Media representation of chronic pain in Aotearoa New Zealand—a content analysis of news media

Chronic pain is the leading cause of disability worldwide.1 It affects one in five New Zealanders and the annual prevalence is rising.2 Chronic pain disproportionately affects older adults, females, Māori and those living in areas of high deprivation.2Not only does chronic pain burden individuals, but also society, costing the New Zealand economy an estimated annual cost of $14.8 billion in 2016 with projections of $24 billion by 2048.3

There are many types of chronic pain where no single cause can be determined.4 Chronic pain is not always well understood, perhaps due to its variety of causes and ambiguous definition.5 The International Association for Study of Pain has recently published the International Classification of Disease, Eleventh Revision (ICD-11)4 definition for chronic pain based on biopsychosocial framework and classified pain conditions into chronic primary pain where chronic pain is the primary disease (eg, fibromyalgia, chronic migraine and chronic low back pain) and chronic secondary pain where pain is a symptom of an underlying condition (eg, pain caused by cancer or post-trauma/surgery or inflammatory joint diseases such as rheumatoid arthritis).4

Best practice care recommends healthcare providers adopt a biopsychosocial framework fostering adaptive behavioural change for people living with chronic pain.6 Best practice care can vary across chronic pain conditions but generally includes a combination of non-pharmacological and pharmacological strategies.7 Non-pharmacological strategies such as psychological therapies (eg, cognitive-behavioural therapy, acceptance and commitment-based therapy and mindfulness-based therapy), pain neurophysiology education, physical activity and distraction techniques used alone or in combination are recommended as preferred management strategies for chronic primary pain8 and chronic musculoskeletal pain.9Pharmacological strategies are recommended for some chronic pain conditions such as chronic cancer pain as part of palliative care and for managing chronic neuropathic pain.10 For other pain conditions, selected pharmacological strategies are recommended to be used with care and caution due to their potential side-effects and limited effectiveness long-term.7 For all chronic pain conditions, active self-management strategies (ie, non-pharmacological strategies) are recommended as primary pain management strategies, modified to be appropriate for the type of pain condition, presence of other comorbid health conditions (eg, depression), and psychosocial profile of the person. People treated using active self-management strategies have shown improved long-term functional outcomes as compared to those who adopt an attitude of reliance on others to fix their pain.11

There are barriers for many people with persistent pain to achieve optimal management of chronic pain usually supported by accessing specialised pain services as they are offered only in secondary or tertiary services.12 Further, Māori and Pasifika and other ethnic minorities are underrepresented in accessing tertiary pain services in New Zealand.13 In addition to access barriers, knowledge deficits, lack of awareness and misconceptions relating to pain management among healthcare providers contribute to inadequate pain management.14 Further, lack of validation of symptoms from healthcare providers, family and friends has been perceived as a major barrier by people living with chronic pain to effectively self-manage their symptoms.15

Media representation can influence societal beliefs in regard to condition management and attitudes towards those living with long-term health conditions.16 With an average of 3.1 million New Zealanders reading newspapers within a one-week period, news media has the potential to disseminate public health messages and influence public health behaviour.17 An exploratory study18 from the US analysing multimedia sources that focused on chronic pain (ie, newspaper reports, video blogs, memes and a movie ‘Cake’) from 2010 to 2015 found varying representations of chronic pain. While the authors concluded that the type of media source can influence the key messages delivered, the study did not intend to analyse if the contents reflect best practice care to influence beliefs at societal level. Another review on multimedia campaigns, including newspaper and video, about chronic pain has shown these can change beliefs and behaviours of the public and healthcare providers about chronic pain.19 Given the potential for media accounts of chronic pain to influence experiences and/or understandings of chronic pain for people with pain, their family and communities and the beliefs of healthcare providers,20 the aim of this study was to explore the representation of chronic pain in New Zealand news media.

Methods

Using a content analysis approach,21 the following methodological framework was used: 1) identifying the research question, 2) study selection, 3) identifying relevant articles, 4) charting data and 5) collating, summarising and reporting the results.

Identifying the research question

The research question guiding our review was: How is chronic pain represented in popular news media in New Zealand?

Study selection

Primary data were collated from print and online media available in the New Zealand public domain. Media articles were included if: they contained any reference to chronic pain in concordance with the ICD-11 definition of chronic pain,4 and published in major New Zealand newspapers, magazines or radio podcasts since 1 January 2015 until 30 June 2019. Relevant radio podcasts were transcribed by the research team. Media articles were excluded if the focus was on acute pain or if access required paid subscriptions.

Identifying relevant articles

Primary search

To identify potentially relevant printed news media articles, Factiva, EBSCO and ProQuest databases were searched on 10 June 2019. Search terms included [“chronic pain” or “persistent pain” and “New Zealand”] (see search strategies in Appendix 1). Search terms were developed with an experienced librarian and refined by team discussion after pilot searches. New Zealand newspapers and magazines identified were: The Press, The Dominion Post, NZ Herald, The Nelson Mail, NZ Doctor, Taranaki Daily News, Waikato Times, The Timaru Herald, The Southland Times, Manawatu Standard, North & South, NZ Listener, The Daily Post, Sunday News, The Marlborough Express, Bay of Plenty Times, Sunday Star Times, Wanganui Chronicle and NZ Newswire. Three authors searched all the databases (YK, DM and LE), duplicates were removed with the remaining primary articles used for screening. Five authors (CA, DM, LE, MS and YK) screened the first 20 news articles from the primary search and discussed findings to ensure consistency before full screening.

Secondary search

A secondary search was performed on websites with Google search engine using primary search terms. The sites searched included major independently owned New Zealand print newspapers (Otago Daily Times and NZ Herald), major commercial or independent radio and/or television media outlets (One News Now, Newshub, Māori Television, Sunday Star Times, Radio New Zealand and Newstalk ZB) along with New Zealand news media websites (Stuff, Spinoff, Noted, Scoop, Voxy, Newsroom). These represent major New Zealand news outlets with an online presence.

Charting the data

Articles that met the initial criteria were charted on Microsoft Excel Sheet® and consequently entered into EndNote X9 library (Clarivate Analytics). The initial screening involved screening of headlines and texts (LE, DM and YK). After the initial screen, the full text of the news articles were examined to exclude duplicates that were not identified in EndNote by meta-data, and articles that did not have a primary focus on chronic pain. Authors then worked in pairs to establish congruence about the inclusion of uncertain articles. A third author (HD) adjudicated any disagreement (n=16). The remaining news articles were included for the content analysis.

Content analysis

A conventional approach to content analysis was used where categories were inductively derived from the data to identify overarching themes within the texts.21 As per this inductive approach, the emergent codes and supporting quotes were established after in-depth reading of texts. Each author made notes of their impressions of these texts, as this iterative process continued, codes were derived that captured more than one key thought.

Coding of data was completed to extract and classify relevant data from the included media.21 To minimise the subjectivity of text interpretation, four of the authors piloted this using 20 news media articles to establish analytic concordance (LE, DM, YK and MS).22 Once finalised, the authors worked in pairs to identify key themes and sub-themes within the texts. The final themes and sub-themes were finalised by a consensus meeting involving the entire research team. To ensure credibility of the analysis, another author (JY) independently coded and thematically analysed a randomly selected subset of 20 included articles to produce themes for comparison.

Results

After the database search and screening, 240 articles were included for content analysis as shown in Figure 1. Most of the articles were excluded as they were not focusing on chronic pain.

Figure 1: News article selection process.

The three overarching themes identified in content analysis were (1) the lived experience and the impact of chronic pain, (2) how chronic pain is managed, (3) the systemic issues influencing healthcare pathways of chronic pain management. The findings are presented in Tables 1–5, with a selection of example quotes from the news articles. The frequency of news articles published since 2015 and the types of news sources are presented in Appendix 2.

The lived experience and the impact of chronic pain

Almost half of the included articles (n=119/240) reported on personal experiences of living with chronic pain, the impact of pain on quality of life and the attitudes towards managing pain (Table 1).

Table 1: Theme #1: The impact and lived experiences of chronic pain.

Chronic pain was reported as a disabling long-term health condition impacting on an individual’s quality of life (n=69/240) and their sense of identity (n=54/240). Chronic pain impacted daily life by affecting an individual’s sleep, ability to participate in social activities and most frequently, placing stress on relationships (Table 1). Another sub-theme encompassed the constant burden of chronic pain, forcing many to stop or reduce working, leading to financial hardship (n=50/240).

An additional subtheme identified was attitudes towards managing pain. We identified two key attitudes among people with chronic pain (Table 1). The first was more a negative attitude towards pain (n=44/240) where chronic pain was described as ‘debilitating’ and a cause of ‘suffering’. Such articles reported primary reliance on pharmacological options, particularly opioids, for managing their symptoms, which frequently led to dependence and addiction. Chronic pain was portrayed as challenging to manage, with people often looking for a ‘quick fix’. As well as experiencing the negative effects of chronic pain, there were some articles (n=28/240) which reported people demonstrating a positive attitude towards living well with pain. Positive attitudes were expressed in the form of people taking active responsibility for their pain management, remained hopeful, and had support and motivation to manage their symptoms. Despite the positive attitudes towards managing pain, very few reports focused on the time, patience and work required to self-manage chronic pain (n=13/240).

How is chronic pain managed?

Information on chronic pain management strategies focused on both passive approaches such as pharmacological management (n=107/240) with opioids (n=67/240) and medicinal cannabis (n=65/240) (Tables 2 and 3), and active approaches such as non-pharmacological management strategies (n=97/240) (Table 4). Articles addressing opioids or cannabis products as treatment options often did so in the context of possible legalisation of cannabis products for medicinal use (n=59/240).

Table 2: Theme #2: Sub-theme: Opioid-based treatment of chronic pain.

The sub-theme of opioid-based painkillers (n=67) included reports of opioids as ineffective for chronic pain, leading to dependence and addiction, producing unwanted side-effects, being prescribed with inadequate information, explanation or advice about alternatives, and overall being perceived as harmful and dangerous (Table 2). In contrast, the sub-theme of medicinal cannabis use for chronic pain (n=65) was portrayed as an effective and safe treatment option with minimal or absent side effects as compared to opioid-based analgesics (Table 3). The expense and inability to source medicinal cannabis legally were highlighted. Medicinal cannabis was portrayed as a solution withheld from people with pain by the New Zealand government and reported as being a last resort, with people reluctantly accessing it illegally. Finally, few articles (n=15/240) mainly from healthcare providers reported a lack of robust scientific evidence supporting the benefit of cannabis products in chronic pain and warranted further research before recommending therapeutic use (Table 3).

Table 3: Theme #2: Sub-theme: Medicinal cannabis use for chronic pain.

Around 40% of the articles (n=97/240) reported on active approaches such as non-pharmacological management strategies and the importance of holistic treatment, avoiding singular focus on pain (Table 4). Holistic approaches for the management of chronic pain included patient-centred care within a multidisciplinary framework (n=36/240), incorporating pain education and acceptance of pain (n=34/240). Other non-pharmacological strategies included use of psychological therapies such as cognitive behavioural therapy, mindfulness and meditation (n=36/240), and encouragement of physical activity (n=34/240). The effectiveness of these non-pharmacological approaches was occasionally noted by both health professionals and people living with chronic pain (Table 4).

Table 4: Theme #2: Sub-theme: Non-pharmacological management of chronic pain.

Table 5: Theme #3: Systemic issues in healthcare associated with chronic pain.

Systemic issues influencing healthcare pathways of chronic pain management

Various healthcare system challenges were reported (n=79/240): lack of healthcare service resources (n=45/240), lack of understanding and not being listened to by healthcare providers (n=30/240), ethnocultural differences that exist when seeking medical care (n=10/79), and delays in receiving diagnosis (n=27/240).

Chronic pain was portrayed as a condition that is not well understood by both healthcare providers and patients (n=28/240). People without diagnosis recalled experiences where they were perceived as ‘malingering’, ‘attention-seeking’ or drug-seeking by healthcare providers (n=13/240). This contributed to people ‘feeling frustrated’ and ‘not being listened to’ when interacting with healthcare providers. Reports of being passed between specialists were also mentioned (n=15/240). These reported experiences led to people giving up seeking medical attention, negatively impacting their prognosis. Many articles highlighted the challenging and lengthy process required to receive a diagnosis. Formal diagnosis was reported to provide relief and validation of their symptoms.

New Zealand’s lack of resources for chronic pain diagnosis and management was a frequent sub-theme reflected in New Zealand news media (n=45/240). Specific issues reported were lack of pain specialists in practice, a shortage of funding available, need for further training of healthcare providers, a need to open more accessible multidisciplinary pain clinics, improving access to existing pain clinics and addressing the prolonged waiting time for appointments with pain specialists.

Ethnocultural issues were also noted (n=10/240), with ethnic minorities having difficulty receiving a diagnosis. Some reports suggested Māori, Pasifika and Asian communities in New Zealand were less likely to seek medical help, regardless of their severity of pain, due to lack of culturally-responsive healthcare services.

Discussion

This content analysis found that chronic pain is often represented in media by focusing on the burden of living life with pain. There were also some reports of people adopting active approaches to successful self-management. The limited emphasis of each of the non-pharmacological strategies such as psychological therapies, physical activity, and pain education and acceptance suggests that the reports failed to communicate that non-pharmacological strategies including active self-management should be prioritised to live well with chronic pain. Reporting on opioids focused on the risk of dependence and adverse effects, however reports regarding medicinal cannabis products largely presented this as a desirable therapeutic option with only limited reporting on lack of scientific data supporting these benefits. There was no reporting of the potential adverse effects of cannabis products. Many reports accurately reported health system limitations leading to challenges with access to appropriate care for chronic pain management that meets health needs particularly for ethnoculturally diverse communities.

The New Zealand news media commonly reported on the impact of living with chronic pain. Chronic pain was portrayed as a condition that is poorly understood unless a person experience it themselves. This has been reported in 69 articles where people with chronic pain reported loss of social roles due to pain impacting their ability to engage in daily tasks. Previous research looking at news media depictions of mental health in New Zealand and Australia found similarities when media reports on personal experience.84,85 People with mental health issues experienced a sense of vulnerability where they too felt an inability to control their own life, affecting their participation within their communities.84,85

New Zealand news media frequently presented chronic pain as a debilitating condition, with only a few reports suggesting the potential for coping well with ongoing pain with adequate support. However, evidence suggests chronic pain can be successfully managed with multidisciplinary health professional input.11 This is represented in a few of the included reports that captured positive experiences of people coping well with pain due to receiving multidisciplinary input from pain services in New Zealand. Further, media reporting has the potential to change public misconceptions, address myths and provide hope and support by offering helpful information.20 Similar to our finding, negative portrayal of people living with mental health conditions in the media was previously reported in New Zealand,86 which led to the development of a media reporting guideline for accurate portrayal of people living with mental health conditions in New Zealand.87

In addition to limited coverage of each of the non-pharmacological approaches, there was limited information on clinical effectiveness of non-pharmacological strategies. Non-pharmacological self-management strategies have sufficient evidence to support their effectiveness for chronic pain management.88 However, much of the information published in the media recommended seeking support from health services or pharmacological strategies instead. As a result, the New Zealand public may not be receiving balanced coverage about potential effective management strategies with a robust evidence base. There was however a clear portrayal of the limited capacity of, and access to specialist pain services. This is not unique to New Zealand; a telephone-based study (n=4,839) conducted in Europe reported that very few people had been introduced to effective pain management strategies despite the high-quality evidence supporting non-pharmacological strategies.89

The extensive reporting of people’s experiences with opioids used for pain management suggest best practice pain management, with avoidance, or at least minimisation of opioid use, may not be widely practised in New Zealand despite existing guidelines.90 Current guidelines recommend not using opioids as a primary pharmacological treatment option in people with chronic non-cancer pain and recommends opioid use only in people with cancer pain and in people with failed non-pharmacological treatments (eg, complex cases). 90 Further, having a care monitoring plan in place is recommended in current opioid users due to the risk of opioid-induced dependence, addiction and other complications (eg, constipation, sedation, depression).90 Some news articles reported opioids were often prescribed as a second-line treatment due to the inability to access specialist pain services (Table 2), this may have contributed to the lack of understanding patients have in regards to best practice care.

The media representations of pharmacological strategies were dominated by personal experiences of people with chronic pain reporting positive benefits from using medicinal cannabis. This coincides with the consideration of the New Zealand government to change legislation surrounding access to medicinal cannabis products.91 All personal experiences in the media focused on the positive effects of cannabis with fewer side effects as compared to opioid-based analgesics suggesting that cannabis use is a safer treatment strategy to manage chronic pain in those using opioids. There is however limited evidence to suggest cannabis as a substitute for opioids92 and a lack of high-quality evidence to support the use of cannabis for chronic pain.93 This lack of evidence was reported in only a few articles featuring input from healthcare providers. Interestingly, there was no reporting on potential adverse effects of medicinal cannabis use especially for young people such as cognitive deficits, dependency and mood changes,94,95 which may outweigh the purported benefits. Therefore, current media reports may not reflect evidence-based information about the clinical effectiveness of medicinal cannabis for chronic pain management. Readers have to be mindful of such information in media reports and consult their healthcare providers for management approaches that would best suit their chronic pain condition.

News media accurately reported that New Zealand is under-resourced for specialist pain management services and has a definite shortage of pain specialists. The UK recommends one pain specialist per 100,000 individuals, while in New Zealand there are only 12 full-time equivalent specialists, falling short of the population-based recommendation of 45 specialists.3 Not only there is a shortage of pain specialists but also pain clinics in New Zealand. Media reporting also failed to emphasise the potential role for the primary care sector and other allied health professions (eg, physiotherapy, psychology and occupational therapy) in supporting people with chronic pain to adopt non-pharmacological self-management strategies. The prevalence of chronic pain in New Zealand is growing, but the capacity for patients remains inadequate, resulting in long wait lists to access healthcare services.3 All these reasons may contribute to the difficulty for chronic pain patients to receive their diagnosis and best practice care.

There was an increasing frequency in coverage on chronic pain within New Zealand’s news media. We can expect that this number may continue to rise due to chronic pain becoming increasingly relevant with the current cannabis bill discussion,91and increasing prevalence with New Zealand’s ageing population.2 This study emphasises the need for New Zealand healthcare providers to be cognisant of the potential for chronic pain reporting by the media to challenge and change people’s beliefs about pain mechanisms and shape patient expectations around management strategies. As few articles included healthcare providers’ views, there is a role for experts to make themselves available to journalists to provide information about evidence-based treatments; and the potential need for public education campaigns with evidence-informed information about chronic pain.20 Media guidelines are available for the portrayal of people with mental health issues in New Zealand to ensure that journalists provide a safe, accurate and respectful representation of this condition.87 This idea has been developed by a New Zealand campaign “Like Minds, Like Mine” where a human rights approach was taken towards enabling people to be free of discrimination and their disabilities being represented.96 A similar approach could be adopted for long-term conditions such as chronic pain, due to its high prevalence and impact in New Zealand. Further, journalists could refer readers to a wide variety of evidence-informed, quality-appraised, educational resources fostering pain self-management accessible to the New Zealand public via the internet.97,98

The strengths of this study include the coverage of all paper and online New Zealand news media. Due to the country’s size it was achievable to include data from 2015, resulting in a large sample size. Independent parallel coding and coding verification added rigor to the analysis. Limitations include the limited generalisability outside New Zealand due to local socio-political considerations. Public debate around legalisation of cannabis before the general parliament election 2017, and subsequent reports on the Misuse of Drugs (Medicinal Cannabis) Amendment Act passed in 2018 influenced the frequency of the cannabis coverage in media related to chronic pain. It is also possible that in countries with higher rates of opioid prescription and unintentional overdose, media reporting may emphasise opioid risk more prominently.

This content analysis identified that chronic pain may have been represented in a somewhat unbalanced manner by popular news media in New Zealand. Many news outlets focused on the struggle associated with living in chronic pain, with a lesser focus on the ability to successfully manage pain and live a meaningful life. Further, the greater emphasis on pharmacological strategies over non-pharmacological approaches suggest that the reports failed to communicate that non-pharmacological strategies should be a key component of self-management for living well with chronic pain. Given the potential for news media reports shaping patient’s health beliefs and treatment expectations, New Zealand healthcare providers and researchers can collaboratively work with the media to provide evidence-based information on both non-pharmacological and pharmacological pain management strategies.

Appendix 1

Appendix 2

Frequency of news articles on chronic pain published since 2015