Abstract
Objective:
Perceived discrimination is associated with chronic pain and depression and contributes to racial health disparities. In a cohort of older adult veterans with osteoarthritis (OA), we sought to examine how membership in multiple socially disadvantaged groups (cumulative disadvantage) was associated with perceived discrimination, pain, and depression. We also tested whether perceived discrimination mediated the association of cumulative disadvantage with depression and pain.
Methods:
We analyzed baseline data from 270 African American and 247 White veterans enrolled in a randomized controlled trial testing a psychological intervention for chronic pain at two VA medical centers. Participants were aged ≥50 years and self-reported symptomatic knee OA. Measures included the Everyday Discrimination Scale, Patient Health Questionnaire Depression Scale (PHQ-8), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain subscale, and demographic variables. Cumulative disadvantage was defined as the number of socially disadvantaged groups to which each participant belonged (i.e., self-reported female gender, African American race, income<$20,000, and/or unemployed due to disability). We used linear regression models and Sobel’s test of mediation to examine hypotheses.
Results:
The average number of social disadvantages was 1.3 (SD=1.0). Cumulative disadvantage was significantly associated with higher perceived discrimination, pain, and depression (p’s<.001). Perceived discrimination significantly mediated the association between cumulative disadvantage and depression symptoms (Z=3.75, p<.001) as well as pain severity (Z=2.24, p=.025).
Conclusion:
Perceived discrimination is an important psychosocial stressor that contributes to poor OA-related mental and physical health outcomes, with greater effects among those from multiple socially disadvantaged groups.
Osteoarthritis (OA) is a leading cause of chronic pain and disability in the United States, with notable sociodemographic disparities and high prevalence among veterans (1,2). The sociodemographic diversity of the veteran population is growing each year (3) and veterans from socially disadvantaged groups (e.g., disabled, racial minority, low-income) are more likely than others to depend on the Veterans Health Administration (VHA) for health care (4). Thus, understanding the nature of OA-related disparities among VHA patients is crucial to improving health equity among veterans.
Individuals from socially disadvantaged groups (i.e., groups that experience historical and ongoing prejudice and systemic oppression) have higher prevalence of OA and greater risk for negative health sequelae (5). In the general population, African Americans and women experience more OA-related severe pain, depression, and functional impairment compared with whites and men, respectively (5-10). Some research suggests that multiple forms of social disadvantage intersect in ways that worsen OA-related outcomes. For example, in a community sample of Black and White adults living above and below the poverty line, the intersection of Black race and living in poverty had a greater impact on pain than either status alone (8). Such research is the exception, however, as most work exploring disparities in OA-related outcomes have focused on a single axis of disadvantage, such as race, gender or socioeconomic status (5,11,12).
Broader health disparities research supports the hypothesis that having multiple disadvantaged identities is associated with worse health outcomes than having one or none, and that this effect may be explained in part by perceived discrimination (13,14). Discrimination refers to the unfair treatment of individuals from marginalized groups by other individuals, institutions and systems (15). Extant research has identified perceived discrimination as an important psychosocial determinant of mental and physical health that impacts individuals belonging to a range of socially disadvantaged groups (16-18). Furthermore, studies have found that higher perceived discrimination is associated with greater bodily pain among African American veterans and women (19,20), greater OA-related pain intensity among African American women (21), and lower pain tolerance among African American adults with knee OA (22). Perceived discrimination is also linked to disparities in depression among individuals with OA; however, this body of research is small and most studies have focused on either race or gender disparities (21,23).
Because reconfiguring one’s membership in socially disadvantaged groups is not a viable strategy to reduce health disparities, research must instead identify intervention targets by focusing on modifiable mechanisms by which belonging to disadvantaged groups leads to worse health outcomes (13,14). While research with veterans has identified significant disparities in arthritis pain management and choice of interventions among VHA patients (24,25), less is understood about psychosocial mechanisms of disparities in OA-related health outcomes. Clarifying the links among cumulative disadvantage, perceived discrimination and health among veterans with OA is particularly important given the increasing diversity and aging nature of the veteran population, their high risk for declines in health, and ongoing efforts by the VHA to eliminate health disparities (3,26).
To our knowledge, no studies have examined perceived discrimination as a psychosocial mechanism by which belonging to multiple disadvantaged groups may impair OA-related mental and physical health. We examined the association between cumulative disadvantage, defined as the number of disadvantaged groups to which one belongs (e.g., based on one’s race, gender, disability), and symptoms of pain and depression in a sample of older adult veterans with OA. We hypothesized that individuals who belong to a greater number of disadvantaged groups would report worse pain and depression symptoms, and that these associations would be mediated by perceived discrimination.
Patients and Methods
Participants and Procedure
Data for this analysis were collected as part of a randomized controlled trial of a positive psychological intervention (Staying Positive with Arthritis) aimed at reducing racial disparities in OA-related knee pain among veterans (27,28). As reported in more detail elsewhere (27,28), participants were recruited from Veterans Affairs (VA) medical centers in Pittsburgh and Philadelphia through study brochures and targeted mailings. Interested veterans were determined eligible via a telephone screen.
The sample included veterans aged 50 years or older who self-identified as non-Hispanic African American or White, reported symptomatic knee pain consistent with knee OA, endorsed pain severity ≥4 on a 0–10 scale, received primary care at one of two participating VA medical centers, and could speak, read and write in English. This pain severity threshold was chosen for eligibility to include a wide range of OA severity while also ensuring that all participants had room to improve with regard to their baseline OA symptom severity (29). Eligible participants met with research staff at their VA medical center to complete written informed consent and baseline questionnaires. All study procedures were approved by the VA Central Institutional Review Board. Current analyses utilized data collected at the baseline study visit, which took place between July 8, 2015, and February 1, 2017.
Primary Exposure Variable
Cumulative Disadvantage Index.
Our goal was to create a variable representing cumulative disadvantage. We considered sociodemographic characteristics that have been linked to discrimination and health disparities in the literature, including race, gender, income, education and disability (13,30,31). For each of these sociodemographic characteristics, we created a dichotomous variable indicating whether participants belonged to the relatively disadvantaged group, specifically: self-reported female gender, African American race, income below $20,000 per year (i.e., near or below federal poverty level) (32), high school education or less, and unemployment due to disability. We examined the main effects of each dichotomous sociodemographic variable on perceived discrimination, as well as interactions with race. Sociodemographic variables with significant main effects or interactions were summed to create a cumulative disadvantage index, with higher scores indicating that a participant had a greater number of disadvantaged sociodemographic characteristics. We collapsed values of 3 or 4 into a single category based on the relatively low prevalence of values greater than 3; thus, the final index ranged from 0 to 3.
Key Study Outcomes
Depression.
Depression symptom severity was measured with the 8-item Patient Health Questionnaire (PHQ-8) (33). The PHQ-8 asks individuals to report how frequently they have experienced eight symptoms of depressive disorders, as defined by the Diagnostic and Statistical Manual of Mental Disorders (34), over the past two weeks on a 4-point scale ranging from “never” to “nearly every day.” The PHQ-8 has a range of 0 to 24, with higher scores indicating more severe symptoms and a score of ≥10 considered probable depression. We used the total sum (Cronbach’s alpha=0.85) as a continuous outcome to model depression severity.
Pain.
OA-related pain severity was assessed via the pain subscale of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) (35). This subscale includes five items that assess the extent to which respondents experienced pain over the past seven days on a five-point Likert-type scale (0=none, 1=mild, 2=moderate, 3=severe, 4=extreme). We summed scores across items (Cronbach’s alpha = 0.80) and normalized scores to range from 0 to 100, with higher scores indicating more severe pain.
Perceived Discrimination.
The Everyday Discrimination Scale assessed the frequency of day-to-day unfair treatment (e.g., treated with less courtesy than others; threatened or harassed; people act as if they are afraid of you) and the attribution for that treatment (e.g., race, gender) (36,37). Participants were asked how often each of nine experiences happened to them in their day-to-day life based on a four-point scale (0=never, 1=rarely, 2=sometimes, 3=often). Responses were averaged across items (Cronbach’s alpha=0.89) and perceived discrimination was treated as a continuous variable in analyses.
For those who provided a response other than “never” for any of the items, we examined their attributions for why discrimination was experienced. Specifically, participants were asked to identify the main reason for the unfair treatment from a list of options (i.e., ancestry or national origins, gender, race, age, religion, height or weight, shade of skin color, sexual orientation, education or income level, physical disability, or other). We combined race, shade of skin, and ancestry or national origins into the category “race” for conciseness.
Those who selected “other” were asked to specify the reason in their own words. Independent coders examined and categorized the qualitative responses to “other” in the following series of steps. First, the “other” responses were examined and recoded into existing categories if possible. If no existing categories applied, the category was determined based on responses to reasons listed at other timepoints in the study; for example, if “other” was chosen at baseline, and “race” was chosen at all other timepoints of the study, then “other” at baseline was recoded as “race” for that participant. If still unable to be categorized, the “other” response at baseline was coded into a new category (i.e., mental health, personality/temperament, other people’s personality/temperament, job related, multiple reasons, don’t know, or unspecified) or left as “other” (n=8) (Supplemental Table 1). Independent coders repeated each of the steps above in batches of 30 and reconciled conflicts through discussion.
Statistical Analyses
We used linear regression to examine main effects and interactions of each disadvantaged status with perceived discrimination. The sociodemographic variables were examined in separate models, with the sociodemographic variable’s main effect entered in the first step, the main effect for race added in the second step, and the sociodemographic variable’s interaction with race entered in the last step.
To examine main hypotheses, linear regression analyses and Sobel tests were used to test total, direct, and indirect effects of cumulative disadvantage on depression and pain symptoms. In adjusted models, we controlled for site of recruitment, age, and body mass index (BMI; based on height and weight abstracted from electronic health records and calculated as kg/m2) (38-40). Results were similar for the models unadjusted and adjusted for covariates; thus, we report results from adjusted models. Analyses were conducted in Stata 16 (41).
Results
Sample Characteristics and Descriptive Analyses
Approximately half of the sample self-identified as African American (52.2%) and most participants were male (72.9%). Among the sample, 22.6% reported unemployment due to disability, 25% reported an annual income of less than $20,000, and 27.9% had a high school education or lower (Table 1).
Table 1.
Baseline Sociodemographic Characteristics of 517 Veterans with Osteoarthritis and Chronic Pain
| Characteristic | N (%) |
|---|---|
| Study site | |
| Philadelphia | 233 (45.1) |
| Pittsburgh | 284 (54.9) |
| Mean (SD) | |
| Age | 63.7 (8.5) |
| BMIa | 32.2 (6.5) |
| Female | 140 (27.1) |
| African American race | 270 (52.2) |
| Employment Status | |
| Employed | 144 (27.8) |
| Retired | 205 (39.7) |
| Unemployed/Other | 51 (9.9) |
| Disabled | 117 (22.6) |
| Annual income^ | |
| <$20,000 | 127 (24.6) |
| >$20-$39,000 | 142 (27.5) |
| >$40,000 | 220 (42.6) |
| Education level | |
| ≤High school | 144 (27.9) |
| Some college | 238 (46.0) |
| ≥4 year degree | 135 (26.1) |
Body mass index (kg/m2)
Income data missing on 28 patients
The majority of the sample (83.5%) reported at least some discrimination, with a mean discrimination score of 0.78 (SD=0.64, range: 0–3), which corresponds to a value between an average response of never and rarely. The sample had a mean depression symptom score of 6.70 (SD=5.41, range: 0–24), indicating mild depression, and a mean pain score of 49.74 (SD=17.14, range: 0–100, with higher scores indicating greater pain severity). Consistent with the sociodemographic variables included in the cumulative disadvantage index, the most frequently cited attributions for discrimination were race (26%), followed by physical disability (11%), education or income (8%), and gender (7%).
Most variables of interest were significantly correlated (Table 2). Perceived discrimination was positively correlated with both depression and pain, and pain and depression were also positively correlated. All sociodemographic characteristics were significantly correlated, except education with race and perceived discrimination. Race and gender were also not significantly correlated.
Table 2.
Zero-order correlations among sociodemographic characteristics, discrimination, depression, and pain
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | |
|---|---|---|---|---|---|---|---|---|
| 1. African American | 1.00 | 0.02 | 0.17 | 0.02 | 0.15 | 0.22 | 0.07 | 0.16 |
| 2. Female | 1.00 | −0.09 | −0.21 | 0.06 | 0.09 | 0.13 | 0.05 | |
| 3. Income < $20,000 | 1.00 | 0.19 | 0.26 | 0.11 | 0.12 | 0.07 | ||
| 4. ≤ HS education | 1.00 | 0.08 | 0.03 | 0.07 | 0.13 | |||
| 5. Disabled | 1.00 | 0.19 | 0.24 | 0.18 | ||||
| 6. Discrimination | 1.00 | 0.39 | 0.20 | |||||
| 7. Depression | 1.00 | 0.36 | ||||||
| 8. Pain | 1.00 |
Statistically significant correlations (p<.05) are bolded
Cumulative Disadvantage Index
In regression analyses, perceived discrimination was significantly associated with African American race (B=.23, 95% CI: .12, .34; p<.001), income <$20,000 per year (B=.21, 95% CI: .08, .34; p=.001), and disability (B=.24, 95% CI: .11, .37; p<.001). Interactions were significant between race and gender (B= −.34, 95% CI: −.58, −.09; p=.007) and between race and disability (B= −.45, 95% CI: −.71, −.18; p=.001). Education was not associated with perceived discrimination (B= −.02, 95% CI: −.14, .11; p=.78) nor was its interaction with race (B=.11, 95% CI: −.14, .35; p=.38). The cumulative disadvantage index thus included race, gender, disability, and income. The percentage of participants with scores of 0, 1, or 2 were 27%, 33%, and 27%, respectively; the remaining 13% with 3 or 4 disadvantaged statuses were combined for subsequent analyses. The average number of social disadvantages was 1.3 (SD=1.0). Mean perceived discrimination, pain, and depression all increased significantly with each increase in the cumulative disadvantage index, with one exception. The mean perceived discrimination score decreased slightly when the cumulative disadvantage index increased from 2 to 3–4 (Table 3).
Table 3.
Perceived discrimination, depression and pain by cumulative disadvantage index
| Perceived Discrimination |
Depression Severity |
Pain Severity |
|
|---|---|---|---|
| Cumulative Disadvantage | Mean (SD) | Mean (SD) | Mean (SD) |
| 0 | 0.52 (0.47) | 5.02 (4.19) | 43.5 (14.6) |
| 1 | 0.80 (0.65) | 6.52 (5.56) | 49.6 (18.2) |
| 2 | 0.94 (0.71) | 7.67 (5.73) | 52.4 (16.2) |
| 3 or 4 | 0.92 (3) | 8.73 (5.50) | 57.7 (16.8) |
Perceived discrimination was measured using Everyday Discrimination Scale. Pain severity was measured using the pain subscale of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Depression severity was measured using the Patient Health Questionnaire Depression Scale (PHQ-8). Mean perceived discrimination, pain, and depression all increased significantly with each increase in the cumulative disadvantage index, with one exception. The mean perceived discrimination score decreased slightly when the cumulative disadvantage index increased from 2 to 3 or 4.
Perceived discrimination as a mediator of the association between cumulative disadvantage and health outcomes
Depression.
In models testing perceived discrimination as a mediator of the association between cumulative disadvantage and depression symptoms (Figure 1), there was a significant total effect of cumulative disadvantage on greater depression symptoms (B=.82, 95% CI: .33, 1.30; p<.001). Cumulative disadvantage was also associated with more perceived discrimination (B=.13, 95% CI: .07, .19; p<.001). When accounting for perceived discrimination, the direct effect of cumulative disadvantage on depression symptoms decreased but remained significant (B=.48, 95% CI: .01, .95; p=.044). A Sobel test confirmed that perceived discrimination partly mediated the impact of cumulative disadvantage on depression symptoms (Z=3.75, p<.001). Perceived discrimination accounted for 41% of the total effect of cumulative disadvantage on depression symptoms.
Figure 1.
Perceived discrimination mediating the association between cumulative disadvantage and depression symptoms. Sobel Z = 3.75 (p<0.001). Proportion of total effect mediated = 0.41 (41%). Model adjusted for age, body mass index, and site of recruitment. Total effect = c; Direct effect = c’. *p<.05.
Pain.
In models testing perceived discrimination as a mediator of the association between cumulative disadvantage and pain severity (Figure 2), there was a significant total effect of cumulative disadvantage on pain severity (B=4.37, 95% CI: 2.81, 5.94; p<.001). When accounting for perceived discrimination, the direct effect of cumulative disadvantage on pain severity decreased slightly but remained significant (B=3.97, 95% CI: 2.39, 5.56; p<.001). A Sobel test confirmed that perceived discrimination partly mediated the impact of cumulative disadvantage on pain severity (Z=2.24, p=.025). Perceived discrimination accounted for 9% of the total effect of cumulative disadvantage on pain severity.
Figure 2.
Perceived discrimination mediating the association between cumulative disadvantage and pain severity. Sobel Z =2.24 (p = 0.025). Proportion of total effect mediated = 0.090 (9%). Model adjusted for age, body mass index, and site of recruitment. Total effect = c; Direct effect = c’. *p<.05.
Discussion
In this sample of VA patients with OA, we found that African American race, female gender, annual income under $20,000, and disability were significantly associated with higher reports of everyday discrimination. When these sociodemographic factors were combined into a cumulative disadvantage index, we found that as the number of disadvantaged statuses increased, so too did depression symptoms and pain severity. Furthermore, perceived discrimination partly mediated the relationship between cumulative disadvantage and depression as well as between cumulative disadvantage and pain.
This is the first study to examine the associations of cumulative disadvantage, perceived discrimination, depression, and pain among veterans with OA. We found that belonging to multiple socially disadvantaged groups was associated with increasingly worse depression symptoms and pain severity, and that these relationships were partly explained by a greater burden of discrimination. Our findings are in line with past work demonstrating that cumulative disadvantage is connected to poorer mental and physical health outcomes via discrimination (13,14).
For a majority of individuals who belong to socially disadvantaged groups, discrimination is a persistent and chronic experience throughout the lifespan (42). The impact of discrimination on health disparities can be conceptualized within a stress-coping framework, whereby chronic discriminatory interactions between an individual and the environment (represented by systems, groups, or individuals) exceed the individual’s ability to cope both psychologically and physiologically, causing stress and threatening health and well-being (42). Discrimination thus contributes to the burden of stress experienced by individuals from marginalized groups, and may contribute to the effects of allostatic load (i.e., biological adaptation in response to chronic stress) on dysfunctions in hormonal, metabolic and immunological systems that influence symptoms of depression (e.g., activation of the hypothalamic-pituitary-adrenal [HPA] axis) and pain severity (e.g., inflammation) (43,44). Ongoing experiences of discrimination also have direct psychological effects on individuals, such as increasing unpleasant emotions (e.g., sadness, worthlessness) and negative cognitive schemas related to the self, others and the world, which can further exacerbate or make manifest symptoms of depression (45). Our findings suggest that the daily indignities experienced by people from multiple marginalized groups have a significant negative association with their mental and physical health.
Depression and pain are very common sequelae of OA, and both interfere with the effective management of this condition (6). Notably, there are significant disparities in arthritis pain management and in choice of interventions among veterans using VHA health care (24,25,46). Current findings suggest that perceived discrimination may be an important mediator of disparities in pain symptoms and that interventions that address the impact of discrimination on health and health care use may enhance equity in arthritis-related health outcomes. Some research suggests that factors such as social support, healthy coping skills and mindfulness buffer the negative health effects of discrimination (16). Interventions that target some or all of these components may have a positive impact on health outcomes among individuals from various socially disadvantaged groups (47). It is important to note that we assessed perceived discrimination using a measure that was not specific to the health care setting; thus, one should not assume that all the reported experiences occurred in the context of health care obtained from the VHA or in any other health care setting. Nonetheless, achieving health equity will necessitate that health care systems also address provider- and system-level factors that may contribute to health disparities, such as provider implicit bias and health care-related discrimination (48,49).
There are several limitations to consider in interpreting our findings. First, though the examination of our hypotheses in an understudied population – older adult veterans with OA – contributes important knowledge, this also limits the generalizability of current findings. The consistency of our findings with past research examining general physical and mental health outcomes in community samples is a positive sign that the relationships we observed are relevant to various populations (13,14). Second, there are other important socially disadvantaged groups that experience discrimination and health disparities, such as sexual minorities, but such data were not collected as part of the current study (14). Sexual minority status will be an important factor to include in future research on cumulative disadvantage and health. Further, we operationalized disability as self-reporting that one was unemployed due to disability. We therefore do not have detailed information about the type of disabilities (e.g., mental or physical, onset, severity, etc.) experienced by participants. It is also likely that some patients with disabilities that did not interfere with their ability to work were not captured by our coding system. Thus, the vulnerability scores generated in this study are likely conservative. Finally, there is evidence that OA-related pain may be exacerbated by depression symptoms (50), a hypothesis that was not examined in the current study due to the cross-sectional nature of data. Longitudinal work will be important to further clarify the causal nature of associations among perceived discrimination, depression and pain.
Conclusions
In the current study, we found that cumulative disadvantage was associated with more depression and pain, and that perceived discrimination mediated the impact of cumulative disadvantage on elevated depression symptoms and greater pain severity. This work adds to a growing body of evidence demonstrating that the impact of social disadvantage on health is cumulative and operates partly through discrimination. Further understanding of how psychosocial vulnerabilities combine to worsen physical and mental health outcomes is warranted to foster health equity in vulnerable populations with chronic arthritic diseases.
Supplementary Material
Significance and Innovations.
In this cohort of African American and white older adult U.S. veterans with osteoarthritis, 83.5% of participants reported experiencing discrimination in their everyday lives.
Participants with more disadvantaged statuses (i.e., African American race, female gender, unemployment due to disability, and/or annual income <$20,000) reported more perceived discrimination, symptoms of depression, and pain severity.
Perceived discrimination partly accounted for the positive associations between cumulative disadvantage and depression as well as pain.
Acknowledgments
Grants and Financial Support: This work was supported by the Veterans Health Administration Health Services Research and Development Service (IIR13–080; Principal Investigator: Dr. Hausmann). Dr. McClendon was supported by the Department of Veterans Affairs, Veterans Health Administration, VISN 1 Career Development Award. Dr. Ibrahim was supported in part by a K24 Mid-Career Development Award from the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS K24AR055259). Dr. Vina was supported in part by a K23 Career Development Award from NIAMS (K23AR067226). The views expressed here are those of the authors and do not represent those of the Department of Veterans Affairs, the National Institute of Arthritis and Musculoskeletal and Skin Diseases, the National Institutes of Health, or the United States Government. All authors report no conflicts of interest.
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