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. Author manuscript; available in PMC: 2021 Jul 1.
Published in final edited form as: J Community Psychol. 2020 Mar 16;48(5):1452–1468. doi: 10.1002/jcop.22339

Examining attitudes towards mental health treatment and experiences with trauma: Understanding needs of trauma exposed middle aged and older adults

Marissa C Hansen 1, Bita Ghafoori 2, Melanie Diaz 1
PMCID: PMC7316604  NIHMSID: NIHMS1574887  PMID: 32176330

Abstract

Aims

Middle-aged and older adults who have been exposed to traumatic events may have developmentally specific needs with respect to engagement in mental health treatment. The current study examined factors that potentially facilitate or inhibit attitudes towards mental health service use (ATMHSU) in a trauma-exposed sample of treatment seeking adults age 50 and older.

Methods

In this mixed-methods study, quantitative data (N=165) were analyzed to examine relationships with trauma exposure, posttraumatic stress disorder (PTSD), quality of life (QOL) and ATMHSU. Semi-structured interviews were conducted assessing similar constructs with a sub-sample of the data (n=12).

Results

Regression analysis revealed higher QOL-environmental well-being as associated with more positive ATMHSU and higher QOL-social support with more negative ATMHSU. Qualitative themes emerged around perceived distress in managing lifelong traumas due to challenges with functioning, coping, and accessing services.

Conclusion

Emphasizing resources to help manage the impact of distress on daily life needs may support aging trauma-exposed populations.

Keywords: Trauma, Mental Health Service Use, Quality of Life, PTSD, Traumatic distress

Introduction

In public healthcare settings, up to 90% of clients report experiencing some form of trauma over the course of their lives (SAMSHA, 2015). Trauma exposure is defined as one event or a series of harmful or life-threatening events that potentially yield lasting adverse physical or emotional effects on an individual’s functioning, health, mental health, social and/or spiritual well-being (SAMSHA, 2015). Traumatic life events are also equated with stressful life events which create a cumulative level of stress impacting adaptive capacities to manage various domains of quality of life and psychological well-being as one ages (Krause, 2004; Maschi, Viola, & Morgen, 2013; Platt, Lowe, Galea, Norris, & Koenen, 2016). Many adults develop posttraumatic stress disorder (PTSD) or other mental health issues as a result of trauma exposure and may greatly benefit from mental health treatment; however, trauma-exposed middle-aged and older aged adults in public care systems are often less likely than younger populations to seek out and engage in care when in need, extending disparities in access and use of mental health services (Mosqueda & Dong, 2011; Teaster, Stansbury, Nerenberg, & Stanis, 2009). Although some studies have identified positive attitudes towards mental health treatment as an important factor associated with engaging in treatment (Elhai & Simmons, 2007; Ghafoori, Fisher, Koresteleva, & Hong, 2014), no study has focused specifically on aging trauma-exposed adults. More work is necessary to understand the components that facilitate and inhibit positive attitudes towards treatment in trauma-exposed middle-aged and older populations.

Cumulative disadvantage theory (Dannefar, 2003) frames the understanding that complicated adjustments to lifetime experiences with health, socioeconomic status, and traumatic life events reduce opportunities to access and engage with social, educational, and healthcare resources creating increased risk for inequalities and disparities in mental health outcomes with age. This theory proposes that early life events, including traumatic events, set up a chain of events that lead to either positive or negative developmental trajectories as one ages (Aldwin, Levenson, & Kelly, 2009). For example, a supportive environment has been found to have lifelong protective effects in veterans who have experienced traumatic events, whereas an environment characterized by conflict has been found to set up lifelong patterns of pessimistic or negative attitudes (Kang, Aldwin, Choun, & Spiro, 2016).

Aging adults are disproportionately affected by trauma, having higher rates of complications relating to self-reported mental health and physical functioning once trauma exposure occurs (Kessler, 2005; Krause, Neal, & Shaw, 2004). Among aging adults, PTSD may be a result of childhood or young adult trauma exposure or a result of a new trauma (Averill & Beck, 2000; van Zelst, deBeurs, Beekman, Deeg, & van Dyck, 2003). Middle-aged and older adults with PTSD have a higher risk for other mental health conditions and medical conditions such as hypertension, stomach disorders, and arthritis (Pietrzak, Goldstein, Southwick, & Grant, 2012).

Service use literature supports the notion that reduced access to healthcare and insurance, perceived need, and support resources create a context that decreases likelihood of formal service use even when evaluated need exists for adults in general (Alegría, Pescosolido, & Canino, 2011; Andersen, 1995). Among adults aged 50 and older in need of mental health care, less than half access services. Only 43% report receipt of outpatient therapy coupled with prescription medication treatment and 34.7% medication only treatment (Federal Interagency Forum on Aging Statistics, 2016). Aging adults with untreated mental health needs report increased rates of healthcare utilization, chronic illness, functional impairment and ultimately decreased quality of life (Blazer, 2003). In trauma-exposed populations, the complications related to service use, competing health demands, and cumulative stress create a burden on managing mental health needs that can increase with age associated losses and life transitions (Glass, DeLeon, Bassuk, & Berkman, 2006; Krause, Shaw, & Cairney, 2004). However, the cumulative impact of early and ongoing trauma related stress can be buffered by protective factors, lessening the adverse effects of trauma exposure and illustrating the potential for resiliency when individuals are appropriately supported (Maschi, Viola, & Morgen 2013).

Attitudes on Service Use and Trauma

Disentangling the interplay between individual attitudes towards managing trauma associated distress and potential facilitators and barriers to use of formal care may clarify how individuals prioritize treatment decisions. A few studies to date on trauma-exposed populations suggest more positive attitudes about mental health treatment have been positively associated with increased mental health service use (Elhai & Simmons, 2007; Ghafoori, Fisher, Koresteleva, & Hong, 2014). After controlling for insurance and access to services, decisions to seek care among trauma-exposed populations have been found to be related to one’s self-perceived need, specifically PTSD, as well as support and prior service use experiences (Davis et al., 2008; Ghafoori et al., 2014).

Quality of life, particularly in later life, has been associated with formal service use in managing psychological distress in non-trauma exposed populations (Hansen & Aranda, 2012; Hansen, Fuentes, & Aranda, 2018; Krause, 2004). Poor quality of life in the area of psychological health and better quality of life in the area of physical health has been found to significantly predict initiation of treatment in trauma-exposed populations (Ghafoori, Hansen, & Garibay, 2019). It is possible that trauma-exposed older adults with lower perceived quality of life may have more negative attitudes towards treatment; however, more research is needed to investigate this relationship. When examining the relevance of person and physical environment congruence (security, safety, connectedness to community resources) within quality of life for midlife and older age adults, current well-being and successful aging connects with perceived future well-being, capacity to positively engage in current life experiences, and balancing out vulnerabilities with available individual resources (Mejía, Ryan, Gonzalez, & Smith, 2017). The influence of such environmental factors can potentially attenuate perceived deficits for those struggling with managing the impact of trauma on their connections to self and others.

Few studies capture the possible service use complications that emerge with age for trauma-exposed populations (Clapp & Beck, 2012). Questions remain as to what factors support attitudes associated with engaging in treatment for trauma-exposed middle and older aged adults. This knowledge will not only highlight risk and protective factors for treatment outcomes in this population but also support future approaches to engage clients in treatment tailored to address the unique needs of trauma-exposed individuals as they age.

The aim of this mixed-methods study was to develop a comprehensive understanding of the relationship between quality of life factors and attitudes towards mental health services among a sample of racially/ethnically diverse trauma-exposed adults aged 50 and older. We explored whether better quality of life, specifically the domains of physical health, psychological health, social relationships, and environmental quality of life, would be associated with more positive attitudes towards mental health service use. Qualitative data from a subset of participants were then used to inform a descriptive review of the nature and extent that trauma related distress impacts daily life and how it can inform treatment attitudes in middle and older adulthood.

Design and Methods

A mixed-methods approach was employed using a two-phase explanatory sequential design (Creswell & Zhang, 2009). In using this approach, secondary client level data were examined (N = 165) in the first phase to assess correlates associated with attitudes towards mental health treatment. In a second phase, data were collected using semi-structured individual interviews (n = 12) to further explore the impact of traumatic distress on attitudes towards treatment. This approach allows for the qualitative inquiry to further investigate experiences and perceptions of the client population reported in the quantitative analysis to explore the study aims at a deeper level (Creswell & Zhang, 2009; Banyard & Williams, 2007).

The first phase of the current study included data extracted from client records of adults who contacted a community-based trauma recovery center in southern California for mental health services. Clients who sought mental health care and participated in an initial assessment to assess qualification for trauma-based care provided data included in the current study. The study was approved by the Long Beach State University, Institutional Review Board (#16–052).

Secondary Quantitative Data

Cross-sectional secondary data were examined from de-identified client level data from a community mental health agency that included 165 adults ages 50 to 78 years (M = 56.3, SD = 5.53) over a 2-year period. Data provided was based on information gathered by clinic staff during the initial consultation session prior to beginning mental health treatment. The agency service eligibility criteria from which the data were obtained included: self-reported having witnessed, experienced, or been confronted with any traumatic event that involved actual or threatened death or serious injury and no cognitive impairment that may interfere with trauma-focused treatment. All clients receiving services from the community mental health agency provided consent upon enrollment for services that information gathered at the intake assessment could be used on a de-identified basis for research purposes as part of the overall mission of the agency. The study from which the presented research is based used the following inclusion criteria for the dataset utilized in the secondary data analysis: participation in the agency consultation session; self-reported as 50-years or older; and English as a primary language. Within the scope of the study, individuals aged 50 – 59 years (77%) of age were considered the middle-aged subset of the sample and 60 years and older the older adult subset (23%). The agency provided a password-protected database containing the following de-identified client data associated with the study aims to support the secondary data analysis: self-reported demographics, experiences with trauma, PTSD symptoms, quality of life indicators, mental health service use history, and attitudes towards mental health treatment.

Measures

Demographic characteristics were reviewed that included self-reported age at time of the assessment, age of last reported trauma, gender, ethnic identity (African-American, Non-Hispanic White, Hispanic, Asian-Pacific Islander, Other, Decline), marital status (single or unmarried versus married or partnership), self-reported annual income, previous mental health service use, and highest level of education achieved (some high school or less, high school degree, associate’s degree or higher). Ethnic identity was included for review of Non-Hispanic Whites compared to those who identified as Hispanic and African-American in the sample independently. Those who identified as Asian-Pacific Islander and “Other” were omitted from the primary regression analysis due to the overall small sample size (less than 5%, n = 8).

Trauma(s) experienced

A comprehensive account of the types of violence experienced and numbers of traumas were obtained using the Life Events Checklist (LEC; Gray, Litz, Hsu, & Lombardo, 2004), a 17-item scale assessing exposure to various types of common traumatic events. The utility of the LEC in assessing exposure to trauma has been previously demonstrated (Gray et al., 2004). The LEC provided the basis for the average number of traumas reported by the participants based on responses totaled from the scale, representing the possibility of exposure to single and/or multiple trauma experiences. In a review of the measure psychometrics, there is strong reliability with the sample (Cronbach’s α =.880).

PTSD - measure of symptomology

The PTSD Checklist for DSM-5 (PCL-5; Weathers et al., 2013) is a 20-item self-report PTSD symptom instrument that has been shown to have good internal consistency, strong correlations with other PTSD scales, and high diagnostic efficiency. Items were summed to yield a total score that serves as a measure of PTSD symptom severity (Cronbach’s α = .922). Following Blevins, Weathers, Davis, Witte, & Domino (2015), we used a cut off score of 33 and over to define probable PTSD in our sample.

Quality of Life

The World Health Organization Quality of Life Brief Scale (WHOQOL-BREF; World Health Organization, 1998) is a 24-item self-report questionnaire on the quality of life. The questionnaire tests four domains: physical health (7 items), psychological health (6 items related to mental well-being), social relationships (3 items), and environmental quality of life (8 items). The physical health domain inquires on degree that engagement with activities with daily living, experiences with medical illness, pain, mobility, and energy levels impact quality of life. Psychological health encompasses assessment of reported positive and negative feelings, self-esteem, coping, and concentration/thinking ability. The social relationship domain within the scale refers to personal relationships, social support, and sexual activity. The environmental domain includes questions assessing financial resources, physical safety and security, perceived access and quality of health and social service based care, quality of the home environment, participation in recreation and leisure activities, opportunities for acquiring new information and skills, and assessment of physical environment related to pollution, traffic, climate, and transportation (World Health Organization, 1998). The items are rated on a Likert scale from 1 to 5, with domains scores ranging from 3 to 37, where higher scores indicate a reported perceived better quality of life (Cronbach’s α = .832).

Attitudes towards treatment

The Attitudes Toward Seeking Professional Psychological Help-Short Form (ATSPPH-SF; Fischer & Farina, 1995) was used to assess this outcome variable. It is a self-report measure comprised of 10 questions assessing treatment seeking behaviors and attitudes. The 10-item measure uses a response set of 0 (disagree) to 3 (agree) representing level of agreement with questions about perceptions of using formal services for mental health needs. A total score is based on a sum score of all the items (reverse scoring 5 of the items). Higher scores represent more positive attitudes towards mental health treatment. The scale has been used and presented with good reliability with similar profiles of trauma exposure among adult samples (Cronbach’s α = .791; Ghafoori et al., 2014)

Quantitative analysis examined associations of perceived quality of life on attitudes towards mental health treatment (ATSPPH-SF) using descriptive analysis and linear regression among a community sample of trauma-exposed middle to older aged adults.

Semi-Structured Interviews

Semi-structured in-depth qualitative interviews were conducted in English with a sub-sample recruited from the agency data (n = 12) to further understand complexities in seeking treatment and the impact of trauma related distress on attitudes towards mental health treatment. Individuals were referred by the agency staff with consent to the lead author if they met the study inclusion criteria and expressed interest in voluntarily participating in the interview. Study information sheets were distributed to eligible clients by the agency front office staff. A consent document to share personal contact information with the study research staff was signed by the interested agency clients and provided to the lead author for follow-up. The lead author contacted the referred client by telephone to review the study in more detail and confirmed inclusion criteria were met. If inclusion criteria were met and the client expressed interest, a time was set up to meet in-person at the agency to complete the informed consent and interview. Reminder calls were made prior to the day of the scheduled meeting to support participation. The lead author and/or a trained research assistant conducted the interviews. All participants received a $15 gift card for completing the one time 1-hour interview.

An interview guide informed by Kleinman’s (1998) framework of explanatory models was used to understand illness narratives as related to reported experience with trauma. The following domains guided by the study aims and resulting quantitative analysis results were explored in the semi-structured interviews: (1) explanatory models of trauma, (2) perceived relations between trauma and current mental health, (3) perceptions of treatment for exposure to trauma, (4) reported mental health treatment experiences for exposure to trauma, and (5) reflections on how to best support individuals as they age in managing trauma related symptoms. Sample questions include a review on experiences with trauma, discussion of the impact of the trauma on daily life and relationships, and a review of formal, informal, and individual resources accessed to manage effects of traumatic experiences. Questions also included those related to the impact of experiences with trauma over the course of life as informed by Dannefar’s (2003) Cumulative Disadvantage Theory, age-related differences in coping and treatment seeking for experiences with trauma previously compared to now, social norms /stigma around treatment seeking and managing mental health needs, and suggestions for community based treatment programs looking to support middle-aged and older adult mental health. Questions were asked about treatment experiences overall and not specific to the agency from which they were currently affiliated.

Analysis

Quantitative data were analyzed using SPSS 24.0. All descriptive analysis, as well as cleaning of data and constructing variables that included examination of outliers and missing data analysis, was done initially. Mean, standard deviation, frequencies, and percentages are presented to describe characteristics of the study sample (Table 1). Bivariate analysis was done using a series of Pearson correlations and independent t-tests to study initial relationships among variables and to identify the significant demographic and clinical functioning variables to be included in the final regression analysis. Direct effects on attitudes regarding mental health treatment among the sample was assessed using linear regression. Missing data were examined and treated with a pairwise deletion method.

Table 1:

Summary of sample characteristics of middle and older aged low-income trauma-exposed adults (N = 165)

Variable (range) % (n) Mean (SD) Pearson r / t-test (df)
Attitudes towards treatment
Age (50–78 years) 56.2 (5.53) .074
 50–60 years of age
 60–78 years of age
Gender: Female		 77.0% (127)
23.0% (38)
75.2% (124)



1.17 (130)
Unmarried - single 74.4% (116) .108
Race/Ethnic Identity
 Non-Hispanic White 31.5% (51) 2.85 (130)*
 African-American 20.4% (33) 1.60 (130)
 Hispanic 42.0% (42) 1.97 (130)*
 Asian-Pacific Islander
 Other – Race/Ethnicity
 Decline		 1.9% (1.9)
3.1% (3.1)
1.2% (2)		 -----
-----
-----
Education level
 Some high school or less
 High school graduate or equivalent
 Associates degree or higher
31.4% (49)
14.1% (22)

54.4% (85)
.169
Experienced Trauma (LEC) −.020
 Assaultive trauma (most frequently reported):
  Physical

76.1% (105)
  Sexual
  Assault with a weapon		 51.8% (72)
46.9% (61)
Number of Traumas Experienced
Quality of Life (WHOQOL-BREF)
  Physical Health
  Psychological Health
  Social Relationships
  Environmental Health
Patient Checklist (PCL-5)
Attitudes Towards Treatment Scale (ATSPPH-SF)		 6.71 (3.43)

18.8(5.53)
16.7(7.03)
7.33(2.69)
22.5(5.94)
51.4(18.1)
24.2(4.64)		 .093

−.020
.127
−.109
.283**
.060
-----
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*

p≤ .05

**

p≤ .01

***

p≤ .001

Qualitative data were gathered from transcripts based on digital recordings of completed semi-structured interviews. All study participants provided permission as part of the informed consent process for the interviews to be recorded. Verbatim transcription was completed by study research assistants and reviewed by the lead author for accuracy. Transcripts were analyzed using strategies based on principles of Grounded Theory (Glaser, 1978). The lead author and a trained research assistant took an iterative approach to examining the narrative data independently using NVivo 11 software. Each reviewed the transcripts independently for initial patterns and themes based on a priori and emerging themes. Analytical memos were written to describe definitions of codes and decisions during the analytic process, highlighting sample text segments for each code. The lead author and the study research assistant met weekly to debrief and discuss the coded data to corroborate or modify themes as they emerged. The finalized codebook was developed from this iterative process that then served as the basis for conducting a line-by-line analysis of the remaining interviews. This enabled us to further the process of axial coding to identify associations between a priori and emergent themes. By constantly comparing the thematic categories with one another, repeated categories were condensed into broad themes as applicable. Inter-coder reliability was assessed using standard methods (Creswell, 2007; Glaser, 1978).

Results

Sample

Demographics

Sample characteristics (N = 165) are summarized in Table 1. The mean age of the sample was 56.2 years (SD = 5.53; 50–59 years 77%, 60–78 years 23%), were predominately female (75.2%), self-reporting as Hispanic (42%), single un-married (74.4%), and living in poverty (80% with income under $18,000). Based on the LEC measure, the top 3 most commonly reported types of traumas experienced and/or witnessed over the course life included assaults identified as physical (76.1%), sexual (51.8%), and with a weapon (46.9%). The average reported age of the last traumatic event experienced was 46.7 (SD = 16.2) with 6.71 (SD = 3.43) average number of lifetime traumas experienced or witnessed. Relating to reported previous mental health service use, 51.6% of the sample reported “yes” to previous use.

Clinical measures

Reported degree of experienced PTSD associated symptoms based on a mean score of the PCL-5 was 51.4 (SD = 18.1) out of the highest possible score of 80. Within the sample, 82.9% met the clinical cut off criteria for probable PTSD (Blevins et al., 2015) reflecting a sample with significant PTSD associated symptoms. Quality of Life (WHOQOL-BREF) presented a range of 7–76 across the four domains with a possible range of 0–100. With higher scores indicating higher quality of life, the sample reflected a low to moderate level within each domain with quality of life related to social relationships as the lowest (physical health M = 18.8, SD = 5.53; psychological health M = 16.7, SD = 7.03; social relationships M = 7.33, SD = 2.69; environmental health M = 22.5, SD = 5.94).

Outcome measure

The average ATSPPH-SF score was 24.2 (SD = 4.64; range 8–30), indicating a moderately positive attitude towards mental health treatment overall for the sample. Correlation analysis revealed significant differences with attitude towards treatment between groups for racial/ethnic identity for those self-reporting as Non-Hispanic White (t(130) = 2.85, p =.05) and Hispanic having a positive association (t(130) = 1.97, p = 0.05). There was also a significant positive association with attitude toward mental health treatment only with the environmental domain for Quality of Life (r = .283, p = .01). No other demographic or functional outcomes measures were associated with attitudes towards mental health treatment, including degree of reported PTSD symptoms or number of reported traumas over the life course.

Secondary Data, Quantitative Results

Multiple regression analysis was done to determine correlates predictive of attitudes towards mental health treatment among a sample of middle and older aged adults with previous exposure to trauma. Predictors included in the model were based on review of significant constructs from the bivariate analysis. Table 2 presents the results. All necessary assumptions of multiple regression analysis were met, including multicollinearity, homoscedasticity, normality, and independence of residuals. Findings reveal a significant model (F(7, 99) =4.74, p = .000) with 25.1% of the variance in the model explained. Significant predictors of more positive attitudes towards treatment included self-reporting as non-Hispanic White (β = .392, p = 0.03) and having a strong environmental domain of the WHOQOL-BREF (β = .475, p = 0.000). The social relationship domain of the WHOQOL-BREF was also negatively significantly associated with attitudes towards treatment (β = −.279, p = 0.01); higher quality of life based on social support factors predicted more negative attitudes towards treatment. However, domains of quality of life representing psychological and physical health were not significant predictors of attitudes towards treatment among the sample.

Table 2:

Results of regression analysis examining correlates with attitudes towards mental health service use for low-income trauma-exposed middle and older aged adults (N = 165)

Variable Unstandardized Beta Standard Error Standardized Beta
Racial/Ethnic Identity
 Non-Hispanic White 3.90 1.80 .392*
 Hispanic 2.06 1.77 .219
 African-American 3.14 1.87 .273
Quality of Life (WHOQOL-BREF)
Physical Health −.187 .096 −.223
 Psychological Health .113 .067 .171
 Social Relationships −.481 .184 −.279**
 Environmental Health .371 .087 .475***
Open in a new tab
*

p≤ .05

**

p≤ .01

***

p≤ .001

Semi-Structured Interviews, Qualitative Results

Based on guidance from the regression analysis results, qualitative semi-structured interviews (n = 12) with a sub-sample of adults from the quantitative analysis was done using a prepared interview guide. The sample included 7 females and 5 males with a mean age of 56.9 (SD = 5.71). The ethnic/racial breakdown of the sample was diverse with 5 identifying as Hispanic, 2 as African-American, 4 as non-Hispanic White, and 1 as “Other”. Three distinct themes relevant to study aims emerged from the semi-structured interviews and domains explored. Participants’ narratives that contributed to the understanding of their experiences with trauma and attitudes towards treatment were rooted in the following: (1) reported experiences with and impact of trauma on daily life including relationships, mental health, work, and finances; (2) perceived age-related differences in coping with trauma associated symptoms; (3) barriers to accessing services in their current life phase.

Experiences with and impact of trauma

Experiences with trauma were discussed with themes associated with emotional impact on the individual that included fear and anger. The depth of this effect was further explored by participants as they talked about not only functioning as survivors of their trauma but feeling that they are meeting the basic level of their daily needs. One female participant discussed how it was difficult to live a life beyond one focused on survival due to uncontrollable emotions around her experience with trauma. She explained her current mental outlook within what she perceives as survival in her current life:

“It’s been kinda feeling like I’m just barely surviving. um…not really able to trust people,

isolate a lot, um, uh, sometimes driving is, is hard I really have to concentrate when I

drive, you know, not to run lights and that kind of thing, really pay attention because um,

sometimes even though you might not be in a trauma at the time, you’re thinking about it.

[living life beyond the trauma means]… to be able to go to the movies and maybe

go out to dinner every once in a while, go for drives, take a vacation…” (Female,

African-American, 58-years old)

The impact of trauma was described as contributing to and/or taking away from perceived personal growth. Commonly, participants spoke about their relationships with family and/or friends or how they interacted with the world as they grew older.

“well you know I, I guess it’s shaped me, you know as like a, shaped me as a man getting older [trauma of physical abuse as a child] … not that just, that, that last incident that happened to me [most recent trauma of being mugged] but it, you, you know the, the trauma kind of and it made me, make me, made me meaner too” (Male, African-American, 66-years old).

Another female participant provided an example of this stress in managing the emotions stemming from experiences with trauma that led to negative emotions in the role as a parent. She reported showing anger she regretted, “I was always arguing with my 7 year old for no reason and I used to cry a lot [about the parental stress]” (Female, Hispanic, 51-years old).

Difficulties with daily functioning were also referenced by the sample as they talked about struggles due to age related disabilities that were enhanced by trauma related emotional distress. Referenced were struggles with arthritis and injuries associated with the trauma, that made daily activities such as going to the grocery store or working stressful. One male participant reported this theme in expressing feeling unequipped with managing the heightened emotions that emerged with physical pain.

“…depression works in a lot of different ways too. And physically it took a toll on me and I know I wouldn’t be able to function if I tried, uh, even going back to work would be, I’d be fine for a minute and then the next minute I’d be an emotional basket so how could I deal to work that way?” (Male, Non-Hispanic White, 50-years old)

Participants’ outlook on life was also discussed as affected negatively. Participants referenced a lack of trust in people, anger, and fear resulting from experienced traumas:

“I just let go, cry, and the other anger is that me being angry I’m always been angry all my life since I can remember when I was little.” (Female, Non-Hispanic White, 63-years old)

One male participant discussed a distrust in humanity that developed after experiencing a physical assault:

“I think for a long time I didn’t really trust people and I didn’t wanna trust people. I just didn’t believe in them.” (Male, Other race/ethnicity, 55 years-old)

Age-related differences in coping with trauma

Participants shifted their focus from their experiences associated with their trauma to their experiences on coping with trauma, comparing how approaches changed or appeared changed as they aged. One of the most commonly reported themes associated with coping with trauma was religion/spirituality as a means to withstand the difficulties in managing trauma related distress.

“Being more aware to what’s, to what’s going on in my life maybe spiritually you know, uh, and try to, you know put myself around positive people … maybe you know start going to church and you know I already go to the senior building … I just think I need to be around you know positive people now”. (Male, African-American, 66-years old)

The ongoing use of faith to manage the numerous traumas experienced was discussed by another study participant.

“…it always had been a biblical and a spiritual, uh, attachment to the body of Christ. And that’s been a strong thing for us and I mean that’s what happened with us both, being able to cope with whatever we did deal with in all of the trauma that we went through in all of our lives.” (Male, Non-Hispanic White, 50-years old)

However, it was also noted that physical changes with age and a perspective of a shortened amount of available time left in life to make change post trauma exposure compounded the coping needs :

“When you are younger, you are more… you have more faith I think, it’s more easy to have faith. But when you are old, you start saying, okay, I’m not the same anymore. You have more problems in your body because it’s not the same [in dealing with stress]” (Female, Hispanic, 55-years of age)

“From my own experience, I think it’s probably a little bit more heightened because of the age. You don’t see a lot of years to get through the trauma itself and then make your life whole again…you see your life as shortened, so you don’t have that extra time that you have when you’re younger to, to move forward, I guess.” (Female, Non-Hispanic White. 63-years old)

Additionally, participants discussed seeking comfort in friends and family after their trauma as a means to incorporate support in their coping. One female participant talked about seeing friends and volunteering her time given she was retired from working as part of this process:

“I try to go visit my friends, try to, because if I don’t do that, you know I don’t feel well… I’m trying to look for volunteer things.” (Female, Hispanic, 57-years old)

Barriers to accessing services

Factors influencing the process of accessing and engaging in mental health care when in need was discussed by the sample. Relevant themes that emerged included perceived societal expectations for older individuals to effectively manage distress, reporting limited knowledge of mental health needs, competing age related priorities in supporting mental health needs, and daily stressors of family and finances. When speaking about concerns rooted in a perceived ill fit with societal expectations on managing distress, participants reported they did not seek mental health care because they did not want to be poorly perceived or were embarrassed that the trauma occurred, especially given their age.

“…the age thing still is there. You’re older you should know better than this and, you know, and…yeah it’s…it’s tough.” (Female, Non-Hispanic White, 64-years old)

There was a broad reference by the sample to feeling one should be able to cope better with distress as one ages given increased life experiences or society’s perception of older people having more skills to manage distress. One female participant spoke about recently leaving a long time abusive spouse and thoughts of shame in her coping associated with her age.

“If I would’ve known that there was help back then, I would’ve gotten help back then [when younger]. And you want to ask for help but you’re ashamed because you’re of certain age, at certain age we think, “Oh we’re not supposed to be abused.”

The same participant went onto share her lack of knowledge of experience with trauma:

“Honestly I didn’t even know that I was being traumatized… people our age they don’t think that… they kind of think like they’re supposed to know how to handle it.” (Female, African-American, 58-years old)

Participants also talked about not having knowledge about mental health symptoms or the available support services that existed. Participants specifically discussed a lack of awareness of the impact of the experienced trauma on well-being. They talked about this and societal age related expectations on how they should cope, which forced them to move through much of their adult years without support. These perceptions created a barrier to needed services.

“Yeah I haven’t done much of anything with mental health. I didn’t really think I had a mental health problem or help was out there” (Female, Hispanic, 55-years of age)

Discussion

Profiling predictors of attitudes towards mental health treatment may assist practitioners in improving outreach and engagement with treatment models for trauma-informed care for middle-aged and older trauma-exposed adults (Ghafoori, Barragan, & Palinkas, 2012; Roberts, Gilman, Breslau, & Koenan, 2011). The presented study results suggested that of all the variables assessed, the environmental domain of quality of life was most relevant in predicting better attitudes towards treatment for the sample. This encompasses considerations related to perceived accessibility and quality of health and social care, financial security, access to information, and feelings of safety. Findings may be reflective of the struggles managing the daily needs of the sample who reside in a predominately high crime and low resourced community. Aligned with the quantitative findings, themes associated with attitudes towards seeking treatment that emerged from the qualitative interviews included maintaining safety and financial security. Respondents noted the impact of their lifelong traumas as contributing to more distress with respect to the ability to work, maintain healthy personal relationships, engage in treatment, and feeling capable to recover as they age.

Study results suggested trauma-exposed middle-aged and older adults who had higher reported environmental quality of life had a higher likelihood to have a more positive attitude towards treatment. This finding is consistent with previous research utilizing cumulative disadvantage theory, such that an experience of a more facilitative environment over the life course has perhaps led to a more positive outlook on treatment in middle and older adulthood (Kang, Aldwin, Choun, & Spiro, 2016). Providing supports that help increase environmental quality of life are crucial in the process of increasing engagement with care for middle-aged and older trauma-exposed adults who need care. Specifically, the degree an individual is made aware of available resources to improve or acquire new skills and access resources focused on addressing financial security and improve safety and a sense of stability are highly relevant with respect to positive attitudes towards treatment seeking (Hansen & Aranda, 2012; Hansen, Fuentes, & Aranda, 2018; Krause, 2004). Accounting for these quality of life considerations in the treatment experience can influence the degree individuals engage and remain in treatment and ultimately may impact outcomes (Hansen & Ghafoori, 2016).

The current study found that a higher level of the quality of life domain of social support was predictive of more negative attitudes towards treatment seeking. It is challenging to disentangle that finding from another result in the study that suggested non-Hispanic Whites were more likely to have a more positive attitude toward treatment. Previous studies in the wider mental health literature have found that family support can be protective for mental health conditions, but may also result in delaying use of services (Stein et al., 2003, Pescosolido & Wright, 2004). Perhaps for the racially/ethnically diverse population studied, which may be particularly underserved with respect to mental health supports, higher social support may become a normative experience contributing to a negative attitude towards treatment (Bleich et al., 2003; Rousseau & Drapeau, 2004). Previous studies have shown that Hispanic and African-American trauma-exposed individuals face multiple barriers to accessing mental health services, including structural barriers such as lack of health insurance, income, and language, as well as barriers such as shame, stigma, and low support (Ghafoori et al., 2014; McVittie & Willock, 2006). Future research is necessary to understand the complex relationships between race/ethnicity, social support, attitudes towards treatment.

The qualitative results from the study showed that overall, participants had ongoing difficulty dealing with their trauma as they aged and felt hopeful once they began treatment. From the apriori themes reviewed in the interview guide, three major domains emerged as relevant for the sample. These included unique experiences that highlighted the developmental complexities in meeting daily needs while managing the impact of the trauma, struggles with coping with distress, and discussion of barriers to care (individual and environmental). Age related needs due to traumatic distress, specifically related to coping and help-seeking, appeared more urgent as health issues, job security, and family/friend relationships changed. Shame as a barrier to engaging in care was also commonly discussed in connection to expectations for the sample in managing their needs. Understanding the role of reported social supports, formal and informal, is important to account for preferences and perceptions about seeking care in managing trauma related distress that emerge in middle and late life (Krause, 2004; Hansen & Aranda, 2012).

Implications for Practice

Services that can support these considerations for trauma-exposed populations as they age may include peer-based models, case management and patient navigation support, and/or formal clinical treatment (Hansen & Ghafoori, 2017). Case management and patient navigation can address connecting to available social services that will allow for increased safety and sense of stability to facilitating one’s capacity to address trauma and associated distress within environmental considerations. Use of peer support models may also help to normalize the acknowledgment of need for treatment, especially among a population such as middle-aged and older adults who struggle with societal stigma and perceived negativities around acknowledging mental health needs (Bartels & Naslund, 2013). Simultaneously integrating both care approaches can build on the sustained supports needed to manage emerging health, social, and emotional needs common for many middle and older aged adults (Bryant, Bei, Gilson, Komiti, Jackson, & Judd, 2012). Further, such approaches will not only support those least likely to seek services independently as needs increase with age, but can enhance capacity for patient centered care strategies that make treatment models more accessible and culturally congruent (Ghafoori et al., 2014). Policy initiatives around supporting mental health and health services needs that promote a concurrent preventative care and a trauma informed lens are widely being adopted at all levels of services. Alignments of Medicare and Medicaid funding for integrated care models as part of the Affordable Care Act foster the needed adjustment in care models for a rapidly emerging large older adult population in the United States with complex integrated care needs (Hudson, 2013).

Limitations

The two-phase explanatory sequential design (Creswell & Zhang, 2009) of the study provided a strong methodology to bring forth a more nuanced understanding from the semi-structured interviews of the significant quality of life dimensions that may be associated with attitudes towards treatment. An acknowledgement of the limitations is also important as the results are considered. Study findings from both the quantitative and qualitative approaches are not generalizable as they represent one set of individuals already receiving services. The sample were not randomly selected. The questionnaires used for data collection were based on self-report. Self-report instruments cannot replace a structured clinical interview and diagnosis; therefore, the external validity of our results is limited. The qualitative findings have limited inference as they present the unique experience of those who agreed to participate in the interviews. It is also important to note that the study sample as a whole received mental health services at no cost, therefore study findings do not account for common barriers to care that includes health insurance limitations, lack of coverage, and financial costs in accessing care. Future studies would benefit from considering how changes in health insurance coverages and finances as one enters older adulthood can influence decisions to seek services.

Conclusion

Despite the limitation, the current study findings allow for insight into potential priorities that should be considered to enhance the treatment experience of middle-aged and older trauma-exposed adults. Findings suggest treatment seeking adults who have perceived access to social and health care, financial resources, skill-building resources, and safety may have more positive attitudes during treatment, which may improve their ability to benefit from trauma-informed care. Perhaps case management or peer models may improve environmental quality of life for trauma-exposed middle and older aged adults. Future research is necessary to further examine how to adapt evidenced-based outreach and intervention approaches that meet the unique mental health and health needs of trauma-exposed adults as they enter middle and late life.

Acknowledgments

The authors would like to acknowledge support for this work from the Department of Education, Project Hispanic Opportunities for Graduate Access and Retention (HOGAR) and the National Institute of Health and National Center on Minority Health & Health Disparities, Loan Repayment Program. Development of the study was based on invaluable consultation with Lawrence Palinkas, PhD, University of Southern California, Dworak-Peck School of Social Work.

Footnotes

Conflicts of Interest - Disclosure statement. Authors received no financial benefit from the completion of the presented research and present with no conflicts of interest.

References

  1. Aldwin CM, Levenson MR, & Kelly LL (2009). Lifespan developmental perspectives on stress-related growth In Park CL, Lechner S, Antoni M, & Stanton A (Eds.), Medical illness and positive life change (pp. 87–104). Washington, DC: American Psychological Association. [Google Scholar]
  2. Alegría M, Pescosolido B, Williams S, & Canino G (2011). Culture, Race/Ethnicity and Disparities: Fleshing out the socio-cultural framework for health services disparities In Pescosolido BA, Martin JK, McLeod JD, & Rogers A (Eds.), Handbook of the Sociology of Health, Illness, and Healing (pp. 363–382): Springer; New York. [Google Scholar]
  3. American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed., Text Revision). Washington, DC: Author. [Google Scholar]
  4. Andersen RM (1995). Revisiting the behavioral model and access to medical care: Does it matter? Journal of Health and Social Behavior, 14, 348–362. [PubMed] [Google Scholar]
  5. Averill PM, & Beck JG (2000). Posttraumatic stress disorder in older adults: A conceptual review. Journal of Anxiety Disorders, 14(2), 133–156. [DOI] [PubMed] [Google Scholar]
  6. Banyard VL, & Williams LM (2007). Women’s voices on recovery: A multi-method study of the complexity of recovery from child sexual abuse. Child abuse & neglect, 31(3), 275–290. [DOI] [PubMed] [Google Scholar]
  7. Bartels SJ, & Naslund JA (2013). The underside of the silver tsunami—older adults and mental health care. New England Journal of Medicine, 368(6), 493–496. [DOI] [PubMed] [Google Scholar]
  8. Bernick L, Grinberg A, Holynaty L, & Rodgers M (2001). Caring for survivors of the Holocaust. The Canadian Nurse, 97(3), 25–34. [PubMed] [Google Scholar]
  9. Blazer DG (2003). Depression in late life: Review and commentary. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences, 58(3), M249–M265. doi: 10.1093/gerona/58.3.M249 [DOI] [PubMed] [Google Scholar]
  10. Bleich A, Gelkopf M, & Solomon Z. (2003). Exposure to terrorism, stress-related mental health symptoms, and coping behaviors among a nationally representative sample in Israel. Journal of American Medical Association, 290(5), 612–620. [DOI] [PubMed] [Google Scholar]
  11. Blevins CA, Weathers FW, Davis MT, Witte TK, & Domino JL (2015). The posttraumatic stress disorder checklist for DSM‐5 (PCL‐5): Development and initial psychometric evaluation. Journal of Traumatic Stress, 28(6), 489–498. doi: 10.1002/jts.22059 [DOI] [PubMed] [Google Scholar]
  12. Bryant C, Bei B, Gilson K, Komiti A, Jackson H, & Judd F (2012). The relationship between attitudes to aging and physical and mental health in older adults. International Psychogeriatrics, 24(10), 1674–1683. [DOI] [PubMed] [Google Scholar]
  13. Clapp JD, & Beck JG (2012). Treatment of PTSD in older adults: Do cognitive-behavioral interventions remain viable? Cognitive and Behavioral Practice, 19(1), 126–135. [DOI] [PMC free article] [PubMed] [Google Scholar]
  14. Creswell JW (2007). Designing and conducting mixed methods research. Thousand Oaks, CA: Sage. [Google Scholar]
  15. Creswell JW & Zhang W (2009). The application of mixed methods designs to trauma research. Journal of Traumatic Stress: Official Publication of The International Society for Traumatic Stress Studies, 22(6), 612–621. [DOI] [PubMed] [Google Scholar]
  16. Dannefer D (2003). Cumulative advantage/disadvantage and the life course: Crossfertilizing age and social science theory. The Journals of Gerontology Series B: Psychological Sciences and Social Sciences, 58(6), S327–S337. doi: 10.1093/geronb/58.6.S327 [DOI] [PubMed] [Google Scholar]
  17. Davis RG, Ressler KJ, Schwartz AC, Stephens KJ, & Bradley RG (2008). Treatment barriers for low‐income, urban African Americans with undiagnosed posttraumatic stress disorder. Journal of Traumatic Stress, 21(2), 218–222. [DOI] [PMC free article] [PubMed] [Google Scholar]
  18. Elhai JD & Simons JS (2007). Trauma exposure and posttraumatic stress disorder predictors of mental health treatment use in college students. Psychological Services, 4(1), 38–45. doi: 10.1037/1541-1559.4.1.38 [DOI] [Google Scholar]
  19. Federal Interagency Forum on Aging Statistics. (2016). Older Americans 2016: Key indicators of well-being. Washington, DC: U.S. Government Printing Office. [Google Scholar]
  20. Fischer EH & Farina A (1995). Attitudes toward seeking professional psychological help: A shortened form and considerations for research. Journal of College Student Development, 36(4), 368–373. [Google Scholar]
  21. Ghafoori B, Barragan B, Tohidian N, & Palinkas L (2012). Racial and ethnic differences in symptom severity of PTSD, GAD, and depression in trauma-exposed, urban, treatment-seeking adults. Journal of Traumatic Stress, 25(1), 106–110. doi: 10.1002/jts.21663 [DOI] [PMC free article] [PubMed] [Google Scholar]
  22. Ghafoori B, Fisher DG, Koresteleva O, & Hong M (2014). Factors associated with mental health service use in urban, impoverished, trauma-exposed adults. Psychological Services, 11(4), 451–459. [DOI] [PubMed] [Google Scholar]
  23. Ghafoori B, Hansen MC, & Garibay E (2019, in-press). Predictors of treatment access and initiation among diverse, low-income victims of violence offered a trauma-focused evidence-based psychotherapy. Journal of Interpersonal Violence. [DOI] [PubMed] [Google Scholar]
  24. Glass TA, De Leon CFM, Bassuk SS, & Berkman LF (2006). Social engagement and depressive symptoms in late life: Longitudinal findings. Journal of Aging and Health, 18(4), 604–628. doi: 10.1177/0898264306291017 [DOI] [PubMed] [Google Scholar]
  25. Gray MJ, Litz BT, Hsu JL, & Lombardo TW (2004). Psychometric properties of the life events checklist. Assessment, 11(4), 330–341. doi: 10.1177/1073191104269954 [DOI] [PubMed] [Google Scholar]
  26. Glaser BG (1978). Theoretical sensitivity: Advances in the methodology of grounded theory. Mill Valley, CA: The Sociology Press. [Google Scholar]
  27. Hansen MC & Aranda MP (2012). Sociocultural influences on mental health service use by Latino older adults for emotional distress: Exploring the mediating and moderating role of informal social support. Social Science & Medicine, 75(12), 2134–2142. [DOI] [PubMed] [Google Scholar]
  28. Hansen MC, Fuentes DF, & Aranda MP (2018). Re-engagement into care: The role of social support on service use for recurrent episodes of mental health distress. Journal of Behavioral Health Services Research, 45(1), 90–104. [DOI] [PubMed] [Google Scholar]
  29. Hansen MC & Ghafoori B (2017). Correlates of psychological distress among urban trauma-exposed adults: Examining the influence of age and coping patterns. Psychological Trauma: Theory, Research, Practice, and Policy, 9(Supp 1), 85–92. [DOI] [PMC free article] [PubMed] [Google Scholar]
  30. Hudson RB (2013). The Geriatric Mental Health Challenge, Public Policy & Aging Report, 23 (3), 2–35. [Google Scholar]
  31. Kessler RC, Demler O, Frank RG, Olfson M, Pincus HA, Walters EE,… Zaslavsky AM (2005). Prevalence and treatment of mental disorders, 1990 to 2003. New England Journal of Medicine, 352(24), 2515–2523. [DOI] [PMC free article] [PubMed] [Google Scholar]
  32. Kleinman A (1998). The illness narratives: Suffering, healing and the human condition. New York: Basic Books. [DOI] [PubMed] [Google Scholar]
  33. Krause N (2004). Lifetime trauma, emotional support, and life satisfaction among older adults. The Gerontologist, 44(5), 615–623. [DOI] [PubMed] [Google Scholar]
  34. Krause N, Shaw BA, & Cairney J (2004). A Descriptive epidemiology of lifetime trauma and the physical health status of older adults. Psychology and Aging, 19(4), 637–648. doi: 10.1037/0882-7974.19.4.637 [DOI] [PubMed] [Google Scholar]
  35. Lee H, Aldwin CM, Choun S, & Spiro A III (2017). Does combat exposure affect well-being in later life? The VA normative aging study. Psychological Trauma: Theory, Research, Practice, and Policy, 9(6), 672–678. [DOI] [PMC free article] [PubMed] [Google Scholar]
  36. Maschi T, Viola D, & Morgen K (2013). Unraveling trauma and stress, coping resources, and mental well-being among older adults in prison: Empirical evidence linking theory and practice. The Gerontologist, 54(5), 857–867. [DOI] [PubMed] [Google Scholar]
  37. McVittie C, & Willock J (2006). “You can’t fight windmills”: How older men do health, ill health, and masculinities. Qualitative Health Research, 16(6), 788–801. [DOI] [PubMed] [Google Scholar]
  38. Mejía ST, Ryan LH, Gonzalez R, & Smith J (2017). Successful Aging as the Intersection of individual resources, age, environment, and experiences of well-being in daily activities. The Journals of Gerontology: Series B, 72(2), 279–289. [DOI] [PMC free article] [PubMed] [Google Scholar]
  39. Mosqueda L, & Dong X (2011). Elder abuse and self-neglect: “I don’t care anything about going to the doctor, to be honest…”. Journal of the American Medical Association, 306(5), 532–540. [DOI] [PubMed] [Google Scholar]
  40. Pescosolido BA, & Wright ER (2004). The view from two worlds: The convergence of social network reports between mental health clients and their ties. Social Science & Medicine, 58(9), 1795–1806. [DOI] [PubMed] [Google Scholar]
  41. Pietrzak RH, Goldstein RB, Southwick SM, & Grant BF (2012). Psychiatric comorbidity of full and partial posttraumatic stress disorder among older adults in the United States: results from wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions. The American Journal of Geriatric Psychiatry, 20(5), 380–390. [DOI] [PMC free article] [PubMed] [Google Scholar]
  42. Platt JM, Lowe SR, Galea S, Norris FH, & Koenen KC (2016). A longitudinal study of the bidirectional relationship between social support and posttraumatic stress following a natural disaster. Journal of Traumatic Stress, 29(3), 205–213. [DOI] [PMC free article] [PubMed] [Google Scholar]
  43. Roberts AL, Gilman SE, Breslau J, Breslau N, & Koenen KC (2011). Race/ethnic differences in exposure to traumatic events, development of post-traumatic stress disorder, and treatment-seeking for post-traumatic stress disorder in the United States. Psychological Medicine, 41(01), 71–83. [DOI] [PMC free article] [PubMed] [Google Scholar]
  44. Rousseau C & Drapeau A (2004). Premigration exposure to political violence among independent immigrants and its association with emotional distress. The Journal of Nervous and Mental Disease, 192(12), 852–856. [DOI] [PubMed] [Google Scholar]
  45. Stein BD, Kataoka S, Jaycox L, Steiger EM, Wong M, Fink A,… & Zaragoza C. (2003). The mental health for immigrants program In Handbook of school mental health advancing practice and research (pp. 179–190). Springer, Boston, MA. [Google Scholar]
  46. Substance Abuse and Mental Health Service Administration (SAMSHA; 2015). Trauma and violence. Retrieved from SAMSHA, http://www.samhsa.gov/trauma-violence. [Google Scholar]
  47. Teaster PB, Stansbury KL, Nerenberg L, & Stanis P (2009). An adult protective services’ view of collaboration with mental health services. Journal of Elder Abuse & Neglect, 21(4), 289–306. [DOI] [PubMed] [Google Scholar]
  48. Van Zelst WH, de Beurs E, Beekman AT, Deeg DJ, & van Dyck R (2003). Prevalence and risk factors of posttraumatic stress disorder in older adults. Psychotherapy and Psychosomatics, 72(6), 333–342. [DOI] [PubMed] [Google Scholar]
  49. Villa VM, Wallace SP, Bagdasaryan S, & Aranda MP (2012). Hispanic baby boomers: Health inequities likely to persist in old age. The Gerontologist, 52(2), 166–176. [DOI] [PMC free article] [PubMed] [Google Scholar]
  50. Weathers F, Litz B, Keane T, Palmieri T, Marx BP, Schnurr P (2013). The PTSD Checklist for DSM-5 (PCL-5) 2013 Scale available from the National Center for PTSD. Retrieved from www.ptsd.va.gov.
  51. World Health Organization Group. (1998). Development of the World Health Organization WHOQOL BREF quality of life assessment. Psychological Medicine, 28(3), 551–8. [DOI] [PubMed] [Google Scholar]

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