Challenges with Pain Treatment for Rural Older Adults: Family Caregivers' Views

Abstract Family caregivers face various challenges in assisting older adults experiencing pain and difficult symptoms. Living in rural areas poses additional obstacles to their caregiving. The purpose of this study was to explore family caregivers’ lived experiences in caring for older adults with pain and discomfort in rural communities. A qualitative research design was adopted to capture the common essence of participants’ experiences through a phenomenological method. Purposeful sampling was used, and the participant criteria was: age 18+, have good thinking skills, resident of Alabama, provide unpaid assistance to a family/relative who has chronic/serious health conditions and experienced pain/discomfort in the last 3 months. Ten participants were recruited from rural counties of Alabama. Individual semi-structured interviews were conducted via phone and were recorded and transcribed verbatim. Inductive, thematic analysis of the data revealed themes in five categories: 1) impact of pain (physical and psychological/emotional toll), 2) coping strategies (faith/contentment with life/logistical adaptation), 3) impact of Covid-19 (physical health/social interaction/mental health/added caregiving), 4) challenges in pain treatment (transportation (time/distance/driver/cost) and non-transportation related problems (healthcare provider issues/health insurance/financial burden)), and 5) suggestions (transportation-related (more transportation options/tailored services) and non-transportation-related support (home-based services/better health insurance coverage)). Findings of this study highlight rural family caregivers’ unique experiences in assisting older adults’ access to pain treatment, particularly during the Covid-19 pandemic. Policy- and program-level intervention is called for to increase individualized transportation options, improve health insurance coverage, and expand financial support for rural older adults experiencing pain and their caregivers.

were discussed and resolved by the PI.We identified 15 studies that met our inclusion criteria, of which 14 met criteria for high methodologic quality.The majority of studies utilized the Coping Strategies Questionnaire to assess differential use of pain-coping strategies.The remaining studies used one of five other questionnaires.Only one study examined the differential effect of age on the efficacy of emotion-focused strategies.Five of the eight studies that examined hoping/prayer coping reported the strategy's positive association with age.Age was not associated with ignoring pain or reinterpreting pain sensations in any of the eight studies in which these strategies were measured.We concluded that older age was associated with the use of praying/hoping as a means of coping with pain.No other consistent associations between age and other measured coping strategies were identified.Future research should account for auxiliary stressors and pain characteristics while investigating the differential effect of age on pain coping efficacy.

ASSOCIATIONS OF PAIN SEVERITY AND MOBILITY WITH AGE IN CHRONIC LOW BACK PAIN: DOES THE TYPE OF ASSESSMENT MATTER?
Taylor Buchanan, Deanna Rumble, Kristen Allen-Watts, Katie O'Neal, Tammie Quinn, Thomas Buford, and Burel Goodin, University of Alabama at Birmingham, Birmingham, Alabama, United States Chronic low back pain (cLBP) can lead to severe pain symptoms as well as disability in adults.As individuals age, pain symptoms and mobility outcomes can become increasingly debilitating.However, current findings regarding the influence of age on symptoms and outcomes are mixed and may be attributed to the assessment methodologies for pain and mobility.Therefore, we sought to examine the association of age with broad and specific assessments of pain severity and mobility commonly implemented in adults with cLBP.cLBP participants (n = 158) completed questionnaires regarding pain intensity and disability including demographics, Clinical Pain Assessment (CPA) and the Oswestry Low Back Pain questionnaire (OLBP).Participants also completed assessments of movement-evoked pain and difficulty by performing the Short Physical Performance Battery (SPPB).Pearson's chi-square tests and regression-based analyses were conducted using SPSS version 26.0.Among cLBP participants, age was associated with pain-related disability indexed by section one of the OLBPS regarding pain intensity (F= 5.0, p<.05), and mobility via total SPPB score (F= 11.7, p<.05).Interestingly, age predicted greater self-reported difficulty climbing stairs (F= 21.7, p<.05), performing chores (F= 17.0, p<.05), walking (F= 14.0, p<.05), and running errands (F= 13.4, p<.05) from the CPA.Further, age predicted total balance (F= 3.2, p<.05), gait speed (F= 7.8, p<.05), and chair stand (F= 6.5, p<.05) scores of SPPB.Age is associated with questionnaires assessing cLBP pain severity and is also associated with mobility outcomes.Future research should seek to understand the influence of age on movement-evoked pain in cLBP.

CHALLENGES WITH PAIN TREATMENT FOR RURAL OLDER ADULTS: FAMILY CAREGIVERS' VIEWS
Hyunjin Noh, 1 Cho Rong Won, 2 and Zainab Suntai, 1 1.University of Alabama, Tuscaloosa, Alabama, United States, 2. University of Alabma, Tuscaloosa, Alabama, United States Family caregivers face various challenges in assisting older adults experiencing pain and difficult symptoms.Living in rural areas poses additional obstacles to their caregiving.The purpose of this study was to explore family caregivers' lived experiences in caring for older adults with pain and discomfort in rural communities.A qualitative research design was adopted to capture the common essence of participants' experiences through a phenomenological method.Purposeful sampling was used, and the participant criteria was: age 18+, have good thinking skills, resident of Alabama, provide unpaid assistance to a family/relative who has chronic/serious health conditions and experienced pain/discomfort in the last 3 months.Ten participants were recruited from rural counties of Alabama.Individual semi-structured interviews were conducted via phone and were recorded and transcribed verbatim.Inductive, thematic analysis of the data revealed themes in five categories: 1) impact of pain (physical and psychological/emotional toll), 2) coping strategies (faith/ contentment with life/logistical adaptation), 3) impact of Covid-19 (physical health/social interaction/mental health/ added caregiving), 4) challenges in pain treatment (transportation (time/distance/driver/cost) and non-transportation related problems (healthcare provider issues/health insurance/ financial burden)), and 5) suggestions (transportation-related (more transportation options/tailored services) and nontransportation-related support (home-based services/better health insurance coverage)).Findings of this study highlight rural family caregivers' unique experiences in assisting older adults' access to pain treatment, particularly during the Covid-19 pandemic.Policy-and program-level intervention is called for to increase individualized transportation options, improve health insurance coverage, and expand financial support for rural older adults experiencing pain and their caregivers.

CONNECTING THE DOTS: PAIN MENTAL MODELS OF SPOUSAL CAREGIVERS OF VETERANS WITH DEMENTIA AND PAIN
Phoebe Block, 1 Srijana Shrestha, 2 Tracy Evans, 3 Michelle Hilgeman, 4 Julia Loup, 5 Mark Kunik, 3  Pain is prevalent among persons with dementia (PWDs), yet often goes underrecognized and undertreated.Exploring caregivers' pain mental models may provide valuable insight into how they conceptualize pain, and how such conceptualizations affect their identification of and response to PWDs' pain.We identified and described the pain mental model(s) of spousal caregivers of community-dwelling veterans with dementia and pain through a secondary qualitative thematic analysis of recordings of a psychosocial intervention aimed at preventing aggression in PWDs with pain.Thirty female spousal caregivers (11 Black, 10 non-Hispanic White, and 9 Hispanic) comprised the present sample.Two themes were identified: Pain Assessment Beliefs and Knowledge (PA) and Pain Management Beliefs and Knowledge (PM).In our proposed mental model framework, PA and PM affect the ways caregivers answer two PA-related questions (Is there a problem?, Is this problem pain?) and three PM-related questions (Is the pain treatable?,Is it worth treating?, How do I prefer to treat it?).Caregivers are moved to action when they "connect the dots" by identifying a problem in PWDs' behavior, labeling the problem as pain, and identifying a response (i.e., a treatment approach) they consider worth trying.Disconnects in caregiver understanding of PWDs' behavior are common in this sample, and predictably lead to inaction.The proposed mental model provides further explanation about how caregivers do or do not synthesize and apply pain knowledge and experience, allowing for the identification of potential areas of intervention (e.g., pain psychoeducation) to improve pain treatment for the PWDs under their care.People who experience persistent pain often require help from a family member, partner, or friend.These caregivers frequently have pain, but are often not included in interventions.Caregivers and care-receivers who both experience pain are more likely to be socially isolated, experience communication conflict, and have decreased quality of life.Interventions should target caregiving dyads to help them manage their pain together.Feasibility studies that include manual development, intervention evaluation, and refinement of intervention manuals support randomized controlled trials and help move interventions from research to practice.Thus, the purpose of this qualitative study was to explore (a) the needs of caregiving dyads, (b) input from medical and allied health experts, and (c) feedback from intervention facilitators and evaluators, informing the development and refinement of an intervention manual for people with persistent pain.A total of 16 caregiving dyads and one individual (caregiver couldn't participate) experiencing pain participated in focus groups.Eight experts then participated in a focus group or one-on-one interview.Lastly, after the intervention ended, 15 intervention facilitators and fidelity evaluators participated in one focus group.Data were uploaded into NVivo software and analyzed using constant comparison.Findings identified the importance of interventions to focus on pain interference, novel and modifiable approaches to managing pain as a dyad, and addressing the emotional and psychological effects of experiencing pain.Using qualitative approaches to develop, test, and refine an intervention manual enhances the relevancy, acceptability, and translation of our intervention to meet the needs of caregiving dyads experiencing pain.

GENDER DIFFERENCES IN PAIN: EXAMINING EXPLANATIONS FOR THE ASSOCIATION
Cherish Michael, and Anne Barrett, Florida State University, Tallahassee, Florida, United States