Does ethnicity affect pain management for people with advanced disease? A mixed methods cross-national systematic review of ‘very high’ Human Development Index English-speaking countries

Abstract

Background Racial disparities in pain management have been observed in the USA since the 1990s in settings such as the emergency department and oncology. However, the palliative care context is not well described, and little research has focused outside of the USA or on advanced disease. This review takes a cross-national approach to exploring pain management in advanced disease for people of different racial and ethnic groups. Methods Mixed methods systematic review. The primary outcome measure was differences in receiving pain medication between people from different racial and ethnic groups. Five electronic databases were searched. Two researchers independently assessed quality using JBI checklists, weighted evidence, and extracted data. The quantitative findings on the primary outcome measure were cross-tabulated, and a thematic analysis was undertaken on the mixed methods studies. Themes were formulated into a conceptual/thematic matrix. Patient representatives from UK ethnically diverse groups were consulted. PRISMA 2020 guidelines were followed. Results Eighteen papers were included in the primary outcome analysis. Three papers were rated ‘High’ weight of evidence, and 17/18 (94%) were based in the USA. Ten of the eighteen (56%) found no significant difference in the pain medication received between people of different ethnic groups. Forty-six papers were included in the mixed methods synthesis; 41/46 (89%) were based in the USA. Key themes: Patients from different ethnically diverse groups had concerns about tolerance, addiction and side effects. The evidence also showed: cultural and social doctor-patient communication issues; many patients with unmet pain management needs; differences in pain assessment by racial group, and two studies found racial and ethnic stereotyping. Conclusions There was not enough high quality evidence to draw a conclusion on differences in receiving pain medication for people with advanced disease from different racial and ethnic groups. The mixed methods findings showed commonalities in fears about pain medication side effects, tolerance and addiction across diverse ethnic groups. However, these fears may have different foundations and are differently prioritised according to culture, faith, educational and social factors. There is a need to develop culturally competent pain management to address doctor-patient communication issues and patients’ pain management concerns. Trial registration PROSPERO-CRD42020167890.

Researching minoritised communities in palliative care: An agenda for change

“…This meant that disproportionate mortality rates among minority ethnic communities were not confirmed for non-hospital deaths. In line with several other countries, the UK is now making the recording of ethnicity on death certificates in England mandatory to mitigate their invisibility and systematic reviews 132 . However, representation of individuals from minoritised communities in the PPI process is currently insufficient 133,134 .…”

“…Patient and public involvement (PPI) in palliative care research are of value to palliative care studies [127][128][129][130][131] and systematic reviews. 132 However, representation of individuals from minoritised communities in the PPI process is currently insufficient. 133,134 This can result in a power imbalance, present in much health services research and may also be evident in palliative care.…”

How does ethnicity affect presence of advance care planning in care records for individuals with advanced disease? A mixed-methods systematic review

“…This inconsistency in ethnicity data from individual studies forced some assumptions and groupings on our part (see Table 2 – groupings for summary analysis). We attempted to overcome this by using previously peer reviewed groupings as a guide [ 87 ], and consulting PPI representatives on the appropriateness of the groupings. To improve this in future research, ethnicity data collected within a research capacity must be detailed, individualised and represented within the social context.…”

Disparities in chronic pain affecting management in Asian populations

“…6 Asian Americans also have the lowest incidence of cancer, 11 lowest prevalence of arthritis, 15 and lowest prevalence of multimorbidity overall. 2 At the same time, the picture is not all rosy. Anti-Asian discrimination and racism have surged over the past few years, especially during the COVID-19 pandemic, 3,18 which may have repercussions for mental and/ or physical health of Asian American adults.…”

“…To summarize, there are racial and ethnic disparities in pain assessment and management across many minority populations. 2,9 Although statistically, Asian Americans have lowest pain prevalence, 9 we should be careful in addressing their individual pain needs. It is important that physicians and healthcare teams practice culturally competent care while providing sufficient education to help these populations understand what may be best for their pain care given the context.…”