BACKGROUND/RATIONALE:
Posttraumatic stress disorder, major depressive disorder, and alcohol use are prevalent among OEF/OIF Veterans. These disorders are associated with high levels of distress, impairment in social and/or occupational functioning, significant economic impact, and morbidity and mortality. Yet, most Veterans with mental health diagnoses do not receive evidence-based interventions. There is tremendous need for widely accessible resources that can assist Veterans with mental health problems who do not seek formal services. Web-based self help represents an innovative and cost-effective solution that has high potential to overcome common access-to-care barriers. Numerous web-based self-help protocols exist for a variety of traumatic stress populations, but none has undergone rigorous large-scale evaluation with Veterans. This line of research attempted to address this major gap in access to care among Veterans.

OBJECTIVE(S):
The primary purposes of this project were to (a) develop Vet Help, an innovative, Web-based intervention for OEF/OIF Veterans to facilitate healthy recovery and address common barriers to care; (b) develop video illustrations to facilitate learning of evidence-based behavioral health approaches featured in Vet Help; (c) develop evaluation mechanisms to assess knowledge change; (d) conduct focus groups to guide development and refinement of intervention content; and (e) preliminarily evaluate the intervention using qualitative interviews with a small sample of OEF/OIF Veterans recruited from the Ralph H. Johnson VA Medical Center.

METHODS:
Vet Help is an innovative web-based intervention for OEF/OIF Veterans. It is fully developed, functional, and ready for evaluation in the context of a future study. Our methodology was primarily qualitative in nature, and included four steps. First, we conducted thematic interviews with 17 VA providers to gain insight into the unique problems and needs of OEF/OIF Veterans, obtain feedback on the proposed content and presentation of Vet Help, and generate suggestions regarding effective delivery of Vet Help. Second, we conducted focus groups with 16 local OEF/OIF Veterans about their impressions and opinions on the Vet Help concept and materials. Third, we received extensive feedback from a human factors usability expert that guided significant improvements to the site. Fourth, we conducted usability testing with 11 OEF/OIF Veterans recruited locally from the Ralph H. Johnson VAMC. Qualitative methods (i.e., individual thematic interviews) were used to collect data relating to steps 1, 2, and 4. A constructivist grounded theory approach guided these steps.

FINDINGS/RESULTS:
(a) Provider interviews: VA providers were receptive to the use of web-based interventions and were vocal in their support for novel approaches and tools. They noted several benefits to web-based interventions such as their ability to circumvent access-to-care barriers and their ease of use and likely appeal to OEF/OIF Veterans. They also noted challenges, including obtaining sufficient motivation and buy-in from all Veterans. Finally, providers offered several recommendations regarding the content and design of Vet Help, as well as strategies for effective marketing and dissemination. We have a manuscript under review that summarizes these findings.

(b) Focus groups with OEF/OIF Veterans: Participating OEF/OIF Veterans primarily were male (94%), aged 21-62 years (M=33), and self-identified as either African American (44%) or White (57%). Most (75%) were deployed at least once. Veterans universally agreed that Vet Help needed to address substance use, depression, and PTSD. They also suggested adding components that were not in our original plan-for example, sleep disturbance, anger, and finding social supports. We therefore addressed these issues in Vet Help. Considerable discussion also centered on addictions, particularly alcohol and drug use problems. A consistent theme was Veterans' concerns about how complex the content would be; participants universally stated they wanted a simple, synergistic approach that integrated topics and addressed multiple problems vs. having a multifaceted disorder-specific intervention. Veterans felt that our proposed multifaceted design was overwhelming. This feedback led us to use a transdiagnostic framework when constructing the intervention.

(c) Usability testing with OEF/OIF Veterans: Usability testing involved having Veterans complete Vet Help modules while being observed by members of the investigative team. One of the main purposes is to identify and repair any issues with the intervention that may prevent task completion, take someone off course, create confusion, or decrease satisfaction. The main themes that emerged from our usability test were as follows: user likes the return visit content and would use the site (19 references); design is interactive (15); hierarchy generation tool is very helpful (9); layout is excellent (53), videos are engaging and facilitate learning (22); options for triggers, targets, and activities are relevant/relatable/comprehensive (27); user learned new ways of approaching a problem on the site (57); user felt the intervention was helpful (17); and users' confidence and motivation to complete treatment increased (11).

IMPACT:
Because this project was focused on development of an intervention, it is very well positioned for impact via completion of a rigorous evaluation phase, but evaluation is necessary before widespread impact can occur. The Vet Help site has very high potential for impact. First, Web-based self help interventions have been found to have efficacy for a wide range of populations. Second, Vet Help uses evidence-based intervention approaches that have been supported in numerous controlled trials. Third, there is tremendous need for widely accessible resources that can be accessed privately and freely. The potential reach of a web-based self-help intervention is great. Fourth, OEF/OIF Veterans are generally very technology savvy and feedback obtained in our project supports the notion that our intervention would be widely used by this population.

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. Strachan M, Gros DF, Ruggiero KJ, Lejuez CW, Acierno R. An integrated approach to delivering exposure-based treatment for symptoms of PTSD and depression in OIF/OEF veterans: preliminary findings. Behavior Therapy. 2012 Sep 1; 43(3):560-9. [view]
2. Price M, Gros DF, McCauley JL, Gros KS, Ruggiero KJ. Nonuse and dropout attrition for a web-based mental health intervention delivered in a post-disaster context. Psychiatry. 2013 Jul 12; 75(3):267-84. [view]
3. Tuerk PW, Fortney J, Bosworth HB, Wakefield B, Ruggiero KJ, Acierno R, Frueh BC. Toward the development of national telehealth services: the role of Veterans Health Administration and future directions for research. Telemedicine journal and e-health : the official journal of the American Telemedicine Association. 2010 Jan 1; 16(1):115-7. [view]

HSR&D or QUERI Articles

1. Ruggiero KJ, Gros DF, Acierno RE, Frueh BC, Grubaugh AL, Egede LE. Telehealth Technologies for the Delivery of Mental Health Services. HSR&D Forum Translating research into quality health care for Veterans. 2010 Nov 1; 6(1): 1-6. [view]

Center Products

1. Ruggiero KJ, Gros DF. Self-Help Tools for OIF/OEF Veterans. [Website]. 2013 Nov 1. [view]

Conference Presentations

1. Price M, Ruggiero KJ, Ferguson P, Patel S, Treiber F, Fakhry SM. A comprehensive data driven approach to information technologies innovation targeting PTSD screening, treatment process, and intervention. Paper presented at: International Society for Traumatic Stress Studies Annual Symposium; 2014 Nov 6; Miami, FL. [view]
2. Ruggiero KJ, Gros DF, Acierno R, Price M, Strachan M. The role of social support in the treatment of PTSD in OEF/OIF Veterans. Poster session presented at: Association for Behavioral and Cognitive Therapies Annual Convention; 2011 Nov 10; Toronto, Canada. [view]
3. Ruggiero KJ. Virtual interprofessional learning. Paper presented at: National Organization of Nurse Practitioner Faculties Annual Conference; 2015 Apr 23; Baltimore, MD. [view]
4. Ruggiero KJ, Stauffacher K, Resnick HS, Wolinsky-Taylor K, Zinzow H, Ruscio A, Schmidt NB, Acierno RE. Web-based intervention for postdisaster mental health: Preliminary efficacy data. Presented at: Association for Behavioral and Cognitive Therapies Annual Convention; 2010 Nov 18; San Francisco, CA. [view]

DRA: Military and Environmental Exposures, Mental, Cognitive and Behavioral Disorders, Substance Use Disorders
DRE: Treatment - Observational, Prevention, Technology Development and Assessment
Keywords: Dual diagnosis – substance abuse and mental health, Operation Enduring Freedom, PTSD
MeSH Terms: none