Strengthening the global one health workforce: Veterinarians in CDC-supported field epidemiology training programs.

Background: Effective prevention, detection, and response to disease threats at the human-animal-environment interface rely on a multisectoral, One Health workforce. Since 2009, the U.S. Centers for Disease Control and Prevention (CDC) has supported Field Epidemiology Training Programs (FETPs) to train veterinarians and veterinary paraprofessionals (VPPs) alongside their human health counterparts in the principles of epidemiology, disease surveillance, and outbreak investigations. We aim to describe and evaluate characteristics of CDC-supported FETPs enrolling veterinarians/VPPs to understand these programs contribution to the strengthening of the global One Health workforce. Methods: We surveyed staff from CDC-supported FETPs that enroll veterinarians and VPPs regarding cohort demographics, graduate retention, and veterinary and One Health relevant curriculum inclusion. Descriptive data was analyzed using R Version 3.5.1. Results: Forty-seven FETPs reported veterinarian/VPP trainees, 68% responded to our questionnaire, and 64% reported veterinary/VPP graduates in 2017. The veterinary/VPP graduates in 2017 made up 12% of cohorts. Programs reported 74% of graduated veterinarians/VPPs retained employment within national ministries of agriculture. Common veterinary and One Health curriculum topics were specimen collection and submission (93%), zoonotic disease (90%) and biosafety practices (83%); least covered included animal/livestock production and health promotion (23%) and transboundary animal diseases (27%). Less than half (41%) of programs reported the curriculum being sufficient for veterinarians/VPPs to perform animal health specific job functions, despite most programs being linked to the ministry of agriculture (75%) and providing veterinary-specific mentorship (63%). Conclusions: Our results indicate that FETPs provide valuable training opportunities for animal health sector professionals, strengthening the epidemiology capacity within the ministries retaining them. While veterinary/VPP trainees could benefit from the inclusion of animal-specific curricula needed to fulfill their job functions, at present, FETPs continue to serve as multisectoral, competency-based, in-service training important in strengthening the global One Health workforce by jointly training the animal and human health sectors.

Field epidemiology training programs contribute to COVID-19 preparedness and response globally.

BACKGROUND: Field epidemiology training programs (FETPs) have trained field epidemiologists who strengthen global capacities for surveillance and response to public health threats. We describe how FETP residents and graduates have contributed to COVID-19 preparedness and response globally. METHODS: We conducted a cross-sectional survey of FETPs between March 13 and April 15, 2020 to understand how FETP residents or graduates were contributing to COVID-19 response activities. The survey tool was structured around the eight Pillars of the World Health Organization's (WHO) Strategic Preparedness and Response Plan for COVID-19. We used descriptive statistics to summarize quantitative results and content analysis for qualitative data. RESULTS: Among 88 invited programs, 65 (74%) responded and indicated that FETP residents and graduates have engaged in the COVID-19 response across all six WHO regions. Response efforts focused on country-level coordination (98%), surveillance, rapid response teams, case investigations (97%), activities at points of entry (92%), and risk communication and community engagement (82%). Descriptions of FETP contributions to COVID-19 preparedness and response are categorized into seven main themes: conducting epidemiological activities, managing logistics and coordination, leading risk communication efforts, providing guidance, supporting surveillance activities, training and developing the workforce, and holding leadership positions. CONCLUSIONS: Our findings demonstrate the value of FETPs in responding to public health threats like COVID-19. This program provides critical assistance to countries' COVID-19 response efforts but also enhances epidemiologic workforce capacity, public health emergency infrastructure and helps ensure global health security as prescribed in the WHO's International Health Regulations.

Factors associated with past and current employment of veterans with spinal cord injury.

Objective: The purpose of this study was to examine variables predictive of post-SCI return to employment and current employment among a large cohort of veterans with Spinal Cord Injury (SCI) treated within the Veterans Health Administration (VHA) SCI System of Care.Design: Cross sectional analysis of data obtained during in-person baseline interviews and follow-up phone interviews.Setting: Seven SCI Centers within Veteran Affairs Medical Centers.Participants: 1047 veterans with SCI receiving inpatient or outpatient care in VHA.Results: Only 29.8% were employed post-SCI, 27.9% reported employment within the immediate 5 years before the baseline interview, but only 9.2% reported current employment at the time of the baseline interview. Significant predictors of current employment among these veterans with SCI included recent employment experience, history of legal problems, duration of SCI, education, and life satisfaction.Conclusions: The baseline employment rate following SCI of a large, representative sample, was 29.8%. Greater duration of SCI predicted unemployment, likely due to the older age of this population. Additional years of education promoted current and post-SCI employment, while a history of legal problems was a barrier to employment.

Economic evaluation of a supported employment program for veterans with spinal cord injury.

Objective: To estimate the net monetary benefit of an individual placement and support-based supported employment program for Veterans with spinal cord injuries.Design: Economic evaluation comparing a supported employment program to treatment as usual, using cost and quality-of-life data from a longitudinal study of Veterans with spinal cord injuries.Setting: Spinal cord injury centers in the Veterans Health Administration.Participants: Subjects (N = 213) who participated in a 24-month supported employment program at seven spinal cord injury centers. Supported employment participants were compared with a group of spinal cord injury Veterans who received treatment as usual in a prior study.Main outcome measures: Costs and quality-adjusted life years using the Veterans Rand-6 Dimension, estimated from the Veterans Rand 36-Item Health Survey.Results: The supported employment program was more effective at both 1- and 2-year periods compared with treatment as usual. Outpatient costs were significantly higher for supported employment, but inpatient costs were not significantly different from treatment as usual. When cost and effectiveness were compared jointly using net monetary benefit, a supported employment program following the core principles of Individual Placement and Supported employment was more effective but not cost-effective at standard willingness to pay thresholds. When we considered a sub-group of the supported employment participants who more closely resemble the treatment as usual group from a randomized trial, there was no significant difference in the cost-effectiveness of supported employment when compared to treatment as usual.Conclusions: With higher effectiveness and similar costs, supported employment for spinal cord injury Veterans has the potential to be cost-effective. Future studies need to randomize participants or carefully match participants based on observable patient characteristics to improve cost-effectiveness evaluations of this population.Implications for RehabilitationSupported employment as part of ongoing rehabilitation care helps individuals with spinal cord injury return to work and improve their quality of life.Many studies show that supported employment programs are cost effective for persons with mental disabilities, but there is only limited economic evaluation data on use of supported employment with persons with spinal cord injury.This study shows that supported employment integrated with ongoing rehabilitation care is more effective in restoring employment and health-related quality of life.

Quality of Life Outcomes for Veterans With Spinal Cord Injury Receiving Individual Placement and Support (IPS).

Background: Individual Placement and Support (IPS) is an evidence-based practice that helps persons with mental and/or physical disabilities, including spinal cord injury, find meaningful employment in the community. While employment is associated with positive rehabilitation outcomes, more research is needed on the impact of IPS participation on non-vocational outcomes, particularly quality of life (QOL). Objective: To identity QOL outcomes experienced with (1) IPS participation and (2) IPS participation leading to employment. Methods: Using a mixed method design, data on quality of life outcomes were collected from 151 interviews and 213 surveys completed by veterans with SCI participating in IPS. Results: At 12 months, participants who obtained competitive employment (CE) and those who did not (no-CE) showed improvement on most measures. In months 12-24, the CE group showed improvements on all study measures while the no-CE group declined on many indices. Statistically significant changes were observed between participants who obtained CE versus no-CE on several measures. Themes were identified from interview data related to productivity and well-being. Productivity themes were (1) contributing to society, (2) earning an income, and (3) maintaining employment. Themes for well-being were (1) mental health/self-confidence, (2) physical health, and (3) goal setting. Themes were associated with IPS participation irrespective of employment outcomes. Conclusion: IPS participants who were competitively employed report consistent improvement in handicap, health-related QOL, and life satisfaction measures across time. Qualitative findings revealed improved QOL outcomes in productivity and well-being for veterans participating in IPS overall, regardless of employment outcomes.

Gender differences in depression among veterans with spinal cord injury.

PURPOSE: Little is known about gender differences in depression among veterans with spinal cord injury (SCI). Accordingly, the main objectives of this study were (a) to examine demographic and clinical characteristics of veterans with SCI; (b) to investigate gender differences in lifetime depression and depressive symptom severity, including probable major depressive disorder (MDD); and (c) to identify contributory factors (e.g., pain, life satisfaction) for gender differences in depression. METHOD: An exploratory secondary analysis was performed on a cross-sectional data set (N = 1,047) from a longitudinal study of health and employment among veterans with SCI. Community-dwelling veterans (N = 135) included women (n = 45) case-matched 1:2 to men (n = 90) based on age, injury level, and time since injury. Group comparisons and regression analyses were used to explore gender differences. RESULTS: Veterans with SCI had significantly higher rates of lifetime depression as compared with the general population. Women, as compared with men, had higher rates of lifetime depression diagnosis and endorsed more depressive symptoms, as measured by the Quick Inventory of Depression Symptomatology-Self Report (QIDS-SR). Among women, satisfaction with life was a significant predictor of QIDS-SR scores. A similar pattern was seen among men, with the addition of bodily pain as a significant predictor. CONCLUSIONS: Given the relationship between depressive symptoms and life satisfaction for women, follow-up depression screenings among veterans with SCI should include quality of life assessments. Additionally, assessment of somatic symptoms, such as pain, in relation to depressive symptomatology is recommended, particularly among men. (PsycINFO Database Record

Relationship Between Comorbidities and Employment Among Veterans with Spinal Cord Injury.

Objective: To determine the relationship between medical and mental health comorbidities in a large cohort of veterans with spinal cord injury (SCI). Methods: Data were collected from interviews and electronic medical records of veterans with SCI (N = 1,047) who received care at 7 geographically diverse SCI centers within the Department of Veterans Affairs across the country (https://clinicaltrials.gov/ct2/show/NCT01141647). Employment, medical, functional, and psychosocial data underwent cross-sectional analysis. Results: Lack of any documented mental health diagnosis correlated strongly with being employed at the time of enrollment. No single comorbidity was associated with employment at enrollment, but an increased number of medical and/or mental health comorbidities ("health burden") were associated with a decreased likelihood of employment at the time of enrollment. Conclusion: Further investigation is needed to clarify whether comorbidity severity or combinations of specific comorbidities predict rehabilitation outcome, including employment.

Rooted in the Community: Assessing the Reintegration Effects of Agriculture on Rural Veterans.

OBJECTIVE: To assess the effect of a veteran-oriented community agricultural initiative on transitioning rural veterans. DESIGN: Convergent mixed-method program evaluation. SETTING: Veteran-oriented farm-to-market community agricultural initiative. PARTICIPANTS: Veterans (N=43) who were members of the community agricultural initiative. MAIN OUTCOME MEASURES: Health, well-being, and reintegration were assessed by self-reported data from interviews, a demographic survey, a validated health quality of life measure (Veterans RAND-12 [VR-12]), a validated reintegration measure (Military to Civilian Questionnaire), and a general satisfaction survey. RESULTS: Veteran participants were primarily white (88.4%, n=38) and men (74.4%, n=32), and most had a service-connected disability rating (58.2%, n=25). Qualitative and quantitative data revealed that the veterans participating in this community agricultural initiative experienced health and reintegration benefits. Results on the Military to Civilian Questionnaire, VR-12, and satisfaction survey suggest that participating in this community agricultural initiative contributed to improved mental, physical, and emotional health and vocational skills, community connectedness, and interpersonal communication. Qualitative interviews supported quantitative findings and revealed that participating in the community agricultural initiative provided veterans with a sense of satisfaction, a sense of belonging, and helped decrease the stigma surrounding their veteran status. CONCLUSIONS: Veterans who participate in this community agricultural initiative reported general improvements in physical and mental health, including improvements in sleep, nutrition, and exercise, and decreases in anxiety, pain, depression, and medication and substance use, all known factors which effect veteran reintegration.

Examination of traumatic brain injury exposure among veterans with spinal cord injury.

OBJECTIVE: The authors investigated lifetime exposure to traumatic brain injury (TBI) among veterans with spinal cord injury (SCI) in order to describe outcome differences as a function of self-reported TBI history. DESIGN: Cross sectional study, veterans with SCI (N = 857) completed the Ohio State University TBI Identification interview method (OSU-TBI); Veterans RAND 36-Item Health Survey (VR-36); Quick Inventory for Depressive Symptomatology, Self-Report (QIDS-SR); Patient Health Questionnaire-9; Satisfaction with Life Scale; Craig Handicap Assessment and Reporting Technique (CHART; along with clinician-rated Functional Independence Measure (FIM) Total, Motor, and Cognitive scores. RESULTS: Probable TBI exposure was described by 77.6% of participants, with 38% reporting sustaining more than one injury. Self-reported TBIs classified as moderate/severe comprised 49.5% of injuries. Participants with self-reported TBI obtained significantly lower scores on the FIM-Cognitive and CHART Cognitive Independence scales and reported more alcohol use. A history of multiple TBIs was additionally associated with lower mental well-being on the VR-36. CONCLUSIONS: These findings highlight the need to consider more than co-occurring injuries and the potential utility of the OSU-TBI for this purpose. Recognizing lifetime exposure to TBI among veterans with SCI may help identify those with broader impairments and enhance the rehabilitation process. (PsycINFO Database Record

A Retrospective Review of Adverse Events Related to Diabetic Foot Ulcers.

The risk of adverse events (AEs) such as infection and amputation related to diabetic foot ulcers (DFUs) has been studied, but less is known about rate of other AEs such as falls. As part of a quality improvement project, AEs in veterans with diabetes mellitus (DM) with and without a DFU were examined. Demographic data including ICD-9 codes, AEs, and comorbidities for all patients with a diagnosis of DM and/or DFU treated between 2009 and 2014 at the James A. Haley Veterans' Hospital, Tampa, FL, were reviewed retrospectively utilizing the Corporate Data Warehouse (CDW) database. Identifiable protected health information data using patient scrambled social security numbers were collected from the CDW to allow the longitudinal data to be linked at the unique patient level. Descriptive statistics (eg, mean, standard deviation) were determined for demographics, AE, and comorbidities. Adjusted models of AE association with DM and DFU were analyzed using regression modeling via a statistical analysis system. The models were adjusted for age, race, gender, marital status, and comorbidities. Data extracted included individuals diagnosed with diabetes with a DFU (n = 3238, average age 66.0 ± 10.6 years) and diabetes without DFU (n= 41 324, average age 64.4 ± 11.5 years). Participants were mostly Caucasian in both the DFU and non-DFU cohorts (2655 [82.0%] and 32 269 [78.1%], respectively) and male (3129 [96.6%] and 39 580 [95.8%], respectively). The most common comorbidities in this population were peripheral vascular disease (PVD, 39.5%) and peripheral neuropathy (PN, 23.2%). PVD was more common in veterans with (39.5%) than without a DFU (9.2%). Compared to individuals with DM, those with DM and DFU were significantly more likely to experience an infection (OR = 9.43; 95% CI 8.54-10.4), undergo an amputation (OR = 7.40; 95% CI 6.16-8.89), or experience a fracture (OR = 3.65; 95% CI 2.59-5.15) or fall (OR = 2.26; 95% CI 1.96-2.60) (P <.01 for all variables). Although the increased risk of infection and amputation among persons with DFUs has been documented, less is known about the rate of falls and fractures. The current findings will serve as baseline data for future implementation trials to reduce DFU-associated AEs, and clinicians may want to consider expanding DFU patient education efforts to include fall risk.

Does functional motor incomplete (AIS D) spinal cord injury confer unanticipated challenges?

PURPOSE/OBJECTIVE: Examine psychological challenges associated with Spinal Cord Injury (SCI) among a cohort of Veterans. Research Method/Design: Cross-sectional descriptive study. SCI Centers participating in a multisite evaluation of longitudinal employment, quality of life, and economic outcomes among a large cohort of veterans with SCI, the Predictive Outcome Model Over Time for Employment (PrOMOTE) project. A total of 1,047 patients from participating SCI Centers provided baseline interviews. Main outcome measures included the Veterans RAND 36-Item Health Survey (VR-36) Mental Component Score (MCS); VR-36 Mental Health Scale; VR-36 Vitality Scale; VR-36 Bodily Pain Scale; Quick Inventory for Depressive Symptomatology, Self-Report (QIDS-SR); Patient Health Questionnaire-Depression Scale (PHQ-9); and Diener Satisfaction with Life Scale (SWLS). RESULTS: ANOVA analysis showed that persons with AIS D SCI evidenced higher self-reported depressive symptoms, higher pain, and a lower subjective quality of life. CONCLUSIONS/IMPLICATIONS: Individuals with functional motor incomplete spinal cord injury are more vulnerable to psychological distress and a low subjective quality of life than might be expected based on functional outcomes. Further study appears warranted to ascertain potential explanations for these findings. (PsycINFO Database Record

Individual Placement and Support in Spinal Cord Injury: A Longitudinal Observational Study of Employment Outcomes.

OBJECTIVE: To determine the effects of a 24-month program of Individual Placement and Support (IPS) supported employment (SE) on employment outcomes for veterans with spinal cord injury (SCI). DESIGN: Longitudinal, observational multisite study of a single-arm, nonrandomized cohort. SETTING: SCI centers in the Veterans Health Administration (n=7). PARTICIPANTS: Veterans with SCI (N=213) enrolled during an episode of either inpatient hospital care (24.4%) or outpatient care (75.6%). More than half the sample (59.2%) had a history of traumatic brain injury (TBI). INTERVENTION: IPS SE for 24 months. MAIN OUTCOME MEASURE: Competitive employment. RESULTS: Over the 24-month period, 92 of 213 IPS participants obtained competitive jobs for an overall employment rate of 43.2%. For the subsample of participants without TBI enrolled as outpatients (n=69), 36 obtained competitive jobs for an overall employment rate of 52.2%. Overall, employed participants averaged 38.2±29.7 weeks of employment, with an average time to first employment of 348.3±220.0 days. Nearly 25% of first jobs occurred within 4 to 6 months of beginning the program. Similar employment characteristics were observed in the subsample without TBI history enrolled as outpatients. CONCLUSIONS: Almost half of the veterans with SCI participating in the 24-month IPS program as part of their ongoing SCI care achieved competitive employment, consistent with their expressed preferences at the start of the study. Among a subsample of veterans without TBI history enrolled as outpatients, employment rates were >50%. Time to first employment was highly variable, but quite long in many instances. These findings support offering continued IPS services as part of ongoing SCI care to achieve positive employment outcomes.

Facilitators and barriers to employment among veterans with spinal cord injury receiving 12 months of evidence-based supported employment services.

BACKGROUND: Return to work is associated with positive rehabilitation outcomes for persons with spinal cord injury (SCI); however, more research is needed on vocational support for persons with disabilities seeking employment. OBJECTIVE: The association between facilitators and barriers of employment and employment outcome was examined among Veterans with SCI who participated in an evidence-based supported employment (EBSE) program. METHODS: Using a mixed-methods, nested case-control design, data on facilitators and barriers to employment were extracted from qualitative interviews and quantitative measures administered in person to 34 Veterans with SCI who completed 12 months of an EBSE program. Participants who did (case) and did not (control) obtain competitive employment were matched on time since SCI. Facilitators and barriers to employment were compared between the groups. RESULTS: Self-report measures administered at baseline were examined; there were no statistically significant factors that predicted employment outcomes after 12 months of EBSE program participation. Qualitative interview data revealed program-specific facilitators and Veteran characteristics that were associated with employment outcomes. CONCLUSIONS: Qualitative data illustrate how the integration of the vocational rehabilitation specialist on the medical team is helpful for addressing identified disability-specific barriers, including practical matters such as transportation and caregiving schedules, to facilitate employment outcomes.

The impact of social support at home on health-related quality of life among veterans with spinal cord injury participating in a supported employment program.

PURPOSE: To investigate the impact of social support at home on health-related quality of life (HRQOL) as measured by the VR-6D utility index for spinal cord injury (SCI) veterans participating in a program of supported employment (SE). METHODS: We calculated a preference-based utility index called the VR-6D from the responses from a 36-item instrument called the VR-36. We estimated a growth curve model to examine the change in the VR-6D utility index over time adjusting for social support status, demographics, and chronic comorbidities. RESULTS: Study participants experienced an increase in HRQOL over time. The initial level and the rate of increase in HRQOL varied by groups based on their support status. The rate of increase in HRQOL diminished over time. Participants reporting no support at home experienced lower initial HRQOL but reached the same level of those who reported having support at home by the ninth month of follow-up. Quality-adjusted life-years, as measured by the area under the curves, were approximately the same for both groups after 2 years. CONCLUSIONS: Differences in the rate of change in HRQOL by support status have important implications for evaluations of SE programs. Participants in this program of SE experienced improvement in HRQOL beyond 12 months and extending to 2 years. Follow-up times for evaluations should extend beyond 12 months to assess complete improvements in HRQOL. Future comparison groups in comparative effectiveness evaluations of SE need to be balanced carefully on support status in addition to other factors.

Spinal cord injury combined with felony history: effect on supported employment for Veterans.

UNLABELLED: In this secondary analysis of data from a randomized controlled trial comparing supported employment with treatment as usual, we sought to evaluate the study incident rate of legal involvement and subsequent effects of legal involvement on employment among 157 job-seeking Veterans with spinal cord injury. The supported employment vocational rehabilitation program, called the Spinal Cord Injury-Vocational Integration Program, adhered as closely as possible to principles of supported employment as developed and described in the individual placement and support model of supported employment for persons with mental illness. Rates of misdemeanor and felony arrests and convictions were analyzed, and their relationship to finding employment was evaluated. Findings indicate that 47% had been arrested and 25% had been convicted of a felony. Overall, those who found employment had fewer average arrests and were significantly less likely to have been convicted of a felony. Future directions and limitations are discussed. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov; NCT00117806.