Real-world impacts from a decade of Quality Enhancement Research Initiative-partnered projects to translate the Diabetes Prevention Program in the Veterans Health Administration.

OBJECTIVES: To describe the impacts of four Veterans Health Administration (VA) Quality Enhancement Research Initiative (QUERI) projects implementing an evidence-based lifestyle intervention known as the Diabetes Prevention Program (DPP). DATA SOURCES AND STUDY SETTING: 2012-2024 VA administrative and survey data. STUDY DESIGN: This is a summary of findings and impacts from four effectiveness-implementation projects focused on in-person and/or online DPP across VA sites. DATA COLLECTION/EXTRACTION METHODS: Patient demographics, participation data, and key findings and impacts were summarized across reports from the VA Diabetes-Mellitus Quality Enhancement Research Initiative (QUERI-DM) Diabetes Prevention Program (VA DPP) Trial, QUERI-DM Online DPP Trial, the Enhancing Mental and Physical Health of Women through Engagement and Retention (EMPOWER) QUERI DPP Project, and EMPOWER 2.0 QUERI Program. PRINCIPAL FINDINGS: Between 2012 and 2024, four VA QUERI studies enrolled 963 Veterans in DPP across 16 VA sites. All participants had overweight/obesity with one additional risk factor for type 2 diabetes (i.e., prediabetes, elevated risk score, or history of gestational diabetes) and 56% (N = 536) were women. In addition to enhancing the reach of and engagement in diabetes prevention services among Veterans, these projects resulted in three key impacts as follows: (1) informing the national redesign of VA MOVE! including recommendations to increase the number of MOVE! sessions and revise guidelines across 150+ VA sites, (2) enhancing the national evidence base to support online DPP delivery options with citations in national care guidelines outside VA, and (3) demonstrating the importance of gender-tailoring of preventive care services by and for women Veterans to enhance engagement in preventive services. CONCLUSIONS: Over the past decade, the evolution of VA QUERI DPP projects increased the reach of and engagement in diabetes prevention services among Veterans, including women Veterans who have been harder to engage in lifestyle change programs in VA, and resulted in three key impacts informing type 2 diabetes and obesity prevention efforts within and outside of VA.

Implementation of long-acting cabotegravir and rilpivirine: primary results from the perspective of staff study participants in the Cabotegravir And Rilpivirine Implementation Study in European Locations.

INTRODUCTION: Cabotegravir plus rilpivirine (CAB + RPV) is the first complete long-acting (LA) regimen recommended for maintaining HIV-1 virological suppression. Cabotegravir And Rilpivirine Implementation Study in European Locations (CARISEL) is an implementation-effectiveness study examining the implementation of CAB+RPV LA administered every 2 months (Q2M) in European HIV centres. We present staff study participant (SSP) perspectives on the administration of CAB+RPV LA over 12 months. METHODS: Eighteen clinics were randomized to one of two implementation support packages: standard arm (Arm-S) or enhanced arm (Arm-E). Arm-S included video injection training and provider/patient toolkits. Additionally, Arm-E included skilled wrap-around team meetings, face-to-face injection training and continuous quality improvement (CQI) calls. SSPs completed surveys on the acceptability, appropriateness and feasibility of CAB+RPV LA as an intervention and its implementation into their clinics, as well as barriers and facilitators to implementation. All surveys were completed at Month (M)1 (baseline), M5 and M12; data collection was completed by February 2022. Qualitative data were obtained from semi-structured interviews at M1, M5 and M12. The primary objective was assessed via formal statistical comparisons between study arms of the Acceptability of Implementation Measure, Implementation Appropriateness Measure and Feasibility of Implementation Measure surveys (1-5 Likert scale ranging from 1 = "completely disagree" to 5 = "completely agree"). Equivalent measures anchored to CAB+RPV LA as a therapy were also assessed. RESULTS: Seventy SSPs completed surveys and interviews at M1, 68 at M5 and 62 at M12. Mean acceptability/appropriateness/feasibility scores were ≥3.8 (out of 5) at M12 for implementation- and intervention-based measures. An analysis of covariance showed no significant differences between study arms for these outcomes. Although barriers were noted, most SSPs were not overly concerned that these would impact implementation; concern about these anticipated barriers also decreased over time. At M12, 90.3% (n = 56/62) of SSPs held a positive opinion about CAB+RPV LA implementation. Qualitative interviews and CQI calls highlighted three top practices that supported implementation: implementation planning; education about CAB+RPV LA clinical efficacy; and education around administering injections and managing pain/discomfort after injections. CONCLUSIONS: CARISEL demonstrated that CAB+RPV LA dosed Q2M was successfully implemented across a range of European locations, with SSPs finding implementation highly acceptable, appropriate and feasible. GOV NUMBER: NCT04399551.

US Military Veteran Perspectives on Eating Disorder Screening, Diagnosis, and Treatment: A Qualitative Study.

OBJECTIVE: We aimed to explore US veteran perspectives on eating disorder screening, diagnosis, patient-provider conversations, and care in the Veterans Health Administration (VHA). METHOD: Rapid qualitative analysis of 30-45 min phone interviews with 16 (N = 16) veterans with an electronic health record ICD-10 eating disorder diagnosis, who received care at one of two VHA healthcare systems in Connecticut or California. Topics covered included: conversations with providers about eating disorder symptoms, diagnosis, and referral to treatment; feedback about an eating disorder screener, and; reflections on eating disorders among veterans and VHA's effort to address them. RESULTS: Most veterans reported difficulty understanding and defining the problems they were experiencing and self-diagnosed their eating disorder before discussing it with a provider. Treatment referrals were almost universally for being overweight rather than for an eating disorder, often leading veterans to feel misunderstood or marginalized. Overall, veterans were enthusiastic about the screener, preferred screening to be conducted by primary care providers, and noted that conversations needed to be non-stigmatizing. There was consensus that VHA is not doing enough to address this issue, that group support and therapy could be beneficial, and that resources needed to be centralized and accessible. DISCUSSION: For the most part, veterans felt that, at best, eating disorders and disordered eating are overlooked, and at worst, conflated with overweight. The majority of veterans got referred for weight loss or weight management services but would welcome the opportunity to be screened for, and referred to, eating disorder treatment.

Navigating grey areas in HIV and mental health implementation science.

INTRODUCTION: Implementation science (IS) offers methods to systematically achieve the Ending the HIV Epidemic goals in the United States, as well as the global UNAIDS targets. Federal funders such as the National Institutes of Mental Health (NIMH) have invested in implementation research to achieve these goals, including supporting the AIDS Research Centres (ARCs), which focus on high-impact science in HIV and mental health (MH). To facilitate capacity building for the HIV/MH research workforce in IS, "grey areas," or areas of IS that are confusing, particularly for new investigators, should be addressed in the context of HIV/MH research. DISCUSSION: A group of IS experts affiliated with NIMH-funded ARCs convened to identify common and challenging grey areas. The group generated a preliminary list of 19 grey areas in HIV/MH-related IS. From the list, the authors developed a survey which was distributed to all ARCs to prioritize grey areas to address in this paper. ARC members across the United States (N = 60) identified priority grey areas requiring clarification. This commentary discusses topics with 40% or more endorsement. The top grey areas that ARC members identified were: (1) Differentiating implementation strategies from interventions; (2) Determining when an intervention has sufficient evidence for adaptation; (3) Integrating recipient perspectives into HIV/MH implementation research; (4) Evaluating whether an implementation strategy is evidence-based; (5) Identifying rigorous approaches for evaluating the impact of implementation strategies in the absence of a control group or randomization; and (6) Addressing innovation in HIV/MH IS grants. The commentary addresses each grey area by drawing from the existing literature (when available), providing expert guidance on addressing each in the context of HIV/MH research, and providing domestic and global HIV and HIV/MH case examples that address these grey areas. CONCLUSIONS: HIV/MH IS is key to achieving domestic and international goals for ending HIV transmission and mitigating its impact. Guidance offered in this paper can help to overcome challenges to rigorous and high-impact HIV/MH implementation research.

The Rapid Implementation Feedback (RIF) report: real-time synthesis of qualitative data for proactive implementation planning and tailoring.

BACKGROUND: Qualitative methods are a critical tool for enhancing implementation planning and tailoring, yet rapid turn-around of qualitative insights can be challenging in large implementation trials. The Department of Veterans Affairs-funded EMPOWER 2.0 Quality Enhancement Research Initiative (QUERI) is conducting a hybrid type 3 effectiveness-implementation trial comparing the impact of Replicating Effective Programs (REP) and Evidence-Based Quality Improvement (EBQI) as strategies for implementing three evidence-based practices (EBPs) for women Veterans. We describe the development of the Rapid Implementation Feedback (RIF) report, a pragmatic, team-based approach for the rapid synthesis of qualitative data to aid implementation planning and tailoring, as well as findings from a process evaluation of adopting the RIF report within the EMPOWER 2.0 QUERI. METHODS: Trained qualitative staff conducted 125 semi-structured pre-implementation interviews with frontline staff, providers, and leadership across 16 VA sites between October 2021 and October 2022. High-priority topic domains informed by the updated Consolidated Framework for Implementation Research were selected in dialogue between EMPOWER 2.0 implementation and evaluation teams, and relevant key points were summarized for each interview to produce a structured RIF report, with emergent findings about each site highlighted in weekly written and verbal communications. Process evaluation was conducted to assess EMPOWER 2.0 team experiences with the RIF report across pre-implementation data collection and synthesis and implementation planning and tailoring. RESULTS: Weekly RIF updates supported continuous EMPOWER 2.0 team communication around key findings, particularly questions and concerns raised by participating sites related to the three EBPs. Introducing the RIF report into team processes enhanced: team communication; quality and rigor of qualitative data; sensemaking around emergent challenges; understanding of site readiness; and tailoring of REP and EBQI implementation strategies. RIF report findings have facilitated rapid tailoring of implementation planning and rollout, supporting increased responsiveness to sites' needs and concerns. CONCLUSIONS: The RIF report provides a structured strategy for distillation of time-sensitive findings, continuous team communication amid a complex multi-site implementation effort, and effective tailoring of implementation rollout in real-time. Use of the RIF report may also support trust-building by enhancing responsiveness to sites during pre- and early implementation. TRIAL REGISTRATION: Enhancing Mental and Physical Health of Women Veterans (NCT05050266); https://clinicaltrials.gov/study/NCT05050266?term=EMPOWER%202.0&rank=1 Date of registration: 09/09/2021.

Informing implementation and dissemination of a specialized primary care medical home for patients with serious mental illness: Clinician and administrator perspectives.

People with serious mental illness (SMI) have lower rates of use of preventative medical services and higher rates of mortality compared to the general population. Research shows that specialized primary care medical homes improve the health care of patients with SMI and are feasible to implement, safe, and more effective than usual care. However, specialized medical homes remain uncommon and model dissemination limited. As part of a controlled trial assessing an SMI-specialized medical home, we examined clinician and administrator perspectives regarding specialized versus mainstream primary care and identified ways to enhance the scale-up of a specialized primary care model for future dissemination. We conducted semistructured interviews with clinicians and administrators at three sites prior to the implementation of an SMI-specialized primary care medical home (n = 26) and at 1-year follow-up (n = 24); one site implemented the intervention, and two sites served as controls. Interviews captured service design features that affected the quality of care provided; contextual factors that supported or impeded medical home implementation; and knowledge, attitudes, and behaviors regarding the care of patients with SMI. Interviews were transcribed and coded. Clinicians and administrators described SMI-specialized primary care medical homes as advancing care coordination and outcomes for patients with SMI. Stakeholders identified elements of a specialized medical home that they viewed as superior to usual care, including having a holistic picture of patients' needs and greater care coordination. However, to enable scale-up, efforts are needed to increase staffing on care teams, develop robust clinician onboarding or training, and ensure close coordination with mental health care providers. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Addressing Pregnancy And Parenting In Mental Health Care: Perspectives Of Women With Serious Mental Illness.

Women living with serious mental illness (SMI) are at increased risk for adverse pregnancy and parenting outcomes. However, little is known about the experiences and preferences of women with SMI related to addressing pregnancy and parenting with their mental health providers. We conducted semistructured interviews with twenty-two reproductive-age cisgender women patients living with SMI. Participants characterized discussions about pregnancy and medication teratogenicity with their mental health providers as limited or unsatisfactory. Participants' openness to discussing pregnancy varied by topic and its perceived relevance to their individual circumstances, and it hinged on participants' trust in their providers. Participants characterized discussions about parenting with their mental health providers as helpful and identified additional opportunities for parenting support. Our findings highlight critical gaps in the delivery of information, support, and resources that can inform efforts to increase providers' capacity to address pregnancy and parenting with women living with SMI.

Enhancing Primary Care and Mental Health Integration for Women Veterans with Complex Healthcare Needs Using Evidence-Based Quality Improvement.

BACKGROUND: Women Veterans with co-morbid medical and mental health conditions face persistent barriers accessing high-quality health care. Evidence-based quality improvement (EBQI) offers a systematic approach to implementing new care models that can address care gaps for women Veterans. OBJECTIVE: This study examines factors associated with the successful deployment of EBQI within integrated health systems to improve primary care for women Veterans with complex mental health needs. DESIGN: Following a 12-site (8 EBQI, 4 control) cluster randomized study to evaluate EBQI effectiveness, we conducted an in-depth case study analysis of one women's health clinic that used EBQI to improve integrated primary care-mental health services for women Veterans. PARTICIPANTS: Our study sample included providers, program managers, and clinic staff at a women Veteran's health clinic that, at the time of the study, had one Primary Care and Mental Health Integration team and one women's health primary care provider serving 800 women. We analyzed interviews conducted 12 months, 24 months, and 4 years post-implementation and call summaries between the clinic and support team. MAIN MEASURES: We conducted qualitative thematic analysis of interview and call summary data to identify EBQI elements, clinic characteristics, and reported challenges and successes within project development and execution. KEY RESULTS: The clinic harnessed core EBQI elements (multi-level stakeholder engagement, data-driven progress-monitoring, PDSA cycles, sharing results) to accomplish pre-defined project goals, strengthen inter-disciplinary partnerships, and bolster team confidence. Clinic characteristics that facilitated implementation success included prior QI experience and an organizational culture responsive to innovation, while lack of pre-existing guidelines and limited access to centralized databases posed implementation challenges. CONCLUSIONS: Successful practice transformation emerges through the interaction of evidence-based methods and site-specific characteristics. Examining how clinic characteristics support or impede EBQI adaptation can facilitate efforts to improve care within integrated health systems.

Testing an implementation package in a housing skills training pilot for homeless-experienced persons with serious mental illness.

Background: Evidence-based practices (EBPs) improve housing and health for persons who have experienced homelessness with serious mental illness (PEH-SMI) but are challenging to implement. We tested a strategy to support pilot implementation of a 12-session housing skills training intervention for PEH-SMI, tailored from effective social skills training interventions. We aimed to optimize the implementation strategy and intervention prior to an implementation trial. Method: We provided training and technical assistance to nine providers to support pilot implementation of this intervention to six groups of PEH-SMI (n = 35) engaged in VA Greater Los Angeles' homeless services. We used scales and semi-structured interviews with 14 PEH-SMI and all interventionists to inform implementation strategy adaptations, identify factors that impacted implementation, and assess perceptions of the intervention. Attendance was tracked and we observed a random sample of each interventionist's groups to assess treatment fidelity. Results: Interventionists perceived the implementation strategy and the intervention favorably. However, interventionists often lacked physical space, staff, and resources (e.g., computers) to conduct the intervention. Interventionists found the content valuable for participants and a few suggested that group engagement should be a prerequisite for obtaining housing services. PEH-SMI were interested in the intervention's content and receptive to the group-based format. Participants attended a mean of 4 ± 3/12 groups; all groups observed had acceptable fidelity. Problems with intervention retention were described, suggesting challenges maintaining group participation when participants transitioned between VA homeless services. Conclusions: To support the implementation of an EBP for PEH-SMI in homeless programs, these data suggest the value of training/technical assistance and strategies that enhance program-level buy-in to address resource concerns. Intervention adaptations, e.g., using a drop-in, open group format, in community-based settings that are easily accessible to PEH-SMI, may also increase adoption. This project was registered as "Improving Housing Outcomes for Homeless Veterans" Trial registration NCT03646149, registered 8/24/2018.

There are effective social skills programs for people with serious psychiatric disorders; we adapted these programs into a 12-session housing skills program for people who had experienced homelessness. We then tested a training and technical assistance package to support the program's delivery by nine providers (e.g., social workers) to six groups of homeless people with serious psychiatric disorders (n = 35). We used surveys and interviews with some participants (n = 14) and all involved providers (n = 9) to understand their perspectives on our training and technical assistance, as well as the program itself; and to assess their views on factors that affected the program's use in real-world settings. We tracked participants' attendance at the groups and observed a random selection of groups to see if providers adhered to key program elements. We found that participants attended an average of one-third of the program's groups (4/12) but that providers were able to deliver the program to include all key elements. Some providers lacked important resources (e.g., classroom space or computers) to deliver the program as it was intended; they liked the training and technical assistance offered. Participants liked the program's content and format. Difficulties with participant retention may relate to drop-out from homeless services in which the program was delivered. This pilot project suggests that getting buy-in from leaders across levels and structuring the program as a drop-in group, in the community, or in places where attendance is easy for participants may increase its likelihood of being used as part of routine homeless services.

Multilevel perceptions of the virtual delivery of the University of California Diabetes Prevention Program on RE-AIM domains due to COVID-19 mandates.

Background: The University of California's Diabetes Prevention Program (UC DPP) Initiative was implemented across all 10 UC campuses in 2018. The COVID-19 pandemic and accompanying mandates required swift changes to program delivery, including pivoting from in-person to virtual delivery (i.e., Zoom). Our goal was to assess multilevel constituent perceptions of the use of a virtual platform to deliver UC DPP due to COVID-19 mandates. Methods: We conducted qualitative interviews with 68 UC DPP participants, coordinators, and leaders to examine the use of virtual platform delivery on the reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) of UC DPP. Transcripts were analyzed using rapid qualitative analysis and emergent themes were categorized using domains corresponding to RE-AIM framework. Results: Among UC DPP participants (n = 42), virtual delivery primarily impacted perceptions of UC DPP effectiveness and implementation. Some participants perceived program effectiveness to be negatively impacted, given their preference for in-person sessions, which they felt provided more engagement, peer support, and accountability. Implementation challenges included problems with virtual format (e.g., "Zoom fatigue"); however, several benefits were also noted (e.g., increased flexibility, maintenance of DPP connections during campus closures). UC DPP coordinators (n = 18) perceived virtual delivery as positively impacting UC DPP reach, since virtual platforms provided access for some who could not participate in-person, and negatively impacting effectiveness due to reduced engagement and lower peer support. UC leaders (n = 8) perceived that use of the virtual format had a positive impact on reach (e.g., increased availability, accessibility) and negatively impacted effectiveness (e.g., less intensive interactions on a virtual platform). Across constituent levels, the use of a virtual platform had little to no impact on perceptions of adoption and maintenance of UC DPP. Conclusion: Perceptions of the reach, effectiveness, and implementation of UC DPP using a virtual platform varied across constituents, although all groups noted a potential negative impact on overall program effectiveness. Unanticipated program adaptations, including virtual delivery, present potential benefits as well as perceived drawbacks, primarily across the effectiveness domain. Understanding differential constituent perceptions of the impact of virtual delivery can help maximize RE-AIM and inform future UC DPP delivery strategies.

Strengths and challenges among Black and Latinx people living with HIV during COVID-19: A mixed-methods investigation of the translation of self-management across syndemic health crises.

Black and Latinx people are disproportionately impacted by HIV, COVID-19, and other syndemic health crises with similar underlying social determinants of health. Lessons learned from the HIV pandemic and COVID-19 response have been invoked to improve health equity at the systemic level in the face of other emergent health crises. However, few have examined the potential translation of strategies between syndemics at the individual level. The current mixed-methods study examined strategies used to manage HIV during the COVID-19 pandemic and the extent to which they were helpful in managing COVID-19 vulnerability among Black and Latinx people living with HIV. Participants (n = 30) were interviewed by telephone and completed demographic, mental health, alcohol and substance use, health literacy, and clinical measures in October and November 2020 in Los Angeles County. Rapid qualitative analysis, descriptive statistics, and mixed-methods merging were used to analyze the data. Qualitative results demonstrated that participants found HIV self-management strategies translated to aspects of the COVID-19 pandemic including hygiene and social distancing and coping with a health-related stressor. Although telemedicine provided continuity of HIV care for most participants, technology access and literacy posed a potential barrier, particularly to those facing other sociodemographic marginalization (i.e., low education, disability). Findings suggest providers can encourage leveraging individual HIV self-management strategies in response to other public health crises. However, these interventions must be culturally responsive and address intersecting social determinants of health. Future research should examine mechanisms that predict individual translation of HIV management strategies to other health concerns. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

The association of HIV-related stigma and psychosocial factors and HIV treatment outcomes among people living with HIV in the Volta region of Ghana: A mixed-methods study.

Stigma and discrimination have been identified as significant barriers to HIV treatment among people living with HIV (PLWH). HIV stigma affects decision to seek HIV testing and early treatment. Evidence shows that HIV stigma undermines antiretroviral therapy (ART) adherence by affecting the psychological process such as adjusting and coping with social support. In Ghana, stigma toward PLWH occurs in many ways including rejection by their communities and family members, ostracism, and refusal to engage in social interactions such as eating, sharing a bed, or shaking hands. Therefore. we examined PLWH's experiences with different forms of HIV-related stigma and the impact on HIV treatment outcome in the Volta region of Ghana. We employed a convergent mixed-method approach consisting of a survey with 181 PLWH, four focus group discussions with 24 survey respondents, and in-depth interviews with six providers. We performed independent samples t-test, ANOVA, and chi-square test to test associations in bivariate analysis and analyzed qualitative data using thematic analysis. In all, 49% of survey respondents reported experiencing high internalized stigma, which was associated with high social support and depression (p<0.001). In qualitative interviews, anticipated stigma was the most salient concern of PLWH, followed by internalized and enacted stigma, which all negatively impacted HIV treatment and care. Stigma was experienced on multiple levels and affected psychosocial and treatment outcomes. Findings suggest urgent need for HIV-stigma reduction intervention among PLWH and their family, providers, and community members.

Factors Associated with Delayed Care Among Women Veterans Actively Engaged in Primary Care.

Background: Delaying needed medical care contributes to greater health risks and higher long-term medical costs. Women Veterans with complex medical and mental health needs face increased barriers to timely care access. Objectives: In a sample of women Veterans with recent engagement in Veterans Administration (VA) primary care, we aimed to compare characteristics of women Veterans who delayed care in the past 6 months with those who did not and examine factors associated with self-reported delayed care. Our study aims to inform interventions focused on eliminating health care access disparities among women Veterans. Materials and Methods: An innovation to improve women Veterans' engagement and retention in evidence-based health care for cardiovascular (CV) risk reduction (CV Toolkit) was implemented across five primary care sites within the VA. Women Veterans who were exposed to at least one CV Toolkit component participated in a mailed survey (n = 253). We used multivariate logistic regression to model factors associated with delaying care, including trust in VA providers, positive mental health screening (i.e., positive screen for either depression or anxiety), traumatic experience, self-rated health, and age. Results: Women with any mental health symptoms (odds ratio [OR] 2.42, 95% confidence interval [CI]: 1.23-4.74) and women who had experienced a traumatic event (OR 2.61, 95%CI: 1.11-6.14) were significantly more likely to report delaying care. Conclusions: Our study identified high rates of delayed care-over one-third of respondents-among women Veterans with recent primary care engagement. Mental health symptoms were the most common reported reason for delay among those who delayed care. Clinical Trial registration: NCT02991534.

The Science of Precision Prevention: Research Opportunities and Clinical Applications to Reduce Cardiovascular Health Disparities.

Precision prevention embraces personalized prevention but includes broader factors such as social determinants of health to improve cardiovascular health. The quality, quantity, precision, and diversity of data relatable to individuals and communities continue to expand. New analytical methods can be applied to these data to create tools to attribute risk, which may allow a better understanding of cardiovascular health disparities. Interventions using these analytic tools should be evaluated to establish feasibility and efficacy for addressing cardiovascular disease disparities in diverse individuals and communities. Training in these approaches is important to create the next generation of scientists and practitioners in precision prevention. This state-of-the-art review is based on a workshop convened to identify current gaps in knowledge and methods used in precision prevention intervention research, discuss opportunities to expand trials of implementation science to close the health equity gaps, and expand the education and training of a diverse precision prevention workforce.

Impact of Evidence-Based Quality Improvement on Tailoring VA's Patient-Centered Medical Home Model to Women Veterans' Needs.

BACKGROUND: Women Veterans' numerical minority, high rates of military sexual trauma, and gender-specific healthcare needs have complicated implementation of comprehensive primary care (PC) under VA's patient-centered medical home model, Patient Aligned Care Teams (PACT). OBJECTIVE: We deployed an evidence-based quality improvement (EBQI) approach to tailor PACT to meet women Veterans' needs and studied its effects on women's health (WH) care readiness, team-based care, and burnout. DESIGN: We evaluated EBQI effectiveness in a cluster randomized trial with unbalanced random allocation of 12 VAMCs (8 EBQI vs. 4 control). Clinicians/staff completed web-based surveys at baseline (2014) and 24 months (2016). We adjusted for individual-level covariates (e.g., years at VA) and weighted for non-response in difference-in-difference analyses for readiness and team-based care overall and by teamlet type (mixed-gender PC-PACTs vs. women-only WH-PACTs), as well as post-only burnout comparisons. PARTICIPANTS: We surveyed all clinicians/staff in general PC and WH clinics. INTERVENTION: EBQI involved structured engagement of multilevel, multidisciplinary stakeholders at network, VAMC, and clinic levels toward network-specific QI roadmaps. The research team provided QI training, formative feedback, and external practice facilitation, and support for cross-site collaboration calls to VAMC-level QI teams, which developed roadmap-linked projects adapted to local contexts. MAIN MEASURES: WH care readiness (confidence providing WH care, self-efficacy implementing PACT for women, barriers to providing care for women, gender sensitivity); team-based care (change-readiness, communication, decision-making, PACT-related QI, functioning); burnout. KEY RESULTS: Overall, EBQI had mixed effects which varied substantively by type of PACT. In PC-PACTs, EBQI increased self-efficacy implementing PACT for women and gender sensitivity, even as it lowered confidence. In contrast, in WH-PACTs, EBQI improved change-readiness, team-based communication, and functioning, and was associated with lower burnout. CONCLUSIONS: EBQI effectiveness varied, with WH-PACTs experiencing broader benefits and PC-PACTs improving basic WH care readiness. Lower confidence delivering WH care by PC-PACT members warrants further study. TRIAL REGISTRATION: The data in this paper represent results from a cluster randomized controlled trial registered in ClinicalTrials.gov (NCT02039856).

Increasing Urban African American Women's Readiness for Pre-exposure Prophylaxis: A Pilot Study of the Women Prepping for PrEp Plus Program (WP3+).

BACKGROUND: African American women are disproportionately at risk for HIV infection. To increase women's readiness to consider taking pre-exposure prophylaxis (PrEP), we conducted a pilot study of Women Prepping for PrEP Plus (WP3+). Adapted from an evidence-based HIV risk reduction intervention for African American couples who are HIV-serodiscordant, WP3+ is a group-based culturally congruent program designed for African American women without HIV. METHODS: Women were screened for eligibility; if eligible, they were invited to participate in the four-session WP3+ group. Participants completed surveys at baseline (n = 47) and post-implementation (n = 28); surveys assessed demographics, HIV and PrEP knowledge, depression and posttraumatic stress (PTS) symptoms, substance use, sexual risk behaviors, health care-related discrimination, and social support. In a process evaluation, a subset of women completed qualitative interviews at baseline (n = 35) and post-implementation (n = 18); the interviews were designed to converge with (e.g., on HIV and PrEP knowledge) and expand upon (e.g., unmeasured perceived impacts of WP3+) quantitative measures. To triangulate with the quantitative data, deductive qualitative analysis concentrated on women's knowledge and awareness of PrEP and HIV, their relationship dynamics and challenges, and their considerations (e.g., barriers, facilitators) related to taking PrEP; inductive analysis focused on women's experiences in the intervention. RESULTS: Participants in the WP3+ intervention reported: improved proportion of condom use in the past 90 days (p < .01) and in a typical week (p < .05); reduced PTS symptoms (p < .05); increased HIV knowledge (p < .0001) and awareness of PrEP (p < .001); and greater consideration of using PrEP (p < .001). In interviews, participants expressed not only increased knowledge but also appreciation for learning how to protect themselves against HIV, communicate with their partners, and take charge of their health, and they expressed greater receptiveness to using PrEP as a result of the knowledge and skills they gained. CONCLUSIONS: The WP3+ pilot study demonstrated preliminary efficacy and acceptability as an HIV-prevention program for African American women. A controlled trial is needed to confirm its efficacy for increasing PrEP use among African American women.

Coping with disruptive patients: Perspectives of primary care employees.

BACKGROUND: The impact of patient aggression on primary health care employees is underexplored, yet imperative to address, given high rates of burnout. OBJECTIVE: We qualitatively explore perceptions of patient aggression among staff in women's health primary care at the Veterans Health Administration (VA). Our objective is to identify coping strategies that staf devised in response to aggressive behavior. METHODS: We conducted semi-structured interviews with 60 VA women's health primary care employees in 2021 and 2022. Informed by the Job Demands-Resources theoretical model, we used rapid qualitative analysis to identify themes related to patient aggression and employee coping strategies. RESULTS: Disruptive behaviors reported by participants included verbal and physical aggression. Staff cited disruptive patient behavior as emotionally draining and perceived a lack of consequences for low-level aggression. Respondents used coping strategies in response to patient aggression at three time points: before, during, and after a negative interaction. At each point, support from team members emerged as a dominant coping mechanism, as well as rapport-building with patients. CONCLUSION: Patient aggression can negatively impact the work experiences of primary care employees. At VA, women's health primary care staff have devised multiple strategies to cope with these interactions. However, the ability to effectively prevent and manage patient aggression is limited by the lack of meaningful repercussions for aggression at the organizational level, which has important implications for employee well-being and retention. Retention of women's health employees in VA is critical given the need for a highly specialized workforce to address the complex health needs of women veterans.

Twelve-Month Reach and Effectiveness of a University-Based Diabetes Prevention Initiative.

INTRODUCTION: The University of California (UC) implemented the Diabetes Prevention Program (DPP) to address diabetes and obesity risk. This project examined the reach and effectiveness of this university-based DPP delivery approach. METHODS: This project compared 12-month weight change among three groups of UC beneficiaries with overweight/obesity: (1) those who received invitation letters and enrolled in UC DPP, (2) those mailed invitation letters but did not enroll, and (3) those who were not mailed letters and did not enroll (controls). Using 2012-2022 EHR, administrative and DPP cohort data, an interrupted time series was conducted in 2022-2023 to compare group differences in rate of weight change. RESULTS: Among 6,231 beneficiaries (132 UC DPP aware enrollees, 1,750 DPP aware non-enrollees, 4,349 controls), UC DPP enrollees were older (mean age 49), mostly women (76%), and more diverse (33% Asian, 8% Black, 20% Hispanic, 4% Multi/Other). Over 12 months of follow-up, UC DPP enrollee postenrollment rate of weight loss was -0.68 lbs./month. UC DPP enrollees had significantly greater weight change from pre- to post-enrollment than DPP aware non-enrollees (adjusted Δ-1.02 vs. Δ-0.07 lbs./month, difference= -0.95, p<0.001). Weight change among all participants who received letters with/without DPP enrollment was similar to controls. CONCLUSIONS: UC DPP reached a diverse group and was effective for weight loss at 12-month follow-up. However, UC DPP invitation letters to raise prediabetes and DPP awareness were not associated with significant weight change in the absence of DPP enrollment. University-based approaches to DPP delivery are effective and may enhance reach of DPP among at-risk adults.

Veteran Caretaker Perspectives of the Need for Childcare Assistance During Health Care Appointments.

PURPOSE: In 2020, Congress passed legislation to establish the national Veterans Child Care Assistance Program (VCAP) targeting eligible veterans receiving care through the Veterans Health Administration (VA). This needs assessment describes the childcare needs of veteran caretakers of young children and explores the implications of inadequate childcare on health care engagement. METHODS: Survey data were collected from 2,000 VA users with dependent children; data were analyzed using standard descriptive statistics. Qualitative data were collected from 19 veterans through focus groups and analyzed using rapid thematic analysis. FINDINGS: More than 75% of veterans surveyed indicated that they required childcare assistance during health care appointments and 73% reported barriers to finding childcare. Prominent barriers included the high cost of childcare and not having a trusted source of childcare. Nearly 58% of survey respondents reported missed or canceled VA health care appointments due to childcare challenges. Furthermore, 35% of surveyed veterans reported that their children had accompanied them to an appointment in the past year. Among these veterans, 59% brought their children into the exam room. Focus group participants discussed how having children present during their health care appointments hampered communication with health care providers. CONCLUSIONS: Veterans report that lack of childcare keeps them from attending and remaining focused on the provider during their health care visits, which could compromise quality of care. As one of the only health systems in the United States that will offer childcare assistance, VCAP presents an opportunity to improve health care access and quality by reducing missed appointments and suboptimal care.