A gulf of difference: disputes over Gulf War-related illnesses

Exploring the acceptability of behavioral interventions for veterans with persistent "medically unexplained" physical symptoms

OBJECTIVE

This study evaluated the factors that led to enrollment in, and satisfaction with, behavioral interventions for Veterans living with Gulf War Illness (GWI).

METHODS

One-on-one interviews were conducted pre- and post-intervention with participants randomized to receive either telephone delivered problem-solving treatment (n = 51) or health education (N = 49). A total of 99 Veterans were interviewed pre-intervention and 60 post-intervention. Qualitative data were thematically coded and similarities in themes across the two interventions were examined.

RESULTS

Before the study began, participants reported desiring to learn new information about their GWI, learn symptom-management strategies, and support improvements to care for other patients with GWI. After the intervention, Veterans felt positively about both interventions because they built strong therapeutic relationships with providers, their experiences were validated by providers, and they were provided GWI information and symptom-management strategies. Results also suggested that interventions do not have to be designed to meet all of the needs held by patients to be acceptable. A minority of participants described that they did not benefit from the interventions.

CONCLUSION

The results suggest that satisfaction with behavioral interventions for GWI is driven by a strong therapeutic relationship, validating patient's experiences with GWI, and the intervention meeting some of the patient's needs, particularly increasing knowledge of GWI and improving symptom management.

Healthcare providers' perceived learning needs and barriers to providing care for chronic multisymptom illness and environmental exposure concerns

OBJECTIVE

Patient provider encounters for chronic multisympom illness (CMI) and/or environmental exposures are difficult often resulting in Veterans and providers having high levels of dissatisfaction. Patients attribute these difficulties to providers lacking knowledge about these health concerns. It is not known whether providers perceive themselves as lacking expertise in CMI and environmental exposure concerns.

METHODS

This needs assessment used a descriptive online survey design. A total of 3632 VA healthcare providers across disciplines were surveyed.

RESULTS

Healthcare providers reported speaking with Veterans about CMI and environmental exposures despite feeling they have minimal to no knowledge of these topics. At the same time, only half of the providers had taken an available training on CMI or environmental exposure within the last year.

CONCLUSION

Healthcare providers recognize a knowledge gap regarding CMI and environmental exposures, despite this, there is low uptake of provider education on these topics.

PRACTICE IMPLICATIONS

A better understanding of barriers to uptake of training on CMI and environmental exposures is needed to increase engagement with these important trainings.

Politicized disease surveillance: A theoretical lens for understanding sociopolitical influence on the monitoring of disease epidemics

Sociopolitical forces commonly influence the collection, analysis, dissemination, and general perceptions of epidemiological information. Yet few theoretical lenses provide insight into the mechanisms through which such influence occurs. In this article, I draw and expand upon empirical findings to propose a novel theoretical lens, politicized disease surveillance, which I define as extreme or undue sociopolitical influence on public health surveillance systems or processes in ways that impact disease incidences and prevalences, or estimates or perceptions thereof. This lens foregrounds disease incidence and prevalence as objects of contestation and policy influence and articulates how certain facets of sociopolitical forces shape disease incidences and prevalences-especially amid an epidemic-through one or more channels: (1) the diagnostic construct; (2) screening tools, procedures, or systems; or (3) the behaviors of individuals who are living with or at risk for a certain disease. I provide several contemporary illustrations of politicized disease surveillance and discuss its theoretical and practical implications.

Protocol for a type 1 hybrid effectiveness/implementation clinical trial of collaborative specialty care for Veterans with Gulf War Illness

AIMS

We describe a clinical trial to determine the effectiveness and understand implementation outcomes for tele-collaborative specialty care for Veterans with GWI.

MAIN METHODS

This study will be a hybrid type 1 randomized effectiveness/implementation trial comparing tele-collaborative specialty care to electronic consultation for Gulf War Veterans with GWI (N = 220). In tele-collaborative specialty care, the specialty provider team will deliver health coaching and problem-solving treatment to Veterans and recommend a plan for analgesic optimization. In electronic consultation, the specialty provider team will make a one-time recommendation to the primary care team for locally delivered health coaching, problem-solving treatment and analgesic optimization. The primary aim will be to determine the effectiveness of tele-collaborative specialty care to reduce disability related to GWI. Our secondary aim will be to understand implementation outcomes.

SIGNIFICANCE

There is a need to improve care for Veterans with GWI. A potentially useful model to address these barriers and improve care is tele-collaborative specialty care where the specialists work with primary care provider to synergistically treat the patients.

DISCUSSION

This is the first clinical trial to prospectively compare different models of care for Veterans with GWI. This responds to multiple calls for research to improve treatment for Veterans with GWI, including from the National Academy of Medicine.

Introducing the System for Observing Medical Alliances (SOMA): A Tool for Studying Concordance in Patient-Physician Relationships

We developed the System for Observing Medical Alliances (SOMA) to study relationships between medical providers and patients with medically unexplained symptoms (MUS). Based on literature in health psychology, medicine, and the psychotherapeutic alliance, the SOMA operationalizes three medical alliance dimensions: Engagement in the Consultation Process, Trust in the Provider, and Concordance of Illness Beliefs and Treatment Recommendations. Specific behavioral indicators, tallied as observed by trained judges, are used as the basis for rating each dimension. In a sample of 33 medical consultations with veterans who had MUS, interrater reliabilities ranged from .79 to .94. Notably, the other dimension ratings accounted for 40% of the variability in Concordance, with Trust in the Provider contributing unique variance. In addition to research, psychologists in integrated health settings can use the SOMA to consult and train medical providers on communication skills that enhance concordance.

Challenging dominant breast cancer research agendas: perspectives on the outcomes of the interagency breast cancer and environment research coordinating committee

BACKGROUND

As breast cancer rates increase globally, there is growing scientific consensus that greater understanding of the causes of breast cancer is needed to better prevent its occurrence. Genetics accounts for a small percentage of cases, thus environmental factors and epigenetics are increasingly suspect in breast cancer etiology. Within the breast cancer and environmental breast cancer social movements, there are longstanding calls for research and policy aimed toward the prevention of breast cancer. To better understand the opportunities and barriers to addressing environmental contributors to breast cancer, this article investigates both outcomes and perceptions of stakeholders involved in the Interagency Breast Cancer and Environment Research Coordinating Committee (IBCERCC). The IBCERCC was mandated by the 2008 U.S. Breast Cancer and Environmental Research Act, a law representing years of advocate and researcher efforts to produce national strategies and federal funding for breast cancer prevention research.

METHODS

To understand the meaning and impact of the IBCERCC advisory committee and final report, Prioritizing Prevention, I draw on fifteen confidential semi-structured interviews with members of the twenty-five person IBCERCC, in addition to six confidential semi-structured interviews with key breast cancer funders, advocates, and researchers affiliated with national reports on environmental contributors to cancer. I examine media coverage, congressional hearing transcripts, and official responses to the release of the IBCERCC report by governmental and non-governmental organizations.

RESULTS

Interviews and publicly available documents reveal a set of direct and indirect outcomes of the 2013 IBCERCC report. Interviewees in government positions perceived the 2014 renewal of the Breast Cancer and the Environment Research Program to result from IBCERCC efforts, notable in the context of declining U.S. federal research funding. Interviews also revealed a suite of potential barriers to the implementation of report recommendations including: distinct interpretations of the federal mandate, disparate assessments of scientific evidence, government funding crises, and lack of specificity around responsibility for implementation of report findings.

CONCLUSION

This article examines efforts to shift institutional research and funding priorities in cancer research towards prevention. Social science research can support efforts to shift institutional priorities by identifying broader social contexts and underlying values typically unnamed in scientific discourse.

Helpful ways providers can communicate about persistent medically unexplained physical symptoms

BACKGROUND

Communication between patients and providers about persistent "medically unexplained" physical symptoms (MUS) is characterized by discordance. While the difficulties are well documented, few studies have examined effective communication. We sought to determine what veterans with Gulf War Illness (GWI) perceive as the most helpful communication from their providers. Veterans with GWI, a type of MUS, have historically had complex relationships with medical providers. Determining effective communication for patients with particularly complex relationships may help identify the most critical communication elements for all patients with MUS.

METHODS

Two hundred and-ten veterans with GWI were asked, in a written questionnaire, what was the most useful thing a medical provider had told them about their GWI. Responses were coded into three categories with 10 codes.

RESULTS

The most prevalent helpful communication reported by patients was when the provider offered acknowledgement and validation (N = 70). Specific recommendations for managing GWI or its symptoms (N = 48) were also commonly reported to be helpful. In contrast, about a third of the responses indicated that nothing about the communication was helpful (N = 63). There were not differences in severity of symptoms, disability or healthcare utilization between patients who found acknowledgement and validation, specific recommendations or nothing helpful.

CONCLUSIONS

Previous research has documented the discord between patients and providers regarding MUS. This study suggests that most patients are able to identify something helpful a provider has said, particularly acknowledgement and validation and specific treatment recommendations. The findings also highlight missed communication opportunities with a third of patients not finding anything helpful.

Evaluating challenges for improving medically unexplained symptoms in US military veterans via provider communication

OBJECTIVES

Medically unexplained symptoms (MUS) are common, with particularly high rates observed in military veterans. Effective patient-provider-communication is thought to be a key aspect of care; however there have been few empirical studies on the association between communication and outcomes for patients with MUS. We evaluate whether discussing veterans' MUS-illness representations and good interpersonal skills have the potential to promote MUS-treatment adherence and improvement.

METHODS

Veterans experiencing MUS (n=204) reported on their primary care providers' communication about illness representations and interpersonal skills; correlation, regression, and bootstrap-mediation analyses were conducted to test hypotheses regarding veteran-reported outcomes. Main outcomes included satisfaction with the provider, MUS-treatment adherence, intentions to adhere, and expectations for MUS improvement.

RESULTS

Veterans reported infrequent discussion of MUS illness representations but high degrees of provider interpersonal skills. Communication regarding patients' illness representations and treatment expectations was significantly related to treatment adherence and adherence intentions; provider interpersonal skills were not. Both were related to veteran satisfaction.

CONCLUSIONS AND PRACTICE IMPLICATIONS

Providers' interpersonal skills may be important in chronic illness contexts, such as MUS, by contributing to satisfaction with the provider. The current study suggests that providers may better promote MUS-treatment adherence through discussing MUS illness representations and treatment expectations.

Disease Campaigns and the Decline of Treatment Advocacy

In the past fifty years, disease advocacy organizations have multiplied and gained political influence, but they have often been reluctant to ask the government to intervene in health care provision. This article asks why. Using original quantitative and qualitative data on the goals and political claims of over one thousand organizations from 1960 through 2014, I find that many early disease advocacy organizations prioritized health care access. But unfavorable political climates discouraged new organizations from focusing on access to treatment. When health care became particularly controversial, even organizations with health care-related missions refrained from pursuing this goal politically. Eventually, politically active organizations began to drop treatment provision from their missions. Over the decades, the troubled politics of health care reshaped the field of disease advocacy, diminishing its focus on medical treatment.

Advocacy, support and survivorship in prostate cancer

Across Australia, prostate cancer support groups (PCSG) have emerged to fill a gap in psychosocial care for men and their families. However, an understanding of the triggers and influencers of the PCSG movement is absent. We interviewed 21 SG leaders (19 PC survivors, two partners), of whom six also attended a focus group, about motivations, experiences, past and future challenges in founding and leading PCSGs. Thematic analysis identified four global themes: illness experience; enacting a supportive response; forming a national collective and challenges. Leaders described men's feelings of isolation and neglect by the health system as the impetus for PCSGs to form and give/receive mutual help. Negotiating health care systems was an early challenge. National affiliation enabled leaders to build a united voice in the health system and establish a group identity and collective voice. Affiliation was supported by a symbiotic relationship with tensions between independence, affiliation and governance. Future challenges were group sustainability and inclusiveness. Study findings describe how a grassroots PCSG movement arose consistent with an embodied health movement perspective. Health care organisations who seek to leverage these community resources need to be cognisant of SG values and purpose if they are to negotiate effective partnerships that maximise mutual benefit.

Integrating medical and environmental sociology with environmental health: crossing boundaries and building connections through advocacy

This article reviews the personal and professional processes of developing an interdisciplinary approach to understanding the complex issues of environmental health in their community, political-economic, social science, and scientific contexts. This interdisciplinary approach includes a synthesis of research, policy work, and advocacy. To examine multiple forms of interdisciplinarity, I examine pathways of integrating medical and environmental sociology via three challenges to the boundaries of traditional research: (1) crossing the boundaries of medical and environmental sociology, (2) linking social science and environmental health science, and (3) crossing the boundary of research and advocacy. These boundary crossings are discussed in light of conceptual and theoretical developments of popular epidemiology, contested illnesses, and health social movements. This interdisciplinary work offers a more comprehensive sociological lens for understanding complex problems and a practical ability to join with scientists, activists, and officials to meet public health needs for amelioration and prevention of environmental health threats.

Negotiating the diagnostic uncertainty of contested illnesses: physician practices and paradigms

In the absence of scientific consensus about contested illnesses such as Chronic Fatigue Syndrome (CFS), Multiple Chemical Sensitivities (MCS), and Gulf War Syndrome (GWS), physicians must make sense of competing accounts and develop practices for patient evaluation. A survey of 800 United States physicians examined physician propensity to diagnose CFS, MCS, and GWS, and the factors shaping clinical decision making. Results indicate that a substantial portion of physicians, including nonexperts, are diagnosing CFS, MCS, and GWS. Diagnosing physicians manage the uncertainty associated with these illnesses by using strategies that enhance bounded rationality and aid in thinking beyond current disease models. Strategies include consulting ancillary information sources, conducting analytically informed testing, and considering physiological explanations of causation. By relying on these practices and paradigms, physicians fit CFS, MCS, and GWS into an explanatory system that makes them credible and understandable to them, their patients, and the medical community. Findings suggest that physicians employ rational decision making for diagnosing contested illnesses, creating a blueprint of how illnesses lacking conclusive pathogenic and etiological explanations can be diagnosed. Findings also suggest that patients with contested illnesses might benefit from working with physicians who use these diagnostic strategies, since they help manage the complexity and ambiguity of the contested illness diagnostic process and aid in diagnosis. In addition, findings provide a window into how emerging illnesses get diagnosed in the absence of medical and scientific consensus, and suggest that diagnosing physicians advance the legitimacy of controversial illnesses by constructing the means for their diagnosis.

Gulf war syndrome: a reaction to psychiatry's invasion of the military?

Following the 1991 Gulf War, a number of soldiers who fought there began to complain of various symptoms and disorders, the collection of which came to be known as Gulf War syndrome (GWS). A debate has raged about the nature and cause of this illness, with many suggesting that it is a psychiatric condition. GWS continues to be a contested illness, yet there is no disputing that many Gulf veterans are ill. This article considers the way in which GWS sufferers understand their illness to be physical in nature and the way in which they negotiate and resist psychological theories of their illness. Based on 14 months of ethnographic fieldwork in the United Kingdom, data for this article were collected mainly by in-depth, semistructured interviews with GWS sufferers, their family members, doctors, and scientists, as well as healthy Gulf veterans. A total of 93 informants were interviewed, including 67 UK Gulf veterans, most of whom were ill. The paper argues that despite the increasing presence of psychiatry in military discourse, GWS reveals the way that people are able to transform, negotiate and even negate its power and assumptions.

Electronic support groups, patient-consumers, and medicalization: the case of contested illness

This article illustrates the role electronic support groups play in consumer-driven medicalization. The analysis is based on an observational study of a year in the life of an electronic support group for sufferers of the contested illness fibromyalgia syndrome. The analysis builds on and extends scholarship concerning the growing influence of lay expertise in the context of medical uncertainty by showing how the dominant beliefs and routine practices of this electronic community simultaneously (and paradoxically) challenge the expertise of physicians and encourage the expansion of medicine's jurisdiction. Drawing on their shared embodied expertise, participants confirm the medical character of their problem and its remedy, and they empower each other to search for physicians who will recognize and treat their condition accordingly. Physician compliance is introduced as a useful concept for understanding the relationship between lay expertise, patient-consumer demand, and contemporary (and future) instances of medicalization.

Public involvement in breast cancer research: an analysis and model for future research

Public involvement in health program planning has been taking place for many years, and has provided a precedent for the emergence of public involvement in research conducted since the early 1990s. Such involvement is now widely seen in breast cancer research, due to the large public concern and major social movement activity. This article reviews current practices and general models of public involvement in research and constructs a prototype. The authors interviewed researchers, program officers, and laypeople in order to understand the obstacles, processes, and benefits. They conclude that public involvement has major ramifications for the democratization of science and the construction of knowledge by teaching lay people about science and sensitizing researchers to concerns of the public. There is growing support on the part of scientists and government agents for public involvement.

Medical modernization, scientific research fields and the epistemic politics of health social movements

As health social movements (HSMs) and complementary and alternative medicine (CAM) professions increasingly mount challenges to the authority of medical knowledge, the tendency for the medical research community and medical profession to dismiss such epistemic challenges (termed here 'paternalistic progressivism') and the corresponding response from challengers that medicine is corrupt (termed here 'medical devolution') has given way to a process of incorporation of challenges under the rubric of evidence-based research (termed here the epistemic dimension of 'medical modernization'). Under conditions of medical modernization the distinction between lay/alternative knowledge and scientific knowledge, upon which the epistemic authority of medicine rested, is submerged in a more complex field of competing scientific networks and research programmes. Furthermore, the older policy of transmitting science to an illiterate public and suppressing dissidents is replaced by an emerging system of the 'public shaping of science', in which there is both greater agency of social movement/lay advocacy organisations and greater recognition of the legitimacy of that agency. Indirect and direct forms of the public shaping of science are discussed, as are emergent problems of co-optation. Understanding the emergent epistemic politics that are characterised here as medical modernization requires an ongoing theoretical integration of medical sociology and the sociology of science.

Clearing the air and breathing freely: the health politics of air pollution and asthma

This study examines the growing debate around environmental causes of asthma in the context of federal regulatory disputes, scientific controversy, and environmental justice activism. A multifaceted form of social discovery of the effect of air pollution on asthma has resulted from multipartner and multiorganizational approaches and from intersectoral policy that deals with social inequality and environmental justice. Scientists, activists, health voluntary organizations, and some government agencies and officials have identified various elements of the asthma and air pollution connection. To tackle these issues, they have worked through a variety of collaborations and across different sectors of environmental regulation, public health, health services, housing, transportation, and community development. The authors examine the role of activist groups in discovering the increased rates of asthma and framing it as a social and environmental issue; give an overview of the current knowledge base on air pollution and asthma, and the controversies within science; and situate that science in the regulatory debate, discussing the many challenges to the air quality researchers. They then examine the implications of the scientific and regulatory controversies over linking air pollution to increases in asthma. The article concludes with a discussion of how alliances between activists and scientists lead to new research strategies and innovations.

Patient activism and the struggle for diagnosis: Gulf War illnesses and other medically unexplained physical symptoms in the US

We examine Gulf War illnesses--which include the fatigue, joint pain, dermatitis, headaches, memory loss, blurred vision, diarrhea, and other symptoms reported by Gulf War veterans--in relation to other medically unexplained physical symptoms such as multiple chemical sensitivity, chronic fatigue syndrome, and fibromyalgia. Our intent is to examine the diagnosis negotiations involved in these mysterious diseases, by showing the different forms of legitimacy involved in such interactions. Factors involved in diagnostic legitimacy are: diagnostic legitimacy in the medical community, lay acceptance of the diagnosis, uncertainty in looking for causes, and social mobilization. We conclude by noting that research may not be able to find any cause for these diseases/conditions; hence, it may be necessary to embrace medical uncertainty, and also to accept patient experience in order to facilitate diagnosis, treatment, and recovery process. Such a change can alter patients' expectations and taken-for-granted assumptions about medicine, and perhaps in turn reduce the frequency with which dissatisfied individuals form illness groups that mobilize to challenge what they see as an unresponsive medical system.