Pain+from+a+Intercultural+Perspective

Name: Sandra Shell Student Number: n8290318 Tutor: Michelle Newcomb

**Pain from an Intercultural Perspective **

Chronic pain can be defined as prolonged pain that lasts for three to six months duration (Clarke and Iphofen, 2007). Chronic pain can result in sleep deprivation, depression, irritability and fatigue, and may affect a person's personal and social relationships.An estimated 20 percent of adult Australians suffer chronic pain (Clarke and Iphofen, 2007). More women than men experience chronic pain. It is most common in women in the 50-54 age bracket and men in the 55-59 age bracket (Clarke and Iphofen, 2007).Injury is the most common cause of chronic pain (38 percent), though a further third of all people who experience chronic pain are unable to identify the original cause. Other identified causes include arthritis, musculoskeletal conditions, headache, cancer-related pain, post surgical persistent pain and non-specific lower back pain (Clarke and Iphofen, 2007).Chronic pain is estimated to cost the Australian economy $34.3 billion each year, which equates to $10,847 for each person with the condition.It is possible to effectively manage 70-80 percent of chronic pain. Despite this, only 10 percent of those affected are getting access to adequate treatment (Clarke and Iphofen, 2007).

This artefact is made of thread and fabric and is from a website called The Pain Exhibit (The Pain Exhibit, 2011). The items of artwork on the website were created by artists from around the world who suffer from chronic pain. The purpose of the exhibit is to educate people in the health care industry and the public about pain. The purpose is also to symbolise the pain of those who suffer in wretched silence. Many people who suffer chronic pain feel misunderstood because they are not believed and this may cause the doctor to infer that the pain is caused by their imagination. The artist of this artefact is a woman named Melissa Keith Hentges from America. It symbolizes Melissa’s head being jumped on by a monkey. Monkeys have a quick, jumping motion as they move which in this image symbolises the throbbing pain she feels when she has a migraine. The lines and colours in the artefact represent the person’s sensitivity to light and noise while she is experiencing the pain. This artistic work is to symbolise when people describe the pain of a migraine as pounding, pulsating or throbbing in the head. The fact that the persons face is blue symbolises the blue, sad feeling that the pain causes. It emphasises the fact that pain is subjective rather than objective so no-one knows what the pain feels like except the person who is experiencing it. Patients sometimes find that doctors will become frustrated with them when no objective evidence for pain can be found ( Burgess, 2008 ). This causes major problems for children who are learning to talk and people from an ethnic background who do not speak English or if English is a second language for them, as 19% of Australia’s population was born overseas. People of an ethnic background can have different views on health and illness from the Western culture as they may practice traditional health practices such as herbal medicines (Jimenez, Garroutte, Kundu, Morales, and Buchwald, 2011).This can cause communication problems. Interpreters  help ethnic patients to understand their illness and provide social support. Interpreters help people of ethnic background to receive adequate assessment and pain relief so that people do not suffer from increased intensity and duration of pain.  This is where the pain scale picture can be useful so that the person can point to a picture to describe their pain rather than having to verbalise it. It also emphasises the need for health care workers to be trained in and have an understanding of how people from other cultures behave while in pain.  From completing this research I have learnt about how people from ethnic backgrounds are treated in health care facilities and how language barriers, religious beliefs, fear of addiction, ethnicity of the health professional and their attitudes, knowledge and beliefs about the patient’s pain can sometimes lead to poor quality care. In the future I will keep in mind these factors when I work with and people from ethnic backgrounds to ensure they receive adequate care.
 * NAME THE PUBLIC HEALTH ISSUE CENTRAL TO YOUR ANALYSIS **

<span style="color: #000000; font-family: 'Times New Roman','serif'; font-size: 16px;">Australia is a multicultural society and 19% of the population was born overseas (Australian Bureau of Statistics ABS, 2006). About 42% of all emergency room visits are pain-related and people from ethnic backgrounds use the emergency room more frequently (Shavers, Bakos and Sheppard, 2010). In the Northern Territory about 40% of all patients were Aboriginals (Thomas, Anderson and Kelaher, 2008). People from an ethnic background are at higher risk for oligoanalgesia, or the ineffective treatment of pain (Bonham, 2010). Therefore health care workers need to have an understanding of how people from other cultures behave while in pain. There are many factors that can influence what care these people receive and in many cases this can create poor quality outcomes. These factors include language barriers, religious beliefs, fear of addiction, ethnicity of the health professional and their attitudes, knowledge and beliefs about the patient’s pain.
 * <span style="color: #000000; font-family: 'Times New Roman','serif'; font-size: 16px;">LITERATURE REVIEW **

<span style="color: #000000; font-family: 'Times New Roman','serif'; font-size: 16px;">The ethnic background of the health professional can also have an effect on the type of medication administered, the dosage or whether any medication is given to the patient at all. People from ethnic backgrounds were less likely to have pain score documented and more likely to have pain underestimated (Briggs, 2008). Sixty percent of patients treated by physicians of an ethnic background reduced their patient’s pain intensity, significantly greater than the 47% of patients treated by Western physicians with no difference in the use of analgesics, except a lower rateof use of opioids. Good care of patients is dependent on a good physician-patient interaction which involves establishing trust, rapport and good communication with the patient (Briggs, 2008). These differences in pain administration could be attributed to the physician’s behaviorsuch as warmth and question asking resulted in a better physician-patient interaction which created better health outcomes for the patient (Heins, et al., 2010). So there is a need for Western doctors to be aware of the way that people of an ethnic background behave while in pain so they can provide adequate care. <span style="color: #000000; font-family: 'Times New Roman','serif'; font-size: 16px;">The religious beliefs of the patient can also play a role in a patient’s behaviour and decision making while experiencing pain. Patients who are Hindu believe that pain is from karma as a consequence of past inappropriate action that happened in their current or past life. Muslims believe that pain is necessary in order to allow self-purification of sinful behavior (Whitman, 2007). Jewish people forbid pain medications such as morphine if the medication will speed up the dying process. Patients who are of a Chinese background may be a Taoist, Buddhist or Confucianist (Whitman, 2007). A Taoist might believe that pain occurs if blood circulation is blocked and that pain can be relieved by maintaining harmony with the universe (Whitman, 2007). A Buddhist might believe that suffering (i.e., pain) can be relieved by following the right ways of life. A Confucian might believe that pain is a necessary part of life that must be suffered and verbalised only when it becomes excruciating (Whitman, 2007). Hispanic patients are more likely to use pain coping strategies including praying or hoping(Edrington, Sun, Wong, Dodd, Padilla, Paul and Miaskowski, 2010). Hindu’s believe that everything, including pain and suffering, is given by God. Some believe that pain is a way to progress on their spiritual path, to be tested and learn from a difficult experience (Whitman, 2007). It is not viewed as punishment but as a consequence of the moral laws of the universe from behaviour of the past. They believe the purpose of pain is to remind them that they fully belong to God. Conservative and Reform Jews allow it if it will reduce a patient’s pain, even if it means death would occur sooner. ( <span class="titleauthoretc" style="color: #000000; font-family: 'Times New Roman','serif'; font-size: 16px;">Woll, Hinshaw and Pawlik, 2008 <span style="color: #000000; font-family: 'Times New Roman','serif'; font-size: 16px;">). Muslims feel that being sick is a way for God to test them. Muslims also believe that pain in this world prevents suffering in the next life. Some patients have difficulty using the 1-10 pain scale and reducing pain to a number as they felt their pain had social and spiritual aspects and was not merely physical symptoms (Jimenez, Garroutte, Kundu, Morales, and Buchwald, 2011). Therefore the religion of the patient can affect the patient’s pain experience as to whether they believe that their God has caused the pain and then if they think that they have the right to have the pain relieved. <span style="color: #000000; font-family: 'Times New Roman','serif'; font-size: 16px;">Communication is a vital part of ensuring that a patient receives adequate care especially if the patient is from an ethnic background. Patients from ethnic backgrounds felt that language <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">barriers resulted in the patients being unable to recall the information about their care given to them from their physician and premature termination of that care (Tripp-Reimer, Choi and Enslein, 2001). Many patients feel that they are not given adequate information on the side effects of prescription medication ( <span style="color: #000000; font-family: 'Times New Roman','serif'; font-size: 16px;">Kumar, Gordon, Barry, Shaw, Horne, and Raza, 2011 <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">). Poor communication between the patients and health professionals, contributes to a lack of understanding about the disease and therapy, and could result in patients taking greater interest in alternative therapies, or relying on their faith which may have an impact on adherence ( <span style="color: #000000; font-family: 'Times New Roman','serif'; font-size: 16px;">Kumar, Gordon, Barry, Shaw, Horne, and Raza, 2011 <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">).

<span style="color: #000000; font-family: 'Times New Roman','serif'; font-size: 16px;">Twenty percent of the Australia’s’ <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">population speak a language other than English at home <span style="color: #000000; font-family: 'Times New Roman','serif'; font-size: 16px;">(Carson, 2009) <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">. <span style="color: #000000; font-family: 'Times New Roman','serif'; font-size: 16px;"> For over 50% of Indigenous people in the Northern Territory (NT), English is a second language (Carson, 2009). The Indigenous concepts of health and illness can be very different from the Western culture which can cause communication problems. There is an Aboriginal Languages Interpreters Service in the NT which has improved communication between Indigenous people and physicians (Carson, 2009). Indigenous health educators help Indigenous patients to understand their illness. These Indigenous health educators help provide social support for patients but there are only a small number of them. Initiatives to increase the number of Indigenous health educators has been implemented but it will take many years to improve the situation (Carson, 2009). It is essential for health care workers to use an interpreter and not a family member of the patient as patients sometimes feel that sometimes family members gave them incorrect information. Using family members may breach confidentiality <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">. When communicating with patient’s health care workers should speak directly to the patient, use short sentences, allow sufficient time and use non technical language <span style="color: #000000; font-family: 'Times New Roman','serif'; font-size: 16px;">(Carson, 2009) <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">. Written information should be provided in English and in the patients primary language so information is available to both patient and to other people in their support system (Tripp-Reimer et al., 2001). The health care workers should ask the patient to repeat the instructions in writing and then ask the patient to repeat instructions in their own words to make sure they understood ( <span style="color: #000000; font-family: 'Times New Roman','serif'; font-size: 16px;">Juckett, 2005 <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">). Some people from ethnic backgrounds do not trust health care workers and patients believe they may be used for experimentation. Trust is enhanced when they are able to communicate with someone who speaks their primary language (Tripp-Reimer et al., 2001). <span style="color: #000000; font-family: 'Times New Roman','serif'; font-size: 16px;">Different cultures have different views on whether it is acceptable behave in a way that communicates pain. In Asian and European cultures expression of pain is seen as shame or weakness. Other cultures believe that pain is unavoidable part of a serious disease and must be accepted. Some culturesbelieve it is disrespectful to ask for pain relief feeling that if it is needed it will be given to them. Certain cultures only take pain relief if the pain is severe. Many cultures underemphasized pain describing even severe pain as ‘‘ache’’ or ‘‘discomfort” and feel that talking of the pain “makes it real.” However, African-American, Hispanic, Jewish, Middle Eastern and Mediterranean cultures, expression of pain is accepted and expected, especially during childbirth (Dees 2007). Patient self-efficacy and behaviour, including assertiveness, question-asking, and self-disclosure can also affect whether the patient receives pain medication (Heins et al., 2010). Some patients learn to not express pain to health professionals called learned helplessness where a perceived lack of control results in passive behaviour (Briggs, 2008). <span style="color: #000000; font-family: 'Times New Roman','serif'; font-size: 16px;">Many patients of other cultures fear becoming addicted to medications or side effects that medications may cause. In a study of patients with cancer 38% of Hispanic were worried about taking too many analgesics while 27% expressed concerns about the side effects of medications. In a survey of terminally ill patients with severe pain, people of ethnic backgrounds more frequently refused additional pain therapy because of fear of addiction (Shavers, Bakos and Sheppard, 2010). Patients may know a family member that became addicted to opiods or may have seen some negative information in the media which may cloud their attitude towards taking pain relief medication. The patient may believe <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">if they take the medicine on a regular basis, their body will “get used to it” and thus the pain medicine will no longer be effective <span style="color: #000000; font-family: 'Times New Roman','serif'; font-size: 16px;">(Shavers, Bakos and Sheppard, 2010) <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">. Patients may be concerned about opioid side effects, especially mental impairment, nausea and constipation. Patients may believe that treating the symptom rather than the cause of the pain (e.g. cancer) is a bad idea. They worry that this may mask the disease’s progression so that future medical decisions are not made in a timely manner <span style="color: #000000; font-family: 'Times New Roman','serif'; font-size: 16px;">(Shavers, Bakos and Sheppard, 2010) <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">. Patients frequently don’t want to ‘worry’ the doctor or ‘bother’ them with complaints. Patients may believe that “good” patients do not complain about pain or ask for more medicine. They may believe that it is better if the patient is “strong,” minimizing their symptoms <span style="color: #000000; font-family: 'Times New Roman','serif'; font-size: 16px;">(Shavers, Bakos and Sheppard, 2010) <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">. Therefore some patients may take less opoids or not take any at all if they fear becoming addicted or worry about possible negative side effects. <span style="color: #000000; font-family: 'Times New Roman','serif'; font-size: 16px;">Patients of other cultures have a different understanding as to what may have caused an illness. These may include believing that they are sick from <span style="color: #231f20; font-family: 'Times New Roman','serif'; font-size: 16px;">evil spirits, a perceived injustice, lack of faith, immoral lifestyle, imbalances of the body and or spirit (hot-cold or wet-dry), a hex or curse ( <span style="color: #000000; font-family: 'Times New Roman','serif'; font-size: 16px;">Dees, 2007 <span style="color: #231f20; font-family: 'Times New Roman','serif'; font-size: 16px;">). This can then affect what course of action they choose to take to help them when they are sick. Many turn to traditional methods of healing called complementary or alternative medicine (CAM) including dietary supplements, herbs, vitamins, <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">homeopathic medicines, acupuncture and massage (Marsh, Hager, Havey, Sprague, Bhandari and Bryant, 2009). <span style="color: #231f20; font-family: 'Times New Roman','serif'; font-size: 16px;"> The use of CAM is a cause of concern for doctors as many CAM therapies can adversely interact with prescription drugs. For example, <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">Gingko Biloba can increase the risk of bleeding if used in conjunction with non steroidal anti inflammatory drugs <span style="color: #231f20; font-family: 'Times New Roman','serif'; font-size: 16px;">( <span style="color: #000000; font-family: 'Times New Roman','serif'; font-size: 16px;">Dees, 2007 <span style="color: #231f20; font-family: 'Times New Roman','serif'; font-size: 16px;">) <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">. <span style="color: #231f20; font-family: 'Times New Roman','serif'; font-size: 16px;">In a study, up to <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">16% of patients combined taking herbs and drugs <span style="color: #231f20; font-family: 'Times New Roman','serif'; font-size: 16px;">. Of these people <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">40% had adverse herb-drug interactions ( <span style="color: #000000; font-family: 'Times New Roman','serif'; font-size: 16px;">Bush, Rayburn, Holloway, and Sanchez-Yamamoto, 2007 <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">). What is more, many doctors were not aware of CAM use by the patient. Only 35% of patients discussed their CAM use. Most patients did not think it was important and 20% did not think the doctor would understand their use of CAM. Fifty five percent of arthritis patients did not discuss their CAM use because the doctor did not ask, the patient forgot to tell the doctor, or feared disapproval. Most doctors lacked basic knowledge about CAM and were reluctant to inquire about their benefits or risk factors ( <span style="color: #000000; font-family: 'Times New Roman','serif'; font-size: 16px;">Bush, Rayburn, Holloway, and Sanchez-Yamamoto, 2007 <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">). A patient’s belief of what caused their illness will influence who they seek help from and whether they take opoids or use CAM to relieve their pain.

<span style="color: #000000; font-family: 'Times New Roman','serif'; font-size: 16px;">Western physicians may provide inadequate care because of discrimination, stereotyping, lack of empathy, or misperception regarding the presence of pain or pain intensity. Some physicians may inaccurately assess the patients’ pain, ignore patient complaints about pain or have doubts about the credibility of reported pain, or have more concern about ethnic patients being drug addicts. In a study in the emergency department it was found that 34% of people from ethnic backgrounds did not receive pain relief they were also three times more likely to be under medicated with analgesics (Shavers, Bakos and Sheppard, 2010). In a study 57% of African American and 38% of Hispanic patients said their physician did not talk to them about pain prior to the patient starting a conversation about pain (Shavers, Bakos and Sheppard 2010). A high proportion of <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">African Americans have sickle cell disease which may cause doctors to think that African Americans seeking pain relief may be drug addicts. In a study health care staff they thought that more than 50% of sickle cell patients were addicted, a belief that is not supported by research on addiction. Only 2–4% of patients with sickle cell disease in a recent survey met Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria for substance dependence <span style="color: #000000; font-family: 'Times New Roman','serif'; font-size: 16px;">(Shavers, Bakos and Sheppard, 2010) <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">. <span style="color: #000000; font-family: 'Times New Roman','serif'; font-size: 16px;">In conclusion it is very important for health care workers to be aware of the way people from ethnic backgrounds experience and express pain as inadequate care can lead to increased intensity and duration of pain for these people. It is essential that the patient feels listened to and understood. Poor quality care can lead to avoidance of medical care causing pain and distress for years. Adequate care of patients from ethnic backgrounds is an important issue that needs to be improved in Australia to prevent further suffering of these people.

<span style="color: #000000; font-family: 'Times New Roman','serif'; font-size: 16px;">Australian Bureau of Statistics ABS (2006). Retrieved from [] <span style="color: #000000; font-family: 'Times New Roman','serif'; font-size: 16px;">Bonham, V. L. (2010). Race, Ethnicity, and Pain Treatment: Striving to Understand the Causes and Solutions to the Disparities in Pain Treatment. //Journal of Law, Medicine & Ethics//, 2852-68. doi:10.1111/j.1748-720X.2001.tb00039.x <span style="color: #000000; font-family: 'Times New Roman','serif'; font-size: 16px;">Briggs, E. (2008). Cultural perspectives on pain management. //The Journal of Perioperative Practice, 18//(11), 468-468-471. Retrieved from @http://search.proquest.com/docview/217746813?accountid=13380 <span style="color: #000000; font-family: 'Times New Roman','serif'; font-size: 16px;">Bush, T. M., Rayburn, K. S., Holloway, S. W., & Sanchez-Yamamoto, D. (2007). Adverse interactions between herbal and dietary substances and prescription medications: A clinical survey. //Alternative Therapies in Health and Medicine, 13//(2), 30-30-5. Retrieved from @http://search.proquest.com/docview/204836174?accountid=13380 <span style="color: #000000; font-family: 'Times New Roman','serif'; font-size: 16px;">Carson, P. J. (2009). Providing specialist services in Australia across barriers of distance and culture. //World Journal of Surgery, 33//(8), 1562-1562-7. doi:10.1007/s00268-009-0088-1 <span style="color: #000000; font-family: 'Times New Roman','serif'; font-size: 16px;">Clarke, K. A., & Iphofen, R. (2007). Believing the patient with chronic pain: A review of the literature. //British Journal of Nursing, 14//(9), 490-490-493. Retrieved from @http://search.proquest.com/docview/199500387?accountid=13380 <span style="color: #000000; font-family: 'Times New Roman','serif'; font-size: 16px;">Dees L. (2007). Culturally Competent Care in the Emergency Medical Services Texas EMS Magazine, 34-39. Retrieved from [|www.dshs.state.tx.us/emstraumasystems/JA07CulturallyCompetentCar] ... <span style="color: #000000; font-family: 'Times New Roman','serif'; font-size: 16px;">Edrington, J., Sun, A., Wong, C., Dodd, M., Padilla, G., Paul, S., & Miaskowski, C. (2010). A pilot study of relationships among pain characteristics, mood disturbances, and acculturation in a community sample of Chinese American patients with cancer. //Oncology Nursing Forum, 37//(2), 172-172-81. Retrieved from @http://search.proquest.com/docview/223111251?accountid=13380 <span style="color: #000000; font-family: 'Times New Roman','serif'; font-size: 16px;">Heins, A., Homel, P., Safdar, B., Toddz, K. (2010). Physician Race/Ethnicity Predicts Successful Emergency Department Analgesia The Journal of Pain, 11(7) 692-697 Retrieved from [] <span style="color: #000000; font-family: 'Times New Roman','serif'; font-size: 16px;">Jimenez, <span style="color: #000066; font-family: 'Times New Roman','serif'; font-size: 16px;"> N., <span style="color: #000000; font-family: 'Times New Roman','serif'; font-size: 16px;">Garroutte, E., Kundu, A.,Morales, L., Buchwald D, ( <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">2011 <span style="color: #000000; font-family: 'Times New Roman','serif'; font-size: 16px;">). <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">The Journal of Pain, //12//(5) 511-522 <span style="color: #000000; font-family: 'Times New Roman','serif'; font-size: 16px;">A Review of the Experience, Epidemiology, and Management ofPain among American Indian, Alaska Native, and AboriginalCanadian Peoples. Retrieved from[]
 * <span style="color: #000000; font-family: 'Times New Roman','serif'; font-size: 16px;">References **

<span style="color: #000000; font-family: 'Times New Roman','serif'; font-size: 16px;">Juckett, G. (2005). Cross-cultural medicine. //American Family Physician, 72//(11), 2267-2267-74. Retrieved from @http://search.proquest.com/docview/234263006?accountid=13380 <span style="color: #000000; font-family: 'Times New Roman','serif'; font-size: 16px;">Kumar, K., Gordon, C., Barry, R., Shaw, K., Horne, R., & Raza, K. (2011). 'It's like taking poison to kill poison but I have to get better': A qualitative study of beliefs about medicines in rheumatoid arthritis and systemic lupus erythematosus patients of south Asian origin. //Lupus, 20//(8), 837-837-844. doi:10.1177/0961203311398512 <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">Marsh, J., Hager, C., Havey, T., Sprague, S., Bhandari, M., & Bryant, D. (2009). Use of alternative medicines by patients with OA that adversely interact with commonly prescribed medications. //Clinical Orthopaedics and Related Research, 467//(10), 2705-2705-22. doi:10.1007/s11999-009-0764-3 <span style="color: #000000; font-family: 'Times New Roman','serif'; font-size: 16px;">Shavers, V. L., Bakos, A., & Sheppard, V. B. (2010). Race, ethnicity, and pain among the U.S. adult population. //Journal of Health Care for the Poor and Underserved, 21//(1), 177-177-220. Retrieved from @http://search.proquest.com/docview/220587831?accountid=13380 <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">The Pain Exhibit, 2011, <span style="color: #000000; font-family: 'Times New Roman','serif'; font-size: 16px;">Retrieved from <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">http://www.painexhibit.com <span style="color: #000000; font-family: 'Times New Roman','serif'; font-size: 16px;">Thomas, D. P., Anderson, I. P., & Kelaher, M. A. (2008). Accessibility and quality of care received in emergency departments by Aboriginal and Torres Strait islander people. //Australian Health Review, 32//(4), 648-648-54. Retrieved from @http://search.proquest.com/docview/231777931?accountid=13380 <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">Tripp-Reimer, T., Choi, E., & Enslein, J. C. (2001). Cultural barriers to care: Inverting the problems. //Diabetes Spectrum, 14//(1), 13-13. Retrieved from <span style="color: #000000; font-family: 'Times New Roman','serif'; font-size: 16px;">@http://search.proquest.com/docview/228609170?accountid=13380 <span style="color: #000000; font-family: 'Times New Roman','serif'; font-size: 16px;">Whitman, S., M. (2007). Pain and Suffering as Viewed by the Hindu Religion. //<span style="font-family: 'Times New Roman','serif'; font-size: 16px;">The Journal of Pain //<span style="font-family: 'Times New Roman','serif'; font-size: 16px;">, //8 (//8), //607-613// Retrieved from <span style="color: #000000; font-family: 'Times New Roman','serif'; font-size: 16px;">[] <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">Woll, M. L., Hinshaw, D. B, & Pawlik, T. M, (2008). Spirituality and religion in the care of surgical oncology patients with life-threatening or advanced illnesses. //Annals of Surgical Oncology, 15//(11), 3048-3048-57. doi:10.1245/s10434-008-0130-9

<span style="font-family: 'Times New Roman','serif'; font-size: 16px;">Comments of other Wiki pages:

<span style="font-family: 'Times New Roman','serif'; font-size: 16px;">Obesity a Capitalist Disease

<span style="font-family: 'Times New Roman','serif'; font-size: 16px;">I enjoyed reading your web page and what surprised at some of your information, particularly the fact that children are exposed to 56 TV ads in a two hour viewing period. This is a lot of ads for children to watch who are often not old enough to know about how to make wise food choices. The weight loss industry is big business as Tony Ferguson can verify. The fact that he is a pharmacist makes people think that using his weight loss program is a healthy choice. But careful reading of his shakes reveal that they are full of sugar and not a healthy life style choice to aid weight loss.

<span style="font-family: 'Times New Roman','serif'; font-size: 16px;">Doctor Patient Relationships – Are we from different planets?

<span style="font-family: 'Times New Roman','serif'; font-size: 16px;">Well done on your analysis of the methodology used in the articles you have read. I have experienced the imbalance of power that nurses experience from doctors in the workplace when I did a prac placement in a hospital. I was shocked to see that the nurses were not treated with respect. So what hope does a patient from another culture have of being treated with respect by a doctor either?