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
Insomnia is a prevalent and debilitating disorder among veterans. Cognitive behavioral therapy for insomnia (CBTI) can be effective for treating insomnia, although many cannot access this care. Technology-based solutions and lifestyle changes, such as physical activity (PA), offer affordable and accessible self-management alternatives to in-person CBTI.This study aims to extend and replicate prior pilot work to examine whether the use of a mobile app for CBTI (cognitive behavioral therapy for insomnia coach app [CBT-i Coach]) improves subjective and objective sleep outcomes. This study also aims to investigate whether the use of the CBT-i Coach app with adjunctive PA improves sleep outcomes more than CBT-i Coach alone.A total of 33 veterans (mean age 37.61 years, SD 9.35 years) reporting chronic insomnia were randomized to use either the CBT-i Coach app alone or the CBT-i Coach app with a PA intervention over 6 weeks, with outcome measures of objective and subjective sleep at pre- and posttreatment.Although the PA manipulation was unsuccessful, both groups of veterans using the CBT-i Coach app showed significant improvement from baseline to postintervention on insomnia (P<.001), sleep quality (P<.001), and functional sleep outcomes (P=.002). Improvements in subjective sleep outcomes were similar in those with and without posttraumatic stress disorder and mild-to-moderate sleep apnea. We also observed a significant but modest increase in objective sleep efficiency (P=.02).These findings suggest that the use of a mobile app-delivered CBTI is feasible and beneficial for improving sleep outcomes in veterans with insomnia, including those with comorbid conditions such as posttraumatic stress disorder or mild-to-moderate sleep apnea.ClinicalTrials.gov NCT03305354; https://clinicaltrials.gov/ct2/show/NCT03305354.
The Veterans Health Administration (VHA) is deploying an automated texting system (aTS) to support patient self-management.We conducted a qualitative evaluation to examine factors influencing national rollout of the aTS, guided by the Nonadoption, Abandonment, Scale-up, Spread, and Sustainability (NASSS) framework, which is intended to support the evaluation of novel technologies.Semistructured interviews were conducted with 33 staff and 38 patients who were early adopters of the aTS. Data were analyzed following deductive and inductive approaches using a priori codes and emergent coding based on the NASSS.We identified themes across NASSS domains: (1) Condition: The aTS was considered relevant for a range of patient needs; however, perceptions of patient suitability were guided by texting experience and clinical complexity rather than potential benefits. (2) Technology: Onboarding of the aTS presented difficulty and the staff had different opinions on incorporating patient-generated data into care planning. (3) Value: Supply-side value relied on the flexibility of the aTS and its impact on staff workload whereas demand-side value was driven by patient perceptions of the psychological and behavioral impacts of the aTS. (4) Adopters: Limited clarity on staff roles and responsibilities presented challenges in incorporating the aTS into clinical processes. (5) Organization: Staff were willing to try the aTS; however, perceptions of leadership support and clinic readiness hindered usage. (6) Wider system: Staff focused on enhancing aTS interoperability with the electronic medical record. (7) Embedding and adaptation over time: The interplay of aTS versatility, patient and staff demands, and broader societal changes in preferences for communicating health information facilitated aTS implementation.VHA's new aTS has the potential to further engage patients and expand the reach of VHA care; however, patients and staff require additional support to adopt, implement, and sustain the aTS. The NASSS highlighted how the aTS can be better embedded into current practices, which patients might benefit most from its functionality, and which aspects of aTS messages are most relevant to self-management.ClinicalTrials.gov NCT03898349; https://clinicaltrials.gov/ct2/show/NCT03898349.
Abstract The present study sought to understand the antecedents to COVID-19 vaccination among those reporting a change in vaccine intention in order to improve COVID-19 vaccine uptake in the United States. We employed semi-structured interviews and one focus group discussion with vaccinated and unvaccinated Veterans Health Administration (VHA) employees and Veterans at three Veterans’ Affairs medical centers between January and June 2021. A subset of these participants (n=21) self-reported a change in COVID-19 vaccine intention and were selected for additional analysis. We combined thematic analysis using the 5C scale (confidence, collective responsibility, complacency, calculation, constraints) as our theoretical framework with a constant comparative method from codes based on the SAGE Working Group on Vaccine Hesitancy. We generated 13 themes distributed across the 5C constructs that appeared to be associated with a change in COVID-19 vaccine intention. Themes included a trusted family member, friend or colleague in a healthcare field, a trusted healthcare professional, distrust of government or politics (confidence); duty to family and protection of others (collective responsibility); perceived health status and normative beliefs (complacency); perceived vaccine safety, perceived risk-benefit, and orientation towards deliberation (calculation); and ease of process (constraints). Key factors in promoting vaccine uptake included a desire to protect family; and conversations with as key factors in promoting vaccine uptake. Constructs from the 5C scale are useful in understanding intrapersonal changes in vaccine intentions over time, which may help public health practitioners improve future vaccine uptake.
BACKGROUND The Veterans Health Administration (VHA) is deploying an automated texting system (aTS) to support patient self-management. OBJECTIVE We conducted a qualitative evaluation to examine factors influencing national rollout of the aTS, guided by the Nonadoption, Abandonment, Scale-up, Spread, and Sustainability (NASSS) framework, which is intended to support the evaluation of novel technologies. METHODS Semistructured interviews were conducted with 33 staff and 38 patients who were early adopters of the aTS. Data were analyzed following deductive and inductive approaches using a priori codes and emergent coding based on the NASSS. RESULTS We identified themes across NASSS domains: (1) Condition: The aTS was considered relevant for a range of patient needs; however, perceptions of patient suitability were guided by texting experience and clinical complexity rather than potential benefits. (2) Technology: Onboarding of the aTS presented difficulty and the staff had different opinions on incorporating patient-generated data into care planning. (3) Value: Supply-side value relied on the flexibility of the aTS and its impact on staff workload whereas demand-side value was driven by patient perceptions of the psychological and behavioral impacts of the aTS. (4) Adopters: Limited clarity on staff roles and responsibilities presented challenges in incorporating the aTS into clinical processes. (5) Organization: Staff were willing to try the aTS; however, perceptions of leadership support and clinic readiness hindered usage. (6) Wider system: Staff focused on enhancing aTS interoperability with the electronic medical record. (7) Embedding and adaptation over time: The interplay of aTS versatility, patient and staff demands, and broader societal changes in preferences for communicating health information facilitated aTS implementation. CONCLUSIONS VHA’s new aTS has the potential to further engage patients and expand the reach of VHA care; however, patients and staff require additional support to adopt, implement, and sustain the aTS. The NASSS highlighted how the aTS can be better embedded into current practices, which patients might benefit most from its functionality, and which aspects of aTS messages are most relevant to self-management. CLINICALTRIAL ClinicalTrials.gov NCT03898349; https://clinicaltrials.gov/ct2/show/NCT03898349
Clinical pharmacists (CPs) with a scope of practice operate as direct care providers and health care team members. Research often focuses on one role or the other; little is understood about the dynamic relationship between roles in practice settings.To identify the challenges CPs face in balancing dual roles as direct care providers and health care team members and the implications for CP effectiveness and quality of care.Pharmacists were interviewed with a primary purpose of informing an implementation effort. Besides the implementation, there were emergent themes regarding the challenges posed for CPs in negotiating dual roles. This study is, therefore, a secondary analysis of semistructured interviews and direct observation of 48 CPs, addressing this phenomenon. Interview data were entered into NVivo 10 and systematically analyzed using an emergent thematic coding strategy.Pharmacists describe role ambiguity, where they perform as direct providers or team members simultaneously or in quick succession. They note the existence of a "transaction cost," where switching causes loss of momentum or disruption of work flow. Additionally, pharmacists feel that fellow providers lack an understanding of what they do and that CP contributions are not evaluated accurately by other health professionals.It is a challenge for CPs to balance the distinct roles of serving as collaborators and primary providers. Frequent role switching is not conducive to optimal work efficiency or patient care. Our findings suggest concrete steps that medical centers can take to improve both CP worklife and quality of patient care.
BACKGROUND: Homeless veterans have complex healthcare needs, but experience many barriers to treatment engagement. While information technologies (IT), especially mobile phones, are used to engage patients in care, little is known about homeless veterans’ IT use. This study examines homeless veterans’ access to and use of IT, attitudes toward health-related IT use, and barriers to IT in the context of homelessness. METHODS: Qualitative interviews were conducted with 30 homeless veterans in different housing programs in Boston, MA. Inductive thematic analysis was used. RESULTS: Most participants (90%) had a mobile phone and were receptive to IT use for health-related communications. A common difficulty communicating with providers was the lack of a stable mailing address. Some participants were using mobile phones to stay in touch with providers. Participants felt mobile-phone calls or text messages could be used to remind patients of appointments, prescription refills, medication taking, and returning for laboratory results. Mobile phone text messaging was seen as convenient, helped participants stay organized because necessary information was saved in text messages. Some reported concerns about the costs associated with mobile phone use (calls and texting), the potential to be annoyed by too many text messages, and not knowing how to use text messaging. CONCLUSION: Homeless veterans use IT and welcome its use for health-related purposes. Technology-assisted outreach among this population may lead to improved engagement in care.
Abstract Background In the United States, discourse on COVID-19 vaccination has become polarized, and the positions of public health officials are met with skepticism by many vaccine-hesitant Americans. This polarization may impact future vaccination efforts as well as clinician-patient relationships. Methods We interviewed 77 vaccine-hesitant patients and 41 clinicians about COVID-19 vaccination communication in primary care as part of a Veterans Affairs (VA) trial evaluating a vaccine-communication intervention. This paper reports the findings of a qualitative analysis focused on one aspect of those interviews—the disconnect between primary care clinicians’ and patients’ perceptions about COVID-19 vaccination communication and decision-making. Results Rapid qualitative analysis of semi-structured interviews revealed fundamental differences in how clinicians and patients understood and described the reasoning, values, and concerns underlying COVID-19 vaccine hesitancy. These differences were significant and value-laden; they included negative judgments that could undermine communication between clinicians and patients and, over time, erode trust and empathy. Conclusion We advocate for empathic listening and suggest communication strategies to bridge the divide between clinicians and vaccine-hesitant patients.
Objectives. We examined the feasibility of using mobile phone text messaging with homeless veterans to increase their engagement in care and reduce appointment no-shows. Methods. We sent 2 text message reminders to participants (n = 20) before each of their outpatient appointments at an urban Veterans Affairs medical center. Evaluation included pre- and postsurvey questionnaires, open-ended questions, and review of medical records. We estimated costs and savings of large-scale implementation. Results. Participants were satisfied with the text-messaging intervention, had very few technical difficulties, and were interested in continuing. Patient-cancelled visits and no-shows trended downward from 53 to 37 and from 31 to 25, respectively. Participants also experienced a statistically significant reduction in emergency department visits, from 15 to 5 (difference of 10; 95% confidence interval [CI] = 2.2, 17.8; P = .01), and a borderline significant reduction in hospitalizations, from 3 to 0 (difference of 3; 95% CI = −0.4, 6.4; P = .08). Conclusions. Text message reminders are a feasible means of reaching homeless veterans, and users consider it acceptable and useful. Implementation may reduce missed visits and emergency department use, and thus produce substantial cost savings.
Research Objective For successful implementation and spread of an intervention, identifying its core components is essential for fidelity, adaptation, replication, and evaluation. However, an intervention’s core components are often gradually refined, as the intervention’s outcomes are repeatedly examined alongside actually implemented components. When empirical evidence is limited, as is often the case with early implementation of innovative interventions, consensus group methods can be used to gather and synthesize expert opinions to determine and refine intervention core components. We used aspects of the Delphi method, hybrid Delphi method, and nominal group technique to determine an intervention’s initial core components. Study Design This approach was devised in the context of the VA’s Post‐Incarceration Engagement (PIE) intervention, which uses peer support to provide better linkage to health care and other needed services to veterans recently released from incarceration. Utilizing an iterative approach, a four‐person expert panel of PIE developers/implementers and a two‐person moderator team followed these steps: Panel members individually suggested PIE intervention core components using a worksheet. Moderators reviewed the suggested components, removing duplicates and consolidated them into a preliminary list of core components categorized by theme. Moderators facilitated a panel meeting to discuss and clarify overlapping/distinct suggestions. Moderators drafted an updated list of core components and their definitions, based on the facilitated panel meeting. Panel members individually suggested revisions to the list, using an updated structured worksheet. Moderators reviewed the suggested revisions, incorporating ones that were consistent across the panel and organizing suggestions into the list. To resolve inconsistent suggestions, moderators may facilitate another panel meeting for consensus reaching and then return to Step 4. If not, the latest list is considered to reflect the initial core components of the innovation. Population Studied The PIE intervention was conducted by two peer support specialists over a two‐year period in one state. The consensus process included an expert panel of four study team members and two moderators. Principal Findings The PIE intervention has three core aims: improve linkage, social support, and skill building for veterans returning to community after incarceration. The consensus effort identified 20 core components at preimplementation, implementation, and sustainment stages. The identified components were sorted into three domains: (i) onboarding of peers; (ii) peers’ veteran‐facing work; and (iii) ongoing peer supervision, coordination, and networking. Iterative review of components determined a final set of 21 core components, refined definitions of roles and tasks, and specified preconditions of implementation. Conclusions The iterative hybrid Delphi approach allowed the research team to determine the initial core components of a complex intervention. As scale‐up continues, analyzing modifications made to the intervention during its spread to other states will be essential to determining the stability of core components. Implications for Policy or Practice When implementing an intervention, specifying the core components is critical to (i) assess the success of the implementation and (ii) prioritize components when resources are limited. The iterative hybrid Delphi approach offers steps toward determining core components of interventions that have yet to be tested. Primary Funding Source Department of Veterans Affairs.
