Equitable approaches to palliative pain management in a structural vulnerability context: a secondary analysis of community-based participatory action studies

Pain management is considered a fundamental human right and a central aspect of palliative care. However, disparities exist in palliative pain management for populations facing intersecting inequities, such as housing insecurity and poverty, which are rooted in colonialism, racism, and stigma. This study aims to examine how palliative pain management is delivered within a structural vulnerability context, drawing attention to how pain is addressed in care delivery among people who experience disparities in pain management including people who experience housing insecurity, people who experience poverty, and people who use substances. This is a secondary analysis of qualitative data generated from two participatory action research studies, Realizing the Benefits of a Palliative Approach for Vulnerable and Marginalized People Living with Cancer, and Building Palliative Care Capacity in Inner-City Communities. Participants included inner-city community workers (housing staff, outreach support, peer workers), a mobile clinical palliative outreach team (nurses, physicians, social workers), caregivers, clients, and decision-makers (policy makers, managers). A total of 28 interviews, 5 focus groups, and 35 observational field notes and meeting minutes were analyzed following a reflexive thematic analysis process guided by a structural vulnerability lens. Findings highlight how community-based and clinical-based service providers worked with clients who often had unmet chronic pain needs and had developed strategies, such as using illicit substances, to manage their pain within the community. Service providers focused on building trust with clients, addressing social determinants through care coordination, and developing tailored approaches to pharmacological pain management that were responsive to clients’ previous negative experiences with healthcare and the social disparities they faced. Broader social factors, such as housing insecurity, home care, and opioid and hospital policies, complicated the delivery of palliative pain management. This study highlights how palliative approaches can legitimize pain among populations with significant histories of unmanaged pain and systemic barriers to care. Findings underscore the need for a multidimensional strategy integrating pharmacological and non-pharmacological approaches, sustained cross-disciplinary collaboration, and a relational approach (e.g., trust-building) to care. The findings emphasize the centrality of a ‘total pain’ approach and sustained investment in community-based palliative care services to achieve equitable pain management.