Development of CRIS Measures of Community Reintegration of Injured Service Members

There are no existing measures of reintegration for injured service members. Some measures are too narrow and unable to cover the aspects or dimensions of community reintegration. Others are too broad by covering two or more dimensions of integration and preventing the assessment of these dimensions as individual constructs. In developing a measure for community reintegration of injured service members, the International Classification of Functioning, Disability and Health (ICF) developed by the World Health Organization was the basis. The ICF defined community reintegration in terms of participation in the community measured through these nine dimensions learning and applying knowledge general tasks and demands communication mobility self-care domestic life interpersonal relationships major life areas and community, social and civic life (Resnik, Plow  Jette, 2009, p. 470).

In adopting these dimensions, two areas were considered. One is functioning and disability specifically assessed through body functioning, structure, activities and participation, with activities and participation merged by not including simple tasks in the measure. The other is contextual considerations pertaining to personal and external environmental factors.

To rationale of the current study is to develop a community reintegration measure for those returning with injuries from serving in Iraq. The outcome supports the evaluation of the reintegration of returning service members in the community to determine reintegration problems for individuals in a timely manner and respond to these problems in a timely manner. The results of the study also fill the gap in measures for community reintegration of injured service personnel.

The purpose of the study is two-fold. One is to create a reintegration measure for returning service members with injuries with focus on participation. The other is to test CRIS in terms of the reliability and validity of the measure.  

The research question, which is implied from the purpose of the study, covered the basis or source of the new community reintegration measure as well as the reliability and validity of the measure. There was no clear mention of the hypotheses of the study in the introduction.

The theoretical background presented in the study is relevant with the ICF comprising the basis of the new community reintegration measure. The dimensions of reintegration based on the ICF also served as a definition of reintegration. An entire section explained the concept of participation, which is one of the dimensions of reintegration. This indicated the focus on participation in measuring community reintegration. There was no theoretical or conceptual discussion of the other dimensions of reintegration.

Indication of the lack of community reintegration measures for injured service personnel justified the need for the study. The study addressed this gap by developing a new measure of community reintegration and testing the measure on injured returning service personnel.

The objectives were clearly identified and set out in the introduction section. The two objectives were numbered and explained in the purpose of the study.

The research question was not explicitly identified. This was implied from the rationale and purpose of the study. There was also no discussion of the hypotheses or expected outcomes in the introduction. There were not identifiable by reading the introduction section alone.

There were two groups of participants in the study. The first group comprise of veterans of Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) (Resnik et al., 2009). In the two pilot studies, the veteran participants were selected through convenience sampling from those obtaining services from Providence VA Medical Center (PVAMC). The veterans provided data on the three dimensions comprising the measure and the resulting measure was tested on veterans. Nevertheless, efforts were made to represent employment, domestic roles and other factors. The second group comprise of professional caregivers and clinicians (Resnik et al., 2009), which were impliedly selected via purposive sampling, to have respondents representing physical and mental health care, with significant experience of cases of returning service personnel. These respondents provided feedback during the formative stage of the study.

Interview was the data collection instrument during the formative stage of the research. The interviews of veterans, caregivers and clinicians targeted the identification of community reintegration problems of injured veterans. The interview responses identified problems categorized under frequency of participation, perceived limitations in participation, and satisfaction with participation (Resnik et al., 2009, p. 471). The interview resulted to the intended outcomes reflecting on the validity of the instrument. These items were translated into a comprehensive questionnaire used as the other data collection instrument in the pilot studies. The testing of the measure indicated significant reliability between the results of the two pilot studies. The assessment of the instrument also showed significant content, construct, convergent and discriminant validity (p.476) as determined by face validity and Rasch residual factor analysis (Resnik et al., 2009.

Positivism is the research paradigm used to define the parameters of the study. The purpose is to create and test a community integration measure for service veterans. This required systematic data providing a scientific explanation of the phenomenon studied (Creswell, 2003). Although the measure was intended to reflect the perspective of veterans and apply to measures to them, the study and the research process are systematic. The study also tested the ICF constructs and the hypotheses on the expected outcomes of the instrument testing.

The study employed a mixed research design combining qualitative and quantitative research (Creswell, 2003). The formative stage is a qualitative study by interviewing veterans, caregivers and clinicians. The two pilot studies and the testing of CRIS scales were quantitative by using questionnaire responses analyzed quantitatively to determine reliability and validity.

The study was done in three stages. In the formative stage, the research collected data on the reintegration issues, focusing on participation. These issues were classified into three dimensions of participation. Within these dimensions are sets of questions formed into a single questionnaire. The first pilot study tested the reliability of the instrument. The second pilot study tested the validity of the instrument. Items determined as misfits from each pilot study were removed or modified. The last stage assessed the three scales (dimensions) of participation.

Using the convenience sampling technique limits external validity. The sample may not be able to represent the range of community reintegration problems faced by the entire population of injured OIF and OEF veterans.

The use of interview in the formative stage and questionnaire in the pilot studies were appropriate in supporting the data requirements of the study. The interview results supported the creation of the measure and the questionnaire responses were used to evaluate the reliability and validity of the study. Other data collection methods may not be able to address the purpose of the study in the same way.
Positivism was the appropriate research paradigm since the thrust of the study was the scientific collection of data to support the development of a community reintegration measure for injured service veterans.

The combination of qualitative and quantitative research was appropriate in addressing the research question implied from the purpose of the study. Qualitative data supported the creation of the instrument measuring community reintegration, with focus on participation. The quantitative data informed on the reliability and validity of the instrument for application to the population of returning service personnel. Using a mono-method research design would not sufficiently address the purpose of the study.

The procedures in the formative stage of the research were not thoroughly explained since these were reported in another study. This study has to be consulted to replicate the formative stage. The procedures for the pilot study were clearly explained to support replication. The results of the CRIS scale scores were not shown in the study to limit the replication of the CRIS scales assessment stage.

Data Analysis
Content analysis is the analytical method used on the qualitative data in the formative stage of the research. Content analysis was used to assess the problems identified in the interview and classify these into the three dimensions or scales of participation. Descriptive and statistical methods were employed to analyze data from the pilot studies and the scales assessment. The descriptive statistics used included frequencies, averages or means and other summative techniques. The Item Response Theory (IRT), specifically the Rasch model is a statistical tool used to measure the reliability and validity of the instrument or scale. Analysis of Variance (ANOVA) was used in determining the variance in the data falling under the three scales. General linear models were employed to assess individual characteristics such as age, employment and post-traumatic stress disorder (PTSD) with the three scales.

The content analysis led to 97 statements on extent of participation, 116 statements on perceived limitation in participation, and 83 statements on participation satisfaction (Resnik et al., 2009) reflecting the various problems encountered by injured veterans during community reintegration. The descriptive and statistical analysis determined the statements considered as misfits based on measures of reliability and validity. The final instrument is comprised of 97statements on extent of participation, 107 statements on perceived limitation in participation, and 85 statements under participation satisfaction (Resnik et al., 2009), with the statements reflecting significant levels of reliability and validity.

The data analysis techniques were adequate by supporting the thorough analysis of the items included in the measure and testing for reliability and validity of the instrument. The data analysis techniques also matched with the qualitative or quantitative nature of data assessed.

The presentation was incomplete. The result of the interview in the formative stage of the research was not shown. The CRIS scale cores analysis was not also shown in the study. The items included under the three scales were not identified and the items changed or modified were also not indicated. While the study identified the three scales comprising the instrument, the items under these scales were not shown in the text or even in an appendix.

The authors identified the limitations in their study as the derivation only of estimates for the entire population based on data from a small sample. The authors also identified the employment of CRIS in a broader population and use of the CRIS as an instrument administered via computer as areas for future research.

Conclusion I
The resulting instrument (CRIS) is comprehensive by focusing on the various participation problems encountered by service veterans. The instrument is a reliable and valid measure of the community reintegration of returning injured service personnel.

Evaluation of internal validity
This conclusion was based on the results of the content analysis, descriptive analysis, and statistical analysis used on the treatment of the data collected from the three stages of the study. The conclusion responds to the research question implied from the purpose of the study by pointing to the creation of a new community integration instrument and the significant levels of reliability and validity of the instrument. The conclusion relates to filling the lack of community integration measures for service veterans mentioned in the introduction. The possible threat to internal validity is the comprehensiveness of the items given that the items were based on interviews of a limited a number of respondents. The study explains this threat by recognizing the value of the items as approximations of the community integration experiences of service veterans. This conclusion is consistent with the results of the study and falls within the scope of the investigation.

Conclusion II
Computer-adapted testing and broader IRT can be used to improve CRIS by minimizing the burden to respondents of answering the lengthy instrument.

Evaluation of internal validity
This conclusion does not directly follow the data analysis. There was no previous discussion of problems in responding to the questions or in analyzing the data because of the length of the instrument. This conclusion is based on the limitations of the study and the areas for future research. This conclusion responds to the research question in so far as to provide direction in further developing CRIS. This conclusion does not relate to any findings discussed in the introduction, which focused on the lack of community measurement instrument and not on the burden of instruments on respondents because of length. The possible threat to internal validity of this conclusion is its characteristic as an after-thought to the development of CRIS and not directly linked to the findings. While this conclusion is not inconsistent with the other conclusion, this is outside of the scope of the findings.

Modifications to the Current Study
A number of modifications in the methodology of the study are recommended to improve the internal validity and allow replication. First is an increase in the number of respondents. There were 14 veteran respondents in the formative stage. Increasing the number of respondents could yield to problems in community reintegration not covered by the current study. There were 50 and 76 respondents in the two pilot studies respectively. Increasing the number can lead not just to approximations but to generalizations. Second is obtaining respondents from different venues, medical and social service institutions for veterans in other states, not just at Providence VA Medical Center. This supports a more geographically and possibly demographically representative sample. Third is the use of stratified random sampling to enhance representation of the research population in terms of socio-demographic, health and other characteristics that lead to better representation and affect the results of the study. These modifications enhance the drawing of inferences and generalizations.


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