Adopting the RE-AIM analytic framework for rural program evaluation: experiences from the Advance Care Planning via Group Visits (ACP-GV) national evaluation.

Introduction: To support rigorous evaluation across a national portfolio of grants, the United States Department of Veterans Affairs (VA) Office of Rural Health (ORH) adopted an analytic framework to guide their grantees' evaluation of initiatives that reach rural veterans and to standardize the reporting of outcomes and impacts. Advance Care Planning via Group Visits (ACP-GV), one of ORH's Enterprise-Wide Initiatives, also followed the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. ACP-GV is a national patient-centered intervention delivered in a large, veterans integrated healthcare system. This manuscript describes how RE-AIM was used to evaluate this national program and lessons learned from ORH's annual reporting feedback to ACP-GV on their use of the framework to describe evaluation impacts. Methods: We used patient, provider, and site-level administrative health care data from the VA Corporate Data Warehouse and national program management databases for federal fiscal years (FY) spanning October 1, 2018-September 30, 2023. Measures included cumulative and past FY metrics developed to assess program impacts. Results: RE-AIM constructs included the following cumulative and annual program evaluation results. ACP-GV reached 54,167 unique veterans, including 19,032 unique rural veterans between FY 2018 to FY 2023. During FY 2023, implementation adherence to the ACP-GV model was noted in 91.7% of program completers, with 55% of these completers reporting a knowledge increase and 14% reporting a substantial knowledge increase (effectiveness). As of FY 2023, 66 ACP-GV sites were active, and 1,556 VA staff were trained in the intervention (adoption). Of the 66 active sites in FY 2023, 27 were sites previously funded by ORH and continued to offer ACP-GV after the conclusion of three years of seed funding (maintenance). Discussion: Lessons learned developing RE-AIM metrics collaboratively with program developers, implementers, and evaluators allowed for a balance of clinical and scientific input in decision-making, while the ORH annual reporting feedback provided specificity and emphasis for including both cumulative, annual, and rural specific metrics. ACP-GV's use of RE-AIM metrics is a key step towards improving rural veteran health outcomes and describing real world program impacts.

Engaging stakeholders to retrospectively discern implementation strategies to support program evaluation: Proposed method and case study.

BACKGROUND: Availability of evidence-based practices (EBPs) is critical for improving health care outcomes, but diffusion can be challenging. Implementation activities increase the adoption of EBPs and support sustainability. However, when implementation activities are a part of quality improvement processes, evaluation of the time and cost associated with these activities is challenged by the need for a correct classification of these activities to a known taxonomy of implementation strategies by implementation actors. DESIGN: Observational study of a four-stage, stakeholder-engaged process for identifying implementation activities and estimating the associated costs. RESULTS: A national initiative in the Veterans Health Administration (VHA) to improve Advance Care Planning (ACP) via Group Visits (ACP-GV) for rural veterans identified 49 potential implementation activities. Evaluators translated and reduced these to 14 strategies used across three groups with the aid of implementation actors. Data were collected to determine the total implementation effort and applied cost estimates to estimate the budget impact of implementation for VHA. LIMITATIONS: Recall bias may influence the identification of potential implementation activities. CONCLUSIONS: This process improved understanding of the implementation effort and allowed estimation of ACP-GV 's budget impact. IMPLICATIONS: A four-stage, stakeholder-engaged methodology can be applied to other initiatives when a pragmatic evaluation of implementation efforts is needed.

Application of motivational interviewing to group: Teaching advance care planning via group visits for clinical professionals.

OBJECTIVE: Advance Care Planning (ACP) via Group Visits (ACP-GV) is an innovative patient-centered intervention used in the United States Department of Veterans Affairs (VA) healthcare system. The goal of ACP-GV is to spread ACP to veterans and caregivers in medically underserved rural areas. Veterans, caregivers and those they trust participate in a group led by clinicians in Veterans Health Administration healthcare and/or community-based settings. To learn how to facilitate ACP-GV, clinicians attend ACP-GV training. The training teaches the ACP-GV group model and the theoretical components of Motivational Interviewing (MI) (Rollnick & Miller, 1995), which are used to empower participants to have conversations about their healthcare values and preferences. Therefore, the aim is to describe the specific MI techniques utilized by group facilitators in the innovative ACP-GV intervention. DISCUSSION: We provide exemplars for how group facilitators apply the MI techniques to the group discussion with participants. Lastly, we provide a scripted case example of a coded MI-concordant session of ACP-GV delivered with veterans in a healthcare setting that can be used in future training and education for clinicians interested in facilitating ACP using a group modality. CONCLUSION: MI is a key aspect of delivering ACP-GV, a high-quality, patient-centered intervention for veterans, caregivers and those they trust.

Veteran Experiences With Suicide Ideation, Suicide Attempt, and Social Support in Safety Planning Within the Department of Veterans Affairs.

INTRODUCTION: This evaluation examined the role of safety plans, one of a host of clinical suicide prevention interventions available for veterans through the United States Department of Veterans Affairs' national network of health care facilities managed by the Veterans Health Administration (VHA). MATERIALS AND METHODS: Interviews were conducted with veterans who had experienced suicidal ideation or a suicide attempt since enrolling in the Department of Veterans Affairs health care system (N = 29). Topics included negative life experiences, triggers for suicidal ideation or a suicide attempt, ability to recall and utilize safety plans in crisis, safety plan elements found most and least useful, and improvements to safety planning. RESULTS: Eighteen (62.07%) of the veterans in the sample had attempted suicide. Drug use was by far the most triggering and overdose was the most negative life event to subsequent ideation or attempt. Although all at-risk veterans should have a safety plan, only 13 (44.38%) created a safety plan, whereas 15 (51.72%) could not recall ever creating a safety plan with their provider. Among those who did recall making a safety plan, identifying warning signs was the most remembered portion. The most useful safety plan elements were: recognizing warning signs, supportive people and distracting social settings, names and numbers of professionals, giving the veteran personal coping strategies, options for using the plan, and keeping their environment safe. For some veterans, safety plans were seen as insufficient, undesirable, not necessary, or lacking a guarantee. The suggested improvements included involving concerned significant others, specific actions to take in a crisis, and potential barriers and alternatives. CONCLUSIONS: Safety planning is a critical component in suicide prevention within VHA. However, future research is needed to ensure safety plans are accessible, implemented, and useful to veterans when in crisis.

Barriers and Facilitators to Dialectical Behavior Therapy Skills Groups in the Veterans Health Administration.

INTRODUCTION: Dialectical behavior therapy (DBT) is a multimodal evidence-based suicide prevention psychotherapy with barriers to full implementation. This study qualitatively examined barriers and facilitators to the DBT skills group treatment mode, which can be implemented as a stand-alone intervention. Using data from a national mixed-methods program evaluation of DBT in the Veterans Health Administration (VHA), this is the first article to examine barriers and facilitators to DBT skills groups implemented with a DBT consultation team or as a stand-alone intervention. MATERIALS AND METHODS: A subset of data from semi-structured telephone interviews of six clinicians and three administrators (n = 9 respondents) was analyzed to provide complementarity and expansion on prior quantitative findings. The data were coded using an iterative process based on content analysis and a codebook based on the Promoting Action on Research Implementation in Health Services framework. The study was approved by the institutional review board for the Palo Alto VA Health Care System. RESULTS: Barriers and facilitators were organized by Promoting Action on Research Implementation in Health Services domains of evidence, context, and facilitation. Results showed how reduced leadership support and low receptivity to providing DBT skills groups functioned as barriers and also identified a barrier not described earlier in the literature: the perception that this group could conflict with expanding access to care for more veterans. The results showed how leadership supported implementation, including by mapping clinic grids and supporting training, and also revealed how a supportive culture among providers facilitated division of labor between skills group providers, and how offering a treatment that filled a gap in services supported the group. At some sites, a provider with prior DBT experience was instrumental in starting DBT skills groups or developing ongoing training. CONCLUSIONS: Qualitatively analyzed barriers and facilitators to a group-delivered suicide prevention intervention, DBT skills groups, expanded on quantitative findings on the importance of leadership support, culture, and training as facilitators. Future work implementing DBT skills group as a stand-alone treatment will need to address the barrier of receptivity and perceived barriers about access to care.

Emergency Departments Treating Veterans for Suicide: Ensuring Quality Care for Veterans Outside of Department of Veterans Affairs Health Care Facilities.

INTRODUCTION: Veterans die by suicide at higher rates than nonveterans. Given that the emergency department is often the first point of entry to healthcare following a suicide attempt, it would be beneficial for community providers to have knowledge of the characteristics, medical issues, and effective treatments most often associated with those having served in the military to ensure guideline concordant and quality suicide care. This study aimed to identify assessment and referral practices of emergency departments at rural community hospitals related to care for suicidal veterans and explore the feasibility and acceptability of identifying veterans in need of postdischarge aftercare. METHODS: This qualitative exploratory study involved content analysis of semistructured interviews. Ten emergency clinicians from 5 rural Arkansas counties with high suicide rates were interviewed about their experiences working with suicidal patients within the emergency department and perceptions of assessment, management, and referral practices. RESULTS: Although most of the emergency departments had a process for assessing for suicide risk, emergency clinicians did not always feel confident in their knowledge of assessing and caring for suicidal patients. Military history was not included in assessment, treatment, or aftercare planning, nor were brief interventions such as safety planning or lethal means safety education provided. DISCUSSION: Best practices for suicide assessment and management of veterans exist; however, challenges specific to the emergency department regarding staff training and engaging the community to effectively link at-risk veterans to needed care hinder implementation. Veteran-inclusive assessment and intervention practices could enhance the quality of care provided in community emergency departments.

Characteristics and Context of Veterans Experiencing Serious Suicidal Ideation or Suicide Attempt by Firearm which led to Hospitalization.

OBJECTIVE: Suicide by former United States military service members is of great public health concern, and one area, veterans' suicide attempts involving firearms, is understudied. One group that has a unique perspective on this are veterans with a psychiatric admission following a firearm-related suicide crisis, such as making a suicide plan or a suicide rehearsal with a firearm within the preceding 72 hours. This study seeks to address this gap in the literature by describing the characteristics and context of non-fatal suicide events involving firearms among veterans. METHOD: This convergent parallel mixed-methods design study collected both quantitative and qualitative data from male veterans (N = 15) who were hospitalized due to a suicide attempt or serious ideation using a firearm. Veterans admitted to a Veterans Affairs Medical Center (VAMC) were interviewed and asked to complete a survey. Qualitative data on characteristics and context were analyzed using a thematic analysis. RESULTS: The fifteen male U.S. military veterans described their personal characteristics, such as their beliefs, family beliefs and structure, emotions, and employment status. Most participants were unemployed (n = 10; 67%), divorced (n = 7; 47%) or married (n = 5; 33%). Seven themes related to context emerged from qualitative interviews to include: combat trauma, non-combat trauma and negative life event(s), current and past suicide attempt(s), firearms, substance use, known deaths by suicide, and protective factors for suicide. CONCLUSION: Results suggest that engaging support networks and communities is essential when developing programs to promote identification of early warning signs and implementation of interventions or programs for reducing veteran suicide.

"Advancing" Advance Care Planning to Veterans in the Veterans Health Administration.

INTRODUCTION: The completion rate of Advance Directive (ADs) in the Veterans Health Administration (VHA) is unknown. There is substantial literature on the need for effective Advance Care Planning (ACP) that leads to an AD to ensure that health care preferences for patients are known. Advance Directive are essential to consider since ACP, which explains and plans Advance Directive, does not reach all individuals. Health inequities, such as those experienced in rural areas, continue to exist. While ACP may disproportionately affect rural-residing veterans and their providers, a VHA program was specifically designed to increase ACP engagement with rural veterans and to address several systemic barriers to ACP. MATERIALS AND METHODS: This descriptive analysis seeks to identify patient, provider, and geographic characteristics associated with higher rates of ACP participation in VHA. An observational examination of the profile of veterans and the types of ACP (e.g., individual or in groups) using administrative data for all beneficiaries receiving VHA health care services in federal fiscal year (FY) 2020 was conducted as part of a national program evaluation. The measures include patient-level data on demographics (e.g., race, ethnicity, gender), unique patient identifiers (e.g., name, social security number), geographic characteristics of patient's location (e.g., rurality defined as Rural-Urban Commuting Areas [RUCA]), VHA priority group; provider-level data (e.g., type of document definition, clinic stop codes, visit date used to verify Advance Care Planning via Group Visits [ACP-GV] attendance; data not shown), and electronic health record note titles that indicated the presence of ACP in VHA (e.g., "Advance Directive [AD] Discussion" note title, "ACP-GV CHAR 4 code"). Pearson's chi-square statistics were used for between-group comparisons based on a two-sided test with a significance level of 0.05. RESULTS: The overall rate of AD discussions among unique VHA users in FY2020 was 5.2% (95% CI: 5.2%-5.2%) and for Advance Care Planning via Group Visits, which targets rural veterans using groups, it was 1.8% (95% CI: 1.8%-1.9%). Advance Directive discussions in VHA are more successful at reaching middle age (M = 64; SD = 16), African Americans, males, veterans living in urban areas, and veterans with a VA disability (Priority Group 1-4). Advance Care Planning delivered in groups is reaching slightly younger veterans under the age of 75 years (M = 62; SD = 15), African Americans, females, disabled veterans (e.g., Priority Group 1-4), and more veterans residing in rural communities compared to the national population of VHA users. CONCLUSION: Advance Directive discussion rates are low across VHA, yet intentional efforts with ACP via group visits are reaching veterans who are considered underserved owing to residing in rural areas. Advance Care Planning needs to be a well-informed clinical priority for VHA to engage with the entire veteran population and to support the completion of ADs.

Association of Medication-Assisted Treatment and Age With Treatment Completion Among Veterans Seeking Non-VA Treatment for Opioid use Disorder at Non-Veterans Health Administration Facilities.

BACKGROUND: Medication-assisted treatment has been shown to be effective in treating opioid use disorder among both older adults and veterans of U.S. Armed Forces. However, limited evidence exists on MAT's differential effect on treatment completion across age groups. This study aims to ascertain the role of MAT and age in treatment completion among veterans seeking treatment in non-Department of Veterans Affairs healthcare facilities for opioid use disorder. METHODS: We used the Treatment Episode Data Set-Discharges (TEDS-D; 2006-2017) to examine trends in treatment and MAT usage over time and TEDS-2017 to determine the role of age and MAT in treatment completion. We examined a subset of those who self-identified as veterans and who sought treatment for an opioid use disorder. RESULTS: Veterans presented in treatment more often as heroin users than prescription opioid users, and older veterans were more likely to get MAT than younger veterans. We found that before propensity score matching, MAT initially appeared to be associated with a lower likelihood of treatment completion in inpatient ($\beta $ = -1.47, 95% CI -1.56 to -1.39) and outpatient ($\beta $ = -1.40, 95% CI -2.21 to -0.58) settings, and age (50+ years) appeared to mediate the effect of MAT on treatment completion ($\beta $ = -0.54, 95% CI -0.87 to -0.21). After matching, older veterans were more likely to complete substance use disorder treatment ($\beta $ = 0.21, 95% CI 0.01-0.42), while age no longer mediated the effect of MAT, and MAT had a significant positive impact on treatment completion in detox settings ($\beta $ = 1.36, 95% CI 1.15-1.50) and inpatient settings ($\beta $ = 1.54, 95% CI 1.37 -1.71). CONCLUSION: The results show that age plays an important role in outpatient treatment completion, while MAT plays an important role in inpatient treatment completion. Implications for veterans are discussed.

Work-Family Conflict, Depression, and Burnout Among Jail Correctional Officers: A 1-Year Prospective Study.

BACKGROUND: Correctional officers (COs) experience elevated rates of mental and physical ill-health as compared with other general industry and public safety occupations. The purpose of this study was to investigate demographic, mental health, job tenure, and work-family characteristics and their prospective association to burnout within and between jail officers during one year of new employment. METHODS: In 2016, newly hired jail officers (N = 144) completed self-reported surveys across four time points in a one-year prospective study at a Midwestern United States urban jail. Linear mixed-effects and growth modeling examined how work-family conflict (W-FC) and depressive symptoms relate to perceptions of burnout over time. RESULTS: Jail officer burnout increased and was related to rises in W-FC and depression symptoms. Within-person variance for W-FC (B pooled  = .52, p < .001) and depression symptoms (B pooled  = .06, p < .01) were significant predictors of burnout. Less time on the job remained a significant predictor of burnout across all analyses (B pooled  = .03, p < .001). CONCLUSIONS: Results from this study indicate that burnout increased during the first year of new employment; and increased W-FC, higher depression, and brief tenure were associated with burnout among jail COs. Future study of correctional workplace health is needed to identify tailored, multilevel interventions that address burnout and W-FC prevention and early intervention among COs.

Consensus on strategies for implementing high priority mental health care practices within the US Department of Veterans Affairs.

Background: Identifying feasible and effective implementation strategies remains a significant challenge. At present, there is a gap between the number of strategies prospectively included in implementation trials, typically four or fewer, and the number of strategies utilized retrospectively, often 20 or more. This gap points to the need for developing a better understanding of the range of implementation strategies that should be considered in implementation science and practice. Methods: This study elicited expert recommendations to identify which of 73 discrete implementation strategies were considered essential for implementing three mental health care high priority practices (HPPs) in the US Department of Veterans Affairs: depression outcome monitoring in primary care mental health (n = 20), prolonged exposure therapy for treating posttraumatic stress disorder (n = 22), and metabolic safety monitoring for patients taking antipsychotic medications (n = 20). Participants had expertise in implementation science, the specific HPP, or both. A highly structured recommendation process was used to obtain recommendations for each HPP. Results: Majority consensus was identified for 26 or more strategies as absolutely essential; 53 or more strategies were identified as either likely essential or absolutely essential across the three HPPs. Conclusions: The large number of strategies identified as essential starkly contrasts with existing research that largely focuses on application of single strategies to support implementation. Systematic investigation and documentation of multi-strategy implementation initiatives is needed. Plain Language Summary: Most implementation studies focus on the impact of a relatively small number of discrete implementation strategies on the uptake of a practice. However, studies that systematically survey providers find that dozens or more discrete implementation strategies can be identified in the context of the implementation initiative. This study engaged experts in implementation science and clinical practice in a structured recommendation process to identify which of the 73 Expert Recommendations for Implementing Change (ERIC) implementation strategies were considered absolutely essential, likely essential, likely inessential, and absolutely inessential for each of the three distinct mental health care practices: depression outcome monitoring in primary care, prolonged exposure therapy for posttraumatic stress disorder, and metabolic safety monitoring for patients taking antipsychotic medications. The results highlight that experts consider a large number of strategies as absolutely or likely essential for supporting the implementation of mental health care practices. For example, 26 strategies were identified as absolutely essential for all three mental health care practices. Another 27 strategies were identified as either absolutely or likely essential across all three practices. This study points to the need for future studies to document the decision-making process an initiative undergoes to identify which strategies to include and exclude in an implementation effort. In particular, a structured approach to this documentation may be necessary to identify strategies that may be endogenous to a care setting and that may not be otherwise be identified as being "deliberately" used to support a practice or intervention.

Evaluation of the national implementation of the VA Diffusion of Excellence Initiative on Advance Care Planning via Group Visits: protocol for a quality improvement evaluation.

BACKGROUND: Traditionally, system leaders, service line managers, researchers, and program evaluators hire specifically dedicated implementation staff to ensure that a healthcare quality improvement effort can "go to scale." However, little is known about the impact of hiring dedicated staff and whether funded positions, amid a host of other delivered implementation strategies, are the main difference among sites with and without funding used to execute the program, on implementation effectiveness and cost outcomes. METHODS/DESIGN: In this mixed methods program evaluation, we will determine the impact of funding staff positions to implement, sustain, and spread a program, Advance Care Planning (ACP) via Group Visits (ACP-GV), nationally across the entire United States Department of Veterans Affairs (VA) healthcare system. In ACP-GV, veterans, their families, and trained clinical staff with expertise in ACP meet in a group setting to engage in discussions about ACP and the benefits to veterans and their trusted others of having an advance directive (AD) in place. To determine the impact of the ACP-GV National Program, we will use a propensity score-matched control design to compare ACP-GV and non-ACP-GV sites on the proportion of ACP discussions in VHA facilities. To account for variation in funding status, we will document and compare funded and unfunded sites on the effectiveness of implementation strategies (individual and combinations) used by sites in the National Program on ACP discussion and AD completion rates across the VHA. In order to determine the fiscal impact of the National Program and to help inform future dissemination across VHA, we will use a budget impact analysis. Finally, we will purposively select, recruit, and interview key stakeholders, who are clinicians and clinical managers in the VHA who offer ACP discussions to veterans, to identify the characteristics of high-performing (e.g., high rates or sustainers) and innovative sites (e.g., unique local program design or implementation of ACP) to inform sustainability and further spread. DISCUSSION: As an observational evaluation, this protocol will contribute to our understanding of implementation science and practice by examining the natural variation in implementation and spread of ACP-GV with or without funded staff positions.

Collective action among US veterans: Understanding the importance of self-efficacy, collective efficacy, and social support.

The purpose of this study was to examine the relationship between collective action, collective efficacy, self-efficacy, and social support among US veterans who formally volunteered in their communities upon their return from military service. The participants were 323 post-9/11/01-era veterans who completed a national nonprofit administered civic service program. Results from the structural equation model indicate that appraisal social support is negatively, directly associated with collective action, while belonging social support is positively, directly associated with collective action. In addition, appraisal social support is positively, indirectly associated with collective action via self-efficacy and collective efficacy. About 44% of the relationship between self-efficacy and collective action is associated via collective efficacy. The model accounts 19.9% of the variance in self-efficacy, 16.5% of the variance in collective efficacy, and 23.7% of the variance in collective action. The role of social support in the model provides additional evidence for the importance of strong social ties in facilitating collective action as veterans gather to volunteer in programs across the country. Results have implications for how national, nonprofit, and community volunteering programs may want to engage veterans and community members in collective action efforts.

Total Worker Health® Needs Assessment to Identify Workplace Mental Health Interventions in Rural and Urban Jails.

IMPORTANCE: Jail officers are an underserved population of public safety workers at high risk for developing chronic mental health conditions. OBJECTIVE: In response to national calls for the examination of stressors related to the unique work contexts of correctional facilities, we implemented a pilot study informed by the Total Worker Health® (TWH) strategy at two urban and two rural jails. DESIGN: Participatory teams guided areas of interest for a mixed-data needs assessment, including surveys with 320 jail officers to inform focus groups (N = 40). SETTING: Urban and rural jails in the midwestern United States. PARTICIPANTS: Jail correctional officers and sheriff's deputies employed at participating jails. MEASURES: We measured mental health characteristics using the Patient-Reported Outcomes Measurement Information System Global Mental Health scale, the Center for Epidemiologic Studies Depression scale, and the two-item Posttraumatic Stress Disorder Checklist. Constructs to identify workplace characteristics included emotional support, work-family conflict, dangerousness, health climate, organizational operations, effectiveness of training, quality of supervision, and organizational fairness. RESULTS: On the basis of general population estimates, we found that jail officers were at higher risk for mental health disorders, including depression and posttraumatic stress disorder. Jail officers identified workplace health interventions to address individual-, interpersonal-, institutional-, and community-level needs. CONCLUSION: Implementation of a TWH needs assessment in urban and rural jails to identify evidence-informed, multilevel interventions was found to be feasible. Using this assessment, we identified specific workplace health protection and promotion solutions. WHAT THIS ARTICLE ADDS: Results from this study support the profession's vision to influence policies, environments, and systems through collaborative work. This TWH study has implications for practice and research by addressing mental health needs among jail officers and by providing practical applications to create evidence-informed, tailored interventions to promote workplace health in rural and urban jails.

Posttraumatic Stress Disorder and Job Burnout Among Jail Officers.

OBJECTIVE: The aim of this study was to explore posttraumatic stress disorder (PTSD) symptom prevalence and health characteristics among jail correctional officers, a generally understudied population of public safety workers. METHOD: A Conservation of Resources (COR)-inspired framework explored relationships to PTSD symptoms among jail officers (N = 320) employed in Midwest US jails. RESULTS: More than half (53.4%) of jail officers screened positively for PTSD. Hierarchical regression analysis indicates that burnout was a significant predictor of symptoms of PTSD (B = 0.25, P < 0.001). Self-efficacy (B = -0.42, P < 0.01), emotional labor (B = 0.20, P < 0.01), and an anxiety- or depression-related diagnosis (B = 0.92, P < 0.001) remained significant predictors of PTSD-related symptoms in the final step. CONCLUSIONS: Our findings highlight the potentially high prevalence and impact of PTSD among jail officers, and offer implications for public safety workplace health interventions.

The health equity implementation framework: proposal and preliminary study of hepatitis C virus treatment.

BACKGROUND: Researchers could benefit from methodological advancements to advance uptake of new treatments while also reducing healthcare disparities. A comprehensive determinants framework for healthcare disparity implementation challenges is essential to accurately understand an implementation problem and select implementation strategies. METHODS: We integrated and modified two conceptual frameworks-one from implementation science and one from healthcare disparities research to develop the Health Equity Implementation Framework. We applied the Health Equity Implementation Framework to a historical healthcare disparity challenge-hepatitis C virus (HCV) and its treatment among Black patients seeking care in the US Department of Veterans Affairs (VA). A specific implementation assessment at the patient level was needed to understand any barriers to increasing uptake of HCV treatment, independent of cost. We conducted a preliminary study to assess how feasible it was for researchers to use the Health Equity Implementation Framework. We applied the framework to design the qualitative interview guide and interpret results. Using quantitative data to screen potential participants, this preliminary study consisted of semi-structured interviews with a purposively selected sample of Black, rural-dwelling, older adult VA patients (N = 12), living with HCV, from VA medical clinics in the Southern part of the USA. RESULTS: The Health Equity Implementation Framework was feasible for implementation researchers. Barriers and facilitators were identified at all levels including the patient, provider (recipients), patient-provider interaction (clinical encounter), characteristics of treatment (innovation), and healthcare system (inner and outer context). Some barriers reflected general implementation issues (e.g., poor care coordination after testing positive for HCV). Other barriers were related to healthcare disparities and likely unique to racial minority patients (e.g., testimonials from Black peers about racial discrimination at VA). We identified several facilitators, including patient enthusiasm to obtain treatment because of its high cure rates, and VA clinics that offset HCV stigma by protecting patient confidentiality. CONCLUSION: The Health Equity Implementation Framework showcases one way to modify an implementation framework to better assess health equity determinants as well. Researchers may be able to optimize the scientific yield of research inquiries by identifying and addressing factors that promote or impede implementation of novel treatments in addition to eliminating healthcare disparities.

Civic Service as an Intervention to Promote Psychosocial Health and Implications for Mental Health in Post-9/11/01 Era Women Veterans.

Background: Women veterans experience significant morbidity with poorer health and mental health outcomes relative to nonveteran counterparts. Little is known about how to best promote health and well-being among reintegrating female veterans. Civic service has been shown to improve mental health in civilians, but its impact on female veterans is unknown. This study characterizes the physical and mental health and psychosocial functioning of female veterans and evaluates changes in these domains following completion of an intensive civic service program. Materials and Methods: Data were obtained from an observational, pre-post cohort study of post-9/11/01 era veterans who completed a 6-month, 20-hour per week civic service program. Of the 346 participants, 107 were women. Participants completed online pre- and post-program surveys. Nine measures of health, mental health, and psychosocial functioning were analyzed. Results: Before starting the program, 47% of women screened positive for a probable diagnosis of post-traumatic stress disorder (PTSD), 24% for depression, and 51% reported seeking assistance for mental health problems. Pre-post change scores indicated significant improvements on nine measures of health, mental health, and psychosocial functioning (p < 0.05). Perceived self-efficacy change scores predicted PTSD change scores, F(1, 93) = 8.00, p < 0.05. Seeking professional assistance for mental health problems and social isolation and loneliness change scores predicted depression change scores, F(2, 95) = 15.618, p < 0.05, explaining 23% of the variance. Conclusions: Civic service has the potential to promote and support the maintenance of psychosocial well-being for returning post-9/11/01 era women veterans with symptoms of PTSD or depression.

Perceived family impact of volunteering among reintegrating Post-9/11 veterans.

Family issues are common among returned Post-9/11 veterans. Traumatic brain injury (TBI), posttraumatic stress disorder (PTSD), and depression are each independently related to divorce while community ties and social support are protective factors for the family during reintegration. Evidence from elders on the benefits of one intervention, community volunteering, may indicate "spillover effects" of these benefits into the family. Few measures exist to assess the impact of military veteran volunteering on the family. We report: (1) an adaption of a benefits measure from elders to veterans, (2) its preliminary reliability and validity, and (3) differences among subgroups. Reintegrating Post-9/11 veterans (N = 346) who completed a 6-month, stipended volunteer program were surveyed. Perceived impact of volunteering on the family was assessed after completion of the program using an 11-item self-report measure. Rank-based nonparametric tests were used to detect significant differences among subgroups. Preliminary findings support the scale's adaptation to veterans, internal consistency, and construct validity. At least one perceived family impact indicator differed significantly (p < .05) between subgroups based on demographic and psychological factors. Veterans in this civic service program perceived that their volunteering may have impacted their families.