Chronic pain among Somali pastoralists: towards understanding and informing culturally sensitive pain management among adult pastoralists in Eastern Ethiopia

Background and context
Chronic pain is one of the most debilitating health concerns and can be considered a disease in its own right. To live with chronic pain means that daily life is challenging with the condition also affecting the social network and the community as a whole. Chronic pain is clearly associated with poor mental health, inability to work, reduced quality of life and increased risk of mortality. Despite chronic pain being one of the leading causes of disability worldwide, it lacks the necessary prioritization in health care agendas. This applies to both high-income and low-/middle-income countries. Pain remains particularly neglected in the global South and among marginalized communities. This is a dire situation in consideration of demographic ageing and more specifically of recent projections that emphasize the growing number of non-communicable diseases, such as cancer and associated pain in the upcoming decades.
Pastoralists are known for their resilience to withstand hardships in everyday life. However, their remoteness, seasonal mobility and exposure to physically challenging work and a harsh environment wracked by conflict, displacement and devastating droughts have made them especially vulnerable to poorer health, including chronic pain. Yet, policy makers have long neglected the Somali pastoralist population in Ethiopia and their limited access to basic health care services.
The requirements and approaches for the treatment of pain are shaped not only by biological dimensions but also by psychosocial, cultural, spiritual and environmental factors. Gaining in-depth insights into how pain is perceived and dealt with among pastoralists can provide valuable information for designing multidimensional and interdisciplinary treatment approaches that better consider pastoralists’ strengths, needs and their unique context. In doing so, pain management can be improved for this marginalized population.
Aims
The main objective of this dissertation is to shed light on the perceptions, notions and burden of chronic pain among adult pastoralists in the Somali Regional State (SRS) of Ethiopia.
The specific aim of the initial qualitative study phase with Somali pastoralists and health professionals was to gain first insights into how pain is perceived and dealt with. The results from the qualitative study phase helped inform the development of a structured questionnaire. This questionnaire was used in a household survey with the primary aim of assessing the overall burden of chronic pain in adult pastoralists in the SRS.
The dissertation is embedded within the Jigjiga University One Health Initiative (JOHI) in the SRS. The initiative strives to improve the health and wellbeing of pastoralists, using transdisciplinary research approaches.
Methods
The dissertation followed a mixed-methods sequential exploratory study design based on Creswell and Plano Clark. Two qualitative studies were the basis for the final quantitative study.
In a first step, the qualitative interview study took place with 17 health professionals (mainly nurses) working in different biomedical care settings – with the intent to explore how they perceive pastoralists in the context of pain management. The initial selection of participants was purposive (secondary and tertiary care) and later entailed an element of theoretical sampling (primary care).
In a second step, a qualitative study was conducted with 20 adult Somali pastoralists suffering from chronic pain. Participants were purposively selected within primary, secondary and tertiary care facilities aiming at maximum variability. At a later stage, participants were also interviewed at their homes. The results of the two qualitative studies were the basis for the development of a pastoralist-specific questionnaire. The questionnaire focused on the burden chronic pain (prevalence, location, severity, frequency and impact) as well as on coping practices and treatment pathways.
In a third step, a quantitative household survey was conducted among adult pastoralists (aged 18 or older, N=299) in six randomly selected villages. In each village, 50 households were randomly selected using GPS-based household location and recruitment. The pastoralist-specific questionnaire was applied in this survey.
Results
Both qualitative studies revealed that chronic pain among pastoralists is perceived as a multicausal and relational experience. To distinguish pain from other symptoms or illnesses, pastoralists had no single word to describe their pain in the local language. Pastoralists described distinct illness beliefs with spirituality and religiosity having a mediating role and experienced communality providing support. However, stigmatization and aspects of stoicism hindered open pain reporting. In addition, the attitudes of health professionals contained demeaning elements. The results of the household survey served to further elaborate on the issues raised in the qualitative studies. The survey findings revealed a chronic pain prevalence among adult Somali pastoralists of nearly 30% with women and the elderly being particularly vulnerable. The body sites most commonly affected by chronic pain were the knees, followed by the lower back. The engagement in physical work, such as loading livestock, as well as household and agricultural work activities, may contribute to the pastoralists’ elevated risk of chronic pain. Moreover, most female participants had experienced the harmful practice of female genital cutting (FGC). The majority of participants with chronic pain visited biomedical health facilities to seek treatment. Nearly half of the pain-affected persons visited a traditional healer. Nevertheless, most participants reported interference of chronic pain with their daily life.
Conclusion
The findings of this dissertation shed light on the high burden of chronic pain that is negatively impacting pastoralists themselves as well as their livelihoods, their animals and surrounding communities. These secondary effects of chronic pain reflect the relevance of integrated “One Health” solutions in this unique setting. Moreover, the consideration of diverse perspectives on this marginalized population allows for a comprehensive picture of this debilitating health concern. The data highlight important aspects that are essential for designing culturally sensitive pastoralist-specific pain management. This also means recognizing the importance of pastoralists' self-care practices and lay health knowledge, and not imposing Western medical approaches without reflection.
The findings are consistent with recent global health agendas advocating for equitable and affordable access to comprehensive health services that leave no one behind, especially not the most vulnerable populations.