@Article{info:doi/10.2196/67673,
author="Little, R. Jeanette
and Rivera-Nichols, Triana
and Pavliscsak, H. Holly
and Badawi, Omar
and Gaudaen, C. James
and Yeoman, R. Chevas
and Hall, S. Todd
and Quist, T. Ethan
and Stoor-Burning, L. Ericka",
title="Demonstrating Tactical Combat Casualty Care in Simulated Environments to Enable Passive, Autonomous Documentation: Protocol for a Prospective Simulation-Based Study",
journal="JMIR Res Protoc",
year="2025",
month="Mar",
day="17",
volume="14",
pages="e67673",
keywords="tactical combat casualty care",
keywords="TCCC, automation",
keywords="medical documentation",
keywords="DD form 1380",
keywords="combat casualty care",
keywords="artificial intelligence",
keywords="AI",
keywords="machine learning",
keywords="ML",
keywords="point of injury",
keywords="POI",
keywords="simulation",
keywords="military health",
keywords="passive data collection",
keywords="sensors",
keywords="algorithms",
keywords="medical record",
abstract="Background: The Telemedicine \& Advanced Technology Research Center (TATRC) commenced a new research portfolio specifically addressing Autonomous Casualty Care (AC2) in 2023. The first project within this portfolio addresses the current and historical challenges of capturing tactical combat casualty care (TCCC) data in operational settings. Objective: The initial autonomous casualty care effort, the Passive Data Collection using Autonomous Documentation research project, conducts systematic, simulated patient and casualty care scenarios, leveraging suites of passive sensor inputs to populate a data repository that will automate future combat care. Methods: To obtain the required datasets, TATRC will engage care provider participants who provided consent in one of 6 randomized simulated TCCC scenarios leveraging an institutional review board--approved office protocol (\#M-11057). These simulations will leverage mannikins (low and high fidelity) and live simulated patients (eg, human actors who provided consent). All consenting participants (eg, both the care providers and live simulated patients) will be equipped with suites of sensors that will passively collect data on care delivery actions and patient physiology. Simulated data is being collected at Fort Detrick, Maryland; Fort Sam Houston, Texas; Fort Indiantown Gap, Pennsylvania; Fort Liberty, North Carolina; and a commercial site in Greenville, North Carolina. Results: Across all research locations, TATRC will collect and annotate approximately 2500 simulation procedures tasks by March 2025. These study data will generate the first machine learning and artificial intelligence algorithms to populate Department of Defense (DD) Form 1380 fields accurately and reliably. Additional data collected past March 2025 will be used to continue to refine and mature the algorithm. Conclusions: The military health care system (MHS) lacks real-world datasets for TCCC care at the point of injury. Developing a data repository of simulated TCCC data is required as an essential step toward automating TCCC care. If TATRC's research efforts result in the ability to automate care delivery documentation, this will alleviate the cognitive burden of TCCC care providers in austere, chaotic environments. By generating a TCCC data repository through this Autonomous Documentation research project, TATRC will have opportunities to leverage this research data to create machine learning and artificial intelligence models to advance passive, automated medical documentation across the health care continuum. International Registered Report Identifier (IRRID): DERR1-10.2196/67673 ",
doi="10.2196/67673",
url="https://www.researchprotocols.org/2025/1/e67673"
}


@Article{info:doi/10.2196/60868,
author="Alichniewicz, Katarzyna Karolina
and Hampton, Sarah
and Romaniuk, Madeline
and Bennett, Darcy
and Guindalini, Camila",
title="Use of Go-Beyond as a Self-Directed Internet-Based Program Supporting Veterans' Transition to Civilian Life: Preliminary Usability Study",
journal="JMIR Form Res",
year="2025",
month="Jan",
day="23",
volume="9",
pages="e60868",
keywords="military transition",
keywords="web-based interventions",
keywords="military-civilian adjustment",
keywords="Go-Beyond",
keywords="internet-based program",
keywords="civilian",
keywords="military service",
keywords="veteran",
keywords="premilitary life",
keywords="mental health issues",
keywords="physical injuries",
keywords="adoption",
keywords="quantitative analysis",
keywords="survey",
keywords="family",
keywords="support",
keywords="digital technology",
keywords="user engagement",
keywords="effectiveness",
keywords="assessment",
abstract="Background: The transition from military service to civilian life presents a variety of challenges for veterans, influenced by individual factors such as premilitary life, length of service, and deployment history. Mental health issues, physical injuries, difficulties in relationships, and identity loss compound the reintegration process. To address these challenges, various face-to-face and internet-based programs are available yet underused. This paper presents the preliminary evaluation of ``Go-Beyond, Navigating Life Beyond Service,'' an internet-based psychoeducational program for veterans. Objective: The study aims to identify the reach, adoption, and engagement with the program and to generate future recommendations to enhance its overall impact. Methods: This study exclusively used data that were automatically and routinely collected from the start of the Go-Beyond program's launch on May 24, 2021, until May 7, 2023. When accessing the Go-Beyond website, veterans were asked to complete the Military-Civilian Adjustment and Reintegration Measure (M-CARM) questionnaire, which produces a unique M-CARM profile of results specifying potential areas of need on the 5 domains of the measure. Users were then automatically allocated to Go-Beyond modules that aligned with their M-CARM profile. Additionally, quantitative and qualitative data were collected from a survey on aesthetics, interactivity, user journey, and user experience, which was optional for users to complete at the end of each module. Results: Results show a conversion rate of 28.5\% (273/959) from the M-CARM survey to the Go-Beyond program. This rate is notably higher compared with similar internet-based self-help programs, such as VetChange (1033/22,087, 4.7\%) and resources for gambling behavior (5652/8083, 14\%), but lower than the MoodGYM program (82,159/194,840, 42.2\%). However, these comparisons should be interpreted with caution due to the limited availability of published conversion rates and varying definitions of uptake and adoption across studies. Additionally, individuals were 1.64 (95\% CI 1.17-2.28) more likely to enroll when they express a need in Purpose and Connection, and they were 1.50 (95\% CI 1.06-2.18) times more likely to enroll when they express the need Beliefs About Civilians, compared with those without these needs. The overall completion rate for the program was 31\% (85/273) and modules' individual completion rates varied from 8.4\% (17/203) to 20\% (41/206). Feedback survey revealed high overall user satisfaction with Go-Beyond, emphasizing its engaging content and user-friendly modules. Notably, 94\% (88/94) of survey respondents indicated they would recommend the program to other veterans, family, or friends. Conclusions: The Go-Beyond program may offer promising support for veterans transitioning to civilian life through digital technology. Our study reveals insights on user engagement and adoption, emphasizing the need for ongoing evaluation to further address the diverse needs of military personnel. Future research should explore predictors of engagement, the addition of peer or facilitator support, and the use of outcome measures for effectiveness assessment. ",
doi="10.2196/60868",
url="https://formative.jmir.org/2025/1/e60868",
url="http://www.ncbi.nlm.nih.gov/pubmed/39847427"
}


@Article{info:doi/10.2196/64412,
author="Hernandez, Belinda
and Shegog, Ross
and Markham, Christine
and Emery, Susan
and Baumler, Elizabeth
and Thormaehlen, Laura
and Andina Teixeira, Rejane
and Rivera, Yanneth
and Pertuit, Olive
and Kanipe, Chelsey
and Witherspoon, Iraina
and Doss, Janis
and Jones, Victor
and Peskin, Melissa",
title="Short-Term Outcomes of a Healthy Relationship Intervention for the Prevention of Sexual Harassment and Sexual Assault in the US Military: Pilot Pretest-Postest Study",
journal="JMIR Form Res",
year="2024",
month="Oct",
day="29",
volume="8",
pages="e64412",
keywords="sexual assault prevention",
keywords="sexual harassment prevention",
keywords="healthy relationships",
keywords="military",
keywords="technology-based interventions",
keywords="intervention mapping",
abstract="Background: Sexual harassment (SH) and sexual assault (SA) are serious public health problems among US service members. Few SH and SA prevention interventions have been developed exclusively for the military. Code of Respect (X-CoRe) is an innovative web-based, multilevel, SA and SH intervention designed exclusively for the active-duty Air Force. The program's goal is to increase Airmen's knowledge and skills to build and maintain respectful relationships, ultimately reducing SH and SA and enhancing Airmen's overall well-being and mission readiness. Objective: This pilot study aimed to assess the short-term psychosocial impact (eg, knowledge, attitudes, and self-efficacy) of the web-based component of X-CoRe on a sample of junior enlisted and midlevel Airmen. Methods: Airmen from a military installation located in the Northeastern United States were recruited to complete the 10 web-based modules in X-CoRe (9/15, 60\% male; 7/15, 54\% aged 30-35 years). Participants were given pretests and posttests to measure short-term psychosocial outcomes associated with SH and SA. Descriptive statistics and paired 2-tailed t tests were conducted to assess differences from preintervention to postintervention time points. Results: After completing X-CoRe, participants had a significantly greater understanding of active consent (P=.04), confidence in their healthy relationship skills (P=.045), and confidence to intervene as bystanders (P=.01). Although not statistically significant (P>.05), mean scores in attitudes about SH, couple violence, and cyberbullying; perceptions of sexual misconduct as part of military life; and relationship skills self-efficacy with a romantic partner and friend also improved. Conclusions: The findings from this study demonstrate X-CoRe's effectiveness in improving critical determinants of SH and SA, making it a promising intervention for SH and SA prevention. More rigorous research is needed to determine X-CoRe's impact on SH and SA victimization and the long-term impact on associated psychosocial determinants. ",
doi="10.2196/64412",
url="https://formative.jmir.org/2024/1/e64412"
}


@Article{info:doi/10.2196/63390,
author="Stathakarou, Natalia
and Kononowicz, A. Andrzej
and Mattsson, Erik
and Karlgren, Klas",
title="Gamification in the Design of Virtual Patients for Swedish Military Medics to Support Trauma Training: Interaction Analysis and Semistructured Interview Study",
journal="JMIR Serious Games",
year="2024",
month="Oct",
day="22",
volume="12",
pages="e63390",
keywords="military trauma",
keywords="gamification",
keywords="game elements",
keywords="serious games",
keywords="virtual patients",
keywords="trauma",
keywords="medical training",
keywords="medical education",
keywords="medical assessment",
keywords="emergency care",
keywords="first aid",
keywords="basic life support",
keywords="trauma care",
keywords="medics",
keywords="military",
abstract="Background: This study explores gamification in the design of virtual patients (VPs) to enhance the training of Swedish military medics in trauma care. The challenges related to prehospital trauma care faced on the battlefield require tailored educational tools that support military medics' education and training. Objective: The aim of the study is to investigate how to design VPs with game elements for Swedish military medics to support learning in military trauma care. By understanding the reasoning and perceptions of military medics when interacting with VPs, this study aims to provide insights and recommendations for designing VPs with game elements that are specifically tailored to their needs. Methods: The study involved 14 Swedish military medics of the Home Guard--National Security Forces participating in a tactical combat care course. Participants interacted with 3 different VP cases designed to simulate military trauma scenarios. Data were collected through think-aloud sessions and semistructured interviews. The data were analyzed using interaction analysis, structured by the unawareness, problem identification, explanation, and alternative strategies or solutions (uPEA) framework, and reflexive thematic analysis to explore participants' reasoning processes and perceptions and identify possible game elements to inform the VP design. Results: Mapping the military medics' reasoning to the uPEA framework revealed that study participants became more creative after making a mistake followed by feedback and after receiving a prompt to make a new decision. The thematic analysis revealed 6 themes: motivation, ``keep on trying''; agency in interaction with VPs; realistic tactical experience; confidence, ``I know that the knowledge I have works''; social influence on motivation; and personalized learning. Participants suggested that game elements such as scoring; badges; virtual goods; progress bars; performance tables; content unlocking; hints; challenge; control; imposed choice; narrative; avatars; sensation; randomness; difficulty adapting; competition; leaderboards; social pressure; progression; and renovation can promote engagement, motivation, and support confidence in decision-making. Conclusions: Gamification in the design of VPs represents a promising approach to military medical training, offering a platform for medics to practice medical and tactical decision-making in a risk-free environment. The insights gained by the study may encourage designing VPs with game elements, as well as including possibly wrong decisions, their consequences, and relevant feedback, that may support military medics' reflections and decision-making. ",
doi="10.2196/63390",
url="https://games.jmir.org/2024/1/e63390",
url="http://www.ncbi.nlm.nih.gov/pubmed/39436692"
}


@Article{info:doi/10.2196/58740,
author="Chen, Qi
and Qin, Yuchen
and Jin, Zhichao
and Zhao, Xinxin
and He, Jia
and Wu, Cheng
and Tang, Bihan",
title="Enhancing Performance of the National Field Triage Guidelines Using Machine Learning: Development of a Prehospital Triage Model to Predict Severe Trauma",
journal="J Med Internet Res",
year="2024",
month="Sep",
day="30",
volume="26",
pages="e58740",
keywords="severe trauma",
keywords="field triage",
keywords="machine learning",
keywords="prediction model",
abstract="Background: Prehospital trauma triage is essential to get the right patient to the right hospital. However, the national field triage guidelines proposed by the American College of Surgeons have proven to be relatively insensitive when identifying severe traumas. Objective: This study aimed to build a prehospital triage model to predict severe trauma and enhance the performance of the national field triage guidelines. Methods: This was a multisite prediction study, and the data were extracted from the National Trauma Data Bank between 2017 and 2019. All patients with injury, aged 16 years of age or older, and transported by ambulance from the injury scene to any trauma center were potentially eligible. The data were divided into training, internal, and external validation sets of 672,309; 288,134; and 508,703 patients, respectively. As the national field triage guidelines recommended, age, 7 vital signs, and 8 injury patterns at the prehospital stage were included as candidate variables for model development. Outcomes were severe trauma with an Injured Severity Score ?16 (primary) and critical resource use within 24 hours of emergency department arrival (secondary). The triage model was developed using an extreme gradient boosting model and Shapley additive explanation analysis. The model's accuracy regarding discrimination, calibration, and clinical benefit was assessed. Results: At a fixed specificity of 0.5, the model showed a sensitivity of 0.799 (95\% CI 0.797-0.801), an undertriage rate of 0.080 (95\% CI 0.079-0.081), and an overtriage rate of 0.743 (95\% CI 0.742-0.743) for predicting severe trauma. The model showed a sensitivity of 0.774 (95\% CI 0.772-0.776), an undertriage rate of 0.158 (95\% CI 0.157-0.159), and an overtriage rate of 0.609 (95\% CI 0.608-0.609) when predicting critical resource use, fixed at 0.5 specificity. The triage model's areas under the curve were 0.755 (95\% CI 0.753-0.757) for severe trauma prediction and 0.736 (95\% CI 0.734-0.737) for critical resource use prediction. The triage model's performance was better than those of the Glasgow Coma Score, Prehospital Index, revised trauma score, and the 2011 national field triage guidelines RED criteria. The model's performance was consistent in the 2 validation sets. Conclusions: The prehospital triage model is promising for predicting severe trauma and achieving an undertriage rate of <10\%. Moreover, machine learning enhances the performance of field triage guidelines. ",
doi="10.2196/58740",
url="https://www.jmir.org/2024/1/e58740"
}


@Article{info:doi/10.2196/50817,
author="Zhu, Siyue
and Li, Zenan
and Sun, Ying
and Kong, Linghui
and Yin, Ming
and Yong, Qinge
and Gao, Yuan",
title="A Serious Game for Enhancing Rescue Reasoning Skills in Tactical Combat Casualty Care: Development and Deployment Study",
journal="JMIR Form Res",
year="2024",
month="Aug",
day="12",
volume="8",
pages="e50817",
keywords="combat casualty care",
keywords="simulation training",
keywords="medical service support",
keywords="virtual reality",
keywords="military exercise",
keywords="medical education",
abstract="Background: Serious games (SGs) have emerged as engaging and instructional digital simulation tools that are increasingly being used for military medical training. SGs are often compared with traditional media in terms of learning outcomes, but it remains unclear which of the 2 options is more efficient and better accepted in the process of knowledge acquisition. Objective: This study aimed to create and test a scenario-based system suitable for enhancing rescue reasoning skills in tactical combat casualty care. Methods: To evaluate the effectiveness of the SGs, a randomized, observational, comparative trial was conducted. A total of 148 members from mobile medical logistics teams were recruited for training. Pre- and posttraining assessments were conducted using 2 different formats: a video-based online course (n=78) and a game simulation (n=70). We designed 3 evaluation instruments based on the first 2 levels of the Kirkpatrick model (reaction and learning) to measure trainees' satisfaction, knowledge proficiency, and self-confidence. Results: There were 4 elements that made up the learning path for the SGs: microcourses (video-based online courses), self-test, game simulation, and record query. The knowledge test scores in both groups were significantly higher after the intervention (t154=--6.010 and t138=--7.867, respectively; P<.001). For 5 simulation cases, the average operation time was 13.6 (SD 3.3) minutes, and the average case score was 279.0 (SD 57.6) points (from a possible total of 500 points), with a score rate of only 44\% (222/500 points) to 67\% (336/500 points). The results indicated no significant difference in trainees' satisfaction between the 2 training methods (P=.04). However, the game simulation method outperformed the video-based online course in terms of learning proficiency (t146=--2.324, P=.02) and self-perception (t146=--5.492, P<.001). Conclusions: Despite the high satisfaction reported by trainees for both training methods, the game simulation approach demonstrated superior efficiency and acceptance in terms of knowledge acquisition, self-perception, and overall performance. The developed SG holds significant potential as an essential assessment tool for evaluating frontline rescue skills and rescue reasoning in mobile medical logistics teams. ",
doi="10.2196/50817",
url="https://formative.jmir.org/2024/1/e50817"
}


@Article{info:doi/10.2196/57146,
author="Baillie Abidi, Catherine
and Patten, San
and Houle, A. Stephanie
and Hoffer, Ken
and Reeves, Kathryn
and B{\'e}langer, St{\'e}phanie
and Nazarov, Anthony
and Wells, Samantha",
title="Canadian Armed Forces Veterans' Perspectives on the Effects of Exposure to Children in Armed Conflict During Military Service: Protocol for a Qualitative Study",
journal="JMIR Res Protoc",
year="2024",
month="Jun",
day="14",
volume="13",
pages="e57146",
keywords="moral injury",
keywords="mental health",
keywords="Canadian Armed Forces Veterans",
keywords="children",
keywords="deployments",
keywords="conflicts",
keywords="military culture",
keywords="trauma-informed research",
keywords="people-centered research",
keywords="participatory action research",
abstract="Background: The mental health of military personnel has garnered increased attention over the last few decades; however, the impacts of perpetuating, observing, or failing to prevent acts that transgress deeply held moral standards, referred to as moral injuries, are less understood, particularly in relation to encounters with children during deployment. This paper describes a multiphased research protocol that centers around the lived experiences of Canadian Armed Forces (CAF) Veterans to understand how encounters with children during military deployments impact the well-being and mental health of military personnel. Objective: This study has four objectives: (1) highlight the lived experiences of CAF Veterans who encountered children during military deployments; (2) improve understanding of the nature of experiences that military personnel faced that related to observing or engaging with children during military service; (3) improve understanding of the mental health impacts of encountering children during military service; and (4) use participatory action research (PAR) to develop recommendations for improving preparation, training, and support for military personnel deployed to contexts where encounters with children are likely. Methods: The research project has 2 main phases where phase 1 includes qualitative interviews with CAF Veterans who encountered children during military deployments and phase 2 uses PAR to actively engage Canadian Veterans with lived experiences of encountering children during military deployments, as well as health professionals and researchers to identify recommendations to better address the mental health effects of these encounters. Results: As of January 26, 2024, a total of 55 participants and research partners have participated in the 2 phases of the research project. A total of 16 CAF Veterans participated in phase 1 (qualitative interviews), and 39 CAF Veterans, health professionals, and researchers participated in phase 2 (PAR). The results for phase 1 have been finalized and are accepted for publication. Data collection and analysis are ongoing for phase 2. Conclusions: Prioritizing and valuing the experiences of CAF Veterans has deepened our understanding of the intricate nature and impacts of potentially morally injurious events involving children during military deployments. Together with health professionals and researchers, the PAR approach empowers CAF Veterans to articulate important recommendations for developing and improving training and mental health support. This support is crucial not only during the deployment cycle but also throughout the military career, helping lessen the effects of moral injury among military personnel. International Registered Report Identifier (IRRID): DERR1-10.2196/57146 ",
doi="10.2196/57146",
url="https://www.researchprotocols.org/2024/1/e57146",
url="http://www.ncbi.nlm.nih.gov/pubmed/38874998"
}


@Article{info:doi/10.2196/44299,
author="Nazarov, Anthony
and Fikretoglu, Deniz
and Liu, Aihua
and Born, Jennifer
and Michaud, Kathy
and Hendriks, Tonya
and B{\'e}langer, AH St{\'e}phanie
and Do, T. Minh
and Lam, Quan
and Brooks, Brenda
and King, Kristen
and Sudom, Kerry
and Jetly, Rakesh
and Garber, Bryan
and Thompson, Megan",
title="Moral Distress, Mental Health, and Risk and Resilience Factors Among Military Personnel Deployed to Long-Term Care Facilities During the COVID-19 Pandemic: Research Protocol and Participation Metrics",
journal="JMIR Res Protoc",
year="2023",
month="Nov",
day="6",
volume="12",
pages="e44299",
keywords="mental health",
keywords="military",
keywords="Canadian Armed Forces",
keywords="operational organization",
keywords="logistics support",
keywords="health care",
keywords="moral distress",
keywords="moral injury",
keywords="deployment",
keywords="risk factors",
keywords="COVID-19",
keywords="quarantine",
keywords="readiness",
keywords="well-being",
keywords="resilience",
keywords="long-term care facility",
keywords="centre de soins de longue dur{\'e}e",
keywords="survey",
keywords="older adult",
keywords="qualitative interviews",
keywords="quantitative",
abstract="Background: The earliest days of the COVID-19 pandemic in Canada were marked by a significant surge in COVID-19 cases and COVID-19--related deaths among residents of long-term care facilities (LTCFs). As part of Canada's response to the COVID-19 pandemic, Canadian Armed Forces (CAF) personnel were mobilized for an initial emergency domestic deployment to the hardest-hit LTCFs (Operation LASER LTCF) to support the remaining civilian staff in ensuring the continued delivery of care to residents. Akin to what was observed following past CAF international humanitarian missions, there was an expected increased risk of exposure to multiple stressors that may be psychologically traumatic and potentially morally injurious in nature (ie, related to core values, eg, witnessing human suffering). Emerging data from health care workers exposed to the unprecedented medical challenges and dilemmas of the early pandemic stages also indicated that such experiences were associated with increased risk of adverse mental health outcomes. Objective: This study aims to identify and quantify the individual-, group-, and organizational-level risk and resilience factors associated with moral distress, moral injury, and traditional mental health and well-being outcomes of Operation LASER LTCF CAF personnel. This paper aimed to document the methodology, implementation procedures, and participation metrics. Methods: A multimethod research initiative was conducted consisting of 2 primary data collection studies (a quantitative survey and qualitative interviews). The quantitative arm was a complete enumeration survey with web-based, self-report questionnaires administered at 3 time points (3, 6, and 12 mo after deployment). The qualitative arm consisted of individual, web-based interviews with a focus on understanding the nuanced lived experiences of individuals participating in the Operation LASER LTCF deployment. Results: CAF personnel deployed to Operation LASER LTCF (N=2595) were invited to participate in the study. Data collection is now complete. Overall, of the 2595 deployed personnel, 1088 (41.93\%), 582 (22.43\%), and 497 (19.15\%) responded to the survey at time point 1 (3 mo), time point 2 (6 mo), and time point 3 (12 mo) after deployment, respectively. The target sample size for the qualitative interviews was set at approximately 50 considering resourcing and data saturation. Interest in participating in qualitative interviews surpassed expectations, with >200 individuals expressing interest; this allowed for purposive sampling across key characteristics, including gender, rank, Operation LASER LTCF role, and province. In total, 53 interviews were conducted. Conclusions: The data generated through this research have the potential to inform and promote better understanding of the well-being and mental health of Operation LASER LTCF personnel over time; identify general and Operation LASER LTCF--specific risk and protective factors; provide necessary support to the military personnel who served in this mission; and inform preparation and interventions for future missions, especially those more domestic and humanitarian in nature. International Registered Report Identifier (IRRID): DERR1-10.2196/44299 ",
doi="10.2196/44299",
url="https://www.researchprotocols.org/2023/1/e44299",
url="http://www.ncbi.nlm.nih.gov/pubmed/37676877"
}


@Article{info:doi/10.2196/42803,
author="Rawat, Singh Bhanu Pratap
and Reisman, Joel
and Pogoda, K. Terri
and Liu, Weisong
and Rongali, Subendhu
and Aseltine Jr, H. Robert
and Chen, Kun
and Tsai, Jack
and Berlowitz, Dan
and Yu, Hong
and Carlson, F. Kathleen",
title="Intentional Self-Harm Among US Veterans With Traumatic Brain Injury or Posttraumatic Stress Disorder: Retrospective Cohort Study From 2008 to 2017",
journal="JMIR Public Health Surveill",
year="2023",
month="Jul",
day="24",
volume="9",
pages="e42803",
keywords="self-harm",
keywords="suicide",
keywords="suicide attempt",
keywords="suicidal ideation",
keywords="veteran",
keywords="suicidal",
keywords="brain injury",
keywords="trauma",
keywords="posttraumatic stress disorder",
keywords="PTSD",
keywords="big data",
keywords="prevalence",
keywords="correlation",
keywords="risk factor",
keywords="traumatic brain injury",
keywords="TBI",
abstract="Background: Veterans with a history of traumatic brain injury (TBI) and/or posttraumatic stress disorder (PTSD) may be at increased risk of suicide attempts and other forms of intentional self-harm as compared to veterans without TBI or PTSD. Objective: Using administrative data from the US Veterans Health Administration (VHA), we studied associations between TBI and PTSD diagnoses, and subsequent diagnoses of intentional self-harm among US veterans who used VHA health care between 2008 and 2017. Methods: All veterans with encounters or hospitalizations for intentional self-harm were assigned ``index dates'' corresponding to the date of the first related visit; among those without intentional self-harm, we randomly selected a date from among the veteran's health care encounters to match the distribution of case index dates over the 10-year period. We then examined the prevalence of TBI and PTSD diagnoses within the 5-year period prior to veterans' index dates. TBI, PTSD, and intentional self-harm were identified using International Classification of Diseases diagnosis and external cause of injury codes from inpatient and outpatient VHA encounters. We stratified analyses by veterans' average yearly VHA utilization in the 5-year period before their index date (low, medium, or high). Variations in prevalence and odds of intentional self-harm diagnoses were compared by veterans' prior TBI and PTSD diagnosis status (TBI only, PTSD only, and comorbid TBI/PTSD) for each VHA utilization stratum. Multivariable models adjusted for age, sex, race, ethnicity, marital status, Department of Veterans Affairs service-connection status, and Charlson Comorbidity Index scores. Results: About 6.7 million veterans with at least two VHA visits in the 5-year period before their index dates were included in the analyses; 86,644 had at least one intentional self-harm diagnosis during the study period. During the periods prior to veterans' index dates, 93,866 were diagnosed with TBI only; 892,420 with PTSD only; and 102,549 with comorbid TBI/PTSD. Across all three VHA utilization strata, the prevalence of intentional self-harm diagnoses was higher among veterans diagnosed with TBI, PTSD, or TBI/PTSD than among veterans with neither diagnosis. The observed difference was most pronounced among veterans in the high VHA utilization stratum. The prevalence of intentional self-harm was six times higher among those with comorbid TBI/PTSD (6778/58,295, 11.63\%) than among veterans with neither TBI nor PTSD (21,979/1,144,991, 1.92\%). Adjusted odds ratios suggested that, after accounting for potential confounders, veterans with TBI, PTSD, or comorbid TBI/PTSD had higher odds of self-harm compared to veterans without these diagnoses. Among veterans with high VHA utilization, those with comorbid TBI/PTSD were 4.26 (95\% CI 4.15-4.38) times more likely to receive diagnoses for intentional self-harm than veterans with neither diagnosis. This pattern was similar for veterans with low and medium VHA utilization. Conclusions: Veterans with TBI and/or PTSD diagnoses, compared to those with neither diagnosis, were substantially more likely to be subsequently diagnosed with intentional self-harm between 2008 and 2017. These associations were most pronounced among veterans who used VHA health care most frequently. These findings suggest a need for suicide prevention efforts targeted at veterans with these diagnoses. ",
doi="10.2196/42803",
url="https://publichealth.jmir.org/2023/1/e42803",
url="http://www.ncbi.nlm.nih.gov/pubmed/37486751"
}


@Article{info:doi/10.2196/35318,
author="Martindale-Adams, Lynn Jennifer
and Clark, Davis Carolyn
and Martin, Roxy Jessica
and Henderson, Richard Charles
and Nichols, Olivia Linda",
title="Text Messages to Support Caregivers in a Health Care System: Development and Pilot and National Rollout Evaluation",
journal="J Particip Med",
year="2022",
month="Oct",
day="17",
volume="14",
number="1",
pages="e35318",
keywords="mobile health",
keywords="mHealth",
keywords="self-care",
keywords="veterans",
keywords="family caregivers",
keywords="emotional stress",
keywords="burden of illness",
keywords="self-efficacy",
keywords="mobile phone",
abstract="Background: Although there are many interventions to support caregivers, SMS text messaging has not been used widely. Objective: In this paper, we aimed to describe development of the Department of Veterans Affairs (VA) Annie Stress Management SMS text messaging protocol for caregivers of veterans, its pilot test, and subsequent national rollout. Methods: The stress management protocol was developed with text messages focusing on education, motivation, and stress-alleviating activities based on the Resources for Enhancing All Caregivers Health (REACH) VA caregiver intervention. This protocol was then tested in a pilot study. On the basis of the pilot study results, a national rollout of the protocol was executed and evaluated. Caregivers were referred from VA facilities nationally for the pilot and national rollout. Pilot caregivers were interviewed by telephone; national rollout caregivers were sent a web-based evaluation link at 6 months. For both evaluations, questions were scored on a Likert scale ranging from completely disagree to completely agree. For both the pilot and national rollout, quantitative data were analyzed with frequencies and means; themes were identified from open-ended qualitative responses. Results: Of the 22 caregivers in the pilot study, 18 (82\%) provided follow-up data. On a 5-point scale, they reported text messages had been useful in managing stress (mean score 3.8, SD 1.1), helping them take care of themselves (mean score 3.7, SD 1.3), and making them feel cared for (mean score 4.1, SD 1.7). Texts were easy to read (mean score 4.5, SD 1.2), did not come at awkward times (mean score 2.2, SD 1.4), were not confusing (mean score 1.1, SD 0.2), and did not cause problems in responding (mean score 1.9, 1.1); however, 83\% (15/18) of caregivers did not want to request an activity when stressed. Consequently, the national protocol did not require caregivers to respond. In the national rollout, 22.17\% (781/3522) of the eligible caregivers answered the web-based survey and reported that the messages had been useful in managing stress (mean score 4.3, SD 0.8), helping them take care of themselves (mean score 4.3, SD 0.8) and loved ones (mean score 4.2, SD 0.8), and making them feel cared for (mean score 4.5, SD 0.8). Almost two-thirds (509/778, 65.4\%) of the participants tried all or most of the strategies. A total of 5 themes were identified. The messages were appreciated, helped with self-care, and made them feel less alone, looking on Annie as a friend. The caregivers reported that the messages were on target and came when they were most needed and did not want them to stop. This success has led to four additional caregiver texting protocols: bereavement, dementia behaviors and stress management, (posttraumatic stress disorder) PTSD behaviors, and taking care of you, with 7274 caregivers enrolled as of February 2022. Conclusions: Caregivers reported the messages made them feel cared for and more confident. SMS text messaging, which is incorporated into clinical settings and health care systems, may represent a low-cost way to provide useful and meaningful support to caregivers. ",
doi="10.2196/35318",
url="https://jopm.jmir.org/2022/1/e35318",
url="http://www.ncbi.nlm.nih.gov/pubmed/36251368"
}


@Article{info:doi/10.2196/30065,
author="Pearson, Rahel
and Carl, Emily
and Creech, K. Suzannah",
title="Computerized Psychological Interventions in Veterans and Service Members: Systematic Review of Randomized Controlled Trials",
journal="J Med Internet Res",
year="2022",
month="Jun",
day="3",
volume="24",
number="6",
pages="e30065",
keywords="computer",
keywords="digital",
keywords="internet",
keywords="interventions",
keywords="veterans",
keywords="service members",
keywords="review",
keywords="mobile phone",
abstract="Background: Computerized psychological interventions can overcome logistical and psychosocial barriers to the use of mental health care in the Veterans Affairs and Department of Defense settings. Objective: In this systematic review, we aim to outline the existing literature, with the goal of describing: the scope and quality of the available literature, intervention characteristics, study methods, study efficacy, and study limitations and potential directions for future research. Methods: Systematic searches of two databases (PsycINFO and PubMed) using PRISMA (Preferred Reporting Item for Systematic Reviews and Meta-Analyses) guidelines were conducted from inception until November 15, 2020. The following inclusion criteria were used: the study was published in an English language peer-reviewed journal, participants were randomly allocated to a computerized psychological intervention or a control group (non--computerized psychological intervention active treatment or nonactive control group), an intervention in at least one treatment arm was primarily delivered through the computer or internet with or without additional support, participants were veterans or service members, and the study used validated measures to examine the effect of treatment on psychological outcomes. Results: This review included 23 studies that met the predefined inclusion criteria. Most studies were at a high risk of bias. Targeted outcomes, participant characteristics, type of support delivered, adherence, and participant satisfaction were described. Most of the examined interventions (19/24, 79\%) yielded positive results. Study limitations included participant characteristics limiting study inference, high rates of attrition, and an overreliance on self-reported outcomes. Conclusions: Relatively few high-quality studies were identified, and more rigorous investigations are needed. Several recommendations for future research are discussed, including the adoption of methods that minimize attrition, optimize use, and allow for personalization of treatment. ",
doi="10.2196/30065",
url="https://www.jmir.org/2022/6/e30065",
url="http://www.ncbi.nlm.nih.gov/pubmed/35657663"
}


@Article{info:doi/10.2196/34984,
author="Forchuk, A. Callista
and Nazarov, Anthony
and Plouffe, A. Rachel
and Liu, W. Jenny J.
and Deda, Erisa
and Le, Tri
and Gargala, Dominic
and Soares, Vanessa
and Bourret-Gheysen, Jesse
and St Cyr, Kate
and Nouri, S. Maede
and Hosseiny, Fardous
and Smith, Patrick
and Dupuis, Gabrielle
and Roth, Maya
and Marlborough, Michelle
and Jetly, Rakesh
and Heber, Alexandra
and Lanius, Ruth
and Richardson, Don J.",
title="Well-being of Canadian Armed Forces Veterans and Spouses of Veterans During the COVID-19 Pandemic: Protocol for a Prospective Longitudinal Survey",
journal="JMIR Res Protoc",
year="2022",
month="Jan",
day="11",
volume="11",
number="1",
pages="e34984",
keywords="well-being",
keywords="mental health",
keywords="veterans",
keywords="military",
keywords="survey",
keywords="COVID-19",
keywords="protocol",
keywords="veteran",
keywords="physical health",
keywords="pandemic",
keywords="longitudinal survey",
keywords="healthcare",
keywords="treatment",
keywords="family support",
keywords="peer support",
abstract="Background: The COVID-19 pandemic has resulted in significant changes to everyday life, including social distancing mandates, changes to health care, and a heightened risk of infection. Previous research has shown that Canadian Armed Forces (CAF) veterans are at higher risk of developing mental and physical health conditions. Veterans and their families may face unique social challenges that can compound with pandemic-related disruptions to negatively impact well-being. Objective: This study aims to longitudinally characterize the mental health of CAF veterans and spouses of CAF veterans throughout the pandemic and to understand the dynamic influences of pandemic-related stressors on psychological health over time. Methods: We employed a prospective longitudinal panel design using an online data collection platform. Study participation was open to all CAF veterans and spouses of CAF veterans residing in Canada. Participants were asked to complete a comprehensive battery of assessments representing psychological well-being, chronic pain, health care access patterns, physical environment, employment, social integration, and adjustment to pandemic-related lifestyle changes. Follow-up assessments were conducted every 3 months over an 18-month period. This study was approved by the Western University Health Sciences and Lawson Health Research Institute Research Ethics Boards. Results: Baseline data were collected between July 2020 and February 2021. There were 3 population segments that participated in the study: 1047 veterans, 366 spouses of veterans, and 125 veterans who are also spouses of veterans completed baseline data collection. As of November 2021, data collection is ongoing, with participants completing the 9- or 12-month follow-up surveys depending on their date of self-enrollment. Data collection across all time points will be complete in September 2022. Conclusions: This longitudinal survey is unique in its comprehensive assessment of domains relevant to veterans and spouses of veterans during the COVID-19 pandemic, ranging from occupational, demographic, social, mental, and physical domains, to perceptions and experiences with health care treatments and access. The results of this study will be used to inform policy for veteran and veteran family support, and to best prepare for similar emergencies should they occur in the future. International Registered Report Identifier (IRRID): DERR1-10.2196/34984 ",
doi="10.2196/34984",
url="https://www.researchprotocols.org/2022/1/e34984",
url="http://www.ncbi.nlm.nih.gov/pubmed/34935624"
}


@Article{info:doi/10.2196/33873,
author="Andrade, Q. Andre
and Calabretto, Jean-Pierre
and Pratt, L. Nicole
and Kalisch-Ellett, M. Lisa
and Kassie, M. Gizat
and LeBlanc, T. Vanessa
and Ramsay, Emmae
and Roughead, E. Elizabeth",
title="Implementation and Evaluation of a Digitally Enabled Precision Public Health Intervention to Reduce Inappropriate Gabapentinoid Prescription: Cluster Randomized Controlled Trial",
journal="J Med Internet Res",
year="2022",
month="Jan",
day="10",
volume="24",
number="1",
pages="e33873",
keywords="audit and feedback",
keywords="digital health",
keywords="precision public health",
keywords="digital intervention",
keywords="primary care",
keywords="physician",
keywords="health professional",
keywords="health education",
abstract="Background: Digital technologies can enable rapid targeted delivery of audit and feedback interventions at scale. Few studies have evaluated how mode of delivery affects clinical professional behavior change and none have assessed the feasibility of such an initiative at a national scale. Objective: The aim of this study was to develop and evaluate the effect of audit and feedback by digital versus postal (letter) mode of delivery on primary care physician behavior. Methods: This study was developed as part of the Veterans' Medicines Advice and Therapeutics Education Services (MATES) program, an intervention funded by the Australian Government Department of Veterans' Affairs that provides targeted education and patient-specific audit with feedback to Australian general practitioners, as well as educational material to veterans and other health professionals. We performed a cluster randomized controlled trial of a multifaceted intervention to reduce inappropriate gabapentinoid prescription, comparing digital and postal mode of delivery. All veteran patients targeted also received an educational intervention (postal delivery). Efficacy was measured using a linear mixed-effects model as the average number of gabapentinoid prescriptions standardized by defined daily dose (individual level), and number of veterans visiting a psychologist in the 6 and 12 months following the intervention. Results: The trial involved 2552 general practitioners in Australia and took place in March 2020. Both intervention groups had a significant reduction in total gabapentinoid prescription by the end of the study period (digital: mean reduction of 11.2\%, P=.004; postal: mean reduction of 11.2\%, P=.001). We found no difference between digital and postal mode of delivery in reduction of gabapentinoid prescriptions at 12 months (digital: --0.058, postal: --0.058, P=.98). Digital delivery increased initiations to psychologists at 12 months (digital: 3.8\%, postal: 2.0\%, P=.02). Conclusions: Our digitally delivered professional behavior change intervention was feasible, had comparable effectiveness to the postal intervention with regard to changes in medicine use, and had increased effectiveness with regard to referrals to a psychologist. Given the logistical benefits of digital delivery in nationwide programs, the results encourage exploration of this mode in future interventions. ",
doi="10.2196/33873",
url="https://www.jmir.org/2022/1/e33873",
url="http://www.ncbi.nlm.nih.gov/pubmed/35006086"
}


@Article{info:doi/10.2196/30975,
author="Bouldin, D. Erin
and Delgado, Roxana
and Peacock, Kimberly
and Hale, Willie
and Roghani, Ali
and Trevino, Y. Amira
and Viny, Mikayla
and Wetter, W. David
and Pugh, Jo Mary",
title="Military Injuries---Understanding Posttraumatic Epilepsy, Health, and Quality-of-Life Effects of Caregiving: Protocol for a Longitudinal Mixed Methods Observational Study",
journal="JMIR Res Protoc",
year="2022",
month="Jan",
day="5",
volume="11",
number="1",
pages="e30975",
keywords="epilepsy",
keywords="military personnel",
keywords="veterans",
keywords="caregiver",
keywords="traumatic brain injury",
keywords="quality of life",
keywords="health status",
keywords="longitudinal studies",
keywords="ecologic momentary assessment",
keywords="qualitative research",
abstract="Background: Veterans with posttraumatic epilepsy (PTE), particularly those with comorbidities associated with epilepsy or traumatic brain injury (TBI), have poorer health status and higher symptom burden than their peers without PTE. One area that has been particularly poorly studied is that of the role of caregivers in the health of veterans with PTE and the impact caring for someone with PTE has on the caregivers themselves. Objective: In this study, we aim to address the following: describe and compare the health and quality of life of veterans and caregivers of veterans with and without PTE; evaluate the change in available supports and unmet needs for services among caregivers of post-9/11 veterans with PTE over a 2-year period and to compare support and unmet needs with those without PTE; and identify veteran and caregiver characteristics associated with the 2-year health trajectories of caregivers and veterans with PTE compared with veterans without PTE. Methods: We conducted a prospective cohort study of the health and quality of life among 4 groups of veterans and their caregivers: veterans with PTE, nontraumatic epilepsy, TBI only, and neither epilepsy nor TBI. We will recruit participants from previous related studies and collect information about both the veterans and their primary informal caregivers on health, quality of life, unmet needs for care, PTE and TBI symptoms and treatment, relationship, and caregiver experience. Data sources will include existing data supplemented with primary data, such as survey data collected at baseline, intermittent brief reporting using ecological momentary assessment, and qualitative interviews. We will make both cross-sectional and longitudinal comparisons, using veteran-caregiver dyads, along with qualitative findings to better understand risk and promotive factors for quality of life and health among veterans and caregivers, as well as the bidirectional impact of caregivers and care recipients on one another. Results: This study was approved by the institutional review boards of the University of Utah and Salt Lake City Veterans Affairs and is under review by the Human Research Protection Office of the United States Army Medical Research and Development Command. The Service Member, Veteran, and Caregiver Community Stakeholders Group has been formed and the study questionnaire will be finalized once the panel reviews it. We anticipate the start of recruitment and primary data collection by January 2022. Conclusions: New national initiatives aim to incorporate the caregiver into the veteran's treatment plan; however, we know little about the impact of caregiving---both positive and negative---on the caregivers themselves and on the veterans for whom they provide care. We will identify specific needs in this understudied population, which will inform clinicians, patients, families, and policy makers about the specific impact and needs to equip caregivers in caring for veterans at home. International Registered Report Identifier (IRRID): PRR1-10.2196/30975 ",
doi="10.2196/30975",
url="https://www.researchprotocols.org/2022/1/e30975",
url="http://www.ncbi.nlm.nih.gov/pubmed/34989689"
}


@Article{info:doi/10.2196/29573,
author="Reilly, Dawna Erin
and Robinson, A. Stephanie
and Petrakis, Ann Beth
and Gardner, M. Melissa
and Wiener, Soylemez Renda
and Castaneda-Sceppa, Carmen
and Quigley, S. Karen",
title="Mobile Intervention to Improve Sleep and Functional Health of Veterans With Insomnia: Randomized Controlled Trial",
journal="JMIR Form Res",
year="2021",
month="Dec",
day="9",
volume="5",
number="12",
pages="e29573",
keywords="cognitive behavioral therapy",
keywords="mobile app",
keywords="physical activity",
keywords="insomnia",
abstract="Background: Insomnia is a prevalent and debilitating disorder among veterans. Cognitive behavioral therapy for insomnia (CBTI) can be effective for treating insomnia, although many cannot access this care. Technology-based solutions and lifestyle changes, such as physical activity (PA), offer affordable and accessible self-management alternatives to in-person CBTI. Objective: This study aims to extend and replicate prior pilot work to examine whether the use of a mobile app for CBTI (cognitive behavioral therapy for insomnia coach app [CBT-i Coach]) improves subjective and objective sleep outcomes. This study also aims to investigate whether the use of the CBT-i Coach app with adjunctive PA improves sleep outcomes more than CBT-i Coach alone. Methods: A total of 33 veterans (mean age 37.61 years, SD 9.35 years) reporting chronic insomnia were randomized to use either the CBT-i Coach app alone or the CBT-i Coach app with a PA intervention over 6 weeks, with outcome measures of objective and subjective sleep at pre- and posttreatment. Results: Although the PA manipulation was unsuccessful, both groups of veterans using the CBT-i Coach app showed significant improvement from baseline to postintervention on insomnia (P<.001), sleep quality (P<.001), and functional sleep outcomes (P=.002). Improvements in subjective sleep outcomes were similar in those with and without posttraumatic stress disorder and mild-to-moderate sleep apnea. We also observed a significant but modest increase in objective sleep efficiency (P=.02). Conclusions: These findings suggest that the use of a mobile app--delivered CBTI is feasible and beneficial for improving sleep outcomes in veterans with insomnia, including those with comorbid conditions such as posttraumatic stress disorder or mild-to-moderate sleep apnea. Trial Registration: ClinicalTrials.gov NCT03305354; https://clinicaltrials.gov/ct2/show/NCT03305354 ",
doi="10.2196/29573",
url="https://formative.jmir.org/2021/12/e29573",
url="http://www.ncbi.nlm.nih.gov/pubmed/34889746"
}


@Article{info:doi/10.2196/29423,
author="DeLaughter, L. Kathryn
and Fix, M. Gemmae
and McDannold, E. Sarah
and Pope, Charlene
and Bokhour, G. Barbara
and Shimada, L. Stephanie
and Calloway, Rodney
and Gordon, S. Howard
and Long, A. Judith
and Miano, A. Danielle
and Cutrona, L. Sarah",
title="Incorporating African American Veterans' Success Stories for Hypertension Management: Developing a Behavioral Support Texting Protocol",
journal="JMIR Res Protoc",
year="2021",
month="Dec",
day="1",
volume="10",
number="12",
pages="e29423",
keywords="texting",
keywords="African American",
keywords="hypertension",
keywords="self-management",
keywords="mobile phone",
abstract="Background: Peer narratives engage listeners through personally relevant content and have been shown to promote lifestyle change and effective self-management among patients with hypertension. Incorporating key quotations from these stories into follow-up text messages is a novel way to continue the conversation, providing reinforcement of health behaviors in the patients' daily lives. Objective: In our previous work, we developed and tested videos in which African American Veterans shared stories of challenges and success strategies related to hypertension self-management. This study aims to describe our process for developing a text-messaging protocol intended for use after viewing videos that incorporate the voices of these Veterans. Methods: We used a multistep process, transforming video-recorded story excerpts from 5 Veterans into 160-character texts. We then integrated these into comprehensive 6-month texting protocols. We began with an iterative review of story transcripts to identify vernacular features and key self-management concepts emphasized by each storyteller. We worked with 2 Veteran consultants who guided our narrative text message development in substantive ways, as we sought to craft culturally sensitive content for texts. Informed by Veteran input on timing and integration, supplementary educational and 2-way interactive assessment text messages were also developed. Results: Within the Veterans Affairs texting system Annie, we programmed five 6-month text-messaging protocols that included cycles of 3 text message types: narrative messages, nonnarrative educational messages, and 2-way interactive messages assessing self-efficacy and behavior related to hypertension self-management. Each protocol corresponds to a single Veteran storyteller, allowing Veterans to choose the story that most resonates with their own life experiences. Conclusions: We crafted a culturally sensitive text-messaging protocol using narrative content referenced in Veteran stories to support effective hypertension self-management. Integrating narrative content into a mobile health texting intervention provides a low-cost way to support longitudinal behavior change. A randomized trial is underway to test its impact on the lifestyle changes and blood pressure of African American Veterans. Trial Registration: ClinicalTrials.gov NCT03970590; https://clinicaltrials.gov/ct2/show/NCT03970590 International Registered Report Identifier (IRRID): DERR1-10.2196/29423 ",
doi="10.2196/29423",
url="https://www.researchprotocols.org/2021/12/e29423",
url="http://www.ncbi.nlm.nih.gov/pubmed/34855617"
}


@Article{info:doi/10.2196/33151,
author="Liu, W. Jenny J.
and Nazarov, Anthony
and Easterbrook, Bethany
and Plouffe, A. Rachel
and Le, Tri
and Forchuk, Callista
and Brandwood, Alec
and St Cyr, Kate
and Auger, Edouard
and Balderson, Ken
and Bilodeau, Mathieu
and Burhan, M. Amer
and Enns, W. Murray
and Smith, Patrick
and Hosseiny, Fardous
and Dupuis, Gabrielle
and Roth, Maya
and Mota, Natalie
and Lavoie, Vicky
and Richardson, Don J.",
title="Four Decades of Military Posttraumatic Stress: Protocol for a Meta-analysis and Systematic Review of Treatment Approaches and Efficacy",
journal="JMIR Res Protoc",
year="2021",
month="Oct",
day="25",
volume="10",
number="10",
pages="e33151",
keywords="military personnel",
keywords="psychotherapy",
keywords="pharmacotherapy",
keywords="stress disorders",
keywords="posttraumatic",
keywords="meta-analysis",
keywords="systematic review",
keywords="therapy",
keywords="stress",
keywords="disorder",
keywords="posttraumatic stress disorder",
keywords="review",
keywords="treatment",
keywords="efficacy",
keywords="military",
keywords="Canada",
keywords="veteran",
abstract="Background: Over 85\% of active members of the Canadian Armed Forces have been exposed to potentially traumatic events linked to the development of posttraumatic stress disorder (PTSD). At the time of transition to civilian life, as high as 1 in 8 veterans may be diagnosed with PTSD. Given the high prevalence of PTSD in military and veteran populations, the provision of effective treatment considering their unique challenges and experiences is critical for mental health support and the well-being of these populations. Objective: This paper presents the protocol for a meta-analysis and systematic review that will examine the effectiveness of treatment approaches for military-related PTSD. Methods: This PROSPERO-preregistered meta-analysis is being conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and Cochrane guidelines. A comprehensive search of the literature was conducted using the databases PsycInfo, Medline, Embase, CINAHL, and ProQuest Dissertation \& Theses. Effect sizes will be computed based on changes in PTSD symptom scores over time across studies using validated PTSD scales. A multilevel meta-analysis will examine the overall effects, between-study effects, and within-study effects of available evidence for PTSD treatments in military populations. Effect sizes will be compared between pharmacotherapeutic, psychotherapeutic, and alternative/emerging treatment interventions. Finally, meta-regression and subgroup analyses will explore the moderating roles of clinical characteristics (eg, PTSD symptom clusters), treatment approaches (eg, therapeutic orientations in psychotherapy and alternative therapies and classifications of drugs in pharmacotherapy), as well as treatment characteristics (eg, length of intervention) on treatment outcomes. Results: The literature search was completed on April 14, 2021. After the removal of duplicates, a total of 12,002 studies were screened for inclusion. As of July 2021, title and abstract screening has been completed, with 1469 out of 12,002 (12.23\%) studies included for full-text review. Full review is expected to be completed in the summer of 2021, with initial results expected for publication by early winter of 2021. Conclusions: This meta-analysis will provide information on the current state of evidence on the efficacy and effectiveness of various treatment approaches for military-related PTSD and identify factors that may influence treatment outcomes. The results will inform clinical decision-making for service providers and service users. Finally, the findings will provide insights into future treatment development and practice recommendations to better support the well-being of military and veteran populations. Trial Registration: PROSPERO CRD42021245754; https://tinyurl.com/y9u57c59 International Registered Report Identifier (IRRID): DERR1-10.2196/33151 ",
doi="10.2196/33151",
url="https://www.researchprotocols.org/2021/10/e33151",
url="http://www.ncbi.nlm.nih.gov/pubmed/34694228"
}


@Article{info:doi/10.2196/32301,
author="Woo, MinJae
and Mishra, Prabodh
and Lin, Ju
and Kar, Snigdhaswin
and Deas, Nicholas
and Linduff, Caleb
and Niu, Sufeng
and Yang, Yuzhe
and McClendon, Jerome
and Smith, Hudson D.
and Shelton, L. Stephen
and Gainey, E. Christopher
and Gerard, C. William
and Smith, C. Melissa
and Griffin, F. Sarah
and Gimbel, W. Ronald
and Wang, Kuang-Ching",
title="Complete and Resilient Documentation for Operational Medical Environments Leveraging Mobile Hands-free Technology in a Systems Approach: Experimental Study",
journal="JMIR Mhealth Uhealth",
year="2021",
month="Oct",
day="12",
volume="9",
number="10",
pages="e32301",
keywords="emergency medical services",
keywords="prehospital documentation",
keywords="speech recognition software",
keywords="natural language processing",
keywords="military medicine",
keywords="documentation",
keywords="development",
keywords="challenge",
keywords="paramedic",
keywords="disruption",
keywords="attention",
keywords="medical information",
keywords="audio",
keywords="speech recognition",
keywords="qualitative",
keywords="simulation",
abstract="Background: Prehospitalization documentation is a challenging task and prone to loss of information, as paramedics operate under disruptive environments requiring their constant attention to the patients. Objective: The aim of this study is to develop a mobile platform for hands-free prehospitalization documentation to assist first responders in operational medical environments by aggregating all existing solutions for noise resiliency and domain adaptation. Methods: The platform was built to extract meaningful medical information from the real-time audio streaming at the point of injury and transmit complete documentation to a field hospital prior to patient arrival. To this end, the state-of-the-art automatic speech recognition (ASR) solutions with the following modular improvements were thoroughly explored: noise-resilient ASR, multi-style training, customized lexicon, and speech enhancement. The development of the platform was strictly guided by qualitative research and simulation-based evaluation to address the relevant challenges through progressive improvements at every process step of the end-to-end solution. The primary performance metrics included medical word error rate (WER) in machine-transcribed text output and an F1 score calculated by comparing the autogenerated documentation to manual documentation by physicians. Results: The total number of 15,139 individual words necessary for completing the documentation were identified from all conversations that occurred during the physician-supervised simulation drills. The baseline model presented a suboptimal performance with a WER of 69.85\% and an F1 score of 0.611. The noise-resilient ASR, multi-style training, and customized lexicon improved the overall performance; the finalized platform achieved a medical WER of 33.3\% and an F1 score of 0.81 when compared to manual documentation. The speech enhancement degraded performance with medical WER increased from 33.3\% to 46.33\% and the corresponding F1 score decreased from 0.81 to 0.78. All changes in performance were statistically significant (P<.001). Conclusions: This study presented a fully functional mobile platform for hands-free prehospitalization documentation in operational medical environments and lessons learned from its implementation. ",
doi="10.2196/32301",
url="https://mhealth.jmir.org/2021/10/e32301",
url="http://www.ncbi.nlm.nih.gov/pubmed/34636729"
}


@Article{info:doi/10.2196/25622,
author="Hendrikx, Josephine Laura
and Murphy, Dominic",
title="Supporting the Mental Health Needs of Military Partners Through the Together Webinar Program: Pilot Randomized Controlled Trial",
journal="JMIR Ment Health",
year="2021",
month="Oct",
day="12",
volume="8",
number="10",
pages="e25622",
keywords="mental health support",
keywords="online group-based support",
keywords="military partners",
abstract="Background: Despite an increased risk of psychological difficulties, there remains a lack of evidence-based support for the mental health needs of military partners. Objective: This study aims to investigate whether the Together Webinar Programme (TTP-Webinar), a 6-week structured, remote access group intervention would reduce military partners' experience of common mental health difficulties and secondary trauma symptoms. Methods: A pilot randomized controlled trial was used to compare the TTP-Webinar intervention with a waitlist control. The sample was UK treatment-seeking veterans engaged in a mental health charity. A total of 196 military partners (1 male and 195 females; aged mean 42.28, SD 10.82 years) were randomly allocated to the intervention (n=97) or waitlist (n=99) condition. Outcome measures were self-reported measures of common mental health difficulties, secondary trauma symptoms, and overall quality of life rating. Results: Compared with the waitlist, military partners in the TTP-Webinar had reduced common mental health difficulties (P=.02) and secondary trauma symptoms (P=.001). However, there was no difference in quality-of-life ratings (P=.06). Conclusions: The results suggest that TTP-Webinar is an effective intervention to support the mental health difficulties of military partners. This study provides promising evidence that webinars may be an appropriate platform for providing group-based support. Trial Registration: ClinicalTrials.gov NCT05013398; https://clinicaltrials.gov/ct2/show/NCT05013398 ",
doi="10.2196/25622",
url="https://mental.jmir.org/2021/10/e25622",
url="http://www.ncbi.nlm.nih.gov/pubmed/34636734"
}


@Article{info:doi/10.2196/29429,
author="Der-Martirosian, Claudia
and Wyte-Lake, Tamar
and Balut, Michelle
and Chu, Karen
and Heyworth, Leonie
and Leung, Lucinda
and Ziaeian, Boback
and Tubbesing, Sarah
and Mullur, Rashmi
and Dobalian, Aram",
title="Implementation of Telehealth Services at the US Department of Veterans Affairs During the COVID-19 Pandemic: Mixed Methods Study",
journal="JMIR Form Res",
year="2021",
month="Sep",
day="23",
volume="5",
number="9",
pages="e29429",
keywords="telehealth",
keywords="telemedicine",
keywords="veterans",
keywords="US Department of Veterans Affairs",
keywords="primary care",
keywords="cardiology",
keywords="home-based primary care",
keywords="COVID-19",
abstract="Background: At the onset of the COVID-19 pandemic, there was a rapid increase in the use of telehealth services at the US Department of Veterans Affairs (VA), which was accelerated by state and local policies mandating stay-at-home orders and restricting nonurgent in-person appointments. Even though the VA was an early adopter of telehealth in the late 1990s, the vast majority of VA outpatient care continued to be face-to-face visits through February 2020. Objective: We compared telehealth service use at a VA Medical Center, Greater Los Angeles across 3 clinics (primary care [PC], cardiology, and home-based primary care [HBPC]) 12 months before and 12 months after the onset of COVID-19 (March 2020). Methods: We used a parallel mixed methods approach including simultaneous quantitative and qualitative approaches. The distribution of monthly outpatient and telehealth visits, as well as telephone and VA Video Connect encounters were examined for each clinic. Semistructured telephone interviews were conducted with 34 staff involved in telehealth services within PC, cardiology, and HBPC during COVID-19. All audiotaped interviews were transcribed and analyzed by identifying key themes. Results: Prior to COVID-19, telehealth use was minimal at all 3 clinics, but at the onset of COVID-19, telehealth use increased substantially at all 3 clinics. Telephone was the main modality of patient choice. Compared with PC and cardiology, video-based care had the greatest increase in HBPC. Several important barriers (multiple steps for videoconferencing, creation of new scheduling grids, and limited access to the internet and internet-connected devices) and facilitators (flexibility in using different video-capable platforms, technical support for patients, identification of staff telehealth champions, and development of workflows to help incorporate telehealth into treatment plans) were noted. Conclusions: Technological issues must be addressed at the forefront of telehealth evolution to achieve access for all patient populations with different socioeconomic backgrounds, living situations and locations, and health conditions. The unprecedented expansion of telehealth during COVID-19 provides opportunities to create lasting telehealth solutions to improve access to care beyond the pandemic. ",
doi="10.2196/29429",
url="https://formative.jmir.org/2021/9/e29429",
url="http://www.ncbi.nlm.nih.gov/pubmed/34477554"
}


@Article{info:doi/10.2196/24295,
author="Geva, A. Gil
and Ketko, Itay
and Nitecki, Maya
and Simon, Shoham
and Inbar, Barr
and Toledo, Itay
and Shapiro, Michael
and Vaturi, Barak
and Votta, Yoni
and Filler, Daniel
and Yosef, Roey
and Shpitzer, A. Sagi
and Hir, Nabil
and Peri Markovich, Michal
and Shapira, Shachar
and Fink, Noam
and Glasberg, Elon
and Furer, Ariel",
title="Data Empowerment of Decision-Makers in an Era of a Pandemic: Intersection of ``Classic'' and Artificial Intelligence in the Service of Medicine",
journal="J Med Internet Res",
year="2021",
month="Sep",
day="10",
volume="23",
number="9",
pages="e24295",
keywords="COVID-19",
keywords="medical informatics",
keywords="decision-making",
keywords="pandemic",
keywords="data",
keywords="policy",
keywords="validation",
keywords="accuracy",
keywords="data analysis",
abstract="Background: The COVID-19 outbreak required prompt action by health authorities around the world in response to a novel threat. With enormous amounts of information originating in sources with uncertain degree of validation and accuracy, it is essential to provide executive-level decision-makers with the most actionable, pertinent, and updated data analysis to enable them to adapt their strategy swiftly and competently. Objective: We report here the origination of a COVID-19 dedicated response in the Israel Defense Forces with the assembly of an operational Data Center for the Campaign against Coronavirus. Methods: Spearheaded by directors with clinical, operational, and data analytics orientation, a multidisciplinary team utilized existing and newly developed platforms to collect and analyze large amounts of information on an individual level in the context of SARS-CoV-2 contraction and infection. Results: Nearly 300,000 responses to daily questionnaires were recorded and were merged with other data sets to form a unified data lake. By using basic as well as advanced analytic tools ranging from simple aggregation and display of trends to data science application, we provided commanders and clinicians with access to trusted, accurate, and personalized information and tools that were designed to foster operational changes and mitigate the propagation of the pandemic. The developed tools aided in the in the identification of high-risk individuals for severe disease and resulted in a 30\% decline in their attendance to their units. Moreover, the queue for laboratory examination for COVID-19 was optimized using a predictive model and resulted in a high true-positive rate of 20\%, which is more than twice as high as the baseline rate (2.28\%, 95\% CI 1.63\%-3.19\%). Conclusions: In times of ambiguity and uncertainty, along with an unprecedented flux of information, health organizations may find multidisciplinary teams working to provide intelligence from diverse and rich data a key factor in providing executives relevant and actionable support for decision-making. ",
doi="10.2196/24295",
url="https://www.jmir.org/2021/9/e24295",
url="http://www.ncbi.nlm.nih.gov/pubmed/34313589"
}


@Article{info:doi/10.2196/26078,
author="Jones, Chelsea
and Miguel-Cruz, Antonio
and Br{\'e}mault-Phillips, Suzette",
title="Technology Acceptance and Usability of the BrainFx SCREEN in Canadian Military Members and Veterans With Posttraumatic Stress Disorder and Mild Traumatic Brain Injury: Mixed Methods UTAUT Study",
journal="JMIR Rehabil Assist Technol",
year="2021",
month="May",
day="13",
volume="8",
number="2",
pages="e26078",
keywords="NCAT",
keywords="PTSD",
keywords="cognitive assessment",
keywords="cognition",
keywords="executive function",
keywords="technology acceptance",
keywords="UTAUT",
keywords="Canadian Armed Forces",
keywords="mTBI",
keywords="concussion",
keywords="digital health",
keywords="neuropsychology",
keywords="neurology",
keywords="post concussive symptoms",
keywords="military",
abstract="Background: Canadian Armed Forces service members (CAF-SMs) and veterans exhibit higher rates of injuries and illnesses, such as posttraumatic stress disorder (PTSD) and traumatic brain injury, which can cause and exacerbate cognitive dysfunction. Computerized neurocognitive assessment tools have demonstrated increased reliability and efficiency compared with traditional cognitive assessment tools. Without assessing the degree of technology acceptance and perceptions of usability to end users, it is difficult to determine whether a technology-based assessment will be used successfully in wider clinical practice. The Unified Theory of Acceptance and Use of Technology model is commonly used to address the technology acceptance and usability of applications in five domains. Objective: This study aims to determine the technology acceptance and usability of a neurocognitive assessment tool, which was titled BrainFx SCREEN, among CAF-SMs and veterans with PTSD by using the Unified Theory of Acceptance and Use of Technology model. Methods: This mixed methods embedded pilot study included CAF-SMs and veterans (N=21) aged 18-60 years with a diagnosis of PTSD who completed pre- and postquestionnaires on the same day the BrainFx SCREEN was used. A partial least squares structural equation model was used to analyze the questionnaire results. Qualitative data were assessed using thematic analysis. Results: Facilitating conditions, which were the most notable predictors of behavioral intention, increased after using the BrainFx SCREEN, whereas effort expectancy decreased. Performance expectancy, effort expectancy, and social interaction were not factors that could predict behavioral intention. Participants who reported a previous mild traumatic brain injury were significantly more likely to report current symptoms of cognitive impairment. The BrainFx SCREEN is a feasible, usable, and accepted assessment tool for CAF-SMs and veterans who experience PTSD. Conclusions: As military health care systems integrate technological innovations to improve the services and care provided, research must continue to address the acceptability and use of these novel assessments and interventions. ",
doi="10.2196/26078",
url="https://rehab.jmir.org/2021/2/e26078",
url="http://www.ncbi.nlm.nih.gov/pubmed/33983125"
}


@Article{info:doi/10.2196/21214,
author="Etingen, Bella
and Amante, J. Daniel
and Martinez, N. Rachael
and Smith, M. Bridget
and Shimada, L. Stephanie
and Richardson, Lorilei
and Patterson, Angela
and Houston, K. Thomas
and Frisbee, L. Kathleen
and Hogan, P. Timothy",
title="Supporting the Implementation of Connected Care Technologies in the Veterans Health Administration: Cross-Sectional Survey Findings from the Veterans Engagement with Technology Collaborative (VET-C) Cohort",
journal="J Participat Med",
year="2020",
month="Sep",
day="30",
volume="12",
number="3",
pages="e21214",
keywords="eHealth",
keywords="mobile health",
keywords="patient engagement",
keywords="telehealth",
keywords="veterans",
abstract="Background: Widespread adoption, use, and integration of patient-facing technologies into the workflow of health care systems has been slow, thus limiting the realization of their potential. A growing body of work has focused on how best to promote adoption and use of these technologies and measure their impacts on processes of care and outcomes. This body of work currently suffers from limitations (eg, cross-sectional analyses, limited patient-generated data linked with clinical records) and would benefit from institutional infrastructure to enhance available data and integrate the voice of the patient into implementation and evaluation efforts. Objective: The Veterans Health Administration (VHA) has launched an initiative called the Veterans Engagement with Technology Collaborative cohort to directly address these challenges. This paper reports the process by which the cohort was developed and describes the baseline data being collected from cohort members. The overarching goal of the Veterans Engagement with Technology Collaborative cohort is to directly engage veterans in the evaluation of new VHA patient-facing technologies and in so doing, to create new infrastructure to support related quality improvement and evaluation activities. Methods: Inclusion criteria for veterans to be eligible for membership in the cohort included being an active user of VHA health care services, having a mobile phone, and being an established user of existing VHA patient-facing technologies as represented by use of the secure messaging feature of VHA's patient portal. Between 2017 and 2018, we recruited veterans who met these criteria and administered a survey to them over the telephone. Results: The majority of participants (N=2727) were male (2268/2727, 83.2\%), White (2226/2727, 81.6\%), living in their own apartment or house (2519/2696, 93.4\%), and had completed some college (1176/2701, 43.5\%) or an advanced degree (1178/2701, 43.6\%). Cohort members were 59.9 years old, on average. The majority self-reported their health status as being good (1055/2725, 38.7\%) or very good (524/2725, 19.2\%). Most cohort members owned a personal computer (2609/2725, 95.7\%), tablet computer (1616/2716, 59.5\%), and/or smartphone (2438/2722, 89.6\%). Conclusions: The Veterans Engagement with Technology Collaborative cohort is an example of a VHA learning health care system initiative designed to support the data-driven implementation of patient-facing technologies into practice and measurement of their impacts. With this initiative, VHA is building capacity for future, rapid, rigorous evaluation and quality improvement efforts to enhance understanding of the adoption, use, and impact of patient-facing technologies. ",
doi="10.2196/21214",
url="http://jopm.jmir.org/2020/3/e21214/",
url="http://www.ncbi.nlm.nih.gov/pubmed/33044944"
}


@Article{info:doi/10.2196/18086,
author="Thota, Darshan",
title="Evaluating the Relationship Between Fitbit Sleep Data and Self-Reported Mood, Sleep, and Environmental Contextual Factors in Healthy Adults: Pilot Observational Cohort Study",
journal="JMIR Form Res",
year="2020",
month="Sep",
day="29",
volume="4",
number="9",
pages="e18086",
keywords="Fitbit",
keywords="sleep",
keywords="healthy",
keywords="mood",
keywords="context",
keywords="waking",
abstract="Background: Mental health disorders can disrupt a person's sleep, resulting in lower quality of life. Early identification and referral to mental health services are critical for active duty service members returning from forward-deployed missions. Although technologies like wearable computing devices have the potential to help address this problem, research on the role of technologies like Fitbit in mental health services is in its infancy. Objective: If Fitbit proves to be an appropriate clinical tool in a military setting, it could provide potential cost savings, improve clinician access to patient data, and create real-time treatment options for the greater active duty service member population. The purpose of this study was to determine if the Fitbit device can be used to identify indicators of mental health disorders by measuring the relationship between Fitbit sleep data, self-reported mood, and environmental contextual factors that may disrupt sleep. Methods: This observational cohort study was conducted at the Madigan Army Medical Center. The study included 17 healthy adults who wore a Fitbit Flex for 2 weeks and completed a daily self-reported mood and sleep log. Daily Fitbit data were obtained for each participant. Contextual factors were collected with interim and postintervention surveys. This study had 3 specific aims: (1) Determine the correlation between daily Fitbit sleep data and daily self-reported sleep, (2) Determine the correlation between number of waking events and self-reported mood, and (3) Explore the qualitative relationships between Fitbit waking events and self-reported contextual factors for sleep. Results: There was no significant difference in the scores for the pre-intevention Pittsburg Sleep Quality Index (PSQI; mean 5.88 points, SD 3.71 points) and postintervention PSQI (mean 5.33 points, SD 2.83 points). The Wilcoxon signed-ranks test showed that the difference between the pre-intervention PSQI and postintervention PSQI survey data was not statistically significant (Z=0.751, P=.05). The Spearman correlation between Fitbit sleep time and self-reported sleep time was moderate (r=0.643, P=.005). The Spearman correlation between number of waking events and self-reported mood was weak (r=0.354, P=.163). Top contextual factors disrupting sleep were ``pain,'' ``noises,'' and ``worries.'' A subanalysis of participants reporting ``worries'' found evidence of potential stress resilience and outliers in waking events. Conclusions: Findings contribute valuable evidence on the strength of the Fitbit Flex device as a proxy that is consistent with self-reported sleep data. Mood data alone do not predict number of waking events. Mood and Fitbit data combined with further screening tools may be able to identify markers of underlying mental health disease. ",
doi="10.2196/18086",
url="http://formative.jmir.org/2020/9/e18086/",
url="http://www.ncbi.nlm.nih.gov/pubmed/32990631"
}


@Article{info:doi/10.2196/17978,
author="Novak, Lovett Laurie
and Simpson, L. Christopher
and Coco, Joseph
and McNaughton, D. Candace
and Ehrenfeld, M. Jesse
and Bloos, M. Sean
and Fabbri, Daniel",
title="Understanding the Information Needs and Context of Trauma Handoffs to Design Automated Sensing Clinical Documentation Technologies: Qualitative Mixed-Method Study of Military and Civilian Cases",
journal="J Med Internet Res",
year="2020",
month="Sep",
day="25",
volume="22",
number="9",
pages="e17978",
keywords="trauma handoffs",
keywords="military field medicine",
keywords="documentation",
keywords="trauma",
keywords="health records",
keywords="hospital",
keywords="emergency",
abstract="Background: Current methods of communication between the point of injury and receiving medical facilities rely on verbal communication, supported by brief notes and the memory of the field medic. This communication can be made more complete and reliable with technologies that automatically document the actions of field medics. However, designing state-of-the-art technology for military field personnel and civilian first responders is challenging due to the barriers researchers face in accessing the environment and understanding situated actions and cognitive models employed in the field. Objective: To identify design insights for an automated sensing clinical documentation (ASCD) system, we sought to understand what information is transferred in trauma cases between prehospital and hospital personnel, and what contextual factors influence the collection, management, and handover of information in trauma cases, in both military and civilian cases. Methods: Using a multi-method approach including video review and focus groups, we developed an understanding of the information needs of trauma handoffs and the context of field documentation to inform the design of an automated sensing documentation system that uses wearables, cameras, and environmental sensors to passively infer clinical activity and automatically produce documentation. Results: Comparing military and civilian trauma documentation and handoff, we found similarities in the types of data collected and the prioritization of information. We found that military environments involved many more contextual factors that have implications for design, such as the physical environment (eg, heat, lack of lighting, lack of power) and the potential for active combat and triage, creating additional complexity. Conclusions: An ineffectiveness of communication is evident in both the civilian and military worlds. We used multiple methods of inquiry to study the information needs of trauma care and handoff, and the context of medical work in the field. Our findings informed the design and evaluation of an automated documentation tool. The data illustrated the need for more accurate recordkeeping, specifically temporal aspects, during transportation, and characterized the environment in which field testing of the developed tool will take place. The employment of a systems perspective in this project produced design insights that our team would not have identified otherwise. These insights created exciting and interesting challenges for the technical team to resolve. ",
doi="10.2196/17978",
url="http://www.jmir.org/2020/9/e17978/",
url="http://www.ncbi.nlm.nih.gov/pubmed/32975522"
}


@Article{info:doi/10.2196/19807,
author="Jones, Chelsea
and O'Toole, Kaitlin
and Jones, Kevin
and Br{\'e}mault-Phillips, Suzette",
title="Quality of Psychoeducational Apps for Military Members With Mild Traumatic Brain Injury: An Evaluation Utilizing the Mobile Application Rating Scale",
journal="JMIR Mhealth Uhealth",
year="2020",
month="Aug",
day="18",
volume="8",
number="8",
pages="e19807",
keywords="psychoeducation",
keywords="mTBI",
keywords="military",
keywords="app",
keywords="smartphone",
keywords="mHealth, concussion",
keywords="Mobile App Rating Scale",
keywords="MARS",
keywords="mobile phone",
abstract="Background: Military personnel have an elevated risk of sustaining mild traumatic brain injuries (mTBI) and postconcussion symptoms (PCS). Smartphone apps that provide psychoeducation may assist those with mTBI or PCS to overcome unique barriers that military personnel experience with stigma and access to health care resources. Objective: This study aims to (1) use the Mobile Application Rating Scale (MARS) to evaluate smartphone apps purporting to provide psychoeducation for those who have sustained an mTBI or a PCS; (2) explore the relevance, utility, and effectiveness of these apps in facilitating symptom management and overall recovery from mTBI and PCS among military personnel; and (3) discuss considerations pertinent to health care professionals and patients with mTBI when considering the use of mobile health (mHealth), including apps for mTBI psychoeducation. Methods: A five-step systematic search for smartphone apps for military members with mTBI or PCS was conducted on January 31, 2020. Cost-free apps meeting the inclusion criteria were evaluated using the MARS and compared with evidence-based best practice management protocols for mTBI and PCS. Results: The search yielded a total of 347 smartphone apps. After applying the inclusion and exclusion criteria, 13 apps were subjected to evaluation. Two apps were endorsed by the US Department of Veterans Affairs and the US Department of Defense; all the others (n=11) were developed for civilians. When compared with evidence-based best practice resources, the apps provided various levels of psychoeducational content. There are multiple considerations that health care professionals and those who sustain an mTBI or a PCS have to consider when choosing to use mHealth and selecting a specific app for mTBI psychoeducation. These may include factors such as the app platform, developer, internet requirement, cost, frequency of updates, language, additional features, acknowledgment of mental health, accessibility, military specificity, and privacy and security of data. Conclusions: Psychoeducational interventions have a good evidence base as a treatment for mTBI and PCS. The use of apps for this purpose may be clinically effective, cost-effective, confidential, user friendly, and accessible. However, more research is needed to explore the effectiveness, usability, safety, security, and accessibility of apps designed for mTBI management. ",
doi="10.2196/19807",
url="http://mhealth.jmir.org/2020/8/e19807/",
url="http://www.ncbi.nlm.nih.gov/pubmed/32808937"
}


@Article{info:doi/10.2196/19216,
author="Damschroder, J. Laura
and Buis, R. Lorraine
and McCant, A. Felicia
and Kim, Myra Hyungjin
and Evans, Richard
and Oddone, Z. Eugene
and Bastian, A. Lori
and Hooks, Gwendolyn
and Kadri, Reema
and White-Clark, Courtney
and Richardson, R. Caroline
and Gierisch, M. Jennifer",
title="Effect of Adding Telephone-Based Brief Coaching to an mHealth App (Stay Strong) for Promoting Physical Activity Among Veterans: Randomized Controlled Trial",
journal="J Med Internet Res",
year="2020",
month="Aug",
day="4",
volume="22",
number="8",
pages="e19216",
keywords="exercise",
keywords="veterans",
keywords="smartphones",
keywords="wearable physical activity tracker",
keywords="behavior change",
keywords="mobile phone",
keywords="online",
keywords="app",
keywords="mobile app",
keywords="wearable",
abstract="Background: Though maintaining physical conditioning and a healthy weight are requirements of active military duty, many US veterans lose conditioning and rapidly gain weight after discharge from active duty service. Mobile health (mHealth) interventions using wearable devices are appealing to users and can be effective especially with personalized coaching support. We developed Stay Strong, a mobile app tailored to US veterans, to promote physical activity using a wrist-worn physical activity tracker, a Bluetooth-enabled scale, and an app-based dashboard. We tested whether adding personalized coaching components (Stay Strong+Coaching) would improve physical activity compared to Stay Strong alone. Objective: The goal of this study is to compare 12-month outcomes from Stay Strong alone versus Stay Strong+Coaching. Methods: Participants (n=357) were recruited from a national random sample of US veterans of recent wars and randomly assigned to the Stay Strong app alone (n=179) or Stay Strong+Coaching (n=178); both programs lasted 12 months. Personalized coaching components for Stay Strong+Coaching comprised of automated in-app motivational messages (3 per week), telephone-based human health coaching (up to 3 calls), and personalized weekly goal setting. All aspects of the enrollment process and program delivery were accomplished virtually for both groups, except for the telephone-based coaching. The primary outcome was change in physical activity at 12 months postbaseline, measured by average weekly Active Minutes, captured by the Fitbit Charge 2 device. Secondary outcomes included changes in step counts, weight, and patient activation. Results: The average age of participants was 39.8 (SD 8.7) years, and 25.2\% (90/357) were female. Active Minutes decreased from baseline to 12 months for both groups (P<.001) with no between-group differences at 6 months (P=.82) or 12 months (P=.98). However, at 12 months, many participants in both groups did not record Active Minutes, leading to missing data in 67.0\% (120/179) for Stay Strong and 61.8\% (110/178) for Stay Strong+Coaching. Average baseline weight for participants in Stay Strong and Stay Strong+Coaching was 214 lbs and 198 lbs, respectively, with no difference at baseline (P=.54) or at 6 months (P=.28) or 12 months (P=.18) postbaseline based on administrative weights, which had lower rates of missing data. Changes in the number of steps recorded and patient activation also did not differ by arm. Conclusions: Adding personalized health coaching comprised of in-app automated messages, up to 3 coaching calls, plus automated weekly personalized goals, did not improve levels of physical activity compared to using a smartphone app alone. Physical activity in both groups decreased over time. Sustaining long-term adherence and engagement in this mHealth intervention proved difficult; approximately two-thirds of the trial's 357 participants failed to sync their Fitbit device at 12 months and, thus, were lost to follow-up. Trial Registration: ClinicalTrials.gov NCT02360293; https://clinicaltrials.gov/ct2/show/NCT02360293 International Registered Report Identifier (IRRID): RR2-10.2196/12526 ",
doi="10.2196/19216",
url="http://www.jmir.org/2020/8/e19216/",
url="http://www.ncbi.nlm.nih.gov/pubmed/32687474"
}


@Article{info:doi/10.2196/16372,
author="Faruqui, Akhter Syed Hasib
and Alaeddini, Adel
and Chang, C. Mike
and Shirinkam, Sara
and Jaramillo, Carlos
and NajafiRad, Peyman
and Wang, Jing
and Pugh, Jo Mary",
title="Summarizing Complex Graphical Models of Multiple Chronic Conditions Using the Second Eigenvalue of Graph Laplacian:  Algorithm Development and Validation",
journal="JMIR Med Inform",
year="2020",
month="Jun",
day="17",
volume="8",
number="6",
pages="e16372",
keywords="graphical models",
keywords="graph summarization",
keywords="graph Laplacian",
keywords="disease network",
keywords="multiple chronic conditions",
abstract="Background: It is important but challenging to understand the interactions of multiple chronic conditions (MCC) and how they develop over time in patients and populations. Clinical data on MCC can now be represented using graphical models to study their interaction and identify the path toward the development of MCC. However, the current graphical models representing MCC are often complex and difficult to analyze. Therefore, it is necessary to develop improved methods for generating these models. Objective: This study aimed to summarize the complex graphical models of MCC interactions to improve comprehension and aid analysis. Methods: We examined the emergence of 5 chronic medical conditions (ie, traumatic brain injury [TBI], posttraumatic stress disorder [PTSD], depression [Depr], substance abuse [SuAb], and back pain [BaPa]) over 5 years among 257,633 veteran patients. We developed 3 algorithms that utilize the second eigenvalue of the graph Laplacian to summarize the complex graphical models of MCC by removing less significant edges. The first algorithm learns a sparse probabilistic graphical model of MCC interactions directly from the data. The second algorithm summarizes an existing probabilistic graphical model of MCC interactions when a supporting data set is available. The third algorithm, which is a variation of the second algorithm, summarizes the existing graphical model of MCC interactions with no supporting data. Finally, we examined the coappearance of the 100 most common terms in the literature of MCC to validate the performance of the proposed model. Results: The proposed summarization algorithms demonstrate considerable performance in extracting major connections among MCC without reducing the predictive accuracy of the resulting graphical models. For the model learned directly from the data, the area under the curve (AUC) performance for predicting TBI, PTSD, BaPa, SuAb, and Depr, respectively, during the next 4 years is as follows---year 2: 79.91\%, 84.04\%, 78.83\%, 82.50\%, and 81.47\%; year 3: 76.23\%, 80.61\%, 73.51\%, 79.84\%, and 77.13\%; year 4: 72.38\%, 78.22\%, 72.96\%, 77.92\%, and 72.65\%; and year 5: 69.51\%, 76.15\%, 73.04\%, 76.72\%, and 69.99\%, respectively. This demonstrates an overall 12.07\% increase in the cumulative sum of AUC in comparison with the classic multilevel temporal Bayesian network. Conclusions: Using graph summarization can improve the interpretability and the predictive power of the complex graphical models of MCC. ",
doi="10.2196/16372",
url="http://medinform.jmir.org/2020/6/e16372/",
url="http://www.ncbi.nlm.nih.gov/pubmed/32554376"
}


@Article{info:doi/10.2196/18890,
author="Linden, Brooke
and Tam-Seto, Linna
and Stuart, Heather",
title="Adherence of the \#Here4U App -- Military Version to Criteria for the Development of Rigorous Mental Health Apps",
journal="JMIR Form Res",
year="2020",
month="Jun",
day="17",
volume="4",
number="6",
pages="e18890",
keywords="mental health services",
keywords="telemedicine",
keywords="mHealth",
keywords="chatbot",
keywords="e-solutions",
keywords="Canadian Armed Forces",
keywords="military health",
keywords="mobile phone",
abstract="Background: Over the past several years, the emergence of mobile mental health apps has increased as a potential solution for populations who may face logistical and social barriers to traditional service delivery, including individuals connected to the military. Objective: The goal of the \#Here4U App -- Military Version is to provide evidence-informed mental health support to members of Canada's military community, leveraging artificial intelligence in the form of IBM Canada's Watson Assistant to carry on unique text-based conversations with users, identify presenting mental health concerns, and refer users to self-help resources or recommend professional health care where appropriate. Methods: As the availability and use of mental health apps has increased, so too has the list of recommendations and guidelines for efficacious development. We describe the development and testing conducted between 2018 and 2020 and assess the quality of the \#Here4U App against 16 criteria for rigorous mental health app development, as identified by Bakker and colleagues in 2016. Results: The \#Here4U App -- Military Version met the majority of Bakker and colleagues' criteria, with those unmet considered not applicable to this particular product or out of scope for research conducted to date. Notably, a formal evaluation of the efficacy of the app is a major priority moving forward. Conclusions: The \#Here4U App -- Military Version is a promising new mental health e-solution for members of the Canadian Armed Forces community, filling many of the gaps left by traditional service delivery. ",
doi="10.2196/18890",
url="https://formative.jmir.org/2020/6/e18890",
url="http://www.ncbi.nlm.nih.gov/pubmed/32554374"
}


@Article{info:doi/10.2196/14116,
author="Saxon, Leslie
and DiPaula, Brooks
and Fox, R. Glenn
and Ebert, Rebecca
and Duhaime, Josiah
and Nocera, Luciano
and Tran, Luan
and Sobhani, Mona",
title="Continuous Measurement of Reconnaissance Marines in Training With Custom Smartphone App and Watch: Observational Cohort Study",
journal="JMIR Mhealth Uhealth",
year="2020",
month="Jun",
day="15",
volume="8",
number="6",
pages="e14116",
keywords="military",
keywords="marines",
keywords="wearable devices",
keywords="wearable technology",
keywords="smartphone",
keywords="mobile app",
abstract="Background: Specialized training for elite US military units is associated with high attrition due to intense psychological and physical demands. The need to graduate more service members without degrading performance standards necessitates the identification of factors to predict success or failure in targeted training interventions. Objective: The aim of this study was to continuously quantify the mental and physical status of trainees of an elite military unit to identify novel predictors of success in training. Methods: A total of 3 consecutive classes of a specialized training course were provided with an Apple iPhone, Watch, and specially designed mobile app. Baseline personality assessments and continuous daily measures of mental status, physical pain, heart rate, activity, sleep, hydration, and nutrition were collected from the app and Watch data. Results: A total of 115 trainees enrolled and completed the study (100\% male; age: mean 22 years, SD 4 years) and 64 (55.7\%) successfully graduated. Most training withdrawals (27/115, 23.5\%) occurred by day 7 (mean 5.5 days, SD 3.4 days; range 1-22 days). Extraversion, positive affect personality traits, and daily psychological profiles were associated with course completion; key psychological factors could predict withdrawals 1-2 days in advance (P=.009). Conclusions: Gathering accurate and continuous mental and physical status data during elite military training is possible with early predictors of withdrawal providing an opportunity for intervention. ",
doi="10.2196/14116",
url="https://mhealth.jmir.org/2020/6/e14116",
url="http://www.ncbi.nlm.nih.gov/pubmed/32348252"
}


@Article{info:doi/10.2196/16371,
author="Seelye, Adriana
and Leese, Isabelle Mira
and Dorociak, Katherine
and Bouranis, Nicole
and Mattek, Nora
and Sharma, Nicole
and Beattie, Zachary
and Riley, Thomas
and Lee, Jonathan
and Cosgrove, Kevin
and Fleming, Nicole
and Klinger, Jessica
and Ferguson, John
and Lamberty, John Greg
and Kaye, Jeffrey",
title="Feasibility of In-Home Sensor Monitoring to Detect Mild Cognitive Impairment in Aging Military Veterans: Prospective Observational Study",
journal="JMIR Form Res",
year="2020",
month="Jun",
day="8",
volume="4",
number="6",
pages="e16371",
keywords="aging",
keywords="mild cognitive impairment",
keywords="activities of daily living",
keywords="technology",
abstract="Background: Aging military veterans are an important and growing population who are at an elevated risk for developing mild cognitive impairment (MCI) and Alzheimer dementia, which emerge insidiously and progress gradually. Traditional clinic-based assessments are administered infrequently, making these visits less ideal to capture the earliest signals of cognitive and daily functioning decline in older adults. Objective: This study aimed to evaluate the feasibility of a novel ecologically valid assessment approach that integrates passive in-home and mobile technologies to assess instrumental activities of daily living (IADLs) that are not well captured by clinic-based assessment methods in an aging military veteran sample. Methods: Participants included 30 community-dwelling military veterans, classified as healthy controls (mean age 72.8, SD 4.9 years; n=15) or MCI (mean age 74.3, SD 6.0 years; n=15) using the Clinical Dementia Rating Scale. Participants were in relatively good health (mean modified Cumulative Illness Rating Scale score 23.1, SD 2.9) without evidence of depression (mean Geriatrics Depression Scale score 1.3, SD 1.6) or anxiety (mean generalized anxiety disorder questionnaire 1.3, SD 1.3) on self-report measures. Participants were clinically assessed at baseline and 12 months later with health and daily function questionnaires and neuropsychological testing. Daily computer use, medication taking, and physical activity and sleep data were collected via passive computer monitoring software, an instrumented pillbox, and a fitness tracker watch in participants' environments for 12 months between clinical study visits. Results: Enrollment began in October 2018 and continued until the study groups were filled in January 2019. A total of 201 people called to participate following public posting and focused mailings. Most common exclusionary criteria included nonveteran status 11.4\% (23/201), living too far from the study site 9.4\% (19/201), and having exclusionary health concerns 17.9\% (36/201). Five people have withdrawn from the study: 2 with unanticipated health conditions, 2 living in a vacation home for more than half of the year, and 1 who saw no direct benefit from the research study. At baseline, MCI participants had lower Montreal Cognitive Assessment (P<.001) and higher Functional Activities Questionnaire (P=.04) scores than healthy controls. Over seven months, research personnel visited participants' homes a total of 73 times for technology maintenance. Technology maintenance visits were more prevalent for MCI participants (P=.04) than healthy controls. Conclusions: Installation and longitudinal deployment of a passive in-home IADL monitoring platform with an older adult military veteran sample was feasible. Knowledge gained from this pilot study will be used to help develop acceptable and effective home-based assessment tools that can be used to passively monitor cognition and daily functioning in older adult samples. ",
doi="10.2196/16371",
url="https://formative.jmir.org/2020/6/e16371",
url="http://www.ncbi.nlm.nih.gov/pubmed/32310138"
}


@Article{info:doi/10.2196/16062,
author="Blonigen, Daniel
and Harris-Olenak, Brooke
and Kuhn, Eric
and Humphreys, Keith
and Timko, Christine
and Dulin, Patrick",
title="From ``Step Away'' to ``Stand Down'': Tailoring a Smartphone App for Self-Management of Hazardous Drinking for Veterans",
journal="JMIR Mhealth Uhealth",
year="2020",
month="Feb",
day="13",
volume="8",
number="2",
pages="e16062",
keywords="veterans",
keywords="hazardous drinking",
keywords="Step Away",
keywords="Stand Down",
keywords="peer support",
abstract="Background: US military veterans who screen positive for hazardous drinking during primary care visits may benefit from a mobile app. Step Away is an evidence-based mobile intervention system for the self-management of hazardous drinking. However, Step Away was not designed for veterans, and differences between veterans and civilians could limit the reach and effectiveness of the app with this population. Objective: The primary objective of this study was to repurpose Step Away to address the needs and preferences of the veteran primary care population. The Method for Program Adaptation through Community Engagement (M-PACE) model was used to guide the adaptation process. This model can serve as a generalizable approach that other researchers and intervention developers can follow to systematically tailor mobile health tools for a new population. Methods: Veteran patients who screened positive for hazardous drinking during a primary care visit (n=12) and peer providers employed by the US Veterans Health Administration (n=11) were recruited to systematically review Step Away and provide feedback on its content and presentation via Web-based surveys and a semistructured interview. Participant feedback was reviewed through an iterative process by key stakeholders who adjudicated which suggested modifications to the app could enhance engagement and effectiveness with veterans while maintaining program integrity. Results: Usability ratings of the individual modules of Step Away were uniformly positive across patients and peers, as was the perceived utility of the app overall. Personalized feedback on the health consequences and costs of drinking, options for customization, and the measurement-based care capabilities of the app were viewed as facilitators of engagement. Conversely, lengthy text, small font, and a lack of interactive features were viewed as potential barriers with the older primary care population. Modifications to create a veteran version of the app (Stand Down: Think Before You Drink) included altering the appearance of the app to incorporate more veteran-centric content, adding links and options for resources and activities for veterans, and reducing the amount of text and adding veteran-specific references and common concerns and triggers for drinking in this population. Conclusions: The M-PACE model provided a systematic approach to repurpose Step Away to fit the needs and preferences of veteran primary care patients who engage in hazardous drinking. Stand Down may serve as an innovative, low-cost means of expanding access to care for veterans who engage in hazardous drinking. ",
doi="10.2196/16062",
url="http://mhealth.jmir.org/2020/2/e16062/",
url="http://www.ncbi.nlm.nih.gov/pubmed/32053118"
}


@Article{info:doi/10.2196/ijmr.2748,
author="Yavnai, Nirit
and Huerta-Hartal, Michael
and Mimouni, Francis
and Pinkert, Moshe
and Dagan, David
and Kreiss, Yitshak",
title="Military Medicine Publications: What has Happened in the Past Two Decades?",
journal="Interact J Med Res",
year="2014",
month="May",
day="28",
volume="3",
number="2",
pages="e10",
keywords="military medicine",
keywords="publication types",
keywords="trend",
abstract="Background: Military medical personnel, like all other physician specialists, face the challenge of keeping updated with developments in their field of expertise, in view of the great amount of new medical information published in the literature. The availability of the Internet has triggered tremendous changes in publication characteristics, and in some fields, the number of publications has increased substantially. The emergence of electronic open access journals and the improvement in Web search engines has triggered a significant change in the publication processes and in accessibility of information. Objective: The objective of this study was to characterize the temporal trends in the number and types of publications in military medicine in the medical literature. Methods: We searched all PubMed-registered publications from January 1, 1990 to December 31, 2010 using the keywords ``military'' or ``army''. We used the publication tag in PubMed to identify and examine major publication types. The trends were tested using the Mann-Kendall test for trend. Results: Our search yielded 44,443 publications in military medicine during the evaluation period. Overall, the number of publications showed two distinct phases over time: (1) a moderate increase from 1990 to 2001 with a mean annual increase of 2.78\% (r2=.79, P<.002), and (2) a steeper mean annual increase of 11.20\% (r2=.96, P<.002) from 2002 to 2010. Most of the examined publication types showed a similar pattern. The proportion of high-quality-of-evidence publication types (randomized controlled trials, systematic reviews, and meta-analyses) increased from 2.91\% to 8.43\% of the overall military medicine publications with a mean annual incremental increase of 14.20\%. These publication types demonstrated a similar dual phase pattern of increase (10.01\%, r2=.80, P<.002 for 1990-2001 and 20.66\%, r2=.88, P<.002 for 2002-2010). Conclusions: We conclude that over the past twenty years, scholarly work in the field of military medicine has shown a significant increase in volume, particularly among high quality publication types. However, practice guidelines remain rare, and meta-analyses are still limited in number. ",
doi="10.2196/ijmr.2748",
url="http://www.i-jmr.org/2014/2/e10/",
url="http://www.ncbi.nlm.nih.gov/pubmed/24870264"
}


@Article{info:doi/10.5210/ojphi.v5i1.4489,
title="Roles of Health Literacy in Relation to Social Determinants of Health and Recommendations for Informatics-Based Interventions: Systematic Review",
journal="Online J Public Health Inform",
year="2013",
volume="5",
number="1",
pages="e4489",
doi="10.5210/ojphi.v5i1.4489",
url=""
}


@Article{info:doi/10.5210/ojphi.v5i1.4406,
title="Roles of Health Literacy in Relation to Social Determinants of Health and Recommendations for Informatics-Based Interventions: Systematic Review",
journal="Online J Public Health Inform",
year="2013",
volume="5",
number="1",
pages="e4406",
doi="10.5210/ojphi.v5i1.4406",
url=""
}


@Article{info:doi/10.5210/ojphi.v5i1.4414,
title="Roles of Health Literacy in Relation to Social Determinants of Health and Recommendations for Informatics-Based Interventions: Systematic Review",
journal="Online J Public Health Inform",
year="2013",
volume="5",
number="1",
pages="e4414",
doi="10.5210/ojphi.v5i1.4414",
url=""
}


@Article{info:doi/10.5210/ojphi.v5i1.4454,
title="Roles of Health Literacy in Relation to Social Determinants of Health and Recommendations for Informatics-Based Interventions: Systematic Review",
journal="Online J Public Health Inform",
year="2013",
volume="5",
number="1",
pages="e4454",
doi="10.5210/ojphi.v5i1.4454",
url=""
}