Natural Product Use Among Veterans with Chronic Pain: A Qualitative Study of Attitudes and Communication with Healthcare Providers.

BACKGROUND: Despite mixed evidence regarding the safety and efficacy of natural products, many are marketed for pain and related symptoms. Use of these products is prevalent among veterans, who have disproportionately high rates of chronic pain. To date, however, there is limited research on veterans' beliefs and attitudes about natural products and their communication with healthcare providers about their natural product use. OBJECTIVE: To explore how veterans experiencing chronic pain make decisions about natural product use, to investigate veterans' beliefs about the safety and efficacy of these products, and to examine veterans' experiences discussing natural products with their providers. DESIGN: Qualitative sub-study conducted as a supplement to a pragmatic randomized controlled trial for chronic pain management. PARTICIPANTS: Twenty veterans experiencing chronic pain who reported using natural products for pain management or related health concerns. APPROACH: Qualitative interviews with veterans were conducted over the phone and audio-recorded. Interviews were guided by an original semi-structured interview guide and qualitative data were analyzed using a template-based rapid analysis technique. KEY RESULTS: Veterans with chronic pain may perceive natural products as safer than pharmaceutical products and may prefer to use natural products. Talking with providers about natural products is important to veterans, who would like information regarding the safety and potential for interaction of natural products with pharmaceutical products. However, veterans were frequently disappointed with these conversations. Veterans felt their providers demonstrated biases against natural products, which negatively impacted patient-provider relationships. CONCLUSIONS: Veterans wish to have more productive conversations with providers about natural products. They value providers' open-mindedness towards natural products and transparency about limitations in their knowledge. Suggestions for how providers and healthcare systems might better support veterans interested in natural products are discussed.

Integration of Health Coaches in a Whole Health Team Model of Chronic Pain Care: a Qualitative Study.

OBJECTIVE: Health coaching has shown promise in helping patients manage their chronic disease and in improving health outcomes, yet the implementation of health coaching in healthcare systems is understudied. Further, evidence suggests that interdisciplinary care teams may be more effective in treating chronic pain than usual care. As such, we sought to examine the benefits and drawbacks to embedding health coaches within interdisciplinary pain care teams ("Whole Health Teams"). DESIGN: As part of a multisite clinical trial (at five Veterans Health Administration sites) investigating the effectiveness of a Whole Health Team (WHT) approach to care for patients with chronic pain, qualitative interviews gathered data on how the experience of treating patients in the WHT differed from the experience treating patients outside the WHT, as well as provider experiences coordinating patient care within the WHT. PARTICIPANTS: Twenty-two WHT members, study investigators, and study coordinators. APPROACH: Data were analyzed using a rapid analysis approach. RESULTS: Overall, stakeholders perceived considerable synergy within the interdisciplinary pain care team. Each provider brought a different perspective to the patient's health concerns, which stakeholders felt was valuable and increased patient progress towards goals. The team model was also viewed as efficient because everyone was committed to working together and communicating as a team. Logistically, however, stakeholders noted challenges to working as a team, especially regarding patient goal setting. Furthermore, multiple stakeholders believed the care team model required a high degree of dedication to teamwork and communication among its members to be successful. CONCLUSIONS: Embedding health coaches within interdisciplinary pain care teams may improve care processes and accelerate patient progress. Successful implementation would require adequate training, role clarification, and expectation setting to facilitate good communication across all care team members. Additional research is needed to evaluate the clinical outcomes of integrating health coaches on WHTs versus other implementation approaches.

Reducing Barriers to Behavioral Treatments for Insomnia: A Qualitative Examination of Veterans' Perspectives of BBTI.

Objective: Although behavioral treatments are recommended for treating insomnia disorder, these treatments are not the most commonly provided treatments due to numerous barriers (e.g., treatment length, time limitations). Brief Behavioral Treatment for Insomnia (BBTI) was developed, in part, to help overcome these barriers. The purpose of the current study was to qualitatively examine the treatment experiences of veterans with insomnia disorder participating in BBTI.Methods: All veterans (n=46) who were randomized to receive BBTI as part of a randomized clinical trial participated in 10-20 minute semi-structured interviews one week after completing treatment. Rapid analysis procedures were used for qualitative analysis.Results: Thirteen qualitative themes were identified: BBTI provided veterans with the skills they believed they needed to continue improving independently post-treatment; beginning BBTI with in-person sessions was valued; phone sessions helped participation; veterans did not perceive that they could cover the same content during phone and in-person sessionsl; materials could be more portable; BBTI created accountability; BBTI required discipline and willingness; BBTI facilitated buy-in; BBTI was aligned with military culture; loved ones could provide important support; BBTI could be improved with more personalization; BBTI challenged expectations of mental health; and BBTI improved awareness of health behaviors beyond sleep.Conclusions: BBTI was successful in overcoming barriers to behavioral insomnia treatment and interviews identified critical treatment aspects that should be maintained to preserve acceptability (e.g., in-person session first). Areas in which BBTI did not fully meet the needs of veterans and targets for improvement (e.g., ameliorating understanding and expectations of phone sessions) were also identified.

Women Veterans' Experiences with Integrated, Biopsychosocial Pain Care: A Qualitative Study.

OBJECTIVES: Biopsychosocial, integrated pain care models are increasingly implemented in the Veterans Health Administration to improve chronic pain care and reduce opioid-related risks, but little is known about how well these models address women veterans' needs. DESIGN: Qualitative, interview-based study. SETTING: San Francisco VA Health Care System Integrated Pain Team (IPT), an interdisciplinary team that provides short-term, personalized chronic pain care emphasizing functional goals and active self-management. SUBJECTS: Women with chronic pain who completed ≥3 IPT sessions. METHODS: Semistructured phone interviews focused on overall experience with IPT, perceived effectiveness of IPT care, pain care preferences, and suggested changes for improving gender-sensitive pain care. We used a rapid approach to qualitative thematic analysis to analyze interviews. RESULTS: Fourteen women veterans (mean age 51 years; range 33-67 years) completed interviews. Interviews revealed several factors impacting women veterans' experiences: 1) an overall preference for receiving both primary and IPT care in gender-specific settings, 2) varying levels of confidence that IPT could adequately address gender-specific pain issues, 3) barriers to participating in pain groups, and 4) barriers to IPT self-management recommendations due to caregiving responsibilities. CONCLUSIONS: Women veterans reported varied experiences with IPT. Recommendations to improve gender-sensitive pain care include increased provider training; increased knowledge of and sensitivity to women's health concerns; and improved accommodations for prior trauma, family and work obligations, and geographic barriers. To better meet the needs of women veterans with chronic pain, integrated pain care models must be informed by an understanding of gender-specific needs, challenges, and preferences.

Tailored to Fit: How an Implementation Framework Can Support Pragmatic Pain Care Trial Adaptation for Diverse Veterans Affairs Clinical Settings.

BACKGROUND: Veterans Affairs (VA) has rolled out a holistic, multicomponent Whole Health care model nationwide, yet no pragmatic trials have been conducted in real-world clinical settings to compare its effectiveness against other evidence-based approaches for chronic pain management in veterans. OBJECTIVES: We describe the adaptation of the first large pragmatic randomized controlled trial of the Whole Health model for chronic pain care for diverse VA clinical settings. RESEARCH DESIGN: Informed by the Promoting Action on Research Implementation in Health Systems implementation framework, we conducted qualitative semistructured interviews to obtain feedback on trial design from VA leadership, frontline clinicians, and veterans with chronic pain at 5 VA enrollment sites. Next, we convened in-person evidence-based quality improvement (EBQI) meetings with study stakeholders (including frontline clinicians and administrators) at each site to discuss study design; review interview themes; and identify site-specific barriers, facilitators, and approaches to implementation. Ethnographic observations from EBQI meetings provided additional insight into implementation strategies. SUBJECTS: Seventy-four veteran and VA staff stakeholders were interviewed; 71 stakeholders participated in EBQI meetings. RESULTS: At each site, unique clinical contexts and varying resources for Whole Health and pain care delivery affected plans for trial implementation. We present examples of local adaptations that emerged through the formative evaluation process to facilitate implementation and yield a more pragmatic trial design. CONCLUSIONS: A systematic formative evaluation can facilitate engagement and buy-in of study stakeholders. Locally tailored pragmatic implementation strategies may improve the likelihood of successful trial execution as well as future implementation of evidence-based pain care approaches in real-world clinical settings.

An Integrated Pain Team Model: Impact on Pain-Related Outcomes and Opioid Misuse in Patients with Chronic Pain.

OBJECTIVE: Biopsychosocial integrated pain team (IPT) care models are being implemented in Veterans Health Administration (VA) and other health care systems to address chronic pain and reduce risks related to long-term opioid therapy, with little evaluation of effectiveness to date. We examined whether IPT improves self-reported pain-related outcomes and opioid misuse. DESIGN: Single-group quality improvement study. SETTING: Large VA health care system. SUBJECTS: Veterans with chronic pain (N = 99, 84% male, mean age [SD] = 60 [13] years). METHODS: Using paired t tests and Wilcoxon matched-pairs signed-ranks tests, we examined pain experience (Brief Pain Inventory, Pain Catastrophizing Scale), opioid misuse (Current Opioid Misuse Measure), treatment satisfaction (Pain Treatment Satisfaction Scale), and pain management strategies among patients with chronic pain before and after three or more IPT encounters. RESULTS: After an average (SD) of 14.3 (9) weeks engaged in IPT, patients reported improvement in pain interference (mean [SD] = 46.0 [15.9] vs 40.5 [16.2], P < 0.001), pain catastrophizing (mean [SD] = 22.9 [13.0] vs 19.3 [14.1], P = 0.01), treatment satisfaction (i.e., "very satisfied" = 13.1% at baseline vs 25.3% at follow-up, P = 0.01), and reduced opioid misuse (mean [SD] = 11.0 [7.5] vs 8.2 [6.1], P = 0.01). Patients reported increased use of integrative (i.e., acupuncture, 11% at baseline vs 26% at follow-up, P < 0.01) and active pain management strategies (i.e., exercise, 8% at baseline vs 16% at follow-up, P < 0.01) and were less likely to use only pharmacological pain management strategies after IPT engagement (19% at baseline vs 5% at follow-up, P < 0.01). CONCLUSIONS: Biopsychosocial, integrated pain care may improve patient-centered outcomes related to opioid misuse and the subjective experience and nonpharmacological self-management of chronic pain.

Whole Health Options and Pain Education (wHOPE): A Pragmatic Trial Comparing Whole Health Team vs Primary Care Group Education to Promote Nonpharmacological Strategies to Improve Pain, Functioning, and Quality of Life in Veterans-Rationale, Methods, and Implementation.

BACKGROUND: The Whole Health model of the U.S. Department of Veterans Affairs (VA) emphasizes holistic self-care and multimodal approaches to improve pain, functioning, and quality of life. wHOPE (Whole Health Options and Pain Education) seeks to be the first multisite pragmatic trial to establish evidence for the VA Whole Health model for chronic pain care. DESIGN: wHOPE is a pragmatic randomized controlled trial comparing a Whole Health Team (WHT) approach to Primary Care Group Education (PC-GE); both will be compared to Usual VA Primary Care (UPC). The WHT consists of a medical provider, a complementary and integrative health (CIH) provider, and a Whole Health coach, who collaborate with VA patients to create a Personalized Health Plan emphasizing CIH approaches to chronic pain management. The active comparator, PC-GE, is adapted group cognitive behavioral therapy for chronic pain. The first aim is to test whether the WHT approach is superior to PC-GE and whether both are superior to UPC in decreasing pain interference in functioning in 750 veterans with moderate to severe chronic pain (primary outcome). Secondary outcomes include changes in pain severity, quality of life, mental health symptoms, and use of nonpharmacological and pharmacological therapies for pain. Outcomes will be collected from the VA electronic health record and patient-reported data over 12 months of follow-up. Aim 2 consists of an implementation-focused process evaluation and budget impact analysis. SUMMARY: This trial is part of the Pain Management Collaboratory, which seeks to create national-level infrastructure to support evidence-based nonpharmacological pain management approaches for veterans and military service personnel.

Moral Injury: An Integrative Review.

Individuals who are exposed to traumatic events that violate their moral values may experience severe distress and functional impairments known as "moral injuries." Over the last decade, moral injury has captured the attention of mental health care providers, spiritual and faith communities, media outlets, and the general public. Research about moral injury, especially among military personnel and veterans, has also proliferated. For this article, we reviewed scientific research about moral injury. We identified 116 relevant epidemiological and clinical studies. Epidemiological studies described a wide range of biological, psychological/behavioral, social, and religious/spiritual sequelae associated with exposure to potentially morally injurious events. Although a dearth of empirical clinical literature exists, some authors debated how moral injury might and might not respond to evidence-based treatments for posttraumatic stress disorder (PTSD) whereas others identified new treatment models to directly address moral repair. Limitations of the literature included variable definitions of potentially morally injurious events, the absence of a consensus definition and gold-standard measure of moral injury as an outcome, scant study of moral injury outside of military-related contexts, and clinical investigations limited by small sample sizes and unclear mechanisms of therapeutic effect. We conclude our review by summarizing lessons from the literature and offering recommendations for future research.

Spanish Abstracts by Asociación Chilena de Estrés Traumático (ACET) Daño Moral: Una revisión integrativa REVISION INTEGRATIVA DE LA INVESTIGACION EN DAÑO MORAL Las personas que están expuestas a eventos traumáticos que violan sus valores morales pueden experimentar una angustia grave y discapacidades funcionales conocidas como "daño moral". En la última década, el daño moral ha captado la atención de proveedores de servicios de salud mental, comunidades espirituales y religiosas, medios de comunicación y el público en general. La investigación sobre daño moral, especialmente entre el personal militar y los veteranos, también ha proliferado. Para este artículo, revisamos la investigación científica sobre el daño moral. Se identificaron 116 estudios epidemiológicos y clínicos relevantes. Los estudios epidemiológicos describieron una amplia gama de secuelas biológicas, psicológicas / conductuales, sociales y religiosas / espirituales asociadas con la exposición a eventos potencialmente dañinos moralmente. Aunque existe una escasez de literatura clínica empírica, algunos autores debatieron cómo el daño moral podría y no podría responder a los tratamientos basados ​​en la evidencia para el trastorno de estrés postraumático (TEPT), mientras que otros identificaron nuevos modelos de tratamiento para abordar directamente la reparación moral. Las limitaciones de la literatura incluyeron definiciones de variables de eventos potencialmente perjudiciales desde el punto de vista moral, la ausencia de una definición consensuada y una medida de gold-estándar de daño moral y sus consecuencias, escaso estudio de daño moral fuera de contextos relacionados con el ejército e investigaciones clínicas limitadas por muestra de tamaño pequeños y mecanismos poco claros del efecto terapéutico. Concluimos nuestra revisión resumiendo las lecciones de la literatura y ofreciendo recomendaciones para futuras investigaciones.

Provider perspectives on a novel moral injury treatment for veterans: Initial assessment of acceptability and feasibility of the Impact of Killing treatment materials.

OBJECTIVE: We assessed whether treatment providers specializing in evidence-based treatment for posttraumatic stress disorder found the Impact of Killing (IOK), a novel treatment for moral injury among combat veterans, acceptable, and feasible. METHODS: Ten providers from a large veterans administration (VA) medical center were provided with materials from IOK. We audio-recorded a semistructured interview with each provider where we elicited open-ended feedback as well as asked five structured questions about the relative advantage, compatibility, complexity/simplicity, trialability, and observability of IOK. RESULTS: All providers found IOK feasible, acceptable, and something they could incorporate into their existing practice. Providers reported that the spiritual and moral concerns addressed in IOK were novel, and that self-forgiveness and making amends were critical components promoting healing from moral injury not emphasized in other treatments. CONCLUSIONS: Among trauma providers, IOK was found acceptable and feasible, offering a novel approach to addressing moral injury among combat veterans.

The Integrated Pain Team: A Mixed-Methods Evaluation of the Impact of an Embedded Interdisciplinary Pain Care Intervention on Primary Care Team Satisfaction, Confidence, and Perceptions of Care Effectiveness.

Objective: To evaluate the impact of the Integrated Pain Team (IPT)-an interdisciplinary chronic pain care intervention embedded in primary care at a large Veterans Affairs health care system. Outcomes evaluated included IPT's impact on the perceived effectiveness of chronic pain care; provider self-confidence; and primary care team satisfaction, stress, and burnout. Method: This mixed-methods quality-improvement study employed: 1) qualitative semistructured interviews of 61 primary care providers, other primary care team members, and organizational stakeholders; and 2) a supplementary quantitative survey of 65 providers, comparing those who had referred patients to IPT with those who had not. Results: Most interview participants reported that IPT improved chronic pain care by providing patients with a comprehensive pain treatment plan, educating them about opioid risks, and introducing multimodal treatment options. Interviewed care team members reported improved patient education and fewer emotionally charged contacts from patients. Interviewed providers felt that IPT allowed them to focus their time on health concerns other than pain. However, our supplemental survey found that IPT-utilizing providers were no more confident than other providers in their own pain care skills or in their relationships with chronic pain patients. Conclusions: Integrating an interdisciplinary chronic pain care intervention into primary care can provide needed support to care teams and may improve chronic pain care. Elements of the IPT model identified as important to its effectiveness include its interdisciplinary biopsychosocial approach and attentive patient follow-up. However, enhancing providers' confidence and self-efficacy in chronic pain care may require educational and support resources beyond the current IPT model.

Does gender still matter in the pursuit of a career in anaesthesia?

A survey sent to fellows of the Australian and New Zealand College of Anaesthetists (ANZCA) aimed to document issues affecting gender equity in the anaesthesia workplace. A response rate of 38% was achieved, with women representing a greater proportion of respondents (64.2%). On average women worked fewer hours than men and spent a larger percentage of time in public practice; however, satisfaction rates were similar between genders. There was a gender pay gap which could not be explained by the number of hours worked or years since achieving fellowship. The rates of bullying and harassment were high among all genders and have not changed in 20 years since the first gender equity survey by Strange Khursandi in 1998. Women perceived that they were more likely to be discriminated against particularly in the presence of other sources of discrimination, and highlighted the importance of the need for diversity and inclusion in anaesthetic workplaces. Furthermore, women reported higher rates of caregiving and unpaid domestic responsibilities, confirming that anaesthetists are not immune to the factors affecting broader society despite our professional status. The overall effect was summarised by half of female respondents reporting that they felt their gender was a barrier to a career in anaesthesia. While unable to be included in statistics due to low numbers, non-binary gendered anaesthetists responded and must be included in all future work. The inequities documented here are evidence that ANZCA's gender equity subcommittee must continue promoting and implementing policies in workplaces across Australia and New Zealand.

Evaluation of a New Integrative Health and Wellness Clinic for Veterans at the San Francisco VA Health Care System: A Mixed-Methods Pilot Study.

Objective: The Integrative Health and Wellness Clinic (IHWC), established in 2019 at the San Francisco VA Health Care System, is an interdisciplinary clinic consisting of a medical provider, dietician, physical therapist, and psychologist trained in complementary and integrative health (CIH) following the VA Whole Health model of care. Veterans with complex chronic conditions seeking CIH and nonpharmacologic approaches are referred to the IHWC. This study evaluated the clinic's acceptability and feasibility among veteran patients and its preliminary impact on health and wellbeing, health-related goals, and use of CIH approaches. Methods: Mixed methods were used to assess patient-reported outcomes and experiences with the IHWC. Participants completed surveys administered at baseline and 6-months and a subset completed a qualitative interview. Pre- and post-scores were compared using t-tests and chi-square tests. Results: Thirty-five veterans completed baseline and 6-month follow up surveys. Of these, 13% were women; 24% < 50 years of age, and 44% identified as racial/ethnic minorities. Compared to baseline, at 6 months, there were significant (P < .05) improvements in overall health, physical health, perceived stress, and perceived helpfulness of clinicians in assisting with goal attainment; there was a trend toward improved mental health (P = .057). Interviews (n = 25) indicated satisfaction with the interdisciplinary clinical model, support of IHWC providers in goal attainment, and positive impact on physical and mental health. Areas for improvement included logistics related to scheduling of multiple IHWC providers and referrals to other CIH services. Conclusion: Results revealed significant improvement in important clinical domains and satisfaction with interprofessional IHWC clinic providers, but also opportunities to improve clinic processes and care coordination. An interdisciplinary clinic focused on CIH and Whole Health is a feasible and acceptable model of care for veterans with complex chronic health conditions in the VA healthcare system.

Lung Cancer Screening Among U.S. Military Veterans by Health Status and Race and Ethnicity, 2017-2020: A Cross-Sectional Population-Based Study.

Introduction: Veterans are at high risk for lung cancer and are an important group for lung cancer screening. Previous research suggests that lung cancer screening may not be reaching healthier and/or non-White individuals, who stand to benefit most from lung cancer screening. We sought to test whether lung cancer screening is associated with poor health and/or race and ethnicity among veterans. Methods: This cross-sectional, population-based study included veterans eligible for lung cancer screening (aged 55-79 years, ≥30 pack-year smoking history, current smokers or quit within 15 years, no previous lung cancer) in the 2017-2020 Behavioral Risk Factor Surveillance System surveys. Exposures were (1) poor health, defined as fair/poor health status and difficulty walking or climbing stairs, aligning with eligibility criteria for a pivotal lung cancer screening trial, and (2) race/ethnicity. The outcome was a receipt of lung cancer screening. All variables were self-reported. Results: Of 3,376 lung cancer screening-eligible veterans representing an underlying population of 866,000 individuals, 20.3% (95% CI=17.3, 23.6) had poor health, and 13.7% (95% CI=10.6, 17.5) identified as non-White. Poor health was strongly associated with lung cancer screening (adjusted RR=1.64, 95% CI=1.06, 2.27); one third of veterans screened for lung cancer would not qualify for a pivotal lung cancer screening trial in terms of health. Marked racial disparities were observed among veterans: after adjustment, non-White veterans were 67% less likely to report lung cancer screening than White veterans (adjusted RR=0.33, 95% CI=0.11, 0.66). Conclusions: Lung cancer screening is correlated with poorer health and White race/ethnicity among veterans, which may undermine its population-level effectiveness. These results highlight the need to promote lung cancer screening, especially for healthier and/or non-White veterans, an important group of Americans for lung cancer screening.

Virtual Worlds Technology to Enhance Training for Primary Care Providers in Assessment and Management of Posttraumatic Stress Disorder Using Motivational Interviewing: Pilot Randomized Controlled Trial.

BACKGROUND: Many individuals with posttraumatic stress disorder (PTSD) first present to primary care rather than specialty mental health care. Primary care providers often lack the training required to assess and treat patients with PTSD. Virtual trainings have emerged as a convenient and effective way of training primary care providers in PTSD assessment and communication methods (ie, motivational interviewing [MI]). OBJECTIVE: The aim of this study was to conduct a pilot randomized controlled trial of a synchronous Virtual Worlds (VW; a virtual world where learners were immersed as avatars) training versus an asynchronous web-based training on PTSD and MI, comparing the feasibility, acceptability, usability, and preliminary efficacy of 2 different training platforms among primary care providers. METHODS: Participating primary care providers were randomized to a VW and a web-based PTSD training. Outcomes were collected at baseline, posttraining, and 90-days follow-up. Standardized patient interviews measured participants' communication skills in assessing and managing patients with PTSD symptoms. RESULTS: Compared to the web-based training, the VW training platform achieved larger learning gains in MI (ie, partnership and empathy) and in discussing pharmacotherapy and psychotherapy for PTSD. Both VW and web-based trainings led to increases in PTSD knowledge and primary care providers' self-confidence. CONCLUSIONS: The asynchronous web-based PTSD training improved PTSD-related knowledge and self-confidence but was not as effective as the VW immersive experience in teaching MI or clinical management. Because VW training is synchronous and new for many learners, it required more time, facilitation, and technical support. As computer technology improves, VW educational interventions may become more feasible, particularly in teaching clinical skills. TRIAL REGISTRATION: ClinicalTrials.gov NCT03898271; https://tinyurl.com/mu479es5.

Advancing health equity by understanding race disparities and other factors associated with PTSD symptom improvement following evidence-based psychotherapy.

Several studies found that Black veterans demonstrate less posttraumatic stress disorder (PTSD) symptom improvement than White veterans following PTSD evidence-based psychotherapies (EBPs). We aimed to understand this disparity among veterans receiving EBPs by modeling race with demographic, clinical, and service utilization factors. Using electronic health records, we employed a cohort study of Iraq and Afghanistan War Veterans who initiated PTSD EBP treatment and completed > 2 PTSD symptom measures (N = 21,751). Using hierarchical Bayesian logistic regressions, we modeled the probability of PTSD symptom improvement. Black race was associated with less PTSD improvement (mean posterior odds ratio [MPOR] = 0.92; 95 % plausibility interval [PI] = 0.84, 1.0), as was group therapy (MPOR = 0.67; 95 % PI = 0.62, 0.73). Factors associated with greatest improvement included prolonged exposure (MPOR = 1.35; 95 % PI = 1.25, 1.45) and treatment density (MPOR = 1.40; 95 % PI = 1.36, 1.45). On average, Black veterans evidenced PTSD EBP improvement disparities. Clinical and utilization did not fully account for these disparities, although disproportionate representation of Black veterans in group CPT may explain some of these differences. Understanding experiences such as race-based trauma and chronic racism and discrimination is critical to provide Black veterans with the most effective PTSD care.

Developing and testing a COVID-19 vaccination acceptance intervention: A pragmatic trial comparing vaccine acceptance intervention vs usual care - Rationale, methods, and implementation.

BACKGROUND: COVID-19 has resulted in significant disability and loss of life. COVID-19 vaccines effectively prevent severe illness, hospitalization, and death. Nevertheless, many people remain hesitant to accept vaccination. Veterans perceive healthcare providers (HCP) and staff as trusted vaccine information sources and thereby are well suited to initiate vaccine discussions. The overall objective of this study is to implement and test a virtual COVID-19 Vaccine Acceptance Intervention (VAI) training that is informed by motivational interviewing (MI) techniques. METHODS: The VAI training is being delivered to VA HCPs and staff within a Hybrid Type 2 pragmatic implementation-effectiveness trial using Implementation Facilitation as the implementation strategy. The implementation team includes external facilitators paired with VA Healthcare System (VAHCS)-level internal facilitators. The trial has three aims: 1) Examine the effectiveness of the VAI versus usual care on unvaccinated veterans' vaccination rates in a one-year cluster randomized controlled trial, with randomization at the level of VAHCS. 2) Determine factors associated with veterans' decisions to accept or decline primary COVID-19 vaccination, and better understand how these factors influence vaccination decisions, through survey and qualitative data; and 3) Use qualitative interviews with HCPs and staff from clinics with high and low vaccination rates to learn what was helpful and not helpful about the VAI and implementation strategies. CONCLUSION: This is the first multisite randomized controlled trial to test an MI-informed vaccine acceptance intervention to improve COVID-19 vaccine acceptance. Information gained can be used to inform healthcare systems' approaches to improve future vaccination and other public health campaigns. CLINICALTRIALS: gov Identifier: NCT05027464.

Barriers to positive airway pressure adherence among veterans with sleep apnea: a mixed methods study.

Rates of adherence to positive airway pressure (PAP) for sleep apnea are suboptimal. Though previous studies have identified individual factors associated with PAP nonadherence, few projects have investigated a wide range of possible barriers directly from the patient perspective. We examined the range of factors that patients identify as barriers to optimal use of PAP as well as the solutions most commonly offered by providers. We employed a mixed methods design including semistructured interviews and medical record review at a US Department of Veterans Affairs Medical Center. Thirty patients identified as nonadherent to PAP participated. Patients were asked to report on current sleep problems, reasons for nonadherence, and solutions proposed by providers. Chart review was used to identify untreated apnea severity, Epworth Sleepiness Scale score, therapy hours, and residual apnea severity. Patients described physical and psychological barriers to adherent use at approximately equal rates: Mask leaks and dry throat/nose were common physical barriers, and anxiety/claustrophobia and worsening insomnia were common psychological barriers. Untreated apnea severity, residual apnea severity, and daytime sleepiness were not associated with therapy hours. Solutions offered by providers most frequently addressed physical barriers, and solutions to psychological barriers were rarely proposed. The most common solution offered by providers was trying different masks. We recommend individualized assessment of each patient's barriers to use as well as increased involvement of behavioral health providers in sleep medicine clinics.

Positive airway pressure (PAP) is an effective treatment for sleep apnea, but many patients have trouble tolerating it. We interviewed 30 veterans at a Department of Veterans Affairs Medical Center who do not use their PAP every day. We interviewed them to identify the most common barriers to use. We also reviewed their medical records to investigate whether other factors, such as the severity of their apnea or their daytime sleepiness, were associated with number of hours of PAP use. In addition, we asked patients what their providers recommended to improve their PAP adherence. We categorized all reported barriers to PAP use into four main groups: physical, psychological, situational, and knowledge. Physical problems and psychological barriers were most commonly reported and were endorsed at approximately equal rates. None of the factors reviewed during chart review were associated with the number of hours PAP was used. The most common solution providers recommended was trying a different mask. Providers rarely suggested solutions to psychological barriers, such as insomnia or claustrophobia. We recommend that sleep medicine clinics involve behavioral health providers in sleep apnea care to help address psychological barriers to PAP use.

Using the ISBAR handover tool in junior medical officer handover: a study in an Australian tertiary hospital.

BACKGROUND: Despite being essential to patient care, current clinical handover practices are inconsistent and error prone. Efforts to improve handover have attracted attention recently, with the ISBAR tool increasingly utilised as a format for structured handover communication. However, ISBAR has not been validated in a junior medical officer setting. OBJECTIVE: To assess the effect of the ISBAR handover tool on junior medical officer (JMO) handover communication in an Australian hospital. METHODS: JMOs who participated in after-hours handover during an 11 week clinical term from June to August 2009 were recruited. After-hours handover was audiotaped, and JMOs completed a survey to assess current handover perception and practice. JMOs then participated in a 1 h education session on handover and use of the ISBAR handover tool, and were encouraged to handover using this method. Following the education session, participants were surveyed to measure perceived changes in handover with use of ISBAR, and handover was again audiotaped to assess differences in information transfer and duration. RESULTS: Following the introduction of ISBAR, 25/36 (71%) of JMOs felt there was an overall improvement in handover communication. Specifically, they perceived improvement in the structure and consistency of handover, they felt more confident receiving handover, and they believed patient care and safety were improved. Audio-tape data demonstrated increased transfer of key clinical information during handover with no significant effect on handover duration. CONCLUSIONS: Use of the ISBAR tool improves JMO perception of handover communication in a time neutral fashion. Consideration should be given to the introduction of ISBAR in all JMO handover settings.

How VA Whole Health Coaching Can Impact Veterans' Health and Quality of Life: A Mixed-Methods Pilot Program Evaluation.

PURPOSE: To examine the impact of a pilot VA Whole Health Coaching program, including whether and how the program helps veterans improve their health and quality of life. INTERVENTION: Whole Health Coaching is a structured program to support veterans in making healthy behavior changes to promote holistic well-being. DESIGN: This mixed-methods quality-improvement evaluation combined surveys (pre- and post-coaching) with follow-up qualitative interviews. SETTING: The setting was a large VA healthcare system, encompassing a medical center and six community-based clinics in Northern California. PARTICIPANTS: 65 veterans completed surveys at both time points; 42 completed qualitative interviews. METHOD: Telephone surveys administered at baseline and 3 months assessed global health (PROMIS-10), perceived stress (PSS-4), and perceived health competency (PHCS-2). Pre- and post-scores were compared using t-tests. A subsample of participants completed a qualitative interview evaluating program experience, goal attainment, and the coaching relationship. RESULTS: Surveys showed significant improvements over baseline in mental health (p = 0.006; d = 0.36), stress (p = 0.003; d = -0.38), and perceived health competence (p = 0.01; d = 0.35). Interviewees were highly satisfied with their coaching experience, describing both effective program components and improvement opportunities. CONCLUSION: Whole Health Coaching can help participants make meaningful progress toward health goals, reduce stress, and improve quality of life. The Whole Health model's emphasis on holistic self-assessment; patient-driven goal-setting; supportive, non-judgmental inquiry; and mindful awareness contributed to program success and enhanced participants' experience.