Stigma and Pain in Adolescents Hospitalized for Sickle Cell Vasoocclusive Pain Episodes

A systematic review of social functioning and peer relationships in adolescents with chronic pain

OBJECTIVE

There is a need for a systematic review on social functioning and peer relationships among adolescents with chronic pain (ACP) given the high prevalence of chronic pain in adolescence and integral role of peer relationships in adolescent development. This review aims to examine the methods used to evaluate social functioning, the types and extent of peer relationship difficulties, and pain characteristics and sociodemographic factors related to social functioning in ACP.

METHODS

A systematic literature search of PubMed, PsycINFO, CINAHL, Web of Science, and Cochrane databases was performed. Included studies were written in English, presented original, quantitative, peer-reviewed research, had a primary focus on social functioning or peer relationships in ACP, and included study participants between the ages of 10 and 18 years. The review was registered in PROSPERO (No. CRD42022364870).

RESULTS

Twenty-eight articles were included in the review. All studies used self-, parent-, or peer-report questionnaires to evaluate social functioning. Most (89%) of the studies were cross-sectional. Findings suggest that ACP experience social difficulties frequently characterized by loneliness, social anxiety, withdrawal, and peer victimization. Studies examining the associations between social functioning and sociodemographic variables, pain location, and pain-related characteristics yielded mixed findings. Study quality was mixed, with 57.14% rated as "good."

CONCLUSIONS

Findings from this review emphasize the increased risk of reduced social connectedness and the complexity of underlying mechanisms associated with poorer social functioning among ACP. Additional research utilizing longitudinal methodologies is needed to understand potential moderators and directionality of associations between chronic pain and social functioning.

Association of Unmet Social Needs With Disease-Related Outcomes in Pediatric Patients With Sickle Cell Disease

BACKGROUND

Social determinants of health (SDoH) are socioeconomic factors that influence health and well-being, though when unmet can greatly contribute to health disparities. Individuals with sickle cell disease (SCD) are at increased risk of mortality, disability, and healthcare utilization. However, there are limited data linking specific social needs with disease outcomes in this population. Therefore, we sought to identify the unmet needs in one institution and their association with healthcare utilization.

METHODS

Children with SCD and their guardians answered demographic and SDoH questionnaires during routine Sickle Cell Clinic appointments. We defined an unmet social need as any positive answer to the SDoH questionnaire. Disease outcome variables were electronic health record (EHR)-documented emergency department (ED) visits, hospitalizations, clinic appointment attendance, and guardian-reported acute SCD events in the previous year.

RESULTS

A total of 114 parent-guardian dyads participated, with 103 having complete data to analyze. In all, 52% of subjects reported at least one unmet social need with food insecurity (36%), trouble paying utility bills (28%), and unemployment (16%) being the most prevalent. Subjects with at least one unmet need had two times the rate of ED visits and/or hospitalizations and were 1.15 times more likely to have an SCD event in the past year. However, only the association with ED visits was statistically significant (p = 0.03).

CONCLUSION

Over half of subjects reported at least one unmet need; the most common being reliable access to food, which has the potential to impact health outcomes of sickle cell patients. Furthermore, unmet social needs are linked to healthcare utilization and SCD-related complications, supporting routine screening for SDoH in this population.

Exploring the impact of stigma on health-related quality of life among individuals with sickle cell disease: a moderated mediation analysis of distress and social support

Despite extensive research on the impact of stigma on the health-related quality of life (HRQoL) of people with sickle cell disease, gaps remain in understanding the mechanisms through which this association occurs. We investigated how stigma impacts HRQoL among people with sickle cell disease (SCD) through distress and the moderating role of social support in this association. Utilizing a cross-sectional design, we sampled 165 people with SCD in Nigeria, who completed relevant measures. Results showed that distress mediated the stigma-HRQoL link, and social support moderated this mediation. Intervention may do well to incorporate psychological therapies and strengthen social support networks to improve the HRQoL of people living with sickle cell disease.

Health-related quality of life of children and adolescents with sickle cell disease: An evolutionary concept analysis

The concept of Health-Related Quality of life (HRQOL) of children and adolescents with Sickle cell disease (SCD) is not clearly understood due to the lack of available studies. This review aimed to elucidate various attributes and related concepts of HRQOL in children and adolescents with SCD using Rodgers' et al. (2018) concept analysis framework. A systematic search was performed to identify studies reporting the attributes, antecedents, consequences, surrogate terms, and related concepts of HRQOL in children and adolescents with SCD. The review included 75 articles, including 70 quantitative, two mixed-methods, and three qualitative studies. These were categorized into attributes, antecedents, consequences, surrogate terms, related concepts, and an exemplar of HRQOL in children and adolescents with SCD. The review identified nine important attributes. It includes multidimensional and dynamic concepts, acknowledging the illness, maintaining emotional balance and self-control, coping with the disease, pain management, stigma and discrimination, treatment burden, palliative care and personal resilience. The antecedents were knowledge and attitude toward the disease, self-efficacy, social support, spirituality and spiritual well-being, disease severity, access to healthcare, environmental factors, and financial considerations. The consequences were independence in personal life, improved physical health outcomes, psychological well-being, family and caregiver well-being, improved family, social and peer relationships and social interactions, improved school performance, and improved overall HRQOL and long-term outcomes. This analysis provides an overview of HRQOL concepts related to children and adolescents with SCD, guiding further research into nursing care and clinical practice.

[Pain-related stigma in patients with breast, colon, prostate or lung cancer : Results of a bicentric register-based cross-sectional study]

BACKGROUND

Studies on cancer patients show a moderately high relevance of perceived stigmatization. However, no studies have explored the perceived stigmatization in relation to cancer-associated pain. In this work, we analysed the relationship between pain and perceived stigmatization across a large sample of four major cancer entities.

METHODS

Quantitative data of 858 patients (45.6% women, mean age 60.7 years) with breast, bowel, lung and prostate cancer were evaluated in a register-based, bicentric study. Perceived stigmatization was measured using the social impact cale (SIS-D), including a total score and four subscales. Pain was assessed with the brief pain inventory (BPI). The data were analysed using correlation und multiple regression with various sociodemographic and medical predictors.

RESULTS

Of all 858 cancer patients, those with lung and breast cancer were characterized by the greatest pain. The intensity of the pain was a predictor of the perceived stigma in patients with breast and colorectal cancer. In addition, younger age was also a predictor for perceived stigmatization. A good quality of life resulted as a protective factor. The final models showed a high goodness of the fit (corr. R2 > 0.35), except for the lung cancer patients.

CONCLUSIONS

Our findings support the assumption that the experience of pain can have an impact on the perceived stigmatization of cancer patients. Depression might influence the perceived stigmatization. Therefore, this group of patients should receive special attention and psycho-oncological care in clinical practice. Further research on the course and mechanisms of action of pain-related perceived stigmatization is also required.

Agreement between youth and caregiver report of pain and functioning in pediatric sickle cell disease: PedsQL sickle cell disease module

ABSTRACT

Pain is a primary symptom of sickle cell disease (SCD) and is often severe and chronic. To treat SCD-related pain, proper assessment of SCD pain among youth, including the degree of concordance or agreement between youth and caregiver reports of pain, is essential but has not yet been adequately evaluated. In this study, 525 youth with SCD and their parents were evaluated as part of the Sickle Cell Clinical Research and Intervention Program (SCCRIP) to examine pain rating concordance and predictors of concordance. Youth and parents completed the Pediatric Quality of Life Inventory Sickle Cell Disease module (PedsQL-SCD) to measure pain, pain interference, and pain-related constructs. Disease, clinical, and demographic variables were obtained from the SCCRIP database. Intraclass correlations demonstrated moderate-to-poor consistency between youth and caregiver reports of pain and pain interference (ICCs range from 0.17 to 0.54). Analysis of covariance and regression models found that patient age, frequency of hospitalizations and emergency department (ED) visits, economic hardship, and fetal hemoglobin levels were significantly associated with varying pain-rating agreement levels among parent proxy and child self-report pain. Concordance of pain assessments among youth with SCD and their caregivers using the PedsQL-SCD Module was moderate at best, corroborating prior research. Youth factors predicting discordance among pain-related factors included increased ED visits, older age, and female sex. Collectively, these results bolster the use of integrated pain assessments to reduce parent-child discrepancies, thereby improving the adequacy of SCD-related pain assessment and treatment.

Poverty and the wellbeing of children with sickle cell disease: The mediating role of parenting stress

BACKGROUND

Living in poverty in the midst of caring for a child with sickle cell disease (SCD) presents with challenges that may be overwhelming for caregivers. Prior research has shown a relationship between poverty and poor outcomes in children; however, no study has investigated the mediating role of parenting stress on health-related quality of life (HRQOL) for such children.

PROCEDURE

A total of 150 patients, ages 8-17 years and their parents, were enrolled and completed measures of parenting stress (caregivers) and HRQOL (patients). Caregivers also completed a demographic information questionnaire, which was used to determine poverty status. The Sobel test was used to analyze the association between poverty and HRQOL by way of parenting stress.

RESULTS

The series of linear regression results show poverty was a significant predictor for decreased HRQOL (B = -7.01, p = .05) among pediatric patients with SCD. Moreover, the regression coefficient measuring the indirect effect of the model measuring the mediating role of parenting stress was statistically significant (B = -1.05, p = .05).

CONCLUSION

The current study found an association between poverty status and HRQOL scores by way of parenting stress. Findings highlight the need for appropriate resource allocation to caregivers in addition to pediatric patients living with SCD.

Stigma of sickle cell disease among Indian tribal population: A multi-centric qualitative study

BACKGROUND

Sickle Cell Disease (SCD) is the most prevalent hemoglobinopathy, impacting around 5% of the global population. The Indian tribal population, which has been a key focus of the Indian SCD program, can experience health-related stigma due to the multidimensional impact of the disease. This preliminary qualitative inquiry delves into the lived experiences of individuals and synthesizes domains to identify the sources of stigma.

METHODOLOGY

The study's framework for developing the stigma tool was rooted in Bronfenbrenner's Ecology of Human Development. The study was implemented in five tribal-dominated districts of India and involved in-depth interviews with sickle cell disease (SCD) patients and their caregivers to explore their stigmatizing experiences.

RESULTS

The analysis revealed four overarching themes and several subthemes explaining the type of stigma, its source, and factors contributing to stigmatization. First, the study focused on elements associated with perceived stigma, such as disclosure, self-isolation/refusal to participate, and self-judgment. The second theme pertained to the internalization of stigma. The third theme addressed experienced stigma concerning the disease's impact on day-to-day events, and the fourth theme explored the support system patients needed. The framework highlighted the varying degrees of stigmatizing components within different aspects of patients' ecology.

CONCLUSION

Our study highlights the importance of addressing stigma at various levels. Policies, programs, and healthcare interventions must target stigma across these levels. Culturally adaptive tools for identifying stigma, implementing appropriate interventions, and improving healthcare participation are essential for enhancing the quality of life and reducing the disease burden.

Effects of Experienced Discrimination in Pediatric Sickle Cell Disease: Caregiver and Provider Perspectives

For Black children with sickle cell disease (SCD) and their families, high disease stigmatization and pervasive racism increase susceptibility to discrimination in healthcare settings. Childhood experiences of discrimination can result in medical nonadherence, mistrust of healthcare providers, and poorer health outcomes across the lifespan. Caregivers and medical providers are essential to childhood SCD management and are therefore well-positioned to provide insight into discrimination in the context of pediatric SCD. This mixed-methods study sought caregivers' and providers' perspectives on processes underlying discrimination and potential solutions to mitigate the negative effects of perceived discrimination among children with SCD. Caregivers (N = 27) of children with SCD (≤ 12 years old) and providers from their hematology clinics (N = 11) participated in individual semi-structured interviews exploring experiences of discrimination and daily SCD management and completed a quantitative measure of discrimination. Qualitative data were collected until themes reached saturation and subsequently transcribed verbatim, coded, and analyzed using applied thematic analysis. Quantitative and qualitative data converged to suggest the pervasiveness of discrimination in healthcare settings. Three qualitative themes emerged: (1) healthcare system factors underlie discrimination, (2) families' challenging interactions with providers lead to perceptions of discrimination, and (3) experiences of discrimination impact caregiver-provider interactions. Both caregivers and providers highlighted building trusting patient-provider relationships and encouraging patients' self-advocacy as means to reduce experiences and impacts of discrimination. These findings offer potential approaches to tangibly mitigate occurrences of discrimination in pediatric healthcare settings by trust building, accountability keeping, and fostering rapport to improve quality of care and pediatric SCD health outcomes.

Analysis of the 2007-2018 National Health Interview Survey (NHIS): Examining Neurological Complications among Children with Sickle Cell Disease in the United States

This study compared neurological complications among a national sample of United States children with or without sickle cell disease (SCD) and evaluated health status, healthcare and special education utilization patterns, barriers to care, and association of SCD status and demographics/socioeconomic status (SES) on comorbidities and healthcare utilization. Data was acquired from the National Health Interview Survey (NHIS) Sample Child Core questionnaire 2007-2018 dataset that included 133,542 children. An affirmation from the guardian of the child determined the presence of SCD. Regression analysis was used to compare the associations between SCD and demographics/SES on neurological conditions at p < 0.05. Furthermore, adjusted odds ratios (AORs) were estimated for having various neurological conditions. Of the 133,481 children included in the NHIS, the mean age was 8.5 years (SD: 0.02) and 215 had SCD. Of the children with SCD, the sample composition included male (n = 110), and Black (n = 82%). The SCD sample had higher odds of having neuro-developmental conditions (p < 0.1). Families of Black children (55% weighted) reported household incomes < 100% of federal poverty level. Black children were more likely to experience longer wait times to see the doctor (AOR, 0.3; CI 0.1-1.1). Compared to children without SCD, those with SCD had a greater chance of seeing a medical specialist within 12 months (AOR 2.3; CI 1.5-3.7). This representative sample of US children with SCD shows higher odds of developing neurological complications, increased healthcare and special education services utilization, with Black children experiencing a disproportionate burden. This creates the urgency to address the health burden for children with SCD by implementing interventions in healthcare and increasing education assistance programs to combat neurocognitive impairments, especially among Black children.

Quality of life of pediatric and adult individuals with osteogenesis imperfecta: a meta-analysis

BACKGROUND

Osteogenesis imperfecta (OI) is a group of rare inheritable disorders of connective tissue. The cardinal manifestations of OI are low bone mass and reduced bone mineral strength, leading to increased bone fragility and deformity that may lead to significant impairment in daily life. The phenotypic manifestations show a broad range of severity, ranging from mild or moderate to severe and lethal. The here presented meta-analysis aimed to analyze existing findings on quality of life (QoL) in children and adults with OI.

METHODS

Nine databases were searched with predefined key words. The selection process was executed by two independent reviewers and was based on predetermined exclusion and inclusion criteria. The quality of each study was assessed using a risk of bias tool. Effect sizes were calculated as standardized mean differences. Between-study heterogeneity was calculated with the I² statistic.

RESULTS

Among the studies included two featured children and adolescents (N = 189), and four adults (N = 760). Children with OI had significantly lower QoL on the Pediatric quality of life inventory (PedsQL) with regards to the total score, emotional, school, and social functioning compared to controls and norms. The data was not sufficient to calculate differences regarding OI-subtypes. In the adult sample assessed with Short Form Health Survey Questionnaire, 12 (SF-12) and 36 items (SF-36), all OI types showed significantly lower QoL levels across all physical component subscales compared to norms. The same pattern was found for the mental component subscales namely vitality, social functioning, and emotional role functioning. The mental health subscale was significantly lower for OI type I, but not for type III and IV. All of the included studies exhibited a low risk of bias.

CONCLUSIONS

QoL was significantly lower in children and adults with OI compared to norms and controls. Studies in adults comparing OI subtypes showed that the clinical severity of the phenotype is not related to worse mental health QoL. Future research is needed to examine QoL in children and adolescents in more sophisticated ways and to better understand the association between clinical severity of an OI-phenotype/severity and mental health in adults.

Examining Mental Health, Education, Employment, and Pain in Sickle Cell Disease

Importance

Pain related to sickle cell disease (SCD) is complex and associated with social determinants of health. Emotional and stress-related effects of SCD impact daily quality of life and the frequency and severity of pain.

Objective

To explore the association of educational attainment, employment status, and mental health with pain episode frequency and severity among individuals with SCD.

Design, Setting, and Participants

This is a cross-sectional analysis of patient registry data collected at baseline (2017-2018) from patients treated at 8 sites of the US Sickle Cell Disease Implementation Consortium. Data analysis was performed from September 2020 to March 2022.

Main Outcomes and Measures

Electronic medical record abstraction and a participant survey provided demographic data, mental health diagnosis, and Adult Sickle Cell Quality of Life Measurement Information System pain scores. Multivariable regression was used to examine the associations of education, employment, and mental health with the main outcomes (pain frequency and pain severity).

Results

The study enrolled a total of 2264 participants aged 15 to 45 years (mean [SD] age, 27.9 [7.9] years; 1272 female participants [56.2%]) with SCD. Nearly one-half of the participant sample reported taking daily pain medication (1057 participants [47.0%]) and/or hydroxyurea use (1091 participants [49.2%]), 627 participants (28.0%) received regular blood transfusion, 457 (20.0%) had a depression diagnosis confirmed by medical record abstraction, 1789 (79.8%) reported severe pain (rated most recent pain crises as ≥7 out of 10), and 1078 (47.8%) reported more than 4 pain episodes in the prior 12 months. The mean (SD) pain frequency and severity t scores for the sample were 48.6 (11.4) and 50.3 (10.1), respectively. Educational attainment and income were not associated with increased pain frequency or severity. Unemployment (β, 2.13; 95% CI, 0.99 to 3.23; P < .001) and female sex (β, 1.78; 95% CI, 0.80 to 2.76; P < .001) were associated with increased pain frequency. Age younger than 18 years was inversely associated with pain frequency (β, -5.72; 95% CI, -7.72 to -3.72; P < .001) and pain severity (β, 5.10; 95% CI, -6.70 to -3.51; P < .001). Depression was associated with increased pain frequency (β, 2.18; 95% CI, 1.04 to 3.31; P < .001) but not pain severity. Hydroxyurea use was associated with increased pain severity (β, 1.36; 95% CI, 0.47 to 2.24; P = .003), and daily use of pain medication was associated with both increased pain frequency (β, 6.29; 95% CI, 5.28 to 7.31; P < .001) and pain severity (β, 2.87; 95% CI, 1.95 to 3.80; P < .001).

Conclusions and Relevance

These findings suggest that employment status, sex, age, and depression are associated with pain frequency among patients with SCD. Depression screening for these patients is warranted, especially among those experiencing higher pain frequency and severity. Comprehensive treatment and pain reduction must consider the full experiences of patients with SCD, including impacts on mental health.

Health Literacy, Perceived Stigma, Self-Efficacy, and HRQOL in Sickle Cell Disease

Little is known about the relationships among self-efficacy, social determinants of health, and health outcomes in adults living with sickle cell disease (SCD). We conducted mediation analyses examining the relationships among health literacy, perceived stigma, self-efficacy, and health outcomes in an online cohort of adults living with SCD. The health outcomes explored were physical and mental health-related quality of life (HRQOL) and pain interference; covariates included gender, disease severity, and depressive symptoms. Data came from a cross-sectional, descriptive study of 60 adults with SCD. Perceived stigma and self-efficacy had significant relationships with the study outcomes, while health literacy did not. Self-efficacy partially mediated the relationship between perceived stigma and physical HRQOL, when controlling for depressive symptoms. Future research should investigate the influence of stigma and self-efficacy on health outcomes in patients with SCD and consider stigma when creating interventions to modify self-efficacy.

Sickle cell disease and social determinants of health: A scoping review

Social determinants of health (SDoH) may impact outcomes in sickle cell disease (SCD). We conducted a comprehensive literature review of five electronic databases to elucidate the relationship between SDoH and SCD, and identify gaps in the literature. Our search yielded 59 articles, which we organized into five SDoH areas: Neighborhood and Built Environment, Health and Healthcare, Social and Community Context, Education, and Economic Stability. We found that social determinants, such as access to healthcare, were inconsistently evaluated. Improved recognition and understanding of SDoH should enhance the development of programs that directly address its detrimental effects on patients with SCD.

Factor analysis of the stigma scale-child in pediatric inflammatory bowel disease

OBJECTIVE

Illness stigma, or perceived stigma related to a chronic health condition, is pervasive among youth with inflammatory bowel disease (IBD). However, no studies exist examining the psychometric properties of illness stigma measures in this population. Using a modified version of the Child Stigma Scale originally developed for youth with epilepsy, the current study investigated the factor structure and validity of this adapted measure (i.e., Stigma Scale - Child; SS-C) in youth with IBD.

METHODS

Factor analyses were conducted to determine the most parsimonious factor structure for the adapted 8-item Stigma Scale - Child in a sample of 180 youth with IBD. Correlations were conducted to assess convergent validity, and a multiple regression was conducted to further evaluate the measure's predictive validity of child depressive symptoms.

RESULTS

The most parsimonious model for the SS-C is a one-factor solution with an error covariance between the two items assessing concealment/disclosure of IBD diagnosis.

CONCLUSIONS

The SS-C is a psychometrically sound illness stigma measure in pediatric IBD that demonstrates strong convergent validity with psychosocial adjustment factors such as thwarted belongingness, illness uncertainty, and illness intrusiveness, as well as strong predictive validity with youth depressive symptoms. The SS-C is a viable option for use as a brief screener in youth with IBD across clinical and research settings.

Psychometrics of the Sickle Cell Disease Health-Related Stigma Scale-Short Form

Health-related stigma, a form of devaluation related to a health condition, is common in individuals with sickle cell disease (SCD). Pain is the hallmark symptom of SCD, and health-related stigma is often described during care-seeking for pain management. Few published instruments measure health-related stigma in individuals with SCD. This study builds on the psychometrics of the 30- and 40-item Sickle Cell Disease Health-Related Stigma Scale (SCD-HRSS). In a sample of 197 adults with SCD, the results support the reliability and validity of a 21-item scale, the SCD-HRSS-Short Form, with an overall Cronbach’s alpha reliability of 0.91 and discriminant validity with the PROMIS-29 subscales (anxiety, depressive symptoms, pain interference, physical fatigue, sleep, and role satisfaction). A shorter yet reliable and valid scale may decrease the burden for this underrepresented, minoritized population while still providing important information regarding their experiences of stigmatization.

Pain-related stigma as a social determinant of health in diverse pediatric pain populations

Pediatric patients with invisible symptomology, such as chronic pain syndromes, are more likely to experience pain-related stigma and associated discrimination by others, including medical providers, peers, school personnel, and family members. The degree of this pain-related stigma may depend on several social dimensions, including observer (e.g., attentional and implicit biases) and patient characteristics (e.g., racial identity, socioeconomic stressors). In this mini-review, we introduce the concept of pain-related stigma, and the intersectionality of stigma, within the context of social determinants of health in pediatric pain populations. Stigma theory, observer attentional biases, healthcare provider implicit/explicit biases, adverse childhood experience, and psychophysiology of socio-environmental stressors are integrated. Several ethical, clinical, and research implications are also discussed. Because the study of pain-related stigma in pediatric pain is in its infancy, the purpose of this conceptual review is to raise awareness of the nuances surrounding this social construct, propose avenues through which stigma may contribute to health inequities, present frameworks to advance the study of this topic, and identify areas for further investigation.

Psychological Aspect and Quality of Life in Porphyrias: A Review

The World Health Organization (WHO) describes “health” as a state of physical, mental, and social well-being and not merely the absence of disease or infirmity. Therefore, a biopsychosocial approach should be considered as an integral part of patients’ management. In this review, we summarize the available data starting from 1986 on the biological, psychological, and social aspects of porphyrias in order to provide a useful tool for clinicians about the missing knowledge within this field. Porphyrias are a group of rare metabolic disorders affecting the heme biosynthetic pathway and can be categorized into hepatic and erythropoietic. Here, a total of 20 articles reporting the psychological and the quality of life (QoL) data of porphyria patients affected by acute hepatic porphyrias (AHPs), Porphyria Cutanea Tarda (PCT), and Erythropoietic Protoporphyria (EPP) were analyzed. These 13 articles include reported quantitative methods using questionnaires, while the reaming articles employed qualitative descriptive approaches through direct interviews with patients by psychology professionals. We conclude that the use of questionnaires limits the complete description of all areas of a patient’s life compared to a direct interview with specialists. However, only a combined use of these methods could be the best approach for the correct disorder management.

The influence of perceived racial bias and health-related stigma on quality of life among children with sickle cell disease

Objectives: Individuals with sickle cell disease (SCD) experience significant health problems that may result in unpredictable pain episodes and frequent healthcare utilization. Disparities in clinical care may contribute to health-related stigma and racial bias for this majority African-American/Black population. There is less known about the influence of health-related stigma and racial bias on the health-related quality of life (HRQOL) of children with SCD. In the present study, we assessed these relationships and identified differences across demographic factors (i.e. age, gender).Design: Data was collected from African American children with SCD aged 8-16 years (57% male, 63% HbSS). Children completed the Childhood Stigma Scale (adapted for SCD), the Child Perceptions of Racism in Children and Youth scale, and the Pediatric Quality of Life Inventory Sickle Cell Disease Module. Caregivers provided demographic information.Results: In the first regression model, health-related stigma (p = .007) predicted HRQOL, but neither age nor gender were significant predictors. In the second regression model, age (p = .03) predicted HRQOL, but neither gender nor racial bias were significant predictors. Of interest, there was a significant interaction between age, gender, and racial bias (p = .02). Specifically, older girls who reported high levels of perceived racial bias had poorer HRQOL.Conclusions: Our study highlights the need for increased awareness about the effects of health-related stigma and racial bias on HRQOL for children with SCD, particularly for older girls who endorse racial bias. Our findings will guide future stigma and bias reduction interventions that may meet the needs of older girls with SCD.

The Epidemiology of Neurological Complications in Adults With Sickle Cell Disease: A Retrospective Cohort Study

Introduction: Risk factors for neurological complications in sickle cell disease differ in the adult and pediatric populations. Here, we focused on neurological complications in adults with sickle cell disease.

Methods: Patients were selected using the audit data from the St George's Hospital Red Cell Database. The genotyping, demographics, clinical data, and investigation findings were collected.

Results: A total of 303 patients were enrolled in the study: hemoglobin S homozygosity (HbSS) genotype 56%, hemoglobin S and C coinheritance (HbSC) genotype 35%, and hemoglobin S and β-thalassemia coinheritance (HbSβ) thalassemia genotype 9%; the mean age was 38.8 years (±13.5 SD) with 46% males. The most common neurological complication was cerebrovascular disease (n = 37, 12%) including those with ischemic stroke (10%), cerebral vasculopathy (3%), and intracranial hemorrhage (1%). Ischemic stroke was common among the HbSS genotype compared with other genotypes (8 vs. 1.6%, p = 0.001). Comparing the patients with sickle cell disease who had suffered a stroke to those who had not, there was a higher proportion of intracranial vasculopathy (p = 0.001, in particular, Moyamoya) and cognitive dysfunction (p < 0.0001).

Conclusion: Our cohort supports previous reports that the most common neurological complication in adult sickle cell patients is cerebrovascular disease. Strategies to prevent cerebral vasculopathy and cognitive impairment should be explored.

"There's Nothing Wrong With You": Pain-Related Stigma in Adolescents With Chronic Pain

OBJECTIVE

Adolescents with chronic pain often experience symptom disbelief and social rejection by others secondary to "medically unexplained" symptoms. Although chronic pain is common in adolescents, limited research has conceptualized these social experiences as pain-related stigma in this population. The purpose of this study was to identify and describe pain-related stigma among adolescents with chronic pain and their parents using focus group methodology.

METHODS

Five adolescent focus groups (N = 18; Age M = 15.33 years, SD = 1.28) and three parent focus groups (N = 9) were conducted. Directed content analysis was used to analyze focus group transcripts. Stigma categories were developed a priori (Felt Stigma, Anticipated Stigma, Internalized Stigma, Concealment, and Controllability) and new categories emerged during analysis. Two coders reached 87.16% agreement for all groups (adolescent group: 90.34%; Parent group: 79.55%) and consensus was achieved for discordant codes.

RESULTS

Adolescents and their parents endorsed pain-related stigma across all social domains. Analyses revealed four main categories for both groups (a) Felt Stigma (subcategories: pain dismissal, faking or exaggerating, and mental health stigma), (b) Anticipated Stigma and Concealment, (c) Internalized Stigma, and (d) Sources of Pain-Related Stigma (subcategories: pain invisibility, lack of chronic pain knowledge, lack of understanding, and controllability).

CONCLUSIONS

Adolescents with chronic pain experience pain-related stigma from medical providers, school personnel, family members, and peers, which may have negative social and health implications. More research is needed to evaluate the link between pain-related stigma and health outcomes for adolescents with chronic pain. Clinical approaches targeting pain-related stigma are discussed.

Navigating Ethical Challenges for Pediatric Sickle Cell Pain Management in the Context of the Opioid Epidemic

OBJECTIVES

The aim was to describe the impact of the opioid epidemic on pain management practices in pediatric sickle cell disease (SCD) and propose a conceptual framework for navigating ethical decision-making in pediatric sickle cell pain management.

METHODS

A review of the literature on ethical challenges in the management of sickle cell pain was conducted and considered in the context of the opioid epidemic and psychosocial factors affecting youth with SCD. The Integrated Ethical Framework for Pain Management (IEFPM) was applied to pediatric sickle cell pain management using a clinical case example.

RESULTS

Implicit bias, health-related stigma, and potential neurocognitive impairment all present unique challenges in ethical decision-making for youth with SCD. National guidelines for prescribing opioid medication may complicate providers' clinical decision-making and affect their sickle cell pain management practices. The IEFPM was found to be applicable to ethical decision-making for pediatric sickle cell pain and captures both patient-related and provider-related aspects of clinical pain management.

DISCUSSION

The opioid epidemic has exacerbated existing ethical challenges for pain management among youth with SCD. The IEFPM provides a conceptual model that can be integrated into health care settings to facilitate ethical decision-making and promote greater health equity in the clinical management of pediatric sickle cell pain.

Content validation of observer-reported sickle cell pain diaries (SCPD-CS and SCPD-CN): results from interviews with caregivers

BACKGROUND

Patients with sickle cell disease (SCD) experience daily pain and acute episodes known as sickle cell pain crises (SCPCs). The Sickle Cell Pain Diary-Caregiver Report (SCPD-C) is an observer-reported diary for use by caregivers of children ages < 12 years with SCD. This study reports on the content validity of the SCPD-C.

METHODS

The SCPD-C was developed based on a literature review, measurement expert input, and a patient advisory board including clinicians. Three rounds of interviews (including both concept elicitation and cognitive debriefing methodologies) were conducted with caregivers of children with SCD aged < 12 to evaluate the content validity of the SCPD-C.

RESULTS

Across three rounds of interviews, caregivers confirmed concepts in the SCPD-C and described observed impacts that were important and were added. Overall, caregivers evaluated the SCPD-C as easy to understand, with some minor adaptations for clarity. Additionally, the diary was split into two versions based on the child's age and school enrollment status (SCPD-CS for school-aged and SCPD-CN for non-school age children).

CONCLUSIONS

Caregivers provided valuable input that led to important additions and changes to the measures. The SCPD-CS and SCPD-CN are appropriate and fit-for-purpose observer-reported outcome measures of SCPC-related pain frequency and severity, and impacts on health-related quality of life.

Biopsychosocial factors related to transition among adolescents and young adults with sickle cell disease: A systematic review

It is critical to support adolescents and young adults (AYAs) with sickle cell disease (SCD) during transition to adult healthcare. We provide a systematic review of literature related to biopsychosocial influences on transition among AYAs with SCD. Data sources included studies published between January 2010 and May 2020. Forty-four studies were included. Biopsychosocial factors related to improved transition outcomes included older AYA age, greater disease severity, intact neurocognitive functioning, and greater pain coping skills. Financial and insurance barriers were noted. The importance of cultural considerations and provider communication were noted across two qualitative studies. Ten studies assessed efficacy of transition interventions, with 80 % resulting in improvements; however, retention in programs was low and gaps in knowledge and skills remained. Incorporation of early, ongoing assessments of transition readiness and barriers into culturally-tailored interventions aimed at improving transition outcomes is recommended. Examination of longitudinal relationships and interactions across biopsychosocial influences is needed.

Health-Related Stigma, Social Support, Self-Efficacy, and Self-Care Actions Among Adults With Sickle Cell Disease in Oman

Stigma contributes to the burden of individuals and families affected by Sickle cell disease (SCD) and causes delay in appropriate care seeking. The aim of this study is to examine the levels and associations between stigma, social support, self-efficacy, and self-care actions among adult patients with SCD in Oman using a cross-sectional, correlational design. Of the 264 participants, 56.1% (n = 148) were males, with mean age of 30.1 years (SD 7.7). Half of the participants were married, and 88.3% had no other associated diseases. The results demonstrate that patients in Oman suffer from health-related stigma. However, social support, self-efficacy, and self-care actions were reported to be high and correlated with several clinical and demographic variables. Based on the results, effective, low-cost interventions such as psycho-educational groups, individual counseling, or group therapies might be developed. They can promote belief in enhanced efficacy and improved SCD adaptation, thereby increasing patient, and provider satisfaction.

The comfort ability program for adolescents with sickle cell pain: Evaluating feasibility and acceptability of an inpatient group-based clinical implementation

BACKGROUND

Integration of nonpharmacological therapies, such as cognitive and behavioral pain management strategies, is recommended to support comprehensive disease and pain management among children and adolescents with sickle cell disease (SCD). The Comfort Ability Program for Sickle Cell Pain (CAP for SCP) introduces psychological and biobehavioral pain management strategies to children and adolescents with SCD. This study aimed to pilot the implementation of the CAP for SCP in a group setting to children and adolescents hospitalized for SCD pain examining feasibility, acceptability, and preliminary effectiveness on improving pain knowledge and coping efficacy.

METHOD

Adaptation of CAP for SCP into a three-session group format was guided by four phases of the Dynamic Adaptation Process model: Exploration, Preparation, Implementation, and Sustainment. Youth with SCD (n = 57) hospitalized for pain participated in at least one session and completed self-report of knowledge of pain management skills, pain coping efficacy, and treatment acceptance. Completion rates of sessions and qualitative feedback were gathered to evaluate feasibility and acceptability.

RESULTS

Feasibility of conducting inpatient group sessions was suboptimal; however, patients and medical providers reported moderate to high levels of treatment acceptance. Patients also reported significant improvements in knowledge of pain management skills following session 1.

CONCLUSIONS

CAP for SCP is a patient-centered first-line psychoeducational intervention that can be integrated into clinical practice settings to introduce youth to cognitive and behavioral pain management strategies to support SCD pain management.

Pain-Related Injustice Appraisals in Youth with Sickle Cell Disease: A Preliminary Investigation

OBJECTIVES

Sickle cell disease (SCD) is a genetic disorder that affects approximately 100,000 Americans, the majority of whom are African American. SCD-related pain often has deleterious effects on functioning and quality of life. The inherited nature of SCD, SCD-related stigma, and serious physical and functional impact of SCD-related pain create a situation ripe for individuals to appraise their SCD-related pain as unfair or unjust. The aim of this preliminary investigation is to explore the extent to which pediatric patients with SCD appraise their pain as unjust and how these appraisals relate to functioning.

METHODS

Participants were youth with SCD (N = 30, mean age = 11.3, 57% boys) who attended a hematology clinic visit. Patients were invited to complete paper-based questionnaires assessing pain-related injustice appraisals, pain catastrophizing, pain and hurt, functional disability, depression, anxiety, and peer relationships.

RESULTS

Results of hierarchical regressions indicate that pain-related injustice significantly predicted functional disability, depression, and anxiety after controlling for patient pain and catastrophizing.

CONCLUSIONS

These findings suggest that pain-related injustice appraisals are an important contributor to the pain experience of youth with SCD. Early identification and remediation of pain-related injustice appraisals could have long-term functional benefits for youth with SCD.

The sociocultural context of pediatric pain: an examination of the portrayal of pain in children's popular media

ABSTRACT

Pain (eg, needle injections, injuries, and chronic pain) is highly prevalent in childhood and occurs in social contexts. Nevertheless, broader sociocultural influences on pediatric pain, such as popular media, have not been empirically examined. This study examined how pain is portrayed and gendered in children's popular media. A cross-section of children's media targeted towards 4- to 6-year-old children was selected based on popularity, including 10 movies and the first season of 6 television shows. Pain instances were extracted and coded using 2 established observational coding systems assessing sufferer pain characteristics and observer responses (eg, empathic responses). Findings identified 454 instances of pain across the selected media. Violent pain (ie, intentionally inflicted) and injuries were most commonly represented, whereas everyday, chronic-type, and procedural pains were infrequently portrayed. Pain instances were more commonly experienced by boy characters, who also expressed greater distress; yet, observers were more responsive (eg, expressed greater concern) towards girl characters' pain. Overall, observer responses to pain were infrequent, with observers witnessing but not responding to nearly half of pain instances. Observers who did respond expressed an overall lack of empathy towards sufferers. These findings reveal a very narrow depiction of pain presented in children's popular media, with an overall underrepresentation of pain, numerous maladaptive portrayals of pain, and gender differences in both sufferer and observer responses. This study underscores the need for further research to inform how children's popular media is perceived by parents and children and how media may be transformed and harnessed for effective pain education in childhood.

Racism and Health-Related Quality of Life in Pediatric Sickle Cell Disease: Roles of Depression and Support

INTRODUCTIONS

Sickle cell disease (SCD) is the most commonly inherited blood disorder in the United States, and it predominately affects the Black community. SCD is characterized by a number of symptoms, including unpredictable pain, which can lead to hospitalizations. Data indicate that people with SCD experience racism and ample data indicate that racism predicts depressive symptoms and impaired health-related quality of life (HRQOL). In contrast, research suggests that social support might buffer the impact of racism on depression. The aim of this study was to explore associations among perceived racism, depressive symptoms, and HRQOL in adolescents with SCD. Consistent with the literature, it was predicted that perceived racism would predict HRQOL through depression, and social support would moderate the negative impact of racism on depression.

METHODS

In a cross-sectional design, 75 inpatient adolescents with SCD completed measures of perceived racism, depressive symptoms, HRQOL, and social support.

RESULTS

This results indicated a moderated mediation model with greater perceived racism predicting more depressive symptoms, which in turn related to poorer HRQOL; greater access to social support from individuals with SCD strengthened the perceived racism-depressive symptom association.

CONCLUSIONS

Findings suggest a model for how racism, depressive symptoms, HRQOL, and social support might interact in hospitalized adolescents with SCD. Longitudinal or experimental designs are needed to substantiate directionality among these variables. Results highlight several areas for future research and clinical avenues to improve the welfare of youth with SCD.

Validation of the Health-Related Felt Stigma and Concealment Questionnaire

OBJECTIVE

Stigma is associated with many health conditions, including chronic pain. Research on health-related stigma is limited by the lack of validated instruments that distinguish among various stigma-related constructs. We aimed to develop and validate such a measure for pediatric functional abdominal pain (FAP). Felt stigma (FS) was defined as comprising both perceived and internalized stigma. Stigma concealment (SC) was defined as efforts by stigmatized individuals to prevent others from learning of their condition.

METHODS

Using a theory-driven approach, we adapted items from existing self-report measures of stigma to construct the health-related FS and Concealment Questionnaire (FSC-Q). Patients with FAP (N = 179, ages 11-17) completed the preliminary FSC-Q and health-related measures hypothesized to be associated with stigma. Cognitive interviewing and exploratory factor analysis (EFA) informed the final version of the measure.

RESULTS

EFA identified a 2-factor model comprised of FS and SC. The FS and SC scales exhibited good internal consistency and construct validity. Consistent with study hypotheses, both factors were significantly associated with anxiety, depression, pain catastrophizing, pain threat, physical symptoms, and pain interference/disability. Higher FS was associated with higher mental healthcare utilization. The subset of participants meeting criteria for irritable bowel syndrome (IBS) reported higher FS and SC compared with those without IBS.

CONCLUSION

The FSC-Q may help advance research on health-related stigma in FAP and other chronic health conditions by allowing for assessment of distinct stigma-related constructs.

Autonomically-mediated decrease in microvascular blood flow due to mental stress and pain in sickle cell disease: A target for neuromodulatory interventions

Pain and vaso-occlusive crises (VOC) are hallmark complications of sickle cell disease (SCD) and result in significant physical and psychosocial impairment. The variability in SCD pain frequency and triggers for the transition from steady state to VOC are not well understood. This paper summarizes the harmful physiological effects of pain and emotional stressors on autonomically-mediated vascular function in individuals with SCD and the effects of a cognitive, neuromodulatory intervention (i.e. hypnosis) on microvascular blood flow. We reviewed recent studies from the authors' vascular physiology laboratory that assessed microvascular responses to laboratory stressors in individuals with SCD. Results indicate that participants with SCD exhibit marked neurally mediated vascular reactivity in response to pain, pain-related fear, and mental stress. Further, pilot study results show that engagement in hypnosis may attenuate harmful microvascular responses to pain. The collective results demonstrate that autonomically-mediated vascular responses to pain and mental stress represent an important SCD intervention target. This ongoing work provides physiological justification for the inclusion of cognitive, neuromodulatory and complementary treatments in SCD disease management and may inform the development of targeted, integrative interventions that prevent the enhancement of autonomic vascular dysfunction in SCD.

Enhancing Pain Assessment in Pediatric Sickle Cell Disease by Applying Quality Improvement Science

Objective

Standardized pain assessment and interventions are recommended for youth hospitalized for pain. This quality improvement (QI) project integrated into a pediatric psychology service aimed to increase the standardized assessment of pain-related functional ability for youth with sickle cell disease (SCD) hospitalized for pain.

Methods

Children and adolescents (n=102) with SCD referred for psychology consultation for poor coping in response to pain during hospitalization completed a validated self-report of functional ability in addition to pain intensity during inpatient psychology visits. At the time of the quality initiative, routine and standardized assessment of pain-related functional ability was not integrated into standard clinical care. Plan, Do, Study, Act (PDSA) cycles determined the feasibility and addressed common barriers of routine assessment and documentation of pain-related functional ability among youth with SCD during inpatient psychology visits with the primary goal to increase assessment of functional ability to at least 85% among patients with SCD referred for pediatric psychology consultation to address pain management within 1 year.

Results

Through iterative PDSA cycles, routine assessment of pain-related functional ability during psychology visits increased to an average of 93% over the course of 12 months. Routine, standardized assessment of functional ability was considered feasible within a pediatric psychology service.

Conclusions/Lessons Learned

This project supported the feasibility of integrating standardized assessment of functional ability to enhance pain assessment for youth hospitalized for SCD pain as part of routine clinical care in a multidisciplinary setting regardless of psychology referral.

Conceptualizing pain-related stigma in adolescent chronic pain: a literature review and preliminary focus group findings

Introduction

Chronic pain in adolescents is a significant medical condition, affecting the physical and psychological well-being of youth and their families. Pain-related stigma is a significant psychosocial factor in adolescents with chronic pain that has been understudied, despite its implications for negative health outcomes, poor quality of life, and increased healthcare utilization.

Objectives

To examine pain-related stigma in the literature documenting pediatric and adult health-related stigma and present preliminary findings from a focus group of adolescents with chronic pain.

Methods

In this narrative review, we explored pain-related stigma research and conceptualized the literature to address pain-related stigma among adolescents with chronic pain. Additionally, we conducted a focus group of four adolescent females with chronic pain and using content analyses, coded the data for preliminary themes.

Results

We propose a pain-related stigma model and framework based on our review and the findings from our focus group. Findings suggest that medical providers, school personnel (ie, teachers and school nurses), peers and even family members enact pain-related stigma toward adolescents with chronic pain.

Conclusions

Based on this narrative review, there is preliminary evidence of pain-related stigma among adolescents with chronic pain and future research is warranted to better understand the nature and extent of this stigma within this population.