At least one in ten Veterans meets criteria for posttraumatic stress disorder (PTSD) related to his or her military experience. Whereas national dissemination initiatives have increased Veterans' access to best-practice interventions for PTSD, treatment-seeking remains low, often due to perceived stigma and other associated barriers. The current project aimed to evaluate Veterans' reactions to AboutFace, a digital storytelling (DST) resource developed by the National Center for PTSD to help Veterans recognize the need to address symptoms of PTSD and motivate them to seek evidence-based treatment. The purpose of this pilot was to set the stage for a large-scale study (i.e., HSR&D Merit application currently under review) that could examine the extent to which AboutFace effectively reduces stigma, improves attitudes toward treatment-seeking among Veterans, and, most importantly, increases the likelihood that Veterans who are good candidates for PTSD treatment initiate and engage in such treatment. If effective, this DST approach may serve as a valuable national model for a variety of treatment-seeking populations in VA and in other settings where stigmatized conditions are prevalent.
The primary objectives of this project were to: (1) conduct a usability evaluation of AboutFace with 20 Veterans referred for PTSD treatment at our local VA facility and use data from the usability evaluation to guide improvements to the AboutFace site; and (2) demonstrate the methodology we propose to use in a future Merit application (under review) comparing AboutFace to enhanced usual care via a feasibility pilot randomized controlled trial with 60 Veterans. The feasibility RCT provided preliminary descriptive data comparing stigma and attitudes toward mental health treatment for Veterans receiving AboutFace vs. Veterans receiving enhanced usual care. We hypothesize in the Merit under review that: (1) Veterans in the AboutFace condition will be more likely to initiate PTSD treatment and to attend more therapy sessions than those assigned to the enhanced usual care condition; and (2) Veterans in the AboutFace condition will have lower stigma and more positive attitudes toward seeking help than those assigned to the enhanced usual care condition, respectively. Our preliminary data from this pilot study positioned us well for the proposed RCT because we demonstrated satisfactory (1) pace of recruitment, (2) retention of participants, (3) fidelity to study protocol, and (4) reactions of Veterans to resources and procedures. Our preliminary data, while underpowered for formal statistical analyses, were encouraging.
This pilot study consisted of usability and feasibility testing phases. Participants included Veterans who presented for an evaluation at the Charleston VAMC PTSD Clinical Team (PCT) and were recommended to receive formal PTSD treatment.
Usability Phase. 20 participants were recruited from our local facility and were encouraged in a controlled office-based setting to freely navigate AboutFace for 45-60 minutes. While they used AboutFace, they were observationally coded and completed a semi-structured interview that addressed general satisfaction with the resource, perceived changes in knowledge about the nature of PTSD treatment, and perceived changes in attitudes toward treatment-seeking.
Feasibility Phase. 60 participants were randomly assigned to receive AboutFace plus standard education (i.e., a pamphlet describing the nature of PTSD and treatment) versus standard education alone. In this phase, baseline and two-week follow-up assessments were conducted to measure stigma and attitudes toward seeking mental health services and treatment access and engagement. We also recorded treatment initiation in both study conditions.
Usability Phase. Participants were primarily male (85%) and half was White (50%), with a mean age of 46.05 years (SD = 13.45). Veterans overwhelmingly described the site as appealing, highly relevant to their experience, and as very helpful in addressing their understanding of PTSD and PTSD treatment via education provided by their peers (i.e., other Veterans). Some participants were confused by some of the navigation features (e.g., did not recognize additional features accessible from the top navigation). Some did not recognize initially that the images of Veterans on the main screen were connected to videos. Veterans offered recommendations for improving the site, including adding a greater diversity of profiles, more search options, and more content describing what PTSD is and how it can be treated. Veterans believed the site would be most beneficial when disseminated to Veterans who were ambivalent about seeking help. More than half of participants (60%) reported an increase in knowledge regarding PTSD symptoms and diagnosis, the impact of their symptoms on family members, and a greater understanding of PTSD and what PTSD treatment involves after visiting the site. The National Center for PTSD completed an update and revision of the AboutFace site using this feedback as a guide. The site is now improved and ready for large-scale evaluation.
Feasibility Phase. The results supported the feasibility of our methodology and recruitment plan for executing a large-scale randomized controlled trial (RCT). Our sample was statistically comparable demographically to our recruitment population with regard to gender (85% male) and was ethnically diverse (50% of the sample was African American). We recruited an average of 12 Veterans per month (60 Veterans were recruited in 5 months), and retention from baseline to follow-up was 81.7%. We found that 92% of Veterans in the experimental arm accessed AboutFace - indicating that Veterans found the study procedures to be acceptable and easy to follow. Our procedures were not burdensome, and most were completed via telephone contact, suggesting that our study design is feasible and that our procedures may closely approximate future implementation protocols. This may speed up dissemination initiatives should our Merit RCT evaluation support the utility of this resource as a cost-effective solution that may improve access and utilization of needed care among Veterans with PTSD. Our preliminary data revealed that 68% of Veterans in enhanced usual care initiated treatment whereas 79% of Veterans in the AboutFace condition initiated treatment. Veterans in both conditions reported improved attitudes toward mental illness from baseline to the two-week follow-up.
We believe that AboutFace has tremendous potential to reduce stigma and improve attitudes toward seeking mental health services. Our preliminary data suggest that AboutFace may indeed increase treatment initiation and engagement among Veterans, although a full RCT is needed to test this hypothesis with adequate statistical power. By hearing Veterans who are featured on the AboutFace site describe what treatment was actually like, what their fears were, and how their lives have improved with treatment, it is anticipated that Veterans considering PTSD treatment who use the site will be more willing to initiate treatment and better prepared to navigate the challenges that may arise during the treatment process. Additionally, this low-cost, highly sustainable and scalable approach to peer education is likely to have particular value for Veterans and other populations with stigmatized conditions. Thus, although the proposed study focuses on Veterans with PTSD, the study design can be easily adapted to Veterans with a range of other stigmatized conditions, and can have far reaching implications in research and practice.
- Kreuze E, Jenkins C, Gregoski M, York J, Mueller M, Lamis DA, Ruggiero KJ. Technology-enhanced suicide prevention interventions: A systematic review. Journal of telemedicine and telecare. 2017 Jul 1; 23(6):605-617.
- Grubaugh AL, Borkman A, Cook DL, Hamblen JL. AboutFace:Pilot Study of a Digital Storytelling Resource used to Reduce Stigma and Increase Treatment-Seeking Behavior among Veterans. Poster session presented at: Association for Behavioral and Cognitive Therapies Annual Convention; 2016 Oct 27; New York City, NY.
- Ruggiero KJ, Resnick HS, Acierno RE, Kilpatrick DG. Adapting a web-based intervention targeting alcohol use and sexual assault risk among heavy episodic drinking female veterans. Paper presented at: VA Rural Health State of the Science Conference; 2016 Sep 12; Washington, DC.
- Ruggiero KJ, Hamblen J, Bippart V, Bunnell B, Davidson T. About Face: A qualitative study of an approach to reduce stigma and improve readiness to seek services among Veterans. Paper presented at: International Society for Traumatic Stress Studies Annual Symposium; 2015 Nov 5; New Orleans, LA.