Immigration, Acculturation and Chronic Back and Neck
Problems Among Latino-Americans
Quynh Bui•Mark Doescher•David Takeuchi•
Published online: 1 August 2010
? The Author(s) 2010. This article is published with open access at Springerlink.com
obesity and depression among Latino-Americans, but not
much is known about how acculturation is related to their
prevalence of back and neck problems. This study examines
whether acculturation is associated with the 12-month prev-
alence ofself-reported chronic back orneckproblems among
logistic regression analysis of data from 2,553 noninstitu-
tionalized Latino adults from the 2002–2003 National Latino
and Asian American Survey (NLAAS). After adjusting for
demographic, physical and mental health indicators, English
proficiency, nativity and higher generational status were all
significantly positively associated with the report of chronic
lifetime in the US was not significantly associated. Our find-
higher among more acculturated Latino-Americans indepen-
dent of health status, obesity, and the presence of depression.
Higher acculturation is associated with increased
Hispanic ? Neck pain
Acculturation ? Back pain ? Latino ?
Among American adults, the three-month prevalence of
having either back or neck pain is estimated to be as high
as 31% . They are leading causes of disability and
Americans who reported having either chronic back or
neck problems had about 65% greater yearly health care
expenditures than those who did not .
The three-month prevalence of back pain is lower in
Latino-Americans than in white Americans . No studies
in the US have examined whether the prevalence of chronic
back or neck pain in Latino-Americans differs by accul-
turation. However, there is evidence that acculturation does
affect the health of immigrants and of their descendants
[4–24]. Factors associated with chronic back or neck pain,
such as increased body mass index [25–31], depression,
[32–40] smoking and heavy alcohol use [31, 41–43] have
also been shown to be higher among more acculturated
Latino-Americans [6, 16, 17, 20].
In Europe, certain immigrant populations have had
higher prevalence of pain compared to native-born subjects
[44, 45]. Immigrants from southern Europe and the Middle
East living in Sweden have higher odds of chronic wide-
spread pain, higher pain-associated psychosocial dysfunc-
tion, and higher rates of disability [45–48]. Similarly,
South Asian immigrants residing in the United Kingdom
had 3.7 times higher odds of reporting widespread mus-
culoskeletal pain than native-born British . Among
these immigrants, higher acculturation was negatively
associated with the report of widespread pain .
Very little is known about how culture affects the
experience or report of chronic back or neck pain. One line
of research suggests that the stress of the immigrant
experience would lead to higher report of chronic back or
neck problems among immigrant and less acculturated
This study has been reviewed and approved by the Institutional
Review Board of the University of Washington.
Q. Bui (&) ? M. Doescher
Department of Family Medicine, University
of Washington, Seattle, WA, USA
School of Social Work, University of Washington,
Seattle, WA, USA
Fred Hutchinson Cancer Research Center, Seattle, WA, USA
J Immigrant Minority Health (2011) 13:194–201
respondents. Alternatively, evidence of the deterioration of
some health behaviors and outcomes in Latino-Americans
with acculturation would lend support for the acculturation
hypothesis which states that migrants from cultures with
protective health practices experience worsening health
with longer exposure to a host culture as they adopt the
host culture’s unhealthy practices [4, 7, 23, 24].
This study investigates whether the 12-month prevalence
of chronic back or neck problems in Latino-Americans is
associated with acculturation measured by nativity, genera-
tion in the US, percentage of lifetime in the US, and English
proficiency. We hypothesize that the prevalence of reported
chronic back or neck problems will be higher in more
acculturated Latino-Americans and that differences in
physical health, depression, and obesity may mediate the
effect of acculturation.
Sample and Data Collection
The 2002–2003 National Latino and Asian American Study
(NLAAS) is a national, representative, household survey of
non-institutionalized adults aged 18 and older residing in
the US who self-identified as Latino or Asian and spoke
English, Spanish, Mandarin, Cantonese, Vietnamese, or
Tagalog. The NLAAS employed two multi-stage proba-
bility sampling components: a core sampling of primary
sampling units, area segments and housing units designed
to be nationally representative of all US populations and a
high-density supplemental sampling which oversampled
geographic areas with greater than 5% residential density
of target ancestry groups (Latino: Cuban, Mexican, Puerto
Rican; Asian: Chinese, Filipino, Vietnamese). Secondary
respondents were recruited from households in which one
eligible member had already been interviewed. Weighting
adjustments developed for the NLAAS account for the
joint probabilities for selection under this sampling design.
The sample design and survey methods of the NLAAS
have been described in detail elsewhere [49, 50].
The NLAAS-weighted sample is similar to the 2000
distribution but different in nativity and household income,
with more US immigrants and lower income respondents in
the NLAAS sample. This analysis focuses on Latino-
American NLAAS respondents. Although the NLAAS tar-
geted Mexican, Puerto Rican, or Cuban individuals, those
Latinos’’ primarily included respondents from the Domini-
can Republic, Colombia, El Salvador, Ecuador, Guatemala,
Honduras, Peru, and Nicaragua. A total of 2,554 Latino-
Americans (2009 primary respondents; 545 secondary
respondents) were recruited between May 2002 and
November 2003 as part of the larger NLAAS survey. The
overall weighted response rate for Latinos was 75.5%.
Detailed sample characteristics have been reported by
Heeringa et al. .
The NLAAS survey instruments have been translated and
back-translated in Spanish, Mandarin, Cantonese, Viet-
namese and Tagalog. A comprehensive process based on a
cultural equivalence conceptual model was used to trans-
late and adapt pre-validated measures. Other authors have
described the development of the full survey instrument in
Chronic Back or Neck Problems
The primary outcome of interest was the 12-month prev-
alence of chronic back or neck problems as reported using
a standard chronic conditions checklist designed for use in
cross-cultural epidemiological research as part of the
World Mental Health Composite International Diagnostic
Interview (WHO-CIDI) . Respondents were considered
to have had chronic back or neck problems or pain in the
past 12 months if they answered ‘‘yes’’ to both the ques-
tions: ‘‘Have you ever had chronic back or neck prob-
lems?’’ and ‘‘During the past 12 months, did you still have
chronic back or neck problems?’’
Nativity and Acculturation Measures
Acculturation is a complex concept that describes the
process that occurs when contact between two cultures
results in substantial change in the culture of the individual
members of one or both groups . Four measures were
used to approximate acculturation: nativity, generational
status, self-rated English proficiency, and percentage of
lifetime spent in the US. Nativity was defined by whether
the respondent reported having been born in or outside the
US. Puerto Ricans were considered US-born if they were
born in one of the fifty US states and were considered
immigrants if they were born in Puerto Rico or another
country. Generational status was defined with immigrants
as the first generation. Respondents were categorized as
belonging to the second generation if they were US-born
and had at least one immigrant parent. US-born respon-
dents with two US-born parents were considered to belong
to the third generation or greater. Respondents rated their
English oral proficiency as ‘‘excellent’’, ‘‘good’’, ‘‘fair’’ or
‘‘poor.’’ The proportion of the respondent’s lifetime spent
in the US was applied only to immigrants and was con-
structed by dividing the number of years spent in the US by
J Immigrant Minority Health (2011) 13:194–201195
the respondent’s current age and is used to partially
account for the age at immigration as well as the time spent
in the US [5, 53, 54].
The respondent provides a self-rating of physical health
by answering the question, ‘‘How would you rate your
overall physical health—excellent, very good, good, fair,
or poor?’’ Smoking status was dichotomized into current
smoker and current non-smoker. Body mass index (BMI) is
defined as the body weight in kilograms divided by the
height in meters squared and was dichotomized at obese
(BMI of 30 or greater) and not obese.
The NLAAS mental health interview was based on the
WMH-CIDI . The NLAAS used WMH-CIDI modules
to measure the lifetime prevalence of alcohol abuse and the
combined 12-month prevalence of two depressive disor-
ders: major depression and dysthymia. Alcohol abuse and
depression were modeled as dichotomous variables.
Respondents were considered to have had alcohol abuse in
their lifetime if they had ever met diagnostic criteria for
alcohol abuse from the Diagnostic and Statistical Manual
of Mental Disorders. They were considered to have
depression if they met criteria for either major depression
or dysthymia in the last year.
Socio-demographic measures included age, sex, years of
education and household income. Age is rescaled such that
one unit of age is equal to 10 years. Years of education were
divided into four categories: less than 12 years, 12 years,
13–15 years, and greater than 16 years of schooling.
poverty level in four categories: below poverty level, 100%
to less than 200%, 200% to less than 300%, and 300% of
poverty level or greater.
All statistical analyses were performed using STATA sta-
tistical software package (version 9.2) . We used cross-
tabulation to illustrate the distributions of demographic and
immigration variables in the NLAAS data. Using the US
Latino population as a denominator, we computed age- and
sex-adjusted 12-month prevalence of chronic back or neck
problems across Latino ethnic subgroups and immigration
groups. Weighted percentage estimates and 95% confi-
dence intervals are reported.
We modeled the association between the 12-month
prevalence of chronic back or neck problems and our mea-
sures of acculturation using weighted logistic regression
analysis with adjustments for age, sex, income, education,
error estimates from logistic regression models were adjus-
ted for the complex sampling design using a first-order
Taylor series approximation . We conducted signifi-
cance tests using a design-adjusted Wald test. For logistic
regression analyses, we report prevalence ratios with 95%
by Zhang and Yu .
The University of Washington institutional review board
has reviewed and approved this study.
Table 1 shows the unweighted study sample characteristics
for Latino-Americans stratified by the presence of reported
chronic back or neck problems in the last 12 months.
Mexican-Americans were the largest ethnic group. The
group reporting chronic back or neck problems had greater
numbers of respondents who were obese, currently smok-
ing, in fair or poor health, or had depressive disorder or
The weighted age- and sex-adjusted 12-month preva-
lence of chronic back or neck problems in all Latinos
sampled was 14.6% (13.2, 16.0). This prevalence was
significantly lower for immigrant Latinos (12.0%, 95% CI:
10.3, 13.8) than for US-born Latinos (20.2%, 95% CI: 17.1,
23.8). This pattern was consistent and significant in each of
the largest Latino ethnic subgroups (Table 2).
Unadjusted associations presented in Table 3 showed
that being born in the US, belonging to the third or greater
generation, and reporting good or excellent English profi-
ciency were all associated with significantly higher risk of
reporting chronic back or neck problems in the past
12 months. Those who reported obesity, poorer physical
health, depression, alcohol abuse, or current smoking also
had significantly greater risk of reporting chronic back or
neck problems compared to those who did not have these
Model 1 in Table 3 shows the relative risks of reporting
chronic back or neck problems in the past 12 months by
generation adjusted for English proficiency, age, sex, and
ethnicity. Compared to immigrants, Latinos in the third
generation or greater were 1.6 times more likely to report
chronic back or neck problems but second generation
Latinos were not at greater risk. Good or excellent English
proficiency was also associated with about 1.6 times the
risk of chronic back or neck problems and was independent
of generational status.
Model 2 also adjusts for education, poverty level, self-
reported health status, depression and alcohol abuse.
196J Immigrant Minority Health (2011) 13:194–201
Depression in the last 12 months was associated with
almost twice the likelihood of chronic back or neck prob-
lems while each unit of poorer self-rated physical health
was associated with a 34% increase in risk. Belonging to
the third generation or greater continued to be significantly
positively associated with chronic back or neck problems
but the relative risk was attenuated (1.31, 95% CI 1.01,
1.67). English proficiency was associated with 1.67 times
the risk of reporting chronic back or neck problems.
Obesity and alcohol abuse also remained positively
In another weighted logistic analysis, we looked at
whether differences exist among immigrants using pro-
portion of lifetime in the US and English proficiency as
measures of acculturation. In a model that was adjusted for
age, sex, ethnicity, education, poverty level, and health
indicators but not for English proficiency, no significant
association was found between proportion of lifetime in the
Table 1 Sample characteristics of Latino respondents from the National Latino- and Asian-American study, 2002–2003
(n = 2,553)
Without back and neck
problems (n = 2,137)
With back and neck
problems (n = 416)
Mean age (SD) 40.6 (15.6) 39.8 (15.5) 44.9 (15.7)
Mexican (n = 868) 34.0 22.3 24.3
Puerto Rican (n = 495) 19.418.424.3
Cuban (n = 577)22.634.829.8
Other Latino (n = 614)24.024.521.6
Nativity—born in US36.2 34.943.0
1st Generation (immigrants)220.127.116.11
3rd Generation or greater15.714.6 21.6
Percent of lifetime in US (Immigrants only) (n = 1630)
0–25% Lifetime in US26.026.623.0
25–50% Lifetime in US30.331.424.3
50–99% Lifetime in US43.742.152.8
Below poverty level25.024.228.1
100–199% Of poverty level21.220.821.4
200–299% Of poverty level13.213.012.7
300% Or greater of poverty level40.742.037.7
11 years or less39.238.739.9
16 years or greater18.104.22.168
Physical health rating
BMI—30 or greater27.025.435.1
Affective disorder in past 12 months22.214.171.124
Alcohol abuse in lifetime8.8 7.914.2
J Immigrant Minority Health (2011) 13:194–201197
US and report of chronic back or neck problems in the last
12 months. Respondents who had been in the US for 50 to
75% of their lifetime had a relative risk of 0.6 (95% CI:
0.34, 1.04) for chronic back or neck problems compared to
those who had spent less than 25% of their lifetime in the
US. Those who had greater than 75% of their lifetime in
the US had a relative risk of 0.97 (95% CI: 0.52, 1.79) for
chronic back or neck problems (data not shown).
Among immigrants, English proficiency was associated
with a 61% increased risk of chronic back or neck prob-
lems (1.61, 95% CI: 1.18, 2.14) in an adjusted model that
did not include proportion of lifetime in the US, but was
not significant (1.5, 95% CI: 0.95, 2.29) when proportion of
lifetime in the US was included (data not shown). A similar
analysis using years residing in the US and age at immi-
gration did not yield any significant differences in chronic
back or neck problems by these measures of acculturation.
These findings support the hypothesis that the report of
chronic back or neck pain is associated with acculturation
in Latino-Americans. While we found a strong association
between chronic back or neck problems and obesity,
depression and poorer self-rated physical health, these
factors did not completely explain the observed genera-
tional or language associations.
Our findings apparently contradict those of a similar
study conducted among South Asians in the United Kingdom
where higher acculturation was negatively associated with
reports of widespread pain . Possibly, the relative
prevalence of health behaviors between the culture of ori-
gin and the host culture helps determine the direction of
change in health behavior and ultimately in health outcome
. In the case of back or neck pain, immigrants and their
descendants who originate from a culture of low preva-
lence of back or neck pain entering a culture of high
prevalence would show an increase in back or neck pain
prevalence with acculturation. Likewise, individuals com-
ing from a culture of high back or neck pain prevalence
entering a culture of low prevalence would experience
lower back or neck pain prevalence with acculturation.
This model of acculturation would predict that the preva-
lence of back or neck pain in the United States is high
relative to the countries of origin of the Latino respondents
in this survey, while this prevalence is higher in the
countries of south Asia than in the United Kingdom. While
direct cross-national comparisons are not available, com-
parisons that do exist suggest that prevalence of chronic
pain in the United States is high compared to other
developed and developing nations . Other cross-
national comparisons of back pain prevalence revealed the
United Kingdom to have a low prevalence compared to
other developed nations [59, 60]. Although this evidence is
not adequate to support this model of acculturation, it
reveals a possible future direction for research in this area.
We found a consistent positive association between
English proficiency and the report of chronic back or neck
pain, even though the survey was conducted in the lan-
guage in which the respondent was more fluent. This
finding suggests that language acculturation may be asso-
ciated with changes in certain health related concepts such
as the definitions of back or neck pain or chronicity.
Alternatively, English proficiency, even independent of
generational status, might be associated with other aspects
of lifestyle such as type of work, social networks, or health
behaviors (e.g., physical activity) which may affect back or
neck pain. Whether acculturation is related to the actual
experience of back or neck problems, the reporting of these
problems, or both cannot be determined from this study.
These findings are compatible with other studies which
have found differing health behaviors, reporting, or out-
comes based on linguistic differences [5, 7, 23].
Our results indicate a strong relationship between
physical health, depression and the report of chronic back
or neck pain. They are consistent with cross-national
findings from the World Mental Health Survey which have
shown significant positive associations between the report
Table 2 Weighted age- and sex-adjusted 12-month prevalence of
chronic back or neck problems by ethnicity and nativity
Prevalence % (95% CI)
Total 14.6 (13.2, 16.0)
Immigrant 12.0 (10.3, 13.8)
US born20.2 (17.1, 23.8)
Total 14.9 (13.5, 16.5)
Immigrant11.8 (10.3, 13.6)
US born 19.9 (16.5, 23.7)
Total 17.2 (13.9, 21.0)
Immigrant12.8 (9.7, 16.7)
US born21.3 (17.2, 26.2)
Total 13.2 (11.2, 15.4)
Immigrant12.3 (10.2, 14.7)
US born20.6 (17.4, 24.2)
Total13.4 (11.3, 15.9)
Immigrant 11.4 (9.5, 13.6)
US born19.2 (14.9, 24.4)
Age and sex adjusted to US Latino population means
198J Immigrant Minority Health (2011) 13:194–201
of chronic pain and that of poor physical health, affective
dysfunction, and alcohol abuse [33, 61, 62]. Our findings
further support the assertion that the relationship between
chronic pain and psychological dysfunction is consistent
This study is the first to demonstrate an association
between acculturation and chronic back or neck problems
among Latino-Americans. Its strengths lie in the use of
data from a national representative survey conducted in
both English and Spanish and developed with attention to
cross-cultural meanings of survey items . We were able
to adjust for many social and physical factors that may
influence the experience or report of chronic back pain
Our study has a number of limitations. As the National
Latino and Asian American Study is cross-sectional, causal
relationships cannot be determined. Additionally, the
report of chronic back or neck problems is not precisely
defined or clinically validated. However, self-reports of
chronic conditions have been found to have good correla-
tion with medical records in several methodological studies
[65, 66], and the use of chronic condition checklists has
been found to elicit more complete reporting than the use
of open-ended questions . Martin et al. used Medical
Expenditure Panel Survey data to show that about 78% of
complaints of back or neck problems that carried diag-
nostic codes had codes that corresponded to ‘‘intervertebral
disk disorders,’’ ‘‘sprains and strains of the back,’’ and
‘‘other and unspecified disorders of back,’’ which include
diagnoses of lumbago, backache, and unspecified symp-
toms of the back . Another limitation is the lack of
adequate power to examine associations within specific
ethnic groups. Weighted age- and sex-adjusted prevalence
by the largest ethnic groups in this survey revealed a
consistent pattern of higher report of chronic back and neck
problems among US-born respondents. Finally, we did not
have data on physical activity and work-related factors that
might affect the experience or report of chronic back or
Table 3 Unadjusted and adjusted prevalence ratios between 12-month report of back or neck problems and acculturation, socio-demographic,
and health factors
PR (95% CI)
PR (95% CI)
PR (95% CI)
Nativity—born in US1.66 (1.29, 2.11)***
1st Generation (immigrants)ReferentReferent
2nd Generation 1.04 (0.77, 1.39)1.04 (0.73, 1.43) 0.90 (0.65, 1.24)
3rd Generation or greater 1.88 (1.41, 2.44)***1.63 (1.17, 2.23)** 1.31 (1.01, 1.67)*
English proficient 1.73 (1.37, 2.15)***1.60 (1.23, 2.03)** 1.67 (1.33, 2.05)***
Age (10 years) 1.14 (1.04, 1.23)**1.17 (1.06, 1.28)** 1.13 (1.03, 1.23)**
Female 1.32 (1.03, 1.24)*1.28 (1.00, 1.61) 1.22 (0.96, 1.54)
Mexican 0.86 (0.73, 1.01)Referent Referent
Puerto Rican1.35 (1.10, 1.66)**1.27 (1.03, 1.57)* 1.32 (1.03, 1.67)*
Cuban 0.89 (0.68, 1.15) 1.06 (0.70, 1.38)1.18 (0.92, 1.48)
Other Latino 1.06 (0.84, 1.32)1.08 (0.86, 1.35) 1.17 (0.97, 1.4)
Education—11 years or less0.94 (0.75, 1.16)Referent
Education—12 years0.91 (0.61, 1.30) 0.93 (0.62, 1.33)
Education—13–15 years1.16 (0.87, 1.52) 1.13 (0.81, 1.52)
Education—greater than 16 years1.08 (0.69, 1.63) 1.21 (0.72, 1.84)
Below poverty level0.90 (0.69, 1.16)1.05 (0.81, 1.34)
100–199% Of poverty level1.17 (0.84, 1.58)1.20 (0.83, 1.64)
200–299% Of poverty level0.94 (0.63, 1.37)1.15 (0.74, 1.67)
300% Or greater of poverty level1.00 (0.77, 1.29) Referent
Low physical health rating1.44 (1.33,1.57)***1.34 (1.23, 1.45)***
DSM-IV criteria for affective disorder in past 12 months2.65 (1.84, 3.61)*** 1.97 (1.36, 2.61)***
BMI—30 or greater1.67 (1.40, 1.99)***1.35 (1.1, 1.62)**
DSM-IV criteria for alcohol abuse in lifetime1.94 (1.40, 2.60)***1.52 (1.03, 2.09)*
Current smoker 1.38 (1.08, 1.74)*1.21 (0.96, 1.49)
Model 1 adjusted for generation, English proficiency, age, sex, and ethnicity. Model 2 added adjustment for education, poverty level, self-rated
physical health, affective disorder, overweight, alcohol abuse, and smoking
Two-tailed P-values: * P B 0.05; ** P B 0.01; *** P B 0.001
J Immigrant Minority Health (2011) 13:194–201199
neck pain. Other unmeasured confounders may affect
Future research should include longitudinal studies to
clarify causal relationships between acculturative processes
and chronic pain conditions. Further investigation into the
possible connections between chronic pain and specific
changes in lifestyle, attitudes, and stressors related to
immigration and acculturation are warranted. Future stud-
ies should also examine differences that may exist across
specific ethnic groups.
Creative Commons Attribution Noncommercial License which per-
mits any noncommercial use, distribution, and reproduction in any
medium, provided the original author(s) and source are credited.
This article is distributed under the terms of the
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