Intersectionality as a theoretical framework for researching health inequities in chronic pain

Reframing pain care: An equity lens on psychosocial and behavioural interventions

This review critically examines psychosocial and behavioural interventions for chronic pain through an equity lens. We interrogate relevant literature drawing on three key organising principles; justice, access, and knowledge, to illustrate systemic inequities in pain interventions. Current approaches often overlook the social dimensions of pain, perpetuating disparities rather than addressing them. We argue for a justice-centred perspective that recognises epistemic injustice and the need for inclusive practices in intervention development and service delivery. By integrating diverse methodologies and amplifying marginalised voices, we can create more effective and equitable treatments, ultimately improving outcomes for those disproportionately affected by chronic pain.

Opioid Prescriptions for Low Back Pain among Military-Connected Older Adults Across Multiple Care Systems

BACKGROUND

Untreated low back pain (LBP) in older adults can lead to disability and development of chronicity. Due to the potential development of medical comorbidities and negative risks associated with pharmacological use, chronic LBP management for older adults requires a responsive approach.

METHODS

The objective of this study is to evaluate the probability of (1) opioid prescription receipt and (2) opioid-sedative coprescription, in a sample of military-service-connected patients enrolled in the Veterans Health Administration (VHA) or TRICARE, ages 30-85 years, receiving care in three systems: VHA, Military Health System (MHS), and nonfederal (civilian) healthcare facilities. Generalized linear models evaluated inequities across intersections of age, race and ethnicity, and care system.

RESULTS

Age was negatively associated with opioid-sedative coprescription receipt (p < 0.001) but was not significantly associated with opioid prescription receipt (p = 0.09). Across both models, Asian and Pacific Islander, Black, and Latine patients were less likely than white patients to receive either outcome (p < 0.001-0.002). Opioid-sedative coprescription probability decreased across age for Asian and Pacific Islander (p = 0.003) and Latine (p = 0.01) patients in the MHS but increased in white patients.

CONCLUSIONS

It is imperative that clinicians and healthcare systems provide effective and sustainable treatment for LBP in older adults, including programming, that enhances shared decision-making and whole-health approach championed by the VHA.

Considerations of equity in the development of tools that identify and respond to end-of-life carer support needs: a scoping review protocol

INTRODUCTION

Informal caregivers are essential in supporting end-of-life patients at home but are often ill-prepared for the carer role. There is growing interest in the development of tools to assess caregiver support needs and a recognised need for a greater focus on addressing inequities in end-of-life care. We plan to undertake a scoping review of available literature to (1) identify and describe tools developed to assess the support needs of informal caregivers in end-of-life care; (2) report on any inequities and under-represented groups in tool development and use.

METHODS AND ANALYSIS

The review will conform to best practice methodological guidance (Joanna Briggs Institute) for scoping reviews. The search strategy will target published and unpublished studies using any methodology, which reports on developing or using tools or measures to assess informal carer support needs in end-of-life/palliative care settings. The following databases will be searched: MEDLINE, CINAHL, PsycINFO, Web of Science, ASSIA and Proquest. Both title/abstract screening and full-text assessment will be undertaken to ensure eligibility. Searches will be conducted between May and December 2024. We will extract data relating to (1) tools/measures identified, and outcome measures used to assess these; (2) participant characteristics. Extracted data will be tabulated with accompanying narrative description to address the review objectives. Data will be extracted and write-up will be completed between January and May 2025.

ETHICS AND DISSEMINATION

This scoping review will provide an overview of the tools developed to identify and assess informal caregiver support needs in palliative and end-of-life care. The identification of any inequities will increase awareness of potentially underserved groups and contexts within the current literature, highlighting how future research and resource can be more equitably focused and implemented in a way that does not further embed disparity. Findings will be made publicly available through the Open Science Framework and disseminated through a peer-reviewed publication. As a scoping review of available literature, this work does not require ethical approval.

Othering and ethics of belonging in migrants' embodied healthcare experiences

At a time when national identities are being reasserted in Western Europe alongside moral and intellectual visions of a cosmopolitan order more inclusive than nationalism, what does belonging mean for immigrants who are non-Europeans, particularly for women from South Asia, Africa and the Middle East? Based on the lived experiences of 23 women of diverse backgrounds, who are first-generation immigrants, regarding their experiences while accessing the healthcare system in Zurich, Switzerland, I illustrate through migrant experiences how Othering and belonging are experienced within the web of chaotic meanings and social space one navigates. By employing a phenomenological-sociological approach, I present how embodied migrant experiences can capture the experiences of being an 'Other', as well as how moral emotions such as shame and humiliation can influence one's moral self and its significance to everyday moral discourse. While much of the academic discourse around belonging focuses on a place and its related connectedness to one's racial, gender and ethnic identity, here, I analyse cosmopolitanism's possibilities through Othering/belonging experiences within the healthcare context, and beyond. I conclude this paper with the key contributions of the ethics of belonging to the normative discourse on migration health.

Pain Disparities Attributed to Linguistic Minoritization in Health Care Settings

There is a paucity of understanding about how language influences pain communication and outcomes for families who speak languages other than English in the United States. This is of great importance because 21.6% (68 million) of the population speak a language other than English, with 8% (25 million) of the population speaking English "less than very well." Thus, the aim of this paper is to present a narrative review that describes how spoken language influences pediatric pain assessment and outcomes for children who speak languages other than English and discuss hypothesized factors that contribute to pain disparities in hospital settings. Results from the narrative review reveal that children and families who speak languages other than English have disparate pain outcomes compared with children from English-speaking families. It is hypothesized that individual (eg, clinician bias), interpersonal (eg, miscommunication of pain concepts), cultural (eg, misunderstanding of cultural concepts of pain), and systemic (eg, lack of access to interpretation services) factors influence disparate pain outcomes for linguistically minoritized children. Empirical research, including randomized control trials, regarding hypothesized factors that contribute to pediatric pain disparities for language other than English-speaking children, is severely lacking. Thus, improved understanding of pain concepts and pain communication processes that center individual, interpersonal, cultural, and systemic factors will enable future research to design interventions that enhance culturally relevant pain assessment and management for families who speak languages other than English. PERSPECTIVE: This article summarizes factors that contribute to pain disparities for children who speak languages other than English. Hypothesized factors that contribute to pain disparities for language other than English-speaking children and families include clinician bias, misunderstanding of pain concepts, and lack of access to interpretation services.

The sociocultural context of adolescent pain: portrayals of pain in popular adolescent media

ABSTRACT

Research has consistently suggested that media consumption plays a vital role in children's socialization, including the socialization of painful experiences. Past research examining young children's popular media revealed worrisome trends in media depictions of pain; it consisted of narrow depictions of pain, gender stereotypes, and an overwhelming lack of empathy from observers, which could contribute to pain-related stigma. Research has not yet examined how pain is portrayed in adolescent media, despite adolescence being the developmental period when chronic pain often emerges. The current study extracted a cross-section of popular adolescent media selected based on popularity, including 10 movies and the first seasons of 6 TV shows. Pain instances were coded using 2 established observational coding schemes assessing sufferer pain characteristics and observer responses. Across 616 instances of pain, there was a preponderance of violence and injuries, whereas everyday, chronic-type, and medical/procedural pains were seldom represented. Individuals from marginalized (ie, gender diverse, girls) and minoritized groups (individuals with racialized identities) were underrepresented in pain instances. Furthermore, regardless of observed gender or "race," observers displayed a lack of empathy for sufferers and rarely engaged in prosocial behaviors. Popular media may serve as an agent of socialization in adolescence; thus, pain depictions may be a powerful force in propagating pain-related stigma and inequities. An opportunity exists to harness popular media to adaptively and accurately portray pain to adolescents.

Documenting Race and Gender Biases in Pain Assessment and a Novel Intervention Designed to Reduce Biases

Disparities in pain care are well-documented such that women and people of color have their pain undertreated and underestimated compared to men and White people. One of the contributors of the undertreatment of pain for people of color and women may be the inaccurate assessment of pain. Understanding the pain assessment process is an important step in evaluating the magnitude of and intervening on pain disparities in care. In the current work, we focus on documenting intersectional race and gender biases in pain assessment and present the results of a novel intervention for reducing these biases. Across 3 studies (N = 532) and a mini meta-analysis using real videotaped people in pain as stimuli, we demonstrate that observers disproportionately underestimated women of color's pain compared to all other groups (men of color, White women, and White men). In study 3 (N = 232), we show that a novel intervention focused on behavioral skill building (ie, practice and immediate feedback) significantly reduced observers' pain assessment biases toward marginalized groups compared to all other types of trainings (raising awareness of societal biases, raising awareness of self-biases, and a control condition). While it is an open question as to how long this type of intervention lasts, behavioral skills building around assessing marginalized people's pain more accurately is a promising training tool for health care professionals. PERSPECTIVE: This article demonstrates the underestimation of pain among people of color and women. We also found support that a novel intervention reduced observers' pain assessment biases toward marginalized groups. This could be used in medical education or clinical care to reduce intersectional pain care disparities.

An ecosystem of accepting life with chronic pain: A meta-ethnography

Background

Chronic pain is a highly prevalent long-term condition, experienced unequally, impacting both the individual living with pain, and wider society. 'Acceptance' of chronic pain is relevant to improved consultations in pain care, and navigating an approach towards evidence-based, long-term management and associated improvements in health. However, the concept proves difficult to measure, and primary qualitative studies of lived experiences show complexity related to our socio-cultural-political worlds, healthcare experiences, and difficulties with language and meaning. We framed acceptance of chronic pain as socially constructed and aimed to conceptualise the lived experiences of acceptance of chronic pain in adults.

Methods

We conducted a systematic search and screening process, followed by qualitative, interpretive, literature synthesis using Meta-ethnography. We included qualitative studies using chronic pain as the primary condition, where the study included an aim to research the acceptance concept. We conducted each stage of the synthesis with co-researchers of differing disciplinary backgrounds, and with lived experiences of chronic pain.

Findings

We included 10 qualitative studies from Canada, Sweden, The Netherlands, Ireland, UK, Australia and New Zealand. Our 'lines of argument' include a fluid and continuous journey with fluctuating states of acceptance; language and meaning of acceptance and chronic pain, a challenge to identity in a capitalist, ableist society and the limits to individualism; a caring, supportive and coherent system. The conceptual framework of the meta-ethnography is represented by a rosebush with interconnected branches, holding both roses and thorns, such is the nature of accepting life with chronic pain.

Conclusion

Our findings broaden conceptualisation of 'acceptance of chronic pain' beyond an individual factor, to a fluid and continuous journey, interconnected with our socio-cultural-political worlds; an ecosystem.

Attending to Marginalization in The Chronic Pain Literature: A Scoping Review

Background

There has been a recent and, for many within the chronic pain space, long-overdue increase in literature that focuses on equity, diversity, inclusion, and decolonization (EDI-D) to understand chronic pain among people who are historically and structurally marginalized.

Aims

In light of this growing attention in chronic pain research, we undertook a scoping review of studies that focus on people living with chronic pain and marginalization to map how these studies were carried out, how marginalization was conceptualized and operationalized by researchers, and identify suggestions for moving forward with marginalization and EDI-D in mind to better support people living with chronic pain.

Methods

We conducted this scoping review using critical analysis in a manner that aligns with dominant scoping review frameworks and recent developments made to scoping review methodology as well as reporting guidelines.

Results

Drawing on 67 studies, we begin with a descriptive review of the literature followed by a critical review that aims to identify fissures within the field through the following themes: (1) varying considerations of sociopolitical and socioeconomic contexts, (2) conceptual conflations between sex and gender, and (3) differing approaches to how people living with chronic pain and marginalization are described.

Conclusion

By identifying strengths and limitations in the research literature, we aim to highlight opportunities for researchers to contribute to a more comprehensive understanding of marginalization in chronic pain experiences.

"Navigating chaos": Urban, Rural, and Remote Patient Experiences in Accessing Healthcare with Indigenous and Non-Indigenous Perspectives of Living with Chronic Low Back Pain

Background

Healthcare access for chronic low back pain is complex and should consider not only the health system, but patient care seeking experiences as well. People who live in rural and remote communities and/or identify as being Indigenous may often encounter additional barriers to accessing care for chronic low back pain; thus, these contexts must be considered to fully understand barriers and facilitators.

Aims

The aim of this study was to understand care-seeking experiences of people living with chronic back pain in Saskatchewan and determine unique experiences facing urban, rural, remote, and/or Indigenous peoples.

Methods

Thirty-three participants with chronic low back pain completed a preliminary survey followed by individual semistructured interviews. Participants were categorized as urban, rural, or remote including Indigenous status. A qualitative interpretive research approach with inductive thematic analysis was employed.

Results

Three overarching themes were identified with the following subthemes: (1) healthcare access challenges: challenges to accessing care, challenges within the health system, and challenges leading to self-directed management/coping strategies; (2) healthcare access facilitators: funded care, participant education and knowledge, patient-provider communication, and care closer to home; and (3) participant recommendations for improved care provision: coordination of care, integrative and holistic care, and patient-centered care and support. Rural and remote participants highlighted travel as a main barrier. Indigenous participant experiences emphasized communication with healthcare providers and past experiences influencing desire to access care.

Conclusion

Participants identified a range of challenges and facilitators as well as recommendations for improving access to care for chronic low back pain, with unique barriers for rural, remote, and Indigenous participants.