- Health Disparity and Health Equity
Health disparity is defined as “a particular type of health difference that is closely linked with economic, social, or environmental disadvantage” . Health equity is consequently “the absence of unfair and avoidable or remediable differences in health among population groups defined socially, economically, demographically or geographically” . Disparities in health outcomes have been documented both within and between countries [14; 25] and are stronger determinants of health outcomes than the quality and availability of medical care .
- Disparities in back pain have been documented worldwide.
A recent systematic review of social determinants of health in low back pain across 17 countries showed important associations between gender, race, ethnicity, education, occupation and socioeconomic status and important facets of low back pain (e.g., prevalence, intensity and level of disability) . Differences in health because of where you live or your race or gender, have important societal and economic costs[20; 24; 32; 37].
- Race and ethnicity are not synonymous.
Race is defined as “physical differences that groups and cultures consider socially significant” while Ethnicity refers to the “shared cultural characteristics such as language, ancestry, practices, and beliefs” . Race and ethnicity when used interchangeably fail to capture the distinction that an individual may be of one race but can be multi-ethnic through language, culture, and religion. In the presence of inequitable race relations in a society, it becomes very difficult to disentangle ethnicity from race in a meaningful way; in such cases the terms race/ethnicity are used jointly .
- Racial and ethnic disparities lead to under-treatment of back pain.
Racial and ethnic disparities in health care  persist even after adjusting for differences in access-related factors, needs, preferences, and appropriateness of the intervention. Specific to back pain, racial and ethnic disparities in opioid prescribing have been documented extensively in emergency departments and outpatient settings [16; 23; 26; 27]. Despite racial/ethnic minorities reporting severe back pain and disability levels, health care providers were more likely to associate less severe pain to them, less likely to refer them for imaging  and more likely to recommend non-opioid therapy .
- Racial and ethnic disparities are undermining measurement and understanding of pain experiences in various populations.
Without culturally adapted pain-related constructs, measurement, and interpretation frameworks, racial and ethnic disparities in back pain will persist. For example, application of measures not adapted for use in Indigenous communities in Australia has prevented fully capturing their pain experience  and consequently impacted on their pain assessment and treatment. This is important considering that in some communities for example, such as Canadian Mi’kmaq community, there is no word for ‘pain’, only expressions for ‘hurt’ . In this context the use of numeric or faces pain scales as descriptors for pain were perceived as lacking meaning. Efforts have been made to create culturally adapted scales. For example, a systematic review of cross-cultural adaptation of a functional disability index for back pain, the Oswestry Disability Index, found 27 different adaptations of the questionnaire . Such efforts are a step in the right direction but much more needs to be done in this domain.
- Women are more likely than men to experience low back pain.
Differences in socially constructed masculinity- and femininity-related ways of being and acting (gender)  and those characteristics that are biologically determined (sex) have been associated with various facets of back pain experience . Prevalence of low back pain is higher in women compared to men (ratio around 1.27), and this difference is greater when women reach the postmenopausal stage [9; 41]. Multiple sex-related (e.g., hormonal, differences in the endogenous opioid system) [9; 21] and gender-related (e.g., traits, role expectations, attitudes, stereotypes, norms, status/power asymmetries, ideologies) factors at the intra-individual, situational, positional and ideological levels have been proposed to explain these differences , however a complete understanding of back pain in minority groups (including LGBTQI), is poorly documented .
- Sex and gender difference in health care access and treatments for low back pain exist.
Women seek health care for low back pain more often and in greater amounts than men [8; 15]. This might reflect generally higher levels of health seeking behaviors among women. But this might also be in part explained by their higher levels of reported pain intensity and severity, leading to more frequent health care encounters or prescription of analgesics for example . A theory-guided qualitative review of gender bias in chronic pain suggests that beyond gender norms about pain and pain-related coping, gender bias is present in the treatment of chronic pain that cannot simply be explained by different medical needs .
- Socioeconomic positions are associated with poor back pain prognosis.
A recent European study showed that socioeconomic inequalities in the prevalence of back pain might be less pronounced compared to other pain conditions (e.g., hand/arm pain); however, there was great regional heterogeneity . Beyond simple pain prevalence, socioeconomic position, for example education level, has been shown to be associated with recurrence of low back pain and disability, more so than it is associated with new back pain onset . The reasons for these inequities are multifactorial and include variability in behavioral and environmental risk factors, occupational status, and barriers to accessing and utilizing health care resources . There is also evidence suggesting that childhood socioeconomic position is a risk factor for back pain in adulthood [18; 29]. The magnitude of these inequities is on the rise and this seems to be particularly true for men  and persist into older adulthood .
- Patient socioeconomic position influences pain assessment and treatment.
Unlike race/ethnic or sex/gender characteristics, the role of classism, or categorization of individuals based on their social class, has been less studied in the context of back pain assessment and treatment [11; 34]. Recent studies of classism in chronic pain more broadly suggest that individuals with low socioeconomic position are assessed by health care providers as experiencing lower pain intensity, being less credible, and as their pain being more strongly influenced by psychological factors compared to individuals with higher socioeconomic status .
- There is reason to hope for a better future.
Different global initiatives have been developed that focus on achieving health equity and minimizing health disparities, for e.g. the US-based Healthy People 2020 initiative , the culturally appropriate education program “My Back on Track, My Future”  project for Indigenous Australian communities. In addition, Pain Revolution (Australia) , Pain BC (Canada) , and Flippin’ Pain (UK)  campaigns are also examples of recent efforts to adopt a more equitable approach to pain literacy and consumer empowerment. While not specific to back pain, these types of initiatives help gather knowledge and inform policies. Such endeavours can be easily adopted for other minority groups to overcome health disparities and achieve health equity in back pain.
1] American Psychological Association. Bias-Free Language. Publication manual of the American Psychological Association. Washington DC: American Psychological ASsociation, 2019.
 Bernardes SF, Keogh E, Lima ML. Bridging the gap between pain and gender research: a selective literature review. Eur J Pain 2008;12(4):427-440.
 Brandao T, Campos L, de Ruddere L, Goubert L, Bernardes SF. Classism in Pain Care: The Role of Patient Socioeconomic Status on Nurses’ Pain Assessment and Management Practices. Pain medicine 2019;20(11):2094-2105.
 Carey TS, Garrett JM. The relation of race to outcomes and the use of health care services for acute low back pain. Spine (Phila Pa 1976) 2003;28(4):390-394.
 Daniel H, Bornstein SS, Kane GC, Health, Public Policy Committee of the American College of P. Addressing Social Determinants to Improve Patient Care and Promote Health Equity: An American College of Physicians Position Paper. Ann Intern Med 2018;168(8):577-578.
 Dionne CE, Von Korff M, Koepsell TD, Deyo RA, Barlow WE, Checkoway H. Formal education and back pain: a review. J Epidemiol Community Health 2001;55(7):455-468.
 Dorlin E. L’historicité du sexe. Sexe, genre et sexualités: Presses universitaires de France, 2008. pp. 33-54.
 Elsamadicy AA, Reddy GB, Nayar G, Sergesketter A, Zakare-Fagbamila R, Karikari IO, Gottfried ON. Impact of Gender Disparities on Short-Term and Long-Term Patient Reported Outcomes and Satisfaction Measures After Elective Lumbar Spine Surgery: A Single Institutional Study of 384 Patients. World Neurosurg 2017;107:952-958.
 Fillingim RB, King CD, Ribeiro-Dasilva MC, Rahim-Williams B, Riley JL, 3rd. Sex, gender, and pain: a review of recent clinical and experimental findings. J Pain 2009;10(5):447-485.
 Flippin’ Pain. https://www.flippinpain.co.uk/.
 Gebauer S, Salas J, Scherrer JF. Neighborhood Socioeconomic Status and Receipt of Opioid Medication for New Back Pain Diagnosis. Journal of the American Board of Family Medicine : JABFM 2017;30(6):775-783.
 Grossschadl F, Stolz E, Mayerl H, Rasky E, Freidl W, Stronegger W. Educational inequality as a predictor of rising back pain prevalence in Austria-sex differences. Eur J Public Health 2016;26(2):248-253.
 Ikeda T, Sugiyama K, Aida J, Tsuboya T, Watabiki N, Kondo K, Osaka K. Socioeconomic inequalities in low back pain among older people: the JAGES cross-sectional study. Int J Equity Health 2019;18(1):15.
 Karran EL, Grant AR, Moseley GL. Low back pain and the social determinants of health: a systematic review and narrative synthesis. Pain 2020;161(11):2476-2493.
 Kent PM, Keating JL. The epidemiology of low back pain in primary care. Chiropractic & osteopathy 2005;13:13.
 King C, Liu X. Racial and Ethnic Disparities in Opioid Use Among US Adults With Back Pain. Spine (Phila Pa 1976) 2020;45(15):1062-1066.
 Krieger N. A glossary for social epidemiology. J Epidemiol Community Health 2001;55(10):693-700.
 Lallukka T, Viikari-Juntura E, Raitakari OT, Kahonen M, Lehtimaki T, Viikari J, Solovieva S. Childhood and adult socio-economic position and social mobility as determinants of low back pain outcomes. Eur J Pain 2014;18(1):128-138.
 Latimer M, Finley GA, Rudderham S, Inglis S, Francis J, Young S, Hutt-MacLeod D. Expression of pain among Mi’kmaq children in one Atlantic Canadian community: a qualitative study. CMAJ Open 2014;2(3):E133-138.
 LaVeist TA, Gaskin D, Richard P. Estimating the economic burden of racial health inequalities in the United States. Int J Health Serv 2011;41(2):231-238.
 Leresche L. Defining gender disparities in pain management. Clin Orthop Relat Res 2011;469(7):1871-1877.
 Lin IB, Ryder K, Coffin J, Green C, Dalgety E, Scott B, Straker LM, Smith AJ, O’Sullivan PB. Addressing Disparities in Low Back Pain Care by Developing Culturally Appropriate Information for Aboriginal Australians: “My Back on Track, My Future”. Pain medicine 2017;18(11):2070-2080.
 Ly DP. Racial and Ethnic Disparities in the Evaluation and Management of Pain in the Outpatient Setting, 2006-2015. Pain medicine 2019;20(2):223-232.
 Mackenbach JP, Meerding WJ, Kunst AE. Economic costs of health inequalities in the European Union. J Epidemiol Community Health 2011;65(5):412-419.
 Marmot M, Friel S, Bell R, Houweling TA, Taylor S, Commission on Social Determinants of H. Closing the gap in a generation: health equity through action on the social determinants of health. Lancet 2008;372(9650):1661-1669.
 Meghani SH, Byun E, Gallagher RM. Time to take stock: a meta-analysis and systematic review of analgesic treatment disparities for pain in the United States. Pain medicine 2012;13(2):150-174.
 Mills AM, Shofer FS, Boulis AK, Holena DN, Abbuhl SB. Racial disparity in analgesic treatment for ED patients with abdominal or back pain. Am J Emerg Med 2011;29(7):752-756.
 Mittinty MM, McNeil DW, Jamieson LM. Limited evidence to measure the impact of chronic pain on health outcomes of Indigenous people. J Psychosom Res 2018;107:53-54.
 Muthuri SG, Kuh D, Cooper R. Longitudinal profiles of back pain across adulthood and their relationship with childhood factors: evidence from the 1946 British birth cohort. Pain 2018;159(4):764-774.
 Pain BC. https://www.painbc.ca/.
 Pain Revolution. https://www.painrevolution.org/.
 Politzer E, Shmueli A, Avni S. The economic burden of health disparities related to socioeconomic status in Israel. Isr J Health Policy Res 2019;8(1):46.
 Promotion OoDPaH. Healthy People 2020, Vol. 2020, 2020.
 Romero DE, Muzy J, Maia L, Marques AP, Souza Junior PRB, Castanheira D. Chronic low back pain treatment in Brazil: inequalities and associated factors. Cien Saude Colet 2019;24(11):4211-4226.
 Samulowitz A, Gremyr I, Eriksson E, Hensing G. “Brave Men” and “Emotional Women”: A Theory-Guided Literature Review on Gender Bias in Health Care and Gendered Norms towards Patients with Chronic Pain. Pain Res Manag 2018;2018:6358624.
 Smedley BD, Stith AY, Nelson AR. Unequal treatment: Confronting racial and ethnic disparities in health care. Washington, DC: Institute of Medicine, 2003.
 Social D, Science Integration Directorate PHAoC. Report summary – The Direct Economic Burden of Socioeconomic Health Inequalities in Canada: An Analysis of Health Care Costs by Income Level. Health Promot Chronic Dis Prev Can 2016;36(6):118-119.
 Solar O, Irwin A. A conceptual framework for action on the social determinants of health. Social Determinants of Health Discussion Paper 2 (Policy and Practice). Geneva: World Health Organization, 2010. p. 79.
 Todd A, McNamara CL, Balaj M, Huijts T, Akhter N, Thomson K, Kasim A, Eikemo TA, Bambra C. The European epidemic: Pain prevalence and socioeconomic inequalities in pain across 19 European countries. Eur J Pain 2019;23(8):1425-1436.
 U.S. Department of Health and Human Services. The Secretary’s Advisory Committee on National Health Promotion and Disease Prevention Objectives for 2020. Phase I report: Recommendations for the framework and format of Healthy People 2020 [Internet]. Section IV: Advisory Committee findings and recommendations, 2010.
 Wang YX, Wang JQ, Kaplar Z. Increased low back pain prevalence in females than in males after menopause age: evidences based on synthetic literature review. Quant Imaging Med Surg 2016;6(2):199-206.
 Wu A, March L, Zheng X, Huang J, Wang X, Zhao J, Blyth FM, Smith E, Buchbinder R, Hoy D. Global low back pain prevalence and years lived with disability from 1990 to 2017: estimates from the Global Burden of Disease Study 2017. Ann Transl Med 2020;8(6):299.
 Yao M, Wang Q, Li Z, Yang L, Huang PX, Sun YL, Wang J, Wang YJ, Cui XJ. A Systematic Review of Cross-cultural Adaptation of the Oswestry Disability Index. Spine (Phila Pa 1976) 2016;41(24):E1470-E1478.
Gabrielle Pagé*, PhD, Assistant professor and research scholar, Department of Anesthesiology and Pain Medicine, Faculty of Medicine, & Department of Psychology, Faculty of Arts and Science, University of Montreal, Montreal, QC, Canada; email@example.com
Manasi Murthy Mittinty, MD (Medicine), PhD, Co-chair of the Sex, Gender and Race Special Interest Group of the International Association for the Study of Pain; Lecturer, Pain Management Research institute, University of Sydney, Australia
Kobina Gyakye deGraft-Johnson, MBChB, FGCS (Anaesthesia), PGDip Interdisc Pain Mgt, Consultant Anaesthetist and Pain Specialist, Korle Bu Teaching Hospital, Accra, Ghana
MG Pagé is a Junior 1 research scholar from the Fonds de recherche du Québec en santé.
Lorimer Moseley AO
Chair in Physiotherapy
UniSA Allied Health & Human Performance
University of South Australia
Sónia F. Bernardes
Associate Professor with Habilitation
Department of Social and Organizational Psychology