Association Between Clinical Depression, Anxiety, and Chronic Pain in the Active Duty Army Personnel.

INTRODUCTION: Chronic pain is highly prevalent among soldiers leading to costly impacts on disability and readiness. Depression and anxiety (D&A) are frequently comorbid with chronic pain, but previous studies tend to focus on reporting the odds of co-occurrence. The aim of this study was to examine the association of properly diagnosed D&A disorders on chronic pain indicators among active duty soldiers. MATERIALS AND METHODS: Data were drawn from the intake assessments of 203 soldiers seen at an Interdisciplinary Pain Management Center. The Diagnostic and Statistical Manual of Mental Disorders-5 diagnostic criteria and the D&A subscales of the Patient Health Questionnaire were used to identify patients who met criteria for clinical depression or anxiety. Of the 203 patients, 129 met neither depression nor anxiety criteria (No D&A), 12 met clinical depression criteria only, 16 met clinical anxiety only, and 46 showed coexisting D&A disorders. The D&A and No D&A groups were compared using validated measures to assess the pain intensity rating and pain effect on well-being, physical functioning, and catastrophizing tendency. Data were analyzed using descriptive statistics and independent samples t-test analyses. RESULTS: Significant differences were found between the D&A and No D&A groups on all pain-related measures (all Ps < .001). Patients in the D&A group reported higher average intensity of pain (6.11 versus 5.05) and greater effect of pain on activity (6.91 versus 5.37), sleep (7.20 versus 4.90), emotional state (7.74 versus 4.47), and stress (8.13 versus 4.78). Depression and anxiety patients also reported higher pain-catastrophizing tendency (38.56 versus 18.50) and greater physical disability (18.20 versus 12.22). CONCLUSIONS: Soldiers who have chronic pain with coexisting D&A disorders experience a greater degree of perceived negative impacts. Consequently, attentiveness to proper diagnosis and treatment of coexisting clinical mood disorders is an essential step in fully addressing chronic pain management.

The Immokalee Community Health Coalition: Operationalizing Trust.

The COVID-19 pandemic disproportionately affected migrant farmworker communities in the United States in case rates and deaths. In rural Immokalee, Florida, human rights, health care, and social support organizations with different strengths joined together to form a coalition that provided health information, tests, vaccines, and social supports. This report offers practical advice on how similar coalitions can overcome barriers to care, improve outcomes, and overall increase trust in the health system.

COVID-19 Pandemic Response in a Migrant Farmworker Community: Excess Mortality, Testing Access and Contact Tracing in Immokalee, Florida.

Background: Migrant and seasonal farmworkers face enormous barriers to health and have been a particularly vulnerable population during the COVID-19 pandemic, but their pandemic experiences and potential inequities have not been well studied. Objectives: We aimed to assess the impact of COVID-19 in Immokalee, Florida, a community with a significant population of migrant and seasonal farmworkers. We evaluated for differences in pandemic experience by language, a known barrier to healthcare, to inform and strengthen future public health efforts. Methods: First, to estimate the burden of COVID in the area, we conducted a descriptive analysis of data on COVID-19 deaths for Collier County from May-August 2020. We then surveyed a cross-sectional, randomized representative sample of 318 adults living in Immokalee from March-November 2020 to assess socio-demographics, workplace conditions, sources of information, ability to follow guidelines, and experiences with testing and contact tracing programs. Results were compared across language groups. Findings: Average excess mortality in Collier County was 108%. The majority surveyed in Immokalee had socio-demographic factors associated with higher COVID risk. Non-English speakers had higher workplace risk due to less ability to work from home. Haitian Creole speakers were less likely to be tested, though all participants were willing to get symptomatic testing and quarantine. Those participants who tested positive or had COVID-19 exposures had low engagement with the contact tracing program, and Spanish-speakers reported lower quality of contact tracing than English speakers. Conclusions: The community of Immokalee, FL is a vulnerable population that suffered disproportionate deaths from COVID-19. This study reveals language inequities in COVID testing and contact tracing that should be targeted in future pandemic response in Immokalee and other migrant farmworker communities.

Early Lessons From Launching an Innovative Community Health Household Model Across 3 Country Contexts.

Community health workers (CHWs) are integrated into health systems through a variety of designs. Partners In Health (PIH), a nongovernmental organization with more than 30 years of experience in over 10 countries, initially followed a vertical approach by assigning CHWs to individual patients with specific conditions, such as HIV, multidrug resistant-TB, diabetes, and other noncommunicable diseases, to provide one-on-one psychosocial and treatment support. Starting in 2015, PIH-Malawi redesigned their CHW assignments to focus on entire households, thereby offering the opportunity to address a wider variety of conditions in any age group, all with a focus on working toward effective universal health coverage. Inspired by this example, PIH-Liberia and then PIH-Mexico engaged in a robust cross-site dialogue on how to adapt these plans for their unique nongovernmental organization-led CHW programs. We describe the structure of this "household model," how these structures were changed to adapt to different country contexts, and early impressions on the effects of these adaptations. Overall, the household model is proving to be a feasible and functional method for organizing CHW programs so that they can contribute toward achieving universal health coverage, but there is no "one-size-fits-all" approach. Other countries planning on adopting this model should plan to analyze and adapt as needed.

Integrated care experiences and out-of-pocket expenditures: a cross-sectional survey of adults receiving treatment for HIV and hypertension in Malawi.

OBJECTIVES: As HIV-positive individuals' life expectancy extends, there is an urgent need to manage other chronic conditions during HIV care. We assessed the care-seeking experiences and costs of adults receiving treatment for both HIV and hypertension in Malawi. DESIGN, SETTING AND PARTICIPANTS: A cross-sectional survey was conducted with HIV-positive adults with hypertension at a health facility in Lilongwe that offers free HIV care and free hypertension screening, with antihypertensives available for purchase (n=199). Questions included locations and costs of all medication refills and preferences for these refill locations. Respondents were classified as using 'integrated care' if they refilled HIV and antihypertensive medications simultaneously. Data were collected between June and December 2017. RESULTS: Only half of respondents reported using the integrated care offered at the study site. Among individuals using different locations for antihypertensive medication refills, the most frequent locations were drug stores and public sector health facilities which were commonly selected due to greater convenience and lower medication costs. Although the number of antihypertensive medications was equivalent between the integrated and non-integrated care groups, the annual total cost of care differed substantially (approximately US$21 in integrated care vs US$90 for non-integrated care)-mainly attributable to differences in other visit costs for non-integrated care (transportation, lost wages, childcare). One-third of those in the non-integrated care group reported no expenditure for antihypertensive medication, and six people in each group reported no annual hypertension care-seeking costs at all. CONCLUSIONS: Individuals using integrated care saw efficiencies because, although they were more likely to pay for antihypertensive medications, they did not incur additional costs. These results suggest that preferences and experiences must be better understood to design effective policies and programmes for integrated care among adults on antiretroviral therapy.

Accompanimeter 1.0: creation and initial field testing of a tool to assess the extent to which the principles and building blocks of accompaniment are present in community health worker programs.

Background: The strategic incorporation of community health workers (CHWs) into health system strengthening efforts is recognized as a critical and high-value approach for meeting the Sustainable Development Goals established by the United Nations in 2015. How to best build CHW programs, however, is prone to a wide variety of opinions and philosophies, many of which are often externally imposed. Partners in Health (PIH) is a non-governmental organization that pioneered an approach to healthcare system strengthening, called accompaniment, in which CHWs play a key role. Learning from PIH is a critical first step in replicating the organization's achievements beyond PIH. As such, PIH has developed a tool, referred to as the 'Accompanimeter 1.0,' that serves to evaluate existing CHW programs and guide adjustments in programming.Objective: To provide a standardized approach for defining, assessing, and implementing accompaniment in CHW programs using a tool called the Accompanimeter 1.0.Methods: Development of this tool included three stages: (1) desk review of literature relevant to the work of CHWs globally, (2) discussions among colleagues and initial field testing, (3) feedback from colleagues who are experts in community health and in the principles of accompaniment.Results: Three core principles of accompaniment in a CHW program were identified: professionalization, CHWs as bridges to institutional strength, and community proximity. These core principles direct five thematic areas that are found in successful CHW programs: Partnering (co-creating engagement with a continuous and intersectoral dialogue to improve the program); Choosing (identifying the right people for the right job); Educating (building CHWs´ capacity); Incentivizing (enabling CHWs to perform their work without financial sacrifice); Supervising (mentoring CHWs for personal growth).Conclusions: The Accompanimeter 1.0 can serve as a helpful tool for CHW program implementation and policy decisions that maximize system-side inputs, community engagement, and support for individuals with medical issues.

'Blood pressure can kill you tomorrow, but HIV gives you time': illness perceptions and treatment experiences among Malawian individuals living with HIV and hypertension.

Non-communicable diseases like hypertension are increasingly common among individuals living with HIV in low-resource settings. The prevalence of hypertension among people with HIV in Malawi, e.g. has been estimated to be as high as 46%. However, few qualitative studies have explored the patient experience with comorbid chronic disease. Our study aimed to address this gap by using the health belief model (HBM) to examine how comparative perceptions of illness and treatment among participants with both HIV and hypertension may affect medication adherence behaviours. We conducted semi-structured interviews with 75 adults with HIV and hypertension at an urban clinic in Lilongwe, Malawi. Questions addressed participants' experiences with antiretroviral and antihypertensive medications, as well as their perspectives on HIV and hypertension as illnesses. Interviews were performed in Chichewa, transcribed, translated into English and analysed using ATLAS.ti. Deductive codes were drawn from the HBM and interview guide, with inductive codes added as they emerged from the data. Self-reported medication adherence was much poorer for hypertension than HIV, but participants saw hypertension as a disease at least as concerning as HIV-primarily due to the perceived severity of hypertension's consequences and participants' limited ability to anticipate them compared with HIV. Differences in medication adherence were attributed to the high costs of antihypertensive medications relative to the free availability of antiretroviral therapy, with other factors like lifestyle changes and self-efficacy also influencing adherence practices. These findings demonstrate how participants draw on past experiences with HIV to make sense of hypertension in the present, and suggest that although patients are motivated to control their hypertension, they face individual- and system-level obstacles in adhering to treatment. Thus, health policies and systems seeking to provide integrated care for HIV and hypertension should be attentive to the complex illness experiences of individuals living with these diseases.

Special operations forces and incidence of post-traumatic stress disorder symptoms.

To determine the rates of Post-traumatic Stress Disorder (PTSD) positive symptom scores in Special Operations Forces (SOF) personnel, an anonymous survey of SOF was employed, incorporating the PTSD Checklist (PCL-M) with both demographic and deployment data. Results indicate that all SOF units studied scored above the accepted cut-offs for PTSD positive screening.1 When total symptom severity score exceeded established cutoff points and were combined with criteria for Diagnostic and Statistical Manual of Mental Disorders, Edition 4 (DSM-IV) diagnosis of PTSD,2 approximately 16?20% of respondents met scoring threshold for positive screening, almost double those of conventional Army units. Collectively, Special Forces (SF) Soldiers and SOF combat-arms Soldiers had significantly higher PLC-M scores than their non-combat-arms SOF counterparts. SOF Soldiers with three or more deployments to Afghanistan had significantly higher PCL-M scores. Considering the evidence suggesting that SOF Soldiers are hyper-resilient to stress, these results should drive further research schemata and challenge clinical assumptions of PTSD within Special Operations.