Among American adults, the three-month prevalence of having either back or neck pain is estimated to be as high as 31% [¹]. They are leading causes of disability and Americans who reported having either chronic back or neck problems had about 65% greater yearly health care expenditures than those who did not [²].

The three-month prevalence of back pain is lower in Latino-Americans than in white Americans [³]. No studies in the US have examined whether the prevalence of chronic back or neck pain in Latino-Americans differs by acculturation. However, there is evidence that acculturation does affect the health of immigrants and of their descendants [⁴–²⁴]. Factors associated with chronic back or neck pain, such as increased body mass index [²⁵–³¹], depression, [³²–⁴⁰] smoking and heavy alcohol use [³¹, ⁴¹–⁴³] have also been shown to be higher among more acculturated Latino-Americans [⁶, ¹⁶, ¹⁷, ²⁰].

In Europe, certain immigrant populations have had higher prevalence of pain compared to native-born subjects [⁴⁴, ⁴⁵]. Immigrants from southern Europe and the Middle East living in Sweden have higher odds of chronic widespread pain, higher pain-associated psychosocial dysfunction, and higher rates of disability [⁴⁵–⁴⁸]. Similarly, South Asian immigrants residing in the United Kingdom had 3.7 times higher odds of reporting widespread musculoskeletal pain than native-born British [³⁰]. Among these immigrants, higher acculturation was negatively associated with the report of widespread pain [⁴⁴].

Very little is known about how culture affects the experience or report of chronic back or neck pain. One line of research suggests that the stress of the immigrant experience would lead to higher report of chronic back or neck problems among immigrant and less acculturated respondents. Alternatively, evidence of the deterioration of some health behaviors and outcomes in Latino-Americans with acculturation would lend support for the acculturation hypothesis which states that migrants from cultures with protective health practices experience worsening health with longer exposure to a host culture as they adopt the host culture’s unhealthy practices [⁴, ⁷, ²³, ²⁴].

This study investigates whether the 12-month prevalence of chronic back or neck problems in Latino-Americans is associated with acculturation measured by nativity, generation in the US, percentage of lifetime in the US, and English proficiency. We hypothesize that the prevalence of reported chronic back or neck problems will be higher in more acculturated Latino-Americans and that differences in physical health, depression, and obesity may mediate the effect of acculturation.

Table 1 shows the unweighted study sample characteristics for Latino-Americans stratified by the presence of reported chronic back or neck problems in the last 12 months. Mexican-Americans were the largest ethnic group. The group reporting chronic back or neck problems had greater numbers of respondents who were obese, currently smoking, in fair or poor health, or had depressive disorder or alcohol abuse.

The weighted age- and sex-adjusted 12-month prevalence of chronic back or neck problems in all Latinos sampled was 14.6% (13.2, 16.0). This prevalence was significantly lower for immigrant Latinos (12.0%, 95% CI: 10.3, 13.8) than for US-born Latinos (20.2%, 95% CI: 17.1, 23.8). This pattern was consistent and significant in each of the largest Latino ethnic subgroups (Table 2).

Unadjusted associations presented in Table 3 showed that being born in the US, belonging to the third or greater generation, and reporting good or excellent English proficiency were all associated with significantly higher risk of reporting chronic back or neck problems in the past 12 months. Those who reported obesity, poorer physical health, depression, alcohol abuse, or current smoking also had significantly greater risk of reporting chronic back or neck problems compared to those who did not have these characteristics.

Model 1 in Table 3 shows the relative risks of reporting chronic back or neck problems in the past 12 months by generation adjusted for English proficiency, age, sex, and ethnicity. Compared to immigrants, Latinos in the third generation or greater were 1.6 times more likely to report chronic back or neck problems but second generation Latinos were not at greater risk. Good or excellent English proficiency was also associated with about 1.6 times the risk of chronic back or neck problems and was independent of generational status.

Model 2 also adjusts for education, poverty level, self-reported health status, depression and alcohol abuse. Depression in the last 12 months was associated with almost twice the likelihood of chronic back or neck problems while each unit of poorer self-rated physical health was associated with a 34% increase in risk. Belonging to the third generation or greater continued to be significantly positively associated with chronic back or neck problems but the relative risk was attenuated (1.31, 95% CI 1.01, 1.67). English proficiency was associated with 1.67 times the risk of reporting chronic back or neck problems. Obesity and alcohol abuse also remained positively associated.

In another weighted logistic analysis, we looked at whether differences exist among immigrants using proportion of lifetime in the US and English proficiency as measures of acculturation. In a model that was adjusted for age, sex, ethnicity, education, poverty level, and health indicators but not for English proficiency, no significant association was found between proportion of lifetime in the US and report of chronic back or neck problems in the last 12 months. Respondents who had been in the US for 50 to 75% of their lifetime had a relative risk of 0.6 (95% CI: 0.34, 1.04) for chronic back or neck problems compared to those who had spent less than 25% of their lifetime in the US. Those who had greater than 75% of their lifetime in the US had a relative risk of 0.97 (95% CI: 0.52, 1.79) for chronic back or neck problems (data not shown).

Among immigrants, English proficiency was associated with a 61% increased risk of chronic back or neck problems (1.61, 95% CI: 1.18, 2.14) in an adjusted model that did not include proportion of lifetime in the US, but was not significant (1.5, 95% CI: 0.95, 2.29) when proportion of lifetime in the US was included (data not shown). A similar analysis using years residing in the US and age at immigration did not yield any significant differences in chronic back or neck problems by these measures of acculturation.

These findings support the hypothesis that the report of chronic back or neck pain is associated with acculturation in Latino-Americans. While we found a strong association between chronic back or neck problems and obesity, depression and poorer self-rated physical health, these factors did not completely explain the observed generational or language associations.

Our findings apparently contradict those of a similar study conducted among South Asians in the United Kingdom where higher acculturation was negatively associated with reports of widespread pain [⁴⁴]. Possibly, the relative prevalence of health behaviors between the culture of origin and the host culture helps determine the direction of change in health behavior and ultimately in health outcome [²⁴]. In the case of back or neck pain, immigrants and their descendants who originate from a culture of low prevalence of back or neck pain entering a culture of high prevalence would show an increase in back or neck pain prevalence with acculturation. Likewise, individuals coming from a culture of high back or neck pain prevalence entering a culture of low prevalence would experience lower back or neck pain prevalence with acculturation. This model of acculturation would predict that the prevalence of back or neck pain in the United States is high relative to the countries of origin of the Latino respondents in this survey, while this prevalence is higher in the countries of south Asia than in the United Kingdom. While direct cross-national comparisons are not available, comparisons that do exist suggest that prevalence of chronic pain in the United States is high compared to other developed and developing nations [³³]. Other cross-national comparisons of back pain prevalence revealed the United Kingdom to have a low prevalence compared to other developed nations [⁵⁹, ⁶⁰]. Although this evidence is not adequate to support this model of acculturation, it reveals a possible future direction for research in this area.

We found a consistent positive association between English proficiency and the report of chronic back or neck pain, even though the survey was conducted in the language in which the respondent was more fluent. This finding suggests that language acculturation may be associated with changes in certain health related concepts such as the definitions of back or neck pain or chronicity. Alternatively, English proficiency, even independent of generational status, might be associated with other aspects of lifestyle such as type of work, social networks, or health behaviors (e.g., physical activity) which may affect back or neck pain. Whether acculturation is related to the actual experience of back or neck problems, the reporting of these problems, or both cannot be determined from this study. These findings are compatible with other studies which have found differing health behaviors, reporting, or outcomes based on linguistic differences [⁵, ⁷, ²³].

Our results indicate a strong relationship between physical health, depression and the report of chronic back or neck pain. They are consistent with cross-national findings from the World Mental Health Survey which have shown significant positive associations between the report of chronic pain and that of poor physical health, affective dysfunction, and alcohol abuse [³³, ⁶¹, ⁶²]. Our findings further support the assertion that the relationship between chronic pain and psychological dysfunction is consistent cross-culturally.

This study is the first to demonstrate an association between acculturation and chronic back or neck problems among Latino-Americans. Its strengths lie in the use of data from a national representative survey conducted in both English and Spanish and developed with attention to cross-cultural meanings of survey items [⁶³]. We were able to adjust for many social and physical factors that may influence the experience or report of chronic back pain [⁶⁴].

Our study has a number of limitations. As the National Latino and Asian American Study is cross-sectional, causal relationships cannot be determined. Additionally, the report of chronic back or neck problems is not precisely defined or clinically validated. However, self-reports of chronic conditions have been found to have good correlation with medical records in several methodological studies [⁶⁵, ⁶⁶], and the use of chronic condition checklists has been found to elicit more complete reporting than the use of open-ended questions [⁶⁷]. Martin et al. used Medical Expenditure Panel Survey data to show that about 78% of complaints of back or neck problems that carried diagnostic codes had codes that corresponded to “intervertebral disk disorders,” “sprains and strains of the back,” and “other and unspecified disorders of back,” which include diagnoses of lumbago, backache, and unspecified symptoms of the back [²]. Another limitation is the lack of adequate power to examine associations within specific ethnic groups. Weighted age- and sex-adjusted prevalence by the largest ethnic groups in this survey revealed a consistent pattern of higher report of chronic back and neck problems among US-born respondents. Finally, we did not have data on physical activity and work-related factors that might affect the experience or report of chronic back or neck pain. Other unmeasured confounders may affect findings.

Future research should include longitudinal studies to clarify causal relationships between acculturative processes and chronic pain conditions. Further investigation into the possible connections between chronic pain and specific changes in lifestyle, attitudes, and stressors related to immigration and acculturation are warranted. Future studies should also examine differences that may exist across specific ethnic groups.

This study has been reviewed and approved by the Institutional Review Board of the University of Washington.

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