Healthcare providers’ perceptions and assessments of patients have a critical impact on treatment outcomes. Researchers Eva Diniz, Paula Castro, Andréa Bousfield, and Sónia Figueira Bernardes recently published a study in the British Journal of Health Psychology revealing some of how judgments made by nurses regarding patient socioeconomic status (SES) can adversely affect treatment quality – specifically, pain care.
“Chronic pain is one of the leading causes of disability worldwide and one of the chronic conditions,” the researchers write. “Moreover, chronic pain is more prevalent among people of low socioeconomic status (SES), who also receive less-specialized treatments. Nevertheless, the psychosocial processes that may help account for this, such as class-based dehumanization, or ‘denial of humanness,’ in health care contexts, are poorly investigated.”
Using a mixed-method approach, the team evaluated a sample of 50 Portuguese nurses’ responses to two women’s similar experiences of pain differing by SES, and results indicated that nurses deemed the lower SES mock patient “less competent, with a more pain-related disability, and recommended her more psychoeducation.”
Nurses in this sample attributed fewer “Uniquely Human” traits to the lower SES patient. The authors suggest that this reflects the dehumanization of certain patients based on SES. Deeply ingrained patterns biases may account for patterns of compromised care experienced by individuals of low SES concerning medical support for pain.
Past research has indicated disparities in healthcare, evidenced by treatment quality varying as a function of patient gender and race. For example, one 2017 study revealed that racial biases among medical students against Black patients resulted in inadequacies in treatment. Another study, published in 2015, identified inherent differences in thresholds for pain for White and Black patients in the context of pediatric appendicitis. Black children were found to receive medication for both moderate and severe expressions of pain at lower rates than White children with identical symptoms.
Concerning gender, a gap in pain care has also been identified, such that providers may underestimate pain experienced by females. Compromised service in clinical encounters experienced by people of color and women alike have been linked to delays in access to treatment as well as denial of access to appropriate treatment for a variety of ailments. Implicit bias may be an important factor contributing to these disparities.
Despite these trends identified concerning gender and race in clinical encounters, Diniz and the team suggest that no studies had occurred before their investigated patterns associated with perceptions of SES and pain assessment in a medical context. Cross-cultural, well-documented relationships between SES, impressions of a person’s inherent value, and dehumanization point to the appropriateness of research in this realm.
“Recently some studies have shown how certain beliefs about class are shared across cultures and across time, consistently presenting people of low SES under a dehumanizing light, for example, by denying them competence and self-control.”
To examine assessments of pain and inferences by providers about patients associated with patient SES, Diniz and team individually exposed participants in a sample of Portuguese female nurses (N=50) to videos featuring two women visibly experiencing pain in everyday scenarios. One subject had visual characteristics associated with low SES, and another, with middle SES. Both demonstrated similar behaviors related to their experiences of pain.
Nurses exposed to the videos then participated in a series of exercises enabling researchers to gather information regarding their impressions. One activity was a free association task in which nurses were instructed to link professional and personal characteristics to the individuals featured in the videos, and the second exercise involved the construction of narrative related to the individuals’ lives, their pain experiences, and treatment recommendations in a story-completion task.
Statistical analysis of free association data and thematic analysis of narrative, story-completion data provided insights consistent with trends contributing to the rationale for the project.
“In a synthetic rendering of the findings, the middle SES woman was imagined as fully human, agentic to manage pain, inserted in a supportive social network, and with a future. The low SES woman was devalued through dehumanizing inferences about personal characteristics denying her agency and competence to manage pain, framed in domestic contexts where others are often a burden, and without a future beyond pain. She was also recommended to psychoeducation.”
In essence, nurses participating in this study perceived differences in the SES of the women in the two pain profiles to which they were exposed, and, despite characteristically similar expressions of pain, significant differences were identified in nurses’ perceptions of the women’s pain experiences, pain management needs, and recommendations for treatment.
This study was not without limitations – one notable limitation is the inauthenticity of the case scenarios and the absence of conditions similar to a formal clinical encounter. Additionally, further research is needed to assess the generalizability of the findings. However, among the most important outcomes was the determination that nurses questioned the agency, resiliency, and strength reserve of a woman experiencing pain in ways they did not when evaluating the middle SES woman’s case.
It could be argued that there is value in nurses’ identification of the need for care associated with pain and inclination to link individuals perceived to be suffering to appropriate supports. Yet, this bright spot is muddied by harmful biases observed in the pain assessment process and underestimation of individual agency and humanity based on SES.
“These findings, by reflecting a clear reproduction of the belief-system of classism in how others of different SES are imagined and referred to treatments, suggest, overall, the importance of future research.”
Diniz, E., Castro, P., Bousfield, A., & Bernardes, S. F. (2019). Classism and dehumanization in chronic pain: A qualitative study of nurses’ inferences about women of different socio‐economic status. British Journal of Health Psychology. DOI: 10.1111/bjhp.12399 (Link)