Approximately 19% of previously deployed service members from Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) have probable traumatic brain injury (TBI). In April 2007, the VA responded by initiating a mandatory TBI screen for all OEF/OIF Veterans in the form of a clinical reminder to identify new cases of TBI in Veterans. Although the goals of screening are laudable, the screening process may have unintended negative consequences. Veterans may attribute symptoms identified through the TBI screening process to brain injury when these symptoms may be due to another treatable condition such as PTSD or depression. A related concern is that Veterans referred to a "TBI/polytrauma" clinic for a comprehensive evaluation may assume their condition is severe and long-lasting.
A growing literature supports the notion that postconcussive symptoms are influenced by factors other than the brain injury itself. One proposed explanation for elevated postconcussive symptoms following head injury is expectancy. That is, people misattribute commonly occurring symptoms to their head injury. Numerous studies confirm that expectations influence recovery. Education provided in a medical setting at the time of screening could provide external information from an authoritative source and serve as a buffer against forming negative illness perceptions.
Our long-term goal is to promote expectations for a positive recovery in Veterans with mTBI. The specific aim is to evaluate the effect of the intervention on Veterans' knowledge and illness perceptions regarding TBI. Hypotheses are that (1) Veterans who receive the educational intervention will have improved knowledge and understanding of TBI and the meaning of a positive TBI screen compared to Veterans who undergo screening as usual and (2) Veterans who screen positive for TBI and receive the educational intervention will have less negative illness perceptions regarding TBI compared to Veterans who screen positive in the control group. Secondary analyses are to identify clinic-level barriers and facilitators to incorporation of the educational handout into the clinical encounter.
We worked with TBI experts to develop the educational handout. The handout is a color brochure that is graphic rich and written at the 7th grade reading level. Information covers key concepts such as: (1) the meaning of a positive screen; (2) symptoms may be due to another condition; and (3) most people with mTBI recover. The handout was piloted with 7 OEF/OIF Veterans and feedback was incorporated into a revised handout that was approved by the TBI experts.
We compared 2 groups of Veterans from four post-deployment clinics. During the first half of the study, all OEF/OIF Veterans that were screened for TBI at one of the four sites were enrolled into the screening as usual control group. During the last half of the study, all OEF/OIF Veterans screened for TBI were enrolled into the intervention group.
Across the four sites, 1236 Veterans were included in the sample. The majority of Veterans in the study were males (84%) between the ages of 20 and 49 (93%). The majority had served in the Army (45%) or Navy (24%) though many (13%) had served in more than one service branch. Approximately half reported a service connected disability, one quarter were diagnosed with PTSD, and 23% screened positive for TBI. The only significant difference between the groups was that there were slightly more members of the National Guard in the intervention group than in the control group (Chi square (1)= 5.37, p = 02).
The primary outcome was knowledge gained about mTBI and illness perception. Findings from a formative evaluation with providers were used to address barriers and facilitators to implementation.
Overall, Veterans had poor understanding of TBI. Consistent with hypothesis 1, Veterans in the intervention group had significantly improved knowledge of mild TBI compared to Veterans screened as usual (t(1168) = 13.5, p <.0001). The average total score on the 10-point knowledge questionnaire was 5.38 (SD = 2.94) in the control group and 7.52 (SD=2.65) in the intervention group. This suggests that without the intervention Veterans are essentially guessing the right answer.
Veterans who screened positive for TBI reported their symptoms were at least moderately due to lack of sleep (67%), PTSD (66%), TBI (58%), pain (55%), depression (53%), deployment stress (53%), and other causes (48%). There were no differences between Veterans in the control group and Veterans in the intervention group. In general Veterans reported negative illness perceptions related to the symptoms. On scales from 0 (low) to 10 (high), Veterans reported that the symptoms affected their life negatively (mean 6.85, sd 2.42), that the symptoms would continue (mean 7.60, sd 2.52), that they were concerned about their symptoms (mean 7.56, sd 2.47), and that the symptoms affected them emotionally (mean 7.44, sd 2.58). They were not positive about how much control they had (mean 4.08, sd 2.74) and how well they understood their symptoms (mean 5.50, sd 2.88). Inconsistent with hypothesis 2, the only significant group difference was that Veterans in the intervention group reported significantly better understanding of their symptoms then Veterans in the control group (t(257) = 2.42, p = 0.016).
Nine providers were involved in conducting the TBI screens and administering the handout. Five gave us feedback on the intervention. Two providers said the handout took 0-2 minutes to administer, two said 6-10 minutes, one said over 10 minutes. Each said the handout was helpful and that the handout helped address common questions that come up as part of the screening. One provider thought that handout interfered with administering the screen and four screeners thought it was feasible for providers to have a discussion about information contained in the screen. Four out of five indicated that they were likely to continue using the handout.
Results indicate that Veterans have poor understanding of TBI at the time of screening and that they are unsure what is causing their symptoms. In addition, Veterans who screen positive for TBI report that their symptoms negatively affect their life, that they are concerned by their symptoms, and that their symptoms affect them emotionally. Education provided in a medical setting at the time of screening improved Veterans knowledge of TBI, but was not significant enough to improve perceptions for recovery. This suggests that the handout could be used as a component of a more complete toolkit to help providers communicate about mTBI with patients, but that further intervention may be necessary to reduce distress and improve outcomes.
- Hamblen JL, Bernardy N, Sayer N, Nelson D, Schnurr P, Forshay E. A Brief Educational Intervention to Improve TBI Screening Outcomes. Poster session presented at: International Society for Traumatic Stress Studies Annual Meeting; 2013 Nov 7; Philadelphia, PA.