Ensuring Optimal Mental Health Programs and Policies for First Responders: Opportunities and Challenges in One U.S. State.

This study examined opportunities and challenges faced by individuals working to advance mental health policy and programming for first responders. We utilized qualitative content analysis and interviews with 16 firefighters, emergency medical services professionals, law enforcement officers, and others involved in programming or policy in the U.S. state of Ohio. Six themes characterized opportunities and challenges encountered: (1) variations in programming and policy exist across jurisdictions; (2) opportunities exist to enhance mental health awareness and self-care training for first responders; (3) need exists for specialized mental health clinicians accustomed to and capable of effectively working with first responders; (4) confidentiality protections are lacking for peer supporters not trained in critical incident stress management; (5) having an internal champion and broader support is key to program and policy advancement; and (6) interdepartmental collaboration provides opportunities for sharing resources and best practices. Results illustrate continued need for strategic policymaking, program development, and coordination.

Pre-implementation evaluation for an HPV vaccine provider communication intervention among primary care clinics.

OBJECTIVES: Interventions to improve health care provider communication about HPV vaccination can increase vaccine acceptance. Our objectives were to (1) identify clinics in locations with high HPV-associated cancer and low HPV-vaccination rates that would potentially benefit from dissemination of a proposed HPV Provider Communication intervention and (2) use qualitative interviews and a dissemination and implementation framework to assess readiness for change and fit of the HPV Provider Communication intervention to the context of these clinics. METHODS: Local HPV-associated cancer and HPV vaccination rates were assigned to Practice-Based Research Network clinics using data from the Colorado Central Cancer Registry, the Colorado Immunization Information System, and the American Community Survey. Staff from 38 clinics located in areas with high numbers of adolescents not up-to-date for HPV vaccine and high rates of HPV-associated cancers were recruited for qualitative interviews. Interview questions used the Promoting Action on Research Implementation in Health Services (PARIHS) conceptual framework and addressed the proposed intervention, current vaccination practices and prior quality improvement (QI) experience. RESULTS: Twenty-seven interviews were completed with clinicians, clinic managers, and other staff across 17 clinics (9 pediatric, 5 family medicine, 3 public/school-based health). Most clinics had some prior QI experience and there were few thematic differences between sites with more or less foundation for QI/immunization work. Participants were motivated to improve the health of their patients and valued both guidelines and local experience as important evidence to consider adopting an intervention. Interviewees were more interested in implementing the proposed intervention if it aligned with existing priorities and fit within clinic workflows. Facilitation needs included adequate time and external facilitation support for data tracking and analysis. CONCLUSIONS: Qualitative interviews to understand clinic context and fit of an HPV Provider Communication intervention can inform implementation in settings with the highest potential for clinical impact.

The Lived Experience of Parents' Receiving the Diagnosis of CDKL5 Deficiency Disorder for Their Child.

CDKL5 deficiency disorder (CDD), a severe developmental and epileptic encephalopathy, is being diagnosed earlier with improved access to genetic testing, but this may also have unanticipated impacts on parents' experience receiving the diagnosis. This study explores the lived experience of parents receiving a diagnosis of CDD for their child using mixed methods. Thirty-seven semistructured interviews were conducted with parents of children with a diagnosis of CDD, which were coded and analyzed to identify themes. Grief was a nearly universal theme expressed among participants. Parents of younger children discussed grief in the context of receiving the diagnosis, whereas parents of older children indicated they were at different stages along the grieving journey when they received the diagnosis. Parents with less understanding of their child's prognosis (poorer prognostic awareness) connected their grief to receiving the diagnosis as this brought a clear understanding of the prognosis. Several themes suggested what providers did well to improve the diagnostic experience for parents, much of which aligns with existing literature around how to provide serious news. Additionally, parents identified long-term benefits of having a diagnosis for their child's medical problems. Although interview data were concordant with a survey of parents' diagnostic experience from a large international cohort, most participants in this study were relatively affluent, white mothers and further research is needed to better understand if other groups of parents have a different diagnostic experience. This study gives context of parental experience that providers should be aware of when conveying new genetic diagnoses to families.

Factors Enhancing Trust in Electronic Communication Among Patients from an Internal Medicine Clinic: Qualitative Results of the RECEPT Study.

BACKGROUND: Electronic health records are now the norm in US healthcare. Bidirectional patient portals allow frequent communication between patients and their healthcare team. Many studies have examined the importance of patient engagement and trust between patients and their healthcare team, typically in the context of face-to-face interactions. Little is known about how patient trust and engagement are built or enhanced through electronic communications. COVID-19 provided a unique time in history for this novel exploration. OBJECTIVE: Our objective was to learn how patients experience trust formation through electronic communication (patient messaging and video visits) with their healthcare team. DESIGN: Our research was guided by grounded theory methodology. Qualitative interviews were conducted between February and December 2020 with patients or their caregivers from an internal medicine clinic in Colorado. PARTICIPANTS: Fifty-one participants were recruited by age group and gender to represent the clinic's adult ambulatory care demographics. Seven were patients' caregivers who were purposefully recruited. Average age was 53 with an educated, middle class, and largely white predominance in our eventual sample. APPROACH: Thirty-minute semi-structured interviews were conducted using an interview guide informed by a validated physician-patient trust scale. Interviews were conducted by telephone, recorded via Zoom, and transcribed. Results were analyzed and coded in ATLAS.ti utilizing the constant comparative method, with two coders. KEY RESULTS: Patients experienced enhanced trust in their healthcare team through electronic communications. Interpersonal and system factors contributed to trust formation. Promptness of reply was the most salient factor in trust formation with a majority desiring same day response. CONCLUSIONS: Patients now rely on electronic communication with their healthcare team. Opportunities exist to leverage this to improve health outcomes. Important research in expanded demographic groups, along with ambulatory healthcare redesign, will be necessary to optimize benefits of electronic communication with patients and meet patient expectations.

Politicized disease surveillance: A theoretical lens for understanding sociopolitical influence on the monitoring of disease epidemics.

Sociopolitical forces commonly influence the collection, analysis, dissemination, and general perceptions of epidemiological information. Yet few theoretical lenses provide insight into the mechanisms through which such influence occurs. In this article, I draw and expand upon empirical findings to propose a novel theoretical lens, politicized disease surveillance, which I define as extreme or undue sociopolitical influence on public health surveillance systems or processes in ways that impact disease incidences and prevalences, or estimates or perceptions thereof. This lens foregrounds disease incidence and prevalence as objects of contestation and policy influence and articulates how certain facets of sociopolitical forces shape disease incidences and prevalences-especially amid an epidemic-through one or more channels: (1) the diagnostic construct; (2) screening tools, procedures, or systems; or (3) the behaviors of individuals who are living with or at risk for a certain disease. I provide several contemporary illustrations of politicized disease surveillance and discuss its theoretical and practical implications.

Qualitative Methods in Health Policy and Systems Research: A Framework for Study Planning.

Qualitative methodologies and methods are commonly used in health policy and systems research but have not been extensively characterized. We describe how qualitative approaches are used within the field and present a framework to aid researchers in study planning. To achieve these aims, we conducted a scoping literature review of 1 year of selected health policy and systems research and then coded publications based on their primary analytical foci. Four core themes emerged: policy or program content, an analysis of the substance of policies or program documents; policy or program environment, a study of the landscape of policies or programs; policy or program implementation, a study of the planned or actual execution of a policy or program; and organization or system operations, a study of the structure or function of health organizations or systems. We provide guidance on utilizing the framework and adhering to qualitative best practices during the process.

Clergy attitudes toward vaccines and vaccine advocacy: a qualitative study.

Background: Recent outbreaks of vaccine-preventable diseases have affected members of religious communities. While major religions support vaccines, the views of individual clergy who practice and propagate major faith traditions are unclear. Our objective was to explore clergy attitudes toward vaccines and vaccine advocacy. Methods: In 2018-2019, we conducted qualitative interviews with clergy in Colorado and North Carolina. We inductively analyzed transcripts using a grounded theory approach, developing codes iteratively, resolving disagreements by consensus, and identifying themes. Results: We interviewed 16 clergy (1 Buddhist, 3 Catholic, 2 Jewish, 1 Hindu, 1 Islamic, 7 Protestant, and 1 Unity). Analyses yielded seven themes: attitudes toward vaccines, congregational needs, public health climate, perceived responsibility, comfort and competing interests, reported advocacy efforts, and clergy health advocacy goals. Most clergy had positive vaccination attitudes and were open to vaccine advocacy, although discomfort with medical concepts and competing interests in their congregations influenced whether many had chosen to advocate for vaccines. Over half reported promoting vaccination in various contexts. Conclusions: In our sample, U.S. clergy held complex attitudes toward vaccines, informed by experience and social norms as much as religious beliefs or Scriptures. Clergy may be open to vaccine advocacy, but a perceived lack of relevance in their faith communities or a lack of medical expertise may limit their advocacy efforts in diverse contexts. Amidst growing vaccine hesitancy, pediatricians could partner with clergy in their communities, answer questions about vaccines, raise awareness of recent outbreaks, and empower clergy in joint educational events.

Supporting and sustaining centralized reminder/recall for immunizations: Qualitative insights from stakeholders.

Centralized reminder/recall (C-R/R) is an evidence-based strategy for increasing vaccination rates that uses a population-level database such as a state immunization information system (IIS) to send notifications across large geographic areas. IISs are usually based in state public health departments, which could initiate C-R/R. While C-R/R is a promising strategy, the factors influencing its initiation and sustainment are not clear. Utilizing qualitative content analysis methodology and interviews with key stakeholders involved in or knowledgeable about C-R/R, we examined the characteristics of these initiatives and factors influencing their success. We identified and spoke with managers and senior leaders across IISs, health plans, health systems, pharmaceutical companies, and advocacy organizations and focused especially on C-R/R activities within IISs. Several considerations were determined important to C-R/R success: decision-making, stakeholder buy-in, partnerships, funding, data and technology, evaluation, and message content. Salient barriers were costs and lack of funding, poor contact data quality (i.e. telephone number, home address), and messaging that is either overly broad or too specific. Pertinent facilitators of C-R/R included notifying health providers in advance of an initiative, conducting a rigorous post-reminder/recall evaluation, and engaging a range of partners. Partnerships were important to stakeholders for multiple reasons including technical assistance, resource sharing, and sharing of best practices. Overall, our results illustrate the many opportunities to advance C-R/R through further collaboration within and across public health departments and potentially via public-private partnerships.

Military Service Member and Veteran Reintegration: A Conceptual Analysis, Unified Definition, and Key Domains.

Returning military service members and veterans (MSMVs) may experience a variety of stress-related disorders and challenges when reintegrating from the military to the community. Facilitating the reintegration, transition, readjustment and coping, and community integration, of MSMVs is a societal priority. To date, research addressing MSMV reintegration has not identified a comprehensive definition of the term or defined the broader context within which the process of reintegration occurs although both are needed to promote valid and reliable measurement of reintegration and clarify related challenges, processes, and their impact on outcomes. Therefore, this principle-based concept analysis sought to review existing empirical reintegration measurement instruments and identify the problems and needs of MSMV reintegration to provide a unified definition of reintegration to guide future research, clinical practice, and related services. We identified 1,459 articles in the health and social sciences literature, published between 1990 and 2015, by searching multiple electronic databases. Screening of abstracts and full text review based on our inclusion/exclusion criteria, yielded 117 articles for review. Two investigators used constant conceptual comparison to evaluate relevant articles independently. We examined the term reintegration and related terms (i.e., transition, readjustment, community integration) identifying trends in their use over time, analyzed the eight reintegration survey instruments, and synthesized service member and veteran self-reported challenges and needs for reintegration. More reintegration research was published during the last 5 years (n = 373) than in the previous 10 years combined (n = 130). The research suggests coping with life stresses plays an integral role in military service member and veteran post-deployment reintegration. Key domains of reintegration include individual, interpersonal, community organizations, and societal factors that may facilitate or challenge successful reintegration, and results suggest that successful coping with life stressors plays an integral role in post-deployment reintegration. Overall, the literature does not provide a comprehensive representation of reintegration among MSMVs. Although, previous research describes military service member and veteran reintegration challenges, this concept analysis provides a unified definition of the phenomenon and identifies key domains of reintegration that may broaden our understanding and guide reintegration research and practice.

Military service member and veteran reintegration: A critical review and adapted ecological model.

Returning military service members and veterans (MSMVs) experience a wide range of stress-related disorders in addition to social and occupational difficulties when reintegrating to the community. Facilitating reintegration of MSMVs following deployment is a societal priority. With an objective of identifying challenges and facilitators for reintegration of MSMVs of the current war era, we critically review and identify gaps in the literature. We searched 8 electronic databases and identified 1,764 articles. Screening of abstracts and full-text review based on our inclusion/exclusion criteria, yielded 186 articles for review. Two investigators evaluating relevant articles independently found a lack of clear definition or comprehensive theorizing about MSMV reintegration. To address these gaps, we linked the findings from the literature to provide a unified definition of reintegration and adapted the social ecological systems theory to guide research and practice aimed at MSMV reintegration. Furthermore, we identified individual, interpersonal, community, and societal challenges related to reintegration. The 186 studies published from 2001 (the start of the current war era) to 2015 included 6 experimental studies or clinical trials. Most studies do not adequately account for context or more than a narrow set of potential influences on MSMV reintegration. Little evidence was found that evaluated interventions for health conditions, rehabilitation, and employment, or effective models of integrated delivery systems. We recommend an ecological model of MSMV reintegration to advance research and practice processes and outcomes at 4 levels (individual, interpersonal, organizational, and societal). (PsycINFO Database Record

Family Resilience in the Military: Definitions, Models, and Policies.

Military life presents a variety of challenges to military families, including frequent separations and relocations as well as the risks that service members face during deployment; however, many families successfully navigate these challenges. Despite a recent emphasis on family resilience, the U.S. Department of Defense (DoD) does not have a standard and universally accepted definition of family resilience. A standard definition is a necessary for DoD to more effectively assess its efforts to sustain and improve family resilience. RAND authors reviewed the literature on family resilience and, in this study, recommend a definition that could be used DoD-wide. The authors also reviewed DoD policies related to family resilience, reviewed models that describe family resilience and identified key family resilience factors, and developed several recommendations for how family-resilience programs and policies could be managed across DoD.

Sleep in the Military: Promoting Healthy Sleep Among U.S. Servicemembers.

Sleep disturbances are a common reaction to stress and are linked to a host of physical and mental health problems. Given the unprecedented demands placed on U.S. military forces since 2001, there has been growing concern about the prevalence and consequences of sleep problems for servicemembers. Sleep problems often follow a chronic course, persisting long after servicemembers return home from combat deployments, with consequences for their reintegration and the readiness and resiliency of the force. Therefore, it is critical to understand the role of sleep problems in servicemembers' health and functioning and the policies and programs available to promote healthy sleep. This study provides the first comprehensive review of sleep-related policies and programs across the U.S. Department of Defense (DoD), along with a set of actionable recommendations for DoD, commanders, researchers, and medical professionals who treat U.S. servicemembers. The two-year multimethod study also examined the rates and correlates of sleep problems among post-deployed servicemembers, finding negative effects on mental health, daytime impairment, and perceived operational readiness. The research reviewed evidence-based interventions to treat sleep disturbances among servicemembers and veterans and exposed several individual- and system-level barriers to achieving healthy sleep. Implementing evidence-based treatments is just one step toward improving sleep across the force; as the research recommendations highlight, it is equally important that policies and programs also focus on preventing sleep problems and their consequences.

PTSD in the U.S. military, and the politics of prevalence.

Despite the long-standing codification of posttraumatic stress disorder (PTSD) as a mental disorder, the diagnosis is a controversial one whose legitimacy is at times disputed, particularly in U.S. military contexts (e.g., McNally and Frueh 2013; McNally, 2003, 2007). These disputes often manifest in a struggle over prevalence rates. Utilizing data from in-depth interviews and relying on situational analysis methodology (Clarke, 2005), I highlight this struggle in the wake of a decade of U.S.-led war in Afghanistan and Iraq. I focus on the objects of contestation employed by public officials, veterans' advocates, and researchers to make or refute claims about PTSD prevalence. These objects of contestation include the diagnostic category and criteria; screening tools, procedures, or systems; and the individuals who express symptoms of the disorder. Based on these claims, I make two key interrelated assertions. First, PTSD is viewed by some public officials as an overly generalized or invalid diagnostic category that is often induced in or falsified by veterans or servicemembers. As such, PTSD is perceived by these stakeholders to be over-diagnosed. Compounding these perceptions are beliefs that PTSD is costly and negatively impacts military duty performance, and thus overall manpower. Second, there exist perceptions, largely on the part of veterans' advocates but also some public officials, that many servicemembers and veterans are not seeking treatment (and thus, a diagnosis) when they experience symptoms of PTSD. Thus, PTSD is perceived by these stakeholders to be under-diagnosed. Paradoxically, some public officials make both claims: that PTSD is over-diagnosed and under-diagnosed. I conclude by exploring the implications of these findings.

Hidden Heroes: America's Military Caregivers - Executive Summary.

While much has been written about the role of caregiving for the elderly and chronically ill and for children with special needs, little is known about "military caregivers"-the population of those who care for wounded, ill, and injured military personnel and veterans. These caregivers play an essential role in caring for injured or wounded service members and veterans. This enables those for whom they are caring to live better quality lives, and can result in faster and improved rehabilitation and recovery. Yet playing this role can impose a substantial physical, emotional, and financial toll on caregivers. This article distills a longer report, Hidden Heroes: America's Military Caregivers, which describes the results of a study designed to describe the magnitude of military caregiving in the United States today, as well as to identify gaps in the array of programs, policies, and initiatives designed to support military caregivers. Improving military caregivers' well-being and ensuring their continued ability to provide care will require multifaceted approaches to reducing the current burdens caregiving may impose, and bolstering their ability to serve as caregivers more effectively. Given the systematic differences among military caregiver groups, it is also important that tailored approaches meet the unique needs and characteristics of post-9/11 caregivers.

Drug use among gay and bisexual men at weekend dance parties: the role of intentions and perceptions of peers' behaviors.

Substance use is high among gay and bisexual men attending weekend dance events, yet little research has investigated motivations for drug use and contextual factors influencing use in these settings. We hypothesized that beliefs about peer drug use interact with individuals' own drug use intentions to predict use. 489 men attending weekend dance events completed an anonymous assessment asking about their own and their beliefs about other attendants' drug use intentions--47 % completed a follow-up assessment after the event. Forty-four percent reported intending to use ecstasy at the event; intentions to use GHB, marijuana, cocaine, unprescribed erectile dysfunction drugs, and poppers were also high. Perceptions about other attendant's drug use predicted use among those intending and those not intending to use drugs. Normative beliefs are important predictors of drug use at weekend dance events; event-specific prevention strategies should encompass messages that correct misperceptions of drug use among party attendants.

Risk behaviors among HIV-positive gay and bisexual men at party-oriented vacations.

OBJECTIVE: This study examined substance use (intended and actual), unprotected sex, and HIV disclosure practices (disclosure and questioning) among HIV-positive men who have sex with men (MSM) at two party-oriented vacations, where substance use and sexual risk may be heightened. METHOD: A random sample of 489 MSM attending one of two party-oriented vacations participated in PartyIntents, a short-term longitudinal survey. Nearly half (47%) completed a follow-up assessment at the event or online for up to 2 weeks after the event. We examined rates of baseline intentions to use substances, actual substance use, and unprotected intercourse among HIV-positive men in attendance.Rates among HIV-negative men were estimated for comparison. Multiple logistic regression was used to assess the impact of illegal drug use and HIV status on unprotected anal intercourse (UAI). RESULTS: HIV-positive attendees (17%) were significantly more likely than HIV-negative attendees to use nitrite inhalants (or "poppers") (24.3% vs. 10.7%). HIV-positive attendees were also significantly more likely to have insertive UAI (64.3% vs. 34.1%) and receptive UAI (68.8% vs. 22.2%). Multivariate models showed associations between HIV status and illegal drug use with UAI (for HIV status, odds ratio [OR] = 4.5, p = .001; for any illegal drug use, OR = 16.4, p < .001). There was no evidence that the influence of drug use moderated risk by HIV status. Rates of HIV disclosure and questioning did not differ by HIV status. CONCLUSIONS: HIV-positive men attending these events engaged in higher rates of illegal drug use and sexual risk than HIV-negative men. Prevention campaigns targeting MSM at high-risk events should include messages geared toward HIV-positive men.

Military Caregivers: Cornerstones of Support for Our Nation's Wounded, Ill, and Injured Veterans.

Military caregivers are an essential part of our nation's ability to care for returning wounded warriors. Far too often, their own needs are neglected. The RAND Corporation and the Elizabeth Dole Foundation collaborated on a first, exploratory phase of a larger research effort regarding this demographic and its needs. The research explores what is known about the number and characteristics of military caregivers, describes the roles and functions they perform, and highlights the effect of caregiving on their own well-being. Most existing literature on family caregivers is heavily focused on an older population caring for persons with chronic conditions or dementia. By comparison, research on military caregivers is scant, and there are notable differences that make this population unique: Military caregivers are spouses with young children, parents with full- and part-time jobs, and sometimes even young children helping shoulder some of the burden. Government services available to this population are in their infancy; community service organizations offer diverse services but they are generally uncoordinated. This article lays the groundwork to inform policy and program development relative to the unique needs of military caregivers.

The Role and Importance of the 'D' in PTSD.

Recently, the American Psychiatric Association (APA) board of trustees voted on changes to the new edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). Among the decisions was one to retain the word "disorder" in the term "posttraumatic stress disorder." U.S. Army leadership initially requested a change in terminology, stating that the word "disorder" is stigmatizing and that removing it would encourage more individuals suffering from symptoms to access care. Although the APA has issued its ruling, the term "posttraumatic stress" is being used informally by some individuals within military communities. It is unclear whether informal use of the term will continue, or whether military leaders will continue to advocate future changes to the DSM. RAND explored the rationales for not changing the diagnostic terminology, and to the extent possible, anticipated what the effects of widespread informal use of new terminology might be.

Health and social services integration: a review of concepts and models.

Health and social services integration is particularly relevant for populations whose needs span physical health, mental health, housing, and disability services, along with others. Veterans, homeless, chronically ill, and aging are among those populations. This review examines recent peer-reviewed literature about different approaches to services integration, rationales behind those approaches, and successes of those approaches, including factors that make them succeed or fail. The focus here is on services that cross disciplinary boundaries; that is, those that integrate health services with social services, health services with mental health services, or one social service with a categorically different social service.

Programs Addressing Psychological Health and Traumatic Brain Injury Among U.S. Military Servicemembers and Their Families.

Over the last decade, U.S. military forces have been engaged in extended conflicts that are characterized by increased operational tempo, most notably in Iraq and Afghanistan. While most military personnel cope well across the deployment cycle, many will experience difficulties handling stress at some point; will face psychological health challenges, such as post-traumatic stress disorder or major depression; or will be affected by the short- and long-term psychological and cognitive consequences of a traumatic brain injury (TBI). Over the past several years, the Department of Defense (DoD) has implemented numerous programs that address various components of psychological health along the resilience, prevention, and treatment continuum and focus on a variety of clinical and nonclinical concerns. This article provides detail from an evaluation of 211 programs currently sponsored or funded by DoD to address psychological health and TBI, along with descriptions of how programs relate to other available resources and care settings. It also provides recommendations for clarifying the role of programs, examining gaps in routine service delivery that could be filled by programs, and reducing implementation barriers. Barriers include inadequate funding and resources, concerns about the stigma associated with receiving psychological health services, and inability to have servicemembers spend adequate time in programs. The authors found that there is significant duplication of effort, both within and across branches of service. As each program develops its methods independently, it is difficult to determine which approaches work and which are ineffective. Recommendations include strategic planning, centralized coordination, and information-sharing across branches of service, combined with rigorous evaluation. Programs should be evaluated and tracked in a database, and evidence-based interventions should be used to support program efforts.