BACKGROUND/RATIONALE:
OEF/OIF/OND Reserve and National Guard (RNG) servicewomen are at significant risk of post-deployment mental health (MH) problems. However, only a minority of these women seek care. Findings from our prior MH QUERI RRP indicated that an on-line intervention could be successfully implemented with VHA, that RNG servicewomen who completed online screening and tailored educational interventions (Web-Ed) had a substantial number of positive screens for post-deployment MH and readjustment conditions, and that RNG servicewomen reported the Web-Ed decreased their discomfort with seeking MH care. These initial findings, combined with methodological lessons raised during implementation, were the rationale for this new RRP to further refine, enhance, and maximize likelihood for the portability and system impact of the Web-Ed interventions.

OBJECTIVE(S):
In a population of female RNG who have returned from deployment to Iraq or Afghanistan within the preceding three years, the objectives of this study were to:
1)Determine effective recruitment approaches for web-based screening and tailored education (Web-Ed) to address post-deployment MH and readjustment concerns.
2)Obtain qualitative feedback from RNG servicewomen regarding their perceptions of the original Web-Ed in order to ensure applicability, buy-in, and comprehensive screening/information.
3)Revise and re-pilot the Web-Ed.
4)Identify currently unknown barriers/facilitators to VA MH services unique to this population.
5)Determine RNG servicewomen's preferences for the portability of their tailored results.
6)Two months following the Web-Ed participation,
a)determine if Web-Ed increased participant's knowledge about their post-deployment conditions, decreased MH care stigma, facilitated entry into the VA or other MH care.
b)identify participant satisfaction and VA utilization through self-report and electronic record confirmation.

METHODS:
Mixed methods were used for this RRP study. VA/DoD Identity Repository identified OEF/OIF/OND RNG servicewomen who returned from deployment from Iraq or Afghanistan in the prior 3 years . Phase 1 sampled from Greater Los Angeles and Iowa City VAs geographic areas, increasing participant diversity (e.g. rurality, race). Qualitative semi-structured interviews (using computer-assisted-telephone interviews (CATI)) were used to collect qualitative data. Subsequent study phases sampled servicewomen from Iowa, California, and North Carolina (consistent with women's practice-based-research network founder sites to leverage their research infrastructures). For Phase 2, Phase 1 qualitative data was used to help refine our existing Web-Ed and then re-pilot it. Phase 3 utilized CATI to confirm Phase 2 participant's Web-Ed perceptions, satisfaction, recruitment methods, and VA utilization through self-report. Lastly, we confirmed VA utilization through VA electronic record review.

FINDINGS/RESULTS:
Phase 1:
Semi-structured interview participants (n=5) consistently observed that the Web-Ed screenings sufficiently covered needed MH or readjustment domains and reported feeling "very well screened." Participant feedback focused on preferences for screens to query longer time frames ("prior three months") and address readjustment issues they face instead of more immediate symptoms ("last two weeks"). Notably, Web-Ed screens are consistent with VHA screening practices, so these would not change. However, participants indicated having Web-Ed available for a longer timeframe after returning home from a deployment would be beneficial. Participants also suggested other information be included in the educational materials (e.g.VA benefits, family related information).

Phase 2:
Differences in participation by e-mail versus both e-mail and postal mail recruitment (7/18/13- 12/5/13). We found that participation was higher for those invited using combined postal and e-mail recruitment methods than e-mail alone (18% vs 11%; n=133 vs n=81). (This response rate was based on research participants with valid postal and e-mail addresses, who met study eligibility and who completed the online Web-Ed). The superior benefit of dual postal and e-mail recruitment was supported by Phase 3 qualitative interviews. Participants reported they perceived dual recruitment to be more effective than solely e-mail recruitment because the added postal mail invitation demonstrated that the study was legitimate. Additional e-mail reminders of the study were viewed by participants as endorsing the importance of the research and they also liked that they were reminded to participate. The e-mail web-link made the study easier to access.

Phase 2 Study Participants:
Participants (n=214) were 37 years old (SD=9;range of 22-58). Most were white (59%), followed by black (23%) and Hispanic or Latino (15%). Participants were well educated with over half (54%) reporting college or greater education. About a third (30%) were single/never married and 48% were currently married or living with a partner. Most (64%) were working full time and 35% were students. The majority (83%) identified sex partners as men only,13% both men and women; and 4% women only. Most reported current service in RNG (84%). The majority of participants were noncommissioned officers (71%; E5-E9), followed by officers (26%; O1-O10), and lower enlisted (2%, E1-E4).

Barriers to VA Care:
The most frequently noted barriers to using VA care were: didn't feel needed (44%); concern about harming their military career (32%); already have a non-VA care provider (32%); concerns about the quality of VA health services (27%) or confidentiality (22%); and because servicewomen didn't want to take medications for their MH concerns (22%). Not knowing if they were eligible for VA care was reported by 21%. Functional barriers to VA care were reported less often (such as child care (6%), not knowing where the VA is (9%), transportation (3%)) with taking time off (17%) the exception as a more frequent concern.

Screening Results
Three quarters of the 214 participants reported trauma experiences and half acknowledged experiencing military sexual trauma (MST).On average, participants had 3.3 positive screens (median=3, SD=2.0, range 0-10). Consequent MH and readjustment symptoms were substantial:
Trauma Exposure 75%
MST 51%
Anger 44%
Prescription Drug Abuse 42%
Substance Abuse 39%
PTSD 32%
Family Readjustment Concerns 17%
Depression 16%
TBI 11%
Intimate Partner Violence (experienced not perpetrated) 5%

Post deployment Illness Perception Concern:
No participants endorsed that they had no concerns about their post-deployment adjustment. Scores of 9 and 10 were endorsed by 10% of participants, indicating extreme concern about their post-deployment adjustment. A mean and median score of 4 was found (in a scale where 0=not at all concerned and 10=extremely concerned).

Satisfaction Survey Results:
About half (48%) of phase 2 Web-Ed participants indicated the screening feedback was accurate and more than a quarter (27%) said the Web-Ed reduced their discomfort with seeking care. Web-Ed appeared to active participant's to seek care; over a third (36%) acknowledged that as a direct result of Web-Ed they would follow up with a VA provider and 32% said they would follow-up with an outside provider. Note, these answers are not mutually exclusive. Over half (55%) indicated that being able to print their results would make it easier to seek care and half (48%) indicated their unique screening results were the most useful aspect of the Web-Ed.

Almost three-fourths of participants (72%) agreed or strongly agreed they would recommend Web-Ed to others and half (54%) indicated they received information through Web-Ed that they might not have otherwise (regarding their post-deployment readjustment and MH). Two-thirds (63%) indicated they used the internet routinely to seek health information and about half (53%) preferred to receive health information from the VA via e-mail.

Phase 3:
Follow Up Interviews two months following Web-Ed

Satisfaction
Women who had completed Web-Ed (N=77) reiterated prior favorable feedback about this online interface. Approximately half (49%) believed that prior to taking Web-Ed that they had or might have post-deployment readjustment or MH conditions and two-thirds (66%) said that the Web-Ed results confirmed their beliefs about whether they did or did not have post-deployment readjustment or MH conditions. Almost half (48%) would have liked someone from the VA to call them soon after they had completed the screenings to answer questions or to help them make a VA appointment. Notably, 39% believed post-deployment readjustment or MH concerns they have may go away without professional care

Preferences for Portability of Results
Participants had pointed preferences for the portability of their tailored screening results. Most (81%) would like to be able to access their post-deployment MH screens prior to their VA appointments and most (82%) would like their screening results linked to a VA secure network (such as My HealtheVet) so that a health care provider could access them. Three-quarters (77%) said they would be more likely to ask questions or send a secure message to a VA health care provider about their results if the Web-Ed was available in MHV or another secure VA network (positive responses included agreed or strongly agreed).

Activation to Seek Care:
28% of participants indicated that they discussed their Web-Ed results with others:
18% Family
16% Friends
7% Some-one else (health care professional, work colleague)
5% Military Peers
5% Clergy
Of these, almost half (48%) said that the discussion of the Web-Ed was important or very important in helping them decide if they should or should not seek professional care.

Over a third (36%, n=28) of phase 3 participants said they had sought care from a health care provider since completing the Web-Ed. Over half (n=16) of those said it was from a VA provider, 9 said they saw a DoD provider, 11 said they sought care from another provider. Of these, more were likely to have sought care from a primary care provider (n=16), than from a mental health care provider (n=13). Note, some participants may have seen more than one type of provider. Of this 28, 32% said they sought care sooner than they might have otherwise.

Phase 4:
VA Chart Review Confirmation
Only 34 participants returned HIPAA and Consent documents allowing review of their VA records. Consequently, there were insufficient numbers to validate VA utilization (especially given self-report of DoD and other health care provider utilization).

IMPACT:
This work has substantial implications for VA post-deployment health services delivery. Findings suggest that our Web-Ed can engage and activate vulnerable and high-risk RNG female populations to seek needed post-deployment MH care that they otherwise report substantial barriers to. Participants who accessed Web-Ed acknowledged substantial trauma exposures and post-deployment readjustment and MH concerns. Many were currently serving in RNG, officers, and/or had career and confidentiality concerns about seeking treatment. Participants reported that they liked the confidentiality and accessibility of Web-Ed.

Our findings can substantially impact potential next steps for portability of Web-Ed results and reshaping VA post-deployment care delivery. Participants noted a preference for having screening results available prior to appointments, within MyHealthe Vet or other confidential servers so that they could have increased interface with providers and address questions. A sub-group of participants acknowledged the belief that their symptoms would resolve without care and avoided VA because of a preference not to receive medications or concerns with VA quality. However, many participants would have liked someone from VA to call and review their screening results with them, which indicates a vital opportunity for on-line screening to promote personal contact with a VA clinician and subsequent care linkage as needed.

Methodologically, we found that a combined postal and e-mail recruitment method appears to be more effective in recruiting participants for online study interventions. Participants interviewed reported dual recruitment increased their participation because it validated legitimacy of the study, confirmed that the study was important. They indicated that e-mail acted as a reminder as well as facilitating participation by providing an easily accessible link to the study website. These methodological findings have implications for subsequent research and care delivery.

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. Mengeling MA, Torner JC, Smith JL, Cook BL, Sadler AG. Online Screening and Personalized Education to Identify Post-Deployment Mental Health Need and Facilitate Access to Care. Military medicine. 2022 Dec 13; DOI: 10.1093/milmed/usac379. [view]
2. Sadler AG, Lindsay DR, Hunter ST, Day DV. The impact of leadership on sexual harassment and sexual assault in the military. Military psychology : the official journal of the Division of Military Psychology, American Psychological Association. 2018 May 21; 252-263. [view]

Conference Presentations

1. Sadler AG, Mengeling M, Torner J, Martin B, Booth B. OEF/OIF Servicewomen’s Post-Deployment Readjustment: Mental Health, Sexual Assault and Other Factors Associated with Use of Guns/Weapons for Personal Safety. Poster session presented at: AcademyHealth Annual Research Meeting; 2015 Jun 15; Minneapolis, MN. [view]
2. Mengeling MA, Booth BM, Smith J, Torner JC, Sadler AG. Online post-deployment mental health screening: Participant satisfaction, care activation, and gender differences. Poster session presented at: American Public Health Association Annual Meeting and Exposition; 2014 Nov 17; New Orleans, LA. [view]
3. Sadler AG, Mengeling MA, Torner JC, Booth BM. Online-Interventions to Improve Reserve/National Guard Servicewomen’s Post-Deployment DoD, VA and Home Transitions. Paper presented at: Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury / National Institutes of Health / VA Trauma Spectrum Annual Conference; 2015 Sep 9; Falls Church, VA. [view]

DRA: Military and Environmental Exposures, Mental, Cognitive and Behavioral Disorders
DRE: Diagnosis, Prevention
Keywords: none
MeSH Terms: none