Longitudinal Analysis of Persistent Postconcussion Symptoms, Probable TBI, and Intimate Partner Violence Perpetration Among Veterans.

OBJECTIVE: To determine veterans' intimate partner violence (IPV) perpetration following report of traumatic brain injury (TBI) and persistent postconcussion symptoms (PPCSs). SETTING: Five Department of Veterans Affairs (VA) medical centers. PARTICIPANTS: Veterans with nonmissing data on main measures, resulting in N = 1150 at baseline and N = 827 at follow-up. DESIGN: Prospective cohort study with secondary data analysis of self-reported TBI, PPCSs, and IPV perpetration, controlling for common predictors of IPV, including binge drinking, marijuana use, pain intensity, and probable posttraumatic stress disorder. MAIN MEASURES: VA TBI Screening Tool to assess for probable TBI and PPCSs; Conflict Tactics Scale-Revised (CTS-2S) to assess for IPV perpetration. RESULTS: Almost half (48%) of participants reported IPV perpetration at follow-up. Both probable TBI and higher PPCSs at baseline were associated with overall IPV perpetration and more frequent IPV perpetration at follow-up. Only PPCSs significantly predicted IPV perpetration after controlling for common predictors of IPV perpetration. Neither probably TBI nor PPCSs predicted frequency of IPV perpetration. CONCLUSION: When considered alongside common risk factors for IPV perpetration, PPCS was uniquely associated with the likelihood of IPV perpetration in this veteran sample. Given post-9/11 veterans' elevated risk for head injury, findings emphasize the distinctive value of PPCSs in understanding risk for IPV perpetration. We recommend increased assessment for PPCSs in clinical practice among veterans enrolled in VA care and highlight several important areas for future research and intervention development.

Understanding Gender Differences in Resilience Among Veterans: Trauma History and Social Ecology.

A social-ecological framework for resilience underscores the importance of conceptualizing individuals embedded within their context when evaluating a person's vulnerability and adaptation to stress. Despite a high level of trauma exposure, most veterans exhibit psychological resilience following a traumatic event. Interpersonal trauma is associated with poorer psychological outcomes than noninterpersonal trauma and is experienced more frequently across the lifespan by women as compared to men. In the present study, we examined gender differences in trauma exposure, resilience, and protective factors among veterans. Participants included 665 veterans who completed a baseline survey assessing traumatic events; 544 veterans (81.8%) completed a 1-year follow-up survey assessing resilience, combat exposure, deployment social support, deployment preparedness, and military sexual trauma (MST). Principal component analyses revealed the Traumatic Life Events Questionnaire categorized into four meaningful components: sexual abuse, interpersonal violence, stranger violence, and accidents/unexpected trauma. Women reported greater exposure to sexual abuse, d = 0.76; interpersonal violence, d = 0.31; and MST, Cramer's V = 0.54; men reported greater exposure to stranger violence, accidents/unexpected trauma, and combat exposure, ds = 0.24-0.55. Compared to women, men also reported greater social support during deployment, d = 0.46. Hierarchical linear regression indicated that men's resilience scores were higher than women's, ß = .10, p = .032, yet this association was no longer significant once we accounted for trauma type, ß = .07, p = .197. Results indicate that trauma type is central to resilience and suggest one must consider the social-ecological context that can promote or inhibit resilient processes.

Intimate partner violence among lesbian, gay, and bisexual veterans.

The present study describes intimate partner violence (IPV) perpetration and victimization alongside theoretically associated variables in a sample of lesbian, gay, and bisexual veterans. We conducted bivariate analyses (chi-square tests and independent t test) to examine whether the frequencies of IPV perpetration and victimization varied by demographic characteristics, military sexual trauma, alcohol use, and mental health symptoms. Out of the 69 lesbian, gay, and bisexual (LGB) veterans who answered the questions on IPV, 16 (23.2%) reported some form of IPV victimization in the past year, and 38 (55.1%) reported past-year perpetration. Among the 43 veterans who reported psychological IPV, roughly half (48.9%) reported bidirectional psychological IPV, 39.5% reported perpetration only, and 11.6% reported victimization only. LGB veterans who reported bidirectional psychological IPV in their relationships were younger and reported greater symptoms of posttraumatic stress disorder symptoms and depression. The results presented here call for universal screening of IPV perpetration and victimization to both accurately assess and ultimately intervene among all veterans. Inclusive interventions are needed for all genders and sexual orientations, specifically interventions that do not adhere to gendered assumptions of perpetrators and victims. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

The Role of Unit and Interpersonal Support in Military Sexual Trauma and Posttraumatic Stress Disorder Symptoms.

Military sexual trauma (MST) is strongly associated with posttraumatic stress disorder (PTSD). Among many potential factors explaining this association are unit and interpersonal support, which have been explored in few studies with veterans who have experienced MST. This project examines unit and interpersonal support as moderators and/or mediators of PTSD symptoms among post-9/11 Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn veterans who experienced MST. MST, unit support, and interpersonal support variables were collected at Time 1 (T1; N = 1,150, 51.4% women), and PTSD symptoms 1 year later at Time 2 (T2; N = 825; 52.3% women). Given gender differences in endorsed MST, models with the full sample (men and women) and women only were examined, while controlling for covariates related to PTSD, and a path model was examined among women veterans. Mediation was supported in the full model and women-only models, with the combination of both mediators demonstrating the strongest mediation effects (full-model: ß = .06, 95% confidence interval [CI] [0.03, 0.10], p < .001; women-only model: ß = .07, [0.03, 0.14], p = .002). Among the women-only model, MST was negatively associated with unit support (ß = -.23, [-0.33, -0.13], p < .001) and interpersonal support (ß = -.16, [-0.27, -0.06], p = .002) and both support types were negatively associated with PTSD symptoms (unit support: ß = -.13, [-0.24, -0.03], p = .014; interpersonal support: ß = -.25, [-0.35, -0.15], p < .001). Moderation was not supported in the full model nor in the women-only model. Experiencing MST is associated with receiving less unit and/or interpersonal support, which in turn is associated with greater PTSD symptoms. More work is needed to understand and improve the impact of unit and community responses to MST on service members who experience MST.

Understanding Veterans' intimate partner violence use and patterns of healthcare utilization.

OBJECTIVE: To understand the association between Veterans' healthcare utilization and intimate partner violence (IPV) use (i.e., perpetration) in order to (1) identify conditions comorbid with IPV use and (2) inform clinical settings to target for IPV use screening, intervention, and provider training. DATA SOURCES AND STUDY SETTING: We examined survey data from a national sample of 834 Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn (OEF/OIF/OND) Veterans. STUDY DESIGN: We assessed associations between past-year IPV use and medical treatment, health issues, and use of Veterans Health Administration (VA) and non-VA services using chi-square tests and logistic regression. DATA COLLECTION/EXTRACTION METHODS: Data were derived from the Department of Defense OEF/OIF/OND Roster. Surveys were sent to all women Veterans and a random sample of men from participating study sites. PRINCIPAL FINDINGS: Half (49%) of the Veterans who reported utilizing VA healthcare in the past year indicated using IPV. Q values using a 5% false discovery rate indicated that Veterans who used IPV were more likely than Veterans who did not use IPV to have received treatment for post-traumatic stress disorder (PTSD; 39% vs. 27%), chronic sleep problems (36% vs. 26%), anxiety or depression (44% vs. 36%), severe chronic pain (31% vs. 22%), and stomach or digestive disorders (24% vs. 16%). Veterans who used IPV were also more likely than Veterans who did not use IPV to have received medical treatment in the past year (86% vs. 80%), seen psychiatrists outside VA (39% vs. 20%), and have outpatient healthcare outside VA (49% vs. 41%). IPV use was not related to whether Veterans received care from VA or non-VA providers. CONCLUSIONS: Veterans' IPV use was related to greater utilization of services for mental health, chronic pain, and digestive issues. Future research should examine whether these are risk factors or consequences of IPV use.

Screening for Intimate Partner Violence Experience and Use in the Veterans Health Administration.

Importance: The practice of screening women for intimate partner violence (IPV) in health care settings has been a critical part of responding to this major public health problem. Yet, IPV prevention would be enhanced with detection efforts that extend beyond screening for IPV experiences to identifying those who use violence in relationships as well. Objective: To determine rates of IPV experiences and use (ie, among perpetrators of IPV) and factors associated with disclosures among adult patients seeking mental health services at the Veterans Health Administration. Design, Setting, and Participants: This cross-sectional study used electronic medical record data drawn from a quality improvement initiative at 5 Veterans Health Administration medical centers conducted between November 2021 and February 2022 to examine IPV disclosures following concurrent screening for IPV experience and use. Participants included patients engaged in mental health services. Data were analyzed in April and May 2023. Exposure: Mental health clinicians were trained to screen for IPV experience and use concurrently and instructed to screen all patients encountered through routine mental health care visits during a 3-month period. Main Outcomes and Measures: Outcomes of interest were past-year prevalence of IPV use and experience, sociodemographic characteristics, and clinical diagnoses among screened patients. Results: A total of 200 patients were offered IPV screening. Of 155 participants (mean [SD] age, 52.45 [15.65] years; 124 [80.0%] men) with completed screenings, 74 (47.7%) denied past-year IPV experience and use, 76 (49.0%) endorsed past-year IPV experience, and 72 (46.4%) endorsed past-year IPV use, including 67 participants (43.2%) who reported IPV experience and use concurrently; only 9 participants (5.8%) endorsed unidirectional IPV experiences and 5 participants (3.2%) endorsed unidirectional IPV use. Patients who reported past-year IPV experience and use were younger than those who denied IPV (experience: mean difference, -7.34 [95% CI, 2.51-12.17] years; use: mean difference, -7.20 [95% CI, 2.40-12.00] years). Patients with a posttraumatic stress disorder diagnosis were more likely to report IPV use (43 patients [59.7%]) than those without a posttraumatic stress disorder diagnosis (29 patients [40.3%]; odds ratio, 2.14; [95% CI, 1.12-4.06]). No other demographic characteristics or clinical diagnoses were associated with IPV use or experience. Conclusions and Relevance: In this cross-sectional study of IPV rates and associated factors, screening for IPV found high rates of both IPV experience and use among patients receiving mental health care. These findings highlight the benefit of screening for IPV experience and use concurrently across gender and age. Additionally, the associations found between PTSD and IPV use underscore the importance of strengthening and developing additional targeted treatment for IPV.

Evaluating an Enterprise-Wide Initiative to enhance healthcare coordination for rural women Veterans using the RE-AIM framework.

Introduction: The Veterans Health Administration (VA) Office of Rural Health (ORH) and Office of Women's Health Services (OWH) in FY21 launched a three-year Enterprise-Wide Initiative (EWI) to expand access to preventive care for rural, women Veterans. Through this program, women's health care coordinators (WHCC) were funded to coordinate mammography, cervical cancer screening and maternity care for women Veterans at selected VA facilities. We conducted a mixed-methods evaluation using the RE-AIM framework to assess the program implementation. Materials and methods: We collected quantitative data from the 14 program facilities on reach (i.e., Veterans served by the program), effectiveness (e.g., cancer screening compliance, communication), adoption, and maintenance of women's health care coordinators (WHCC) in FY2022. Implementation of the program was examined through semi-structured interviews with the facility WHCC funding initiator (e.g., the point of contact at facility who initiated the request for WHCC funding), WHCCs, and providers. Results: Reach. The number of women Veterans and rural women Veterans served by the WHCC program grew (by 50% and 117% respectively). The program demonstrated effectiveness as screening rates increased for cervical and breast cancer screening (+0.9% and +.01%, respectively). Also, maternity care coordination phone encounters with Veterans grew 36%. Adoption: All facilities implemented care coordinators by quarter two of FY22. Implementation. Qualitative findings revealed facilitators and barriers to successful program implementation and care coordination. Maintenance: The EWI facilitated the recruitment and retention of WHCCs at respective VA facilities over time. Implications: In rural areas, WHCCs can play a critical role in increasing Reach and effectiveness. The EWI demonstrated to be a successful care coordination model that can be feasibly Adopted, Implemented, and Maintained at rural VA facilities.

Coordinating women's preventive health care for rural veterans.

PURPOSE: As the number of women veterans receiving care from the Veterans Health Administration (VHA) continues to increase, so does the need to access gender-specific preventive health care services through the VHA. In rural areas, women veterans are the numeric minority, so many preventive screenings are performed outside of the VA by community providers. As the numbers of veterans utilizing both VHA and non-VHA providers for their preventive care continue to increase, so does the need to coordinate this care. This research examines the role of the Women Veterans' Care Coordinator (WVCC) at rural facilities and their perceptions of coordinating preventive care. METHODS: Between March and July 2019, semi-structured telephone interviews were conducted with WVCCs at 26 rural VA facilities. Each interview was digitally recorded and transcribed verbatim. Transcripts were loaded into Atlas.ti for further analysis. Once the codes were refined, the investigators coded the 26 interviews independently and conferred to achieve consensus on the underlying themes. FINDINGS: Five themes arose from the WVCC interviews: (1) Rural women veterans have varying needs of coordination; (2) Fragmented communication between the VA and non-VA care settings hinders effective coordination; (3) Difficulties in prioritizing rural care coordination; (4) Care coordination impacts patient care; and (5) WVCC recommendations to improve rural care coordination. CONCLUSIONS: The recent addition of WVCCs to rural facilities has expanded the VA's reach to veterans living in the most rural areas. As a result, many of these women are now receiving timely, quality, and coordinated health care.

Staff and Patient Perspectives on Bystander Intervention Training to Address Patient-Initiated Sexual Harassment in Veterans Affairs Healthcare Settings.

INTRODUCTION: One in four women veteran patients experience public harassment by men veterans at Veterans Affairs (VA) health care facilities. Bystander intervention training-teaching bystanders to identify harassment, assess appropriate responses, and safely intervene before, during, or after an event-is a popular strategy for addressing harassment in military and education settings. We explored staff and veteran patient perspectives on bystander intervention training to address harassment of women veterans in VA health care settings. METHODS: We conducted 24 staff interviews and 15 veteran patient discussion groups (eight men's groups and seven women's groups) at four VA Medical Centers. We analyzed transcripts using the constant comparative method. RESULTS: Participants expressed divergent views about bystander intervention training to address harassment of women veteran patients at VA. Most participants supported training staff in bystander intervention, but support for training patients was mixed. Participants identified potential benefits of bystander intervention, including staff and patient empowerment and improvements to organizational culture. They also identified potential concerns, including provocation of conflict between patients, lack of buy-in among the VA community, and difficulty in identifying intervention-appropriate situations. Finally, participants offered recommendations for tailoring training content and format to the VA context. CONCLUSIONS: Bystander intervention training has the potential to raise collective responsibility for addressing harassment of women in VA and other health care contexts. However, our results illustrate divergent stakeholder views that underscore the importance of engaging and educating stakeholders, securing buy-in, and tailoring bystander intervention programs to local contexts before implementation.

Evaluating Bystander Intervention Training to Address Patient Harassment at the Veterans Health Administration.

PURPOSE: One in four women veteran patients report experiencing sexual and gender harassment when attending the Veterans Health Administration (VA) for health care. Bystander intervention-training community members how to intervene when witnessing inappropriate behaviors-is a common approach for addressing harassment in school and military settings. We evaluated implementation of a VA harassment awareness and bystander intervention training that teaches health care staff how to identify and intervene in the harassment of women veteran patients. METHODS: Participants included 180 VA staff, including both providers and administrative staff from one VA state health care system, who participated in harassment training during the first year of implementation. Pretest and post-test evaluation surveys included questions on acceptability of training length and relevance, staff experiences with harassment, perceptions of the training, and four short-term attitudinal outcomes: awareness of harassment, barriers to intervening, self-efficacy for intervening, and intentions to intervene. RESULTS: At pretest, most staff reported witnessing harassment, yet fewer than one-half had intervened. By post-test, staff reported significantly decreased barriers to intervening and increased awareness, self-efficacy, and intentions to intervene. Belief that harassment is a problem increased from 42.4% to 75.0%. The majority of staff found the training relevant and appropriate in length. Staff felt the most useful aspects of the training were learning how to intervene, group discussion, effective facilitation, and information on harassment. CONCLUSIONS: We found that a bystander approach was acceptable to health care staff and efficacious on short-term outcomes. Bystander intervention may be a promising strategy to address harassment among patients in medical facilities.