# Collaborative tailoring of the Reach Out, Stay Strong Essentials (ROSE) program for pregnant veterans in the U.S. Veterans Health Administration: a qualitative case study of contextual conditions and adaptations

## TL;DR

This study explores how the ROSE program was adapted to better meet the mental health needs of pregnant veterans across U.S. VA sites.

## Contribution

The paper presents a pragmatic model for tailoring evidence-based interventions in large healthcare systems through collaborative adaptation.

## Key findings

- Sites reported high demand for ROSE due to gaps in mental health care for pregnant veterans.
- Adaptations included aligning ROSE with VA guidelines and expanding training to more providers.
- Co-produced adaptations improved feasibility and acceptability of ROSE delivery.

## Abstract

Reach Out, Stay Strong Essentials (ROSE) is an evidence-based intervention for preventing post-partum depression being implemented across U.S. Veterans Health Administration (VA) sites as part of the EMPOWER 2.0 implementation trial comparing Replicating Effective Programs (REP) and Evidence-Based Quality Improvement (EBQI) strategies for improving women’s health care. As both REP and EBQI support adaptation to meet local needs, the EMPOWER 2.0 implementation team and participating sites have collaboratively developed adaptations of ROSE to better serve pregnant veterans. We describe contextual conditions arising during the first three years of implementation, associated adaptations to the intervention and implementation approach, and implications for pragmatic tailoring and diffusion of evidence-based interventions.

We conducted a qualitative case study that included rapid qualitative analysis of 50 periodic reflections (brief guided discussions with templated notes) completed with EMPOWER 2.0 implementation team members February 2021-February 2024. Contextual conditions were characterized according to domains of the updated Consolidated Framework for Implementation Research (CFIR); adaptations were characterized using the Framework for Reporting Adaptations and Modifications to Evidence-Based Interventions (FRAME) and Framework for Reporting Adaptations and Modifications to Evidence-based Implementation Strategies (FRAME-IS).

Sites reported high demand for ROSE in response to perceived gaps in care for pregnant veterans’ mental health needs. Site-level challenges included the need to locate ROSE within existing services, although the salience of contextual conditions evolved across implementation phases. Notable adaptations included updates to the ROSE intervention (e.g., improving alignment with VA clinical practice guidelines) and adaptations to the implementation approach (e.g., offering training to VA providers beyond the original EMPOWER sites). Although the trial is ongoing, expansion of ROSE training has resulted in a total of 256 VA providers trained across 48 VA facilities nationwide.

In implementing ROSE across a national sample of VA sites, co-produced adaptations emerged to improve feasibility of delivery and increase acceptability of ROSE for pregnant veterans. Implementation of ROSE in EMPOWER 2.0 provides a pragmatic model for supporting rapid iteration and diffusion of adaptations to address perinatal mental health needs within large healthcare systems.

ClinicalTrials.gov: Enhancing Mental and Physical Health of Women Veterans (NCT05050266).

Registration Date: 09/09/2021.

https://clinicaltrials.gov/study/NCT05050266?term=EMPOWER%202.0&rank=1.