Aim

We address the research gap by aiming to gain first insights into pastoralists’ perceptions and notions of chronic pain. Therefore, the leading research question at the heart of this article is: How do Somali pastoralists perceive their chronic pain?

This study is part of a larger research program addressing pain management in the Somali Region. As part of the Jigjiga One Health Initiative (JOHI), our study follows a transdisciplinary approach, involving academic and non-academic actors in a transformational research process integrating systemic and practical knowledge [33–35]. JOHI is a research-development project implemented in the Somali Regional State (SRS) in Ethiopia and reaching out to Somaliland and Somalia. It aims to create innovative integrated health systems addressing the health and wellbeing of pastoralist communities.

Study design

To explore sociocultural aspects of pain perception and corresponding experiential and existential domains, we chose an explorative qualitative design guided by the Framework Method [36, 37]. This method seemed particularly suitable for working in multidisciplinary teams with people of different professional and cultural backgrounds. Moreover, this approach to exploring pain perception also provided the possibility of informing both policy and practice [38]. To report this study, we used the Consolidated criteria for reporting qualitative research (COREQ) checklist (S1 Appendix) [39].

Theoretical framework

The Enactive Approach to Pain proposed by Stilwell and Harman [14] served as the theoretical framework for this study. It complements Engel’s biopsychosocial model [40]. The original biopsychosocial model attempts to incorporate the social, psychological and behavioral dimensions of illness into the biomedical disease model. It intends to improve the understanding of a person’s perceived illness in a broader manner compared to preceding models representing a strict biological focus [40]. The enactive pain approach goes beyond the biopsychosocial model by doing justice to the lived embodied experience of persons affected and to the importance of their perceived sense of social agency. Positioned at the center of the enactive framework, is the idea of a “field of affordances” [14, 41], a concept first introduced by Gibson in 1979 [42]. Coninx and Stilwell [41] conceptualize pain in terms of “affordances” defined as “perceived possibilities for action” (p. 7837). The enactive approach comprises three central domains: the physiological domain, the phenomenal-existential domain, and the socio-cultural domain. The phenomenal-existential domain refers to the individuals’ self-perception of pain and of the world around them.

This framework is especially compatible with our study since it gives room for persons’ lived experience of chronic pain and considers the impact of the environment on individual pain experience. Its holistic and integrative nature steers against the methodological risk of reductionist fragmentation and allows to overcome strictly separated disciplinary domains in research and clinical practice. The enactive approach to pain stipulates that the biological, psychological and social domains are continuously conditioned by each other and subject to cross-cutting processes [14, 41].

Sampling

Eligible were adult pastoralists or agro-pastoralists with chronic pain, as defined by the International Association for the Study of Pain (IASP) [1]. Pastoralists with cognitive impairment and/or communication difficulties, as well severely ill patients (determined by the responsible health professionals) were excluded from our study. Initially, we identified participants by using a purposive sampling strategy aiming at maximum variability (e.g., concerning age, gender and additional diagnoses) [43]. At a later stage, the study also followed a chain referral sampling for pastoralists with chronic pain not treated within a healthcare facility. This technique is particularly useful to gain access to hard to reach population segments [44].

Setting and recruitment

The study took place in primary, secondary and tertiary care facilities in the SRS as well as in pastoralist communities. We selected the study sites based on considerations of regional diversity and rural/urban differences. In doing so, we intended to gain insights into heterogeneous perceptions of chronic pain. In addition, we were interested in differences in pain severity across study sites, organizational features and care. For instance, we anticipated that we might speak to patients with more severe pain conditions in the hospital setting.

On the primary care level, we interviewed patients in two health centers in a rural area, each treating up to 25 patients per day. On the secondary care level, we recruited patients in a hospital with about 100 beds, also located in a rural area. On the tertiary care level, we recruited patients of a hospital in a more urban region. The tertiary care hospital is the largest hospital of the SRS, with more than 300 beds. We recruited pastoralist patients in these healthcare facilities with the support of the responsible health professionals. We discussed whether the current health condition of purposively selected patients allowed participation in our study.

Finally, we also interviewed pastoralists in rural communities. We chose this additional setting to reach pastoralists with chronic pain who were not receiving biomedical care. Thereby, we hoped to gain insight into possible reservations about health facilities, among other things. Pastoralist community representatives acted as gatekeepers introducing us to potential participants.

Data collection

This study was conducted between July 2020 and January 2021. We selected semi-structured interviews for data collection to explore sociocultural aspects of pain perception, in addition to corresponding experiential and existential domains [41]. Preceding the interviews, we conducted two preliminary focus group discussions with a convenience sample of pastoralist community members. To ensure that participants felt free to express their opinions and thoughts on the topic, we separated males (n = 11) and females (n = 8) for discussion. In the focus group discussions, we addressed (among other things) the topic of chronic pain in general. In the open-ended questions, we for instance asked: “What health concerns are currently most important for you and/or your community?” or “How do you experience pain in your everyday life?” [26, p. 2–3]. In addition, we also organized a stakeholder workshop and discussed the topic together with pastoralist community representatives, health professionals and policy makers. During this preliminary project phase, we wrote down first impressions related to pain perceptions. We also drafted the interview guide inspired by Kleinman’s explanatory model of illness [45]. The guide addressed five principal questions concerning, for example, etiology, pathophysiology, time, course and treatment of an illness. This approach contributed to the culture-specific understanding of a sickness episode. The findings from the focus group discussions and the workshop informed us that pain was a challenging concept to speak about [26]. We found no specific term for pain in the Somali language, as described in other research [46]. Therefore, we paid particular attention to this terminological challenge during the development of the interview guide (S2 Appendix). We piloted the guide through rigorous internal and field testing with two health professionals and two pastoralists. To encourage detailed descriptions and explanations, the questions of the semi-structured interviews were open-ended, followed by neutral probes [47]. The interview started by inquiring on general perceptions of the person’s pain, followed by more specific questions concerning the impact of pain on daily life and personal pain treatment practices.

The interview language was Somali. Interviews lasted from 20 to 36 minutes. Three members of the research team conducted the interviews, including two interpreters who were fluent in Somali and familiar with the Somali pastoralist culture. For cultural reasons and due to experiences during preliminary work, female researchers conducted the interviews with female pastoralists.

Interviews in the health centers took place in a quiet location outside the building. In secondary and tertiary care hospitals, interviews took place at the patient’s bedside. Within pastoralist communities, we interviewed the participants in front of their residences. After each interview the research team discussed first impressions and noted them in a research diary [36]. We audio-recorded the interviews, transcribed them word for word and anonymized them (EB, SA). A member of the research team fluent in both English and Somali translated the transcripts into English.

Data analysis

To systematically analyze the data on a case by code basis, we applied the Framework Method according to Gale et al. [36]. This matrix-based analytic method facilitates rigorous and transparent data management. It allowed us to perform all stages of the analysis in a systematic manner [37, 48]. The Framework Method permitted us to move back and forth between different levels of abstraction without losing sight of the original data [37]. Three researchers (EB, PvE, SA) experienced in qualitative research were involved in the data analysis. We used MAXQDA 2022 software for support.

After becoming familiar with the transcripts and field notes (stage 1), we wrote initial reflective memos and discussed them with the team in regular analysis meetings (stage 2). Inductive coding allowed us to remain open to unexpected concepts (stage 3). After coding several transcripts, we agreed on a set of codes that we applied to the other transcripts, thereby forming an analytical framework (stage 4). We clearly defined codes that we had grouped together as categories. After applying the framework to all remaining interviews (stage 5), we charted the data (including illustrative quotations) into the framework matrix–with the aim of comparing the identified themes in the text (stage 6). In the final stage (7), EB wrote four extensive analytic threads and discussed them with the research team [49]. Due to the richness of the data, we decided to focus on one analytic thread in more detail at the heart of this article.

Context of the researchers

The first author is a PhD student experienced in applying as well as teaching qualitative research methods. She has a background in nursing and spent time working as a nurse in the Global South. Prior to conducting this research in Ethiopia, the first author was not familiar with the local context and culture. For initial familiarization, she participated in a stakeholder workshop with pastoralist community representatives and in two focus group discussions about more general health problems and needs with pastoralists in the Somali Region.

The second author is an experienced lecturer at Jigjiga University (JJU) in the Department of Health Science. He has a background in nursing and works in different research projects as a supervisor and researcher.

Trustworthiness

To ensure trustworthiness, we followed the criteria proposed by Lincoln and Guba [50]. By triangulating data derived from the researcher’s notes from the preliminary focus group discussions, stakeholder workshop, and interviews, we addressed credibility. We ensured transferability by providing detailed information on the study context, the methods and the research procedure, by ensuring a heterogenous sample in various settings and by considering rich descriptions of participants’ experiences. This allows for a clustering of patterns in similar contexts and, based on this grouping, a certain generalizability. To increase dependability, we repeatedly discussed initial patterns and interpretations of the emerging codes within the multidisciplinary research team. This contributed to a high degree of reliability and consistency of the research findings. The team members established confirmability by discussing the reflective memos portraying the respondents’ statements. This is a way of minimizing researchers’ biases and assumptions. One co-author (PvE) supported data analysis and was not involved in the data collection process in the field. Therefore, he provided a more external perspective on the results and interpretations.

Ethical considerations

The University of Jigjiga Ethical Review Board in the SRS approved this study (Ref. No: RERC/020/2012E.C). The Ethics Committee of Northwest and Central Switzerland (EKNZ) confirmed the fulfilment of ethical and scientific standards (Ref. No: 2020–00338). Half of interviewees were illiterate. Therefore, we also informed orally about the study and made sure a family member was present who was able to understand the written study-related information. All interviewees signed an informed consent form prior to the interview. If the interviewee was illiterate, the consent form was signed by a fingerprint. In addition, the participant’s literate representative also signed the consent form. Participation was voluntary and could be discontinued at any time. We performed this research in line with the ethical standards in the Declaration of Helsinki [51].

Participant demographics and their pain conditions

We interviewed a total of 20 pastoralists with chronic pain. All were Muslim and except for one from the Somali ethnic group. Seven participants were agro-pastoralists, the other participants were mobile pastoralists. Most participants were married and had an average number of five children. The average number of household members was nine. Half of the participants had completed at least primary school, with the other half having no formal school training. Further sociodemographic and pain-related information is depicted in Table 1. We recruited five pastoralists (ID16 –ID20) outside the health facilities and interviewed them at their homes. At the time of the interview, participants in the hospitals and health centers reported a higher pain intensity on average than participants in the community.

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Table 1. Sociodemographic information and pain allocation.

https://doi.org/10.1371/journal.pone.0293137.t001

Table 1 allowed us to consider the epistemological differentiation proposed by Kleinman [52]. “Disease” is conceptualized as a biological phenomenon (outsider’s or etic view) and “illness” as a cultural construction (insider’s or emic view). Based on this distinction, the category of “pain localization” (Table 1) represents the subjective emic perspective of pastoralists: How did they themselves describe their pain and how did they understand their lived illness experience? By contrast, the category “suspected (other) diagnoses, (potential) causes of pain” provided information on the objective, scientific etic perspective held by health professionals. This category was based on the diagnosis provided in the health facility and thus represents the biomedical diagnosis.

Pastoralists’ perceptions of pain

Our analysis suggests that participants’ perceptions of their chronic pain can be clustered into six different themes: “Pain as a symptom of harsh daily life”, “Pain descriptions and dimensions”, “Temporality of pain”, “Stigma and stoicism”, “Mediating role of spirituality”; and “Impact of pain on daily life activities”. These themes are related to the main domains of the biopsychosocial model [40] and the approach of Stilwell and Harman (Fig 1) [14].

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Fig 1. Chronic pain perception of Somali pastoralists.

Inspired by Coninx and Stilwell [41] and de Haan [53].

https://doi.org/10.1371/journal.pone.0293137.g001

We deliberately avoided a clear attribution of chronic pain perception to one specific domain since this would lead to a significant loss of notion and experience. Hence, the model represents the overlap of domains and is intended to represent the fluid and dynamic nature of pain perception.

Pain as a symptom of harsh daily life

Most participants and particularly pastoralists from rural areas described pain as something normal everyone must face. Pain was part of their daily life and, therefore, something they had learned to live with. The majority of interviewees described loading animals, harvesting or fetching and carrying water over long distances as strenuous activities that were part of their daily routines. However, they rarely described such daily activities as the sole cause of their pain. A few participants mentioned that they had experienced female genital cutting (FGC) themselves or knew someone in their community who had undergone FGC. Yet they did not bring up that they currently suffered from pain due to FGC.

At first, the interviewees often described pain as an acute event related either to an injury from an accident or fight or to childbirth. By applying more in-depth probing questions, we could also reveal their perceptions of chronic pain. In rural areas, such as at the primary care level or in the community, pastoralists most commonly associated their chronic pain with a communicable disease such as malaria, typhus or tuberculosis. This became evident when interviewees spoke of being sick in general or having a fever. This was not surprising due to the connotation of the word (i.e., the Somali word for “pain” meaning both pain and illness). As an example, a woman in a rural area referred to the harsh conditions she and the members of her community live in:

“In our entire life, everybody will experience pain, you might suffer from labor pain. […] We may feel headache, even you may feel headache in the evening if you work and walk during the day. There also may be malaria. But we receive medication for that. I have not suffered from headache. But I did get malaria. So, I got treatment for it within a short time. Everyone who stays here might get malaria.” (ID20, line 16)

Participants described pain as a distinctly relational phenomenon, a bodily sensation that rarely existed on its own. They associated it as a symptom of some other form of physical ailment. Interestingly, one participant stated that the health professionals were the ones who gave pain a particular name. This allowed the participant to make sense of his pain. Interviewees perceived chronic pain as something that often changed its intensity over time, for instance, depending on the sort of activity they had to undertake or depending on the time of the day.

In secondary and tertiary health facilities, however, we found that patients described their pain as no longer “bearable” in daily life. They had tried to “stay” with the pain as long as possible at home before taking on the often very long and costly journey to the next hospital. The pastoralists decided to come to the hospital when they were no longer able to cope with their pain. Commonly, they described this experience as no longer being able to conduct the chores expected of them.

Pain descriptions and dimensions

To communicate the pain experience, pastoralists often used figurative language, metaphors or anthropomorphisms. They compared their pain with something that resembles it–in order to create understanding. Metaphors and anthropomorphisms served as a means to convey the quality of the pain, its duration and association. Most participants mentioned that their pain was very severe when they had decided to seek care. At the time of the interview, most participants stated having moderate pain. To illustrate the severity of pain and its consequences, an elderly man used a figurative language:

“People were recommending me to stay and wait until it disappears on its own and then I felt severe pain. Even my hair became grey last year from the tumor due to the pain.” (ID16, line 17)

While talking to us, the man pointed at this hair. With this gesture, he directed our attention to the obvious consequences of severe pain–his white hair as a visible proof of very intensive pain. Another participant mentioned the self-treatment for pain by burning his own skin. When this treatment did not help, he described the anthropomorphism of “haunting” pain–as if pain were a human being persecuting the pain-affected person. Pain “breaking legs and toes” or “sucking a person’s blood” were further anthropomorphisms. Moreover, anthropomorphisms also served to indicate the effect of medication. A patient mentioned that the drug he received restituted his mobility:

“At first, I was in pain for a long time but it was not so severe and I just kept going so I used to take a pill called in local language “Habartosiye” which means a pill that makes old women stand up.” (ID7, line 17)

A female patient compared her pain experience with the feeling of her stomach “being cut”. She questioned the efficacy of the medication received for treatment. Her pain continued to be so unbearable at times that the only possible response was “to run away‟:

“Occasionally, I run away from my home due to the severity of the pain. I could not bear it. […] It is due to the severity of the pain, which is from gastritis. Sometimes I feel like my stomach is being cut. And maybe the medication is not the right one.” (ID9, line 13)

Participants clearly stated the importance of medication to treat their pain. In health facilities, they expected to receive a pharmacologic therapy. However, several of the interviewees reported that they did not receive the necessary pain medication. This was especially the case in primary care. The lack of pain relief resulted in doubts about the ‟right therapy‟. Patients’ non-compliance and discontinuation of medication were the consequences.

Some participants clearly attributed the pain to a specific location in the body. However, for others describing the pain location was more difficult. A female participant with several chronic conditions stated:

“My pain is generalized to most parts of my body. I cannot locate the exact place.” (ID4, line 16)

In addition, several participants used gestures, pointed to the pain location on their body or touched the painful area. Even when they were not able to determine the location or the direct cause, they perceived pain as a bodily issue and not as a psychological or psychosomatic problem. However, some pastoralists mentioned that their physical pain triggered negative emotions like sadness, anxiety or aggression.

Temporality of pain

Participants reported very different pain durations ranging from a couple of months to several years. Particularly, community members in rural areas mentioned having chronic pain for a very long time, even since childhood or adolescence. Although we focused on chronic pain in this study, some participants also reported acute painful conditions they experienced at the same time:

”I have been suffering from gastritis for around one year. Eating different meals aggravates the problem but currently I have been suffering from backpain and from a cough for fifteen days. Moreover, I have a headache, which is almost continuous. Now the pain I feel worst is backpain.” (ID8, line 12)

Another temporal aspect of chronic pain perception was the time of highest pain intensity. The majority of participants mentioned that their pain felt worse during the night. According to some interviewees, this was due to cold temperatures at night. One younger woman in primary care explained this assumption in the following way:

“Since it is cold at night, most of the body works less because the blood gets cold. Therefore, when you try to sleep, you feel more pain. But during the day, it is different because your body is hot and it works more.” (ID15, line 45)

Another young male participant in secondary care described his experience in a similar manner:

Q: “Why do you think pain is worse at night?”

A: “I don’t know why it is worse at night. Maybe it is due to the cold of the night.” (ID6, line 43)

Several participants mentioned their “blood becoming cold” at night. They related this to higher pain intensity. Only very few participants felt that the intensity of their pain was the same throughout the day and in the night.

Stigma and stoicism

In both genders, stoicism with regard to pain expression and reporting of pain was an issue that was often touched upon. Particularly in rural areas, stoicism or impassiveness was a topic–associated with age and marital status. Younger, unmarried adults and especially women were more inclined to bear or hide their pain, since they were more worried about stigma:

”Young unmarried women hide their pain but married women show their pain to their husband. […] She is afraid of being stigmatized, and also men may not come close to her due to her health condition.” (ID17, line 58)

In one interview, a woman mentioned hiding her pain to not worry other persons. She associated this attitude with her Muslim religion:

“The reason why we don’t describe our pain early when the pain is minor is–since we are a Muslim society–it is not good to terrify or scare people to worry them by complaining more about some minor pains.” (ID15, line 36)

Another female participant also described bearing her pain when it is less severe:

“It depends on the severity of the pain. If the pain is very severe and if I am able to communicate with the people, I can report the pain I am feeling. But if the pain is mild or minor, I will try to bear the pain, keep it to myself.” (ID9, line 40)

Similarly, an older male participant also stated that young men might not show their pain out of fear of social stigma:

“Young men also hide their pain, because they are afraid of being called a coward and maybe stigmatized while old men show their pain.” (ID17, line 56)

However, several men were of the opinion that women are particularly vulnerable towards pain because they “hide” or bear it and seek care at a very late stage. A male participant from a rural area, for instance, made the following statement:

“Men can bear the pain compared to women but women hide their pain. Women are being taken to the health center. They deliver there. So, they dislike that male health providers may observe or administer injections so they hide their pain. […] Currently, women get broken teeth frequently, because they hold their teeth tightly to stand the pain. Women frequently get sick, because when they get sick, they don’t seek health care.” (ID16, 53)

Pastoralist women themselves did not explicitly mention this kind of pain vulnerability. Some women, however, did describe uneasiness with regard to male health providers and difficulty reporting their pain to others. Several men mentioned that women felt ashamed or feared further health interventions or diagnostics if they informed others about their pain. From their point of view this may result in additional check-ups performed by male health providers.

Mediating role of spirituality

The vast majority of pastoralists expressed deeply religious feelings. Their statements revealed that spirituality played a crucial part in the perception of their pain. According to their religious conviction, pastoralists from rural areas mentioned that their destiny is in the hands of Allah:

“Allah is the one who causes the pain, everyone will get it.” (ID20, line 31)

Participants mentioned that they trusted Allah to know the source of their pain. For example, an elderly man said:

“I don’t know why I am suffering from this pain; Allah may know.” (ID8, line 64)

Similarly, a younger woman answered the question “Why do you think you are suffering from this pain?” in the following way:

“Allah may know, I took a lot of medications.” (ID9, line 17)

Another woman emphasized that her fate is in Allah’s hands:

“My illnesses will be either managed or not managed. Thanks to Allah.” (ID18, line 9)

In rural primary care as well as in the community setting, dealing with pain was strongly associated with spiritual practices. Participants mentioned praying and reciting the Koran as the most important initial care practices to improve one’s health or the health of other sufferers. One participant described her faith and care seeking behavior in the following way:

“Religion is the backbone of our life. Whenever somebody gets sick, we first recite the Koran and then we may go to the health center.” (ID18, line 27)

For pastoralist patients, practicing Islam was a way to deal with their pain in an early stage, commonly followed by home remedies/traditional medicine or visits to the traditional healer–before finally seeking care in a biomedical health facility.

Impact on daily life activities

On the one hand, participants emphasized that pain was part of their daily life. On the other hand, they also described the negative impact of chronic pain on their daily lives. Most participants mentioned the consequences of severe pain on their work. They were no longer able to carry out their chores as required due to their impaired mobility. Several male participants mentioned that taking care of their livestock and sustaining the family became difficult due to their chronic pain. This could finally lead to feelings of hopelessness:

“It [the pain] affected me more even I could not keep my sheep and one of the sheep got a leg fracture [i.e., the animals were neglected]. And I have six children and I couldn’t do anything for my children. That was the impact of the pain on daily life.” (ID3, line 56)

Women reported no longer being able to clean and cook or feed their children. One participant’s husband described that men are affected when women are in pain:

“When the woman gets sick, is suffering from pain–the whole home is affected and everyone in the home feels it. Most of the home activities are not done well.” (ID1, line 89)

Interviewees described becoming more and more dependent on other family members. They also mentioned financial difficulties and precarious situations due to loss of income:

“The pain had a great impact on my wealth, my life and my family, slaughtering and selling different sheep or goats, visiting different health facilities, and also I lost weight. It was hard for me to work.” (ID17, line 81)

Moreover, some participants reported that families were forced to sell their animals to pay for treatment:

“Currently we only own few livestock, we used to have more, we sold some of our animals to pay for her treatment and some others died due to the drought.” (ID9, line 55)

In this context, a participant described his situation as follows:

“I used to own more animals, but they became less. Some got lost because there was no one who could tend to them, while some others covered my expenses for treatment.” (ID17, line 93)

The majority of participants mentioned their threatened position within the community as a consequence of chronic pain. They were no longer able to engage in social and religious activities. Social isolation or marginalization became evident in the interviews when several participants expressed their wish to keep to themselves when in severe pain:

“I don’t like to stay with my friends because I can’t talk with them. They want me to converse with them like before so I can’t do that and I prefer to stay alone and take rest.” (ID2, line 40)

However, spending time with others and seeking distraction from pain was also a coping mechanism when pain was less severe:

“If the intensity of the pain is increasing, the person will be in bed even if the person is male. Now I feel better while I am conversing with you but when you leave the pain will relapse.” (ID1, line 93)

Strengths and limitations

In this study we interviewed a heterogeneous purposive sample of pastoralists with different chronic pain conditions. By applying ethnographic research techniques, we were able to gain a broader and more in-depth understanding of pastoralist patients’ chronic pain perceptions. By considering various settings, including urban and rural contexts as well as primary, secondary and tertiary levels of care, we were able to draw interesting comparisons. Importantly, we also interviewed pastoralists at their homes.

Our multidisciplinary research team allowed complementary, mutually enriching perspectives and, therefore, added to overall trustworthiness of the findings. Furthermore, our preliminary focus group discussions with 19 additional pastoralists increased the credibility of our findings.

A limitation of this study refers to a potential social desirability bias. Some participants might have described a more positive experience with health services in order to be in accordance with the researchers’ opinion. We minimized such bias by applying different strategies recommended by Bergen and Labonté [68]. For example, we stated that the expression of one’s personal opinion will not have any consequences. Furthermore, we tried to create a trusting environment with the interviewees by showing interest, empathy and respect. We also ensured confidentiality and a private atmosphere without the presence of a third person in most interviews. In the hospital setting it was not always possible to talk to women in private. Their husbands or other family members often remained at their bedside. Yet, we also learned that family members provided additional insights. Their presence sometimes motivated patients to share their story with us.

Another limitation refers to the lack of any direct observations concerning participants’ daily lives on a household level. Moreover, it was not possible to conduct additional interviews or to repeat interviews in order to fully establish data saturation of all themes due to political unrest and drought in the region during our field study. Finally, the sample size of 20 purposively selected pastoralists calls for recommendations to be considered with caution. Nevertheless, the qualitative findings allow a more in-depth understanding of pastoralists’ perceptions of chronic pain. They provide novel insights into their illness experience in diverse settings. The results contribute valuable knowledge on this marginalized population and can guide future studies with a larger sample size.