Chronic pain and health inequalities: why we need to act

Cassandra Macgregor; David N. Blane; S. Josephine Pravinkumar; Gregory Booth

doi:10.1515/sjpain-2022-0148

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Chronic pain and health inequalities: why we need to act

Cassandra Macgregor , David N. Blane , S. Josephine Pravinkumar und Gregory Booth

Veröffentlicht/Copyright: 21. Dezember 2022

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Aus der Zeitschrift Scandinavian Journal of Pain Band 23 Heft 2

The study by Jain et al. [1] in this edition draws attention to the mismatch in provision of pain care, relative to needs, in England. They raise a similar concern to Moore et al. [2] regarding outcomes for a pain management programme in Scotland; given the known higher prevalence and severity of chronic pain in areas of deprivation, these needs are not reflected in service provision. In this editorial, we draw attention to health inequalities in chronic pain, how we can better understand them, and what we can do about them. We focus on the UK, which has wider socioeconomic and health inequalities than our Scandinavian counterparts [3].

Health inequalities are commonly defined as: systematic, avoidable and unfair differences in health outcomes between groups of people [4]. Health inequalities can be conceptualised in relation to the literature on social determinants of health: the social, economic, and political conditions that influence individual and population health [5, 6]. The fundamental, ‘causes of causes’ of health inequalities are an unequal distribution of income, power and wealth reflecting wider socioeconomic inequality [7]. Countries with higher income inequality tend to have worse population health outcomes [8]. The ‘causes of causes’ include macro policies governing access to education, reproductive rights, housing, secure employment, de/regulation and marketization of healthcare. These can be understood as upstream factors, which flow ‘downstream’ to the ‘effects of causes’ including individual behaviours, lifestyle and biological factors [5, 9], [10], [11].

The distribution, quality, and access to healthcare are also important [5, 12]. Jain et al. [1] and Moore et al. [2] draw attention to the ‘Inverse care law,’ which states: “the availability of good medical care tends to vary inversely with the need for it in the population served.” [13] These studies both focused on chronic pain services, however, most patients with chronic pain in the UK receive care in general practice, where the inverse care law also persists, with the most deprived areas, where need is also greatest, remaining underfunded and under-doctored [14].

Chronic pain is a leading cause of global disease burden impacted by health inequalities [15]. People living in more deprived areas are more likely to have chronic pain, and experience more disabling pain, with more medication prescribing, than those in less deprived areas [16], [17], [18]. Pain is common with multi-morbidity, where combined physical and mental health conditions increase with deprivation [19]. Furthermore, in predominantly white, high-income countries (e.g., UK and US), the prevalence of pain is higher among racially minoritised groups [17, 20], and female gender/sex [17, 21]. Therefore, we support an intersectional conceptualisation of health inequalities in chronic pain, incorporating a nuanced, contextual understanding, including place [10].

Current events could widen inequalities in chronic pain, including the Covid-19 response and ‘digital divide’, climate change and the cost of living crisis in the UK. Action should be taken on addressing barriers to digital healthcare, including access to technology, digital skills and education [22]. Emerging evidence further suggests remotely delivered pain management programmes may be less acceptable to some due to issues with confidentiality and childcare [23]. Climate change, including periods of extreme heat, will place higher risk on older people, further exacerbating inequalities experienced with aspects of deprivation [24].

What can we do about health inequalities in chronic pain?

Jain et al. [1] stress the differing level of need with deprivation for chronic pain services. Marmot’s ‘proportionate universalism’ is useful here, emphasising the need to target resources to where needs are greatest. Population health centres health inequalities in analysis and public health teams can make an important contribution to chronic pain service planning, across domains of health intelligence, improvement and service delivery [12, 25]. It is important to collect sufficient data to understand health inequalities at the service level. Outcome datasets for pain services such as Laskawska et al. [28] could be understood in the context of area deprivation level, gender, ethnicity, and other protected characteristics, helping to better understand who does and does not benefit from services across population groups and highlight areas for improvement.

Greater appreciation of the intersectional nature of health inequalities should lead us to question assumptions we may make about our patients, leading to more informed and shared decisions about healthcare access and needs. As clinicians, we should routinely enquire about capacity to ‘make ends meet’ [26], and signpost to supporting services. We play a role in supporting patients to adapt to living with long term pain and this can include the complex issue of managing work, at the interface of multiple social determinants of health [27]. Given the comorbidity of chronic pain and mental health conditions, and complex biopsychosocial impact of distress, we endorse a trauma informed approach to chronic pain services [28].

Researchers should be mindful that many studies are exclusionary, and this has implications for guideline development, health and healthcare. Future research should focus on including marginalised/underserved groups to improve their representation in chronic pain research [9, 29, 30]. Like healthcare, there is need to improve data collection and analysis on aspects of inequalities/social determinants of health. Reporting guidance such as the PRISMA equity extension for systematic reviews includes ethnicity, occupation, gender/sex, education and socioeconomic status [31] and the authors acknowledge the important contextual nature of these potential categories of discrimination.

Summary

The UK has reduced public expenditure and real terms funding for both the NHS and local authorities, causing significant concerns for health equity [3]. Health inequities could be reduced by appropriate government policies [6], with downstream actions likely to be less effective if not accompanied by upstream actions [5]. Therefore, given the fundamental causes of health inequalities as unequal distribution of income, power and wealth, this involves macroeconomic policies of wealth redistribution. While in healthcare, we can take actions to mitigate the impact of inequalities, we should be cautious of attempts to move responsibility for inequalities away from government with the current direction of travel one of significant concern for health inequalities [32]. Improving population health requires multisector working including government at all levels [12] and we should advocate for this.

Corresponding author: Cassandra Macgregor, Department of Physiotherapy and Paramedicine, School of Health and Life Sciences, Glasgow Caledonian University, Cowcaddens rd., Glasgow, UK, E-mail: Cassandra.Macgregor@gcu.ac.uk

Funding source: Cassandra receives a jointly funded GCU NHSL PhD studentship

Research funding: This work was funded by GCU NHSL PhD studentship.

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Published Online: 2022-12-21

Published in Print: 2023-04-25

Artikel in diesem Heft

https://doi.org/10.1515/sjpain-2022-0148