A qualitative analysis of multi-level influences on chronic pain among Spanish-speaking older Latino adults in a community clinic in the United States

Abstract

Spanish-speaking older Latino adults living with chronic musculoskeletal pain in the United States (US) experience worse pain outcomes than English-speaking and non-Latino older adults. This is partly because most pain interventions have been designed and tested primarily among English-speaking individuals. To address this, existing interventions for chronic musculoskeletal pain should be tailored to reflect the multilayered factors that impact and are impacted by chronic pain identified by Spanish-speaking older Latino adults. As such, we conducted three focus groups and five individual interviews (N=16) with Spanish-speaking older Latino adults (≥55 years old). Focus groups and individual interviews were guided by a semi-structured script, audio-recorded, and later transcribed verbatim for qualitative coding. Informed by the socio-ecological model, data analysis followed a hybrid deductive-inductive approach to elucidate specific themes. Within the individual domain, pain co-occurred with complex medical needs and behavioral and psychological responses. In the interpersonal domain, participants described pushing through pain to meet family obligations, and how caregiving demands, relationship strain, and isolation worsened pain. In the structural domain, participants identified the presence of racial discrimination and the disproportionate burden of pain among Latinos, and physically intensive jobs shaping pain trajectories. Findings highlight the complex interplay of individual, interpersonal, community, cultural, and structural factors influencing pain outcomes. We discuss clinical and research implications to inform the cultural tailoring of interventions for Spanish-speaking older Latino adults living with chronic pain.

Introduction

Chronic musculoskeletal pain (i.e., lasting more than three months) is common and impacts approximately 40%–60% of older adults (55+) in the United States (US; Dahlhamer, 2018; Welsh et al., 2020). Among this patient population, older adults who identify as Latino and monolingual Spanish-speakers experience higher pain intensity and severity than their non-Latino and English-speaking counterparts, even after adjusting for socioeconomic status and health confounders (Lor & Koleck, 2022; Yang et al., 2022). Despite the growing need to address pain-related disparities, current interventions have been developed and tested among ethnolinguistically homogenized populations (Morone & Greco, 2007). As such, a significant gap remains in understanding the lived experiences of older Latino patients with chronic pain and limited English proficiency, particularly in settings where they are underrepresented and underserved. Elucidating the socio-cultural and contextual factors that influence—and are influenced by—chronic pain and situating these experiences within the broader social and ecological landscape, is essential to inform the cultural tailoring of evidence-based pain management interventions for Spanish-speaking older Latino adults.

While Latino and Spanish-speakers tend to self-report higher pain severity than their non-Latino and English-speaking counterparts (Lor & Koleck, 2022), existing research has primarily focused on individual-level explanations for pain disparities, failing to consider the complex, intersecting social and structural factors shaping pain experiences and outcomes (Hood et al., 2023; Mathur et al., 2022). Much of the literature has emphasized experiences within healthcare settings, documenting significant barriers to accessing language-concordant pain management services (Bifulco et al., 2023; Plys et al., 2024; Vonderheide et al., 2025). More recently, studies have begun to highlight broader social and structural contributors to pain disparities, such as the disproportionate representation of Latinos in physically demanding occupations and their heightened exposure to everyday racial discrimination, both of which have been linked to a higher prevalence of severe and high-impact chronic pain (Hollingshead et al., 2016; Spector et al., 2023). Yet, the cumulative impact of these social and structural challenges on socioeconomically vulnerable individuals with chronic pain remains poorly understood, underscoring the need for qualitative research to inform the development of culturally responsive and effective treatments (van Rysewyk et al., 2023).

From a socio-ecological perspective, chronic pain can be conceptualized as occurring in the context of the complex interaction between different levels of the social ecology (Bronfenbrenner, 1979). The Socio-Ecological Model (SEM) examines how individual, interpersonal, organizational, societal, and environmental factors affect chronic pain and what can be addressed on each of these levels (Wu et al., 2019). Recent applications of the socio-ecological model in pain research argue that pain experiences are not merely a function of personal characteristics such as race or language, but are deeply influenced by the structural, cultural, and societal treatment of individuals with those identities (Hood et al., 2023; Mathur et al., 2022). To the best of our knowledge, the SEM has been used to explore the experiences of English-speaking older adults (McDermott et al., 2024) as well as Spanish-speaking Latino patients (aged 18 and older) and their healthcare providers (Bifulco et al., 2023). To date, no study has explored the lived experiences of Spanish-speaking older Latino adults (55 +) with chronic pain residing in a medically underserved community setting in the Northeast of the United States. Using qualitative data collection methods, we sought to elucidate the social, cultural, and structural domains influencing pain experiences among this patient population (van Rysewyk et al., 2023). Findings aimed to inform clinical research and policy efforts addressing pain-related disparities among racially and linguistically diverse populations.

Methodology

Study Design

This qualitative study was part of a larger mixed-methods study aimed at culturally and linguistically tailoring and implementing a mind-body, activity-based program for underserved English- and Spanish-speaking older adults seeking care at an urban community health clinic in the New England region of the US. The larger project included a total of 11 focus groups and 12 semi-structured interviews with English and Spanish-speaking older adult patients with chronic pain and their healthcare providers. In the present study, we explored the lived experiences of Spanish-speaking older Latino adults, with a focus on the factors that impact and are impacted by chronic pain. These findings informed the feasibility testing of a mind-body activity program for English and Spanish-speaking adults in an underserved community setting (McDermott et al., 2025). We present findings from three focus groups (each with 3–4 participants) and five individual interviews conducted with Spanish-speaking older Latino adults (aged 55 and above) living with heterogeneous musculoskeletal chronic pain (N = 16). See McDermott et al., 2023 for an overview of the methods. To improve accessibility and promote inclusivity for the participants, individual interviews were offered to those experiencing logistical or structural barriers to focus group participation (Heath et al., 2018). The interview guide (available in supplementary materials) was consistent across both interview and focus group modalities to ensure methodological rigor. We followed the Consolidated Criteria for Reporting Qualitative Research (COREQ) to conduct and report this qualitative study (Tong et al., 2007). All study procedures were approved by the [Mass General Brigham] Institutional Review Board.

Setting and Recruitment

We recruited and enrolled exclusively patients who self-identified as Latinos, Spanish-speaking, and older adults with chronic musculoskeletal pain at an integrated primary care clinic serving an ethnically and economically underserved patient population. We recruited participants through referrals from providers, including primary care physicians, medical interpreters, support staff, and via flyers detailing the study purpose, inclusion criteria, and participation requirements. Recruitment flyers, detailing the study purpose, inclusion criteria, and participation requirements in Spanish, were posted in the clinic lobby, waiting areas, and exam rooms. A Spanish-fluent research assistant contacted interested participants via phone to discuss the study. If participants provided verbal consent, the assistant proceeded with screening. Eligible participants received a study fact sheet and consented to participate before the qualitative focus group or individual interview was scheduled. Before the interviews, the facilitator discussed confidentiality and each participant’s right to stop participating at any time. Eighteen older adults were eligible and invited to participate in the study. Of these, 16 were available for focus groups and five participated in qualitative interviews due to scheduling conflicts.

Participants

Participants were eligible if the following criteria was met: they identified as Latinos, were fluent in Spanish, received care at the participating community health clinic, self-reported chronic musculoskeletal pain lasting more than three months, reported a pain score of 4 or higher on the Numerical Rating Scale (NRS; Farrar et al., 2001), were able to walk for at least six minutes and had 55 years of age or older, based on evidence of accelerated aging among individuals with lower socioeconomic status (Green et al., 2003; Grol-Prokopczyk, 2017; Steptoe & Zaninotto, 2020). Participants were excluded if they did not self-identify as Latino and were not fluent in Spanish. Participants with self-reported cognitive challenges that would interfere with participation (e.g., cognitive impairment or dementia), had a current active, untreated psychotic or substance use disorder, or had a serious medical illness expected to worsen within the next six months (e.g., cancer) were also excluded from participation. None of the participants recruited had a prior relationship with the interviewer, and the interviewer did not provide clinical services within the clinic.

All participants (N = 16) self-identified as both Latino and Spanish speakers. The average age of the participants was 64.6 years (SD = 7.9), with a range of 55 to 85 years. Most participants were women (n = 13; 81.3%). As measured by the NRS, pain intensity reports ranged from moderate to high, with a mean score of 8.0 (SD = 1.2), exceeding the clinically significant benchmark for chronic pain intensity (Farrar et al., 2001). Participants identified their country of birth as Guatemala (18.8%), Puerto Rico (18.8%), Colombia (18.8%), Peru (18.8%), Mexico (6.3%), Nicaragua (6.3%), El Salvador (6.3%), and one preferred not to answer (6.3%). The average length of time spent living in the United States was 21.5 years (SD = 10.2). Household incomes were less than $10,000 (n = 3), $10,000–$24,999 (n = 5), $25,000–$34,999 (n = 1), and $50,000–$74,999 (n = 1), with a large number choosing not to answer this question (n = 6). Only one participant spoke both English and Spanish. None of the participants withdrew from the study. Refer to Table 1 for additional demographic information.

Table 1.

Characteristics of study participants (N=16)

Variable	Mean (SD) or N (%)
Age	64.6 (7.9)
Sex (% Female)	13 (81.3%)
Gender (% Women)	13 (81.3%)
Ethnicity (% Hispanic or Latino)	16 (100%)
Country of Birth
Guatemala	3 (18.8%)
Puerto Rico	3 (18.8%)
Colombia	3 (18.8%)
Mexico	1 (6.3%)
Nicaragua	1 (6.3%)
El Salvador	1 (6.3%)
Peru	3 (18.8%)
Prefer not to Answer	1 (6.3%)
Education
Less than High School	6 (37.5%)
Some Secondary School or High School	3 (18.8%)
High School or Secondary School Complete	2 (12.5%)
Associates or Technical Degree Complete	2 (12.5%)
College or Baccalaureate Degree Complete	2 (12.5%)
Doctoral or Post Graduate Education	0
Prefer not to Answer	1 (6.3%)
Employment Status
Full-time employment	2 (12.5%)
Part-time employment	4 (25%)
Not employed	9 (56.3%)
Prefer not to Answer	1 (6.3%)
Household Income
Less than $10,000	3 (18.8%)
$10,000 – $24,999	5 (31.3%)
$25,000 – $34,999	1 (6.3%)
$35,000 – $49,999	0
$50,000 – $74,999	1 (6.3%)
Prefer not to Answer	6 (37.5%)
Years in U.S.	21.5 (10.2)
Language(s) Spokena
English	1 (6.3%)
Spanish	16 (100%)

^aParticipants may select multiple options so percentages may exceed 100%

Procedure

Participants could be referred by clinic staff or express interest in participating by inquiring directly. Three bilingual, English and Spanish-speaking study members contacted these potentially interested patients by telephone to discuss the study in more depth, including the review of all risks and benefits of participation. If interested, study staff would administer the eligibility assessment. The first author, a PhD-level native Spanish speaker with clinical and research experience working with Latino communities, facilitated all interviews. The second author, a bilingual research assistant, observed and completed field notes using a standardized form specifically designed for the current study. All qualitative interviews were conducted in Spanish and lasted between 60 and 70 minutes. We used a semi-structured interview guide with questions within predetermined individual, interpersonal, community, and structural domains informed by the SEM (Salihu et al., 2015). To create the Spanish interview script, the original English version was back-translated by bilingual staff members and tailored to the needs of Spanish-speaking individuals (See supplementary materials). The semi-structured script remained unchanged throughout the study but allowed for flexibility in instances where thematic saturation was reached. The interview guide included questions to elicit older Spanish-speaking adults’ perspectives on how aspects of their 1) personal Latino background, 2) environment (e.g., socioeconomic, employment, finances, caregiver roles), 3) communities and culture (e.g., culture, social support), 4) behavioral responses to pain (e.g., behavioral changes and unique responses to pain), and 5) medical factors (e.g., health needs, type of pain, and comorbidities) interrelate with their pain. All interviews were conducted between June and October 2023 and were audio-recorded, de-identified, and transcribed using a HIPAA-approved transcription service. Interview transcripts were translated from Spanish to English by bilingual and bicultural staff members before conducting data analysis in English. All study data were stored in an encrypted and password-protected device.

Data Management and Analysis

We implemented a two-phase qualitative data analysis strategy, beginning with Rapid Data Analysis (RDA) techniques as described by Vindrola-Padros and Johnson (2020). Following each patient interview or focus group, a research assistant conducted rapid data analysis (RDA) and compiled the results into a matrix, which facilitated the team’s determination of thematic saturation and sample size adequacy (Vasileiou et al., 2018). RDA was critical in clarifying the main findings within a relatively short period. To enhance rigor, all RDA capturing key participant responses were completed promptly and comprehensively reviewed by the team. The second phase involved a more in-depth hybrid thematic analysis, combining both inductive and deductive strategies, using the Framework Method for the management and analysis of qualitative data, as presented in Figure 1 (Gale et al., 2013).

Figure 1. Data Analysis Process Following Gale Framework Methods for Thematic Analysis (2022).

We sought trustworthiness by reflecting on how our own identities influenced the interpretation of the data. For example, the first author led the interviews and analysis process. Coding was conducted by two bilingual and bicultural Spanish-speaking researchers who self-identified as Latino (Puerto Rican, Mexican American) and a US-born White American and English speaker. Educational backgrounds of coders ranged from bachelor’s to doctoral degrees. Reflexivity was intentionally embedded throughout the analytic process. The team engaged in ongoing discussions about how individual identities, values, and lived experiences may shape the interpretation of the data. To enhance analytic rigor and minimize interpretive bias, coders regularly consulted with other study team members. Team meetings included critical reflection on how cultural and professional identities may influence data interpretation. Analytic memos were also used to document insights and decision-making throughout the analysis. The team minimized bias in the analysis by having one research assistant (also present during the interviews) code alongside another research assistant with prior experience in analyzing qualitative data. All other co-authors served as external colleagues and consultants during this stage of data interpretation.

Results

Using a hybrid deductive-inductive qualitative approach, we identified 11 themes organized within four domains (i.e., individual, interpersonal, community, and structural) that were mapped to the Socio-Ecological Model (SEM). Figure 2 displays a summary of the themes across the domains.

Figure 2. Socio-ecological model of stressors experienced by Spanish-speaking older Latino adults with chronic pain.

Individual Domain

Within the individual domain, two primary themes were identified: 1) pain co-occurring with complex medical needs and 2) behavioral and psychological responses to pain. Table 2 presents domain themes and supporting quotes in English.

Table 2.

Individual domain

Themes	Definition	Supporting quotes
Pain co-occurring with complex medical needs	This theme captured how chronic pain was compounded by multiple health conditions and medical treatments.	“[In addition to chronic pain], I had surgery on my colon and my vagina, which has left me with problems. For instance, if I need to go to the bathroom, I have to rush because I can’t hold it in... leaving the house is a problem.” “[In addition to chronic pain], I had hernia surgery. After they operated on my heart, they replaced the aortic valve and some other valves... with so much pain, life is no longer the same.” “I take pills for diabetes, and I take four pills, two in the morning and two in the afternoon, and I inject insulin... I also take medications for blood pressure, for cholesterol...”
Behavioral and psychological responses to pain	This theme described the diverse ways participants reacted emotionally and behaviorally to their pain, ranging from ignoring and distracting themselves from symptoms to becoming physically active.	“[Pain] depresses you, sometimes you don’t know what to do, the discomfort is overwhelming. Also, for example, your temper can be affected sometimes. “What’s wrong with you?” “Pain here.” “Where?” “But why?” You get mad at yourself. Sometimes you get angry, you feel powerless, that’s the word. That’s the word, helplessness, seeing the pain you have and not being able to—sometimes you can’t bear the pain.” “I get up and walk in a way that I don’t think--I regularly walk a lot, I spend all day walking, maybe all day standing. I do get tired, but I try to do it so I don’t feel the pain.” “Well, you see, regarding pain, I never paid much attention to the pain because I started working from a very young age [14 years of age]... these things [life experiences and responsibilities] make you forget about the pain.”

Pain co-occurring with complex medical needs

Participants indicated that their chronic musculoskeletal pain—such as arthritis, fibromyalgia, and related conditions—often co-occurred with a range of other complex and chronic health issues. These included diabetes, cancer, anemia, gastrointestinal disorders, cardiovascular disease, and histories of major surgeries, many of which increased their pain severity. They described how the presence of other health conditions worsened the intensity and burden of chronic pain, making day-to-day activities and physical functioning difficult. Across interviews, pain was noted to trigger significant disruptions to their sleep and exacerbate fatigue. The bidirectional relationship between pain and the presence of multiple chronic conditions was perceived to impact their overall well-being and ability to manage co-existing chronic conditions.

Behavioral and psychological responses to pain

Chronic pain also co-occurred with depression, anxiety [“nervios”], panic attacks, anger, irritability, and crying spells. One participant noted: “When you feel those pains, it is so strong that you let yourself be defeated so horribly… the first thing that comes to mind is to cry and cry and cry.” Responses to pain varied across participants. Some shared that adaptive coping strategies, such as walking and maintaining a hopeful attitude toward pain relief, helped in managing their pain: “I endure the pain. I go for a walk and say: ‘This pain has to go away.’“ In contrast, pain led others to engage in avoidance and maladaptive coping behaviors that resulted in a lack of motivation to engage in activities of daily living and walking: “Pain affects me a lot when I walk, so I do not want to walk.” Some managed pain with stoicism, often masking or avoiding the expression of discomfort. Several participants indicated a desire to appear strong, as one participant noted: “…people ask me, ‘How are you?’ and even though I have pain, I do not complain. I say, ‘Good.’“ The masking or avoidance of emotion or distraction was a common strategy when coping with pain: “I do not know if the word is ‘hide’ pain and if that is the right thing, but I try to think of other things.”

Interpersonal domain

Within the interpersonal domain, three primary themes were identified related to the bidirectional effects between chronic pain and family caregiving responsibilities: 1) pushing through pain to fulfill family roles, 2) pain intensified by caregiving demands, and 3) relationship strain and isolation worsening pain. Table 3 presents themes and supporting quotes.

Table 3.

Interpersonal domain

Themes	Definition	Supporting quotes
Pushing through pain to fulfill family roles	This theme reflects how participants prioritized family responsibilities and needs over their own, enduring pain to avoid burdening loved ones.	“We have to have the motivation to do this, we have to motivate ourselves, it’s for our own good... it’s also for the family because they shouldn’t see us crying or complaining.” “I have put the pain aside - even if you don’t believe me - because I have a family. I’m talking about 20, 30 years ago, I had a family to take care of, so I had to choose between worrying about the pain or worrying about the family.”
Pain intensified by caregiving demands	This theme highlights how caregiving roles exacerbate both emotional and physical pain, limiting adequate self-care.	“The ideal would be to focus on oneself. But other responsibilities, I believe, in a way, limit you. So, if you were alone, I think you would have more opportunities to take care of yourself.” “My husband suffered a stroke (a brain hemorrhage). So, all of that accumulates and affects you emotionally because you accumulate a lot of stress, a lot of tension. I’m taking care of my husband, and I have to take care of myself too.”
Relationship strain and social isolation worsening pain	This theme reflected a complex link between chronic pain and relationships, resulting in a perceived lack of social support and a desire to isolate.	“I have difficulties with my husband. He never pays attention ... These things also affect you. They lower your self-esteem, make you feel worthless. And I think that influences my illnesses.” “After the knee surgery... I got very depressed. I felt abandoned, like no one was visiting me. That’s when I missed my family” “Pain is horrible. One’s life is no longer the same; you don’t want to go out anymore; you think, “Why should I go out and have the pain hit me?” It’s horrible.”

Pushing through pain to fulfill family roles

Familial relationships (i.e., parent-child, mother-daughter, and spouse) were identified as a source of support and distraction from pain. Participants illustrated how familial roles and responsibilities pushed them to fulfill financial needs despite the presence of pain. A commitment to provide for one’s family (even those residing in their country of origin) became a motivation to overcome pain, mainly in the context of experiencing financial hardships: “I had the responsibility to send enough money so that they could live there and live well.” This pushing through pain because of family responsibilities was observed across male and female participants: “I put the pain aside…I have a family to take care of, so I had to choose between worrying about the pain or worrying about the family.” Supportive family relationships helped individuals persevere in the face of pain: “I could not tell you about emotion…I have other things; my wife, an excellent woman; my children…these things make you forget about the pain.” Participants also expressed a preference for being perceived as strong and capable of managing their pain during family interactions: “It is for our good and the family because they should not see us crying or complaining [about pain].”

Pain intensified by caregiving demands

Participants responsible for caring for adult children with disabilities, other disabled family members, and grandchildren reported a high impact of these roles on their pain. Stress related to caregiving roles was perceived to impact health negatively: “These things increase one’s stress, and stress generates more illnesses [pain].” Some participants expressed fears and uncertainty about the future being the primary support for their family members and highlighted the lack of adequate support: “I worry a lot, as I have my two children with special needs - thinking that I will not be with them for long, and that these pains might deteriorate me physically and mentally.” Others reported being overwhelmed with the demands of caregiving roles and often being left with little time or energy for self-care activities (i.e., pain management).

Relationship strain and social isolation worsening pain

Several participants noted that marital strain and conflict negatively impacted pain severity: “I have difficulties with my husband… that influences my illnesses [including chronic pain].” A bidirectional relationship between chronic pain and isolation was reported to have an impact on their lack of engagement in community activities. One participant stated: “When I have too much pain, I am not performing as I should, I feel tired, exhausted, without energy. So, I choose not to go instead.” Despite the availability of programs in the community, some felt unable to engage meaningfully: “There are programs for exercise, but sometimes, I feel so much pain that I give up on going for a day because [my body] will not respond.” Pain severity was reported to decrease among those living in multigenerational families, with grandchildren and children being a primary source for social interaction and distraction from pain.

Community and cultural domain

Within the community and cultural domain, three themes were identified from participants’ reports on culturally driven values, beliefs, and attitudes that influence pain: 1) pain acceptance influenced by faith and fatalism; 2) persevering through pain to maintain occupational roles; and 3) Latino identity and gender roles as drivers of pain coping (See Table 4).

Table 4.

Community and cultural domain

Themes	Definition	Supporting quotes
Pain acceptance influenced by faith and fatalism	This theme captures how participants draw on faith and cultural beliefs to accept and endure chronic pain.	“Regarding spiritual life, well, I cling to God. I know He exists, and that’s how I hold on. I don’t know, it hits you hard that way.” “Unfortunately, as the years go by, right now, we’re affected in these areas, and it will be worse later on. Five more years, and we’ll be worse.” [patient reflecting the cultural mindset of fatalismo] “I put myself in the doctor’s hands. I say, “I entrust myself to the doctor, to God, and to you all.” And I have accepted everything... I have a lot of faith.”
Pain and the struggle to maintain occupational roles	This theme reflected how chronic pain disrupted participants’ lifelong work identities and struggles with unemployment.	“I was an active worker, I worked in construction, and I liked my job. I’ve worked since I was eight years old in the country where I come from.”” “After working all my life and suddenly being unemployed, I could not do it.” “I was in bad shape because of the broken knee... The year when I didn’t work, I got very depressed.” “I stopped working when I was 65 years old; I can’t work anymore. That’s very painful for me because sometimes you want to do your things and you can’t.”
Latino identity and gender roles as drivers of pain coping	This theme illustrated the influence of culture and gender roles in coping with pain.	“It is that [Peruvian] strength that I think pushes us to be stronger, to endure this pain we have.” “We [Latinos] won’t let ourselves be defeated, by anything, because I have to do it, and I have to do it, and you do it.” “Even with pain, we [Latinos] ’re still there. I feel happy to work and to have accomplished something throughout the day.” “I have to appear strong in front of him, only God and I know the pain I'm feeling, just to encourage him.” [female reflecting on her role as a wife].”

Pain acceptance influenced by faith and fatalismo

Faith was identified as crucial for coping with and accepting pain. Participants described suffering as something predetermined by a higher power. Faith in God contributed to an acceptance of their pain and suffering: “Everything is God’s decision. I have accepted everything.” Learning to live with pain was strongly linked to faith and religious beliefs: “You have to learn to live with pain, and if we know how to endure pain, we help Christ.” Nevertheless, other participants communicated fatalistic beliefs related to the worsening of their pain over time: “Five more years, and [pain] will be worse.” Fatalismo, a cultural concept in Latino communities consisting of fatalistic beliefs and behaviors in the face of illness and uncertainty, informed their views towards pain: “As they say in my country, if you have chronic pain, it is because you are very bad and you are about to die.” These culturally and religiously driven beliefs led to the suppression of emotions: “As we say in my country, ‘The procession goes on inside.’“

Pain and the struggle to maintain occupational roles

Several participants emphasized the importance of staying engaged in work and community activities even when experiencing pain. Many expressed joy in being active as they grew up in environments where work and productivity were highly valued. This upbringing led to the normalization of working long hours in physically demanding jobs, as one participant stated: “As Latinos, we work from morning until 11:30 at night.” Beliefs about productivity motivated participants to persevere through pain, even as they aged and faced chronic pain. For them, the need to remain productive outweighed the challenges posed by chronic pain. However, these attitudes about productivity clashed with their inability to obtain and maintain jobs in their community due to their chronic pain and occupational insecurity, as noted by one participant: “I had already seen two [pain] doctors, and they told me I had two options, change jobs or retire because the pain would continue.”

Latino identity and gender roles as drivers of pain coping

Participants’ identity and culture were identified as a driving force in the face of adversity and as a source of strength: “It is our culture that drives us”. However, beliefs from their country of origin were reported to influence their need to minimize displaying vulnerability: “We try not to cry, not to show weakness…In Puerto Rico, seeing a man cry, they say, ‘Are you a girl?’ and they bully you for that.” Another male participant discussed sharing his emotions only with his wife: “I do tell her how I feel with the pain, but with no one else, not even a friend.” The cultural expectation for males to suppress emotions because of cultural roles contributed to avoidance and an emphasis on being self-reliant even with pain: “They will have to deal with their pain, and I have to deal with mine.” Self-sacrifices and wanting to be perceived as a caring wife and strong woman were evident among those who were a caregiver to their spouses (See Table 4).

Structural domain

Within the structural domain, two themes were identified: 1) racial discrimination and disproportionate impact of pain on Latinos, and 2) physically intensive jobs shaping pain trajectories (See Table 5).

Table 5.

Structural domain

Themes	Definition	Supporting quotes
Racial discrimination and disproportionate impact of pain on Latinos	This theme reflected participants’ perceptions of how racial and ethnic discrimination shaped their lived experiences and access to pain care.	“...because when they see [‘Puerto Rican’ by] my name [in the medical record], they provide an interpreter, and the doctor tells the interpreter to ask me if I [...], and I continue answering the doctor in English.” “Latinos face more challenges in society ...I don’t know if it’s because I’m Hispanic, but I have felt, at times, discriminated against.”
Physically intensive jobs shaping pain trajectories	This theme highlighted how physically demanding occupational roles worsened their pain experiences.	“Every time I work, I have a lot of numbness in the lower part of my waist and pain in my back. It’s like I go in at 5 feet 3 inches and come out at 4 feet 11 inches. When I finish working, I come out all hunched over.” “When you clean, that’s tough... bending down to wash the bathrooms, and so on. I also worked in a hotel, and that was heavy work. So, all these things add up to muscle pain and everything.”

Racial discrimination and disproportionate impact of pain on Latinos

Participants described facing discrimination related to their age, race, limited mobility, and chronic pain. In the workplace, the discrimination faced was related to a decrease in hours and limited accommodations as a result of their chronic pain. Some participants reported losing their jobs: “My boss saw me limping and said, ‘You can’t work.’ So, they suspended me.” Despite their willingness to continue working, some participants perceived discriminatory hiring practices and the lack of job opportunities due to their pain worsening, as one participant noted: “We don’t perform like a healthy person [someone without chronic pain]. So, they give us fewer hours or do not hire us. Of course, in this country, they do discriminate in that sense.” Participants reflected on the disproportionate impact of chronic pain: “We Latinos are the ones who suffer the most from this [chronic pain],” and perceived disparities were related to their lifestyles. They had racialized and internalized negative beliefs when reflecting on their experiences compared to their White counterparts: “I think that for us Latinos… we do not take care of ourselves as we should, we are not as active in exercising.”

Physically intensive jobs shaping pain trajectories

Participants described that chronic pain experiences were the result of their disproportionate employment in physically demanding jobs and unsafe work environments (e.g., increased risk of falls and injuries, wear and tear, etc.). One participant narrated: “I fell at work, and because of that accident, it has affected my shoulder, my leg, and my head.” Persistent musculoskeletal discomfort in the waist and back, described as numbness and poor posture, was linked to working in multiple and physically intensive jobs that negatively impacted their pain trajectories. Their limited educational background and English proficiency restricted their access to upward mobility and job security, as well as their continued engagement in unsafe physical activities. These working conditions were described as an unavoidable consequence of their socioeconomic position and a significant contributor to their chronic pain.

Discussion

In this qualitative study, we applied the Socio-Ecological Model (SEM; Bronfenbrenner & Ceci, 1994) to explore the multi-level influences on chronic pain experiences among Spanish-speaking older Latino adults in a community clinic located in the Northeastern United States. Using a hybrid deductive-inductive thematic analysis, we identified 11 themes that mapped to the SEM domains (i.e., individual, interpersonal, community, and structural). Broadly, participants’ experiences revealed complex and bidirectional relationships between chronic pain and the various SEM domain levels. Within the individual domain, chronic pain co-occurred with complex medical needs, including multimorbidity that interfered with sleep quality, physical functioning, and mood stability. Additionally, participants described dealing with pain-related depression and anxiety with perseverance. Many reported engaging in daily walking and engaging in activities that helped with distraction. These psychological and behavioral responses mirror those reported by other older adults living with chronic pain (McDermott et al., 2025), but also highlight a diminished quality of life and mobility among this population, further compounded by complex healthcare needs.

Within the interpersonal domain, participants expressed a motivation to push through pain in order to fulfill family obligations and responsibilities. In contrast, others endorsed isolation, limited social interactions, and lost relationships because of their chronic pain. Older adults described a multilevel and bidirectional relationship between chronic pain and their interpersonal relationships. In other words, chronic pain interfered with their engagement in family, home, and meaningful roles. Consistent with previous quantitative studies (Yang et al., 2021), the impact of chronic pain is significantly greater among middle-aged and older adults from racial and linguistic minority groups in the U.S., potentially due to their socioeconomic vulnerability and the multiple roles and responsibilities they carry (e.g., caregiving). Our findings highlight the potential impact of caregiving-related stress and isolation on persistent pain disparities and underscore the need for interventions that engage family systems and strengthen social support to improve the management of chronic conditions (Borja et al., 2024; Lee et al., 2020).

Within the community and cultural domain, we identified the influence of faith on pain acceptance, the struggles to maintain occupational roles, and the presence of gender roles as drivers of pain coping. We found that spiritual practices, such as reading the Bible and daily prayers, provided a strong sense of support and relief in times of pain. Contrastingly, other participants communicated feeling powerless and had the belief that chronic pain was a sign of being closer to death. Findings suggested a strong presence of fatalism, a culturally driven belief that may increase Latinos’ propensity to feel hopeless and lacking control over their pain (Maercker et al., 2019). Traditional Latino gender roles, such as machismo and marianismo, were identified as influencing how participants expressed their pain. Male participants highlighted difficulties showing emotions and hesitancy to discuss their pain with anyone outside their immediate family. In contrast, female participants described the need to appear strong in front of their partners while remaining supportive. Within this domain, participants’ stories revealed a struggle to maintain their occupational roles despite the pain, as their livelihoods depended on being able-bodied (Hollingshead et al., 2016). Findings underscore the importance of developing culturally responsive pain management interventions that thoughtfully address the influence of gender roles, spiritual beliefs, and practices on pain experiences (Campesino & Schwartz, 2006; Hernandez & Gibb, 2019; Lucchetti et al., 2021; Mueller et al., 2001). Failure to adequately address the socio-cultural characteristics of Latinos, such as aligning programs with their social, occupational, and community roles, may worsen existing pain disparities (Nuñez et al., 2016).

Within the structural domain, participants described experiencing racial discrimination and biases in the workplace and healthcare settings. Participants perceived a disproportionate burden of chronic pain among Latinos, which was closely linked to the physical toll of labor-intensive jobs and the lack of accommodations needed to maintain their jobs. Our findings align with previous research indicating that Spanish-speaking older Latino adults are at elevated risk for severe chronic pain due to overrepresentation in physically demanding and hazardous occupations, as well as sustained exposure to racial discrimination (Anderson et al., 2000; Grzywacz et al., 2012; Hollingshead et al., 2016; Tamargo et al., 2023). Findings from this domain underscore the urgent need for policy efforts to address the structural and social determinants shaping the chronic pain trajectories of Spanish-speaking older Latino adults.

Strengths and Limitations

This qualitative study has several strengths that are important to consider along with its limitations. Our sample included a heterogeneous representation of older Spanish-speaking adults from diverse regions in Latin America, including the Caribbean, Central, and South America (i.e., Colombia, Perú, México, Puerto Rico, Nicaragua, Guatemala, El Salvador). While the study provided insight into the needs of an ethnically diverse Spanish-speaking patient sample, it was limited by the underrepresentation of male participants and other intersecting identities. Additionally, because nearly all participants were monolingual (93.7%) and only one was bilingual (6.3%), our analysis focused on socio-cultural and contextual rather than linguistic experiences. Future research should examine the role of language more directly when developing intervention content and assess how Spanish-speaking older Latino adults engage with culturally and linguistically tailored programs. However, it is important to note that the cultural and linguistic needs identified in this patient sample, with an average of 21.5 years in the United States, may be differ from recently immigrated community-dwelling older adults who may have unique language-related needs and face greater pain-related challenges. Studying diverse experiences will be critical to refining the language and delivery of pain management interventions among Spanish-speaking populations. Another strength of this qualitative work was its rigorous design, which yielded rich and inferential insights, rather than generalizable conclusions on the complex and nuanced relationships between chronic pain and multilevel factors shaping their pain experiences. Lastly, we used back-translation to ensure the linguistic accuracy of the interview script and translated transcripts from Spanish to English to facilitate data analysis with a third coder who was non-Spanish speaking. Translating qualitative stories from Spanish to English and the back-translation of interview scripts may have resulted in the loss of the essence of participants’ perspectives or the cultural relevance of the questions being asked and the content of the transcriptions. To minimize this, two bilingual and bicultural researchers reviewed and compared the translations in English next to Spanish to ensure accuracy and relevance.

Conclusions

Our study is the first to use the SEM framework and qualitative methods to understand the lived experiences of Spanish-speaking Latino older adults with chronic pain in a community setting. Findings of this qualitative study enabled us to culturally tailor a mind-body and activity-based pain management intervention for a socioeconomically disadvantaged sample of Spanish-speaking older Latino adults. This study adds to the limited knowledge of the complex and multilayered factors contributing to the worsening of their chronic pain experiences. It underscores the need to address factors at the interpersonal, community/cultural, and structural levels for individuals to overcome pain. Overall, the narratives across all socio-ecological levels of analysis present an opportunity to inform multilevel interventions paralleled with public health efforts that address the holistic needs of older adults with chronic pain. The SEM model will be important in the tailoring of pain management policies and programs that are accessible for socioeconomically disadvantaged older adults residing in medically underserved community settings. Failure to address structural factors perceived to be worsening and impacting pain may not improve access and engagement of racially and linguistically diverse older adults in much-needed clinical interventions.