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RRP 09-134 – HSR Study

RRP 09-134
Evaluating a Peer Visitor Program for OIF/OEF Veterans with Polytrauma
Rhonda M. Williams, PhD
VA Puget Sound Health Care System Seattle Division, Seattle, WA
Seattle, WA
Funding Period: October 2010 - March 2012
Peer mentorship (PM) provides people with a particular injury or illness with an opportunity to meet with a "peer mentor"- a person who has successfully managed a similar condition. While anecdotal evidence suggests PM is helpful, there is a paucity of evidence about its effectiveness and there is no standard way of selecting or training mentors. The goal of the present study was to empirically evaluate the feasibility and effectiveness of a PM training program amongVeterans who had some combination of injuries ("polytrauma") related to their service in Iraq or Afghanistan and who were identified by the clinical team as demonstrating successful coping and adjustment. The PM training program developed in a previous QUERI-funded grant (RRP-07-289).

This pilot study was designed to provide proof of concept and early evidence of effect magnitude.

Aim 1: Demonstrate the feasibility of using the Polytrauma Veteran PM Training Manual and associated materials to train and certify 12-18 Veteran Peer Mentors (VPMs). Assess acquisition of knowledge and skills covered in the training via pre- and post-training tests and via trainer evaluations completed post-training.

Aim 2: Evaluate the feasibility and effectiveness of the PM program in a small within-subject trial. A pre-post design was used to compare outcomes after receiving at least one visit from a VPM. Additionally, brief post-visit surveys were administered to evaluate satisfaction.

Aim 3: Identify and describe any psychological benefits associated with becoming a VPM using a pre-post within-subjects design.

Research Design: To evaluate the feasibility of the PM training program (Aim 1), we used a within- subjects design to evaluate the knowledge and skills of mentors before and after training. Knowledge assessed included understanding of role requirements and boundaries, communication skills, relevant local resources, referral procedures, and risk factors. To evaluate the effectiveness (Aim 2), we used a within-subjects pre-post design to evaluate changes in recipients after receiving up to five visits from a VPM. To address Aim 3, we used a within-subjects pre-post design to assess mentors' mood and symptoms prior to training and at completion of the study. Each VPM was required to provide up to five peer visits, determined by the interest and needs of the recipient. Matching of VPMs to recipients was coordinated by a polytrauma clinician.
Two groups of participants were recruited: (1) 9 Mentors: Veterans who were selected to participate in the 2-day training; (2) 9 Recipients. Outcome measures for the recipients included: self-efficacy, activation, post-traumatic growth, perceived stress, coping behaviors, and PTSD and depressive symptoms. Outcome measures for the mentors included depressive symptoms, PTSD symptoms, and post-traumatic growth.

Feasibility and Effectiveness of the Training Program. 30 Veterans were nominated by the clinical team as potential mentors. Of these, 14 enrolled and completed baseline data (1 woman, 13 men; Mean age 35 years, range 26-62 years; 8 married/partnered; 12 retired Army, 2 retired Marines); all 14 previously held enlisted ranks); 1 VPM with amputations, 1 with burns, 13/14 with at least one mild TBI; 8 meeting criteria for PTSD). Subsequently, six withdrew (5/6 secondary to moving out of state) prior to study completion. Of the 9 Veterans who started training, 8 completed it and were certified as PMs. Comparison of pre- and post-training knowledge test scores suggested that the training resulted in significant improvement in knowledge (t (7,1) = -4.2, p < .01).
Effectiveness of Mentorship Visits. 8 Veterans enrolled in the study as recipients (Mean age 36 years; 7 males, 1 female; 6/8 married, 2/8 divorced; 100% had TBI). The feasibility of coordinating and completing visits was demonstrated: average number of visits requested was 3, range was 1-5. Mean length of visits was 75 minutes (range 40-210 minutes). Average recipient Quality Rating for Visits was 4/5 (range 3-5, on a scale where 0 = very poor and 5 = excellent).
Paired t-tests were used to examine change in outcome scores from pre- to post-intervention. Among recipients, improvement was seen for depressive symptoms, as measured by the Patient Health Questionnaire-9 (mean baseline score was 27.4, mean follow-up score was 25.9, t (5,6) = 5.5, p < .01), Anger (, t (7,6) = 3.6, p < .05), and in perceived stress (t (3,4) = 2.4, p < .10). Although not significant, there appeared to be improved activation (as measured by the Patient Activation Measure) and Self Efficacy, and reduced symptoms of PTSD. There also appeared to be a trend towards increased use of positive coping behaviors and a decrease in use of negative coping behaviors, both measured using the Brief COPE. There was no significant change in post-traumatic growth associated with participation. These findings suggest some preliminary efficacy of the intervention for recipients.
Effect of Visits on Mentors
There were no significant differences in demographics, baseline PTSD, or baseline depression scores between mentors who completed the study vs. those who did not. There were two unexpected findings, however. Peer Mentors showed a significant increase in PTSD (t (8,9) = 2.99, p < .05) and depressive symptoms over the course of the study (t (8,9) = 3.29, p < .05). Notably, levels of depressive symptoms were elevated among the mentor sample at baseline also. Thus, while the findings suggest it is feasible to identify and successfully train peer mentors, and while mentor participants self-reported that they found the experience of mentorship rewarding, the findings suggested some possible adverse outcomes associated with the mentor role.

This study had several positive impacts:
1) Results suggest that Veteran Peer Mentors can be successfully recruited, trained, and retained to provide peer mentor visits. Feasibility of methods for selecting, recruiting, and training Veterans was demonstrated. Training materials have been developed and pilot tested. This project established a relationship between the Polytrauma Network Site staff and Voluntary Services.
2) Results suggest that PM may serve as a useful adjunct to Polytrauma therapies. It was demonstrated that individuals with significant cognitive impairment (e.g., moderate to severe TBI) were able to engage with a peer mentor and reported it was beneficial. It was also demonstrated that individuals with TBI history are capable of completing the training and providing useful mentorship. Potential benefits to recipients include reduction in mental health symptoms (e.g., depressive symptoms, PTSD, expressed anger), improved coping skills, and reduced perception of stress.
3) Barriers to implementation were identified that can be addressed in future studies. 4) This project has resulted in Rehabilitation Care Service Leadership at the study site supporting the establishment of a clinical PM Program .
5) Although the sample size was small, this study has highlighted the potential challenges associated with being a peer mentor. Further examination of the data will be conducted to ascertain possible factors associated with increased distress among VPMs (PTSD and Depression).
7) As a result of this project, the PI was invited to write a review paper on PM which was subsequently included in the Journal of Head Trauma Rehabilitation in a special section focusing on best practices within VHA. This review resulted in the generation of specific recommendations for areas of future study.

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DRA: Acute and Combat-Related Injury, Military and Environmental Exposures
DRE: Treatment - Observational
Keywords: Complex care, Operation Enduring Freedom, Operation Iraqi Freedom
MeSH Terms: none

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