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RRP 11-434 – HSR Study

RRP 11-434
A Video Educational Intervention to Improve Outcomes of VA TBI Screening
Karen H Seal, MD MPH
San Francisco VA Medical Center, San Francisco, CA
San Francisco, CA
Funding Period: October 2012 - March 2014
VA nurses routinely conduct a first-level Traumatic Brain Injury (TBI) screen on all veterans returning home from deployment, but do not routinely offer post-screen counseling to explain what the screen means. Veterans who screen positive for TBI are referred for second-level TBI evaluation, yet many Veterans fail to follow-up. Veterans who screen negative for TBI often have other mental health problems, such as PTSD, and could benefit medical treatment or mental health referral. Consequently, the VA TBI screening process may raise Veteran awareness about brain injury, but fails to provide adequate information about common postconcussive and mental health symptoms, expected outcomes, or recovery expectations.

The main objective of this project was to develop and pilot two TBI educational videos that explain the meaning of positive and negative screen results. To achieve this objective, we proposed the following three specific aims:
Aim 1: To produce two educational TBI videos for use after the VA first-level TBI screen in primary care, one for Veterans who screen negative and one for those who screen positive.
Aim 2: To refine post-screen TBI educational videos for OEF/OIF/OND Veterans in primary care.
Aim 3: To evaluate the effect of the TBI educational videos. Hypothesis: In before/after comparisons, after viewing the TBI educational videos, Veterans will demonstrate greater knowledge about the meaning of a positive (or negative) TBI screen.
Aim 4: To pilot the use of the TBI educational videos in primary care with OEF/OIF/OND Veterans following the TBI first-level screen.

We designed a multi-phase, cross-sectional Hybrid Type 1 implementation study to develop and pilot test two new TBI screening educational videos. We employed a participatory process that engaged TBI experts, health care providers, and veterans. During Phase 1, we collected qualitative data from both focus groups and semi-structured interviews. We conducted separate focus groups for veterans who screened positive (n=4) and negative (n=14) for TBI, as well as focus groups with TBI experts and multidisciplinary providers (n=8). In addition, we conducted semi-structured interviews with key informants in leadership and administration (n=7). Results were analyzed using rapid qualitative analysis techniques to support the development of two scripts, one for positive and one for negative educational video content. In Phase 2, we hired a videographer to film and produce the two videos with professional actors. Before finalizing the video content and format, we conducted follow-up qualitative semi-structured interviews with Veterans who screened TBI positive (n=8) and TBI negative (n=8); and focus groups with TBI experts and multidisciplinary providers (n=5) as well as primary care nursing staff (n=20). These data were used to finalize video content and format, and to plan a dissemination strategy. In Phase 3, the educational videos were pilot tested with Veterans (n=4 to date) immediately after the nurse-administered TBI screen. Finally, in Phase 4, the videos are being disseminated nationally through a VA mobile application, "Concussion Coach", and we are preparing to upload them to several different VA websites.

In Phase 1, qualitative focus group with veterans confirmed that patients often do not understand what a health screen is, how a screen differs from other kinds of tests, and how results are subsequently used. When developing video scripts, veterans suggested incorporating understandable language that clearly explains the purpose of the TBI screen and its meaning. The TBI expert and health care provider focus groups provided suggestions to explain the TBI screen and how the results are used. Providers recommended that the videos cultivate a sense of hope regarding recovery from mild TBI. In Phase 2, we produced two 4-minute educational videos to be viewed by Veterans after positive and negative screen results. We conducted qualitative interviews with equal numbers of Veterans with both screen results. Qualitative analysis indicated that after seeing the videos on an iPad, veterans increased their understanding of TBI, the TBI screen, and the meaning of the screen results. Specifically, veterans demonstrated improved knowledge about the meaning of a TBI screen, though veterans who screened positive improved more. After viewing the video in a qualitative focus group, primary care nursing staff appreciated the educational content, but raised logistical concerns about incorporating videos into clinical work flow, citing lack of time, privacy concerns, and iPad accountability. In Phase 3, our small pilot demonstrated that incorporating the videos into the clinic visit is feasible, but required an additional 4-6 minutes. Further, we found that the videos may encourage veterans to discuss TBI or mental health symptoms with their providers, but primary care providers may not perceive a significant difference. Finally, in Phase 4, we are working to embed the videos into a VA/DoD sponsored mobile application, Concussion Coach, and online as part of the main VA website Mental Health website ( and the Veterans Health Library in the section that deals with TBI (,S,41381_VA).

This project used a participatory process with veteran, provider, and expert stakeholders to develop two original post-screening TBI educational videos. Educational TBI videos have the potential to improve veterans' knowledge of TBI, the TBI screening process, and the meaning of the TBI screen result. Multimedia educational videos may be an effective way to provide post-screening counseling to veterans, but logistical issues may prevent the wide-spread use of videos during clinical visits.

External Links for this Project

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None at this time.

DRA: Brain and Spinal Cord Injuries and Disorders
DRE: none
Keywords: none
MeSH Terms: none

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