Implementing quality improvement efforts in clinics is challenging. Assessment of organizational “readiness” for change can set the stage for implementation by providing information regarding existing strengths and deficiencies, thereby increasing the chance of a successful improvement effort. This paper discusses organizational assessment in specialty mental health, in preparation for improving care for individuals with schizophrenia. To assess organizational readiness for change in specialty mental health in order to facilitate locally tailored implementation strategies. EQUIP-2 is a site-level controlled trial at nine VA medical centers (four intervention, five control). Providers at all sites completed an organizational readiness for change (ORC) measure, and key stakeholders at the intervention sites completed a semi-structured interview at baseline. At the four intervention sites, 16 administrators and 43 clinical staff completed the ORC, and 38 key stakeholders were interviewed. The readiness domains of training needs, communication, and change were the domains with lower mean scores (i.e., potential deficiencies) ranging from a low of 23.8 to a high of 36.2 on a scale of 10–50, while staff attributes of growth and adaptability had higher mean scores (i.e., potential strengths) ranging from a low of 35.4 to a high of 41.1. Semi-structured interviews revealed that staff perceptions and experiences of change and decision-making are affected by larger structural factors such as change mandates from VA headquarters. Motivation for change, organizational climate, staff perceptions and beliefs, and prior experience with change efforts contribute to readiness for change in specialty mental health. Sites with less readiness for change may require more flexibility in the implementation of a quality improvement intervention. We suggest that uptake of evidence-based practices can be enhanced by tailoring implementation efforts to the strengths and deficiencies of the organizations that are implementing quality improvement changes.

We examined African American women's experiences of communication with their male intimate partners a couple of hours before and after an incident of unwanted sex. We also examined women's experiences of disclosure following an incident of unwanted sex. Semi-structured qualitative interviews were conducted with a community-based sample of sexually active African American women (n = 19) reporting at least one incident of sexual coercion (i.e., being pressured into unwanted sex without consent) by an intimate male partner since the age of 18. Our analysis was guided by "the sexual division of power" from Connell's (1987) theory of gender and power. Data were analyzed inductively by examining the interviews for common themes in the following domains: communication before the unwanted sex, communication after the unwanted sex, and disclosure to others. Men pressured partners for unwanted sex through verbal and non-verbal tactics, ranging from pestering and blunt requests for sex to verbal bullying and violence. Many women responded by clearly saying no. However, many women also described eventually ceasing to resist their partners and engaging in unwanted sex. After the unwanted sex, men actively and passively avoided discussing the incident. Although many women discussed the unwanted sex with family and friends, less women disclosed to trained professionals. In some cases, women did not discuss the incident with anyone at all. These findings indicate that, when addressing sexual violence against women, there is a need to target men as well as the norms of masculinity that underpin physical and sexual violence against women.

Families are rarely included in clinical care despite research showing that family involvement has a positive effect on individuals with schizophrenia by reducing relapse, improving work functioning, and social adjustment. The VA QUERI study, EQUIP (Enhancing QUality of care In Psychosis), implemented family services for this population. At two VA medical centers, veterans with schizophrenia and their clinicians were interviewed separately at baseline and 15 months. A family intervention was implemented, and a process evaluation of the implementation was conducted. Veterans with schizophrenia (n = 173) and their clinicians (n = 29). Consent to contact family was obtained, mailers to engage families were sent, families were prioritized as high need for family services, and staff volunteers were trained in a brief three-session family intervention. Of those enrolled, 100 provided consent for family involvement. Seventy-three of the 100 were sent a mailer to engage them in care; none became involved. Clinicians were provided assessment data on their patients and notified of 50 patients needing family services. Of those 50, 6 families were already involved, 34 were never contacted, and 10 were contacted; 7 new families became involved in care. No families were referred to the family psychoeducational program. Uptake of the family intervention failed due to barriers from all stakeholders. Families did not respond to the mailer, patients were concerned about privacy and burdening family, clinicians had misperceptions of family-patient contact, and organizations did not free up time or offer incentives to provide the service. If a full partnership with patients and families is to be achieved, these barriers will need to be addressed, and a family-friendly environment will need to be supported by clinicians and their organizations. Applicability to family involvement in other disorders is discussed.

In mental health care, consumer providers (CPs) are individuals with serious mental illness (SMI) who draw upon their lived experiences while providing services to others with SMI. Implementation of CPs has proven to be challenging in a variety of settings. The PEER project (Peers Enhancing Recovery) involved rolling out CPs using an implementation science model and evaluating implementation and impact in mental health treatment settings (three intervention, three control). In qualitative interviews, facilitators and challenges to implementation were described by the CPs, their team members, clients, and study researchers. Site preparation, external facilitation, and positive, reinforcing experiences with CPs facilitated implementation. Role definitions and deficiencies in CPs' technical knowledge posed challenges to implementation. Sustainability was not realized due to insufficient resources. However, implementation was positive overall, characterized by diffusion of innovation concepts of high relative advantage, strong trialability, compatibility with prevailing norms, compelling observability, and relatively low complexity. By preparing and working systematically with intervention sites to incorporate new services, implementation was strengthened and challenges were minimized.

Objective

By combining supportive services with independent housing, permanent supportive housing (PSH) programs effectively address homelessness. Yet, many persons with serious mental illness struggle to attain and retain housing in these programs. Social skills-which facilitate social interactions and instrumental tasks-predict premature exit from PSH. This project aimed to build consensus on a set of social skills that supports independent housing attainment and retention among homeless persons with serious mental illness, with a clinical focus on PSH programs.

Methods

Guided by the RAND/University of California, Los Angeles, appropriateness method, the set of social skills was developed by using literature review; key informant interviews (N=12), a national consensus panel of experts in psychosocial rehabilitation and homelessness (N=11), and two focus groups with homeless persons with serious mental illness (N=17).

Results

These methods identified 24 social skills in seven domains: finding and renting an apartment, using one's time well, getting closer to people, managing finances, avoiding problems with drugs and alcohol, solving interpersonal problems, and managing one's health. Expert panelists and focus group participants agreed that these social skills were feasible for inclusion in social skills training and could strongly affect housing outcomes in PSH settings.

Conclusions

Consensus was reached about a set of social skills relevant to housing attainment and retention for persons with serious mental illness engaged in PSH. Next steps include modifying social skills training interventions to this skill set, making contextual modifications relevant to the setting and context of PSH, and studying the effectiveness and implementation of the adapted intervention in PSH.

Background

Inner context organizational factors proximally shape therapist experiences with evidence-based practice (EBP) implementation and may influence therapist self-efficacy, which has been linked to sustained use of EBPs in community mental health settings. Research has primarily focused on constructs such as implementation leadership and climate. However, the effects of such factors may depend upon other inner context dimensions, such as psychological safety. Psychologically safe environments are conducive to taking risks, speaking up about problems, and requesting feedback and may promote therapist self-efficacy during implementation. This study examines whether organizational sustainment leadership and sustainment climate relate to therapist EBP self-efficacy only under conditions of psychological safety.

Methods

Data were collected from 410 clinicians in 85 programs during the sustainment phase of a system-driven implementation of multiple EBPs in children's mental health services. Therapists reported on their organization's sustainment leadership, sustainment climate, psychological safety, and their own self-efficacy in delivering specific EBPs. Multilevel regression analyses were conducted to account for nested data structure.

Results

Among program-level variables, sustainment leadership and psychological safety both significantly predicted therapist self-efficacy. However, there were no significant interactions between program-level sustainment climate and psychological safety. Exploratory post-hoc analyses revealed a significant interaction between program-level sustainment leadership and therapist-level perceptions of psychological safety such that that the conditional effect of psychological safety on EBP self-efficacy was significant at high levels of sustainment leadership, but not at low or average levels.

Conclusion

We noted independent links between sustainment leadership, organizational psychological safety and therapists feelings of confidence and mastery with EBPs. Therapists' individual perceptions of psychological safety were linked to self-efficacy only in programs with high sustainment leadership. Thus, sustainment leadership and psychological safety may both represent implementation intervention targets, but it may not be critical to assess for perceptions of psychological safety before deploying organizational leadership strategies.Plain language abstract Therapist self-efficacy is a therapist's belief that they are capable, knowledgeable, and skilled enough to deliver evidence-based practices (EBPs), and is thought to promote improved clinical and implementation outcomes, such as therapists' sustained use of EBPs. Conditions within community mental health organizations may influence therapists' sense of EBP self-efficacy. Leaders' support and expectations for EBP implementation, and collective staff perceptions about the organization's climate to support EBPs are linked to positive therapist attitudes and EBP adoption. However, less is known about how these implementation-specific organizational factors associated with therapist EBP self-efficacy in the long-term, and how this may depend on general workplace conditions. Specifically, psychologically safe environments - where therapists feel safe taking risks such as asking questions, admitting mistakes, and trying new skills - may be needed to promote self-efficacy when therapists are tasked with learning and using complex multi-component EBP innovations. The current study tested the prediction that leader-driven and program-wide focus on EBP sustainment may promote therapist EBP self-efficacy only in organizations where conditions for learning are psychologically safe. Our findings confirmed that fostering strong sustainment focused leadership and psychologically safe environments may each be important for increasing therapists' EBP self-efficacy. The model results suggested that individual therapist perceptions of psychological safety were more strongly related to EBP self-efficacy in programs with greater implementation leadership. Findings suggest the importance of increasing EBP leadership behavior to fully potentiate other facilitating conditions for therapist learning in the sustainment phase of EBP implementation initiatives.

Background

Sexually transmitted infections (STIs) are prevalent in the U.S. military. However, there are limited data on risk-factor differences between sexes.

Methods

We used data from the 2008 Department of Defense Survey of Health Related Behaviors among active duty military personnel to identify risk factors for self-reported STIs within the past 12 months and multiple sexual partners among sexually active unmarried service members.

Results

There were 10,250 active duty personnel, mostly white (59.3%) aged 21 to 25 years (42.6%). The prevalence of any reported STI in the past 12 months was 4.2% for men and 6.9% for women. One-fourth of men and 9.3% of women reported 5 or more sexual partners in the past 12 months. Binge drinking, illicit substance use, and unwanted sexual contact were associated with increased report of sexual partners among both sexes. Family/personal-life stress and psychological distress influenced number of partnerships more strongly for women than for men (Adjusted Odds Ratio [AOR]=1.58, 95% Confidence Interval [CI]=1.18-2.12 and AOR=1.41, 95% CI=1.14-1.76, respectively). After adjusting for potential confounders, we found that the report of multiple sexual partners was significantly associated with the report of an STI among men (AOR, 5.87 [95% CI, 3.70-9.31], for ≥5 partners; AOR, 2.35 [95% CI, 1.59-3.49], for 2-4 partners) and women (AOR, 4.78 [95% CI, 2.12-10.80], for ≥5 partners; AOR, 2.35 [95% CI, 1.30-4.25], for 2-4 partners).

Conclusions

Factors associated with the report of increasing sexual partnerships and report of an STI differed by sex. Sex-specific intervention strategies may be most effective in mitigating the factors that influence risky sexual behaviors among military personnel.

This study examined the relationship between herbal medication and dietary supplement (HMDS) use and mental health characteristics. Data are drawn from a national household survey of the United States’ civilian, non-institutionalized population (N = 9,585). Psychiatric medication and HMDS use, psychiatric diagnoses and treatment needs, utilization and satisfaction were assessed. Compared to non-users, HMDS users were more likely to perceive themselves as having mental health needs, to have received mental health and primary care treatment, and to be dissatisfied with their overall healthcare. Psychiatric medication use was not related to HMDS use, and in multivariate analyses, HMDS use was associated with perceived mental health needs. Differences in use of specific HMDS between those with and without a psychiatric disorder were also examined. The use of HMDS warrants particular attention in persons with perceived mental health problems as these individuals may be turning to HMDS use for treatment of their symptoms.

Many U.S. military women are exposed to unwanted sexual contact during military service, which can have important implications for mental health. Using data from the 2008 Department of Defense Survey of Health Related Behaviors, we employed multiple logistic regression methods to examine whether unwanted sexual contact was associated with stress, screening positive for mental disorders, or substance use, among active duty service women. The sample included 7,415 female military personnel, of whom 13.4% reported unwanted sexual contact (including any touching of genitals) since entering the military. After adjusting for potentially confounding variables, factors independently associated with unwanted sexual contact included military-related stress (adjusted odds ratio [AOR] = 2.44), family/personal life-related stress (AOR = 1.78), and gender-related stress (AOR = 1.98) in the past 12 months. In addition, screening positive for depression, anxiety, posttraumatic stress disorder, or psychological distress, and suicidal ideation or attempt were associated with unwanted sexual contact (AOR = 1.57-2.11). For drug/alcohol use, only misuse of tranquilizers/muscle relaxers (past 12 months) was associated with report of unwanted sexual contact (AOR = 1.35). Given the prevalence of unwanted sexual contact and corresponding adverse health outcomes in this sample of active duty women, strategies to create military structural/cultural changes and reduce gender-related stress and sexism are needed.

Women in the US military report a high prevalence of sexual risk behaviours, such as binge drinking and new or multiple sexual partnerships. However, demographical differences pose challenges to making comparisons with civilians. Two public-use datasets were used to compare prevalence of sexual risk behaviours between sexually active military and civilian women, after adjusting for demographic factors. It was found that women in the military reported a higher prevalence of binge drinking and new/multiple sexual partners as compared with civilians, which suggests that military women are a high-risk group and the military environment may at least partially facilitate these risk behaviours.