Exploring the Social Determinants of Health Outcomes for Adults with Low Back Pain or Spinal Cord Injury and Persistent Pain: A Mixed Methods Study

  • Emma L. Karran
    Address reprint requests to Emma L. Karran, PhD, Innovation, Implementation & Clinical Translation (IIMPACT) in Health, Kaurna Country, University of South Australia, GPO Box 2471, Adelaide, SA, 5001, Australia.
    Innovation, Implementation & Clinical Translation (IIMPACT) in Health, Kaurna Country, University of South Australia, Adelaide, South Australia, Australia.
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  • Caroline E. Fryer
    Innovation, Implementation & Clinical Translation (IIMPACT) in Health, Kaurna Country, University of South Australia, Adelaide, South Australia, Australia.
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  • James W. Middleton
    State Spinal Cord Injury Service, NSW Agency for Clinical Innovation, Sydney, Australia.

    John Walsh Centre for Rehabilitation Research, Kolling Institute, Royal North Shore Hospital Sydney, Australia.

    Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.
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  • G. Lorimer Moseley
    Innovation, Implementation & Clinical Translation (IIMPACT) in Health, Kaurna Country, University of South Australia, Adelaide, South Australia, Australia.
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      • There is potential to improve outcomes by understanding the life-contexts of those seeking care.
      • This study suggests a strong relationship between greater social isolation and poorer health.
      • Adverse social determinants of health were related to lower quality of life and poorer health status.
      • Consideration of these relationships is important to improve health equity for adults with pain.


      Developing a greater understanding of the social and environmental factors that are related to differential outcomes for individuals who experience persistent pain and disability is important for achieving health equity. In this study, we aimed to develop insights into the role of the social determinants of health (SDH) in care experiences and health status for socio-economically disadvantaged adults who experience persistent low back pain or persistent pain following spinal cord injury. Our objectives were to investigate 1) relationships between the SDH and health outcomes, 2) care experiences, and 3) perceived barriers and facilitators to optimal pain care. We conducted a mixed-methods convergent parallel study involving an online survey and semistructured interviews. We analyzed the data from each method separately and integrated the findings. One hundred sixty-four adults completed the survey and 17 adults completed the semistructured interviews. We found large or moderate-sized correlations between greater selfreported social isolation and poorer health outcomes. Experiencing a higher number of adverse SDH was moderately correlated with lower quality of life and was significantly correlated with all other outcomes. We generated 5 themes from the qualitative analysis: active strategies are important for well-being; low agency; facilitators of optimal care; barriers to optimal care; and health inequities, and derived meta-inferences that highlight the complex inter-relationships between the SDH and health outcomes in this cohort. The findings of our study can importantly inform endeavors to improve equity of pain care for adults with low back pain or spinal cord injury and persistent pain.


      This study illustrates the complex interplay between adverse social determinants of health and poorer health status for adults with persistent pain and provides evidence to support the important role of social isolation. Developing an understanding of the life-contexts of those seeking care is a vital step towards addressing health inequities.

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