Brady B1,2, Andary T3, Jennings M4, Liamputtong P2, Dennis S5,6, Boland R3, Pavlovic N3, Zind M2, Tcharkhedian E7, Chipchase L2
1Liverpool Hospital, Department of Pain Medicine, Liverpool, Australia, 2Western Sydney University, School of Science and Health, Campbelltown, Australia, 3Fairfield Hospital, Physiotherapy Department, Fairfield, Australia, 4Liverpool Hospital, Hospital Executive, Liverpool, Australia, 5Sydney University, Faculty of Health Sciences, Sydney, Australia, 6South West Sydney Local Health District, Allied Health, Liverpool, Australia, 7Liverpool Hospital, Physiotherapy Department, Liverpool, Australia
Background: Chronic pain accounts for 10-16% of Emergency Department (ED) visits, creating significant pressure on already limited resources. Culturally and linguistically diverse (CALD) migrant communities are among the most vulnerable groups living with chronic pain and they have been observed to have a different pattern of ED usage than non-migrant cohorts in some countries. Despite this, the challenges faced by CALD communities with chronic pain and factors contributing to their presentation to ED are poorly understood.
Purpose: This mixed methods study sought to explore factors contributing to ED attendance at two Australian public health facilities, among CALD patients with chronic pain.
Methods: Consecutive migrants from CALD backgrounds presenting to two public hospital EDs with a chronic neuromusculoskeletal pain condition between November 2017 and May 2018 were eligible for inclusion. Forty-five patients from 20 CALD backgrounds underwent structured pain, health literacy and physiotherapy assessments, and they were provided with up to three recommendations to facilitate management of their conditions. Participants were then invited to participate in a qualitative phase. Thirteen completed a semi-structured individual interview, and 10 participated in a focus group that explored their experiences of chronic pain management and the factors underpinning their ED presentation. Interviews and focus groups were conducted in the preferred language of participants, audio-recorded, translated, and transcribed into English for inductive thematic analysis. Participants were followed-up 6-months later to evaluate their progress in response to recommendations and management experiences.
Results: Participants presented with high pain severity (Brief Pain Inventory mean 6.9, SD 1.9), high pain catastrophising (Pain Catastrophising Scale mean 38.8, SD 11.2) and low health literacy (Health Literacy Questionnaire). Multiple social challenges participants faced included high rates of unemployment (60%), absence of healthcare insurance (93%) and limited English skills (49%). Pain and demographic profiles were consistent with the key qualitative findings that identified distress as a primary driver for ED attendance. Distress was a product of social pressures, access challenges, experiences of discrimination/stigma, unmet expectations, past trauma and identity disruption. Follow-up assessment revealed nine re-presentations by six participants to ED over the 6-month period. Despite the low re-presentation rate, only 58% of recommendations were implemented, with a lack of support the most common reason for inaction.
Conclusion(s): CALD patients with chronic pain who attend the ED present with complex health profiles and challenges that are unlikely to be addressed in this setting. Structural and healthcare provider barriers contributed the most to participant distress. This study emphasises the need for more efficacious approaches to chronic pain management for CALD communities that recognise the social, cultural, structural and behavioural issues underpinning their distress.
Implications: There is a need for healthcare providers operating at all points in the healthcare system to recognise the social, cultural and structural issues underpinning the experience of pain and pain-related distress in CALD communities. Targeted efforts towards such strategies might reduce re-presentation rates for CALD patients, which would reduce a preventable burden on finite ED resources, while also optimising pain outcomes for vulnerable communities.
Keywords: Cultural diversity, chronic pain, Emergency Department
Funding acknowledgements: Funding support from South West Sydney Research. The primary author was supported by a PhD Scholarship from the Menzies Foundation.
Purpose: This mixed methods study sought to explore factors contributing to ED attendance at two Australian public health facilities, among CALD patients with chronic pain.
Methods: Consecutive migrants from CALD backgrounds presenting to two public hospital EDs with a chronic neuromusculoskeletal pain condition between November 2017 and May 2018 were eligible for inclusion. Forty-five patients from 20 CALD backgrounds underwent structured pain, health literacy and physiotherapy assessments, and they were provided with up to three recommendations to facilitate management of their conditions. Participants were then invited to participate in a qualitative phase. Thirteen completed a semi-structured individual interview, and 10 participated in a focus group that explored their experiences of chronic pain management and the factors underpinning their ED presentation. Interviews and focus groups were conducted in the preferred language of participants, audio-recorded, translated, and transcribed into English for inductive thematic analysis. Participants were followed-up 6-months later to evaluate their progress in response to recommendations and management experiences.
Results: Participants presented with high pain severity (Brief Pain Inventory mean 6.9, SD 1.9), high pain catastrophising (Pain Catastrophising Scale mean 38.8, SD 11.2) and low health literacy (Health Literacy Questionnaire). Multiple social challenges participants faced included high rates of unemployment (60%), absence of healthcare insurance (93%) and limited English skills (49%). Pain and demographic profiles were consistent with the key qualitative findings that identified distress as a primary driver for ED attendance. Distress was a product of social pressures, access challenges, experiences of discrimination/stigma, unmet expectations, past trauma and identity disruption. Follow-up assessment revealed nine re-presentations by six participants to ED over the 6-month period. Despite the low re-presentation rate, only 58% of recommendations were implemented, with a lack of support the most common reason for inaction.
Conclusion(s): CALD patients with chronic pain who attend the ED present with complex health profiles and challenges that are unlikely to be addressed in this setting. Structural and healthcare provider barriers contributed the most to participant distress. This study emphasises the need for more efficacious approaches to chronic pain management for CALD communities that recognise the social, cultural, structural and behavioural issues underpinning their distress.
Implications: There is a need for healthcare providers operating at all points in the healthcare system to recognise the social, cultural and structural issues underpinning the experience of pain and pain-related distress in CALD communities. Targeted efforts towards such strategies might reduce re-presentation rates for CALD patients, which would reduce a preventable burden on finite ED resources, while also optimising pain outcomes for vulnerable communities.
Keywords: Cultural diversity, chronic pain, Emergency Department
Funding acknowledgements: Funding support from South West Sydney Research. The primary author was supported by a PhD Scholarship from the Menzies Foundation.
Topic: Pain & pain management; Service delivery/emerging roles
Ethics approval required: Yes
Institution: South West Sydney Local Health District
Ethics committee: SWSLHD HREC
Ethics number: HREC/17/LPOOL/411
All authors, affiliations and abstracts have been published as submitted.
