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.

Patient and provider barriers, facilitators, and implementation preferences of intimate partner violence perpetration screening.

BACKGROUND: The substantial prevalence and consequences of intimate partner violence (IPV) underscore the need for effective healthcare response in the way of screening and follow up care. Despite growing evidence regarding perspectives on healthcare-based screening for IPV experiences (i.e., victimization), there is an extremely limited evidence-base to inform practice and policy for detecting IPV use (i.e., perpetration). This study identified barriers, facilitators, and implementation preferences among United States (US) Veterans Health Administration (VHA) patients and providers for IPV use screening. METHODS: We conducted qualitative interviews with patients enrolled in VHA healthcare (N = 10) and focus groups with VHA providers across professional disciplines (N = 29). Data was analyzed using thematic and content analyses. RESULTS: Qualitative analysis revealed convergence between patients' and providers' beliefs regarding key factors for IPV use screening, including the importance of a strong rapport, clear and comprehensive processes and procedures, universal implementation of screening, and a self-report screening tool that assesses for both IPV use and experiences concurrently. CONCLUSIONS: Findings provide foundational information regarding patient and provider barriers, facilitators, and preferences for IPV use screening that can inform clinical practice and next steps in this important but understudied aspect of healthcare.

Screening for Military Sexual Trauma Is Associated With Improved HIV Screening in Women Veterans.

OBJECTIVE: To examine factors associated with HIV screening among women veterans receiving health care in the Department of Veterans Affairs. MATERIALS AND METHODS: Cross-sectional study of women veterans receiving Veterans Affairs care between 2001 and 2014 derived from the Women Veteran's Cohort Study. Descriptive and bivariate statistics were calculated comparing patients with and without an HIV screen. Generalized estimating equations were conducted to estimate the odds of HIV screening among women screened for military sexual trauma (MST) and the subset with a positive MST screen. Multivariable analyses were adjusted for demographic characteristics, mental health diagnoses, pregnancy, HIV risk factors, and facility level clustering. RESULTS: Among the 113,796 women veterans in the sample, 84.3% were screened for MST and 13.2% were screened for HIV. Women screened for MST were over twice as likely to be tested for HIV (odds ratio, 2.8; 95% confidence interval, 2.2-3.5). A history of MST was inversely associated with HIV screening (odds ratio, 0.9; 95% confidence interval, 0.8-0.9). CONCLUSIONS: Women veterans screened for sexual trauma received more comprehensive preventive health care in the form of increased HIV screening.

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.

Military sexual trauma-related posttraumatic stress disorder service-connection: Characteristics of claimants and award denial across gender, race, and compared to combat trauma.

The current study characterizes a cohort of veteran claims filed with the Veterans Benefits Administration for posttraumatic stress disorder secondary to experiencing military sexual trauma, compares posttraumatic stress disorder service-connection award denial for military sexual trauma-related claims versus combat-related claims, and examines military sexual trauma -related award denial across gender and race. We conducted analyses on a retrospective national cohort of veteran claims submitted and rated between October 2017-May 2022, including 102,409 combat-related claims and 31,803 military sexual trauma-related claims. Descriptive statistics were calculated, logistic regressions assessed denial of service-connection across stressor type and demographics, and odds ratios were calculated as effect sizes. Military sexual trauma-related claims were submitted primarily by White women Army veterans, and had higher odds of being denied than combat claims (27.6% vs 18.2%). When controlling for age, race, and gender, men veterans had a 1.78 times higher odds of having military sexual trauma-related claims denied compared to women veterans (36.6% vs. 25.4%), and Black veterans had a 1.39 times higher odds of having military sexual trauma-related claims denied compared to White veterans (32.4% vs. 25.3%). Three-fourths of military sexual trauma-related claims were awarded in this cohort. However, there were disparities in awarding of claims for men and Black veterans, which suggest the possibility of systemic barriers for veterans from underserved backgrounds and/or veterans who may underreport military sexual trauma.

Child Maltreatment, Adult Trauma, and Mental Health Symptoms Among Women Veterans: A Scoping Review of Published Quantitative Research.

The objective of this scoping review was to describe and synthesize the measures, methods, and key findings of published quantitative research examining the influence of child maltreatment (i.e., abuse and/or neglect) and adult trauma exposure on mental health symptoms among women Veterans. A systematic search from database inception to June 2023 generated 18,861 unique articles retrieved and independently screened for eligibility. A total of 21 articles met pre-established inclusion criteria: (a) quantitative data and results within a sample or subsample of U.S. women veterans, (b) published in a peer-reviewed journal, and (c) examining variables of interest simultaneously (i.e., child maltreatment, adult trauma exposure, mental health symptom) in quantitative analyses. Reviewed literature showed a lack of uniformity in measurement and methodologies to evaluate women veterans' lifetime trauma exposure in relation to mental health. Studies most frequently used self-report survey data to evaluate exposure to child maltreatment and/or adult trauma with convenience samples of women veterans (52.4%, n = 11) and examined depressive and/or posttraumatic stress symptomatology. Findings demonstrate the need for additional research attending to the interplay between child maltreatment and adult trauma exposures in relation to women veterans' mental health using comprehensive assessment, longitudinal methods, and understudied as well as more representative samples.

Implementation and Impact of Intimate Partner Violence Screening Expansion in the Veterans Health Administration: Protocol for a Mixed Methods Evaluation.

BACKGROUND: Intimate partner violence (IPV) is a significant public health problem with far-reaching consequences. The health care system plays an integral role in the detection of and response to IPV. Historically, the majority of IPV screening initiatives have targeted women of reproductive age, with little known about men's IPV screening experiences or the impact of screening on men's health care. The Veterans Health Administration (VHA) has called for an expansion of IPV screening, providing a unique opportunity for a large-scale evaluation of IPV screening and response across all patient populations. OBJECTIVE: In this protocol paper, we describe the recently funded Partnered Evaluation of Relationship Health Innovations and Services through Mixed Methods (PRISM) initiative, aiming to evaluate the implementation and impact of the VHA's IPV screening and response expansion, with a particular focus on identifying potential gender differences. METHODS: The PRISM Initiative is guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) and Consolidated Framework for Implementation Research (CFIR 2.0) frameworks. We will use mixed methods data from 139 VHA facilities to evaluate the IPV screening expansion, including electronic health record data and qualitative interviews with patients, clinicians, and national IPV program leadership. Quantitative data will be analyzed using a longitudinal observational design with repeated measurement periods at baseline (T0), year 1 (T1), and year 2 (T2). Qualitative interviews will focus on identifying multilevel factors, including potential implementation barriers and facilitators critical to IPV screening and response expansion, and examining the impact of screening on patients and clinicians. RESULTS: The PRISM initiative was funded in October 2023. We have developed the qualitative interview guides, obtained institutional review board approval, extracted quantitative data for baseline analyses, and began recruitment for qualitative interviews. Reports of progress and results will be made available to evaluation partners and funders through quarterly and end-of-year reports. All data collection and analyses across time points are expected to be completed in June 2026. CONCLUSIONS: Findings from this mixed methods evaluation will provide a comprehensive understanding of IPV screening expansion at the VHA, including the implementation and impact of screening and the scope of IPV detected in the VHA patient population. Moreover, data generated by this initiative have critical policy and clinical practice implications in a national health care system. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/59918.

Patterns of Intimate Partner Violence Among Veterans: A Latent Class Analysis.

The majority of intimate partner violence (IPV) research is unidirectional, focusing on IPV use (i.e., perpetration) or experience (i.e., victimization). However, when IPV use and experience data are simultaneously included in analyses, bidirectional IPV often emerges as a common IPV pattern. The objective of this study was to examine patterns of IPV use and experience, risk factors that may be associated with these patterns, and potential gender differences within a sample of post-9/11 Veterans. This study included a national sample of post-9/11 Veterans (N = 1,150; 50.3% women) who completed self-report measures at two timepoints. We performed a latent class analysis (LCA) to determine the appropriate number of IPV classes, conducted sensitivity analyses, and examined factors potentially associated with IPV class membership. We identified three distinct classes of IPV: Low to no IPV, Bidirectional Psychological IPV, and Bidirectional Multiform IPV. Men and women reported similar rates of IPV use and experience, and there were no gender differences in the LCA model. However, race and ethnicity, employment status, children in the household, marital status, child abuse or witnessing family violence, lifetime physical assault, posttraumatic stress symptoms, and binge drinking were differentially associated with class membership. This study extends existing knowledge on patterns of IPV among Veterans and factors associated with these patterns. Bidirectional IPV was the most common IPV pattern, underscoring the importance of examining IPV use and experience concurrently within research and clinical samples, and developing comprehensive IPV screening and treatment strategies that incorporate bidirectional IPV in work to advance relationship health and safety among Veterans.

Twelve-Month Sustainment of IPV Screening and Response Programs in Primary Care: Contextual Factors Impacting Implementation Success.

PURPOSE: The Veterans Health Administration (VHA) employed implementation facilitation (IF) as a strategy to boost uptake of intimate partner violence (IPV) screening programs in primary care. This study examined the sustainment of screening uptake 1 year after IF and identified factors impacting sustainment success. METHODS: A mixed-methods evaluation using quantitative and qualitative data was conducted. IPV screening rates from the conclusion of the IF period (i.e., initial adoption) through the 1-year sustainment period served as the primary outcome. We categorized sites into four groups of screening adoption and sustainment success (high adoption and high sustainment, moderate adoption and moderate sustainment, low adoption and low sustainment, and no adoption and/or no sustainment). Qualitative analysis of key informant interviews was used to identify contextual factors affecting screening 12 months post-IF. A mixed sustainment analysis matrix integrated quantitative and qualitative findings and enabled the identification of cross-site patterns. MAIN FINDINGS: Seven of the nine sites sustained IPV screening at the most basic level (saw static or increased screening rates). High adopting and high sustaining sites (n = 3) were marked by consistently supportive medical center leadership, ongoing training for clinicians, clear protocols for responding to positive screens, and robust referral options for women experiencing IPV. Nonsustaining sites (n = 2) were marked by a host of barriers including staffing shortages, competing priorities, and inconsistent messaging from leadership regarding the importance of IPV screening. CONCLUSIONS: Knowing barriers and facilitators to successful IPV screening sustainment can inform health care systems to tailor IF and other implementation strategies to sustain IPV screening in primary care. Sustainment of IPV screening requires attention to a combination of facilitators (e.g., consistent leadership support and robust referral options) as well as addressing key barriers (e.g., staff turnover and competing priorities).

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.

Military Sexual Trauma and its Association with Mental Health Among Sexual Minority and Heterosexual Veterans in the United States.

Purpose: The purpose of this study was to examine the prevalence of military sexual trauma (MST) by sexual orientation, characteristics of sexual minority (SM) and heterosexual veterans who have experienced MST, and associations between sexual orientation and mental health symptoms among veterans who have experienced MST. Methods: Data were analyzed from a nationally representative web-based survey of 4069 U.S. veterans (4.9% SM), which assessed sociodemographic (e.g., age, sexual orientation) and military (e.g., branch) characteristics, and lifetime and current mental health symptoms. Bivariate analyses compared sociodemographic and military characteristics and mental health symptoms among veterans who have experienced MST by sexual orientation. Multivariable logistic regressions examined associations between sexual orientation and mental health symptoms among veterans who have experienced MST, while controlling for differences in sociodemographic characteristics and non-MST traumatic events. Results: The prevalence of MST (7.5% of weighted sample) was higher among SM veterans compared to heterosexual veterans, with bisexual/pansexual/queer veterans endorsing the highest prevalence (22.7%), followed by gay/lesbian (17.0%) and heterosexual (6.5%) veterans. SM veterans who experienced MST were more likely than heterosexual veterans to screen positive for lifetime and current posttraumatic stress disorder (odds ratio [OR] = 3.06 and 3.38, respectively), and current drug use disorder (OR = 3.53). Conclusions: This study adds to growing evidence that mental health symptoms associated with MST disproportionately impact SM veterans relative to heterosexual veterans. Approaches to reducing barriers and tailoring MST-related care to SM veterans, including through addressing cumulative effects of minority stress, are discussed.

Compensation and Pension Exams for Military Sexual Trauma-Related Posttraumatic Stress Disorder: Examiner Perspectives, Clinical Impacts on Veterans, and Strategies.

BACKGROUND: It is estimated that in one in three women veterans experience military sexual trauma (MST), which is strongly associated with posttraumatic stress disorder (PTSD). A 2018 report indicated the Veterans Benefits Administration (VBA) processed approximately 12,000 disability claims annually for PTSD related to MST, most of which are filed by women. Part of the VBA adjudication process involves reviewing information from a Compensation and Pension (C&P) exam, a forensic diagnostic evaluation that helps determine the relationship among military service, diagnoses, and current psychosocial functioning. The quality and outcome of these exams may affect veteran well-being and use of Veterans Health Administration (VHA) mental health care, but no work has looked at examiner perspectives of MST C&P exams and their potential clinical impacts on veteran claimants. METHODS: Thirteen clinicians ("examiners") who conduct MST C&P exams through VHA were interviewed. Data were analyzed using rapid qualitative methods. RESULTS: Examiners described MST exams as more clinically and diagnostically complex than non-MST PTSD exams. Examiners noted that assessing "markers" of MST (indication that MST occurred) could make veterans feel disbelieved; others raised concerns related to malingered PTSD symptoms. Examiners identified unique challenges for veterans who underreport MST (e.g., men and lesbian, gay, bisexual, transgender, and queer [LGBTQ+] veterans), and saw evaluations as a conduit to psychotherapy referrals and utilization of VHA mental health care. Last, examiners used strategies to convey respect and minimize retraumatization, including a standardized process and validating the difficulty of the process. CONCLUSIONS: Examiners' responses offer insight into a process entered by thousands of veterans annually with PTSD. Strengthening the MST C&P process is a unique opportunity to enhance trust in the VBA claims process and increase likelihood of using VHA mental health care, especially for women veterans.

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.

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).

Using the Matrixed Multiple Case Study approach to identify factors affecting the uptake of IPV screening programs following the use of implementation facilitation.

BACKGROUND: Intimate partner violence (IPV) is a prevalent social determinant of health. The US Preventive Services Task Force recommends routine IPV screening of women, but uptake remains variable. The Veterans Health Administration (VHA) initiated implementation facilitation (IF) to support integration of IPV screening programs into primary care clinics. An evaluation of IF efforts showed variability in IPV screening rates across sites. The follow-up study presented here used a Matrixed Multiple Case Study (MMCS) approach to examine the multilevel factors impacting IPV screening program implementation across sites with varying levels of implementation success. METHODS: This mixed methods study is part of a larger cluster randomized stepped wedge Hybrid-II program evaluation. In the larger trial, participating sites received 6 months of IF consisting of an external facilitator from VHA's Office of Women's Health working closely with an internal facilitator and key site personnel. Recognizing the heterogeneity in implementation outcomes across sites, the MMCS approach was used to enable interpretation of qualitative and quantitative data within and across sites to help contextualize the primary findings from the larger study. Qualitative data collection was guided by the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework and included interviews with key informants involved in IPV screening implementation at eight sites. Quantitative data on IPV screening uptake was derived from medical records and surveys completed by key personnel at the same eight sites to understand implementation facilitation activities. RESULTS: Fifteen factors influencing IPV screening implementation spanning all four i-PARIHS domains were identified and categorized into three distinct categories: (1) factors with enabling influence across all sites, (2) factors deemed important to implementation success, and (3) factors differentiating sites with high/medium versus low implementation success. CONCLUSIONS: Understanding the influencing factors across multi-level domains contributing to variable success of IPV screening implementation can inform the tailoring of IF efforts to promote spread and quality of screening. Implementation of IPV screening programs in primary care with IF should consider consistent engagement of internal facilitators with clinic staff involved in implementation, the resourcefulness of external facilitators, and appending resources to IPV screening tools to help key personnel address positive screens. TRIAL REGISTRATION: ClinicalTrials.gov NCT04106193. Registered on September 26, 2019.

Integrating Intimate Partner Violence Screening Programs in Primary Care: Results from a Hybrid-II Implementation-Effectiveness RCT.

INTRODUCTION: The Veterans Health Administration initiated implementation facilitation to integrate intimate partner screening programs in primary care. This study investigates implementation facilitation's impact on implementation and clinical effectiveness outcomes. STUDY DESIGN: A cluster randomized, stepped-wedge, hybrid-II implementation-effectiveness trial (January 2021-April 2022) was conducted amidst the COVID-19 pandemic. SETTING/PARTICIPANTS: Implementation facilitation was applied at 9 Veterans Health Administration facilities, staged across 2 waves. Participants were all women receiving care at participating primary care clinics 3 months before (pre-implementation facilitation n=2,272) and 9 months after initiation of implementation facilitation (implementation facilitation n=5,149). INTERVENTION: Implementation facilitation included an operations-funded external facilitator working for 6 months with a facility-funded internal facilitator from participating clinics. The pre-implementation facilitation period comprised implementation as usual in the Veterans Health Administration. MAIN OUTCOME MEASURES: Primary outcomes were changes in (1) reach of intimate partner violence (IPV) screening programs among eligible women (i.e., those seen within participating clinics during the assessment period; implementation outcome) and (2) disclosure rates among screened women (effectiveness outcome). Secondary outcomes included disclosure rates among all eligible women and post-screening psychosocial service use. Administrative data were analyzed. RESULTS: For primary outcomes, women seen during the implementation facilitation period were nearly 3 times more likely to be screened for IPV than women seen during the pre-implementation facilitation period (OR=2.70, 95% CI=2.46, 2.97). Women screened during the implementation facilitation period were not more likely to disclose IPV than those screened during the pre-implementation facilitation period (OR=1.14, 95% CI=0.86, 1.51). For secondary outcomes, owing to increased reach of screening during implementation facilitation, women seen during the implementation facilitation period were more likely to disclose IPV than those seen during the pre-implementation facilitation period (OR=2.09, 95% CI=1.52, 2.86). Women screened during implementation facilitation were more likely to use post-screening psychosocial services than those screened during pre-implementation facilitation (OR=1.29, 95% CI=1.06, 1.57). CONCLUSIONS: Findings indicate that implementation facilitation may be a promising strategy for increasing the reach of IPV screening programs in primary care, thereby increasing IPV detection and strengthening connections to support services among the patient population. TRIAL REGISTRATION: This study is registered at www. CLINICALTRIALS: gov NCT04106193.

New directions in capacity building: incorporating cultural competence into the interactive systems framework.

The UMBC Psychology Department's Center for Community Collaboration (CCC) provides training and support for capacity building to promote substance abuse and mental health treatment as well as adherence improvement in community agencies funded through the Ryan White Act serving persons living with HIV/AIDS. This article describes an approach to dissemination of Evidence Based Practices (EBPs) for these services that uses the Interactive Systems Framework (ISF) and incorporates a collaborative process involving trainer cultural competence, along with a comprehensive assessment of organizational needs, culture, and climate that culminates in tailored training and ongoing collaboration. This article provides: (1) an overview of the CCC's expanded ISF for the effective dissemination of two EBPs-motivational interviewing and the stages of change perspective; (2) an examination of the role of trainer cultural competence within the ISF framework, particularly attending to organizational culture and climate; and (3) case examples to demonstrate this approach for both general and innovation-specific capacity building in two community based organizations.

Psychology trainee and supervisor perspectives of multicultural supervision.

The development and dissemination of multicultural competence in the field of clinical psychology is garnering increased attention. Providing multicultural supervision enhances multicultural competence and benefits the supervisor, supervisee, and client. However, there is little research on how multicultural supervision is provided and how it could be improved. The purpose of this study was to evaluate multicultural supervision and identity-related harassment within two cohorts of interns (N = 18) and 40 psychology supervisors from a large New England Veterans affairs (VA) Healthcare System. Response rates were 72.2% for trainees and 42.5% for supervisors. Respondents indicated there is significant variability across supervisors in the types and frequency of supervision techniques used. Trainees identified behaviors they would like supervisors to offer more; the most common were "discussion of client's cultural or ethnic background as it relates to clinical presentation or client perspective of challenges" and "discuss how aspects of diversity, power, privilege could influence the therapy relationship." Supervisors also indicated what behaviors they would like to offer more, with the most common being "provide examples of conceptualization or theory that directly incorporate identity" and "provide time/opportunity in supervision for my own self-reflection and examination." A majority of trainees and supervisors (76.9% and 68.8%, respectively) reported experiencing harassment based on an aspect of their identity, most commonly originating from clients. We discuss recommendations for improving multicultural supervision and addressing harassment. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Intimate Partner Violence Screening for Women in the Veterans Health Administration: Temporal Trends from the Early Years of Implementation 2014-2020.

Thousands of women Veterans experience intimate partner violence (IPV) each year. The Veterans Health Administration (VHA) has encouraged IPV screening in Veterans Affairs medical centers (VAMCs) since 2014. Through retrospective analysis of VHA administrative data from fiscal year (FY) 2014 into FY2020, we examined IPV screening implementation outcomes of reach and adoption, as well as screen-positive rates using descriptive and multivariate linear regression analyses. We examined reach and screen-positive rates overall and as a function of childbearing age (18-44 vs. 45+ years). In FY2014 only one VAMC was screening women for IPV; by FY2020, over half of VAMCs had adopted IPV screening. This rollout of IPV screening was associated with a large increase in the number of women primary care patients screened (from fewer than 500 in FY2014, to nearly 35,000 in early FY2020). Overall, among women screened, 6.7% screened positive for IPV; this rate was higher among women of childbearing age (8.1% vs. 5.6%). Despite the spread of IPV screening practices during the early years of implementation in VHA, additional work is needed. This study is the first comprehensive analysis of implementation outcomes associated with VHA's IPV screening efforts, and lays the groundwork for ongoing evaluation and quality improvement.