Structural and Individualized Racism Drives Racial Disparities in Chronic Low Back Pain: A Cross-Sectional Serial Mediation Analysis

J Pain. 2026 Jun 11:106351. doi: 10.1016/j.jpain.2026.106351. Online ahead of print.

ABSTRACT

This cross-sectional study examined whether individualized racism, as measured by experiences of discrimination, internalized stigma of chronic pain, and perceived injustice, as well as structural racism, as measured by the Area Deprivation Index (ADI), mediates racial disparities in nonspecific chronic low back pain (CLBP) outcomes among non-Hispanic Blacks (NHBs) and non-Hispanic Whites (NHWs). 258 adults completed questionnaires assessing pain severity, pain interference, discrimination, internalized stigma, and perceived injustice. The mean pain severity and pain interference scores were 61.59 (SD = 19.98) and 47.46 (SD = 29.17), respectively. Serial mediation analysis, adjusting for age and sex, revealed that discrimination and internalized stigma mediated the association of race with pain severity and interference, with significant indirect effects: β = -1.357, 95% CI [ -2.557, -0.367] and β = -2.576, 95% CI [ -4.657, -0.721], respectively. Serial mediation analysis also revealed that discrimination and perceived injustice mediated the association of race with pain severity and pain interference, with significant indirect effects: β = -1.519, 95% CI [ -2.932, -0.400] and β = -2.804, 95% CI [ -5.330, -0.809], respectively. ADI also significantly mediated the indirect effects of race on pain severity (β = -3.138, 95% CI [-5.646, -0.962]) and pain interference (β = -4.238, 95% CI [-8.123, -1.067]). Thus, racial disparities in CLBP severity and interference may be explained by multilevel mechanisms: an individual's race is linked to discrimination, which predicts internalized stigma and perceived injustice; these factors, in turn, predict CLBP outcomes; and race also correlates with ADI, which in turn correlates with CLBP outcomes.

PERSPECTIVES: Racial pain disparities are well documented. These findings suggest that intrapersonal (internalized stigma of chronic pain), interpersonal (experiences of discrimination and perceived injustice) and structural (neighborhood deprivation) racism-related factors indirectly mediate the relationship between race and chronic low back pain outcomes.

PMID:42276535 | DOI:10.1016/j.jpain.2026.106351