Intersectional pain disparities and resilience in Veterans with chronic pain

Abstract: OBJECTIVE: Although racial and ethnic pain disparities are well-documented, fewer studies have examined rural and socioeconomic disparities or investigated how identities might intersect to predict pain outcomes. Moreover, little research has explored the protective role resilience may play in mitigating disparities. Guided by Booker's Hierarchy of Health Disparities Research framework, this study aimed to (a) investigate intersectional racial, ethnic, rural, and socioeconomic pain disparities and (b) examine the role of resilience in reducing pain disparities. METHOD: We sampled a diverse group of 498 Veterans with osteoarthritis who were scheduled for total knee arthroplasty and were enrolled in a randomized controlled trial. Participants completed a battery of validated instruments to assess demographics, pain outcomes, and resilience (pain acceptance, values-aligned behaviors). RESULTS: Participants were primarily older adult males from diverse backgrounds (25% Black; 8% Hispanic; 26% rural; 70% >50th national percentile for socioeconomic disadvantage). Only race was significantly associated with pain outcomes across intersectional groups. There was no evidence of rural pain disparities. Socioeconomic status moderated the relationship between race, physical functioning, and psychological distress, such that racial disparities decreased as socioeconomic disadvantage increased. No other significant socioeconomic disparities emerged. Resilience did not moderate the relationship between race and pain. Rather, resilience was associated with better pain outcomes across racial groups. CONCLUSIONS: Findings highlight the robust connection between race and pain. They also suggest that socioeconomic and rural and pain disparities may be less prevalent in Veterans. Resilience may be a modifiable factor that can improve pain outcomes in Black patients.