2024/07/03 by Daniel M. Blonigen, Eric B. Elbogen, Justeen K. Hyde +1
Health Professions · Psychology · #Employment and Welfare Studies #Posttraumatic Stress Disorder Research #Sleep and Work-Related Fatigue
paper · doi:10.1097/mlr.0000000000002035
“Human needs arrange themselves in hierarchies of pre-potency. The appearance of one need usually rests on the prior satisfaction of another, more pre-potent need.” —Abraham Maslow, Hierarchy of Needs: A Theory of Human Motivation The Department of Veterans Affairs (VA) State of the Art (SOTA) conference on March 29-30, 2023, on the measurement of whole-person outcomes (ie, indices of well-being that capture what matters most to patients rather than what is the matter with them) reflects growing recognition in health care of the value of moving beyond disease-focused models of care. This SOTA, along with other forums on the state of well-being measurement in health care,1 has reignited critical discussions of what it means to provide “patient-centered” care. Although perspectives are varied and nuanced, there appears to be a consensus that the characteristics of a patient population and the clinical settings in which they are served should factor into decisions about which whole-person outcome measures are most applicable. Accordingly, the conversation is shifting from talking about whole-person measures to whole-person measurement strategies in health care. In this commentary, we argue that for populations deficient in basic needs such as food or shelter, a whole-person measurement strategy must not neglect the assessment of one’s personal growth needs (eg, meaningful social connections). Among military veterans, those who struggle with chronic homelessness, under-employment, or cyclical involvement in the criminal justice system have long been recognized as a high-priority group in the VA. Sometimes referred to as “vulnerable” veterans, numerous VA initiatives have focused on how to expand access to care for these individuals while minimizing the significant costs they incur on the health care system.2 By definition, vulnerable veterans tend to have a wide range of social needs, such as unstable housing, food insecurity, legal problems, employment problems, safety concerns, and social isolation. In the Whole Person SOTA, these needs were discussed in the context of social determinants of health––the conditions in which people are born, live, work, and age that shape their health and are driven primarily by social and environmental forces.3 In this vein, a whole-person measurement strategy for vulnerable veterans would ostensibly prioritize social determinants of health under the assumption that one’s quality of life, well-being, and overall health cannot be improved until their basic needs are met. This assumption implies a linear framework in which social determinants can predict, but are largely distinct from, well-being and overall health. Maslow’s theory of human motivation exemplifies many of these assumptions about the centrality of social determinants of health in whole-person measurement for vulnerable veterans.4,5 The traditional version of this theory posited that there are 5 tiers of human needs, which are organized into a hierarchy. The lower 2 tiers reflect deficiency needs that are essential for (i) basic survival – for example, food, shelter, and clothing; and (ii) safety. The top 3 tiers of the hierarchy reflect growth needs related to (iii) social connection, (iv) self-acceptance, and (v) self-actualization (ie, reaching one’s full potential). These growth needs align with some definitions of psychological and social well-being in the literature (eg, personal growth, flourishing).6,7 Cross-national research supports the reliability of these needs, regardless of cultural differences.8 Though personality differences and external circumstances may determine what needs are prioritized for a given individual at a given point in time, the theory assumes that deficiency needs must be satisfied before individuals can attend to growth needs. Though perhaps not explicitly based on Maslow’s theory, the VA’s screening and measurement efforts with vulnerable veterans, which are focused on housing status and food insecurity,9 seem implicitly founded on this approach. Notwithstanding the evidence for Housing First principles,10 a closer look at the literature on vulnerable veterans suggests that prioritizing measurement of deficiency (vs. growth) needs is not always supported. For example, among homeless veterans, improvements in housing alone are insufficient to improve quality of life,11 and there is evidence that the impact of housing subsidies on improvements in quality of life is primarily mediated through the size and availability of one’s social support network.12 Other research using a nationally representative sample of post-9/11 veterans found that both deficiency needs (eg, housing stability) and growth needs (eg, social support, psychological resilience) were significant predictors of suicidal ideation.13 Even research directly testing Maslow’s theory has suggested that the ordering of needs within the hierarchy is variable across populations, and prioritization of deficiency needs cannot always be assumed.8 For example, social connections may not be a higher-level need14 and may play a central role in determining one’s health and well-being.15 In sum, extant research suggests that in a whole-person measurement strategy for vulnerable populations, integrating measurement of deficiency and growth needs, rather than prioritizing the former, is warranted. An ongoing study involving veterans with housing instability that we are conducting may serve as a useful model for how to integrate measurement of deficiency and growth needs and examine if and how this approach can impact the health outcomes for this population.16 In this multisite trial, we are testing the effectiveness of an intervention that integrates peer support with Whole Health Coaching to reduce hospitalizations and improve health outcomes among veterans in the VA’s Homeless Registry. Whole Health Coaching is an approach to helping patients identify what matters most to them, using the Circle of Health framework (8 areas of self-care) to collaboratively develop personal health plans oriented to what matters most to a patient and coaching patients on how to create specific, measurable goals and problem-solve barriers as they emerge.17 Veterans in primary care on the Registry’s super-utilizer clinical dashboard (defined as those with ≥2 emergency department visits or ≥1 hospitalizations in the past quarter) are enrolled and randomized to either an enhanced usual care (EUC) condition or EUC plus individual sessions with a peer specialist trained in Whole Health Coaching (“Peer-WHC”). Peer specialists are veterans with lived experience of substance use, mental health, and/or homelessness who are trained to support veterans who are actively struggling with these issues by assisting them with care navigation and linkage to healthcare and psychosocial services. Through this program of research, we have learned 2 critical lessons, which we believe can inform a whole-person measurement strategy for vulnerable veterans. First, findings from a pilot study of the Peer-WHC intervention suggested that for veterans who have a high number of social needs, their motivation and/or ability to engage in WHC, particularly setting and taking action on personal health goals, is lower.18 However, the pilot study lacked systematic measurement of social needs, leaving unanswered the question of which social needs are most relevant. To address this, our ongoing trial includes the ACORN (Assessing Circumstances & Offering Resources for Needs), a measure of social needs across 10 domains: employment, technology, social isolation, legal, transportation, education, interpersonal safety, food security, housing, and utilities.19 Second, though the ACORN covers a wide range of human needs, per Maslow’s theory it is primarily a measure of deficiency needs. Other efforts to develop and implement a measure of social determinants of health in VHA seem similarly focused on deficiency needs.20,21 None of these measurement efforts, however, capture dimensions from established models of psychological well-being, which align with the growth needs from Maslow’s hierarchy (eg, personal growth, purpose in life). In our Peer-WHC intervention, these growth needs are measured through the completion of the Personal Health Inventory (PHI) and discussions with the patient of the Circle of Health and how certain domains from this model may pertain to what matters most to them. On the one hand, the separate measurement of deficiency needs (through ACORN) and growth needs (via PHI) in this trial will afford a test of whether the latter provides incremental contribution over the former in predicting the health outcomes of the vulnerable veteran participants. Conversely, the distinct assessment approaches and frameworks of ACORN and PHI raise questions about the corresponding clinical approach(es) that should be prioritized for vulnerable veterans. In revisiting Maslow’s theory and considering our lessons learned from the Peer-WHC intervention, we believe that a whole-person measurement strategy for vulnerable veterans should be based on a framework that integrates the assessment of deficiency and growth needs. In our estimation, however, the field lacks validated measurement tools that target both of these needs. A measure of well-being that was recently developed in veterans and focuses on domains of psychosocial functioning and role competence may be consistent with this approach.22 Other existing validated measures such as the Mental Health Continuum-Short Form may also suffice.23 Alternatively, the PHI could be modified to capture both the deficiency and growth needs associated with the existing domains of the Circle of Health. For example, a Veteran may prioritize the domain of “Surroundings” because they feel they lack housing options that provide safety as well as proximity to activities that are consistent with their values. Regardless of the specific approach, a whole-person measurement strategy for vulnerable veterans that adopts a more integrated view of Maslow’s hierarchy can help recognize the strengths of a given veteran and, in turn, a sense of who they are as a “whole person.”