Objective

Millions of military personnel and veterans live with chronic mental and physical health conditions that often do not respond well to pharmacological treatments. Serious side effects and lack of treatment response have led to widespread efforts to study and promote non-pharmacological and behavioral health treatments for many chronic health conditions. Yoga is an increasingly popular mind-body intervention that has growing research support for its efficacy and safety. Our objective was to explore the attitudes, perspectives, and preferences of military personnel and veterans toward yoga as a therapeutic modality, thus providing needed information for designing and promoting yoga interventions for this population.

Methods

Participants included 24 individuals with yoga experience and current or past military service and 12 instructors who have taught yoga for military personnel and/or veterans. A semi-structured set of questions guided interviews with each participant.

Results

Five themes emerged from the interviews: (1) mental health benefits experienced from yoga practice; (2) physical health benefits experienced from yoga practice; (3) important yoga elements and conditions that support effective practice; (4) facilitators for engaging military in yoga practice; and (5) challenges and barriers to yoga practice for military.

Conclusions

The study highlights consistent reports of mental and physical benefits of yoga practice, ongoing stigma resulting in the need for combatting and demystifying yoga and other complementary and integrative health (CIH) practices, the importance of designing interventions to address the unique mental health issues and perspectives of this population, and the importance of efforts by military leadership to bring CIH to military personnel and veterans. Rigorous research addressing these findings, along with further research on the efficacy and effectiveness of yoga interventions for treating various conditions are needed.

Background

Many health care systems are beginning to encourage patients to use complementary and integrative health (CIH) therapies for pain management. Many clinicians have anecdotally reported that patients combining self-care CIH therapies with practitioner-delivered therapies report larger health improvements than do patients using practitioner-delivered or self-care CIH therapies alone. However, we are unaware of any trials in this area.

Design

The APPROACH Study (Assessing Pain, Patient-Reported Outcomes and Complementary and Integrative Health) assesses the value of veterans participating in practitioner-delivered CIH therapies alone or self-care CIH therapies alone compared with the combination of self-care and practitioner-delivered care. The study is being conducted in 18 Veterans Health Administration sites that received funding as part of the Comprehensive Addiction and Recovery Act to expand availability of CIH therapies. Practitioner-delivered therapies under study include chiropractic care, acupuncture, and therapeutic massage, and self-care therapies include tai chi/qi gong, yoga, and meditation. The primary outcome will be improvement on the Brief Pain Inventory 6 months after initiation of CIH as compared with baseline scores. Patients will enter treatment groups on the basis of the care they receive because randomizing patients to specific CIH therapies would require withholding therapies routinely offered at VA. We will address selection bias and confounding by using sites' variations in business practices and other encouragements to receive different types of CIH therapies as a surrogate for direct randomization by using instrumental variable econometrics methods.

Summary

Real-world evidence about the value of combining self-care and practitioner-delivered CIH therapies from this pragmatic trial will help guide the VA and other health care systems in offering specific nonpharmacological approaches to manage patients' chronic pain.

We are in a new era of partner-based implementation research, and we need clear strategies for how to navigate this new era. Drawing on principles from community-based participatory research, the Clinical Public Health group of the Department of Veterans Affairs and the HIV/Hepatitis Quality Enhancement Research Initiative (HHQUERI) forged a longstanding partnership that has improved the care of Veterans with Human Immunodeficiency Virus (HIV) and Hepatitis C Virus. An exemplar HIV testing project epitomizes this partnership and is discussed in terms of the lessons learned as a result of our high level of collaboration around design, analysis, implementation, and dissemination across projects over the past several years. Lessons learned through this partnered testing program involve respecting different time horizons among the partners, identifying relevant research questions for both parties, designing flexible studies, engaging all partners throughout the research, and placing an emphasis on relationship building at all times. These lessons and strategies can benefit others conducting partner-based research both within the Veterans Health Administration (VA) and in other integrated healthcare systems.

Background

Traditional research approaches do not promote timely implementation of evidence-based innovations (EBIs) to benefit patients. Embedding research within health systems can accelerate EBI implementation by blending rigorous methods with practical considerations in real-world settings. A state-of-the-art (SOTA) conference was convened in February 2019 with five workgroups that addressed five facets of embedded research and its potential to impact healthcare. This article reports on results from the workgroup focused on how embedded research programs can be implemented into heath systems for greatest impact.

Methods

Based on a pre-conference survey, participants indicating interest in accelerating implementation were invited to participate in the SOTA workgroup. Workgroup participants (N = 26) developed recommendations using consensus-building methods. Ideas were grouped by thematic clusters and voted on to identify top recommendations. A summary was presented to the full SOTA membership. Following the conference, the workgroup facilitators (LJD, CDH, NR) summarized workgroup findings, member-checked with workgroup members, and were used to develop recommendations.

Results

The workgroup developed 12 recommendations to optimize impact of embedded researchers within health systems. The group highlighted the tension between "ROI vs. R01" goals-where health systems focus on achieving return on their investments (ROI) while embedded researchers focus on obtaining research funding (R01). Recommendations are targeted to three key stakeholder groups: researchers, funders, and health systems. Consensus for an ideal foundation to support optimal embedded research is one that (1) maximizes learning; (2) aligns goals across all 3 stakeholders; and (3) implements EBIs in a consistent and timely fashion.

Conclusions

Four cases illustrate a variety of ways that embedded research can be structured and conducted within systems, by demonstrating key embedded research values to enable collaborations with academic affiliates to generate actionable knowledge and meaningfully accelerate implementation of EBIs to benefit patients.

Implications

Embedded research approaches have potential for transforming health systems and impacting patient health. Accelerating embedded research should be a focused priority for funding agencies to maximize a collective return on investment.