Navigating the Roadmap for Trauma-Informed Medical Education: Application of Undergraduate Medical Education Competencies.

BACKGROUND: Trauma is common in the United States, increases risk of long-term adverse health effects, and individuals who experience it often find seeking medical care difficult. Trauma-informed care (TIC) builds trust and fosters healing relationships between clinicians and patients; however medical education has lacked consistent training in TIC. Using recently published competencies for undergraduate medical education (UME), this manuscript provides curricular examples across 8 domains to assist faculty in developing educational content. METHODS: The authors identified published curricula for each of the 8 competency domains using a published search strategy and publicly available database. Inclusion criteria were published works focused on UME in the United States; abstracts and curricula not focused on UME were excluded. The authors used a consensus-based process to review 15 eligible curricula for mapping with the competencies. RESULTS: Of 15 published UME curricula, 11 met criteria and exemplify each of the 8 UME competency domains. Most of the available curricula fall into the Knowledge for Practice and Patient Care domains. Most were offered in the first 2 years of medical school. CONCLUSION: Competency-based medical education for TIC is new, and most current educational offerings are foundational in nature. Additional innovation is needed in the competency domains of Professionalism, Systems-Based Practice, Interprofessional Collaboration, and Personal/Professional Development. This manuscript offers a set of curricular examples that can be used to aid efforts at implementing TIC competencies in UME; future work must focus on improving assessment methods and developmental sequencing as more students are exposed to TIC principles.

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.

Roadmap for Trauma-Informed Medical Education: Introducing an Essential Competency Set.

Research has established that trauma is nearly universal and a root cause of numerous health and social problems, including 6 of the 10 leading causes of death, with devastating consequences across the life course. Scientific evidence now recognizes the complex injurious nature of structural and historical trauma (i.e., racism, discrimination, sexism, poverty, and community violence). Meanwhile, many physicians and trainees grapple with their own trauma histories and face direct and secondary traumatization on the job. These findings substantiate the profound impact of trauma on the brain and body and why trauma training is critical to the education and practice of physicians. However, a critical lag remains in translating essential research insights into clinical teaching and care. Recognizing this gap, the National Collaborative on Trauma-Informed Health Care Education and Research (TIHCER) formed a task force charged with developing and validating a summary of core trauma-related knowledge and skills for physicians. In 2022, TIHCER released the first-ever validated set of trauma-informed care competencies for undergraduate medical education. The task force focused on undergraduate medical education so that all physicians would be taught these foundational concepts and skills from the outset of training, recognizing that faculty development is needed to achieve this goal. In this Scholarly Perspective, the authors offer a roadmap for implementation of trauma-informed care competencies starting with medical school leadership, a faculty-student advisory committee, and sample resources. Medical schools can use the trauma-informed care competencies as a scaffold to customize integration of curricular content (what is taught) and efforts to transform the learning and clinical environments (how it is taught). Using the lens of trauma will ground undergraduate medical training in the latest science about the pathophysiology of disease and provide a framework to address many of our greatest challenges, including health disparities and professional burnout.

Women Veterans' Healthcare Needs, Utilization, and Preferences in Veterans Affairs Primary Care Settings.

BACKGROUND: The Veterans Health Administration (VA) is the largest integrated health system in the US and provides access to comprehensive primary care. Women Veterans are the fastest growing segment of new VA users, yet little is known about the characteristics of those who routinely access VA primary care in general or by age group. OBJECTIVE: Describe healthcare needs, utilization, and preferences of women Veterans who routinely use VA primary care. PARTICIPANTS: 1,391 women Veterans with 3+ primary care visits within the previous year in 12 VA medical centers (including General Primary Care Clinics, General Primary Care Clinics with designated space for women, and Comprehensive Women's Health Centers) in nine states. METHODS: Cross-sectional survey (45% response rate) of sociodemographic characteristics, health status (including chronic disease, mental health, pain, and trauma exposure), utilization, care preferences, and satisfaction. Select utilization data were extracted from administrative data. Analyses were weighted to the population of routine users and adjusted for non-response in total and by age group. KEY RESULTS: While 43% had health coverage only through VA, 62% received all primary care in VA. In the prior year, 56% used VA mental healthcare and 78% used VA specialty care. Common physical health issues included hypertension (42%), elevated cholesterol (39%), pain (35%), and diabetes (16%). Many screened positive for PTSD (41%), anxiety (32%), and depression (27%). Chronic physical and mental health burdens varied by age. Two-thirds (62%) had experienced military sexual trauma. Respondents reported satisfaction with VA women's healthcare and preference for female providers. CONCLUSIONS: Women Veterans who routinely utilize VA primary care have significant multimorbid physical and mental health conditions and trauma histories. Meeting women Veterans' needs across the lifespan will require continued investment in woman-centered primary care, including integrated mental healthcare and emphasis on trauma-informed, age-specific care, guided by women's provider preferences.

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

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

"Recovering from intimate partner violence through Strengths and Empowerment (RISE): Development, pilot testing, and refinement of a patient-centered brief counseling intervention for women": Correction.

Reports an error in "Recovering from intimate partner violence through Strengths and Empowerment (RISE): Development, pilot testing, and refinement of a patient-centered brief counseling intervention for women" by Katherine M. Iverson, Sara B. Danitz, Mary Driscoll, Dawne Vogt, Alison B. Hamilton, Megan R. Gerber, Shannon Wiltsey Stirman, Danielle R. Shayani, Michael K. Suvak and Melissa E. Dichter (Psychological Services, Advanced Online Publication, Jun 10, 2021, np). In the original article, the columns in Table 3 were misaligned such that the data presented in the columns did not correspond with the correct variable. Additionally, for clarity, the table should have presented a separate column "n" for sample size and displayed total scores for the Personal Progress Scale (PPS) as opposed to mean scores. None of these errors impacted the results or conclusions. All versions of this article have been corrected. (The following abstract of the original article appeared in record 2021-53476-001). This article describes the rationale, development, and preliminary examination of a brief, variable-length (up to six sessions), modular-based counseling intervention for women who experience intimate partner violence (IPV). Recovering from IPV through Strengths and Empowerment (RISE) is an empowerment and skills-focused treatment that incorporates Motivational Interviewing. RISE was developed to fill the gap in interventions for women who disclose IPV within integrated healthcare settings such as the Veterans Health Administration (VHA). Fifteen women Veterans with past-year IPV participated in an open trial at two VHA hospitals to evaluate the potential helpfulness, feasibility, and acceptability of RISE using a mixed-methods approach to assessment. Qualitative feedback from women Veterans and five RISE clinicians (psychologists and social workers) was collected posttreatment. Descriptive analyses of quantitative psychosocial outcomes before and after the intervention provide evidence of support for RISE as potentially helpful in improving psychosocial well-being. High retention and high satisfaction ratings, along with positive qualitative feedback from both IPV survivor participants and clinicians, supported intervention feasibility and acceptability. Overall, this pilot study offers feasibility and acceptability data for RISE as a potentially helpful intervention for women experiencing past-year IPV. Refinements to RISE based on the open trial and subsequent testing of the clinical effectiveness of the intervention are discussed. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

What Drives Women Veterans' Trust in VA Healthcare Providers?

INTRODUCTION: Little is known about women veterans' trust in Veterans Affairs (VA) health care and what factors promote trust in VA providers. We examined provider behaviors and characteristics of women veterans associated with trust in their VA providers. METHODS: We used a 2015 survey of women veterans who were routine users of primary care at 12 VA medical centers (n = 1,395). Patient trust in their VA provider was measured on a seven-item scale. We used multiple logistic regression to examine associations of patient-provider communication and gender appropriateness with complete trust in VA provider (100 [complete trust] vs. <100 [less than complete trust]), controlling for patient characteristics. RESULTS: On average, 39.7% of women veterans reported complete trust in their VA providers. Those with complete trust reported greater patient-provider communication and gender appropriateness of VA services than those with less-than-complete trust (all ps ≤ .001). In multiple logistic regression models, higher ratings of provider communication (adjusted odds ratio, 2.37), gender-appropriate care (adjusted odds ratio, 1.93), and trauma-sensitive communication (adjusted odds ratios, 1.79-6.08) were associated with a higher likelihood of reporting complete trust in their VA provider. CONCLUSIONS: Women veterans reported high levels of trust in their VA providers. Provider communication, gender-appropriate care, and trauma-sensitive communication were associated with greater patient trust. Although it is important to highlight the steps already taken by VA to increase the quality of care for women veterans, current findings suggest that women veterans' trust may be further increased by interventions to improve trauma-informed care by VA providers.

Mini-Residencies to Improve Care for Women Veterans: A Decade of Re-Educating Veterans Health Administration Primary Care Providers.

Background: Many primary care providers (PCPs) in the Veterans Health Administration need updated clinical training in women's health. The objective was to design, implement, and evaluate a training program to increase participants' comfort with and provision of care to women Veterans, and foster practice changes in women's health care at their local institutions. Methods: The Women's Health Mini-Residency was developed as a multi-day training program, based on principles of adult learning, wherein knowledge gleaned through didactic presentations was solidified during small-group case study discussions and further enhanced by hands-on training and creation of a facility-specific action plan to improve women Veterans' care. Pre, post, and 6-month surveys assessed attendees' comfort with and provision of care to women. The 6-month survey also queried changes in practice, promulgation of program content, and action plan progress. Results: From 2008 to 2019, 2912 PCPs attended 26 programs. A total of 2423 (83.2%) completed pretraining and 2324 (79.3%) completed post-training surveys. The 6-month survey was sent to the 645 attendees from the first 14 programs; 297 (46.1%) responded. Comparison of pre-post responses indicated significant gains in comfort managing all 19 content areas. Six-month data showed some degradation, but comfort remained significantly improved from baseline. At 6 months, participants also reported increases in providing care to women, including performing more breast and pelvic examinations, dissemination of program content to colleagues, and progress on action plans. Conclusions: This interactive program appears to have been successful in improving PCPs' comfort in providing care for women Veterans and empowering them to implement institutional change.

Recovering from intimate partner violence through Strengths and Empowerment (RISE): Development, pilot testing, and refinement of a patient-centered brief counseling intervention for women.

[Correction Notice: An Erratum for this article was reported online in Psychological Services on May 12 2022 (see record 2022-63047-001). In the original article, the columns in Table 3 were misaligned such that the data presented in the columns did not correspond with the correct variable. Additionally, for clarity, the table should have presented a separate column "n" for sample size and displayed total scores for the Personal Progress Scale (PPS) as opposed to mean scores. None of these errors impacted the results or conclusions. All versions of this article have been corrected.] This article describes the rationale, development, and preliminary examination of a brief, variable-length (up to six sessions), modular-based counseling intervention for women who experience intimate partner violence (IPV). Recovering from IPV through Strengths and Empowerment (RISE) is an empowerment and skills-focused treatment that incorporates Motivational Interviewing. RISE was developed to fill the gap in interventions for women who disclose IPV within integrated healthcare settings such as the Veterans Health Administration (VHA). Fifteen women Veterans with past-year IPV participated in an open trial at two VHA hospitals to evaluate the potential helpfulness, feasibility, and acceptability of RISE using a mixed-methods approach to assessment. Qualitative feedback from women Veterans and five RISE clinicians (psychologists and social workers) was collected posttreatment. Descriptive analyses of quantitative psychosocial outcomes before and after the intervention provide evidence of support for RISE as potentially helpful in improving psychosocial well-being. High retention and high satisfaction ratings, along with positive qualitative feedback from both IPV survivor participants and clinicians, supported intervention feasibility and acceptability. Overall, this pilot study offers feasibility and acceptability data for RISE as a potentially helpful intervention for women experiencing past-year IPV. Refinements to RISE based on the open trial and subsequent testing of the clinical effectiveness of the intervention are discussed. (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.

Recovering From Intimate Partner Violence Through Strengths and Empowerment: Findings From a Randomized Clinical Trial.

Objective: Recovering from Intimate Partner Violence through Strengths and Empowerment (RISE) is a brief, variable-length (1-6 sessions), modular, individualized psychosocial counseling intervention for women experiencing intimate partner violence (IPV). Pilot findings demonstrated the potential helpfulness, acceptability, and feasibility of RISE; however, a randomized clinical trial (RCT) is needed to support program effectiveness.Methods: This RCT enrolled 60 women who experienced IPV within the prior year. Participants were recruited from an urban Veterans Health Administration hospital (October 2018 to September 2020). Participants completed a pretreatment assessment that included measures of relevant outcomes (primary: empowerment, self-efficacy, patient activation, and valued living; secondary: depression symptoms, IPV, and satisfaction with the intervention) and were randomly assigned to RISE or an enhanced care as usual (ECAU) condition. RISE participants received 1 to 6 sessions. ECAU participants received a single session consisting of psychoeducation, safety planning, resources, and referrals. Participants were reassessed 10 and 14 weeks after enrollment.Results: Intent-to-treat analyses using unconditional growth models revealed significant time-by-condition effects: RISE participants demonstrated higher increases in empowerment (d = 3.46) and self-efficacy (d = 1.09). RISE participants also experienced significant improvements in valued living (d = 0.53), depression symptoms (d = 0.49), and IPV reduction (d = 1.07) over time; however, the lack of a significant difference by condition suggested similar effectiveness of the interventions on these outcomes. Satisfaction was significantly higher for RISE than ECAU (d = 1.23).Conclusions: Results indicate the effectiveness of RISE in enhancing psychosocial well-being, especially empowerment and self-efficacy, among women experiencing IPV, for whom accessible health care-based interventions are needed.Trial Registration: ClinicalTrials.gov identifier: NCT03261700.

Getting Routine Intimate Partner Violence Screening Right: Implementation Strategies Used in Veterans Health Administration (VHA) Primary Care.

BACKGROUND: Evidence supports the clinical effectiveness of intimate partner violence (IPV) screening programs, but less is known about implementing and sustaining them. This qualitative study identified implementation strategies used to integrate IPV screening programs within Veterans Health Administration (VHA) women's health primary care. METHODS: Thirty-two administrators and clinician key informants from 11 VHA facilities participated in semistructured interviews. Implementation strategies were identified using established definitions from implementation science literature, through multistep content analysis, involving site comparisons by implementation status. RESULTS: We identified 8 implementation strategies. Three were present across all sites: (1) conduct ongoing IPV trainings, (2) conduct educational meetings and outreach visits, and (3) develop and distribute educational materials. Five strategies were unique to early adopting sites: (4) identify and prepare champions, (5) change record systems to remind clinicians, (6) create a learning collaborative through advisory boards or workgroups, (7) audit and provide feedback with relay of clinical data to providers, and (8) access new funding. DISCUSSION: Strategies align with and extend literature addressing barriers to screening. Evidence shows that effective IPV screening implementation in primary care requires a bundle of well-defined, carefully selected strategies. CONCLUSIONS: Implementation strategies used collectively can enable integration of IPV screening programs in primary care.

Strides Toward Recovery From Intimate Partner Violence: Elucidating Patient-Centered Outcomes to Optimize a Brief Counseling Intervention for Women.

Women in the United States continue to experience intimate partner violence (IPV) at unprecedented rates, necessitating the development and implementation of personalized, effective healthcare-based interventions. Methods of developing patient-centered interventions for IPV should elicit the voice of the target population (i.e., women who experience IPV) while assuring that outcomes identified as important are incorporated into the refined intervention. This pilot study is part of a multiphase, larger study aiming to refine an IPV intervention and clinical outcome measurements prior to formal evaluation of the effectiveness of the intervention. Specifically, this study elucidates patient-centered outcomes identified by women who have experienced IPV. Women patients of the Veterans Health Administration (VHA) in New England participated in focus groups to provide feedback and desired outcomes of a new IPV intervention. Patient-centered outcomes were defined by the participants. Focus groups were transcribed and analyzed using conventional content analysis and matrix analysis. A total of 25 women participated in focus groups (n = 5) at two large VHA facilities. Participant feedback revealed five common themes related to desired outcomes. Women opined increased feelings of empowerment as a key outcome of engaging in an IPV intervention. Women desired increased social connectedness and support to be gained during treatment, citing providers and other survivors of IPV as exemplary sources. Self-esteem was viewed as critical to enhancing recovery, as was increased knowledge across domains of IPV (e.g., warning signs, the link between mental and physical health for self and children). Finally, women identified valued action and goal setting, such as achieving more independence, as an optimal outcome. Addressing IPV against women requires patient-centered interventions that specifically target the types of outcomes deemed important by the end users: women who experience IPV. Findings have implications for tailoring treatments for IPV and selecting measures that tap into women's desired outcomes.

A Multisite Quality Improvement Initiative to Enhance the Adoption of Screening Practices for Intimate Partner Violence Into Routine Primary Care for Women Veterans.

OBJECTIVE: The Veterans Health Administration established comprehensive women's health clinics (CWHCs) to provide coordinated, high-quality primary care to women veterans. Intimate partner violence (IPV) is prevalent among women using these clinics. The Veterans Health Administration recommends screening women for IPV, yet screening uptake is low in CWHCs nationwide. We describe a multisite quality improvement initiative to enhance the adoption of IPV screening practices in the Veterans Health Administration's CWHCs. METHODS: This quality improvement initiative, implemented in 2017-2018, included 4 steps in which we (1) conducted a baseline survey of screening practices at CWHCs throughout the United States; (2) selected and tailored evidence-based implementation strategies based on identified barriers and facilitators; (3) deployed multicomponent implementation support, targeting low-adopting facilities; and (4) conducted a follow-up survey to evaluate changes in IPV screening practices from baseline (winter 2017) to 1-year follow-up (winter 2018) using quantitative and qualitative analyses. RESULTS: Responders from 62 CWHC sites provided information on IPV screening practices and barriers; 42 low-adopting sites were targeted for implementation support. At follow-up, responders provided information on IPV screening practices, perceived usefulness of implementation support strategies, and continued barriers. Among sites that responded to both surveys (n = 47), the number of sites that implemented recommended screening practices increased by 66.7%, from 15 at baseline to 25 at follow-up (P = .02). Emergent themes reflected barriers and facilitators for IPV screening implementation. CONCLUSIONS: Improvement in IPV screening practices in CWHCs is a pivotal step toward enhancing care for women. Yet, even with numerous implementation supports, barriers to adoption persist at many sites. Findings on modifiable barriers and unique facilitators can inform next steps for increasing screening uptake.

Self-Efficacy for Adoption and Maintenance of Exercise Among Fibromyalgia Patients: A Pilot Study.

Objective. While multimodal treatment approaches for fibromyalgia (FM), incorporating exercise, have been found most effective, information about factors associated with exercise adoption and maintenance is lacking. Design, Setting, and Methods. Women veterans with FM (N = 19) completed an anonymous Internet survey measuring FM impact (FI), adoption of exercise behavior, and self-efficacy for exercise. Using classifications of behavior specified by the transtheoretical model, the self-efficacy of participants classified in the action or maintenance (AM) stages was compared with those in earlier stages (precontemplation through preparation) of exercise readiness. Multivariate analysis of variance analyses examined differences in FI domains by stage of change. Analysis of covariance examined whether exercise self-efficacy differed by stage of change while controlling for FI. Results. Higher levels of self-efficacy were detected among participants in the AM stages. Participants in the AM stages also reported higher levels of FI symptoms. After controlling for FI, self-efficacy did not differ significantly between the 2 groups; however the effect size was large (η2 = .11). Conclusions. Findings of this pilot study suggest a role for self-efficacy in exercise adoption and maintenance, even in the setting of higher FM symptoms. Replication of this study with a larger sample size is warranted.

Trauma-Informed Telehealth in the COVID-19 Era and Beyond.

BACKGROUND: The Veterans Health Administration (VHA) entered the COVID-19 pandemic crisis with an existing and robust telehealth program, but it still faces a fundamental paradigm shift as most routine outpatient in-person care was converted to telehealth visits. Veterans are a highly trauma-exposed population, and VHA has long offered effective telemental health services. Natural disasters and pandemics like COVID-19 are known to be traumatic. Those with preexisting trauma exposure and mental health conditions are often at greater risk than the general population for long-term adverse health sequelae. Application of trauma-informed principles to telehealth care is critical and timely. OBSERVATIONS: Trauma-focused care (including telemental health) refers to evidence-based treatment models that directly facilitate recovery from trauma-related conditions like posttraumatic stress disorder. Despite the widespread availability of trauma-focused treatment in VHA, not all veterans chose to engage in it. In contrast, trauma-informed care (TIC) is a global, "universal precautions" approach to providing strengths-based, collaborative quality medical care in any discipline or location. In this article the authors, all primary care and mental health clinicians at VHA, advocate for the application of the 6 Substance Abuse and Mental Health Services Administration principles of trauma-informed care to telehealth. Using examples from telehealth research conducted in trauma-exposed patient populations, we illustrate the characteristics of telehealth that are well suited to delivery of trauma-informed care and suggest readily applicable strategies that can be used across disciplines including primary care and medical/surgical specialties. A primary care patient case scenario is included to illustrate how telehealth visits can be trauma-informed. CONCLUSIONS: Telehealth expansion has occurred nationally out of necessity during the COVID-19 pandemic. Trauma-informed virtual care has the potential to ensure and even expand continuity of medical care by fostering safe and collaborative interactions between patients and the health care team.

Association of Depression and Post-Traumatic Stress Disorder with Receipt of Minimally Invasive Hysterectomy for Uterine Fibroids: Findings from the U.S. Department of Veterans Affairs.

BACKGROUND: When hysterectomy is used to treat uterine fibroids, a minimally invasive versus open abdominal approach is preferred. Depression and post-traumatic stress disorder (PTSD) may be associated with surgical mode. We sought to examine whether depression and PTSD are associated with minimally invasive hysterectomy (MIH). METHODS: This was a cross-sectional study of veterans with uterine fibroids undergoing hysterectomy in the Department of Veterans Affairs between 2012 and 2014. Diagnoses and procedures were identified by International Classification of Disease, Ninth Revision, codes. MIH was defined as laparoscopic, vaginal, or robotic-assisted versus open abdominal. A dichotomous variable indicated presence of depression or PTSD. Clinical variables, including uterine size, were abstracted from the medical record. We employed generalized linear models to estimate adjusted percentages and 95% confidence intervals (CIs) of MIH by presence of depression or PTSD and sequentially adjusted for sociodemographic variables and health indicators (model 1), and then gynecologic and reproductive history variables, including uterine size (model 2). RESULTS: We included 770 veterans in our analytic sample. Veterans with depression or PTSD were more likely than those without such diagnoses to have a MIH (49% vs. 42%). Differences were attenuated in model 1 (47% [95% CI, 37%-57%] vs. 43% [95% CI, 34%-52%]) and no longer detectable in model 2 (45% [95% CI, 36%-54%] vs. 44% [95% CI, 36%-52%]). CONCLUSIONS: Veterans with depression or PTSD were more likely that those without to have a MIH, possibly owing to smaller uterine size, suggesting that they may be undergoing hysterectomy earlier in the disease process. Further research is needed to understand whether this reflects high-quality, patient-centered care.