Addressing Social Determinants of Health Among Rural Veterans
Project Number1I01HX003492-01
Contact PI/Project LeaderGUREWICH, DEBORAH
Awardee OrganizationVA BOSTON HEALTH CARE SYSTEM
Description
Abstract Text
Background: Rural Veterans represent over one third of all Veterans served by the Department of Veterans
Affairs and rural America is strikingly different than urban areas with respect to the social and economic
conditions that drive health. Based on research documenting the relationship between social adversity (e.g.,
homelessness, food insecurity) and health, policy makers suggest routine screening and referral (S&R) for
unmet social and economic needs (hereafter: “unmet needs”) in the clinical setting. This call has catalyzed a
small but promising evidence base, indicating that efficacy of S&R. However, the S&R evidence base focuses
on unmet needs in urban settings. This means we lack the knowledge needed to adapt unmet need S&R for
the unique needs of rural VA settings and the rural Veterans they serve.
Significance: Our study addresses the HSR&D priorities to mitigate the unmet needs of Veterans and to
integrate heath care solutions as much as possible into existing care, rather than depending on new personnel
and resources. This study will advance these priorities by adapting the specifications of evidence-based S&R
to align with existing unmet needs and unmet need resources in rural VA settings. This study will also establish
a process for adapting S&R that can be replicated across VISNs and facilities.
Innovation and Impact: This research is highly innovative as we know of no research that is implementing
unmet need interventions for rural Veterans. We will provide novel knowledge about unmet needs among rural
Veterans, the mechanism by which these needs manifest, and the social service infrastructure within the VA
and community that serve rural Veterans. Our research is also innovative in our use of user-centered design
(UCD) methods to adapt the specifications of an S&R intervention. Specifically, throughout the process of
adapting S&R to the target local sites, we will engage and solicit feedback from the eventual end-users,
including Veterans.
Specific Aims: 1) Determine unmet needs among rural Veterans and their associations with health outcomes;
2) Assess existing systems for addressing unmet needs and adapt S&R to fit local conditions and stakeholder
preferences; 3) Pilot test the adapted intervention and develop an Adaptation Playbook.
Methodology: Guided by the Replicating Effective Programs (REP) framework, we propose a 3-year mixed-
methods study. We will survey rural Veterans served by VISN 1 about their unmet needs and merge survey
data with secondary VA data to assess the scope and scale of unmet needs and their associations with health
care outcomes. We will conduct qualitative interviews with key stakeholders (Veterans, VA providers and staff,
representatives of community agencies) to understand how unmet needs manifest among rural Veterans, the
existing infrastructure for identifying unmet needs and referring for services, and opportunities and preferences
for adapting S&R. We will use the information gathered from these interviews and UCD methods to adapt the
specifications of S&R. Finally, we will pilot the adapted S&R intervention, refine as needed, and develop an
Adaptation Playbook detailing how other facilities can adapt S&R to their local conditions.
Next Steps/Implementation: Upon completion of the IIR, we will have moved through the first two of four REP
phases (pre-conditions and pre-implementation). By doing so, we will understand the key components
necessary for REP phases three and four, which will be the focus of future work (full-scale implementation of
the adapted S&R intervention and evaluation) in on-going collaboration with our operational partners the New
England Veterans Integrated Service Network, Office of Rural Health and Office of Social Work.
Public Health Relevance Statement
Given the strong relationship between social adversity (e.g., homelessness, food insecurity) and health, policy
makers suggest routine screening and referral (S&R) for unmet social and economic needs in the clinical
setting. This call has catalyzed a small but promising evidence base indicating that unmet need S&R can lead
to patients’ connection to resources, unmet need reduction, and potential improvements in health. However,
this evidence base focuses on unmet needs in urban settings. This means we lack the knowledge needed to
adapt unmet need S&R to the unique needs of rural VA facilities and the rural Veterans they serve. We
propose to examine unmet needs among rural Veterans, how they manifest, and the infrastructure available to
identify and address these needs. With this knowledge and in collaboration with the individuals in the setting
where the intervention will ultimately be implemented, the study will develop the specifications for the adapted
unmet need S&R intervention for rural Veterans. Future study will implement and evaluate the intervention.
NIH Spending Category
No NIH Spending Category available.
Project Terms
AccountingAddressCOVID-19Cardiovascular DiseasesCaringCharacteristicsClinicalCollaborationsCommunitiesDataDevelopmentDiseaseEconomic ConditionsEconomicsEffectivenessEpidemiologyEvaluationFeedbackFutureGoalsHealthHealth PolicyHealth Services ResearchHealthcareHomelessnessHuman ResourcesIndividualInfrastructureInterventionInterviewKnowledgeLeadLogisticsMedical centerMethodologyMethodsMissionModelingNew EnglandOutcomePatientsPhasePlant RootsPolicy MakerPopulationPositioning AttributePrevalenceProcessProviderRandomized Controlled TrialsReplicating Effective ProgramsResearchResourcesRiskRuralRural CommunityRural HealthScientific Advances and AccomplishmentsService settingServicesSiteSocial ConditionsSocial NetworkSocial WorkSuicideSurveysSystemTimeUnited States Department of Veterans AffairsVeteransVeterans Health AdministrationWorkbasecare outcomescomorbidityeconomic needeffectiveness implementation studyeffectiveness studyevidence baseexperiencefood insecurityhealth equityimplementation barriersimprovedinnovationnovelpilot testpreferenceresearch and developmentroutine screeningrural Americarural settingscreeningsocialsocial adversitysocial health determinantsurban areaurban settinguser centered design
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