Impact of veteran-led peer mentorship on posttraumatic stress disorder.

Peer mentorship shows promise as a strategy to support veteran mental health. A community-academic partnership involving a veteran-led nonprofit organization and institutions of higher education evaluated a collaboratively developed peer mentor intervention. We assessed posttraumatic stress disorder (PTSD), postdeployment experiences, social functioning, and psychological strengths at baseline, midpoint, and 12-week discharge using the PTSD Checklist for DSM-5 (PCL-5), Deployment Risk and Resilience Inventory-2, Social Adaptation Self-evaluation Scale, and Values in Action Survey. Brief weekly check-in surveys reinforced mentor contact and assessed retention. The sample included 307 veterans who were served by 17 veteran peer mentors. Mixed-effects linear models found a modest effect for PTSD symptom change, with a mean PCL-5 score reduction of 4.04 points, 95% CI [-6.44, -1.64], d = 0.44. More symptomatic veterans showed a larger effect, with average reductions of 9.03 points, 95% CI [-12.11, -5.95], d = 0.77. There were no significant findings for other outcome variables. Compared to younger veterans, those aged 32-57 years were less likely to drop out by 6 weeks, aORs = 0.32-0.26. Week-by-week hazard of drop-out was lower with mentors ≥ 35 years old, aHR = 0.62, 95% CI [0.37, 1.05]. Unadjusted survival differed by mentor military branch, p = .028, but the small mentor sample reduced interpretability. Like many community research efforts, this study lacked a control group, limiting the inferences that can be drawn. Continued study of veteran peer mentorship is important as this modality is often viewed as more tolerable than therapy.

Foundations of Community Engagement: A Series for Effective Community-Engaged Research.

Introduction: Medical students lack systematic exposure to community engagement. Community-engaged research (CEnR) is an effective approach to improve community health, and community-engaged physicians are better attuned to the community context of their patients' health and well-being. The Medical College of Wisconsin (MCW) Office of Community Engagement began offering the educational series Foundations of Community Engagement in 2021 to meet this need. Methods: We developed and implemented a four-session series for medical students at MCW and the University of Nebraska Medical Center. A 1-hour session on the foundations of CEnR was held for all learners. Three 1-hour sessions dove deeper into CEnR principles for a self-selected cohort. These small-group sessions involved discussion between faculty and community partners and facilitated small-group discussion. Students completed evaluations after each session. Results: A total of 160 students participated in the introductory session; 36 took part in the follow-up series. Survey response rates varied from 38% to 67% for each session. Overall, 87% of students in all sessions felt their session was worthwhile, with 85% of large-group and 96% of small-group respondents reporting they learned something they would use in their practice or profession. Qualitative responses included appreciation for addressing a curricular gap and desire for more time and more sessions to continue discussions. Discussion: The program was effective at stimulating medical student self-reported gains in skills, attitudes, and future intentions regarding CEnR in an efficient manner. Effective programs that transfer positive CEnR skills and attitudes to future physicians can promote CEnR within academic medicine.

The Stacked Community Engagement model: A practical model for developing community-engaged academic medical faculty.

Introduction: There is an increasing recognition of the benefits of sustained community engagement (CE) that accrue to academic health centers and the communities they serve. However, the success and sustainability of CE projects rely on the efforts of individual faculty, learners, and community members, for whom CE efforts are typically added to their professional and personal priorities and responsibilities. This competition for time and resources between priorities and CE can discourage academic medical faculty from participating in CE activities. The Stacked Community Engagement model is proposed to synergize or "stack" responsibilities and goals onto the scaffolding of CE projects. Methods: We examined the literature and expert CE practitioner opinion to identify the challenges faced by community-engaged academic faculty and the key characteristics of CE projects that successfully align and integrate with the priorities of faculty, learners, and community members. We synthesized this information to develop the conceptual Stacked CE model for developing CE academic medical faculty, then illustrated the model in heterogeneous CE programs to explore its generalizability, validity, and robustness. Results: The Stacked CE model, when applied to a specific nutrition education program (The Food Doctors) and outreach program (StreetLife Communities), provided a practical framework for examining the sustained success of a partnership between Medical College of Wisconsin faculty and medical students and the community. Conclusions: The Stacked CE model is a meaningful framework for developing community-engaged academic medical faculty. By identifying overlap and integrating CE into professional activities with intention, CE practitioners can benefit from the deeper connections and sustainability.

Impact Evaluation of Patient-Centered, Community-Engaged Health Modules for Homeless Pregnant Women.

PURPOSE: Pregnant women who experience homelessness are at a greater risk for poor birth outcomes than the general population. This pilot study describes results of a service-learning program informed by previously identified unmet perinatal health needs. In this patient-centered service-learning program, medical students partnered with homeless women currently residing in a shelter in Milwaukee, Wisconsin. METHODS: Medical students in the Health Advocacy in Pregnancy and Infancy (HAPI) project at the Medical College of Wisconsin developed and taught 6 service-learning modules to shelter residents: healthy cooking, mental health, perinatal nutrition, infant care/safety, breastfeeding, and contraception. Implemented between 2018 and 2021, modules were hosted in person and via electronic videoconferences. We gathered qualitative data on participants' perceived impact of the modules and used grounded theory analysis to examine written comments and verbal feedback. RESULTS: A total of 141 participants attended 42 learning sessions. Participants included pregnant and postpartum mothers and women interested in learning about pregnancy-related health. Qualitative analysis revealed 3 universal themes regarding the impact of the sessions on participants: "Knowledge," "Intention to Change," and "Empowerment." CONCLUSIONS: Our community-engaged health education partnership program between homeless pregnant women and medical students focused on perinatal health. This well-received, effective strategy cultivated new knowledge, empowering participants to not only change their own behaviors, but to teach and support others. This study demonstrates the ability of using community-based teaching sessions to enhance participants' understanding of pregnancy and postpartum health and empower others to implement changes.

Rural Residence Predicts Lower Cardiac Mortality and Better Mental Health Outcomes.

INTRODUCTION: Previous studies have found higher rates of heart disease and worse mental health outcomes among individuals residing in rural areas. To our knowledge, no research has used county-level data to measure the effect of "ruralness" (the degree to which a county is rural) on heart disease and mentally unhealthy days while controlling for other sociodemographic factors. This study analyzes the effect of ruralness on heart disease death rates and the average number of mentally unhealthy days on a county-level. METHODS: Linear regressions were performed using county-level data to analyze the effect of "Ruralness" on heart disease death rates and mental unhealthiness while controlling for confounding variables. Geographic analysis was also used. RESULTS: Higher rural-urban continuum codes predict lower rates of cardiac mortality (ß = -.075 deaths per 100,000 people/continuum code, t = -4.36, P <.001) and fewer mentally unhealthy days (ß = -.265 monthly mentally unhealthy days/continuum code, t = -16.45, P < .001). CONCLUSION: Being from a rural area correlates with lower rates of heart disease death and mental unhealthiness after controlling for sociodemographic confounders. This adds nuance to the previously reported trend of heart disease being more prevalent in rural areas.

Needs Assessment for Creating a Patient-Centered, Community-Engaged Health Program for Homeless Pregnant Women.

PURPOSE: Women who experience homelessness during pregnancy have poorer birth outcomes than the general population. This exploratory research describes the needs assessment of homeless women currently living at a shelter in Milwaukee, Wisconsin, to identify unmet needs related to maternal and infant perinatal health as the first step in designing a mutually beneficial patient-centered service-learning program for medical students to address these needs. METHODS: Two 1-hour focus groups were held at a shelter for women who are homeless and/or victims of domestic violence. A total of 13 women participated in each session; four medical students and a physician served as facilitators and scribes at each session. The facilitators alternated asking predetermined open- and close-ended questions, followed by discussion among participants. Questions elicited experiences during pregnancy, what went well, what women living in the shelter struggled with, and what support they wished for but did not have. Scribes captured the conversation through hand-written notes and used content analysis in order of frequency. RESULTS: Thirteen themes were identified. The 5 most frequently identified themes were a need for pregnancy education, access/transportation, baby care, advocacy, and material necessities. Participating shelter residents and the medical students expressed interest in working with one another and forming a long-term partnership with the shelter. CONCLUSIONS: Results of this needs assessment will inform the creation of a new shelter-based medical education program that will meet homeless women's needs while preparing medical students for patient-centered, community-responsive care.

Grant writing: Moving from generating ideas to applying to grants that matter.

There is an extraordinary burden placed upon the healthcare system and people as a result of health disparities that exist within the United States. If there is going to be a concerted effort to develop innovative strategies to reduce health disparities, input from the community and behavioral scientists can and should be included in this approach and narrative. Grant writing provides one vehicle to express the narrative and to provide a means to fund research and programs within clinic-based and community settings. This paper describes a four-step inquiry process to guide healthcare professionals with varying degrees of clinical and scholarship interests through the grant writing process. They include: (1) Why write grants (motivations), (2) what is the area of focus? (Interests), (3) whom should be on the project? (partnerships), and (4) what needs to happen next to move the idea forward? (actions) The complexity of psychosocial issues means that behavioral science is well suited to develop both hypotheses-driven and phenomenological research to understand bio-psycho-social health issues. Grant writing does not need to be mysterious or daunting. It can provide a means to an end, not only to fund research but also as a means to an end of health disparities.

Empirically Derived Lessons Learned about What Makes Peer-Led Exercise Groups Flourish.

BACKGROUND: Physical exercise confers many health benefits, but it is difficult to motivate people to exercise. Although community exercise groups may facilitate initiation and persistence in an exercise program, reports regarding factors that allow such groups to flourish are limited. OBJECTIVES: We performed a prospective qualitative evaluation of our experience starting a program of community-based, peer-led exercise groups for military veterans to identify important lessons learned. METHODS: We synthesized data from structured observations, post-observation debriefings, and focus groups. Our participants were trained peer leaders and exercise group members. Our main outcomes consisted of empirically derived lessons learned during the implementation of a peer-led group exercise program for veterans at multiple community sites. We collected and analyzed data from 40 observation visits (covering 14 sites), 7 transcribed debriefings, and 5 focus groups. RESULTS: We identified five lessons learned. (1) The camaraderie and social aspect of the exercise groups provided motivation for people to stay involved. (2) Shared responsibility and commitment to each other by the group members was instrumental to success. (3) Regular meeting times encouraged participation. (4) Variety, especially getting outdoors, was very popular for some groups. (5) Modest involvement of professionals encouraged ongoing engagement with the program. CONCLUSIONS: Both social and programmatic issues influence implementation of group exercise programs for older, predominantly male, veterans. These results should be confirmed in other settings.

Continuity in Community Medicine Training: Is It Time to Rethink the Block Rotation?

BACKGROUND AND OBJECTIVES: Family medicine residency training emphasizes the importance of community medicine. Recent scholarship has helped to identify important elements of community partnerships, including bidirectionality and continuity. Given the importance of continuity in family medicine and community partnerships, this study explores the relationship between continuity in community medicine curricula, partnership quality, and residents' community medicine competency. METHODS: Survey questions were included in the 2015-2016 Council of Academic Family Medicine Educational Research Alliance (CERA) Family Medicine Program Director survey that probed community medicine curricular structures, partnership quality, and outgoing resident competency in community medicine. Multivariate logistic regression was used to test the impact of continuity on the outcomes of partnership quality and residents' community medicine competency. RESULTS: Respondents represented 227 of 461 family medicine programs (49%). Block rotation, used in 150 (66%) programs, was the approach most commonly used to deliver community medicine curriculum. Eighty-five (45%) programs self-reported high quality partnerships and about one-third described outgoing residents as highly proficient in community medicine competencies. Program-level continuity in community partnerships was significantly correlated to high quality partnerships (odds ratio [OR] 3.51, 95% confidence interval [CI] 1.79-6.89, P<0.001) and educational outcomes (OR 2.85, 95% CI 1.38-5.89, P=0.005), while resident-level continuity was not. CONCLUSIONS: Our findings support the importance of continuity to the quality of family medicine residency community partnerships as well as resident education in community medicine. Further research is needed to understand the importance of continuity at the program level versus individual resident level.

Patient perceptions of weight loss: Implications for patients, providers, and trainees.

OBJECTIVES: The prevalence of overweight and obese individuals in the United States is growing, and primary health care represents a setting in which providers may address weight with their patients. However, many providers and medical trainees feel ill-prepared to address the full scope of complexities associated with weight loss. This study sought to investigate patients' perceptions of the barriers and facilitators they encountered in their weight loss journeys. The results of the mixed-methods study will be used to inform a better understanding among providers and medical students of how to address weight loss with their patients. This study was approved by the institutional review board of Medical College of Wisconsin. METHODS: Participants were selected from patient panels at a Family Medicine Residency Program. Participants who enrolled in the study completed a survey that collected attitudes and behaviors about weight loss and demographics. The patients also participated in a 60- to 90-min guided interview. Interviews were transcribed verbatim and analyzed using open-coding techniques and principles of grounded theory. RESULTS: To date, five participants completed the study. All were female with a mean age of 52 years. Two primary themes emerged from a grounded theory model. The first theme centered on individual's knowledge, attitudes, and behaviors to lost weight. The second theme emphasized that societal relationships serve as both a barrier and a facilitator to weight loss. CONCLUSION: The overarching conclusion of this study is that individuals often have the knowledge to make positive health behaviors changes, but multiple factors may prohibit this from occurring. When a supportive environment exists, healthy behavior changes are more attainable. Physicians, mid-level providers, and medical trainees and even medical systems can provide appropriate support to join the patient on their weight loss journey.

Community Veterans' Decision to Use VA Services: A Multimethod Veteran Health Partnership Study.

BACKGROUND: Ensuring veterans' access to healthcare is a national priority. Prior studies of veterans' use of Veterans Health Administration (VA) healthcare have had limited success in evaluating barriers to access for certain vulnerable veteran subpopulations. OBJECTIVES: Our coalition of researchers and veteran community members sought to understand factors affecting use of VA, particularly for those less likely to participate in traditional survey studies. METHODS: We recruited 858 veterans to complete a collaboratively designed survey at community events or via social media. We compared our results regarding VA use with the 2010 National Survey of Veterans (NSV) using chi-square tests, multiple logistic regression to identify predictors of VA use, and content analysis for open-ended descriptions of barriers to VA use. RESULTS: Veterans in our study were more likely than NSV respondents to report using VA healthcare ever (76% vs. 28%; p<0.0001). Within this group, more veterans in our sample were current VA users (83% vs. 68%; p<0.0001). In multivariable analysis, VA use was predicted by self-reported physical problems (comparing "a lot" vs. "none" for each variable, adjusted odds ratio [OR], 8.35), thinking problems (OR, 1.14), need for smoking cessation (OR, 1.54), need for pain management (OR, 1.65), and need for other mental health services (OR, 3.04). We identified 15 themes summarizing veterans' perceived barriers to VA use. CONCLUSION: Persistent actual and perceived barriers prevent some veterans from using VA services. The VA can better understand and address these issues through community-academic partnerships with veterans' organizations.

A Multielement Community Medicine Curriculum for the Family Medicine Clerkship.

INTRODUCTION: Many medical schools provide opportunities for students to learn about health disparities, social determinants of health, and the role physicians play in promoting health equity. The family medicine clerkship exposes medical students to these topics to help them understand the health status of patients. A multielement curriculum was incorporated into the core family medicine clerkship to provide the full medical school class exposure to community medicine and was updated in 2014 to increase the emphasis on clinical correlation of community medicine concepts. METHODS: This curriculum consists of a community medicine orientation, a community-based experience, a didactic session, and a reflection paper. The orientation serves as an introduction to the course, and the community-based experience provides hands-on understanding of community medicine. The didactic session encompasses a half-day session of preparatory work, team-based exercises, an interactive lecture, individual reflection, and a seminar-style discussion. Students share their experience with the curriculum in their reflection papers. RESULTS: Since 2014, 286 have students completed the updated curriculum, and reactions have been highly favorable. Most students have agreed or strongly agreed that the sessions met the learning objectives. Student preparation was demonstrated by individual quiz scores (average: 87%, n = 93). Learning and behavior change were evaluated using structured rubric scoring of reflection papers (average: 94%, n = 67). DISCUSSION: Overall, this community medicine curriculum includes a variety of learning experiences for medical students to gain knowledge, attitudes, and skills that are applicable to care in all specialties and may be easily adapted to use in other settings.