Introduction
Norway is a welfare state of a social-democratic type. This implies that public welfare is universal, comprehensive, and generous when compared with other welfare regimes. The major income maintenance system is social insurance. All citizens who fulfill specific criteria are entitled to social insurance benefits. One crucial criterion for most benefits is a work record. Rights to social insurance (e.g., unemployment benefit, sickness pay) are earned by previous labor market participation. People who have not earned the right to or exhausted their rights to social insurance and are unable to support themselves, are eligible for social assistance. Unlike social insurance, social assistance provides the last safety net and is a means tested benefit. Usually, social assistance is not as generous as unemployment benefits.
In 2005, approximately 3% of the general population in Norway over 17 years of age received social assistance [
1]. Forty-two percent of these individuals were long-term social assistance recipients (LTRs) defined as having received social assistance as their main source of income for at least 6 of the last 12 months. These LTRs experience economic strain and have a simpler housing standard than the general population [
2]. Of note, in 2005, 71% of LTRs reported serious financial difficulties compared to only 13% of the general population [
3]. In general, LTRs are less educated, have less social resources, lower incomes, and poorer health than the general population [
4]. In addition, LTRs and welfare recipients struggle with numerous health issues, (e.g., poorer functional health, depression, anxiety, increased risk of cardiovascular disease, pain), have a higher level of psychological distress, and reduced psychological well-being [
5‐
9]. LTRs are more likely to experience domestic violence, experience feelings of loneliness, and report problems with alcohol and illicit drugs [
4,
6]. The mortality rate of this vulnerable and disadvantaged group is two to three times higher than that of the general population [
10].
Chronic pain is a significant and rapidly growing health problem in the general population worldwide [
11]. In fact, population-based studies suggest that chronic pain occurs in 11 to 30% of the general population in the United States and Europe [
12‐
15]. Chronic pain is a medical condition in which biological, psychological, and social factors dynamically interact with each other [
11]. In fact, numerous studies have demonstrated that chronic pain leads to negative outcomes for patients, including fear of pain, avoidance of activities that elicit pain, stress-related symptoms, and disability [
16‐
21]. In addition, chronic pain has a negative impact on the health-related quality of life (HRQOL) of individuals in the general population, as well as of individuals with different chronic conditions [
22‐
29]. However, only one study has reported on pain in a sample of social security recipients [
8]. In this study, that compared pain locations in social security recipients and non-recipients, social security recipients reported pain more frequently in their hands and legs than non-LTRs.
A variety of definitions of quality of life (QOL) are reported in the literature. In addition, researchers use a number of different paradigms to evaluate HRQOL. For example, many social scientists tend to focus on functional status and overall well-being, and how financial circumstances, social structures, and institutions influence HRQOL. In contrast, clinical researchers may focus on how biomedical and psychological factors influence the HRQOL of LTRs [
30].
Four studies were found that evaluated the self-reported health status of welfare recipients or LTRs [
5‐
8] and three of these studies compared welfare recipients or LTRs with non-recipients [
5,
7,
8]. In a study that compared single mothers affected by welfare reform (Woman’s Employment Study (WES)) with a national sample of woman, woman over 24 years in the WES sample had significantly lower levels of physical functioning [
5]. In another study of 284 LTRs (97% female), two-fifths of the LTRs rated their health as fair or poor. Compared to the total state welfare population, LTRs were more likely to have mental and physical health problems [
6]. Data from the National Population Health survey in Canada found that welfare recipients were more likely to report poor/fair health, poor functional health, and depression compared to non-welfare recipients [
7]. In a Swedish study, social security recipients had significantly poorer health measured using the GHQ-12 than non-recipients [
8]. Finally, in a study from Canada [
9], 56% of the woman and 45% of the men on social assistance reported a higher level of distress than other individuals living in the same neighborhood.
An individuals’ HRQOL and the relationship between HRQOL and chronic pain can differ with gender [
27,
31], age [
25], and employment status [
24,
32,
33]. For example, in one study [
33], younger individuals who were unemployed reported a lower QOL than employed individuals of the same age and older individuals who were employed [
33]. In contrast, in a study of young unemployed adults, the majority (67%) reported their QOL as good [
32].In a third study of young unemployed Australians, that used the SF-36 [
34], lower health status was reported by those who were unemployed. In one study that examined the relationship between unemployment and QOL [
32], the feeling of loneliness was evaluated. No differences in loneliness were found between the unemployed group and the reference group. However, a study of loneliness as a predictor of HRQOL among older caregivers found that loneliness was the most important factor that predicted lower HRQOL among caregivers, as well as older people in general [
35]. Loneliness is defined by Peplau and Perlman as an unpleasant experience that arises when a person’s network and social relations are deficient [
36]. In this study, because a recent report suggested that loneliness was a problem in LTRs, the relationship between loneliness and HRQOL was evaluated.
Several studies have examined the impact of alcohol and substance abuse on HRQOL [
37‐
40]. However, in a recent review, the authors noted that it is difficult to draw valid conclusions about the impact of alcohol and substance abuse on HRQOL. One of the major reasons for these inconclusive results is the number of different ways that QOL was defined and measured across studies [
37]. In addition, the study samples were rather heterogeneous. However, in a study that used SF-12 to measure HRQOL of adults treated for substance abuse, their HRQOL was lower than that of GP and as low as or lower than patients with other chronic medical conditions [
38].
In summary, a limited amount of data suggests that LTRs struggle with a number of chronic health issues, report chronic pain and loneliness, and are more likely to abuse alcohol and illicit drugs. Taken together, all these factors may have a negative impact on HRQOL. However, no studies were found that evaluated the impact of these factors on HRQOL of LTRs with and without chronic pain. Therefore, the purposes of this study were to compare the HRQOL of LTRs with and without chronic pain and determine the effect of select demographic, social, pain, alcohol and illicit drug use characteristics on the physical and mental components of their HRQOL.
Discussion
This study is the first to examine the impact of chronic pain on the HRQOL of LTRs. Consist with previous studies [
23,
28,
29,
47], LTRs with chronic pain rated both the physical and mental components of HRQOL lower than LTRs without chronic pain. These differences in HRQOL represent not only statistically, but clinically significant differences in both dimensions of HRQOL (i.e.,
d = 1.2, and
d = 0.4) [
48]. In addition, the fact that LTRs with chronic pain were older and had more problems with alcohol than LTRs without chronic pain is consistent with a recent Canadian study of predictors of chronic non-cancer pain [
49].
It is interesting to note that LTRs with chronic pain had a significantly lower PCS score than normative data reported for individuals with chronic low back pain (PCS = 45.96,
P < .001) [
45]. However, the LTRs without chronic pain had a mean PCS score that was significantly higher than normative data for the general population (PCS 50.3,
P = 0.014, age 18–74) [
50]. In fact, LTRs with chronic pain had a lower PCS score than patients with rheumatoid arthritis (PCS = 39.60,
P < .001) and cancer (PCS = 40.76,
P ≤ .001) [
45]. A potential reason why the physical component of HRQOL of LTRs with chronic pain was lower than that of an age-matched sample of patients with low back pain is that chronic pain in LTRs is a symptom of a number of chronic medical conditions that impact their HRQOL. Previous studies found that LTRs struggle with numerous health problems [
5‐
9] and have chronic conditions that have a negative impact on their HRQOL [
51,
52]. In addition, LTRs are more likely to experience violence, which may result in chronic pain and decrease their physical health [
6,
53].
The mean MCS scores for both groups of LTRs were lower than population norms (i.e., 50.6, both
P ≤ .001) [
50]. However, LTRs with chronic pain had lower MCS scores than LTRs without chronic pain. The fact that LTRs with chronic pain had a lower MCS score is consistent with several studies that found that chronic pain has a negative impact on the HRQOL [
23,
25,
27,
47] as well as on the ability of an individual to remain employed.
One potential reason for the low mental score in both groups of LTRs is that these individuals have poorer health, less social resources, lower incomes, lower education [
4], and experience more economic strain than the general population [
2]. In addition, LTRs were more likely to have mental problems and depression symptoms [
5,
7,
8]. Another potential reason for the low MCS scores is that these individuals experience a number of disadvantages over the course of their lives. LTRs experience more childhood difficulties [
4,
54] and have a lifestyle with higher rate of accidents or medical conditions associated with a poorer diet and higher rates of smoking and alcohol consumption than the general population [
4,
6,
8].
In the present study, chronic pain explained the largest percentage of the variance in PCS scores. This result is not that surprising given the fact that chronic pain has a negative impact on physical function [
27,
29,
49] and that physical function decreases with age [
31]. Findings from this study suggest that clinicians who care for LTRs should screen these individuals for the presence of chronic pain.
While chronic pain explained the largest percentage of the variance in physical health, loneliness explained the largest percentage of variance in the mental health scores. Only one study was found that evaluated loneliness as a predictor of HRQOL among elderly caregivers [
35], and no studies have evaluated the impact of loneliness on the HRQOL of LTRs. Loneliness is not the same as being alone, but people with small social network usually feel more loneliness than people with larger social networks [
55,
56]. In addition, women report more loneliness than men; older people report feelings of loneliness more often than younger individuals, excluding young people between the ages of 19 and 29 who feel more loneliness than adults [
43]. One study found that loneliness was the most important factor predicting low HRQOL of older caregivers as well as older people in general [
35]. Recent findings suggest that loneliness may lead to depression, sleep disturbances, anxiety, and desperation [
57]. A recent study found that social loneliness impacted QOL in individuals with serious mental illness who lived in a group home [
58]. While loneliness is emerging as a concept that influences HRQOL, additional research is warranted to replicate the findings from this study.
In the present study, illicit drug use was associated with poorer mental health. This finding is consistent with a previous study [
38]. However, a recent review noted that it was difficult to draw valid conclusions about the impact of alcohol and substance abuse on HRQOL because of heterogeneous study samples and different ways that QOL was defined and measured [
37]. Additional research is warranted on this relationship.
Several limitations of this study need to be acknowledged. First, only a limited amount of information is available on those LTRs who did not return the study questionnaires. When administrative data from 2005 were used to compare the recipients who met the inclusion criteria to those who completed the questionnaire, no significant differences were found in gender, age, work experience, previous receipt of social assistance, and social security benefits [
42]. Another limitation is that all of the information was obtained through self-report measures, and some of the questions may be subject to recall bias. It should be noted that one of the questions on SF-12 asked about how pain had impaired on individual’s work and daily life which is likely to be related to the PCS score. However, the bivariate correlation between chronic pain and PCS was 0.59. It is not that high, so chronic pain is not all that the PCS score is measuring. Finally, the QOL scores of the LTRs in this study may be higher than the total population of LTRs, because LTRs with serious illness or severe substance abuse problems were excluded from this study.