The VA Women's Health Practice-Based Research Network: amplifying women veterans' voices in VA research

Summary and Roadmap of Breast Cancer Research in the Veterans Affairs

Women are the largest growing population of Veterans within the U.S. Department of Veterans Affairs (VA) Health Care System. Among women Veterans, breast cancer is the most common malignancy (30% of all cancers), yet little is known about the unique needs of women Veterans with cancer and how to provide them with high quality care. The VA health care system has initiated multiple system-wide systemic efforts, including launching the Breast and Gynecologic Cancer System of Excellence (BGSOE) to address this knowledge gap. This report summarizes the outcomes of the inaugural 2023 VA Women's Cancer Research Conference, which assembled 37 multidisciplinary clinicians, scientists, the VA and civilian partners with a shared goal of advancing VA breast cancer research. Conference objectives were to build a collective vision for improving: (1) referral patterns for breast cancer treatment and patient-level outcomes and (2) molecular and genetic testing patterns across the breast cancer continuum among women Veterans. The meeting hosted 15 speakers at the Houston VA Medical Center. Future research priorities for women Veterans with cancer were identified from discussions and a post-conference survey. We then administered a 13-question post-conference survey to conference attendees. Respondents ranked the research priorities. The survey results show that the cross-cutting cancer research priorities designed to transform cancer care for women Veterans at the VA fit into 5 broad areas of study, including (1) care quality for treatment, (2) improving treatment, (3) care quality of molecular and genetic testing, (4) risk reduction through risk assessment and germline genetic testing, and (5) establishing strategic partnerships. Our data elucidate areas for further investigation to improve the delivery of cancer care.

Impact of Evidence-Based Quality Improvement on Tailoring VA's Patient-Centered Medical Home Model to Women Veterans' Needs

BACKGROUND

Women Veterans' numerical minority, high rates of military sexual trauma, and gender-specific healthcare needs have complicated implementation of comprehensive primary care (PC) under VA's patient-centered medical home model, Patient Aligned Care Teams (PACT).

OBJECTIVE

We deployed an evidence-based quality improvement (EBQI) approach to tailor PACT to meet women Veterans' needs and studied its effects on women's health (WH) care readiness, team-based care, and burnout.

DESIGN

We evaluated EBQI effectiveness in a cluster randomized trial with unbalanced random allocation of 12 VAMCs (8 EBQI vs. 4 control). Clinicians/staff completed web-based surveys at baseline (2014) and 24 months (2016). We adjusted for individual-level covariates (e.g., years at VA) and weighted for non-response in difference-in-difference analyses for readiness and team-based care overall and by teamlet type (mixed-gender PC-PACTs vs. women-only WH-PACTs), as well as post-only burnout comparisons.

PARTICIPANTS

We surveyed all clinicians/staff in general PC and WH clinics.

INTERVENTION

EBQI involved structured engagement of multilevel, multidisciplinary stakeholders at network, VAMC, and clinic levels toward network-specific QI roadmaps. The research team provided QI training, formative feedback, and external practice facilitation, and support for cross-site collaboration calls to VAMC-level QI teams, which developed roadmap-linked projects adapted to local contexts.

MAIN MEASURES

WH care readiness (confidence providing WH care, self-efficacy implementing PACT for women, barriers to providing care for women, gender sensitivity); team-based care (change-readiness, communication, decision-making, PACT-related QI, functioning); burnout.

KEY RESULTS

Overall, EBQI had mixed effects which varied substantively by type of PACT. In PC-PACTs, EBQI increased self-efficacy implementing PACT for women and gender sensitivity, even as it lowered confidence. In contrast, in WH-PACTs, EBQI improved change-readiness, team-based communication, and functioning, and was associated with lower burnout.

CONCLUSIONS

EBQI effectiveness varied, with WH-PACTs experiencing broader benefits and PC-PACTs improving basic WH care readiness. Lower confidence delivering WH care by PC-PACT members warrants further study.

TRIAL REGISTRATION

The data in this paper represent results from a cluster randomized controlled trial registered in ClinicalTrials.gov (NCT02039856).

Enhancing Primary Care and Mental Health Integration for Women Veterans with Complex Healthcare Needs Using Evidence-Based Quality Improvement

BACKGROUND

Women Veterans with co-morbid medical and mental health conditions face persistent barriers accessing high-quality health care. Evidence-based quality improvement (EBQI) offers a systematic approach to implementing new care models that can address care gaps for women Veterans.

OBJECTIVE

This study examines factors associated with the successful deployment of EBQI within integrated health systems to improve primary care for women Veterans with complex mental health needs.

DESIGN

Following a 12-site (8 EBQI, 4 control) cluster randomized study to evaluate EBQI effectiveness, we conducted an in-depth case study analysis of one women's health clinic that used EBQI to improve integrated primary care-mental health services for women Veterans.

PARTICIPANTS

Our study sample included providers, program managers, and clinic staff at a women Veteran's health clinic that, at the time of the study, had one Primary Care and Mental Health Integration team and one women's health primary care provider serving 800 women. We analyzed interviews conducted 12 months, 24 months, and 4 years post-implementation and call summaries between the clinic and support team.

MAIN MEASURES

We conducted qualitative thematic analysis of interview and call summary data to identify EBQI elements, clinic characteristics, and reported challenges and successes within project development and execution.

KEY RESULTS

The clinic harnessed core EBQI elements (multi-level stakeholder engagement, data-driven progress-monitoring, PDSA cycles, sharing results) to accomplish pre-defined project goals, strengthen inter-disciplinary partnerships, and bolster team confidence. Clinic characteristics that facilitated implementation success included prior QI experience and an organizational culture responsive to innovation, while lack of pre-existing guidelines and limited access to centralized databases posed implementation challenges.

CONCLUSIONS

Successful practice transformation emerges through the interaction of evidence-based methods and site-specific characteristics. Examining how clinic characteristics support or impede EBQI adaptation can facilitate efforts to improve care within integrated health systems.

Ask and Ask Again: Repeated Screening for Smoking Increases Likelihood of Prescription for Cessation Treatment Among Women Veterans

BACKGROUND

Preventive screening at the point of care can increase desired clinical outcomes. However, the impact of repeated screening for tobacco use on receiving smoking cessation treatment among women Veteran population has not been documented.

OBJECTIVE

To examine screening for tobacco use using clinical reminders and the association between the number of screenings and prescription for cessation treatment.

DESIGN

A retrospective analysis using data from a 5-year implementation trial for cardiovascular risk identification conducted between December 2016 and March 2020.

SUBJECTS

Women patients who had at least one primary care visit with a women's health provider during the study period at five primary care clinics in the Veterans Affairs (VA) Healthcare System.

MEASURES

The outcome is prescription of pharmacotherapy or referral to behavioral counseling for smoking cessation on or after the screening date. The exposure is the number of screenings for tobacco use from the trial and the annual VA national clinical reminders during the study period.

RESULTS

Of 6009 eligible patients, 5788 (96.3%) were screened at least once for tobacco use over five calendar years, and 2784 of those screened (48.1%) were reported as current and former smokers. Among current and former smokers, 709 (25.5%) received a prescription and/or referral for smoking cessation. In the adjusted model, the average predicted probability of prescription and/or referral for smoking cessation was 13.7% among current and former smokers screened once over 5 years, 18.6% among screened twice, 26.5% among screened thrice, 32.9% among screened four times, and 41.7% among screened five or six times.

CONCLUSIONS

Repeated screening was associated with higher predicted probabilities of being prescribed smoking cessation treatment.

Common Sense Models of Obesity: a Qualitative Investigation of Illness Representations

BACKGROUND

The Common Sense Model provides a framework to understand health beliefs and behaviors. It includes illness representations comprised of five domains (identity, cause, consequences, timeline, and control/cure). While widely used, it is rarely applied to obesity, yet could explain self-management decisions and inform treatments. This study answered the question, what are patients' illness representations of obesity?; and examined the Common Sense Model's utility in the context of obesity.

METHODS

Twenty-four participants with obesity completed semi-structured phone interviews (12 women, 12 men). Directed content analysis of transcripts/notes was used to understand obesity illness representations across the five illness domains. Potential differences by gender and race/ethnicity were assessed.

RESULTS

Participants did not use clinical terms to discuss weight. Participants' experiences across domains were interconnected. Most described interacting life systems as causing weight problems and used negative consequences of obesity to identify it as a health threat. The control/cure of obesity was discussed within every domain. Participants focused on health and appearance consequences (the former most salient to older, the latter most salient to younger adults). Weight-related timelines were generally chronic. Women more often described negative illness representations and episodic causes (e.g., pregnancy). No patterns were identified by race/ethnicity.

CONCLUSIONS

The Common Sense Model is useful in the context of obesity. Obesity illness representations highlighted complex causes and consequences of obesity and its management. To improve weight-related care, researchers and clinicians should focus on these beliefs in relation to preferred labels for obesity, obesity's most salient consequences, and ways of monitoring change.

Unmet needs of homeless U.S. veterans by gender and race/ethnicity: Data from five annual surveys

There has been insufficient research on gender, race, and ethnic differences in unmet needs of homeless populations. This study analyzed 5 years of data collected by Project Community Homelessness Assessment, Local Education, and Networking Groups (CHALENG) surveys from 2012 to 2016 to examine gender, race, and ethnic differences in "literally homeless" veterans (i.e., veterans living in the streets, shelters, vehicles, or any other place not meant for habitation). Of 7,040 participants, there were 6,335 male and 705 female literally homeless veterans from 4 self-identified racial/ethnic categories (White, Black, Hispanic, and Other). The results showed that homeless female veterans were significantly more likely to report unmet needs related to emergency shelter, transitional housing, and dental care than male veterans. Among men, White veterans reported greater unmet needs in housing, healthcare, basic needs, and specialized needs than racial/ethnic minority veterans. Among women, veterans who were racial/ethnic minorities reported greater unmet needs than their White counterparts. These findings suggest programmatic attention to gender, race, and ethnicity is important in addressing diverse needs of homeless veterans and specialized services may be needed to address their specific and consistent unmet needs. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Increasing Engagement of Women Veterans in Health Research

BACKGROUND

Meaningful engagement of patients in health research has the potential to increase research impact and foster patient trust in healthcare. For the past decade, the Veterans Health Administration (VA) has invested in increasing Veteran engagement in research.

OBJECTIVE

We sought the perspectives of women Veterans, VA women's health primary care providers (WH-PCPs), and administrators on barriers to and facilitators of health research engagement among women Veterans, the fastest growing subgroup of VA users.

DESIGN

Semi-structured qualitative telephone interviews were conducted from October 2016 to April 2018.

PARTICIPANTS

Women Veterans (N=31), WH-PCPs (N=22), and administrators (N=6) were enrolled across five VA Women's Health Practice-Based Research Network sites.

APPROACH

Interviews were audio-recorded and transcribed. Consensus-based coding was conducted by two expert analysts.

KEY RESULTS

All participants endorsed the importance of increasing patient engagement in women's health research. Women Veterans expressed altruistic motives as a personal determinant for research engagement, and interest in driving women's health research forward as a stakeholder or research partner. Challenges to engagement included lack of awareness about opportunities, distrust of research, competing priorities, and confidentiality concerns. Suggestions to increase engagement include utilizing VA's patient-facing portals of the electronic health record for outreach, facilitating "warm hand-offs" between researchers and clinic staff, developing an accessible research registry, and communicating the potential research impact for Veterans.

CONCLUSIONS

Participants expressed support for increasing women Veterans' engagement in women's health research and identified feasible ways to foster and implement engagement of women Veterans. Given the unique healthcare needs of women Veterans, engaging them in research could translate to improved care, especially for future generations. Knowledge about how to improve women Veterans' research engagement can inform future VA policy and practice for more meaningful interventions and infrastructure.

Do Depressive Symptoms Predict Blood Pressure Control in US Veterans?

BACKGROUND

High blood pressure is the most common chronic condition among US veterans. Blood pressure control is essential to preventing and managing cardiovascular diseases. While depressive symptoms are a known risk factor for uncontrolled blood pressure and veterans experience high rates of depressive symptoms, no research has examined the relationship between depressive symptoms and blood pressure control among US veterans.

OBJECTIVE

We examined whether moderately severe-to-severe depressive symptoms, compared to none-to-minimal, are associated with higher risk of uncontrolled blood pressure among US veterans.

DESIGN

We analyzed a population-based sample of veterans from the National Health and Nutrition Examination Survey (2013-2016). Logistic regression models were adjusted for marital status, age, and body mass index. All analyses were weighted; results are generalizable to US veterans.

PARTICIPANTS

A sample of 864 veterans was analyzed, representing approximately 18.8 million US veterans.

MAIN MEASURES

Depressive symptoms were assessed by the Patient Health Questionnaire-9. Uncontrolled blood pressure was defined as average systolic blood pressure ≥ 130 and/or diastolic blood pressure ≥ 80.

KEY RESULTS

For depressive symptoms, 78.2% (SE = 1.6) of US veterans had none-to-minimal, 18.2% (SE = 1.2) had mild-to-moderate, and 3.5% (SE = 0.8) had moderately severe-to-severe. Forty-three percent (SE = 3.0) of US veterans had uncontrolled blood pressure. Moderately severe-to-severe depressive symptoms, compared to none-to-minimal, were associated with lower risk for uncontrolled blood pressure (aOR = .28, 95% CI [.09, .85]). Mild-to-moderate depressive symptoms were not associated with blood pressure control (aOR = .98, 95% CI [.59, 1.65]).

CONCLUSIONS

US veterans with moderately severe-to-severe depressive symptoms were less likely to have uncontrolled blood pressure than veterans with none-to-minimal symptoms. Future research should examine factors unique to veterans that may explain findings opposite of the hypothesized relationship between depressive symptoms and blood pressure control.

Patient-centered behavioral services for women veterans with mental health conditions

The Veterans Health Administration (VHA) is undergoing a transformational shift from disease-focused care to a Whole Health model that emphasizes physical, mental, emotional, and spiritual health and well-being. As this shift is occurring, women veterans using VHA services face challenges navigating a system that has historically served a primarily male demographic, without consistent consensus on which services require specialization by gender. A quality improvement project was conducted to solicit feedback on VHA behavioral and wellness programs from women veterans enrolled in VHA mental healthcare services. A multi-disciplinary work group of clinical researchers and healthcare providers developed a needs assessment survey to assess patient needs and preferences for behavioral health services. A convenience sample of female veterans using VHA mental healthcare services within a comprehensive Women's Health Clinic were invited to complete this anonymous survey. 107 women Veterans 18-65+ years old (65.3% African American; 5.9% LatinX; 54.2% aged under 55) completed the survey. Over 50% of patients endorsed relationships, physical activity, sleep/nightmares, pain management, anger, or spiritual/moral pain as top wellness priorities. Programatic preferences included location (located at the main VA Hospital) and gender composition (female only group formats). Schedule conflicts were the most frequently cited barriers. Results from this quality improvement project highlight considerations for tailoring the content and delivery of behavioral services for women veterans with mental health conditions.

Staff and Patient Perspectives on Bystander Intervention Training to Address Patient-Initiated Sexual Harassment in Veterans Affairs Healthcare Settings

INTRODUCTION

One in four women veteran patients experience public harassment by men veterans at Veterans Affairs (VA) health care facilities. Bystander intervention training-teaching bystanders to identify harassment, assess appropriate responses, and safely intervene before, during, or after an event-is a popular strategy for addressing harassment in military and education settings. We explored staff and veteran patient perspectives on bystander intervention training to address harassment of women veterans in VA health care settings.

METHODS

We conducted 24 staff interviews and 15 veteran patient discussion groups (eight men's groups and seven women's groups) at four VA Medical Centers. We analyzed transcripts using the constant comparative method.

RESULTS

Participants expressed divergent views about bystander intervention training to address harassment of women veteran patients at VA. Most participants supported training staff in bystander intervention, but support for training patients was mixed. Participants identified potential benefits of bystander intervention, including staff and patient empowerment and improvements to organizational culture. They also identified potential concerns, including provocation of conflict between patients, lack of buy-in among the VA community, and difficulty in identifying intervention-appropriate situations. Finally, participants offered recommendations for tailoring training content and format to the VA context.

CONCLUSIONS

Bystander intervention training has the potential to raise collective responsibility for addressing harassment of women in VA and other health care contexts. However, our results illustrate divergent stakeholder views that underscore the importance of engaging and educating stakeholders, securing buy-in, and tailoring bystander intervention programs to local contexts before implementation.

Challenges to Addressing Patient-Perpetrated Sexual Harassment in Veterans Affairs Healthcare Settings

BACKGROUND

Patient-perpetrated sexual harassment adversely affects healthcare organizations, staff, and other patients, yet few institutions have clear policies to address it. Understanding the challenges to addressing patient-perpetrated harassment can inform development of institutional guidelines and interventions.

OBJECTIVE

To identify challenges and stakeholder-driven recommendations for addressing patient-perpetrated sexual harassment of women staff and patients at Veterans Health Administration (VA) facilities.

DESIGN

We conducted qualitative interviews with 24 staff, clinicians, and administrators across four VA healthcare facilities.

PARTICIPANTS

We used snowball sampling to identify stakeholders with expertise in overseeing care environments, providing care to women patients, and/or managing disruptive patient behavior.

APPROACH

We interviewed participants in-person or via phone using a semi-structured guide. Two members of the research team analyzed the interview data using the constant comparative method.

KEY RESULTS

Participants identified challenges to addressing patient-perpetrated harassment of women staff and patients that were interrelated and spanned multiple levels. Perceived organizational-level challenges included a climate of tolerance for harassment, lack of formal policies, and insufficient leadership support. At the staff level, perceived challenges included ambiguity around defining harassment, fear of negatively impacting patient-staff dynamics, and competing priorities. Finally, participants identified patient-level challenges, including patient characteristics such as age, cognitive impairment, and psychiatric diagnoses that complicated assessments of intentionality and culpability. Participant recommendations focused on development and implementation of policies, reporting systems, public norms campaigns, staff and patient education, and bystander intervention training.

CONCLUSIONS

VA offers unique opportunities for studying patient-perpetrated harassment of women staff and patients due to its majority-male patient population, culture informed by military gender norms, and commitment to reducing harassment at its facilities. Our findings highlight the complexity of addressing patient-perpetrated harassment and underscore the need for systemic, multilevel interventions.

Women Veterans' Experiences of Harassment and Perceptions of Veterans Affairs Health Care Settings During a National Anti-Harassment Campaign

PURPOSE

In 2017, Veterans Health Administration (VA) launched a social marketing and training campaign to address harassment of women veterans at VA health care facilities. We assessed women veterans' experiences of harassment, reported perpetrators of harassment, and perceptions of VA in 2017 (before campaign launch) and 2018 (1 year after campaign implementation).

METHODS

We administered surveys to women veterans attending primary care appointments (2017, n = 1,300; 2018, n = 1,711). Participants reported whether they experienced sexual harassment (e.g., catcalls) and gender harassment (e.g., questioning women's veteran status) from patients and/or staff at VA in the past 6 months. They also indicated whether they felt welcome, felt safe, and believed the VA is working to address harassment. We compared variables in 2017 versus 2018 with χ² analyses, adjusting for facility-level clustering.

RESULTS

There were no significant differences in percentages of participants reporting sexual harassment (20% vs. 17%) or gender harassment (11% vs. 11%) in 2017 versus 2018. Men veterans were the most frequently named perpetrators, but participants also reported harassment from staff. Participant beliefs that VA is working to address harassment significantly improved from 2017 to 2018 (52% vs. 57%; p = .05).

CONCLUSIONS

One year after campaign launch, women veterans continued to experience harassment while accessing VA health care services. Findings confirm that ongoing efforts to address and monitor both staff- and patient-perpetrated harassment are essential. Results have implications for future anti-harassment intervention design and implementation and highlight additional opportunities for investigation.

Options for Meaningful Engagement in Clinical Research for Busy Frontline Clinicians

In order for health care innovations to be effective and actionable, they must align with the needs and practice patterns of those delivering care at the bedside. While research has started to incorporate the patient voice, it has yet to fully invest in the expertise of frontline clinicians. Frontline clinicians carry a wealth of clinical knowledge and the lived experience of providing real-world medical care that the research community seeks to improve. We consider options for clinicians as research stakeholders along a continuum of engagement as outlined by the UCSF Clinical and Translational Science Institute from minimal to supportive to participatory. In order to make an effective value proposition to support reallocation of clinician time to research engagement, we advocate evaluating the impact of clinicians as stakeholders at both the process level (e.g., clinician satisfaction, study recruitment rates) and endpoint level (e.g., clinical outcomes). Investing in clinicians as research stakeholders can offer benefits for the individual, health system, and population by increasing the generalizability, adoption, and sustainability of effective interventions.

Promoting learning health system feedback loops: Experience with a VA practice-based research network card study

Background:

We tested the capacity of the 60-site VA Women’s Health Practice-Based Research Network (WH-PBRN), embedded within VA, to employ a multisite card study to collect women Veterans’ perspectives about Complementary and Integrative Health (CIH) and to rapidly return findings to participating sites and partnered national policy-makers in support of a Learning Health System (LHS) wherein evidence generation informs ongoing improvement.

Methods:

VA primary care clinic clerks and nurses distributed anonymous surveys (patient feedback forms) at clinics for up to two weeks in fiscal year 2017, asking about CIH behavior and preferred delivery methods. We examined the project’s feasibility, representativeness, acceptability, and impact via a tracking system, national administrative data, debriefing notes, and three surveys of WH-PBRN Site Leads.

Results:

Twenty geographically diverse and largely representative VA Medical Centers and 11 Community-Based Outpatient Clinics volunteered to participate. Over six months, N = 1191 women Veterans responded (median 57; range 8–151 per site). In under three months, we returned local findings benchmarked against multisite findings to all participating sites and summary findings to national VA partners. Sites and partners disseminated results to clinical and leadership stakeholders, who then applied results as warranted.

Conclusions:

VA effectively mobilized an embedded PBRN to implement a timely, representative, acceptable and impactful operations project.

Implications:

Card studies by PBRNs within large, national healthcare systems can provide rapid feedback to participating sites and national leaders to guide policies, programs, and practices.

Level of Evidence:

Self-selected respondents could have biased results.

Screening High-Risk Women Veterans for Breast Cancer

BACKGROUND

Within the US Department of Veterans Affairs (VA), breast cancer prevalence has more than tripled from 1995 to 2012. Women veterans may be at an increased breast cancer risk based on service-related exposures and posttraumatic stress disorder (PTSD).

METHODS

Women veterans aged ≥ 35 years with no personal history of breast cancer were enrolled at 2 urban VA medical centers. We surveyed women veterans for 5-year and lifetime risks of invasive breast cancer using the Gail Breast Cancer Risk Assessment Tool (BCRAT). Data regarding demographics, PTSD status, eligibility for chemoprevention, and genetic counseling were also collected. Descriptive statistics were used to determine results.

RESULTS

A total of 99 women veterans participated, of which 60% were Black. In total, 35% were high risk with a 5-year BCRAT > 1.66%. Breast biopsies had been performed in 22% of our entire population; 57% had a family history positive for breast cancer. Comparatively, in our high-risk Black population, 33% had breast biopsies and 94% had a family history. High-risk patients were referred for chemoprevention; 5 accepted and 13 were referred for genetic counseling. PTSD was present in 31% of the high-risk subgroup.

CONCLUSIONS

A high percentage of Black patients participated in this pilot study, which also showed an above average rate of PTSD among women veterans who are at high risk for developing breast cancer. Historically, breast cancer rates among Black women are lower than those found in the general population. High participation among Black women veterans in this pilot study uncovered the potential for further study of this population, which is otherwise underrepresented in research. Limitations included a small sample size, exclusively urban population, and self-selection for screening. Future directions include the evaluation of genetic and molecular mutations in high risk Black women veterans, possibly even a role for PTSD epigenetic changes.

Accelerating Research on Suicide Risk and Prevention in Women Veterans Through Research-Operations Partnerships

BACKGROUND

Suicide rates for women veterans are increasing faster than for nonveterans. The 2017 suicide rate for women veterans was more than double that for women nonveterans. However, research to inform improved suicide prevention for women veterans is scant.

OBJECTIVES

To accelerate research on women veterans' unique risks and resiliencies for suicide, the Department of Veterans Affairs (VA) Women's Health Research Network launched a Women Veterans Suicide Prevention Research Work Group to target technical support for researchers, promote collaboration with national VA program offices, and ultimately increase dissemination and translation of research into clinical practice, public health strategies, and policies. The objective of this paper is to report on the process and outcomes of the Work Group's strategic planning efforts to identify and fill gaps in suicide prevention research among women veterans.

METHODS

An in-person meeting of 20 researchers and operational leaders was convened to summarize existing research evidence and identify research priorities and challenges.

RESULTS

Research priorities included civilian reintegration, community connections, psychosocial stressors (eg, social determinants of health) and trauma, risk assessment, clinical interventions, upstream prevention, and health care access. The importance of increasing evidence on gender differences and for women veterans not using VA health care was emphasized.

CONCLUSIONS

Research to inform suicide prevention tailored to meet women veterans' needs is essential; however, many priorities and challenges remain unaddressed. Although Work Group efforts have achieved funding gains, further work to formalize, promote and meet the demands of a suicide prevention research agenda for women veterans requires is ongoing focus.

Mobilizing embedded research and operations partnerships to address harassment of women Veterans at VA medical facilities

Key insights: A: Addressing a complex problem like harassment in VA medical facilities requires committed, engaged collaboration at multiple levels of the organization. B: Timely feedback of initial research findings to operations partners enabled rapid and more responsive development of new programs and policies. C: Our research-clinical partnership has enabled us to pursue targeted change from the outset, while incorporating real-time findings from embedded researchers working to develop a comprehensive understanding of the problem.

Factors Associated with Sexual Satisfaction among Veterans Who Have Experienced Military Sexual Trauma

Veterans who have experienced military sexual trauma (MST) report lower sexual satisfaction than veterans without a history of MST. The current study examined the relationship between demographic, physical health, mental health, and trauma variables and sexual satisfaction among a national sample of U.S. veterans who endorsed MST. Results demonstrated that lower sexual satisfaction was associated with uncoupled relationship status, poor physical health, and symptoms of depression, post-traumatic stress disorder, and sexual dysfunction among male and female veterans. Several additional factors were related to lower sexual satisfaction among female veterans. Findings highlight the importance of gender-targeted assessment, prevention, and treatment of sexual satisfaction problems.

Women's Participation in Research on Intimate Partner Violence: Findings on Recruitment, Retention, and Participants' Experiences

BACKGROUND

Research on intimate partner violence (IPV) faces unique challenges to recruitment and retention. Little is known about successful strategies for recruiting and retaining in research women who have experienced IPV, and their experiences of research participation.

PURPOSE

This article presents findings on recruitment, retention, and research participation experiences from a longitudinal observational study of IPV among women receiving care through the Veterans Health Administration.

METHODS

Administrative tracking data were analyzed to identify strengths, challenges, and outcomes of multiple recruitment strategies for an observational study of women patients who had experienced past-year IPV. Qualitative interviews with a purposively selected subset of the larger sample were used to identify motivations for and experiences of study participation.

RESULTS

Of the total sample (N = 169), 92.3% were recruited via direct outreach by the research team (63.3% via letter, 29.0% in person), compared with provider or patient self-referral (3.6% and 4.1%, respectively); 88% returned for a follow-up assessment. In qualitative interviews (n = 50), participants expressed a desire to help others as a primary motivation for study participation. Although some participants experienced emotional strain during or after study visits, they also expressed perceiving value in sharing their experiences, and several participants found the experience personally beneficial. Participants expressed that disclosure was facilitated by interviewers' empathic and neutral stance, as well as the relative anonymity and time-limited nature of the research relationship.

CONCLUSIONS

Direct outreach to women Veterans Health Administration patients to participate in research interviews about IPV experience was feasible and effective, and proved more fruitful for recruitment than reliance on provider or patient self-referral. Women who have experienced IPV may welcome opportunities to contribute to improvements in care through participation in interviews.

Primary Care Providers' Perspectives on Providing Care to Women Veterans with Histories of Sexual Trauma

BACKGROUND

One in four women Veterans who use the Veterans Health Administration (VA) screen positive for military sexual trauma and may need trauma-sensitive care and coordination. VA primary care providers (PCPs), women veterans' main source of care, need to be well-versed in trauma-sensitive approaches to care. Women veterans' numerical minority in the VA can make provider exposure to female patients inconsistent, which may impede PCP experience in providing appropriate care. To inform strategies for improving trauma-sensitive primary care, we sought to better understand PCPs' current approaches to providing care to women veterans with sexual trauma histories.

METHODS

We conducted semistructured telephone interviews with PCPs (n = 28) practicing in VA primary care clinics. Participants were asked about their experiences delivering trauma-sensitive care as well as best practices. Interviews were recorded, transcribed, and analyzed for major themes regarding barriers to and facilitators of trauma-sensitive care.

RESULTS

Participants expressed challenges delivering care to women with sexual trauma histories, including 1) insufficient time, 2) lack of perceived proficiency and/or personal comfort (with general physical examinations as well as gender-specific care such as Pap, breast, and pelvic examinations), and 3) difficulties with fostering positive patient-provider relationships. Access to mental health resources was noted as a key facilitator of providing trauma-sensitive care. Participants also shared existing (and potential) best practices and recommendations, such as paying special attention to patient behavioral cues related to comfort.

CONCLUSIONS

PCPs delivering care to women in VA facilities may benefit from an increased awareness of best practices to facilitate the delivery of trauma-sensitive care.

Local Leaders' Perspectives on Women Veterans' Health Care: What Would Ideal Look Like?

BACKGROUND

The Veterans Health Administration (VHA) faces challenges in providing comprehensive, gender-sensitive care for women. National policies have led to important advancements, but local leadership also plays a vital role in implementing changes and operationalizing national priorities. In this article, we explore the notions of ideal women veterans' health care articulated by women's health leaders at local VHA facilities and regional networks, with the goal of identifying elements that could inform practice and policy.

METHODS

We conducted semistructured interviews with 86 local and regional women's health leaders at 12 VHA medical centers across four regions. At the conclusion of interviews about women's primary care, participants were asked to imagine "ideal care" for women veterans. Interviews were transcribed and coded using a hybrid inductive/deductive approach.

RESULTS

In describing ideal care, participants commonly touched on whether women veterans should have separate primary care services from men; the need for childcare, expanded reproductive health services, resources, and staffing; geographic accessibility; the value of input from women veterans; the physical appearance of facilities; fostering active interest in women's health across providers and staff; and the relative priority of women's health at the VHA.

CONCLUSIONS

Policy and practice changes to care for women veterans must be mindful of key stakeholders' vision for that care. Specific features of that vision include clinic construction that anticipates a growing patient population, providing childcare and expanded reproductive health services, ensuring adequate support staff, expanding mechanisms to incorporate women veterans' input, and fostering a culture oriented towards women's health at the organizational level.

Selection of Higher Risk Pregnancies into Veterans Health Administration Programs: Discoveries from Linked Department of Veterans Affairs and California Birth Data

OBJECTIVE

To describe variation in payer and outcomes in Veterans' births.

DATA/SETTING

Secondary data analyses of deliveries in California, 2000-2012.

STUDY DESIGN

We performed a retrospective, population-based study of all live births to Veterans (confirmed via U.S. Department of Veterans Affairs (VA) enrollment records), to identify payer and variations in outcomes among: (1) Veterans using VA coverage and (2) Veteran vs. all other births. We calculated odds ratios (aOR) adjusted for age, race, ethnicity, education, and obstetric demographics.

METHODS

We anonymously linked VA administrative data for all female VA enrollees with California birth records.

PRINCIPAL FINDINGS

From 2000 to 2012, we identified 17,495 births to Veterans. VA covered 8.6 percent (1,508), Medicaid 17.3 percent, and Private insurance 47.6 percent. Veterans who relied on VA health coverage had more preeclampsia (aOR 1.4, CI 1.0-1.8) and more cesarean births (aOR 1.2, CI 1.0-1.3), and, despite similar prematurity, trended toward more neonatal intensive care (NICU) admissions (aOR 1.2, CI 1.0-1.4) compared to Veterans using other (non-Medicaid) coverage. Overall, Veterans' birth outcomes (all-payer) mirrored California's birth outcomes, with the exception of excess NICU care (aOR 1.15, CI 1.1-1.2).

CONCLUSIONS

VA covers a higher risk fraction of Veterans' births, justifying maternal care coordination and attention to the maternal-fetal impacts of Veterans' comorbidities.

Patient-Rated Access to Needed Care: Patient-Centered Medical Home Principles Intertwined

BACKGROUND

Primary care teams can facilitate access to care by helping patients to determine whether and when care is needed, and coordinating care across multiple clinicians and settings. Appointment availability metrics may or may not capture these contributions, but patients' own ratings of their access to care provide an important alternative view of access that may be more closely related to these key functions of care teams.

PROCEDURES

We used a 2015 telephone survey of 1,395 women veterans to examine associations between key care team functions and patient-rated access to needed care. The care team functions were care coordination, in-person communication (between patient and care team), and phone communication (timely answers to health questions). We controlled for sociodemographics, health status, care settings, and other experience of care measures.

KEY FINDINGS

Overall, 74% of participants reported always or usually being able to see a provider for routine care, and 68% for urgent care. In adjusted analyses, phone communication was associated with better ratings of access to routine care (odds ratio [OR], 4.31; 95% CI, 2.65-6.98) and urgent care (OR, 2.26; 95% CI, 1.23-4.18). Care coordination was also associated with better ratings of access to routine care (OR, 1.66; 95% CI, 1.01-2.74) and urgent care (OR, 2.26; 95% CI, 1.23-4.18). Associations with in-person communication were not significant.

CONCLUSIONS

Access, communication, and care coordination are interrelated. Approaches to improving access may prove counterproductive if they compromise the team's ability to coordinate care, or diminish the team's role as a primary point of contact for patients.

Engaging multilevel stakeholders in an implementation trial of evidence-based quality improvement in VA women's health primary care

The Veterans Health Administration (VHA) has undertaken primary care transformation based on patient-centered medical home (PCMH) tenets. VHA PCMH models are designed for the predominantly male Veteran population, and require tailoring to meet women Veterans' needs. We used evidence-based quality improvement (EBQI), a stakeholder-driven implementation strategy, in a cluster randomized controlled trial across 12 sites (eight EBQI, four control) that are members of a Practice-Based Research Network. EBQI involves engaging multilevel, inter-professional leaders and staff as stakeholders in reviewing evidence and setting QI priorities. The goal of this analysis was to examine processes of engaging stakeholders in early implementation of EBQI to tailor VHA's medical home for women. Four inter-professional regional stakeholder planning meetings were conducted; these meetings engaged stakeholders by providing regional data about gender disparities in Veterans' care experiences. Subsequent to each meeting, qualitative interviews were conducted with 87 key stakeholders (leaders and staff). Stakeholders were asked to describe QI efforts and the use of data to change aspects of care, including women's health care. Interview transcripts were summarized and coded using a hybrid deductive/inductive analytic approach. The presentation of regional-level data about gender disparities resulted in heightened awareness and stakeholder buy-in and decision-making related to women's health-focused QI. Interviews revealed that stakeholders were familiar with QI, with regional and facility leaders aware of inter-disciplinary committees and efforts to foster organizational change, including PCMH transformation. These efforts did not typically focus on women's health, though some informal efforts had been undertaken. Barriers to engaging in QI included lack of communication across clinical service lines, fluidity in staffing, and lack of protected time. Inter-professional, multilevel stakeholders need to be engaged in implementation early, with data and discussion that convey the importance and relevance of a new initiative. Stakeholder perspectives on institutional norms (e.g., gender norms) and readiness for population-specific QI are useful drivers of clinical initiatives designed to transform care for clinical subpopulations.

Practice-based research networks add value to evidence-based quality improvement

Background

Evidence-Based Quality Improvement (EBQI) is a systematic, multilevel approach to implementing research evidence into clinical settings. Little is known about EBQI effectiveness in the context of Practice-Based Research Networks (PBRNs), which are themselves designed to foster practice-based change. We evaluated EBQI implementation in a PBRN setting to determine the extent to which the PBRN infrastructure added value.

METHODS

We conducted a four-site cluster randomized trial of an EBQI approach to tailoring an evidence-based gender awareness curriculum in the VA Women’s Health PBRN (WH-PBRN). After curriculum implementation, site teams identified impacts of the WH-PBRN context on EBQI processes using qualitative methods, including a formal review of project call minutes, post-project debriefing calls, and structured site team input. WH-PBRN site feedback was mapped to the Replicating Effective Programs implementation phases: pre-condition, pre-implementation, implementation, and maintenance/evolution.

RESULTS

The pre-condition phase benefited from the existing WH-PBRN research-clinician relationships to facilitate stakeholder engagement and build project buy-in at local sites. During pre-implementation, differences across WH-PBRN sites offered variations in local tailoring of EBQI elements. The WH-PBRN Coordinating Center helped resolve process complexities stemming from local resource differences and the sharing of mid-project adaptations during implementation. Local efforts were amplified in the maintenance phase by WH-PBRN dissemination of findings.

Conclusions

The PBRN strengthened multi-site EBQI activities across all implementation phases.

Implications

PBRNs contribute to the uptake of evidence into everyday practice, and may serve as an important component of the future implementation of evidence-based initiatives. Level of evidence: V.

Challenges with Implementing a Patient-Centered Medical Home Model for Women Veterans

BACKGROUND

The Veterans Health Administration (VA) Patient Aligned Care Team (PACT) initiative aims to ensure that all patients receive care consistent with medical home principles. Women veterans' unique care needs and minority status within the VA pose challenges to delivery of equitable, comprehensive primary care for this population. Currently, little is known about whether and/or how PACT should be tailored to better meet women veterans' needs.

METHODS

In 2014, we conducted semistructured interviews with 73 primary care providers and staff to examine facilitators and barriers encountered in providing PACT-principled care to women veterans. Respondents were located in eight VA medical centers in eight different states across the United States.

RESULTS

Respondents perceived PACT as improving continuity of care for patients and as increasing ability of nursing staff to practice at the top of their license. However, the implementation of core medical home features and team huddles was inconsistent and varied both within and across medical centers. Short staffing, inclusion of part-time providers on teams, balancing performance requirements for continuity and same-day access, and space constraints were identified as ongoing barriers to PACT implementation. Challenges unique to care of women veterans included a higher prevalence of psychosocial needs, the need for specialized training of primary care personnel, and short staffing owing to additional sharing of primary care support staff with specialist providers.

CONCLUSION

Providers and staff face unique challenges in delivering comprehensive primary care to women veterans that may require special policy, practice, and management action if benefits of PACT are to be fully realized for this population.

Cluster randomized trial of a multilevel evidence-based quality improvement approach to tailoring VA Patient Aligned Care Teams to the needs of women Veterans

BACKGROUND

The Veterans Health Administration (VA) has undertaken a major initiative to transform care through implementation of Patient Aligned Care Teams (PACTs). Based on the patient-centered medical home (PCMH) concept, PACT aims to improve access, continuity, coordination, and comprehensiveness using team-based care that is patient-driven and patient-centered. However, how VA should adapt PACT to meet the needs of special populations, such as women Veterans (WVs), was not considered in initial implementation guidance. WVs' numerical minority in VA healthcare settings (approximately 7-8 % of users) creates logistical challenges to delivering gender-sensitive comprehensive care. The main goal of this study is to test an evidence-based quality improvement approach (EBQI) to tailoring PACT to meet the needs of WVs, incorporating comprehensive primary care services and gender-specific care in gender-sensitive environments, thereby accelerating achievement of PACT tenets for women (Women's Health (WH)-PACT).

METHODS/DESIGN

EBQI is a systematic approach to developing a multilevel research-clinical partnership that engages senior organizational leaders and local quality improvement (QI) teams in adapting and implementing new care models in the context of prior evidence and local practice conditions, with researchers providing technical support, formative feedback, and practice facilitation. In a 12-site cluster randomized trial, we will evaluate WH-PACT model achievement using patient, provider, staff, and practice surveys, in addition to analyses of secondary administrative and chart-based data. We will explore impacts of receipt of WH-PACT care on quality of chronic disease care and prevention, health status, patient satisfaction and experience of care, provider experience, utilization, and costs. Using mixed methods, we will assess pre-post practice contexts; document EBQI activities undertaken in participating facilities and their relationship to provider/staff and team actions/attitudes; document WH-PACT implementation; and examine barriers/facilitators to EBQI-supported WH-PACT implementation through a combination of semi-structured interviews and monthly formative progress narratives and administrative data.

DISCUSSION

Lack of gender-sensitive comprehensive care has demonstrated consequences for the technical quality and ratings of care among WVs and may contribute to decisions to continue use or seek care elsewhere under the US Affordable Care Act. We hypothesize that tailoring PACT implementation through EBQI may improve the experience and quality of care at many levels.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02039856.

Racial and Ethnic Health Care Disparities Among Women in the Veterans Affairs Healthcare System: A Systematic Review

BACKGROUND

Women are a rapidly growing segment of patients who seek care in the Veterans Affairs (VA) Healthcare System, yet many questions regarding their health care experiences and outcomes remain unanswered. Racial and ethnic disparities have been well-documented in the general population and among veterans; however, prior disparities research conducted in the VA focused primarily on male veterans. We sought to characterize the findings and gaps in the literature on racial and ethnic disparities among women using the VA.

METHODS

We systematically reviewed the literature on racial and ethnic health care disparities exclusively among women using the VA Healthcare System. We included studies that examined health care use, satisfaction, and/or quality, and stratified data by race or ethnicity.

RESULTS

Nine studies of the 2,591 searched met our inclusion criteria. The included studies examined contraception provision/access (n = 3), treatment of low bone mass (n = 1), hormone therapy (n = 1), use of mental health or substance abuse-related services (n = 2), trauma exposure and use of various services (n = 1), and satisfaction with primary care (n = 1). Five of nine studies showed evidence of a significant racial or ethnic difference.

CONCLUSION

In contrast with the wealth of literature examining disparities both among the male veterans and women in non-VA settings, only nine studies examine racial and ethnic disparities specifically among women in the VA Healthcare System. These results demonstrate that there is an unmet need to further assess health care disparities among female VA users.

Binge Eating among Women Veterans in Primary Care: Comorbidities and Treatment Priorities

BACKGROUND

Little is known about the clinical profile and treatment priorities of women with binge eating disorder (BED), a diagnosis new to the fifth edition of Diagnostic and Statistical Manual of Mental Disorders. We identified comorbidities and patients' treatment priorities, because these may inform implementation of clinical services.

METHODS

Data were collected from women veteran primary care patients. Analyses compared those who screened positive for BED (BED+), and those without any binge eating symptoms (BED-).

RESULTS

Frequencies of comorbid medical and psychological disorders were high in the BED+ group. The BED+ group's self-identified most common treatment priorities were mood concerns (72.2%), weight loss (66.7%), and body image/food issues (50%). Among those with obesity, a greater proportion of the BED+ group indicated body image/food issues was their top treatment priority (12.9% vs. 2.8%; p < .01), suggesting that these patients may be more apt to seek treatment beyond weight management for their problematic eating patterns.

CONCLUSIONS

Women primary care patients with BED demonstrate high medical and psychological complexity; their subjective treatment priorities often match objective needs. These findings may inform the development of targeted BED screening practices for women with obesity in primary care settings, and the eventual adoption of patient-centered BED treatment resources.

Effectiveness of an Evidence-Based Quality Improvement Approach to Cultural Competence Training: The Veterans Affairs' "Caring for Women Veterans" Program

INTRODUCTION

Although providing culturally sensitive health care is vitally important, there is little consensus regarding the most effective strategy for implementing cultural competence trainings in the health care setting. Evidence-based quality improvement (EBQI), which involves adapting evidence-based practices to meet local needs, may improve uptake and effectiveness of a variety of health care innovations. Yet, to our knowledge, EBQI has not yet been applied to cultural competence training. To evaluate whether EBQI could enhance the impact of an evidence-based training intended to improve veterans affairs health care staff gender sensitivity and knowledge (Caring for Women Veterans; CWV), we compared the reach and effectiveness of EBQI delivery versus standard web-based implementation strategies of CWV and assessed barriers and facilitators to EBQI implementation.

METHODS

Workgroups at four diverse veterans affairs health care sites were randomized to either an EBQI or standard web-based implementation condition (SI). All EBQI sites selected a group-based implementation strategy. Employees (N = 84) completed pretraining and posttraining assessments of gender sensitivity and knowledge, and focus groups/interviews were conducted with leadership and staff before and after implementation.

RESULTS

Reach of CWV was greater in the EBQI condition versus the SI condition. Whereas both gender sensitivity and knowledge improved in the EBQI condition, only gender sensitivity improved in the SI condition. Qualitative analyses revealed that the EBQI approach was well received, although a number of barriers were identified.

DISCUSSION

Findings suggest that EBQI can enhance the uptake and effectiveness of employee trainings. However, the decision to pursue EBQI must be informed by a consideration of available resources.

Patient-centered mental health care for female veterans

OBJECTIVE

Mental health services for women vary widely across the Veterans Health Administration (VHA) system, without consensus on the need for, or organization of, specialized services for women. Understanding women's needs and priorities is essential to guide the implementation of patient-centered behavioral health services.

METHODS

In a cross-sectional, multisite survey of female veterans using primary care, potential stakeholders were identified for VHA mental health services by assessing perceived or observed need for mental health services. These stakeholders (N=484) ranked priorities for mental health care among a wide range of possible services. The investigators then quantified the importance of having designated women's mental health services for each of the mental health services that emerged as key priorities.

RESULTS

Treatment for depression, pain management, coping with chronic general medical conditions, sleep problems, weight management, and posttraumatic stress disorder (PTSD) emerged as women's key priorities. Having mental health services specialized for women was rated as extremely important to substantial proportions of women for each of the six prioritized services. Preference for primary care colocation was strongly associated with higher importance ratings for designated women's mental health services. For specific types of services, race, ethnicity, sexual orientation, PTSD symptoms, and psychiatric comorbidity were also associated with higher importance ratings for designated women's services.

CONCLUSIONS

Female veterans are a diverse population whose needs and preferences for mental health services vary along demographic and clinical factors. These stakeholder perspectives can help prioritize structural and clinical aspects of designated women's mental health care in the VHA.

Design of VA Cooperative Study #591: CERV-PTSD, comparative effectiveness research in veterans with PTSD

CERV-PTSD is a randomized controlled trial of two of the most effective treatments for PTSD, Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT). Despite solid evidence that both treatments are effective, there is limited evidence about their effectiveness relative to one another. The primary objective is to compare the effectiveness of PE and CPT for reducing PTSD symptom severity in a healthcare system that offers both treatments. The secondary objective is to compare the effectiveness of PE and CPT for reducing the severity of comorbid mental health problems and service utilization as well as improving functioning and quality of life. The tertiary objective is to examine whether discrepancy between patient preferences and treatment assignment reduces the effectiveness of each treatment. Exploratory analyses will examine whether demographic and clinical characteristics predict differential response to PE and CPT. The study is designed to randomize 900 male and female veterans with PTSD due to any traumatic military event to receive PE or CPT. The standard dose of treatment is 12 weekly sessions but veterans who improve more rapidly may finish in fewer sessions and veterans who improve more slowly may have additional sessions. The primary outcome is improvement in PTSD symptoms, measured during and after treatment and then 3 and 6 months later. As a large multi-site trial with men and women, CERV-PTSD is designed to advance the delivery of care for PTSD by providing conclusive information about whether one treatment is better than the other, overall, and for different types of patients.

Improving care of chronic conditions for women veterans: identifying opportunities for comparative effectiveness research

This article aims to critically analyze research focused on the findings for five chronic conditions: chronic pain, diabetes, cardiovascular disease, HIV and cancer among women veterans to identify opportunities for comparative effectiveness research. We provide a descriptive analysis from the relevant articles in prior systematic reviews. In order to identify potential gaps in research for these specific conditions, we also conducted a literature search to highlight studies focusing on women veterans published since the last systematic review. While the scientific knowledge base has grown for these chronic conditions among women veterans, the vast majority of the published literature remains descriptive and/or observational, with only a few studies examining gender differences and even fewer clinical trials. There is a need to conduct comparative effectiveness research on chronic conditions among women veterans to improve health and healthcare.

Guidance for research-practice partnerships (R-PPs) and collaborative research

PURPOSE

The purpose of this paper is to provide evidence based guidance to researchers and practice personnel about forming and carrying out effective research partnerships.

DESIGN/METHODOLOGY/APPROACH

A review of the literature, interviews and discussions with colleagues in both research and practice roles, and a review of the authors' personal experiences as researchers in partnership research.

FINDINGS

Partnership research is, in some respects, a distinct "approach" to research, but there are many different versions. An analysis of research publications and of their research experience led the authors to develop a framework for planning and assessing the partnership research process, which includes defining expected outcomes for the partners, their roles, and steps in the research process.

PRACTICAL IMPLICATIONS

This review and analysis provides guidance that may reduce commonly-reported misunderstandings and help to plan more successful partnerships and projects. It also identifies future research which is needed to define more precisely the questions and purposes for which partnership research is most appropriate, and methods and designs for specific types of partnership research.

ORIGINALITY/VALUE

As more research moves towards increased participation of practitioners and patients in the research process, more precise and differentiated understanding of the different partnership approaches is required, and when each is most suitable. This article describes research approaches that have the potential to reduce "the research-practice gap". It gives evidence- and experience-based guidance for choosing and establishing a partnership research process, so as to improve partnership relationship-building and more actionable research.