Screening for Elder Abuse in the Veterans Health Administration: Varied Approaches Across a National Health System.

BACKGROUND: Elder abuse (EA) is common and has devastating health consequences yet is rarely detected by healthcare professionals. While EA screening tools exist, little is known about if and how these tools are implemented in real-world clinical settings. The Veterans Health Administration (VHA) has experience screening for, and resources to respond to, other forms of interpersonal violence and may provide valuable insights into approaches for EA screening. OBJECTIVE: Describe EA screening practices across a national integrated healthcare system serving a large population of older adults at risk for EA. DESIGN: Survey of all 139 VHA medical centers from January to August 2021. PARTICIPANTS: Surveys were completed by the Social Work Chief, or delegate, at each site. MAIN MEASURES: The survey assessed the presence and characteristics of EA-specific screening practices as well as general abuse/neglect screening conducted with patients of all ages, including older adults. Follow-up emails were sent to sites that reported screening requesting additional details not included in the initial survey. KEY RESULTS: Overall, 130 sites (94%) responded. Among respondents, 5 (4%) reported screening older adults for EA using a previously published tool, while 6 (5%) reported screening for EA with an unstudied or locally developed tool. Forty-eight percent reported screening patients of all ages for general abuse/neglect using unstudied questions/tools, and 44% reported no EA screening at their site. Characteristics of screening programs (e.g., frequency, clinical setting, provider type) varied widely between sites, as did respondents' understanding of the definition of screening. CONCLUSIONS: High variability in screening practices for abuse/neglect and lack of EA-specific screening in a system that has successfully deployed other standardized screening approaches present an important opportunity to standardize and improve EA detection practices. Lessons learned in VHA could help advance the evidence base for EA screening more broadly to increase overall detection rates for EA nationally.

Gender Differences in Connecting Veterans to Care Through the Veterans Crisis Line: A Mixed Methods Evaluation of Referrals to Suicide Prevention Coordinators.

BACKGROUND: Suicide is a major public health crisis within the US military veteran community, with distinct gender differences in suicide risk and behavior. The Veterans Crisis Line (VCL) is a component of the Veterans Health Administration (VHA) suicide prevention program; through VCL, veterans may be referred to a VHA Suicide Prevention Coordinator (SPC) to arrange follow-up care. Research shows that engagement with an SPC is a strong protective factor in reducing veteran suicide risk. METHODS: We evaluated SPC referral acceptance and assessed correlates of SPC referral decline using VCL administrative data for contacts: (1) made between January 1, 2018, through December 31, 2019; (2) by veterans contacting VCL on their own behalf; (3) with gender identified; and (4) current thoughts of suicide. Then, among a subsample of 200 veterans, evenly distributed by gender, we examined data from call synopsis notes to identify reasons given for veterans declining an SPC referral. RESULTS: We found it was generally callers rated as lower risk by responders, and callers with loneliness as a reason for contacting VCL, who more frequently declined the SPC referral. An analysis of reasons given for declining SPC referral found that concerns with/about Veterans Affairs care were a key concern, particularly among women veterans articulating specific negative care experiences. Other reasons for referral decline included managing the veteran's needs directly on the call or via alternative resources. CONCLUSION: The VCL as an intervention provides an important opportunity to re-engage vulnerable veterans into care, one that may be more challenging for women veterans.

Opportunities to More Comprehensively Assess Sexual Violence Experience in Veterans Health Administration Medical Records Data.

INTRODUCTION: Experience of sexual violence (SV) is prevalent among the Veteran population and associated with many negative mental and physical health outcomes including suicidal behavior, obesity, post-traumatic stress disorder, anxiety, depression, and poor sexual and reproductive functioning. Although Veterans of any gender may experience SV, women Veterans are particularly at risk. Research on SV among Veterans has focused primarily on the experience of SV during military service (military sexual trauma, MST), although Veterans may also experience SV prior to and following military service. The aim of the current study was to construct a more comprehensive method of identifying SV among Veterans Health Administration (VHA) patients as documented in medical records in a national cohort of 325,907 Veterans who used VHA care between 2000 and 2018 in order to inform future research in this area. METHOD: We used three indicators to identify SV in VHA medical records: (a) the MST screen, (b) the sexual violence item of the intimate partner violence (IPV) screen, and (c) International Classification of Disorders (ICD) codes (versions 9 and 10) representing adult sexual abuse and assault. Univariate descriptive analyses were conducted to determine the exclusivity and overlap of the SV measures. RESULTS: The universal MST screen was the most commonly identified indicator of SV in the data. However, including the IPV and ICD indicators identified an additional 5% of Veterans who had experienced SV, accounting for thousands of patients. DISCUSSION: The results of the current study indicate that using the three-pronged approach of SV collection is a more comprehensive method of identifying patient SV experience through VHA medical records and contributes uniquely to the methodology of studying social factors' impact on health care. Clinical screening and documentation of SV allow for the assessment of health impacts and trends through examination of medical records data.

Effects of Intimate Partner Violence During COVID-19 and Pandemic-Related Stress on the Mental and Physical Health of Women Veterans.

BACKGROUND: Little is known about women veterans' intimate partner violence (IPV) experiences during the COVID-19 pandemic or the impacts of pandemic-related stress on their mental and physical health. OBJECTIVES: To identify IPV experiences among women veterans prior to and during the pandemic, pandemic-related stressors, and examine their respective contributions to mental and physical health. DESIGN: National sample of women veterans drawn from a larger web-based longitudinal study. Relationships between recent IPV and pandemic-related stressors were tested with linear regressions, controlling for pre-pandemic IPV and mental and physical health symptoms, demographic, and military-related covariates. PARTICIPANTS: One hundred forty-two women veterans (Mage=58.8 years). MAIN MEASURES: We assessed IPV (CTS-2), PTSD (PCL-5), depression (CESD), anxiety (DASS-A), physical health (PHQ-15), and physical health-related quality of life (SF-12) prior to the pandemic (June 2016-December 2016/January 2017) and during the pandemic study period (March 2020-December 2020/January 2021). We assessed pandemic-related stressors (EPII) during the pandemic study period. KEY RESULTS: Over a third (38.7%) of participants experienced IPV during the pandemic study period (psychological: 35.9%, physical: 9.9%, sexual: 4.2%). Overall rates, frequency, and severity of IPV experience did not significantly differ between the pre-pandemic and pandemic study periods. Few participants tested positive for COVID-19 (4.2%); however, most participants reported experiencing pandemic-related stressors across life domains (e.g., social activities: 88%, physical health: 80.3%, emotional health: 68.3%). IPV during the pandemic and pandemic-related stressors were both associated with greater PTSD and depressive symptoms. Pandemic-related stressors were associated with worse anxiety and physical health symptoms. Neither IPV during the pandemic nor pandemic-related stressors were associated with physical health-related quality of life. CONCLUSIONS: IPV experiences during the pandemic were common among women veterans, as were pandemic-related stressors. Although IPV did not increase in the context of COVID-19, IPV experiences during the pandemic and pandemic-related stressors were linked with poorer mental and physical health.

Gender Differences in the Predictors of Suicide-related Morbidity Among Veterans Reporting Current Housing Instability.

BACKGROUND: Veterans experiencing housing instability are at increased risk of suicide. Research is needed to identify gender differences in the predictors of both suicidal ideation and suicide attempt, particularly among Veterans who are unstably housed. OBJECTIVES: The objective of the present study was to explore whether correlates of suicide-related morbidity among unstably housed Veterans vary by gender and identify implications for improved care for these Veterans. METHODS: The study cohort included 86,325 Veterans who reported current housing instability between October 1, 2013, and September 30, 2016. This cross-sectional study assessed differences in demographic and outcome variables by gender using χ2 analyses and a series of multiple logistic regressions predicting suicidal ideation and suicide attempt, stratified by gender. RESULTS: Among unstably housed female Veterans, being younger than 40 years was associated with more than double the odds of having an indicator of suicidal ideation and >12 times the odds of having an indicator of a suicide attempt. The effect sizes associated with age were much less pronounced among unstably housed male Veterans. The presence of mental health and substance use conditions as well as a positive screen for military sexual trauma were associated with increased risk of suicide morbidity among both women and men. CONCLUSIONS: Intervention and prevention among unstably housed Veterans may be complicated by unpredictable living situations; further research should explore tailored interventions to address the complex needs of unstably housed Veterans and how suicide prevention can be woven throughout.

Accelerating Research on Suicide Risk and Prevention in Women Veterans Through Research-Operations Partnerships.

BACKGROUND: Suicide rates for women veterans are increasing faster than for nonveterans. The 2017 suicide rate for women veterans was more than double that for women nonveterans. However, research to inform improved suicide prevention for women veterans is scant. OBJECTIVES: To accelerate research on women veterans' unique risks and resiliencies for suicide, the Department of Veterans Affairs (VA) Women's Health Research Network launched a Women Veterans Suicide Prevention Research Work Group to target technical support for researchers, promote collaboration with national VA program offices, and ultimately increase dissemination and translation of research into clinical practice, public health strategies, and policies. The objective of this paper is to report on the process and outcomes of the Work Group's strategic planning efforts to identify and fill gaps in suicide prevention research among women veterans. METHODS: An in-person meeting of 20 researchers and operational leaders was convened to summarize existing research evidence and identify research priorities and challenges. RESULTS: Research priorities included civilian reintegration, community connections, psychosocial stressors (eg, social determinants of health) and trauma, risk assessment, clinical interventions, upstream prevention, and health care access. The importance of increasing evidence on gender differences and for women veterans not using VA health care was emphasized. CONCLUSIONS: Research to inform suicide prevention tailored to meet women veterans' needs is essential; however, many priorities and challenges remain unaddressed. Although Work Group efforts have achieved funding gains, further work to formalize, promote and meet the demands of a suicide prevention research agenda for women veterans requires is ongoing focus.

Intimate Partner Violence Among Pregnant Veterans: Prevalence, Associated Mental Health Conditions, and Health Care Utilization.

BACKGROUND: Intimate partner violence (IPV) is a prevalent and serious health concern for women veterans, associated with mental and physical health symptoms. The adverse impacts of IPV are exacerbated during pregnancy, with added risks for pregnancy and postpartum outcomes. OBJECTIVE: Identify the scope of IPV among pregnant veterans and associations with health outcomes. DESIGN: Data were obtained from a national retrospective cohort study. PARTICIPANTS: Study participants were 442 pregnant veterans using VHA maternity care benefits. MAIN MEASURES: Mental health history was assessed via self-report measure and chart review; history of IPV and perinatal depression were assessed via brief validated self-report measures. KEY RESULTS: Fourteen percent of the sample reported past-year IPV. Report of past-year IPV was associated with higher self-reported rates of lifetime mental health disorders including depression (p = 0.01), posttraumatic stress disorder (p = 0.02), anxiety disorders (p = 0.05), mood disorders (p = 0.01), bipolar disorder (p = 0.001), and eating disorders (p = 0.003); past-year IPV was also associated with the diagnosis of posttraumatic stress disorder during pregnancy (p = 0.002). Additionally, past-year IPV was associated with higher rates of military sexual trauma (MST; p = 0.03), pregnancy health risk behaviors (i.e., smoking, alcohol, and drug use; p = 0.004), greater number of VHA mental health visits during pregnancy (p = 0.04), and a lower likelihood of seeking social support from a spouse or partner (p < 0.0001). CONCLUSIONS: Results indicate substantial rates of IPV among pregnant veterans, and high rates of mental health conditions which may be exacerbated by MST experience and lower likelihood of seeking social support. Clinicians treating pregnant veterans should screen for and address IPV and mental health treatment needs, and risks should be assessed among pregnant veterans experiencing IPV.

Awareness of HIV Preexposure Prophylaxis Among People at Risk for HIV: Results From the 2017-2019 National Survey of Family Growth.

BACKGROUND: Although daily preexposure prophylaxis (PrEP) is now widely accepted as a safe and effective method for reducing the risk of HIV in high-risk groups, uptake has been slow. The goal of this analysis was to identify factors associated with PrEP awareness among individuals at risk for HIV. METHODS: This investigation analyzed data from the Centers for Disease Control and Prevention nationally representative survey, National Survey of Family Growth, for the years 2017 to 2019. Logistic regression was used to explore the relationship between PrEP awareness and demographics, HIV risk factors, and provider HIV risk screening. RESULTS: Only 37% of survey respondents with an increased risk of HIV were aware of PrEP. Several segments of the at-risk population had lower odds of being aware of PrEP, including heterosexual women, heterosexual men, individuals younger than 20 years, and individuals with lower levels of education. Those who participate in sex in exchange for money or drugs had significantly lower odds of being aware of PrEP. In comparison, PrEP awareness was significantly higher among nonheterosexual men and both men and women whose partners were HIV positive. Lastly, those who had been screened by a provider for HIV risk had significantly higher odds of being aware of PrEP. CONCLUSIONS: This research supports the need for policies and programs to increase awareness of PrEP, especially among certain segments of the population at increased risk for HIV.

Middle-aged Women's Experiences of Intimate Partner Violence Screening and Disclosure: "It's a private matter. It's an embarrassing situation".

BACKGROUND: National guidelines indicate that healthcare providers should routinely screen women of reproductive age for experience of intimate partner violence. We know little about intimate partner violence (IPV) screening and disclosure experience among women older than reproductive age. OBJECTIVE: To examine the perspectives of middle-aged women who had experienced past-year IPV regarding IPV screening and disclosure in the healthcare setting. DESIGN: Individual semi-structured qualitative interviews were conducted in-person as part of a larger study examining IPV screening and response services through the Veterans Health Administration. PARTICIPANTS: Twenty-seven women aged 45-64 (mean age 53) who experienced past-year IPV and received care at one of two Veterans Affairs Medical Centers. APPROACH: Interviews were digitally recorded and transcribed. Data were sorted and analyzed using templated notes and line-by-line coding, based on codes developed by the study team through an initial review of the data. Themes were derived from further analysis of the data coded for "screening" and "disclosure" for respondents aged 45 and older. KEY RESULTS: Barriers to disclosure of IPV to a healthcare provider included as follows: (a) feelings of shame, stigma, and/or embarrassment about experiencing IPV; (b) screening context not feeling comfortable or supportive, including lack of comfort with or trust in the provider and/or a perception that screening was conducted in a way that felt impersonal and uncaring; and (c) concerns about privacy and safety related to disclosure. Provider demonstrations of care, empathy, and support facilitated disclosure and feelings of empowerment following disclosure. CONCLUSIONS: Middle-aged women may benefit from routine IPV screening and response in the healthcare setting. Such interventions should be sensitive to concerns regarding stigma and privacy that may be prevalent among this population.

Social Determinants and Military Veterans' Suicide Ideation and Attempt: a Cross-sectional Analysis of Electronic Health Record Data.

BACKGROUND: Health care systems struggle to identify risk factors for suicide. Adverse social determinants of health (SDH) are strong predictors of suicide risk, but most electronic health records (EHR) do not include SDH data. OBJECTIVE: To determine the prevalence of SDH documentation in the EHR and how SDH are associated with suicide ideation and attempt. DESIGN: This cross-sectional analysis included EHR data spanning October 1, 2015-September 30, 2016, from the Veterans Integrated Service Network Region 4. PARTICIPANTS: The study included all patients with at least one inpatient or outpatient visit (n = 293,872). MAIN MEASUREMENTS: Adverse SDH, operationalized using Veterans Health Administration (VHA) coding for services and International Statistical Classification of Diseases and Related Health Problems (ICD)-10 codes, encompassed seven types (violence, housing instability, financial/employment problems, legal problems, familial/social problems, lack of access to care/transportation, and nonspecific psychosocial needs). We defined suicide morbidity by ICD-10 codes and data from the VHA's Suicide Prevention Applications Network. Logistic regression assessed associations of SDH with suicide morbidity, adjusting for socio-demographics and mental health diagnoses (e.g., major depression). Statistical significance was assessed with p < .01. KEY RESULTS: Overall, 16.4% of patients had at least one adverse SDH indicator. Adverse SDH exhibited dose-response-like associations with suicidal ideation and suicide attempt: each additional adverse SDH increased odds of suicidal ideation by 67% (AOR = 1.67, 99%CI = 1.60-1.75; p < .01) and suicide attempt by 49% (AOR = 1.49, 99%CI = 1.33-1.68; p < .01). Independently, each adverse SDH had strong effect sizes, ranging from 1.86 (99%CI = 1.58-2.19; p < .01) for legal issues to 3.10 (99%CI = 2.74-3.50; p < .01) for non-specific psychosocial needs in models assessing suicidal ideation and from 1.58 (99%CI = 1.10-2.27; p < .01) for employment/financial problems to 2.90 (99%CI = 2.30-4.16; p < .01) for violence in models assessing suicide attempt. CONCLUSIONS: SDH were strongly associated with suicidal ideation and suicide attempt even after adjusting for mental health diagnoses. Integration of SDH data in EHR could improve suicide prevention.

Adverse social factors and all-cause mortality among male and female patients receiving care in the Veterans Health Administration.

Social factors account more for health outcomes than medical care, yet health services research in this area is limited due to the lack of social factors data contained within electronic health records (EHR) systems. Few investigations have examined how cumulative burdens of co-occurring adverse social factors impact health outcomes. From 293,872 patients in one region of the Veterans Health Administration (VHA), we examined how increasing numbers of adverse social factors extracted from the EHR were associated with mortality across a one-year period for male and female patients. Adverse social factors were identified using four sources in the EHR: responses to universal VHA screens, International Classification of Disease (ICD) diagnostic codes that indicate social factors, receipt of VHA services related to social factors, and templated social work referrals. Seven types of adverse social factors were coded: violence, housing instability, employment or financial problems, legal issues, social or familial problems, lack of access to care or transportation, and nonspecific psychosocial needs. Overall, each increase in an adverse social factor was associated with 27% increased odds of mortality, after accounting for demographics, medical comorbidity, and military service-related disability. Non-specific psychosocial factors were most strongly associated with mortality, followed by social or familial problems. Although women were more likely than men to have multiple adverse social factors, social factors were not associated with mortality among women as they were among men. By incorporating social factors data, health care systems can better understand patient all-cause mortality and identify potential prevention efforts built around social determinants.

Social determinants and emergency department utilization: Findings from the Veterans Health Administration.

BACKGROUND: Social determinants of health (SDH) are strong predictors of morbidity and mortality but health care systems struggle to integrate documentation of SDH into health records in ways that can be used for health services research. Given the impact of social factors on health, it is important to examine the relationship with emergency department (ED) utilization. OBJECTIVE: To examine the association between seven indicators of SDH and ED utilization using electronic health record (EHR) data from the Veterans Health Administration (VHA). METHODS: This cross-sectional analysis included data from all patients who had at least one health care visit in the Veterans Integrated Service Network region 4 from October 1, 2015 through September 30, 2016 (n=293,872). Seven categories of adverse SDH included violence, housing instability, employment or financial problems, legal problems, social or family problems, lack of access to care or transportation, and non-specific psychosocial needs identified through structured coding in EHR. Negative binomial regression was used to examine the association of the count of adverse SDH (0-7) with the count of ED visits, adjusting for socio-demographic and health-related factors. RESULTS: Approximately 18% of patients visited the ED during the observation period. After adjusting for covariates, adverse SDH were positively associated with VHA ED utilization. Each of the SDH indicators, other than legal issues, was positively associated with increased ED utilization. CONCLUSION: Even after accounting for several demographic and health-related factors, adverse SDH demonstrated strong positive associations with VHA ED utilization.

Screening for Housing Instability: Providers' Reflections on Addressing a Social Determinant of Health.

BACKGROUND: The Veterans Health Administration (VHA) has a long history of addressing social determinants of health, including housing. In 2012, the VA integrated a two-question Homelessness Screening Clinical Reminder (HSCR) into the electronic medical record in outpatient clinics to identify Veterans experiencing housing instability and ensure referral to appropriate services. OBJECTIVE: This study explores perspectives of VA clinical providers regarding administration of the HSCR, their role in addressing housing status, and how a patient's housing status impacts clinical decision-making. DESIGN: We conducted a qualitative study using in-depth semi-structured interviewing. PARTICIPANTS: Twenty-two providers were interviewed (20 physicians and two nurse practitioners) between March and September 2016. APPROACH: Interviews were conducted with Veterans Health Administration (VHA) physician and non-physician practitioners who had administered the HSCR and documented at least five positive screens between 2013 and 2015. Our interview guide investigated provider experiences with administering the HSCR and addressing affirmative responses. The guide also elicited details about how patients' housing instability was identified (if at all) prior to implementation of the screening reminder, and how practices changed following implementation of the HSCR. Transcripts were analyzed using a modified grounded theory approach. KEY RESULTS: Providers reported that the HSCR prompted them to incorporate patient housing status into routine assessment, which they typically did not do prior to its implementation. Providers discussed adverse impacts of housing instability on patients' overall health and described how they factored patients' housing instability into clinical decision-making. Although providers viewed the health system as having an important role in addressing housing concerns, there were mixed opinions on whether it was the role of providers to directly administer the screening. CONCLUSIONS: Integration of a screener for housing instability into the electronic medical record increased provider attention to housing instability into the social history, and positive responses commonly impacted plans of care.

Intimate Partner Violence Screening Programs in the Veterans Health Administration: Informing Scale-up of Successful Practices.

OBJECTIVES: Screening women for intimate partner violence (IPV) is increasingly expected in primary care, consistent with clinical prevention guidelines (e.g., United States Preventive Services Task Force). Yet, little is known about real-world implementation of clinical practices or contextual factors impacting IPV screening program success. This study identified successful clinical practices, and barriers to and facilitators of IPV screening program implementation in the Veterans Health Administration (VHA). DESIGN: Descriptive, qualitative study of a purposeful sample of 11 Veterans Affairs Medical Centers (VAMCs) categorized as early and late adopters of IPV screening programs within women's health primary care clinics. VAMCs were categorized based on performance measures collected by VHA operations partners. PARTICIPANTS: Thirty-two administrators and clinician key informants (e.g., Women's Health Medical Directors, IPV Coordinators, and physicians) involved in IPV screening program implementation decisions from six early- and five late-adopting sites nationwide. MAIN MEASURES: Participants reported on IPV screening and response practices, and contextual factors impacting implementation, in individual 1-h semi-structured phone interviews. Transcripts were analyzed using rapid content analysis with key practices and issues synthesized in profile summaries. Themes were identified and iteratively revised, utilizing matrices to compare content across early- and late-adopting sites. KEY RESULTS: Five successful clinical practices were identified (use of two specific screening tools for primary IPV screening and secondary risk assessment, multilevel resource provision and community partnerships, co-location of mental health/social work, and patient-centered documentation). Multilevel barriers (time/resource constraints, competing priorities and mounting responsibilities in primary care, lack of policy, inadequate training, and discomfort addressing IPV) and facilitators (engaged IPV champions, internal and external supports, positive feedback regarding IPV screening practices, and current, national attention to violence against women) were identified. CONCLUSIONS: Findings advance national efforts by highlighting successful clinical practices for IPV screening programs and informing strategies useful for enhancing their implementation within and beyond the VHA, ultimately improving services and women's health.

Housing Instability Characteristics Among Transgender Veterans Cared for in the Veterans Health Administration, 2013-2016.

Objectives. To characterize housing instability among transgender veterans using Veterans Health Administration (VHA) health care in the United States.Methods. We used administrative data on veterans screened for housing instability from 2013 to 2016; participants included 5717 transgender veterans and 17 133 cisgender veterans. We defined housing instability by a positive screen or VHA Homeless Program use. We identified gender from medical records, reflecting either birth sex or gender identity. We identified transgender identity through transgender-related International Classification of Diseases, Ninth Revision and Tenth Revision codes. A multiple logistic regression assessed the association of transgender identity with housing instability.Results. Prevalence of housing instability was nearly 3 times higher among transgender veterans than among cisgender veterans (19.9% vs 6.7%; P < .001). The difference persisted when we adjusted for sociodemographics (adjusted odds ratio = 2.32; 95% confidence interval = 2.09, 2.57). Transgender veterans experiencing housing instability were more likely than cisgender veterans to be women, younger, unmarried, and White.Conclusions. Transgender veterans experience housing instability more frequently than do cisgender veterans. An increased focus on transgender identity is critical for reducing veteran homelessness.

"The Idea of Categorizing Makes Me Feel Uncomfortable": University Student Perspectives on Sexual Orientation and Gender Identity Labeling in the Healthcare Setting.

As healthcare settings are increasingly adding sexual orientation and gender identity (SO/GI) to routinely collected patient demographic information, it is important to understand how patients conceptualize and label these identities. This study explored university students' perspectives on and experiences with choosing SO/GI labels in the healthcare setting. We employed a mixed-method approach, collecting survey data on self-identified SO/GI labels across various contexts and conducting focus groups centered around experiences of SO/GI data collection and labeling in healthcare. Thirty-four graduate and undergraduate university students completed the survey and participated in six one-time focus groups. While many participants indicated that their self-identified SO/GI labels were consistent across contexts/relationships, 47% indicated that they used different labels to describe their SO or GI depending on the context. The focus group discussions revealed ways in which participants struggled to label their SO/GI on forms: They reported that (1) their authentic SO/GI labels were not among the commonly listed labels or (2) they felt that labeling their SO/GI identities was problematic. Participants reported that choosing a label that did not fit their lived experience was not only inaccurate, but could also feel painful and alienating. These findings hold implications for the collection and interpretation of patient SO/GI information, both for epidemiological purposes and for patient-centered care.

When user-centered design meets implementation science: integrating provider perspectives in the development of an intimate partner violence intervention for women treated in the United States' largest integrated healthcare system.

BACKGROUND: Intimate partner violence (IPV) against women is a global health problem that is a substantial source of human suffering. Within the United States (US), women veterans are at high risk for experiencing IPV. There is an urgent need for feasible, acceptable, and patient-centered IPV counseling interventions for the growing number of women treated in the US's largest integrated healthcare system, the Veterans Health Administration (VHA). Implementation science and user-centered-design (UCD) can play an important role in accelerating the research-to-practice pipeline. Recovering from IPV through Strengths and Empowerment (RISE) is a flexible, patient-centered, modular-based program that holds promise as a brief counseling intervention for women veterans treated in VHA. We utilized a UCD approach to develop and refine RISE (prior to formal effectiveness evaluations) by soliciting early feedback from the providers where the intervention will ultimately be implemented. The current study reports on the feedback from VHA providers that was used to tailor and refine RISE. METHOD: We conducted and analyzed semi-structured, key-informant interviews with VHA providers working in clinics relevant to the delivery of IPV interventions (n = 23) at two large medical centers in the US. Participants' mean age was 42.6 years (SD = 11.6), they were predominately female (91.3%) and from a variety of relevant disciplines (39.1% psychologists, 21.7% social workers, 17.4% physicians, 8.7% registered nurses, 4.3% psychiatrists, 4.3% licensed marriage and family therapists, 4.3% peer specialists). We conducted rapid content analysis using a hybrid inductive-deductive approach. RESULTS: Providers perceived RISE as highly acceptable and feasible, noting strengths including RISE's structure, patient-centered agenda, and facilitation of provider comfort in addressing IPV. Researchers identified themes related to content and context modifications, including requests for additional safety check-ins, structure for goal-setting, and suggestions for how to develop and implement RISE-specific trainings. CONCLUSIONS: These findings have guided refinements to RISE prior to formal effectiveness testing in VHA. We discuss implications for the use of UCD in intervention development and refinement for interventions addressing IPV and other trauma in health care settings globally. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT03261700; Date of registration: 8/25/2017, date of enrollment of first participant in trial: 10/22/2018. Unique Protocol ID: IIR 16-062.

Provider Perspectives on the Application of Patient Sexual Orientation and Gender Identity in Clinical Care: A Qualitative Study.

BACKGROUND: The federal government and other organizations have recommended that healthcare institutions collect and document patient sexual orientation and gender identity (SO/GI) information in order to advance the understanding of the health of sexual and gender minority populations and to combat existing health disparities. Little is known, however, about provider perception of the clinical relevance of, or how they might use, patient SO/GI information in individual care. OBJECTIVE: To explore providers' perspectives on and experiences with collection of patient SO/GI information and how the knowledge of this information may impact clinical care. DESIGN: Qualitative study using in-depth individual interviews of healthcare providers. PARTICIPANTS: Twenty-five healthcare providers, including physicians, physician assistants, and nurse practitioners, from the fields of family medicine, internal medicine, gynecology, and urology within a single healthcare system in an east coast city. APPROACH: Interviews were recorded and transcribed verbatim. Transcripts were coded and analyzed using principles of grounded theory and thematic analysis to identify themes emerging from the data. KEY RESULTS: Providers recognized the importance of collecting patient SO/GI information for understanding population-level public health concerns and disparities, as well as understanding and respecting the context of patients' lives. However, providers also emphasized the importance of knowing patients' sexual behaviors and physical anatomy for addressing health risk and preventive care needs-and noted the distinction between these characteristics and patient SO/GI. Providers cautioned that assumptions based on knowledge of patient SO/GI may unintentionally obscure accurate profiles of patient behavior and anatomy. CONCLUSIONS: Along with the potential benefits of routine collection of patient SO/GI, it is important that providers continue to inquire about patient behaviors and anatomy to inform individual risk and needs assessments. Findings from this study can inform the development of guidelines, trainings, and practices for incorporation of patient SO/GI along with existing assessment practices to improve individual and population health.

Women's Healthcare Utilization Following Routine Screening for Past-Year Intimate Partner Violence in the Veterans Health Administration.

BACKGROUND: Experience of intimate partner violence (IPV) can have adverse health impacts and has been associated with elevated rates of healthcare service utilization. Healthcare encounters present opportunities to identify IPV-related concerns and connect patients with services. The Veterans Health Administration (VHA) conducts IPV screening within an integrated healthcare system. OBJECTIVE: The objectives of this study were to compare service utilization in the 6 months following IPV screening between those screening positive and negative for past-year IPV (IPV+, IPV-) and to examine the timing and types of healthcare services accessed among women screening IPV+. DESIGN: A retrospective chart review was conducted for 8888 female VHA patients across 13 VHA facilities who were screened for past-year IPV between April 2014 and April 2016. MAIN MEASURES: Demographic characteristics (age, race, ethnicity, marital status, veteran status), IPV screening response, and healthcare encounters (based on visit identification codes). KEY RESULTS: In the 6 months following routine screening for past-year IPV, patients screening IPV+ were more likely to utilize outpatient care (aOR = 1.85 [CI 1.26, 2.70]), including primary care or psychosocial care, and to have an inpatient stay (aOR = 2.09 [CI 1.23, 3.57]), compared with patients screening IPV-. Among those with any utilization, frequency of outpatient encounters within the 6-month period following screening was higher among those screening IPV+ compared with those screening IPV-. The majority of patients screening positive for past-year IPV returned for an outpatient visit within a brief time frame following the screening visit (> 70% within 14 days, >95% within 6 months). More than one in four patients screening IPV+ had an emergency department visit within the 6 months following screening. CONCLUSIONS: Women who screen positive for past-year IPV have high rates of return to outpatient visits following screening, presenting opportunities for follow-up support. Higher rates of emergency department utilization and inpatient stays among women screening IPV+ may indicate adverse health outcomes related to IPV experience.

Will Veterans Answer Sexual Orientation and Gender Identity Questions?

BACKGROUND: The Veterans Health Administration does not routinely collect and document sexual orientation and gender identity (SOGI) data, despite existing health disparities among sexual and gender minority Veterans. Because of the legacy of previous Department of Defense (DoD) policies that prohibited disclosure of sexual or gender minority identities among active duty personnel, Veterans may be reluctant to respond to SOGI questions. OBJECTIVES: This population-based study assesses item nonresponse to SOGI questions by Veteran status. RESEARCH DESIGN: This is a secondary analysis of data from a population-based sample of adults in 20 US states that elected to administer a SOGI module in the 2014 Behavioral Risk Factor Surveillance System survey. Prevalence of SOGI refusals and responses of "don't know" were compared for Veterans and non-Veterans. SUBJECTS: Veterans (n=22,587) and non-Veterans (n=146,475) were surveyed. RESULTS: Nearly all Veteran respondents (≥98%) completed the SOGI questions, with 95.4% identifying as heterosexual, 1.2% as gay or lesbian, 1.2% as bisexual, and 0.59% as transgender. A significantly lower proportion of Veterans than non-Veterans refuse to answer sexual orientation (1.5% vs. 1.9%). There was no difference between Veterans and non-Veterans in responses for gender identity. CONCLUSIONS: Veterans are just as likely as non-Veterans to complete SOGI items in survey research. Asking Veterans about SOGI is unlikely to yield significant nonresponse. These data suggest that future research should investigate Veterans' perspectives on being asked about SOGI in research settings and as part of routine clinical care.