Clinical Psychology Review 52 (2017) 52–68
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Clinical Psychology Review journal homepage: www.elsevier.com/locate/clinpsychrev
Perceived barriers and facilitators of mental health service utilization in adult trauma survivors: A systematic review Viktoria Kantor ⁎, Matthias Knefel, Brigitte Lueger-Schuster Faculty of Psychology, University of Vienna, Liebiggasse 5, 1010 Vienna, Austria
H I G H L I G H T S • • • • •
Many trauma survivors seem to be reluctant to seek mental health treatment. Trauma survivors perceive a number of barriers to treatment. Facilitators are neglected in research but important to understand treatment use Similarities between trauma survivors of general and military population Highlights limitations in prior research and points to future directions
a r t i c l e
i n f o
Article history: Received 12 September 2016 Available online 08 December 2016 Keywords: Mental health service utilization Barriers Facilitators PTSD Adult trauma survivors Military
a b s t r a c t Many trauma survivors seem to be reluctant to seek professional help. The aim of the current review was to synthesize relevant literature, and to systematically classify trauma survivors' perceived barriers and facilitators regarding mental health service utilization. The systematic search identified 19 studies addressing military personnel and 17 studies with trauma survivors of the general population. The data analysis revealed that the most prominent barriers included concerns related to stigma, shame and rejection, low mental health literacy, lack of knowledge and treatment-related doubts, fear of negative social consequences, limited resources, time, and expenses. Perceived facilitators lack attention in research, but can be influential in understanding mental health service use. Another prominent finding was that trauma survivors face specific trauma-related barriers to mental health service use, especially concerns about re-experiencing the traumatic events. Many trauma survivors avoid traumatic reminders and are therefore concerned about dealing with certain memories in treatment. These perceived barriers and facilitators were discussed regarding future research and practical implications in order to facilitate mental health service use among trauma survivors. © 2016 Elsevier Ltd. All rights reserved.
Contents 1.
2.
3.
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.1. Characteristics associated with MHS use . . . . . . . . . . . . . . . . 1.2. Individuals self-perceived reasons for use or non-use of MHS . . . . . . . 1.3. Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.1. Search strategy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.2. Eligibility criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.3. Study selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.4. Data extraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.5. Data analyses . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.6. Andersen's behavioral model of health service use as theoretical framework Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.1. Study characteristics . . . . . . . . . . . . . . . . . . . . . . . . .
⁎ Corresponding author. E-mail address:
[email protected] (V. Kantor).
http://dx.doi.org/10.1016/j.cpr.2016.12.001 0272-7358/© 2016 Elsevier Ltd. All rights reserved.
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3.2.
Sample characteristics . . . . . . . . . . . . . . . . . . . . . 3.2.1. Year and location of studies . . . . . . . . . . . . . . . 3.2.2. Participants' age and gender . . . . . . . . . . . . . . 3.2.3. Traumatic experiences . . . . . . . . . . . . . . . . . 3.2.4. MH status . . . . . . . . . . . . . . . . . . . . . . . 3.2.5. MHS use among participants . . . . . . . . . . . . . . 3.3. Perceived barriers and facilitators . . . . . . . . . . . . . . . . 3.3.1. Assessment of perceived barriers and facilitators . . . . . 3.3.2. Perceived barriers and facilitators in the qualitative studies 3.4. Perceived barriers and facilitators in the quantitative studies . . . . 4. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.1. Predisposing factors . . . . . . . . . . . . . . . . . . . . . . 4.2. Enabling factors . . . . . . . . . . . . . . . . . . . . . . . . 4.3. Need factors . . . . . . . . . . . . . . . . . . . . . . . . . . 4.4. Strengths and limitations . . . . . . . . . . . . . . . . . . . . 5. Conclusion and future directions . . . . . . . . . . . . . . . . . . . . Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . Appendix A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Search protocol and illustrative search strategy . . . . . . . . . . A.1. PsycINFO [Abstract] . . . . . . . . . . . . . . . . . . . . . . Web of Science [Topic] . . . . . . . . . . . . . . . . . . . . . Pubmed [Title, Abstract] . . . . . . . . . . . . . . . . . . . . Scopus [Article Title, Abstract, Keywords] . . . . . . . . . . . . Cochrane [Title, Abstract, Keywords]. . . . . . . . . . . . . . . Appendix B. Supplementary data . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1. Introduction Experiencing or witnessing traumatic events, such as being exposed to or threatened by death, serious injury or sexual violence (DSM-5, APA), can lead to mental disorders,1 like PTSD, major depression, substance abuse or personality changes (Bremner, Southwick, Darnell, & Charney, 1996; Breslau, 2001; Scheiderer, Wood, & Trull, 2015; Shalev et al., 1998; Yehuda, Halligan, & Grossman, 2001). It is of great importance to treat pathological stress response promptly, as untreated disorders can exacerbate and become chronic conditions (Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995). An extensive body of research provides evidence for the efficacy of a variety of evidence-based treatments for psychopathological trauma sequelae (Bradley, Greene, Russ, Dutra, & Westen, 2005; Ehring et al., 2014; Van Etten & Taylor, 1998) and effective psychopharmacology (Friedman, 2000; Jacques-Tiura, Tkatch, Abbey, & Wegner, 2010). Unfortunately, only a few trauma survivors with MD who would benefit from professional treatment engage in psychotherapy or use other mental health services2 (Bramsen & van der Ploeg, 1999b; Gavrilovic, Schützwohl, Fazel, & Priebe, 2005; McChesney, Adamson, & Shevlin, 2015). A similar picture emerges regarding people with MD who did not experience traumatic events: About only one third of individuals with treatable disorders actually seek mental health3 treatment (Kessler et al., 2005). While the importance of engaging trauma survivors in adequate treatment is obvious for the above-mentioned reasons, research has shown that survivors are facing a range of obstacles towards MHS use. We employ the definition of MHS as formal facilities where specialized professionals (e.g. psychiatrists, psychotherapists, psychologists) apply evidence-based methods to treat MD to facilitate psychological well-being (Alonso et al., 2004; Kessler et al., 2005). Barriers comprise internal (e.g. fear of being judged) and external (e.g. no MH facilities available) obstacles to service use, while facilitators are internal (e.g. wish for change) and external factors (e.g. general practitioner advices to seek trauma treatment) that aid to increase MHS use. Investigating both barriers and facilitators is crucial to enhance trauma survivors' MHS use. Prior
1 2 3
MD MHS MH
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research mainly pursued two strategies to explore barriers as well as facilitators towards MHS use. 1.1. Characteristics associated with MHS use First, correlational studies focused on characteristics of MHS use and investigated factors associated with seeking MHS (e.g. Boscarino et al., 2004; Koenen, Goodwin, Struening, Hellman, & Guardino, 2003). In their systematic review of correlates among heterogeneous trauma survivors' MHS utilization, Gavrilovic et al. (2005) identified a range of positively associated factors with treatment seeking. They used Andersen's (1995) behavioral model of health service use to classify their results in three categories: (1) predisposing factors: female gender, higher education, living in an urban area, being Caucasian; (2) enabling factors: low to medium income, coverage through medical insurance; and (3) need factors: severity of current psychopathology, somatic symptoms, general health status. Inconsistencies were reported especially in the predisposing factors, as for example both older and younger age predicted treatment seeking, which was also the case for being employed and unemployed, as well as the marital status (Gavrilovic et al., 2005). Elhai and Ford (2009) focused on less heterogeneous types of trauma survivors and reviewed MHS use among directly exposed disaster survivors. They identified as predisposing factors: young and middle age, being Caucasian, and the extent of disaster exposure. As need factor they reported that being diagnosed with major depression and PTSD as comorbid disorders is strongly associated with MHS use (Elhai & Ford, 2009). 1.2. Individuals self-perceived reasons for use or non-use of MHS In the second applied research strategy, survivors' subjectively perceived barriers and facilitators were explored with interviews and questionnaires (e.g. Bance et al., 2014; Chapman et al., 2014a). Gulliver, Griffiths, and Christensen (2010) reviewed and summarized studies of young persons' perceived barriers and facilitators towards MHS use. The most important obstacles towards treatment seeking were stigma and embarrassment, a low MH literacy and a preference of solving problems on their own. Although research generally neglected facilitating factors, positive experiences with prior MHS use and encouragement from significant others seemed to positively influence treatment-
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seeking behavior. In the field of trauma research, Pietrzak, Johnson, Goldstein, Malley, and Southwick (2009) surveyed a sample of veterans and reported that negative beliefs towards MHS and little unit support were associated with stigma and barriers to MH care. Stecker, Fortney, Hamilton, and Ajzen (2007) also found stigma to be a major barrier to receiving MH care in veterans. They further reported a preference for self-reliance and the tendency not to accept the fact of being affected by a MD. Boscarino, Adams, Stuber, and Galea (2005) explored a sample of survivors of the 2001 World Trade Center terror attacks and found similar barriers: Many participants mentioned that they did not think they had a problem, others tried to solve it on their own, some feared treatment. In addition, time, access, and financial barriers were reported as perceived reasons why trauma-affected individuals with MD did not seek help from MHS, which seems to be consistent with the results of correlational studies. It appears that self-perceived barriers and facilitators may vary between specifically trauma-related disorders (e.g. PTSD) and other MD (e.g. other anxiety disorders, mood disorders). Survivors might have to cope with the traumatic event on various levels. Depending on the traumatic event – aside from the psychological consequences – trauma survivors face further demanding conditions. They might be affected or disabled by physical (e.g. injuries), social (e.g. financial burden, loss of property), or societal (e.g. political instability) consequences that prevent them from seeking MHS. These challenges would go far beyond the scope of this review; however, the effects on MH are severe. Compared to other MH problems, trauma-specific symptoms (e.g. intrusive re-experiencing) and reactions to traumatic experiences (e.g. avoiding traumatic memories) can be even more detrimental for the treatment-seeking process. Koenen et al. (2003) highlighted more barriers to MH care for individuals with PTSD than for individuals with other anxiety disorders. In their study, traumatized participants specifically reported concerns about being judged by others, as well as uncertainty about where to seek help. So far, a considerable amount of research has been carried out on trauma survivors' perceived barriers and facilitators. Even if facilitators still lack attention (Gavrilovic et al., 2005), a systematic synthesis of the existing literature is of importance to provide an extensive summary of prior and current studies of barriers and facilitators towards MHS use. To our knowledge, no previous study systematically reviewed the existing quantitative and qualitative studies on these matters. 1.3. Objectives This study aimed to synthesize relevant literature, and to systematically classify trauma survivors' perceived barriers and facilitators regarding MHS utilization. Further, this review aimed to help policymakers and practitioners to gain an extensive overview of the recent literature and relevant outcomes to improve their approaches to facilitate access to MHS and encourage non-users to seek professional care. 2. Method Following the PRISMA-Guidelines (Shamseer et al., 2015), a review protocol was designed and data extraction forms were developed. Therefore, the rationale and objectives, methods of the systematic search and the data analysis have been specified and documented. The protocol was registered (CRD4201502497) at PROSPERO (International Prospective Register of Systematic Reviews). 2.1. Search strategy Systematic searches were conducted in five academic databases: PsycINFO, Web of Science, PubMed, Scopus, and Cochrane Database of Systematic Reviews. Google Scholar, article references, relevant reviews and book chapters were further searched for additional relevant publications.
The search strategy was based on synonyms of the primary search terms: (1) barriers and/or facilitators, AND (2) trauma, AND (3) MHS use. The search was tailored for each database, truncations and wildcards were used where appropriate. The search terms for barriers and facilitators were adapted from Gulliver et al. (2010). The full database search strategies, including dates of searches and complete numbers of identified studies per database, are provided in Appendix A. 2.2. Eligibility criteria Studies that met the following criteria were included in the systematic review: (1) published before the date of the last search (April 11, 2016); (2) participants were adult trauma survivors (aged 18 years or older); (3) studies considered self-perceived barriers and/or facilitators to MHS utilization. Studies that were not included in this review: (1) studies on help seeking for problems not directly related to MH (e.g. disclosure of experienced violence); (2) systematic reviews as well as nonpeer-reviewed work; (3) articles that reported the perspective of others (e.g. MHS professionals, spouses); (4) articles that addressed children and adolescents; and (5) studies with no evaluable data on self-perceived barriers and/or facilitators. 2.3. Study selection The database search yielded 1596 papers, after duplicates were removed. Further, 16 additional studies were identified through manual search in relevant reference lists. The study selection was carried out in two stages. First, after the full database search was completed, the first (VK) and second author (MK) independently screened the same 200 abstracts, and developed and adapted a standardized eligibility assessment based on the primarily defined characteristics (see eligibility criteria). Second, the remaining abstracts were then divided into two groups and screened independently by each researcher. Any disagreement regarding inclusion criteria was consulted with the senior author (BLS) and resolved by discussion. A total of 1468 records were excluded in this early stage of study selection. Third, from the remaining 146 records, full text articles were assessed independently (VK, MK) for the final selection of eligible studies, again disagreement was resolved by discussion under supervision of the senior author (BLS). Overall, 110 records did not meet the inclusion criteria and were excluded from further analysis, leaving 36 studies eligible for inclusion. See Table B.1 (Appendix B) for a summary of the excluded studies grouped by exclusion criteria. The full process of study selection was carried out according to PRISMA guidelines and is illustrated in the flowchart (see Fig. 1). 2.4. Data extraction The first author (VK) extracted data from the included 16 qualitative and 21 quantitative studies using a data extraction sheet that was developed and adapted based on the PRISMA guidelines (Shamseer et al., 2015) and the Cochrane Consumers and Communication Group's (2015) data extraction template. The second author (MK) doublechecked the extracted information for accuracy. See Appendix B for the full extracted study characteristics. 2.5. Data analyses All qualitative and quantitative studies reporting trauma survivors' subjectively perceived barriers and facilitators to MHS use were included in the analysis. The qualitative studies were analyzed using thematic analysis (Braun & Clarke, 2006), a recently frequently used method for identifying and analyzing patterns (themes) in qualitative data. Initially, after all barriers were extracted from the 16 included qualitative papers, the first (VK) and second author (MK) were searching for patterns of meaning in these barriers, grouped them according to content and
V. Kantor et al. / Clinical Psychology Review 52 (2017) 52–68
55
Fig. 1. Flow diagram.
gave them working titles. This grouping process was constantly supervised by the senior author (BLS), disagreements were solved by discussion. The emerging groups of collated barriers were refined and the working titles were adjusted to the final names of the key themes. All key themes are presented in Table 2. The same strategy was applied to the extracted facilitators (see Table 3). The collated barriers and facilitators, including the corresponding study references as well as the key themes, are illustrated in detail in Table B.1, Appendix B. All included quantitative studies used a survey method to gather relevant information regarding barriers and facilitators. All reported barriers and facilitators were extracted and rated according to the highest percentage of participants' agreement or the upmost mean ratings. The most frequently reported or top rated barriers and facilitators were reassigned to the key themes developed in the analysis of qualitative data. The aim was to enable a structured discussion of various barriers and facilitators under a common heading. Detailed results can be found in Table 4. In case of further interest, the supplementary file (Appendix B) provides all extracted barriers and facilitators of the included studies. The relevant data of one study (Owens et al., 2009) was included in the thematic analysis (answers to open-ended questions) as well as in the results of the quantitative studies (quantitative measure).
2.6. Andersen's behavioral model of health service use as theoretical framework Andersen's behavioral model is used in this systematic review as a framework to group and discuss the results (Andersen, 1995). It was
continuously developed and revised over the last decades, as well as transferred and applied in research towards MHS use (Elhai & Ford, 2009; Gavrilovic et al., 2005; Huynh, Caron, & Fleury, 2016). It distinguishes between contextual and individual perspectives on predisposing, enabling and need characteristics to help understanding the complex factors that influence access to health care (Andersen, 1995, 2008; Andersen & Davidson, 2007). As this review aims to summarize individuals' subjective reasons for the use or non-use of MHS, the main results will be discussed within the framework of the models' individual perspectives. In the general discussion, also the contextual perspective will be considered.
3. Results 3.1. Study characteristics Overall, 36 papers were included in the systematic review. Therefrom, 20 (55.56%) used quantitative, 15 (41.67%) qualitative, and one (2.78%) study used quantitative and qualitative methods to assess relevant aspects for this review. Further information regarding the included studies is presented in Table 1 and Appendix B. Regarding the studies referred to as “using qualitative methods” it has to be mentioned that many of the original studies actually applied a mixed-methods strategy. For the present systematic review only the results of the qualitative approach were of importance. We will refer to these studies as “qualitative studies”. Of the included studies 19 (52.77%) were examining military samples, therefore differences and similarities compared to non-military trauma samples will be presented and discussed.
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V. Kantor et al. / Clinical Psychology Review 52 (2017) 52–68
Table 1 Characteristics of all studies included in the systematic review. #
Study
Location N
Studies included in the quantitative analysis General population (1) Fox et al. (2012) USA
150
(2)
Koenen et al. (2003)
USA
2713
(3)
Lowe et al. (2015)
USA
658
(4)
Rodriguez et al. (2003)
USA
197
(5)
Stuber et al. (2006)
USA
2752
(6)
Tiburcio Sainz et al. (2010)
MEX
135
(7)
Topper et al. (2015)
ZA
977
(8)
Wang et al. (2007)
USA
1043
Military population (9) Chapman et al. (2014a)
USA
452
(10) Chapman et al. (2014b)
USA
(11) Crawford et al. (2015)
USA
(12) Elbogen et al. (2013)
USA
(13) Fikretoglu et al. (2008)
CA
(14) Gorman et al. (2011)
USA
(15) Hoge et al. (2004)
USA
(16) Iversen et al. (2011)
UK
(17) Osorio, Jones, Fertout, & Greenberg (2013)
UK
(18) Ouimette et al. (2011)
USA
(19) Owens et al. (2009)c
USA
(20) Tsai et al. (2015)
USA
(21) Valenstein et al. (2014)
USA
% Sample (trauma) type Female
Type
Approach
[n.r.] 38.3 7.8 [18–65+] n.r. n.r. [18+] n.r. n.r. [18+] 38.1 10.9 [18–65+] n.r. n.r. [18–55+] n.r. n.r. [18–40] n.r. n.r. [18–60+] n.r. n.r.
22
Police officers exposed to stressful events
Quan.
Self-report survey
82.5
Individuals with PTSD
Quan.
Video; self-report survey; MH professional
n.r.
Hurricane survivors
Quan.
Survey, mostly conducted via telephone
80
Patients in general medical practice with PTSD
Quan.
Self-report survey; structured face-to-face-interview
54
Survivors of WTC-attacks
Quan.
Telephone survey
100
Victims of intimate partner violence
Quan.
Household self-report survey
47.8
PTSD after diverse traumatic events
Quan.
Structured face-to-face interview
n.r.
Hurricane survivors
Quan.
Telephone survey
32.2a
U.S. Army Combat Medics
Quan.
Self-report survey
26
U.S. Army Combat Medics
Quan.
Self-report survey
15.6
OEF/OIF veterans
Quan.
Self-report survey
33
OEF/OIF veterans
Quan.
Web-based survey
17.3
Active duty soldiers
Quan.
Structured face-to-face interviews
13b
National Guard members after combat
Quan.
Self-report survey
2
OEF/OIF veterans
Quan.
Self-report survey
12.3
Active duty soldiers
Quan.
Structured telephone survey
7.1
U.K. military personnel deployed to Afghanistan and/or Iraq Veterans with PTSD using VA health system
Quan.
Self-report survey
Quan.
Self-report survey
100
OEF/OIF female veterans
Quan./Qual
Web-based survey
100
Female veterans
Quan.
Web-based survey
10.8
National Guard soldiers after deployment
Quan.
Self-report survey
41.4a
Transit workers exposed to traumatic events
Qual.
Semi-structured interview
58.1
WTC-attacks survivors with MH
Quan./Qual. Structured telephone survey; open-ended
[n.r.] 28.23a 6.73a 799 [n.r.] 28.11 6.48 279 [n.r.] 36.8 9.8 1388 [n.r.] 36.2 10.1 1220 [17–45+] n.r. n.r. [18–51+]b 332b n.r. n.r. 3671 [18–40+] n.r. n.r. 821 [b25–40+] n.r. n.r. 23,101 [18–45+] n.r. n.r. 490 [18–69] 41 13.37 50 [n.r.] 34.7 9.4 478 [n.r.] 48.8 17.2 1954 [18–51+] n.r. n.r.
Studies included in the qualitative analysis General population (22) Bance et al. (2014) CA
29
(23) Boscarino et al. (2005)
473
USA
[Age range] Mean age SD
[n.r.] 44.19a 8.39a [18–65+]
47.1
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Table 1 (continued) #
Study
Location N
(24) Chikovani et al. (2015)
GE
3600
(25) Ghafoori et al., 2014)
USA
178
(26) Jankovic et al. (2011)
UK, DE, HR, RS
212
(27) Kaltman, Hurtado-de-Mendoza, Gonzales, & Serrano (2014)
USA
120
(28) Larsen et al. (2014)
DE
6
(29) Prospero & Vohra-Gupta (2008)
USA
200
(30) Zungu-Dirwayi et al. (2004)
ZA
134
Military population (31) Murphy et al. (2014)
UK
8
(19) Owens et al. (2009)c
USA
50
(32) Sayer et al. (2009)
USA
44
(33) Stecker et al. (2007)
USA
20
(34) Stecker et al. (2013)
USA
143
(35) True, Rigg, & Butler (2014)
USA
29
(36) Turchik et al. (2013)
USA
20
[Age range] Mean age SD n.r. n.r. [18–60+] n.r. n.r. [18–55+] n.r. n.r. [1–70] 43.4 n.r. [n.r.] 45.56 9.19 [20–49] 35.5 n.r. [18–25+] n.r. n.r. [25–86] 53 14.3
[22–51] n.r. n.r. [n.r.] 34.7 9.4 [20–62] 42.11 15.99 [21–51+] n.r. n.r. [19–50] 28.0 5.2 [26–57] 31d n.r. [n.r.] 62.22 12.85
% Sample (trauma) type Female
Type
problems
Approach
questions
65
Adults affected by armed conflicts
Quan./Qual. Household face-to-face interview; open questions
33.7
Urban trauma exposed individuals
Quan./Qual. Self-report survey; semi-structured interview
51.9
War-related trauma survivors
Quan./Qual. Structured face-to-face interview; open-ended questions
100
Trauma-exposed Latina immigrants
Quan./Qual. Self-report survey; card-sorting task; open questions
100
Female survivors of intimate partner violence
Qual.
68.7
Survivors of intimate partner violence
Quan./Qual. Self-report survey; open-ended questions
53.7
Survivors of gross human rights violations
Qual.
Semi-structured interview; open questions
25
Military personnel with PTSD
Qual.
Self-report survey; semi-structured interview
100
OEF/OIF female veterans
Quan./Qual. Web-based survey
32
OEF/OIF veterans
Qual.
Self-report survey; semi-structured interview
10
OIF veterans
Qual.
Structured telephone survey; open-ended questions
16
OEF/OIF veterans
Qual.
Telephone intervention; structured telephone survey; open-ended questions
20.69
OEF/OIF veterans
Qual.
Participatory action research; group discussion; unstructured interview guide
0
Male veterans who experienced military sexual trauma
Qual.
Semi-structured interview
Semi-structured interview
a
= Calculated for whole sample. = National guard members only; Quan. = quantitative study design; Qual. = qualitative study design. c = Included in quant. and qual. analyses. d = Median age; OIF = Operation Iraqi Freedom; OEF = Operation Enduring Freedom (Afghanistan); VA = Veterans Affairs; PTSD = post-traumatic stress disorder; CA = Canada; DE = Germany; GE = Georgia; HR = Croatia; MX = Mexico; RS = Serbia; UK = United Kingdom; ZA = South Africa. b
In the majority of the included studies, participants were asked to complete self-report measures or were interviewed in structured faceto-face interviews (Chapman et al., 2014a, 2014b; Crawford et al., 2015; Fikretoglu et al., 2008; Fox et al., 2012; Gorman et al., 2011; Hoge et al., 2004; Koenen et al., 2003; Osorio et al., 2013; Ouimette et al., 2011; Rodriguez et al., 2003; Tiburcio Sainz et al., 2010; Topper et al., 2015; Valenstein et al., 2014). Few studies provided web-based inquiries (Elbogen et al., 2013; Owens et al., 2009; Tsai et al., 2015), whereas some applied structured telephone surveys (Iversen et al., 2010; Lowe et al., 2015; Stuber et al., 2006; Wang et al., 2007). The qualitative studies applied mostly open-ended questions (Boscarino et al., 2005; Chikovani et al., 2015; Jankovic et al., 2011; Prospero & Vohra-Gupta, 2008; Zungu-Dirwayi et al., 2004), semi-structured (Bance et al., 2014; Ghafoori et al., 2014; Larsen et al., 2014; Murphy et al., 2014; Sayer et al., 2009; Turchik et al., 2013; Zungu-Dirwayi et
al., 2004) or unstructured in-depth interviews (True et al., 2014). Stecker et al. (2007) and Stecker et al. (2013) applied structured telephone surveys, including open-ended questions. One study used a participatory action research strategy by implementing a photovoice technique and group-discussions (True et al., 2014). Further, a cardsorting task and related open questions were methods of choice in one particular study (Kaltman et al., 2014) (see Table 1). 3.2. Sample characteristics Overall, the systematic review includes 17 studies with samples from the general population and 19 with samples of military personnel. The overall number of participants ranged from six to 23,101. Among those studies that used qualitative methods, eight (50%) included between six and 50 participants. The remaining studies that were referred
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V. Kantor et al. / Clinical Psychology Review 52 (2017) 52–68
to as qualitative studies included 120 to 3600 participants. From the 21 quantitative studies, one (4.76%) included 50 participants, and five (23.81%) reported between 135 and 332 participants. In the majority of studies, the sample sizes ranged from 452 to 3671 participants, one study involved 23,101 participants. The median of the sample sizes of the included studies was 297 (interquartile range [IQR] = 120–977). 3.2.1. Year and location of studies Although no limits concerning the year of publication were set for the database search, the resulting relevant studies were published in the years 2003 to 2015. In total, 25 (69.44%) studies were conducted in the United States. From the remaining studies, three (8.33%) were conducted in the United Kingdom (Iversen et al., 2010; Murphy et al., 2014; Osorio et al., 2013), two (5.55%) in Canada (Bance et al., 2014; Fikretoglu et al., 2008) and in South Africa (Topper et al., 2015; Zungu-Dirwayi et al., 2004), and one each (2.77%) in Georgia (Chikovani et al., 2015), Germany (Larsen et al., 2014) and Mexico (Tiburcio Sainz et al., 2010). One study which investigated survivors of the Balkan wars was conducted in four countries, namely Serbia, Croatia, United Kingdom, and Germany (Jankovic et al., 2011). No limit was set regarding the publication language. Nevertheless, all but one study were published in English, except Tiburcio Sainz et al. (2010), which was published in Spanish. 3.2.2. Participants' age and gender In general, the participants' age ranged from 18 to 86 years, the reported mean ages range from 28.00 to 62.22. Most of the studies (83.33%, n = 30) included males and females. Five (13.88%) studies exclusively investigated women (Kaltman et al., 2014; Larsen et al., 2014; Owens et al., 2009; Tiburcio Sainz et al., 2010; Tsai et al., 2015), one (2.77%) only men (Turchik et al., 2013). One further study did not report neither participants' age nor gender in detail (Lowe et al., 2015). 3.2.3. Traumatic experiences The traumatic experiences reported in the included studies comprised a range of various stressful events. Within the 19 military-related studies, mostly active duty soldiers or veterans exposed to combat-duty and their respective deployment-related traumata were investigated. One study investigated male survivors of military sexual trauma (Turchik et al., 2013). Only four (21.05%) out of these 19 studies assessed traumata or wartime stressors using a specific measure (Chapman et al., 2014a; Gorman et al., 2011; Hoge et al., 2004; Owens et al., 2009). Turchik et al. (2013) reported the use of two questions to systematically gather military sexual trauma. Within the general population, the 17 included studies addressed survivors of heterogeneous traumatic events: hurricanes (Lowe et al., 2015; Wang et al., 2007), intimate partner violence (Larsen et al., 2014; Prospero & Vohra-Gupta, 2008; Tiburcio Sainz et al., 2010), war or armed conflicts (Chikovani et al., 2015; Jankovic et al., 2011), terroristic attacks (Stuber et al., 2006), gross human rights violations (ZunguDirwayi et al., 2004), and several traumatic events (Ghafoori et al., 2014; Kaltman et al., 2014; Koenen et al., 2003; Rodriguez et al., 2003; Topper et al., 2015). One study investigated police officers exposed to stressful events during service (Fox et al., 2012). Another study focused on transit workers exposed to work-related traumatic events (Bance et al., 2014). In total, 13 (36.66%) studies systematically examined the type of trauma exposure with quantitative measures of traumatic events (Bance et al., 2014; Boscarino et al., 2005; Chapman et al., 2014b; Ghafoori et al., 2014; Gorman et al., 2011; Hoge et al., 2004; Kaltman et al., 2014; Lowe et al., 2015; Prospero & Vohra-Gupta, 2008; Rodriguez et al., 2003; Stuber et al., 2006; Tiburcio Sainz et al., 2010; Zungu-Dirwayi et al., 2004). Further, Topper et al. (2015) described that trauma exposure was surveyed using a specifically developed questionnaire, but no further information concerning questions or design of the instrument was provided by the authors.
3.2.4. MH status In 31 (86.11%) of the studies included in this review, psychiatric symptoms were assessed systematically with widely used measures or their purposeful adapted versions (Boscarino et al., 2005; Chapman et al., 2014a, 2014b; Chikovani et al., 2015; Crawford et al., 2015; Elbogen et al., 2013; Fikretoglu et al., 2008; Fox et al., 2012; Ghafoori et al., 2014; Gorman et al., 2011; Hoge et al., 2004; Iversen et al., 2010; Jankovic et al., 2011; Kaltman et al., 2014; Koenen et al., 2003; Lowe et al., 2015; Murphy et al., 2014; Osorio et al., 2013; Ouimette et al., 2011; Owens et al., 2009; Rodriguez et al., 2003; Sayer et al., 2009; Stecker et al., 2007; Stecker et al., 2013; Stuber et al., 2006; Tiburcio Sainz et al., 2010; Topper et al., 2015; Tsai et al., 2015; Valenstein et al., 2014; Wang et al., 2007; Zungu-Dirwayi et al., 2004). The authors of the remaining five (13.88%) studies did not systematically assess psychopathological problems of trauma survivors in the course of the research process (Bance et al., 2014; Larsen et al., 2014; Prospero & Vohra-Gupta, 2008; True et al., 2014; Turchik et al., 2013). 3.2.5. MHS use among participants Overall, most of the included studies provided a heterogeneous assessment of MHS, and in many of these studies it is not clear how MHS were defined for the purpose of the particular research and what kind of services were considered in the analysis. In 14 (41.18%) of those studies that assessed MHS utilization, lists of possible MH professionals were presented and participants were asked to choose from different providers or types of treatment (Boscarino et al., 2005; Chapman et al., 2014a, 2014b; Chikovani et al., 2015; Elbogen et al., 2013; Gorman et al., 2011; Hoge et al., 2004; Iversen et al., 2010; Ouimette et al., 2011; Prospero & Vohra-Gupta, 2008; Rodriguez et al., 2003; Stuber et al., 2006; Tiburcio Sainz et al., 2010; Valenstein et al., 2014; Wang et al., 2007). Tsai et al. (2015) and Rodriguez et al. (2003) defined MH treatment in terms of receiving psychotropic medication or psychotherapy for MH-related problems, while Fikretoglu et al. (2008) specified MH treatment with MH related psychoeducational information, medication, and counseling/therapy. Lowe et al. (2015) used a modified version of the Perceived Need for Care Questionnaire (Meadows, Burgess, Fossey, & Harvey, 2000) to assess unmet service needs. Jankovic et al. (2011) referred to “psychological or psychiatric treatment” (p. 101), but applied treatment engagement as an exclusion criterion. Similarly, Stecker et al. (2013) excluded possible participants who experienced PTSD treatment and Turchik et al. (2013) excluded participants who received trauma-related treatment. Several studies (23.53%, n = 8) assessed MHS use, but did not define the intended services or MH professionals (Bance et al., 2014; Crawford et al., 2015, Ghafoori et al., 2014; Koenen et al., 2003; Murphy et al., 2014; Owens et al., 2009; Sayer et al., 2009; Topper et al., 2015; Zungu-Dirwayi et al., 2004). Stecker et al. (2007) did not assess the actual or former MHS use, but specified physicians or MH specialists as professionals to treat MH issues. Similarly, Kaltman et al. (2014) did not gather information about participants' actual or former treatment, but presented several treatment modalities and types of psychotherapy with card sorting tasks (the participants were asked to rank their treatment preferences). In three (8.33%) studies, neither MHS nor MH professionals were defined as well as the use of MHS was not surveyed (Larsen et al., 2014; Osorio et al., 2013; True et al., 2014). Three studies referred to a theoretical model as a framework for their study design. Andersen's Behavioral Model of Health Service Use (Andersen, 1995) was applied by Fikretoglu, Brunet, Schmitz, Guay, and Pedlar (2006) and Ghafoori et al. (2014), while Stecker et al. (2007) referred to Ajzen's (1985) theory of planned behavior model. 3.3. Perceived barriers and facilitators Perceived barriers were addressed in all included qualitative and quantitative studies, perceived facilitators were investigated in eight (23.53%) studies – of those, seven were carried out within a qualitative approach.
V. Kantor et al. / Clinical Psychology Review 52 (2017) 52–68
3.3.1. Assessment of perceived barriers and facilitators 3.3.1.1. Quantitative studies. Procedures of how self-perceived barriers and facilitators were measured are very heterogeneous across the different studies. Hoge et al. (2004) and Tsai et al. (2015) developed questions based on previous research to evaluate barriers to utilize care (Britt, 2000; Britt et al., 2008). Several studies used questions (modified or directly derived) from or referred their research strategy to Hoge et al. (2004) (Chapman et al., 2014a, 2014b; Crawford et al., 2015; Gorman et al., 2011; Iversen et al., 2010; Owens et al., 2009; Valenstein et al., 2014). Osorio et al. (2013) assessed stigmatizing beliefs based on questions developed by Hoge et al. (2004) and Britt et al. (2008). Elbogen et al. (2013) adapted statements from Hoge et al. (2004) and Burnam et al. (2008). Fikretoglu et al. (2008), Stuber et al. (2006), and Rodriguez et al. (2003) developed lists of barriers based on prior research to elicit their respondents' views. Wang et al. (2007) used a list of potential reasons to assess why participants did not use or did not continue to use services. This list included statements related to low need, lack of enabling, and lack of predisposing factors. However, the rationale of how these statements were selected was not reported. This information was also not provided in the study of Koenen et al. (2003) which, however, used a list of barriers. Fox et al. (2012) piloted potential treatment concerns prior to fielding the study and included them in their questionnaire. Ouimette et al. (2011) assessed perceived barriers to care based on literature research and several items from the Barriers to Help Seeking Scale (Mansfield, Addis, & Courtenay, 2005), which was developed and evaluated to measure men's helpseeking behavior. Lowe et al. (2015) derived a survey with care beliefs based on the findings of three cited studies. Tiburcio Sainz et al. (2010) adapted questions from the Composite International Diagnostic Interview - CIDI (Robins et al., 1988) that assess reasons for delayed help seeking. Within the quantitative studies, this was the only survey which considered perceived facilitators to care. In one study (Topper et al., 2015) it was not reported in detail how reasons for not seeking care were examined.
3.3.1.2. Qualitative studies. Similar to the quantitative records, perceived barriers and facilitators have been assessed in heterogeneous ways in the qualitative studies. As mentioned above, seven qualitative studies (43.57%) explored both barriers and facilitators (Bance et al., 2014; Ghafoori et al., 2014; Kaltman et al., 2014; Murphy et al., 2014; Owens et al., 2009; Sayer et al., 2009; Stecker et al., 2007). Kaltman et al. (2014) asked participants to sort cards according to five logistical factors that might influence access to care (cost, location, hours of service, gender, providers' language ability) and four potential barriers (uncertainty of what it means to go to a MH professional, fear of immigration issues, not wanting to be judged as crazy, and preferring to seek help only from the family). They had been derived from literature research and the authors' professional experiences. Sayer et al. (2009) also developed their interview guideline based on prior research and the authors' clinical experience, but did not provide detailed questions. Stecker et al. (2007) developed semi-structured interview questions based on the theory of planned behavior and described how they assessed participants' behavioral, normative, and control beliefs towards seeking MH treatment. Owens et al. (2009) asked their participants from a military sample to list difficulties in accessing Veterans Affairs (VA) services and reported the full wording of the questions. Further, participants were asked to suggest improvements to VA services, which will be described here in terms of facilitators. Bance et al. (2014) developed a semi-structured interview to investigate perceived barriers and motivating factors in seeking MH treatment, but did not provide detailed information regarding the design of questions or the precise wording. Similarly, Murphy et al. (2014) as well as Ghafoori et al. (2014) developed questions to assess knowledge, attitudes, and beliefs about MH treatment, barriers, and factors which enable participants to overcome
59
them. They likewise did not report the process of question design or further detailed information. A similar picture is present in some of the studies that focused on barriers only. Some authors developed semi-structured interviews or open-ended questions to examine perceived barriers to or beliefs about professional MH care, or to explore reasons why participants did not use MHS, but the theoretical background or detailed questions remain unclear (Boscarino et al., 2005; Chikovani et al., 2015; Prospero & Vohra-Gupta, 2008; Stecker et al., 2013; Zungu-Dirwayi et al., 2004). Larsen et al. (2014) adapted an interview guide from Wilson, Silberberg, Brown, and Yaggy (2007), but did not report detailed information about how barriers were explored. In contrast to the underreporting of procedures in some studies, Turchik et al. (2013) investigated soldiers' knowledge about military sexual trauma care as well as potential barriers towards help seeking, and provided the full wording of their questions. Jankovic et al. (2011) also presented the wording of the open-ended questions used. An exhaustive summary of the extracted information regarding the assessment of perceived barriers and facilitators can be consulted in the supplementary file (Appendix B). 3.3.2. Perceived barriers and facilitators in the qualitative studies The thematic analysis of the barriers and facilitators which were extracted from the qualitative studies resulted in 13 key barrier themes and six key facilitator themes. They will be specified below. An exhaustive description of all derived barriers and facilitators, and how they were merged in the analysis is depicted in Table B.2, Appendix B. 3.3.2.1. Perceived barriers. The key barriers that emerged from the thematic analysis are shown in Table 2. They were ordered by the totaled number of studies which addressed the particular themes in the general population or in the military-related studies. Each key barrier theme is assigned a number in squared brackets ([1]–[13]) and presented with an example of the associated barriers extracted from the studies. It is noteworthy that the distribution of military and general population-related studies is about equally dispersed in many of the key themes (e.g. low MH literacy; time constraints). Barriers regarding expenses or availability/resources were more often mentioned in studies of the general population. The same applies for lack of knowledge and treatment-related doubts. Contrary, twice as many studies in the military population identified barriers which were allocated to the theme concerns related to stigma, shame and rejection. 3.3.2.2. Perceived facilitators. The key facilitator themes identified in the thematic analysis are shown in Table 3. They were consecutively numbered from [14] to [19]. Facilitators were only investigated in a small number of studies; the resulting key themes were mentioned in between one to three studies. Three of nine studies in the general population and four out of seven studies of the military population explored facilitators. An additional key theme was merged and named wishes and suggestions. It does not belong entirely to the other facilitators per se, but includes service-related desires mentioned by respondents from four studies, mainly from the military population. The participants addressed primarily a lack of resources: wish for more female therapists; shorter waiting time for appointments; locus of control towards treatment options; more community-based facilities; convenient, comfortable, confident, non-threatening treatment. 3.4. Perceived barriers and facilitators in the quantitative studies All quantitative studies assessed perceived barriers and facilitators with some type of questionnaire. Facilitators were assessed only in one study (Tiburcio Sainz et al., 2010). The entire dataset with all extracted barriers and facilitators is depicted in Appendix B. After all barriers and facilitators have been retrieved from the studies, the toprated answers (ranked by the highest percentage of respondents'
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V. Kantor et al. / Clinical Psychology Review 52 (2017) 52–68
Table 2 Key barrier themes addressed in qualitative studies (n = 16). #
Barrier theme [example]
na
[1]
Low MH literacy [not believing that symptoms are part of mental illness]
10 Ghafoori, Barragan, & Palinkas (2014) Jankovic et al. (2011) Larsen, Krohn, Pueschel, & Seifert, 2014 Prospero & Vohra-Gupta (2008) Zungu-Dirwayi, Kaminer, Mbanga, & Stein (2004)
[2]
Availability/resources [access problems; language barriers]
[3]
Concerns related to stigma, shame & rejection [embarrassment; fear of being labeled]
10 Bance et al. (2014) Boscarino et al. (2005) Chikovani et al. (2015) Ghafoori et al. (2014) Jankovic et al. (2011) Zungu-Dirwayi et al. (2004) 9 Jankovic et al., 2011 Kaltman et al. (2014) Prospero & Vohra-Gupta (2008)
[4]
Time constraints [no time]
8
[5]
Lack of knowledge and treatment-related doubts [lack of knowledge about services]
8
[6]
Trauma specific barriers [didn't want to talk about trauma]
8
[7]
Expenses [financial problems]
7
[8]
Mistrust and concerns about confidentiality [fears about privacy]
7
[9]
Alternative ways of dealing with MH problems [wish for self-reliance; tried to solve problems on own; alcohol and drug abuse]
6
[10] Fear of negative social consequences [fear of consequences on career]
5
General population
Chikovani et al. (2015) Ghafoori et al. (2014) Jankovic et al. (2011) Larsen et al. (2014) Chikovani et al. (2015) Ghafoori et al. (2014) Jankovic et al. (2011) Kaltman et al. (2014) Prospero & Vohra-Gupta (2008) Boscarino et al. (2005) Ghafoori et al. (2014) Jankovic et al. (2011) Zungu-Dirwayi et al. (2004) Boscarino et al., 2005 Chikovani et al., 2015 Ghafoori et al., 2014 Jankovic et al., 2011 Prospero & Vohra-Gupta (2008) Chikovani et al. (2015) Jankovic et al. (2011) Kaltman et al. (2014) Zungu-Dirwayi et al. (2004) Boscarino et al., 2005 Chikovani et al., 2015 Jankovic et al., 2011 Jankovic et al. (2011) Kaltman et al. (2014)
[11] Lack of encouragement to seek professional help [social network discouragement 4 of help seeking] [12] Negative experiences with professional help [prior bad experiences] 3
Bance et al. (2014) Jankovic et al. (2011) –
[13] Prioritizing needs of others [others need more help]
Jankovic et al. (2011)
a
3
Military Murphy, Hunt, Luzon, & Greenberg (2014) Sayer et al. (2009) Stecker et al. (2007) Stecker, Shiner, Watts, Jones, & Conner (2013) Turchik et al. (2013) Sayer et al. (2009) Stecker et al. (2013) True et al. (2014) Turchik et al. (2013)
Murphy et al. (2014) Sayer et al. (2009) Stecker et al. (2007) Stecker et al. (2013) True et al. (2014) Turchik et al. (2013) Owens, Herrera, & Whitesell (2009) Sayer et al. (2009) Stecker et al. (2007) Stecker et al. (2013) Sayer et al. (2009) Stecker et al. (2013) Turchik et al. (2013)
Sayer et al. (2009) Stecker et al. (2013) True et al. (2014) Turchik et al. (2013) Sayer et al. (2009) Turchik et al. (2013)
Sayer et al. (2009) Stecker et al. (2013) Turchik et al. (2013) Sayer et al., 2009 Stecker et al., 2007 True et al. (2014) Stecker et al. (2007) Stecker et al. (2013) True et al. (2014) Sayer et al. (2009) Stecker et al. (2007) Owens et al. (2009) Sayer et al. (2009) True et al. (2014) True et al. (2014) Turchik et al. (2013)
Number of studies reporting addressed key barrier.
consent) have been extracted and matched with the key themes of the thematic analysis. Table 4 presents the two highest rated responses including the percentage of respondents for each study. Further, it shows the associated key theme. Three barriers did not fit the key themes, which is why they were merged in the residual category “other”. Table 5 provides an overview of the dedicated key themes which are ranked by the number of the associated studies. As can be seen above, barriers linked to concerns related to stigma, shame & rejection and fear of negative social consequences received the highest response rates in most of the studies and were addressed mainly in military-related studies. Barriers regarding alternative ways of dealing with MH problems were extracted more homogeneously in both study groups. None of the studies reported strong responses to obstacles associated with trauma-
specific barriers or negative experiences with professional help. The results in the study on facilitators fitted best in the key theme severity of disorder & wish for change.
4. Discussion This is the first study that systematically reviewed perceived barriers and facilitators to MHS use among trauma survivors with various traumatic experiences. All included studies reported perceived barriers to MHS use, while facilitators were generally under-researched, as also illustrated in prior studies (e.g. Gavrilovic et al., 2005; Gulliver et al., 2010). Overall, the analysis of all extracted barriers and facilitators
V. Kantor et al. / Clinical Psychology Review 52 (2017) 52–68
61
Table 3 Key facilitator themes addressed in qualitative studies. na General population
Military
[14] Social support from significant others or professionals [peer support]
3
Bance et al. (2014)
[15] Severity of disorder & wish for change [reaching a crisis point]
3
Bance et al. (2014)
[16] Positive experience with professional help [to be given a psychological explanation for difficulties]
3
–
[17] Avoiding negative social interactions [to avoid burdening family members]
2
Sayer et al. (2009) Stecker et al. (2007) Murphy et al. (2014) Stecker et al. (2007) Murphy et al. (2014) Sayer et al., 2009 Stecker et al. (2007) –
Bance et al., 2014 Kaltman et al. (2014) – Sayer et al. (2009) Ghafoori et al. (2014) Owens et al. (2009) Murphy et al. (2014) Stecker et al. (2007)
#
Facilitator theme [example]
[18] Experiences of trust, reduced stigma and social acceptance [recognition and acceptance of PTSD, and availability of help] 1 [19] Wishes and suggestions 4
a
Number of studies reporting addressed key facilitator.
revealed a broad spectrum of self-perceived reasons for use or non-use of MHS. The discussion will focus on the most prominent key themes that emerged from the data analysis in the qualitative and quantitative studies, and their occurrence in general population- or military-related studies. The key themes were embedded in the theoretical framework of Andersen's behavioral model of health service use and assigned to the three main factors (predisposing, enabling, need factors) which characterize MHS use (Andersen & Davidson, 2007). 4.1. Predisposing factors Predisposing factors are preexisting individual or contextual conditions that might influence a person's use or non-use of MHS (Andersen & Davidson, 2007). The most prominent reported barrier themes in both qualitative and quantitative studies were concerns related to stigma, shame and rejection. Clement et al. (2015) revealed in a systematic review that especially individuals with an ethnic minority background, young people, men, military service personnel, and health professionals were deterred from seeking professional help by fear of stigma. Fears about being negatively judged or rejected by others because of MH problems are well-known as an important barrier to MHS use in veterans (Vogt, 2011). It seems that stigma and negative attitudes towards MH problems and MHS use are the most influential factors across various groups of trauma survivors and therefore a major challenge for the public health sector. Although numerous programs were developed to reduce stigma among MH beliefs, Mackenzie, Erickson, Deane, and Wright (2014) found an increasingly negative change in attitudes towards seeking MHS within the last 40 years. The authors explain this development – among other reasons – with the marketing strategies of pharmaceutical industries to medicalize MH treatment, which could especially influence the public view on MH and psychological interventions. Wilson, Drozdek, and Turkovic (2006) describe the crucial influence of posttraumatic shame across different psychological dimensions. Shame is known to impede help seeking among trauma survivors in the general population (Jankovic et al., 2011) as well as military service personnel, especially combined with embarrassment among survivors of sexual violence (Turchik et al., 2013). Ellis (2002) reviewed literature on male rape survivors and showed that they were mostly treated poorly regarding professionals' empathy and understanding. The author highlighted the importance of trauma-specific training of professionals in the health sector. Fear of negative social consequences was especially prominent in the quantitative studies of the military population, which might be explained by the fact that these studies mainly used questions based on Hoge et al. (2004) that screened for concerns relating to consequences for the military career. Further prominent perceived barriers were low MH literacy as well as lack of knowledge regarding treatment and
treatment-related doubts. Jorm et al. (1997) defined MH literacy as knowledge and beliefs about MD which aid their recognition, management or prevention” (p. 182). Chikovani et al. (2015) considered low knowledge about MH as an influential barrier to MHS use. They found that one third of their participants who screened positive for a mental disorder did not recognize the symptoms as treatable with professional help. A similar finding was reported by Prospero and Vohra-Gupta (2008), their participants reported that they did not believe that treatment could help them coping with their emotional problems. Negative beliefs in the sense of assuming that the effectiveness of professional help would be equal to or even worse than receiving no help at all was found in one third of the participants in a European epidemiological study on MH (ten Have et al., 2010). The difficulties in identifying symptoms of a mental disorder, acknowledging them as treatable with professional help, knowing which services are available, and what to expect from particular treatment methods was also discussed in previous reviews (Jorm, 2000; Rickwood, Deane, Wilson, & Ciarrochi, 2005). The need of psychoeducation for trauma survivors regarding MH in general, possible MH problems following traumatization, and information about available trauma therapy have an outstanding importance on the pathway towards facilitating MHS use among survivors of the general as well as the military population. Media campaigns could be of great help to publicize that MHS provide a secure and supporting environment, trauma treatment has various proven positive effects, and that further difficulties could emerge from avoiding traumatic memories (Stecker et al., 2013). Beaudoin (2009) evaluated a media campaign after Hurricane Katrina and reported improvements in survivors' PTSD beliefs and preventive strategies. Similar public health strategies could also lower trauma-specific barriers to MHS use previously revealed in the present review. In many of the qualitative studies, participants expressed fears regarding feeling helpless about the traumatic memories, the wish to avoid talking or thinking about their experiences, and concerns about re-evoking distressing memories. Reluctance to seek professional help after disasters to avoid painful memories was also identified by Schwarz and Kowalski (1992). It is interesting that those trauma-specific barriers were not considered in the quantitative studies. An explanation could be that questionnaires about barriers towards MHS use were not developed specifically for trauma survivors; however, as trauma-specific barriers seem to impede MHS use, they should be considered in future research. Olff (2015) reviewed and discussed recent developments in smartphone applications that were aimed to improve access to psychoeducation, enable individuals to self-identify symptoms of a mental disorder and need for treatment, and to encourage MHS use. The self-help smartphone app “PTSD Coach”, for instance, was developed for military service personnel. It provides information and helps users to self-manage their symptoms, but also facilitates help seeking towards MHS (Kuhn et al., 2014). Mobile health tools are cost-effective, easily accessible, and – if examined and validated thoroughly – have
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Table 4 Highest rated barriers and facilitators in quantitative studies. Study General population Fox et al. (2012) Koenen et al. (2003) Lowe, Fink, Norris, & Galea (2015)
Barriers
Key barrier themesa
1. Concerns over confidentiality (35.0%) 2. Potential negative impact on one's career (16.7%) 1. Not sure where to get help (39.5%) 2. Can handle it on my own (28.7%) 1. I think it is better to pray or seek spiritual guidance (57.9%) 2. I wanted to solve the problem on my own (55.8%)
1. [3] 2. [10] 1. [5] 2. [9] 1. [9] 2. [9]
Rodriguez et al. (2003)
Reasons for not receiving psychotropic medication: 1. Physician did not recommend medication (45%) 2. Did not believe in taking medication as way of dealing with emotional problems (33%) Reasons for not receiving psychological treatment: 1. Did not believe had a problem for which psychological treatment was necessary (26%) 2. Did not believe in psychotherapy as way of dealing with emotional problems (25%)
1. [11] 2. [5]
1 [1]
Stuber, Galea, Boscarino, & Schlesinger (2006)
1. Altruistic concerns, like: others needed MHS more than themselves (58%) 2. Time constraints (42%)
Tiburcio Sainz, Natera Rey, & Berenzon Gorn (2010)
1. Not knowing what to do (35.0%) 2. Being ashamed (27.5%) 1. Should be able to cope with problem (74.07%) 2. Got help from another source (64.81%) 2. Shame of being emotionally troubled (64.81%)
Topper, van Rooyen, Grobler, van Rooyen, & Andersson (2015)
Wang et al. (2007)
Military population Chapman et al. (2014a)
1. Finances (39.13%) 2. Availability (22.83%)
1. My unit leadership might treat me differently (69%) 2. I would be seen as weak (56%)
Chapman et al. (2014b)
1. My unit leadership might treat me differently (62%) 2. I would be seen as weak (53%)
Crawford et al. (2015)
1. It's up to me (3.49) 2. Don't want medication (3.41) 1. It's up to me to work out my own problems (64.8%) 1. I don't want to be prescribed medication (64.8%) 2. It might harm my career (42.6%)
Elbogen et al. (2013)
2. [5] 1. [13] 2. [4] 1. [5] 2. [3] 1. [9] 2. [9] 2. [3] 1. [7] 2. [2]
1. [10] 2. [3] 1. [10] 2. [3] 1. [9] 2. Otherd 1. [9] 1. Other 2. [10]
Fikretoglu, Guay, Pedlar, & Brunet (2008)
Gorman, Blow, Ames, & Reed (2011)
Hoge et al. (2004) Iversen et al. (2011)
Barriers towards medication: 1. Mistrust in military (44.8%) 2. Other barrier (34.1%) Barriers towards counseling/therapy: 1. Mistrust in military (51.9%) 2. Time barriers (34.5%) 1. I don't want it on my military records (45%) 2. I would be seen as weak (31%) 1. I would be seen as weak (65%) 2. My unit leadership might treat me differently (63%) 1. Members of my unit might have less confidence in me (73.2%) 2. My unit bosses might treat me differently (71.3%)
Osorio et al. (2013)
1. My commanders would treat me differently (34.6%) 2. I would be seen as weak (32.0%)
Ouimette et al. (2011)
1. Privacy is important to me, and I don't want other people to know about my problems (2.72)b 2. I don't like to talk about feelings (2.66)
Owens et al. (2009)
1. Would be seen as weak (57%) 1. Would be too embarrassing (57%) 2. Do not feel welcome at the local VAc (43%) 1. Getting treatment costs too much money (28.0%) 2. I would be seen as weak (15.7%)
Tsai, Mota, & Pietrzak (2015)
Valenstein et al. (2014)
1. Don't want it in military records (27.0%) 2. Care costs too much money (16.4%)
1. [8] 2. Other 1. [8] 2. [4] 1. [10] 2. [3] 1. [3] 2. [10] 1. [3] 2. [10] 1. [10] 2. [3] 1. [8]
2. [5] 1. [3] 1. [3] 2. Other 1. [7] 2. [3] 1. [10] 2. [7]
V. Kantor et al. / Clinical Psychology Review 52 (2017) 52–68
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Table 4 (continued) Study
Barriers
Key barrier themesa
Study
Facilitators
Tiburcio Sainz et al. (2010)
1. Thought really needed help (28.7%) 2. Feeling very nervous (26.8%)
Key facilitator themes 1. [15] 2. [15]
a b c d
= Numerical assignment for key themes, see Tables 2 and 3. = Mean ratings reported by study authors. = Veteran Affairs. = Residual category.
great potential to reduce or prevent symptoms. Suggestions for further interventions to overcome barriers towards help seeking among military personnel were given by Zinzow, Britt, McFadden, Burnette, and Gillispie (2012): (1) group workshops to provide information, address stigma, and screen for symptoms, (2) need for policy changes including the increase of access and support for treatment seeking, strengthen confidence in MHS, and reducing concerns towards negative effects on military career. Interventions should not address individuals only, but
should be developed and further elaborated for trauma-affected communities and the society (Maercker & Hecker, 2016). 4.2. Enabling factors Enabling factors comprise individual resources as well as conditions of the community and the health system that impede or facilitate MHS use (Andersen & Davidson, 2007). Perceived barriers according to
Table 5 Key barrier and key facilitator themes in quantitative studies' highest rated barriers and facilitators. Barrier theme Concerns related to stigma, shame & rejection [3]
b
na
General population
Military
11
Fox et al. (2012) Tiburcio Sainz et al. (2010) Topper et al. (2015)
Chapman et al. (2014a) Chapman et al. (2014b) Gorman et al. (2011) Hoge et al. (2004) Iversen et al. (2011) Osorio et al. (2013)
Fear of negative social consequences [10]
9
Fox et al. (2012)
Alternative ways of dealing with MH problems [9]
5
Lack of knowledge and treatment-related doubts [5]
4
Koenen et al. (2003) Lowe et al. (2015) Topper et al. (2015) Koenen et al. (2003) Rodriguez et al. (2003) Tiburcio Sainz et al. (2010)
Otherc
4
Expenses [7]
3
Mistrust and concerns about confidentiality [8]
2
Time constraints [4] Low MH literacy [1] Availability/resources [2] Lack of encouragement to seek professional help [11] Prioritizing needs of others [13] Trauma-specific barriers [6] Negative experiences with professional help [12]
2 1 1 1 1 0 0
Stuber et al. (2006) Rodriguez et al. (2003) Wang et al. (2007) Rodriguez et al. (2003) Stuber et al. (2006)
Facilitator theme Severity of disorder & wish for change [15]
na 1
General population Tiburcio Sainz et al. (2010)
a b c
= Number of studies reporting barriers/facilitators which match the proposed key themes. = Numerical assignment for key themes Tables 2 and 3. = Residual category.
Wang et al. (2007)
Owens et al. (2009) Tsai et al. (2015) Chapman et al. (2014a) Chapman et al. (2014b) Elbogen et al. (2013) Gorman et al. (2011) Hoge et al., 2004 Iversen et al. (2011) Osorio et al. (2013) Valenstein et al. (2014) Crawford et al. (2015) Elbogen et al. (2013) Ouimette et al. (2011)
Crawford et al. (2015) Elbogen et al. (2013) Fikretoglu et al. (2008) Owens et al. (2009) Tsai et al. (2015) Valenstein et al., 2014 Fikretoglu et al. (2008) Ouimette et al. (2011) Fikretoglu et al. (2008)
Military
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V. Kantor et al. / Clinical Psychology Review 52 (2017) 52–68
availability of MHS or lack of service-associated resources (e.g. language barriers; lack of different treatment options) were reported in studies of the general population as well as military personnel. Living in an urban area is known to predict MHS use in the general population (Gavrilovic et al., 2005; Bland, Newman, & Orn, 1997), while military-related studies mainly found no relationship between rural living and lack of MHS use (Elhai, North, & Frueh, 2005). It is also important to acknowledge and enable patients' treatment (Stecker et al., 2013) or provider gender preferences (Turchik et al., 2013) to facilitate MHS use, as well as to reduce language barriers, e.g. by the use of translators (Jankovic et al., 2011). The latter is of special importance in the treatment of traumatized refugees, as language-appropriate MHS are needed (Gong-Guy, Cravens, & Patterson, 1991) and the use of translators in trauma therapy seems to be successful (Neuner, Schauer, Klaschik, Karunakara, & Elbert, 2004). Another prominent enabling factor includes having financial possibilities to afford MHS use or possessing an insurance coverage. Particularly in general population studies, financial problems, not being insured, or too expensive treatment were perceived as barriers to care, which contributes to previous research that investigated enabling factors associated with MHS use (Gavrilovic et al., 2005). Elhai et al. (2005) showed in their review that possessing a health insurance does not necessarily predict MHS use and also household income seemed to have little influence. Larsen et al. (2014) pointed out that it depends on the different health and insurance systems in different countries, and therefore also studies of financial constraints matter relating to MHS use. The use of MHS often does not only demand financial, but also time resources as treatment is usually based on regular appointments, approximately once a week. In a number of studies of the general as well as the military population, participants reported difficulties in getting time off work, work- or childcare-related schedule challenges, and the importance of urgent personal duties. The need of flexible treatment options including appointments in early mornings, late evenings or on weekends should be discussed by clinicians and policy-makers, while also alternative treatment options that include telephone or mediabased delivery strategies should be promoted. For example, Miller and Weissman (2002) investigated a 12-week pilot clinical trial that delivered Interpersonal Psychotherapy for women with depression via telephone and showed significant symptom reduction. 4.3. Need factors Need factors include an individual's perceived or professionally evaluated need, health-related conditions of the physical and socio-cultural environment, as well as population health indicators (Andersen, Rice, & Kominski, 2007). Need factors were dominantly represented by facilitators, especially the severity of disorder and in this context a dominant wish for change. The perceived level of psychological distress and symptom severity were reported as crucial reasons for engaging in MH treatment, which was consistent with prior findings of factors associated with treatment seeking (Gavrilovic et al., 2005). The wish to avoid negative social interactions was another facilitator to MHS use. Trauma survivors who realized a negative impact on their families were motivated to seek professional help by the desire not to burden their loved ones (Bance et al., 2014). Furthermore, social support from significant others or professionals was designated as a facilitator. This facilitator seems to span a continuum to the barrier “lack of encouragement” to seek professional help. Friends and family are known as important gatekeepers to MHS utilization, as they can encourage those affected by MD to seek professional treatment (Arria et al., 2011; Vogel, Wade, Wester, Larson, & Hackler, 2007). Harding and Fox (2014) investigated enablers to men's MH help seeking and revealed that mostly partners or female friends encouraged them to seek professional help, and that also the support of general practitioners (GP) played an important role in the help-seeking process. This latter aspect was also reported in prior
research (e.g. Smith, Robertson, & Houghton, 2006). Rodriguez et al. (2003) discovered that GP of patients with PTSD rarely recommend psychopharmacological or psychological treatment, and highlighted the need of appropriate educational interventions regarding MH problems and evidence-based treatment strategies. Bramsen and van der Ploeg (1999a) indicated the importance of the primary health care system to recognize PTSD symptoms for referring those affected to professional MH services. A barrier – within the need factors – to MHS use was the wish for self-reliance and dealing with MH problems by oneself. These findings match those observed in other studies (Greene-Shortridge, Britt, & Castro, 2007). For example, Stecker et al. (2007) identified veterans' strong beliefs towards the need to handle MH problems on one's own as the most commonly reported barrier, which was mainly stated wishing to deny MH problems. These barriers could also be addressed by the interventions suggested above. 4.4. Strengths and limitations This review extends our knowledge of what impedes, but also encourages trauma survivors to seek help from MHS. We discussed our findings with regard to clinical implications and offered suggestions for policy-makers and future research. However, several limitations need to be considered. Firstly, as with any systematic review the publication records might not be exhaustive. In order to find as many relevant papers as possible we did not set limits to the publication year or study language in the database search. Certainly, even though we did not set language limits, our search terms were in English and therefore only papers with English abstracts were identified in the screening process. Our review includes studies that were typically conducted in the United States, but also covers studies done in Canada, Mexico, South Africa, United Kingdom, Georgia, and Germany. Nevertheless, the selfperceived barriers and facilitators presented here might not be generalizable in other countries and important findings – especially culturally sensitive factors – might not have been identified. Second, the search terms were initially broadly selected to cover as much of the relevant literature as possible, but nevertheless our search results might not include all relevant literature. Third, the measures used in the included studies were heterogeneous, as were the terms describing MHS and MH professionals. Many studies did not provide a definition of these terms of interest. The lack of homogenous definitions regarding MHS and MH professionals might interfere with the comparability of the different studies. Future research should address this issue by using consistent terminology and general classifications of MHS and MH professionals. For this purpose, Rickwood and Thomas (2012) presented a list of formal (and informal) providers in the MH field who emerged from their systematic review on how help seeking for MH problems was conceptualized and measured. Similarly, only few studies systematically investigated the traumatic experiences of trauma survivors, and no study highlighted differences between single traumatic events and repeated or prolonged traumatic experiences – a distinction that was considered to be important by prior research (Herman, 1992; Terr, 1991) and that could possibly influence self-perceived barriers to help seeking. 5. Conclusion and future directions Trauma survivors perceive a number of barriers to MHS use and many of these barriers seem to be present regardless of the traumatic incidents and within different populations. One result deserves to be particularly highlighted: trauma survivors face specific trauma-related barriers to MHS use. Especially concerns about re-experiencing the traumatic events and the avoidance of traumatic reminders – essential symptoms of PTSD (American Psychiatric Association, 2013) – are a major challenge in facilitating MHS use among those affected by MD following traumatic experiences. These issues need to be considered in future research on interventions that aim to increase MHS utilization. This
V. Kantor et al. / Clinical Psychology Review 52 (2017) 52–68
review has shown that too little is known about what actually facilitates MHS use from the survivors' perspective, which contributes to similar findings by Gavrilovic et al. (2005) and Gulliver et al. (2010). Therefore, future research should investigate treatment seekers' reasons for MHS use and their successful steps towards seeking professional help. Continued research is needed in multiple areas, particularly regarding easily accessible interventions (e.g. mobile health tools) that could contribute to reducing or preventing PTSD symptoms or trauma-related disorders and facilitate help seeking. Mobile health applications could provide psychoeducation and self-screenings for PTSD symptoms and suggest self-help interventions or, if necessary, advise users to contact specialized MHS. This might contribute to lowering the top barriers discussed in this review. Above all, research should be guided by theoretical models. The model by Andersen and Davidson (2007) attempts to conceptualize and measure access to health care and the framework for help-seeking measurement by Rickwood and Thomas (2012) considers different steps within the help-seeking process. Both models could serve as a useful theoretical framework to better understand and explain that barriers and facilitators may vary across different phases after traumatization. Adaptations of these models should address traumatized individuals – initial moves in this direction were done by Schreiber, Renneberg, and Maercker (2009) with their integrative model of seeking psychological care after interpersonal violence. The studies included in our review investigated heterogeneous samples of trauma survivors. It is interesting to note that we nevertheless found similar barriers and facilitators across these different groups, especially according to stigma, low MH literacy, treatment-related doubts, and trauma specific barriers, or the importance of social support from significant others. We conclude that these factors are important to address in interventions to facilitate help seeking among survivors in the general population as well as military personnel. Acknowledgements We thank Tobias Glück, Ulrich Tran, Agnes Kapias, Alexander Haselgruber, Leonie Traub, and Julia Fietz for their valuable contribution to this article. This project was supported by the Austrian Science Fund (FWF): P26584. Appendix A Search protocol and illustrative search strategy Barrier- and facilitator-related terms: barrier* OR hurdle OR obstacle OR obstruct* OR refusal OR impedim* OR promot* OR facilitat* OR support* OR enabl* OR cause* OR reasons. Trauma-related terms: trauma* OR PTSD OR posttraumatic OR posttraumatic OR maltreatment OR childabuse OR violen* OR victim* OR catastroph* OR disaster OR war. MHS use-related terms: helpseek* OR seek* help OR seek* treatment OR help seeking behavio?r OR service utili* OR mental health service use OR mental health service utili#ation OR treatment utili#ation OR treatment use OR psychotherapy use OR psychotherapy utili#ation OR seek* professional treatment OR seek* professional care OR seek* professional help OR psychological counseling. A.1. PsycINFO [Abstract] Barrier* OR Hurdle OR Obstacle OR Obstruct* OR refusal OR Impedim* OR Promot* OR Facilitat* OR Support* OR Enabl* OR Cause* OR Reasons. AND Trauma* OR PTSD OR Posttraumatic OR Post-traumatic OR maltreatment OR Childabuse OR Violen* OR Victim* OR catastroph* OR disaster OR war.
65
AND Helpseek* OR Seek* help OR Seek* treatment OR Help Seeking Behavio?r OR Service Utili* OR Mental health service “use” OR mental health service utili#ation OR treatment utili#ation OR treatment “use” OR psychotherapy “use” OR psychotherapy utili#ation OR Seek* professional treatment OR Seek* professional care OR Seek* professional help OR psychological counseling. NNSearch conducted 19/08/2015 – results: 621. Last search 11/04/ 2016–38 new records, 0 relevant. Web of Science [Topic] Barrier* OR Hurdle OR Obstacle OR Obstruct* OR refusal OR Impedim* OR Promot* OR Facilitat* OR Support* OR Enabl* OR Cause* OR Reasons. AND Trauma* OR PTSD OR Posttraumatic OR Post-traumatic OR maltreatment OR Childabuse OR Violen* OR Victim* OR catastroph* OR disaster OR war. AND Helpseek* OR Seek* + help OR Seek* + treatment OR Help + Seeking + Behavio$r OR Service + Utili* OR Mental + health + service + use OR mental + health + service + utili$ation OR treatment + utili$ation OR treatment + use OR psychotherapy + use OR psychotherapy + utili$ation OR Seek* + professional + treatment OR Seek* + professional + care OR Seek* + professional + help OR psychological + counseling. NNSearch conducted 20/08/2015 – results: 943. Last search 11/04/ 2016 – 90 new records, 0 relevant. Pubmed [Title, Abstract] Barrier* OR Hurdle OR Obstacle OR Obstruct* OR refusal OR Impedim* OR Promot* OR Facilitat* OR Support* OR Enabl* OR Cause* OR Reasons. AND Trauma* OR PTSD OR Posttraumatic OR Post-traumatic OR maltreatment OR Child abuse OR Violen* OR Victim* OR catastroph* OR disaster OR war. AND Helpseek* OR “Seek* help” OR “Seek* treatment” OR “Help Seeking Behavior” OR “Service Utili*” OR “Mental health service use” OR “mental health service utilization” OR “treatment utilization” OR “treatment use” OR “psychotherapy use” OR “psychotherapy utilization” OR “Seek* professional treatment” OR “Seek* professional care” OR “Seek* professional help” OR “psychological counseling”. NNSearch conducted 24/08/2015 – results: 248. Last search 11/04/ 2016 – 15 new records, 0 relevant. Scopus [Article Title, Abstract, Keywords] Barrier* OR Hurdle OR Obstacle OR Obstruct* OR refusal OR Impedim* OR Promot* OR Facilitat* OR Support* OR Enabl* OR Cause* OR Reasons. AND Trauma* OR PTSD OR Posttraumatic OR Post-traumatic OR maltreatment OR {Child abuse} OR Violen* OR Victim* OR catastroph* OR disaster OR war. AND Helpseek* OR {Seek* help} OR {Seek* treatment} OR {Help Seeking Behavior} OR {Service Utili*} OR {Mental health service use} OR {mental health service utilization} OR {treatment utilization} OR {treatment use} OR {psychotherapy use} OR {psychotherapy utilization} OR {Seek* professional treatment} OR {Seek* professional care} OR {Seek* professional help} OR {psychological counseling}. NNSearch conducted 24/08/2015 – results: 426. Last search 11/04/ 2016–55 new records, 0 relevant. Cochrane [Title, Abstract, Keywords] Barrier* OR Hurdle OR Obstacle OR Obstruct* OR refusal OR Impedim* OR Promot* OR Facilitat* OR Support* OR Enabl* OR Cause* OR Reasons.
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AND Trauma* OR PTSD OR Posttraumatic OR Post-traumatic OR maltreatment OR Child abuse OR Violen* OR Victim* OR catastroph* OR disaster OR war. AND Helpseek* OR “Seek* help” OR “Seek* treatment” OR “Help Seeking Behavior” OR “Service Utili*” OR “Mental health service use” OR “mental health service utilization” OR “treatment utilization” OR “treatment use” OR “psychotherapy use” OR “psychotherapy utilization” OR “Seek* professional treatment” OR “Seek* professional care” OR “Seek* professional help” OR “psychological counseling”. NNSearch conducted 24/08/2015 – results: 23. Last search 11/04/ 2016 – 0 new records. Appendix B. Supplementary data Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.cpr.2016.12.001. References Ajzen, I. (1985). From intentions to actions: A theory of planned behavior. In J. Kuhl, & J. Beckmann (Eds.), Action control: from cognition to behavior (pp. 11–39). 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