Improving Care for Veterans' Environmental Exposure Concerns: Applications of the Consolidated Framework for Implementation Research in Program Evaluation

Overview

Journal BMC Health Serv Res

Publisher Biomed Central

Specialty Health Services

Date 2024 Feb 23

PMID 38395810

Authors

Katharine Bloeser

Justin M Kimber

Susan L Santos

Chana B Krupka

Lisa M McAndrew

Affiliations

Soon will be listed here.

Abstract

Background: Healthcare systems, like the US Department of Veterans Affairs (VA), need policies and procedures for delivering care to special populations including those with environmental exposure concerns. Despite being common and pervasive, especially among Veterans, environmental exposures are largely overlooked by healthcare providers. To successfully implement care for Veterans with military environmental exposure concerns, an understanding of contextual factors impeding care on the provider (e.g., knowledge and beliefs) and organizational (e.g., leadership's priorities) level is needed. Our goal was to conduct an operational needs assessment of providers to examine provider educational needs regarding Veterans' military environmental exposure concerns.

Methods: In 2020, we surveyed 2,775 VA medical and behavioral health providers. Our cross-sectional assessment was informed by the Consolidated Framework for Implementation Research (CFIR) and assessed barriers and facilitators to the uptake and application of knowledge regarding interdisciplinary care for environmental exposure concerns. The web-based survey was emailed to providers across the United States representing a variety of disciplines and practice settings to reflect the interdisciplinary approach to care for environmental exposures. We used bivariate statistics to investigate the intervention setting, inner setting, and individual characteristics of providers regarding care for environmental exposure concerns.

Results: Approximately one-third of VA medical and behavioral health clinicians report low to no knowledge of environmental exposure concerns. We find 88% of medical and 91% of behavioral health providers report they are ready to learn more about environmental exposures. Half of medical and behavioral health providers report they have access to information on environmental exposures and less than half report care for environmental exposures is a priority where they practice.

Conclusions: Our findings suggest interdisciplinary providers' knowledge of and discussion with Veterans about environmental exposures may be influenced by contextual factors at the organizational level. Considering individual-level factors and organizational culture is important to consider when supporting care for environmental exposures. Since this needs assessment, VA established targeted programs to improve care related to military environmental exposures in response to legislation; future exploration of these same variables or contextual factors is warranted.

References

Kegler M, Beasley D, Liang S, Cotter M, Phillips E, Hermstad A . Using the consolidated framework for implementation research to understand safety net health system efforts to increase colorectal cancer screening rates. Health Educ Res. 2018; 33(4):315-326. DOI: 10.1093/her/cyy019. View

Lange G, McAndrew L, Ashford J, Reinhard M, Peterson M, Helmer D . War Related Illness and Injury Study Center (WRIISC): a multidisciplinary translational approach to the care of Veterans with chronic multisymptom illness. Mil Med. 2013; 178(7):705-7. DOI: 10.7205/MILMED-D-13-00053. View

Baldwin N, Rudquist R, Lava-Parmele S, Trembley J, Butterick T, Bach R . Improving Health Care for Veterans With Gulf War Illness. Fed Pract. 2019; 36(5):212-219. PMC: 6530665. View

Riley M, Patterson V, Lane J, Won K, Ranalli L . The Adolescent Champion Model: Primary Care Becomes Adolescent-Centered via Targeted Quality Improvement. J Pediatr. 2017; 193:229-236.e1. DOI: 10.1016/j.jpeds.2017.09.084. View

Bove F, Ruckart P, Maslia M, Larson T . Evaluation of mortality among marines and navy personnel exposed to contaminated drinking water at USMC base Camp Lejeune: a retrospective cohort study. Environ Health. 2014; 13(1):10. PMC: 3943370. DOI: 10.1186/1476-069X-13-10. View

Helmer D, Rossignol M, Blatt M, Agarwal R, Teichman R, Lange G . Health and exposure concerns of veterans deployed to Iraq and Afghanistan. J Occup Environ Med. 2007; 49(5):475-80. DOI: 10.1097/JOM.0b013e318042d682. View

Bloeser K, McCarron K, Merker V, Hyde J, Bolton R, Anastasides N . "Because the country, it seems though, has turned their back on me": Experiences of institutional betrayal among veterans living with Gulf War Illness. Soc Sci Med. 2021; 284:114211. DOI: 10.1016/j.socscimed.2021.114211. View

Robbins R, Helmer D, Monahan P, Hunt S, McAndrew L, Nazario M . Management of Chronic Multisymptom Illness: Synopsis of the 2021 US Department of Veterans Affairs and US Department of Defense Clinical Practice Guideline. Mayo Clin Proc. 2022; 97(5):991-1002. DOI: 10.1016/j.mayocp.2022.01.031. View

Weisskopf M, Wright R, Schwartz J, Spiro 3rd A, Sparrow D, Aro A . Cumulative lead exposure and prospective change in cognition among elderly men: the VA Normative Aging Study. Am J Epidemiol. 2004; 160(12):1184-93. DOI: 10.1093/aje/kwh333. View

10.

Grandjean P, Heilmann C, Weihe P, Nielsen F, Mogensen U, Timmermann A . Estimated exposures to perfluorinated compounds in infancy predict attenuated vaccine antibody concentrations at age 5-years. J Immunotoxicol. 2017; 14(1):188-195. PMC: 6190594. DOI: 10.1080/1547691X.2017.1360968. View

11.

Ballard D, Nicewander D, Qin H, Fullerton C, Winter Jr F, Couch C . Improving delivery of clinical preventive services: a multi-year journey. Am J Prev Med. 2007; 33(6):492-7. DOI: 10.1016/j.amepre.2007.07.040. View

12.

Liu J, Lezama N, Gasper J, Kawata J, Morley S, Helmer D . Burn Pit Emissions Exposure and Respiratory and Cardiovascular Conditions Among Airborne Hazards and Open Burn Pit Registry Participants. J Occup Environ Med. 2016; 58(7):e249-55. DOI: 10.1097/JOM.0000000000000776. View

13.

Zhao J, Stockwell T, MacDonald S . Non-response bias in alcohol and drug population surveys. Drug Alcohol Rev. 2009; 28(6):648-57. DOI: 10.1111/j.1465-3362.2009.00077.x. View

14.

Hamilton W, Ryder D, Cooper Jr H, Williams D, Weinberg A . Environmental health: a survey of Texas primary care physicians. Tex Med. 2006; 101(10):62-70. View

15.

Elnahal S, Clancy C, Shulkin D . A Framework for Disseminating Clinical Best Practices in the VA Health System. JAMA. 2017; 317(3):255-256. DOI: 10.1001/jama.2016.18764. View

16.

Kimerling R, Street A, Gima K, Smith M . Evaluation of universal screening for military-related sexual trauma. Psychiatr Serv. 2008; 59(6):635-40. DOI: 10.1176/ps.2008.59.6.635. View

17.

Siantz E, Henwood B, Rabin B, Center K, Fenwick K, Gilmer T . A Mixed-method Evaluation of the Behavioral Health Integration and Complex Care Initiative Using the Consolidated Framework for Implementation Research. Med Care. 2021; 59(7):632-638. DOI: 10.1097/MLR.0000000000001569. View

18.

Maule A, Heaton K, Cadarette B, Taylor K, Guerriere K, Haven C . Effect of Environmental Temperature and Humidity on Permethrin Biomarkers of Exposure in U.S. Soldiers Wearing Permethrin-Treated Uniforms. Am J Trop Med Hyg. 2020; 102(6):1455-1462. PMC: 7253132. DOI: 10.4269/ajtmh.19-0543. View

19.

Engel Jr C, Adkins J, Cowan D . Caring for medically unexplained physical symptoms after toxic environmental exposures: effects of contested causation. Environ Health Perspect. 2002; 110 Suppl 4:641-7. PMC: 1241219. DOI: 10.1289/ehp.02110s4641. View

20.

Keith R, Crosson J, OMalley A, Cromp D, Taylor E . Using the Consolidated Framework for Implementation Research (CFIR) to produce actionable findings: a rapid-cycle evaluation approach to improving implementation. Implement Sci. 2017; 12(1):15. PMC: 5303301. DOI: 10.1186/s13012-017-0550-7. View