Trajectories of functioning in a population-based sample of veterans: contributions of moral injury, PTSD, and depression.

BACKGROUND: Although research has shown that exposure to potentially traumatic and morally injurious events is associated with psychological symptoms among veterans, knowledge regarding functioning impacts remains limited. METHODS: A population-based sample of post-9/11 veterans completed measures of intimate relationship, health, and work functioning at approximately 9, 15, 21, and 27 months after leaving service. Moral injury, posttraumatic stress, and depression were assessed at ~9 months post-separation. We used Latent Growth Mixture Models to identify discrete classes characterized by unique trajectories of change in functioning over time and to examine predictors of class membership. RESULTS: Veterans were assigned to one of four functioning trajectories: high and stable, high and decreasing, moderate and increasing, and moderate and stable. Whereas posttraumatic stress, depression, and moral injury associated with perpetration and betrayal predicted worse outcomes at baseline across multiple functioning domains, moral injury associated with perpetration and depression most reliably predicted assignment to trajectories characterized by relatively poor or declining functioning. CONCLUSIONS: Moral injury contributes to functional problems beyond what is explained by posttraumatic stress and depression, and moral injury due to perpetration and depression most reliably predicted assignment to trajectories characterized by functional impairment over time.

Pathway to Healing and Recovery: Alleviation of Survivor Worries in Sexual Assault Nurse Examiner-Led Sexual Assault Telehealth Examinations.

INTRODUCTION: The purpose of this study is to understand the pre-examination worries of individuals who experience sexual assault, and whether those worries were experienced or resolved during a telehealth-enabled, sexual assault nurse examiner-led sexual assault examination. METHODS: Patient surveys were administered to understand pre-examination worries, whether those worries were ultimately experienced during the consultation, and patient perceptions of care quality, telehealth consultation, and whether the examination helped individuals feel better. Data analysis was conducted using descriptive statistics and binomial proportion tests. RESULTS: Surveys were collected from 74 adolescents and adults who obtained sexual assault care at 6 rural and 2 suburban hospitals. Study findings showed individuals overcome substantial worries to access care, with 66% having at least 1 worry and 41% endorsing 3 or more pre-examination worries. Most participants felt believed (83%) and did not feel judged (88%) or blamed (85%) during their examination. Analysis of pre-examination worries and worry resolution during the examination showed 88% to 100% resolution of worries related to being believed, judged, blamed or lacking control. Participants highly rated the quality of care received (92%) and 84% stated the examination helped them feel better, suggesting a sexual assault nurse examiner-led examination is an important step toward recovery and healing. DISCUSSION: These findings have implications for emergency department support for sexual assault nurse examiner-led care and public health messaging to demystify sexual assault care, allay fears, and highlight care benefits.

The Moral Injury Symptoms Scale-Military Version-Short Form: Further Scale Validation in a U.S. Veteran Sample.

This study assessed the Moral Injury Symptoms Scale - Military Version - Short Form's (MISS-M-SF) factor structure and construct validity. Participants included 3650 combat-deployed U.S. veterans who answered all 10 MISS-M-SF items from the sixth wave of The Veterans Metric Initiative (TVMI). EFA results suggested a two-factor solution, based on item wording, fit best. CFA results indicated a bifactor model (one general factor and two method factors, based on item wording) fit best. Further investigation revealed that a one-factor model could be used despite the data's multidimensionality. Item-level analyses revealed four items represented the general factor exceptionally well, potentially simplifying assessment in research and clinical applications. Construct validity was also demonstrated through moderate to high correlations with conceptually related measures.

But they weren't being careful! Role of theory of mind in moral judgments about victim and transgressor negligence.

Previous research showed that children are influenced not only by intentions and outcomes but also by transgressor negligence in their moral judgments. The current study investigated the role of transgressor and victim negligence on children's moral judgments. Children's false-belief theory of mind understanding (FBU ToM) was examined as a possible factor that might shape moral judgments in contexts involving negligence. Children (N = 117, Mage = 5.41 years, range = 3-8) were presented with two stories involving property damage and physical harm where negligence was manipulated and with a series of questions assessing moral judgments regarding act acceptability of the transgressor and victim, punishment, and assessments of alternative actions. FBU ToM was measured with a false-content task. Children with higher FBU ToM were more likely to consider both transgressor and victim negligence in their moral judgments across different transgressions. The findings have implications for how social cognitive abilities interact with transgressor and victim negligence in moral decisions.

Moral Injury and Social Well-Being: A Growth Curve Analysis.

Moral injury (MI) may occur in the context of committing transgressions (i.e., self-directed MI reactions), witnessing transgressions, or being the victims of others' transgressions (i.e., other-directed MI reactions) that violate an individual's moral principles. Veterans with MI may experience impaired social well-being (SWB). Studies on MI and veterans' SWB have focused almost exclusively on social support and used cross-sectional data. The present study used growth curve analyses to examine the associations between self- and other-directed MI reactions and veterans' levels of social support, social functioning, social activities, and social satisfaction over the first 18 to 21 months of their transition to civilian life (N = 9,566). The results demonstrated declines in all SWB outcomes, with self- and other-directed MI reactions having differential effects. Higher versus lower levels of other-directed MI reactions were related to lower baseline scores on all SWB outcomes, ßs = -.06 to -.20, and steeper declines over time in social functioning, ß = -.09, and social satisfaction, ß = -.10. Higher versus lower levels of self-directed MI reactions were related to lower baseline levels of social functioning, ß = -.07, but higher baseline levels of social activity, ß = .04. Higher versus lower levels of self-directed MI reactions were related to a steeper decline in social activity over time, ß = -.10. These findings present a more nuanced picture than that depicted by current MI theoretical frameworks and support further research to uncover moderators of the associations between self- and other-directed MI reactions and SWB outcomes.

Social exclusion: the interplay of group goals and individual characteristics.

Past research has shown that adolescents justify social exclusion based on concerns for group functioning, and yet, to date, no study has evaluated whether group functioning justifications shift or remain stable across different exclusion contexts. In this study, we systematically manipulated exclusion context (i.e., competitive or noncompetitive soccer groups) and individual characteristics of the target of exclusion to test the nature of the interaction between these factors during exclusion judgments. Adolescents' (N = 201; 61% Female) exclusion judgments differed across contexts only when an individual's ability was under consideration. Intergroup (i.e., gender, nationality) and interpersonal (i.e., aggression, shyness) characteristics overwhelmed contextual considerations. Results indicate the complexity of factors weighed by adolescents when making exclusion judgments, and suggest the need for extension of the present findings to understand more fully the interaction between the context of exclusion and individual characteristics in exclusion judgments.

Meeting Complex Needs of Sexually Assaulted Incarcerated Individuals: Impact of Expert Sexual Assault Nurse Examiner Care via Telehealth.

Sexual violence within prisons is a complex issue. The Prison Rape Elimination Act identifies standards to guide the provision of care to meet the medical and forensic needs of individuals who experience sexual assault (SA) while incarcerated. The standards include access to care by a Sexual Assault Nurse Examiner (SANE) whenever possible. Telehealth is one solution to ensure expert SANE access. This brief report addresses the pre-examination concerns/worries and immediate post-examination perceptions and experiences of six individuals who experienced SA while incarcerated. Findings show resolution of pre-examination worries, high satisfaction with care, high telehealth acceptability rates, and universal endorsement that examinations should occur outside of correctional facilities. Although not generalizable, this report provides preliminary insight into care in an understudied population with unique health care needs.

The Impact of COVID-19 Restrictions on Victim Advocacy Agency Utilization Across Pennsylvania.

This brief report highlights the impact of the COVID-19 restrictions on the utilization of Victim Advocacy Agencies' (VAAs') services across Pennsylvania, using VAA utilization data from 2019-2020. VAA utilization data in this report were collected from 2019-2020 by the Pennsylvania Coalition Against Rape (PCAR). VAA utilization data were anchored to COVID-19 restriction timelines, defined by the Pennsylvania Office of the Governor. For each month, a percent change in VAA utilization (e.g., Jan 2020 utilization compared to Jan 2019 utilization) was calculated. A one-way ANOVA was run to assess whether the association between restriction phase and percent change in overall VAA utilization from 2019 to 2020 was statistically significant. A substantial decrease in VAA utilization was observed once lockdown restrictions were enacted, as well as a sustained decrease in utilization between 2019 and 2020. When restrictions were eased, an increase in service utilization was noted. This pattern of findings held for the three variables assessed: hotline utilization, new client, and medical accompaniments for FREs per month. The one-way ANOVA confirmed a statistically significant decrease in overall VAA utilization when comparing the most severe COVID-19 related restrictions to both pre-COVID and less severe restrictions. A variety of barriers (e.g., financial instability, loss of childcare, technology access, chronic physical proximity to abuser, hospital visitation restrictions, fears of contracting the virus) may result in decreased utilization of VAA services. Future research should investigate the relevance of potential causal mechanisms behind VAA utilization to help inform intervention approaches.

Local recurrence following complete radiologic response in patients treated with transarterial chemoembolization for hepatocellular carcinoma.

PURPOSE: The purpose of this study was to determine the local progression rate and identify factors that may predict local progression, in patients who achieve a complete response (CR) radiologically after undergoing transarterial chemoembolization (TACE) for hepatocellular carcinoma (HCC). MATERIALS AND METHODS: One-hundred-forty-seven patients, who achieved CR of 224 HCCs after TACE, were retrospectively reviewed. There were 109 men and 38 women with a mean age of 61.6 ± 6.8 (SD) years (range: 45.4-86.9 years). Logistic mixed-effects and Cox regression models were used to evaluate associations between clinical factors and local progression. RESULTS: A total of 75 patients (75/147; 51%) and 99 (99/224,44.2%) lesions showed local progression at a median of 289.5 days (Q1: 125, Q3: 452; range: 51-2245 days). Pre-treatment, international normalization ratio (INR) (1.17 ± 0.15 [SD] vs. 1.25 ± 0.16 [SD]; P <0.001), model for end-stage liver disease (9.4 ± 2.6 [SD] vs. 10.6 ± 3.2 [SD]; P = 0.010) and Child-Pugh score (6 ± 1 [SD] vs. 6.4 ± 1.3 [SD]; P = 0.012) were significantly lower while albumin serum level (3.4 ± 0.62 [SD] vs. 3.22 ± 0.52 [SD]; P = 0.033) was significantly greater in those who showed local progression as compared to those who did not. In terms of local-recurrence free survival, the number of TACE treatments (hazard ratio [HR]: 2.05 [95% CI: 1.57-2.67]; P<0.001), INR (HR: 0.13 [95% CI: 0.03-0.61]; P = 0.010) and type of TACE (P = 0.003) were significant. Patients with local progression on any tumor did not differ from those who did in terms of overall survival (P = 0.072), however, were less likely to be transplanted (20/75, 26.7%) than those who did not (33/72; 36.1%) (P = 0.016). CONCLUSION: A significant number of patients who achieve CR of HCC after TACE have local progression. This emphasizes the importance of long-term follow up.

Who Is to Blame? Children's and Adults' Moral Judgments Regarding Victim and Transgressor Negligence.

Research has documented that individuals consider outcomes, intentions, and transgressor negligence when making morally relevant judgments (Nobes, Panagiotaki, & Engelhardt, 2017). However, less is known about whether individuals attend to both victim and transgressor negligence in their evaluations. The current study measured 3- to 6-year-olds (N = 70), 7- to 12-year-olds (N = 54), and adults' (N = 97, ages 18-25 years) moral judgments about scenarios in which an accidental transgression occurred involving property damage or physical harm. Participants were either assigned to conditions where the victim or the transgressor was negligent. Results revealed attention to negligence among all participants across a range of different moral judgment measures (including acceptability judgments, punishment judgments, and attributions of blame), with age-related increases in attention to negligence evident. Results provide novel evidence that children and adults consider not just outcomes and intentions, but also the role of negligence in both victims and transgressors, when making social decisions.

Military Mental Health Personnel Deployment Survey: A Secondary Analysis.

INTRODUCTION: Military mental health personnel (MMHP) have increasingly engaged in deployment-related roles in closer proximity to combat environments. Although studies examining deployment-related outcomes among military health care personnel have found combat exposure (CE) positively related to psychological problems, no studies of MMHP have investigated CE or its association with psychological outcomes. This study seeks to provide descriptive data on CE and perceived impacts associated with deployment, as well as explore how CE, perceptions of preparedness for deployment, difficulties during deployment (DDD), and meaningful work during deployment relate to appraisal of problems after deployment (ie, sleep problems, interpersonal withdrawal, depressive symptoms, and work problems). MATERIALS AND METHODS: Archival postdeployment survey data from 113 U.S. Air Force MMHP previously deployed to Iraq or Afghanistan were utilized to determine descriptive statistics on CE and other factors. Additionally, hierarchical linear regression was utilized to test relationships between CE, DDD, preparation for deployment, and meaningful work with reports of sleep problems, interpersonal withdrawal, work problems, and depression symptoms. The study was approved by the Institutional Review Board of the U.S. Air Force Academy. RESULTS: MMHP reported an average of 1.58 (standard deviation = 1.03) combat-related events and DDD included: (1) being away from family/close friends (62%), (2) uncertain redeployment date (35%), (3) difficulty adapting to a new situation (35%), and (4) working long hours (31%), with 66% endorsing two or more areas of difficulty. Most MMHP reported feeling prepared for deployment both professionally (91%) and personally (87%), as well as that their family was prepared (83%). Additionally, nearly all reported at least one meaningful work experience while deployed (96%) with positive impacts on their clients, being the most frequent (89%). Furthermore, CE predicted both sleep difficulties and interpersonal withdrawal. MMHP who perceived their deployment experience as difficult also had higher rates of postdeployment difficulties. Finally, we found no relationship between perceived deployment preparation and postdeployment outcomes. CONCLUSIONS: This is the first study of MMHP reporting CE rates and examining relationships between perceived outcomes and CE, deployment preparation, difficulties during deployment, and meaningful work. The vast majority of MMHP were exposed to more than one combat-related event; however, this rate of CE appears lower than what has been reported among a similar sample of military health care personnel. Although CE predicted difficulties, appraisals of difficulties during deployment experience predicted the highest rates of postdeployment difficulties, accounting for nearly a quarter or more of the outcome variance. The lack of relationship between deployment preparation and meaningful work is inconsistent with prior research and may be because of the limited response range in our sample. Additionally, other methodological limitations include: (1) cross-sectional study design, (2) lack of validated measures, and (3) the long-term retrospective nature of the assessment. Future research should incorporate more rigorous methodologies and assess constructs absent in this archival data set. Despite these limitations, this study provides important preliminary data to support future research development and funding. Additionally, the results may be used to normalize associated impacts and promote help seeking among MMHP.

Examining the Factor Structure of the Moral Injury Events Scale in a Veteran Sample.

INTRODUCTION: Interest in moral injury has burgeoned over the last decade as an increasing number of professionals recognize that current conceptualizations of trauma are not sufficient to explain some of the challenges that military service members face. The Moral Injury Events Scale (MIES) was the first instrument developed to measure exposure to military events that could produce moral injury (Nash et al., 2013). Two previously published validation studies that focused on service members still in uniform reveal some discrepancies regarding the scale's factor structure. Bryan and colleagues (2016) documented a three-factor solution (i.e., transgressions-others, transgressions-self, and betrayal), while Nash and colleagues (2013) noted a two-factor solution (i.e., perceived transgressions and perceived betrayals). MATERIALS AND METHODS: With an interest in further scale validation, the present study utilized survey data from a group of veterans recently separated from service, to test the fitness of the two- or three-factor model and to examine the invariance of the scale across gender and branch. The investigators followed the policies governing the protection of human subjects as prescribed by ICF Institutional Review Board. RESULTS: Findings revealed a two-factor structure that differed from previous factor solutions (transgressions-self and transgressions-others) and was invariant across gender and branch. High intercorrelations among the MIES items that addressed exposure and reaction to events suggested that these experiences tend to co-occur. Removal of the event items did not significantly impact model fit. CONCLUSIONS: The factor structure identified in the present study aligns with current theoretical conceptualizations of moral injury. The inability to distinguish between event and reaction items and the lack of impact on the factor structure when event items were removed from the model suggest the MIES is more accurately described as a measure of moral pain as compared to a measure of potentially morally injurious experiences (PMIEs). Given that all events associated with moral injury have impinged upon welfare, justice, rights, and fairness considerations, one could argue that little would be gained by focusing attention on the development of a measure of PMIEs. Given the lack of convergence in factor structure across samples, future directions may profit from a focus on further clarifying the temporal stability of the MIES factor structure.

A novel approach for evaluating programs designed to serve military veterans: Using an adapted common components analysis.

Evaluators are challenged to keep pace with the vast array of Veteran support programs operating in the United States, resulting in a situation in which many programs lack any evidence of impact. Due to this lack of evidence, there is no efficient way to suggest which programs are most effective in helping Veterans in need of support. One potential solution to this dilemma is to reconceptualize program evaluation, by moving away from evaluating programs individually to evaluating what is common across programs. The Common Components Analysis (CCA) is one such technique that aggregates findings from programs that have undergone rigorous evaluation at the level of program components (e.g., content, process, barrier reduction). Given that many Veteran programs lack outcome evidence from rigorous studies, an adaptation to CCA is needed. This report examines cross-sectional data from a pilot study using an adapted CCA across five domains of well-being (i.e., employment, education, legal/financial/housing, mental/physical health, and social/personal relationships). The purpose of this preliminary study is to determine the feasibility of eliciting program nominations and program components from Veterans via an online survey. When coupled with a longitudinal research design, this adaptation to CCA will allow for stronger causal claims about the expected impact of different program components within and across a variety of domains.

Common components analysis: An adapted approach for evaluating programs.

Common Components Analysis (CCA) summarizes the results of program evaluations that utilize randomized control trials and have demonstrated effectiveness in improving their intended outcome(s) into their key elements. This area of research has integrated and modified the existing CCA approach to provide a means of evaluating components of programs without a solid evidence-base, across a variety of target outcomes. This adapted CCA approach (a) captures a variety of similar program characteristics to increase the quality of the comparison within components; (b) identifies components from four primary areas (i.e., content, process, barrier reduction, and sustainability) within specific programming domains (e.g., vocation, social); and (c) proposes future directions to test the extent to which the common components are associated with changes in intended program outcomes (e.g., employment, job retention). The purpose of this paper is to discuss the feasibility of this adapted CCA approach. To illustrate the utility of this technique, researchers used CCA with two popular employment programs that target successful Veteran reintegration but have limited program evaluation - Hire Heroes USA and Hire Our Heroes. This adapted CCA could be applied to longitudinal research designs to identify all utilized programs and the most promising components of these programs as they relate to changes in outcomes.

Let's get technical: Enhancing program evaluation through the use and integration of internet and mobile technologies.

Program evaluation has become increasingly important, and information on program performance often drives funding decisions. Technology use and integration can help ease the burdens associated with program evaluation by reducing the resources needed (e.g., time, money, staff) and increasing evaluation efficiency. This paper reviews how program evaluators, across disciplines, can apply internet and mobile technologies to key aspects of program evaluation, which consist of participant registration, participant tracking and retention, process evaluation (e.g., fidelity, assignment completion), and outcome evaluation (e.g., behavior change, knowledge gain). In addition, the paper focuses on the ease of use, relative cost, and fit with populations. An examination on how these tools can be integrated to enhance data collection and program evaluation is discussed. Important limitations of and considerations for technology integration, including the level of technical skill, cost needed to integrate various technologies, data management strategies, and ethical considerations, are highlighted. Lastly, a case study of technology use in an evaluation conducted by the Clearinghouse for Military Family Readiness at Penn State is presented and illustrates how technology integration can enhance program evaluation.

The accidental transgressor: morally-relevant theory of mind.

To test young children's false belief theory of mind in a morally relevant context, two experiments were conducted. In Experiment 1, children (N = 162) at 3.5, 5.5, and 7.5 years of age were administered three tasks: prototypic moral transgression task, false belief theory of mind task (ToM), and an "accidental transgressor" task, which measured a morally-relevant false belief theory of mind (MoToM). Children who did not pass false belief ToM were more likely to attribute negative intentions to an accidental transgressor than children who passed false belief ToM, and to use moral reasons when blaming the accidental transgressor. In Experiment 2, children (N = 46) who did not pass false belief ToM viewed it as more acceptable to punish the accidental transgressor than did participants who passed false belief ToM. Findings are discussed in light of research on the emergence of moral judgment and theory of mind.

Attributions of intentions and fairness judgments regarding interracial peer encounters.

To investigate how adolescents interpret ambiguous actions in hypothetical interracial peer encounters, we conducted a study in which 8th- and 11th-grade students (N = 837) evaluated 4 interracial peer encounters in which the intentions of the protagonist were ambiguous. The sample was evenly divided by gender and included both African American and European American adolescents. European American students, male adolescents, and 8th graders were more likely to attribute negative intentions to the protagonist in interracial exchanges than were African American students, female adolescents, and 11th graders. Although all participants viewed peer and teacher accusations of wrongdoing in ambiguous situations as unfair, ethnic minority students as well as female adolescents rated accusations of wrongdoing as more unfair than did ethnic majority or male adolescents. Eleventh graders were more likely to view accusations of wrongdoing for protagonists with a prior history of transgression as fair than were 8th graders. The findings are discussed in light of efforts to reduce prejudice and to facilitate positive intergroup peer interactions.