Social Determinants and Consequences of Pain: Towards Multilevel, Intersectional, and Life Course Perspectives.

Despite wide endorsement of a biopsychosocial framework for pain, social aspects of pain remain rarely addressed in the context of pain prevention and management. In this review, we aim to: 1) examine the broad scope of social determinants and consequences of pain and their interactions across multiple levels of organization, and 2) provide a framework synthesizing existing concepts and potential areas for future work on social aspects of pain, drawing upon socioecological, intersectional, and life course approaches. Integrating interdisciplinary theory and evidence, we outline pathways through which multilevel social factors and pain may affect each other over time. We also provide a brief summary of intrapersonal aspects of pain which are thought to operate at the interface between individuals and the social context. Progressing from micro- to macro-level factors, we illustrate how social determinants of pain can directly or indirectly contribute to pain experiences, expression, risk, prognosis, and impact across populations. We consider: a) at the interpersonal level, the roles of social comparison, social relatedness, social support, social exclusion, empathy and interpersonal conflict; b) at the group or community level, the roles of intimacy groups, task groups, social categories, and loose associations; and c) at the societal level, the roles of political, economic, and cultural systems, as well as their policies and practices. We present examples of multilevel consequences of pain across these levels and discuss opportunities to reduce the burden and inequities of pain by expanding multilevel social approaches in pain research and practice. PERSPECTIVE: Despite wide endorsement of a biopsychosocial framework for pain, social aspects of pain are often unclearly defined, hindering their use in pain prevention, management, and research. We summarize the scope of social aspects of pain and provide a framework synthesizing existing concepts and potential areas for future work.

The perception, understanding and experience of flourishing in young people living with chronic pain: A Q-methodology study.

Much research has adopted a deficits-based approach to chronic pain, neglecting the study of flourishing. Using a Q-methodological framework, this study sought to explore how individuals experience, understand and perceive flourishing in the context of young people living with chronic pain. Fifty-four individuals completed a Q-sorting task, indicating their level of agreement and disagreement with 52 statements. Q-analysis generated three factors that represented clear viewpoints of participants: 'Pain is not a barrier to flourishing', 'Adapting to a new life' and 'Adopting a positive perspective'. Factors expressed the viewpoints that flexibility is key to enjoying life despite chronic pain, while resilience, management of stressors, acceptance and problem-solving may be required to flourish with chronic pain. Participants' understanding of flourishing also focused on the appreciation and enjoyment of life and achievements. This study provides a useful contribution towards furthering our understanding of flourishing in young people living with chronic pain.

Looking on the bright side: The relationships between flourishing and pain-related outcomes among adolescents living with chronic pain.

A deficits-based approach to adolescent chronic pain currently dominates the literature, to the exclusion of positive approaches, such as flourishing. Addressing this knowledge gap, this study examined the relationships between flourishing and pain-related outcomes in adolescent chronic pain. Seventy-nine adolescents aged 11-24 years were asked to complete self-report measures of three domains of flourishing and four pain-related outcomes. Correlation coefficients and four hierarchical linear regression analyses were conducted, controlling for age and gender. Flourishing mental health was associated with, and significantly contributed to explaining, anxiety and depressive symptoms, and social and family functioning impairment. Benefit finding and posttraumatic growth were each associated with social and family functioning impairment, while posttraumatic growth was also associated with anxiety and depressive symptoms. Additionally, benefit finding significantly contributed to explaining pain intensity. Study findings underscore the importance of assessing the relationships between flourishing and pain-related outcomes in adolescents with chronic pain.

Glass half full: A diary and interview qualitative investigation of flourishing among adolescents living with chronic pain.

BACKGROUND: Counter to paediatric pain literature that typically highlights the deleterious impacts associated with adolescent chronic pain, evidence suggests that some adolescents flourish in their experience of pain. This study sought to explore how adolescents experience, understand and perceive flourishing while living with chronic pain. METHODS: Twenty-four adolescents aged 11-24 years were recruited via clinical and online settings. All adolescents were asked to complete daily diary entries, with a subset of 10 participants asked to complete follow-up interviews. RESULTS: Inductive reflexive thematic analysis generated two themes: 'Appreciating the moment' and 'Becoming a better version of myself'. Themes addressed how self and other comparisons facilitated a renewed appreciation for achievements and pleasures in life due to living with chronic pain. Adolescents further demonstrated a perception of continued personal and social growth in their experience of chronic pain, including increased emotional maturity, resilience, positivity, kindness and improved communication skills. CONCLUSIONS: We conclude that adolescents can experience positive changes in functioning and flourish in some domains of life despite, or resulting from, chronic pain. Further research with an exclusive focus on flourishing is needed to build on this work and address this important gap in knowledge. SIGNIFICANCE: We present evidence that adolescents can flourish when living with chronic pain. Such knowledge may inform the development of positive psychological treatment strategies that are focused on reinforcing adolescents' existing strengths, to expand on current treatment options for adolescents living with chronic pain.

The role of perceived organisational justice in the experience of pain among male and female employees.

This study examined the association of organisational justice with pain among employees of a large organisation. Employees (n = 1829) completed measures of pain, fair pay, organisational justice, job satisfaction and stress. Logistic regression analyses found that organisational justice was unrelated to pain among women, but men with higher perceptions of fair pay were more likely to report chronic pain as were men with lower perceptions of distributive justice. This is the first study indicating that fair pay and distributive justice are both unique predictors of chronic pain in men. The findings have implications for supporting employees with chronic pain.

Parenting an adolescent with complex regional pain syndrome: A dyadic qualitative investigation of resilience.

OBJECTIVES: Adolescent chronic pain exists within a social context, affecting the lives of adolescents, parents, peers, and wider family members. Typically, parental research has focussed on the negative impact on parents associated with parenting an adolescent with chronic pain. However, a small number of studies have identified positive parental outcomes and functioning, with a focus on parental resilience. This study sought to extend existing knowledge by providing a detailed and contextualized understanding of how parental dyads experience and demonstrate resilience in response to parenting an adolescent with Complex Regional Pain Syndrome (CRPS) and the meaning that parents ascribe to these shared experiences. DESIGN: An Interpretative Phenomenological Analysis (IPA) was used to conduct an in-depth qualitative interview study of parents of an adolescent with CRPS. METHODS: Semi-structured interviews were conducted via Skype with eight mother-father parental dyads of an adolescent aged 11-25 years with CRPS. RESULTS: A single prominent theme 'masking reality in the face of pain' dominated the parental discourse and experience of resilience. Resilience was experienced as an incongruence between private distress and the perceived obligation to display socially desirable resilience behaviours to protect their child from their own distress. CONCLUSIONS: Study findings highlight the benefits of strength-based interventions to enhance parental resilience. This is particularly important since parental behaviours have been shown to influence child pain outcomes. Future research should seek to explore resilience in different populations such as lone parents, siblings, and those parenting an adolescent with pain conditions other than CRPS.

Flourishing among adolescents living with chronic pain and their parents: A scoping review.

Evidence exists regarding the impact of flourishing in individuals living with chronic pain, but there are currently no reviews which collate the literature on flourishing in adolescents living with chronic pain and their parents. Therefore, the aim of this scoping review was to map and review the current literature, to document how flourishing is defined and understood in the literature, and to identify gaps in the field. Six databases were searched (Web of Science, Medline, Embase, APA PsycNet and the Cochrane Central Register of Controlled Trials). In addition, a limited gray literature search was conducted. The resulting data were collated and reported in relation to the review questions, by examining the included papers to search for the presence of flourishing. Database searches resulted in 7326 papers after duplicate removal, with eight remaining papers being assessed for full-text eligibility. Following full-text screening, a final four papers were included in the review. Within the papers, flourishing was defined in relation to commonalities of benefit finding, enhanced maturity and growth, and social support. Gaps in the literature and directions for future research are considered. This review suggests that there is a dearth of knowledge and research regarding flourishing among adolescents living with chronic pain and their parents, despite aspects of flourishing identified in limited literature. This warrants further investigation.

A scoping review to ascertain the parameters for an evidence synthesis of psychological interventions to improve work and wellbeing outcomes among employees with chronic pain.

BACKGROUND: Psychological interventions have mixed effects on improving employee outcomes, partly due to significant variability across studies and a lack of focus on mechanisms of action. This scoping review reports on the parameters of these interventions and examines intervention content to bring clarity to this heterogeneous topic area and direct future systematic review work. METHOD: Six databases were searched (Cinahl, Cochrane, Embase, Medline, PsychINFO and Web of Science) from April 2010 to August 2020, and a grey literature search was undertaken. Screening was undertaken independently by two authors. The results summarised country, participant and employment characteristics, psychological interventions and work, health and wellbeing outcomes. 10% of the papers were analysed to determine the feasibility of coding intervention descriptions for theory and behaviour change technique (BCT) components. RESULTS: Database searches yielded 9341 titles, of which 91 studies were included. Most studies were conducted in Europe (78%) and included males and females (95%) ranging in age from 31-56.6 years although other demographic, and employment information was lacking. Musculoskeletal pain was common (87%). Psychological interventions commonly included cognitive behavioural therapy (30%) and education (28%). Most studies employed a randomised control trial design (64%). Over half contained a control group (54%). Interventions were delivered in mostly healthcare settings (72%) by health professionals. Multiple outcomes were often reported, many of which involved measuring sickness absence and return-to-work (62%) and pain and general health (53%). Within the feasibility analysis, most papers met the minimum criteria of containing one paragraph of intervention description, but none explicitly mentioned theory or BCTs. CONCLUSION: Psychological interventions for employees with chronic pain vary in their nature and implementation. We have shown scoping reviews can be used to assess the feasibility of applying tools from health psychology to identify the content of these interventions in future systematic review work to improve intervention development.

What are the 'active ingredients' of interventions targeting the public's engagement with antimicrobial resistance and how might they work?

OBJECTIVES: Changing public awareness of antimicrobial resistance (AMR) represents a global public health priority. A systematic review of interventions that targeted public AMR awareness and associated behaviour was previously conducted. Here, we focus on identifying the active content of these interventions and explore potential mechanisms of action. METHODS: The project took a novel approach to intervention mapping utilizing the following steps: (1) an exploration of explicit and tacit theory and theoretical constructs within the interventions using the Theoretical Domains Framework (TDFv2), (2) retrospective coding of behaviour change techniques (BCTs) using the BCT Taxonomy v1, and (3) an investigation of coherent links between the TDF domains and BCTs across the interventions. RESULTS: Of 20 studies included, only four reported an explicit theoretical basis to their intervention. However, TDF analysis revealed that nine of the 14 TDF domains were utilized, most commonly 'Knowledge' and 'Environmental context and resources'. The BCT analysis showed that all interventions contained at least one BCT, and 14 of 93 (15%) BCTs were coded, most commonly 'Information about health consequences', 'Credible source', and 'Instruction on how to perform the behaviour'. CONCLUSIONS: We identified nine relevant TDF domains and 14 BCTs used in these interventions. Only 15% of BCTs have been applied in AMR interventions thus providing a clear opportunity for the development of novel interventions in this context. This methodological approach provides a useful way of retrospectively mapping theoretical constructs and BCTs when reviewing studies that provide limited information on theory and intervention content. Statement of contribution What is already known on this subject? Evidence of the effectiveness of interventions that target the public to engage them with AMR is mixed; the public continue to show poor knowledge and misperceptions of AMR. Little is known about the common, active ingredients of AMR interventions targeting the public and information on explicit theoretical content is sparse. Information on the components of AMR public health interventions is urgently needed to enable the design of effective interventions to engage the public with AMR stewardship behaviour. What does this study add? The analysis shows very few studies reported any explicit theoretical basis to the interventions they described. Many interventions share common components, including core mechanisms of action and behaviour change techniques. The analysis suggests components of future interventions to engage the public with AMR.

Catastrophizing Mediates the Relationship Between the Personal Belief in a Just World and Pain Outcomes Among Chronic Pain Support Group Attendees.

Health-related research suggests the belief in a just world can act as a personal resource that protects against the adverse effects of pain and illness. However, currently, little is known about how this belief, particularly in relation to one's own life, might influence pain. Consistent with the suggestions of previous research, the present study undertook a secondary data analysis to investigate pain catastrophizing as a mediator of the relationship between the personal just world belief and chronic pain outcomes in a sample of chronic pain support group attendees. Partially supporting the hypotheses, catastrophizing was negatively correlated with the personal just world belief and mediated the relationship between this belief and pain and disability, but not distress. Suggestions for future research and intervention development are made.

Nine lessons and recommendations from the conduct of focus group research in chronic pain samples.

PURPOSE: The view of the patient is central to their care. Focus group methodology has been used in health psychology to capture patient views on health and illness. However, the process of conducting focus group research with patient groups has received scarce attention. The purpose of this paper was to highlight lessons learned from the conduct of focus groups in psychological research with chronic pain samples. METHODS: Lessons were taken from three structured focus groups containing participants recruited from General Practice. Each group contained five, four, and six chronic pain sufferers from upper, middle and lower socioeconomic areas, respectively. RESULTS: Nine lessons were learned about the conduct of focus group research in general, and also with chronic pain sufferers in particular. The lessons relate to (1) translating study interest into group attendance, (2) ensuring the environment maximizes the opportunity to learn from participants, (3) understanding participant motivations for attendance as well as (4) what participants take from the group, (5) ensuring adequate question specificity, accommodating the needs of particular groups in (6) moderation style and (7) discussion time scales, (8) considering the function of conflict in the group and (9) paying due attention to simultaneous dialogue. Recommendations for addressing the lessons are made. CONCLUSION: Patient groups have specific requirements and the conduct of focus groups should be driven by these needs to maximize inclusion and quality contributions in the group. Time, resources, and flexibility are needed to ensure the successful transition of these groups into focus group research.

It's not fair: an Interpretative Phenomenological Analysis of discourses of justice and fairness in chronic pain.

Quantitative research suggests that perceiving injustice can impact negatively upon physical and psychological health in chronic pain. However, little is known about the experience and perceptions of injustice in this context. This study examines the phenomenology of justice and injustice in chronic pain. Fifteen chronic pain sufferers recruited from General Practices in upper, middle and lower socioeconomic areas participated in one of three focus group discussions. Semi-structured interviews were conducted to interrogate justice-related conceptions. All discussions were observed, audio-recorded, transcribed verbatim and subjected to Interpretative Phenomenological Analysis. The dominant theme of the upper socioeconomic group was 'seeking equality'. For the middle socioeconomic group the dominant theme was 'battle for quality of life' and for the lower socioeconomic group the dominant theme was 'the unfair advantage of others'. It is concluded that this group of chronic pain sufferers prioritize justice-related issues in terms of what is dominant to their social concerns and personal needs.

Just world beliefs moderate the relationship of pain intensity and disability with psychological distress in chronic pain support group members.

The impact of pain beliefs on coping and adjustment is well established. However, less is known about how beliefs unrelated to pain might impact upon this experience. In particular, just world beliefs could impact upon and be influenced by chronic pain, given that pain is not experienced in a vacuum but instead is experienced in a social context where justice issues are potentially salient. The focus of this study was the ability of personal and general just world beliefs to moderate the relationships psychological distress held with pain intensity and disability in chronic pain. The sample (N=95) was recruited from members of arthritis and fibromyalgia support groups to investigate these social beliefs in a controlled community pain context. A cross-sectional, questionnaire design was adopted. The personal just world belief was endorsed significantly more than the general just world belief, and endorsement of the personal just world belief was negatively correlated with pain intensity, disability and psychological distress, while the general just world belief was unrelated to these variables. When interaction terms relating to personal and general just world beliefs were entered simultaneously into regression analyses, the personal just world belief did not predict psychological distress. However, pain intensity positively predicted psychological distress at low but not high levels of the general just world belief, while disability predicted psychological distress at low and high levels of this belief. This suggests that a strong general just world belief has implications for psychological well-being in chronic pain, and as such this belief may occupy a potential coping function in this context.

A thematic analysis of attributions to others for the origins and ongoing nature of pain in community pain sufferers.

Research suggests that pain sufferers can attribute their pain to others. However, this work is scarce, lacking in detail and does not focus on any particular time during the pain experience. To understand how these attributions operate in pain, this study sought to examine as an exclusive focus the types, context of, and rationale for attributions made to others for the origins and ongoing nature of pain. A community pain sample was voluntarily recruited into the study to gain a comprehensive understanding of these attributions and minimise potential group-specific bias. Sixty-two participants were interviewed using semi-structured questions about cause, responsibility and blame for pain. Data were analysed using a thematic analysis. Attributions to others emerged across interview questions. Acquaintances, professionals and strangers were implicated in pain onset for reasons including negligence, accident and attack. Few additional attributions were made for pain now. Those made were mostly to medical professionals for perceived poor treatment of an original pain condition encompassing issues related to compliance, diagnosis and treatment and searching for alternative pain solutions. This research provides insight into the social context in which pain attributions to others are reported, and provides the basis for research into largely untapped areas including the implications particular attributions have for adjustment to pain and relationships with others.