Gala True

Warring Identities: Identity Conflict and the Mental Distress of American Veterans of the Wars in Iraq and Afghanistan

Drawing from 26 life story interviews of recent American veterans, this paper analyzes the identity struggle faced by soldiers returning from Operation Iraqi Freedom and Operation Enduring Freedom and reentering the civilian world. Instead of examining veterans’ problems as a consequence of post-combat mental illnesses such as PTSD and major depression, we analyze the contrast between the participants’ identities as soldiers and their identities as civilians. We find that the postwar transition causes adverse mental health effects that stem from contrasts between the military’s demands for deindividuation, obedience, chain-of-command, and dissociation and the civilian identity expectations of autonomy, self-advocacy, and being relational. Veterans’ reintegration to civilian society is further hindered by a culture that is perceived (by veterans) as having decreased understanding of the soldier/veteran experience itself. These identity conflicts—what we term warring identities—have an important yet understudied effect on veterans’ combat-related mental health problems.

Misbehaviors of Front-Line Research Personnel and the Integrity of Community-Based Research

There has been little empirical research into misconduct and misbehavior among community research workers who recruit and collect data in vulnerable and marginalized health populations and are also members of those same communities. We conducted qualitative interviews with community research workers and traditional research assistants to understand the context and consequences of misbehaviors that pose a threat to research ethics and data integrity. In our sample, more community research workers acknowledged engaging in research wrongdoing than did traditional research assistants. These behaviors were most prevalent among community research workers who were not well-integrated into the research team. We suggest best practices for investigators to promote an environment that supports research integrity in research projects that employ community research workers.

Teamwork and Delegation in Medical Homes: Primary Care Staff Perspectives in the Veterans Health Administration

ABSTRACTBACKGROUNDThe patient-centered medical home (PCMH) relies on a team approach to patient care. For organizations engaged in transitioning to a PCMH model, identifying and providing the resources needed to promote team functioning is essential.OBJECTIVETo describe team-level resources required to support PCMH team functioning within the Veterans Health Administration (VHA), and provide insight into how the presence or absence of these resources facilitates or impedes within-team delegation.DESIGNSemi-structured interviews with members of pilot teams engaged in PCMH implementation in 77 primary care clinics serving over 300,000 patients across two VHA regions covering the Mid-Atlantic and Midwest United States.PARTICIPANTSA purposive sample of 101 core members of pilot teams, including 32 primary care providers, 42 registered nurse care managers, 15 clinical associates, and 12 clerical associates.APPROACHInvestigators from two evaluation sites interviewed frontline primary care staff separately, and then collaborated on joint analysis of parallel data to develop a broad, comprehensive understanding of global themes impacting team functioning and within-team delegation.KEY RESULTSWe describe four themes key to understanding how resources at the team level supported ability of primary care staff to work as effective, engaged teams. Team-based task delegation was facilitated by demarcated boundaries and collective identity; shared goals and sense of purpose; mature and open communication characterized by psychological safety; and ongoing, intentional role negotiation.CONCLUSIONSOur findings provide a framework for organizations to identify assets already in place to support team functioning, as well as areas in need of improvement. For teams struggling to make practice changes, our results indicate key areas where they may benefit from future support. In addition, this research sheds light on how variation in medical home implementation and outcomes may be associated with variation in team-based task delegation.

Understanding Barriers to Mental Health Care for Recent War Veterans Through Photovoice

Despite an urgent need for mental health care among U.S. service members returning from deployments to Iraq and Afghanistan, many veterans do not receive timely or adequate treatment. We used photovoice methods to engage veterans in identifying barriers to utilizing mental health services. Veterans described how key aspects of military culture and identity, highly adaptive during deployment, can deter help-seeking behavior and hinder recovery. Veterans’ photographs highlighted how mental health symptoms and self-coping strategies operated as barriers to care. Many veterans’ photos and stories revealed how negative health care encounters contributed to avoidance and abandonment of treatment; some veterans described these experiences as re-traumatizing. Visual methods can be a powerful tool for engaging recent war veterans in research. In particular, community-based participatory research approaches, which have rarely been used with veterans, hold great promise for informing effective interventions to improve access and enhance provision of patient-centered care for veterans.

Practical Guidance and Ethical Considerations for Studies Using Photo-Elicitation Interviews

Photo-elicitation is a qualitative interviewing technique that has gained popularity in recent years. It is the foundation for photovoice projects and is a tool well-suited for community-based participatory research. Photo-elicitation yields rich data, and interview participants say these interviews encourage community awareness and engagement. This article draws on 9 studies, conducted by researchers at 3 institutions (the University of Pennsylvania, the Philadelphia Veterans Affairs Medical Center, and the Geisel School of Medicine at Dartmouth) in partnership with community-based organizations and students, in which 303 participants completed photo-elicitation interviews. We offer 8 practical suggestions for overcoming challenges encountered during photo-elicitation research and for managing ethical concerns about the use of visual data in public health research. Our guidelines can inform study design, protocol development, and institutional review board approval.

Family care giving for patients at life's end: report from the cultural variations study (CVAS).

OBJECTIVE To investigate differences between African American and White family caregivers in self-reported health, use of social support and external resources, and emotional and financial strain in the context of their care of a family member with advanced cancer. METHODS Sixty-nine patient-designated family caregivers of patients with advanced lung or colon cancer interviewed between December 1999 and July 2001. RESULTS Most African American and White family caregivers were able to identify someone else who was helping them in the care of their family member. Few caregivers used outside resources (e.g., home-based medical care, meal delivery, pastoral care, outside social support visitor) to assist in the support and care of the patient. At baseline, White caregivers were more likely to agree that caregiving caused work adjustments, (p=.28, p=.02) and emotional difficulties (p=.32, p=.008) and that caregiving had been completely overwhelming (p=.19, p=.12) than were African American caregivers. At follow-up, among family caregivers of patients who had died, 44% reported having to quit work to provide personal care for the patient. Twenty-five percent of family caregivers reported using most or all of the familys saving in caring for the patient. SIGNIFICANCE OF RESULTS Caregivers of patients at end of life experience substantial emotional and financial difficulties related to caregiving. Family caregiving is a private undertaking with little use of outside resources to mitigate the burden.

Proximity, Ethical Dilemmas, and Community Research Workers

Background: In community-engaged research (CEnR), recruitment and data collection are often assigned to community research workers (CRWs). CRWs are hired because of close ties with target communities and presumed greater success recruiting and gathering data from marginalized populations. The value conflicts and personal stress facing CRWs have been described in the international context; however, less attention has been paid to these issues in U.S. settings. Methods: Qualitative interviews were held with CRWs about their experiences with CEnR. Interviews were transcribed and coded using Atlas.ti. Results: The data indicate that CRWs working in settings controlled by the participants, such as neighborhood streets and participant homes, are more likely to face conflicts between following the norms of research and meeting what they perceive to be their everyday obligations to help specific others (duties of relational ethics) and to keep themselves safe. This suggests that “physical proximity” (understood as degree of penetration into the physical domain of the target research community) is an important factor in the ethics of actual practice in CEnR. Conclusions: CRWs often experience ethical complexities that are simply not in the realm of experience of most higher level researchers. How CRWs navigate conflicting ethical obligations can affect the quality and usefulness of the data collected and thereby affect communities by influencing policies informed by these data. Soliciting the perspectives of CRWs early in the process of research design and development is recommended to maximize the benefits achievable through CEnR.

“This Is the Story of Why My Military Career Ended Before It Should Have” Premature Separation From Military Service Among U.S. Women Veterans

Women who serve in the military benefit from unique opportunities but face strains as a minority population and, compared to men, report greater dissatisfaction with their service and have shorter military careers. We interviewed 35 U.S. women veterans about their decisions to enter and leave military service. Premature separation—leaving military service before one plans, expects, or wants to—was a prominent theme and was often precipitated by gender-based experiences, including interpersonal violence, harassment, and caregiving needs. Findings can inform efforts to improve the length and quality of women’s military careers and support women during and after service.

Moral Stress, Moral Practice, and Ethical Climate in Community-Based Drug-Use Research: Views From the Front Line

Background: The role of front-line researchers, those whose responsibilities include face-to-face contact with participants, is critical to ensuring the responsible conduct of community-based drug use research. To date, there has been little empirical examination of how front-line researchers perceive the effectiveness of ethical procedures in their real-world application and the moral stress they may experience when adherence to scientific procedures appears to conflict with participant protections. Methods: This study represents a first step in applying psychological science to examine the work-related attitudes, ethics climate, and moral dilemmas experienced by a national sample of 275 front-line staff members whose responsibilities include face-to-face interaction with participants in community-based drug-use research. Using an anonymous Web-based survey we psychometrically evaluated and examined relationships among six new scales tapping moral stress (frustration in response to perceived barriers to conducting research in a morally appropriate manner); organizational ethics climate; staff support; moral practice dilemmas (perceived conflicts between scientific integrity and participant welfare); research commitment; and research mistrust. Results: As predicted, front-line researchers who evidence a strong commitment to their role in the research process and who perceive their organizations as committed to research ethics and staff support experienced lower levels of moral stress. Front-line researchers who were distrustful of the research enterprise and frequently grappled with moral practice dilemmas reported higher levels of moral stress. Conclusion: Applying psychometrically reliable scales to empirically examine research ethics challenges can illuminate specific threats to scientific integrity and human subjects protections encountered by front-line staff and suggest organizational strategies for reducing moral stress and enhancing the responsible conduct of research.

Remote Ambulatory Management of Veterans with Obstructive Sleep Apnea

STUDY OBJECTIVES Despite significant medical sequelae of obstructive sleep apnea (OSA), the condition remains undiagnosed and untreated in many affected individuals. We explored the feasibility of a comprehensive, telemedicine-based OSA management pathway in a community-based Veteran cohort. METHODS This prospective, parallel-group randomized pilot study assessed feasibility of a telemedicine-based pathway for OSA evaluation and management in comparison to a more traditional, in-person care model. The study included 60 Veterans at the Philadelphia Veterans Affairs Medical Center and two affiliated community-based outpatient clinics. Telemedicine pathway feasibility, acceptability, and outcomes were assessed through a variety of quantitative (Functional Outcomes of Sleep Questionnaire, dropout rates, positive airway pressure [PAP] adherence rates, participant satisfaction ratings) and qualitative (verbal feedback) metrics. RESULTS There was no significant difference in functional outcome changes, patient satisfaction, dropout rates, or objectively measured PAP adherence between groups after 3 months of treatment. Telemedicine participants showed greater improvement in mental health scores, and their feedback was overwhelmingly positive. CONCLUSIONS Our pilot study suggests that telemedicine-based management of OSA patients is feasible in terms of patient functional outcomes and overall satisfaction with care. Future studies should include larger populations to further elucidate these findings while assessing provider- and patient-related cost effectiveness.