Overview of research addressing ethical dimensions of participation in traumatic stress studies: autonomy and beneficence

Objective Response of Saliva Biomarkers After High-Stress and Mass Casualty Scenarios: A Pilot Study

INTRODUCTION

Surgeons and military personnel are subjected to high-stress scenarios, which leads to greater rates of burnout. There is room to optimize performance and longevity in these careers by better understanding the body's stress response and applying it to stress management training. This study aims to understand the physiological response in those engaged in trauma scenarios by examining 6 hormones and 42 cytokines during the Intensive Surgical and Trauma Skills Course held at Strategic Operations Inc in San Diego, CA.

METHODS

Thirty-seven military medical students participated in full immersion, hyper-realistic, and experiential mass casualty high-stress scenarios. Participants were exposed to both operating and emergency room scenarios. Saliva samples were taken after stress inoculation (postinoculation) and again 1 hr after each scenario (recovery). Saliva samples were analyzed using plex assays from Eve Technologies. Data were grouped and analyzed by location and timing using mixed effect nonlinear models. Distributions were compared by location and were analyzed with respect to biomarker levels over the 4-day training period.

RESULTS

For emergency room scenarios, there was a decrease in the following cytokines from postinoculation to recovery: epidermal growth factor (EGF), granulocyte colony stimulating factor (G-CSF), epidermal growth factor, granulocyte colony stimulating factor, interleukin 1alpha (IL-1α), interleukin 1beta (IL-1 β), IL-1RA, IL-4, IL-8, IL-10, IL-18, monocyte chemotactic protein (MCP) 1, macrophage colony stimulating factor (M-CSF), macrophage derived chemokine (MDC), CXC motif ligand 9 (MIG/CXCL9), regulated upon activation, normal T cell expressed and secreted (RANTES), and vascular endothelial growth factor (P < 0.05, t > 3.0). For operating room scenarios, there was a decrease in the following cytokines: EGF, G-CSF, IL-1α, IL-1 β, IL-1RA, IL-6, IL-8, IL-10, IL-18, M-CSF, MDC, MIG/CXCL9, RANTES, and tumor necrosis factor alpha. In operating room scenarios, an increase in the hormone levels of progesterone and triodothyronine were observed. The cytokines observed in both groups included EGF, IL-1α, RANTES, MDC, EGF, G-CSF, IL-1RA, IL-18, MIG/CXCL9, IL-8, IL-1β, M-CSF, and IL-10. These significant biomarkers were also graphed and visualized as variable throughout the week.

CONCLUSIONS

These preliminary data narrow a wide array of stress biomarkers to a smaller, significant group. Surgeons and military personnel are subjected to extraordinary levels of stress with narrow margins for error. To optimize performance and outcomes, it is pertinent to understand the physiological stress response. Future investigation and pairing of cytokine measurements with neuropsychological and performance-based testing will target opportunities to direct training and identify profiles of individuals well suited for stressful environments.

Research with women sexual assault survivors presenting for emergency care is safe: Results from a multi-site, prospective observational cohort study

A barrier to research with sexual assault survivors is the concern that research participation might be a negative experience for participants. We report the experiences with research of adult women sexual assault survivors participating in a large-scale, multi-site, prospective observational study that enrolled participants at the time of presentation for emergency care. Participants (n = 706, M = 28 years of age; 57% white, 15% Black) self-reported their experience with research 1 week, 6 weeks, 6 months, and 1 year post-assault. The vast majority rated the research experience as positive (95-97%), reported no drawbacks (84-89%), and felt that participating was worth it (93-95%). Positive experiences with research remained stable across the year, were generally consistent across demographic and clinical groups, and were reflected in qualitative comments. Given the tremendous morbidity experienced by sexual assault survivors and lack of progress in developing improved treatments for this population, ethically-conducted research with sexual assault survivors receiving emergency care should be encouraged.

Reactions to Participating in Sexual and Dating Violence Research Among Native American Youth

The purpose of the current study was to explore the reactions of Native American adolescents to participating in survey research on sexual and dating violence. Participants were 149 Native American adolescents who completed a survey in school. Survey items included sexual assault, dating violence, sexual harassment, and demographic questions. At the end of the survey, participants were asked if they were upset by the survey. Results showed that almost a quarter of youth were upset by the survey (24.2%), victims were more likely than non-victims to be upset by the survey, perpetrators were more likely than non-perpetrators to be upset by the survey, and sexual minorities were more likely than non-sexual minorities to be upset by the survey. Sex and age did not emerge as significantly associated with being upset. Participants were asked to describe why they were upset, and a content analysis revealed four categories of responses (i.e., feeling awkward or weird, topic of the survey, reminders, and "other"). Overall, although the research was well tolerated by most of the participants, researchers should consider adding information about what might increase feelings of upset in parental consent and youth assent forms, such as being reminded of a past upsetting experience and/or feeling awkward or weird because of some of the questions.

Developing Trauma-Informed Research Methods: Using Proxy Respondents to Assess Sexual Assault Survivors' Experiences Seeking Medical Forensic Exams

In research on sexual assault victims' help-seeking, proxy data sources are often utilized because outreach to survivors immediately postassault may increase a study's risk-to-benefit ratio. Victim advocates and services providers are common proxy respondents, but empirical research comparing the accuracy of their information is needed. We collaborated with seven sexual assault nurse examiner (SANE) programs to collect de-identified, paired data from nurses and advocates regarding the help-seeking experiences of N = 744 adult victims. Using pairwise McNemar tests, we found statistically significant agreement on victim demographics, assault characteristics, and victims' decisions regarding medical forensic exams, sexual assault kit (SAK) collection, and release of SAKs for forensic DNA testing. Nurses and advocates had different information regarding victims' disclosure histories and their reasons for seeking SANE care.

A scoping review of recommendations in the English language on conducting research with trauma-exposed populations since publication of the Belmont report; thematic review of existing recommendations on research with trauma-exposed populations

OBJECTIVE

To identify recommendations for conducting public health research with trauma-exposed populations.

METHODS

Researchers searched Embase, PubMed, Scopus, Web of Science, Open Grey, and Google Scholar for recommendations. Trauma that causes psychological impact was our exposure of interest and we excluded clinical articles on treating physical trauma. We reviewed titles and abstracts of 8,070 articles and full text of 300 articles. We analyzed recommendations with thematic analysis, generated questions from the existing pool of recommendations, and then summarized select gaps.

RESULTS

We abstracted recommendations from 145 articles in five categories: community benefit, participant benefit, safety, researcher well-being, and recommendations for conduct of trauma research.

CONCLUSIONS

Gold standards to guide the conduct of trauma-informed public health research do not yet exist. The literature suggests participation in trauma research is not inherently harmful, and current recommendations concern using research to benefit communities and participants, protecting participants and researchers from harm, and improving professional practice. As public health researchers increasingly analyze trauma as a determinant of health, gold standards for the conduct of trauma-informed public health research would be appropriate and timely.

Photo-experiencing and reflective listening: A trauma-informed photo-elicitation method to explore day-to-day health experiences

Despite the promise of photography in research, few methods offer a guide to leverage this medium in conjunction with experience sampling to facilitate individual reflection while capturing the experiences of participants as they interact with their social world. The purpose of this paper is to introduce a new photo-elicitation method to add to the photography research repertoire, Photo-experiencing and Reflective Listening (PEARL). PEARL leverages the benefits of experience sampling, mindful self-awareness, and trauma-informed interviewing to document daily health experiences. After engaging in an at-home photography activity, participants meet for a one-on-one interview to share and cluster their photographs to discuss key themes and needs going forward. Using a study aimed to understand the recovery experiences of survivors of sexual violence, we illustrate how PEARL can be applied to study a population of interest. The products developed through PEARL provide rich opportunities for analysis, dissemination, story amplification, and action, making it a research method helpful for those interested in improving health equity and catalyzing social change. Because of the high satisfaction voiced by the participants of this approach, PEARL shows promise as a therapeutic data collection method, where the participants leave with some benefit through new awareness gained.

Predicting the Effects of Sexual Assault Research Participation: Reactions, Perceived Insight, and Help-Seeking

This study examined effects of participating in survey research for women sexual assault survivors with other trauma histories to understand the role of study participation on perceived insight and long-term help-seeking behaviors. A diverse sample of 1,863 women from a large Midwestern city participated in a 3-year study on women's experiences with sexual assault. Regression analyses were conducted to (a) examine predictors of immediate positive and negative reactions to survey participation and (b) assess the impact of the survey on perceived insight and women's long-term help-seeking behavior. Overall, most women in the study had a higher positive than negative reaction to the survey (92%), with a significant proportion indicating they sought additional services as a result of participation (55%). Women with child sexual abuse (CSA), more emotion dysregulation, and more characterological self-blame had more negative reactions to the survey, whereas those with more education and individual adaptive coping had more positive reactions. Women who said they gained insight from answering survey questions were most likely to seek additional help. This study extends the literature by examining cumulative trauma and postassault symptoms in relation to the effects of survey participation. This is also the first study of women sexual assault survivors to find a relationship between gaining perceived insight from research and subsequent help-seeking. Participating in sexual assault research may help survivors gain greater insight into their recovery, which can lead them to seek out more resources for their ongoing trauma-related problems.

Maltreatment history, trauma symptoms and research reactivity among adolescents in child protection services

OBJECTIVE

There is a well-documented link between child maltreatment and poor health across the lifespan. This provides a strong case for ongoing research with youth involved in the child welfare system to reduce negative outcomes and support resilience while being inclusive of youth voices. However, detailed inquiries about maltreatment history and health consequences may cause re-experiencing of events and psychological distress for study participants. Data that accounts for different contexts, such as severity of maltreatment history and current trauma symptomatology, have been limited in considering the question of potential harms to youth who participate in research-especially longitudinal studies.

METHODS

This study compared self-reported impact of research participation against maltreatment history and current post-traumatic stress symptomatology among a randomly selected group of adolescents (< 18 years old) in the child protection service (CPS) system.

RESULTS

Adolescents who report more serious child maltreatment and current trauma symptom severity reported higher scores on distress questions from pre- to post-assessment participation. Critically, participants who were more negatively impacted by study involvement also reported greater benefit from study involvement.

CONCLUSION

The increase in both negative and positive impact does not shift the risk/reward ratio for participation, as risks alone do not increase for this vulnerable group of CPS involved youth. These results are consistent with previous findings from studies involving non-CPS populations and underlies the importance of empirical data to address the question of change in the risk/reward ratio and what factors might play a role in any change. This information can inform inclusion/exclusion criteria for future research with these vulnerable populations, thereby reducing the risk of distress among study participants.

Risk Perceptions for Trauma-Related Research: An Exploratory Study of Undergraduate Student Researchers in Psychology

The purpose of this study was to examine student researchers' perceptions of risks associated with trauma-related research. The participants were 92 students enrolled in an introductory Research Methods course. Students evaluated (a) trauma-exposed participants' ability to provide informed consent and (b) the potential consequences of participating in trauma-focused research. Risk perceptions were assessed at the beginning of the course, after completion of the Collaborative Institutional Training Initiative (CITI) ethics education, and at the end of the course. Results show that student researchers' perceptions of risk changed significantly across time. After completing the CITI ethics education, students perceived trauma-exposed individuals as less able to provide informed consent and also perceived greater potential for negative consequences from participation in trauma-focused research, perceptions that were relatively maintained throughout the remainder of the course.

Perceived Risks and Benefits in IPV and HIV Research: Listening to the Voices of HIV-Positive African American Women

African American women living with HIV were asked to reflect on the perceived risks and benefits of research participation after completing a study examining socially sensitive issues in their lives, including intimate partner violence (IPV) and HIV. Administration of standardized quantitative instruments yielded positive responses to the research experience. However, qualitative assessments of perceived risks and benefits revealed more nuanced responses. For example, confidentiality concerns were more prominent in open-ended responses as was participants' positive attitudes toward monetary compensation. In addition, some women reported that study participation provided them with new insights about their experiences with IPV. Findings suggest that empirical studies on research protections involving potentially distressing and socially sensitive experiences with vulnerable populations require both quantitative and qualitative assessments of perceived risks and benefits. We discuss implications of our findings for ethics practices in trauma-related research among populations with multiple social vulnerabilities.

College Students' Reactions to Participating in Relational Trauma Research: A Mixed Methodological Study

Using a mixed methodology, the present study compared men's and women's perceived benefits and emotional reactions with participating in research that inquired about child maltreatment and intimate partner violence (IPV) victimization and perpetration. Participants consisted of 703 college students (357 women, 346 men), ages 18 to 25 who reported on their childhood maltreatment, adolescent and adult IPV victimization and perpetration, and their reactions (perceived benefits and emotional effects) to participating. Participants' reactions to participating were assessed using quantitative scales, as well as open-ended written responses that were content coded by researchers. Women reported more personal benefits from research, whereas men and women reported similar levels of emotional reactions to research participation. Furthermore, greater frequencies of child maltreatment and IPV victimization were related to higher levels of emotional reactions. Common self-identified reasons for emotional reactions (e.g., not liking to think about abuse in general, personal victimization experiences) and benefits (e.g., reflection and awareness about oneself, learning about IPV) were also presented and analyzed. These data underscore the importance of future research that examines the behavioral impact of research participation utilizing longitudinal and in-depth qualitative methodologies. Findings also highlight the potential psychoeducational value of research on understanding the reasons underlying participants' benefits and emotional effects.

The Perceived Impact of Trauma-Focused Research on Forensic Psychiatric Patients With Lifetime Victimization Histories

This study examined the perceived costs, benefits, and motivations for participating in individual trauma-focused interviews among forensic psychiatric patients ( N = 74). The majority of our participants were male, and 100% endorsed adverse childhood experiences (e.g., abuse, neglect) or exposure to potentially traumatic events (e.g., assault). Levels of posttraumatic avoidance (41.9%), reexperiencing (59.5%), and increased arousal (51.3%) were high. In line with previous studies, our findings suggest an overall positive research experience in this sample. In spite of extensive histories of lifetime victimization we did not find an association between victimization, posttraumatic symptomatology, and a negative research experience. Our findings suggest that participation in trauma-focused research is not only possible with, but also potentially beneficial for forensic patients.

Reactions to Participating in Intimate Partner Violence and Minority Stress Research: A Mixed Methodological Study of Self-Identified Lesbian and Gay Emerging Adults

The purpose of this study was to examine lesbian and gay (LG) young adults' reactions to participating in intimate partner violence (IPV) and minority stress research using a mixed methodological design. Participants were 277 U.S. college students currently involved in same-sex relationships and self-identified cisgender LG who completed an online questionnaire that included closed- and open-ended questions. Results suggested that IPV research was well tolerated by the vast majority of participants; close to one in 10 participants reported being upset by the study questions, yet 75% of upset individuals reported some level of personal benefit. Reasons for upset as identified in the open-ended responses included thinking about personal experiences with IPV, as the perpetrator or friend of a victim, as well as thinking about the uncertainty of their future with their current partner. The correlates of emotional reactions and personal benefits to research participation were also examined, and these varied among gay men and lesbian women. Implications of these findings underscore the importance of accurate reflection of risk and benefits in informed consent documents as well as systematic evaluation of sexual minority participants' reactions to research participation in an effort to conduct ethically sound sexual science research.

Acute effects of trauma-focused research procedures on participant safety and distress

The ethical conduct of research on posttraumatic stress disorder (PTSD) requires assessing the risks to study participants. Some previous findings suggest that patients with PTSD report higher distress compared to non-PTSD participants after trauma-focused research. However, the impact of study participation on participant risk, such as suicidal/homicidal ideation and increased desire to use drugs or alcohol, has not been adequately investigated. Furthermore, systematic evaluation of distress using pre- and post-study assessments, and the effects of study procedures involving exposure to aversive stimuli, are lacking. Individuals with a history of PTSD (n=68) and trauma-exposed non-PTSD controls (n=68) responded to five questions about risk and distress before and after participating in research procedures including a PTSD diagnostic interview and a behavioral task with aversive stimuli consisting of mild electrical shock. The desire to use alcohol or drugs increased modestly with study participation among the subgroup (n=48) of participants with current PTSD. Participation in these research procedures was not associated with increased distress or participant risk, nor did study participation interact with lifetime PTSD diagnosis. These results suggest some increase in distress with active PTSD but a participant risk profile that supports a favorable risk-benefit ratio for conducting research in individuals with PTSD.

Experiences from coordinating research after the 2011 terrorist attacks in Norway

This brief report presents some of the lessons learned from coordinating research in which people directly affected by terrorist attacks in Norway in 2011 are taking part. After the terrorist attacks, it was decided to establish a national coordinating function in order to protect those who were affected when they participate in research. By gathering key stakeholders, it is possible to avoid duplication of research through practical measures such as information sharing, facilitating cooperation, and working toward sharing of data. In addition, a coordinating function provides a platform for working to increase the impact of the research among practitioners and policy makers, and inform the general public. The conclusions are that coordination should be interdisciplinary, that it is important to plan for the sharing and reuse of data, and that both the research community and the research infrastructure should take steps to improve preparedness when disaster inevitably strikes again.

The burden of research on trauma for respondents: a prospective and comparative study on respondents evaluations and predictors

The possible burden of participating in trauma research is an important topic for Ethical Committees (EC's), Review Boards (RB's) and researchers. However, to what extent research on trauma is more burdensome than non-trauma research is unknown. Little is known about which factors explain respondents evaluations on the burden: to what extent are they trauma-related or dependent on other factors such as personality and how respondents evaluate research in general? Data of a large probability based multi-wave internet panel, with surveys on politics and values, personality and health in 2009 and 2011, and a survey on trauma in 2012 provided the unique opportunity to address these questions. Results among respondents confronted with these events in the past 2 years (N = 950) showed that questions on trauma were significantly and systematically evaluated as less pleasant (enjoyed less), more difficult, but also stimulated respondents to think about things more than almost all previous non-trauma surveys. Yet, the computed effect sizes indicated that the differences were (very) small and often meaningless. No differences were found between users and non-users of mental services, in contrast to posttraumatic stress symptoms. Evaluations of the burden of previous surveys in 2011 on politics and values, personality and health most strongly, systematically and independently predicted the burden of questions on trauma, and not posttraumatic stress symptoms, event-related coping self-efficacy and personality factors. For instance, multiple linear regression analyses showed that 30% of the variance of how (un)pleasant questions on trauma and life-events were evaluated, was explained by how (un)pleasant the 3 surveys in 2011 were evaluated, in contrast to posttraumatic stress symptoms (not significant) and coping self-efficacy (5%). Findings question why EC's, RB's and researchers should be more critical of the possible burden of trauma research than of the possible burden of other non-trauma research.

Men's reactions to participating in interpersonal violence research

This study assessed college men's reactions immediately following and 2 months after completing self-report measures of interpersonal violence. Results showed that 4.3% of men experienced immediate negative emotional reactions. Greater immediate negative reactions were related to personal benefits to research participation, anticipation of future distress, experiences of childhood physical abuse and psychological abuse/neglect, and physical abuse perpetration either in adolescence or adulthood. Attrition from the study over the 2-month follow-up was predicted by fewer perceived personal benefits to study participation but not by negative emotional reactions. None of the participants who returned for the 2-month follow-up reported experiencing negative emotional reactions to research participation over the interim.

Advancing the study of violence against women using mixed methods: integrating qualitative methods into a quantitative research program

A mixed methods approach, combining quantitative with qualitative data methods and analysis, offers a promising means of advancing the study of violence. Integrating semi-structured interviews and qualitative analysis into a quantitative program of research on women's sexual victimization has resulted in valuable scientific insight and generation of novel hypotheses for testing. This mixed methods approach is described and recommendations for integrating qualitative data into quantitative research are provided.