Victoria J. Madden

Acute pain in hospitalised patients is common, yet African data are scarce. We conducted a prospective point-prevalence study of hospitalised adult patients across Africa to determine acute pain prevalence and severity and investigate associations of pain with critical illness and 7-day mortality. On a single day, investigators assessed patients' worst pain in the preceding 24 hours using a 0 to 10 visual-numerical scale and recorded vital signs. Critical illness was defined as ≥1 vital sign out of range, in line with an international consensus definition. In-hospital mortality was assessed at day 7. Data are presented as median [interquartile range], n (%), and odds ratios with 95% confidence intervals. Between September and December 2023, 19,438 patients from 180 hospitals in 22 African nations were included (age 40 [29; 59] years; 10,874 [56%] female). Pain prevalence [95% CI] was 67.9% [67.9-68.5], with 2795 (14.4%) patients reporting severe pain (≥7/10). Pain was more common among patients admitted for emergency or trauma care and in surgical and high-care wards. Pain severity did not differ meaningfully between sexes. There was no evidence of an association between pain severity and critical illness; however, increasing pain severity was associated with a higher likelihood of 7-day mortality. These findings are comparable to data from high-income countries despite substantial differences in healthcare resources, suggesting that acute pain remains a persistent and underaddressed problem globally. This study provides the first large-scale evidence of acute pain burden in African hospitals and lays a foundation for future research aimed at comprehensively characterising in-hospital pain.

Group-based randomized controlled trials (RCTs) in clinical pain research in low- and middle-income settings (LMIS) face distinct challenges, including resource-related limitations and contextual barriers. In addition, evidence garnered through RCTs in high-income settings is often not directly relevant to LMIS. We briefly discuss alternative group-based study designs that can address some of these challenges. We then introduce single-case experimental designs as a complementary approach that may be more efficient than traditional group-based methods in these contexts. Single-case experimental designs focus on the individual person in relation to at least one independent variable over time under different conditions. Unlike RCTs, they require small sample sizes and provide more granular insights into how a pain intervention affects each individual rather than the average group response. Single-case experimental designs can also accommodate more diverse participants in terms of age, ethnic backgrounds, and comorbidities, making them resource-efficient, clinically relevant, and pragmatic, which can facilitate more clinical trials in LMIS, and thereby a better understanding and scientific evidence for the effects of treatments in these settings.

Objective: There is a bidirectional relationship between emotional distress and pain. However, this relationship is understudied in people with HIV in low-resource settings. This study sought to describe the temporal relationship between emotional distress and pain in people with HIV. Design: Longitudinal observational study. Methods: Participants with virally suppressed HIV, reporting either no pain or persistent pain at baseline, provided weekly remote ratings of distress, worst pain, and average pain using 0-10 visual analogue scales. Within-individual fluctuations in distress and pain were visualised over time. Group-level correlations were determined using Spearman’s correlation tests. Cumulative link mixed models assessed whether distress and pain each predicted the other in the following week. Results: 72 participants provided responses over 49 weeks. The participants had a median (IQR) age of 43 (37-51) years, 63% (n=45) were unemployed and most were females (n=51;71%). Distress and pain fluctuated concurrently within individuals: distress was positively correlated with worst pain (ρ=0.66, 95% CI= 0.60-0.72, p<0.001) and average pain (ρ=0.70, 95% CI=0.64-0.75, p<0.001) intensity within the same week. Worst pain (OR=1.42, 95% CI=1.17-1.71, p<0.001) and average pain (OR=1.43, 95% CI=1.20-1.71, p<0.001) intensity both predicted distress in the next week. Distress predicted worst pain intensity (OR=1.25, 95% CI=1.07-1.46, p=0.023) but not average pain intensity (OR=1.19, 95% CI=1.01-1.40, p=0.152) in the next week. Conclusions: The temporal relationship between distress and worst pain intensity was bidirectional, whereas distress did not temporally predict average pain intensity. Both pain and emotional distress should receive attention from HIV research and clinical care in low-resource settings.

Objective Dysmenorrhoea is highly prevalent and affects participation and quality of life. However, little is known about dysmenorrhoea-related knowledge and sociocultural beliefs in South Africa. We investigated dysmenorrhoea frequency, knowledge differences between menstruating and non-menstruating individuals, and associated generational, cultural, and religious beliefs in a South African university cohort. Methods We analysed cross-sectional survey data from university staff and students. Participants completed demographic and dysmenorrhoea-related knowledge questions and an adapted Working Ability, Location, Intensity, Days of Pain, Dysmenorrhoea (WaLIDD) questionnaire. Free-text responses exploring generational, cultural, and religious beliefs were analysed using reflexive thematic analysis. Results Of 863 participants, 578 were current or past menstruators. Dysmenorrhoea frequency was 75.4% (95%CI 71.7-78.9), with 53% reporting moderate and 31% severe dysmenorrhoea symptoms. Knowledge of dysmenorrhoea was higher among participants who had menstruated than those who had never menstruated (80.4% vs 55.3%, p<0.001). Most participants (85.1%) wanted more dysmenorrhoea education. Analysis of 246 free-text responses identified five themes: (1) menstrual pain is normalised, dismissed, and expected to endure, (2) reproductive meanings attached to menstrual pain, (3) moral, spiritual, and cultural interpretations of menstrual pain, (4) negotiating competing explanations for menstrual pain, and (5) managing and controlling menstrual pain symptoms. These themes reflected intersecting sociocultural and biomedical understandings of menstrual pain. Conclusion Dysmenorrhoea was common and symptoms were frequently moderate or severe. Sociocultural beliefs shaped how menstrual pain was understood, communicated, legitimised, and managed. Findings highlight the need to integrate sociocultural perspectives into menstrual health education, support, and healthcare services.

Acute pain in hospitalised patients is common, yet African data are scarce. We conducted a prospective point-prevalence study of hospitalised adult patients across Africa to determine acute pain prevalence and severity, and investigate associations of pain with critical illness and 7-day mortality. On a single day, investigators assessed patients’ worst pain in the preceding 24 hours using a 0–10 visual-numerical scale and recorded vital signs. Critical illness was defined as ≥1 vital sign out of range, in line with an international consensus definition. In-hospital mortality was assessed at day 7. Data are presented as median [IQR], n (%), and odds ratios with 95% confidence intervals. Between September and December 2023, 19438 patients from 180 hospitals in 22 African nations were included (age 40 [29; 59] years; 10874 (56%) female). Pain prevalence [95%CI] was 67.9% [67.9 – 68.5], with 2795 (14.4%) patients reporting severe pain (≥7/10). Pain was more common among patients admitted for emergency or trauma care, and in surgical and high-care wards. Pain severity did not differ meaningfully between sexes. There was no evidence of an association between pain severity and critical illness; however, increasing pain severity was associated with a higher likelihood of 7-day mortality. These findings are comparable to data from high-income countries despite substantial differences in healthcare resources, suggesting that acute pain remains a persistent and under-addressed problem globally. This study provides the first large-scale evidence of acute pain burden in African hospitals and lays a foundation for future research aimed at comprehensively characterising in-hospital pain.

Social factors are consequences and determinants of chronic pain, yet little is known about how informal social support operates for people with chronic pain and HIV. The overlapping burdens of emotional distress and chronic pain in people living with HIV raise the need to identify targets for culturally resonant treatments. This qualitative study explored how people living with chronic or recurrent pain and HIV seek informal social support for pain and distress from their social networks, how these networks operate, and how social support is influenced by socio-ecological factors. Adults with virally suppressed HIV who endorsed pain over repeated weeks were purposively sampled (n=18). Semi-structured, individual in-depth interviews explored individuals’ experiences of living with HIV and chronic pain, distress and its relationship to pain, and help-seeking behaviours for chronic pain and distress. Codebook thematic analysis was used within an interpretivist epistemological approach. Support for pain involved more tangible actions by fewer people than support for distress. Disruptions in social support were more likely when the person with pain was irritable, socially withdrawn, or unable to fulfil social roles. Interpersonal conflict could also cause or increase pain and distress. Current pain assessments rarely identify the social interference of pain identified here. This work identified potential targets for individual-level interventions to sustain informal social support: individuals’ abilities to cope with daily stressors, pain self-management strategies to facilitate socialisation and engagement in valued life activities, and strategies to prevent support fatigue in informal social networks.

Longitudinal pain studies present an opportunity to understand intra-individual variations in pain. However, current methods to quantify the anatomical extent of pain fail to capture variations across multiple body sites over time. Our aims were to (1) describe patterns of intra-individual variation in pain sites over time, (2) develop a metric that quantifies intra-individual variation in pain sites over time, and (3) determine whether this metric is related to other indicators of pain burden. We used data from a longitudinal cohort of 72 participants (51 female; median (IQR) age 43 (37-51) years) living with virally suppressed HIV, who provided weekly reports of pain severity, pain site(s), and distress over 49 weeks. Participant reports showed noteworthy intra-individual changes in pain sites over time. The pain sites variation metric, based on 727 consecutive reports from 53 participants, reflected intra-individual temporal variation in pain sites, and distinguished participants with consistent pain sites from participants with high temporal variation in pain sites. The metric was positively associated with pain severity and emotional distress, but only when unadjusted for the count of painful sites. Thus, using a longitudinal cohort, we developed a metric that quantifies individual temporal variability in pain sites and demonstrated its relationship to two frequently used metrics of pain burden, namely pain severity and distress. This metric provides an opportunity to study whether the number of, and variability in, pain sites contributes to pain burden and clinical outcomes.

Childhood adversity is linked to persistent pain in adulthood. Nociceptive upregulation may play a role in this relationship. We investigated whether childhood adversity is associated with measures of nociceptive processing, and whether these associations differ by sex. In this experimental observational study, we enrolled pain-free adults with varying severity of childhood adversity, scored on the Childhood Trauma Questionnaire-Short Form. Measures of nociceptive processing included the surface area and magnitude of induced secondary hyperalgesia, temporal summation, and conditioned pain modulation. We used linear regression to investigate whether childhood adversity was associated with increased surface area or magnitude of secondary hyperalgesia, increased temporal summation, or reduced conditioned pain modulation, and whether these relationships differed by sex. Ninety-five participants (61 female; median age 23 [IQR: 9] years) completed the study. Childhood adversity was positively associated with the surface area of secondary hyperalgesia (β=0.32 [95%CI: 0.01; 0.62], p = 0.04), with no evidence of an interaction effect of sex. Childhood adversity was unrelated to the magnitude of secondary hyperalgesia, temporal summation, or conditioned pain modulation. These data suggest that childhood adversity may influence the distribution rather than the magnitude of evoked ascending nociception. Perspective