Barriers to pain treatment in low socio-economic groups

By: Dalainey Gervais

What is pain-bias?

Pain-bias is a sociological concept which views certain minority groups' pain as less valid than others, highlighting the inequities of healthcare. Often tied to the systematics dehumanization of lower income groups, individuals with low socio-economic status are overlooked in pain management treatment.

Research on poverty and pain

In the last year, Dr. Summers and their colleagues published research suggesting western stereotypes characterizing individuals of low socio-economic status as lazy and of frequently taking advantage of government programs such as pain management treatments provided by our healthcare system. These ideologies are detrimental in all settings, however even more dangerous in a health care setting.

The same study listed the following stereotypes of people living in poverty as those that most influence pain-bias:

1. Low socio-economic individuals are viewed as unbothered by pain as they are dehumanized (Summers et al, 2020)

This is the idea that low socio-economic status individuals are viewed as “less human” than the rest of the population. This infers that in being less human, the pain felt by low socio-economic individuals is less important and by default, less of a problem. The effects of the dehumanization of those living in poverty result in the rest of the population losing the sense of empathy for this group and invalidating their physical and mental pain.

1. Life hardships of low socio-economic people cause those individuals to be accustomed to pain and thus do not need pain management treatment. (Summers et al, 2020)

This stereotype suggests that the general population believes that those living with low socio-economic status have endured a painful life and are simply less sensitive to pain than those of higher socio-economic status. This ideology additionally suggests that those of higher status are more deserving of pain management as they have not lived as many hardships as those living in poverty. These biases make pain management treatment more accessible to those groups.

Although there is truth in the thinking that some groups have suffered more pain than others, it is dangerous to assume that the pain of those groups is less valid than others. Undermining the severity of people's pain can lead to horrible outcomes, with sickness and disease of low socio-economic individuals often being missed or ignored by health care professionals due to stereotyping.

Being turned away from healthcare services leads to a dangerous phenomenon labeled as poverty-induced self-medication. For many, taking a day off work to access healthcare services just to be turned away is not an option. And thus, rather than seeking appropriate medical advice, will turn to taking expired antibiotics, pharmaceutical drugs prescribed to someone else, or taking large doses of over the counter medication in hopes of getting better. The main danger of self-medication is overdose, and the creation of dependencies on non-prescribed drugs, leading to more health complications.

To evaluate the prevalence of stereotypes of low socio-economic groups, Dr. Summers and their team asked 126 mostly white middle-class Americans to rate their pain sensitivity in 18 situations on a 4-point scale, where 1 point is associated with un-painful situations, and 4 points is associated with extremely painful situations.

The same participants were then asked to complete the same task however to rate, using the same 4-point pain scale, how they believed 20 random white males would react to the same situations. The participants were given photographs of these men, where each was looking straight into the camera with a neutral facial expression. The photographs were additionally labeled with the men’s professions: 10 of these men were labeled with low-income jobs, and the other 10 were labeled with high-income jobs.

The results suggested that people do in fact have the assumption that those with lower income jobs would attribute higher pain tolerance to situations that high income individuals would rate as extremely painful.

Call to Action: Why addressing your underlying prejudices is so important

It's important to share information on how pain-bias is created by stereotypes of low socio-economic groups, as well as its relationship to healthcare, because we live in a culture reliant on accessibility to healthcare services. The diverse group of individuals with low socio-economic status have all lived different lives, and all must be addressed equitably through our healthcare systems.

We can no longer disregard the prevalence of pain-bias as it affects many communities outside the low- socio-economic population. Another minority group often facing the consequences of pain-bias are women, who visit health care professionals for mental and physical pains and are turned away. Pains caused by fertility based illnesses such as endometriosis and polycystic ovarian syndrome are historically undermined by medical professionals due to the prominent effects of pain-bias in our culture.

A 2017 article published by Harvard Health Publishing identifies that in the United States, women in hospital emergency rooms for acute abdominal pain wait on average 16 minutes longer than men experiencing the same symptoms.

A 2000 study highlights a leading cause of gender based pain-bias, reminding us that the majority of medical research is based on male physiology suggesting a lack of research and understanding of women physiology and pain. The study conducted by Dr. Nabel from the Bethesda National Heart, Lung, and Blood Institute indicates the importance of research in women’s heart disease. Symptoms of heart attacks and strokes present differently in men and women, resulting in largely preventable diseases being unrecognized in women.

Shared experiences of being undermined by healthcare providers may also create a culture of fear and distrust of the healthcare system by individuals with low-socioeconomic status. As part of the Right Place, Right Time: Health Information & Vulnerable Populations research program funded by the Robert Wood Johnson Foundation, interviews were conducted with individuals from vulnerable populations to better understand their concerns with the healthcare system. The 2016 Marketplace Perspectives on Providing Health Information to Vulnerable Populations Report included interviews from low-income communities, caregivers and Spanish speakers. The report concluded that an overwhelming amount of the low-income community do not trust their healthcare providers as they feel looked down on based on their income and insurance status. Additionally, the lack of accessible jargon-free healthcare information perpetuates fear in low socio-economic communities, where individuals worry that healthcare providers gate-keep services from those without insurance.

Talking about and sharing the stereotypes that perpetuate pain-bias in our communities is the first step in reshaping our views of low socio-economic groups and health care. Addressing pain-bias in the face of adversity is a much-needed step towards a safer and more inclusive health care system.