Experiences of Pain Among Indigenous Peoples Globally: A Qualitative Systematic Review

ABSTRACT

Background

Indigenous Peoples continue to face colonisation and oppressive policies that intentionally disrupt their ways of life and wellbeing. The increased experience of disease for Indigenous Peoples, due to colonial processes, is confounded by immense difficulties accessing culturally secure healthcare. The experience of pain for Indigenous Peoples within this unjust socio‐political context encompasses physical, emotional, spiritual, and mental pain.

Objective

This systematic review aims to explore factors related to the experience of pain for Indigenous Peoples globally.

Search Strategy

Four databases: PubMed, EMBASE, Scopus, and Web of Science were searched utilising a pre‐established search strategy to identify qualitative papers that focused on experiences and understandings of pain among global Indigenous Communities.

Data Extraction and Synthesis

Two independent reviewers performed title, abstract and full text screening, which resulted in the inclusion of 26 papers. Data extraction and synthesis was done in two stages which involved grouping illustrations from papers into categories, and then into four overarching synthesised findings.

Main Results

The synthesised findings aligned with social ecological theories and included: intrapersonal, interpersonal, institutional and cultural levels. For Indigenous Peoples, pain is situated within a complex network of social, historical, and political determinants of health.

Discussion

The creation of a judgement‐free space, accessibility of traditional healing practices and a greater inclusion of family and Community throughout treatment processes were identified as facilitators to care for Indigenous Peoples experiencing pain.

Conclusion

By ascertaining and prioritising patient desires throughout the pain management experiences, practitioners can actualise self‐determination of patient wellbeing and ensure provision of culturally respectful and comprehensive care.

Highlights

• Indigenous Peoples face systemic barriers to culturally safe pain care.

• This review explores pain experiences among Indigenous Peoples globally.

• Findings span intrapersonal, interpersonal, institutional, and cultural levels.

• Culturally grounded care and self‐determination improve pain management.

1. Introduction

The International Association for the Study of Pain defines pain as ‘an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage’ [1]. However, the experience and expression of pain varies significantly across individuals and cultures. Within Western healthcare services, pain management strategies are predominantly based on evidence from Eurocentric contexts that do not necessarily reflect the needs of all patients [2]. Health models must account for the biological, cultural, emotional, and socioeconomic diversity of those accessing care [3].

For Indigenous Peoples, the experience of pain extends beyond physical symptoms to include emotional, relational and spiritual components, grounded in holistic concepts of wellbeing [4, 5]. Illness is often seen as a result from imbalances among these interconnected aspects of wellbeing [4]. Indigenous Peoples are the first peoples of their lands, with deep‐rooted and ongoing connections to land, language, culture, and Community. They are sovereign Nations with distinct identities, worldviews, and ways of knowing, being, and doing, found across the globe from the Arctic to the South Pacific [5].

The ongoing impacts of colonisation, structural racism, and intergenerational trauma have resulted in significant barriers to culturally secure healthcare access for many Indigenous Communities globally [5, 6, 7]. These impacts include the loss of culture and language, the forcible removal of children, and dispossession from traditional lands [7], all of which contribute to entrenched cycles of disease burden [8]. Additional challenges such as communication barriers, protective expressions of pain shaped by historical and ongoing trauma, and mistrust stemming from past healthcare trauma further hinder communication and treatment outcomes [9, 10]. Trauma informed care, which recognises the impact of trauma across healthcare and social services, is crucial in addressing these issues [11].

To the best of our knowledge, there are no other systematic reviews exploring the nature of pain experiences for Indigenous Peoples at a global level through a holistic understanding [12]. This is critical, as measures of pain must comprehensively consider lived experiences beyond the physical implications, including spiritual and cultural dimensions, to ensure care that is appropriate, safe, and trusted by the patient [10]. Inadequate recognition or treatment of pain can erode patient‐clinician trust and contribute to poorer outcomes, perpetuating cycles of culturally unresponsive care [12]. This review therefore seeks to explore multidimensional understandings of pain among Indigenous Peoples globally.

2. Materials and Methods

This systematic review has been registered with PROPSPERO (CRD 42022333430) and the Joanna Briggs Institute systematic review registry. This review was conducted and is reported in alignment with the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) guidelines [13] (Supporting Information S1: Appendix 1).

2.1. Positionality Statement

Acknowledging the relational processes of Indigenous research, we would like to position ourselves in relation to this work [14, 15, 16]. We are a team led by a Mushkegowuk woman and comprising of Indigenous Peoples as well as non‐Indigenous colleagues from Canada, Australia, and Aotearoa/New Zealand. We come to this work from a place of learning and gratitude, as we all share the immense honour of working in partnership with Indigenous Communities both within Canada and Australia across numerous projects that relate to self‐determination of Indigenous wellbeing. Throughout the review process, we engaged in reflexive dialogue as a team to acknowledge our diverse perspectives and ensure that the synthesis was carried out with accountability, cultural integrity, and respect for Indigenous knowledges.

2.2. Theoretical Framing

This review is grounded in Indigenous research methodologies that centre relationality, accountability, and respect for Indigenous ways of knowing, being, and doing [14, 15, 16]. Guided by the leadership of Indigenous team members, we approached the review through a decolonial lens that challenges dominant Western research paradigms and prioritises Indigenous sovereignty and lived experience. The entire process was shaped by a commitment to honouring Indigenous knowledges, rather than extracting or reducing them.

2.3. Identifying Studies for Inclusion

The review team utilised a pre‐established search strategy [17] which involved combining terms describing the population and phenomena of interest being researched. The search strategy was tailored per the design of four databases: PubMed, EMBASE, Scopus, and Web of Science (Supporting Information S2: Appendix 2). Articles that were published from database inception until May 2024 were eligible for inclusion in this review. Titles and abstracts were screened by two reviewers independently to assess eligibility (M.C., B.P., and A.R.), with those considered relevant by either investigator advancing to full text review. The investigators then fully screened studies to identify which fulfiled the following inclusion criteria: qualitative study design, research focused on a comprehensive understanding of pain (both physical and spiritual), and Indigenous populations (any age or gender). All geographical locations and languages were eligible for inclusion in this review, the final studies identified were predominantly from high‐income or OECD countries. Any discrepancies between the two reviewers were discussed in conjunction with the wider team and resolved.

2.4. Critical Appraisal

A critical appraisal of all included studies was conducted using the JBI System for the Unified Management, Assessment and Review of Information (SUMARI) tool for qualitative research [18]. This tool includes ten questions regarding sample sizes, locations, methods used, techniques used, and findings. Critical appraisal was completed by two reviewers (A.R. and B.P.) for all papers, to determine the methodological rigour of each of the included studies. Questions were scored as either yes, no, unclear, or not applicable. No studies were excluded solely on the basis of methodological rigour [19]. Although some included studies had small sample sizes, their methodological rigour was assessed using criteria that focused on credibility, dependability, and coherence of findings.

2.5. Data Extraction & Analysis

Data was extracted in two phases for this review. For the first phase, study characteristics were extracted and uploaded into JBI SUMARI, including study aim, country, population, data analysis, and main findings. Next, the qualitative findings were comprehensively identified and extracted from each of the included studies, including thematic findings and associated illustrations. Each of the qualitative findings were scored within JBI SUMARI as either ‘Credible (C)’, ‘Not Supported (NS)’, or ‘Unequivocal (U)’. The synthesis of findings was completed manually by the review team and in alignment with the JBI methodological approach for qualitative meta‐aggregations. This involved writing all findings on a white board and identifying any common themes, words, or connections between them. The common themes were grouped together, and then transferred from the whiteboard to the JBI SUMARI tool and each individual finding was placed within the appropriate category. Upon review of each category, findings were then comprehensively grouped into overarching synthesised findings [20]. To enhance rigour and ensure consistency, team members independently reviewed theme groupings and engaged in collaborative discussions to resolve any differing interpretations. Decisions were reached through consensus, supported by regular team reflections to maintain alignment with the review's theoretical and methodological framework.

During the analysis process, the research team identified that categories existed at different levels of society, from the individual to institutional level. Factors related to experiences and management of pain for Indigenous Peoples exist as processes of bi‐directional and reciprocal relationships between individuals and their surrounding environments [21]. Therefore, the final conceptual model was developed in alignment with social ecological theories of health [22].

3. Results

3.1. Search Results

The systematic search returned 6427 records, of which 2127 were duplicates and consequently excluded, leaving 4300 records. After being screened against the inclusion and exclusion criteria, 93 studies were retrieved in full; of these, 26 fully satisfied the inclusion criteria (Figure 1).

FIGURE 1.

PRISMA flow diagram.

3.2. Critical Appraisal

The majority of studies performed well across the tool, although three of the criterion were poorly fulfiled by the included studies, including: the congruity between philosophical perspective and methodologies, a statement locating the researcher culturally and theoretically, as well as discussions around the influence of the researcher on the research [23]. The average inter‐reviewer score of the appraisals was 8.4, which indicates a high level of agreement between the two reviewers (Supporting Information S3: Appendix 3).

3.3. Study Characteristics

The 22 studies included in the review were from four different countries: Australia [4, 10, 24, 25, 26, 27, 28], the United States [2, 29, 30, 31, 32, 33, 34, 35], Aotearoa (New Zealand) [36, 37, 38], and Canada [9, 39, 40, 41]. Data collection methods varied, but most commonly including structured/semi‐structured interview groups [2, 4, 9, 10, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 37, 40], questionnaires [32, 34, 37, 41], or talking circles [28, 32, 35, 38, 39, 40, 41]. Sample sizes for the groups varied, with the smallest group being five [36] people, and the largest being 220 [9]. The included studies interviewed Indigenous individuals, some of whom were cancer survivors, suffering from chronic pain, or had a history of abuse. Participants also included families of individuals who suffered chronic pain, including parents and children, and healthcare practitioners (Table 1).

TABLE 1.

Study characteristics.

Study	Phenomena of interest	Country	Participant characteristics and sample size	Setting/context/culture	Methods for data collection and analysis
Amey S, MacLeod E, Paul K, Latimer M, Finley GA, Sylliboy JR, et al. 2020. (Latimer et al., 2020) [9]	To gather perspectives related to pain expression, care experiences, and strategies to improve healthcare encounters for Indigenous Peoples with chronic pain.	Canada	N = 220 (188 first nations participants and 32 healthcare practitioners)	Community members from three Mi'kmaq and one Wolastoq First Nations Community	Interviews grounded in Two‐Eyed seeing methodology
Bernardes Maresch C, Houkamau K, Lin I, Taylor M, Birch S, Claus A, Bryant M, Meuter R, Isua J, Gray P, Kluver P J, Jones C, Ekberg S, Pratt G. 2022 [42].	Examines the communication experiences of Aboriginal and Torres Strait Islander patients and Aboriginal and Torres Strait Islander Hospital Liaison Officers (ATSIHLOs), to improve understanding of how pain is managed in and through patient‐health professional communication.	Australia	N = 21	Patients attending three persistent pain clinics and ATSIHLOs working in two hospitals in Queensland, Australia.	Focus groups and in‐depth interviews.
Crocketta K, Lovoa S, Irvinea A, Trask C, Oosman S, McKinney V, McDonald T, Sari N, Martinez‐Rueda R, Aiyer H, Carnegie B, Custer M, McIntosh S, Bath B. 2024 [43]	This study aimed to (1) understand care‐seeking experiences of people living with CBP in Saskatchewan and (2) determine the unique experiences (including additional barriers) facing urban, rural, remote, and/or Indigenous Peoples.	Canada	N = 33	People living with chronic back pain in Saskatchewan and determine unique experiences facing urban, rural, remote, and/or indigenous peoples	Semi structured interviews
Devan H, Jones B, Davies C, Perry M, Hale L, Grainger R, et al. 2021 [31].	To explore kaiāwhina (Māori community health practitioners) perspectives on supporting whānau (Māori) with chronic pain, and to understand their views on the use of online resources for pain management.	Aotearoa (New Zealand)	N = 13	Māori Peoples in Wellington, Aotearoa (New Zealand)	Focus groups
Duwe EAG. 2019. (Duwe 2019) [29]	To understand urban American Indians' experiences of pain and the impact on social, psychological, and cultural life.	United States	N = 40	Urban American Indian Peoples in Indiana, Illinois, and Oklahoma	Interviews
Ehrhardt MD, Gray KN, Kuhn BL, Lannon EW, Palit S, Sturycz CA, et al. 2020. (Ehrhardt et al. 2022) [2]	To conceptualise pain within American Indians context.	United States	N = 152 (94 female & 58 male American Indian Community members)	American Indian Communities in Oklahoma	Interviews
Fenwick C, Stevens J. 2004.(Fenwick & Stevens 2004b) [10]	To investigate postoperative pain experiences in Central Australian Aboriginal women and the interpretation of pain by non‐Indigenous female nurses.	Australia	N = 17 (5 female Community members, 8 non‐Indigenous nurses & 4 Indigenous health workers)	Central Australian Aboriginal Communities	Interviews
Goodkind JR, Hess JM, Gorman B, Parker DP. 2012. (Jessica R Goodkind et al. 2012) [30]	To understand the relevance of addressing historical trauma and current structural stressors on individual and community strength through healing and social transformation.	United States	N = 37 (14 youth, 15 parents & 8 grandparents)	Diné (Navajo) Community	Interviews
Goodman A, Fleming K, Markwick N, Morrison T, Lagimodiere L, Kerr T. 2017. (Goodman, Fleming, Markwick, Morrison, Lagimodiere, Kerr, et al. 2017) [39]	To investigate the healthcare experiences of Indigenous Peoples who use illicit drugs or alcohol living in Vancouver's inner city.	Canada	N = 30	Indigenous Peoples living in Vancouver's Downtown Eastside	Talking circles & field notes
Greensky C, Stapleton MA, Walsh K, Gibbs L, Abrahamson J, Finnie DM, et al. 2014. (Greensky, Stapleton, Walsh, Gibbs, Abrahamson, Finnie, Hathaway, Vickers‐Douglas, et al. 2014) [31]	To solicit information from adult American Indian Peoples with chronic pain regarding the use of traditional health practices for pain reduction.	United States	N = 21 (10 women & 11 men)	The Min No Aya Win Human Reserve Centre, Fond du Lac Band Reservation in Cloquet, Minnesota	Interviews
Haozous E. 2004.(Haozous 2004) [32]	To understand experiences of cancer pain among American Indian Peoples from the Northern Plains region of the United States.	United States	N = 10	Southeastern Montana	Interviews & Brief Pain Inventory‐ Short Form.
Haozous EA, Knobf MT. 2013. (E. A. Haozous and M. T. Knobf 2013) [34]	To describe the experience of cancer and cancer pain in a sample of Southwestern American Indian Peoples.	United States	N = 24 (13 cancer patients & 11 healthcare practitioners)	Southwestern America Indian Peoples in New Mexico	Ethnographic interviews & 2 questionnaires (demographic and pain)
Haozous EA, Doorenbos AZ, Stoner S. (Haozous et al. 2016) [33]	To explore the chronic pain experience and establish the cultural appropriateness of cognitive behavioural pain management techniques for American Indian and Alaskan Native Peoples.	United States	N = 25	Southwest and Pacific Northwest of the United States	3 focus group interviews
Hodge FS, Itty TL, Samuel‐Nakamura C, Cadogan M. 2020.(Hodge et al. 2020) [35]	To understand the reasons for reduced communication between American Indian cancer patients and healthcare practitioners.	United States	N = 33	Arizona	Focus groups
Latimer M, Finley GA, Rudderham S, Inglis S, Francis J, Young S, et al. 2014.(M. Latimer et al., 2014) [40]	To understand how First Nation Mi'kmaq children and youth express pain and how others interpret it.	Canada	N = 114	Atlantic Canadian Mi'kmaq Community	Conversation groups involving children, parents, teachers or healthcare practitioners and individual interviews with elders.
Latimer M, Sylliboy JR, MacLeod E, Rudderham S, Francis J, Hutt‐MacLeod D, et al. 2018. (Latimer et al. 2018) [41]	To understand how youth from 4 First Nations Communities express pain using narratives and art‐based methods to inform culturally appropriate assessment and treatment.	Canada	N = 42 children	First Nation Communities in the Mi'kmaw and Wolastoqey regions	Demographic questionnaire, talking circles & artwork with accompanying video explaining the art.
Lawson‐Te Aho K. 2014. (Aho 2014) [36]	To understand the process of narrating historical trauma as a starting point for healing.	Aotearoa (New Zealand)	N = 5	Māori Community in Aotearoa (New Zealand)	Multiple interviews with each participant.
Lin IB, O'Sullivan PB, Coffin JA, Mak DB, Toussaint S, Straker LM. (Lin et al. 2012) [24]	To understand the chronic low back pain experience for Aboriginal Peoples living with the condition.	Australia	N = 15 (11 Aboriginal Community leaders & 4 non‐Indigenous representatives)	Regional town in Western Australia	Yarning interviews
Lin IB, O'Sullivan PB, Coffin JA, Mak DB, Toussaint S, Straker LM. 2013. (Lin et al. 2013) [26]	To determine the low back pain beliefs of Aboriginal Peoples in Australia.	Australia	N = 32	One rural and two remote towns in Western Australia	Yarning interviews
Lin I, O'Sullivan P, Coffin J, Mak DB, Toussaint S, Straker L. 2014. (Lin et al. 2014) [25]	To identify ways communication can be improved from the perspective of aboriginal peoples living with chronic low back pain.	Australia	N = 32	One rural and 2 remote towns in Western Australia	Yarning interviews
McGavock Z, Barnes HM, Lyons A. 2012.(McGavock 2011) [37]	To understand the way chronic pain impacts and manifests in the lives of Māori Peoples.	Aotearoa (New Zealand)	N = 7	Māori adults in Aotearoa (New Zealand)	Questionnaire & interview
McGrath P. 2006.(McGrath 2006) [27]	To understand issues associated with pain management for rural and remote Aboriginal Peoples.	Australia	N = 72 (10 patients, 19 carers, 11 Indigenous Health Workers, 30 healthcare practitioners and 2 interpreters)	Regions in the Northern Territory: East Arnhem Land, Katherine Region, Alice Springs and Darwin	Interviews
Mittinty MM, Hedges J, Jamieson L. (Mittinty et al. 2022) [4]	To examine the experience of pain and coping for Indigenous Peoples in South Australia.	Australia	N = 13	South Australia	Interviews
Morunga E, Bean D, Tuahine K, Hohepa K, Lewis G, Ripia D, Terry G. 2023 [44]	To understand kaumātua (Māori elder) views on the effects of pain, traditional pain management practices, and mātauranga (Māori knowledge) relating to managing pain.	Aotearoa (New Zealand)	N = 14	Aotearoa New Zealand	Interviews and the hui/focus group
Signal V, Jones R, Davies C, Stairmand,‐ Moira Smith J, Adler J, K. Gurney J. 2023 [45]	To investigated the experiences of pain and pain management among Maori with cancer in Aotearoa (New Zealand).	Aotearoa (New Zealand)	N = 24	Maori health provider in a region of Aotearoa	Focus groups and interviews
Strong J, Nielsen M, Williams M, Huggins J, Sussex R. 2015. (Strong et al. 2015) [28]	To explore the nature of experiences Aboriginal Peoples have when communicating their pain.	Australia	N = 40	One regional town and one rural Community in Queensland	Focus groups

3.4. Meta‐Aggregation Findings

Four overarching synthesised findings were collated during the analysis, including intrapersonal factors, interpersonal factors, institutional factors, cultural context (Figure 2).

FIGURE 2.

Social ecological model representing Indigenous Peoples' experiences of pain.

3.5. Intrapersonal Factors

Intrapersonal factors were mentioned by Community members in majority of the included studies. Participants sought ways to navigate and respond to their pain, embodying different aspects of the human experience, whether through resilience [9, 29, 31, 33, 41, 46], shifting perspectives on pain [36], recognition of pain [42], or grappling with distrust [29, 31, 37, 40], denial [27, 36, 40], fear [26, 35], shame [37, 41], and loneliness [29, 37, 41, 47]. For some people, it was important to acknowledge the limitations of living with pain [26, 34, 37] and others worked to find effective coping mechanisms [27, 37]. One participant described the limitation of living with pain in their life, and the deep impact pain has on their everyday life:

I see my body change by itself. I see myself deteriorate right before your own eyes. It’s like pulling a rabbit out of a hat, like a magician the hand is faster than the eye. The cancer is like that, it fools your mind. I watch my back just deteriorate. I went from limping to crutches. I went from crutches to a walker. I went from a walker to a wheelchair. I went from a wheelchair to bed. It’s like a magician doing stuff, especially when your mind is sound and you watch yourself fade away and your mental state of mind, it will really tear you up. I think I’ve made myself sick with some of this.

[48]

Changing one's perception of pain liberated and empowered individual's minds and spirits, enabling them to recognise the potential for growth within their experiences [36]. One Māori individual described this process:

Having seen the mamae (pain) that ravaged my whanau [family], having awareness that somehow my tūpuna (elders) lived through it, and knowing it is still threatening my mokopuna (grandchildren), I am older, wiser and can see mamae (pain) for what it is…it is an opportunity for recovery, to rebuild, reclaim and heal ourselves. Without the mamae, the will to fight is not needed and yet the fight is good for us, it needs our commitment, our courage, fierce hope, single mindedness and determination.

[30]

Another Community member shared her sister's story, whose endurance of chronic pain has led to depression. Despite efforts to seek treatment for the underlying cause and articulate her suffering to healthcare professionals, she was prescribed medications to manage symptoms rather than the root cause; leaving her struggling to reclaim her life [48].

For some individuals, the diagnosis of chronic pain brought about a sense of denial, leading them to withdraw into themselves and adopt a stoic approach to life, choosing to keep struggles hidden hoping not to burden others with their emotions [35]. This inward focus led some people to self‐manage pain and believe they could simply will it away, as explained by one participant: ‘It's all in your mind. Pain is always in your mind… You just think about something else and forget about the pain eventually. The pain will just disappear’ [40]. Shame and embarrassment [37, 40] further compounded pain‐related struggles, causing individuals to conceal pain to avoid appearing weak or vulnerable to others. Describing the reluctance to express pain, one participant stated: ‘I have a really hard time describing [my pain]… I feel embarrassed or wimpy if I do’ [41]. Fear [26, 35] also influenced Community member's experiences of pain due to apprehension to acknowledge pain and diagnosis of diseases that result in pain.

For Indigenous Peoples experiencing pain, immense personal strength and resilience [9, 29, 31, 33, 41, 46] enabled individuals to accomplish goals in the face of adversity [29], build tolerance to experiences of pain [9, 41], and maintain normality of one's life [41]. For some participants, resilience was part of their core being, ‘I'm just doing what I was taught… growing up. To heal yourself… and be peaceful and balanced and centred’ [31]. Participants highlighted the unique considerations of each situation and the importance of travelling one's own road [33].

3.6. Interpersonal Factors

Five of the included studies described relational factors related to experiences of pain at the interpersonal level [24, 27, 32, 41, 43, 44, 45, 46]. Community support provided strength for participants through communication with family and friends [30], as well as Elder guidance and advice [24]. There was a collective nature when it came to experiences of pain at an individual level, that was shared and supported at a Community level: ‘when she had her heart attack, and how much it hurt her and hurt me and hurt all the other people who knew her too’ [41]. These examples demonstrate that, despite systemic barriers, many individuals drew on cultural teachings, Community strength, and personal resilience to navigate their pain journeys with determination and a deep sense of purpose.

3.7. Institutional Factors

Many of the included studies discussed factors at the institutional level that impact experiences of pain through interactions between patients and healthcare practitioners. Implicit bias [10, 28, 32, 37, 39, 42] was a commonly discussed factor at this ecological level that was a frequent and recurrent experience for participants: ‘They treated me like crap and I know it was because I was Native. We all know because of the look—there's a look. When you need the medical care we put up with it. We shouldn't have to. We bleed the same way, we birth the same way’ [39]. Patients reflected on the healthcare system's failure to deliver pain relief and voiced their exasperation with unfulfilled promises made by practitioners:

I have learnt to be very leery of doctors who say, ‘Do this, it will take care of your pain and you will never have it again’ and when I took a call back to the office and said, ‘This isn’t working, what else can I try?’ ‘Oh we don’t have anything else,’ is what goes through the receiver. And he promised in the beginning that he was going to help me.

[33]

Negative experiences with healthcare practitioners [10, 25, 32, 35, 37], coupled with poor communication, increasingly limited support for participants to implement lifestyle changes that might improve wellbeing and reduce pain symptoms [25]. Inconsistent monitoring of pain levels and complicit ignorance of patient experiences [35] resulted in insufficient administration of medications to manage pain [37]. In contrast to patients who did not receive correct medication, some participants preferred to suffer without pain relief rather than take narcotics, due to drowsy effects [37] and addictive properties [35]: ‘Elders are hesitant to take narcotics. They aren't up front about it, but they won't take them. The older folks would rather suffer with the pain than feel they were out of touch with the earth and world. They don't like the hazy feeling’ [34].

Healthcare practitioners often failed to share health‐related outcomes with participants in the included studies [25, 37]. For example, one Community member described their experience of undergoing a magnetic resonance imaging (MRI) and never having results shared with them [37]. Furthermore, the failure to communicate in a culturally respectful manner [10, 25, 27, 28, 35, 42] which necessitates practitioners understand that English may be second or third language for some, left participants feeling vulnerable, excluded, and lonely [9, 29, 32, 37, 41]. Many healthcare practitioners continue to use complex medical jargon, which disregards patient comprehension and self‐determination to manage their own wellbeing. This, in turn, fosters misconceptions and can result in a mismanagement of patient expectations [25, 28, 35].

Some participants disclosed their innate shame [39] when visiting a doctor, which was exacerbated by negative assumptions about education and health literacy levels [37]. Participants felt that their pain was made insignificant by practitioners and that they received ‘sub‐par treatment’ because healthcare practitioners assume Indigenous patients did not ‘care about their own health’. This is demonstrated through the following quote, ‘In our clinic we have a really huge misconception that anyone that comes in with pain is seeking narcotics. What I would like to see is when someone comes in they are not seen as a drug seeker, they are met with compassion. …I don't like to be stereotyped or labelled because a person is in pain [47]’.

The challenges faced by participants in the healthcare system are multifaceted, including implicit bias [10, 28, 32, 37, 39, 42], empty promises [32], negative experiences with healthcare practitioners [10, 25, 32, 35, 37, 42, 43] the importance of relationships with healthcare practitioners [25, 27, 35, 42, 43, 45], failure to report findings [25, 27], unmet needs [27, 31, 32, 34, 35, 37, 42, 43, 44] and a lack of culturally appropriate communication [10, 25, 27, 28, 35, 42, 43] and accessible services [43, 49]. These experiences highlight systemic issues within the healthcare system that contribute to feelings of exclusion and vulnerability among Indigenous patients.

While many participants recounted challenges in accessing culturally safe care, some also shared positive experiences where respectful communication [9, 42] and relational continuity [25, 40, 46] made a meaningful difference. These examples highlight the importance of relationship‐based approaches and the value of integrating cultural understandings of pain into mainstream care.

3.8. Culture

At the cultural level, narratives not only revealed the complex and interconnected nature of pain across physical and spiritual experiences [4, 28, 34, 37, 41, 45], cultural considerations [27], and traditional healing practices [9, 31, 33, 35, 41, 46] that require a more holistic approach to pain management, but also highlighted culturally grounded health practices, inner strength, and the importance of traditional approaches to care [9, 31, 33, 35, 41, 46].

The experience of pain can be all consuming, impacting an individual both physically and spiritually. One participant described the progressive deterioration of their physical state due to cancer, reflecting on the emotional toll of ‘watching [themselves] fade away’ and feeling as though pain was ‘fooling the mind’ [34].

The intensity of pain can evoke a profound questioning of spirituality, challenging one's beliefs and prompting a search for meaning and understanding in the face of suffering. Some participants who experienced this and wonder, ‘Why did you create me just to watch me suffer?’ [34]. Patients found solace and experienced both physical and spiritual healing of their pain through prayer and traditional healing practices, shedding light on the constraints of Western medicine from the Indigenous viewpoint: ‘When you have nothing left, I've found relief. Even if it's temporary relief for some of my pain from going to many different [spiritual religious] healers. Western medicine doesn't have all the answers’ [31].

4. Discussion

This review aimed to explore factors that influence the experiences of pain for Indigenous Peoples globally. This review included 26 studies from the United States of America, Australia, Canada, and New Zealand. The findings highlight the interconnected relationship between physical, spiritual, and emotional pain for Indigenous Peoples, and complement emerging research from other regions and methodological approaches [50, 51, 52], while offering a unique global synthesis focused on the holistic and relational dimensions of pain. Whilst commonly defined as separate entities, these three experiences of pain intertwined by Community members across the included studies, contributing to a multi‐dimensional experience of pain at both individual and Community levels.

These stories reveal not only the resilience and strength of Indigenous individuals facing pain but also the distrust and continued malpractice resulting from medical and historical injustices and unfulfilled promises. Despite efforts to navigate pain and seek healing, participants encounter barriers such as denial, shame, and fear, highlighting the need for greater cultural awareness and empathy in healthcare practices. Such narratives are common within Indigenous Communities, reflecting insufficient interactions with healthcare professionals that have fostered deep‐seated distrust, a pattern rooted in the ongoing impacts of colonisation and historical injustice [39, 42]. Ultimately, resilience emerges as a guiding force, empowering Indigenous patients to reclaim agency over their health and well‐being while navigating the complexities of pain within their personal and cultural contexts.

Examining both the extrinsic and intrinsic positive experiences, participants commonly drew support from Community and Indigenous Health Workers. The prioritisation of traditional healing practices provided individuals with strength and resilience not afforded by Western approaches, which consider physical pain in isolation to one's holistic wellbeing. One of the more divisive findings from this review was the inclusion of traditional healing practices into Western treatment approaches. Whilst some participants felt that the inclusion of traditional healing practices allowed them to come together with their Community and nourish the spirit, others felt that it was inappropriate for Western doctors to include these practices into treatment routines.

Across several regions, programs have emerged that offer models for integrating traditional health practices into healthcare systems. For instance, the Healthy roots initiative, led by Haudenosaunee Peoples in Eastern Turtle Island, revived traditional food practices over a 90‐day period and resulted in positive health outcomes related to metabolic health [53]. In South Australia, advocacy by Aboriginal leaders enabled a hospital‐based ceremonial practices to support a kidney transplant recipient, illustrating how ceremonial practices can be respectfully incorporated into biomedical care [54]. These examples reflect the depth of healing and increased wellbeing that can be supported through traditional healing practices. To enable wider implementation, policies that protect ceremonial practices in clinical settings, support Indigenous governance, and fund culturally grounded care pathways are urgently needed [5, 55].

Findings from this review demonstrate that Indigenous Peoples experience pain in various ways, offering valuable insights for practitioners to better understand variances beyond Western pain models. Evidence suggests that practitioner racial bias can inappropriately influence decision making about pain management [56]. While power differentials may limit patient ability to vocalise needs or to assume that practitioners ‘know best’. To circumvent the impact these circumstances, have on mismanagement of pain, ensuring provisions are put in place that support effective and appropriate communication between Indigenous patients and non‐Indigenous healthcare practitioners is needed. This could include the use of an Indigenous liaison officer, which has previously been successful for Indigenous patients living with kidney disease and heart disease [57, 58], or the use of an interpreter that speaks the patient's dominate language. Furthermore, allowing the involvement of family or Community members in the health journey may allow the patient a comfortable pathway to share their feelings regarding their pain, and ultimately, create a more effective environment for pain relief to be facilitated.

Overwhelmingly, most findings from this review related to negative experiences shared by Indigenous participants [2, 10, 25, 26, 27, 28, 29, 31, 32, 34, 35, 37, 38, 39, 40, 41]. Consistently, implicit biases, racism, and deficit focused assumptions held by healthcare practitioners negatively impacted the ways in which pain was managed for Indigenous Peoples. The ways through which racism impacts healthcare provision for Indigenous Peoples is far from a new conclusion [39, 59, 60, 61]. However, it is the systematic racism that Indigenous Peoples face, which are reinforced by socio‐political ideologies and policies that facilitate low socioeconomic status, which widen existing barriers to healthcare [40]. The unique context in which Indigenous Peoples experience pain [2, 4, 9, 27, 28, 30, 31, 33, 34, 35, 36, 37, 41] is directly related to the emotional and spiritual pain of ongoing settler colonialism, which is cemented through continuous experiences of institutionalised racism.

4.1. Limitations

Studies from only four countries, primarily high‐income or OECD contexts, were included in this review, despite all geographic locations and languages being eligible. As a result, the findings cannot be generalised globally across all Indigenous Communities, particularly those whose experiences may differ due to diverse cultural, historical, and structural contexts. There remains a need for pain management approaches that are tailored to the specific needs, knowledges, and priorities of Indigenous Peoples at both individual and Community levels. Some included studies had small sample sizes, which may limit the transferability of their findings. While small samples are not uncommon in qualitative research and can still yield rich insights, they may not fully capture the diversity of experiences within each Community.

5. Conclusion

This systematic review provides an overview of the experiences of Indigenous Peoples in accessing culturally secure and effective pain management. Culturally secure healthcare refers to care environments where Indigenous Peoples feel safe, respected, and understood, free from racism and power imbalances [62]. Across the included studies, participants described both significant challenges, such as systemic racism and poor communication, as well as sources of strength, including personal resilience, Community support, and culturally grounded healing practices.

Supporting patient self‐determination, each patient's right to define and direct their own healthcare journey [5, 63], is essential to improving care. This includes enabling the involvement of Indigenous liaison officers in appointments, and the inclusion of family and Community when discussing a patient's medical management. Developing care provision models that support the inclusion of traditional healing practices, where desired by patients, would better align with the interconnected experience of physical, emotional, and spiritual pain. These services should be offered as adjunctive treatment options alongside biomedical treatment, acknowledging that some patients may choose to engage with traditional practices independently. Fundamentally, culturally safe and effective pain care requires healthcare practitioners to actively practice reflexivity. This includes critically examining their own assumptions and biases, and committing to care practices that are accountable, respectful, and aligned with the needs and rights of Indigenous Peoples.

Funding

The authors have nothing to report.

Ethics Statement

The authors have nothing to report.

Consent

The authors have nothing to report.

Supporting information

Supporting Informtion S1

Supporting Information S2

Supporting Information S3

Data Availability Statement

The data that supports the findings of this study are available in the supplementary material of this article.