Romy Parker

Background. Hypertensive disorders of pregnancy restrict perioperative analgesic choices because of multisystem involvement and safety concerns related to non-steroidal anti-inflammatory drugs and neuraxial opioids. Despite the high prevalence of these disorders in southern Africa, postoperative pain outcomes in this population have not been previously compared. Objectives. To compare maximum and minimum postoperative pain scores within 24 hours after caesarean section in women with and without hypertensive disorders of pregnancy, and to describe associated analgesic practices. Methods. A retrospective descriptive study analysed 377 women enrolled in the PAIN OUT SA registry at Tygerberg Hospital between 1 October 2021 and 31 August 2022. Primary outcomes were maximum and minimum numerical rating scale (NRS) pain scores within 24 hours postoperatively. Secondary outcomes included analgesic use, side-effects, pain relief and patient satisfaction. Results. A total of 377 women were included, of whom 81 (21.5%) had hypertensive disorders of pregnancy. Maximum NRS pain scores were similar between groups (median (interquartile range (IQR)) 6 (4 - 8) v. 6 (4 - 8); p=0.171)), as were minimum scores (2 (1 - 4.5) v. 3 (1 - 4); p=0.557). Hypertensive patients more frequently received wound infiltration (p=0.038), whereas postoperative ibuprofen use was more common among normotensive patients (p=0.001). Pain relief and satisfaction did not differ significantly. Conclusion. Women with hypertensive disorders of pregnancy experienced similar postoperative pain scores and similar pain relief compared with normotensive women, despite differences in analgesic regimens. Further research should explore whether postoperative care setting or monitoring practices contribute to pain outcomes in high-risk obstetric populations.

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.

Background: Comprehensive pain management in children requires a specialized skillset, with a limited number of clinicians possessing the level of expertise required to successfully navigate the complexities of holistic care. The emergence of pediatric anesthesia fellowship programs in sub‐Saharan Africa presents an opportunity to embed a pediatric pain curriculum for trainees, improving the availability of specialist skill and knowledge in the field. Existing pain curricula fall short in addressing the sociocultural aspects of pediatric pain identified through research as being unique to the African context, and do not include elements of leadership and advocacy training required to navigate the complexities of resource‐constrained healthcare settings. Methods: A Delphi survey including literature review, iterative rounds of surveys and expert consensus was used to establish a pediatric pain curriculum for pediatric anesthesia fellows undertaking advanced training in sub‐Saharan Africa. The 22‐member expert panel included anesthetists, nurses, surgeons, pharmacists, pediatricians, a physiotherapist and a patient‐caregiver dyad with a lived experience of pain. After completing three rounds of surveys, a steering committee of five members was assembled to resolve outstanding items to achieve the final curriculum. Results: The process yielded a curriculum containing 20 knowledge items and 23 skills items. Attitudes are a key component of the curriculum and were grouped into six themes. A further aspect of the process was the identification of foundational knowledge with which trainees should enter a fellowship training program. This was termed the foundational curriculum. Conclusion: Using a Delphi method, consensus has been achieved on a pediatric pain curriculum for pediatric anesthesia fellows in sub‐Saharan Africa with potential to meet the identified need for transformative pain care in this patient population.

Introduction: Chronic pain significantly contributes to global disability, but data from South Africa and other low- and middle-income countries are limited. Objectives: We assessed the association between chronic pain (pain/discomfort ≥3 months) and disability using data from a large, population-based household survey. As an exploratory analysis, we also assessed for differences between individuals with high-impact chronic pain (HICP) (chronic pain with significant disability) to those with low-impact chronic pain (chronic pain with no disabilities) in demographics and health status variables. Methods: This cross-sectional, descriptive, secondary analysis used data collected in the 2016 South African Demographic and Health Survey, including 10336 adults. Disability was assessed using the Washington Group on Disability items. Statistical analyses were conducted using R v4.2.0 with the survey package. Results: Chronic pain prevalence was 18.3% (95% confidence interval [CI]: 16.9–19.7), with 27.8% (95% CI: 25.2–30.5) of individuals with chronic pain experiencing some form of disability. Chronic pain was associated with difficulties in cognition (adjusted odds ratio = 1.74 [95% CI: 1.41–2.14]) and mobility (AOR = 2.07 [95% CI: 1.70–2.52]), but not self-care (AOR = 1.07 [95% CI: 0.71–1.62]). The HICP group represented 1.7% (95% CI: 1.4–2.0) of the population and 9.2% (95%: 7.7–10.7) of those with chronic pain. Compared to the low-impact chronic pain group, the HICP group tended to be older and were more likely to be female, to receive a government grant, and to perceive their health as poor. Conclusion: Weak and moderately strong positive associations were found between chronic pain and greater cognitive and mobility disability, respectively.

Background: Less than half of all orthopaedic patients undergoing surgery report adequate pain relief. PAIN OUT is an international registry that collects and compares patient–reported outcomes to support quality improvement in postoperative pain management. Aim: The aim of this study was to assess the impact of implementing a four–part perioperative pain management bundle by comparing pain outcomes pre– and post–bundle implementation in orthopaedic patients at a private hospital in Gauteng, South Africa. Setting: A single private hospital providing elective orthopaedic surgical care in Gauteng, South Africa. Methods: A pre–post observational audit was conducted using the PAIN OUT registry. Baseline data were collected from 86 patients (November 2021–March 2023), and post–implementation data from 105 patients (September 2023–March 2024). The bundle included patient education, non–opioid analgesia, regional anaesthesia and structured pain assessment. Results: In the post–implementation group, 95.23% of participants had their pain assessed and reassessed regularly, compared with 58.13% at baseline. All participants received regional anaesthesia and/or wound infiltration, compared with 30.23% at baseline. Overall, 65.71% of patients received all four elements of the bundle compared with 0% before implementation. Total pain composite scores, pain–related interference and side effects of pain management significantly improved post–implementation. Fewer patients reported wanting more analgesia (21.9% vs 48.84%; p < 0.01). Conclusion: Implementation of a four–part perioperative pain management bundle improved postoperative pain outcomes among orthopaedic patients and supports broader application of bundled approaches in diverse settings. Contribution: This study provides South African PAIN OUT data and demonstrates the feasibility and effectiveness of a standardised perioperative pain management bundle in the private hospital setting.