Veteran Engagement in Health Services Research: a Conceptual Model.

With 20 million living veterans and millions more immediate family members, and approximately 9 million veterans enrolled in the nationally networked VA healthcare system, representing the interests and needs of veterans in this complex community is a substantial endeavor. Based on the importance of engaging Veterans in research, the VA Health Services Research and Development (HSR&D) Service convened a Working Group of VA researchers and Veterans to conduct a review of patient engagement models and develop recommendations for an approach to engage Veterans in health research that would incorporate their unique lived experiences and interests, and their perspectives on research priorities. The Working Group considered the specific context for Veteran engagement in research that includes other VA stakeholders from the operational and clinical leadership of the VA Health Administration (VHA). The resulting model identifies the range of potential stakeholders and three domains of relevant constructs-processes expected to facilitate Veteran engagement in research with other stakeholders, individual stakeholder and external factors, and outcomes. The expectation is that Veteran engagement will benefit research to policy and practice translation, including increasing the transparency of research and producing knowledge that is readily accepted and implemented in healthcare.

Research translation for military and veteran health: research, practice, policy.

Military service presents unique challenges and opportunities for health care and public health. In the USA, there are over 2 million military servicemembers, 20 million veterans, and millions more military and veteran family members. Military servicemembers and eligible family members, many veterans, and retirees receive health care through the two largest learning health care systems in the USA, managed and delivered through the Departments of Defense (DoD), Veterans Affairs (VA), and contracted health care organizations. Through a network of collaborative relationships, DoD, VA, and partnering health care and research organizations (university, corporate, community, and government) accelerate research translation into best practices and policy across the USA and beyond. This article outlines military and veteran health research translation as summarized from a collaborative workshop led by experts across health care research, practice, and administration in DoD, VA, the National Institutes of Health, and affiliated universities. Key themes and recommendations for research translation are outlined in areas of: (a) stakeholder engagement and collaboration; (b) implementation science methods; and (c) funding along the translation continuum. Overall, the ability to rapidly translate research into clinical practice and policy for positive health outcomes requires collaborative relationships among many stakeholders. This includes servicemembers, veterans, and their families along with researchers, health care clinicians, and administrators, as well as policymakers and the broader population.

Psychiatric History, Deployments, and Potential Impacts of Mental Health Care in a Combat Theater.

Introduction: Increasing numbers of U.S. service members access mental health care while deployed and at home station. Multiple deployments carry with them a higher risk of exposure to combat as well as the impact of cumulative stressors associated with separation from family, hostile environments, and high operations tempo. However, mental health care resources continue to be underutilized, potentially because of higher levels of stigma regarding mental health care and concerns about career impact among service members. Some studies indicate that service members who have previously sought mental health care are likely to continue to do so proactively as needed. This study examined the associations between prior deployments, prior mental health treatment, and subsequent career-impacting recommendations (e.g., duty limitations and medical evacuation) among deployed service members seeking mental health care. Materials and. Methods: This study is a retrospective review of clinical records from three U.S. military Combat and Operational Stress Control units in Afghanistan. Data were drawn from the mental health records of 1,639 Army service members presenting for outpatient mental health services while deployed in Afghanistan from years 2006 to 2008. Results: In an unadjusted logistic regression model, service members with at least one prior deployment had a 38% greater odds (odds ratio [OR] = 1.38, 95% confidence interval [95% CI] 1.06, 1.80; p < 0.05) of receiving career-impacting recommendations than those without a prior deployment. However, after adjusting for demographics (age, gender, marital status, rank, and military status), there was no association between prior deployments and career-impacting recommendations (OR = 1.06, 95% CI 0.78, 1.43; p = 0.716). In the second unadjusted model, service members with prior mental health treatment had a 57% lower odds (OR = 0.43, 95% CI 0.34, 0.56; p < 0.001) of receiving career-impacting recommendations than those without prior mental health treatment. After adjusting for demographics and number of prior deployments, service members with prior mental health treatment had a 58% lower odds (OR = 0.42, 95% CI 0.33, 0.56; p < 0.001) of receiving career-impacting recommendations than those without prior mental health treatment. Conclusion: Among service members who had a clinical mental health encounter, prior deployment was not associated with career-impacting recommendations and prior mental health treatment appeared to be protective against career-impacting recommendations. These results are in line with research indicating that service members who have previous experience with mental health care tend to seek help sooner than those without prior treatment. Those service members who had previously sought care were more likely to express decreased stigma and seek mental health care while deployed. Consequently, service members who have prior mental health treatment may seek care before their concerns become marked enough to warrant duty-limiting recommendations to command. These findings have important implications for campaigns to reduce stigma and promote early help-seeking among service members. Efforts should continue to study and respectively make known the rates of career impact with the goal of increased early service utilization and increased ability to sustain service members' military readiness and personal functioning.

Racial/Ethnic Differences in the Associations Between Physical Activity and Sleep Duration: A Population-Based Study.

BACKGROUND: This study examined associations between physical activity (recreational, nonrecreational) and sleep duration among a nationally representative diverse sample of U.S. adults. METHODS: We used cross-sectional data from 9,205 National Health and Nutrition Examination Survey 2007 to 2012 participants aged 20 to 65 years who identified as White, Black, or Hispanic. Activity (ie, recreation, occupation, and transportation activity) was categorized into quartiles. Sleep duration was categorized as short (≤6 hours/night) or normal (>6 to ≤9 hours/night). Logistic regression was used to estimate associations of activity with sleep duration. RESULTS: Recommended levels of recreation activity and moderate levels of transportation activity were associated with normal sleep duration [Odds Ratio (OR): = 1.33, 95% Confidence Interval (CI) = 1.08, 1.65; OR = 1.28, 95% CI = 1.02, 1.62, respectively]. High occupation physical activity was associated with shorter sleep duration (OR = 0.59, 95% CI = 0.49, 0.71). Differences were observed by race/ethnicity in associations of recreation and occupation activity with sleep duration. CONCLUSIONS: White individuals who engaged in some recreation activity, relative to being inactive, had more favorable sleep duration; whereas, high levels of occupation activity were associated with worse sleep duration among White and Black individuals. Physical activity was not associated with sleep duration among Hispanics.

Military and veteran health behavior research and practice: challenges and opportunities.

There are 2.1 million current military servicemembers and 21 million living veterans in the United States. Although they were healthier upon entering military service compared to the general U.S. population, in the longer term veterans tend to be of equivalent or worse health than civilians. One primary explanation for the veterans' health disparity is poorer health behaviors during or after military service, especially areas of physical activity, nutrition, tobacco, and alcohol. In response, the Department of Defense and Department of Veterans Affairs continue to develop, evaluate, and improve health promotion programs and healthcare services for military and veteran health behavior in an integrated approach. Future research and practice is needed to better understand and promote positive health behavior during key transition periods in the military and veteran life course. Also paramount is implementation and evaluation of existing interventions, programs, and policies across the population using an integrated and person centered approach.

Fruit and vegetable intake as a moderator of the association between depressive symptoms and cigarette smoking.

BACKGROUND: Studies have consistently reported associations among depression, cigarette smoking, and fruit and vegetable intake (FVI). This study evaluated FVI as a moderator of the association between depressive symptoms and smoking. METHODS: The authors analyzed data from the National Longitudinal Survey of Youth 1979: Child and Young Adult. The study sample was adults aged 19-33 years at baseline in the year 2004 from the Young Adult Survey portion. Moderation analyses were performed using the Johnson-Neyman technique to assess whether baseline FVI moderated the association between depressive symptoms and smoking status cross-sectionally and as a predictor of smoking cessation longitudinally at 4-year follow-up. RESULTS: Cross-sectionally, at lower levels of FVI (<4.9 times/day), there was a significant association between smoking and depressive symptoms (P < .05), but not at higher levels of FVI (≥4.9 times/day; P > .05). Longitudinally, there was an inverse association between depressive symptoms and quitting smoking at FVI <1.2 times/day (P < .05), but there was not a significant association at FVI ≥1.2 times/day (P ≥ .05). CONCLUSIONS: FVI moderated the association between depressive symptoms and cigarette smoking cross-sectionally and longitudinally. The cross-sectional findings might be partially explained by the longitudinal findings paired with prior research; there might be fewer smokers with high FVI because depressive symptoms are removed as an impediment to cessation. Further experimental research is warranted to test the efficacy of increased FVI as an adjunct to smoking cessation, with a possible mechanism of action being reduced depressive symptoms during quit attempts.

Physical activity counseling in overweight and obese primary care patients: Outcomes of the VA-STRIDE randomized controlled trial.

The purpose of this 2-arm randomized clinical trial was to evaluate the effectiveness of a 12-month, expert system-based, print-delivered physical activity intervention in a primary care Veteran population in Pittsburgh, Pennsylvania. Participants were not excluded for many health conditions that typically are exclusionary criteria in physical activity trials. The primary outcome measures were physical activity reported using the Community Healthy Activities Model Program for Seniors (CHAMPS) questionnaire and an accelerometer-based activity assessment at baseline, 6, and 12 months. Of the 232 Veterans enrolled in the study, 208 (89.7%) were retained at the 6-month follow-up and 203 (87.5%) were retained at 12 months. Compared to the attention control, intervention participants had significantly increased odds of meeting the U.S. recommended guideline of ≥ 150 min/week of at least moderate-intensity physical activity at 12 months for the modified CHAMPS (odds ratio [OR] = 2.86; 95% CI: 1.03-7.96; p = 0.04) but not at 6 months (OR = 1.54; 95% CI: 0.56-4.23; p = 0.40). Based on accelerometer data, intervention participants had significantly increased odds of meeting ≥ 150 min/week of moderate-equivalent physical activity at 6 months (OR = 6.26; 95% CI: 1.26-31.22; p = 0.03) and borderline significantly increased odds at 12 months (OR = 4.73; 95% CI: 0.98-22.76; p = 0.053). An expert system physical activity counseling intervention can increase or sustain the proportion of Veterans in primary care meeting current recommendations for moderate-intensity physical activity. Trial Registration Clinical trials.gov identifier: NCT00731094 URL: http://www.clinicaltrials.gov/ct2/show/NCT00731094.

An evaluation of fruit and vegetable consumption and cigarette smoking among youth.

INTRODUCTION: Research across the past 4 decades has supported a cross-sectional association between adult cigarette smoking and lower fruit and vegetable consumption (FVC), and emerging research suggests higher FVC may predict cessation. Among youth, findings are limited to a few cross-sectional studies with somewhat mixed results. Here we evaluated the FVC-smoking association among youth both cross-sectionally and longitudinally. METHODS: We analyzed data from a subsample of the National Longitudinal Survey of Youth 1979: Child and Young Adult. The subsample included adolescents aged 14-18 years at baseline in the year 2004. Multivariable cross-sectional analyses assessed whether baseline FVC was associated with smoking frequency among ever-smokers (n = 578). Longitudinally, the study assessed whether baseline FVC predicted smoking progression among baseline never-smokers who tried a cigarette by 4-year follow-up (n = 388). Multivariable regression models adjusted for age, gender, race/ethnicity, parental education, and health behavior orientation. RESULTS: Cross-sectionally, youth who consumed fruit ≥2 times per day were 53% less likely (RR = 0.47; p < .05) than those who typically did not consume fruit to be in a higher smoking frequency category. Longitudinally, the fruit consumption and smoking association was not significant (RR = 0.61; p = .282). There were no significant associations observed between vegetable consumption and smoking. CONCLUSIONS: Fruit consumption, but not vegetable consumption, was inversely associated with smoking frequency cross-sectionally but not longitudinally. Further research is needed to provide information on the consistency of the FVC-smoking relationship among youth and may help to elucidate possible explanatory mechanisms.

Moving toward integrated behavioral intervention for treating multimorbidity among chronic pain, depression, and substance-use disorders in primary care.

INTRODUCTION: The importance of using integrated treatment for multimorbidity has been increasingly recognized. One prevalent cluster of health conditions is multimorbidity of chronic pain, depression, and substance-use disorders, a common triad of illnesses among primary care patients. This brief report brings attention to an emerging treatment method of an integrated behavioral approach to improve health outcomes for individuals with these 3 conditions in the outpatient setting, particularly primary care. METHODS: A multidatabase search was conducted to identify studies of behavioral interventions targeting co-occurrence or multimorbidity among the 3 health conditions in the adult outpatient setting. An independent screening of the articles was accomplished by all authors with consensus on the final inclusion for review. RESULTS: Three studies met formal inclusion criteria for this review. The included studies evaluated cognitive behavioral therapy or combined motivational interviewing with cognitive behavioral therapy. Key findings from other reviews and additional studies are also included in this review to further inform the development of a common approach for treating this triad of conditions in primary care. CONCLUSIONS: Although there has been increased recognition for more effective and practical behavioral treatments for patients with multiple chronic health conditions, the evidence-base to inform practice remains limited. The findings from this review suggest that a common approach, rather than a distinct intervention for chronic pain, depression, or substance-use disorders, is indicated and that best care can be provided within the context of a coordinated, interdisciplinary, and patient-centered primary care team.

A longitudinal evaluation of fruit and vegetable consumption and cigarette smoking.

INTRODUCTION: Cross-sectional studies consistently find that cigarette smokers consume fewer fruits and vegetables each day than do nonsmokers. However, there are no published cohort studies on this relationship. This study evaluated the longitudinal relationship between fruit and vegetable consumption (FVC) and cigarette smoking, including measures of dependence and abstinence in a national population-based cohort analysis. METHODS: A national random-digit-dialed sample of 1,000 smokers (aged 25 years and older) assessed baseline FVC and indicators of general health orientation. Multivariable analyses were used to assess whether baseline FVC was associated with smoking intensity, time to first cigarette (TTFC), and total score on an abbreviated version of the Nicotine Dependence Syndrome Scale (NDSS), adjusting for age, gender, race/ethnicity, education, and household income. The study also assessed whether baseline FVC predicted 30-day abstinence from all tobacco products at 14-month follow-up among baseline cigarette smokers, with additional adjustment for indicators of general health orientation (heavy drinking, exercise, and illicit drug use). RESULTS: Higher FVC was associated with fewer cigarettes smoked per day, longer TTFC, and lower NDSS score. Those in the highest quartile of FVC were 3.05 times more likely (p < .01) than those in the lowest quartile to be abstinent for at least 30 days at follow-up. CONCLUSIONS: FVC was inversely associated with indicators of nicotine dependence and predicted abstinence at follow-up among baseline cigarette smokers. Further observational studies and experimental research would provide useful information on the consistency of the relationship and help elucidate possible mechanisms.