Social Determinants and Consequences of Pain: Toward Multilevel, Intersectional, and Life Course Perspectives

Abstract

Despite wide endorsement of a biopsychosocial framework for pain, social aspects of pain remain rarely addressed in the context of pain prevention and management. In this review, we aim to 1) examine the broad scope of social determinants and consequences of pain and their interactions across multiple levels of organization, and 2) provide a framework synthesizing existing concepts and potential areas for future work on social aspects of pain, drawing upon socioecological, intersectional, and life course approaches. Integrating interdisciplinary theory and evidence, we outline pathways through which multilevel social factors and pain may affect each other over time. We also provide a brief summary of intrapersonal aspects of pain, which are thought to operate at the interface between individuals and the social context. Progressing from micro- to macrolevel factors, we illustrate how social determinants of pain can directly or indirectly contribute to pain experiences, expression, risk, prognosis, and impact across populations. We consider 1) at the interpersonal level, the roles of social comparison, social relatedness, social support, social exclusion, empathy, and interpersonal conflict; 2) at the group or community level, the roles of intimacy groups, task groups, social categories, and loose associations; and 3) at the societal level, the roles of political, economic, and cultural systems, as well as their policies and practices. We present examples of multilevel consequences of pain across these levels and discuss opportunities to reduce the burden and inequities of pain by expanding multilevel social approaches in pain research and practice. PERSPECTIVE: Despite wide endorsement of a biopsychosocial framework for pain, social aspects of pain are often unclearly defined, hindering their use in pain prevention, management, and research. We summarize the scope of social aspects of pain and provide a framework synthesizing existing concepts and potential areas for future work.

Keywords: Social structure; health equity; intersectional framework; life course perspective; social determinants of health.

Figure 1.

Continuum of natural systems. (Reproduced with permission from Engel, G.L., 1980. The Clinical Application of the Biopsychosocial Model. Am. J. Psychiatry 137, 535–544.)

Figure 2.

Towards a multilevel, intersectional, and life course framework of determinants and consequences of pain. I. Intrapersonal determinants of pain Pain experiences and expression are modulated by cognitive, affective, behavioral, and sensory processes that allow for learning and adaptation to social cues about threats to integrity. Individual psychological and biological determinants of pain are the result of historical and ongoing interactions between genetic, epigenetic, and environmental conditions, which are embedded in and shaped by multilevel social factors. II. Multilevel social determinants of pain Across nested levels of organization (e.g., interpersonal, group, societal), social positions, processes, and systems shape the conditions in which people are born, develop, play, work, and age. These social factors determine experiences, resources, and opportunities to prevent and manage pain, which contribute to the distribution of pain across populations. III. Multilevel consequences of pain Especially when chronic, pain is consequential to biological, psychological, and social wellbeing. Pain may impact individual self-perception, interpersonal relationships, and participation in valued social groups, with substantial impact on social systems and the population burden of disability. IV. Life course and intergenerational dimensions Life stages are associated with changes in biopsychosocial functions relevant to exposure to pain, stress reactivity, as well as pain sensitivity, meaning appraisal, and coping. Critical and/or sensitive periods may present optimal points for interventions to prevent and manage chronic pain. The effects of multilevel determinants of pain may accumulate and interact over the life course, potentially contributing to intergenerational transmission of pain and its consequences. V. Intersectional systems of inequity Systems of inequity are human-made to create and maintain social stratification and inequitable hierarchies (e.g., racism, sexism, classism, ableism, ageism, nativism, heterosexism, gender binarism). These systems jointly produce effects beyond their separate influences and, thus, are called intersectional. They manifest across all levels of determinants and consequences of pain (e.g., institutional, interpersonal, and internalized inequities), creating generally more favorable conditions for people in positions of greater power and status.

Figure 3.

Potential avenues to apply a multilevel conceptualization of social aspects of pain to advance equitable pain prevention and management.