Well-Being Domains in U.S. Military Veterans: Identifying Modifiable Factors to Promote Whole Health.

The U.S. Department of Veterans Affairs is actively transitioning away from a disease-centric model of healthcare to one that prioritizes disease prevention and the promotion of overall health and well-being. Described as Whole Health, this initiative aims to provide personalized, values-centered care that optimizes physical, behavioral, spiritual, and socioeconomic well-being. To inform this initiative, we analyzed cross-sectional data from a nationally representative sample of primarily older U.S. military veterans to estimate levels of well-being across these domains, and identify sociodemographic, military, and potentially modifiable health and psychosocial correlates of them. Results revealed that, overall, veterans reported high domain-specific well-being (average scores ranging from 6.7 to 8.3 out of 10), with the highest levels in the socioeconomic domain and lowest in the physical domain. Several modifiable factors, including purpose in life, resilience, and social support, were strongly associated with the examined well-being domains. Interventions targeting these constructs may help promote well-being among U.S. veterans.

Suicidal Thoughts and Behaviors in Older U.S. Military Veterans: Results From the National Health and Resilience in Veterans Study.

OBJECTIVE: To identify the prevalence and correlates associated with suicidal thoughts and behaviors (STBs) in a nationally representative sample of older (55+) US military veterans. METHODS: Data were analyzed from the 2019-2020 National Health and Resilience in Veterans Study (N = 3,356; mean age = 70.6). Self-report measures of past-year suicidal ideation (SI), lifetime suicide plan, lifetime suicide attempt(s), and future suicide intent were examined in relation to sociodemographic, neuropsychiatric, trauma, physical health, and protective factors. RESULTS: A total of 6.6% (95% CI = 5.7%-7.8%) of the sample endorsed past-year SI, 4.1% (CI = 3.3%-5.1%) a lifetime suicide plan, 1.8% (CI = 1.4%-2.3%) a lifetime suicide attempt, and 0.9% (CI = 0.5%-1.3%) future suicide intent. Higher levels of loneliness and lower levels of purpose in life were most strongly associated with past-year SI; lifetime history of major depressive disorder with suicide plan and suicide attempt; and frequency of past-year SI and more negative expectations regarding emotional aging with future suicide intent. CONCLUSION: These findings provide the most up-to-date nationally representative prevalence estimates of STBs among older military veterans in the United States. Several modifiable vulnerability factors were found to be associated with suicide risk in older US military veterans, suggesting that these factors may be targets for intervention in this population.

Purpose in life and physical health in older U.S. military veterans: Cross-sectional results from the National Health and Resilience in Veterans Study.

General population studies suggest purpose in life (PIL) is associated with a number of positive outcomes, including better mental and physical health. At present, however, scarce research has examined how PIL relates to these outcomes in veterans. The goal of this study was to determine the current prevalence of different levels of PIL and their associations with reported physical health in a nationally representative sample of predominantly older U.S. veterans. Cross-sectional data were analyzed from the 2019-2020 National Health and Resilience in Veterans Study (N = 4069; M(age) = 62.2). Veterans were classified into low, average, and high PIL. Self-report assessments were administered to assess physical health conditions and physical functioning. Results showed most veterans endorsed average PIL (71.7%), while 16.0% endorsed low PIL and 12.3% endorsed high PIL. Low PIL was associated with lower overall self-reported health and physical and cognitive functioning, as well as higher bodily pain, somatic symptoms, and physical role limitations (Cohen's d = 0.06-0.77). Low PIL was also associated with elevated rates of several physical health conditions, including sleep disorders, as well as obesity and disability with activities of daily living (i.e., ADLs) or instrumental activities of daily living (i.e., IADLs). These results suggest low PIL is associated with physical health difficulties, and underscore the importance of assessing and monitoring PIL, and evaluating whether interventions to promote PIL may help improve physical health and vice versa.

Identifying significant correlates of purpose in life in older US military veterans: results from the national health and resilience in veterans study.

OBJECTIVE: Perceived purpose in life (PIL) has been linked to a broad range of adverse physical, mental, and cognitive outcomes. However, limited research has examined factors associated with PIL that can be targeted in prevention and treatment efforts in aging populations at heightened risk of adverse outcomes. Using data from predominantly older US veterans, we sought to identify important correlates of PIL. METHODS: Cross-sectional data were analyzed from the 2019-2020 National Health and Resilience in Veterans Study, which surveyed a nationally representative sample of 4069 US military veterans (Mage = 62.2). Elastic net and relative importance analyses were conducted to evaluate sociodemographic, military, health, and psychosocial variables that were strongly associated with PIL. RESULTS: Of the 39 variables entered into an elastic net analysis, 10 were identified as significant correlates of PIL. In order of magnitude, these were resilience (18.7% relative variance explained [RVE]), optimism (12.1%), depressive symptoms (11.3%), community integration (10.7%), gratitude (10.2%), loneliness (9.8%), received social support (8.6%), conscientiousness (8.5%), openness to experience (5.4%), and intrinsic religiosity (4.7%). CONCLUSIONS: Several modifiable psychosocial factors emerged as significant correlates of PIL in US military veterans. Interventions designed to target these factors may help increase PIL and mitigate risk for adverse health outcomes in this population.

Dispositional hope as a potential outcome parameter among patients with advanced malignancy: An analysis of the ENABLE database.

BACKGROUND: Hopefulness, whether inherently present (dispositional hope) or augmented (by enhancement techniques), may affect outcomes. This study was performed to determine the association of dispositional hope with survival among patients diagnosed with advanced cancer. METHODS: Data from ENABLE (Educate, Nurture, Advise, Before Life Ends), a palliative care intervention, were reanalyzed to determine the association of higher dispositional hope and patient survival. This was a secondary analysis of data combined from the ENABLE II and ENABLE III randomized controlled trials (RCTs) with respect to dispositional hope and survival. A dispositional hope index was created from 3 hope items from 2 validated baseline questionnaires. Dispositional hope and survival data were collected during the 2 RCTs. In ENABLE II, participants were randomly assigned to the ENABLE intervention or to usual care. In ENABLE III, participants were randomly assigned to receive the intervention immediately or 12 weeks after enrollment. RESULTS: In all, 529 persons were included in Cox proportional hazards regression analyses to model the effects of dispositional hope on survival. An initial analysis without covariates yielded a significant effect of hope (Wald statistic, 8.649; hazard ratio, 0.941; confidence interval, 0.904-0.980; P = .003), such that higher dispositional hope was associated with longer survival. In a subsequent analysis that included all covariates, the effect of dispositional hope approached statistical significance (Wald statistic, 2.96; hazard ratio, 0.933; confidence interval, 0.863-1.010; P = .085). CONCLUSIONS: Higher levels of dispositional hope were associated with longer survival in patients with advanced cancer. Prospective trials are needed to determine the effects of dispositional and augmented hope on the outcomes of patients with advanced cancer.

Hoping to Pass: Randomized Trial of a One-Time Hope Intervention on Standardized Exam Passing Rates in BSN Students.

BACKGROUND: National standardized nursing exams serve as critical measures of student readiness for practice and carry significant consequences for students and academic institutions. Educational interventions that can enhance a student's performance increase the probability of academic success. Previous studies link hope to grade point average in college students and on standardized exam (SE) scores in nursing students, yet it is not clear if hope can be increased utilizing a one-time intervention in ways that produce lasting benefits for passing SEs. AIMS: Aim 1 tested the efficacy of a one-time hope intervention on increasing SE passing rates among BSN nursing students. Aim 2 examined the role of the interventions, selected state-mechanism variables, and trait characteristics in predicting SE passing. METHOD: This comparative-effectiveness trial utilized a randomized, controlled, multiple-cohort experimental design to compare a one-time 90-minute hope intervention to an attention-matched progressive muscle relaxation intervention on SE passing scores among BSN nursing students. RESULTS: Levels of hope briefly increased following the hope intervention. Both interventions demonstrated short-term improvement in state-level psychosocial indicators but did not affect SE scores. Among trait and mechanism factors, only academic self-efficacy was linked with passing SEs. CONCLUSIONS: This study demonstrated that a single-session hope intervention can increase short-term hope. In this sample of 292 BSN students, there was no statistically significant long-term effect on passing SEs; however, this study may lay the groundwork for future interventions investigating booster sessions, or how to modify the intervention for struggling students.

The science of hope.

Hope is a contextual term that has different connotations depending on the setting. We analyse the concept of hope with respect to its applicability for oncology. We review studies that present hope as a direct or secondary mediator of outcome. We posit that an individual's level of hope is often determined by innate personality characteristics and environmental factors, but can also be physiologically influenced by immune modulators, neurotransmitters, affective states, and even the underlying disease process of cancer. We argue that hope can be a therapeutic target and review evidence showing the effects of hope-enhancing therapies. Given the potential for hope to alter oncological outcomes in patients with cancer and the opportunity for improvement in quality of life, we suggest further research directions in this area.

Stepwise Psychosocial Palliative Care: A New Approach to the Treatment of Posttraumatic Stress Disorder at the End of Life.

Although evidence-based therapies for Posttraumatic Stress Disorder (PTSD) exist for physically healthy populations, these often do not adequately address PTSD in dying patients. Particularly because these interventions require 8-16 weekly sessions, and the median stay in U.S. hospices is 17.5 days (National Hospice and Palliative Care Organization [NHPCO], 2015 ), there is a potentially serious timing mismatch. Moreover, these treatments may temporarily increase trauma symptoms (Nishith, Resick, & Griffin, 2002 ), resulting in some patients dying in greater distress than had they not received care. The Stepwise Psychosocial Palliative Care (SPPC) model presented in this article compensates for these difficulties by embracing a palliative care approach to PTSD. Although it utilizes techniques drawn from existing PTSD interventions, these are re-ordered and utilized in a time-responsive, patient-centered manner that takes into account prognosis, fatigue, and logistical concerns. The SPPC approach is further considered with respect to existing social work palliative care competencies (Gwyther et al., 2005 ) and a case study is used to demonstrate its application.

Treatment of posttraumatic stress disorder at the end-of-life: application of the Stepwise Psychosocial Palliative Care model.

OBJECTIVES: Feldman (2011) has proposed a new approach to the treatment of posttraumatic stress disorder (PTSD) in individuals at the end-of-life known as Stepwise Psychosocial Palliative Care (SPPC). This approach helps to compensate for the disadvantages of existing PTSD interventions with regard to treating patients with life-limiting and terminal illnesses by employing a palliative care philosophy. The model relies on cognitive and behavioral techniques drawn from evidence-based approaches to PTSD, deploying them in a stage-wise manner designed to allow for interventions to track with patents' needs and prognoses. Because this model is relatively new, we seek to explore issues related to its implementation in the complex settings in which providers encounter patients at the end-of-life. We also seek to provide concrete guidance to providers regarding the management of PTSD at the end-of-life in diverse palliative care settings. METHODS: We examine three specific cases in which the SPPC model was utilized, highlighting particular treatment challenges and strategies. These case studies provide information regarding the SPPC model's application to patients in two distinct palliative care settings-a palliative care consult team and an inpatient palliative care unit. RESULTS: The SPPC model's stage-wise approach allows for its flexible use given a variety of constraints related to setting and patient issues. SIGNIFICANCE OF RESULTS: The SPPC model provides an alternative to existing psychosocial treatments for PTSD that may be more appropriate for patients at the end of life.

Feeling hopeful: development and validation of the trait emotion hope scale.

While prominent measures of hope are largely cognitive in nature, many scholars and laypeople view hope primarily as an emotion. Although Snyder's Elaborated Hope Theory attempts to theoretically balance these two perspectives, no measure yet exists of hope as a purely emotional process, only as a cognitive process. Overlooking the emotional features of hope limits our ability to more fully and precisely understand this construct. As such, across three studies (N = 2,900), we develop and validate the Trait Emotion Hope Scale (TEHS). In Study 1, we report on item development and piloting of the TEHS, examining internal consistency as well as convergent and discriminant validity. Study 2 includes an exploratory factor analysis (EFA) and further examines internal consistency and construct validity. Finally, in Study 3 we report a confirmatory factor analysis (CFA) to cross-validate the factor structure identified in Study 2 in a large, international sample. Importantly, we find that the TEHS accounts for significant unique variance beyond cognitive hope, indicating that the two constructs are distinct and not redundant. Taken together, these three studies demonstrate that the TEHS is psychometrically sound and provides a valid measure for those interested in examining hope as an emotion in their research.

Hope during somber times: a defining moment.

In addition to the diverse educational materials the National Cancer Institute provides to patients, caregivers, and health-care professionals, the NCI maintains an online dictionary that provides concise definitions of terms used in modern oncology. The dictionary is regarded as a valuable data reserve because it is updated frequently and employs language that facilitates comprehension among lay users and professionals alike. In this commentary, we call attention to the absence of the word hope as an entry in this important digital resource. Moreover, we propose not only including the concept of hope in this vital reference text but also basing its meaning on C. R. Snyder's model of "hope theory," which stresses the importance of 3 entities: goals, pathways thinking, and agency. Finally, we argue that hope can be taught as a skill to relevant stakeholders (eg, patients, caregivers, and health-care professionals) through brief workshops that have recently been expanded from in-person encounters to virtual platforms revolving around a user-friendly mobile app called "Hopetimize."

Hope and cancer.

Two models of hope have predominated in the literature pertaining to cancer-Snyder's "Hope Theory" and Herth's hope model-both of which have produced brief self-report measures. Growing evidence demonstrates that hope, as operationalized in these models, is associated with a number of psychological variables in individuals with cancer, including depression, distress, coping, symptom burden, and posttraumatic growth. Emerging evidence also suggests that hope may predict probability of survival in advanced cancer. Surveys show that patients and families generally prefer healthcare communication that authentically conveys prognosis; such communication is not associated with decreased hope, but may actually foster hope. Finally, several interventions have been developed to enhance hope in people with cancer, which generally demonstrate medium effects.

The Relationships of Hope, Optimism, and Academic Motivation With GPA Among University Students in Hong Kong.

Research demonstrates the relationship between dispositional hope and GPA, but mixed results regarding the relationship between dispositional optimism and GPA. Hope and optimism also have been shown to predict academic motivation. However, no study has yet investigated all of these factors together, and most research concerns only Western samples. In a cross-sectional sample of 129 Hong Kong university students, we administered measures of internal hope (hope regarding one's own capabilities), external-family hope (hope derived from family), optimism, and intrinsic and extrinsic academic motivation. We found significant zero-order correlations between internal hope and GPA, but not between external-family hope nor optimism and GPA. Mediation analyses showed that internal hope directly related to GPA, and did not appear mediated by academic motivation. Given our findings, future studies testing hope-based interventions in similar samples may be warranted. We discuss implications for culturally adapting hope interventions.

Purpose in life protects against the development of suicidal thoughts and behaviors in U.S. veterans without a history of suicidality: A 10-year, nationally representative, longitudinal study.

OBJECTIVES: To determine the incidence of suicidal ideation and suicide attempts (STBs) in veterans without an endorsed history of STBs and identify baseline predictors of these outcomes over a 10-year period. METHODS: Population-based prospective cohort study of 2307 US military veterans using five waves of the 2011-2021 National Health and Resilience in Veterans Study. Baseline data were collected in 2011, with follow-up assessments conducted 2-(2013), 4-(2015), 7-(2018), and 10-years (2021) later. RESULTS: In total, 10.1 % (N = 203) of veterans endorsed incident suicidal ideation (SI) over the 10-year period and 3.0 % (N = 55) endorsed an incident suicide attempt (SA). Multivariable regression analyses revealed the following baseline predictors of incident SI: lower annual household income, current posttraumatic stress disorder, current alcohol use disorder (AUD), disability with activities of daily living (i.e., ADLs) or instrumental activities of daily living (i.e., IADLs), lower perceived social support, lower community integration, and lower purpose in life. Current AUD, greater cumulative trauma burden, and lower purpose in life at baseline were predictive of incident SA. Relative importance analyses revealed that lower purpose in life was the strongest predictor of both incident SI and SA. CONCLUSIONS: Psychosocial determinants of health, such as purpose in life, may be more reliable predictors of incident suicidal thoughts and behaviors than traditional risk factors (e.g., psychiatric distress; history of SA) in those without a history of STBs. Evidence-based interventions that facilitate purpose in life and feelings of connectedness and belonging should be examined as possible treatments for STBs.

Feasibility and acceptability of an online intervention to enhance hopefulness among oncology professionals.

BACKGROUND: Patients prefer medical communication including both hopefulness and realism, though health-care professional (HCPs) struggle to balance these. Providers could thus benefit from a detailed personal understanding of hope, allowing them to model and convey it to patients. Additionally, given that hope is associated with lower levels of burnout, HCPs may benefit from tools designed to enhance their own personal hopefulness. Several investigators have proposed offering HCPs interventions to augment hope. We developed an online workshop for this purpose. METHODS: Feasibility and acceptability of the workshop were assessed in members of the SWOG Cancer Research Network. Three measures were used: the Was-It-Worth-It scale, a survey based on the Kirkpatrick Training Evaluation Model, and a single item prompting participants to rate the degree to which they believe concepts from the workshop should be integrated into SWOG studies. RESULTS: Twenty-nine individuals signed up for the intervention, which consisted of a single 2-hour session, and 23 completed measures. Results from Was-It-Worth-It items indicate that nearly all participants found the intervention relevant, engaging, and helpful. Mean ratings for Kirkpatrick Training Evaluation Model items were high, ranging from 6.91 to 7.70 on 8-point scales. Finally, participants provided a mean rating of 4.44 on a 5-point scale to the item "To what degree do you believe it may be useful to integrate concepts from this workshop into SWOG trials/studies?" CONCLUSIONS: An online workshop to enhance hopefulness is feasible and acceptable to oncology HCPs. The tool will be integrated into SWOG studies evaluating provider and patient well-being.

A focused intervention for 1st-year college students: promoting hope, sense of coherence, and self-efficacy.

Many students experience elevated psychological distress during their 1st year at college. Within the salutogenic paradigm (A. Antonovsky, 1987), sense of coherence (SOC), self-efficacy, and hope (in terms of hope theory; C. R. Snyder, 2002) are considered as protective factors in the demanding academic system. Study goals were to examine the outcomes of a focused workshop for 43 students, targeting the promotion of hope, sense of coherence, and self-efficacy for enhancing students' academic adjustment as expressed through their grades. Results revealed an effect over the 3 measurement time-points (before the workshop, immediately after it, and after 1 month), as well as the interactions of time and hope levels. Although their mean grades were not statistically different before the intervention, students who achieved higher levels of hope following the workshop got higher grades in the semester following the intervention. SOC and self-efficacy scores were significantly related both to hope levels after 1 month and to mean grades. The implications of this study for promoting a hopeful orientation in educational systems are discussed, and future interventional research is suggested.

Development of a measure of clinicians' self-efficacy for medical communication (SEMC).

OBJECTIVES: Studies of clinician-patient communication have used varied, ad hoc measures for communication efficacy. We developed and validated the Self-Efficacy for Medical Communication (SEMC) scale as a standard, quantitative measure of clinician-reported skills in communicating difficult news. METHODS: Using evidence-based scale development guidelines, we created two 16-item forms of the SEMC, one assessing communication with patients and one assessing communication with families. Clinicians providing oncological care in four organisations were invited to participate and provided consent. Participant demographics, responses to the SEMC items and responses to convergent and discriminant measures (those expected to relate strongly and weakly to the SEMC) were collected online. We performed analyses to determine the convergent and discriminant validity of the SEMC as well as its reliability and factor structure. RESULTS: Overall, 221 oncology clinicians (including physicians, residents, fellows, medical students, nurses, nurse practitioners and physician assistants) participated. The patient and family forms both demonstrated high internal consistency reliability (alpha=0.94 and 0.96, respectively) and were strongly correlated with one another (r=0.95, p<0.001). Exploratory factor analysis demonstrated that the SEMC measures a unitary construct (eigenvalue=9.0), and its higher mean correlation with convergent (r=0.46) than discriminant (r=0.22) measures further supported its validity. CONCLUSIONS: Our findings support the SEMC's validity and reliability as a measure of clinician-rated communication skills regarding conducting difficult conversations with patients and families. It provides a useful standard tool for future research in oncology provider-patient serious illness communication.

Posttraumatic stress disorder at the end of life: extant research and proposed psychosocial treatment approach.

According to some estimates, 84% of people experience a traumatic event during their lives (Vrana & Lauterbach, 1994), and 15% to 24% then develop posttraumatic stress disorder (PTSD). Many carry with them lasting effects of trauma as they age and enter the last phase of life. PTSD manifests in unique ways at the end of life, possibly disrupting factors associated with a positive dying process, including social support, medical communication, life review, and acceptance of death. Terminally ill people with PTSD may suffer more emotional distress, lower quality of life, and poorer medical prognosis than those without PTSD. Unfortunately, healthcare providers may not be trained to address this issue. This article reviews the literature concerning how PTSD may affect the end of life and proposes an intervention model based on a palliative care philosophy.

Hope, Burnout, and Life Satisfaction: An Intriguing Trinity Among Investigators of the SWOG Cancer Research Network.

PURPOSE: Although hope has been explored in patients, few studies have investigated hopefulness in health care professionals. We surveyed oncology professionals within the SWOG Cancer Research Network, exploring relationships among personal hopefulness, social support, work stress, burnout, and life satisfaction. We hypothesized that hope would mediate the relationships between these other variables and life satisfaction. METHODS: SWOG members were randomly selected for an online survey containing measures of hope, social support, work stress, burnout, and satisfaction with life. Of 1,000 invitees, 226 responded. RESULTS: We tested a multiple mediational model using Hayes' bootstrapping approach (ie, PROCESS v3.4). As hypothesized, hope partially mediated the relationships between burnout and life satisfaction as well as between social support and life satisfaction. In particular, hopefulness was associated with lower burnout (-0.23; P = .005), greater social support (0.23; P = .005), and greater life satisfaction (0.50; P < .001). Work stress was associated with greater burnout (0.57; P < .001) but was not associated with general life satisfaction. Finally, social support was associated with lower burnout (-0.16; P = .005) and greater life satisfaction (0.24; P < .001). CONCLUSION: Our results suggest that hope may mitigate the effects of burnout. The combination of hope and social support may prove helpful for reducing burnout and improving life satisfaction. Single-session hope-enhancement interventions incorporating both hope and social support have previously been shown to increase hope and well-being in non-health care professionals. Such interventions for health care providers warrant further study.