Improving care for veterans' environmental exposure concerns: applications of the consolidated framework for implementation research in program evaluation.

BACKGROUND: Healthcare systems, like the US Department of Veterans Affairs (VA), need policies and procedures for delivering care to special populations including those with environmental exposure concerns. Despite being common and pervasive, especially among Veterans, environmental exposures are largely overlooked by healthcare providers. To successfully implement care for Veterans with military environmental exposure concerns, an understanding of contextual factors impeding care on the provider (e.g., knowledge and beliefs) and organizational (e.g., leadership's priorities) level is needed. Our goal was to conduct an operational needs assessment of providers to examine provider educational needs regarding Veterans' military environmental exposure concerns. METHODS: In 2020, we surveyed 2,775 VA medical and behavioral health providers. Our cross-sectional assessment was informed by the Consolidated Framework for Implementation Research (CFIR) and assessed barriers and facilitators to the uptake and application of knowledge regarding interdisciplinary care for environmental exposure concerns. The web-based survey was emailed to providers across the United States representing a variety of disciplines and practice settings to reflect the interdisciplinary approach to care for environmental exposures. We used bivariate statistics to investigate the intervention setting, inner setting, and individual characteristics of providers regarding care for environmental exposure concerns. RESULTS: Approximately one-third of VA medical and behavioral health clinicians report low to no knowledge of environmental exposure concerns. We find 88% of medical and 91% of behavioral health providers report they are ready to learn more about environmental exposures. Half of medical and behavioral health providers report they have access to information on environmental exposures and less than half report care for environmental exposures is a priority where they practice. CONCLUSIONS: Our findings suggest interdisciplinary providers' knowledge of and discussion with Veterans about environmental exposures may be influenced by contextual factors at the organizational level. Considering individual-level factors and organizational culture is important to consider when supporting care for environmental exposures. Since this needs assessment, VA established targeted programs to improve care related to military environmental exposures in response to legislation; future exploration of these same variables or contextual factors is warranted.

Veteran Beliefs About the Causes of Gulf War Illness and Expectations for Improvement.

BACKGROUND: Individuals' beliefs about the etiology of persistent physical symptoms (PPS) are linked to differences in coping style. However, it is unclear which attributions are related to greater expectations for improvement. METHOD AND RESULTS: A cross-sectional regression analysis (N = 262) indicated that Veterans with Gulf War Illness (GWI) who attributed their GWI to behavior, (e.g., diet and exercise), had greater expectations for improvement (p = .001) than those who attributed their GWI to deployment, physical, or psychological causes (p values > .05). CONCLUSIONS: Findings support the possible clinical utility of exploring perceived contributing factors of PPS, which may increase perceptions that improvement of PPS is possible. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02161133.

Treatment and life goals among veterans with Gulf War illness.

Medically unexplained syndromes (MUS), also termed persistent physical symptoms, are both prevalent and disabling. Yet treatments for MUS are marked by high rates of patient dissatisfaction, as well as disagreement between patients and providers on the management of persistent physical symptoms. A better understanding of patient-generated goals could increase collaborative goal setting and promote person-centered care, a critical component of MUS treatment; yet research in this area is lacking. This paper aimed to develop a typology of treatment and life goals among Gulf War veterans with a medically unexplained syndrome (Gulf War Illness). We examined participants' responses to open-ended questions about treatment and life goals using Braun and Clarke's thematic analysis methodology. Results showed that treatment goals could be categorized into four overarching themes: 1) Get better/healthier, 2) Improve quality of life, 3) Improve or seek additional treatment, and 4) Don't know/Don't have any. Life goals were categorized into six overarching themes: 1) Live a fulfilling life, 2) Live a happy life, 3) Live a healthy life, 4) Be productive/financially successful, 5) Manage GWI, and 6) Don't know/Don't have any. Treatment goals were largely focused on getting better/healthier (e.g., improving symptoms), whereas life goals focused on living a fulfilling life. Implications for the treatment of Gulf War Illness and patient-provider communication are discussed. ClinicalTrials.gov Identifier: NCT02161133.

'She thought the same way I that I thought:' a qualitative study of patient-provider concordance among Gulf War Veterans with Gulf War Illness.

Objective: Medically unexplained symptoms (MUS), such as chronic fatigue syndrome, irritable bowel syndrome, and Gulf War Illness (GWI), are difficult to treat. Concordance-shared understanding between patient and provider about illness causes, course, and treatment-is an essential component of high-quality care for people with MUS. This qualitative paper focuses on the experiences of United States military Veterans living with GWI who have endured unique healthcare challenges. Methods & Measures: Qualitative interviews were conducted with 31 Veterans with GWI to explore factors that contribute to and detract from concordance with their Veteran Affairs (VA) healthcare providers. In addition to being seen by VA primary care, over half of participants also sought care at a War Related Illness and Injury Study Center, which specializes in post-deployment health. Deductive and inductive codes were used to organize the data, and themes were identified through iterative review of coded data. Results: Major themes associated with patient-provider concordance included validation of illness experiences, perceived provider expertise in GWI/MUS, and trust in providers. Invalidation, low provider expertise, and distrust detracted from concordance. Conclusion: These findings suggest providers can foster concordance with MUS patients by legitimizing patients' experiences, communicating knowledge about MUS, and establishing trust.

Associations between risky alcohol use, disability, and problem-solving impairment among Veterans with Gulf War Illness: Secondary data analysis of a randomized clinical trial.

OBJECTIVE: Gulf War Illness (GWI) and alcohol use are both major sources of disability among Gulf War Veterans. The goal of this secondary data analysis was to examine associations between risky alcohol use, problem-solving impairment, and disability among Veterans in a randomized clinical trial of problem-solving treatment (PST) for GWI. We examined cross-sectional associations and conducted longitudinal analyses to test if alcohol use moderated treatment outcome of PST. METHODS: Participants were 268 United States military Veterans with GWI randomized to PST or a control intervention. Participants were assessed at four timepoints. Measures included the World Health Organization Disability Assessment Schedule 2.0 (WHO-DAS 2.0), Problem Solving Inventory (PSI), and Alcohol Use Disorders Identification Test-Concise (AUDIT-C). We conducted multivariate regression (cross-sectional) and mixed model analyses (longitudinal) with separate models for WHO-DAS 2.0 and PSI. All models included AUDIT-C and household income. This analysis was pre-registered on the Open Science Framework. RESULTS: Cross-sectional analyses revealed a significant negative association with small effect size between AUDIT-C and WHO-DAS 2.0 (p = 0.006; f2 = 0.05); worse disability was associated with less risky alcohol use. There was no evidence that risky alcohol use moderated effects of PST on disability or PSI. CONCLUSION: If replicated, the cross-sectional findings suggest high levels of disability may deter heavy drinking among Veterans with GWI. We did not find evidence that risky alcohol use moderated treatment outcome of PST for GWI. More research is needed to identify moderators of GWI interventions and to understand risky drinking among Veterans with complex health problems.

Randomized controlled trial protocol of health coaching for veterans with complex chronic pain.

BACKGROUND: Pain predominant multisymptom illness (pain-CMI) refers to symptom-based conditions where pain is a primary symptom. There is initial evidence that health coaching may be efficacious in treating pain-CMI because it can be tailored to the veteran's goals and emphasizes long-term behavior change, which may indirectly impact the maintaining factors of pain-CMI (e.g., catastrophizing, poor pain control, and limited activity). This paper describes the study protocol and rationale of a randomized controlled trial that will compare the efficacy of remote-delivered health coaching in reducing disability and pain impairment for veterans with pain-CMI to remote-delivered supportive psychotherapy. METHODS: This randomized controlled trial will consist of two treatment arms: remote-delivered health coaching and remote-delivered supportive psychotherapy, the active control. Each treatment condition will consist of twelve, weekly one-on-one meetings with a study provider. In addition to the baseline assessment, participants will also complete 6-week (mid-treatment), 12-week (post-treatment), and 24-week (follow-up) assessments that consist of questionnaires that can be completed remotely. The primary aims for this study are to determine whether health coaching reduces disability and pain impairment as compared to supportive psychotherapy. We will also examine whether health coaching reduces physical symptoms, catastrophizing, limiting activity, and increasing pain control as compared to supportive psychotherapy. DISCUSSION: This study will contribute to the existing literature on pain-CMI and report the effectiveness of a novel, remote-delivered behavioral intervention.

Exploring the acceptability of behavioral interventions for veterans with persistent "medically unexplained" physical symptoms.

OBJECTIVE: This study evaluated the factors that led to enrollment in, and satisfaction with, behavioral interventions for Veterans living with Gulf War Illness (GWI). METHODS: One-on-one interviews were conducted pre- and post-intervention with participants randomized to receive either telephone delivered problem-solving treatment (n = 51) or health education (N = 49). A total of 99 Veterans were interviewed pre-intervention and 60 post-intervention. Qualitative data were thematically coded and similarities in themes across the two interventions were examined. RESULTS: Before the study began, participants reported desiring to learn new information about their GWI, learn symptom-management strategies, and support improvements to care for other patients with GWI. After the intervention, Veterans felt positively about both interventions because they built strong therapeutic relationships with providers, their experiences were validated by providers, and they were provided GWI information and symptom-management strategies. Results also suggested that interventions do not have to be designed to meet all of the needs held by patients to be acceptable. A minority of participants described that they did not benefit from the interventions. CONCLUSION: The results suggest that satisfaction with behavioral interventions for GWI is driven by a strong therapeutic relationship, validating patient's experiences with GWI, and the intervention meeting some of the patient's needs, particularly increasing knowledge of GWI and improving symptom management.

Effect of Problem-solving Treatment on Self-reported Disability Among Veterans With Gulf War Illness: A Randomized Clinical Trial.

Importance: Few evidence-based treatments are available for Gulf War illness (GWI). Behavioral treatments that target factors known to maintain the disability from GWI, such as problem-solving impairment, may be beneficial. Problem-solving treatment (PST) targets problem-solving impairment and is an evidence-based treatment for other conditions. Objective: To examine the efficacy of PST to reduce disability, problem-solving impairment, and physical symptoms in GWI. Design, Setting, and Participants: This multicenter randomized clinical trial conducted in the US Department of Veterans Affairs compared PST with health education in a volunteer sample of 511 Gulf War veterans with GWI and disability (January 1, 2015, to September 1, 2019); outcomes were assessed at 12 weeks and 6 months. Statistical analysis was conducted between January 1, 2019, and December 31, 2020. Interventions: Problem-solving treatment taught skills to improve problem-solving. Health education provided didactic health information. Both were delivered by telephone weekly for 12 weeks. Main Outcomes and Measures: The primary outcome was reduction from baseline to 12 weeks in self-report of disability (World Health Organization Disability Assessment Schedule). Secondary outcomes were reductions in self-report of problem-solving impairment and objective problem-solving. Exploratory outcomes were reductions in pain, pain disability, and fatigue. Results: A total of 268 veterans (mean [SD] age, 52.9 [7.3] years; 88.4% male; 66.8% White) were randomized to PST (n = 135) or health education (n = 133). Most participants completed all 12 sessions of PST (114 of 135 [84.4%]) and health education (120 of 133 [90.2%]). No difference was found between groups in reductions in disability at the end of treatment. Results suggested that PST reduced problem-solving impairment (moderate effect, 0.42; P = .01) and disability at 6 months (moderate effect, 0.39; P = .06) compared with health education. Conclusions and Relevance: In this randomized clinical trial of the efficacy of PST for GWI, no difference was found between groups in reduction in disability at 12 weeks. Problem-solving treatment had high adherence and reduced problem-solving impairment and potentially reduced disability at 6 months compared with health education. These findings should be confirmed in future studies. Trial Registration: ClinicalTrials.gov Identifier: NCT02161133.

Assessing Change in Participation in Clinical Evaluations of Deployed Veterans with Medically Unexplained Symptoms.

Many deployed veterans experience issues reintegrating into civilian life. Addressing this in a clinical setting can prove challenging; however, assessing participation, defined as involvement in a life situation by the World Health Organization's International Classification of Functioning, Disability and Health, may be helpful. The Community Reintegration of Injured Service Members-Computer Adaptive Test (CRIS-CAT) is a measure of participation developed and validated in veteran populations. The War Related and Illness and Injury Study Center, which provides comprehensive evaluations to veterans with medically unexplained deployment-related concerns, used the CRIS-CAT as part of their social work evaluations during these visits and follow-up telephone calls. This retrospective review of clinical data examines the link between participation as assessed by the CRIS-CAT and factors that are mutable (such as relationships with others) and immutable (personal characteristics) as assessed in the social work evaluation over 12 months. The findings indicate that these veteran patients did not experience change in their participation as measured by the CRIS-CAT. Multivariable regression models demonstrated relationships only between change in CRIS-CAT scales and baseline scores and race. Article concludes by discussing lessons learned from this evaluation of the utility of the CRIS-CAT in clinical care and in longitudinal evaluation.

BYSTANDER INTERVENTION AMONG DRINKING GAMERS Bystander Intervention Among College Student Drinking Gamers: Sexual Assault Attitudes, Self-Efficacy, and Intent to Intervene.

Heavy drinking and sexual assault warrant significant concern on U.S. college campuses as emerging evidence suggests that the risk for sexual victimization is amplified in the context of high-risk drinking behavior. Despite recent attention to sexual assault (e.g., MeToo Movement), rates of perpetration remain largely unchanged. In applying the bystander intervention framework, our understanding of the relation between key factors that may facilitate or prevent behavioral action, or when and how these factors are most salient, is limited. The present study examined whether bystander attitudes and bystander self-efficacy interact to predict bystander intent to intervene. Hypotheses were tested among college student drinking gamers, a group at particular risk for involvement in situations of sexual violence. Participants (N = 964) were traditional college-aged student drinking gamers recruited from three universities across the East and Southern Central United States. After controlling for Greek affiliation, prior intervention training and social desirability, hypotheses were partially supported. Higher rape supportive attitudes (rape myth acceptance) were negatively associated with bystander intent to intervene across all participants, but bystander self-efficacy significantly moderated the relation between bystander attitudes (rape myth acceptance) and bystander intent to intervene only among women college student drinking gamers. The interaction effect was not significant among men. For all participants, there was a significant relation between bystander self-efficacy and bystander intent to intervene such that as self-efficacy increases, bystander intent to intervene increases. The discussion addresses implications for sexual assault prevention programs on college campuses and directions for future research.

The common-sense model and mental illness outcomes: A meta-analysis.

Psychotherapists can improve their patients' outcomes during and after therapy by improving patients' self-management. Patients who do not effectively manage their mental illness generally have worse outcomes. Leventhal's Common-Sense Model of Self-Regulation theorizes that patients' perceptions of their illness (illness representations) guide their self-management, influencing health outcomes. The present study quantified the relations between illness representations, self-management and outcomes for mental illnesses. We conducted a meta-analysis and included articles if they reported (1) on adults with mental illnesses and (2) the correlation between mental illness representations and mental illness outcomes. Twenty-five articles were included which represented 28 independent samples. The pattern of correlations among illness representations (identity, consequences, timeline, control, coherence and emotional representations), self-management strategies (attendance, engagement and adherence to treatment) and mental illness outcomes (symptom severity and quality of life) was consistent with analyses from previous studies of mental and physical illnesses. The results found threat-related illness representations mostly had a large relationship with worse mental illness outcomes and self-management. Protective illness representations had a small-to-large relationship with better mental illness outcomes and self-management. The results suggest patients' perceptions of their mental illness may be a critical indicator of their mental illness outcomes, including symptom severity and quality of life. This theory-driven meta-analysis supports calls for the inclusion of illness representations in psychotherapy for mental illness.

Knowledge gaps and educational needs of Veterans Affairs healthcare providers regarding COVID-19 at the start of the pandemic.

This study describes Veterans Affairs providers' perceived knowledge gaps for addressing COVID-19 concerns among Veterans generally and specifically among Veterans with a history of military exposures. A needs assessment was conducted through an online survey of 2,818 medical and behavioral health care providers. Results highlight the importance of ongoing education, even in topics for which providers endorsed adequate knowledge (eg, handwashing). Results also accentuated the need for educating providers about effectively communicating with patients regarding concerning medical topics when scientific data is scarce. Implications are discussed.

Symptom attribution to a medically unexplained syndrome is associated with greater perceived severity and bothersomeness of symptoms in US military veterans.

OBJECTIVE: Medically unexplained symptoms (MUS) are prevalent among veteran and non-veteran populations. Current biopsychosocial theory implicates a multitude of factors in MUS development and perpetuation. The current study tests whether physical symptom attribution to MUS is associated with perceived symptom severity and bothersomeness and thereby might function to perpetuate MUS, as suggested by existing theory. DESIGN AND MAIN OUTCOME MEASURES: Military combat veterans (n = 243) answered postal-mail questions about their physical symptoms, severity of experienced symptoms, and attributions of these symptoms to MUS (e.g. Gulf War Illness) versus non-MUS conditions. RESULTS: Independent t-tests showed support for the first hypothesis-that those who experience the symptom and attribute it to MUS will perceive it to be more severe and bothersome than those who experience the symptom but do not attribute it to MUS. Paired-sample t-tests showed support for the second hypothesis-that experienced symptoms attributed to MUS by an individual will be perceived as more severe and bothersome than experienced symptoms the individual does not attribute to MUS. CONCLUSIONS: Results highlight a potential role of symptom attribution in MUS perpetuation, through greater perceived severity and bothersomeness of MUS-attributed symptoms. Possible intervention targets may include behavior ramifications, such as coping strategies; more research is needed.

Protocol for a type 1 hybrid effectiveness/implementation clinical trial of collaborative specialty care for Veterans with Gulf War Illness.

AIMS: We describe a clinical trial which is seeking to determine the effectiveness and understand implementation outcomes for tele-collaborative specialty care for Veterans with Gulf War Illness (GWI). MAIN METHODS: This study will be a hybrid type 1 randomized effectiveness-implementation trial comparing tele-collaborative specialty care to electronic consultation for Gulf War Veterans with GWI (N = 220). In tele-collaborative specialty care, the specialty provider team will deliver health coaching and problem-solving treatment to Veterans and recommend a plan for analgesic optimization. In electronic consultation, the specialty provider team will make a one-time recommendation to the primary care team for locally delivered health coaching, problem-solving treatment and analgesic optimization. The primary aim will be to determine the effectiveness of tele-collaborative specialty care as compared to electronic consultation to reduce disability related to GWI. Our secondary aim will be to understand implementation outcomes. SIGNIFICANCE: There is a need to improve care for Veterans with GWI. A potentially useful model to improve care is tele-collaborative specialty care, where the specialists work with the primary care provider to synergistically treat the patients. DISCUSSION: This is the first clinical trial to prospectively compare different models of care for Veterans with GWI. This responds to multiple calls for research to improve treatment for Veterans with GWI, including from the National Academy of Medicine.

Under-recognition of medically unexplained symptom conditions among US Veterans with Gulf War Illness.

OBJECTIVE: Conditions defined by persistent "medically unexplained" physical symptoms and syndromes (MUS) are common and disabling. Veterans from the Gulf War (deployed 1990-1991) have notably high prevalence and disability from MUS conditions. Individuals with MUS report that providers do not recognize their MUS conditions. Our goal was to determine if Veterans with MUS receive an ICD-10 diagnosis for a MUS condition or receive disability benefits available to them for these conditions. METHODS: A chart review was conducted with US Veterans who met case criteria for Gulf War Illness, a complex MUS condition (N = 204, M = 53 years-old, SD = 7). Three coders independently reviewed Veteran's medical records for MUS condition diagnosis or service-connection along with comorbid mental and physical health conditions. Service-connection refers to US Veterans Affairs disability benefits eligibility for conditions or injuries experienced during or exacerbated by military service. RESULTS: Twenty-nine percent had a diagnosis of a MUS condition in their medical record, the most common were irritable colon/irritable bowel syndrome (16%) and fibromyalgia (11%). Slightly more Veterans were service-connected for a MUS condition (38%) as compared to diagnosed. There were high rates of diagnoses and service-connection for mental health (diagnoses 76% and service-connection 74%), musculoskeletal (diagnoses 86%, service-connection 79%), and illness-related conditions (diagnoses 98%, service-connection 49%). CONCLUSION: Given that all participants were Gulf War Veterans who met criteria for a MUS condition, our results suggest that MUS conditions in Gulf War Veterans are under-recognized with regard to clinical diagnosis and service-connected disability. Veterans were more likely to be diagnosed and service-connected for musculoskeletal-related and mental health conditions than MUS conditions. Providers may need education and training to facilitate diagnosis of and service-connection for MUS conditions. We believe that greater acknowledgement and validation of MUS conditions would increase patient engagement with healthcare as well as provider and patient satisfaction with care.

Healthcare providers' perceived learning needs and barriers to providing care for chronic multisymptom illness and environmental exposure concerns.

OBJECTIVE: Patient provider encounters for chronic multisympom illness (CMI) and/or environmental exposures are difficult often resulting in Veterans and providers having high levels of dissatisfaction. Patients attribute these difficulties to providers lacking knowledge about these health concerns. It is not known whether providers perceive themselves as lacking expertise in CMI and environmental exposure concerns. METHODS: This needs assessment used a descriptive online survey design. A total of 3632 VA healthcare providers across disciplines were surveyed. RESULTS: Healthcare providers reported speaking with Veterans about CMI and environmental exposures despite feeling they have minimal to no knowledge of these topics. At the same time, only half of the providers had taken an available training on CMI or environmental exposure within the last year. CONCLUSION: Healthcare providers recognize a knowledge gap regarding CMI and environmental exposures, despite this, there is low uptake of provider education on these topics. PRACTICE IMPLICATIONS: A better understanding of barriers to uptake of training on CMI and environmental exposures is needed to increase engagement with these important trainings.

"Because the country, it seems though, has turned their back on me": Experiences of institutional betrayal among veterans living with Gulf War Illness.

People living with medically unexplained symptoms (MUS) often have poor quality of life and health outcomes. Many struggle to engage with and trust in healthcare systems. This qualitative study examined how experiences with institutions influence perceptions of medical care for MUS by applying the theoretical framework of institutional betrayal to narratives of U.S. military Veterans living with Gulf War Illness (GWI). Institutional betrayal refers to situations in which the institutions people depend upon for safety and well-being cause them harm. Experiences of institutional betrayal both during active military service and when first seeking treatment appeared to shape perceptions of healthcare in this sample. Veterans expressed the belief that the military failed to protect them from environmental exposures. Veterans' concerns regarding subsequent quality of healthcare were intrinsically linked to a belief that, despite official documentation to the contrary, the predominant paradigm of both the U.S. Department of Defense and the U.S. Department of Veterans Affairs (VA) is that GWI does not exist. Veterans reported that providers are not adequately trained on treatment of GWI and do not believe Veterans' descriptions of their illness. Veterans reported taking up self-advocacy, doing their own research on their condition, and resigning themselves to decrease engagement with VA healthcare or seek non-VA care. The study's findings suggest institutional level factors have a profound impact on perceptions of care and the patient-provider relationship. Future research and policy aimed at improving healthcare for people living with MUS should consider the concept of institutional betrayal.

Veterans with Gulf War Illness perceptions of management strategies.

AIMS: Gulf War Illness (GWI) is a prevalent and disabling condition characterized by persistent physical symptoms. Clinical practice guidelines recommend self-management to reduce the disability from GWI. This study evaluated which GWI self-management strategies patients currently utilize and view as most effective and ineffective. MATERIALS AND METHODS: Data were collected from 267 Veterans during the baseline assessment of a randomized clinical trial for GWI. Respondents answered 3 open-ended questions regarding which self-management strategies they use, view as effective, and view as ineffective. Response themes were coded, and code frequencies were analyzed. KEY FINDINGS: Response frequencies varied across questions (in-use: n = 578; effective: n = 470; ineffective: n = 297). Healthcare use was the most commonly used management strategy (38.6% of 578), followed by lifestyle changes (28.5% of 578), positive coping (13% of 578), and avoidance (13.7% of 578). When asked about effective strategies, healthcare use (25.9% of 470), lifestyle change (35.7% of 470), and positive coping (17.4% of 470) were identified. Avoidance was frequently identified as ineffective (20.2% of 297 codes), as was invalidating experiences (14.1% of 297) and negative coping (10.4% of 297). SIGNIFICANCE: Patients with GWI use a variety of self-management strategies, many of which are consistent with clinical practice guidelines for treating GWI, including lifestyle change and non-pharmacological strategies. This suggests opportunities for providers to encourage effective self-management approaches that patients want to use.

Rapid review of virus risk communication interventions: Directions for COVID-19.

OBJECTIVE: In response to COVID-19, we conducted a rapid review of risk communication interventions to mitigate risk from viruses to determine if such interventions are efficacious. METHODS: We searched for risk communication interventions in four databases: Medline, PsycInfo, the ProQuest Coronavirus Research Database, and CENTRAL. The search produced 1572 articles. Thirty-one articles were included in the final review. RESULTS: Results showed risk communication interventions can produce cognitive and behavior changes around viruses. Results were more consistently positive for interventions focused on HIV/AIDS as compared to influenza. There was no consistent best intervention approach when comparing peer health, audio/visual, and intensive multi-media interventions. Tailoring risk communication toward a target population, in comparison to not tailoring, was related to better outcomes. CONCLUSION: The results suggest that risk communication interventions can be efficacious at reducing risk from viruses. They also highlight the complexity of risk communication interventions. Additional research is needed to understand the mechanisms that lead risk communication to reduce risk from viruses. PRACTICAL VALUE: Results support risk communication interventions to reduce risk from viruses.

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.