Partnership building for scale-up in the Veteran Sponsorship Initiative: Strategies for harnessing collaboration to accelerate impact in suicide prevention

OBJECTIVE

To evaluate the implementation and trust-building strategies associated with successful partnership formation in scale-up of the Veteran Sponsorship Initiative (VSI), an evidence-based suicide prevention intervention enhancing connection to U.S. Department of Veterans Affairs (VA) and other resources during the military-to-civilian transition period.

DATA SOURCES AND STUDY SETTING

Scaling VSI nationally required establishing partnerships across VA, the U.S. Department of Defense (DoD), and diverse public and private Veteran-serving organizations. We assessed partnerships formalized with a signed memorandum during pre- and early implementation periods (October 2020-October 2022). To capture implementation activities, we conducted 39 periodic reflections with implementation team members over the same period.

STUDY DESIGN

We conducted a qualitative case study evaluating the number of formalized VSI partnerships alongside directed qualitative content analysis of periodic reflections data using Atlas.ti 22.0.

DATA COLLECTION/EXTRACTION METHODS

We first independently coded reflections for implementation strategies, following the Expert Recommendations for Implementing Change (ERIC) taxonomy, and for trust-building strategies, following the Theoretical Model for Trusting Relationships and Implementation; a second round of inductive coding explored emergent themes associated with partnership formation.

PRINCIPAL FINDINGS

During this period, VSI established 12 active partnerships with public and non-profit agencies. The VSI team reported using 35 ERIC implementation strategies, including building a coalition and developing educational and procedural documents, and trust-building strategies including demonstrating competence and credibility, frequent interactions, and responsiveness. Cultural competence in navigating DoD and VA and accepting and persisting through conflict also appeared to support scale-up.

CONCLUSIONS

VSI's partnership-formation efforts leveraged a variety of implementation strategies, particularly around strengthening stakeholder interrelationships and refining procedures for coordination and communication. VSI implementation activities were further characterized by an intentional focus on trust-building over time. VSI's rapid scale-up highlights the value of partnership formation for achieving coordinated interventions to address complex problems.

Starting early: Case study of mentoring for undergraduate training through the Veterans Health Administration and implications for promoting equity

Undergraduate mentoring and research internships promote entry into graduate training, academic success, research productivity, and greater career satisfaction. Most pathway programs to enhance representation within academia and health care intervene at the graduate level, leaving a critical gap in undergraduate training. The Veterans Health Administration's (VHA's) national network of clinicians and researchers is uniquely suited to provide equitable access to quality mentorship and education for undergraduates interested in health care careers. We present a program evaluation case study of a VHA undergraduate training program incorporating empirically supported components that promote success and transition to graduate school, including tiered mentorship, a didactic-preceptor model, hands-on experience, and interdisciplinary work. We describe participant characteristics and consider the program elements that may contribute to trainees' success, highlighting the importance of undergraduate training within a health care system like VHA. We found that all program completers attained their bachelor's degree and nearly 70% advanced to graduate studies. Despite some differences based on participant characteristics, all program components were deemed useful preparation for professional success, with hands-on research experience and mentoring cited as the most helpful. The promising results of our case study demonstrate the feasibility of successfully implementing an undergraduate training program to provide a pathway to advanced careers in health care within the VHA. We posit that programs like ours can serve as a framework for creating pathway training programs that target undergraduates traditionally underrepresented, subsequently empowering them to pursue health care careers, and ultimately increasing diversity by training professionals who are better prepared to assist with diverse patient needs. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

A practical risk calculator for suicidal behavior among transitioning U.S. Army soldiers: results from the Study to Assess Risk and Resilience in Servicemembers-Longitudinal Study (STARRS-LS)

BACKGROUND

Risk of suicide-related behaviors is elevated among military personnel transitioning to civilian life. An earlier report showed that high-risk U.S. Army soldiers could be identified shortly before this transition with a machine learning model that included predictors from administrative systems, self-report surveys, and geospatial data. Based on this result, a Veterans Affairs and Army initiative was launched to evaluate a suicide-prevention intervention for high-risk transitioning soldiers. To make targeting practical, though, a streamlined model and risk calculator were needed that used only a short series of self-report survey questions.

METHODS

We revised the original model in a sample of n = 8335 observations from the Study to Assess Risk and Resilience in Servicemembers-Longitudinal Study (STARRS-LS) who participated in one of three Army STARRS 2011-2014 baseline surveys while in service and in one or more subsequent panel surveys (LS1: 2016-2018, LS2: 2018-2019) after leaving service. We trained ensemble machine learning models with constrained numbers of item-level survey predictors in a 70% training sample. The outcome was self-reported post-transition suicide attempts (SA). The models were validated in the 30% test sample.

RESULTS

Twelve-month post-transition SA prevalence was 1.0% (s.e. = 0.1). The best constrained model, with only 17 predictors, had a test sample ROC-AUC of 0.85 (s.e. = 0.03). The 10-30% of respondents with the highest predicted risk included 44.9-92.5% of 12-month SAs.

CONCLUSIONS

An accurate SA risk calculator based on a short self-report survey can target transitioning soldiers shortly before leaving service for intervention to prevent post-transition SA.

Supporting servicemembers and veterans during their transition to civilian life using certified sponsors: A three-arm randomized controlled trial

Transitioning servicemembers and veterans (TSMVs) face difficulties throughout their reintegration to civilian life, including challenges with employment, poor social connection, and elevated risk for suicide. To meet the needs of this high-risk population, national initiatives have leveraged community-based interventions. Authors conducted a three-arm randomized controlled trial (n = 200) to evaluate two community-based interventions. The first, Team Red, White, and Blue (RWB), connects TSMVs to their community through physical/social activities. The second, Expiration Term of Service Sponsorship Program (ETS-SP) provides one-on-one certified sponsors to TSMVs who provide support during the reintegration process. TSMVs were assessed at baseline, 3, 6, and 12 months. The primary hypothesis was not supported as reintegration difficulties and social support were not significantly different for participants randomly assigned to the two community-based interventions (Arm-2/RWB and Arm-3/RWB + ETS-SP), when the data from the separate arms were collapsed and combined, compared to the waitlist. The results did support the secondary hypothesis as Arm-3/RWB + ETS-SP had less reintegration difficulties over 12 months and initially had more social support compared to Arm-2/RWB, which suggest that augmenting interventions with sponsors outperforms participation in community-based interventions alone. Overall, the results show some limitations of the studied community-based interventions, as implemented and researched within this study. The authors identified factors that may have contributed to the null findings for the primary hypothesis, which can be addressed in future studies, such as addressing the unique needs of TSMVs, enrolling TSMVs into interventions prior to military discharge, measuring and improving participation levels, and providing stepped-care interventions based on risk levels. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Partnered implementation of the veteran sponsorship initiative: protocol for a randomized hybrid type 2 effectiveness-implementation trial

BACKGROUND

The USA is undergoing a suicide epidemic for its youngest Veterans (18-to-34-years-old) as their suicide rate has almost doubled since 2001. Veterans are at the highest risk during their first-year post-discharge, thus creating a "deadly gap." In response, the nation has developed strategies that emphasize a preventive, universal, and public health approach and embrace the value of community interventions. The three-step theory of suicide suggests that community interventions that reduce reintegration difficulties and promote connectedness for Veterans as they transition to civilian life have the greatest likelihood of reducing suicide. Recent research shows that the effectiveness of community interventions can be enhanced when augmented by volunteer and certified sponsors (1-on-1) who actively engage with Veterans, as part of the Veteran Sponsorship Initiative (VSI).

METHOD/DESIGN

The purpose of this randomized hybrid type 2 effectiveness-implementation trial is to evaluate the implementation of the VSI in six cities in Texas in collaboration with the US Departments of Defense, Labor and Veterans Affairs, Texas government, and local stakeholders. Texas is an optimal location for this large-scale implementation as it has the second largest population of these young Veterans and is home to the largest US military installation, Fort Hood. The first aim is to determine the effectiveness of the VSI, as evidenced by measures of reintegration difficulties, health/psychological distress, VA healthcare utilization, connectedness, and suicidal risk. The second aim is to determine the feasibility and potential utility of a stakeholder-engaged plan for implementing the VSI in Texas with the intent of future expansion in more states. The evaluators will use a stepped wedge design with a sequential roll-out to participating cities over time. Participants (n=630) will be enrolled on military installations six months prior to discharge. Implementation efforts will draw upon a bundled implementation strategy that includes strategies such as ongoing training, implementation facilitation, and audit and feedback. Formative and summative evaluations will be guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework and will include interviews with participants and periodic reflections with key stakeholders to longitudinally identify barriers and facilitators to implementation.

DISCUSSION

This evaluation will have important implications for the national implementation of community interventions that address the epidemic of Veteran suicide. Aligned with the Evidence Act, it is the first large-scale implementation of an evidence-based practice that conducts a thorough assessment of TSMVs during the "deadly gap."

TRIAL REGISTRATION

ClinicalTrials.gov ID number: NCT05224440 . Registered on 04 February 2022.

Circumventing the Vasovagal Fainting Response

A novel method of in vivo exposure therapy was administered to a 26-year-old female with injection phobia. She had a history of fainting at the sight of syringes, needles, and other medical devices and went to great lengths to avoid physicians and optometrists, putting off receiving necessary examinations and vaccinations. The patient was treated in one long session. The session began with presentation of a series of noninvasive fear-evoking stimuli (i.e., still and video images) shown briefly, but repeatedly, with increasing trial durations, followed by invasive exposures (i.e., finger pricks & a sham injection). Self-report measures showed significant changes that were maintained after 10 months. In addition, the patient donated blood, had an eye examination, and received three vaccinations, all without fainting. Traditional treatments employ prolonged exposures to fear-evoking stimuli; the results of this intervention suggest that a massed series of brief exposures might provide a less aversive alternative.