"The Materials Didn't Really Seem to Apply to Me": A Focus-Group Study on Young Women's Needs and Perspectives on Breast Cancer Educational Material.

Young women breast cancer survivors face unique challenges in navigating diagnosis and treatment information while also navigating their own life demands (i.e., fertility, childcare, careers). Special consideration to printed and online cancer educational materials distributed to young women should be evaluated for their suitability, but few studies have investigated the educational preferences and needs of young women cancer survivors. We sought to explore young women breast cancer survivors' needs and preferences regarding cancer educational material from diagnosis to survivorship. We used a qualitative design with convenience sampling of young women breast cancer survivors who completed active treatment at a medical center within the last 5 years to participate in semi-structured online focus groups from November 2020 to May 2021. Thirty-three young women (75.8% White, 12.1% Black, 12.1% other) participated in one of seven online focus groups, each lasting approximately 2 h. Four dominant themes emerged from the data: (1) initial interaction with online materials; (2) reasons for seeking printed and online materials; (3) disconnection of visuals; and (4) recommendations. Our findings revealed that young women were initially hesitant to seek online information, but later sought printed and online information after specific endorsement of materials. Current breast cancer materials lack content specific to young women's needs (i.e., reconstruction options), and graphics have little age and racial diversity. Oncology nurses may consider novel methods of education delivery, such as short videos to be shared easily on social media for specific content like scarring results and reconstruction options.

Heart Disease Knowledge and Awareness in African American and Hispanic Women.

OBJECTIVES: Coronary heart disease (CHD) is the leading cause of morbidity and mortality among US women. Minority women have higher rates of CHD and are more likely to experience adverse outcomes. Because of racial disparities in CHD outcomes, the purpose of this study was to assess CHD knowledge and awareness in African American and Hispanic women. METHODS: Using a survey research design, a convenience sample of African American and Hispanic women was surveyed in their local communities. CHD knowledge, awareness, and demographic data were collected using an online survey. The survey was administered in English and Spanish using an iPad. CHD knowledge was assessed using a 7-item survey based on the American Heart Association's Life's Simple 7 brochure. CHD awareness was assessed using a 7-item survey adapted from the American Heart Association's Survey of Women's Cardiovascular Disease Awareness. CHD knowledge was scored on a scale of 0 to 7, and awareness was assessed based on responses to each question. The data analysis consisted of cross-tabulations and multivariable repeated measures analysis. We assessed differences in CHD knowledge and awareness based on race/ethnicity. We hypothesized that there would be statistically significant differences in CHD knowledge and awareness based on specific demographic factors (eg, age, income, education, health literacy). RESULTS: A total of 100 African American (n=50) and Hispanic (n = 50) women participated in the study. Results revealed that CHD knowledge and awareness were limited for both groups. Seventy-three percent of participants (African American 66%; Hispanic 80%) did not know that CHD is the leading cause of death in women and 75% (African American 60%; Hispanic 90%) were moderately or not at all informed about CHD. CONCLUSIONS: These findings support the need for more research on innovative strategies to improve CHD knowledge and awareness, particularly in African American and Hispanic women who are at highest risk, thereby addressing racial/ethnic and gender disparities in CHD morbidity and mortality.

Ten-Year Differences in Women's Awareness Related to Coronary Heart Disease: Results of the 2019 American Heart Association National Survey: A Special Report From the American Heart Association.

BACKGROUND: High awareness that cardiovascular disease is the leading cause of death (LCOD) among women is critical to prevention. This study evaluated longitudinal trends in this awareness among women. METHODS AND RESULTS: Online surveys of US women (≥25 years of age) were conducted in January 2009 and January 2019. Data were weighted to the US population distribution of sociodemographic characteristics. Multivariable logistic regression was used to evaluate knowledge of the LCOD. In 2009, awareness of heart disease as the LCOD was 65%, decreasing to 44% in 2019. In 2019, awareness was greater with older age and increasing education and lower among non-White women and women with hypertension. The 10-year awareness decline was observed in all races/ethnicities and ages except women ≥65 years of age. The greatest declines were among Hispanic women (odds ratio of awareness comparing 2019 to 2009, 0.14 [95% CI, 0.07-0.28]), non-Hispanic Black women (odds ratio, 0.31 [95% CI, 0.19-0.49]), and 25- to 34-year-olds (odds ratio, 0.19 [95% CI, 0.10-0.34]). In 2019, women were more likely than in 2009 to incorrectly identify breast cancer as the LCOD (odds ratio, 2.59 [95% CI, 1.86-3.67]), an association that was greater in younger women. Awareness of heart attack symptoms also declined. CONCLUSIONS: Awareness that heart disease is the LCOD among women declined from 2009 to 2019, particularly among Hispanic and non-Hispanic Black women and in younger women (in whom primordial/primary prevention may be most effective). An urgent redoubling of efforts by organizations interested in women's health is required to reverse these trends.

Revising Recruitment for Focus Groups to Meet Shifting Needs During COVID-19.

BACKGROUND: The COVID-19 pandemic forced researchers to modify recruitment strategies to meet accrual goals for qualitative studies. Traditional methods of in-person recruiting and using paper marketing material were eliminated almost overnight at the onset of the pandemic. Researchers quickly adapted their recruitment strategies, but researchers had to shift local, in-person recruitment efforts to solely using online platforms. The shifting recruitment strategies were accompanied with unexpected challenges, but we were able to meet our accrual goal for focus groups. OBJECTIVES: The objective of this brief report is to explore new recruitment strategies that developed during the COVID-19 pandemic and offer suggestions for future online-based qualitative studies. RESULTS: Prior to COVID-19, we designed four main strategies (research registry, marketing material, social media, and provider endorsement) to recruit potential participants for focus groups as part of a qualitative, descriptive study involving young women breast cancer survivors. After the onset of COVID-19, we successfully adapted each of our initial four strategies to recruit potential participants in an incremental process. Using these adapted strategies, a total of 62 young women completed the first part of the data collection process prior to participating in a focus group. Thirty-three women participated in the focus groups, and the remaining 29 participants were lost to follow-up. The vast majority of participants were recruited through marketing material and social media after making strategic changes to recruitment. DISCUSSION: The most effective method of recruitment was the strategic use of marketing material and social media, and we offer suggestions for researchers considering online recruitment methods. We recommend that researchers use various social media platforms and specific hashtags and target their sample population at the onset of the study. The data collection changes initiated by the effects of COVID-19 may remain, and researchers can consider implementing permanent recruitment strategies to best meet the needs of this new landscape of conducing online focus groups.

What's in Between the Lines: Assessing the Readability, Understandability, and Actionability in Breast Cancer Survivorship Print Materials.

Educational print materials for young women breast cancer survivors (YBCS) are supplemental tools used in patient teaching. However, the readability of the text coupled with how well YBCS understand or act upon the material are rarely explored. The purpose of this study was to assess the readability, understandability, and actionability of commonly distributed breast cancer survivorship print materials. We used an environmental scan approach to obtain a sample of breast cancer survivorship print materials available in outpatient oncology clinics in the central region of a largely rural Southern state. The readability analyses were completed using the Flesch-Kincaid (F-K), Fry Graph Readability Formula (Fry), and Simple Measure of Gobbledygook (SMOG). Understandability and actionability were analyzed using Patient Education Materials Assessment Tool for Printable Materials (PEMAT-P). The environmental scan resulted in a final sample of 14 materials. The mean readability of the majority of survivorship materials was "difficult," but the majority scored above the recommended 70% in both understandability and actionability. The importance of understandability and actionability may outweigh readability results in cancer education survivorship material. While reading grade level cannot be dismissed all together, we surmise that patient behavior may hinge more on other factors such as understandability and actionability. Personalized teaching accompanying print material may help YBCS comprehend key messages and promote acting upon specific tasks.

Self-management Needs of Adults With Congenital Heart Disease.

BACKGROUND: Adults with congenital heart disease (CHD) are an emerging adult heart disease subset, now outnumbering the pediatric population with CHD. OBJECTIVE: We aimed to gain understanding and knowledge of what adults with CHD perceive as important for self-management and describe these needs across demographic factors, developmental characteristics, lesion severity, and quality of life. METHODS: We used a descriptive mixed-methods online survey merging 4 instruments: Adult CHD Self-management Experience Questionnaire; Adult CHD Demographic Questionnaire; Adaptive Behavior Assessment System, Third Edition; and Stanford Quality of Life Visual Numeric. Participants with CHD 18 to 30 years of age with initial defect repair before 12 months of age were recruited through support from the Adult Congenital Heart Association, clinic adult CHD support groups, and newspaper advertising. Thematic analysis for short-answer questions, descriptive analysis for demographic data and the visual numeric, and intrument-specific scoring assistant software for the Adaptive Behavior Assessment System were used. RESULTS: We received 22 responses from 13 women and 9 men. These individuals represented 15 different heart defect diagnoses, mostly of moderate or complex lesion severity. Most had postsecondary education and were employed. Four prominent themes emerged related to self-management: desire for connectivity-psychological support; a plan for the future-education about health and life expectations; coping needs-skills for mental stress; and access to care-navigation of healthcare systems. CONCLUSIONS: Future longitudinal research and replication studies with larger samples are needed. Educational materials and targeted interventions that promote self-management benefit the aging adult with CHD population.

Developing and Launching a Research Participant Registry.

BACKGROUND: A major challenge in clinical research today is the difficulty that studies have in meeting recruitment goals. Up to 48% of studies do not meet accrual goals within the specified timeframe, significantly delaying the progress of projects and the dissemination of findings. This pervasive problem is a recruitment crisis. We developed a representative, ethnically and racially diverse research participant registry in a predominantly rural state with high levels of health care disparities and minority populations. We sought input at each step of development from members of community advisory boards (CABs) across Arkansas. We report how community involvement in the development of the registry was implemented. METHODS: Members of CABs were partners in developing all aspects of the registry website, including the name, content, appearance, educational messages, and testimonials used. Constructs from the Health Belief Model informed the educational messages and supported the intense multimedia campaign used to launch and promote ongoing registrations. Using CAB guidance, community events were held throughout the state of Arkansas at venues with diverse racial and ethnic attendance. RESULTS: From April 1, 2016 to September 1, 2017, 4,002 people registered statewide who match the demographic profile of Arkansas. CONCLUSION: CAB involvement in the registry, multiple cues to action, and face-to-face contact with diverse lay audiences throughout the state were key components of the successful registry launch.

Impact of the INBRE summer student mentored research program on undergraduate students in Arkansas.

The Institutional Development Award (IDeA) program, housed within the National Institute for General Medical Sciences, administers the Networks of Biomedical Research Excellence (INBRE) as a strategic mission to broaden the geographic distribution of National Institutes of Health (NIH) funding within the United States. Undergraduate summer student mentored research programs (SSMRP) are a common feature of INBRE programs and are designed to increase undergraduate student interest in research careers in the biomedical sciences. Little information is available about student perspectives on how these programs impact their choices relative to education and careers. Therefore, we conducted qualitative interviews with 20 participants from the Arkansas INBRE SSMRP in the years 2002-2012. Each telephone interview lasted 30-45 min. An interview guide with a broad "grand tour" question was used to elicit student perspectives on SSMRP participation. Interviews were digitally recorded, then transcribed verbatim, and the transcript checked for accuracy. Content analysis and constant comparison were used to identify nine themes that were grouped into three temporal categories: before, during, and after the SSMRP experience. Students viewed the experience as positive and felt it impacted their career choices. They emphasized the value of mentoring in the program, and some reported maintaining a relationship with the mentor after the summer experience ended. Students also valued learning new laboratory and presentation skills and felt their research experience was enhanced by meeting students and scientists with a wide range of career interests. These data suggest that the Arkansas INBRE and the NIH IDeA program are successfully meeting the goal of increasing interest in research among undergraduates.

"I'm Not Fighting Anymore So What Do I Do Now?" Young Women's Challenges While Transitioning Out of Active Breast Cancer Treatment and into Survivorship.

Young women (18-45 years of age) with breast cancer often view the end of active treatment as a significant milestone. While completing treatment is largely celebrated, little is known about the immediate time after completing active treatment. The purpose of this qualitative, descriptive study was to explore the needs of young women survivors transitioning out of active breast cancer treatment and into survivorship. We used a qualitative design with convenience sampling of young women who completed active breast cancer treatment within the last 5 years to participate in semi-structured online focus groups from November 2020 to May 2021. Thematic analysis was used to reveal the needs as women transitioned out of active treatment and into survivorship. Thirty-three young women breast cancer survivors (75.8% White, 12.1% Black, 12.1% other) participated in 7 online focus groups each lasting approximately 90 min. Three dominant themes with accompanying subthemes emerged from the data: (1) "feeling like a different kind of woman" (physical [cognitive, weight, sexual] changes, emotional changes [defining normal, loss of purpose]); (2) lingering emotional trauma (active treatment, survivorship); and (3) recommendations (services needed, content needed). Participants in this study did not feel prepared for the physical and emotional changes associated with the transition from active treatment and into survivorship as identified in our 2 main themes of "feeling like a different kind of woman" and lingering emotional trauma. Participants recommended more thorough communication about expectations in survivorship focusing on physical aspects like cognitive, weight, and sexual changes as well emotional challenges like loss of identity in survivorship. More communication specific to young women could assist in the transition to survivorship.

Impact of Attitudes and Rurality on Veterans' Use of Veterans Health Administration Mental Health Services.

OBJECTIVE: Veterans, especially those residing in rural areas, continue to underutilize mental health care. This longitudinal study assessed attitudes relevant to seeking mental health care services from the Veterans Health Administration (VHA) over 12 months, adjusting for residence. METHODS: A questionnaire addressing attitudes, sociodemographic factors, residence, place identity, perceived health status and needs, and structural barriers was administered by telephone to 752 veterans with previous VHA service use. Service use data were obtained from a VHA database. RESULTS: In adjusted models, four attitudes were significantly associated with underuse of VHA mental health care (no use vs. any use; no use vs. nonsustained use vs. sustained use). Higher levels of mistrust of others (adjusted odds ratio [AOR]=1.06, p=0.046), emotional stoicism (AOR=1.08, p=0.003), belief in the self-resolving nature of mental health problems (AOR=1.91, p=0.015), and belief in the efficacy of religious counseling for such problems (AOR=1.09, p=0.022) were associated with no subsequent service use versus any use. Place identity (suburban), older age, and greater need were associated with greater odds of VHA use. For the comparison of no use versus sustained use, women had lower odds of no use (AOR=0.49, p<0.001); similarly, women had lower odds of nonsustained use versus sustained use (AOR=0.45, p<0.001). CONCLUSIONS: The association of potentially modifiable attitudes with underuse of VHA mental health services suggests that attitudes offer useful targets for efforts to increase mental health care use. That these attitudes were influential regardless of residence suggests that programs addressing attitudinal barriers can be broadly targeted.

Cluster analysis of women's prodromal and acute myocardial infarction symptoms by race and other characteristics.

BACKGROUND AND OBJECTIVE: Although research has identified women's prodromal and acute myocardial infarction (MI) symptoms, diagnosing coronary heart disease in women remains challenging. Knowing how individual symptoms cluster by race and other characteristics would provide key diagnostic information. We performed a secondary analysis to: (a) generate naturally occurring symptom clusters based on prodromal and acute MI symptom scores separately, (b) examine the association between women's characteristics and symptom clusters, and (c) describe the percentage of women who reported experiencing the same symptoms in both prodromal and acute MI phases. SUBJECT AND METHODS: The database contained retrospective self-reported data obtained by telephone survey from 1270 women (43% black, 42% white, 15% Hispanic) with a confirmed MI recruited from 15 geographically diverse sites. Data included frequency and severity of 33 prodromal symptoms, intensity of 37 acute MI symptoms, and comorbidities/risk factors. We used both bivariate and multivariate analyses to examine associations between cluster assignment and characteristics/risk factors. Because of the possibility of complex interactions, we explored nonlinear interactions with recursive partitioning. RESULTS: Cluster analysis yielded 3 naturally occurring clusters for each of the prodromal and acute symptom sets. Each cluster contained women who reported increasing frequency and severity of symptoms. Six characteristics (age, race, body mass index, personal history of heart disease, diabetes, smoking status) were strongly associated with the clusters. Body mass index was the most important factor in classifying prodromal symptoms, whereas age was for acute symptoms. CONCLUSIONS: Black women younger than 50 years were more likely to report frequent and intense prodromal symptoms, whereas older white women reported the least. Younger, obese, diabetic black women reported the most acute symptoms, whereas older nonobese, nondiabetic white women reported the fewest. Symptom clusters and characteristics of women in these clusters provide valuable diagnostic information. Further research with a control group is needed.

Challenges in tailored intervention research.

Although individuals and nurses value tailored health interventions, incorporating tailored interventions into research is fraught with pitfalls. This manuscript provides guidance on addressing challenges on developing, implementing, and evaluating tailored interventions (TIs). The initial step in designing TIs involves selecting the individual characteristics on which to tailor the intervention. After selecting critical characteristics for tailoring, researchers must decide how to assess these characteristics. Then researchers can use manuals, algorithms, or computer programs to tailor an intervention and maintain treatment fidelity. If desired outcomes are not achieved, focus groups or individual interviews may be conducted to gather information to improve the intervention for specific individuals/groups. Then, incorporating study arms of TIs in intervention studies, investigators may compare TIs with standardized interventions statistically and clinically. We believe TIs may have better outcomes, promote better adherence, and be more cost efficient.

Barriers and solutions to implementing a pragmatic diabetes education trial in rural primary care clinics.

INTRODUCTION: The purpose of this report is to describe barriers and solutions to the implementation and optimization of a pragmatic trial that tests an evidence-based, patient-centered, low literacy intervention promoting diabetes self-care in rural primary care clinics. METHODS: The two-arm pragmatic trial has been implemented in six rural family medicine clinics in Arkansas. It tests a self-management education and counseling intervention for patients with type 2 diabetes compared to enhanced usual care. Barriers and solutions were identified as issues arose and through interviews with clinic directors and clinic administrators and a focus group, interviews, and tracking reports with clinic health coaches who delivered the intervention. RESULTS: Barriers to optimizing enrollment, intervention delivery, and data collection were addressed through targeted education of and relationship building with leadership, changing enrollment oversight, and ongoing training of health coaches. CONCLUSIONS: Successful implementation and optimization of this pragmatic clinical trial in rural primary care clinics was achieved through establishing common goals with clinic leadership, minimizing demands on clinic staff and administration, frequent contact and ongoing support of health coaches, and collaborative troubleshooting of issues with delivering the intervention.

Rationale and development of a randomized pragmatic trial to improve diabetes outcomes in patient-centered medical homes serving rural patients.

Proper diabetes self-care requires patients to have considerable knowledge, a range of skills, and to sustain multiple health behaviors. Self-management interventions are needed that can be readily implemented and sustained in rural clinics with limited resources that disproportionately care for patients with limited literacy. Researchers on our team developed an evidence-based, patient-centered, low literacy intervention promoting diabetes self-care that includes: 1) the American College of Physicians (ACP) Diabetes Guide that uses plain language and descriptive photographs to teach core diabetes concepts and empower patients to initiate behavior change; 2) a brief counseling strategy to assist patients in developing short-term, explicit and attainable goals for behavior change ('action plans'); and 3) a training module for health coaches that prepares them to assume educator/counselor roles with the Diabetes Guide as a teaching tool. While the intervention has previously been field tested and found to significantly improve patient knowledge, self-efficacy, and engagement in related health behaviors, its optimal implementation is not known. This project took advantage of a unique opportunity to modify and disseminate the ACP health literacy intervention among patients with type 2 diabetes cared for at rural clinics in Arkansas that are Patient-Centered Medical Homes (PCMH). These practices all had health coaches that could be leveraged to provide chronic disease self-management mostly via phone, but also at the point-of-care. Hence we conducted a patient-randomized, pragmatic clinical trial in 6 rural PCMHs in Arkansas, targeting individuals with uncontrolled type 2 diabetes.

Women's prehospital delay associated with myocardial infarction: does race really matter?

UNLABELLED: BACKGROUND/RESEARCH OBJECTIVE: Well-documented disparities in cardiovascular health account for approximately one third of the difference in life expectancy between blacks and whites. Mortality from cardiovascular disease is greater among black women than among white women, and black women report longer delays in treatment seeking following onset of symptoms of acute myocardial infarction (AMI). Despite this disparate burden, there is little race-specific data on correlates of delay for black or white women. This secondary data analysis compares duration and correlates of delay in treatment seeking by race following onset of AMI symptoms. SUBJECTS/METHODS: We analyzed self-report data from 509 black and 500 white women, interviewed 4 to 6 months after AMI, using multivariable logistic and linear regression. RESULTS/CONCLUSIONS: Median delay time was nonsignificantly shorter for black than for white women (1.0 vs 1.5 hours). Equal proportions of black and white women (57% vs 54%) sought treatment within 2 hours of symptom onset. In multivariable analyses, correct attribution of symptoms to AMI was a significant predictor of treatment seeking within 2 hours of symptom onset for black and white women (odds ratios = 2.79 and 3.86, respectively); eligibility for public insurance was a significant predictor for black women only (odds ratio = 2.3). Common comorbidities, AMI risk factors, and other demographics were not significantly associated with delay time. Insurance coverage and the correct attribution of symptoms to cardiac causes are substantial and modifiable predictors of delay in seeking treatment of AMI.

Using the McSweeney Acute and Prodromal Myocardial Infarction Symptom Survey to Predict the Occurrence of Short-Term Coronary Heart Disease Events in Women.

BACKGROUND: Few instruments capture symptoms that predict cardiac events in the short-term. This study examines the ability of the McSweeney Acute and Prodromal Myocardial Infarction Symptom Survey to predict acute cardiac events within 3 months of administration and to identify the prodromal symptoms most associated with short-term risk in women without known coronary heart disease. METHODS: The McSweeney Acute and Prodromal Myocardial Infarction Symptom Survey was administered to 1,097 women referred to a cardiologist for initial coronary heart disease evaluation. Logistic regression models were used to examine prodromal symptoms individually and in combination to identify the subset of symptoms most predictive of an event within 3 months. RESULTS: Fifty-one women had an early cardiac event. In bivariate analyses, 4 of 30 prodromal symptoms were significantly associated with event occurrence within 90 days. In adjusted analyses, women reporting arm pain or discomfort and unusual fatigue were more likely (OR, 4.67; 95% CI, 2.08-10.48) to have a cardiac event than women reporting neither. CONCLUSIONS: The McSweeney Acute and Prodromal Myocardial Infarction Symptom Survey may assist in predicting short-term coronary heart disease events in women without known coronary heart disease.

A Review of the Literature on Cardiac Symptoms in Older and Younger Women.

OBJECTIVE: To describe acute and prodromal cardiac symptoms in older and younger women. DATA SOURCES: PubMed, CINAHL, MEDLINE, and Web of Science databases were searched for articles published between January 2000 and January 2015. STUDY SELECTION: A combination of the MESH terms acute coronary syndrome, myocardial infarction, symptoms, prodromal symptoms, sex, gender, and age was used. The search was limited to studies on humans published in English and original articles related to symptoms of acute coronary syndrome (ACS) in women with symptoms stratified by age or analyses adjusted for age and/or sex. DATA EXTRACTION: A total of 432 articles were identified, and 20 met the inclusion criteria. DATA SYNTHESIS: Key findings for differences in acute ACS symptoms for women based on age included the following: (a) typical chest pain and pain of any kind were less likely in older women (≥65 years); (b) women were more likely to have nonpain symptoms of nausea, dyspnea, and fatigue after adjustment for age; (c) most researchers did not adjust for menopausal status or hormone replacement therapy; and (d) findings were consistent across international cohorts. The most common prodromal symptoms in women after adjustment for age included unusual fatigue, discomfort in arms, sleep disturbance, anxiety, general chest discomfort, discomfort in jaws/teeth, and shortness of breath. Although chest symptoms were reported by some women, they were not reported by most women. CONCLUSION: Women older than 65 years with ACS experienced fewer symptoms, more ambiguous symptoms, less chest pain, and more dyspnea. Women older than 50 years were more likely to report prodromal symptoms that include sleep disturbance. Many symptom differences that were statistically significant by age, such as chest pain and shortness of breath, may not be clinically relevant.

Overcoming Barriers to Sustained Engagement in Mental Health Care: Perspectives of Rural Veterans and Providers.

PURPOSE: To better understand the attitudes, beliefs, and values that influence use of mental health care among rural veterans. METHODS: In-depth, semistructured interviews were conducted with 25 rural veterans and 11 rural mental health care providers in 4 states. Experienced qualitative interviewers asked participants about the attitudinal factors they thought most influenced rural veterans' decisions to seek and sustain mental health care. Verbatim transcriptions were analyzed using content analysis and constant comparison. FINDINGS: Rural veterans and their mental health care providers reported the same major attitudinal barriers to veterans' mental health treatment-seeking. Pre-eminent among those barriers was the importance rural veterans place on independence and self-reliance. The centrality of self-reliance was attributed variously to rural, military, religious, and/or gender-based belief systems. Stoicism, the stigma associated with mental illness and health care, and a lack of trust in the VA as a caring organization were also frequently mentioned. Perceived need for care and the support of other veterans were critical to overcoming attitudinal barriers to initial treatment-seeking, whereas critical facilitators of ongoing service use included "warm handoffs" from medical to mental health care providers, perceived respect and caring from providers, as well as provider accessibility and continuity. CONCLUSIONS: Attitudes and values, like self-reliance, commonly associated with rural culture may play an important role in underutilization of needed mental health services. System support for peer and provider behaviors that generate trust and demonstrate caring may help overcome attitudinal barriers to treatment-seeking and sustained engagement in mental health care among rural veterans.