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. Author manuscript; available in PMC: 2017 Oct 1.
Published in final edited form as: Pain Manag Nurs. 2016 Aug 21;17(5):294–301. doi: 10.1016/j.pmn.2016.05.007

The Relationship between Pain, Disability and Gender in African Americans

Janiece L Walker 1, Roland J Thorpe Jr 2,3,4, Tracie C Harrison 5, Tamara A Baker 6, Michael Cary 7, Sarah L Szanton 1,2, Jason C Allaire 8, Keith E Whitfield 4,9
PMCID: PMC5035583  NIHMSID: NIHMS792116  PMID: 27553130

Abstract

Older African Americans consistently report diminished capacities to perform activities of daily living (ADL) compared to other race groups. It remains unclear the extent to which bodily pain is related to declining abilities to perform ADL/ADL disability in African Americans and if this relationship exists in both African American men and women to the same degree. In order for nurses to provide optimal care for older African Americans, a better understanding of the relationship between bodily pain and ADL disability and how it may differ by gender is needed. The aim of this study was to examine if pain, age, education, income, marital status and/or comorbid conditions were associated with ADL disabilities in older African American women and men. This was a cross-sectional descriptive study. The sample included 598 participants (446 women, 152 men) from the first wave of the Baltimore Study on Black Aging. African American women (Odds Ratio (OR) = 4.06; 95% confidence interval [CI] 2.63–6.26) and African American men (OR= 6.44; 95% CI =2.84–14.57) who reported bodily pain had greater ADL disability than those who did not report bodily pain. Having two or more comorbid conditions was also significantly associated with ADL disability in African American women (OR=3.95; 95% CI: 2.09–7.47). Further work is needed to understand pain differences between older African American women and men in order to develop interventions that can be tailored to meet the individual pain needs of both groups.

Keywords: Activities of Daily Living, Disability, Pain Management, African Americans, Aging

Introduction

Older African Americans experience a disproportionate rate of Activities of Daily Living (ADL) disability in comparison to non-Hispanic Whites (Fuller-Thomson, Yu, Nuru-Jeter, Guralnik, & Minkler, 2009; Thorpe Jr, Szanton, Bell, & Whitfield, 2013; Whitson et al., 2011). ADL disability is defined as difficulty in accomplishing activities of daily living such as eating, drinking, bathing etc. (Katz, Ford, Moskowitz, Jackson, & Jaffe, 1963). ADL disability is significantly related to higher mortality rates, poorer health outcomes, and more cognitive decline in African Americans. (Ayotte, Allaire, & Whitfield, 2013; Furner, Giloth, Arguelles, Miles, & Goldberg, 2004; World Health Organization, 2015). It is essential to identify factors that are related to ADL disability in older African Americans because addressing these factors may provide essential knowledge needed to decrease the disparities in ADL disability experienced by older African Americans (Thorpe Jr et al., 2011, 2013).

It is well documented that pain can contribute to ADL disability in older adults (Andrews, Cenzer, Yelin, & Covinsky, 2013; Eggermont et al., 2014). Pain is related to ADL disabilities in African Americans (Baker & Whitfield, 2006) ; however, it unknown if this relationship differs in men versus women. To date there is scant literature on pain outcomes within African American women and men and how they are related to ADL disability. It is important to know if a relationship between pain and ADL disability exists within older African American women and men and if a difference exists between gender groups, in order to determine if interventions targeting pain should be tailored by gender (Wilson, 2006).

Previous studies have examined the association between pain and ADL disability by comparing African American men and/or women to other racial/ethnic groups (Green, Baker, Sato, Washington, & Smith, 2003; Wildgaard et al., 2011). Researchers have reported that a significant relationship exists between pain and disability within African Americans and non-Hispanic White samples (Cano, Mayo, & Ventimiglia, 2006; Green, Hart-Johnson, & Loeffler, 2011; Kutner, Zhang, Allman, & Bowling, 2014; Leveille, Bean, Ngo, McMullen, & Guralnik, 2007; Rejeski, Miller, Foy, Messier, & Rapp, 2001). Researchers have also reported that African Americans experienced more disability related pain than other racial ethnic groups (Ndao-Brumblay & Green, 2005; Ruehlman, Karoly, & Newton, 2005) and African American women experience more pain related disability than non-Hispanic White women in particular (Ndao-Brumblay & Green, 2005). Within African American samples, researchers have reported that more pain was significantly related to poorer physical functioning (Baker & Green, 2005; Baker & Whitfield, 2006; Walker, Harrison, Brown, Thorpe, & Szanton, 2016).

There are biological differences as well as different societal expectations that exist between African American men and women that may influence their trajectory to disability. For example, biological (e.g. hormonal) changes after menopause often predispose women to developing various types of arthritis, which may initiate the disablement process in women (Neogi & Zhang, 2013). Using accommodations such as special shoes may be a threat to women’s femininity expectation within society and lack of use of these accommodations may influence disability outcomes (Harrison, Stuifbergen, Walker, Scott, & Choban, 2011). Men may have societal expectations to show strength and independence and this may affect their decision to report pain or address their pain, which may be related to their disability outcomes (Evans, Frank, Oliffe, & Gregory, 2011). Further knowledge of ADL disability outcomes in the two groups may assist nurses and health care entities in improving health care and rehabilitation for the respective genders (Griffith, Ellis, & Allen, 2013; Harrison et al., 2011). When examining differences among African American men and women, researchers can begin to tease out how pain may influence ADL disability in older African American men and older African American women.

The aim of this study was to examine if pain, age, education, income, marital status and/or comorbidities were associated with ADL disabilities in older African American women and men. The theoretical framework used for this study is the disablement process model developed by Verbrugge and Jette (1994). There are various factors that may influence any part of the disablement process (Verbrugge & Jette, 1994). Pain can be considered a biological factor that can influence disablement outcomes (Harrison, 2009). In the current study we sought to understand if the biological factor of pain was associated with ADL disability in older African American women and/or men.

The current study is unique in that we examined outcomes in a specific racial/ethnic group and did not compare across race/ethnicities. By examining the within group variability, researchers studying health disparities can provide further knowledge surrounding what specific factors may adversely affect this group (Whitfield, Allaire, Belue, & Edwards, 2008). A better understanding of bodily pain and its effects on ADL disability is important information for nurses in order for them to provide optimal care for older African Americans. Because pain management is a critical nursing role, knowledge provided from this study may guide the development of effective strategies to minimize pain, which may improve the ability to perform ADL.

Methods

Design

A cross-sectional study design was used for this study to determine if bodily pain and other factors were significantly associated with ADL disability in older African American men and women. Data were taken from the Patterns of Cognitive Aging (PCA) study, which is part of a larger group of aging studies known as the Baltimore Study of Black Aging (BSBA). The overarching goal of the BSBA was to examine the trajectory of cognition, health, and other critical factors in older African Americans.

Participants

Participants were recruited from 29 senior independent living housing facilities that consisted of African Americans primarily living in the West Baltimore area. Participants were provided information sessions in each of the buildings and called the BSBA project office if they were interested in the study. All participants signed a written informed consent agreement approved by the institutional review boards at Pennsylvania State University and Duke University. Participants received $30 compensation for the first interview and $60 for the second. Participants were individually tested in their apartment buildings by a trained interviewer. Each interviewer was given two weeks of training on the instrument and recruitment protocols. Their work was subjected to random checks for accuracy. Data collection lasted 18 months and took place between 2006 and 2008. The exclusion criteria included: (1) cognitive impairment as indicated by a Mini-Mental State Examination (MMSE) cut-off score of 20; (2) inability to communicate verbally with interviewer. The interviews lasted 2.5 hours on average and consisted of a face-to-face interview, a battery of cognitive tests, and information collected on physical and mental health. The analytic sample for this study included 152 men and 446 women for a total of 598 participants with complete information on gender and bodily pain.

Measures

ADL Disability

ADL disability, the outcome variable for this study, was derived from participants’ reports of difficulty in performing basic ADL. ADL were measured across seven areas including eating, dressing, grooming, walking, bathing, toileting, and transferring in and out of bed (Katz, Ford, Moskowitz, Jackson, & Jaffe, 1963). The possible responses for each task were: (1) never need help, (2) have difficulty but can do without help, (3) have difficulty and need help, (4) and never do the activity. Higher scores on the scales indicated poorer function/ability to perform the task. Researchers have previously used these measures in samples that included African Americans (Cummings, Neff, & Husaini, 2003; Furner, Giloth, Arguelles, Miles, & Goldberg, 2004; Thorpe Jr, Szanton, Bell, & Whitfield, 2013).

A binary variable was created for each ADL task, which indicated whether the participants had any difficulty performing tasks in that area. After summing across the seven areas, a dichotomous variable for ADL disability was created to identify those participants who had difficulty in at least one of the tasks (ADL disability) or no difficulty with tasks (no ADL disability). Researchers have previously used this method to measure ADL disability (Freedman, Martin, Schoeni, & Cornman, 2008; Thorpe Jr et al., 2013; Thorpe, Szanton, & Whitfield, 2009).

Pain

Bodily pain was the main independent variable for this study. Participants were asked to rate their overall severity of bodily pain with the following responses: (1) indicating none at all, (2) indicating slight, (3) indicating moderate, (4) indicating quite a bit, and (5) indicating extreme. Bodily pain was made into a dichotomous variable that included two categories with one category consisting of none at all, or slight and the other category consisted of moderate, quite a bit, and extreme. This question was part of the Short Form Health Survey 36 (RAND Health, 2015).

Demographic Characteristics

The demographic characteristics included in this study were age, gender (1=female, 0=male), marital status (1=married; 0=not married), education, and income. Age was a continuous variable measured by number of years. Education was measured as a binary variable that was created to identify those participants who were high school graduates. Family income was based on participants’ responses to 1 of 23 categories ranging from $100 per month to $2,300 or more per month. The income categories were divided into $100 increments.

Comorbid Health Conditions

Participants were asked if they had been diagnosed with any of the following medical conditions: angina, asthma, arthritis, cancer, diabetes, stroke, heart attack and/or hypertension. Each of the conditions were coded as binary variables (1=present; 0=absent) and then the conditions were summed to create a variable that represented the total number of comorbid health conditions. The comorbid health conditions variable was then dichotomized as having two or more comorbid conditions or having one to zero comorbid conditions. Measuring comorbid health conditions as a binary variable is consistent with other studies examining comorbid health conditions (Anderson et al., 2004; Thorpe et al., 2009).

Analytic Approach

Descriptive statistics were calculated to provide demographic data for the sample. Student’s t tests were used for continuous variables and Chi-square tests were used for categorical variables in order to calculate means and differences by gender for the demographic measures, comorbid health conditions, and ADL disability. Logistic regression was used to examine the relationship between pain and ADL disability, which is the recommended method when the outcome variable is categorical (Tabachnick & Fidell, 2013). In order to determine the impact of each block of variables on the parameter estimate for bodily pain, we examined three logistic regression models. Separate models were run in women and men. Analyses were conducted using SAS, version 9.1.3, software (SAS Institute, Inc., Cary, NC).

Results

Sample Description

The baseline characteristics of the total sample by gender groups are presented in Table 1, with means, standard deviations (SD) and/or percentages shown. The mean age of the total sample was 69.1 (SD= 9.77) years. Over half of the sample were high school graduates, female, reported two or more comorbid conditions, and reported ADL disability. When examining the distribution of the baseline characteristics by gender, women were older on average and had a higher proportion reporting two or more comorbid conditions than men. A higher proportion of women were high school graduates. A total of 59% (n=263) of the women reported ADL disability compared to 50% (n=76) of the men. A total of 53% (n=236) of the women reported having moderate to extreme bodily pain and 40% (n=61) of the men reported moderate to extreme bodily pain.

Table 1.

Distribution of Select Characteristics of the Total Sample and by Gender for participants in the Baltimore Study on Black Aging

Characteristic Total
(N=598)		 Women
(N=446)		 Men
(N=152)		 p-value
Age in years (mean and SD) 69.1 ± 9.7 69.9± 9.7 66.6±9.2 0.00
Men (%) 25.4
High School Graduate (%) 57.1 60.5 47.0 0.00
Income (mean and SD) 10.2±5.7 10.1±5.5 10.5±6.3 0.46
Married (%) 11.2 10.1 14.5 0.13
Two or more prevalent health conditions (%)† 80.8 83.4 73.0 0.00
Disability (%)‡ 56.7 59.1 50.0 0.04
Pain (%) 50.0 53.3 40.1 0.00
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†

Prevalent health conditions consisted of ever being told by a doctor that you have: diabetes, heart disease, hypertension, or arthritis.

‡

Disability was defined as reported difficulty in performing at least one of the seven basic activities of daily living (i.e. eating, bathing, grooming, walking, dressing, transferring in and out of bed, and using the toilet).

Factors Associated with ADL Disability

We conducted three models to determine factors associated with ADL disability. In the Model 1 we looked at bodily pain and age, in Model 2 we looked at bodily pain, age, education, income, and marital status, and in Model 3 we looked at the variables in Model 2 as well two or more comorbid conditions in both gender groups. Among the women bodily pain was significantly associated with ADL disability in all three models, and income was significantly associated with ADL disability in Model 2 (OR=0.94; 95% CI: 0.90–0.98) but not Model 3. Among the women in Model 3 the variables that were significantly associated with ADL disability were bodily pain (OR= 4.06; 95% confidence interval (CI): 2.63–6.26) and having two or more health conditions (OR=3.95; 95% CI: 2.09–7.47). Among the men bodily pain was the only variable significantly associated with ADL disability (OR=6.44; 95% CI: 2.84–14.57). The association of pain, age, education, income, marital status and/or comorbidities with ADL disability is presented in Table 2.

Table 2.

Logistic Regression Showing Factors Related to ADL Disability by Gender in the Baltimore Study of Black Aging

Characteristic Odds Ratio (95% Confidence Interval)
Model 1 Model 2 Model 3
Women
 Bodily Pain 4.67 (3.10–7.03) 4.48 (2.93–6.83) 4.06 (2.63–6.26)
 Age 1.02 (0.99–1.04) 1.02 (0.99–1.04) 1.01 (0.99–1.04)
 Education 1.10 (0.69–1.75) 1.30 (0.81–2.09)
 Income 0.94 (0.90–0.98) 0.94 (0.90–0.99)
 Married 1.52 (0.71–3.26) 1.56 (0.71–3.46)
 Two or more prevalent comorbid conditions 3.95 (2.09–7.47)
Men
 Bodily Pain 7.06 (3.29– 15.14) 7.01 (3.21–15.32) 6.44 (2.84–14.57)
 Age 1.05 (1.01–1.10) 1.05 (0.99–1.09) 1.05 (0.99–1.09)
 Education 0.74 (0.34–1.60) 0.73 (0.34–1.60)
 Income 0.99 (0.93–1.06) 0.99 (0.93–1.06)
 Married 0.88 (0.28–2.79) 0.84 (0.26–2.69)
 Two or more prevalent comorbid conditions 1.34 (0.57–3.15)
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Discussion

It is essential that we develop our understanding of how pain relates to ADL disability in older African American women and men in order to address pain and decrease the onset of ADL disability in this growing population. In this study we sought to examine the relationship between bodily pain and ADL disability in a sample of older African American women and men. The findings showed that pain increased the odds of ADL disability in both women and men, which is consistent with previous findings in mixed ethnic samples (Kutner, Zhang, Allman, & Bowling, 2014; Louie & Ward, 2011). These findings demonstrate the importance of adequately managing bodily pain in older African Americans in order to improve their ADL disability outcomes. Among women, having multiple comorbid conditions was also significantly associated with ADL disability. These results are consistent with other studies in which researchers reported that comorbid conditions were significantly related to ADL limitations in older African American women (Dunlop et al., 2005; Thorpe et al., 2016).

In the current study a strong association of bodily pain with ADL disability was shown in both men and women, with men having higher odds of ADL disability than women. Men may experience more pain or poorer health outcomes in later life due to their participation in hard labor jobs and exposure to harsh social and physical environments throughout their lives (Calasanti, 2004; Thorpe et al., 2015). Further work is needed in order to examine how earlier life occupations influence health outcomes in older African American men. Furthermore, this study counters previous assumptions that African American men may not report pain due to societal expectations of strength or masculinity (Evans et al., 2011). The men in our study did report pain and it is demonstrated that their pain had an effect on their ADL. Further research surrounding pain and treatment of pain in older African American men is needed at this juncture (Burgess et al., 2009).

Among both African American men and women ADL disability was associated with bodily pain. Understanding the pain experience among older African Americans, and how this experience differs by gender, warrants further investigation. Due to the strong cultural and ethnic components that are involved in treating pain it is essential that further work is done to understand the pain experience and symptom duration of pain in older African Americans (Green et al., 2003). Furthermore, it is important to understand factors that may influence older African American men and their treatment options and choices, access to health care, and beliefs surrounding pain. Among the women two or more comorbid conditions were associated with ADL disability. Research identifying better ways of managing multiple comorbid conditions and their symptoms might reduce ADL disability in older African American women.

Limitations

Several limitations were noted in this study. First, findings from this study are limited to older African Americans residing in one geographic location (Mid-Atlantic) and therefore cannot be generalized to all older African Americans. Second, this study used a cross-sectional design therefore causality cannot be assumed. Third, the data from this study was based on self-report, which can contain several potential sources of bias. Lastly, the number of men in the sample was relatively small. Despite the limitations, the knowledge from this study provides insight into significant factors associated with ADL disability in older African American men and women. In addition, although we describe self-report as a limitation it is important to take into account that there is a subjective component to both pain and ADL disability. A person’s perceptions and understanding of an illness and/or pain, may shape how they negotiate treatment with their providers (Meghani & Houldin, 2007).

Implications for Nursing

Research Implications

Without evidence to inform pain management older African Americans may continue to experience high rates of unresolved and/or inadequate pain relief. Further work is needed to help nurses understand which interventions work effectively in community-based settings. Prospective and randomized controlled trials involving community-dwelling older African Americans might help to uncover causal mechanisms, which would highlight specific factors to address that may lead to improved pain. It is also important that future nursing pain management research focuses on how clinical practice, diagnostic tests, and treatment options differ by gender within the clinical setting (LeResche, 2011). In addition, nurse researchers can focus on the mechanism between comorbid conditions, pain and ADL disability among African American women. Effective pain management in minority older adults with comorbid conditions can significantly improve their ability to perform ADL (Gilmour H., 2006). Furthermore, interventions targeting management of symptoms associated with comorbid conditions may decrease the risk of ADL disability among older African American women.

In addition, understanding and addressing other factors related to pain and disability may be effective ways to improve pain and disability outcomes in older African Americans. For example, empirical evidence suggests racial discrimination among African Americans is associated with greater bodily pain (Burgess et al, 2009) and disability (Walker, Harrison, Brown, Thorpe, & Szanton, 2016). Very few investigators have studied the effects of pain on ADL disability and whether or not racial discrimination moderates this relationship. In addition, there is a strong emotional/psychological component associated with pain and disability (Linton & Shaw, 2011) and further understanding how these mechanisms intersect with gender in older African Americans may help researchers understand how to develop effective pain interventions in this population. Psychological interventions and other non-pharmacological interventions for pain within older African American groups is a promising area that needs more exploration (Park, Lavin, & Couturier, 2014).

Practice Implications

It is essential that nurses adequately assess pain and effectiveness of pain treatments in older African Americans when pain interferes with daily activities (Puia & McDonald, 2014). Using a holistic, culturally sensitive approach when assessing and treating pain that takes into account individual experiences and beliefs may be an effective way for nurses to approach pain in older African Americans (Booker, Pasero, & Herr, 2015; Booker, 2015; Tait & Chibnall, 2014). Effective pain management in older African Americans and minority older adults with comorbid conditions in general may significantly improve their ability to perform ADL (Gilmour., 2006; Szanton et al., 2011).

Conclusion

In summary, understanding factors that lead to ADL disability in older adults should be a research priority, especially among those who are disproportionately impacted. In this study we provided evidence that in a sample of community dwelling older African Americans, bodily pain is significantly associated with ADL disability in both women and men. This study was unique in that a within group approach was taken to examine factors associated with ADL disability in African American women and men. In this study we identified that comorbid conditions in African American women and bodily pain in both African American men and women are associated with ADL disability, which is a contribution to the literature that effective pain management in African Americans and symptom management of comorbid conditions in African American women may be pathways for improved ADL outcomes in these groups. If older African Americans have improved abilities to perform ADL this may lead to more independence and better quality of life (Stuifbergen, Brown, & Phillips, 2009).

Acknowledgments

The Baltimore Study of Black Aging was funded by a grant from the National Institute on Aging (1R01-AG 24108-01A1) to the last author (PI: K.E.W.). The first author (J.L.W.) is supported by the Johns Hopkins University Interdisciplinary Training Program in Biobehavioral Pain Research (T32-NS070201).

Footnotes

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References

  1. Anderson KO, Mendoza TR, Payne R, Valero V, Palos GR, Nazario A, Cleeland CS. Pain education for underserved minority cancer patients: A randomized controlled trial. Journal of Clinical Oncology: Official Journal of the American Society of Clinical Oncology. 2004;22(24):4918–4925. doi: 10.1200/JCO.2004.06.115. [DOI] [PubMed] [Google Scholar]
  2. Andrews JS, Cenzer IS, Yelin E, Covinsky KE. Pain as a risk factor for disability or death. Journal of the American Geriatrics Society. 2013;61(4):583–589. doi: 10.1111/jgs.12172. [DOI] [PMC free article] [PubMed] [Google Scholar]
  3. Ayotte BJ, Allaire JC, Whitfield KE. Social support, physical functioning, and cognitive functioning among older African American adults. Aging, Neuropsychology, and Cognition. 2013;20(4):494–510. doi: 10.1080/13825585.2012.761669. [DOI] [PubMed] [Google Scholar]
  4. Baker TA, Green CR. Intrarace differences among black and white Americans presenting for chronic pain management: The influence of age, physical health, and psychosocial factors. Pain Medicine. 2005;6(1):29–38. doi: 10.1111/j.1526-4637.2005.05014.x. [DOI] [PubMed] [Google Scholar]
  5. Baker TA, Whitfield KE. Physical functioning in older blacks: An exploratory study identifying psychosocial and clinical predictors. Journal of the National Medical Association. 2006;98(7):1114–1120. [PMC free article] [PubMed] [Google Scholar]
  6. Booker SS, Pasero C, Herr KA. Practice recommendations for pain assessment by self-report with African American older adults. Geriatric Nursing. 2015;36(1):67–74. doi: 10.1016/j.gerinurse.2014.08.014. [DOI] [PubMed] [Google Scholar]
  7. Booker SQ. Controlling pain: Are nurses prepared to care for black American patients in pain? Nursing. 2015;45(1):66–69. doi: 10.1097/01.NURSE.0000458944.81243.eb. [DOI] [PubMed] [Google Scholar]
  8. Burgess DJ, Grill J, Noorbaloochi S, Griffin JM, Ricards J, Van Ryn M, Partin MR. The effect of perceived racial discrimination on bodily pain among older African American men. Pain Medicine. 2009;10(8):1341–1352. doi: 10.1111/j.1526-4637.2009.00742.x. [DOI] [PubMed] [Google Scholar]
  9. Calasanti T. Feminist gerontology and old men. (Series B, Psychological Sciences and Social Sciences).The Journals of Gerontology. 2004;59(6):S305–14. doi: 10.1093/geronb/59.6.s305. [DOI] [PubMed] [Google Scholar]
  10. Cano A, Mayo A, Ventimiglia M. Coping, pain severity, interference, and disability: The potential mediating and moderating roles of race and education. The Journal of Pain. 2006;7(7):459–468. doi: 10.1016/j.jpain.2006.01.445. [DOI] [PMC free article] [PubMed] [Google Scholar]
  11. Cummings SM, Neff JA, Husaini BA. Functional impairment as a predictor of depressive symptomatology: The role of race, religiosity, and social support. Health & Social Work. 2003;28(1):23–32. doi: 10.1093/hsw/28.1.23. [DOI] [PubMed] [Google Scholar]
  12. Dunlop DD, Semanik P, Song J, Manheim LM, Shih V, Chang RW. Risk factors for functional decline in older adults with arthritis. Arthritis & Rheumatism. 2005;52(4):1274–1282. doi: 10.1002/art.20968. [DOI] [PMC free article] [PubMed] [Google Scholar]
  13. Eggermont LH, Leveille SG, Shi L, Kiely DK, Shmerling RH, Jones RN, Bean JF. Pain characteristics associated with the onset of disability in older adults: The maintenance of balance, independent living, intellect, and zest in the elderly Boston study. Journal of the American Geriatrics Society. 2014;62(6):1007–1016. doi: 10.1111/jgs.12848. [DOI] [PMC free article] [PubMed] [Google Scholar]
  14. Evans J, Frank B, Oliffe JL, Gregory D. Health, illness, men and masculinities (HIMM): A theoretical framework for understanding men and their health. Journal of Men’s Health. 2011;8(1):7–15. [Google Scholar]
  15. Freedman VA, Martin LG, Schoeni RF, Cornman JC. Declines in late-life disability: The role of early-and mid-life factors. Social Science & Medicine. 2008;66(7):1588–1602. doi: 10.1016/j.socscimed.2007.11.037. [DOI] [PMC free article] [PubMed] [Google Scholar]
  16. Fuller-Thomson E, Yu B, Nuru-Jeter A, Guralnik JM, Minkler M. Basic ADL disability and functional limitation rates among older AMERICANS from 2000–2005: The end of the decline? (Series A, Biological Sciences and Medical Sciences).The Journals of Gerontology. 2009;64(12):1333–1336. doi: 10.1093/gerona/glp130. [doi] [DOI] [PMC free article] [PubMed] [Google Scholar]
  17. Furner SE, Giloth BE, Arguelles L, Miles TP, Goldberg JH. A co-twin control study of physical function in elderly African American women. Journal of Aging and Health. 2004;16(1):28–43. doi: 10.1177/0898264303260391. [DOI] [PubMed] [Google Scholar]
  18. Gilmour H, Park J. Dependency, chronic conditions and pain in seniors. Health Reports. 2006;16(suppl):21–31. [PubMed] [Google Scholar]
  19. Green CR, Hart-Johnson T, Loeffler DR. Cancer-related chronic pain examining quality of life in diverse cancer survivors. Cancer. 2011;117(9):1994–2003. doi: 10.1002/cncr.25761. [DOI] [PubMed] [Google Scholar]
  20. Green CR, Baker TA, Sato Y, Washington TL, Smith EM. Race and chronic pain: A comparative study of young black and white Americans presenting for management. The Journal of Pain. 2003;4(4):176–183. doi: 10.1016/s1526-5900(02)65013-8. [DOI] [PubMed] [Google Scholar]
  21. Griffith DM, Ellis KR, Allen JO. An intersectional approach to social determinants of stress for African American men: Men’s and women’s perspectives. American Journal of Men’s Health. 2013;7(4 Suppl):19S–30S. doi: 10.1177/1557988313480227. [doi] [DOI] [PMC free article] [PubMed] [Google Scholar]
  22. Harrison T, Stuifbergen A, Walker J, Scott T, Choban R. The meaning of gender while aging with paralytic polio. Journal of Gerontological Social Work. 2011;54(2):138–158. doi: 10.1080/01634372.2010.529864. [DOI] [PMC free article] [PubMed] [Google Scholar]
  23. Harrison T. Health disparities among Latinas aging with disabilities. Family & Community Health. 2009;32(1 Suppl):S36–45. doi: 10.1097/01.FCH.0000342838.05607.63. [doi] [DOI] [PMC free article] [PubMed] [Google Scholar]
  24. Katz S, Ford AB, Moskowitz RW, Jackson BA, Jaffe MW. Studies of illness in the aged The index of ADL: A standardized measure of biological and psychosocial function. Journal of the American Medical Association. 1963;185(12):914–919. doi: 10.1001/jama.1963.03060120024016. [DOI] [PubMed] [Google Scholar]
  25. Kutner NG, Zhang R, Allman RM, Bowling CB. Correlates of ADL difficulty in a large hemodialysis cohort. Hemodialysis International. 2014;18(1):70–77. doi: 10.1111/hdi.12098. [DOI] [PMC free article] [PubMed] [Google Scholar]
  26. Linton SJ, Shaw WS. Impact of psychological factors in the experience of pain. Physical therapy. 2011;91(5):700–711. doi: 10.2522/ptj.20100330. [DOI] [PubMed] [Google Scholar]
  27. Leresche L. Defining gender disparities in pain management. Clinical Orthopaedics and Related Research. 2011;469(7):1871–1877. doi: 10.1007/s11999-010-1759-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
  28. Leveille SG, Bean J, Ngo L, McMullen W, Guralnik JM. The pathway from musculoskeletal pain to mobility difficulty in older disabled women. Pain. 2007;128(1):69–77. doi: 10.1016/j.pain.2006.08.031. [DOI] [PMC free article] [PubMed] [Google Scholar]
  29. Louie GH, Ward MM. Socioeconomic and ethnic differences in disease burden and disparities in physical function in older adults. American Journal of Public Health. 2011;101(7):1322–1329. doi: 10.2105/AJPH.2010.199455. [DOI] [PMC free article] [PubMed] [Google Scholar]
  30. Meghani SH, Houldin AD. The meanings of and attitudes about cancer pain among African Americans. Oncology Nursing Forum. 2007;34(6):1179–1186. doi: 10.1188/07.ONF.1179-1186. [DOI] [PubMed] [Google Scholar]
  31. Ndao-Brumblay SK, Green CR. Racial differences in the physical and psychosocial health among black and white women with chronic pain. Journal of the National Medical Association. 2005;97(10):1369–1377. [PMC free article] [PubMed] [Google Scholar]
  32. Neogi T, Zhang Y. Epidemiology of osteoarthritis. Rheumatic Disease Clinics of North America. 2013;39(1):1–19. doi: 10.1016/j.rdc.2012.10.004. [DOI] [PMC free article] [PubMed] [Google Scholar]
  33. Park J, Lavin R, Couturier B. Choice of nonpharmacological pain therapies by ethnically diverse older adults. Pain Management. 2014;4(6):389–406. doi: 10.2217/pmt.14.43. [DOI] [PubMed] [Google Scholar]
  34. Puia D, McDonald DD. Older black adult osteoarthritis pain communication. Pain Management Nursing. 2014;15(1):229–235. doi: 10.1016/j.pmn.2012.09.001. [DOI] [PMC free article] [PubMed] [Google Scholar]
  35. Rand Health. 36-Item short form survey from the RAND medical outcomes study. 2015 Retrieved from http://www.rand.org/health/surveys_tools/mos/mos_core_36item.html.
  36. Rejeski WJ, Miller ME, Foy C, Messier S, Rapp S. Self-efficacy and the progression of functional limitations and self-reported disability in older adults with knee pain. (Series B, Psychological Sciences and Social Sciences).The Journals of Gerontology. 2001;56(5):S261–5. doi: 10.1093/geronb/56.5.s261. [DOI] [PubMed] [Google Scholar]
  37. Ruehlman LS, Karoly P, Newton C. Comparing the experiential and psychosocial dimensions of chronic pain in African Americans and Caucasians: Findings from a national community sample. Pain Medicine. 2005;6(1):49–60. doi: 10.1111/j.1526-4637.2005.05002.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
  38. Stuifbergen A, Brown A, Phillips L. Predictors and moderators of the disablement process in persons with multiple sclerosis. Neurorehabilitation. 2009;24(2):119–129. doi: 10.3233/NRE-2009-0461. [DOI] [PubMed] [Google Scholar]
  39. Szanton SL, Thorpe RJ, Boyd C, Tanner EK, Leff B, Agree E, Weiss CO. Community aging in place, advancing better living for elders: A Bio-Behavioral-Environmental intervention to improve function and Health-Related quality of life in disabled older adults. Journal of the American Geriatrics Society. 2011;59(12):2314–2320. doi: 10.1111/j.1532-5415.2011.03698.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
  40. Tabachnick BG, Fidell L. Using multivariate statistics (6th international edition) Boston, Mass.: Pearson Tait; 2013. pp. 131–141. [Google Scholar]
  41. Tait RC, Chibnall JT. Racial/ethnic disparities in the assessment and treatment of pain: Psychosocial perspectives. American Psychologist. 2014;69(2):131–141. doi: 10.1037/a0035204. [DOI] [PubMed] [Google Scholar]
  42. Thorpe RJ, Jr, Wynn AJ, Walker JL, Smolen JR, Cary MP, Szanton SL, Whitfield KE. Relationship between Chronic Conditions and Disability in African American Men and Women. Journal of the National Medical Association. 2016;108(1):90–98. doi: 10.1016/j.jnma.2015.12.012. [DOI] [PMC free article] [PubMed] [Google Scholar]
  43. Thorpe RJ, Jr, Kennedy-Hendricks A, Griffith DM, Bruce MA, Coa K, Bell CN, LaVeist TA. Race, social and environmental conditions, and health behaviors in men. Family & Community Health. 2015;38(4):297–306. doi: 10.1097/FCH.0000000000000078. [DOI] [PMC free article] [PubMed] [Google Scholar]
  44. Thorpe RJ, Jr, Szanton SL, Bell CN, Whitfield KE. Education, income and disability in African Americans. Ethnicity and Disease. 2013;23(1):12–17. [PubMed] [Google Scholar]
  45. Thorpe RJ, Jr, Koster A, Kritchevsky SB, Newman AB, Harris T, Ayonayon HN, Health, Aging, and Body Composition Study Race, socioeconomic resources, and late-life mobility and decline: Findings from the health, aging, and body composition study. (Series A, Biological Sciences and Medical Sciences).The Journals of Gerontology. 2011;66(10):1114–1123. doi: 10.1093/gerona/glr102. [doi] [DOI] [PMC free article] [PubMed] [Google Scholar]
  46. Thorpe RJ, Jr, Szanton SL, Whitfield K. Association between lung function and disability in African Americans. Journal of Epidemiology and Community Health. 2009;63(7):541–545. doi: 10.1136/jech.2008.084418. [doi] [DOI] [PMC free article] [PubMed] [Google Scholar]
  47. Verbrugge LM, Jette AM. The disablement process. Social Science & Medicine. 1994;38(1):1–14. doi: 10.1016/0277-9536(94)90294-1. doi: org/10.1016/0277-9536(94)90294-1. [DOI] [PubMed] [Google Scholar]
  48. Walker JL, Harrison TC, Brown A, Thorpe RJ, Szanton SL. Factors associated with disability among middle-aged and older African American women with osteoarthritis. Disability and Health Journal. 2016 doi: 10.1016/j.dhjo.2016.02.004. [DOI] [PMC free article] [PubMed] [Google Scholar]
  49. Whitfield KE, Allaire JC, Belue R, Edwards CL. Are comparisons the answer to understanding behavioral aspects of aging in racial and ethnic groups? (Series B, Psychological Sciences and Social Sciences).The Journals of Gerontology. 2008;63(5):P301–8. doi: 10.1093/geronb/63.5.P301. [DOI] [PMC free article] [PubMed] [Google Scholar]
  50. Whitson HE, Hastings SN, Landerman LR, Fillenbaum GG, Cohen HJ, Johnson KS. Black–white disparity in disability: The role of medical conditions. Journal of the American Geriatrics Society. 2011;59(5):844–850. doi: 10.1111/j.1532-5415.2011.03401.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
  51. Wildgaard K, Ravn J, Nikolajsen L, Jakobsen E, Jensen TS, Kehlet H. Consequences of persistent pain after lung cancer surgery: A nationwide questionnaire study. Acta Anaesthesiologica Scandinavica. 2011;55(1):60–68. doi: 10.1111/j.1399-6576.2010.02357.x. [DOI] [PubMed] [Google Scholar]
  52. Wilson JF. The pain divide between men and women. Annals of Internal Medicine. 2006;144(6):461–464. doi: 10.7326/0003-4819-144-6-200603210-00031. [DOI] [PubMed] [Google Scholar]
  53. World Health Organization. Disability and health fact sheet. 2015 Retrieved from http://www.who.int/mediacentre/factsheets/fs352/en/

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