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Understanding and addressing barriers to care for Iraq and Afghan War Veterans: findings from a photovoice study

True JG, Fritch ES. Understanding and addressing barriers to care for Iraq and Afghan War Veterans: findings from a photovoice study. Poster session presented at: AcademyHealth Annual Research Meeting; 2013 Jun 24; Baltimore, MD.


Research Objective: More than two million Veterans have returned from deployments in support of the wars in Iraq and Afghanistan; meeting the health care needs of these Veterans will be a leading public health challenge over the next 50 years. However, studies have documented low rates of health care utilization among this cohort of Veterans. We conducted a community-engaged research project with Iraq and Afghan war Veterans to identify factors contributing to treatment avoidance, failure to follow-up on recommended care, and discontinuation of care. Study Design: A Photovoice approach was used to collaborate with Veterans of Operations Enduring Freedom (OEF) and Iraqi Freedom (OIF). Veterans were given a camera and asked to take photos of their daily lives or contribute photos from their personal collections to describe the impact of military service on their health, health care needs, and experiences with health care. Each Veteran was then interviewed individually to elicit the meaning behind their photos. Interview transcripts and photos were coded and analyzed by members of the research team to identify preliminary themes, and to select exemplary photos and quotes. Themes were refined and revised through small group discussions with Veteran participants. Population Studied: Forty OEF/OIF Veterans who were representative of the current military force in terms of gender, age, race/ethnicity, branch of service, and number of deployments. Principal Findings: We identified key barriers to treatment-seeking and initiation, engagement with care, and following a recommended course of treatment. These barriers fell into three broad categories: 1. characteristics of military service and culture; 2. organization and culture of healthcare delivery; and 3. patient-level causes. Characteristics of military service that impacted Veterans' willingness to engage in care included: cultural norms of stoicism, silence, and self-reliance; prioritizing the needs of fellow soldiers over one's own needs; and mixed messages from military command prior to the end of a deployment. Veterans described features of healthcare organization and delivery that posed barriers to care: an overwhelming or unwelcoming bureaucracy; negative encounters with staff or providers; inability to have primary needs addressed during early visits; and perception of the system as overburdened. A number of factors emerged specific to individual patients or subgroups of Veteran patients; for example, Veterans who were dealing with housing instability, alcohol or drug addiction, or those who had experienced Military Sexual Trauma. Veterans' photos and quotes will be used to illustrate and illuminate each theme. Conclusions: Photovoice is a powerful tool for engaging Veterans in research. Our study identified barriers to care from the Veterans' perspective, and generated ideas for improving access to care for returning combat Veterans. In keeping with a community-engaged research approach, many Veteran participants have collaborated on dissemination of findings including making presentations to healthcare providers. Implications for Policy, Delivery, or Practice: Understanding the perspectives and experiences of OEF/OIF Veterans in their own words, and utilizing their expertise to educate providers, is an important step toward providing patient-centered care and improving healthcare utilization for OEF/OIF Veterans. The success of this project provides a blueprint for conducting community-engaged research with a variety of Veteran populations.

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