Pain that lasts at least three months—or chronic pain—can affect daily life and well-being.

Chronic pain is associated with decreased quality of life and increased anxiety and depression, according to the U.S. Centers for Disease Control. It’s one of the top reasons adults seek medical care.

Nearly one-quarter of U.S. adults reported chronic pain in 2023. Some groups are more likely to struggle with pain. More than one-third of people age 65 and older have chronic pain. People with limited English proficiency experience disparities in pain assessment and treatment.

Research by University of Wisconsin–Madison School of Nursing Associate Professor Maichou Lor, PhD, RN, FAAN, showed that language and cultural barriers between patients and healthcare providers make it particularly difficult to communicate about pain.

Now, she’s working on a solution.

“We know that effective communication leads to better health outcomes,” says Lor. “I hope when people can understand each other, patients will be able to get the treatment that they want.”

Much of Lor’s work involves the Hmong community. The Hmong are Wisconsin’s largest Asian American ethnic group. They’re also especially at risk for pain disparities and poor communication with healthcare providers.

It’s common for U.S. healthcare providers to ask patients how severe their pain is, on a scale of one to ten.

However, as Lor points out, “There’s a whole other world of how people quantify and describe pain that doesn’t get represented in a linear number but makes use of other parts of language.”

Hmong older adults use metaphors, such as, “It hurts like chicken pecking.” They may elongate vowels or raise the pitch of their voice to describe the severity of their pain. The meaning is often unclear to interpreters and providers.

Lor worked with Hmong community members and interpreters to develop a Hmong pain assessment visualization tool. The tool uses icons of Hmong pain metaphors to describe the type of pain. It includes facial expressions and changes in skin tone to indicate the severity of the pain. There’s a body diagram, used to show where pain is felt. The tool also provides English medical pain terms for providers and translations of Hmong pain metaphors for interpreters, to help bridge cultural and language differences.

At first, Lor asked medical interpreters to fill out the pain assessment visualization tool with Hmong patients.

“Interpreters reported that having them help with the written completion of the tool was out of their scope of practice,” says Lor. “We quickly learned that in almost 80 percent of visits with patients, family caregivers were present. Why haven’t we included them?”

She has since focused on family caregivers. She developed an online training that explains how to use the pain assessment visualization tool, includes videos of case studies, and covers strategies for clear communication with healthcare providers.

After completing the training and using the tool, caregivers said they “learned new ways to describe pain in the Hmong language,” says Lor. “They valued the tool because it helped them better prepare for healthcare visits. They also felt empowered.”

One thing surprised Lor. When she was recruiting Hmong caregivers for her study, many non-Hmong people expressed interest. That helped her realize that the tool could be adapted for different communities.

“The core principles—soliciting personalized information about pain intensity, location, and characteristics—remain the same regardless of caregiver background,” says Lor. “The pain metaphors, which are really about the pain characteristics, need to change because they are very community specific.”

She’s now working with UW–Madison School of Medicine and Public Health Assistant Professor Maria Mora Pinzon, MD, MS to adapt the tool for Spanish-speaking communities.

“We sent out a survey to healthcare providers asking what are the common pain metaphors that they hear from their Hispanic / Latino patients,” says Lor. “Then we take those findings to the community to ask, ‘What does this mean to you?’ And we map their responses the same way we did for the Hmong patients.”

She’s also exploring adapting the tool for both rural and urban English-speaking older adults.

“My goal is to adapt my pain communication training program for all caregivers,” says Lor.

–Diane Farsetta