Understanding Barriers to Mental Health Care for Recent War Veterans Through Photovoice

A Scoping Review of Military Culture, Military Identity, and Mental Health Outcomes in Military Personnel

INTRODUCTION

The military is a unique cultural institution that significantly influences its members, contributing to the development and transformation of their identities. Despite growing interest in identity research in the military, challenges persist in the conceptualization of military identity, including understanding how it forms, assessing the influence of military culture on identity development, and evaluating the implications for mental health. The primary objective of this scoping review was to map the complexities of military culture's impact on military identity and its effects on mental health.

MATERIALS AND METHODS

A scoping review of the literature was conducted using the Joanna Briggs Institute Scoping Review Methodology. Studies were included if they described military culture, military identity, and mental health, resulting in 65 eligible studies. The extracted data were thematically analyzed to identify how military culture impacts military identity and mental health and well-being.

RESULTS

Multiple identities were evident within the military population, with 2 overarching identities, loyalty and military, overall conferring positive mental health outcomes. Where these identities were hidden or disrupted, poorer mental health outcomes were observed.

CONCLUSIONS

The scoping review conducted in this study challenges the notion of military identity as a singular concept promoting positive mental health outcomes. It highlights its multifaceted nature, revealing that individuals may face identity concealment and disruptions during periods of transition or adjustment, resulting in adverse mental health outcomes. To capture the complexity of military identity, the authors developed the Military Identity Model (MIM). Military leaders, policymakers, and health care professionals are encouraged to recognize the complex nature of military identity and its impact on mental health and well-being. We recommend using the Military Identity Model to explore military identity and adjustment-related difficulties.

A Feasibility and Acceptability Assessment of Photo-experiencing and Reflective Listening (PEARL): An Intervention to Promote Recovery Engagement After Gender-Based Harm

Photo-experiencing and Reflective Listening (PEARL) is a trauma-informed intervention developed to promote recovery engagement in survivors of gender-based violence (GBV). This study aimed to understand the feasibility and acceptability of PEARL and identify potential healing elements. GBV survivors were recruited in Philadelphia through an online survey (n = 20). Participants completed the PEARL intervention, a postintervention survey, and a follow-up interview. Results revealed PEARL to be both feasible and acceptable, with thematic analysis revealing its ability to facilitate purposeful reflection, connection to the present, and progress toward healing goals. PEARL shows promise as an engaging strategy to promote healing for survivors of GBV.

Impact of Primary Care-Mental Health Care Integration on Mental Health Care Engagement Across Racial and Ethnic Groups

OBJECTIVE

Receiving mental health services as part of primary care in the Veterans Health Administration (VHA) might increase engagement in specialty mental health care. The authors reexamined the association between primary care-mental health integration (PCMHI) and continued engagement in specialty mental health care for VHA patients and assessed differences by race and ethnicity.

METHODS

The study included 437,051 primary care patients with a first in-person specialty mental health encounter in 2015-2016 (no specialty mental health encounters in prior 12 months), including 46,417 patients with new PCMHI encounters in the year before the first specialty mental health encounter. Multivariable logistic regression assessed odds of follow-up specialty mental health care within 3 months of the first specialty mental health encounter. The dependent variable was care engagement (attending a second specialty mental health appointment); independent variables were whether patients were seen by PCMHI on the same day as the primary care appointment ("same-day access"), the time between PCMHI and first specialty mental health appointments, and race and ethnicity.

RESULTS

PCMHI was associated with increased engagement in specialty mental health care for all patients, with a greater likelihood of engagement among non-Hispanic White patients. Same-day access to PCMHI was positively associated with care engagement, with no significant differences by race or ethnicity. PCMHI care within 3 months before a first specialty mental health encounter was associated with greater care engagement.

CONCLUSIONS

PCMHI, especially same-day access to PCMHI care, may boost engagement in mental health care, although the study design precluded conclusions regarding causal relationships.

Conceptualizing care partners' burden, stress, and support for reintegrating Veterans: a mixed methods study

Background

People who support Veterans as they transition from their military service into civilian life may be at an increased risk of psychological distress. Existing studies focus primarily on paid family caregivers, but few studies include spouses and informal non-family "care partners." We sought to identify key challenges faced by care partners of Veterans with invisible injuries.

Methods

Semi-structured interviews were conducted with 36 individuals involved in supporting a recently separated US military Veteran enrolled in a 2-year longitudinal study. CPs completed validated measures on perceived stress, caregiving burden, quality of their relationship, life satisfaction, and flourishing. Independent t-tests were used to compare cases in these groups on caregiving burden, quality of their relationship, life satisfaction, and flourishing. Care partners were categorized as reporting high and low levels of stress. Exemplar cases were used to demonstrate divergences in the experiences of CPs with different levels of stress over time.

Results

Care partners reported shifts in self-perception that occurred from supporting a Veteran, emphasizing how they helped Veterans navigate health systems and the processes of disclosing health and personal information in civilian contexts. Exemplar cases with high and low burdens demonstrated divergent experiences in self-perception, managing multi-faceted strain, and coping with stress over time. Case studies of specific care partners illustrate how multi-faceted strain shifted over time and is affected by additional burdens from childcare, financial responsibilities, or lack of education on mental health issues.

Conclusions

Findings suggest the unique needs of individuals who support military Veterans with invisible injuries, highlighting variations and diachronic elements of caregiving. This sample is younger than the typical caregiver sample with implications for how best to support unpaid care partners caring for Veterans in the early to mid-period of their use of VA and civilian health services.

Identifying factors related to stigma toward psychiatric illness and mental health services and attitudes of help-seeking among Japan Ground Self-Defense Force members

The stigma that military personnel feel toward mental illness and mental healthcare hinders their access to mental health services. Stigma is influenced by culture-specifically, that held by military personnel is closely related to military culture. To our knowledge, this is the first large-scale investigation aimed at identifying the factors, including demographic factors and elements of military culture, related to stigma among members of the Japan Ground Self-Defense Force. An anonymous questionnaire was administered to 4754 members. The questionnaire included items regarding demographic factors, history of psychiatric visits, military rank, overseas deployment experience, disaster relief experience, supervisor leadership, unit cohesion, general psychological distress, stigma toward perceived mental illness, and attitudes toward help-seeking. Multiple regression analysis was used to identify the various factors related to stigma. Responses were obtained from 4305 (90.5%) participants, among which 3723 (78.3%) were valid. Multiple regression analyses revealed that a variety of factors including age, psychiatric consultation, leadership, and cohesiveness were markedly associated with stigma and attitudes toward help-seeking. This study revealed that various factors including demographic factors and military culture factors such as supervisor leadership and unit cohesion are related to stigma and attitudes toward mental health services among Japan Ground Self-Defense Force personnel. Further studies are needed to examine the results in depth.

Social determinants of health among noncitizen deported US veterans: A participatory action study

This qualitative study examines the social determinants of health among noncitizen deported United States veterans. We utilized Photovoice, a participatory action research method used to inform structural level change, with 12 veterans. Audio-recorded semi-structured interviews explored photos and discussed deportation's effects on veteran health. We performed rapid template and matrix analysis of interview transcripts. Interviews were conducted in Tijuana, Mexico from December 2018 to January 2019. Study findings show that veterans prioritize returning to the United States to improve their quality of life. Analysis of photos and narrative text indicated that deportation caused social, economic, and political insecurities. Veterans struggled to maintain access to necessities post-deportation. Disrupted social networks compounded their situation, resulting in chronic stress and poor health outcomes. The findings from this study offer insight into the ways deportation acts as a social determinant of health. The findings suggest modifying veteran reintegration programs, as well as reforming criminal justice and immigration laws, such as creating more Veteran Treatment Courts and allowing immigration judges to consider military history during deportation proceedings involving noncitizen veterans.

Building capacity to create community change (BC4): A model to support successful program planning and implementation

Community-based interventions (CBIs) are increasingly used to address health problems and are usually implemented by organizations outside and/or inside the community. CBIs are complex and organizations need to have, or be able to build the capacity needed to implement CBIs effectively. The importance of organizational capacity building is well established in the literature, but less attention is focused on how to build capacity, particularly for prevention-focused and mental health CBIs. As part of the longitudinal process evaluation of a national initiative to promote the mental health and wellbeing of men and boys in the United States, this study developed a capacity-building model to identify areas and associated factors that were integral to grantee organizations' ability to build capacity to create change in their communities. The findings identified five domains used to comprise the Building Capacity to Create Community Change model, which contributed to organizational capacity building and as a result, implementation progress: Administrative Support, Leadership, Vision and Mission, Partnership Development, and Community Engagement. Strength in each domain increased grantees' capacity to impact the lives of participants and progress towards the goal of creating community change.

Perspectives on learning to practice reflexivity while engaging communities in implementation science

Background

As implementation scientists and practitioners engage community members and service users, reflexivity rises as a critical approach for managing power imbalances and effective collaborative work to promote equity. Reflexivity is an approach for acknowledging scientists' own positions, including their understanding and limits of how they view their phenomena of inquiry. We describe our perspective practicing reflexivity as an implementation science team new to community engagement.

Methods

We spent over two years learning principles of Community-Based Participatory Research (CBPR) to inform implementation science and practice, then applied CPBR principles into a new community-academic partnership in August 2020 for and with veterans of the United States Military living in rural Arkansas. We used five methods to practice reflexivity for the first time: identifying positionality, writing fieldnotes, obtaining mentorship on technical aspects, comparing head notes, and consulting reference materials.

Discussion

We found multiple methods for practicing reflexivity to be feasible, although difficult to stay consistent with busy schedules. Fieldnotes especially required commitment and were important not to minimize. Written fieldnotes enabled us to reflect on successes and missteps, funneling into action planning. Head notes allowed emotional catharsis and to generate insights based on each other's perspectives. Referencing books or course modules reminded us of ideal CBPR principles. Discussion with mentors helped us with technical aspects and balancing real-world challenges with ideal CBPR principles. Our methods to practice reflexivity were valuable and directly impacted process and research outcomes. Future training for implementation science and practice might consider reflexivity practice as a core competency.

'It Makes You Sit Back and Think Where You Wanna Go': Veteran experiences in virtual whole health peer-led groups

BACKGROUND

The Veterans Health Administration (VHA) is building a Whole Health system of care that aspires to empower and equip each Veteran to pursue a personally meaningful vision of health and well-being. As part of this effort, VHA has developed Taking Charge of My Life and Health (TCMLH), a peer-led, group-based programme that seeks to support Veterans in setting and pursuing health and well-being goals. Prior research showed TCMLH groups to positively impact Veteran outcomes; yet, little is known about Veterans' own experiences and perspectives.

METHODS

We completed semi-structured telephone interviews with 15 Veterans across 8 sites who had participated in TCMLH groups offered by the VHA in the virtual format between Summer 2020 and Fall 2021. Inductive thematic analysis was applied to interview transcripts to generate themes.

FINDINGS

We identified five themes regarding Veterans' experiences with TCMLH: (1) navigating the virtual format; (2) internalizing the value of health engagement; (3) making healthy lifestyle changes; (4) forging social connections; and (5) taking on a more active role in healthcare.

CONCLUSION

Veterans perceived virtual TCMLH groups as meaningful and beneficial, yet also highlighted several challenges. Their perspectives speak to the need to supplement time-limited programmes like TCMLH with ongoing, community-based support. Virtual group-based well-being programmes are a promising innovation. Other healthcare systems may draw on VHA's experience while tailoring format and content to the needs of their patient populations.

PATIENT OR PUBLIC CONTRIBUTION

Veterans were involved as evaluation participants. A Veteran consultant, who is a coauthor on this paper, was engaged through the conceptualization of the evaluation, development of data collection materials (interview guide) and writing.

Engaging the Wisdom of Older Veterans to Enhance VA Healthcare, Research, and Services

BACKGROUND

Stakeholder engagement helps ensure that research is relevant, clinical innovations are responsive, and healthcare services are patient-centered.

OBJECTIVE

Establish and sustain a Veteran engagement board involving older Veterans and caregivers to provide input on aging-related research and clinical demonstration projects.

DESIGN AND PARTICIPANTS

The Older Veteran Engagement Team (OVET)-a group of eight Veterans and one caregiver who range in age from 62 to 92-was formed in November 2017 and has met monthly since January 2018. The OVET provides feedback on topics that reflect the foci of the VA Eastern Colorado Geriatric Research Education and Clinical Center (GRECC) (e.g., physical functioning, hearing health, and emotional wellness/mental health). Ongoing evaluation documents the return on investment of Veteran engagement.

MAIN MEASURES

The OVET member and provider/investigator meeting evaluations with longitudinal follow-up at 6 and 12 months.

RESULTS

Return on investment of Veteran engagement is multi-faceted. For OVET, ROI ranges from grant support to improved healthcare quality/efficiency to social-emotional benefits. To date, funding awards total over $2.3 M for NIH and VA-funded projects to which OVET provided substantive feedback. Documented impacts on healthcare services include reductions in patient wait times, more appropriate utilization of services and increased patient satisfaction. Social-emotional benefits include generativity, as OVET members contribute to improving clinical and community-based supports for other Veterans. The OVET provides an opportunity for older Veterans to share their lived experience with trainees and early career investigators who are preparing for careers serving Veterans.

CONCLUSION

The OVET is similar to other established stakeholder engagement groups; team members offer their individual viewpoints at any stage of research, clinical demonstration, or quality improvement projects. The OVET provides a mechanism for the voice of older Veterans and caregivers to shape aspects of individual projects. Importantly, these projects support patient-centered care and promote the characteristics of an age-friendly healthcare system.

What about Using Photovoice for Health and Safety?

The positive reception of Wang and Burris' photovoice method, published in 1997, has led to a proliferation of ways in which professionals deploy photovoice in a widening range of application fields, e.g., public health, social development and phenomenological research of human experiences. A scoping review method is used to obtain an overview of current photovoice designs and of application examples in the health and safety domain. The results show a variety of method designs. Our findings indicate that all of the photovoice designs are composed from different combinations of eleven process steps. Five generic objectives cover the range of application examples found in our literature study. We therefore condensed the variety into five generic photovoice designs for: (a) communication, (b) education, (c) exploration, (d) awareness, and (e) empowerment purposes. We propose this for use in a classification system. The potential for application of these photovoice designs in safety management is illustrated by the existence of various safety related application examples. We argue that the five generic designs will facilitate the implementation and usage of photovoice as a tool. We recommend that both a theoretical framework and guidance are further developed. We conclude that photovoice holds potential for application in health and safety management.

Acceptance and Commitment Training for Veterans with polytrauma: A randomized controlled trial protocol

BACKGROUND

Mild traumatic brain injury (mTBI) is a signature wound of Veterans of operations in Iraq and Afghanistan (i.e., OIF/OEF/OND). Most Veterans with mTBI also experience stress-based psychopathology (e.g., depression, posttraumatic stress disorder) and chronic pain. This combination - referred to as polytrauma - results in detrimental long-term effects on social, occupational, and community reintegration. This study will compare the efficacy of a one-day Acceptance and Commitment Training plus Education, Resources, and Support (ACT+ERS) workshop to a one-day active control group (ERS) on symptoms of distress and social, occupational, and community reintegration. We will also examine mediators and moderators of treatment response.

METHODS

This is an ongoing randomized clinical trial. 212 OIF/OEF/OND Veterans with polytrauma are being recruited. Veterans are randomly assigned to a one-day ACT+ERS or a one-day ERS workshop with two individualized booster sessions approximately two- and four-weeks post-workshop. Veterans complete assessments prior to the workshop and again at six weeks, three months, and six months post-workshop. Of note, workshops were converted to a virtual format due to the COVID-19 pandemic.

RESULTS

The primary outcomes are symptoms of distress and reintegration; secondary outcomes are post-traumatic stress disorder symptoms and pain interference. Secondary analyses will assess whether changes in avoidance at three months mediate changes in distress and reintegration at six months.

CONCLUSION

Facilitating the psychological adjustment and reintegration of Veterans with polytrauma is critical. The results of this study will provide important information about the impact of a brief intervention for Veterans with these concerns.

Photo-elicitation: Reflections on a method to study food insecurity among low-income, post-9/11 veterans

Photo-elicitation is a research method in which participants use visual images (e.g., photographs) to convey their experiences. It is a useful method for public health nurses to research complex topics among vulnerable populations. This article focuses on the granular details of one research team's implementation of photo-elicitation to study food insecurity among low-income veterans raising children. They detail three sessions with participants during which they: (1) described the process of photo-elicitation; (2) completed photo-guided interviews; and (3) sought participant input through member checking. The article also includes reflections on their experiences as researchers implementing the photo-elicitation process. Among their insights was an appreciation for the range of emotions participants experienced as they shared their narratives. These emotions and the associated photos contributed to the rich data generated from the interviews. The researchers used the images and participant captions generated through photo-elicitation to raise awareness of and build empathy for the challenges and situations veterans who are food insecure experience. In this way, photo-elicitation may be used as an advocacy tool to capture the attention of policymakers and other key stakeholders.

The Battle Against Mental Health Stigma: Examining How Veterans with PTSD Communicatively Manage Stigma

Veterans experiencing combat-related PTSD often refrain from seeking mental health services due to the stigma attached, which can lead to extreme and life-threatening consequences including depression, substance abuse, and suicide. Attaining a better understanding of coping mechanisms is important because it has the ability to help veterans better manage their stigma in the future and potentially help them survive PTSD and the stigma associated with it. Thus, the current study uses stigma management communication theory to uncover the ways in which veterans with PTSD communicatively manage their stigmatized identity. In-depth one-on-one interviews with United States veterans show that veterans with PTSD manage stigma using all six major strategies of stigma management communication. Some veterans managed stigma by blending contradictory strategies together. In addition, new stigma management communication strategies appeared. Not only do these results offer advancement for communication theory, but they could aid in the development of military training, military policy, mental health assessments, interventions, and destigmatizing campaigns.

The rationales for and challenges with employing arts-based health services research (ABHSR): a qualitative systematic review of primary studies

Health services research (HSR) is an interdisciplinary field that investigates and improves the design and delivery of health services from individual, group, organisational and system perspectives. HSR examines complex problems within health systems. Qualitative research plays an important role in aiding us to develop a nuanced understanding of patients, family, healthcare providers, teams and systems. However, the overwhelming majority of HSR publications using qualitative research use traditional methods such as focus groups and interviews. Arts-based research-artistic and creative forms of data collection such as dance, drama and photovoice-have had limited uptake in HSR due to the lack of clarity in the methods, their rationales and potential impacts. To address this uncertainty, we conducted a qualitative systematic review of studies that have employed arts-based research in HSR topics. We searched four databases for peer-reviewed, primary HSR studies. Using conventional content analysis, we analysed the rationales for using arts-based approaches in 42 primary qualitative studies. We found four rationales for using arts-based approaches for HSR: (1) Capture aspects of a topic that may be overlooked, ignored or not conceptualised by other methods (ie, quantitative and interview-based qualitative methods). (2) Allow participants to reflect on their own experiences. (3) Generate valuable community knowledge to inform intervention design and delivery. (4) Formulate research projects that are more participatory in nature. This review provides health services researchers with the tools, reasons, rationales and justifications for using arts-based methods. We conclude this review by discussing the practicalities of making arts-based approaches commensurable to HSR.

Combining Self-Determination Theory and Photo-Elicitation to Understand the Experiences of Homeless Women

Homelessness is a complex and gendered experience. To understand this complexity, novel theoretical frameworks and appropriate research methods are required. Most women living without homes have experienced some form of abuse or mental health issues before becoming, being or exiting homelessness and there is high prevalence of trauma in this vulnerable population. Researchers investigating women's homelessness need to ensure the research process is not retraumatising. This paper proposes a theoretical framework that combines self-determination theory (SDT) and photo-elicitation to support and guide research conducted with women who are at risk of negative effects of power imbalances and retraumatisation in research. The framework offers new opportunities to sensitively study women's homelessness by leveraging a strengths-based premise and empowering procedures to increase women's control in the research process. Embedding this method within the SDT research framework repositions women from objects of research to being competent, autonomous, active and empowered agents in the research process.

Outcomes of Ending Self-Stigma, a Group Intervention to Reduce Internalized Stigma, Among Individuals With Serious Mental Illness

OBJECTIVE

Ending Self-Stigma is a nine-session group intervention designed to teach individuals experiencing mental illness a set of tools and strategies to effectively deal with self-stigma and its effects. The authors examined the efficacy of Ending Self-Stigma with an active comparison group focused on general health and wellness education (the Health and Wellness intervention) in a cohort of veterans.

METHODS

Veterans with serious mental illness (N=248) were randomly assigned to either the Ending Self-Stigma or the Health and Wellness intervention. Participants completed assessments of symptoms, internalized stigma, recovery, sense of belonging, and other aspects of psychosocial functioning at baseline, posttreatment, and 6-month follow-up. Repeated-measures, mixed-effects models were used to examine the effects of group × time interactions on outcomes.

RESULTS

Individuals in both groups experienced significant but modest reductions in self-stigma and increases in psychological sense of belonging after the treatments. The Ending Self-Stigma and Health and Wellness interventions did not significantly differ in primary (self-stigma) or secondary (self-efficacy, sense of belonging, or recovery) outcomes at posttreatment. Significant psychotic symptoms moderated treatment effects on self-stigma, such that among individuals with significant psychotic symptoms at baseline, those who participated in Ending Self-Stigma had a significantly greater reduction in internalized stigma than those in the Health and Wellness intervention.

CONCLUSIONS

Interventions directly targeting self-stigma and those that may address it more indirectly may be helpful in reducing internalized stigma. Individuals experiencing psychotic symptoms may be more likely to benefit from interventions that specifically target self-stigma.

The big picture of recovery: a systematic review on the evidence of photography-based methods in researching recovery from mental distress

Background: In the context of a growing body of literature on incorporating visual media in researching well-being and mental health, this systematic review examined the evidence of using photography-based research methods in exploring recovery from mental distress, their outcomes, but also limitations and challenges encountered by researchers.Methodology: Six cross-disciplinary electronic databases (CINAHL, MEDLINE, Web of Science, Scopus, PsycINFO, Arts & Humanities) were systematically searched resulting in a total of 15 qualitative and mixed-methods studies included in a thematic synthesis.Results: Photo-elicitation and photovoice were identified as the main photographic methods employed in recovery research along with less common, but nonetheless creative, techniques. Four key themes were identified through thematic analysis in photography-based recovery studies: enhanced understanding, collaboration and empowerment, situatedness, and storytelling. The results of this review revealed photography as a valuable methodological tool with potential to contribute to conceptualising recovery from the stance of research participants, but also facilitate and support their recovery processes.Conclusions: Recovery research can benefit from the use of photographic methods that are widely accessible, versatile, and interactive. They may offer mental health researchers alternative ways to explore individuals' perspective on recovery in ways that are creative, empowering, and supportive of their recovery.

Mental health treatment utilization among U.S. military veterans with suicidal ideation: Results from the National Health and Resilience in Veterans Study

BACKGROUND

Despite advances in the treatment of suicidality over the last decade, a significant proportion of veterans with suicidal ideation do not utilize mental health treatment. To date, however, few population-based studies have examined factors that may facilitate or impede mental healthcare engagement among veterans currently contemplating suicide. This study examined barriers and facilitators of current mental healthcare utilization in a nationally representative sample of U.S. military veterans who endorsed current suicidal ideation.

METHODS

Using data from the National Health and Resilience in Veterans Study (n = 3157), collected in 2011, multivariable analyses were conducted to identify predisposing (e.g., age), enabling (e.g., social support), and need (e.g., psychiatric history) characteristics, as well as perceptions of stigma and barriers to care, associated with current mental healthcare utilization.

RESULTS

A total of 7.3% (n = 231) of veterans endorsed current suicidal ideation, of which 36.1% (n = 84) were engaged in current mental health treatment. Younger age, female sex, current depression, lifetime suicide attempt(s), and number of lifetime traumas and medical problems were associated with treatment utilization. Mistrust of mental health providers and fear of treatment harming one's reputation were associated with lower likelihood of treatment engagement, over and above the effects of these predisposing, enabling, and need characteristics.

DISCUSSION

More than 3 of 5 U.S. veterans endorsing current suicidal ideation are not engaged in mental health treatment. Results underscore the importance of multi-modal suicide prevention and treatment engagement efforts that target need-based factors, and perceptions of stigma and negative beliefs about mental healthcare in this population.

Leadership that promotes successful implementation of community-based mental health interventions

Community-based interventions (CBIs) have become an effective approach to promote mental well-being. To increase organizational capacity and effectively deliver CBIs, leadership is crucial. The current study aims to identify leadership qualities that are facilitators of CBI implementation. This paper presents evaluation findings from a national effort emphasizing CBIs for improving the mental well-being of men and boys in 16 local communities. The study utilized a mixed-method design, including both examining each grantee as a case study and conducting a cross-site evaluation. Findings revealed five leadership qualities that contributed to CBIs' success: personal vision, value-based leadership, relationship-oriented leadership, task-oriented leadership, and leadership development. The results outline strategies for strengthening organizational capacity through these leadership qualities. This study adds to the limited literature on leadership qualities that strengthen organizational capacity to successfully implement CBIs and can serve as a guide for funders, program planners, and evaluators.

The journey to professional mental health support: a qualitative exploration of the barriers and facilitators impacting military veterans' engagement with mental health treatment

Background: It is often claimed that military veterans are reticent to seek help for mental disorders, even though delayed treatment may impair recovery and impact the wellbeing of those close to the veteran. Objective: This paper aims to explore the barriers and facilitators to accessing professional mental health support for three groups of veterans who met criteria for a probable mental health disorder and: (1) do not recognize a probable mental disorder; (2) recognize they are affected by a mental disorder but are not seeking professional support; or (3) are currently seeking professional mental health support. Method: Qualitative telephone interviews were conducted with 62 UK military veterans. Thematic analysis identified core themes along an illustrative journey towards professional mental health support. Results: Distinct barriers and facilitators to care were discussed by each group of veterans depicting changes as veterans moved towards accessing professional mental health support. In contrast to much of the literature, stigma was not a commonly reported barrier to care; instead care-seeking decisions centred on a perceived need for treatment, waiting until a crisis event occurred. Whilst the recognition of treatment need represented a pivotal moment, our data identified numerous key steps which had to be surmounted prior to care-seeking. Conclusion: As care-seeking decisions within this sample appeared to centre on a perceived need for treatment future efforts designed to encourage help-seeking in UK military veterans may be best spent targeting the early identification and management of mental health disorders to encourage veterans to seek support before reaching a crisis event.

“Institutions Don’t Hug People:” A Roadmap for Building Trust, Connectedness, and Purpose Through Photovoice Collaboration

The Department of Veterans Affairs (VA) has recently increased support for inclusion of Veterans and family caregivers as collaborators on the research that affects them. In this article, the authors—two VA investigators, two Veterans, and two caregivers—draw from nearly a decade of participatory action research to highlight the methods we have employed to build and sustain collaboration. These methods include the following: using ethnographic approaches to engender trust, treating informed consent as an ongoing process, and sustaining engagement through shared dissemination of findings. We also consider impacts of engaged research that lie outside the parameters of what traditionally “count” as outcomes and that have helped us maintain our collaborative relationships even during periods between funding. We provide examples of how community engagement has bridged Veteran communities and VA, and how the use of visual and narrative methods of dissemination has led to social connectedness and repurposing of Veterans’ and caregivers’ mission as advocates. Our goal is to inform those who wish to conduct this type of research, to further pull research efforts in this direction, and to demonstrate the value of collaborative research from the point of view of those who have been engaged in it.

Community-based behavioral health interventions: Developing strong community partnerships

The popularity of community-based interventions has experienced a revival over the last two decades. The general theme behind this trend is that greater community involvement provides researchers and practitioners with culturally relevant information to make interventions successful. This involvement is usually solicited through the formation of community coalitions and advisory boards. Although the positive influence of community partnerships is well established, strategies for successfully developing and sustaining these partnerships are less clear. To address this gap, this paper presents evaluation findings from The Making Connections Initiative, a national effort emphasizing community-level prevention strategies for improving the mental health of men/boys. Sixteen grantees were tasked with developing a coalition of community organizations to provide input into the development and implementation of a local prevention initiative. An evaluation of the 16 grantees' planning activities identified four themes related to developing and sustaining successful community partnerships. This article reports on the strategies that were found most successful across grantees. With the increasing popularity of community-based programs, strategies for successfully partnering with local organizations are particularly important. This study adds to the limited research on best practices for forming community partnerships and should serve as a guide for community-based evaluators and program planners.

The Role of Primary Care Experiences in Obtaining Treatment for Depression

BACKGROUND

Managing depression in primary care settings has increased with the rise of integrated models of care, such as patient-centered medical homes (PCMHs). The relationship between patient experience in PCMH settings and receipt of depression treatment is unknown.

OBJECTIVE

In a large sample of Veterans diagnosed with depression, we examined whether positive PCMH experiences predicted subsequent initiation or continuation of treatment for depression.

DESIGN AND PARTICIPANTS

We conducted a lagged cross-sectional study of depression treatment among Veterans with depression diagnoses (n = 27,362) in the years before (Y1) and after (Y2) they completed the Veterans Health Administration's national 2013 PCMH Survey of Healthcare Experiences of Patients.

MAIN MEASURES

We assessed patient experiences in four domains, each categorized as positive/moderate/negative. Depression treatment, determined from administrative records, was defined annually as 90 days of antidepressant medications or six psychotherapy visits. Multivariable logistic regressions measured associations between PCMH experiences and receipt of depression treatment in Y2, accounting for treatment in Y1.

KEY RESULTS

Among those who did not receive depression treatment in Y1 (n = 4613), positive experiences in three domains (comprehensiveness, shared decision-making, self-management support) predicted greater initiation of treatment in Y2. Among those who received depression treatment in Y1 (n = 22,749), positive or moderate experiences in four domains (comprehensiveness, care coordination, medication decision-making, self-management support) predicted greater continuation of treatment in Y2.

CONCLUSIONS

In a national PCMH setting, patient experiences with integrated care, including care coordination, comprehensiveness, involvement in shared decision-making, and self-management support predicted patients' subsequent initiation and continuation of depression treatment over time-a relationship that could affect physical and mental health outcomes.

Culture as a Double-Edged Sword: The Posttraumatic Experience of Indigenous Ethnic Minority Veterans

The applicability of Western concepts regarding the treatment of trauma in soldiers from indigenous ethnic minority backgrounds has scarcely been researched. This study explored the subjective meaning of living with chronic posttraumatic stress disorder (PTSD) among indigenous Bedouin veterans of the Israel Defense Forces (IDF), who are of Arab ethnicity and Muslim faith. In-depth, semistructured qualitative interviews were conducted with 10 Bedouin veterans suffering from PTSD and three Bedouin mental health clinicians working with this population. Two themes emerged: "I wanted to be like everyone else," referring to participants' experiences during their military service, and "Fluctuating between belonging and abandonment," referring to veterans' experiences of living with mental health problems in a traditional minority community. These findings highlight the importance of conducting a comprehensive inquiry into the complex cultural and social backgrounds of indigenous minority veterans suffering from PTSD, and the interplay between the conflicted identities and multiple "realities" they experience.

A national evaluation of homeless and nonhomeless veterans' experiences with primary care

Persons who are homeless, particularly those with mental health and/or substance use disorders (MHSUDs), often do not access or receive continuous primary care services. In addition, negative experiences with primary care might contribute to homeless persons' avoidance and early termination of MHSUD treatment. The patient-centered medical home (PCMH) model aims to address care fragmentation and improve patient experiences. How homeless persons with MHSUDs experience care within PCMHs is unknown. This study compared the primary care experiences of homeless and nonhomeless veterans with MHSUDs receiving care in the Veterans Health Administration's medical home environment, called Patient Aligned Care Teams. The sample included VHA outpatients who responded to the national 2013 PCMH-Survey of Health Care Experiences of Patients (PCMH-SHEP) and had a past-year MSHUD diagnosis. Veterans with evidence of homelessness (henceforth "homeless") were identified through VHA administrative records. PCMH-SHEP survey respondents included 67,666 veterans with MHSUDs (9.2% homeless). Compared with their nonhomeless counterparts, homeless veterans were younger, more likely to be non-Hispanic Black and nonmarried, had less education, and were more likely to live in urban areas. Homeless veterans had elevated rates of most MHSUDs assessed, indicating significant co-occurrence. After controlling for these differences, homeless veterans reported more negative and fewer positive experiences with communication; more negative provider ratings; and more negative experiences with comprehensiveness, care coordination, medication decision-making, and self-management support than nonhomeless veterans. Homeless persons with MHSUDs may need specific services that mitigate negative care experiences and encourage their continuation in longitudinal primary care services. (PsycINFO Database Record

Trends in Health Insurance and Type Among Military Veterans: United States, 2000-2016

OBJECTIVES

To describe long-term national trends in health insurance coverage among US veterans from 2000 to 2016 in the context of recent health care reform.

METHODS

We used 2000 to 2016 National Health Interview Survey data on veterans aged 18 to 64 years to examine trends in insurance coverage and uninsurance by year, income, and state Medicaid expansion status. We also explored the current proportions of veterans with each type of insurance by age group.

RESULTS

The percentage of veterans with private insurance decreased from 70.8% in 2000 to 56.9% in 2011, whereas between 2000 and 2016 Department of Veterans Affairs (VA) health care coverage (only) almost tripled, Medicaid (without concurrent TRICARE or private coverage) doubled, and TRICARE coverage of any type tripled. After 2011, the percentage of veterans who were uninsured decreased. In 2016, low-income veterans in Medicaid expansion states had double the Medicaid coverage (41.1%) of low-income veterans in nonexpansion states (20.1%).

CONCLUSIONS

Our estimates, which are nationally representative of noninstitutionalized veterans, show marked increases in military-related coverage through TRICARE and VA health care. In 2016, only 7.2% of veterans aged 18 to 64 years and 3.7% of all veterans (aged 18 years or older) remained uninsured.

Substance Use and Self-Harm: Case Studies From Patients Admitted to an Urban Hospital Following Medically Serious Self-Harm

Few qualitative studies have explored the relationship between substance use and self-harm. We employed a multiple-case study research design to analyze data from 80 patients who were admitted to a hospital in South Africa following self-harm. Our analysis revealed, from the perspective of patients, a number of distinct ways in which substance use is implicated in self-harm. Some patients reported that substance intoxication resulted in poor decision making and impulsivity, which led to self-harm. Others said substance use facilitated their self-harm. Some participants detailed how in the past their chronic substance use had served an adaptive function helping them to cope with distress, but more recently, this coping mechanism had failed which precipitated their self-harm. Some participants reported that substance use by someone else triggered their self-harm. Findings suggest that there are multiple pathways and a host of variables which mediate the relationship between substance use and self-harm.

A Concept Analysis of Stigma Perceived by Military Service Members Who Seek Mental Health Services

PROBLEM

The aim of this concept analysis is to clarify military service members' stigma associated with seeking mental health services (MHS). Since 2001, over 2 million military service members have been deployed for or assigned to support military operations. Many service members develop a mental health concern during or after a deployment. Although researchers have assessed perceptions of stigma associated with accessing MHS, defining stigma is difficult, and conceptual clarity regarding stigma is lagging behind studies focused on its effects.

METHODS

Stigma was explored using Walker and Avant's method of concept analysis. Thirty articles were found in the PsycARTICLES, PsycINFO, and PubMed databases and selected for inclusion and synthesis.

FINDINGS

Military service member stigma is a set of beliefs, based on the member's military and prior civilian enculturation, that seeking MHS would be discrediting or embarrassing, cause harm to career progression, or cause peers or superiors to have decreased confidence in the member's ability to perform assigned duties.

CONCLUSIONS

Nurses are ideally suited and situated to play an important role in decreasing stigma inhibiting service members from seeking MHS. Healthcare providers and civilian and uniformed leaders must communicate the value of seeking MHS to ensure service members' health, unit readiness, and overall force preparedness.

Perceived barriers and facilitators of mental health service utilization in adult trauma survivors: A systematic review

Many trauma survivors seem to be reluctant to seek professional help. The aim of the current review was to synthesize relevant literature, and to systematically classify trauma survivors' perceived barriers and facilitators regarding mental health service utilization. The systematic search identified 19 studies addressing military personnel and 17 studies with trauma survivors of the general population. The data analysis revealed that the most prominent barriers included concerns related to stigma, shame and rejection, low mental health literacy, lack of knowledge and treatment-related doubts, fear of negative social consequences, limited resources, time, and expenses. Perceived facilitators lack attention in research, but can be influential in understanding mental health service use. Another prominent finding was that trauma survivors face specific trauma-related barriers to mental health service use, especially concerns about re-experiencing the traumatic events. Many trauma survivors avoid traumatic reminders and are therefore concerned about dealing with certain memories in treatment. These perceived barriers and facilitators were discussed regarding future research and practical implications in order to facilitate mental health service use among trauma survivors.

Racial/Ethnic Differences in Primary Care Experiences in Patient-Centered Medical Homes among Veterans with Mental Health and Substance Use Disorders

BACKGROUND

Patient-Centered Medical Homes (PCMH) may be effective in managing care for racial/ethnic minorities with mental health and/or substance use disorders (MHSUDs). How such patients experience care in PCMH settings is relatively unknown.

OBJECTIVE

We aimed to examine racial/ethnic differences in experiences with primary care in PCMH settings among Veterans with MHSUDs.

DESIGN

We used multinomial regression methods to estimate racial/ethnic differences in PCMH experiences reported on a 2013 national survey of Veterans Affairs patients.

PARTICPANTS

Veterans with past-year MHSUD diagnoses (n = 65,930; 67 % White, 20 % Black, 11 % Hispanic, 1 % American Indian/Alaska Native[AI/AN], and 1 % Asian/Pacific Island[A/PI]).

MAIN MEASURES

Positive and negative experiences from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) PCMH Survey.

RESULTS

Veterans with MHSUDs reported the lowest frequency of positive experiences with access (22 %) and the highest frequency of negative experiences with self-management support (30 %) and comprehensiveness (16 %). Racial/ethnic differences (as compared to Whites) were observed in all seven healthcare domains (p values < 0.05). With access, Blacks and Hispanics reported more negative (Risk Differences [RDs] = 2 .0;3.6) and fewer positive (RDs = -2 .3;-2.3) experiences, while AI/ANs reported more negative experiences (RD = 5.7). In communication, Blacks reported fewer negative experiences (RD = -1.3); AI/ANs reported more negative (RD = 3.6) experiences; and AI/ANs and APIs reported fewer positive (RD = -6.5, -6.7) experiences. With office staff, Hispanics reported fewer positive experiences (RDs = -3.0); AI/ANs and A/PIs reported more negative experiences (RDs =  3.4; 3.7). For comprehensiveness, Blacks reported more positive experiences (RD = 3.6), and Hispanics reported more negative experiences (RD = 2.7). Both Blacks and Hispanics reported more positive (RDs = 2.3; 4.2) and fewer negative (RDs = -1.8; -1.9) provider ratings, and more positive experiences with decision making (RDs = 2.4; 3.0). Blacks reported more positive (RD = 3.9) and fewer negative (RD = -5.1) experiences with self-management support.

CONCLUSIONS

In a national sample of Veterans with MHSUDs, potential deficiencies were observed in access, self-management support, and comprehensiveness. Racial/ethnic minorities reported worse experiences than Whites with access, comprehensiveness, communication, and office staff helpfulness/courtesy.

The big picture unfolds: Using photovoice to study user participation in mental health services

BACKGROUND

User participation is advocated on the basis that consumers know their own needs better than anyone else. Photovoice is a participatory research method that empowers the grass-root population to give voice on concerned issues for eliciting social change.

AIM

This study explores the experience and impact of user participation in mental health services (MHS) in Hong Kong through photovoice. It also examines the effects of this method in studying user participation.

METHOD

In this qualitative inquiry, authors, two peer researchers and three participants were involved in the various stages of research design, data collection and data analysis. Participants took photos showing their perception and experiences of being involved in different MHS systems. They shared their narratives through these images and reflected on the participatory experience of photovoice.

RESULTS

User participation was experienced as a gradual process of assuming control that involved personal responsibility, connection with peers, collaboration with staff, redefinition of boundaries and social inclusion. Meaningful participation gave rise to a sense of contribution, interpersonal connection and self-worth and transformed one's identity. Participants enjoyed the mutual interaction and derived benefit from the photovoice process. Issues such as consent and confidentiality arose in implementation.

CONCLUSION

Participation entails partnership among service users, providers and peers. Photovoice opens up new space for unfolding expert knowledge. Further application of this participatory approach with the local community is suggested in order to develop person-centered care.

A Bourdieusian Analysis of U.S. Military Culture Ground in the Mental Help-Seeking Literature

This theoretical treatise uses the scientific literature concerning help seeking for mental illness among those with a background in the U.S. military to posit a more complex definition of military culture. The help-seeking literature is used to illustrate how hegemonic masculinity, when situated in the military field, informs the decision to seek formal treatment for mental illness among those men with a background in the U.S. military. These analyses advocate for a nuanced, multidimensional, and situated definition of U.S. military culture that emphasizes the way in which institutional structures and social relations of power intersect with individual values, beliefs, and motivations to inform and structure health-related practices.