Improving care for veterans' environmental exposure concerns: applications of the consolidated framework for implementation research in program evaluation.

BACKGROUND: Healthcare systems, like the US Department of Veterans Affairs (VA), need policies and procedures for delivering care to special populations including those with environmental exposure concerns. Despite being common and pervasive, especially among Veterans, environmental exposures are largely overlooked by healthcare providers. To successfully implement care for Veterans with military environmental exposure concerns, an understanding of contextual factors impeding care on the provider (e.g., knowledge and beliefs) and organizational (e.g., leadership's priorities) level is needed. Our goal was to conduct an operational needs assessment of providers to examine provider educational needs regarding Veterans' military environmental exposure concerns. METHODS: In 2020, we surveyed 2,775 VA medical and behavioral health providers. Our cross-sectional assessment was informed by the Consolidated Framework for Implementation Research (CFIR) and assessed barriers and facilitators to the uptake and application of knowledge regarding interdisciplinary care for environmental exposure concerns. The web-based survey was emailed to providers across the United States representing a variety of disciplines and practice settings to reflect the interdisciplinary approach to care for environmental exposures. We used bivariate statistics to investigate the intervention setting, inner setting, and individual characteristics of providers regarding care for environmental exposure concerns. RESULTS: Approximately one-third of VA medical and behavioral health clinicians report low to no knowledge of environmental exposure concerns. We find 88% of medical and 91% of behavioral health providers report they are ready to learn more about environmental exposures. Half of medical and behavioral health providers report they have access to information on environmental exposures and less than half report care for environmental exposures is a priority where they practice. CONCLUSIONS: Our findings suggest interdisciplinary providers' knowledge of and discussion with Veterans about environmental exposures may be influenced by contextual factors at the organizational level. Considering individual-level factors and organizational culture is important to consider when supporting care for environmental exposures. Since this needs assessment, VA established targeted programs to improve care related to military environmental exposures in response to legislation; future exploration of these same variables or contextual factors is warranted.

Institutional Courage in Healthcare: An Improvement Project Exploring the Perspectives of Veterans Exposed to Airborne Hazards.

BACKGROUND: Military environmental exposures and care for subsequent health concerns have been associated with institutional betrayal, or a perception on the part of veterans that the US government has failed to adequately prevent, acknowledge, and treat these conditions and in doing so has betrayed its promise to veterans. Institutional courage is a term developed to describe organizations that proactively protect and care for their members. While institutional courage may be useful in mitigating institutional betrayal, there is a lack of definitions of institutional courage in healthcare from the patient perspective. METHODS: Using qualitative methods, we sought to explore the notions of institutional betrayal and institutional courage among veterans exposed to airborne hazards (i.e., airborne particulate matter such as open burn pits; N = 13) to inform and improve clinical practice. We performed initial interviews and follow-up interviews with veterans. RESULTS: Veterans' depictions of courageous institutions contained key themes of being accountable, proactive, and mindful of unique experiences, supporting advocacy, addressing stigma related to public benefits, and offering safety. Veterans described institutional courage as including both individual-level traits and systems or organizational-level characteristics. CONCLUSIONS: Several existing VA initiatives already address many themes identified in describing courageous institutions (e.g., accountability and advocacy). Other themes, especially views of public benefits and being proactive, hold particular value for building trauma-informed healthcare.

Exploring the acceptability of behavioral interventions for veterans with persistent "medically unexplained" physical symptoms.

OBJECTIVE: This study evaluated the factors that led to enrollment in, and satisfaction with, behavioral interventions for Veterans living with Gulf War Illness (GWI). METHODS: One-on-one interviews were conducted pre- and post-intervention with participants randomized to receive either telephone delivered problem-solving treatment (n = 51) or health education (N = 49). A total of 99 Veterans were interviewed pre-intervention and 60 post-intervention. Qualitative data were thematically coded and similarities in themes across the two interventions were examined. RESULTS: Before the study began, participants reported desiring to learn new information about their GWI, learn symptom-management strategies, and support improvements to care for other patients with GWI. After the intervention, Veterans felt positively about both interventions because they built strong therapeutic relationships with providers, their experiences were validated by providers, and they were provided GWI information and symptom-management strategies. Results also suggested that interventions do not have to be designed to meet all of the needs held by patients to be acceptable. A minority of participants described that they did not benefit from the interventions. CONCLUSION: The results suggest that satisfaction with behavioral interventions for GWI is driven by a strong therapeutic relationship, validating patient's experiences with GWI, and the intervention meeting some of the patient's needs, particularly increasing knowledge of GWI and improving symptom management.

Disproportionate multimorbidity among veterans in middle age.

BACKGROUND: Little is known about the prevalence of multimorbidity among middle-aged veterans. Multimorbidity holds implications for planning for a population with high health care utilization, poor quality of life and marked need for interdisciplinary care. METHODS: The current study used the US 2017 Behavior Risk Factor Surveillance System to measure multimorbidity in three ways: (1) reporting two or more health conditions, (2) reporting two or more conditions controlling for demographic characteristics (e.g. income) and health risk behaviors (e.g. smoking) and (3) a weighted index using health-related quality of life. RESULTS: After age 25, veterans' risk for multimorbidity increased across all age groups. The increased odds of reporting multimorbidity was highest when comparing veterans aged 35-44 to non-veterans of the same ages. Veterans aged 35-44 are 50% (adjusted odds ratios (AOR) 1.50, 95% confidence interval (CI) 1.16, 1.94) to 80% (AOR 1.80, 95% CI 1.46, 2.23) more likely to report multimorbidity when compared with same aged non-veterans. CONCLUSIONS: Younger veterans may benefit from comprehensive interdisciplinary services to aid in the treatment of multiple medical conditions. Failure to account for the impact of chronic conditions on quality of life may lead to an underestimate of the health care needs of veterans across the lifespan.

"Because the country, it seems though, has turned their back on me": Experiences of institutional betrayal among veterans living with Gulf War Illness.

People living with medically unexplained symptoms (MUS) often have poor quality of life and health outcomes. Many struggle to engage with and trust in healthcare systems. This qualitative study examined how experiences with institutions influence perceptions of medical care for MUS by applying the theoretical framework of institutional betrayal to narratives of U.S. military Veterans living with Gulf War Illness (GWI). Institutional betrayal refers to situations in which the institutions people depend upon for safety and well-being cause them harm. Experiences of institutional betrayal both during active military service and when first seeking treatment appeared to shape perceptions of healthcare in this sample. Veterans expressed the belief that the military failed to protect them from environmental exposures. Veterans' concerns regarding subsequent quality of healthcare were intrinsically linked to a belief that, despite official documentation to the contrary, the predominant paradigm of both the U.S. Department of Defense and the U.S. Department of Veterans Affairs (VA) is that GWI does not exist. Veterans reported that providers are not adequately trained on treatment of GWI and do not believe Veterans' descriptions of their illness. Veterans reported taking up self-advocacy, doing their own research on their condition, and resigning themselves to decrease engagement with VA healthcare or seek non-VA care. The study's findings suggest institutional level factors have a profound impact on perceptions of care and the patient-provider relationship. Future research and policy aimed at improving healthcare for people living with MUS should consider the concept of institutional betrayal.

Social rehabilitation for military veterans with traumatic brain injury, psychological trauma, and chronic neuropsychiatric symptoms: Intervention development and initial outcomes.

OBJECTIVE: A subset of military veterans who have experienced both traumatic brain injury and psychological trauma present with chronic neuropsychiatric symptoms and experience persistent obstacles to social reintegration. This project aimed to develop a novel treatment targeting the unmet social rehabilitation needs of these veterans. Initial intervention development, feasibility, and outcome data are explored. METHOD: Four treatment groups were conducted (n = 20). A treatment workbook was developed during Groups 1 and 2 (n = 10) and research data were collected from Groups 3 and 4 (n = 10). RESULTS: There was a 0% attrition rate across all groups with unanimous requests for additional sessions. T test effect sizes were analyzed with bias-corrected Hedges' g. Improvements were observed on measures of depression (p = .026, g = 0.73), empathic perspective taking (p = .007, g = 0.94), social cognition (p = .002-.678, g = 0.27-1.30 across multiple measures), social relationships (p = .007, g = 1.50), traumatic brain injury-related quality of life (social: p = .014, g = 0.68, emotional: p = .009, g = 1.28) and nonsocial executive functioning (p = .006, g = 0.54). CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Preliminary evidence from this exploratory study suggests that targeting multiple layers of social competence using a combined psychotherapy and cognitive rehabilitation approach holds promise. Larger, controlled studies are needed to further evaluate the feasibility and efficacy of this intervention. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Perceived Race as Variable: Moderating Relationship Between Perceived Discrimination in the Workplace and Mentally Unhealthy Days.

Since race is a social construct, the experience of racial discrimination occurs based on perceived race. This study explores the moderating effects of self-identified race and perceived racial identity on the relationship between perceived discrimination in the workplace and mentally unhealthy days using data derived from the four states (Arizona, Minnesota, Mississippi, and New Mexico) that responded to the 2014 Reactions to Race module of the Behavioral Risk Factor Surveillance System. The study hypothesized that self-identified White people, also perceived as White (WW), would have less perceived workplace discrimination and less mentally unhealthy days than self-identified non-White people perceived as White (NWW); NWW would have less perceived discrimination associated with mentally unhealthy days than self-identified White perceived as non-White (WNW); and, WNW would have less perceived discrimination associated with mentally unhealthy days than self-identified non-White perceived as non-White (NWNW). The study was conducted under the regulating body of the City University of New York in 2017. Findings suggest that being perceived as White is a protective factor as analysis determined that NWW experienced less discrimination in the workplace associated with mentally unhealthy days than NWNW.

Evaluating challenges for improving medically unexplained symptoms in US military veterans via provider communication.

OBJECTIVES: Medically unexplained symptoms (MUS) are common, with particularly high rates observed in military veterans. Effective patient-provider-communication is thought to be a key aspect of care; however there have been few empirical studies on the association between communication and outcomes for patients with MUS. We evaluate whether discussing veterans' MUS-illness representations and good interpersonal skills have the potential to promote MUS-treatment adherence and improvement. METHODS: Veterans experiencing MUS (n=204) reported on their primary care providers' communication about illness representations and interpersonal skills; correlation, regression, and bootstrap-mediation analyses were conducted to test hypotheses regarding veteran-reported outcomes. Main outcomes included satisfaction with the provider, MUS-treatment adherence, intentions to adhere, and expectations for MUS improvement. RESULTS: Veterans reported infrequent discussion of MUS illness representations but high degrees of provider interpersonal skills. Communication regarding patients' illness representations and treatment expectations was significantly related to treatment adherence and adherence intentions; provider interpersonal skills were not. Both were related to veteran satisfaction. CONCLUSIONS AND PRACTICE IMPLICATIONS: Providers' interpersonal skills may be important in chronic illness contexts, such as MUS, by contributing to satisfaction with the provider. The current study suggests that providers may better promote MUS-treatment adherence through discussing MUS illness representations and treatment expectations.

CAM utilization among OEF/OIF veterans: findings from the National Health Study for a New Generation of US Veterans.

BACKGROUND: Complementary and alternative medicine (CAM) is increasingly seen as an adjunct to traditional plans of care. This study utilized a representative sample of Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) veterans and OEF/OIF-era veterans to explore the prevalence and characteristics of CAM users. RESEARCH DESIGN: The National Health Study for a New Generation of US Veterans (NewGen) is a longitudinal health study of a population-based cohort of OEF/OIF (deployed) and OEF/OIF-era (nondeployed) veterans. Data from the 2009-2011 NewGen survey (n=20,563) were analyzed to determine prevalence of CAM use by demographic and military characteristics, the types of CAM modalities used, and where the modalities were sought. Results were weighted to the entire population of OEF/OIF and OEF/OIF-era veterans. RESULTS: There was no statistically significant association between CAM use and deployment. Those who used Department of Veterans Affairs (VA) health care after separation were more likely to be CAM users compared with those who did not use VA care; however, the majority of veterans using CAM are using it outside the VA health care system. Massage was the most prevalent CAM modality followed by chiropractic treatment; males were less likely to use CAM than women. CONCLUSIONS: CAM modalities are being utilized by OEF/OIF veterans for health problems mainly outside the VA. Policymakers should determine appropriate use of these modalities.

PTSD diagnoses among Iraq and Afghanistan veterans: comparison of administrative data to chart review.

To guide budgetary and policy-level decisions, the U.S. Department of Veterans Affairs (VA) produces quarterly reports that count the number of Iraq and Afghanistan veterans with International Classification of Diseases, 9(th) Revision, Clinical Modification (ICD-9-CM) codes for posttraumatic stress disorder (PTSD; 309.81) in their electronic medical record administrative data. We explored the accuracy of VA administrative data (i.e., diagnostic codes used for billing purposes), by comparing it to chart review evidence of PTSD (i.e., medical progress notes and all other clinical documentation contained in the entire VA medical record). We reviewed VA electronic medical records for a nationwide sample of 1,000 Iraq and Afghanistan veterans with at least one ICD-9-CM code for PTSD in their VA administrative data. Among veterans sampled, 99.9% had 2 or more ICD-9-CM codes for PTSD. Reviewing all VA electronic medical record notes for these 1,000 veterans for the full course of their VA health care history revealed that PTSD was diagnosed by a mental health provider for 89.6%, refuted for 5.6%, and PTSD was never evaluated by a mental health provider for 4.8%. VA treatment notes for the 12 months preceding chart review showed that 661 veterans sampled received a VA PTSD diagnosis during that 12-month timeframe, and of these 555 were diagnosed by a mental health provider (83.9%). Thus, the presence of an ICD-9-CM code for PTSD approximated diagnoses by VA mental health providers across time points (89.6% for entire treatment history and 83.9% for 12 months prior to chart review). Administrative data offer large-scale means to track diagnoses and treatment utilization; however, their limitations are many, including the inability to detect false-negatives.

Mental health outreach and screening among returning veterans: are we asking the right questions?

This study looked at predictors of mental health treatment utilization in a unique cohort of recently separated Veterans coming to the Department of Veterans Affairs (VA) (N=152). This convenience sample voluntarily completed questionnaires, which included mental health screening tools, during an outreach event at a large urban VA Medical Center. Researchers reviewed computerized medical records of these consenting participants to record VA treatment utilization. There is a statistically significant association between posttraumatic stress disorder screening results, functional impairment, and treatment-seeking. Certain functional impairments increase the odds of participation in VA mental health care. These include problems with school and/or work (odds ratio (OR)=2.8), physical fights (OR=2.8), physical health problems (OR=3.0), financial difficulties (OR=3.0), irritability/anger (OR=3.4), isolation (OR=3.8), drug use (OR=5.7), and problems with social support (OR=7.0). This study concluded that asking about symptoms alone may not capture the breadth and nature of Veterans' postdeployment difficulties.