Veteran peer suicide prevention: A community-based peer prevention model.

OBJECTIVE: The purpose of this study was to develop a conceptual model of community-based veteran peer suicide prevention. METHOD: We conducted a qualitative study in which semi-structured interviews were followed by three focus groups. Participants (n = 17) were chosen from community-based organizations who had peers working on veteran suicide prevention; the sample included veteran peers, non-peers, program managers, and community stakeholders. Interview data were analyzed thematically and inductively to identify key components and subcomponents of veteran peer suicide prevention. A draft model was shared with each focus group to elicit feedback and refine key concepts. RESULTS: A conceptual model containing nine components and twenty-six subcomponents was developed. Participants emphasized key organizational, relational, and practical elements needed to achieve positive outcomes. In addition, they described critical contextual and cultural factors that impacted veteran peers' ability to prevent suicide and promote overall wellness. CONCLUSIONS: Community-based veteran peer efforts are a promising public health approach to preventing veteran suicide. Provided veteran peers are supported and fully allowed to contribute, these efforts can complement existing clinic-based efforts. Future research on community-based veteran peer suicide prevention should document a range of outcomes (e.g., clinical, wellness, financial) and allow for considerable flexibility in peer approaches.

Processes and outcomes of a communalization of trauma approach: Vets & Friends community-based support groups.

Veterans often experience challenges related to processing traumatic experiences and community reintegration, yet there is a dearth of research on promising community-driven approaches. This paper describes core processes and outcomes of Vets & Friends (V&F), a community-based support program that promotes veteran reintegration by healing trauma and moral injury using a communalization of trauma (CoT) approach. We conducted focus groups with 23 V&F group members. A mix of inductive and deductive codes were generated during thematic analysis. Critical themes identified included processes such as sharing narratives, connecting emotionally with experiences, feeling heard and accepted by group members, and listening as others shared their experiences. Outcomes included restoration of trust, connection with group members, building skills to manage trauma, and community acceptance and engagement. V&F shows promise in meeting veteran-specific needs by employing CoT approaches that offer opportunities to restore community trust and acceptance.

A Systematic Review of Factors Impacting Suicide Risk Among Rural Adults in the United States.

PURPOSE: Suicide rates continue to be significantly higher in rural compared to urban communities in the United States, with the suicide rate disparity continuing to grow since 1999. This systematic review synthesizes rural-specific factors related to increased suicide risk. METHODS: OVID Medline, EMBASE, OVID PsycINFO, Web of Science, SocINDEX, Cochrane Library, and Google Scholar were searched for articles published after 2003 investigating rural adult suicide in the United States. Selection criteria were: (1) study participants > 18 years old; (2) included rural participants or communities; (3) included suicidal self-directed violence outcomes; (4) within the United States; (5) published after 2003; (6) presented peer-reviewed original data; (7) identified rural-specific risk or protective factors for suicide or barriers to treatment. FINDINGS: Of the 1,058 records screened, 34 studies were included. The strength of evidence was relatively stronger for individual level factors including lethal means, alcohol and substance use. CONCLUSIONS: Access to firearms is strongly related to elevated rural US suicide rates, with substance use, economic stress, and behavioral health care utilization as additional individual level factors that may contribute to the disparity. At the community level, economic distress and access to care were commonly identified factors. Future research should better quantify how risk factors contribute to rural suicide and examine interdependence across social-ecological levels. Suicide prevention efforts for the rural United States must address access to lethal means, in particular the use of firearms, and navigate limited access to quality behavioral health care.

Teaching Community Health Needs Assessment to First Year Medical Students: Integrating with Longitudinal Clinical Experience in Rural Communities.

Community health education is especially important for physicians who will practice in rural communities. However, the majority of efforts to teach community and population health in medical school appear in later years and focus on non-rural contexts. This article presents data from a formative evaluation of a newly developed curricular component on population health and community health assessment for first year medical students in a rural longitudinal clinical preceptorship. Curricular elements included: a classroom lecture and review of online community health databases, an individual homework assignment and a classroom debriefing session. In a sample of 210 students, pre- and post-course surveys and exam questions assessed gains in awareness and skills over the course period. Analyses of data aggregated over four academic years (2013-2014 to 2016-2017) showed that first year medical students reported significant increases in familiarity with online resources (29.5% pre vs. 94.8% post, p < .001), understanding the importance of community health assessments (67.5% pre vs. 96.7%, p < .001), knowing how to plan a community health assessment (20.0% pre vs. 90.5%, p < .001), and awareness of Affordable Care Act expectations for community health assessments (12.4% pre vs. 82.4% post, p < .001). Further, students performed well on exam questions and reported that this component fit well with the objectives of the rural longitudinal clinical preceptorship course. Later-year education should reinforce early learnings and future studies involving long-term follow-up of physicians could assess the impact of early exposure to community health education on physician behaviors.

Factors contributing to the effective functioning of veterans mental health councils.

Veterans Mental Health Councils (VMHCs) have been established at many Veterans Affairs (VA) medical centers to promote recovery and improve mental health services. Though research shows that consumer-led advisory councils may produce a number of positive outcomes, the aspects of implementation critical for VMHC effectiveness have not been identified. The purpose of this study was to identify factors influencing effective functioning of VMHC, including contextual factors affecting council success. A key goal was to understand how participants defined effective council functioning. In-depth semistructured phone interviews were conducted with 15 council members and VA-employed staff liaisons sampled purposively from a broader group of volunteer participants. Inductive and iterative grounded theory analytic techniques were used to identify influential structural and process elements. Findings suggested that characteristics of council members, staff liaisons, and VA medical centers interact over time to shape council implementation and the effective functioning of councils along two dimensions-setting and accomplishing council goals and supporting recovery among members. VMHCs can develop members and improve the quality of VA mental health services when they are well implemented and supported. Mental health clinicians and supervisors can support councils in several ways. Additional research is needed to explore contextual differences in councils and to quantify the value added to VA mental health services by effective VMHCs. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Bhutanese Older Adult Refugees Recently Resettled in the United States: A Better Life With Little Sorrows.

PURPOSE: This study explores the experiences and adjustment process among older Bhutanese refugees resettled in the United States and identifies their unmet health and social service needs. DESIGN: This phenomenological study design included the conduction of nine in-depth semistructured interviews in the respondents' native language. The researchers adhered to the steps outlined by Moustakas for data analysis. RESULTS: The five identified themes included the following: a better life but with little sorrows, cultural tensions related to adaptation, language as a barrier to success in the United States, isolation and loneliness, and worries about citizenship and its impact on the future. Discussion/Implications for Practice: Psychological adjustment to life in the United States can have profound impact on the health of Bhutanese older adults. Nurses and health care providers should integrate culturally congruent health care, raise awareness of the unique needs, and advocate for policy changes that will benefit this group of older adult refugees whose lives have frequently been upended.

Military Families' Perceptions of Neighborhood Characteristics Affecting Reintegration: Development of an Aggregate Measure.

This pilot study evaluated the validity and reliability of an Experience of Neighborhood (EON) measure developed to assess neighborhood characteristics that shape reintegration opportunities for returning service members and their families. A total of 91 post-9/11 veterans and spouses completed a survey administered at the Minnesota State Fair. Participants self-reported on their reintegration status (veterans), social functioning (spouses), social support, and mental health. EON factor structure, internal consistency reliability, and validity (discriminant, content, criterion) were analyzed. The EON measure showed adequate reliability, discriminant validity, and content validity. More work is needed to assess criterion validity because EON scores were not correlated with scores on a Census-based index used to measure quality of military neighborhoods. The EON may be useful in assessing broad local factors influencing health among returning veterans and spouses. More research is needed to understand geographic variation in neighborhood conditions and how those affect reintegration and mental health for military families.

People awakening: collaborative research to develop cultural strategies for prevention in community intervention.

The consequences of alcohol use disorder (AUD) and suicide create immense health disparities among Alaska Native people. The People Awakening project is a long-term collaboration between Alaska Native (AN) communities and university researchers seeking to foster health equity through development of positive solutions to these disparities. These efforts initiated a research relationship that identified individual, family, and community protective factors from AUD and suicide. AN co-researchers next expressed interest in translating these findings into intervention. This led to development of a strengths-based community intervention that is the focus of the special issue. The intervention builds these protective factors to prevent AUD and suicide risk within AN youth, and their families and communities. This review provides a critical examination of existing literature and a brief history of work leading to the intervention research. These work efforts portray a shared commitment of university researchers and community members to function as co-researchers, and to conduct research in accord with local Yup'ik cultural values. This imperative allowed the team to navigate several tensions we locate in a convergence of historical and contemporary ecological contextual factors inherent in AN tribal communities with countervailing constraints imposed by Western science.

Participant experiences in peer- and clinician-facilitated mental health recovery groups for veterans.

OBJECTIVE: The purpose of the study was to characterize and compare participants' experiences of peer-facilitated versus clinician-facilitated recovery groups for veterans with mental illness. METHOD: We analyzed qualitative data from 24 interviews with veterans who participated in mental health recovery groups led by peer or clinician facilitators. RESULTS: Subtle differences in group structure, participation/communication and utility/relevance between peer- and clinician-facilitated groups were identified. Participants experienced both peer and clinician facilitators as helpful in promoting recovery, though they appeared to do this in different ways. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Peer and clinician facilitators offer different strengths in the promotion of mental health recovery.

Between and within-site variation in qualitative implementation research.

BACKGROUND: Multisite qualitative studies are challenging in part because decisions regarding within-site and between-site sampling must be made to reduce the complexity of data collection, but these decisions may have serious implications for analyses. There is not yet consensus on how to account for within-site and between-site variations in qualitative perceptions of the organizational context of interventions. The purpose of this study was to analyze variation in perceptions among key informants in order to demonstrate the importance of broad sampling for identifying both within-site and between-site implementation themes. METHODS: Case studies of four sites were compared to identify differences in how Department of Veterans Affairs (VA) medical centers implemented a Primary Care/Mental Health Integration (PC/MHI) intervention. Qualitative analyses focused on between-profession variation in reported referral and implementation processes within and between sites. RESULTS: Key informants identified co-location, the consultation-liaison service, space, access, and referral processes as important topics. Within-site themes revealed the importance of coordination, communication, and collaboration for implementing PC/MHI. The between-site theme indicated that the preexisting structure of mental healthcare influenced how PC/MHI was implemented at each site and that collaboration among both leaders and providers was critical to overcoming structural barriers. CONCLUSIONS: Within- and between-site variation in perceptions among key informants within different professions revealed barriers and facilitators to the implementation not available from a single source. Examples provide insight into implementation barriers for PC/MHI. Multisite implementation studies may benefit from intentionally eliciting and analyzing variation within and between sites. Suggestions for implementation research design are presented.

Grounded theory of barriers and facilitators to mandated implementation of mental health care in the primary care setting.

Objective. There is limited theory regarding the real-world implementation of mental health care in the primary care setting: a type of organizational coordination intervention. The purpose of this study was to develop a theory to conceptualize the potential causes of barriers and facilitators to how local sites responded to this mandated intervention to achieve coordinated mental health care. Methods. Data from 65 primary care and mental health staff interviews across 16 sites were analyzed to identify how coordination was perceived one year after an organizational mandate to provide integrated mental health care in the primary care setting. Results. Standardized referral procedures and communication practices between primary care and mental health were influenced by the organizational factors of resources, training, and work design, as well as provider-experienced organizational boundaries between primary care and mental health, time pressures, and staff participation. Organizational factors and provider experiences were in turn influenced by leadership. Conclusions. Our emergent theory describes how leadership, organizational factors, and provider experiences affect the implementation of a mandated mental health coordination intervention. This framework provides a nuanced understanding of the potential barriers and facilitators to implementing interventions designed to improve coordination between professional groups.

The Effectiveness of Cultural Adjustment and Trauma Services (CATS): generating practice-based evidence on a comprehensive, school-based mental health intervention for immigrant youth.

A collaborative study of Cultural Adjustment and Trauma Services (CATS), a comprehensive, school-based mental health program for traumatized immigrant children and adolescents, was conducted to generate practice-based evidence on the service delivery model across two school districts. Program effectiveness was assessed by testing whether client functioning and PTSD symptoms improved as a result of 7 separate service elements. An array of clinical services including CBT, supportive therapy, and coordinating services were provided to all students, and an evidence-based intervention for trauma, TF-CBT, was implemented with a subset of students. Greater quantities of CBT and supportive therapy increased functioning, while greater quantities of coordinating services decreased symptoms of PTSD. TF-CBT services were associated with both improved functioning and PTSD symptoms, although TF-CBT was implemented with fidelity to the overall comprehensive service model rather than the structured intervention model. Results suggest the comprehensive school-based model was effective, though different service components affected different student outcomes. Implications of these findings for immigrant mental health interventions and implementing structured evidence-based practices into community mental health programs are discussed. Suggestions are made for future research on existing mental health practices with immigrants.

Advancing the science of community-level interventions.

Community interventions are complex social processes that need to move beyond single interventions and outcomes at individual levels of short-term change. A scientific paradigm is emerging that supports collaborative, multilevel, culturally situated community interventions aimed at creating sustainable community-level impact. This paradigm is rooted in a deep history of ecological and collaborative thinking across public health, psychology, anthropology, and other fields of social science. The new paradigm makes a number of primary assertions that affect conceptualization of health issues, intervention design, and intervention evaluation. To elaborate the paradigm and advance the science of community intervention, we offer suggestions for promoting a scientific agenda, developing collaborations among professionals and communities, and examining the culture of science.

International Family, Adult, and Child Enhancement Services (FACES): a community-based comprehensive services model for refugee children in resettlement.

The development of evidence-based mental health interventions for refugees is complicated by the cultural and linguistic diversity of the participants, and the need to balance treatment of past traumatic experiences with ongoing support during the process of acculturation. In an effort to gather "practice-based evidence" from existing mental health services for refugees, a collaborative study of International Family, Adult, and Child Enhancement Services (FACES), a comprehensive, community-based mental health program working with refugee children, was conducted to describe the program participants and service delivery model and to assess whether participants improved over time as a function of services. Results showed that participants improved, but that the improvement was not related to dosage of services. Implications of these findings for refugee mental health services are discussed and suggestions are made for future evaluation research of mental health services with refugees.