Mindful-Veteran: the implementation of a brief stress reduction course

"A reinstilled hope that they can change": Facilitator perspectives on a self-care and health promotion peer group program for veterans

Introduction

This study assessed the relevance, value, and effectiveness of "Taking Charge of My Life and Health" (TCMLH), a patient wellbeing peer group program for U.S. veterans focused on empowering them to identify what really matters in their lives and to work toward health goals that align with their mission, aspirations, or purpose in life. The potential of TCMLH to empower veterans to engage in self-care behaviors, make health behavior changes, and participate in health care decision making is important, as veterans are more likely than the general population to suffer from multiple chronic conditions that require ongoing self-management.

Methods

We conducted individual semi-structured interviews with 19 TCMLH facilitators serving in eight U.S. Veteran's Health Administration medical centers. Data were analyzed using an inductive approach to identify salient themes in facilitators' experiences.

Results

Facilitators reported that TCMLH participants demonstrated positive attitude changes (e.g., greater confidence and hope) and behavior changes (e.g., making healthcare appointments and implementing self-care practices) by program completion. Further, findings show that mindful awareness practices, the peer group setting, Whole Health assessment tools, and goal setting tools were perceived as the most impactful program elements leading to positive health behavior change.

Conclusion

Overall, findings suggest that this non-clinical peer group program can enhance patient wellbeing, and that there are certain program elements of TCMLH that are driving key attitudinal and behavioral changes.

Achieving Whole Health: A Preliminary Study of TCMLH, a Group-Based Program Promoting Self-Care and Empowerment Among Veterans

OBJECTIVE

An emerging literature suggests patients with chronic illnesses can benefit from integrated, person-centric approaches to health care, including group-based programs. However, much of the research in this area is disease specific. The objective of this study was to collect preliminary evidence on the efficacy of Taking Charge of My Life and Health (TCMLH), a Whole Health group-based program that emphasizes self-care and empowerment on the overall health and well-being of veterans, a population burdened with high rates of multiple chronic conditions.

METHOD

Self-reported outcomes, including standardized survey measures, were collected at pretest, posttest, and 2-month follow-up from 77 participants across 15 groups at four VA sites. Random intercept mixed-model regressions were used to analyze data.

RESULTS

Results from this initial study showed high satisfaction with the program and facilitators, and high attendance. There were significant pre-post gains in self-care attitudes and behaviors, patient motivation, meaning and purpose, mental health, perceived stress, goal progress, and goal-specific hope. Outcomes were maintained at 2-month follow-up for patient motivation, perceived stress, goal-specific hope, and goal progress. Significant gains were observed in health care empowerment and physical health from pretest to follow-up.

CONCLUSIONS

Preliminary findings support the efficacy of TCMLH, a Whole Health group-based program that emphasizes patient empowerment, self-care practices, and peer support. Future research priorities include a rigorous evaluation with a larger sample size and control group to assess effectiveness.

A Brief Report on an 8-Week Course of Mindfulness-based Care for Chronic Pain in the Treatment of Veterans With Back Pain: Barriers Encountered to Treatment Engagement and Lessons Learned

BACKGROUND

Chronic pain and associated symptoms are debilitating for veterans. Medical costs of treatments are high and current treatment options, most notably with opioid medications, have been associated with significant risk. Mindfulness-based interventions appear promising for chronic pain, but require additional testing in veteran care settings.

OBJECTIVE

This project was designed to test the feasibility of engaging and retaining veterans with chronic lower back pain in a new mindfulness protocol tailored for veterans, mindfulness-based care for chronic pain (MBCP). Clinical outcomes were also assessed.

DESIGN

An open pilot trial of an 8-week MBCP course that included meditation, gentle yoga, and psychoeducation.

SUBJECTS

Twenty-two veterans (mean age=49.77; 18% women) were recruited from a VA Medical Center in the Northeastern US. After screening for inclusion/exclusion criteria, 20 were eligible at baseline.

MEASURES

Veterans were assessed at baseline and postintervention for functional impairment, pain intensity and bothersomeness, depression, and mindfulness.

RESULTS

The average number of sessions completed was 5; only 4 (20%) attended all sessions. Eleven of the 20 participants (55%) attended 5 or more sessions and had complete preintervention and postintervention visits. Five of the 11 had a clinically meaningful decrease in pain intensity and in depressive symptoms, while 6 of 11 had a meaningful decrease in pain bothersomeness and functional impairment.

CONCLUSIONS

It was challenging to enroll and retain participants in this study, even with our intervention designed for veterans. We discuss possible adaptations and refinements in MBCP for veterans with chronic pain to enhance feasibility and improve upon these interventions.

Treatment Engagement and Outcomes of Mindfulness-Based Cognitive Therapy for Veterans with Psychiatric Disorders

Objectives: The aim of this study was to evaluate utilization and outcomes of mindfulness-based cognitive therapy (MBCT) provided to veterans with psychiatric disorders.

Design: Retrospective chart review.

Settings: Veterans Administration Medical Center (VAMC).

Subjects: Ninety-eight veterans with psychiatric illness who were enrolled in an MBCT class between May of 2012 and January of 2016. Subjects were predominately white (95%), male (81%), and >50 years old (74%). The most common psychiatric conditions were any mood disorder (82%) and post-traumatic stress disorder (54%).

Intervention: Eight-week MBCT class.

Outcome measures: Session attendance and pre- to postintervention changes in numbers of emergency department (ED) visits and psychiatric hospitalizations.

Results: The average number of sessions attended was 4.87 of 8 and only 16% were present for all sessions. Veteran demographic variables did not predict the number of MBCT sessions attended. However, both greater numbers of pre-MBCT ED visits (p = 0.004) and psychiatric admissions (p = 0.031) were associated with attending fewer sessions. Among patients who experienced at least one pre- or post-treatment psychiatric admission in the 2 years pre- or postintervention (N = 26, 27%), there was a significant reduction in psychiatric admissions from pre to post (p = 0.002). There was no significant change in ED visits (p = 0.535).

Conclusions: MBCT may be challenging to implement for veterans with psychiatric illness in, at least some, outpatient VAMC settings due to a high attrition rate. Possible mediation approaches include development of methods to screen for high dropout risk and/or development of shorter mindfulness-based interventions (MBIs) and/or coupling MBIs with pleasurable activities. The finding of a significant decrease in psychiatric hospitalizations from pre- to post-MBCT suggests that prospective studies are warranted utilizing MBCT for veterans at high risk for psychiatric hospitalization.

Refining a Church-Based Lifestyle Intervention Targeting African-American Adults at Risk for Cardiometabolic Diseases: A Pilot Study

Objective

The pilot study was intended to test the feasibility of a multiple-component lifestyle intervention targeting African American adults in a weight control and cardiometabolic risk reduction program on diet, activity, and stress, using community-engagement principles.

Methods

Applying mixed qualitative and quantitative measures, the intervention had a two-part sequential study design consisting of 12 weekly small group sessions that provided individual and group counseling in nutrition, exercise, and mindfulness, while incorporating focus group and interactive techniques to learn about barriers and acceptable practices for this population. The program was implemented at an African-American church in Nashville, Tennessee.

Results

Thirty-four participants (aged 56.1 ± 11 years, body mass index (BMI) 36.7 ± 6.6 kg/m²) completed the intervention. Lifestyle changes after the 12 weekly sessions showed some positive trends including reduced sodium intake (from 2725.3 ± 326.5 to 2132 ± 330, mg/day, P = 0.008), increased walking steps (from 4392.1 ± 497.2 to 4895.3 ± 497.9, steps/day, not significant), and slightly decreased Perceived Stress Scale (PSS) scores (from 13.7 ± 1.4 to 12.4 ± 1.5, not significant). Body fat % among male participants decreased significantly (from 33.8 ± 2.6 to 28 ± 2.6, %, P = 0.043). Among cardiometabolic risk biomarkers, hemoglobin A1c (HbA1c) decreased significantly (from 6.6 ± 0.2 to 6.1 ± 0.2, %, P < 0.001). The baseline PSS score was positively associated with baseline adiposity levels (e.g., weight, β = 2.4, P = 0.006). Twenty-one participants took part in focus groups during the program to identify barriers to healthy lifestyle changes. Primary barriers reported were price, time for preparing healthy meals, unfamiliarity with mindfulness activities, their health condition, and daily schedule available for physical activities.

Conclusions

This church-based pilot intervention was proven feasible by showing modest progress in reducing adiposity and decreasing HbA1c levels. The focus group and interactive methods facilitated program direction. Future full-scale studies are warranted to identify key strategies that provide more personalized approaches and supportive environments to sustain a healthy lifestyle among these at risk minorities with limited resources.

A systematic scoping review of complementary and alternative medicine mind and body practices to improve the health of veterans and military personnel

BACKGROUND

Meditation, imagery, acupuncture, and yoga are the most frequently offered mind and body practices in the Department of Veterans Affairs. Yet, the research on mind and body practices has been critiqued as being too limited in evidence and scope to inform clinical treatment.

OBJECTIVES

We conducted a systematic scoping review of mind and body practices used with veterans or active duty military personnel to identify gaps in the literature and make recommendations for future primary research.

RESEARCH DESIGN

Following systematic literature review methodology, we searched 5 databases using 27 different National Center for Complementary and Alternative Medicine-defined mind and body practices as text words, keywords, and MeSH terms through June 30, 2014. We also conducted handsearches of 4 previous reviews.

SUBJECTS

Active duty military members or veterans 18 years or older participating in mind and body practice interventions globally.

MEASURES

Data were extracted from studies meeting 5 inclusion criteria. The quality of randomized controlled trials (RCTs) was assessed using an existing checklist.

RESULTS

Of 1819 studies identified, 89 interventions (50 RCTs) published between 1976 and 2014, conducted in 9 countries, using 152 different measures to assess 65 health and well-being outcomes met our inclusion criteria. Most interventions took place in the United States (n=78). Meditation practices (n=25), relaxation techniques including imagery (n=20), spinal manipulation including physical therapy (n=16), and acupuncture (n=11) were the most frequently studied practices. Methodological quality of most RCTs was rated poorly.

CONCLUSIONS

Meditation and acupuncture practices are among the most frequently offered and studied mind and body practices. Future research should include yoga as it is currently understudied among veterans and military personnel. A repository of mind and body intervention outcome measures may further future research efforts, as would conducting pragmatic trials and more robust RCTs.

Experiences of racism and the incidence of adult-onset asthma in the Black Women's Health Study

BACKGROUND

Chronic stress resulting from experiences of racism may increase the incidence of adult-onset asthma through effects on the immune system and the airways. We conducted prospective analyses of the relation of experiences of racism with asthma incidence in the Black Women's Health Study, a prospective cohort of black women in the United States followed since 1995 with mailed biennial questionnaires.

METHODS

Among 38,142 participants followed from 1997 to 2011, 1,068 reported incident asthma. An everyday racism score was created based on five questions asked in 1997 and 2009 about the frequency in daily life of experiences of racism (eg, poor service in stores), and a lifetime racism score was based on questions about racism on the job, in housing, and by police. We used Cox regression models to derive multivariable incidence rate ratios (IRRs) and 95% CIs for categories of each racism score in relation to incident asthma.

RESULTS

The IRRs were 1.45 (95% CI, 1.19-1.78) for the highest compared with the lowest quartile of the 1997 everyday racism score (P for trend<.0001) and 1.44 (95% CI, 1.18-1.75) for the highest compared with the lowest category of 1997 lifetime racism. Among women who reported the same levels of racism in 1997 and 2009, the IRRs for the highest categories of everyday and lifetime racism were 2.12 (95% CI, 1.55-2.91) and 1.66 (95% CI, 1.20-2.30), respectively.

CONCLUSIONS

Given the high prevalence of experiences of racism and asthma in black women in the United States, a positive association between racism and asthma is of public health importance.

Racism, segregation, and risk of obesity in the Black Women's Health Study

We assessed the relation of experiences of racism to the incidence of obesity and the modifying impact of residential racial segregation in the Black Women's Health Study, a follow-up study of US black women. Racism scores were created from 8 questions asked in 1997 and 2009 about the frequency of "everyday" racism (e.g., "people act as if you are dishonest") and of "lifetime" racism (e.g., unfair treatment on the job). Residential segregation was measured by linking participant addresses to 2000 and 2010 US Census block group data on the percent of black residents. We used Cox proportional hazard models to estimate incidence rate ratios and 95% confidence intervals. Based on 4,315 incident cases of obesity identified from 1997 through 2009, both everyday racism and lifetime racism were positively associated with increased incidence. The incidence rate ratios for women who were in the highest category of everyday racism or lifetime racism in both 1997 and 2009, relative to those in the lowest category, were 1.69 (95% confidence interval: 1.45, 1.96; Ptrend < 0.01) and 1.38 (95% confidence interval: 1.15, 1.66; Ptrend < 0.01), respectively. These associations were not modified by residential segregation. These results suggest that racism contributes to the higher incidence of obesity among African American women.