OBJECTIVES:To investigate if sociodemographic factors are associated with selection to an interdisciplinary pain rehabilitation program (IPRP) in Swedish tertiary care, in an intersectional perspective. METHODS:This study involved 39,346 patients referred to tertiary care, who were registered in the Swedish Quality Registry for Pain Rehabilitation during 2009-2016. Self-reported sociodemographic data, and data related to pain and its consequences, were registered prior to IPRP (at baseline). Self-reported data on pain and its consequences were also registered directly after the IPRP and at a 12 months' follow-up. Patients not selected for IPRP reported only baseline data. The statistical analyses used logistic regressions including interaction terms, and the results were analyzed in an intersectional framework to emphasize unequal health care. RESULTS:Sex, age, education, and region of birth were found to influence the likelihood of being selected to IPRP. Non-Nordic-born patients with elementary education had the lowest proportion of selection to IPRP, with a similar proportion for men and women. Other subgroups showed a smaller difference between Nordic and non-Nordic countries in the proportion selected to IPRP. For several groups, longer education had a positive impact on the proportion of selection. Selection increased with age to a peak in middle age and then decreased. Unexpectedly, the youngest patients were less likely than middle-aged patients to be selected. CONCLUSIONS:In Swedish tertiary care, sex, age, education, and region of birth influence selection to IPRP as combinations but not necessarily as single factors. More knowledge is needed to ensure equal, knowledge-based rehabilitation for patients with chronic pain. The regional ethics review board in Uppsala (IRB/REC 2018/036) and the Swedish ethical review authority (IRB/REC 2020-00828) issued ethical approvals.

Pain is a universal human experience and the most common reason to seek medical care. Although women report more frequent and disabling pains than men, their pains are more often underassessed and undertreated in clinical encounters. Understanding the 'whens' and 'whys' of this gender paradox is vital to promote pain care equity and efficiency. Yet, the atheoretical and descriptive nature of most studies on provider gender biases in pain care is stalling the research field. To overcome this gap, we first propose the novel Gender Biases in Pain Care Model, which conceptualises the contextual nature of gender biases in pain care. It is an interaction-based socioecological model that integrates assumptions of gender-related theories and dual process models of person perception and stereotyping. Second, we conduct a theory-driven review of current evidence addressing the model's theoretical contentions. Sixty-six articles (8 reviews and 58 primary studies), mostly published in 2010-2024, were included. Although findings provide preliminary support for the model's four contentions, important empirical gaps are still unaddressed. We discuss how this model is a steppingstone to the generation of novel research questions and testable hypotheses that may fill current knowledge gaps and contribute to the development of equitable pain practices and policies.

IntroductionPsychosocial resources, psychological and social factors like self-efficacy and social support have been suggested as important assets for individuals with chronic pain, but the importance of psychosocial resources for the development of pain is sparsely examined, especially sex and gender differences. The aim of this study was to investigate associations between psychosocial resources and sex on the development of frequent pain in a general population sample, and to deepen the knowledge about sex and gender patterns.MethodsA sample from the Swedish Health Assets Project, a longitudinal cohort study, included self-reported data from 2263 participants, 53% women, with no frequent pain at baseline. The outcome variable was frequent pain at 18-months follow-up. Psychosocial resources studied were general self-efficacy, instrumental and emotional social support. Log binomial regressions in a generalised linear model were used to calculate risk ratios (RRs), comparing all combinations of men with high psychosocial resources, men with low psychosocial resources, women with high psychosocial resources and women with low psychosocial resources.ResultsWomen with low psychosocial resources had higher risk of frequent pain at follow-up compared to men with high resources: general self-efficacy RR 1.82, instrumental social support RR 2.33 and emotional social support RR 1.94. Instrumental social support was the most important protective resource for women, emotional social support was the most important one for men. Results were discussed in terms of gender norms.ConclusionsThe psychosocial resources general self-efficacy, instrumental and emotional support predicted the risk of developing frequent pain differently among and between men and women in a general population sample. The results showed the importance of studying sex and gender differences in psychological and not least social predictors for pain.

Background The study of sex and gender patterns in psychosocial resources is a growing field of interest in pain research with importance for pain rehabilitation and prevention. The aims of this study were first, to estimate cross-sectional differences in psychosocial resources (general self-efficacy and social support) across men and women in a population with frequent musculoskeletal pain (pain in the back or neck/shoulder nearly every day or now and again during the week for the last 12 months) and to compare these differences with a population with no frequent pain. Second, to examine if psychosocial resources at baseline were associated with pain at follow-up among men and women in the frequent pain population. Methods This study was based on survey data from the Swedish Health Assets Project, including The General Self-Efficacy Scale and social support questions. Participants ( n = 4010, 55% women) were divided into no frequent pain ( n = 2855) and frequent pain ( n = 1155). General self-efficacy and social support were analyzed (cross-sectional and longitudinal data) with linear and logistic regressions. Results Men, with and without frequent pain, had higher general self-efficacy than the corresponding groups in women. Women, with and without frequent pain, had stronger emotional social support than the corresponding groups in men. Men with no frequent pain had weaker instrumental social support than women with no frequent pain (OR = 0.64 (95% CI 0.47–0.87)), men with frequent pain did not (OR = 1.32 (95% CI 0.86–2.01)). In the frequent pain population, the interaction between sex and strong (compared to weak) emotional social support was statistically significant ( p = 0.040) for no frequent pain at follow-up, with women having OR = 1.81 and men OR = 0.62. Among women, strong emotional social support was associated with no frequent pain at follow-up. Among men, strong emotional social support was associated with frequent pain at follow-up. Conclusion Some of the associations between general self-efficacy, social support and musculosceletal pain showed unexpected sex patterns. Gendered expectations might have relevance for some of the results.

Abstract Background Despite the importance of psychosocial resources such as self-efficacy and social support for pain coping, sex differences in populations with and without chronic pain, and the impact of psychosocial resources on pain prospectively is sparsely examined. Methods Data from the Health Assets Project, a longitudinal cohort study with two data collections (2008 and 2009) in Sweden was used. We analyzed self-efficacy, emotional and instrumental social support among 1155 people with chronic pain and 2855 people with pain more seldom, including sex differences and the interaction between pain and sex. Among people with chronic pain we examined prospective associations between self-efficacy and social support in 2008 and pain in 2009. All regression models were analyzed unadjusted and adjusted for age, education and place of birth. Results People with chronic pain had lower psychosocial resources than people with pain more seldom (p<.001). People with pain more seldom showed sex differences for all psychosocial resources (p<.001), people with chronic pain did not show sex differences for instrumental social support. In addition, the interaction between sex and pain was significant for instrumental social support (p=.006, p=.005). Men with pain more seldom had the highest prevalence of low instrumental social support. High compared to low instrumental social support in 2008 was associated with lower odds of chronic pain in 2009, especially for women (OR = 2.2, 95%CI=1.19-4.28). The association between pain 2009 and the interaction between sex and high emotional social support was significant (p=.040). Women with high compared to low emotional support 2008 had 55% higher chance to have pain more seldom 2009, men had a 28% lower chance. Conclusions People with chronic pain showed less sex differences in psychosocial resources, compared to people with pain more seldom. In addition, for women, social support was associated with lower pain frequency during one-year follow-up. Key messages Men and women with chronic pain reported more alike on psychosocial resources than men and women with pain more seldom. For women only, both high instrumental and high emotional social support were associated with lower pain frequency during one-year follow-up.

Introduction: Patients are often given preoperative information by a physical therapist with the aim of decreasing the risk of developing postoperative pulmonary complications and to facilitate recovery after major abdominal surgery. Studies are scarce about the effect. The aim of this study was to evaluate two different approaches for preoperative information.Design: Randomized controlled trial.Setting: University Hospital.Methods: This is a study comparing information by the Teach-Back Method (TBM) with traditional information. Fifty patients were included. They were randomized to either of the groups when attending the preoperative visit. A follow up by telephone was conducted a few days after. The patients were asked to recall the information received. A list of 29 statements was used to record whether participants recalled the given information.Results: The number of correct answers for the 29 statements was, in average 30.0% after TBM compared to 25.4% after traditional information (P = 0.179). In total, the patients recalled 27% of the information given. There were no significant differences between those who spontaneously gave positive feed-back regarding the information or not, those younger or older than 65 years of age, or for those who had read the written information.Conclusion: The patients recalled no more than 27% of the preoperative information and there were only minor and non-significant differences between the groups given information by TBM or traditionally. It is of importance to further discuss and evaluate when to inform the patients and which information to give when preparing patients prior to abdominal surgery.

BACKGROUND:Health care on equal terms is a cornerstone of the Swedish health care system. Total hip arthroplasty (THA) is considered a success story in Sweden with low frequency of reoperations and restored health-related quality of life (HRQoL). Administratively, health care in Sweden is locally self-governed by 21 counties. In this longitudinal nation-wide observational study we assessed the possible geographical variations in 1-year follow-up patient-reported outcomes (PROs): EQ-5D index, EQ VAS, Pain VAS and Satisfaction VAS. METHODS:Study population consisted of 36,235 Swedish THA patients, operated during 2008 to 2012 due to hip osteoarthritis. Individual data came from Swedish Hip Arthroplasty Register, Statistics Sweden and National Board of Health and Welfare. We used descriptive statistics together with multivariable regression analysis to analyse the data. RESULTS:We observed county level differences in both preoperative and postoperative PROs. The results showed that the differences observed in preoperative PROs could not fully explain the differences observed in postoperative PROs, even after adjustment for patient demographics (age, sex, BMI, Elixhauser comorbidity index, marital status, educational level and disposable income). This indicates that other factors might influence the outcome after THA. CONCLUSION:Likely, structural and process differences such as indication for surgery have an influence on PROs after surgery. Standardization of care at hospital levels may decrease geographical variations in postoperative HRQoL. Remaining differences will then possibly be associated to patient demographics.

Objective Long-lasting pain is a challenge for pa-tients’ everyday lives. The aim of this study was to examine how women and men who have participa-ted in multimodal pain rehabilitation experience its impact in their everyday lives. Patients and methods Individual semi-structured interviews with 5 women and 3 men who had parti-cipated in multimodal pain rehabilitation at a clinic in Sweden, analysed using qualitative content ana-lysis. Results Participants perceived that their “sense of control” increased, which had a positive impact in their everyday life. Sense of control consisted of 3 categories: importance of the patient-provider re-lationship, knowledge gained (especially on body functions and medication), and pain in a social con-text. Three results were discussed in particular: (i) a trustful patient-provider relationship based on confidence in the provider’s expertise was a pre-requisite for pain acceptance; (ii) patients were aware of gender norms in healthcare; (iii) social support was not stressed as important to cope with pain. Conclusion The importance of patients’ confidence in the provider’s expertise and patients’ awareness about gender norms need consideration in terms of the patient-provider encounter. The value of social support for pain rehabilitation was found to be less important compared with previous research; this should be explored further. LAY ABSTRACT We interviewed 5 women and 3 men with long-lasting pain and asked them how pain rehabilitation had affec-ted their everyday life. The interviews were analyzed with a technique called “qualitative content analysis”.The participants experienced a trustful patient-provi-der relation, particularly trust in the providers’ exper-tise, as necessary for their pain acceptance. Pain ac-ceptance, in turn, together with knowledge about body functions and medication, helped the participants to gain a sense of control over their pain and everyday life. Whilst highlighting a positive patient-provider re-lation, they saw gender norms as a potential obsta-cle that could affect relations with health care nega-tively. As research has emphasized social support as important to deal with pain in everyday life we asked about it. Surprisingly, social support was perceived as neither important to handle pain in daily life nor as af-fected by pain rehabilitation.

Abstract Background More women than men report chronic pain but despite the large body of research on sex differences there is a lack of knowledge on the influence of social and cultural gender. As gender norms can lead to gender bias in health care it is important to raise awareness about them. The purpose of this study was to illustrate gendered norms about men and women with chronic pain in scientific journals, and to analyze how societal norms are reproduced in health care. Methods A literature search of the databases PsycINFO, CINAHL and PubMed was conducted, January 2000 to April 2015, with the search term chronic pain combined with femininity, masculinity, gender bias, gender stereotypes and gender roles. A total of 77 articles met the inclusion criteria and were analyzed qualitatively. The integrative approach enabled a review of articles from both social and medical sciences, and to include qualitative and quantitative research. The material was sorted into theoretical categories and further coded into substantive categories. Results The included articles showed a variety of gendered norms about men’s and women’s experience and expression of pain, their identity, lifestyle and coping style. Women were described as emotional and hysterical, constantly dealing with mistrust from health care. Men were pictured as brave, stoic and struggling with their sense of masculinity. Prevailing societal norms are consolidated in health care, positioning the masculine man as the ideal patient. Conclusions Gender stereotypes are reproduced in healthcare, which can lead to gender bias in the treatment of patients with pain. The findings were used to develop a tool, “the pain cube”, aimed to improve health care providers’ consciousness about gendered norms. Key messages Men and women with chronic pain are depicted in a stereotypical way in scientific articles. Increased awareness about gendered norms can support health care professionals in providing equitable care.

Background . Despite the large body of research on sex differences in pain, there is a lack of knowledge about the influence of gender in the patient-provider encounter. The purpose of this study was to review literature on gendered norms about men and women with pain and gender bias in the treatment of pain. The second aim was to analyze the results guided by the theoretical concepts of hegemonic masculinity and andronormativity. Methods . A literature search of databases was conducted. A total of 77 articles met the inclusion criteria. The included articles were analyzed qualitatively, with an integrative approach. Results . The included studies demonstrated a variety of gendered norms about men’s and women’s experience and expression of pain, their identity, lifestyle, and coping style. Gender bias in pain treatment was identified, as part of the patient-provider encounter and the professional’s treatment decisions. It was discussed how gendered norms are consolidated by hegemonic masculinity and andronormativity. Conclusions . Awareness about gendered norms is important, both in research and clinical practice, in order to counteract gender bias in health care and to support health-care professionals in providing more equitable care that is more capable to meet the need of all patients, men and women.

SammanfattningHälsolitteracitet, en persons förmåga att få tag på, förstå, kommunicera, värdera och använda sig av hälsoinformation är en förutsättning för patientens delaktighet i sin vård. Studier har visat att hälsolitteracitet kan påverka när och hur patienter söker vård, deltar i screeningprogram, följer behandlingsrekommendationer med mera. Hur patienten använder hälsoinformation påverkas dels av individuella förutsättningar men ännu mer av hälso- och sjukvårdens förmåga att kommunicera och ge information som är lätt att förstå, inkluderande och tillgänglig. Tre konkreta metoder som kan användas för att göra hälso- och sjukvården mer hälsolitterat är: Förstå mig rätt/teach-back, personcentrerad patientutbildning och kommunikationsstöd med bilder. AbstractHealth literacy, the ability to obtain, understand, communicate, evaluate and use health information, is a prerequisite for patient participation. Studies have shown that health literacy can affect how and when patients seek health care, participate in screening programs, follow treatment recommendations, and so on. Patients’ utilization of health information depend on individual preconditions, but even more on health care providers’ capability to communicate and to provide inclusive and accessible information which is easy to understand. Three methods which can be used to improve health care organizations’ health literacy are: Teach-back/Förstå mig rätt, person centered patient education, and communication support with pictures.