Post-Traumatic Stress Disorder (PTSD) is a common and often debilitating mental health issue for military veterans. The U.S. Department of Veterans Affairs has invested heavily in hiring and training clinicians able to deliver proven therapies for PTSD, known as evidence-based therapies (EBT). Despite this, many veterans with PTSD do not seek or receive these therapies. We sought to address two barriers to EBT uptake—lack of awareness of EBT and suspicion that they are of limited efficacy or fraught with adverse side effects—by engaging veterans in a participatory design process and dissemination of veteran-centric educational materials about EBT. Collaborative design (co-design) is a tool of community-based participatory research and an effective way to tailor communications. Our goal was to enhance these veterans’ capacity to talk about the benefits of EBT and thereby increase clinical care seeking among their peers. Using a 5-step creative process approach, we developed printable and electronic materials to support their efforts. We readily identified veterans who were engaged around mental health issues. We also learned that they were most interested in ensuring that fellow veterans with PTSD recognize their symptoms and receive help, rather than advocating for use of specific EBT’s. This paper outlines the process and lessons learned in developing a collaborative design project, offering a model to improve clinical engagement through culturally tailored communications.

Peer mentorship shows promise as a strategy to support veteran mental health. A community-academic partnership involving a veteran-led nonprofit organization and institutions of higher education evaluated a collaboratively developed peer mentor intervention. We assessed posttraumatic stress disorder (PTSD), postdeployment experiences, social functioning, and psychological strengths at baseline, midpoint, and 12-week discharge using the PTSD Checklist for DSM-5 (PCL-5), Deployment Risk and Resilience Inventory-2, Social Adaptation Self-evaluation Scale, and Values in Action Survey. Brief weekly check-in surveys reinforced mentor contact and assessed retention. The sample included 307 veterans who were served by 17 veteran peer mentors. Mixed-effects linear models found a modest effect for PTSD symptom change, with a mean PCL-5 score reduction of 4.04 points, 95% CI [-6.44, -1.64], d = 0.44. More symptomatic veterans showed a larger effect, with average reductions of 9.03 points, 95% CI [-12.11, -5.95], d = 0.77. There were no significant findings for other outcome variables. Compared to younger veterans, those aged 32-57 years were less likely to drop out by 6 weeks, aORs = 0.32-0.26. Week-by-week hazard of drop-out was lower with mentors ≥ 35 years old, aHR = 0.62, 95% CI [0.37, 1.05]. Unadjusted survival differed by mentor military branch, p = .028, but the small mentor sample reduced interpretability. Like many community research efforts, this study lacked a control group, limiting the inferences that can be drawn. Continued study of veteran peer mentorship is important as this modality is often viewed as more tolerable than therapy.

Background: Homelessness is about survival and more than an issue of bricks and mortar. It is not a static dimension and alludes to a troubled age and brokenness of society. Despite dramatic declines in numbers of people presently homeless, the issue continues to be a public health issue. The number of veterans currently homeless continues to be of national concern despite application of resources. More needs to be done to better understand the concerns of veterans, once homeless and now housed. Method: Qualitative research in the form of interviews provided insights from the veterans on their experience around achieving housing. Qualitative methods are often used in evaluations as they speak of the experience of the program being evaluated by capturing and then communicating the narratives of the participants. This study was grounded in community-based participatory research where a member of community was a part of all phases of the research process. Results: Seven interviews with formerly homeless veterans were conducted. Themes included the following: Burnt Brides and Regrets, Survival, Spirituality, Recovery and Stress, Supportive Care, Reunite Family, and Sickness and Health. Discussion: The themes provide insight into the experience of the veterans and a means to better understand the healing process. Understanding of the healing process includes the following: Acknowledging the Courage to go Deep, Time, Veterans Giving Back, and Recovery is Ongoing. Despite what was learned, further research is needed to better understand the long-term implications of people formerly homeless now housed.

Veterans are at an increased risk of developing alcohol use disorder (AUD) and other comorbid psychiatric disorders, yet they often underutilize professional mental health services. Peer mentorship programs offer an alternative option for those seeking help for mental health problems. The purpose of this study was to examine alcohol use in veterans enrolled in a peer mentorship program, determine the effects of peer mentorship on alcohol use and posttraumatic stress disorder (PTSD) symptoms, and assess the interaction between AUD risk and PTSD symptoms over time. Veterans were enrolled in a 12-week peer mentorship program at Dryhootch in Milwaukee, Wisconsin. Measures of AUD risk (Alcohol Use Disorders Identification Test) and PTSD symptoms (PTSD Checklist for DSM-5) were collected before and after 12 weeks. Additionally, the participants reported their total drinks consumed each week throughout the program. Results showed that veterans were at an increased risk for AUD compared with civilian populations. The risk of developing AUD was associated with more PTSD symptoms. While PTSD symptoms were significantly lower after 12 weeks in the program, Alcohol Use Disorders Identification Test scores and the average number of weekly drinks were not significantly different. Further community work should address alcohol use in veterans to achieve better mental health outcomes in the program.

Suicide rates among veterans remain high, underscoring the necessity of identifying modifiable suicide risk and protective factors that can be targeted through public health approaches. One way to ensure that survey-based research yields information necessary to translate findings into patient-centered interventions is through veteran engagement. The current manuscript describes perspectives of members of a national Veterans Engagement Board (VEB) in contributing to the Assessing Social and Community Environments with National Data (ASCEND) for Veteran Suicide Prevention project. Contributions have included strengthening communication with potential veteran participants, addressing sensitive survey topics such as firearms and suicide, and ensuring that ASCEND is responsive to current national and global events. Additionally, Veterans Engagement Board members described the personal impact of engagement. These contributions highlight the value of veteran engagement as an integral component of suicide risk and prevention research.

Veteran community engagement is an evolving discipline informed by traditional community-based participatory research, veteran studies, and veterans themselves. This Special Issue suggests that research collaborations including military veterans, soldiers, and their families as co-researchers is a critical next step toward a design thinking perspective in social and healthcare systems for this population. This Special Issue was conceptualized through a veteran community-academic partnership formed over a decade ago. This partnership hosted several Warrior Summit conferences from 2013 to present, with the last of this series calling for academic contributions. The resulting papers drawn from the conference and other authors form this issue, and include a wide range of topics: veteran microdosing and psychedelic self-medication; a historical view of the impact of education exchange between U.S. and South Korean military nurses; strategies for engaging veterans in research of a theater-based intervention for PTSD; interprofessional approaches to addressing veteran identity considerations through collaborations between chaplain service and psychologists in the VA Healthcare System; an international perspective exploring a community collaborative with veterans in Montréal, Canada; efforts to build long-term and sustainable models for veteran engagement in health services research; community-engaged strategies to address veteran homelessness within broader housing stability efforts; and examining the role of veteran peer mentorship programs in alcohol recovery. These projects represent an emerging movement and offer a multidisciplinary roadmap toward honoring veterans voices in research, clinical services, and program development.

Background Environmental cleaning and disinfection are important for preventing healthcare-associated infections (HAIs) via contaminated surfaces. Hospital cleanliness plays a large role in patient perception and satisfaction regarding their healthcare. However, patient perceptions of environmental cleaning procedures remain unclear. The objective of the study was to engage patients in achieving patient-centered care and examine patient perspectives on environmental cleaning work systems in healthcare. Methods A qualitative descriptive study was conducted using semi-structured interviews with hospitalized patients at a Midwestern Veterans Administration Hospital. Interviews were audio recorded, transcribed, then coded to identify recurring themes. Results Fifteen patient interview were conducted. Patients reported expecting a clean hospital room. Some patients expressed feeling "in the way" during cleaning, possibly rushing cleaning procedures. Patients expressed confidence in Environmental Management Service (EMS) staff's skilled work and noted "soft skills" as desirable attributes, including camaraderie which can develop between Veteran patients and Veteran staff during room cleaning. Conclusions Patients identified environmental cleaning as a priority for HAI patient-centered infection prevention practices. Cleaning occupied rooms may be an important entry point for intervention to address actual or perceived disruption to patients or build upon Veteran peer relationships. Cleaning procedures may become more patient-centric if cleaning procedures were explained and based on patient preferences.

My involvement in Veteran research began about 10-15 years ago through researchers at the Medical College of Wisconsin (MCW) and the Milwaukee VA. They were interested in Dryhootch of America, where I served as Cofounder and Director of Community Programs and Peer Coordinator. We partnered in the Dryhootch Partners for Veteran Health – Veteran Centered Research and Action project to support mental health initiatives. I am an Army Veteran in recovery, and my passion for the past 15 years has been working on Veterans’ issues and helping Veterans in their journey of transition to living a productive life, especially at points when they may not think they can. I'm also involved in some other peer support programs supporting suicide prevention (Captain John D. Mason Peer Support Program, the Growing Rural Outreach through Veteran Engagement 'GROVE' project and Assessing Social and Community Environments with National Data 'ASCEND').

With 20 million living veterans and millions more immediate family members, and approximately 9 million veterans enrolled in the nationally networked VA healthcare system, representing the interests and needs of veterans in this complex community is a substantial endeavor. Based on the importance of engaging Veterans in research, the VA Health Services Research and Development (HSR&D) Service convened a Working Group of VA researchers and Veterans to conduct a review of patient engagement models and develop recommendations for an approach to engage Veterans in health research that would incorporate their unique lived experiences and interests, and their perspectives on research priorities. The Working Group considered the specific context for Veteran engagement in research that includes other VA stakeholders from the operational and clinical leadership of the VA Health Administration (VHA). The resulting model identifies the range of potential stakeholders and three domains of relevant constructs-processes expected to facilitate Veteran engagement in research with other stakeholders, individual stakeholder and external factors, and outcomes. The expectation is that Veteran engagement will benefit research to policy and practice translation, including increasing the transparency of research and producing knowledge that is readily accepted and implemented in healthcare.

BACKGROUND:Patient engagement in research agenda setting is increasingly being seen as a strategy to improve the responsiveness of healthcare to patient priorities. Implementation of low-dose computed tomography (LDCT) screening for lung cancer is suboptimal, suggesting that research is needed.OBJECTIVES:This study aimed to describe an approach by which a Veteran patient group worked with other stakeholders to develop a research agenda for LDCT screening and to describe the research questions that they prioritized.METHODS:We worked with Veterans organizations to identify 12 Veterans or family members at risk for or having experience with lung cancer to form a Patient Advisory Council (PAC). The PAC met repeatedly from June 2018 to December 2020, both independently and jointly, with stakeholders representing clinicians, health administrators and researchers to identify relevant research topics. The PAC prioritized these topics and then identified questions within these areas where research was needed using an iterative process. Finally, they ranked the importance of obtaining answers to these questions.RESULTS:PAC members valued the co-learning generated by interactions with stakeholders, but emphasized the importance of facilitation to avoid stakeholders dominating the discussion. The PAC prioritized three broad research areas-(1) the impact of insurance on uptake of LDCT; (2) how best to inform Veterans about LDCT; and (3) follow-up and impact of screening results. Using these areas as guides, PAC members identified 20 specific questions, ranking as most important (1) innovative outreach methods, (2) the impact of screening on psychological health, and (3) the impact of outsourcing scans from VA to non-VA providers on completion of recommended follow-up of screening results. The latter two were not identified as high priority by the stakeholder group.CONCLUSIONS:We present an approach that facilitates co-learning between Veteran patients and providers, researchers and health system administrators to increase patient confidence in their ability to contribute important information to a research agenda. The research questions prioritized by the Veterans who participated in this project illustrate that for this new screening technology, patients are concerned about the practical details of implementation (e.g., follow-up) and the technology's impact on quality of life.PATIENT OR PUBLIC CONTRIBUTION:Veterans and Veteran advocates contributed to our research team throughout the entire research process, including conceiving and co-authoring this manuscript.

Post-Traumatic Stress Disorder (PTSD) is one of the most common mental health disorders prevalent in the US. Most alarming, PTSD occurs at double the rate for combat veterans compared to the general population. Severity of PTSD is associated with risk taking behaviors such as substance abuse, non-suicidal self-injury, sexual risk behaviors, among other negative behaviors. Psychological disorders are often preceded by crisis events, thus monitoring for crisis events can help prevent risky behavior in veterans. Ecological momentary assessment techniques are effective in capturing possible crisis events for veterans. Mobile apps are commonly used to gather such behavioral changes in participants. Crisis events collected from m-health can be analyzed for the identification of long- term PTSD risk. Early identification of risk can help in planning intervention to mitigate the risk. Many scholars have used traditional statistical and machine learning methods for the prediction of mental health issues in individuals. But these models lack transparency in how decisions are made. Providing justifications for the predictions can increase the reliability of the model. Our research focused on developing an explainable prediction model using class association rules to identify veterans at risk of persistent PTSD. The generated association rules serve as precursors to the long-term crisis in veterans. Results of the analysis showed that having no family support, little or no interest in hobbies, stress and lack of sleep are some of the influencing factors of persistent PTSD in veterans.

This paper seeks to establish a machine learning driven method by which a military veteran with Post-Traumatic Stress Disorder (PTSD) is classified as being in a crisis situation or not, based upon a given set of criteria. Optimizing alerting decision rules is critical to ensure that veterans at highest risk for mental health crisis rapidly receive additional attention. Subject matter experts in our team (a psychologist, a medical anthropologist, and an expert veteran), defined acute crisis, early warning signs and long-term crisis from this dataset. First, we used a decision tree to find an early time point when the peer mentors (who are also veterans) need to observe the behavior of veterans to make a decision about conducting an intervention. Three different machine learning algorithms were used to predict long term crisis using acute crisis and early warning signs within the determined time point.

Early intervention for veterans in crisis represents a crucial area of study to reduce the psychological and health burdens for this population. Traumatic experiences associated with military service are associated with drug and alcohol abuse, suicidality, anger, and disrupted work and family relationships. This project used machine learning (ML) models to integrate data from sociodemographic, self-report baseline symptoms, weekly brief Ecological momentary assessment (EMA) survey of veterans in a community-based 12-week peer support program to predict the discharge PTSD severity level. The ML predictions place the participants into one of the three risk levels: low, medium, and high PCL-5 score. The models were evaluated at different timepoints (weekly intervals) of the program for identifying the earliest week to guide early intervention and reduce veterans' engagement in risky behaviors. The best results were achieved from a voting classifier with an average f-score of 0.69 at week 4.

Text classification using machine learning can be applied in various contexts such as in classifying research papers, identifying relevant news stories, and detecting fake reviews. Training an algorithm to perform such tasks generally requires a dataset with predefined labels. Valid labels for texts in a given domain can be predefined by domain experts. However, when it comes to free-form text from messaging applications and social networking sites it is difficult to predict what labels may be extracted from the text. Grounded theory provides a method by which concepts that emerge from data can be expressed as categories and properties. These categories and properties can then be arranged in a hierarchical class label structure that can be used to build a dataset for training models. This study focuses on text related to veterans with post traumatic stress disorder and identifies a hierarchical class label structure, with the future goal of applying this to prevent crisis situations.

This research focuses on establishing a psychological treatment system especially for Milwaukee based veterans outside the traditional clinical environment of Veterans Affairs (VA). As part of this process, a 12- week intervention had been made. Data had been collected related to different health aspects and psychological measurements. With the help of expert veterans and psychologist, we had defined early warning signs, acute crisis and long-term crisis from this dataset. We had used different algorithms to predict long term crisis using acute crisis and early warning signs. At the end, we had established a clinical decision-making rule to assist peer mentor veterans to help their fellow mentee veterans especially those suffering from PTSD.

Background: Ensuring veterans' access to healthcare is a national priority. Prior studies of veterans' use of Veterans Health Administration (VA) healthcare have had limited success in evaluating barriers to access for certain vulnerable veteran subpopulations.Objectives: Our coalition of researchers and veteran community members sought to understand factors affecting use of VA, particularly for those less likely to participate in traditional survey studies.Methods: We recruited 858 veterans to complete a collaboratively designed survey at community events or via social media. We compared our results regarding VA use with the 2010 National Survey of Veterans (NSV) using chi-square tests, multiple logistic regression to identify predictors of VA use, and content analysis for open-ended descriptions of barriers to VA use.Results: Veterans in our study were more likely than NSV respondents to report using VA healthcare ever (76% vs. 28%; p < 0.0001). Within this group, more veterans in our sample were current VA users (83% vs. 68%; p < 0.0001). In multi variable analysis, VA use was predicted by self-reported physical problems (comparing "a lot" vs. "none" for each variable, adjusted odds ratio [OR], 8.35), thinking problems (OR, 1.14), need for smoking cessation (OR, 1.54), need for pain management (OR, 1.65), and need for other mental health services (OR, 3.04). We identified 15 themes summarizing veterans' perceived barriers to VA use.Conclusion: Persistent actual and perceived barriers prevent some veterans from using VA services. The VA can better understand and address these issues through community academic partnerships with veterans' organizations.