Research Project Proposal

Post-traumatic stress disorder (PTSD) is a mental health condition with symptoms resulting from exposure to trauma such as physical or sexual assault or active combat. Among military veterans, the existence of war-induced psychological trauma is as old as war itself. In fact, accounts of psychological symptoms following military trauma are well documented and theorized that soldiers in ancient times suffered post-traumatic stress in the same way as modern-day veterans. Consequently, it is estimated that in modern society, PTSD is more prevalent among military veterans as compared to ordinary citizens. For instance, in one major study that targeted 60,000 Iraq and Afghan soldiers, at least 13.5 percent screened positive for PTSD (Reisman, 2016). Other studies show that more than 500,000 U.S. veterans who served over the past 13 years have been diagnosed with PTSD. Nonetheless, although PTSD has been in existence for a long time, treatment of this psychiatric disorder is has been limited to only a few psychotherapeutic and pharmacological treatments. The situation is even worse because a significant number of people do not have access to these medications due to some personal and socio-economic reasons as well as lack of adequate mental health services and mental specialists. Drawing evidence from anecdotal reports and research studies, this study hypothesized that a high number of military veterans returning home from Afghanistan and Iraq are at a risk of PTSD. However, the healthcare sector is not trained or experienced enough to handle such cases. The proposed hypothesis is set up to pave the way for further investigation on the impact of lack of proper treatment programs to veterans and what should be done to remedy the situation.

Background and Significance of the Problem

Post-traumatic stress disorder is a response to a traumatic event such as perceived personal threat, physical assault, and participation in active combat among veterans. Ideally, a considerable number of military veterans coming back from Afghanistan and Iraq experience major trauma and go on to develop PTSD, giving it a high prevalence level in this particular population. Veterans with this condition may experience impaired productivity, difficulties adapting to normal life after they come back, and decline in their overall health. Consequently, despite efforts to increase access to appropriate health care for veterans with PTSD, a majority of them face barriers getting treatment. For instance, it is hypothesized that there is an acute shortage of mental health specialists in primary care and mental health facilities. Majority of these specialists are also concentrated in urban areas, making it hard for veterans living in the countryside to access care. As we move on into the future of healthcare in the United States, this study will pave the way for further investigation on what needs to be done to improve the state of mental health treatment for veterans in the country.

Statement of the Problem and Purpose of the Study

More than one decade ago, the war in the Middle East has resulted in a dramatic increase in the number of veterans with PTSD. Although PTSD extends beyond the war veterans, the condition is more prevalent among military veterans due to their exposure to trauma in their line of duty. The large number of combat veterans coming back with PTSD presents an ever-increasing need to come up with treatment programs to manage their condition. In conjunction with the Department of Veteran Affairs, the Department of Defense Services has set up numerous programs and services designed to screen and diagnose military veterans returning home with PTSD. There are also some early interventions and treatment programs for managing PTSD delivered to military veterans. Unfortunately, even with the efforts by the Veterans Affairs department and the DOD, a significant number of veterans remain undiagnosed for PTSD, while others do not seek professional help for their condition. Ideally, a majority of the servicemen and even ordinary men fail to seek professional help due to the stigma associated with PTSD. Others are afraid of sinking their careers due to their illness. However, the ultimate question remains, are those the only reasons why military veterans do not seek treatment. As stated earlier, there is a high number of military veterans coming back from war and a healthcare sector that is not ready or skilled enough to handle this demographic. The purpose of the study is set up against this as the background information to provide a conceptual framework to establish the impact of the unpreparedness of the healthcare to take care of military men with PTSD. More specifically, the study seeks to determine if the healthcare sector in the United States is capable of providing screening and treatment programs to veterans with PTSD. We will also review the impact of lack of proper treatment among veterans with PTSD and come up with recommendations on ways the healthcare sector can be improved to meet the demands of this specific demographic.

Literature Review

Although PTSD extends beyond the military, the problem is especially chronic among war veterans. In the research article by Reisman (2016), the author acknowledged that PTSD in combat veterans is a war-induced psychological trauma and is as old as war itself. However, even with this fact, the symptoms and syndrome only became apparent during the Civil War of 1861-1865, which also marked the beginning of formal medical research to address the psychological effect of war on veterans. Unfortunately, contrary to expectations, diagnosis and assessment of PTSD in veterans are still complicated, a factor that has contributed to high rates of psychiatric comorbidity. Ideally, according to Reisman, there are two main types of assessment used to help diagnose PTSD in veterans and evaluate its severity. The PTSD checklist for DSM-5 (PCL-5) is one of the widely used self-report, uses a 20-item questionnaire, and can be completed within five to seven minutes. The other self-report is the Mississippi Scale for Combat-Related PTSD. The patient is required to fill in a 35-item questionnaire as they rate how they feel. There is also a wide range of treatment options for veterans with PTSD. Nonetheless, despite efforts to increase access to appropriate health care for veterans with PTSD, many patients continue to face barriers to getting treatment. More specifically, the largest barrier of access to care among veterans is an acute shortage of doctors in primary care in the VA, combined with a rising population of veterans seeking treatment. The country also lacks an adequate number of mental health services, presenting a major significant barrier for veterans. Consequently, mental health specialists often tend to concentrate in the major urban areas, which leaves veterans living in the countryside with less or no access to care due to the greater distance to be covered. Further research also indicates that mental health providers in community-based facilities are also not well prepared to caring for the needs of veterans and their families. Ultimately, there has been limited dissemination and implementation of effective psychotherapies in these community-based facilities making it hard to deal with after war trauma.

Although military service has several potential health problems, healthcare professionals rarely understand the health needs of veterans. In reality, veterans are likely to present overlapping symptoms of mental and physical health such as abuse of alcohol, aggressive behavior towards family members and friends, anxiety, depression, and PTSD among others. Female veterans also present complicated health issues such as sexual trauma. The focus of the investigation by Fullwood (2015) was on the state of healthcare needs of veterans with PTSD in the United Kingdom. It is hypothesized that, apart from maybe a few countries, veteran health care needs are universal in almost all the countries of the world. In light of this information, the results of the study assert that the rates of PTSD were similar for both U.S. and UK military veterans. In addition, the study also acknowledged that U.S. war veterans from Iraq were more likely to be affected due to the nature of war in the specific country. Alongside mental illness, war veterans are also likely to experience chronic pain from physical trauma. As mentioned earlier, patients with post-traumatic stress disorder often experience long-term cognitive impairment, alcohol abuse, violence offending and aggressive behavior.  In this context, Fullwood (2015) notes that mental illness is not easily identified and healthcare professionals should be aware of the various ways to assess and diagnose mental illness among veterans.  For instance, when assessing individuals, it is important to ask them about their employment history, because if the individual has served in the military, they may suffer implications in their health. Along with that, to assess and identify veterans who are at risk of excessive alcohol consumption, healthcare professionals should ascertain correct information on patient’s weekly alcohol consumption through the Alcohol Use Disorder Identification Test. Care providers should also be able to identify and diagnose female veterans who may have experienced military sexual trauma. Unfortunately, dealing with the health needs of military personnel is challenging for healthcare professionals who are not aware of the needs of veterans. The problem is escalated since the psychological and psychosocial issues of veterans often overlap with mental and physical conditions alongside other problems such as family reintegration.  Nonetheless, as Fullwood recommends, it is essential that healthcare professionals be trained with the knowledge and skills to support the health needs of war veterans.

Post-traumatic stress disorder with comorbid chronic medical conditions is highly prevalent among U.S. veterans, amidst growing healthcare navigation problems. To complicate matters further, even after veterans are diagnosed with PTSD, the limited number of healthcare facilities and a shortage of care professionals dealing with PTSD among veterans makes it hard to avail treatment options. As a result, Whealin, Jenchura, and Wong (2016) note that a majority of the veterans with PTSD do not receive the necessary healthcare treatment, often resulting in self-care treatment programs. In particular, veterans are now resulting in eHealth resources to promote wellness and manage their PTSD condition. In general, at least 70 percent of veterans have access to the web, and many of those rely on eHealth to manage their illness.  The qualitative findings of the study showed that veterans used eHealth resources to manage their PTSD conditions. They also used web support services to interact with others, access information from providers, and promote coordination of care. Further, the findings show that veterans also used technology to communicate with providers and track medication. One limitation of eHealth is that it fails to address the health needs of the veterans with PTSD comprehensively. Therefore, it is recommended that VA should continue to disseminate diagnosis and treatment tools to help maximize the effectiveness of eHealth in the management of PTSD.

Consistent with any treatment procedure, the ultimate question remains whether the use of mental health services helps alleviate the severity or PTSD. Similarly, it is also important to understand if veterans with PTSD utilize mental health services. Ideally, Miles, Harik, and Hundt (2017) note accurate estimate of service utilization among veterans is imperative for the healthcare sector in the United States to be able to design and provide high-quality care to veterans with PTSD. The study focused on veterans with traumatic brain injury, since they are comorbid with post-traumatic stress disorders. The study also hypothesized that veterans with TBI injuries are more likely to attribute their symptoms to the head injury as opposed to a mental health disorder. From the study findings, it was clear that veterans with traumatic brain injury history often attended psychotherapy and medication management as compared to those without TBI history. Nonetheless, further research is recommended to examine if increased use of mental health services resulted in the reduction of mental health symptoms and full recovery.

While there has been a significant advancement in the understanding and treatment of PTSD, the increasing number of veterans in the United States with post-traumatic stress disorder continues to be considerably high. The acute shortage of qualified personnel who can deal with PTSD is an urgent need that should be addressed immediately. Community providers also play a key role in addressing healthcare issues facing the society. Therefore, it is critical that the health professionals serving in these facilities receive training and tools necessary to improve their knowledge and skills to address the needs of this unique population. eHealth seems like a better alternative that can be used to help the military personnel with PTSD to manage their condition as the healthcare sector looks for ways to develop and innovate the means to overcome barriers to treating veterans with post-traumatic stress disorder.

Research Questions, Hypothesis, and Variables

Healthcare professionals in primary care are usually the first to encounter veterans with post-traumatic stress disorders and their families. One suggested way, of identifying veterans with PTSD is including in the initial patient assessment a question whether the individual has served in the armed forces. From there, it becomes easy to screen for posttraumatic stress disorders and its associates. However, are the medical professionals knowledgeable and skilled enough to address post-traumatic stress disorder among veterans? Are the treatment and management options available helping veterans to combat PTSD? What should be done to ensure people who experience PTSD are effectively treated and do not suffer a relapse? Lastly, what should be done to ensure the health professionals are well prepared in response to the increasing needs of veterans with PTSD? Drawing on the research questions it is hypothesized that the number of veterans with post-traumatic stress disorder is significantly high, but healthcare professionals are not trained or experienced enough to handle these individuals, and this greatly affects the health status of the individual veterans with PTSD

Theoretical Framework

Overview and Guiding Propositions

The increasing number of veterans coming back from Afghanistan and Iraq poses a problem for the U.S. health care sector. The veterans who have been exposed to trauma are at a high risk of developing posttraumatic stress disorder, amidst a health care sector that is not prepared to meet the needs of this particular population. The shortage of mental health services and specialists can be explained using the social inequality theory. The theory perceives the society as a dynamic entity that is constantly changing and driver by conflict of class. In essence, the inequality in the society using the conflict theory can be used to elaborate the shortage of mental health services and specialists to take care of the high number of veterans with PTSD.

Application of Theory to Study Focus

            According to the perspective of the conflict theory, society is made up of individuals who are constantly competing for limited resources. Competition over inadequate resources is at the heart of everything in the society. In the case of veterans with PTSD, the mental health services and mental specialists are scarce and contribute to limited care to veterans. Additionally, the conflict theory emphasizes the need for change over resources and the conflict drives social change. Using this theory, the study challenges the scarcity of health care specialists and mental health services by recommending how the unequal distribution of services can be solved.

Methodology

Sample/Setting

The study will consider two groups of participants. The first group is healthcare professionals from the community health facilities, the private clinics, and the public hospitals. The study targets at least 100 health professionals who will be approached using a questionnaire, to establish whether patients who attended the facility underwent a comprehensive series of evaluation before beginning treatment. The care providers will also be expected to indicate whether during their patient medical assessment test they came across military veterans and whether they screened them for PTSD. The other target group will be focused on at least 200 war veterans who will be selected from the Veterans Hospital with the recommendation of the person-in-charge. The study will focus on knowing if the individuals attended other health facilities and the level of care they received concerning their PTSD. The sampling frame will run for three months.

Sampling Strategy

The research will draw on a quantitative study design and consider the use of a probability sampling technique because it allows for statistical inference from the population selected. Ideally, this sampling method is preferred because it provides external validity of the research findings (Gravetter & Forzano, 2016). Essentially, it is necessary to compare the number of veterans who received treatment from other health facilities apart from the Veterans Hospitals and the number of care providers who were able to provide care to veterans with PTSD. Similarly, since we will use data from a large population, the study will use simple random sampling strategy, where a random selection of care providers will represent the entire population.

Research Design

The study will use correlation research, which attempts to explain the relationship between two or more variables through statistical data (Gravetter & Forzano, 2016). With this design, facts about the inadequacy of healthcare providers to take care of veterans with PTSD will be interpreted using the trends and patterns in the data collected.

Extraneous Variables

The first extraneous variables that the study will not manipulate include the probability of veterans seeking treatment options in urban facilities where there is a high concentration of mental health specialists, instead of the community hospitals where there is a limited number or no specialists. The second extraneous variable is the probability of veterans not visiting community health facilities for fear of stigma and instead choosing to go to other healthcare organizations outside their locality or not getting treatment altogether. The other extraneous variable is the probability of interviewing healthcare professionals who have never attended to military veterans. We cannot ignore the likelihood that maybe on the days the healthcare professional was on duty, no military veteran came to the facility. While we will not manipulate these extraneous variables, they have a potential to affect the performance scores of health care professionals attending to veterans with PTSD. Other extraneous variables may relate to the probability of picking veterans who have never sought treatment in a community health facility based on their socio-economic status. Military veterans with a high socio-economic class are less likely to attend community facilities or public hospitals. Instead, they will most likely seek treatment from public clinics in urban areas or Veteran Hospitals.

Instruments

The extraneous variable will be controlled by either holding the variable constant or matching the values across the conditions. In this case, the extraneous variable on healthcare professionals will be managed through random sampling. The other control method of the extraneous variable will be by use of control groups. The validity and reliability of the experiment rely on the ability to make comparisons between participants in differential experimental conditions to come up with relevant findings (Wood & Kerr, 2011).

Description of the Intervention

            Ideally, as Wood and Kerr (2011) elaborate, random sampling relates to internal validity and relies on the way the participants are assigned to experimental conditions. With random sampling, independent samples will be created such that each participant has an equal chance of being selected for the experimental condition. The study will use quantitative data collection methods that rely on random sampling. However, for reliability, the reach will consider participant and situational characteristics to avoid influencing the dependent or the study findings. Since the intent is to generalize from a larger population, the study will consider the use of probability sampling to select participants and help in comparing the health care providers who encountered military veterans with PTSD and were able or unable to screen and provide care.

The use of the control group will rely on the person-in-charge at the Veterans Hospital to identify and recommend one group of participants who may have to attend other health facilities based on their medical history. The participants will be required to indicate whether they receive proper care in the other health facilities. The comparison group will be separate veterans randomly picked who may or may not have attended other health facilities.

Data Collection Procedures

The sampling strategy will include the recruitment of General Physicians. The sample will be stratified according to the type of clinic; local, public hospitals, small private medical clinics and medium medical clinics with more than three physicians. The inclusion criteria will be used for those working full time or part-time. For each GP selected, a pamphlet will be provided that will contain questions explaining the procedure and objectives of study. The person in-charge will be consulted to help with the veterans who are viable for the survey and handed pamphlets to give to the participants who will be participating.

Data Analysis Plans

            The demographic variables that will be tested include gender, social-economic class, and the location of the veterans. When measuring these variables, the nominal scale will be used to measure the variables and will be categorized by gender, social, economic class, and location. The study variables rely on the incidence of veterans with PTSD visiting community facilities, public or private hospitals, being screened by healthcare professionals, and getting started on treatment or referred for treatment. The number of veterans who visited public hospitals and were screened for PTSD will interpret the cumulative incidence. The rate of the ability of the healthcare professionals to screen and treat veterans with PTSD is calculated from the number of veterans who visited the hospitals against the ones who were tested. The standardized incidence ratio will be used to compare the incidence of military veterans visiting hospitals and being screened. The SIR will be calculated by dividing the observed number of veterans who visited the clinics against the number of veterans who received treatment. The Standardized incidence ratio will also apply to the number of healthcare professionals able to attend to veterans with PTSD. In this case, the SIR will be calculated using the number of veterans who visited the hospitals against the number of healthcare professionals who were able to screen for PTSD.

Ethical Issues

            The ethical issues relating to the conduct of this clinical research involve the principle of informed consent and respect for privacy. According to Fouka and Mantzorou (2011), informed consent is a means by which the right of the patient to autonomy is protected. Participants need to make informed consent before undertaking the survey. However, informed consent can also turn into a challenge if participants decide to withdraw in the middle of the study. The right to privacy is another ethical issue that may be encountered during the study. Patients’ private information is protected by “A Patient’s Bill of Rights,” and physicians and medical personnel are expected to maintain this privacy. Violation of patient rights may be violated during the research, when getting information regarding veterans from the person in charge of VH.

Limitations of Proposed Study

            Due to the limited time, the study sample is relatively small and this can affect the significant relationship from the data collected. The study also relies on self-reported data, which can contain several potential biases and cannot be independently verified. Access to participants, especially veterans might also be a challenge.

Implications for Practice

If the results of the study find that the healthcare sector is not ready to take care of military veterans with PTSD, this will pave way for further research on the strategies that should be implemented to solve this problem. Currently, the healthcare sector in the United States is undergoing some critical transformation in preparation to meet the growing needs of the patient population.

References

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Fouka, G., & Mantzorou, M. (2011). What are the major ethical issues in conducting research? is there a conflict between the research ethics and the nature of nursing?. Health Science Journal, 5(1), 3-14.

Fullwood, D. (2015). Understanding and managing the health needs of veterans. Nursing Standard, 30(10), 37-43.

Gravetter, F. J., & Forzano, L.-A. B. (2016). Research Methods for the Behavioral Sciences. Delmar Cengage Learning.

Miles, S. R., Harik, J. M., Hundt, N. E., Mignogna, J., Pastorek, N. J., Thompson, K. E., Freshour, J. S., … McDonald, S. (2017). Delivery of mental health treatment to combat veterans with psychiatric diagnoses and TBI histories. Plos One, 12(9), 1-14.

Reisman, M. (2016). PTSD treatment for veterans: What’s working, what’s new, and what’s next. P and T, 41(10), 623-634.

Reisman, M. (2016). PTSD treatment for veterans: What’s working, what’s new, and what’s next. P and T, 41(10), 623-634.

Whealin, J. M., Jenchura, E. C., Wong, A. C., & Zulman, D. M. (2016). How veterans with post-traumatic stress disorder and comorbid health conditions utilize ehealth to manage their health care needs: A Mixed-Methods Analysis. Journal of Medical Internet Research, 18(10), 1-24.

Wood, M. J., & Kerr, J. C. (2011). Basic steps in planning nursing research: From question to proposal. Sudbury, Mass: Jones and Bartlett.