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Veterans enrolled in postsecondary education may experience service-related health conditions that undermine their success on campus. Supported education services can target student Veterans' self-advocacy skills, thereby facilitating their acquisition of academic accommodations that foster academic success. The purpose of this study was to (1) investigate change in student Veterans' self-advocacy skills and academic performance over time receiving supported education services, and (2) investigate factors that influence change in their self-advocacy skills and academic performance. We collected measures of "self-advocacy skills" (Student Veterans Self-advocacy Skills Assessment [SV-SASA]) and "academic performance" (grade point average) at six time points for 99 student Veterans enrolled in the New Start for Student Veterans (NSSV) supported education program. We used multilevel modelling to determine whether self-advocacy skills and academic performance changed over time receiving supported education services, and whether first-generation status and dosage of intervention explained change in these outcomes. We additionally investigated whether SV-SASA score influenced change in academic performance. Results indicate that student Veterans' self-advocacy skills improved over time receiving supported education services. Further, a greater dose of NSSV services was associated with greater self-advocacy skills across the semesters, irrespective of how long they received services. Student Veterans' academic performance did not change over time spent in the supported education program. We discuss the implications of findings for research and practice.

Veterans of Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn enrolled in postsecondary education may experience disabilities that impact their successful participation in the academic environment. Accommodations are made available to college students with disabilities to provide opportunities for success in this environment, but in order to receive these accommodations it is essential that the student discloses their disability and informs the institution of their needs. Therefore, it is critical to understand the self-advocacy skills of student veterans with disabilities as a factor that may influence their academic success. The Student Veteran Self-Advocacy Skills Assessment (SV-SASA) is an assessment of self-advocacy skills among student veterans with disabilities. Regression analysis was conducted on a sample of 49 participants in a supported education program for student veterans with disabilities to investigate factors that explain their self-advocacy skills and academic performance, and to evaluate the psychometric properties of the SV-SASA. Results indicated that first-generation status, extent of exposure to a supported education program for student veterans, number of credits attempted, and number of self-reported health conditions explain the self-advocacy skills of student veterans with disabilities. Results also indicated that student veterans with greater self-advocacy skills achieved a higher grade point average. The SV-SASA demonstrated adequate psychometric properties as an assessment of self-advocacy skills in the sample. Implications for service providers in the postsecondary education setting working with this population and suggestions for future research are discussed.

Objective: To understand whether symptoms of health conditions explain the negative association between combat exposure and student Veterans' achievement of a meaningful life. Participants: 153 combat Veterans enrolled in college between November 2013 and April 2018. Methods: Through an online survey, participants reported combat exposure, health status (symptoms of conditions such as depression), and aspects of a meaningful life (belonging, self-understanding, and doing) at two time points. Path analysis was used to explore whether baseline health status mediated the relationship between combat exposure and belonging, self-understanding, and doing at follow-up. Results: Indirect effects indicated that the negative influence of combat on student Veterans' sense of belonging, self-understanding, and doing at follow-up was mediated by poor health at baseline. Conclusions: Combat exposure may contribute to the development of health conditions, which in turn limit student Veterans' experience of three aspects of a meaningful life: a sense of belonging, self-understanding, and doing.

Objective: The authors sought to investigate whether utilization of inpatient occupational therapy (OT) was associated with reduced risk for 30-day psychiatric readmission in the Veterans Health Administration (VHA). Methods: The authors conducted a secondary analysis of VHA medical record data for veterans who received inpatient psychiatric care from 2015 to 2020 (N=176,889). Mixed-effects logistic regression was used to model psychiatric readmission within 30 days of discharge (yes or no) as a function of inpatient psychiatric OT utilization (none, one, two, three, or four or more encounters) and other care utilization (e.g., previous psychiatric hospitalization), as well as clinical (e.g., primary diagnosis), sociodemographic (e.g., race-ethnicity), and facility (e.g., complexity) characteristics. Sensitivity analyses were conducted to evaluate the robustness of findings (e.g., stratification by discharge disposition). Results: Relatively few veterans received inpatient psychiatric OT (26.2%), and 8.4% were readmitted within 30 days. Compared with veterans who did not receive inpatient psychiatric OT, those with one (OR=0.76), two (OR=0.64), three (OR=0.67), or four or more encounters (OR=0.64) were significantly (p<0.001) less likely to be readmitted within 30 days. These findings were consistent across all sensitivity analyses. Conclusions: Veterans who received inpatient OT services were less likely to experience psychiatric readmission. A clear dose-response relationship between inpatient psychiatric OT and readmission risk was not identified. These findings suggest that OT services may facilitate high-value inpatient psychiatric care in the VHA by preventing readmissions that stymie recovery and incur high costs. Future research may establish the causality of this relationship, informing policy regarding increased access to inpatient psychiatric OT. [ABSTRACT FROM AUTHOR]

This study examined relationships between instructor autonomy support, academic self-efficacy, academic problems and academic achievement among student service members/veterans (SSM/V). Participants included veterans, active duty or National Guard/Reservists of the US military (N = 172) enrolled in a postsecondary institution. Online surveys generated responses to indicators of instructor autonomy support, academic self-efficacy, and academic problems. Grade point average (GPA) was obtained from the institution. Multiple regression models found that academic self-efficacy and academic problems independently predicted GPA. Health-related factors (e.g. depression) explained academic self-efficacy, academic problems and academic achievement. Academic self-efficacy and academic problems independently mediated the relationship between instructor autonomy support and GPA. Results indicate that greater academic self-efficacy, fewer academic problems and an autonomy-supportive education environment may promote academic achievement in SSM/V despite the presence of health-related factors such as depression, posttraumatic stress and mild traumatic brain injury. Supported education programs may further academic achievement among SSM/V.

Comparing self-reported symptom scores across time requires longitudinal measurement invariance (LMI), a psychometric property that means the measure is functioning identically across all time points. Despite its prominence as a measure of depression symptom severity in both research and health care, LMI has yet to be firmly established for the Patient Health Questionnaire–9 depression module (PHQ-9), particularly over the course of antidepressant pharmacotherapy. Accordingly, the objective of this study was to assess for LMI of the PHQ-9 during pharmacotherapy for major depressive disorder. This was a secondary analysis of data collected during a randomized controlled trial. A total of 1,944 veterans began antidepressant monotherapy and completed the PHQ-9 six times over 24 weeks of treatment. LMI was assessed using a series of four confirmatory factor analysis models that included all six time points, with estimated parameters increasingly constrained across models to test for different aspects of invariance. Root-mean-square error of approximation of the chi-square difference test values below 0.06 indicated the presence of LMI. Exploratory LMI analyses were also performed for separate sex, age, and race subgroups. Root-mean-square error of approximation of the chi-square difference test showed minimal change in model fits during invariance testing (≤0.06 for all steps), supporting full LMI for the PHQ-9. LMI was also supported for all tested veteran subgroups. As such, PHQ-9 sum scores can be compared across extended pharmacotherapy treatment durations. Public Significance Statement: The Patient Health Questionnaire–9 depression module displayed longitudinal measurement invariance over a 24-week medication trial for depression. These findings support the use of the Patient Health Questionnaire–9 depression module to monitor changes in depression symptoms during treatment with antidepressants. [ABSTRACT FROM AUTHOR]

To understand factors influencing adherence to recommended treatment for insomnia and obstructive sleep apnea (OSA) among Veterans with mild traumatic brain injury (mTBI). Semi-structured interviews (n = 49) with 29 clinical stakeholders and 20 Veterans were conducted. Clinical stakeholders included Veterans Health Administration providers and policymakers involved in the management of mTBI and/or sleep disorders. Veterans included those with a clinician-confirmed mTBI with a recent history of insomnia disorder and/or OSA treatment. Themes were identified using a Descriptive and Interpretive approach. Barriers to sleep disorder treatment adherence included factors associated with the patient (e.g., negative appraisal of treatment benefit), intervention (e.g., side effects), health conditions (e.g., cognitive challenges), health care system (e.g., limited availability of care), and socioeconomic status (e.g., economic instability). Similarly, facilitators of adherence included patient- (e.g., positive appraisal of treatment benefit), intervention- (e.g., flexible delivery format), condition- (e.g., accommodating cognitive impairments), health care system- (e.g., access to adherence support), and socioeconomic-related factors (e.g., social support). Interviews revealed the multi-faceted nature of factors influencing adherence to sleep disorder treatment among Veterans with mTBI. Findings can inform the development of novel interventions and care delivery models that meet the complex needs of this population. [ABSTRACT FROM AUTHOR]

Objective: To identify distinct subgroups of veterans with mild traumatic brain injury (mTBI) based on configurations of postconcussive symptom (PCS) endorsement, and to examine predictors of subgroup membership. Setting: Outpatient Veterans Health Administration (VHA). Participants: Veterans with clinician-confirmed mTBI who completed the Neurobehavioral Symptom Inventory (NSI), determined using the Comprehensive Traumatic Brain Injury Evaluation database. Individuals who tended to overreport symptoms were excluded via an embedded symptom validity scale. Design: Retrospective cohort study leveraging national VHA clinical data from 2012 to 2020. Latent class analysis (LCA) with a split-sample cross-validation procedure was used to identify subgroups of veterans. Multinomial logistic regression was used to examine predictors of subgroup membership. Main Measures: Latent classes identified using NSI items. Results: The study included 72 252 eligible veterans, who were primarily White (73%) and male (94°/o). The LCA supported 7 distinct subgroups of veterans with mTBI, characterized by diverging patterns of risk for specific PCS across vestibular (eg, dizziness), somatosensory (eg, headache), cognitive (eg, forgetfùlness), and mood domains (eg, anxiety). The most prevalent subgroup was Global (20.7%), followed by Cognitive-Mood (16.3%), Headache-Cognitive-Mood (H-C-M; 16.3%), Headache-Mood (14.2%), Anxiety (13.8%), Headache-Sleep (10.3%), and Minimal (8.5%). The Global class was used as the reference class for multinomial logistic regression because it was distinguished from others based on elevated risk for PCS across all domains. Female (vs male), Black (vs White), and Hispanic veterans (vs non-Hispanic) were less likely to be members of most subgroups characterized by lesser PCS endorsement relative to the Global class (excluding Headache-Mood). Conclusion: The 7 distinct groups identified in this study distill heterogenous patterns of PCS endorsement into clinically actionable phenotypes that can be used to tailor clinical management of veterans with mTBI. Findings reveal empirical support for potential racial, ethnic, and sex-based disparities in PCS among veterans, informing efforts aimed at promoting equitable recovery from mTBI in this population. [ABSTRACT FROM AUTHOR]

Importance: Veterans receiving inpatient psychiatric services with limitations in activities of daily living (ADLs) benefit from occupational therapy, yet disparities in access are unknown. Objective: To investigate whether ADL limitations, an indicator of occupational therapy need, was associated with inpatient psychiatric occupational therapy utilization in the Veterans Health Administration (VHA) and whether this relationship differs by facility characteristics. Design: Secondary analysis of VHA data. Modified Poisson regression modeled occupational therapy utilization as a function of ADL limitations, facility characteristics, and covariates. Interactions estimated whether the relationship between ADL limitations and occupational therapy utilization differed across facility characteristics. Setting: VHA inpatient psychiatric setting. Participants: Veterans receiving VHA inpatient psychiatric care from 2015 to 2020 (N = 133,844). Outcomes and Measures: Occupational therapy utilization. Results: Veterans with ADL limitations were more likely to receive occupational therapy. Veterans receiving care in facilities with higher complexity and greater inpatient psychiatric care quality were more likely to receive occupational therapy. Additionally, Black veterans were less likely to receive occupational therapy relative to their White, non-Hispanic counterparts. Interactions indicated that the extent to which ADL limitations drove access to occupational therapy utilization was weaker within facilities with higher complexity and care quality. Conclusions and Relevance: Veterans with ADL limitations were more likely to access inpatient psychiatric occupational therapy, suggesting that such services are generally allocated to veterans in need. However, findings indicate disparities in access across patient-level (e.g., Black race) and facility-level (e.g., facility complexity) factors, informing efforts to eliminate barriers to accessing these valuable services. Plain-Language Summary: This is the first study, to our knowledge, to examine disparities in access to inpatient psychiatric occupational therapy in the Veterans Health Administration (VHA). The study findings show that access to inpatient psychiatric occupational therapy is partly driven by the needs of the patient. However, nonclinical factors, such as a patient's race and the characteristics of the facility at which they receive care (complexity, number of psychiatric beds available, and the quality of psychiatric care), are also important drivers of access. Identifying factors influencing access to these valuable services is the first step in developing strategies that reduce barriers to access for veterans in need. This is the first study to examine disparities in access to inpatient psychiatric occupational therapy in the Veterans Health Administration. [ABSTRACT FROM AUTHOR]

Occupational therapy has been identified as a required service in the neuro critical care unit (NCCU), however who receives occupational therapy services and what services they receive are not well understood. We sought to determine if arousal deficits impacted patients' likelihood to receive an occupational therapy evaluation or specific types of occupational therapy interventions in the NCCU. When compared to patients without arousal deficits, patients who were experiencing agitation or light sedation, but not deep sedation, were more likely to receive occupational therapy interventions in the therapeutic activities category. Arousal deficits were not associated with receipt of occupational therapy services or occupational therapy interventions in the self-care or therapeutic exercise categories. Determining predictors of occupational therapy services will help ensure the timely delivery of services by improving the allocation of resources and identifying potential gaps in care. [ABSTRACT FROM AUTHOR]

Objective: To examine the impact of community-level social determinants of health (SDoH) on the onset of occupational therapy (OT) and physical therapy (PT) services among individuals hospitalized for traumatic brain injury (TBI). Setting: 14 acute care hospitals in the state of Colorado. Participants: We studied 5825 adults with TBI. Design: In a secondary analysis of de-identified electronic health record data, we performed multivariable logistic and linear regressions to calculate odds ratios (ORs) and 95% CIs for the likelihood of receiving services and duration to initiation of services among those who received them. Main Measures: Community-level SDoH, receipt of rehabilitation services, and onset of rehabilitation services. Results: Multivariable logistic and linear regressions revealed that those in top quartiles for community income were associated with duration to OT services, ranging from OR = 0.33 [05% CI, 0.07, 0.60] for quartile 2 to 0.76 [0.44, 1.08] for quartile 4 compared with those with the lowest quartile. Only the top quartile differed significantly for duration to PT services (0.63 [0.28, 0.98]). Relative to those with below the median community percentage of high school degree, those with above the median were associated with duration to PT services only (−0.32 [−0.60, −0.04]). Neither community percentage with bachelor's degree nor rural-urban designation was associated with duration to either therapy service. Conclusion: Further research is needed to determine whether our SDoH variables were too diffuse to capture individual experiences and impacts on care or whether community-level education and income, and rurality, truly do not influence time to therapy for patients hospitalized with TBI. Other, individual-level variables, such as age, comorbidity burden, and TBI severity, demonstrated clear relationships with therapy onset. These findings may help therapists evaluate and standardize equitable access to timely rehabilitation services. [ABSTRACT FROM AUTHOR]