HHS Public Access Author manuscript Author Manuscript
Mil Med. Author manuscript; available in PMC 2017 February 01. Published in final edited form as: Mil Med. 2016 February ; 181(2): 106–110. doi:10.7205/MILMED-D-14-00685.
Veterans’ Preferences for Receiving Information about VA Services: Is Getting the Information You Want Related to Increased Healthcare Utilization? CJ Eubanks Fleming, PhD1,2, Eric F. Crawford, PhD2,1, Patrick S. Calhoun, PhD2,1, Harold Kudler, MD2,1, and Kristy A. Straits-Troster, PhD3,1 1Duke
Author Manuscript
University Medical Center, Department of Psychiatry & Behavioral Sciences, 2213 Elba St. Durham, NC 27705
2Veterans
Affairs Mid-Atlantic Region Mental Illness Research, Education and Clinical Center, 508 Fulton St. Durham, NC 27705 3Phoenix
Veterans Affairs Healthcare System, 650 E Indian School Rd. Phoenix, AZ 85012
Abstract
Author Manuscript
Although the current cohort of returning veterans has engaged more fully with care from the Department of Veterans Affairs (VA) than have veterans from previous eras, concern remains regarding low engagement with VA services,1 particularly for specialty services for diagnoses that can most negatively impact quality of life. The current study used the framework of the Andersen model2 to examine factors related to VA healthcare use in Operation Enduring Freedom/Operation Iraqi Freedom (OEF-OIF) veterans. Match between veterans’ preferences for source of information about VA programs and veterans’ actual sources of information about VA services was examined as an additional predictor of help seeking. The study included 1,161 veterans recruited from the southeast United States. Results suggested that veterans prefer to receive information from VA publications and the web, while they actually receive information from VA publications and other veterans. Logistic regression suggested that number of deployments, income, distance to VA, VA disability rating, self-rated health, and match between preferred source of information and actual source of information were significantly related to use of VA services since deployment. These results suggest that future outreach efforts should focus on targeting veterans’ health needs and preferences for care and source of information.
Author Manuscript
Keywords Veterans Affairs; Veterans; Health Care Preferences; Help Seeking; Andersen Model Access to and utilization of Department of Veterans Affairs (VA) Healthcare are issues that have garnered significant attention. Recent analyses have suggested that a majority (59%) of veterans serving in support of Operations Iraqi or Enduring Freedom (OEF-OIF) are enrolled in VA care, which represents an increase in use over past service eras3. For example, only about 20% of deployed Persian Gulf Veterans had enrolled in VA care by the year 2009.4 While recent policy changes have been enacted to improve access to services for veterans from all eras5, concerns remain regarding OEF-OIF veterans’ low engagement with
Fleming et al.
Page 2
Author Manuscript
VA services1 as well as specialty services for diagnoses that can most negatively impact quality of life, such as post-traumatic stress disorder6,7 (PTSD). For example, a 2004 study of returning veterans8 found that out of those veterans who screened positive for PTSD postdeployment, only 23% of OEF veterans and 29–40% of OIF veterans had received mental health services in the past year. The current study seeks to identify potential factors that might increase OEF-OIF veterans’ utilization of VA Healthcare, with a focus on how veterans prefer to receive information about VA programs.
Author Manuscript
Many studies have used the Andersen Model2,9 to describe access to health care10,11. This framework suggests that healthcare utilization is related to predisposing factors, such as demographic variables, enabling factors, such as income and health insurance, and need factors, including mental and physical health problems. A study of Vietnam veterans examined the Andersen Model in the prediction of any healthcare use over the prior 6 months, and indicated that although predisposing and enabling factors including age, income, and combat exposure were significantly related to mental and physical healthcare use, that the need variables were most strongly related to healthcare use11. A similar study based on the 2001 National Survey of Veterans found that older age, male gender, minority racial status, lower levels of education, unmarried status, combat exposure, lower income, lack of insurance, and overall greater symptom severity were all related to increased help seeking10. This study also found that need-based variables were the most significant predictors of utilization. Although the model has not been formally tested in OIFOEF veterans, a recent study of mental health care utilization in returning veterans found that probable need for services, income, combat exposure, and perceptions of VA care were significantly related to use12.
Author Manuscript Author Manuscript
A majority of the research addressing healthcare utilization in returning veterans has focused on barriers to care such as cost, stigma, and health beliefs, with the intention of identifying targets for intervention for overcoming these barriers1,13. Relatively recent research has begun to focus additionally on veterans’ preferences for care, with an eye towards creating tailored programs and outreach14,15 that might draw patients towards needed care. In a qualitative study of veterans who had an active disability claim for PTSD, veterans reported that acceptance of diagnosis, availability of help, treatment encouraging beliefs, system facilitation, and social network encouragement were the major issues that factored into their treatment seeking14. In a national sample of OIF-OEF veterans, Sayer et al further found that veterans enrolled in VA care were highly interested in receiving information on VA services, particularly information on benefits (83%), occupational assistance (80%), selfhelp materials (75%), educational classes (62%) and individual therapy (61%). This research also suggested that veterans preferred information about VA services from the VA (57%), on the Internet (53%) or by mail (53%) or e-mail (43%). These studies bring to light the importance of attention to veterans’ preferences for care and information, but to date, only limited research has examined the relationship between veterans’ healthcare preferences and actual help seeking behavior16. The current study uses the framework of the Andersen model to investigate the potential role of veterans’ preferences for receiving information about VA programs in relation to their use of VA
Mil Med. Author manuscript; available in PMC 2017 February 01.
Fleming et al.
Page 3
Author Manuscript
programs. In particular, the current research examines the match between veterans’ preferred method of receiving information (e.g. television, website) and how they actually received this information. The researchers hypothesize that match between preference for and actual receipt of information about VA programs will be positively related to veterans’ use of available services, in addition to the factors predicted by the Andersen Model.
Methods Participants
Author Manuscript
Participants included 1,161 OIF-OEF veterans recruited from the VA Veterans Integrated Service Network 6 covering North Carolina and parts of Virginia and West Virginia. Veterans had an average age of 39 years(standard deviation [SD] = 9.9), an average income of $54,500 (SD = 33,000), and an average of 1.6 deployments (SD = 0.9). For further descriptive statistics, see Table 1. Recruitment and Procedures A list of potential separated active duty personnel, National Guard members and Reservists who had deployed to Iraq or Afghanistan was obtained from the Defense Manpower Data Center. Out of approximately 70,000 eligible veterans in the Veterans Integrated Service Network 6 area, 5,000 were randomly sampled. Out of the 5,000 surveys, 1.4% were uncompleted due to extenuating circumstances, 18.5% were undeliverable, and 80% were successfully delivered. Of the 4,004 surveys that were delivered, 1161 were completed and returned for a final cooperation rate of 29%.
Author Manuscript
A survey contractor was used throughout the study to enhance privacy protections, so no identifying information was obtained by study researchers. A Dillman Total Design Method17 was used, and participants were first sent an alert letter 1 week in advance of the study informing them of the nature and purpose of the research project. They then received the survey package which included the survey as well as a cover letter with study contact information, informed consent and confidentiality information. A follow-up packet was mailed if the veteran had not responded within 5 weeks, and veterans were considered nonresponders if they did not respond within 5 weeks of the second survey mailing. This study was approved by the Durham VA Medical Center Institutional Review Board and the VA Office of Management and Budget. Measures
Author Manuscript
The complete survey consisted of questions regarding demographic information, military history, rating of physical and mental health, and health care service utilization. The selection of items was informed by qualitative needs assessment utilizing six 10–12 person focus groups18. In this study, the outcome variable of interest was binary response to the question, “Since your last deployment, have you used VA for healthcare services?” Also examined were predisposing factors including gender, ethnicity, marital status, and number of deployments in addition to the enabling variable of income. Need for services was represented by level of VA disability, rated on a scale from 0% to 100% disability in increments of 10%, and on self-reported rating of health ranging from Excellent to Poor.
Mil Med. Author manuscript; available in PMC 2017 February 01.
Fleming et al.
Page 4
Author Manuscript
At the conclusion of the survey, veterans were asked to respond to the following question, “People learn about VA programs from different sources. Did you receive any information about VA programs from the following sources?” and asked to indicate yes/no if they had received information from: newspapers, TV, radio, VA information or publications, other government publications, other veterans, discharge counseling, Posdeployment Health Reassessment (PDHRA), veterans’ organizations, website, friends/family/co-workers, chaplain/religious leader, command/superiors, family readiness groups, combat stress control/behavioral health contacts, toll-free hotline, Military OneSource, or other. They were then asked, “In the last column above, please indicate how you would prefer to receive information in the future.” For the purposes of this study, a variable was computed that represented a count of the number of matches between the format in which veterans received information about VA programs vs. the format in which they would prefer to receive such information.
Author Manuscript
Data Analysis Individual items were initially examined to determine veterans’ preferences for information source as well as the number of matches between their preferences for and actual receipt of information. A chi-square test was used to examine the relationship between match and service utilization, and a multivariate logistic regression was used to predict service utilization with demographics, need variables, and match factors included as covariates.
Results
Author Manuscript
Results were first analyzed by examining the relative frequencies of how veterans actually received information about VA programs versus how veterans would prefer to receive information about VA programs (See Table II). Frequency data indicated that most veterans received information through VA publications, and most veterans also preferred this method of communication. However, relatively few veterans indicated a preference for receiving information from other veterans and from discharge counseling, although the number receiving information in these formats was quite high.
Author Manuscript
Preliminary analysis of the relationship between information source match and VA use revealed a significant chi-square, X2(1) = 3.47, p < .05 (1 sided), and indicated that 207 veterans in this study had used VA services since deployment and had at least 1 match between how they preferred to receive information and how they actually received information. An exploratory logistic regression was then performed with gender, racial status, age, marital status, number of deployments, information source match, employment status, income, distance to closest VA hospital, self-reported health level, and VA disability level as predictors of VA health care use. Although the overall model was significant X2(6, N=1070) = 245.88, p < .001, a number of the predictors were not, including gender, age, race, marital status, and employment status (p = .43 – .89). The model was respecified using only the significant predictors, and the results of this analysis are presented in Table III. Predisposing factors (i.e. number of deployments), enabling factors (i.e. income, distance to VA), need factors (i.e. health rating and VA disability), and matched preferences for receiving information were each associated with VA
Mil Med. Author manuscript; available in PMC 2017 February 01.
Fleming et al.
Page 5
Author Manuscript
healthcare utilization. Odds ratios indicated that an increase in match in information source was related to a 13% increase in the likelihood of help seeking. Health status was the strongest predictor of VA healthcare use, with a decrease in health status increasing the likelihood of seeking help by 45%
Discussion
Author Manuscript
The results of this study both confirm and extend the application of the Andersen Model in a VA healthcare population. These results suggest that predisposing, enabling, and need factors, including number of deployments, income, distance to VA, health rating, and disability rating, are relevant predictors of VA service utilization. Notably, preferences for care also emerged as a key variable in the prediction of VA help seeking. Results suggest a strong relationship between service utilization and match between how veterans receive information about VA services versus how they would prefer to receive information, such that an increase in match of information source is related to an increase in service use. Although need, represented by disability and self-evaluation of health, was the strongest predictor of service use, these findings suggest that veterans’ preferences are an important component that should be considered in the modeling of help seeking behavior.
Author Manuscript
As stated, the variables representing need for care, including decreased rating of one’s health and increased level of disability, both predicted increases in help seeking as expected based on previous research12. The enabling factors in this study, including income and distance to closest VA, were also significant predictors of service use. Further distance to VA was related to decreased help seeking, confirming that access to care has an important relationship to use of care. Income was predictive of help seeking, but in an unexpected direction. Although income is typically seen as enabling the help seeking process2, in this study higher income led to less VA healthcare use. This is likely due to the higher rates of VA healthcare utilization by enlisted personnel and those without private insurance3,18.
Author Manuscript
The predisposing variable of exposure to combat was negatively related to service use in this study, which was surprising, given that combat exposure has been related to increased service use in previous research10. This discrepancy may be due to sampling. Whereas veterans in previous studies had a wide range of combat exposure, including many who had seen no combat, all veterans in the current study were deployed in the service of OIF/OEF. In light of this sample, it is possible that combat exposure is related to decreased service use due to increased barriers commonly associated with immersion in military culture such as reluctance to acknowledge problems and ask for help. Other predisposing factors, including gender, age, race, marital status, and employment status, were not related to VA healthcare use in this study. Results from past studies have been variable regarding the significance of similar demographic variables. However, this result is generally consistent with the finding that more treatment-related variables, such as need and preferences for care, have stronger relationships with service utilization than do predisposing variables. Overall, this study demonstrated that the Andersen Model is a relevant conceptualization of help-seeking behavior in the veteran population, with particular contributions from veteran characteristics reflecting need for and access to care. However, this study also suggests an
Mil Med. Author manuscript; available in PMC 2017 February 01.
Fleming et al.
Page 6
Author Manuscript
extension of this model to include veterans’ preferences for information about VA programs. Several recent articles14,15 have begun to call for attention to veterans’ preferences in our attempts to increase VA service utilization, and the current study again confirms that preferences are indeed a relevant factor in veterans’ use of care. Although many veterans are receiving information in a way in which they prefer, often from VA publications, results from this sample indicate that many veterans are receiving information in ways that they would not prefer (such as from other veterans), and that many veterans would like to receive more information from the web. It appears that one potential way to bridge the gap between veterans and the wide range of VA healthcare services available to them may be to tailor outreach and advertising campaigns to the preferences for receiving information as well as the most pressing health concerns of returning veterans.
Author Manuscript
The study is limited by a restricted response rate, and consequently, results should be interpreted cautiously. As with preferences for information about care, it appears that veterans in this era have relatively low response rates for paper-and-pencil techniques19 and may respond better to research queries online. Despite this limitation, sample characteristics closely map on to those of larger studies of OIF/OEF veterans1,20 and appear to match closely with figure representing veterans of this era. Future studies might focus on these issues at a national level, and could likely improve cooperation rates by employing data collection techniques that might appeal more to returning veterans. In conjunction with other recent studies addressing the critical role of veterans’ preferences for care, this study indicates the need for further research on the preferences for type of care and source of information about care in returning veterans of this era. Targeted marketing and outreach tailored to the current cohort’s preferences may play a key role in engaging this group of veterans in VA care.
Author Manuscript
References
Author Manuscript
1. Elbogen EB, Wagner H, Johnson SC, Kinneer P, Kang H, Vasterling J, Beckham J. Are Iraq and Afghanistan veterans using mental health services? New data from a national random-sample survey. Psychiatr Serv. 2013; 64(2):134–141. [PubMed: 23475498] 2. Andersen RM. Revisiting the behavioral model and access to medical care: does it matter? J Health Soc Behav. 1995; 36:1–10. [PubMed: 7738325] 3. Veterans Health Administration, Department of Veterans Affairs: Epidemiology Program, PostDeployment Health Group, Office of Public Health. Analysis of VA Health Care Utilization among Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn Veterans, from 1st Qtr FY 2002 through 2nd Qtr FY 2014. Washington, DC: 2014. Retrieved from: http:// www.publichealth.va.gov/docs/epidemiology/healthcare-utilization-report-fy2014-qtr1.pdf accessed August 4, 2014 4. U.S. Department of Veterans Affairs. Gulf War Era Veterans report: Pre 9/11. Retrieved from: www.va.gov/vetdata/docs/specialreports/gw_pre911_report.pdf accessed March 1, 2015 5. U.S. Department of Veterans Affairs. Accelerating Access to Care Initiative Fact Sheet. Retrieved from: http://www.va.gov/health/docs/052714AcceleratingAccessFactSheet.PDF accessed August 4, 2014 6. Milliken CS, Auchterlonie JL, Hoge CW. Longitudinal assessment of mental health problems among active and reserve component soldiers returning from the Iraq War. JAMA. 2007; 298(18) 7. Seal KH, Maguen S, Cohen B, Gima KS, Metzler TJ, Ren L, Bertenthal D, Marmar CR. VA mental health services utilization in Iraq and Afghanistan veterans in the first year of receiving new mental health diagnoses. J Trauma Stress. 2010; 23:5–16. [PubMed: 20146392]
Mil Med. Author manuscript; available in PMC 2017 February 01.
Fleming et al.
Page 7
Author Manuscript Author Manuscript Author Manuscript
8. Hoge CW, Castro CA, Messer SC, McGurk D, Cotting DI, Koffman RL. Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. N Engl J Med. 2004; 351:13–22. [PubMed: 15229303] 9. Andersen, RM. Behavioral Model of Families’ Use of Health Services. Chicago, IL: Center for Health Administration Studies, University of Chicago; 1968. Research Series No. 25 10. Elhai JD, Grubaugh AL, Richardson JD, Egede LE, Creamer M. Outpatient medical and mental healthcare utilization models among military veterans: Results from the 2001 National Survey of Veterans. J Psychiatr Res. 2008; 42:858–867. [PubMed: 18005993] 11. Maguen S, Schumm JA, Norris RL, Taft C, King LA, King DW, Litz B. Predictors or mental and physical health service utilization among Vietnam veterans. Psychol Serv. 2007; 4(3):168–180. 12. Di Leone BAL, Vogt D, Gradus JL, Street AE, Giasson HL, Resick PA. Predictors of mental health care use among male and female veterans deployed in support of the wars in Afghanistan and Iraq. Psychol Serv. 2013; 10(2):145–151. [PubMed: 23730960] 13. Wells TS, LeardMann CA, Fortuna SO, Smith B, Smith TC, Ryan MAK, Millennium Cohort Study Team. A prospective study of depression following combat deployment in support of the wars in Iraq and Afghanistan. Am J of Public Health. 2010; 100:90–99. [PubMed: 19910353] 14. Sayer NA, Friedemann-Sanchez G, Spoont M, Murdoch M, Parker LE, Chiros C, Rosenheck R. A qualitative study of determinants of PTSD treatment initiation in veterans. Psychiatry. 2009; 72:238–255. [PubMed: 19821647] 15. Crawford EF, Elbogen EB, Wagner HR, et al. Surveying treatment preferencesin U.S. Iraq– Afghanistan veterans with PTSD symptoms: a step toward veteran‐centered care. J Trauma Stress. 2015; 28(2):118–26. [PubMed: 25820339] 16. Sayer NA, Noorbaloochi S, Frazier P, Carlson K, Gravely A, Murdoch M. Reintegration problems and treatment interests among Iraq and Afghanistan combat veterans receiving VA medical care. Psychiatr Serv. 2010; 61:589–597. [PubMed: 20513682] 17. Dillman, DA. Mail and Internet Surveys: The Tailored Design Method (Volume 2). New York, NY: Wiley; 2000. 18. Straits-Troster, K.; Gierisch, JM.; Calhoun, PS.; Strauss, JL.; Voils, C.; Kudler, H. Living in transition: Young veterans’ health and the postdeployment shift to family life. In: Kelly, DC.; Howe-Barksdale, S.; Gitelson, D., editors. Treating young veterans: promoting resilience through practice and advocacy. New York, NY: Springer; 2011. 19. Shen Y, Hendricks A, Wang F, Gardner J, Kazis LE. The impact of private insurance coverage on veterans’ use of VA Care: Insurance and selection effects. Health Serv Res. 2008; 43(1):267–286. [PubMed: 18211529] 20. Eisen SV, Schultz MR, Vogt D, Glickman ME, Elwy AR, Drainoni ML, Martin J. Mental and physical health status and alcohol and drug use following return from deployment to Iraq or Afghanistan. Am J Public Health. 2012; 102:S66–S73. [PubMed: 22390605] 21. Calhoun PS, Elter JR, Jones ER, Kudler H, Straits-Troster K. Hazardous alcohol use and receipt of risk-reduction counseling among U.S. veterans of the wars in Iraq and Afghanistan. J Clin Psychiatry. 2008; 69:1686–1693. [PubMed: 19012816]
Author Manuscript Mil Med. Author manuscript; available in PMC 2017 February 01.
Fleming et al.
Page 8
Table 1
Author Manuscript
Descriptive Statistics N
%
Male
959
82.7
Female
196
16.9
White
818
70.5
African-American
198
17.1
Latino
78
6.7
Variable
Ethnicity
Author Manuscript
Other
79
7.1
Married
816
70.3
Unmarried
331
28.5
Dependent Children
727
64.5
No Dependents
412
35.5
Currently Employed
859
74.1
Currently Unemployed
301
25.9
None
612
52.8
0 – 40%
332
28.5
≥ 50%
182
15.79
Excellent
135
11.6
Very Good
304
26.2
Good
443
38.2
Fair
205
17.7
Poor
47
4.1
Reserves
219
18.9
National Guard
220
19.0
Active Duty
VA Disability Rating
Current Health Rating
Author Manuscript
Military Component
689
59.4
Officer
299
25.7
Enlisted
850
73.3
Army
567
48.9
Navy
249
21.5
Air Force
165
14.2
Marines
154
13.3
0
609
52.5
1
205
17.7
2
180
15.5
3
142
12.2
Military Branch
Author Manuscript
Match between preferred and actual info source
Mil Med. Author manuscript; available in PMC 2017 February 01.
Fleming et al.
Page 9
Author Manuscript
Variable
N
%
4+
24
2.0
No
756
65.2
Yes
404
34.8
Used VA Services since Deployment
Author Manuscript Author Manuscript Author Manuscript Mil Med. Author manuscript; available in PMC 2017 February 01.
Fleming et al.
Page 10
Table 2
Author Manuscript
Frequency Data Comparing Veterans’ Receipt of Information vs. Preferences for Information Source Source
% of Veterans that received info this way
% of Veterans that would prefer to receive info this way
VA Publications
74
37
Other Veterans
69
6
Counseling at Discharge
59
11
Internet
57
33
Author Manuscript Author Manuscript Author Manuscript Mil Med. Author manuscript; available in PMC 2017 February 01.
Author Manuscript
Author Manuscript
.37
.18
−.23
−.27
−.20
Health
VA Disability
Income
# Deployments
Distance to VA
7.65
8.97
54.72
72.00
20.03
.01
.00
.00
.00
.00
.03
Sig
.13
Match
4.63
B
Variable
Wald
28.2
1146.34
.82
.76
.79
1.20
1.45
1.13
Exp(B)
Nagelkerke R2
Overall Model
−2 Log Likelihood
.71–.94
.64–.91
.74–.84
1.15–1.25
1.23–1.70
1.01–1.27
95% CI
10.00
X2
Author Manuscript
Logistic Regression Predicting VA Healthcare Utilization
Author Manuscript
Table 3 Fleming et al. Page 11
Mil Med. Author manuscript; available in PMC 2017 February 01.
Mil Med. Author manuscript; available in PMC 2017 February 01. Published in final edited form as: Mil Med. 2016 February ; 181(2): 106–110. doi:10.7205/MILMED-D-14-00685.
Veterans’ Preferences for Receiving Information about VA Services: Is Getting the Information You Want Related to Increased Healthcare Utilization? CJ Eubanks Fleming, PhD1,2, Eric F. Crawford, PhD2,1, Patrick S. Calhoun, PhD2,1, Harold Kudler, MD2,1, and Kristy A. Straits-Troster, PhD3,1 1Duke
Author Manuscript
University Medical Center, Department of Psychiatry & Behavioral Sciences, 2213 Elba St. Durham, NC 27705
2Veterans
Affairs Mid-Atlantic Region Mental Illness Research, Education and Clinical Center, 508 Fulton St. Durham, NC 27705 3Phoenix
Veterans Affairs Healthcare System, 650 E Indian School Rd. Phoenix, AZ 85012
Abstract
Author Manuscript
Although the current cohort of returning veterans has engaged more fully with care from the Department of Veterans Affairs (VA) than have veterans from previous eras, concern remains regarding low engagement with VA services,1 particularly for specialty services for diagnoses that can most negatively impact quality of life. The current study used the framework of the Andersen model2 to examine factors related to VA healthcare use in Operation Enduring Freedom/Operation Iraqi Freedom (OEF-OIF) veterans. Match between veterans’ preferences for source of information about VA programs and veterans’ actual sources of information about VA services was examined as an additional predictor of help seeking. The study included 1,161 veterans recruited from the southeast United States. Results suggested that veterans prefer to receive information from VA publications and the web, while they actually receive information from VA publications and other veterans. Logistic regression suggested that number of deployments, income, distance to VA, VA disability rating, self-rated health, and match between preferred source of information and actual source of information were significantly related to use of VA services since deployment. These results suggest that future outreach efforts should focus on targeting veterans’ health needs and preferences for care and source of information.
Author Manuscript
Keywords Veterans Affairs; Veterans; Health Care Preferences; Help Seeking; Andersen Model Access to and utilization of Department of Veterans Affairs (VA) Healthcare are issues that have garnered significant attention. Recent analyses have suggested that a majority (59%) of veterans serving in support of Operations Iraqi or Enduring Freedom (OEF-OIF) are enrolled in VA care, which represents an increase in use over past service eras3. For example, only about 20% of deployed Persian Gulf Veterans had enrolled in VA care by the year 2009.4 While recent policy changes have been enacted to improve access to services for veterans from all eras5, concerns remain regarding OEF-OIF veterans’ low engagement with
Fleming et al.
Page 2
Author Manuscript
VA services1 as well as specialty services for diagnoses that can most negatively impact quality of life, such as post-traumatic stress disorder6,7 (PTSD). For example, a 2004 study of returning veterans8 found that out of those veterans who screened positive for PTSD postdeployment, only 23% of OEF veterans and 29–40% of OIF veterans had received mental health services in the past year. The current study seeks to identify potential factors that might increase OEF-OIF veterans’ utilization of VA Healthcare, with a focus on how veterans prefer to receive information about VA programs.
Author Manuscript
Many studies have used the Andersen Model2,9 to describe access to health care10,11. This framework suggests that healthcare utilization is related to predisposing factors, such as demographic variables, enabling factors, such as income and health insurance, and need factors, including mental and physical health problems. A study of Vietnam veterans examined the Andersen Model in the prediction of any healthcare use over the prior 6 months, and indicated that although predisposing and enabling factors including age, income, and combat exposure were significantly related to mental and physical healthcare use, that the need variables were most strongly related to healthcare use11. A similar study based on the 2001 National Survey of Veterans found that older age, male gender, minority racial status, lower levels of education, unmarried status, combat exposure, lower income, lack of insurance, and overall greater symptom severity were all related to increased help seeking10. This study also found that need-based variables were the most significant predictors of utilization. Although the model has not been formally tested in OIFOEF veterans, a recent study of mental health care utilization in returning veterans found that probable need for services, income, combat exposure, and perceptions of VA care were significantly related to use12.
Author Manuscript Author Manuscript
A majority of the research addressing healthcare utilization in returning veterans has focused on barriers to care such as cost, stigma, and health beliefs, with the intention of identifying targets for intervention for overcoming these barriers1,13. Relatively recent research has begun to focus additionally on veterans’ preferences for care, with an eye towards creating tailored programs and outreach14,15 that might draw patients towards needed care. In a qualitative study of veterans who had an active disability claim for PTSD, veterans reported that acceptance of diagnosis, availability of help, treatment encouraging beliefs, system facilitation, and social network encouragement were the major issues that factored into their treatment seeking14. In a national sample of OIF-OEF veterans, Sayer et al further found that veterans enrolled in VA care were highly interested in receiving information on VA services, particularly information on benefits (83%), occupational assistance (80%), selfhelp materials (75%), educational classes (62%) and individual therapy (61%). This research also suggested that veterans preferred information about VA services from the VA (57%), on the Internet (53%) or by mail (53%) or e-mail (43%). These studies bring to light the importance of attention to veterans’ preferences for care and information, but to date, only limited research has examined the relationship between veterans’ healthcare preferences and actual help seeking behavior16. The current study uses the framework of the Andersen model to investigate the potential role of veterans’ preferences for receiving information about VA programs in relation to their use of VA
Mil Med. Author manuscript; available in PMC 2017 February 01.
Fleming et al.
Page 3
Author Manuscript
programs. In particular, the current research examines the match between veterans’ preferred method of receiving information (e.g. television, website) and how they actually received this information. The researchers hypothesize that match between preference for and actual receipt of information about VA programs will be positively related to veterans’ use of available services, in addition to the factors predicted by the Andersen Model.
Methods Participants
Author Manuscript
Participants included 1,161 OIF-OEF veterans recruited from the VA Veterans Integrated Service Network 6 covering North Carolina and parts of Virginia and West Virginia. Veterans had an average age of 39 years(standard deviation [SD] = 9.9), an average income of $54,500 (SD = 33,000), and an average of 1.6 deployments (SD = 0.9). For further descriptive statistics, see Table 1. Recruitment and Procedures A list of potential separated active duty personnel, National Guard members and Reservists who had deployed to Iraq or Afghanistan was obtained from the Defense Manpower Data Center. Out of approximately 70,000 eligible veterans in the Veterans Integrated Service Network 6 area, 5,000 were randomly sampled. Out of the 5,000 surveys, 1.4% were uncompleted due to extenuating circumstances, 18.5% were undeliverable, and 80% were successfully delivered. Of the 4,004 surveys that were delivered, 1161 were completed and returned for a final cooperation rate of 29%.
Author Manuscript
A survey contractor was used throughout the study to enhance privacy protections, so no identifying information was obtained by study researchers. A Dillman Total Design Method17 was used, and participants were first sent an alert letter 1 week in advance of the study informing them of the nature and purpose of the research project. They then received the survey package which included the survey as well as a cover letter with study contact information, informed consent and confidentiality information. A follow-up packet was mailed if the veteran had not responded within 5 weeks, and veterans were considered nonresponders if they did not respond within 5 weeks of the second survey mailing. This study was approved by the Durham VA Medical Center Institutional Review Board and the VA Office of Management and Budget. Measures
Author Manuscript
The complete survey consisted of questions regarding demographic information, military history, rating of physical and mental health, and health care service utilization. The selection of items was informed by qualitative needs assessment utilizing six 10–12 person focus groups18. In this study, the outcome variable of interest was binary response to the question, “Since your last deployment, have you used VA for healthcare services?” Also examined were predisposing factors including gender, ethnicity, marital status, and number of deployments in addition to the enabling variable of income. Need for services was represented by level of VA disability, rated on a scale from 0% to 100% disability in increments of 10%, and on self-reported rating of health ranging from Excellent to Poor.
Mil Med. Author manuscript; available in PMC 2017 February 01.
Fleming et al.
Page 4
Author Manuscript
At the conclusion of the survey, veterans were asked to respond to the following question, “People learn about VA programs from different sources. Did you receive any information about VA programs from the following sources?” and asked to indicate yes/no if they had received information from: newspapers, TV, radio, VA information or publications, other government publications, other veterans, discharge counseling, Posdeployment Health Reassessment (PDHRA), veterans’ organizations, website, friends/family/co-workers, chaplain/religious leader, command/superiors, family readiness groups, combat stress control/behavioral health contacts, toll-free hotline, Military OneSource, or other. They were then asked, “In the last column above, please indicate how you would prefer to receive information in the future.” For the purposes of this study, a variable was computed that represented a count of the number of matches between the format in which veterans received information about VA programs vs. the format in which they would prefer to receive such information.
Author Manuscript
Data Analysis Individual items were initially examined to determine veterans’ preferences for information source as well as the number of matches between their preferences for and actual receipt of information. A chi-square test was used to examine the relationship between match and service utilization, and a multivariate logistic regression was used to predict service utilization with demographics, need variables, and match factors included as covariates.
Results
Author Manuscript
Results were first analyzed by examining the relative frequencies of how veterans actually received information about VA programs versus how veterans would prefer to receive information about VA programs (See Table II). Frequency data indicated that most veterans received information through VA publications, and most veterans also preferred this method of communication. However, relatively few veterans indicated a preference for receiving information from other veterans and from discharge counseling, although the number receiving information in these formats was quite high.
Author Manuscript
Preliminary analysis of the relationship between information source match and VA use revealed a significant chi-square, X2(1) = 3.47, p < .05 (1 sided), and indicated that 207 veterans in this study had used VA services since deployment and had at least 1 match between how they preferred to receive information and how they actually received information. An exploratory logistic regression was then performed with gender, racial status, age, marital status, number of deployments, information source match, employment status, income, distance to closest VA hospital, self-reported health level, and VA disability level as predictors of VA health care use. Although the overall model was significant X2(6, N=1070) = 245.88, p < .001, a number of the predictors were not, including gender, age, race, marital status, and employment status (p = .43 – .89). The model was respecified using only the significant predictors, and the results of this analysis are presented in Table III. Predisposing factors (i.e. number of deployments), enabling factors (i.e. income, distance to VA), need factors (i.e. health rating and VA disability), and matched preferences for receiving information were each associated with VA
Mil Med. Author manuscript; available in PMC 2017 February 01.
Fleming et al.
Page 5
Author Manuscript
healthcare utilization. Odds ratios indicated that an increase in match in information source was related to a 13% increase in the likelihood of help seeking. Health status was the strongest predictor of VA healthcare use, with a decrease in health status increasing the likelihood of seeking help by 45%
Discussion
Author Manuscript
The results of this study both confirm and extend the application of the Andersen Model in a VA healthcare population. These results suggest that predisposing, enabling, and need factors, including number of deployments, income, distance to VA, health rating, and disability rating, are relevant predictors of VA service utilization. Notably, preferences for care also emerged as a key variable in the prediction of VA help seeking. Results suggest a strong relationship between service utilization and match between how veterans receive information about VA services versus how they would prefer to receive information, such that an increase in match of information source is related to an increase in service use. Although need, represented by disability and self-evaluation of health, was the strongest predictor of service use, these findings suggest that veterans’ preferences are an important component that should be considered in the modeling of help seeking behavior.
Author Manuscript
As stated, the variables representing need for care, including decreased rating of one’s health and increased level of disability, both predicted increases in help seeking as expected based on previous research12. The enabling factors in this study, including income and distance to closest VA, were also significant predictors of service use. Further distance to VA was related to decreased help seeking, confirming that access to care has an important relationship to use of care. Income was predictive of help seeking, but in an unexpected direction. Although income is typically seen as enabling the help seeking process2, in this study higher income led to less VA healthcare use. This is likely due to the higher rates of VA healthcare utilization by enlisted personnel and those without private insurance3,18.
Author Manuscript
The predisposing variable of exposure to combat was negatively related to service use in this study, which was surprising, given that combat exposure has been related to increased service use in previous research10. This discrepancy may be due to sampling. Whereas veterans in previous studies had a wide range of combat exposure, including many who had seen no combat, all veterans in the current study were deployed in the service of OIF/OEF. In light of this sample, it is possible that combat exposure is related to decreased service use due to increased barriers commonly associated with immersion in military culture such as reluctance to acknowledge problems and ask for help. Other predisposing factors, including gender, age, race, marital status, and employment status, were not related to VA healthcare use in this study. Results from past studies have been variable regarding the significance of similar demographic variables. However, this result is generally consistent with the finding that more treatment-related variables, such as need and preferences for care, have stronger relationships with service utilization than do predisposing variables. Overall, this study demonstrated that the Andersen Model is a relevant conceptualization of help-seeking behavior in the veteran population, with particular contributions from veteran characteristics reflecting need for and access to care. However, this study also suggests an
Mil Med. Author manuscript; available in PMC 2017 February 01.
Fleming et al.
Page 6
Author Manuscript
extension of this model to include veterans’ preferences for information about VA programs. Several recent articles14,15 have begun to call for attention to veterans’ preferences in our attempts to increase VA service utilization, and the current study again confirms that preferences are indeed a relevant factor in veterans’ use of care. Although many veterans are receiving information in a way in which they prefer, often from VA publications, results from this sample indicate that many veterans are receiving information in ways that they would not prefer (such as from other veterans), and that many veterans would like to receive more information from the web. It appears that one potential way to bridge the gap between veterans and the wide range of VA healthcare services available to them may be to tailor outreach and advertising campaigns to the preferences for receiving information as well as the most pressing health concerns of returning veterans.
Author Manuscript
The study is limited by a restricted response rate, and consequently, results should be interpreted cautiously. As with preferences for information about care, it appears that veterans in this era have relatively low response rates for paper-and-pencil techniques19 and may respond better to research queries online. Despite this limitation, sample characteristics closely map on to those of larger studies of OIF/OEF veterans1,20 and appear to match closely with figure representing veterans of this era. Future studies might focus on these issues at a national level, and could likely improve cooperation rates by employing data collection techniques that might appeal more to returning veterans. In conjunction with other recent studies addressing the critical role of veterans’ preferences for care, this study indicates the need for further research on the preferences for type of care and source of information about care in returning veterans of this era. Targeted marketing and outreach tailored to the current cohort’s preferences may play a key role in engaging this group of veterans in VA care.
Author Manuscript
References
Author Manuscript
1. Elbogen EB, Wagner H, Johnson SC, Kinneer P, Kang H, Vasterling J, Beckham J. Are Iraq and Afghanistan veterans using mental health services? New data from a national random-sample survey. Psychiatr Serv. 2013; 64(2):134–141. [PubMed: 23475498] 2. Andersen RM. Revisiting the behavioral model and access to medical care: does it matter? J Health Soc Behav. 1995; 36:1–10. [PubMed: 7738325] 3. Veterans Health Administration, Department of Veterans Affairs: Epidemiology Program, PostDeployment Health Group, Office of Public Health. Analysis of VA Health Care Utilization among Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn Veterans, from 1st Qtr FY 2002 through 2nd Qtr FY 2014. Washington, DC: 2014. Retrieved from: http:// www.publichealth.va.gov/docs/epidemiology/healthcare-utilization-report-fy2014-qtr1.pdf accessed August 4, 2014 4. U.S. Department of Veterans Affairs. Gulf War Era Veterans report: Pre 9/11. Retrieved from: www.va.gov/vetdata/docs/specialreports/gw_pre911_report.pdf accessed March 1, 2015 5. U.S. Department of Veterans Affairs. Accelerating Access to Care Initiative Fact Sheet. Retrieved from: http://www.va.gov/health/docs/052714AcceleratingAccessFactSheet.PDF accessed August 4, 2014 6. Milliken CS, Auchterlonie JL, Hoge CW. Longitudinal assessment of mental health problems among active and reserve component soldiers returning from the Iraq War. JAMA. 2007; 298(18) 7. Seal KH, Maguen S, Cohen B, Gima KS, Metzler TJ, Ren L, Bertenthal D, Marmar CR. VA mental health services utilization in Iraq and Afghanistan veterans in the first year of receiving new mental health diagnoses. J Trauma Stress. 2010; 23:5–16. [PubMed: 20146392]
Mil Med. Author manuscript; available in PMC 2017 February 01.
Fleming et al.
Page 7
Author Manuscript Author Manuscript Author Manuscript
8. Hoge CW, Castro CA, Messer SC, McGurk D, Cotting DI, Koffman RL. Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. N Engl J Med. 2004; 351:13–22. [PubMed: 15229303] 9. Andersen, RM. Behavioral Model of Families’ Use of Health Services. Chicago, IL: Center for Health Administration Studies, University of Chicago; 1968. Research Series No. 25 10. Elhai JD, Grubaugh AL, Richardson JD, Egede LE, Creamer M. Outpatient medical and mental healthcare utilization models among military veterans: Results from the 2001 National Survey of Veterans. J Psychiatr Res. 2008; 42:858–867. [PubMed: 18005993] 11. Maguen S, Schumm JA, Norris RL, Taft C, King LA, King DW, Litz B. Predictors or mental and physical health service utilization among Vietnam veterans. Psychol Serv. 2007; 4(3):168–180. 12. Di Leone BAL, Vogt D, Gradus JL, Street AE, Giasson HL, Resick PA. Predictors of mental health care use among male and female veterans deployed in support of the wars in Afghanistan and Iraq. Psychol Serv. 2013; 10(2):145–151. [PubMed: 23730960] 13. Wells TS, LeardMann CA, Fortuna SO, Smith B, Smith TC, Ryan MAK, Millennium Cohort Study Team. A prospective study of depression following combat deployment in support of the wars in Iraq and Afghanistan. Am J of Public Health. 2010; 100:90–99. [PubMed: 19910353] 14. Sayer NA, Friedemann-Sanchez G, Spoont M, Murdoch M, Parker LE, Chiros C, Rosenheck R. A qualitative study of determinants of PTSD treatment initiation in veterans. Psychiatry. 2009; 72:238–255. [PubMed: 19821647] 15. Crawford EF, Elbogen EB, Wagner HR, et al. Surveying treatment preferencesin U.S. Iraq– Afghanistan veterans with PTSD symptoms: a step toward veteran‐centered care. J Trauma Stress. 2015; 28(2):118–26. [PubMed: 25820339] 16. Sayer NA, Noorbaloochi S, Frazier P, Carlson K, Gravely A, Murdoch M. Reintegration problems and treatment interests among Iraq and Afghanistan combat veterans receiving VA medical care. Psychiatr Serv. 2010; 61:589–597. [PubMed: 20513682] 17. Dillman, DA. Mail and Internet Surveys: The Tailored Design Method (Volume 2). New York, NY: Wiley; 2000. 18. Straits-Troster, K.; Gierisch, JM.; Calhoun, PS.; Strauss, JL.; Voils, C.; Kudler, H. Living in transition: Young veterans’ health and the postdeployment shift to family life. In: Kelly, DC.; Howe-Barksdale, S.; Gitelson, D., editors. Treating young veterans: promoting resilience through practice and advocacy. New York, NY: Springer; 2011. 19. Shen Y, Hendricks A, Wang F, Gardner J, Kazis LE. The impact of private insurance coverage on veterans’ use of VA Care: Insurance and selection effects. Health Serv Res. 2008; 43(1):267–286. [PubMed: 18211529] 20. Eisen SV, Schultz MR, Vogt D, Glickman ME, Elwy AR, Drainoni ML, Martin J. Mental and physical health status and alcohol and drug use following return from deployment to Iraq or Afghanistan. Am J Public Health. 2012; 102:S66–S73. [PubMed: 22390605] 21. Calhoun PS, Elter JR, Jones ER, Kudler H, Straits-Troster K. Hazardous alcohol use and receipt of risk-reduction counseling among U.S. veterans of the wars in Iraq and Afghanistan. J Clin Psychiatry. 2008; 69:1686–1693. [PubMed: 19012816]
Author Manuscript Mil Med. Author manuscript; available in PMC 2017 February 01.
Fleming et al.
Page 8
Table 1
Author Manuscript
Descriptive Statistics N
%
Male
959
82.7
Female
196
16.9
White
818
70.5
African-American
198
17.1
Latino
78
6.7
Variable
Ethnicity
Author Manuscript
Other
79
7.1
Married
816
70.3
Unmarried
331
28.5
Dependent Children
727
64.5
No Dependents
412
35.5
Currently Employed
859
74.1
Currently Unemployed
301
25.9
None
612
52.8
0 – 40%
332
28.5
≥ 50%
182
15.79
Excellent
135
11.6
Very Good
304
26.2
Good
443
38.2
Fair
205
17.7
Poor
47
4.1
Reserves
219
18.9
National Guard
220
19.0
Active Duty
VA Disability Rating
Current Health Rating
Author Manuscript
Military Component
689
59.4
Officer
299
25.7
Enlisted
850
73.3
Army
567
48.9
Navy
249
21.5
Air Force
165
14.2
Marines
154
13.3
0
609
52.5
1
205
17.7
2
180
15.5
3
142
12.2
Military Branch
Author Manuscript
Match between preferred and actual info source
Mil Med. Author manuscript; available in PMC 2017 February 01.
Fleming et al.
Page 9
Author Manuscript
Variable
N
%
4+
24
2.0
No
756
65.2
Yes
404
34.8
Used VA Services since Deployment
Author Manuscript Author Manuscript Author Manuscript Mil Med. Author manuscript; available in PMC 2017 February 01.
Fleming et al.
Page 10
Table 2
Author Manuscript
Frequency Data Comparing Veterans’ Receipt of Information vs. Preferences for Information Source Source
% of Veterans that received info this way
% of Veterans that would prefer to receive info this way
VA Publications
74
37
Other Veterans
69
6
Counseling at Discharge
59
11
Internet
57
33
Author Manuscript Author Manuscript Author Manuscript Mil Med. Author manuscript; available in PMC 2017 February 01.
Author Manuscript
Author Manuscript
.37
.18
−.23
−.27
−.20
Health
VA Disability
Income
# Deployments
Distance to VA
7.65
8.97
54.72
72.00
20.03
.01
.00
.00
.00
.00
.03
Sig
.13
Match
4.63
B
Variable
Wald
28.2
1146.34
.82
.76
.79
1.20
1.45
1.13
Exp(B)
Nagelkerke R2
Overall Model
−2 Log Likelihood
.71–.94
.64–.91
.74–.84
1.15–1.25
1.23–1.70
1.01–1.27
95% CI
10.00
X2
Author Manuscript
Logistic Regression Predicting VA Healthcare Utilization
Author Manuscript
Table 3 Fleming et al. Page 11
Mil Med. Author manuscript; available in PMC 2017 February 01.
