Consumer Perceptions of Integrated Trauma-Informed Services Among Women with Co-Occurring Disorders

Implementation of trauma-informed care and trauma-responsive services in clinical settings: a latent class regression analysis

Introduction

Engagement and retention in health care is vital to sustained health among people living with HIV (PLWH), yet clinical environments can deter health-seeking behavior, particularly for survivors of interpersonal violence. PLWH face disproportionate rates of interpersonal violence; clinical interactions can provoke a re-experiencing of the sequalae of trauma from violence, called re-traumatization. Trauma-informed care (TIC) is a strengths-based approach to case that minimizes potential triggers of re-traumatization and promotes patient empowerment, increasing acceptability of care. Yet, Ryan White HIV/AIDS clinics, at which over 50% of PLWH received care, have struggled to IMPLEMENT TIC. In this analysis, we sought to (1) identify unique sub-groups of HIV clinics based on clinical attributes (i.e., resources, leadership, culture, climate, access to knowledge about trauma-informed care) and (2) assess relationships between sub-group membership and degree of implementation of TIC and trauma-responsive services offered.

Methods

A total of 317 participants from 47 Ryan White Federally-funded HIV/AIDS clinics completed a quantitative survey between December 2019 and April 2020. Questions included assessment of inner setting constructs from the Consolidated Framework for Implementation Research (CFIR), perceived level of TIC implementation, and trauma-responsive services offered by each respondent's clinic. We employed latent class analysis to identify four sub-groups of clinics with unique inner setting profiles: Weak Inner Setting (n = 124, 39.1%), Siloed and Resource Scarce (n = 80, 25.2%), Low Communication (n = 49, 15.5%), and Robust Inner Robust (n = 64, 20.2%). We used multilevel regressions to predict degree of TIC implementation and provision of trauma-responsive services.

Results

Results demonstrate that clinics can be distinctly classified by inner setting characteristics. Further, inner setting robustness is associated with a higher degree of TIC implementation, wherein classes with resources (Robust Inner Setting, Low Communication) are associated with significantly higher odds reporting early stages of implementation or active implementation compared to Weak class membership. Resourced class membership is also associated with availability of twice as many trauma-responsive services compared to Weak class membership.

Discussion

Assessment of CFIR inner setting constructs may reveal modifiable implementation setting attributes key to implementing TIC and trauma-responsive services in clinical settings. Introduction.

A Trauma-Informed HIV Intervention (LinkPositively) to Improve HIV Care Among Black Women Affected by Interpersonal Violence: Protocol for a Pilot Randomized Controlled Trial

BACKGROUND

Black women bear a disproportionate burden of HIV, accounting for nearly 60% of new diagnoses among US women. Black women living with HIV often experience mutually reinforcing epidemics, known as syndemics, including interpersonal violence and substance use. Syndemics are associated with decreased HIV care engagement and treatment adherence and worsening HIV outcomes. Few HIV services and resources are tailored to be culturally and gender-responsive and trauma informed for Black women living with HIV. Technology-based, psychoeducational, and peer navigation programs offer promising pathways to tailored HIV support and improved HIV care outcomes. Therefore, the web-based, trauma-informed intervention LinkPositively was developed in collaboration with Black women living with HIV to promote uptake of HIV care and ancillary support services.

OBJECTIVE

This study primarily determines the feasibility and acceptability of the LinkPositively intervention among Black women living with HIV affected by interpersonal violence. The secondary aim is to examine the preliminary impact of the LinkPositively intervention on retention in HIV care, antiretroviral therapy adherence, and viral suppression while evaluating the role of mechanism of change variables (eg, social support) in the associations.

METHODS

The LinkPositively trial is a pilot randomized controlled trial conducted in California, United States, among 80 adult Black women living with HIV who have experienced interpersonal violence. Core components of LinkPositively include one-on-one peer navigation with phone and SMS text message check-ins; 5 weekly one-on-one video sessions to build coping and care navigation skills; and a mobile app that contains a peer support social networking platform, an educational database with healthy living and self-care tips, a GPS-enabled HIV and ancillary care resource locator, and a medication self-monitoring and reminder system. Participants are randomly assigned to the intervention (n=40) or control (Ryan White standard of care; n=40) arm, with follow-up at 3 and 6 months. At each assessment, participants complete an interviewer-administered survey and submit hair samples for the assessment of HIV medication adherence. All research staff and investigators adhere to ethical principles and guidelines for conducting research activities. Data will be analyzed using generalized estimating equations.

RESULTS

Final development and testing of the LinkPositively app were completed in July 2021. As of May 2023, we have screened 97 women for eligibility. Of the 97 women screened, 27 (28%) were eligible and have been enrolled in the study. The dissemination of preliminary results will occur in 2024.

CONCLUSIONS

This trial will advance HIV prevention science by harnessing technology to promote engagement in HIV care while improving social support through peers and social networking-all while being trauma informed for Black women living with HIV with experiences of interpersonal violence. If shown to be feasible and acceptable, LinkPositively has the potential to improve HIV care outcomes among Black women, a marginalized key population.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/46325.

Measuring Trauma- (and Violence-) Informed Care: A Scoping Review

Trauma- (and violence-) informed care (T(V)IC) has emerged as an important practice approach across a spectrum of care settings; however how to measure its implementation and impact has not been well-examined. The purpose of this scoping review is to describe the nature and extent of available measures of T(V)IC, including the cross-cutting concepts of vicarious trauma and implicit bias. Using multiple search strategies, including searches conducted by a professional librarian from database inception to Summer 2020, 1074 articles were retrieved and independently screened for eligibility by two team members. A total of 228 were reviewed in full text, yielding 13 measures that met pre-defined inclusion criteria: 1) full-text available in English; 2) describes the initial development and validation of a measure, that 3) is intended to be used to evaluate T(V)IC. A related review of vicarious trauma measures yielded two that are predominant in this literature. Among the 13 measures identified, there was significant diversity in what aspects of T(V)IC are assessed, with a clear emphasis on "knowledge" and "safety", and less on "collaboration/choice" and "strengths-based" concepts. The items and measures are roughly split in terms of assessing individual-level knowledge, attitudes and practices, and organizational policies and protocols. Few measures examine structural factors, including racism, misogyny, poverty and other inequities, and their impact on people's lives. We conclude that existing measures do not generally cover the full potential range of the T(V)IC, and that those seeking such a measure would need to adapt and/or combine two or more existing tools.

Development of a universal short patient satisfaction questionnaire on the basis of SERVQUAL: Psychometric analyses with data of diabetes and stroke patients from six different European countries

Objective

A short questionnaire which can be applied for assessing patient satisfaction in different contexts and different countries is to be developed.

Methods

Six items addressing tangibles, reliability, responsiveness, assurance, empathy, and communication were analysed. The first five items stem from SERVQUAL (SERVice QUALity), the last stems from the discussion about SERVQUAL. The analyses were performed with data from 12 surveys conducted in six different countries (England, Finland, Germany, Greece, the Netherlands, Spain) covering two different conditions (type 2 diabetes, stroke). Sample sizes for included participants are 247 in England, 160 in Finland, 231 in Germany, 152 in Greece, 316 in the Netherlands and 96 in Spain for the diabetes surveys; and 101 in England, 139 in Finland, 107 in Germany, 58 in Greece, 185 in the Netherlands, and 92 in Spain for the stroke surveys. The items were tested by (1) bivariate correlations between the items and an item addressing ‘general satisfaction’, (2) multivariate regression analyses with ‘general satisfaction’ as criterion and the items as predictors, and (3) bivariate correlations between sum scores and ‘general satisfaction’.

Results

The correlations with ‘general satisfaction’ are 0.48 for tangibles, 0.56 for reliability, 0.58 for responsiveness, 0.47 for assurance, 0.53 for empathy, and 0.56 for communication. In the multivariate regression analysis, the regression coefficient for assurance is significantly negative while all other regression coefficients are significantly positive. In a multivariate regression analysis without the item ‘assurance’ all regression coefficients are positive. The correlation between the sum score and ‘general satisfaction’ is 0.608 for all six items and 0.618 for the finally remaining five items. The country specific results are similar.

Conclusions

The five items which remain after removing ‘assurance’, i.e. the SERVQUAL-MOD-5, constitute a short patient satisfaction index which can usefully be applied for different medical conditions and in different countries.

Effectiveness of 1-day trauma-informed care training programme on attitudes in psychiatric hospitals: A pre-post study

Many patients in mental health settings are likely to have histories of interpersonal traumatic experiences. Mental health providers are recommended to adopt trauma-informed care (TIC) to ensure sensitivity and responsiveness to the impact of trauma on patients. However, few studies have examined the effectiveness of a TIC training programme using standardized measures with follow-up assessments. The aim of the study was to evaluate the effects of a TIC training programme on attitudes towards TIC in mental health professionals. The study involved a pre-post design with 3-month follow-up assessments conducted between March and June 2018. In total, 65 mental health professionals from 29 psychiatric hospitals in Tokyo and its suburban prefectures participated in the study. Mental health professionals participated in a 1-day programme consisting of a 3.5-hour lecture and 1-hour group discussion. Development of favourable attitudes towards TIC was the primary outcome, as assessed by using the Attitude Related Trauma-Informed Care scale. The majority of participants were women (86%), and the mean age was 42.2 years. The mean score of the Attitude Related Trauma-Informed Care scale scores increased significantly from 5.1 during pre-training to 5.5 immediately after training (mean difference: 0.4; 95% confidence interval: 0.3-0.5) and 5.4 after 3 months (mean difference: 0.3; 95% confidence interval: 0.2-0.4). Furthermore, half of the participants claimed to have implemented TIC practice in daily clinical settings at the 3-month follow-up. These results suggested that this brief TIC training programme improved attitudes towards TIC practice significantly.

Action steps using ACEs and trauma-informed care: a resilience model

This paper 1) discusses two important contributions that are shaping work with vulnerable and under-resourced populations: Kaiser Permanente's (1998) Adverse Childhood Experiences Study (ACE) which includes the impact of adverse experiences in childhood on adult health and health behaviors and the more recent advent of what has come to be known as Trauma-Informed Care (TIC), programs which incorporate knowledge of the impact of early trauma into policies and programs. 2) Despite many positive benefits that have come from both contributions there are unintended consequences, described in the paper, that have an impact on research and program evaluation as well as social policies and programs. 3) Three key neuroscience concepts are recommended for inclusion in Trauma-Informed Care programs and practices in ways that can enrich program design and guide the development of practical, resilience-oriented interventions that can be evaluated for outcomes. 4) Finally, a resilience-oriented approach to TIC is recommended that moves from trauma information to neuroscience-based action with practical skills to build greater capacity for self-regulation and self-care in both service providers and clients. Examples from criminal justice are used.

Literature review of trauma-informed care: Implications for mental health nurses working in acute inpatient settings in Australia

Trauma-informed care (TIC) is increasingly recognized as an approach to improving consumers' experience of, and outcomes from, mental health services. Deriving consensus on the definition, successful approaches, and consumer experiences of TIC is yet to be attained. In the present study, we sought to clarify the challenges experienced by mental health nurses in embedding TIC into acute inpatient settings within Australia. A systematic search of electronic databases was undertaken to identify primary research conducted on the topic of TIC. A narrative review and synthesis of the 11 manuscripts retained from the search was performed. The main findings from the review indicate that there are very few studies focussing on TIC in the Australian context of acute mental health care. The review demonstrates that TIC can support a positive organizational culture and improve consumer experiences of care. The present review highlights that there is an urgency for mental health nurses to identify their role in delivering and evaluating TIC, inclusive of undertaking training and clinical supervision, and to engage in systemic efforts to change service cultures.

The Client Satisfaction Questionnaire-8: Psychometric properties in a cross-sectional survey of people attending residential substance abuse treatment

INTRODUCTION AND AIMS

The Client Satisfaction Questionnaire (CSQ-8) is one of a limited number of standardised satisfaction measures that have been used widely across mental health services. This study examined the CSQ-8 as a measure of general satisfaction within residential substance abuse treatment. It compared the CSQ-8 with another established measure of client satisfaction that was developed for substance abuse treatment settings (Treatment Perceptions Questionnaire, TPQ). It also sought to examine the relationship between the CSQ-8 and commonly used process measures.

DESIGN AND METHODS

Cross-sectional data was collected from across 14 Australian residential medium-to-long term alcohol and other drug treatment facilities (N = 1378). Demographic, substance abuse and mental health characteristics were collected, as well as process measures of craving, general functioning, self-perceptions, recovery and symptom distress.

RESULTS

A confirmatory factory analysis established that the CSQ-8 retains a single factor. The scale was strongly correlated with the TPQ, suggesting high concurrent validity. However, while the TPQ was normally distributed, the CSQ-8 was highly negatively skewed. Significant associations were found between the CSQ-8 and cross-sectional process measures.

DISCUSSION AND CONCLUSIONS

Results suggest that that CSQ-8 is an appropriate measure to be used in residential substance abuse treatment settings. However, because of the high levels of negative skew, it is likely that the TPQ is more accurate in capturing clients' dissatisfaction than the CSQ-8. Future research should include longitudinal studies of satisfaction in order to examine how changes in satisfaction may be related to client characteristics, outcome measures, dropout or re-engagement in treatment. [Kelly PJ, Kyngdon F, Ingram I, Deane FP, Baker AL, Osborne BA. The Client Satisfaction Questionnaire-8: Psychometric properties in a cross-sectional survey of people attending residential substance abuse treatment. Drug Alcohol Rev 2018;37:79-86].

Which kind of psychometrics is adequate for patient satisfaction questionnaires?

The construction and psychometric analysis of patient satisfaction questionnaires are discussed. The discussion is based upon the classification of multi-item questionnaires into scales or indices. Scales consist of items that describe the effects of the latent psychological variable to be measured, and indices consist of items that describe the causes of this variable. Whether patient satisfaction questionnaires should be constructed and analyzed as scales or as indices depends upon the purpose for which these questionnaires are required. If the final aim is improving care with regard to patients' preferences, then these questionnaires should be constructed and analyzed as indices. This implies two requirements: 1) items for patient satisfaction questionnaires should be selected in such a way that the universe of possible causes of patient satisfaction is covered optimally and 2) Cronbach's alpha, principal component analysis, exploratory factor analysis, confirmatory factor analysis, and analyses with models from item response theory, such as the Rasch Model, should not be applied for psychometric analyses. Instead, multivariate regression analyses with a direct rating of patient satisfaction as the dependent variable and the individual questionnaire items as independent variables should be performed. The coefficients produced by such an analysis can be applied for selecting the best items and for weighting the selected items when a sum score is determined. The lower boundaries of the validity of the unweighted and the weighted sum scores can be estimated by their correlations with the direct satisfaction rating. While the first requirement is fulfilled in the majority of the previous patient satisfaction questionnaires, the second one deviates from previous practice. Hence, if patient satisfaction is actually measured with the final aim of improving care with regard to patients' preferences, then future practice should be changed so that the second requirement is also fulfilled.

A critical black feminist ethnography of treatment for women with co-occurring disorders in the psychiatric hospital

The purpose of this study was to explore the perspectives of women diagnosed with co-occurring disorders on the treatments provided by a state psychiatric hospital so that appropriate recommendations for changes in treatment may be made. Critical ethnography was used and the data was viewed through the lens of intersectionality from the black feminist perspective. Seven women hospitalized in one psychiatric hospital in the Mid-Atlantic region participated in the study. Data was collected via semistructured interviews, Consumer Perceptions of Care survey, researcher's observations, and archival data. Three major findings emerged: (1) Dialectical Behavioral Therapy (DBT) was identified as a beneficial treatment, (2) a lack of trust in the system and people in the system, and (3) housing or homelessness was perceived as a barrier. Based on the results of this study, it is recommended clinicians, administrators, and policy makers listen closely to individuals receiving treatment to make decisions regarding treatment accordingly.

Satisfaction measurement instruments for healthcare service users: a systematic review

Patient satisfaction surveys can be an interesting way to improve quality and discuss the concept of patient-centered care. This study aimed to conduct a systematic review of the validated patient satisfaction measurement instruments applied in healthcare. The systematic review searched the MEDLINE/PubMed, LILACS, SciELO, Scopus and Web of Knowledge. The search strategy used the terms: "Patient Satisfaction" AND "Patient centered care" AND "Healthcare survey OR Satisfaction questionnaire" AND "Psychometric properties". 37 studies were included and almost all studies showed that satisfaction is a multidimensional construct. In these studies, 34 different instruments were used and most surveys contained the dimension patient-healthcare professional interactions, physical environment and management process. The COSMIN score for methodological quality showed that most of them scored a good or fair average. We can conclude that there is not a gold standard instrument for patient satisfaction assessment but some dimensions are essential for this construct.

Consumer perceptions of trauma assessment and intervention in substance abuse treatment

Substance abuse treatment programs are increasing their use of integrated interventions for trauma and substance abuse. While positive behavioral outcomes have been associated with this model, the purpose of this study was to determine consumers' satisfaction with it. Participants were 51 men and 102 women who received trauma assessments and interventions through a drug treatment court. Satisfaction with treatment was measured through the Consumer Perception of Care (CPC). Participants were generally satisfied with the trauma assessments and interventions they received. Number of traumatic experiences, measured by the Adverse Childhood Experiences (ACE) scale, and level of distress, as assessed on the Trauma Symptom Inventory (TSI), were significantly associated with assessment and treatment satisfaction. Gender differences were noted, with men reporting fewer traumatic experiences and trauma-symptoms and less satisfaction with trauma assessment. Implications for the integration of trauma and substance abuse interventions in drug treatment courts and other programs are discussed.

Trauma-informed care in inpatient mental health settings: a review of the literature

Trauma-informed care is an emerging value that is seen as fundamental to effective and contemporary mental health nursing practice. Trauma-informed care, like recovery, leaves mental health nurses struggling to translate these values into day-to-day nursing practice. Many are confused about what individual actions they can take to support these values. To date, the most clearly articulated policy to emerge from the trauma-informed care movement in Australia has been the agreement to reduce, and wherever possible, eliminate the use of seclusion and restraint. Confronted with the constant churn of admissions and readmissions of clients with challenging behaviours, and seemingly intractable mental illness, the elimination of seclusion and restraint is seen to be utopian by many mental health nurses in inpatient settings. Is trauma-informed care solely about eliminating seclusion and restraint, or are there other tangible practices nurses could utilize to effect better health outcomes for mental health clients, especially those with significant abuse histories? This article summarizes the findings from the literature from 2000-2011 in identifying those practices and clinical activities that have been implemented to effect trauma-informed care in inpatient mental health settings.

Dual diagnosis clients' treatment satisfaction - a systematic review

BACKGROUND

The aim of this systematic review is to synthesize existing evidence about treatment satisfaction among clients with substance misuse and mental health co-morbidity (dual diagnoses, DD).

METHODS

We examined satisfaction with treatment received, variations in satisfaction levels by type of treatment intervention and by diagnosis (i.e. DD clients vs. single diagnosis clients), and the influence of factors other than treatment type on satisfaction. Peer-reviewed studies published in English since 1970 were identified by searching electronic databases using pre-defined search strings.

RESULTS

Across the 27 studies that met inclusion criteria, high average satisfaction scores were found. In most studies, integrated DD treatment yielded greater client satisfaction than standard treatment without explicit DD focus. In standard treatment without DD focus, DD clients tended to be less satisfied than single diagnosis clients. Whilst the evidence base on client and treatment variables related to satisfaction is small, it suggested client demographics and symptom severity to be unrelated to treatment satisfaction. However, satisfaction tended to be linked to other treatment process and outcome variables. Findings are limited in that many studies had very small sample sizes, did not use validated satisfaction instruments and may not have controlled for potential confounders. A framework for further research in this important area is discussed.

CONCLUSIONS

High satisfaction levels with current treatment provision, especially among those in integrated treatment, should enhance therapeutic optimism among practitioners dealing with DD clients.

Outcomes of mandated treatment for women with histories of abuse and co-occurring disorders

Although there is much momentum for behavioral health policies supporting mandated treatment, there is little evidence supporting its safety and effectiveness for individuals with complex issues. The authors used a national study of women with co-occurring psychiatric, substance use disorders and histories of trauma to compare mandated and voluntary treatment by examining psychiatric, substance use, and trauma-related outcomes following treatment. This quasi-experimental study included 2,726 women, with measures completed at baseline, 6-month, and 12-month follow-up. Two-way analyses of covariance examined the main and interactive effects of coercive status (mandated vs. voluntary) and condition (integrated treatment vs. services as usual) on psychiatric distress, trauma-related symptoms, and substance use outcomes. Women did better with integrated treatment and with mandated treatment regardless of treatment condition for psychiatric, trauma, and substance use outcomes at both follow-ups. Further research clarifying unintended side effects and change mechanisms of mandated treatment is needed to inform policy decisions.