1. Introduction
Pain as an object of study, as well as its interpretation, must always be framed within a historical moment (Moscoso, 2013); in fact, in different periods in history, they have been approached from different theoretical and interpretative frameworks. In the beginning, these were basically biomedical, although in recent decades other disciplines have also tried to account for the elements that biomedicine did not completely resolve. Sociology is one of the last disciplines to tackle this complex topic (Biedma Velázquez et al., 2019). Today, pain is understood as a multidimensional concept encompassing physical, psychological, cultural, and social elements, all of which are included in the definition of the concept provided by the International Association for the Study of Pain (IASP): “an unpleasant sensory and emotional experience associated or similar to that associated with actual or potential tissue damage” (Raja et al., 2020). Pain, as an experience, is always personal and subjective and, at the same time, social and intersubjective, that is, shared and interpreted by a society. This means that the way in which a person assesses their own or other people’s pain, the personal and social meaning given to it, affects pain itself, the way it is experienced, the expectations about its duration, the way it is faced (Jensen et al., 1991), and its social legitimacy.
In addition, despite being universal and experienced by nearly everyone throughout their life, pain is also influenced by differences in the social structure, based on social inequalities (Zajacova et al., 2021), which also require social analysis in order to be understood.
Pain has been intended to be measured and compared from different disciplines and approaches, through different scales (Andersen’s scale, the McGill Pain Questionnaire, Latineen test, VAS, etc.), most of them based on biomedical, self-reported measurements (Karcioglu et al., 2018; Melzack, 1975). Results have been in general unsatisfactory because of a lack of an agreed standardized measurement tool.
The objective of the research group presenting this paper has been to approach pain from a sociological perspective, for which a broad study has been developed, going more deeply into the knowledge of the social legitimacy of pain. This research has used both qualitative techniques (in-depth interviews and focus groups) and quantitative techniques. This short paper briefly presents the content and main results of the survey.
2. Material and Methods
A quantitative design was adopted, using a cross-sectional survey with a questionnaire designed for that purpose, drawn up on the basis of a broad qualitative study based on personal interviews and focus groups. The questionnaire addressed the following topics: health of the respondent (perceived physical health, depression, perceived loneliness); actual pain (type of pain, duration, intensity); daily life implications of current pain; sensations that cause pain, stereotypes and beliefs about pain and health; legitimacy of different types of pain (social support, credibility, social groups and physical, psychological and emotional pain); and sociodemographic and classification variables. 1600 people living in Spain were surveyed, both men and women, over 18 years old. The surveyed was conducted through online interviews from a citizen panel (Computer Assisted Web Interviewing: CAWI). Sex quotas crossed by age and education level were also considered, in order to ensure the representativeness of the sample.
The assumed sampling error, to achieve a confidence level of 95.5% (two sigma), and P = Q, was ±2.45% for the complete sample and under simple random sampling assumption.
The field work was conducted from May 31st to June 18th, 2021.
3. Results
The main descriptive results of the survey are set out below. First of all, Table 1 includes the sociodemographic characteristics of the sample. Specifically, 48% of men and 51% of women were surveyed, with ages ranging from 18 years to over 65, following the percentage of quotas established to represent the total population. Less than 4% of the sample did not complete primary education, while 30% of the total had university studies, with the rest having completed or incomplete secondary education. Regarding their employment situation, 50% are working, 14% are unemployed, and 24% are retired or pensioners.
In general, the people surveyed have a positive self-perception of their physical health, with almost no differences according to sex, not so much so in the different age groups. Younger groups have a better perception of their own health. More than half the people surveyed state not having had to limit their everyday activities because of a health problem, a third says that they have had to limit their activities to some extent, and less than 10% say that they had to limit them a great deal. Women consider that they had to limit their everyday activities to a greater extent than men. As for their psychological health, a large majority of the people surveyed stated that they did not feel lonely. In turn, one in three people surveyed says they never feel depressed, as opposed to more than 50% who say that they are depressed sometimes, with a very low percentage of people stating that they are always depressed. Women show higher values both in the loneliness and in the depression indicators (Table 2).
At the moment of the survey, 56.6% of the people surveyed affirmed having pain (13% more women than men), with pain increasing according to age (Figure 1).
The most common type of pain was bone and muscle pain, with a higher percentage of men affected by this type than women. The following most frequent kinds of pain were caused by anxiety, depression, or stress; headache, earache, or toothache, and, after that, pain caused by tiredness with no apparent reason. For its better understanding, the different types of pain have been grouped up according to their origin (see Table 3).
In addition, people who stated having pain at present also said that they had been suffering it for quite a long time. Only 6% said that they had had pain for
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Table 1. Profile of the people surveyed.
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Table 2. Physical and psychological health.
less than a week, as opposed to 33% who said that they had been having pain for more than three years. According to the type of pain, we have observed that physical pain is the one with the longest duration, followed by psychological pain and, finally, emotional pain.
As for its intensity, an average of 5.7 is obtained, in a 0 - 10 scale (Table 4). Women reported a higher average intensity (6.0) than men (5.4). The most
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Table 4. Intensity pain of types of pain.
intense pain is emotional pain (6.6), followed by psychological pain (5.9), with physical pain having the lowest average intensity (5.6).
Three out of five people surveyed state that having had pain has meant worsening their quality of life, yet the majority says that they have adapted and are able to lead a normal life. In turn, almost half of the people in pain surveyed affirm that there are moments when they are only able to think about it, although they do not consider that it affects their work life, where, for the most part, they state not having had problems. Lastly, more than half of the people surveyed suffering pain say that their family and friends understand the situation they are going through, as opposed to 18% who say that the people around them do not understand them (Figure 2).
Either having pain in a given moment or not, pain may provoke different feelings. The two most mentioned feelings are concern and tiredness (more than 70%). On the other hand, the least felt feelings are shame or guilt, or the feeling of being judged by others because of the pain suffered, with over 70% - 80% respectively answering “no”. The two remaining feelings show similar percentages in “yes” and “no” answers. Psychological pain is the one with a higher score in most of the feelings, with a difference that gets to 27%. As far as emotional pain is concerned, the lack of interest for things stands out if compared to the total, as it is 22.8% higher, or the feeling of shame or guilt, which increases 13% if compared to the total. In contrast, less tiredness and irritation than in the general average is reported. Physical pain provokes, in general, fewer negative feelings (Figure 3).
The most socially accepted belief is that women in general endure more pain than men, with an average of 6.8 out of 10, being higher among women, with a value of 7.5. The less accepted belief is that children hardly suffer any pain, with an average of 3.5, followed by the belief that people with lower financial resources endure pain better than people with more resources (4.0).
As for other beliefs or stereotypes about pain, they have been grouped in order to describe them better, according to the average value obtained in a 0 - 10 scale:
a) First of all, those obtaining scores over 6 (there are more people for than against the statements), which would be: doctors do not always know the cause of pain (average: 7.37); people lie about their pain in order to obtain economic benefits (average: 7.21); physical pain conceals emotional problems (7.16), and people lie to get attention and recognition (6.55). In two of them the modal value is 10, “completely agree”: people lie about their pain in order to obtain economic benefits, and doctors do not always know the cause of pain.
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Figure 2. Experience of pain. *DK: Do not know/DA: Prefers not to answer.
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Figure 3. Feelings provoked by pain according to the pain suffered at the moment.
b) Secondly, the beliefs with scores around the midpoint of 5, where interviewees do not agree, neither disagree. These are: there are people who complain and in fact nothing is wrong with them (5.99); it is possible to lead a normal life with pain (5.94); there are people who wallow in their own pain (5.57); people who suffer chronic pain self-isolate (5.50); painkillers are overused (5.40), and sometimes pain is not real, it is in our mind (5.05).
Both the average and the mode are at the midpoint of 5, although the median does get to 6. More lost values than in other variables are also observed, which also shows than people were not able to define their position in some of these indicators.
c) Thirdly, the items with values under the midpoint, thus showing a higher percentage of disagreement with the quoted statements, are: you have to keep on working as if you were not in pain in order not to be branded as lazy (4.20), and pain should not be paid much attention because everyone has some kind of pain (3.25). In both statements, the modal value is 0, which shows a great disagreement with the statements, especially the one dealing with paying little attention to pain, which shows a lower average and median. On the other hand, in both items there are few people who do not want or do not know how to define their position.
Finally, it has been observed that the support given to different types of pain caused by different illnesses or social situations differs. Using a 0 - 10 scale to respond, the population considers that pain caused by cancer or the loss of a loved one receive more social support (with averages of 7.4 and 6.3, respectively), while the pains caused by alcoholism or obesity are the ones that receive a lower social support (with averages of 3.88 and 3.74, respectively). Also under 5, we can find the pain caused by osteoarthritis (4.99), fibromyalgia (4.82), depression (4.53), and anxiety (4.32).
4. Conclusion
The main results of a sociological study conducted through a survey have been presented, dealing with various aspects of the social dimension of pain, with an emphasis on its legitimacy. It is a survey of the general population, which differs from others focusing on a population with a diagnosis of a specific pathology, and allows us to assess the social dimension of pain as an experience. It is observed that, even if the population mostly states that they have some kind of pain at the moment of the survey, and that they have been having it for quite a while and with relative intensity, that does not prevent them from having a generally positive self-perception of their health. This seems to point out that the population lives with pain with a certain naturality, even with chronic pain, so its mere presence does not always mean that they perceive they are in poor health, despite the contrasted link between both variables (Zajacova et al., 2021).
Because of its implications in practice for public health (Beiter et al., 2015), we consider that the presence of pain caused by anxiety, depression, or stress as the second most frequent pain is especially relevant, as well as, in general, the prevalence of pains of a psychological origin, which, as has been explained, have an important influence on the quality of life of the people who suffer them (Connell et al., 2014; Goosby, 2013). Our results confirm that this type of pain, of a psychological origin (Merskey, 1965), pre-eminently affects women (Werner et al., 2004), and it also provokes more feelings of guilt and of being judged by others, which must be taken into account in medical practice, as the people suffering this pain are more sensitive to feeling that they are being judged and thus less inclined to ask for help to ease their pain.
Another point that bears highlighting due to its future implications is the pain of an emotional origin (Eisenberger, 2015), which is the one experienced more intensely (Biedma-Velázquez et al., 2018). This must be known by healthcare professionals, as it is the one receiving less professional care, either because of cultural elements that make the people suffering it not turn to healthcare services, or because healthcare services themselves underdiagnose this type of pain, making patients feel “questioned” in their pain (Upshur et al., 2010).
The analyzed population has overcome many stereotypes about pain (Bernardes et al., 2015; Schwarz et al., 2019) that used to prejudge certain groups of population as more or less prone to suffer certain painful situations, although it is still thought that some people lie about their pain in order to obtain financial benefits or attention.
It is especially relevant to analyze the hierarchy of pain established by the society, like those pains that have more social support, with cancer being on top. Alcoholism and obesity are at the bottom, as they are the ones with the lowest support. This fact may be linked to several factors, such as the “visibility” or “invisibility” of certain illnesses or situations, which is transferred to the pain caused by them (Barker, 2002), and affects the way the medical community itself and the healthcare system treat those illnesses and make them visible (Zajacova et al., 2021).
In any case, creating and analyzing in depth this type of information will be extremely important in order to go deeper into the analysis of pain from an analytical framework not exclusively limited to strictly biomedical aspects.
This is undoubtedly the main contribution of this work to the multidisciplinary understanding of pain. Knowing what citizens think is essential, not only to have a complete understanding of the phenomenon studied, but also because of the implications it may have on health policy and the implementation of pain-oriented health services.
Funding
This research has received funding from the Project “social legitimacy of pain” (ref. RTI2018-099483-B-I00), corresponding to the 2018 call of the National R&D&I Program Focusing on Societal Challenges.