stigma and barriers to care - Uniformed Services University of the ...

Conference Recommendations 99
Several models we have implicitly been using as we move toward making
recommendations. We approach problems from certain angles. One approach is
our traditional primary, secondary, and tertiary prevention. How do we respond,
and how do we prevent disability Another approach is the IOM suggestions from
1994, which asks things such as, “Is this for the entire population Is it for those at
risk, or is it for those at significantly high risk” Where does what we are doing fit
in that frame
If we think about war, disaster, and terrorism — as in the Haddon Matrix —
there are also a pre-stage that we have to work in; an event stage in which we operate,
and a post-event stage. Therefore, thinking from the perspective of preventive
interventions, primary, secondary, tertiary, universal, selective, and indicated are all
very helpful. If we were really good, we would take everything we say today and
put them into those categories.
The Haddon matrix had much of its original importance with the question of
motor vehicle accidents. It is essentially a three by three table in which you have the
agent, the vector, and the population. You could think of the agent as malaria, the
vector as mosquito, and then choose your population: children, workers, et cetera.
So, what would be the pre-event intervention to address the agent One might take
anti-malarial drugs as a pre-event, to decrease the malaria load. Each of those boxes
should be filled in to disrupt the disease process.
Is there a similar way to apply the three by three models to barriers to care and
stigma This was accomplished in the IOM report that I and others worked on
for a number of psychological issues, so it can be done, but it needs to be thought
through. How would it work if we said that the agent was stigma, the vector was
the sergeant, and we are worried about the squad members How would we address
stigma or barriers to care across those nine squares
Disease occurs across multiple domains, and stigma and barriers to care are
going to be different across different domains. We have the disorder, say PTSD, but
we also have symptoms, and symptom presentations, and perhaps partial disorders.
We have nightmares separate from PTSD. We also have to address the question
of impairment of function, and how will barriers to care address impairment of
function, which is not the same as disability. Disability tends to be an attribute that
usually accompanies the award of funds. There is also the question of comorbid
conditions. If we are thinking of one condition, what else goes with it, and how do
the barriers to care interact with those comorbidities If we are dealing with PTSD
and barriers to care, are we really dealing with the issues of depression and the barriers
to care Are we working toward answering the questions of substance abuse
and the barriers to care
There is a system of care, so where in the system are we focused A particular
example addresses PTSD, and we go from the question of screening and surveillance
to education around battle mind, to buddy care, to RESPECT-MIL, Chuck Engel’s
program, to DESTRESS, down to the issues of complicated disorder, and the question
of care for care givers.
Whenever clinicians use the word “manipulating,” it is usually a sign that the
clinician is overworked, and has begun to feel the burden of care as more, in fact,
than they can do. During that time, there is a new barrier to care that has been created
by the clinician within the clinician, and the management of that barrier also
needs to be addressed.
Now lets return to our goal, to come up with recommendations. I want us to