Marc D. Weiner

Gender Differences in the Risk and Protective Factors Associated With PTSD: A Prospective Study of National Guard Troops Deployed to Iraq

This study examines gender differences in post-traumatic stress symptoms (PTSS) and PTSS risk/protective factors among soldiers deployed to Iraq. We pay special attention to two potentially modifiable military factors, military preparedness and unit cohesion, which may buffer the deleterious psychological effects of combat. Longitudinal data were collected on 922 New Jersey National Guard soldiers (91 women) deployed to Iraq in 2008. Anonymous surveys administered at pre- and post-deployment included the PTSD Checklist (PCL), the Unit Support Scale, and a preparedness scale adapted from the Iowa Gulf War Study. Bivariate analyses and hierarchical multiple regression were used to identify predictors of PTSS and their explanatory effects on the relationship between gender and PTSS. Women had a higher prevalence of probable post-deployment PTSD than men (18.7% vs. 8.7%; OR = 2.45; CI [1.37, 4.37]) and significantly higher post-deployment PTSS (33.73 vs. 27.37; p = .001). While there were no gender differences in combat exposure, women scored higher on pre-deployment PTSS (26.9 vs. 23.1; p ≤ .001) and lower on military preparedness (1.65 vs. 2.41; p ≤ .001) and unit cohesion (32.5 vs. 38.1; p ≤ .001). In a multivariate model, controlling for all PTSS risk/resilience factors reduced the gender difference as measured by the unstandardized Beta (B) by 45%, with 18% uniquely attributable to low cohesion and low preparedness. In the fully controlled model, gender remained a significant predictor of PTSS but the effect size was small (d = .26). Modifiable military institutional factors may account for much of the increased vulnerability of women soldiers to PTSD.

Public Support for Policies to Reduce Risk After Hurricane Sandy

A phone survey was conducted in New Jersey in 2013 four months after the second of two major devastating tropical storms (Sandy in 2012 and Irene in 2011). The objective was to estimate public support for restricting land uses in flood zones, requiring housing to be built to resist storm waters, and otherwise increasing mitigation and resilience. Respondents who supported these mitigation and resilience policies disproportionately were concerned about global climate change, trusted climate scientists and the federal government, and were willing to contribute to a redevelopment program through taxes, bonds, and fees. They also tended to have collectivist and egalitarian worldviews. Half of the respondents supported at least four of the seven risk-reducing policies. How their support translates into public policy remains to be seen. Lack of willingness to personally fund these policies is an obstacle.

Risk-Reducing Legal Documents: Controlling Personal Health and Financial Resources

Every adult can eliminate the risk of losing control of personal health decisions and financial resources by having a last will and testament, health proxy, power of attorney, and living trust. Yet evidence suggests that less than a majority of adult Americans have these documents. We surveyed 900 adult Americans (25 plus years old) to determine what factors predict the possession of these risk-reducing documents. In total, 46% had a living will and testament, 32% a durable power of attorney, 30% a health proxy, and 18% a living trust. Events that prompt people with wealth to secure these documents, such as increasing age, getting married, having children, and experiencing a life-threatening event were the strongest predictors of having a will. These were also among the strongest predictors of having a health proxy, along with a personal history of being proactive, and a family history that fostered trust of attorneys. Affluence, age, and education were the strongest predictors of having a living trust, and the strongest correlate of having a durable power of attorney was having faced a life-threatening event, positive experiences with attorneys, and higher educational achievement.

Keeping surveys valid, reliable, and useful: a tutorial.

This tutorial focuses on how to produce reliable and generalizable data from random-digit-dialing (RDD) landline and cell phone surveys. The article notes that RDD response rates have declined and explores the impact of this pronounced decline. The tutorial addresses order, response mode, and many other biases, sample size, cooperation and response rates, weighting, and hybrid designs-all using examples from risk analysis to illustrate the key points. The article ends with a brief review of the advantages and disadvantages of major Internet and paper surveys tools, and how these can be molded and sometimes combined in repeated, longitudinal, and other designs to answer questions about risk preferences and perceptions.

Eye-tracking technology, visual preference surveys, and urban design: preliminary evidence of an effective methodology

Abstract Urban planners and designers use visual preference surveys to gather public opinion on potential designs for developments. Using eye-tracking technology, we administered a visual preference survey to a convenience sample to evaluate quantitatively the ways in which individuals process and rank images used in public settings for urban planning. We combined both a subjective qualitative analysis with quantitative evaluation of the eye-tracking data. The analysis largely confirms that various new urbanist components of the images, namely people, pedestrian features, and greenery, lead to higher rankings. Images with cars and parking receive negative rankings. Buildings, which are a key component of architectural design, had mixed results. The analysis demonstrates the efficacy of visual preference surveys. We show a way for transportation and urban planners to extract greater value from visual preference surveys, consistent with efforts to increase pedestrian activity while reducing motor vehicle traffic in cities.

Morbid thoughts and suicidal ideation in Iraq war veterans: the role of direct and indirect killing in combat

Although research has identified numerous risk factors for military suicide, the contribution of combat exposure to suicide risk has not been clearly established. Previous studies finding no association of suicidality with combat exposure have employed overgeneral measures of exposure, which do not differentiate among the varieties of combat experiences. This study disaggregated the forms of combat exposure to assess the contribution of combat‐related killing to morbid thoughts and suicidal ideation (MTSI) in National Guard troops deployed to Iraq.

Are Cell Phone Samples Needed for Studies of Walking Activity

The growth in cell phone–only households represents a challenge for the collection of survey data. Cell phone–only households have distinct sociodemographic characteristics, which may result in different travel behavior. To explore those differences, as well as to investigate the impact of including a cell phone component in active transportation research, a representative sample of New Jersey households was surveyed with a random digit dial survey that included 1,200 completed interviews (800 based on a statewide landline sample, 400 from a landline over sample of Jersey City) and 311 statewide cell phone interviews, of which 80 were cell phone–only respondents. The survey explored walking behavior and perceived characteristics of the pedestrian environment. Sociodemographic characteristics, the frequency of walking, and home location characteristics were compared with chisquare tests of significance between sample pairs as well as multivariate analysis (ordered probit). Cell phone–only respondents were typically younger and poorer, with a greater proportion of renters, carless households, and minorities. It was found that cell phone–only household members walked more frequently, but this finding was because of their distinct sociodemographic characteristics, not their cell phone use per se. The implication for any analysis of rates or trends in walking (and probably other travel behavior) is that cell phone–only households must be included through a cell phone sample supplementing a landline sample. However, in the absence of a cell phone supplement, multivariate analysis of the correlates of walking may not be overly biased if sociodemographics relevant to cell phone–only respondents are collected and included in the analysis.

Rationale and study design of a trial of mindfulness-based cognitive therapy for preventing suicidal behavior (MBCT-S) in military veterans

BACKGROUND Although suicide ranks 10th as a cause of death in the United States, and 1st among active military personnel, there are surprisingly few evidence-based therapies addressing suicidality, and development of new treatments is limited. This paper describes a clinical trial testing a novel therapy for reducing suicide risk in military veterans. The intervention, Mindfulness-Based Cognitive Therapy for Preventing Suicide Behavior (MBCT-S), is a 10-week group intervention adapted from an existing treatment for depression (Mindfulness-Based Cognitive Therapy - MBCT). MBCT-S incorporates the Safety Planning Intervention, which is currently implemented throughout the Veterans Health Administration (VHA) for veterans at high suicide risk. METHODS MBCT-S is being tested in a VHA setting using an intention-to-treat, two-group randomized trial design in which 164 high suicide risk veterans are randomized to either VHA Treatment As Usual (TAU; n=82) or TAU+MBCT-S (n=82). Our primary outcome measure, suicide-related event, defined to include suicide preparatory behaviors, self-harm behavior with suicidal or indeterminate intent, suicide-related hospitalizations and Emergency Department (ED) visits, will be measured through five assessments administered by blinded assessors between baseline and 12months post-baseline. We will measure suicide attempts and suicide deaths as a secondary outcome, because of their anticipated low incidence during the study period. Secondary outcomes also include severity of suicidal ideation, hopelessness and depression. SIGNIFICANCE This study has the potential to significantly enhance the quality and efficiency of VHA care for veterans at suicide risk and to substantially improve the quality of life for veterans and their families.

The Effect of Poverty on the Propensity to Adopt Broadband: Household-Level Evidence from the Broadband Technology Opportunities Program

The authors focus on the lack-of-access component of the digital divide. Against a backdrop of federal policy that entwines poverty with broadband access, the authors use original statewide data to test a two-step model, drawn from the New Poverty Studies, of barriers to household-level broadband adoption. The authors generate a measure of the propensity to adopt broadband and test the relative role of poverty in the household decision-making process. The authors conclude by noting the continuing relevance of access as a component of the digital divide and providing support for the continuation of assistance efforts to close the household broadband access gap.

Controlling Personal Health Decisions for the Oldest Old

Public health practitioners help the oldest old (persons aged 75 years and older) prevent falls, protect against communicable disease threats, cope with arthritis and many other chronic ailments, and deal with the loss of loved ones and lifelong friends. Collectively, assisting the oldest old as they manage their health is a core objective of public health practice. Warren DeWitt (right), aged 76 years, moved into the Peters household in Gladesville, West Virginia, to help look after Maxine and Arden, both aged 90 years. At the time this photograph was taken (2000), Warren had lived with the couple for over a year, cooking, cleaning, and maintaining the grounds. His chores also included trimming Arden’s hair. Photograph by Ed Kashi. Printed with permission of Ed Kashi Photography. Available at http://www.EdKashi.com. When M.R.G suggested this theme issue at a Journal editors meeting, he had another set of health-related controls in mind—specifically, the legal documents that allow us to direct the course of our life when we cannot. When thinking about these controls, most people usually consider only the prospect of documents that address one’s final affairs after death, such as a last will and testament, a living trust, or an organ donor card. A will allows a person to control the distribution of his or her wealth and personal property in accordance with his or her wishes and minimizes the tax impact of those transfers. A living trust is an approach to distributing wealth after death, which is set up and funded during life to avoid the burden of probate. An organ donor card authorizes the gift of a decedent’s organs for the benefit of transplant recipients. Perhaps more important, though, are the legal documents that structure the control of one’s medical and financial affairs during a period of incapacity, whether preliminary to the end of life or as a consequence of a traumatic injury or disease. The most significant of these documents are the general durable power of attorney, which appoints someone to act as an agent for legal, financial, and sometimes health matters when the principal is unable to do so, and the advance medical directive, which is also known as a “health proxy.” A health proxy—which is often accompanied by a health care power of attorney—is a set of directions that advises family members and medical professionals about wishes for medical life-support and other intervention. Also applicable to periods of incapacity is a contract for long-term health care insurance, which provides coverage for long-term conditions not covered by or limited by more traditional health care insurance. Preparation of these documents has traditionally fallen to attorneys; accordingly, addressing the issues covered by these documents has not been a core objective of public health practitioners. Ironically—and often, tragically—the implications of not having these legal protections in place falls most heavily on health practitioners and family members. Without a general durable power of attorney or a health proxy for an incapacitated person, health providers may be placed in the uncomfortable position of choosing the type and duration of treatment, which are all too often life-and-death choices. Moreover, the court system—impersonal, bureaucratic, and expensive as it is—is often invoked to make decisions that can have unalterable impacts on the mental health of family members. We cannot understate the anguish felt by family members who argue with other members about treatment and financial matters, sometimes to the point of lawsuits and family disintegrations. Conversely, many of us have witnessed a sense of relief for the oldest old who have prepared these documents. Without question, possessing up-to-date legal documents advances the dignity and autonomy of the incapacitated and dying and enhances public health and clinical public health practice.