Prevalence and Associations of Protracted Torture-Related Physical Pain, Hypertension, and Stroke History in Refugees: A Longitudinal Cohort Study

PROJECT SUMMARY AND ABSTRACT. We will establish a cohort of 250 globally representative adult refugees who are >10 years post-torture and follow them for 24 months to: (1) Determine the prevalence of protracted torture-related physical pain, and (2) Determine the prevalence of hypertension and stroke history in refugees with protracted torture-related physical pain. We will characterize the associations of protracted torture-related physical pain, hypertension, and stroke history with factors related to pain, mental health, and social determinants of health. Our long-term goal is to improve the evidence-based clinical care of refugee torture survivors. Our primary objective here is to determine the prevalence of protracted torture-related physical pain, hypertension, and stroke history in refugee torture survivors. We evaluate a global population of refugees at our medical-legal clinic and are one of the only such clinics in the U.S. with NIH-funded investigators. We have a 10+ year track record of refugee health research, including the successful feasibility study for the Aims proposed here. Aim 1. Determine the prevalence of protracted torture-related physical pain in refugees. Our preliminary data indicate that torture-related pain may persist for >10 years. Hypothesis: >75% of refugee torture survivors experience protracted (i.e., >10 years) torture-related physical pain. In our cohort of 250, we will assess pain using a physical exam (PE) and the validated Brief Pain Inventory Short Form (BPISF), and time since torture using the standard United Nations Istanbul Protocol. At baseline, 12-, and 24-months, we will characterize the associations of protracted torture-related physical pain with factors related to pain (i.e., mechanism of injury, pain type, time since torture, BMI), mental health (validated Harvard Trauma Questionnaire (HTQ)/Hopkins Symptoms Checklist (HSCL) for posttraumatic stress, depression, anxiety), and social determinants of health (SDOH, validated PRAPARE protocol, e.g., legal status, insurance, sex, origin country, time since U.S. arrival). Aim 2. Determine the prevalence of hypertension and stroke history in refugees with protracted torture-related physical pain. Our preliminary data in refugees with chronic pain after torture found a high burden of HTN and stroke history, despite their young age. Hypothesis: In refugees with protracted torture- related physical pain, at least 30% will have American Heart Association (AHA)-defined HTN and/or stroke history. In cohort participants with protracted torture-related physical pain, we will assess HTN using AHA- defined cutoffs and stroke history using the validated Questionnaire to Verify Stroke Free Status. At baseline, 12-, and 24-months, we will characterize the associations of HTN and stroke history with factors related to pain, mental health, and SDOH. We will control for ASCVD risk factors (e.g., dyslipidemia, smoking, BMI). IMPACT. Millions of refugee torture survivors reside in the U.S. However, evidence to guide care is lacking. This first-in-kind cohort will establish critical knowledge on modifiable or preventable illness in refugees, and in others with complex pain such as sexual assault survivors and U.S. veterans.