugees who had completed the MWP between December 2023 and December 2024 were invited to participate. The (recent) 12‐month timeframe was selected to ensure that participants would be likely to be able to recall key details of the program. During this period, six culturally specific groups completed the program and were included. Some were single‐gender; others were mixed‐gender—STTARS tailors the group composition to reflect the cultural preferences of the participating group. The groups from which participants were recruited were: Karen women (an ethnic group originating from southeastern Myanmar, also known as Burma); Afghan men; Afghan women; Uyghur elders (an ethnic group from East Turkistan, found in the northwestern part of China); Ukrainian men and women; Latin American women (Spanish‐speaking women from different parts of South America such as Honduras, Venezuela and Colombia). All participants had to be 18 years or older and able to provide informed consent, and communication with participants was done with the assistance of an interpreter. Throughout the research process, careful consideration was given to balancing trauma‐informed practices that support participant safety, empowerment and agency with the need to avoid unduly shaping or sanitising participants' accounts.

The study aimed to recruit 50% of refugee participants involved in each (culture‐specific) group program for the focus group discussion, as a pragmatic benchmark to support a breadth of perspectives within each group discussion and minimise the risk of a non‐representative picture of participant perspectives. Recruitment was carried out with the assistance of STTARS staff, who phoned to inform program participants of the study. Interpreters were used when required. For programs still ongoing, author RPA visited a group session to explain the research with the help of an interpreter. Interested participants provided their contact details and were later contacted to arrange a convenient time and accessible location for the focus group discussion. Participants were given the option of undertaking individual interviews; this intent was omitted from our OSF‐lodged protocol in error. In the few days leading up to the focus group/interview, interpreters/bilingual staff contacted interested participants by phone to remind them of the date and time.

2.4. Procedure and Data Collection

All focus groups and potential interviews were facilitated by author RPA with an interpreter and held at a location close to where the participants lived to reduce barriers to access and transportation costs. A second research team member or STTARS staff (BC, KP) was present during the focus groups for assistance and safety reasons, for example, as a familiar face and/or to assist in the case of a participant showing signs of distress during the group discussion, with a predefined distress protocol in place to guide our response if required (Supplementary File S3). All research team members engaging with participants (RPA, KP, BC) received formal training in mental health first aid and trauma‐informed care for refugees, and those principles (outlined above) shaped their interactions with participants and the conduct of the focus groups.

Focus group participants were offered refreshments upon arrival, and introductions were made. The purpose and details of the study were explained, as well as the planned format of the focus group. Participants were given the opportunity to ask questions. Written informed consent was then obtained with the assistance of the interpreter, and the demographic details and pain characteristics of each participant were collected. The demographic data collected (Supplementary File S4) were consistent with current recommendations, generated by a multi‐stage global consensus process (Karran, Cashin, Barker, et al. ^2025a; Karran, Cashin, Chiarotto, et al. ^2025c) (see www.ISSHOOs.org). The focus groups were scheduled to run for 90–120 min.

The focus group discussions (and individual interview) followed a semi‐structured discussion guide collaboratively developed by the research team with STTARS staff to ensure it was user‐friendly, trauma‐informed and culturally appropriate, and included prompts designed to elicit both positive and critical reflections (Supplementary File S5). The session started with an icebreaker that was intended to build rapport and foster psychological safety (i.e., ‘state what brings you joy’), then explored participant experiences with the pain management program, components they found acceptable and/or enjoyed, their current pain education concepts, barriers to participation or access and recommendations for improvement. The groups were conducted in English and interpreted into the participants' language in real‐time by interpreters, with the moderator probing further to clarify concepts and participants' opinions when necessary, for example, asking participants to expand on statements like “the program made me feel better”. All interpreters except one were certified by the Australian national standards board for certifying interpreters (NAATI), and they had all established trusting relationships with the participants, having previously worked with the refugee groups to translate during the delivery of the MWP program.

The focus groups and interview were held from October to November 2024. They were conducted in‐person, audio‐recorded and transcribed verbatim with the help of the online AI‐powered transcription tool, Descript (Descript Inc., California, USA). Only the interpreted aspects of the data (in English) were transcribed; there was no back‐translation of participants' original words. Author RPA reviewed the transcripts for accuracy and coherence.

2.5. Data Analysis

The analysis was underpinned by a critical realist paradigm, derived from realist ontology (Haigh et al. 2019; Levers ²⁰¹³), which recognises an external reality independent of human perception. However, this reality can only be accessed and interpreted indirectly, meaning that any understanding is inherently partial, situated and open to revision. This approach was grounded in a contextualist epistemology, which views knowledge as context‐dependent and shaped by the researcher's perspective (Braun and Clarke ^{2021a, 2021b}). Together, these ontological and epistemological positions allow us to acknowledge participants' subjective experiences of the program while recognising that these experiences are influenced by real‐world structures, contexts, and mechanisms.

The qualitative data were analysed using Braun and Clarke's (2021b) reflexive thematic analysis (RTA), a method used to identify, analyse and interpret patterns of meaning, or ‘themes,’ within qualitative data while embracing and acknowledging the researcher's experiences and viewpoints as integral to knowledge generation (Braun and Clarke ^2021b; Clarke and Braun ²⁰¹⁷). This method was chosen because it is an appropriate and flexible analytical tool for exploring participants' experiences without a priori framework.

Author RPA gained familiarity with the data by conducting the focus groups and interview, listening to the audio recordings, transcribing the data and repeatedly reading the transcripts. NVivo Version 14 (2024) was used for data management. Thematic analysis was carried out using a primarily inductive approach, allowing codes and themes to be generated directly from the data, and following Braun and Clarke's six steps (Braun and Clarke ^2021b). Initial coding was conducted in NVivo through an iterative process, whereby codes were developed, revisited, and refined (Steps 1 and 2—familiarisation and coding). Initial codes were clustered into provisional themes, which were continuously reviewed and refined through iterative team analysis meetings with the research team (EK, GLM, KM, RPA) to collaboratively gain a more in‐depth analysis and incorporate a diversity of viewpoints (Steps 3 and 4—generating and reviewing themes). Once considered satisfactory, the themes were defined and then presented with exemplar data extracts (quotes) in the report (Steps 5 and 6—defining themes and report‐writing). Throughout the data analysis process, tracks and notes of refinements on codes, themes and sub‐themes generation were maintained. The analysis considered both explicit (semantic) and underlying (latent) meanings. Findings are reported according to the Standards for Reporting Qualitative Research (SRQR) guideline (O'Brien et al. ²⁰¹⁴) and Braun and Clarke's good quality checklist for reflexive thematic analysis (Braun and Clarke ^2021a; O'Brien et al. ²⁰¹⁴).

The research team brings together individuals from diverse professional backgrounds, including physiotherapy (BC, ELK, GLM, KM, KP), medicine (RPA), social work and yoga (AA), training in social science (KM) and psychology (ELK). ELK, GLM, and KM have published extensively in the areas of chronic pain, pain science education, equity, and patient engagement in pain research. While none of the researchers have lived experience as refugees—a limitation that may result in the omission of relevant perspectives—the team includes members with significant professional experience working with refugees and other marginalised populations. Two researchers involved in data analysis (ELK, KM) have conducted research with refugees and minoritised groups; two authors (ELK, GLM) have extensive clinical experience with refugees, asylum seekers, and trauma survivors; authors RPA and KP have worked with refugees accessing pain services through an internship at STTARS. Authors AA and BC are currently employed at STTARS, with AA having over a decade of experience working closely with refugee communities and BC with 2 years of experience facilitating the STTARS MWP for refugee groups. Four members of the team (AA, KM, KP, RPA) identify as culturally and linguistically diverse. During data analysis, researchers made the effort to be culturally responsive, acknowledge their assumptions, and consider how their viewpoints might have influenced their interpretation of the data.

Demographic data were analysed in Microsoft Excel (Microsoft, Washington, USA) using descriptive statistics and are presented in Table 1.

TABLE 1.

Participant characteristics (n = 31).

Characteristic	N (%)
Age a (Median—years) 65
Sex a , *
Female	23 (74)
Male	8 (26)
Gender a , *
Men	8 (26)
Non‐binary	0 (0)
Women	23 (74)
Country of origin
Afghanistan	13 (42)
Burma	4 (13)
Colombia	1 (3)
East Turkistan	6 (19)
Honduras	1 (3)
Ukraine	5 (16)
Venezuela	1 (3)
Religion
Christian	12 (39)
Muslim	18 (58)
Unspecified	1 (3)
Languages spoken
Dari	12 (39)
Karen	4 (13)
Pashto	1 (3)
Spanish	3 (10)
Ukrainian	5 (16)
Uyghur	6 (19)
Highest level of education a , *
No formal schooling	8 (26)
Primary school	5 (16)
Secondary/high school	9 (29)
Some higher education (college/university)	7 (23)
Post‐graduate degree	1 (3)
Vocational/trade school	1 (3)
Years lived in Australia (Mean (SD)) 10 (10)
Interim Country (Did you spend some time in an interim country aside from your home country before settling in Australia?)
Yes	20 (65)
No	11 (35)
Years lived in interim country (Mean (SD)) 20 (18)
Interim countries
Indonesia	2 (10)
Iran	4 (20)
Kazakhstan	1 (5)
Mexico	1 (5)
Pakistan	6 (30)
Poland	1 (5)
Thailand	4 (20)
Work situation a , *
At home parent	3 (10)
Retired	14 (45)
Seeking work	2 (6)
Student	4 (13)
Unable to work due to disability	1 (3)
Unemployed	13 (42)
Financial situation (How easily are you able to meet your basic living expenses? (e.g., food, housing, healthcare)) a , *
Cannot meet	2 (6)
Can meet sometimes but not always	11 (35)
Can just meet	12 (38)
Can meet easily	6 (19)
Pain status
Currently experiencing chronic pain	29 (94)
No chronic pain	2 (6)
Years lived with chronic pain (Mean (SD)) 10 (7)
Body part with pain
Arms	4 (14)
Back	18 (60)
Head	8 (28)
Lower limbs (knees, legs)	18 (60)
Neck	6 (21)
Shoulder	10 (34)
Trunk	2 (7)

^a denotes demographic items from ISSHOOs Set A (Karran et al. 2025).

^* denotes demographic items with other response options not presented here. Refer to Supplementary file S4 for more information.

3. Results

3.1. Participant and Study Characteristics

Six focus groups, including thirty participants, were conducted. One participant preferred an individual interview. Focus groups lasted for an average of 53 min, and the individual interview lasted for 35 min. The number of participants involved in each focus group ranged from three to eight. Participants' ages ranged from 27 to 85 (median 65 years), and they were all cisgender, with 74% being female. Fifty‐eight percent of participants had at least a secondary school level of formal education, and the length of time spent in Australia ranged from 1 to 44 years, with a median of 5 years. Approximately two‐thirds of the sample had spent a median of 12 years in an interim country before arriving in Australia. Almost all participants (94%) had chronic pain, with the prevailing chronic pain conditions being back and lower limb pain (60% each). The 6% of refugee participants without chronic pain had been involved in the MWP as carers or close family members of refugees with chronic pain program to support the primary participant's engagement and continuity of care, and to help integrate pain management strategies into the home environment. Further participants' demographic characteristics are depicted in Table 1.

The goal of recruiting 50% of refugee participants involved in each (culture‐specific) group program for the focus group discussion was only achieved in the Afghan women's cultural group, due to some participants not answering the researchers' calls or declining the invitation to participate. Across all six groups, the mean recruitment rate was 41%, indicating that while the target was not fully met, a substantial proportion of participants still contributed to the data.

3.2. Thematic Analysis

Five themes relating to the experiences of refugees engaged in pain management programs were generated. While themes are presented separately for analytic clarity, they are understood as relational and overlapping, reflecting the complexity of participants' experiences. The themes were: (1) We learned to rethink pain as complex and not just physical, (2) Exercise does wonders for our pain and more, (3) We valued connecting with (our) people, (4) We found great value and meaning in the program and want it to continue, and (5) Our engagement with the program is impacted by broader life challenges.

Of note, some interpreters chose to translate participants' contributions as a group instead of individual participants' statements. As such, the quotes in the results section were attributed to the cultural group rather than the specific participants. To preserve the anonymity of the individual interview participant, their cultural background was not identified.

3.3. We Learned to Rethink Pain as Complex and Not Just Physical

Throughout the program, participants gained a deeper understanding that pain is not just a sensory signal but is influenced by a wide range of factors. They learned that the brain shapes their pain. This learning enabled a broader perspective of pain management and empowered them to take a more active self‐management approach and explore holistic approaches.

More specifically, many participants recognised the significant impact of emotional, psychological and environmental factors on their pain experience. They became more aware of how their mental state and social surroundings could increase and decrease their pain. This emphasised awareness allowed them to identify specific triggers and patterns in their pain experience, also helping them make more informed decisions about their wider health and well‐being.

What she said is that sometimes she knows the pain is physical, but when sadness or not feeling well – depression – comes, she has noticed that the pain is worse all over her body. But at the same time, she remembers what she learned, like going for little walks or just drink some water or do some breathing exercises. That's helped her a lot as well to manage her pain. (Latin American women)

We are happy to come here. When we see you guys [program facilitators], when we see each other, we are having a good time, maybe we feel less pain. When we go home, we are left alone at home thinking about lots of things. And then we think that, okay, we learned this or this today, so we feel a little bit better, or we try to feel better. (Afghan women)

The role of life stressors in exacerbating pain was also a key concern for many refugees. Settling into a new country was filled with complicated housing‐related challenges, financial difficulties, family responsibilities and uncertainties about the future, which were recognised to contribute to heightened pain levels. Some participants shared that during particularly stressful times, even minor pain became overwhelming. These insights reinforced the idea that pain management requires addressing both physical and emotional challenges.

I can give you another example of this kind of pain. Three months ago, there was a storm and the fence was a very old fence, wooden fence, was destroyed by the storm. And I told my landlord that, look, I have two girls at home and my wife. I don't say that I have any gold or jewellery or valuable items, but still, they get scared when there is no fence around. Can you come and fix it? He said, no, there would not be any break‐in… And just three nights ago, there was a break‐in. They took two bicycles, the bicycle helmets, and a box full of cricket equipment, which I got from his [another participant's] friend. It was at my house. And then I called the landlord and said, look what has happened… And since then, I have a very, very severe headache. For two nights, I had this headache, and I couldn't sleep. (Afghan men)

Recognising the multifaceted nature of pain also led participants to adopt more holistic approaches to their condition. Many became more mindful of their mental well‐being, recognising the value in relaxation techniques, engaging in enjoyable activities, maintaining social connections to reduce stress and isolation and improving their sleep. They also embraced non‐pharmacological strategies such as walking and continued the exercises they had learned during the program.

She noticed before, when she say, had a very bad headache, she'll usually take a lot of medication, but from the group, they learned that if you have headache, you need to take more water and hydrate more. So, she's been doing that more and she notices that she's not relying on medication. (Karen women)

When the pain comes, I try to actually engage myself. I try to distract myself. I may go out, I may go to visit a friend, sit, talk, chit chat, not focus on the pain. That's my strategy. (Afghan women)

She learned through the sessions something about talking to herself. So she said that sometimes when she's not feeling well, she'll just look at the mirror and talk to herself. That's been a way to actually relieve, um, a few things, and get out of things, you know, and just feel better. (Latin American women)

These conceptual shifts were not universal, however. Some participants reported that the chronic nature of their pain made improvement impossible, conceiving that nothing could truly relieve their discomfort, while others placed their hope for pain relief in divine intervention. Participants did not explicitly describe the reasons for holding onto these perspectives. Nevertheless, it seems there is an entanglement between participants' understandings of pain, their lived experience of persistent pain and their cultural or religious frameworks, with some viewing their pain as being in God's control or as immutable based on its chronicity to date.

We think that our pains are very, very old pains. I think the remedy or treatment is just in God hands about those very old things. (Afghan women)

These programs are good, attending these sessions are good, it's helping, but our pains are chronic pains you know, they are not disappearing or even getting less because of this kind of sessions. (Afghan men)

3.4. Exercise Does Wonders for Our Pain and More

This theme highlights the significance refugees placed on exercise as a crucial part of the pain management program. Participants emphasised the profound impact of exercise, not only in alleviating pain but also in enhancing their overall well‐being. The benefits extended beyond physical gains—exercise also provided emotional uplift, mental clarity, a sense of accomplishment and an opportunity to connect with others.

Several participants reported that engaging in physical exercise contributed to noticeable improvements in their pain. They described feeling a sense of relief and lightness after exercising, which made movement easier and reduced overall discomfort. They also acknowledged that the exercises boosted their mood and made them feel good, giving them a greater sense of control over their situation and reducing their reliance on medication.

The best part that we loved, all of us loved most is the exercise, the exercise time. Because after that exercise we feel lighter and our body is so light and we feel a lot lighter and we can feel a lot comfortable, very relaxing. (Uyghur group)

Participants expressed appreciation that the exercises introduced during the sessions were simple, easy to follow, and suitable for their age and physical abilities. They considered the exercises to be thoughtfully designed, allowing them to participate without feeling overwhelmed or physically strained.

There was a couple of movements that were new to us, and, because usually for them, they say, they will only learn from YouTube, but coming here and having someone to train you, to show you visually, and going home and doing the [exercise]. And the little book when we do the exercise that they get to take home. They're provided with the image of the exercise. (Karen women)

Many participants came to understand that regular physical activity was key to managing their pain effectively. However, the relief they experienced was often short‐term, indicating that consistency was crucial in maintaining benefits. Many participants continued exercising at home, incorporating the routines into their daily lives. Some participants mentioned setting aside specific times each day while others integrated the exercises into their daily activities.

Participants highlighted that the benefits of the exercises extended beyond just pain relief. Many described how engaging in physical activity helped them relax, reducing stress and tension in their bodies. This may be particularly beneficial for refugees, many of whom have been exposed to traumatic events that might have negatively impacted their mental health.

One form of exercise that was positively highlighted in discussions was hydrotherapy—the exercise sessions conducted in water. Many participants described hydrotherapy as one of the most effective therapeutic activities that eased their pain. Although participants could not pinpoint exactly why or how hydrotherapy alleviated their pain, they frequently reported finding it to be of great benefit.

She had pretty bad back pain on the last hydrotherapy session, last Saturday. She thought, oh, should I come or should I not come? She decided to come. And once she jumped into the water, she forgot about her pain, and the pain went away, she came back really good and happy with no pain. (Uyghur group)

The novelty of hydrotherapy may have been a contributing factor to its popularity; most participants had not experienced gentle exercising in water before, and the sensation of moving in a warm, supportive environment was said to be new and enjoyable. The unfamiliar yet pleasant experience appeared to heighten their engagement and enthusiasm, making the sessions feel unique from other types of exercise they had tried.

So she said that she was very happy with the hydrotherapy. And then when she was coming back home, she was still able to bring that joyness and happiness. And she just said that she was the happiest woman in the world after every session of hydro. She was singing all night and was able to eat because that's something she's been struggling with. Sometimes eating wasn't a great choice for her, but after the hydro, she was just eating, dancing, cleaning. So I think the main benefit was that they could get that extra boost of energy. (Latin American women)

Many participants expressed a desire for the hydrotherapy sessions to continue. The appeal of hydrotherapy was so strong that one participant even suggested restructuring the entire program to focus solely on alternating between exercise and hydrotherapy sessions. Some groups began exploring ways to organise hydrotherapy sessions independently, outside the program, to continue benefiting from this form of exercise. From participants' accounts, they highly valued the hydrotherapy sessions, and for many, it was one of the most treasured aspects of the entire program.

3.5. We Valued Connecting With (Our) People

This theme illustrates the deep value participants placed on building meaningful relationships and social connections throughout the program. Many expressed that their involvement in the program fostered a sense of belonging and community; their motivation to attend regularly was driven by the opportunity to engage with others—both within and outside their community, for example, with STTARS staff and program facilitators.

Participants particularly valued the opportunity to connect with others from their own cultural background because it provided a deep sense of belonging and understanding. Being part of a group where they could speak their native language, share common traditions and relate to each other's experiences helped create a supportive and comforting environment. Many participants expressed that forming these connections was an essential part of their emotional well‐being, as it allowed them to share their struggles, offer encouragement, and feel a sense of unity with others who had gone through similar challenges to being a refugee.

Again, the best part that we like the most is, to be able to talk to our friends in our community in our language. Because of our English limited language, we are so limited to talk to someone. And we are so shy. But in general, our nationality is friendly. We're social people. We all love to socialise. We can't live alone. We wanted to have someone, or at least another friend, or at least someone, another same nationality group from same community. So, yeah, going there with them, it's mostly enjoyable part for us. (Uyghur group)

For some, especially those who had recently arrived in Australia, the chance to bond with others was invaluable. One participant shared how the group provided much‐needed social connection during a time when they felt isolated and alone after leaving their home country and arriving in Australia. Engaging with the group helped them navigate the challenges of resettlement, alleviated feelings of loneliness, and gave them a renewed sense of belonging. The support network they built within the group was a source of comfort and strength, reinforcing the importance of social connection in their overall well‐being.

That time, I was, like most of us newcomers, felt really lost and scared and we needed more chances to be together and especially with some people who try to help us to manage with our stress. I found it very useful and even in general, because people try to help, and I appreciate this. I can't say that all sessions influenced me in a positive way, but it was nice to communicate with people. (Ukrainian group)

These connections extended far beyond the sessions themselves, becoming a meaningful source of support in participants' everyday lives. Several participants shared that the relationships they formed during the program continued outside of the sessions, evolving into genuine friendships. One participant, for example, expressed how a bond they had developed with another group member helped them navigate challenges with housing: “He found the accommodation place for us to rent. He found a good place for my daughter. Now I'm relying on him to find another place for me to move, a bigger one” (Afghan men).

Many refugees described experiencing loneliness, sadness, and a heavy emotional burden when alone at home. For some, this isolation was a significant challenge, and the extended time spent alone intensified rumination, worry and emotional distress, contributing to feelings of unhappiness and disconnection. However, attending the program provided them with much‐needed social interaction, helping to ease these emotions. Participants shared that engaging with others during the sessions not only lifted their spirits but also gave them a sense of companionship and belonging.

For me, I'm encouraged to participate again because when I'm here I feel much better compared to when I'm at home, alone. I feel numb at home, I feel heavy in here [points to heart], but while I'm here with the group and my friends, I feel much better. (Afghan men)

Refugees particularly valued the care and understanding provided by program facilitators. They expressed that facilitators went out of their way to create an environment where their feelings were validated, and they felt seen, heard and understood. Their trauma was acknowledged, and their experiences were met with empathy and respect. Participants appreciated that facilitators took the time to listen to their concerns, validate their struggles and offer encouragement.

Nobody has asked us how we are feeling, why we are feeling sad, what we have gone through in our life from childhood… Which kind of difficulties we had in our life; the life journey which we have gone through. Nobody is asking us, but you [program facilitators] do. That makes us very happy. (Afghan women)

This sense of being genuinely cared for may be somewhat unique to this care setting, as most mainstream healthcare programs seem unprepared to support refugees in their specific needs. As the quote above suggests, most of the usual programs lack a trauma‐informed lens on their approach. That, coupled with providers who lack understanding of the refugee backgrounds, may make navigating mainstream services a big challenge for them. This may have made the safe and supportive space provided by the program a lot more precious to refugees, making them comfortable enough to share their emotions.

One participant, however, mentioned having some trouble with the group format of the program as she felt she needed more one‐on‐one support because of her personal circumstances. She did acknowledge that even though she needed more, the group program had a great number of benefits, and socialising with others boosted her mental health.

The program served as more than just an intervention—it became a meaningful social anchor that enriched their overall experience.

3.6. We Found the Great Value and Meaning in the Program and Want It to Continue

Participants had a deep appreciation for the program. Many expressed a clear desire for the program to continue long‐term, recognising its broad and diverse benefits and its ongoing importance to their overall well‐being.

Nearly all the refugee groups expressed their gratitude to the organisers and the Australian government for providing such a comprehensive and supportive initiative. This strong appreciation may be rooted in the unique challenges faced by the participants, who reported often experiencing limited access to healthcare and social services, so presented with this opportunity of participating in the pain program, they might have felt especially appreciative (sometimes to the point of overlooking shortcomings) because such opportunities are rare. Alternatively, participants might have feared that voicing criticism could jeopardise their access to future programs or support.

For many participants, the program represented a much‐needed opportunity to improve their well‐being, making it an essential resource in their lives.

We came just to try for one or two sessions, and we found it useful. We thought that it's useful for us, mentally and physically. People were coming, guest speakers and other activities were useful, so we kept coming. (Afghan women)

Some participants expressed that attending the program served as a welcome distraction from their daily realities, some of which were often unpleasant and overwhelming. Study participants, like many refugees, faced numerous challenges when resettling, including navigating unfamiliar systems, dealing with language barriers, experiencing trauma from past conflicts and adjusting to new cultural environments. These difficulties created a constant emotional and mental burden. In the program, participants could momentarily forget about these troubles and focus solely on learning new skills and engaging with others. This brief escape allowed them to experience a sense of normalcy, providing joy and a break from their struggles.

And attending this group was useful for me, was beneficial for me. At least for the time that we have been here, I could get rid or distract my head from the thoughts which is always here. And thanks to you, the organiser and the government of Australia as well. (Afghan men)

It was a good distraction for me going to that excursion. I was not thinking about my problem, my family who are not here. It was a good distraction. (Afghan men)

Some participants mentioned they kept coming to the sessions because they had few other activities keeping them engaged at home. Many of these individuals were retired or not employed, which seemed to lead to a lack of structure in their daily routines. Coupled with a possible lack of resources to engage in other activities, feelings of boredom and loneliness were frequently reported. For participants, attending the program provided a meaningful way to fill their days, engage in joyful activities and as noted in the third theme, connect with others.

I was not doing anything at home, but the time that I was spending. here was good for me, because it was making me happy. And a couple of hours after that, when I was going home, it had an actually emotional or mental effect on me about feeling or managing the pain. (Afghan men)

I kept coming. Because I had nothing else to do and I thought that joining this group attending, I can just kill time and would, it would make me somehow happy. That's why I kept coming. (Afghan men)

Each of the benefits outlined in previous themes contributed to participants' finding that being part of the program had a positive impact on their mental well‐being. Some mentioned feeling strengthened and more resilient, better able to cope with their personal challenges, that the sense of community and support they found in the program gave them renewed motivation to work on improving their lives.

Because if we don't come here, at home, it wouldn't be just sit and watch TV for us, cook maybe, and then do house chores as usual. And that's a bit more depression for us, seeing our relatives back in our home country, the children that we can't see, can't even have communication. So it kind of brings more pressure for us. So our mental health is ruining because of the things we think too much about; the depressions, about the genocide that happening to our home country and our relatives… So, coming here makes us a bit more happy. We can get benefit from this exercise by doing for our physical health as well as mental health. That's why we loved it. We enjoyed it and we wanted to continue. We wanted to have more sessions like this in the future as well. (Uyghur group)

In regards to every session, has been kind of like, to recharge their batteries so that they can keep going with their lives and go home and have a different mood from what it was when they arrived for the session. (Latin American women)

I did not realise what will help me. But this program show me the way – what will [help me] and I choose this way now. I follow this way and start to recover… Without this program, I had tried by myself, but I was trying that, trying that, trying that. But here, they show me the road. (Ukrainian group)

Overall, participants were adamant that they did not want the program to end, expressing that it felt too short. Some participants even expressed a willingness to contribute both personally and financially to ensure the continuation of the program. Participants wanted more: more opportunities to engage, learn and connect with others in the supportive environment the program provided.

3.7. Our Engagement With the Program Is Impacted by Broader Life Challenges

Participants described a range of significant challenges in their lives that shaped how they were able to engage with the program. While they acknowledged the program's benefits, many highlighted difficulties in their personal lives that extended outside the scope of what the program was designed to address. Many of these issues affected their ability to consistently engage with the program. Their reflections revealed an opportunity to bolster the program by focusing on support to navigate daily demands so as to maximise access to, and participation in, the program.

Limited access to transportation was one of the most frequent challenges reported. Many noted that their inability to drive significantly hindered their participation in the program, as they often relied on others for transport or public transport, which was often inadequate for their needs. These transport barriers affected not only attendance at the program but also participants' broader capacity to engage in social activities or pursue personal interests, contributing to feelings of isolation and frustration. Several participants felt that being picked up from their homes for the program would greatly facilitate participation and enhance its benefits.

There are other things which we like to do and we enjoy, but we cannot do that. For example, we like to go to little trips, but we don't know how to drive. There is nobody to take us. We don't have our drivers' license. Or we like to attend more exercise groups, but sometimes it's too far. We cannot make it there. (Afghan women)

Family responsibilities and competing appointments often limited participants' attendance. Many were primary caregivers for children or elderly family members, and these duties, along with medical appointments for themselves or family, sometimes conflicted with program sessions. Participants generally perceived these competing demands as unavoidable aspects of daily life and therefore did not propose specific solutions to mitigate their impact on attendance.

So I think the most difficult for them was when they, sometimes in the week, have appointments or they have to care for their family. Those are the biggest ones, and for them, themselves being sick was like the difficult obstacle to come to the classes. But apart from that, they would really want to come like every week. (Karen women)

Some participants described challenges relating to learning in general, which influenced their ability to retain the information they were taught. These difficulties were not limited to this program but were also encountered in other educational contexts, such as vocational education and English language classes. These could possibly be due to language barriers or cultural differences in learning styles, or even literacy limitations.

We talked about what we remember and what we learned about this group. But we consider that our brains are not very fresh. Our heart is not very fresh. So, we learn very, very slowly. We remember things just a little by little. (Afghan women)

Difficulties communicating in English were a recurrent source of frustration and isolation, and participants were particularly grateful that the program used interpreters to engage with them. Participants described how limited English proficiency affected their ability to socialise and build connections with people outside their communities. Simple tasks, such as asking for directions, making appointments, or engaging in casual conversations, became daunting and discouraging. Some participants wished they had more opportunities to practice English in supportive environments. The inability to communicate fluently also affected their confidence, making them hesitant to step outside their comfort zones and interact with new people.

We are very happy that we are here. But the sad thing is that when we go out of here and somebody says hi to us, we cannot reply back. That makes us very sad that we cannot learn even to say hi back to somebody. What can we do? (Afghan women)

Unfortunately, language barrier makes my communication limited. I feel unhappy when just today morning I met a very elderly couple who were first, who met me here, I appreciate our friendship, but they speak in a very Aussie way and uh, woman, I understand a bit, but man, you know, so that is why I don't say that this make me so happy. And sometimes people, Ukrainian people and me says, oh my God, how tired I am with this language. I want to go home to speak in normal way. So language is a serious barrier. (Ukrainian group)

Participants sought assistance with financial difficulties, navigating government services, securing stable housing, and even reconciling with estranged family members. Some did not know where to access support for their various challenges and needs and therefore turned to the program facilitators, with whom they had developed trusting relationships. From the Afghan men's group, one participant asked the program facilitators to assist them with bringing their family to Australia and another to assist them with financial issues. One of the interpreters (Afghan men) observed that facilitators frequently found themselves using scheduled session time to help participants navigate various challenges, such as sorting out fines and parking tickets and navigating the healthcare system. While this support was appreciated, it sometimes took away from the intended focus of the program. He recommended that facilitators of future programs consider allocating time to helping participants with their non‐program‐related challenges.

One participant (Ukrainian group) shared that despite completing the program, she continued to struggle with a range of personal challenges. She expressed a strong desire for ongoing, individualised support to help her navigate her trauma and personal difficulties, which included “the death of a child” and “terrible sleepless nights”. While the program had been beneficial to her and the larger group, she felt that a more personalised approach, such as one‐on‐one counselling with “professional advice or professional psychologist” or tailored assistance, would better address her specific needs and provide her with the support necessary to cope with her ongoing struggles.

4. Discussion

This exploration of refugees' experiences with a community‐based pain management program generated five themes. The first reflects a core principle of contemporary pain science, emphasising pain as a complex, interconnected experience rather than a purely physical one, and underscores the importance of the program's educational component. Learning this concept has been repeatedly identified as critical by recovered non‐refugee patients (Leake et al. 2022), linked to subsequent recovery in audits of clinical outcomes for non‐refugee patients (Moseley et al. 2025) and in mediation analyses of clinical trials (Cashin et al. 2023); this concept is therefore prioritised in community‐facing pain education (Moseley et al. 2025). In this study, this concept seems to be a platform to discover new coping strategies. Importantly, the way in which pain science education was delivered here appeared to be key to its impact. Education was tailored to participants' cultural and religious beliefs, literacy, and conveyed through metaphors and culturally meaningful stories. Notably, the STTARS MWP developers intentionally integrated pain science education with culturally responsive and safe social and physical activities, which aligns with non‐refugee pain education recommendations (Moseley et al. 2025) and with a training manual/guide for physiotherapists treating refugees in the Middle East and North Africa (Karrer et al. 2022, 2020), itself highly influenced by the research of our team.

The second theme highlighted the importance of the program's exercise component. Participants' reports that being active reduced their pain and its impact aligns with broad evidence on exercise being beneficial for chronic pain (Borisovskaya et al. 2020; Geneen et al. ²⁰¹⁷; Grooten et al. ²⁰²²; Hayden et al. ²⁰²¹). While some refugee studies support this (Knappe et al. 2025; Nilsson et al. ²⁰¹⁹), others do not (Hasha et al. 2020; Knappe et al. ²⁰²⁴; Nordbrandt et al. ²⁰²⁰). Notably, however, qualitative studies have reported positive effects and quantitative studies have not. This may reflect different dimensions of pain captured by qualitative and quantitative methods, or bias, or both. Regardless, it highlights the value of integrating both methods where complex, cross‐cultural, and multifactorial implementation processes are under examination (Richards et al. 2019).

Including refugees in the design of the MWP may have optimised the benefit from exercise. Knappe et al. (2025) reported similar benefit from a program that had involved refugees in development and iterative refinements over time. In our study, the program was also intentionally delivered in a trauma‐informed, non‐clinical way that centred collective healing and cultural strengths, which we suspect contributed to exercise benefits beyond pain reduction—improved sleep, mood and a sense of control over one's pain and body. Whether exercise was actually the key mediator of these benefits is unclear, but studies not specifically involving refugees suggest that it is possible (Ambrose and Golightly 2015; Geneen et al. ²⁰¹⁷; Grooten et al. ²⁰²²; Hayden et al. ²⁰²¹). Longitudinal and mixed‐method studies could explore further how participants' pain experience with movement‐based interventions evolves; selecting outcomes that are culturally meaningful and aligned with participants' priorities would seem important.

The third theme emphasised the value of connecting with people, particularly those of similar cultural backgrounds. This aligns with other refugee group program findings (Abo‐Rass et al. ²⁰²⁵; Block et al. ²⁰¹⁸; Im and Rosenberg ²⁰¹⁶; Knappe et al. ²⁰²⁵; Nilsson et al. ²⁰¹⁹) and is consistent with the United Nations Refugee Agency's (UNHCR ^2024b) emphasis on social connections for integration (UNHCR). Isolation and social disconnection, cultural differences, language barriers and the loss of familiar support systems are almost ubiquitous among refugees (Nguyen et al. 2024; Strang and Quinn ²⁰²¹), and strengthening social connections among refugees and local residents has been demonstrated to deliver a wide range of benefits (Bletscher and Spiers 2023; Greene ²⁰¹⁹; Murray et al. ²⁰²²; Song et al. ^{2024, 2025}; Stites and Humphrey ²⁰²⁰; UNHCR; Vera‐Espinoza et al. ²⁰²³; Ziersch et al. ²⁰²³). The current work suggests that the benefits of connection may also be rooted in processes of collective healing. Many refugees experience collective trauma as families and communities, which can leave widespread and enduring impacts (Hirschberger 2018; Silove ²⁰¹³). Creating safe opportunities for shared activities, such as dancing, games or celebrating cultural traditions, may foster healing in ways that individual‐focused approaches cannot.

The fourth theme revealed how highly valued the program was by participants. That interview and focus group participants, particularly of refugee or minoritised backgrounds, often offer predominantly positive reflections on programs with which they have engaged (Bergen and Labonté 2020; Nguyen ²⁰¹³), suggests some caution in interpreting this theme. Notwithstanding, that they reported that being seen and respected was at times more meaningful than improvements in pain itself reflects that truly supportive trauma‐informed care is important and may be lacking in mainstream health care (Asgary and Segar 2011; Hadgkiss and Renzaho ²⁰¹⁴; Im and Swan ²⁰²¹; Jolof et al. ²⁰²⁵). Fostering trust and empowerment are highly relevant to addressing the complex social and emotional needs of refugees and overcoming the systemic barriers that refugees often encounter when accessing mainstream healthcare (Coumans and Wark 2024; Mangrio and Sjögren Forss ²⁰¹⁷). Doing so requires deliberate attention to physical and emotional safety (as was prioritised in this program) to avoid disengagement. The benefit of trauma‐informed and culturally responsive engagement strategies such as community consultation and co‐design, consistent interpreter use, trusted community settings, and relationship‐based recruitment is unlikely to be confined to refugee populations. Future research could examine their relevance for other marginalised or under‐represented populations in pain research; we suspect these approaches may be valuable core components of inclusive pain research more broadly.

The final theme underlines the importance of viewing pain management in refugees within the context of intersecting social, structural and systemic barriers to health and wellbeing (Coumans and Wark 2024; Mangrio and Sjögren Forss ²⁰¹⁷; Peprah et al. ²⁰²³). Complementing refugee health interventions with social, psychological, and material supports is recommended (WHO European Region ²⁰¹⁸). Practical strategies might include formal cross‐sectoral partnerships with housing services, employment agencies, legal aid, counselling services and community‐based organisations, co‐locating services, developing shared referral pathways and prioritising inter‐agency collaboration.

4.1. Strengths, Limitations and Methodological Considerations

Including several cultural groups with varying resettlement durations enhanced the external validity of our results. We collaborated closely with program deliverers to carry out the study within a trauma‐informed and culturally responsive framework, applied rigorous qualitative methods and lodged the study protocol prior to commencement as recommended for transparency and reporting in all pain studies (Lee et al. 2018). We obtained demographic data using a robustly derived tool (Karran, Cashin, Chiarotto, et al. ^2025c). However, we urge caution when extending our results to refugee populations from other cultural groups, resettlement stages and locations—71% of refugees are resettled in low‐ and middle‐income countries (UNHCR ^2024a). Relying on interpreters may have influenced the depth, nuance and individual voices within our data, a common concern for interpreter practice and research accuracy (National Accreditation Authority for Translators and Interpreters (NAATI) ²⁰²³). Author BC was involved in delivering the MWP for four of the six groups and attended the corresponding focus groups. This may have influenced participant responses, although we could not detect such an influence. Finally, recruitment targets were unmet in some groups, and we did not include people who had disengaged from the program prior to completion, so important, potentially negative perspectives may be missing.

4.2. Implications for Research and Practice

Our findings support the prioritisation of trauma‐informed care, cultural safety and responsiveness, intentionally fostering social connection, and partnering with refugee communities to tailor content and delivery to their strengths, literacy, cultural background and lived experiences. That individuals' surrounding social conditions can limit program effectiveness and pain‐related outcomes (Karran, Cashin, Barker, et al. ^2025b; Karran et al. ²⁰²²) underscores the need for integrated, cross‐sectoral social and material support to complement clinical care. It seems unlikely that these considerations are only relevant to refugees, but are capable of strengthening the quality, relevance and equity of pain research more broadly.

The MWP separated groups by cultural background. Structuring group interventions as culturally homogeneous or heterogeneous has varying benefits and potential risks (Salvendy 1999; Shechtman et al. ²⁰⁰⁸). Homogeneous groups may foster shared understanding and safety; heterogeneous groups may promote broader connection and learning. Heterogeneous groups will require skilled facilitation to navigate power dynamics, differing cultural norms around pain and health, gender roles, and communication styles and preferences, and may require multiple interpreters. In heterogeneous settings, exploring how to convey core pain concepts through metaphors and experiences that are relevant across cultures—such as caring for children, stories of danger and safety, or simple exercises such as walking or stretching—would be beneficial. Facilitators of heterogeneous groups could emphasise cross‐cutting principles such as respect, choice, collaboration and acknowledgement of resettlement stressors.

5. Conclusion

Effective pain management for refugees extends beyond symptom reduction. A multidimensional trauma‐informed approach integrating pain science education, exercise, social connection and culturally responsive care brought substantial benefits and showed that significant challenges remain. Our results point to important considerations in planning and delivery of pain programs for refugees and have implications for program delivery more broadly.

Author Contributions

This study was conceived and designed by R.P.A., E.L.K., A.A. and G.L.M. The data were collected by R.P.A., B.C. and K.P., and analysed by R.P.A., K.M., E.L.K. and G.L.M. The results were critically examined by all authors. R.P.A. had a primary role in preparing the manuscript, which was reviewed and edited by K.M., E.L.K., A.A., K.P., B.C. and G.L.M. All authors have approved the final version of the manuscript and agree to be accountable for all aspects of the work.

Funding

R.P.A. is supported by the University of South Australia Enterprise Research Scholarship (ERS). K.M. is a Postdoctoral Associate supported by a Social Sciences and Humanities Research Council funding for the project on Partnership for the Engagement of People in Pain Research (PEPR). E.L.K. has received support from an Australian National Health and Medical Research Council Leadership Investigator Grant to G.L.M. (NHMRC ID 1178444) and is supported by the Mayday Fund. A.A. and B.C. are supported by the Forum of Australian Services for Survivors of Torture and Trauma (FASSTT) and the Adelaide Primary Health Network (PHN). K.P. is supported by an Australian Government Research Training Program (RTP) scholarship. G.L.M. is supported by an Australian National Health and Medical Research Council Leadership Investigator Grant (NHMRC ID 1178444).

Conflicts of Interest

G.L.M. has received support unrelated to the current work from: Reality Health, ConnectHealth UK, Institutes of Health California, AIA Australia, Workers' Compensation Boards and professional sporting organisations in Australia, Europe, South and North America. Professional and scientific bodies have reimbursed him for travel costs related to the presentation of research on pain and pain education at scientific conferences/symposia. He has received speaker fees for lectures on pain, pain education and rehabilitation. He receives royalties for books on pain and pain education. He is a nonpaid CEO of the non‐profit Pain Revolution. E.L.K. has received support unrelated to the current work. Professional and scientific bodies have reimbursed her for travel costs related to the presentation of research on pain and health equity at scientific conferences/symposia. All other authors have no conflicts of interest to declare.

Supporting information

Data S1: Supporting Information.

Data Availability Statement

The qualitative datasets generated during this study are not publicly available due to the sensitive nature of the data and ethical obligations to protect participant confidentiality.