Association of neighborhood characteristics and chronic pain in children and adolescents in the United States

Abstract

Objective:

To determine the associations between neighborhood characteristics and chronic pain during childhood and adolescence in the United States, 2020-2021.

Methods:

Cross-sectional analysis of the 2020 and 2021 National Survey of Children’s Health (NSCH). NSCH grouped parents’ responses to questions about neighborhood characteristics into five categories: neighborhood support, neighborhood safety, school support, neighborhood amenities, and presence of detracting neighborhood elements. Chronic pain was defined as parents reporting their children had “frequent or chronic difficulty with repeated or chronic physical pain, including headache or other back or body pain during the past 12 months.” Multivariable Poisson regression analyses estimated associations between neighborhood characteristics and chronic pain, adjusted for sociodemographic characteristics.

Results:

The sample contained 55,387 children (6-17 years), weighted to represent 44 million nationally. Children had significantly increased rates of chronic pain if they lived in neighborhoods that were unsupportive, unsafe, had unsafe schools, fewer amenities, and greater numbers of detracting elements (p<0.0001). After adjusting for covariates, children had significantly increased chronic pain if they lived in neighborhoods that were not supportive (adjusted prevalence rate ratio=1.7, (95% Confidence interval: 1.5-1.9, p<0.0001), with similar patterns observed for living in neighborhoods characterized as not safe, that did not have safe schools, with fewer amenities, and/or more detracting elements.

Discussion:

Disadvantageous neighborhood characteristics are associated with pediatric chronic pain prevalence. Future research should investigate underlying mechanisms of this association, and guide neighborhood interventions aimed at preventing and decreasing childhood chronic pain and its associated burdens.

Introduction

Pediatric chronic pain is a significant public health concern in the United States. According to national estimates, 6% - 26% of children 6-17 years of age experience frequent or chronic physical pain, including headache, musculoskeletal, and abdominal pain^1,2. Pediatric chronic pain is associated with a substantial impact on mental and physical health resulting in a significant societal burden, including increased rates of school absenteeism and healthcare expenditures estimated at $11.8 billion annually in the United States. Well known individual risk factors/contributors to chronic pain include anxiety, depression, physical inactivity, deconditioning, inadequate sleep, fear-avoidance, family SES, and adverse childhood experiences^3–10. Both the biopsychosocial and social-ecological models of pain recognize the physical and social environment as relevant social determinants to developing and maintaining pediatric chronic pain¹¹. However, the specific relationship between neighborhood characteristics and pediatric chronic pain remains poorly described in national samples.

Neighborhoods can be conceptualized as a “bundle of spatially based attributes associated with clusters of residences, sometimes in conjunction with other land uses”¹². Neighborhood characteristics refer to the physical (structural, public services, environmental) and social (social-interactive) conditions of an individual’s environment¹³. In the United States, neighborhoods influence the future economic opportunities and intergenerational mobility of children¹⁴. Moreover, since 1987, a significant body of evidence demonstrates associations between neighborhood characteristics and health outcomes¹⁵. Challenging neighborhood conditions are associated with pediatric chronic conditions, both physical (e.g., obesity, asthma) and psychological (e.g., depression, anxiety)^16,17. Mechanisms underlying these associations include: access to resources (recreation, green space, nutritious food, health care), environmental exposures (toxins, pollutants), chronic stress from environmental threat (physical and social disorder, physical deterioration, crime), and social support (physical/social isolation, resilience, psychological health)^18–20. Neighborhood conditions also impact on health behaviors (healthy eating, physical activity, healthcare utilization)²¹.

Emerging research suggests an association between neighborhood conditions and pediatric chronic pain. Supportive neighborhood features (e.g. proximity to parks, walkability, increased proportion of residents with college degrees) were associated with lower levels of pain and pain-related disability among a cohort of children at increased risk for chronic pain¹⁹. Neighborhood socioeconomic distress is a significant independent predictor of physical health-related quality of life among children living with sickle cell disease²². Environmental factors (e.g. neighborhood socioeconomic status (SES) (as measured by area deprivation index)) predicted evoked pain responses beyond clinical pain and psychological factors in a cohort of children with functional abdominal pain²³. One longitudinal study found that neighborhood features of health care barriers, perceived environmental safety, and violence experienced (in addition sex and race/ethnicity) are significant risk factors for adolescent chronic pain^24,25. However, previous studies examining associations between neighborhood conditions and pain symptoms are limited by small and unrepresentative samples, a focus on specific clinical pain populations, limited geographical variability, and the absence of standardized neighborhood measures.

Recognition of neighborhood characteristics as a social determinant of health could guide targeted public health interventions and policy toward improving the physical and social conditions of neighborhoods and therefore improving pediatric chronic pain outcomes. The primary aim of this study was to determine the associations between neighborhood characteristics and chronic pain among children and adolescents in the United States using a large, nationally representative survey. We hypothesize finding higher rates of chronic pain among school-aged children and adolescents (ages 6-17 years) living in more challenging neighborhoods, characterized as being less supportive, more unsafe, having unsafe schools, fewer amenities, and more detracting elements.

Methods

Study Design and Data Source

This study is a cross-sectional analysis of data captured in the 2020 and 2021 National Survey of Children’s Health (NSCH) available at https://www.childhealthdata.org. NSCH is funded by the Health Resources and Services Administration’s Maternal and Child Health Bureau and is fielded by the US Census Bureau. NSCH is designed to provide national level data on the health and wellness of children 0-17 years of age in the United States. All 50 states and the District of Columbia are represented, with each contributing between 1.5-4.0% of survey participants. Caregivers of children selected for inclusion were the primary survey respondents; however, results are weighted to reflect the population of children 0-17 years of age. All participants provided consent. Data are available to the public for free. The Institutional Review Board at Seattle Children’s Research Institute deemed this study exempt from review. We followed the Strengthening the Report of Observational Studies in Epidemiology (STROBE) reporting guidelines for cross-sectional analyses.

Study Population

The final sample for 2020-2021 NSCH contained 93,669 participants, however we excluded children 0-5 years of age because their caregivers were not asked about school safety (n=32,860). We also excluded those with missing data on any of the variables of interest (n=5,422) for a final sample of 55,387 participants available for analysis. After survey weighting, our sample are fully representative of the national population of children 6-17 years of age living in the United States as per NSCH’s design. Minority groups were not oversampled.

Neighborhood and Built Environment

Neighborhood characteristics were categorized by NSCH²⁵. Respondents were surveyed about 5 characteristics related to neighborhood and the built environment, including neighborhood support, neighborhood safety, school safety, neighborhood amenities, and neighborhood detracting elements (Table 1). These measures have been used in previous NSCH publications to describe neighborhood characteristics^26–28.

Table 1.

Survey questions, response options, and categorization of responses related to neighborhood characteristics captured in the 2020-2021 National Survey of Children’s Health (NSCH).

Neighborhood characteristic	Survey description	Survey questions	Survey response	NSCH categorization of survey responses
Neighborhood support	Does this child live in a supportive neighborhood?	1) People in this neighborhood help each other out 2) We watch out for each other’s children in this neighborhood 3) When we encounter difficulties, we know where to go for help in our community	Definitely agree Somewhat agree Somewhat disagree Definitely disagree	1)Yes 2)No In the NSCH, children are considered to live in supportive neighborhoods if their parents reported “definitely agree” to at least one of the items and “somewhat agree” or “definitely agree” to the other two items.
Neighborhood safety	Does this child live in a safe neighborhood?	This child is safe in our neighborhood	Definitely agree Somewhat agree Somewhat disagree Definitely disagree	Safe: Definitely agree or somewhat agree Not safe: Somewhat/Definitely disagree
School safety	Is this child safe at school?	This child is safe at school	Definitely agree Somewhat agree Somewhat disagree Definitely disagree	Safe: Definitely agree or somewhat agree Not safe: Somewhat/Definitely disagree
Neighborhood amenities	Does this child live in a neighborhood that contains certain amenities -- parks, recreation centers, sidewalks, or libraries?	In your neighborhood are there: • Sidewalks or walking paths? • A park or playground? • A recreation center, community center, or boys’ and girls’ club? • A library or bookmobile?	Yes/No to each question This measure counts how many of four amenities are present in the child’s neighborhood	Number of amenities: 1)All 4 amenities 2) 3 amenities 3) 2 amenities 4) 1 amenity 5) None
Neighborhood detracting elements	Does this child live in a neighborhood where there is litter or garbage on the street or sidewalk, poorly kept or rundown housing, or vandalism such as broken windows and graffiti?	In your neighborhood are there: • Litter or garbage on the street/sidewalk? • Poorly kept or rundown housing? • Vandalism such as broken windows or graffiti?	Yes/No to each question This measure counts how many of three detracting elements are present in the child’s neighborhood	Number of detracting elements: 1)None 2) 1 detracting element 3) 2 detracting elements 4) All 3 detracting elements

NSCH classified children as living in a supportive neighborhood environment if their caregivers responded “definitely agree” to at least one of the following items and “somewhat agree” or “definitely agree” to the other two items, including: 1) “People in this neighborhood help each other out”, 2) “We watch out for each other’s children in this neighborhood,” and 3) “When we encounter difficulties, we know where to go for help in our community.” NSCH classified children as living in a safe neighborhood if their caregivers responded, “definitely agree” or “somewhat agree” to the survey question: “Does this child live in a safe neighborhood?” Children were considered to attend a safe school if their caregivers responded, “definitely agree” or “somewhat agree” to the survey question: “Is this child safe at school?” To assess for the presence of neighborhood amenities (favorable resources) caregivers were asked four survey questions (responses: yes or no), including whether each of the following was present in the neighborhood: 1) sidewalks or walking paths, 2) a park or playground, 3) a recreation center, community centers, or boys’ and girls’ club, and 4) a library or bookmobile. NSCH then summed the number of amenities present to create a score ranging from 0-4 amenities present in the neighborhood. To assess for the presence of neighborhood detracting elements caregivers were asked to three survey questions (responses: yes/no) including whether each of the following was present in the neighborhood: 1) litter or garbage on the street or sidewalk, 2) poorly kept or rundown housing, and 3) vandalism such as broken windows or graffiti. NSCH then summed the number of detracting elements to create a score ranging from 0-3 detracting elements present within the neighborhood. The measured neighborhood characteristic of “detracting elements” describes measures of social and physical disorder (vandalism and litter respectively) as well as neighborhood deterioration (poorly kept buildings)^21,29.

Chronic Pain

NSCH asked caregivers “During the past 12 months, has this child had frequent or chronic difficulty with repeated or chronic physical pain, including headache or other back or body pain?” We classified children of caregivers who responded “Yes” as having chronic pain. This measure of pediatric chronic pain has been used in several previous NSCH studies by different research groups^30,31.

Covariates

To select confounders for inclusion in multivariable models, we identified variables plausibly associated with both the exposure of interest (neighborhood characteristics) and the outcome of interest (chronic pain) based on existing research (Figure 1). These confounding variables included in our multivariate models were household income based on federal poverty status (0-99% Federal Poverty Level (FPL), 100%-199% FPL, 200%-399% FPL, 400% or greater FPL), child health insurance status (private, public only, and uninsured), and caregiver education (less than high school, high school and some college/associates degree, college degree or higher)^24,32,33.

Figure 1.

Covariates/confounders and mediators of the association between parent perception of neighborhood characteristics and pediatric chronic pain.

Moreover, while age and biological sex are not plausibly associated with an increased probability of living in neighborhoods with certain characteristics, both variables are associated with chronic pain prevalence in child and adolescents’ populations (e.g. age and sex: male/female) and were also included in our models³². Similarly, adolescent race and ethnicity (reported by parents/caregivers and categorized by NSCH as: White, non-Hispanic; Black, non-Hispanic; Hispanic, and Other, non-Hispanic) are disproportionally associated with poorer neighborhood characteristics and were also included in models³³.

We also considered several other variables for inclusion in our models, not limited to caregiver mental health, physical health, and child adverse childhood experiences (Figure 1). However, existent literature suggest that these may be mediators in the causal pathway between neighborhood characteristics and chronic pain, therefore were not adjusted for in our models^17,34,35. Sensitivity analyses including these variables in our models did not significantly change size or direction of associations between our exposure and outcome variables.

Data Analysis Plan

Data were analyzed using Stata V14.2. Hypothesis testing was 2-sided, and p-values set to < 0.05. We adjusted for the complex survey design of NSCH, and all estimates presented here are nationally representative of the childhood population (6-17 years) in the United States. We used descriptive statistics to create frequencies for all sociodemographic and neighborhood characteristics variables.

To address our primary aim, we estimated the crude national prevalence of pediatric chronic pain for each neighborhood characteristic. Prevalence rates across neighborhood characteristics were compared between those with chronic pain and those without chronic pain using design-adjusted Pearson chi-square tests. We next conducted multivariable Poisson regression analyses to estimate adjusted prevalence rate ratios (aPR) and 95% confidence intervals (CI) of associations between neighborhood characteristics and chronic pain. Models were adjusted for all covariates, including age, biological sex, race and ethnicity, family poverty level, child health insurance, and caregiver education. Prevalence rate ratios with corresponding 95% confidence intervals were reported.

We also conducted correlation analyses to assess for possible correlation between neighborhood characteristics variables.

Results

Our study included 55,387 children 6-17 years of age, representing 44 million nationwide. Sociodemographic characteristics are presented in Table 2 and are reflective of the estimated sociodemographics of children living in the United States 2020-2021. Overall, 42.8% of children lived in supportive neighborhoods, 66.9% lived in neighborhoods that were safe, 28.1% in neighborhoods that were somewhat safe, while 5.1% reported that they lived in neighborhoods that were not safe (Table 3.) In addition, 74.4% reported that their schools were safe and 23.2% that their schools were somewhat safe, with 2.4% reporting that schools were not safe. A third (35.9%) lived in neighborhoods with all amenities surveyed; while 10.5% lived in neighborhoods with none of these amenities. Most (74.3%) lived in neighborhoods with no detracting elements, with 4.1% living in neighborhoods with all three detracting elements.

Table 2.

Sociodemographic characteristics of the study population. Source: 2020-2021 National Survey of Children’s Health.

Characteristic	Number in sample	Weighted %	95% CI
Age category
6-11 years	29,112	58.1	(57.2-59.0)
12-17 years	26,275	41.9	(41.0-42.8)
Biological sex of child
Male	28,760	51	(50.0-51.9)
Female	26,627	49	(48.1-50.0)
Race and ethnicity
White, non-Hispanic	36,967	51.2	(50.2-52.1)
Black, non-Hispanic	3,624	12.8	(12.2-13.5)
Hispanic	7,333	25.5	(24.5-26.6)
Asian, non-Hispanic	3,050	4.5	(4.2-4.9)
Other/multiracial, non-Hispanic	4,413	6	(5.6-6.3)
Poverty category
0-199% FPL	15,770	38.3	(37.4-39.3)
200% FPL or greater	39,617	61.7	(60.7-62.6)
Child insurance status
Private	40,933	63.8	(62.8-64.8)
Public only	11,811	29	(28.1-29.9)
Uninsured	2,643	7.2	(6.6-7.8)
Parent education
Less than high school	1,484	9.3	(8.5-10.2)
High School and some college/associates degree	19,993	40.1	(39.2-41.1)
College degree or higher	33,910	50.6	(49.6-51.5)

Table 3.

Prevalence of neighborhood characteristics. Source: 2020-2021 National Survey of Children’s Health.

	N	Total	Total
	N in sample	Weighted %	95% CI
Children live in supportive neighborhoods
Yes	34,087	57.2	(56.3-58.2)
No	21,300	42.8	(41.8-43.7)
Children live in safe neighborhood
Definitely agree	39,236	66.9	(65.9-67.8)
Somewhat agree	14,312	28.1	(27.2-29.0)
Somewhat/Definitely disagree	1,839	5.1	(4.6-5.6)
Safe schools- age 6-17 years
Definitely agree	41,483	74.4	(73.5-75.2)
Somewhat agree	12,559	23.2	(22.4-24.0)
Somewhat or definitely disagree	1,345	2.4	(2.1-2.7)
Number of neighborhood amenities present
All 4 amenities	19,726	35.9	(35.0-36.8)
3 amenities	13,002	23.5	(22.7-24.3)
2 amenities	10,091	18.1	(17.4-18.9)
1 amenity	6,225	11.9	(11.2-12.6)
None	6,343	10.5	(10.0-11.0)
Number of detracting neighborhood elements present
None	42,991	74.3	(73.4-75.2)
1 detracting element	7,949	16	(15.2-16.7)
2 detracting elements	2,593	5.6	(5.1-6.1)
3 detracting elements	1,854	4.1	(3.7-4.6)

The crude estimated national prevalence of chronic pain among children in the United States was estimated at 7.2% across study years, representing an annual population of 3.2 million children reporting frequent or chronic difficulty with repeated or chronic physical pain. Prevalence rates of chronic pain were significantly lower among children living in favorable neighborhoods (all p<0.0001). The prevalence of chronic pain was 5.5% among children living in supportive neighborhoods, while it almost doubled to 9.4% among children living in neighborhoods reported as being non-supportive. Of note, the prevalence of chronic pain was 5.7% among children reporting their schools as safe, while it increased to 18.3% among children who reported their schools as not being safe. This pattern was repeated among the other measured neighborhood characteristics, with those living in safe neighborhoods, greater number of neighborhood amenities, and lower numbers of detracting elements all reporting lower rates of chronic pain.

Multivariate analysis confirmed associations between neighborhood characteristics and chronic pain. Living in a neighborhood not characterized as supportive was associated with a 1.7 times increased prevalence rate of chronic pain after controlling for sociodemographic covariates (aPR=1.7, 95%CI: 1.5-1.9, p<0.0001). Less favorable neighborhood characteristics were associated with increased prevalence rate ratios of chronic pain across all measured neighborhood characteristics (Table 4.), with the exception of neighborhood amenities. Living in a neighborhood with only three or two of the measured amenities was not associated with statistically significant increased prevalence rates of chronic pain relative to living in a neighborhood with all four amenities. However, living in a neighborhood with only one (aPR=1.3, 95%CI: 1.0-1.6, p=0.023) or none (aPR=1.4, 95%CI: 1.1-1.7, p=0.002) of the amenities measured were associated with increased chronic pain (relative to living in a neighborhood with four amenities).

Table 4.

Prevalence, and adjusted prevalence rate ratio, of chronic pain by neighborhood characteristics. Source: 2020-2021 National Survey of Children’s Health.

	Chronic pain prevalence	95 % CI	aPR*	95% CI	p-value
Overall
Children who live in supportive neighborhood
Yes	5.5	(5.0-5.9)	ref
No	9.4	(8.6-10.4)	1.7	(1.5-1.9)	<0.0001
Children live in safe neighborhood
Definitely agree	5.9	(5.5-6.4)	ref
Somewhat agree	9.0	(8.1-10.1)	1.5	(1.3-1.7)	<0.0001
Somewhat/Definitely disagree	13.1	(9.8-17.3)	2.2	(1.6-2.8)	<0.0001
Safe schools- age 6-17 years
Definitely agree	5.7	(5.2-6.2)	ref
Somewhat agree	10.7	(9.5-12.0)	1.7	(1.4-1.9)	<0.0001
Somewhat or definitely disagree	18.3	(14.6-22.8)	2.7	(2.1-3.4)	<0.0001
Number of neighborhood amenities present
All 4 amenities	6.1	(5.3-6.9)	ref
3 amenities	7.4	(6.4-8.4)	1.2	(1.0-1.4)	0.114
2 amenities	7.1	(6.2-8.1)	1.1	(0.9-1.3)	0.257
1 amenity	8.4	(7.0-10.0)	1.3	(1.0-1.6)	0.023
None	9.2	(7.9-10.7)	1.4	(1.1-1.7)	0.002
Number of detracting neighborhood elements present
None	6.3	(5.9-6.8)	ref
1 detracting element	8.9	(7.5-10.6)	1.3	(1.1-1.6)	0.001
2 detracting elements	10.1	(7.9-12.9)	1.2	(1.2-1.9)	0.002
All 3 detracting elements	11.0	(8.8-13.8)	1.0	(1.2-2.0)	<0.0001

Percentages and confidence intervals obtained using complex survey weights. aPR=Adjusted prevalence ratio for the association of neighborhood characteristics with pediatric chronic pain; CI=Confidence intervals. Prevalence rate ratio adjusted for child age, sex, race and ethnicity, family poverty level, child health insurance status, parent education.

Correlation analysis shows low correlation between neighborhood characterstics variables.

Discussion

We estimated associations between (caregiver perception of) neighborhood characteristics and chronic pain prevalence in a large national sample of children 6-17 years of age living in the United States. As hypothesized, we found that challenging neighborhood characteristics were associated with higher prevalence rates of pediatric chronic pain. This study expands understanding of the risk factors for chronic pain from a focus on individual to environmental and collective risk factors. Understanding and addressing individual factors contributing to chronic pain is incomplete and will likely be ineffective. Our findings support previously demonstrated associations between pediatric chronic pain with less safe schools and neighborhood conditions²⁴. This study expands current knowledge by demonstrating associations of increased prevalence of pain for those living in neighborhoods with decreased social support, fewer amenities and increased detracting elements. Mechanisms underlying the relationship between the neighborhood environment and pain are yet unexplored, but may include health behaviors, access to physical and social resources, chronic stress, and social support.

Social and physical neighborhood conditions influence health behaviors and attitudes that impact pain^{18,20,21,36–40}. Our findings of the association between challenging social and physical neighborhood conditions and increased pain prevalence may reflect the impact of neighborhood conditions on health behaviors and attitudes, such as physical activity⁴¹. Neighborhood characteristics impact youth (and parent) attitudes about physical activity, which in turn predicts level of physical activity in youth, such that positive attitude predicts increased activity and negative attitudes predict decreased activity³⁷. In youth at risk for chronic pain, attitude about physical activity is also predictive of physical function, pain intensity, and pain-related disability¹⁹. Children with chronic pain have lower levels of physical activity (total active minutes a day as well as decreased peak activity levels), which is associated with worse pain outcomes^36,38,39. Clinicians should include assessment of caregiver and youth perceptions of their neighborhood environment when promoting physical activity and other health behaviors as this may be an important missing contextual barrier.

In addition to attitudes and perceptions, actual access to neighborhood resources that enable health-promoting behaviors likely contribute to chronic pain outcomes. Additional neighborhood amenities (not included in our study) include access to primary care and food options. Previous work using geospatial analysis revealed that children at risk of chronic pain tend to live in neighborhoods with fewer amenities (parks and walkability) and have decreased physical function (sit-to-stand test and 10-m walk test)¹⁹. Our study expands on this, and is the first to our knowledge, to demonstrate an association between decreased neighborhood amenities and increased chronic pain prevalence in youth. Our findings revealed an association between very limited (one) or no amenities and increased prevalence of pain, as compared to having four amenities (which was not maintained when comparing two or three versus four amenities). This suggests that perception of the resource level of a neighborhood environment (well-resourced versus under-resourced) is implicated in the development and maintenance of chronic pain.

Growing up in challenging neighborhood environments may contribute to a state of chronic stress, which is implicated in the development and maintenance of chronic pain^42–44. Challenging neighborhood conditions are associated with increased chronic stress burden in youth^{27,32,38–40}. Understanding causes of stress is critical for youth with chronic pain as it is both common and clinically impactful (increasing stress is associated with functional impairment, anxiety, depression, and quality of life)^37,43,44. The relationship between stress and chronic pediatric pain has primarily been investigated at the individual level (e.g. adverse childhood experiences, physiological (hyperarousal, HPA-activation), cognitive (catastrophizing), psychological (depression, anxiety), but little is known about societal and environmental sources of stress^{27,31,35,40,45–49}. In the general population, neighborhood social support is known to contribute to stress when poor and buffer against stress when robust^38,42. This study captured potential sources of stress at the neighborhood level that were associated with increased prevalence of chronic pain including: (diminished) social support, decreased safety, neighborhood (social and physical) disorder, and neighborhood physical deterioration. Future work should examine longitudinal chronic stress burden in youth with chronic pain in relation to neighborhood characteristics.

The social neighborhood environment is an integral but less understood part of the contextual setting for pain experience^21,50. Youth with chronic pain commonly experience disrupted social support (including social marginalization, fewer and less reciprocal peer relationships and family conflict) which can be disruptive during critical social and relational developmental periods such as adolescence^44,51,52. For these youth, strong social support at the individual level can buffer against the functional impacts of the pain experience in the school setting (e.g. absenteeism, experience of bullying)^35,46–49. Our study is the first to our knowledge to demonstrate an association of diminished neighborhood social support and chronic pain in youth. Social support at the neighborhood level may affect outcomes for youth with chronic pain through impact on general well-being, mental health, degree of social isolation, exacerbating or buffering against frequently disrupted social support systems, resilience, fear-related avoidance, and cultural factors affecting perceived salience^53,54. Individual resilience mechanisms (e.g. psychological flexibility, committed action, and self-efficacy) and family support are associated with improved outcomes for youth with chronic pain⁵⁵. Community and social resources are also foundational to resilience, however the contribution of neighborhood social support is not understood⁵⁶. Future work should investigate the role of social isolation and fear-related avoidance of unsafe neighborhood environments as it relates to fear-related avoidance of activities (which is known to contribute to chronic pain outcomes).

Our study has several strengths and extends this area of research by demonstrating associations between neighborhood characteristics and chronic pain on a national level in the United States. To our knowledge only one other nationally representative study examined adolescent self-report and found association of chronic pain with violence, perceived safety, white race, and health care barriers²⁴. Our study adds additional dimensions of neighborhood characteristics with exploration of overall neighborhood resource level (sum of amenities including walkability, proximity to parks, recreation areas, and libraries/book mobiles), social and physical disorder (vandalism and litter respectively), neighborhood deterioration (poorly kept buildings), and broadens measures of the social environment. The use of parental report is a proxy that provides information on parental perception and attitudes about environment which can influence child attitudes and behaviors^57–59. Our findings suggest that caregiver perception is important to understanding the environmental context of their child’s pain, consistent with ecological systems framework⁵⁹. Future work should further explore the nature of the relationship of caregiver perceptions, child perceptions, and child outcomes in the context of the proximal neighborhood environment and development.

This study has several limitations. Due to the cross-sectional design, it is not possible to confer a definitive causal relationship between neighborhood characteristics and chronic pain development. While there is a strong body of evidence supporting associations between neighborhood conditions and health outcomes it is difficult to establish causation. However, this may reflect the difficulties in studying such a complex and dynamic system rather than a true lack of the impact of the neighborhood environment. Indeed, a recent innovative, longitudinal study, capturing mobility data of over 7 million families demonstrated a causal relationship such that each year of exposure to “better” neighborhood conditions (defined by outcomes of youth currently living there) in youth predicted a 4% (linear) change in future economic indicators (higher education rates, earnings, marriage patterns, and fertility)¹⁴. NSCH collects data from parents and caregivers, which may affect the accuracy of chronic pain prevalence without the use of specific criteria to diagnose chronic pain conditions. In addition, neighborhood characteristics were reported retrospectively by parents and caregivers, which could lead to the potential for reporting bias. Selection and non-response bias are potential limitations of all survey-based studies. However, NSCH evaluated survey data for potential non-response bias and did not find strong or consistent evidence of nonresponse bias after survey weighting procedures ⁶⁰. There is no standard psychometric questionnaire for neighborhood characteristics. For measurement of neighborhood characteristics, our study relied on parental perception of the neighborhood environment and did not incorporate other measures such as geospatial data, census data, or trained observers which are considered more objective measures. Perceptions have been proposed as “filters” which mediate the association between objective measures and outcomes. Previous comparing perceived and objective neighborhood characteristics found similar impacts on health and a stronger association between perceived characteristics and health behaviors (e.g. physical activity)^41,61,62. Additionally, mobility data was not available given the cross-sectional study design.

This study adds to our understanding of the potential role of the neighborhood and built environment in increasing risk for and maintenance of chronic pediatric pain. The health of children requires not only targeting individual health behaviors but also the social and physical environment through place-based and upstream public health interventions (Figure 2). There is ample opportunity to advise and collaborate with the US community development sector, which describes a vast network of policies, organizations, and financial resources that spends $300 billion annually working to address health and well-being at the neighborhood level^20,63. Indeed, our findings may help inform funding allocation and policy development aimed at decreasing pediatric chronic pain such as improving neighborhood cohesion, increasing green-space, shifting attitudes about physical activity, and improving neighborhood and school safety. These changes may lead to reduced prevalence of childhood chronic pain. Moreover, our findings suggest that clinicians evaluating children with chronic pain should consider social determinants of health, including neighborhood characteristics, as a critical aspect of routine care with the potential to identify unmet needs for patients with (or at risk for) chronic pain. Recognition of important neighborhood features could help clinicians direct resources to children most at risk for poorer health and functional outcomes.

Figure 2.

Implications and future directions for addressing neighborhood characteristics in relation to chronic pain at the individual, community, and policy level.

Neighborhood characteristics are associated with chronic pain prevalence among school-aged children living in the United States. More research is needed to better understand and investigate mechanisms by which the exposure of neighborhood characteristics affects chronic pain prevalence and severity to ultimately identify opportunities for preventing and decreasing childhood chronic pain and its associated burdens.