Improving care for veterans' environmental exposure concerns: applications of the consolidated framework for implementation research in program evaluation.

BACKGROUND: Healthcare systems, like the US Department of Veterans Affairs (VA), need policies and procedures for delivering care to special populations including those with environmental exposure concerns. Despite being common and pervasive, especially among Veterans, environmental exposures are largely overlooked by healthcare providers. To successfully implement care for Veterans with military environmental exposure concerns, an understanding of contextual factors impeding care on the provider (e.g., knowledge and beliefs) and organizational (e.g., leadership's priorities) level is needed. Our goal was to conduct an operational needs assessment of providers to examine provider educational needs regarding Veterans' military environmental exposure concerns. METHODS: In 2020, we surveyed 2,775 VA medical and behavioral health providers. Our cross-sectional assessment was informed by the Consolidated Framework for Implementation Research (CFIR) and assessed barriers and facilitators to the uptake and application of knowledge regarding interdisciplinary care for environmental exposure concerns. The web-based survey was emailed to providers across the United States representing a variety of disciplines and practice settings to reflect the interdisciplinary approach to care for environmental exposures. We used bivariate statistics to investigate the intervention setting, inner setting, and individual characteristics of providers regarding care for environmental exposure concerns. RESULTS: Approximately one-third of VA medical and behavioral health clinicians report low to no knowledge of environmental exposure concerns. We find 88% of medical and 91% of behavioral health providers report they are ready to learn more about environmental exposures. Half of medical and behavioral health providers report they have access to information on environmental exposures and less than half report care for environmental exposures is a priority where they practice. CONCLUSIONS: Our findings suggest interdisciplinary providers' knowledge of and discussion with Veterans about environmental exposures may be influenced by contextual factors at the organizational level. Considering individual-level factors and organizational culture is important to consider when supporting care for environmental exposures. Since this needs assessment, VA established targeted programs to improve care related to military environmental exposures in response to legislation; future exploration of these same variables or contextual factors is warranted.

'She thought the same way I that I thought:' a qualitative study of patient-provider concordance among Gulf War Veterans with Gulf War Illness.

Objective: Medically unexplained symptoms (MUS), such as chronic fatigue syndrome, irritable bowel syndrome, and Gulf War Illness (GWI), are difficult to treat. Concordance-shared understanding between patient and provider about illness causes, course, and treatment-is an essential component of high-quality care for people with MUS. This qualitative paper focuses on the experiences of United States military Veterans living with GWI who have endured unique healthcare challenges. Methods & Measures: Qualitative interviews were conducted with 31 Veterans with GWI to explore factors that contribute to and detract from concordance with their Veteran Affairs (VA) healthcare providers. In addition to being seen by VA primary care, over half of participants also sought care at a War Related Illness and Injury Study Center, which specializes in post-deployment health. Deductive and inductive codes were used to organize the data, and themes were identified through iterative review of coded data. Results: Major themes associated with patient-provider concordance included validation of illness experiences, perceived provider expertise in GWI/MUS, and trust in providers. Invalidation, low provider expertise, and distrust detracted from concordance. Conclusion: These findings suggest providers can foster concordance with MUS patients by legitimizing patients' experiences, communicating knowledge about MUS, and establishing trust.

Exploring the acceptability of behavioral interventions for veterans with persistent "medically unexplained" physical symptoms.

OBJECTIVE: This study evaluated the factors that led to enrollment in, and satisfaction with, behavioral interventions for Veterans living with Gulf War Illness (GWI). METHODS: One-on-one interviews were conducted pre- and post-intervention with participants randomized to receive either telephone delivered problem-solving treatment (n = 51) or health education (N = 49). A total of 99 Veterans were interviewed pre-intervention and 60 post-intervention. Qualitative data were thematically coded and similarities in themes across the two interventions were examined. RESULTS: Before the study began, participants reported desiring to learn new information about their GWI, learn symptom-management strategies, and support improvements to care for other patients with GWI. After the intervention, Veterans felt positively about both interventions because they built strong therapeutic relationships with providers, their experiences were validated by providers, and they were provided GWI information and symptom-management strategies. Results also suggested that interventions do not have to be designed to meet all of the needs held by patients to be acceptable. A minority of participants described that they did not benefit from the interventions. CONCLUSION: The results suggest that satisfaction with behavioral interventions for GWI is driven by a strong therapeutic relationship, validating patient's experiences with GWI, and the intervention meeting some of the patient's needs, particularly increasing knowledge of GWI and improving symptom management.

Effect of Problem-solving Treatment on Self-reported Disability Among Veterans With Gulf War Illness: A Randomized Clinical Trial.

Importance: Few evidence-based treatments are available for Gulf War illness (GWI). Behavioral treatments that target factors known to maintain the disability from GWI, such as problem-solving impairment, may be beneficial. Problem-solving treatment (PST) targets problem-solving impairment and is an evidence-based treatment for other conditions. Objective: To examine the efficacy of PST to reduce disability, problem-solving impairment, and physical symptoms in GWI. Design, Setting, and Participants: This multicenter randomized clinical trial conducted in the US Department of Veterans Affairs compared PST with health education in a volunteer sample of 511 Gulf War veterans with GWI and disability (January 1, 2015, to September 1, 2019); outcomes were assessed at 12 weeks and 6 months. Statistical analysis was conducted between January 1, 2019, and December 31, 2020. Interventions: Problem-solving treatment taught skills to improve problem-solving. Health education provided didactic health information. Both were delivered by telephone weekly for 12 weeks. Main Outcomes and Measures: The primary outcome was reduction from baseline to 12 weeks in self-report of disability (World Health Organization Disability Assessment Schedule). Secondary outcomes were reductions in self-report of problem-solving impairment and objective problem-solving. Exploratory outcomes were reductions in pain, pain disability, and fatigue. Results: A total of 268 veterans (mean [SD] age, 52.9 [7.3] years; 88.4% male; 66.8% White) were randomized to PST (n = 135) or health education (n = 133). Most participants completed all 12 sessions of PST (114 of 135 [84.4%]) and health education (120 of 133 [90.2%]). No difference was found between groups in reductions in disability at the end of treatment. Results suggested that PST reduced problem-solving impairment (moderate effect, 0.42; P = .01) and disability at 6 months (moderate effect, 0.39; P = .06) compared with health education. Conclusions and Relevance: In this randomized clinical trial of the efficacy of PST for GWI, no difference was found between groups in reduction in disability at 12 weeks. Problem-solving treatment had high adherence and reduced problem-solving impairment and potentially reduced disability at 6 months compared with health education. These findings should be confirmed in future studies. Trial Registration: ClinicalTrials.gov Identifier: NCT02161133.

Knowledge gaps and educational needs of Veterans Affairs healthcare providers regarding COVID-19 at the start of the pandemic.

This study describes Veterans Affairs providers' perceived knowledge gaps for addressing COVID-19 concerns among Veterans generally and specifically among Veterans with a history of military exposures. A needs assessment was conducted through an online survey of 2,818 medical and behavioral health care providers. Results highlight the importance of ongoing education, even in topics for which providers endorsed adequate knowledge (eg, handwashing). Results also accentuated the need for educating providers about effectively communicating with patients regarding concerning medical topics when scientific data is scarce. Implications are discussed.

Healthcare providers' perceived learning needs and barriers to providing care for chronic multisymptom illness and environmental exposure concerns.

OBJECTIVE: Patient provider encounters for chronic multisympom illness (CMI) and/or environmental exposures are difficult often resulting in Veterans and providers having high levels of dissatisfaction. Patients attribute these difficulties to providers lacking knowledge about these health concerns. It is not known whether providers perceive themselves as lacking expertise in CMI and environmental exposure concerns. METHODS: This needs assessment used a descriptive online survey design. A total of 3632 VA healthcare providers across disciplines were surveyed. RESULTS: Healthcare providers reported speaking with Veterans about CMI and environmental exposures despite feeling they have minimal to no knowledge of these topics. At the same time, only half of the providers had taken an available training on CMI or environmental exposure within the last year. CONCLUSION: Healthcare providers recognize a knowledge gap regarding CMI and environmental exposures, despite this, there is low uptake of provider education on these topics. PRACTICE IMPLICATIONS: A better understanding of barriers to uptake of training on CMI and environmental exposures is needed to increase engagement with these important trainings.

"Because the country, it seems though, has turned their back on me": Experiences of institutional betrayal among veterans living with Gulf War Illness.

People living with medically unexplained symptoms (MUS) often have poor quality of life and health outcomes. Many struggle to engage with and trust in healthcare systems. This qualitative study examined how experiences with institutions influence perceptions of medical care for MUS by applying the theoretical framework of institutional betrayal to narratives of U.S. military Veterans living with Gulf War Illness (GWI). Institutional betrayal refers to situations in which the institutions people depend upon for safety and well-being cause them harm. Experiences of institutional betrayal both during active military service and when first seeking treatment appeared to shape perceptions of healthcare in this sample. Veterans expressed the belief that the military failed to protect them from environmental exposures. Veterans' concerns regarding subsequent quality of healthcare were intrinsically linked to a belief that, despite official documentation to the contrary, the predominant paradigm of both the U.S. Department of Defense and the U.S. Department of Veterans Affairs (VA) is that GWI does not exist. Veterans reported that providers are not adequately trained on treatment of GWI and do not believe Veterans' descriptions of their illness. Veterans reported taking up self-advocacy, doing their own research on their condition, and resigning themselves to decrease engagement with VA healthcare or seek non-VA care. The study's findings suggest institutional level factors have a profound impact on perceptions of care and the patient-provider relationship. Future research and policy aimed at improving healthcare for people living with MUS should consider the concept of institutional betrayal.

Rapid review of virus risk communication interventions: Directions for COVID-19.

OBJECTIVE: In response to COVID-19, we conducted a rapid review of risk communication interventions to mitigate risk from viruses to determine if such interventions are efficacious. METHODS: We searched for risk communication interventions in four databases: Medline, PsycInfo, the ProQuest Coronavirus Research Database, and CENTRAL. The search produced 1572 articles. Thirty-one articles were included in the final review. RESULTS: Results showed risk communication interventions can produce cognitive and behavior changes around viruses. Results were more consistently positive for interventions focused on HIV/AIDS as compared to influenza. There was no consistent best intervention approach when comparing peer health, audio/visual, and intensive multi-media interventions. Tailoring risk communication toward a target population, in comparison to not tailoring, was related to better outcomes. CONCLUSION: The results suggest that risk communication interventions can be efficacious at reducing risk from viruses. They also highlight the complexity of risk communication interventions. Additional research is needed to understand the mechanisms that lead risk communication to reduce risk from viruses. PRACTICAL VALUE: Results support risk communication interventions to reduce risk from viruses.

Helpful ways providers can communicate about persistent medically unexplained physical symptoms.

BACKGROUND: Communication between patients and providers about persistent "medically unexplained" physical symptoms (MUS) is characterized by discordance. While the difficulties are well documented, few studies have examined effective communication. We sought to determine what veterans with Gulf War Illness (GWI) perceive as the most helpful communication from their providers. Veterans with GWI, a type of MUS, have historically had complex relationships with medical providers. Determining effective communication for patients with particularly complex relationships may help identify the most critical communication elements for all patients with MUS. METHODS: Two hundred and-ten veterans with GWI were asked, in a written questionnaire, what was the most useful thing a medical provider had told them about their GWI. Responses were coded into three categories with 10 codes. RESULTS: The most prevalent helpful communication reported by patients was when the provider offered acknowledgement and validation (N = 70). Specific recommendations for managing GWI or its symptoms (N = 48) were also commonly reported to be helpful. In contrast, about a third of the responses indicated that nothing about the communication was helpful (N = 63). There were not differences in severity of symptoms, disability or healthcare utilization between patients who found acknowledgement and validation, specific recommendations or nothing helpful. CONCLUSIONS: Previous research has documented the discord between patients and providers regarding MUS. This study suggests that most patients are able to identify something helpful a provider has said, particularly acknowledgement and validation and specific treatment recommendations. The findings also highlight missed communication opportunities with a third of patients not finding anything helpful.

Dissemination and implementation of an educational tool for veterans on complementary and alternative medicine: a case study.

BACKGROUND: We developed and disseminated an educational DVD to introduce U.S. Veterans to independently-practiced complementary and alternative medicine (CAM) techniques and encourage CAM experimentation. The project's goal was to determine optimal dissemination methods to facilitate implementation within the Veteran's Health Administration. METHODS: In the first phase, the DVD was disseminated using four methods: passive, provider-mediated, active, and peer-mediated. In the second, implementation phase, "champion" providers who supported CAM integrated dissemination into clinical practice. Qualitative data came from Veteran focus groups and semi-structured provider interviews. Data from both phases was triangulated to identify common themes. RESULTS: Effective dissemination requires engaging patients. Providers who most successfully integrated the DVD into practice already had CAM knowledge, and worked in settings where CAM was accepted clinical practice, or with leadership or infrastructure that supported a culture of CAM use. Institutional buy-in allowed for provider networking and effective implementation of the tool. Providers were given autonomy to determine the most appropriate dissemination strategies, which increased enthusiasm and use. CONCLUSIONS: Many of the lessons learned from this project can be applied to dissemination of any new educational tool within a healthcare setting. Results reiterate the importance of utilizing best practices for introducing educational tools within the healthcare context and the need for thoughtful, multi-faceted dissemination strategies.

Approaches for describing and communicating overall uncertainty in toxicity characterizations: U.S. Environmental Protection Agency's Integrated Risk Information System (IRIS) as a case study.

Single point estimates of human health hazard/toxicity values such as a reference dose (RfD) are generally used in chemical hazard and risk assessment programs for assessing potential risks associated with site- or use-specific exposures. The resulting point estimates are often used by risk managers for regulatory decision-making, including standard setting, determination of emission controls, and mitigation of exposures to chemical substances. Risk managers, as well as stakeholders (interested and affected parties), often have limited information regarding assumptions and uncertainty factors in numerical estimates of both hazards and risks. Further, the use of different approaches for addressing uncertainty, which vary in transparency, can lead to a lack of confidence in the scientific underpinning of regulatory decision-making. The overarching goal of this paper, which was developed from an invited participant workshop, is to offer five approaches for presenting toxicity values in a transparent manner in order to improve the understanding, consideration, and informed use of uncertainty by risk assessors, risk managers, and stakeholders. The five approaches for improving the presentation and communication of uncertainty are described using U.S. Environmental Protection Agency's (EPA's) Integrated Risk Information System (IRIS) as a case study. These approaches will ensure transparency in the documentation, development, and use of toxicity values at EPA, the Agency for Toxic Substances and Disease Registry (ATSDR), and other similar assessment programs in the public and private sector. Further empirical testing will help to inform the approaches that will work best for specific audiences and situations.

Veteran Perceptions, Interest, and Use of Complementary and Alternative Medicine.

An analysis of a veteran survey on complementary and alternative medicine services revealed that health-related self-efficacy predicted their use.

Implementing medication reconciliation from the planner's perspective: a qualitative study.

BACKGROUND: Medication reconciliation can reduce adverse events associated with prescribing errors at transitions between sites of care. Though a U.S. Joint Commission National Patient Safety Goal since 2006, at present organizations continue to have difficulty implementing it. The objective of this study was to examine medication reconciliation implementation from the perspective of individuals involved in the planning process in order to identify recurrent themes, including facilitators and barriers, that might inform other organizations' planning and implementation efforts. METHODS: We performed semi-structured interviews with individuals who had a role in planning medication reconciliation implementation at a large urban academic medical center in the U.S. and its affiliated Veterans Affairs hospital. We queried respondents' perceptions of the implementation process and their experience with facilitators and barriers. Transcripts were coded and analyzed using a grounded theory approach. The themes that emerged were subsequently categorized using the Consolidated Framework for Implementation Research (CFIR). RESULTS: There were 13 respondents, each with one or more organizational roles in quality improvement, information technology, medication safety, and education. Respondents described a resource- and time- intensive medication reconciliation planning process. The planning teams' membership and functioning were recognized as important factors to a successful planning process. Implementation was facilitated by planners' understanding of the principles of performance improvement, in particular, fitting the new process into the workflow of multiple disciplines. Nevertheless, a need for significant professional role changes was recognized. Staff training was recognized to be an important part of roll-out, but training had several limitations. Planners monitored compliance to help sustain the process, but acknowledged that this did not ensure that medication reconciliation actually achieved its primary goal of reducing errors. Study findings fit multiple constructs in the CFIR model. CONCLUSIONS: Study findings suggest that to improve the likelihood of a successful implementation of medication reconciliation, planners should, among other considerations, involve a multidisciplinary planning team, recognize the significant professional role changes that may be needed, and consider devoting resources not just to compliance monitoring but also to monitoring of the process' impact on prescribing.

Self-reported stressors of National Guard women veterans before and after deployment: the relevance of interpersonal relationships.

BACKGROUND: With their rapidly expanding roles in the military, women service members experience significant stressors throughout their deployment experience. However, there are few studies that examine changes in women Veterans' stressors before and after deployment. OBJECTIVE: This study examines the types of stressors women Veterans report before deployment, immediately after deployment, 3 months after deployment, and 1 year post-deployment. DESIGN: Descriptive data on reported stressors was collected at four time points of a longitudinal study (HEROES Project). Open-ended responses from the Coping Response Inventory (CRI) were coded into six possible major stressor categories for analysis. PARTICIPANTS: Seventy-nine Army National Guard and Reserve female personnel deploying to Operation Enduring Freedom (OFF)/Operation Iraqi Freedom (OIF) were surveyed prior to deployment. Of these participants, 35 women completed Phase 2, 41 completed Phase 3, and 48 completed Phase 4 of the study. KEY RESULTS: We identified six major stressor categories: (1) interpersonal (i.e., issues with family and/or friends), (2) deployment-related and military-related, (3) health concerns, (4) death of a loved one, (5) daily needs (i.e., financial/housing/transportation concerns), and (6) employment or school-related concerns. At all time points, interpersonal issues were one of the most common type of stressor for this sample. Daily needs concerns increased from 3 months post-deployment to 1 year post-deployment. CONCLUSIONS: Interpersonal concerns are commonly reported by women Veterans both before and after their combat experience, suggesting that this is a time during which interpersonal support is especially critical. We discuss implications, which include the need for a more coordinated approach to women Veterans' health care (e.g., greater community-based outreach), and the need for more and more accessible Veterans Affairs (VA) services to address the needs of female Veterans.

Organizational psychosocial factors and deployment-related exposure concerns in Afghanistan/Iraq War veterans.

OBJECTIVE: Environmental exposure concerns are associated with adverse health outcomes in soldiers deployed to South West Asia. There is little data on factors associated with the reporting of exposure concerns. We explored the relationship between deployment-related preparedness/support and exposure concerns. METHODS: Retrospective chart review of 489 Afghanistan/Iraq veterans evaluated at a Veterans Affairs tertiary center for postdeployment health. RESULTS: Virtually all subjects were concerned about environmental exposure(s). There were no significant demographic differences in exposure concerns, preparedness/support variables, or both. Preparedness/support correlated inversely with exposure concerns. Mental health function mediated the relationship between preparedness/support and exposure concerns. CONCLUSIONS: Deployment-related preparedness/support is associated with exposure concerns and mental health functioning. Definitive studies will provide data and insight on how the military may better prepare/support soldiers to optimize their resilience and reduce deployment-related exposure concerns.

Risk communication in deployment-related exposure concerns.

OBJECTIVE: Veterans Affairs and Department of Defense health care providers and educators serve as primary channels of communication with veterans but may not understand the importance and benefits of risk communication to inform and empower veterans about actions to take or not take to improve the quality of their health. This article describes the importance of understanding and applying risk communication principles in communicating to veterans about the potential for health concerns/impacts from deployment-related exposures. RESULTS: The principles of risk communication as relevant to clinical encounters are presented, focusing on a review of risk perception factors influencing deployment-related exposure concerns. Results show that risk communication can impact how veterans will take in and process information about deployment-related exposures. CONCLUSION: This article illustrates how providers can effectively use risk communication to structure better clinical encounters and communication with veterans.

Medication reconciliation: barriers and facilitators from the perspectives of resident physicians and pharmacists.

BACKGROUND: Medication reconciliation can prevent medication errors and harm when patients transition between hospital and other care settings. Though a Joint Commission hospital Patient Safety Goal since 2006, organizations continue to have difficulty implementing the process. OBJECTIVE: To determine factors that influence performance of medication reconciliation in a hospital setting with a computerized medication reconciliation tool. DESIGN: Cognitive task analysis (CTA) and focus group interviews. SETTING: Urban, academic, tertiary-care Veterans Affairs medical center. PARTICIPANTS: Internal medicine house staff physicians (n = 23) and inpatient staff pharmacists (n = 12). MEASUREMENTS: CTA participants verbalized their thoughts while they completed medication reconciliation with the computerized tool. Focus group participants described medication reconciliation's purpose and effectiveness, how they completed the task, and its barriers and facilitators. Interviews were recorded and analyzed using social science methods for analyzing qualitative data. RESULTS: Participants agreed that a central goal of medication reconciliation is to prevent prescribing errors, but disagreed about whether it achieves this goal. Computerization facilitated the task, but participants said that computers and patients can be unreliable sources of information. Participants varied in how they sequenced components of the task. When time was limited, physicians considered other responsibilities higher priority. Both physicians and pharmacists expressed low self-efficacy, ie, low perceived capability to achieve the objectives of the process. CONCLUSION: Key barriers to medication reconciliation are unreliable sources of medication information and tasks that compete for providers' time and attention that they consider higher priority. Addressing these barriers while increasing providers' self-efficacy might improve medication reconciliation and its outcomes.