Virginia Lewis

Longitudinal Analyses of Family Functioning in Veterans and Their Partners Across Treatment

OBJECTIVE This study evaluated the relations between posttraumatic stress disorder (PTSD) symptoms and poor family functioning in veterans and their partners. METHOD Data were collected from Caucasian veterans with PTSD (N = 1,822) and their partners (N = 702); mean age = 53.9 years, SD = 7.36. Veterans completed the Posttraumatic Checklist Military Version (PCL-M) and, along with their partners, completed the McMaster Family Assessment Device (FAD-12). Assessments were conducted at intake into a treatment program at 3 months and 9 months posttreatment. RESULTS Structural equation models (SEMs) were developed for veterans as well as for veterans and their partners. Poor family functioning for veterans at intake predicted intrusion (β = .08), hyperarousal (β = .07), and avoidance (β = .09) at 3 months posttreatment. At 3 months posttreatment, family functioning predicted hyperarousal (β = .09) and avoidance (β = .10) at 9 months. For veterans and their partners, family functioning at intake predicted avoidance (β = .07) at 3 months, and poor family functioning at 3 months predicted intrusion (β = .09) and hyperarousal (β = .14) at 9 months. The reverse pathways, with PTSD symptoms predicting poor family functioning, were only evident with avoidance (β = .06). CONCLUSION Family functioning may play a role in treatment for veterans.

Successful Aging: Development and Testing of a Multidimensional Model Using Data From a Large Sample of Older Australians

To develop a multidimensional statistical model that could assess the contribution of, and interrelationships between, measures likely to contribute to an individuals successful aging, defined as aging well across a number of dimensions.

Utility of the dimensions of anger reactions-5 (DAR-5) scale as a brief anger measure

Anger is a common emotional sequel in the aftermath of traumatic experience. As it is associated with significant distress and influences recovery, anger requires routine screening and assessment. Most validated measures of anger are too lengthy for inclusion in self‐report batteries or as screening tools. This study examines the psychometric properties of a shortened 5‐item version of the Dimensions of Anger Reactions (DAR), an existing screening tool.

Teaching general practitioners and doctors-in-training to discuss advance care planning: evaluation of a brief multimodality education programme

Objective To develop and evaluate an interactive advance care planning (ACP) educational programme for general practitioners and doctors-in-training. Design Development of training materials was overseen by a committee; informed by literature and previous teaching experience. The evaluation assessed participant confidence, knowledge and attitude toward ACP before and after training. Setting Training provided to metropolitan and rural settings in Victoria, Australia. Participants 148 doctors participated in training. The majority were aged at least 40 years with more than 10 years work experience; 63% had not trained in Australia. Intervention The programme included prereading, a DVD, interactive patient e-simulation workshop and a training manual. All educational materials followed an evidence-based stepwise approach to ACP: Introducing the topic, exploring concepts, introducing solutions and summarising the conversation. Main outcome measures The primary outcome was the change in doctors’ self-reported confidence to undertake ACP conversations. Secondary measures included pretest/post-test scores in patient ACP e-simulation, change in ACP knowledge and attitude, and satisfaction with programme materials. Results 69 participants completed the preworkshop and postworkshop evaluation. Following education, there was a significant change in self-reported confidence in six of eight items (p=0.008 –0.08). There was a significant improvement (p<0.001) in median scores on the e-simulation (pre 7/80, post 60/80). There were no significant differences observed in ACP knowledge following training, and most participants were supportive of patient autonomy and ACP pretraining. Educational materials were rated highly. Conclusions A short multimodal interactive education programme improves doctors’ confidence with ACP and performance on an ACP patient e-simulation.

Quality of advance care planning policy and practice in residential aged care facilities in Australia

Objectives To assess existing advance care planning (ACP) practices in residential aged care facilities (RACFs) in Victoria, Australia before a systematic intervention; to assess RACF staff experience, understanding of and attitudes towards ACP. Design Surveys of participating organisations concerning ACP-related policies and procedures, review of existing ACP-related documentation, and pre-intervention survey of RACF staff covering their role, experiences and attitudes towards ACP-related procedures. Setting 19 selected RACFs in Victoria. Participants 12 aged care organisations (representing 19 RACFs) who provided existing ACP-related documentation for review, 12 RACFs who completed an organisational survey and 45 staff (from 19 RACFs) who completed a pre-intervention survey of knowledge, attitudes and behaviour. Results Findings suggested that some ACP-related practices were already occurring in RACFs; however, these activities were inconsistent and variable in quality. Six of the 12 responding RACFs had written policies and procedures for ACP; however, none of the ACP-related documents submitted covered all information required to meet ACP best practice. Surveyed staff had limited experience of ACP, and discrepancies between self reported comfort, and levels of knowledge and confidence to undertake ACP-related activities, indicated a need for training and ongoing organisational support. Conclusions Surveyed organisations â policies and procedures related to ACP were limited and the quality of existing documentation was poor. RACF staff had relatively limited experience in developing advance care plans with facility residents, although attitudes were positive. A systematic approach to the implementation of ACP in residential aged care settings is required to ensure best practice is implemented and sustained.

Psychological first aid following trauma: implementation and evaluation framework for high-risk organizations.

International clinical practice guidelines for the management of psychological trauma recommend Psychological First Aid (PFA) as an early intervention for survivors of potentially traumatic events. These recommendations are consensus-based, and there is little published evidence assessing the effectiveness of PFA. This is not surprising given the nature of the intervention and the complicating factors involved in any evaluation of PFA. There is, nevertheless, an urgent need for stronger evidence evaluating its effectiveness. The current paper posits that the implementation and evaluation of PFA within high risk organizational settings is an ideal place to start. The paper provides a framework for a phasic approach to implementing PFA within such settings and presents a model for evaluating its effectiveness using a logic- or theory-based approach which considers both pre-event and post-event factors. Phases 1 and 2 of the PFA model are pre-event actions, and phases 3 and 4 are post-event actions. It is hoped that by using the Phased PFA model and evaluation method proposed in this paper, future researchers will begin to undertake the important task of building the evidence about the most effective approach to providing PFA in high risk organizational and community disaster settings.

Naturalistic comparison of models of programmatic interventions for combat-related post-traumatic stress disorder.

Objectives: Post-traumatic stress disorder (PTSD) is a difficult-to-treat sequel of combat. Data on effectiveness of alternate treatment structures are important for planning veterans’ psychiatric services. The present study compared clinical presentations and treatment outcomes for Australian veterans with PTSD who participated in a range of models of group-based treatment. Method: Participants consisted of 4339 veterans with combat-related PTSD who participated in one of five types of group-based cognitive behavioural programmes of different intensities and settings. Data were gathered at baseline (intake), as well as at 3 and 9 month follow up, on measures of PTSD, anxiety, depression and alcohol misuse. Analyses of variance and effect size analyses were used to investigate differences at intake and over time by programme type. Results: Small baseline differences by programme intensity were identified. Although significant improvements in symptoms were evident over time for each programme type, no significant differences in outcome were evident between programmes. When PTSD severity was considered, veterans with severe PTSD performed less well in the low-intensity programmes than in the moderate- or high-intensity programmes. Veterans with mild PTSD improved less in high-intensity programmes than in moderate- or low-intensity programmes. Conclusion: Comparable outcomes are evident across programme types. Outcomes may be maximized when veterans participate in programme intensity types that match their level of PTSD severity. When such matching is not feasible, moderate-intensity programmes appear to offer the most consistent outcomes. For regionally based veterans, delivering treatment in their local environment does not detract from, and may even enhance, outcomes. These findings have implications for the planning and purchasing of mental health services for sufferers of PTSD, particularly for veterans of more recent combat or peacekeeping deployments.

Development and evaluation of an aged care specific Advance Care Plan

Objectives To report on the quality of advance care planning (ACP) documents in use in residential aged care facilities (RACF) in areas of Victoria Australia prior to a systematic intervention; to report on the development and performance of an aged care specific Advance Care Plan template used during the intervention. Design An audit of the quality of pre-existing documentation used to record resident treatment preferences and end-of-life wishes at participating RACFs; development and pilot of an aged care specific Advance Care Plan template; an audit of the completeness and quality of Advance Care Plans completed on the new template during a systematic ACP intervention. Participants and setting 19 selected RACFs (managed by 12 aged care organisations) in metropolitan and regional areas of Victoria. Results Documentation in use at facilities prior to the ACP intervention most commonly recorded preferences regarding hospital transfer, life prolonging treatment and personal/cultural/religious wishes. However, 7 of 12 document sets failed to adequately and clearly specify the residents preferences as regards life prolonging medical treatment. The newly developed aged care specific Advance Care Plan template was met with approval by participating RACFs. Of 203 Advance Care Plans completed on the template throughout the project period, 49% included the appointment of a Medical Enduring Power of Attorney. Requests concerning medical treatment were specified in almost all completed documents (97%), with 73% nominating the option of refusal of life-prolonging treatment. Over 90% of plans included information concerning residents’ values and beliefs, and future health situations that the resident would find to be unacceptable were specified in 78% of completed plans. Conclusions Standardised procedures and documentation are needed to improve the quality of processes, documents and outcomes of ACP in the residential aged care sector.

Factors associated with multiple barriers to access to primary care: an international analysis

BackgroundDisparities in access to primary care (PC) have been demonstrated within and between health systems. However, few studies have assessed the factors associated with multiple barriers to access occurring along the care-seeking process in different healthcare systems.MethodsIn this secondary analysis of the 2016 Commonwealth Fund International Health Policy Survey of Adults, access was represented through participant responses to questions relating to access barriers either before or after reaching the PC practice in 11 countries (Australia, Canada, France, Germany, Norway, the Netherlands, New Zealand, Sweden, Switzerland, the United Kingdom, and United States). The number of respondents in each country ranged from 1000 to 7000 and the response rates ranged from 11% to 47%. We used multivariable logistic regression models within each of eleven countries to identify disparities in response to the access barriers by age, sex, immigrant status, income and the presence of chronic conditions.ResultsOverall, one in five adults (21%) experienced multiple barriers before reaching PC practices. After reaching care, an average of 16% of adults had two or more barriers. There was a sixfold difference between nations in the experience of these barriers to access. Vulnerable groups experiencing multiple barriers were relatively consistent across countries. People with lower income were more likely to experience multiple barriers, particularly before reaching primary care practices. Respondents with mental health problems and those born outside the country displayed substantial vulnerability in terms of barriers after reaching care.ConclusionA greater understanding of the multiple barriers to access to PC across the stages of the care-seeking process may help to inform planning and performance monitoring of disparities in access. Variation across countries may reveal organisational and system drivers of access, and inform efforts to improve access to PC for vulnerable groups. The cumulative nature of these barriers remains to be assessed.

Evaluation of the Dimensions of Anger Reactions-5 (DAR-5) Scale in combat veterans with posttraumatic stress disorder

After a traumatic event many people experience problems with anger which not only results in significant distress, but can also impede recovery. As such, there is value to include the assessment of anger in routine post-trauma screening procedures. The Dimensions of Anger Reactions-5 (DAR-5), as a concise measure of anger, was designed to meet such a need, its brevity minimizing the burden on client and practitioner. This study examined the psychometric properties of the DAR-5 with a sample of 163 male veterans diagnosed with Posttraumatic Stress Disorder. The DAR-5 demonstrated internal reliability (α=.86), along with convergent, concurrent and discriminant validity against a variety of established measures (e.g., HADS, PCL, STAXI). Support for the clinical cut-point score of 12 suggested by Forbes et al. (2014, Utility of the dimensions of anger reactions-5 (DAR-5) scale as a brief anger measure. Depression and Anxiety, 31, 166-173) was observed. The results support considering the DAR-5 as a preferred screening and assessment measure of problematic anger.