"Something Has to Be Done to Make Women Feel Safe": Women Veterans' Recommendations for Strengthening the Veterans Crisis Line for Women Veterans.

OBJECTIVE: Women represent 15% of veteran callers to the Veterans Crisis Line (VCL); there has been little research identifying the experiences and needs of women veterans who use the VCL. The objective of this study was to identify women veterans' experiences with and recommendations for strengthening VCL services for women. METHOD: We conducted qualitative interviews with 26 women veterans across the United States who had contacted the VCL in the preceding year. Interviews were conducted by telephone in 2022 and were audio recorded and transcribed. A team-based content analysis approach was used to identify participants' concerns around contacting the VCL and recommendations for strengthening the service. RESULTS: Interviews revealed women veterans' concerns with regard to contacting the VCL related to responder gender, appropriateness of VCL services for veterans not at imminent risk for suicide, and potential consequences of contacting the VCL. Key recommendations included letting veterans select the gender of the responder who takes their call, providing more information to potential callers about what to expect from VCL calls, and raising awareness about and maintaining options for caller anonymity. CONCLUSIONS: This study uniquely focused on women veterans' experiences and perspectives, in their own voices. Findings point to trauma-informed approaches supporting women veteran callers to the VCL and may also hold implications for other similar crisis hotline services.

Relationship between Veterans Crisis Line risk rating and subsequent suicidal self-directed violence among veteran callers: A gender comparison.

BACKGROUND: Disparities in suicide rates by veteran status are particularly striking for women. Veterans Crisis Line (VCL) is a preventive strategy. OBJECTIVES: Examine the relationships and gender differences between VCL risk rating, and subsequent suicidal self-directed violence (SSDV) in the 12-months following VCL index call. METHODS: Cohort study of VCL callers in 2018. OUTCOMES: Dichotomized composite SSDV (non-fatal suicide event and/or suicide) in the 12 months following VCL call. RESULTS: Veterans with high/moderate VCL risk had significantly higher odds of SSDV (OR = 4.02, 95% CI: 3.75, 4.30). There were no gender/VCL risk interaction (p = 0.3605). We also examined the association of gender, combination of VCL risk and suicide attempt (SA) history, on SSDV. Differential odds of SSDV for gender and combined VCL risk and SA history combinations were observed (p = 0.0005). Compared to those with lower VCL risk without SA history, those with high/moderate VCL risk with SA history showed higher odds of SSDV. Magnitude was higher for men, than for women veterans. CONCLUSIONS AND RELEVANCE: Veterans Crisis Line risk assessment performs relatively stable across the gender binary and highlights potential gender differences when factoring in SA history. Combining risk assessment and attempt history may lead to effective suicide prevention strategies.

Improving suicide prevention for women veterans: Recommendations from VHA suicide prevention coordinators.

OBJECTIVE: Women are a minority veteran subpopulation experiencing particular risk for suicide and facing distinct challenges in accessing Veterans Health Administration (VHA) care. As part of efforts to enhance suicide prevention, the VHA established Suicide Prevention Coordinators (SPC) as clinicians who work exclusively to connect high-risk veterans to the scope of VHA's services. To understand the experiences of women veterans with suicide risk who access care, this study presents findings from qualitative interviews with SPCs regarding the care needs, preferences, and concerns of women veterans who utilize VHA for enhanced suicide-related care. METHODS: We conducted qualitative interviews with 20 SPCs from 13 VAMCs around the United States. We specifically asked SPCs to share perspectives on women veterans' barriers to accessing care and their recommendations to improve suicide prevention for this subpopulation. We conducted a thematic content analysis to extract key themes. RESULTS: SPCs revealed that women veterans opt to avoid VHA due to prior negative experiences, often related to provider sensitivity to women's issues. Safety was another key concern, specifically related to feeling unwelcome or intimidated in the male dominated veteran community. Key provider recommendations include increasing the availability of gender-sensitive providers and making changes to the physical spaces of the VHA to better facilitate women veterans' access to care. CONCLUSIONS: SPCs underscored the importance of comfort and relatability between women patients and providers, especially in relation to enhanced care for suicide risk. This study presents important evidence in support of enhancing suicide prevention by better engaging women veterans in care that is more inclusive and more sensitive to their experiences and identity, in and outside VHA.

Characterizing Twitter Content About HIV Pre-exposure Prophylaxis (PrEP) for Women: Qualitative Content Analysis.

BACKGROUND: HIV remains a persistent health problem in the United States, especially among women. Approved in 2012, HIV pre-exposure prophylaxis (PrEP) is a daily pill or bimonthly injection that can be taken by individuals at increased risk of contracting HIV to reduce their risk of new infection. Women who are at risk of HIV face numerous barriers to HIV services and information, underscoring the critical need for strategies to increase awareness of evidence-based HIV prevention methods, such as HIV PrEP, among women. OBJECTIVE: We aimed to identify historical trends in the use of Twitter hashtags specific to women and HIV PrEP and explore content about women and PrEP shared through Twitter. METHODS: This was a qualitative descriptive study using a purposive sample of tweets containing hashtags related to women and HIV PrEP from 2009 to 2022. Tweets were collected via Twitter's API. Each Twitter user profile, tweet, and related links were coded using content analysis, guided by the framework of the Health Belief Model (HBM) to generate results. We used a factor analysis to identify salient clusters of tweets. RESULTS: A total of 1256 tweets from 396 unique users were relevant to our study focus of content about PrEP specifically for women (1256/2908, 43.2% of eligible tweets). We found that this sample of tweets was posted mostly by organizations. The 2 largest groups of individual users were activists and advocates (61/396, 15.4%) and personal users (54/396, 13.6%). Among individual users, most were female (100/166, 60%) and American (256/396, 64.6%). The earliest relevant tweet in our sample was posted in mid-2014 and the number of tweets significantly decreased after 2018. We found that 61% (496/820) of relevant tweets contained links to informational websites intended to provide guidance and resources or promote access to PrEP. Most tweets specifically targeted people of color, including through the use of imagery and symbolism. In addition to inclusive imagery, our factor analysis indicated that more than a third of tweets were intended to share information and promote PrEP to people of color. Less than half of tweets contained any HBM concepts, and only a few contained cues to action. Lastly, while our sample included only tweets relevant to women, we found that the tweets directed to lesbian, gay, bisexual, transgender, queer (LGBTQ) audiences received the highest levels of audience engagement. CONCLUSIONS: These findings point to several areas for improvement in future social media campaigns directed at women about PrEP. First, future posts would benefit from including more theoretical constructs, such as self-efficacy and cues to action. Second, organizations posting on Twitter should continue to broaden their audience and followers to reach more people. Lastly, tweets should leverage the momentum and strategies used by the LGBTQ community to reach broader audiences and destigmatize PrEP use across all communities.

Multidisciplinary teams, efficient communication, procedure services, and telehealth improve cirrhosis care: A qualitative study.

BACKGROUND: Cirrhosis care and outcomes are improved with access to subspecialty gastroenterology and hepatology care. In qualitative interviews, we investigated clinicians' perceptions of factors that optimize or impede cirrhosis care. METHODS: We conducted 24 telephone interviews with subspecialty clinicians at 7 Veterans Affairs medical centers with high- and low-complexity services. Purposive sampling stratified Veterans Affairs medical centers on timely post-hospitalization follow-up, a quality measure. We asked open-ended questions about facilitators and barriers of care coordination, access to appointments, procedures, transplantation, management of complications, keeping up to date with medical knowledge, and telehealth use. RESULTS: Key themes that facilitated care were structural: multidisciplinary teams, clinical dashboards, mechanisms for appointment tracking and reminders, and local or virtual access to transplant and liver cancer specialists through the "specialty care access network extension for community health care outcomes" program. Coordination and efficient communication between transplant and non-transplant specialists and between transplant and primary care facilitated timely care. Same-day access to laboratory, procedural, and clinical services is an indicator of high-quality care. Barriers included lack of on-site procedural services, clinician turnover, patient social needs related to transportation, costs, and patient forgetfulness due to HE. Telehealth enabled lower complexity sites to obtain recommendations for complex patient cases. Barriers to telehealth included lack of credit (eg, VA billing equivalent), inadequate staff, lack of audiovisual technology support, and patient and staff discomfort with technology. Telehealth was optimal for return visits, cases where physical examination was nonessential, and where distance and transportation precluded in-person care. Rapid telehealth uptake during the COVID-19 pandemic was a positive disruptor and facilitated use. CONCLUSIONS: We identify multi-level factors related to structure, staffing, technology, and care organization to optimize cirrhosis care delivery.

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.

Outreach to the Veterans Crisis Line During the COVID-19 Pandemic: A Mixed-Methods Analysis.

OBJECTIVE: The mental health impacts of the COVID-19 pandemic have been widely felt among already vulnerable populations, such as U.S. military veterans, including a heightened risk for depression and suicidal ideation. Support hotlines such as the Veterans Crisis Line (VCL) took a central role in addressing various concerns from callers in distress; research has yet to examine the concerns of veterans who used the VCL during the early months of the pandemic. METHODS: A mixed-methods analysis of characteristics of veteran outreach to the VCL during the first year of the COVID-19 pandemic in the United States was conducted on 342,248 calls during April-December 2020; 3.8% (N=12,869) of calls were coded as related to COVID-19. Quantitative examination was conducted regarding COVID-19-related reasons for contact, suicide risk screens, and caller concerns; 360 unique calls with synopsis notes that included a COVID-19 flag were qualitatively analyzed. RESULTS: Quantitative analysis of the calls with a COVID-19 flag revealed mental health concerns, loneliness, and suicidal thoughts as top reasons veterans contacted the VCL during the pandemic. Qualitative analysis identified specific economic and mental health concerns, including negative impacts on income and housing, increased feelings of depression or anxiety, and pandemic-specific concerns such as testing and vaccine availability. Disrupted access to resources for coping, including support groups or gyms, had negative perceived impacts and sometimes exacerbated preexisting problems such as substance abuse or depression. CONCLUSIONS: These findings emphasize the role of VCL as providing general support to veterans experiencing loneliness and supplying assistance in coping with pandemic-related distress.

Gender differences in veterans' use of the Veterans Crisis Line (VCL): Findings from VCL call data.

OBJECTIVE: To compare characteristics of calls to the Veterans Crisis Line (VCL) by caller gender and identify potentially unique needs of women callers. METHOD: Retrospective review of clinical data collected during VCL calls, comparing call characteristics between women and men veteran callers. RESULTS: The data included 116,029 calls by women veterans and 651,239 calls by men veterans between January 1, 2018-December 31, 2019. Timing (hour/day/season) of VCL calls was similar between women and men callers. We observed gender differences in reason for call, with the most salient differences in reasons related to interpersonal violence, including sexual trauma (e.g., military sexual trauma as reason for call - prevalence ratio (PR) for women vs. men = 9.13, 95% CI = 8.83, 9.46). Women callers were also more likely than men callers to screen positive for suicide risk (PR = 1.28, 95% CI = 1.26, 1.29), receive a higher suicide risk assessment rating (PR = 1.05, 95% CI = 1.02, 1.07), and be referred to a VA Suicide Prevention Coordinator for follow-up (PR = 1.09, 95% CI = 1.09, 1.11). CONCLUSIONS: Analysis of VCL call data indicated both similarities and differences across genders in call characteristics, including interpersonal relationships and experiences of abuse and assault as particularly salient factors prompting women veterans' calls to VCL. This study also suggests the presence of increased suicide risk among women versus men veteran VCL callers.

"That is Care That you Just can't fake!": Identifying Best Practices for the Care of Vietnam Veterans at End of Life.

CONTEXT: We reviewed the Veterans Health Administration Bereaved Family Survey's open-ended responses to understand end-of-life (EOL) care best practices for Vietnam and pre-Vietnam Veterans. OBJECTIVES: To identify 1) recommendations for improved EOL care enhancements for older Veterans, 2) a model of best practices in EOL care for Veterans, and 3) any relevant differences in best practices between Vietnam and prior war eras. METHODS: We examined five years of Bereaved Family Survey data (n = 2784), collected between 2013 and 2017, from bereaved family members of Veterans focusing on 2 open-ended questions: 1) Is there anything else you would like to share about the Veteran's care during his last month of life? 2) Is there anything else you would like to share about how the care could have been improved for the Veteran? Applied thematic analysis identified successes and challenges in the experience of the bereaved of Vietnam and pre-Vietnam era Veterans. RESULTS: Regardless of war era and death venue, a patient-centered approach to EOL care with readily available staff who could 1) provide ongoing support, comfort, honor, and validation; 2) routinely adjust to the patient's changing needs; 3) and provide clear, honest, timely, compassionate communication was important to the bereaved. Consideration of the uniqueness of Vietnam Veterans is beneficial. CONCLUSIONS: Patient-centered EOL care should include assigning a point of contact that follows the patient, educates the family on expectations, ensures the patient's changing needs are met, ensures the family has appropriate support, and communicates updates to the family throughout the patient's care continuum.

The Gears of Knowledge Translation: Process Evaluation of the Dissemination and Implementation of a Patient Engagement Toolkit.

BACKGROUND: Patient engagement is a key tenet of patient-centered care and is associated with many positive health outcomes. To improve resources for patient engagement, we created a web-based, interactive patient engagement toolkit to improve patient engagement in primary care across the Veterans Health Administration (VHA). OBJECTIVE: To use the knowledge translation (KT) framework to evaluate the dissemination and implementation of a patient engagement toolkit at facilities across one region in the VHA. DESIGN: Using a mixed-methods approach, this process evaluation involved phone monitoring via semi-structured interviews and group meetings, during which we explored barriers and facilitators to KT. Outcomes were assessed using a structured rubric and existing patient satisfaction measures. PARTICIPANTS: We enlisted implementers at 40 VHA facilities primarily serving Pennsylvania, New Jersey, and Delaware to implement patient engagement practices at their sites. Sites were randomly assigned into a high or low coaching group to assess whether external support influenced implementation. KEY RESULTS: Sites with high rubric scores employed and possessed several elements across the KT trajectory from identification of the problem to sustainment of knowledge use. Key factors for successful implementation and dissemination included implementer engagement, organizational support, and strong collaborators. The most frequently cited barriers included short staffing, time availability, lack of buy-in, and issues with leadership. Successful implementers experienced just as many barriers, but leveraged facilitators to overcome obstacles. While sites that received more coaching did not have different outcomes, they were more likely to revisit the toolkit and indicated that they felt more accountable to local personnel. CONCLUSIONS: Because leveraging available resources is a key component of successful implementation, future toolkits should highlight the type of facilitators necessary for successful implementation of toolkit content in healthcare settings. The ability to tailor interventions to local context is critical for overcoming barriers faced in most healthcare settings.

Improving Patient-centered Care: How Clinical Staff Overcome Barriers to Patient Engagement at the VHA.

BACKGROUND: While patient engagement can be beneficial for patient care, there are barriers to engaging patients. These barriers exist for health care organizations, for health care personnel, and for the patients themselves. Solutions to barriers are not well documented. OBJECTIVES: Our objective was to explore barriers to patient engagement efforts and their corresponding solutions. RESEARCH DESIGN: Qualitative interviews and site visits from a national sample of primary care facilities within the Veterans Health Administration were analyzed to understand patient engagement barriers and solutions. SAMPLING: We conducted a total of 155 phone and in-person semistructured interviews with primary care providers, mental health staff, social workers, pharmacists, patient advocates, health behavior coaches, and administrative staff at 27 Veterans Health Administration sites. Participants were asked to describe the obstacles they had to overcome in their efforts to improve patient engagement at their site. RESULTS: Barriers to patient engagement are overcome by strategically updating data analytics; enhancing organization-wide processes and procedures; being creative with space design, staff hiring, and time commitments; cultivating staff collaborations; and addressing patient care issues such as access, customer service, and patient education. A key component of successful implementation is to create a culture, supported by leadership that promotes patient engagement. CONCLUSIONS: Participants understood the patient centered approach, despite experiencing a lack of resources and training and could push through solutions to patient engagement barriers while working within the limits of their settings.

Influence of Community-Level Cultural Beliefs about Autism on Families' and Professionals' Care for Children.

This qualitative study aimed to understand how community-level cultural beliefs affect families' and professionals' care for children with autism and developmental delays in immigrant communities, as a first step towards promoting early identification and access to early intervention services. The study was part of the larger New York City (NYC) Korean Community Autism Project, which was designed to identify strategies to increase awareness of autism and reduce delays in treatment seeking within the NYC Korean-American community. Our study elicited early childcare workers' and church leaders' beliefs about autism and developmental disorders and, in particular, early intervention. We also elicited responses to newly developed outreach materials targeting this community. An inductive approach was used to identify concepts and categories associated with autism. Our study confirmed that discomfort, stigma and discrimination are the prevailing community attitudes toward autism and developmental disorders in the Korean-American community. Families' and professionals' understanding of autism and their care for children are affected by these community beliefs. Approaching immigrant communities with general information about child development and education rather than directly talking about autism and developmental disorders is likely to engage more families and professionals in need for diagnostic evaluation and early intervention for autism.

Creating a Toolkit to Reduce Disparities in Patient Engagement.

BACKGROUND: Patient engagement has become a major focus of health care improvement efforts nationally. Although evidence suggests patient engagement can be beneficial to patients, it has not been consistently defined, operationalized, or translated into practice. OBJECTIVES: Our objective was to develop a toolkit to help providers increase patient engagement and reduce disparities in patient engagement. RESEARCH DESIGN: We used qualitative interviews and observations with staff at primary care sites nationally to identify patient engagement practices and resources used to engage patients. We then used a modified Delphi process, that included a series of conference calls and surveys, where stakeholders reduced lists of engagement practices based on perceived feasibility and importance to develop a toolkit for patient engagement. SAMPLING: Sites were selected for interviews and site visits based on the concentration of minority patients served and performance on a measure of patient engagement, with the goal of highlighting practices at sites that successfully serve minority patients. RESULTS: We created a toolkit consisting of patient engagement practices and resources. No identified practice or resource specifically targeted patient engagement of minorities or addressed disparities. However, high-performing, high-minority-serving sites tended to describe more staff training opportunities and staff feedback mechanisms. In addition, low-performing and high-minority-serving sites more often reported barriers to implementation of patient engagement practices. CONCLUSIONS: Stakeholders agreed on feasible and important engagement practices. Implementation of this toolkit will be tracked to better understand patient engagement and its effect on patient-centered care and related disparities in care.