Veterans' experiences with and perspectives on insomnia treatment: A qualitative study.

Qualitative interviews were conducted with veterans to understand their experiences and perceptions about insomnia and its treatment, with a focus on cognitive-behavioral therapy for insomnia (CBT-I) and brief behavioral treatment for insomnia (BBTI). There is a lack of knowledge about veterans' understanding of this prevalent disorder, yet their experiences and perceptions can influence treatment delivery and treatment outcomes. The Department of Veterans Affairs (VA) can improve insomnia care by considering and responding to this valuable information from veteran stakeholders. Twenty veterans with an insomnia diagnosis or complaint were interviewed about their experiences with insomnia, its treatment, and their preferences for care. Transcripts from the audio-recorded interviews were independently analyzed by 2 coders using content analysis, and discrepancies were resolved through negotiated consensus. The 20 veterans were mostly male (85%), older (60.4 years ± 9.0), and white (60%). Experiences with insomnia and perspectives regarding treatment focused on (a) insomnia symptoms, (b) comorbid symptoms, (c) seeking treatment, (d) intervention experiences, (e) intervention preferences and expectations, and (f) patient attributes. Barriers to care included a lack of knowledge about treatment and a lack of options that fit veterans' preference for delivery. These results provide insight into veterans' experiences with and perspectives on insomnia treatment that is crucial to the support, development, and implementation of interventions. A focus on increasing knowledge of, and expectations for, insomnia treatments as well as offering multiple delivery options has the potential to improve utilization and access to quality insomnia care. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

The Future of Nursing Education: Multidisciplinary Community-Engaged Research for Undergraduate Nursing Students.

BACKGROUND: Undergraduate nursing students with research experience are more likely to pursue graduate education. Community-engaged research mentoring facilitates not only this process but also student engagement in topics such as cultural relevance and community partnerships. METHOD: Two cohorts of undergraduate students participated in a novel yearlong multidisciplinary mentored research experience based in a predominantly Black community. A qualitative, descriptive study using semistructured interviews was conducted with undergraduate students to describe effects of a multidisciplinary, community-engaged mentored research experience on cultural sensitivity, acquisition of research skills, and intent to pursue graduate study. RESULTS: Both cohorts of students demonstrated cultural sensitivity, acquired basic research skills, and had favorable attitudes toward or a definitive plan to pursue graduate education influenced by their participation in the mentored research experience. CONCLUSION: This approach may represent a viable strategy for increasing the number of graduate-prepared nurses and reducing health disparities via the provision of culturally competent care. [J Nurs Educ. 2020;59(6):341-344.].

Wise Women's Provision of Maternal-Child Health Information and Support for Urban, African American Women.

Introduction: The United States is experiencing a maternal-child health (MCH) crisis including racial inequalities in mortality. This study explored the roles of lay experts who provide information and support to women of childbearing age (i.e., Wise Women) and cultural norms for sharing MCH information and support in an urban, predominantly African American community. Methodology: This qualitative community-engaged study (N = 49) of social networks utilized a semistructured guide and brainstorming activities with eight focus groups (three community leader, three community women, and two Wise Women). Results: Although several sources of MCH information and support were noted, Wise Women were the most frequently reported culturally normative sources. Emergent themes included positive affirmations for informal exchange of MCH information among women and roadblocks to MCH information exchange and support. Discussion: Results suggest a need for culturally relevant interventions that would strengthen lines of communication and social connectedness among African American women.

Mental health treatment preferences and challenges of living with multimorbidity from the veteran perspective.

OBJECTIVE: To explore middle-aged and older veterans' current disease-management practices, mental health treatment preferences, and challenges of living with multiple chronic health conditions (i.e., multimorbidity). METHODS: Semi-structured qualitative interviews and self-report measures were collected from 28 middle-aged and older (50 years of age or older) veterans with multimorbidity. RESULTS: Our sample of veterans with multimorbidity was, on average, mildly depressed and anxious with elevated stress and disability. Veterans acknowledged the interaction of physical and emotional symptoms, which caused greater difficulty with health care management and daily functioning. Veterans had many concerns regarding their physical and emotional health conditions, such as continued disease progression and the addition of other emotional and physical health complications. Veterans also identified specific self-care approaches for disease management (e.g., medication, healthy lifestyle practices, and psychological stress management techniques), as well as barriers to engaging in care (e.g., money, transportation, and stigma). Participants preferred a combination of medication, psychotherapy, and healthy lifestyle practices for mental health treatment. The majority of participants (88.5%) agreed that these mental health treatments would be beneficial to integrate into disease management for older veterans with multimorbidity. Lastly, veterans provided an array of recommendations for improving Veteran's Administration services and reducing mental health stigma. CONCLUSIONS: These findings provide support for patient-centered approaches and integrated mental and physical health self-management in the Veteran's Administration for middle-aged and older veterans with multiple chronic conditions. Copyright © 2016 John Wiley & Sons, Ltd.

Racial Differences in Veterans' Satisfaction With Addiction Treatment Services.

OBJECTIVES: Racial minorities experience lower rates of alcohol treatment completion than whites. Treatment satisfaction is an important factor in alcohol treatment retention, yet few studies have explored the satisfaction of racial minorities while in treatment. This study examined racial differences in addiction treatment satisfaction and explored factors that might mediate or moderate racial differences in satisfaction. METHODS: We surveyed non-Hispanic black and non-Hispanic white veterans with an alcohol-related diagnosis about addiction treatment services at a large Veterans Affairs medical center. Treatment satisfaction was measured using the 8-item Client Satisfaction Questionnaire, dichotomized as low versus non-low satisfaction in analyses. The χ and logistic regression methods were used to test for associations of race and sociodemographic characteristics with treatment satisfaction. RESULTS: Among 271 black and 304 white veterans with an alcohol-related diagnosis, race was not statistically associated with treatment satisfaction in bivariate analyses (P > 0.05). However, we identified significant interactions of race with mental health diagnoses in predicting treatment satisfaction in multivariable analyses (adj odds ratio = 0.55; 95% confidence interval [CI] = 0.39-0.78). In post hoc comparisons among veterans with zero mental health diagnoses, black veterans had a greater probability of reporting low satisfaction than whites (marginal difference = 0.13; 95% CI = 0.04-0.22). In veterans with 4 or more diagnoses, whites had a greater probability than blacks of reporting low satisfaction (marginal difference = 0.28, 95% CI = 0.10-0.46). Regardless of race, past homelessness was associated with low satisfaction (adj odds ratio = 2.09; 95% CI = 1.19-3.67). CONCLUSIONS: Racial minorities, veterans with unstable housing, and white veterans with co-occurring mental health disorders may be at risk of experiencing low treatment satisfaction.

Suicidal Ideation Associated with PCL Checklist-Ascertained PTSD among Veterans Treated for Substance Abuse.

This manuscript begins by reviewing the literature concerning the use of the SCID versus the PCL for diagnosing PTSD, and by reviewing the literature regarding the presence of suicidal ideation as a clinical correlate of PTSD. This manuscript then describes our recent study involving PTSD among Veterans, which assessed the presence of suicidal ideation as a clinical correlate of PTSD, as diagnosed by the SCID versus as diagnosed by the PCL. We hypothesized that the presence of suicidal ideation would be associated with a diagnosis of PTSD. Subjects were 101 Veterans recruited from VA behavioral health and substance use treatment clinics in the VA Pittsburgh Healthcare System. The study compared correlations of suicidal ideation with PTSD as determined with the PTSD Checklist versus the Structured Clinical Interview for DSM-IV, and utilized question 9 of the Beck Depression Inventory for assessing presence of SI. PTSD was diagnosed in 15 subjects using the SCID, and in 15 subjects using the PTSD Checklist. SI were reported by 16 subjects. The presence of SI was significantly associated with the diagnosis of PTSD on the PCL (chi-square=5.73, df=1, p=0.017) but not on the SCID (chi-square=0.08, df=1, p=0.773). These findings suggest that SI associated with the diagnosis of PTSD among Veterans are better ascertained by the PCL as compared to the more elaborate diagnostic algorithm used in the SCID. The current study finding raises the possibility that a less complicated diagnostic assessment instrument such as the PCL may be superior to the SCID, a more complicated instrument for diagnosing PTSD, at least in some populations.

Factor structure and risk factors for the health status of homeless veterans.

Homeless veterans have numerous health problems that have been previously characterized as falling into four major subgroups; addiction, psychosis, vascular disorders, and generalized medical and psychiatric illness. Comorbid conditions are common, often involving a combination of psychiatric and medical disorders. Using data from the same survey of homeless veterans that was used to establish these subgroups with cluster analysis, the present study examined the structure of these subgroup patterns through the use of factor analysis. This analysis yielded a five factor solution. They were named "Cardiac", Mood, Stress, Addiction, and Psychosis factors. Factor scores were computed and an odds ratio analysis was accomplished to determine the association between obtaining a high score on a given factor with a number of sociodemographic and homelessness related variables. It was concluded that health status of homeless veterans is a complex condition, but has a clear latent structure demonstrated by factor analysis. Scoring high or low on a particular factor is associated with numerous historical and sociodemographic considerations, notably age, ethnicity, and employment status.

Veterans' decision-making preferences and perceived involvement in care for chronic heart failure.

BACKGROUND: Patients with heart failure require a great deal of information about their disease, but it is also important to know about their preferences for involvement in medical decision making and about factors that may influence their preferences so that patients' needs, values, and preferences can be met by clinicians. OBJECTIVES: We assessed patients' preferred role and perceived level of involvement in medical decision making and tested the effects of patients' age and role preference on perceived involvement in medical decision making. METHODS: We conducted a telephone survey of 90 adults being treated for heart failure by a Veterans Affairs primary care provider or cardiologist. Patients' preferred role in treatment decisions was assessed using the Control Preferences Scale. Perceptions about their involvement in decision making during the most recent clinic visit was measured using a subscale of the Perceived Involvement in Care Scale. Descriptive, correlational, and generalized linear regression analyses were conducted. RESULTS: Most patients were elderly (mean = 70.1 years), male (94.4%), and white (85.6%), and had New York Heart Association class II disease (55.6%). Forty-three patients (47.8%) preferred a passive role in decision making, 19 patients (21.1%) preferred an active role, and 28 patients (31.1%) preferred a collaborative role. Most patients believed that their decision-making involvement was relatively passive, as indicated by a mean score of .96 (range, 0-4) on the Perceived Involvement in Care Scale decision-making subscale. Older age was associated with passive role preference (r = .263; P < .05) and less perceived involvement in decision making (r = -.279; P < .01). In addition, less perceived involvement in decision making during the last clinic visit was associated with a preference for a more passive decision-making role (r = rho.355; P < .01). Generalized linear regression analysis indicated that when patients' perceived decision-making involvement was regressed on age and patients' role preferences, age was no longer significantly associated with involvement (beta = -.196; P = .061), but that control preferences continued to exhibit an independent effect on perceived involvement in medical decision making (beta = -.341; P = .003). CONCLUSION: The results suggest that the preferences of patients with heart failure for a more passive role in decision making may be a stronger independent predictor of patients' perceived involvement in decision making than patients' age.

"They diagnosed bad heart": a qualitative exploration of patients' knowledge about and experiences with heart failure.

BACKGROUND: Patient education is central to the management of individuals with heart failure; therefore, it is important to know what these patients understand and experience both clinically and personally. OBJECTIVES: This study qualitatively explored patients' knowledge regarding a heart failure diagnosis, their understanding of their cardiac care providers' treatment recommendations, and their views concerning the impact of heart failure on their daily lives and prognosis. METHODS: A qualitative study was conducted whereby data were collected through 25 telephone interviews with adults being followed for heart failure at a Veterans Affairs medical center. Subjects were interviewed using semistructured open-ended questions. Audiotaped responses were analyzed using grounded theory methods. RESULTS: The majority of participants were elderly, male, and white, and had New York Heart Association class II disease. Participants without angina typically experienced a lengthy and difficult diagnostic delay, with symptoms misattributed to comorbid diseases. Most understood the importance of self-monitoring and adhering to physician recommendations, and their discussions of life-changing effects typically focused on loss of physical functioning and decreased quality of life. Although participants wanted to know their prognosis, most had not received information about it or about advance care planning. CONCLUSION: Patients require opportunities for enhanced communication with physicians and health care team members during the challenging diagnostic period and subsequently need more information about their medical condition and prognosis.

Racial differences in expectations of joint replacement surgery outcomes.

OBJECTIVE: Prior studies have indicated racial differences in patients' expectations for joint replacement surgery outcomes. The goal of this study was to measure these differences using a well-validated survey instrument and to determine if the differences could be explained by racial variation in disease severity, socioeconomic factors, literacy, or trust. METHODS: Detailed demographic, clinical, psychological, and social data were collected from 909 male patients (450 African American, 459 white) ages 50-79 years with moderate or severe osteoarthritis (OA) of the hip or knee receiving primary care at 2 veterans affairs medical centers. The previously validated Joint Replacement Expectations Survey was used to assess expectations for pain relief, functional improvement, and psychological well-being after joint replacement. RESULTS: Among knee OA patients (n = 627), the unadjusted mean expectation score (scale 0-76) for African American patients was 48.7 versus 53.6 for white patients (mean difference 4.9, P < 0.001). For hip OA patients (n = 282), the unadjusted mean expectation score (scale 0-72) for African Americans was 45.4 versus 51.5 for whites (mean difference 6.1, P < 0.001). Multivariable adjustment for disease severity, socioeconomic factors, education, social support, literacy, and trust reduced these racial differences to 3.8 points (95% confidence interval [95% CI] 1.2, 6.3) among knee OA patients and 4.2 points (95% CI 0.4, 8.0) among hip patients. CONCLUSION: Among potential candidates for joint replacement, African American patients have significantly lower expectations for surgical outcomes than white patients. This difference is not entirely explained by racial differences in demographics, disease severity, education, income, social support, or trust.

Arthritis-specific health beliefs related to aging among older male patients with knee and/or hip osteoarthritis.

BACKGROUND: Disease-specific beliefs may impact patients' perceptions of the efficacy of various treatment options, thus, it is important to understand these beliefs. We examined the relationship between patients' demographic characteristics and arthritis-specific beliefs related to aging. METHODS: We performed a cross-sectional survey of 591 elderly primary care patients, who had symptomatic osteoarthritis (OA) of the knee and/or hip, at the Louis Stokes VA Medical Center in Cleveland, Ohio. Data were collected on age, race, educational level, income, and whether patients agreed or disagreed with four statements regarding aging and arthritis. We also assessed OA symptom severity using the Western Ontario McMaster Universities Index (WOMAC) and depressive symptoms using the Geriatric Depression Scale. We used logistic regression analyses to examine relationships between patients' age, race, and educational level and arthritis-specific health beliefs, while adjusting for OA symptom severity, radiographic confirmation of OA, OA joint burden, depressive symptoms, and income. RESULTS: Patients 70 years old or older, as compared to patients 50-59 years old, were more likely to believe that: arthritis is a natural part of growing old; people should expect that when they get older, they won't be able to walk as well, and people should expect to live with pain as they grow older. CONCLUSION: Among older, male veterans, health beliefs regarding the relationship between aging and arthritis vary by age. Clinicians should consider these differences when discussing treatment strategies with their patients with knee and/or hip OA.

African American veterans' experiences with mobile geriatric care.

To explore perspectives concerning use of a mobile geriatrics unit (MGU) by underserved populations in low-income urban neighborhoods, we recruited 18 elderly African American patients and engaged them in in-depth semistructured interviews. Using grounded theory techniques of constant comparative analysis, we found that most patients learned about the MGU from community members and initially visited it to determine whether it would be worth using in the future. In describing their MGU experiences, patients tended to focus on three main factors: quality of care, accessibility of services, and ambience of the care setting. They reported that the MGU allowed them to have their health conditions and medications monitored regularly and functioned as a central link to the larger Veterans Affairs health care system. The findings suggest that using MGUs is an acceptable and effective way to help medically underserved populations receive primary medical care and referrals to specialty care.

Polypharmacy and health beliefs in older outpatients.

BACKGROUND: Polypharmacy is a significant problem among older adults. Patient-related characteristics and beliefs have not been the focus of prior research in this area, which has primarily evaluated the effects of patients' health status and health care system factors. OBJECTIVE: The goal of this research was to determine the prevalence and predictors of unnecessary drug use in older veteran outpatients, with a focus on patient-related factors and health beliefs. METHODS: Community-dwelling veterans aged > or =60 years, with > or =5 self-administered medications per day, not cognitively impaired, able to speak and/or write English, and receiving primary care and medications from a large urban Veterans Affairs Medical Center were eligible for study. Assessment of unnecessary drug use was determined by clinical pharmacists applying the criteria of the Medication Appropriateness Index to each regularly scheduled medication. Those drugs that received an inappropriate rating for indication, effectiveness, or therapeutic duplication were defined as unnecessary. Health beliefs regarding medication use were assessed with decisional balance, self-efficacy, and health locus of control scales. RESULTS: A total of 128 veterans (mean [SD] age, 72.0 [8.9] years; 93.0% white; 93.0% male) were enrolled. Analysis showed that 58.6% of patients had > or =1 unnecessary prescribed drug; the most common reason for a medication being considered inappropriate was lack of effectiveness (41.4%). The most commonly prescribed unnecessary drug classes were central nervous system (19.5%), gastrointestinal (18.0%), and vitamins (16.4%). Factors with tendency for association (P < 0.20) with any unnecessary drug use included race (white), income (<$30,000/year), number of prescription medications (mean [SD], 6.8 [2.8]), and lack of belief in a "powerful other" for their health locus of control. CONCLUSIONS: We found a very high prevalence of unnecessary drug use in this older veteran outpatient population. Race, income, and polypharmacy, as well as health-related beliefs, were central factors associated with unnecessary drug use.