Threats to social safety and pain: A global study

Pain is distributed unevenly across countries, with prevalence rates varying from as low as 10% in some countries to as high as 50% in others. Prior work links macro-level sociostructural factors to pain, yet findings are inconsistent. We examined whether threats to social safety can explain these inconsistencies. We tested whether 1) micro-level interpersonal difficulties (ID) predict pain, 2) whether macro-level structural stigma (SS) predicts pain, and 3) whether SS amplifies the relationship between interpersonal difficulties (ID) and pain. We linked individual data from 253,659 adults in 67 countries participating in the World Health Survey (2002-2004) with cross-national measures of SS from the Varieties of Democracy project. Ordinal logistic regression models, including pooled, country fixed effects, and mixed effects specifications, were estimated adjusting for age, gender, education, and self-rated health. ID showed a strong association with more severe pain across all models (ORs = 1.32-1.78, all p < 0.001). SS did not predict pain as a main effect (OR = 1.08, p = 0.79) but significantly amplified the ID-pain association (interaction OR = 1.25, p = 0.003), yielding much higher predicted probabilities of severe and extreme pain for individuals reporting high ID in high-SS contexts. These findings suggest that SS may not shift average pain directly but instead strengthens the effect of interpersonal social safety threat on pain, offering a potential explanation for some inconsistencies in cross-national research on pain prevalence. PERSPECTIVE: This global study shows that interpersonal difficulties are strongly associated with pain and that structural stigma (i.e., the degree to which political power, civil liberties, public services, and economic opportunities are distributed unequally across social groups) amplifies this relationship. Reducing pain burden may require interventions that enhance social safety at both interpersonal and societal levels.