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RRP 09-420 – HSR&D Study

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RRP 09-420
National Guard Outreach and Linkage to Treatment
Marcia T. Valenstein MD AB
VA Ann Arbor Healthcare System, Ann Arbor, MI
Ann Arbor, MI
Funding Period: February 2010 - February 2011

BACKGROUND/RATIONALE:
Soldiers returning from Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) commonly experience symptoms of PTSD, depressive disorders, and interpersonal difficulties. Forty-two percent of National Guard (NG) soldiers report symptoms suggesting a need for evaluation. Unfortunately, only half with mental health needs initiate treatment in the VA or elsewhere. Stigma remains an important barrier. Proactive peer outreach may successfully address stigma and facilitate appropriate treatment use. In the recently implemented Michigan Guard Buddy*to*Buddy (B2B) program, all returning MIARNG soldiers are assigned a first-tier "Buddy" from their unit who systematically telephones them to "check in" regarding key areas of functioning and symptoms. Soldiers may also be referred to second-tier Buddies, veterans outside the Guard trained in motivational interviewing and supervised by professional staff. The goal of the program is to identify soldiers in need of evaluation and connect them to care in a timely fashion.



OBJECTIVE(S):
Symptoms of PTSD, depressive disorders, and reports of interpersonal difficulties are common among soldiers following their return from Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF). Forty-two percent of National Guard/Reserve soldiers report mental health issues suggesting a need for evaluation following return from deployments. Unfortunately, many with problematic symptoms do not access care. Important barriers to treatment include soldier beliefs that those who received mental health care are viewed as "weak" and their careers harmed. Initiatives are needed that successfully address stigma and facilitate treatment connection and retention.

The goal of this RRP is to assess the need for AND the feasibility of a larger VA study that would use a strong quasi-experimental design (time series analysis with comparison groups) to examine the impact of the B2B program on returning NG veteran mental health treatment initiation, retention, symptoms, and functional outcomes.

Specific RRP aims are to:
1.Prepare for and initiate a formative evaluation of the Buddy*to*Buddy
program in the Michigan Army National Guard (MI ARNG).
2.Develop and determine the feasibility of confidential surveys for
National Guard veterans in Michigan and Indiana that elicit information
regarding B2B processes (in MI ARNG), VA outreach processes, mental
health symptoms, substance use, and treatment initiation and
retention.
3.Construct a de-identified linked dataset consisting of PDHA/PDHRA
data, Military Treatment Facility/TRICARE service provider use, and VA
service use for MI ARNG and NG soldiers in contiguous states of Indiana
and Ohio. Conduct preliminary analyses of these data.


METHODS:
Preliminary work was completed in two areas. We began a formative evaluation of the implementation of the B2B program, using an augmented qualitative RE-AIM Plus framework, multiple data sources and data collection techniques, and conducting field observations and interviews with program stakeholders. Personnel at all levels, including NG leadership, Buddies, and soldiers, were part of this process.

We also developed and refined survey items relevant to understanding B2B implementation and soldier symptom and functional status. We tested procedures for fielding this survey in Michigan and a comparison state, assessed response rates, and used data to inform the design of a larger study of soldier outcomes.


FINDINGS/RESULTS:
Interviews and focus groups were conducted during drill weekends at two Michigan National Guard Armories. Topics covered in the interviews and focus groups included deployment experiences, reintegration issues and concerns, leadership in the guard, reintegration programs in the ARNG, views on the B2B program, and process questions on the interview format. We completed 5 individual interviews with soldiers and leadership. In addition, we conducted two focus groups with 4-6 members per group (n=10). Thus a total of 15 participants provided qualitative feedback on reintegration issues and the Buddy2Buddy program.

Audio-recordings of the interviews were transcribed for data analyses. To develop the analytic coding scheme, research team members independently read the transcripts and reached consensus on relevant codes and their definitions. All transcripts were then coded and summaries of each code constructed. The interview and focus group questions were then revised based on the experience of the interviewees and the feedback from participants.

The creation of a survey to understanding B2B implementation and soldier symptom and functional status was developed in three phases. Phase I involved conducting a review of individual survey items with individuals from the relevant groups (returned soldiers, Buddy Ones), asking them to read through the survey in a "think aloud" fashion, noting which items they found difficult to understand or irrelevant to the outreach programs. We also assessed the cognitive demands and thought processes soldiers use when attempting to answer survey items. After these initial cognitive reviews were completed, the survey was revised to improve question flow, wording of problematic items, and elimination of items perceived as duplicative.

In the second phase the revised survey instrument was pre-tested with groups of soldiers, recruited from National Guard Armories during drill weekends. Time for survey completion was assessed and pretest participants were debriefed immediately following the pre-test as to question comprehensibility and relevance. Again, after analyses of pre-test survey responses, the survey instrument was revised to improve question flow and eliminate items that did not demonstrate sufficient response variation.

The third phase involved distribution of the survey to a larger sample of 150 Michigan National Guard soldiers (an additional 150 will be mailed to Indiana National Guard soldiers in the coming weeks). The survey was distributed through the mail using a slightly modified version of the methodology proposed by Dillman. Pre-alert letters were sent through postal mail one week before survey mailing. The second mailing included the survey and HIPAA authorization forms allowing access to VA service use data as well as National Guard PDHA/PDHRA data. Participants were informed that they could complete only the survey if they did not want to sign the authorization forms. A thank you/reminder post card was mailed one week after the survey. A second letter and replacement questionnaire were mailed 3 weeks after initial survey mailing to non-respondents and a final letter and replacement questionnaire was UPSed to remaining non-respondents 7 weeks after the initial survey mailing.

The above procedures resulted in a 50% response rate for the survey (n=69 returned surveys). Sixty-eight percent of respondents also returned one or both HIPAA authorization forms allowing access to VA service use data and National Guard PDHA/PDHRA data.



IMPACT:
This preliminary work has supported the design of a larger study examining the efficacy of a stepped peer outreach program, BuddytoBuddy (B2B), implemented in the Michigan National Guard. B2B was designed to link OEF/OIF National Guard veterans to appropriate care. This RRP proposal was developed in close consultation with Mental Health QUERI leadership and addresses several goals in QUERI's Strategic Plan, including developing strategies to promote consumer-driven mental health care, improving treatment adherence, and expanding the evidence base for reducing the stigma of receiving mental health care.


PUBLICATIONS:

Journal Articles

  1. Nelson CB, Zivin K, Walters H, Ganoczy D, MacDermid Wadsworth S, Valenstein M. Factors Associated With Civilian Employment, Work Satisfaction, and Performance Among National Guard Members. Psychiatric services (Washington, D.C.). 2015 Dec 1; 66(12):1318-25.
  2. Valenstein M, Gorman L, Blow AJ, Ganoczy D, Walters H, Kees M, Pfeiffer PN, Kim HM, Lagrou R, Wadsworth SM, Rauch SA, Dalack GW. Reported barriers to mental health care in three samples of U.S. Army National Guard soldiers at three time points. Journal of traumatic stress. 2014 Aug 1; 27(4):406-14.
  3. Burnett-Zeigler I, Ilgen M, Valenstein M, Zivin K, Gorman L, Blow A, Duffy S, Chermack S. Prevalence and correlates of alcohol misuse among returning Afghanistan and Iraq veterans. Addictive Behaviors. 2011 Aug 1; 36(8):801-6.
  4. Burnett-Zeigler I, Valenstein M, Ilgen M, Blow AJ, Gorman LA, Zivin K. Civilian employment among recently returning Afghanistan and Iraq National Guard veterans. Military medicine. 2011 Jun 1; 176(6):639-46.
  5. Dalack GW, Blow AJ, Valenstein M, Gorman L, Spinner J, Marcus S, Kees M, McDonough S, Greden JF, Ames B, Francisco B, Anderson JR, Bartolacci J, Lagrou R. Public-academic partnerships: working together to meet the needs of Army National Guard soldiers: an academic-military partnership. Psychiatric services (Washington, D.C.). 2010 Nov 1; 61(11):1069-71.


DRA: Military and Environmental Exposures, Mental, Cognitive and Behavioral Disorders
DRE: Treatment - Observational, Prevention
Keywords: Operation Enduring Freedom, Operation Iraqi Freedom, Prevention, QUERI Implementation
MeSH Terms: none