Purpose: With the obesity epidemic ever increasing, the purpose of this quality improvement project is to assess if Veteran’s Administration (VA) primary care providers have knowledge of and/or application barriers of the Veteran’s Administration/Department of Defense Clinical Practice Guideline for Screening and Management of Overweight and Obesity (SMOOG) in the VA primary care clinic in southern Arizona. Background: The prevalence of obesity seen in adults in the U.S. escalated from 15% to 34%, which is more than double from 1980 to 2008. Active military and Veterans obesity rates rose in similar fashion. The implementation of practice guidelines is critical to effective treatment to counteract the rising rates of overweight and obesity. Adherence to clinical practice guidelines often remains low causing an omission of therapies recommended in the guidelines. Methods: This quality improvement project used a descriptive methodology. Initially, SMOOG was evaluated using the AGREE II instrument. Next, a survey was administered to primary care providers to identify provider knowledge of and barriers to utilization of the SMOOG guidelines. Inclusion criteria for this study are: VA employed primary care provider and practicing primary care for at least 1 year. The 20-question survey measured providers’ knowledge and perceptions of their use of the VA/DoD SMOOG. Results: Evaluation using the AGREE II tool revealed the lowest possible quality scores observed in the Applicability domain. Based upon the results of the evaluation SMOOG is recommended for use with modifications specifically improving its applicability. Fifteen primary care providers participated in the survey. The results revealed that few primary care providers use SMOOG in clinical practice and barriers exist to implementation of SMOOG. Conclusions: Assessing providers’ knowledge, perceptions, and barriers to SMOOG provides insight towards the next steps in addressing the rising prevalence of obesity among U.S. Veterans. An appraisal of SMOOG revealed that the guideline was developed with a high quality in the areas of evidence and clear presentation, but is clearly deficient in its applicability of implementation of the recommendations. The data obtained serves as an initial step to inform future research into synthesizing and guiding an implementation strategy.

Essentially, the subject of this thesis is the problem of multiple hospital admissions, and the possible psychosocial etiology of these admissions. Chronic readmissions to hospital are of concern to social workers, to hospital personnel, and to the wider community, in view of the numerous and varied concommitant problems which may involve not only the patient, but any number of other persons or projects in the community. A survey of the several hundred referrals made to the Medical Social Service Department at Shaughnessy Hospital, Vancouver, during the fiscal year studied (1952-53) points up the fact that more than half of this referral group constitutes patient readmissions, and that at least one-quarter of the readmitted group might be considered as having a chronic readmission pattern. The manner in which this present study is approached is through detailed examination of data on district office files and medical social service case records, relative to a group of fifty-one veteran patients with a chronic readmission pattern, referred to the Medical Social Service Department at Shaughnessy, for varied medical-social problems. Findings of this study indicate that psychosocial factors, at least among the group selected, weigh heavily in a pattern of chronic hospital readmissions. Judging from the retarded referrals, there does not seem to be a sufficient awareness, on the part of a number of hospital personnel, that the admission pattern of many veterans contains a substantial psychosocial element, and/or if such is realized, that medical social services might be beneficial in rehabilitating the patients concerned. The onus for remedying this situation lies not only with the staff of the Medical Social Service Department at Shaughnessy, but with administration, with the medical staff, and with all DVA personnel interested in helping the veteran to function adequately outside the hospital setting. / Arts, Faculty of / Social Work, School of / Graduate

Vitamin D deficiency (25(OH)D < 20 ng/mL) is likely to be present in about 40% of veterans and is associated with much higher health care costs and service use. The prevalence of vitamin D deficiency is likely to be higher in certain subgroups such as ethnic minorities, those who are chronically ill, and nursing home residents. The lack of adequate sunlight exposure and poor dietary intake are common contributors to this deficient state. Moreover, vitamin D deficiency has also been noted in individuals taking vitamin D supplements within the recommended daily intake. To achieve a 25(OH)D value in the normal range (30-100 ng/mL), many studies indicate a much higher daily oral intake than currently recommended is needed. Inadequate vitamin D dosing may account for failure of some studies to show a benefit. Testing for vitamin D insufficiency levels remains suboptimal and serial monitoring in veterans to assess if a vitamin D-replete state has been achieved also remains less than adequate. The lack of evidence-based guidelines for testing and monitoring has hampered optimal management of this very common condition. The cardiovascular, immunologic, anti-infective, and oncologic benefits of a vitamin D-replete state are becoming recognized. Achieving a vitamin D-replete state may prolong longevity. Achieving adequate vitamin D status in US veterans is an important health measure that should be undertaken.

The purpose of this two phase policy alignment analysis is to evaluate the degree to which the Interstate Compact on Educational Opportunity for Military Dependent Children has been aligned in the Virginia Compact statute and the degree to which three school divisions heavily populated by military dependent students have aligned local school policy to the statute. The Interstate Compact was intended to mitigate the transitional challenges military dependent students experienced as they navigated a patchwork of local policies through the establishment of aligned state statute in all states to add a layer of uniform policy in each school system. School personnel rely on local school policy to provide uniform guidance for student records and enrollment, placement and attendance, eligibility, and graduation. This qualitative approach used document analysis to first compare the content of the Interstate Compact to the Virginia statute, then second, analyzed local school division policy documents using priori codes derived from the Virginia statute to determine the degree of alignment to the Virginia statute. The findings reveal a loose coupling of state statute to local policy impacting military dependent students. The Compact was developed collaboratively at the national level, however gaps in policy alignment at the local level may continue to hinder school personnel from providing uniform guidance according the data from this policy analysis.

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Suicide is a significant public health concern in the U.S., with over 40,000 suicides reported in 2014. For veterans, risk for suicide is even greater; for instance, of the over 40,000 suicides in 2014, 18% were comprised of veterans, although veterans account for only 8% of the U.S. population. Heightened suicide risk in veterans may be due to increased exposure to trauma (e.g., military sexual trauma, combat) and its negative cognitive-emotional sequelae (i.e., shame, guilt, PTSD). However, not all veterans who experience these negative symptoms manifest suicide risk, potentially due to the presence of protective factors. One such factor, self-compassion, involves responding to oneself in a caring and helpful manner in times of distress and may buffer against suicide risk by allowing the individual to look past global negative self-evaluations (i.e., shame), breaking the ruminative cycle over past actions (i.e., guilt), and helping to alleviate PTSD symptoms. This premise, however, has not been tested. We hypothesized that shame/guilt and PTSD symptoms (in two separate models) would mediate the relation between self-compassion and suicide risk, such that higher levels of self-compassion will be associated with lower levels of shame/guilt and, in turn, to decreased PTSD symptoms and reduced suicide risk. Participants (N=317; 65.6% male (n=208); 83.6% Caucasian (n=265), Mean Age=47.54, SD=16.34) were community-dwelling veterans who self-identified as having experienced a trauma, and completed the Self-Compassion Scale-Short Form, Differential Emotions Scale-IV, PTSD Checklist-Military Version, and the Suicide Behaviors Questionnaire-Revised. Bivariate correlations and serial mediation analyses were conducted covarying age, sex, ethnicity, VHA usage, service era, and depressive symptoms. Supporting hypotheses, in serial mediation analyses (10000 bootstrapped samples), the direct effect of self-compassion on suicide risk was reduced, but remained significant, when shame and PTSD symptoms (Model 1; c'=-.846, p=.002, CI=-1.39 to -.306) and guilt and PTSD symptoms (Model 2; c'=-.588, p=.043, CI=-1.15 to -.020), were added as mediators, indicating mediation. Further, there were significant total and specific indirect effects in both models. Our results suggest that the relation between self-compassion and suicide risk may be due, in part, to beneficial changes in cognitive-emotional factors and subsequent decreased severity of PTSD symptoms. Engaging in self-kindness and mindfulness may provide a more-balanced, rather than judgmental and overly-responsible, view of one’s self, thereby reducing risk for psychopathology and suicide. Our findings may have clinical implications. Encouraging the development of self-compassion (e.g., Mindful Self-Compassion, Compassion-Focused Therapy) and addressing shame, guilt, and PTSD symptoms (e.g., Cognitive Processing Therapy, Adaptive Disclosure), may reduce suicide risk in the veteran population.

This project reports on the results of a study that investigated the social networking use of student and non-student veterans, with a particular focus on the narrative building and identity presentation practices involved in this use. In this dissertation, I argue that stereotypical and exclusionary tropes of the veteran, such as the veteran as war hero and the veteran as wounded warrior, are damaging to our veterans and to others, in both the society and the classroom. However, through the detailed analysis of survey data and data collected from an interview and social networking profile tour with one student veteran participant, I highlight the exclusionary nature of these tropes and argue that the complex digital narratives crafted in social networking spaces can offer resistance to popular tropes of the veteran. The complexity of my participants' digital narratives also offers support for the argument that elements of one's social networking profiles, when viewed independently and decontextualized, can lead to invalid and unfair assumptions about the users' identity. Additionally, I argue that, for my participants, many of whom demonstrated a nuanced and critical understanding of audience, decisions to self-identify as military personnel in social networking spaces are intertwined with perceptions of privacy. Finally, this project culminates in the identification of a number of digital literacy practices present in my participants' social networking use, as well as a set of pedagogical and programmatic recommendations for writing teachers and writing program administrators interested in aiding student veterans in the process of transition and reintegration.

The negative effects of traumatic combat experiences on combatants' psychological functioning is well documented in the literature. The Global War on Terrorism (GWOT) has resulted in many veterans returning from deployments with mental health conditions related to trauma exposure, such as posttraumatic stress disorder, depression, general anxiety, and suicidality. Past researchers found significant ethnic differences in psychological functioning, with Latino-American veterans reporting more symptoms of PTSD. Furthermore, Latino-American cultural values place importance on collective orientation and secrecy of mental health concerns which may affect treatment. Thus, this study built on limited research about Latino-American male combat veterans by focusing on the effects of social support and working therapeutic alliance during mental health treatment. Using a cross-sectional design, a sample of 42 GWOT Latino-American Veterans undergoing mental health treatment at a VA Medical Center in the Southeastern U.S. was recruited and surveyed. Participants completed a set of nine questionnaires (Beck Scale for Suicidal Ideation, PTSD Checklist – Military Version, Beck Depression Inventory – 2nd Edition, Beck Anxiety Inventory, Postdeployment Social Support Scale, Combat Exposure Scale, Working Alliance Inventory – Short Form. Network Orientation Scale, and Multidimensional Scale of Perceived Social Support). Descriptive and bivariate statistics were calculated, and regression models were tested. The results indicate that social support improved overall PTSD and intrusive symptoms, separately, but working therapeutic alliance had a marginal effect on avoidance symptoms. Working alliance was found to exert a negative effect on depressive symptoms. The study did not yield evidence to support significant effects of social support or working alliance on suicidality and generalized anxiety. These results have implications for mental health service systems and for future research. Therapists serving veterans with PTSD should work with the patient/client to increase perceived social support. When serving veterans with depressive symptoms, therapists should place special effort on developing a strong working alliance.

This dissertation examined the relationship between meaningful employment and self-esteem in male veterans. Meaningful employment is an important element of reintegration, the process all veterans go through to transition from active duty military service back into society. Reintegration involves three major areas: physical and mental health, employment, and family and friend relationships. A sample of 30 male veterans were interviewed. After the interviews, two instruments were used to further examine the variables (meaningful employment and self-esteem). The instruments were administered to measure the individual's perception regarding meaningful employment and level of self-esteem. The interviews were the primary focus, with the instruments providing additional evidence to support the information gathered in the interviews. This mixed-methods study involved analyzing the interviews for consistent themes related to answering the research questions and, through systematic coding, identifying and categorizing the connectivity of concepts and trends. The two instruments were analyzed using cross-tabulations to triangulate information gathered in the interviews. A significant correlation was found between meaningful employment and self-esteem in male veterans. The study also identifies traits male veterans consider necessary for employment to be meaningful. Future studies should examine the relationship between meaningful employment and veteran suicides.