How can we predict how well a person will cope with pain or respond to management in terms of chronic back pain? It might sound like an unanswerable question, but in a recent blog, we discussed research predicting how well a person will respond to chiropractic care. Now there is research with another predictor that applies to chronic back and neck pain sufferers more broadly. As it turns out, the income level of the sufferer may be such a predictor. Far from being an isolated variable, it ties to a person’s level of self-efficacy when it comes to initiating and maintaining actions that contribute to better outcomes. Armed with such research, clinicians may be able to more accurately ascertain who needs more support in maintaining their care plan.
Self-efficacy, the belief an individual has in their ability to execute behaviours to achieve desired outcomes, has long been identified as a precursor to health outcomes. It has been used in the explanation of why some people are better able to cope with chronic health conditions and have better outcomes relating to chronic illness and pain.
In fact, “In the field of chronic pain, self-efficacy can predict chronic pain-related outcomes such as pain intensity, disability, fatigue and stiffness, and depression .”
Thus, understanding ways in which we can increase or predict levels of self-efficacy are of great value when it comes to supporting individuals presenting for chiropractic care. In the constructing of care plans, discussing expected outcomes, and implementing home-care measures, a patient’s level of self-efficacy and the factors that may influence it should be considered to ensure we are working with the individual in the most effective way possible.
One such factor, and the focus of the study at hand, is income.
- Socioeconomic status influences education and access to various supports (healthcare, insurance, hiring help, time off etc)
- Can socioeconomic status predict a patient’s ability to cope with pain (self-efficacy) and thus inform what to expect from treatment (this needs some rewording)
Pain-related self-efficacy can be approached in two ways; an individual’s perceived ability to function normally despite pain, and an individual’s perceived ability to manage pain and symptoms effectively. The current study focuses on the latter of these two categories.
So how did they study it?
The study was conducted using 1,364 chronic low back pain (CLBP) patients. Two scales were used to determine level of perceived self-efficacy; “pain self-efficacy (PSE), which is linked to disability, pain intensity, fatigue, and stiffness, and coping self-efficacy (CSE), which is linked to depression, hopeless-ness, and affective distress .”
A single question regarding approximate gross yearly income was used to determine socioeconomic status. Age and sex were controlled in the study so as to ensure data reliability. In the full models, education (highest level of education attained) was also controlled to more clearly assess the relationship between income and perceived self-efficacy. Chronic neck pain comorbidity, catastrophizing score, and health insurance status were considered and controlled for.
The authors of the study stated that their goals were “to determine whether income was a significant predictor of PSE and of CSE among a population of patients with CLBP”
The Main Findings:
Among the 1,364 chiropractic patients with chronic low back pain, “patients had on average high levels of PSE and CSE. Income was positively associated with both types of self-efficacy even after controlling for education, health insurance, and other potential confounders .”
It’s interesting to consider that insurance status and education did not seem to influence self-efficacy that much in this study, or at least they didn’t seem to sufficiently explain the disparity.
The researchers noted that “Average self-efficacy scores increased in tandem with income, and the most prominent differences in self-efficacy scores were between the lowest and highest income levels .”
In terms of data sensitivity, it is good to see that researchers did an analysis adjust for the number of people in the household, controlling for clustering at the clinic level. They were also careful to consider any significant differences between those excluded from the study and those included in the study. People were excluded from the study if they didn’t fill out the form, or missed significant details on the form. The only major difference was in age; the included group were (on average) approximately 4.6 years younger than the excluded group.
Money can be a taboo topic for many. Thus, taking on the issue in order to find out its relationship to chronic low back pain outcomes is courageous. While the usefulness of the data is significant, it does leave the practitioner to grapple with how to deal with this information with discretion.
The study offers up some strong conclusions: “Given our findings, income may have mediated the relationship between employment and pain self-efficacy. Alternatively, employment could have had a separate effect on self-efficacy, perhaps by increasing participants’ sense of self-worth .”
Now we know income can impact/predict levels of perceived self-efficacy, but only future research can tell us why and how this effect exists, and which aspects of lower income restrict perceived self-efficacy. Another logical avenue for future research on this issue would be in how clinicians implement this knowledge and break down any existing barriers caused by a lower socioeconomic status, or how do we compensate for any advantages impacting self-efficacy caused by higher socioeconomic status.
We look forward to seeing what emerges, so we can further support people in accessing the full benefits of chiropractic care.
- Whitley MD, Herman PM, Aliyev GR, Sherbourne CD, Ryan GW, Coulter ID. Income as a Predictor of Self-Efficacy for Managing Pain and for Coping With Symptoms Among Patients With Chronic Low Back Pain. J Manipulative Physiol Ther. 2021. 44(6):433-444. doi: 10.1016/j.jmpt.2021.05.004. PMID: 34470698