Severity of musculoskeletal pain: relations to socioeconomic inequality

doi:10.1016/S0277-9536(01)00018-1

Social Science & Medicine

Volume 54, Issue 2, January 2002, Pages 221-228

https://doi.org/10.1016/S0277-9536(01)00018-1 Get rights and content

Abstract

The main aim of the study was to investigate possible associations between severity of non-inflammatory musculoskeletal pain and residential areas of contrasting socioeconomic status. A 4-page questionnaire inquiring about musculoskeletal pain, and also physical disability, mental health, life satisfaction and use of health services was sent to 10,000 randomly selected adults in Oslo, Norway. For the purpose of this study, we analysed data from respondents living in two socioeconomically contrasting areas of the city.

Measures of pain (intensity, duration, localisation), physical disability (MHAQ), mental distress (SCL-5, sleep disturbances), life satisfaction and use of health services (general practitioner, rheumatologist, medication, involvement in and satisfaction with own care) were compared between respondents living in the two areas (n=870 and n=892 respondents, respectively) of whom 493 in each area reported non-inflammatory musculoskeletal pain.

Multiple regression analyses adjusting for age revealed that living in the less affluent area was associated with strong and widespread pain, with high levels of physical disability and mental distress and with low life satisfaction. Living in the less affluent area was also associated with frequent use of analgesics and with low level of involvement in own health care, after adjustment for age, pain intensity and levels of physical disability and mental distress.

Non-inflammatory musculoskeletal pain seems to be a more serious condition in a population living in a less affluent residential area compared with a more affluent one, even in an egalitarian society like Norway. Increased disease severity may thus amplify the impact of greater chronic morbidity in the disadvantaged part of the population. This should have implications for health care provision if the goal is treatment according to needs.

Introduction

There is growing evidence of a widening health gap related to socioeconomic inequality even in western democracies (Mackenbach, Kunst, Cavelaars, Groenhof, & Geurts, 1997; Ross et al., 2000; Shaw, Orford, Brimblecomb, & Dorling, 2000). Norway is an affluent social democracy, where economic equalization and universal access to health care have been central political goals for decades. In spite of this, health-related inequalities still exist (Rognerud, Strand, & Hesselberg, 2000). These are most easily observed in the capital, Oslo, which is the biggest city of Norway with 500,000 inhabitants. The mortality rate for men is 3.3 times higher in the least compared to the most affluent area of Oslo, and for women the ratio is 2.2 (Rognerud, Krüger, Gjertsen, & Thelle, 1998). Thus the current male life expectancy is 69 years in the inner eastern area of the city, compared to 76 years in the western areas. Oslo is divided into 25 local authority districts, each maintaining their own schools, primary health care and social services. The inequalities in mortality are strongly correlated to the districts’ socioeconomic status. Well-known risk factors for atherosclerotic disease like smoking, physical inactivity and overweight, as well as the incidence of these diseases and of several forms of cancer, show similar correlation (Jenum, Thelle, Stensvold, & Hjerman, 1998).

We thus have ample data on socioeconomic inequality regarding mortality and morbidity, but we know far less about inequalities in the dimension of disease severity, in Oslo as elsewhere (Eachus, Chan, Pearson, Propper, & Smith, 1999). In a previous study we found that patients with rheumatoid arthritis living in two socioeconomically contrasting areas of Oslo were equal regarding objective disease process and joint damage measures, while in measures reflecting perceived physical and psychosocial health status, patients in the less affluent area reported higher levels of disease severity (Brekke, Hjortdahl, Thelle, & Kvien, 1999). The present study expands this research by investigating possible relations between socioeconomic environment and disease severity in a totally different patient group: persons with non-inflammatory musculoskeletal pain. Our hypothesis was that persons in a deprived environment experienced more severe pain and were more disabled than persons in a more affluent area. Our primary objective was therefore to investigate the severity of self-reported pain and disability related to geographical area, and the secondary was to explore mental distress, use of and satisfaction with health care across the two areas.

Section snippets

The areas

Oslo's 25 local authority districts can be ranked according to socioeconomic variables: income level, education, employment, industrial insurance disability, mortality, housing standard and number of third world immigrants. Some of these factors are specified for age groups and gender, giving rise to 18 indicators (Høverstad, 1992). Three districts in the western part of the city are on the top of this ranking list, indicating the best socioeconomic conditions (districts No 23, 24 and 25—here

Results

After persons reporting an inflammatory disease had been excluded, 493 out of 870 respondents in “east” and 493 out of 892 respondents in “west” reported pain during the last month. Between area differences regarding demographic and lifestyle measures were consistent in respondents with and without pain: Respondents in “west” were older than in “east”, they were better educated, a larger proportion was married, they smoked less and exercised more often. Gender distribution and the percentage

Discussion

Even if good epidemiological studies have been difficult to do, we know that chronic pain is a major problem in the community, and that pain in back, joints or muscles are the most common reported types of chronic pain (Elliott, Smith, Penny, Smith, & Chambers, 1999). Analyses of sociodemographic factors have identified high age, female gender, poor housing tenure, bad working conditions and unemployment as factors significantly associated with chronic pain (Urwin et al., 1998), and studies

References (39)

M Brekke et al.
Disease activity and severity in patients with rheumatoid arthritisRelations to socioeconomic inequality
Social Science and Medicine
(1999)
A.M Elliott et al.
The epidemiology of chronic pain in the community
The Lancet
(1999)
M.I Gould et al.
Analyzing perceived limiting long-term illness using UK Census Microdata
Social Science and Medicine
(1996)
M Heliovaara et al.
Reliability and validity of interview data on chronic diseases. The Mini-Finland Health Survey
Journal of Clinical Epidemiology
(1993)
K Jones et al.
Individuals and their ecologiesAnalysing the geography of chronic illness within a multilevel modelling framework
Health and Place
(1995)
K Jones et al.
Death and deprivationAn exploratory analysis of deaths in the health and lifestyle survey
Social Science and Medicine
(2000)
T Pincus et al.
Most chronic diseases are reported more frequently by individuals with fewer than 12 years of formal education in the age 18–64 United States population
Journal of Chronic Diseases
(1987)
M Shaw et al.
Widening inequalitiy in mortality between 160 regions of 15 European countries in the early 1990s
Social Science and Medicine
(2000)
Antonovsky, A. (1984). The sense of coherence as a determinant of health. In J. D. Matarazzo et al. (Eds.), Behavioral...
N Blank et al.
Social inequalities in the experience of illness in SwedenA “double suffering”
Scandinavian Journal of Social Medicine
(1996)

H Bosma et al.

Socioeconomic inequalities in mortality and importance of perceived controlCohort study

British Medical Journal

(1999)

C.H Braddock et al.

Informed decision making in outpatient practiceTime to get back to basics

Journal of the American Medical Association

(1999)

Brekke, M., Hjortdahl P., Kvien, T. K. Changes in health status in rheumatoid arthritis are influenced by the level of...

J Eachus et al.

An additional dimension to health inequalitiesDisease severity and socioeconomic position

Journal of Epidemiology and Community Health

(1999)

J Eachus et al.

Deprivation and cause specific morbidityEvidence from the Somerset and Avon survey of health

British Medical Journal

(1996)

J.F Fries et al.

Measurement of patient outcome in arthritis

Arthritis and Rheumatism

(1980)

S Geyer et al.

Income, occupational position, qualification and health inequalities—competing risks? (comparing indicators of social status)

Journal of Epidemiology and Community Health

(2000)

K.B Hagen et al.

Musculoskeletal pain and quality of life in patients with noninflammatory joint pain compared to rheumatoid arthritisA population survey

Journal of Rheumatology

(1997)

J.T Hart

The inverse care law

The Lancet

(1971)

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Severity of musculoskeletal pain: relations to socioeconomic inequality

Abstract

Introduction

Section snippets

The areas

Results

Discussion

Social Science and Medicine

The Lancet

Social Science and Medicine

Journal of Clinical Epidemiology

Health and Place

Social Science and Medicine

Journal of Chronic Diseases

Social Science and Medicine

Social inequalities in the experience of illness in SwedenA “double suffering”

Scandinavian Journal of Social Medicine

Socioeconomic inequalities in mortality and importance of perceived controlCohort study

British Medical Journal

Informed decision making in outpatient practiceTime to get back to basics

Journal of the American Medical Association

An additional dimension to health inequalitiesDisease severity and socioeconomic position

Journal of Epidemiology and Community Health

Deprivation and cause specific morbidityEvidence from the Somerset and Avon survey of health

British Medical Journal

Measurement of patient outcome in arthritis

Arthritis and Rheumatism

Income, occupational position, qualification and health inequalities—competing risks? (comparing indicators of social status)

Journal of Epidemiology and Community Health

Musculoskeletal pain and quality of life in patients with noninflammatory joint pain compared to rheumatoid arthritisA population survey

Journal of Rheumatology

The inverse care law

The Lancet