Connecting Women to Care: Home-based Psychotherapy for Women with MST Living in Rural Areas

背景-退伍军人中的军事性创伤（MST）是一个流行病比例的问题 与严重的心理健康和功能障碍以及获得护理的大量障碍有关。 监测数据表明，四分之一的女性退伍军人在筛查时报告MST。女性相比 有其他服务相关压力的退伍军人，那些经历MST的人有更大的心理健康问题， 更有可能报告在社会，家庭和亲密关系中运作困难， 失业，并报告找工作的困难。然而，患有MST的女性参与较少， 经常在VA医疗保健比其他妇女退伍军人。护理的障碍包括与专业的距离 服务、经济困难、育儿和家庭责任以及与性别有关的不适， 主导设施。过去十年的研究已经确定了妇女的问题和关切 患有MST的退伍军人，但计划解决他们的心理健康需求并对已识别的障碍做出反应 缺乏。拟议的研究通过评估对性别问题有敏感认识的循证技能， 通过基于家庭的视频技术提供的培训计划。 具体目标-本研究将进行混合1型有效性-实施研究， 目标。第一个是确定乙肝病毒治疗的有效性，情感调节技能培训 （STAIR）相对于HBV递送的非特异性活性对照药物，当前中心治疗（PCT） 女性退伍军人与MST假设STAIR在以下方面的改善上级PCT： CAPS PTSD症状（主要结局）以及感知的社会支持和社会参与 （次要结果）。第二个目标是进行多利益攸关方的混合方法评价， 通过HBVT识别实施STAIR的障碍和促进因素，制定未来潜在的实施计划， 对治疗过程和临床有效性的定量数据进行情境化和解释。 方法学-这是一项为期4年的双中心混合1型有效性-实施研究设计。共 将招募200名患有MST和PTSD症状（DSM-5 PTSD筛查临界值> 3）的女性退伍军人 进入书房参与者将按代表全国人口比例的农村状况进行分层。 人口（34%农村人口对66%非农村人口）。分层将确保资源专门用于征聘 确定的农村妇女人数。在每个分层水平内，受试者将被随机分配至以下之一： 两种治疗条件，STAIR或PCT，每种治疗条件包括每周10次治疗。评估将 在5个时间点进行：基线（第0周）、治疗中期（第5周）、治疗后即刻（第10周）、 10）、2个月随访（第18周）和4个月随访（第26周）。乡村性将作为协变量纳入， 评估保留和结果等方面的差异，这将有助于为未来的实施提供信息 布局关于STAIR和使用家庭交付的多利益攸关方混合方法过程评价 服务将包括管理员、临床医生和患者利益相关者。预期结果和预期 对退伍军人医疗保健的影响-预计拟议的研究有可能改善 通过建立社会技能干预的有效性来提高VA医疗保健的质量， 通过家庭视频技术（HBVT）向女性提供情感和人际调节（STAIR） 患有MST的退伍军人，特别是生活在农村地区的退伍军人。治疗同时解决社会问题 关注和创伤后应激障碍症状，这两者都是女性退伍军人谁经历了确定的需求 MST。STAIR已被证明在社区人群和妇女试点数据中有效 退伍军人与MST表明类似的结果，改善感知社会支持，社会 参与和创伤后应激障碍症状。HBVT的使用有可能增加对这一问题的护理。 地理上分散和得不到充分服务的人口。

Background – Military Sexual Trauma (MST) among women Veterans is a problem of epidemic proportion associated with significant mental health and functional impairment and substantial access to care barriers. Surveillance data indicate that one in four women Veterans reports MST when screened. Compared to women Veterans with other service-related stressors, those experiencing MST have greater mental health problems, are more likely to report difficulty in functioning in social, family and intimate relationships and are more likely to be unemployed and to report difficulties in finding a job. Nevertheless, women with MST engage less frequently in VA health care than other women Veterans. Barriers to care include distance from specialty services, financial difficulties, childcare and family responsibilities, and gender-related discomfort in male- dominated VA facilities. Research over the past decade has identified the problems and concerns of women Veterans with MST but programs addressing their mental health needs and responsive to identified barriers are lacking. The proposed study addresses this gap by evaluating a gender-sensitive, evidence-based skills training program delivered via home-based video technology. Specific Aims – The study will conduct a Hybrid Type 1 effectiveness-implementation study to accomplish two aims. The first is to determine the effectiveness of the HBVT-delivered, Skills Training in Affective Regulation (STAIR) relative to a HBVT-delivered nonspecific active comparator, Present Centered Therapy (PCT) among women Veterans with MST. It is hypothesized that STAIR will be superior to PCT in regards to improvement in CAPS PTSD symptoms (primary outcome) as well as in perceived social support and social engagement (secondary outcomes). The second aim is to conduct a multi-stakeholder, mixed method evaluation to inform future potential implementation plans by identify barriers and facilitators of implementing STAIR via HBVT and to contextualize and interpret the quantitative data on treatment processes and clinical effectiveness. Methodology – This is a four-year, two-site Hybrid Type 1 effectiveness-implementation study design. A total of 200 women Veterans with MST and PTSD symptoms (with DSM-5 PTSD Screen cut-off > 3) will be enrolled into the study. Participants will be stratified by rurality status in a proportion representative of the national population (34% rural vs. 66% nonrural). Stratification will ensure that resources are dedicated to recruit the identified number of rural women. Within each level of stratification, participants will be randomized into one of two treatments conditions, STAIR or PCT, each of which is comprised of 10 weekly sessions. Assessments will be conducted at five time-points: baseline (week 0), midtreatment (week 5), immediately posttreatment (week 10), 2-month follow-up (week 18) and 4-month follow-up (week 26). Rurality will be included as a covariate and assessed for variations in aspects such as retention and outcome, which will help inform future implementation plans. Multi-stakeholder mixed-method process evaluation concerning STAIR and the use of in-home delivery of services will include administrator, clinician and patient stakeholders. Expected Results and Anticipated Impacts on Veterans Healthcare – It is expected that the proposed study has the potential to improve the quality of VA healthcare by establishing the effectiveness of a social skills intervention, Skills Training in Affective and Interpersonal Regulation (STAIR) delivered via home-based video technology (HBVT) to women Veterans with MST, particularly those living in rural areas. The treatment simultaneously addresses social concerns and PTSD symptoms, both of which are identified needs of women Veterans who have experienced MST. STAIR has been demonstrated as efficacious in community populations and pilot data with women Veterans with MST indicate similar outcomes regarding improvements in perceived social support, social engagement and PTSD symptoms. The use of HBVT has the potential of increasing access to care to this geographically dispersed and underserved population.