Background: Considerations of psychological and emotional health in the Veteran community often center on post-traumatic stress disorder (PTSD), with approximately 7% of Veterans suffering from PTSD at some time in their lives. Recently, however, moral injury (MI) has emerged as potentially much more prevalent among Veterans, affecting an estimated 37-65% of Veterans. MI symptoms can include feelings of guilt, shame, and unworthiness, avoidance of intimacy and loss of faith in religion or humanity.

Description: Moral injury is a common psychological, emotional, and ethical response to moral trauma. It results from perceived acts of commission or omission that violate one’s deeply held values of honor, duty, or morality or of having been betrayed. MI primarily manifests from a Veteran’s sense of guilt for their acts or omissions in war situations and often affects a Veterans self-perception as an immoral person. MI, which is often mis- or un-identified by health professionals, can be addressed through a combination of individual and group therapy to help Veterans reassess their moral culpability and by finding ways for Veterans to engage in pro-social community-based activities that help them to re-establish their moral identity.

Lessons Learned: The Building Veteran Healthy Communities (BVHC) project includes moral injury in its community toolkit to promote awareness of this condition that affects a large proportion of Veterans.

Implications: Further research and dissemination of evidence about MI can improve clinical diagnosis and treatment and prompt communities to engage with Veterans to help them overcome this widespread issue.

Background:

Millions of combat Veterans face significant health risks from prolonged exposure to toxic, airborne hazards. Burn Pits 360 (BP360), a nonprofit Veteran support organization, brings visibility to these invisible injuries by uniting experts to enhance post-deployment health. The U.S. Promise to Address Comprehensive Toxics Act of 2022 (PACT Act) highlights the need to address Veterans' care gaps. Despite the shared burden of health challenges among Veterans and their families affected by war, effective systems of support remain scarce.

Objective:

To conduct an evaluation of Burn Pit 360’s achievements that facilitates program accountability and alignment with Veterans' needs. This theoretically rooted evaluation method will leverage data-driven insights to refine program implementation, garner community support, and secure funding and partnerships.

Methods:

A community-based participatory approach will guide the evaluation, using triangulated data from donors, beneficiaries, and community assessments through surveys, interviews, and records. The Burn Pits 360 independent registry, chronicling thousands of voluntarily reported Veterans' exposures and health concerns, is a critical and previously unexplored resource for pinpointing community needs.

Results:

This evaluation will yield an actionable report, a stakeholder engagement plan, and a community mobilization strategy within 12 months, realigning BP360’s activities with data-driven tailored interventions that foster trust among Veterans with public health and scientific experts. Importantly, it reaffirms BP360’s commitment to safeguarding the well-being of Veterans, active-duty military, and civilians against deployment-related health threats. This comprehensive framework will serve as an ongoing resource to BP360’s mission to protect those facing emerging health risks from their service.

Context: Veterans of the United States military face unique challenges following their time in service. These challenges factor into a range of mental health diagnoses such as post-traumatic stress disorder, depression, suicidal ideation, and suicide attempts. There were 6392 Veteran suicide deaths in 2021, and significant disparities in suicide rates exist between Veteran and non-Veteran populations across many factors, including rurality.

Description: Many mental health issues for Veterans are rooted in their loss of community upon discharge from service. A novel method of combatting this loss is participation in local-level agricultural vocations. This can re-establish a Veteran’s sense of purpose as they provide quality food to their local community. Many Veterans come from, and return to, rural regions where agricultural knowledge and interest is prevalent. In fact, up to 40% of Veterans settle in rural areas. In addition to improved community reintegration, Veterans also benefit from nature-based therapies, a promising complement to standard psychotherapy and medication.

Lessons Learned and Implications: The Veterans Affairs Farming and Recovery Mental-Health Services (VA FARMS) is an example of an innovative pilot program utilizing this method to improve Veteran mental health. As communities become more aware of the challenges Veterans face upon reintegrating into civilian life, maximizing opportunities for rural Veterans to work in the agricultural sector is an important strategy to improve Veteran mental health and well-being.

The lack of trust Veterans report having with the Veteran’s Affairs (VA) healthcare system is multifactorial and compounded by long wait times for appointments and barriers to accessing care. Medical social workers serve a vital role of employing Ecological Systems Theory to understand how a Veteran’s interactions within their microsystems and macrosystems affect their health. Medical social workers take time to meet with Veterans during hospital stays to better understand their goals of care and how these goals translate to their lives outside the hospital. However, when a provider accesses a Veteran’s Electronic Health Record (EHR), there is rarely a clear picture of the patient beyond their past medical history. At present, important social aspects are often buried in notes within the EHR. By integrating a Person-In-Environment (P.I.E.) profile into the EHR, providers would be able to view a summary of self-reported social factors as quickly and easily as they can view a Veteran’s medical history. The P.I.E. profile would present important aspects, including but not limited to a Veteran’s physical and social environment. By making it a priority to consider how Veterans relate to the world around them, the VA healthcare system would be better able to appreciate Veterans’ holistic profiles, allowing the VA to yield better health outcomes through increased engagement and partnership in Veterans’ health care journey.

Background: Patients who discontinue long-term opioid therapy (LTOT) may experience worsening of pain and mental health symptoms. Buprenorphine is an FDA-approved medication for opioid use disorder and is used for patients who have difficulty tapering after LTOT; little research has quantified benefits of using buprenorphine in this context.

Objective: To compare changes in pain and mental health outcomes between Veterans who initiated buprenorphine following LTOT discontinuation to those who did not.

Methods: This prospective cohort study enrolled a national sample of 1,381 U.S. Veterans receiving LTOT. Participants completed surveys every 6 months for 2 years. Surveys assessed demographic characteristics, pain severity and interference as measured by the Brief Pain Inventory, depressive and anxiety symptoms as measured by the PHQ-9 and GAD-7, respectively. The current study included a subsample of LTOT discontinuers from the larger cohort. Generalized estimating equations examined changes in pain and mental health outcomes following LTOT discontinuation, comparing those who initiated buprenorphine to those who did not.

Results: Participants (N=172) were predominantly female (57%). Forty-nine percent identified with a minoritized race or ethnicity. Eighteen participants (10%) initiated buprenorphine following LTOT discontinuation. Both pain and mental health outcomes remained constant after LTOT discontinuation and did not differ by buprenorphine status. However, across timepoints, participants who initiated buprenorphine reported significantly lower pain interference (-B=1.23, p=0.02) and anxiety symptoms (-B=3.16, p=0.02).

Conclusions: Patients on buprenorphine experience less pain interference and anxiety both while on LTOT and following its discontinuation. Additional research is needed to identify explanations for this observed association.

Little is known about how veterans make decisions regarding where they receive their health care. Although most veterans have access to VHA care, many choose to utilize civilian healthcare providers. As veterans are vulnerable to health challenges related to their military service, understanding their health care decision-making processes and experiences are important to identifying and addressing barriers to care.

Eight online focus groups were conducted with 59 veterans. Groups were divided by VHA users and non-users (4 each). Participants were recruited through an email invitation and answered questions regarding health care decisions, experiences and satisfaction. Focus groups were recorded and transcribed for analysis. Two rounds of thematic analysis were conducted using line by line coding revealing several themes.

Veterans utilizing VHA care were driven by financial reasons (low cost) and high quality of care. VHA users reported high satisfaction but challenges with bureaucracy and continuity of care. Women reported gender sensitive care deteriorated outside of primary care providers. Non-VHA users either chose outside care or were not eligible for VHA care. Choice non-VHA users were driven by negative perceptions of the VHA. Ineligible non-VHA users wanted to utilize the VHA but were deemed ineligible, primarily due to financial reasons (high income). Non-VHA users overwhelmingly reported satisfaction with their healthcare. Findings have important implications for veteran health care. These include continued improvements to VHA care, expanding gender sensitive care, reducing negative VHA perceptions, addressing surprising income barriers to VHA use, and improving access to civilian providers for veterans.

Background:Access to healthcare services is crucial for rural veterans, particularly those with chronic conditions. However, research on access to care among this population remains limited. This study aimed to develop and validate the Rural Access to Care and Services Scale and investigate its associations with demographic and clinical characteristics among rural veterans.

Methods:Data were collected from 500 veterans living in rural areas in the U.S. The survey included demographic questions, assessment of access to care and services, service-connected disability status, and clinical status. Exploratory Factor Analysis (EFA) and Confirmatory Factor Analysis (CFA) were conducted to validate the scale. Hierarchical multiple regression were performed to examine associations between access to care and health outcomes.

Results:The EFA and CFA supported the one-factor structure of the Rural Access to Care and Services Scale, with excellent model fit indices. The scale demonstrated high internal consistency reliability (α=0.89) and concurrent validity. Participants reported a range of health conditions, with depression and anxiety being the most prevalent. Minority veterans reported significantly higher difficulties in accessing care compared to non-minority ones. Additionally, rural veterans with disabilities experienced greater challenges in accessing care compared to those without disabilities.

Conclusion:The findings highlight the importance of addressing access to care among rural veterans, particularly those with disabilities. The Rural Access to Care and Services Scale provides a valuable tool for monitoring access to care in this population. Interventions aimed at improving access to care for rural veterans, especially minorities, are warranted to enhance health outcomes and reduce healthcare disparities.