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South Med J. Author manuscript; available in PMC 2016 August 01. Published in final edited form as: South Med J. 2015 August ; 108(8): 488–493. doi:10.14423/SMJ.0000000000000326.
Understanding the Health Needs and Barriers to Seeking Health Care of Veteran Students in the Community Anita D. Misra-Hebert, MD, MPH, Laura Santurri, PhD, MPH, Richard DeChant, BA, Brook Watts, MD, MS, Michael Rothberg, MD, MPH, Ashwini R. Sehgal, MD, and David C. Aron, MD, MS
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Center for Value Based Care Research, Medicine Institute, Cleveland Clinic, Cleveland, Ohio, the Department of Health Promotion and Human Performance, Jerry & Vickie Moyes College of Education, Weber State University, Ogden, Utah, Veterans Services and Programs, Cuyahoga Community College, Cleveland, Ohio, the Department of Medicine, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, Ohio, and the Center for Reducing Health Disparities, Case Western Reserve University, Cleveland, Ohio.
Abstract Objectives—Access to care at Veterans Affairs facilities may be limited by long wait times; however, additional barriers may prevent US military veterans from seeking help at all. We sought to understand the health needs of veterans in the community to identify possible barriers to healthseeking behavior.
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Methods—Focus groups were conducted with veteran students at a community college until thematic saturation was reached. Qualitative data analysis involved both an inductive content analysis approach and deductive elements. Results—A total of 17 veteran students participated in 6 separate focus groups. Health needs affecting health-seeking behavior were identified. Themes included lack of motivation to improve health, concern about social exclusion and stigma, social interactions and behavior, limited access to affordable and convenient health care, unmet basic needs for self and family, and academics competing with health needs.
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Conclusions—Veterans face a range of personal, societal, and logistical barriers to accessing care. In addition to decreasing wait times for appointments, efforts to improve the transition to civilian life, reduce stigma, and offer assistance related to work, housing, and convenient access to health care may improve health in veteran students.
Correspondence to Dr Anita D. Misra-Hebert, Department of Internal Medicine, Center for Value Based Care Research, Medicine Institute, Cleveland Clinic, 9500 Euclid Ave, G10, Cleveland, OH 44195. [email protected].. The views expressed are solely those of the authors and do not represent those of the Veterans Health Administration or any other agency. An earlier version of this work was presented at the American Public Health Association meeting, Boston, Massachusetts, on November 6, 2013, and at the Society of General Internal Medicine national meeting, San Diego, California, on April 25, 2014. The remaining authors have no financial relationships to disclose and no conflicts of interest to report.
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Keywords veterans; health promotion; health behavior; health services research Providing high-quality care to US military veterans is a national priority. Although recent focus has been on wait times at Veterans Affairs (VA) facilities,1,2 additional factors may prevent veterans in the community from seeking or accessing care. Veterans have a higher burden of illness than civilians,3 but fewer than one-third of individuals deployed to Iraq or Afghanistan since 2001 have used VA healthcare services.4 Issues of stigma and “not being able to ask for help” have been identified as barriers to seeking treatment.5–11 Mental health concerns,4,12,13 including issues related to substance abuse,14 stress related to multiple deployments,15 and family reintegration problems,16 may increase health risks17 but also may affect health-seeking behavior and use of non–mental health outpatient services.18
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Veterans returning to civilian life often pursue higher education through the GI Bill. Partnerships between VA medical centers and community colleges offer an opportunity for VA medical centers to engage with veteran students and better assess their healthcare needs.19–21 We used one such partnership to conduct focus groups of student veterans. Our goal was to understand veterans’ beliefs regarding their health needs and to explore modifying factors that could affect their health-seeking behavior. We hypothesized that barriers other than the ability to access health care affect health-seeking behavior of veteran students.
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Setting and Participants Our study was conducted at Cuyahoga Community College, Cleveland, Ohio, in collaboration with the US Department of Veterans Services and Programs. Cuyahoga Community College is the largest public community college in Ohio, with 4 main campuses, serving >60,000 students annually.22 The eligible study population included all student veterans of military service (875 students) identified by the community college who were enrolled at Cuyahoga Community College in the 2012 fall semester. Design
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Our study used a basic interpretive, qualitative research design.23 No personal identifiers were collected. The protocol was granted an exemption by the institutional review board and approved by the research and development committee at the Louis Stokes Cleveland Veterans Affairs Medical Center and was approved by the institutional review board at Cuyahoga Community College. Purposeful sampling24 was used for the focus groups. Invitations were initially extended to veterans of the recent conflicts in Iraq or Afghanistan and those veterans of previous conflicts to attend separate focus groups. Male and female veterans also were invited to separate focus groups. Later groups were opened to all veterans.
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An announcement was sent in an electronic newsletter to all veterans enrolled at Cuyahoga Community College during the 2012 fall semester, inviting them to participate. A $25 grocery store gift card was offered as an incentive. Four additional e-mail reminders were sent during the next 6 weeks, with two specifically addressing female veterans to ensure representation of women. All focus groups were conducted on campus, lasted for 90 minutes each, and were completed by early December 2012. The interview guide (Appendix, http:// links.lww.com/SMJ/A31) was created by the principal investigator (***A) with input from co-investigators and revised through an iterative process. It included questions about health attitudes, health risks, health communication, and motivation to improve health or seek health care. Each focus group was facilitated by ***B. The discussions were audio recorded and transcribed verbatim. Data Analysis
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Focus groups were conducted until thematic saturation was reached (ie, no new codes arose from the data). All of the transcripts were coded and data were managed using Microsoft Excel (Microsoft, Redmond, WA). Our analysis involved both deductive and inductive elements.25 An inductive content analysis approach was initially used for coding and thematic development,26 deriving our codes during the analysis without using predetermined categories.26 Two research team members (*** and ***C) coded each transcript independently and met to discuss the codes to reach consensus in developing the codebook through an iterative process. The final codes were organized conceptually to produce major thematic categories of data. The deductive analysis was based upon the health belief model (HBM)27,28 and its components of modifying factors and individual beliefs as they relate to cues to actions pursued by the individual. The HBM has been used to understand compliance behavior in veteran patients.28 In our work, the final thematic categories were grouped into individual beliefs and modifying factors.
Results
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A total of 17 veterans volunteered to participate in 6 focus groups. Participants included veterans from conflicts in Iraq and Afghanistan, as well as those from previous conflicts, female veterans, and those who had sought health care both at the VA and civilian facilities. Participants discussed life priorities, motivations to improve health, and perceptions of health care. Initial coding of transcripts yielded 72 individual codes. From these codes, 12 themes emerged, which were then grouped into 6 major thematic categories. Our final model (Fig.) depicts the factors affecting health-seeking behavior in the student veteran, including the major thematic group categories and whether each thematic group contributes to individual beliefs or modifying factors based upon the HBM. Thematic Groups Lack of Motivation to Improve Health (Individual Belief)—Veterans expressed several beliefs about health. A feeling of “disconnection” after returning from deployment APls insert initials of principal investigator. BPls insert initials of group facilitator. CPls insert research team members’ initials. South Med J. Author manuscript; available in PMC 2016 August 01.
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was prevalent and this affected their sense of overall health and well-being, both emotionally and physically, as well as their desire to seek health care. One veteran stated, “You know, I’m proud to say that I was a professional soldier, and that means complete dedication and also pretty deep conditioning. So once you get out of that, then take a look at yourself and who you’ve become, you know one realizes that one is disconnected from normal life,” and “socially and mentally when I came back I was pretty far out there.”
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Others expressed the lack of motivation to improve health stating, “I just don’t think about it too much, ‘cause if I feel all right, I just keep on going and really don’t think about other things that could be wrong.” Many faced challenges remaining physically fit without a mandated fitness requirement and lack of access to fitness facilities. One veteran explained, “‘cause that whole thing there the military has in place for you, you’re constantly being monitored and all that is gone, and then it’s up to you.” Another lamented, “I used to be very physically fit. I used to love to run, very active. Now this is most of my day is sitting around watching TV. My wife, we’ve been constantly to the point where mentally I was never there. My mind was always off in the war zone somewhere.”
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In this regard, female veterans were perceived to have an advantage. According to one focus group participant, “It seems gender based, too. You know males don’t tend to take care of themselves as well as females do.” Generational differences in veterans of different wars seemed to contribute to the sense of disconnection after returning from active duty. Veterans of conflicts before the Iraq and Afghanistan wars expressed that more recent veterans were different even as the differences related to their health issues. One veteran stated, “I see people with some of the same injuries, but I have no type of connection with them whatsoever,” or as a Persian Gulf war veteran stated, “I just feel such a disconnection when speaking about Afghan-Iraq veterans.” Another veteran commented, “New guys … they don’t tend to care until it’s … they’re in some kind of ailment or some kind of abyss.” Not all of the veterans lacked motivation to improve health. One reported, “I know it sounds crazy, but I read this short story, right? I’m in class and I read the story and it’s about an alcoholic, right? And that story scared the daylight out of me, right? This story scared me like crazy and I was just like ‘Okay, I need to stop,’ so I stopped. So I just completely stopped.”
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Concern about Social Exclusion and Stigma (Individual Belief)—In addition to their personal feeling of disconnection, veterans were concerned that veteran status and stigma may exclude them from employment and thus were hesitant to seek health care for any conditions that may lead to their being excluded. One veteran believed he could not admit to having flashbacks or seek care for them, stating, “I was at work one day and I had a flashback, so I wasn’t comfortable at work to tell anyone, ‘cause if I were to have told anyone what really happened, I would’ve lost my job. So, that’s a good reason not to seek health care.” Another veteran commented, “It's almost like you’re I guess the term would be ‘damaged goods’.” The concern extended to connecting regarding health issues through social media, as one veteran remarked, “It’s difficult too because sometimes you don’t want to get on any social networks because it’s like you don’t want to get there because you might be selling yourself out.” Other veterans noted, “To tell you the truth, I really don’t trust
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social media,” and “all of a sudden now someone catches wind of that and they can use that against you. It’s just ammo.”
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Social Interactions and Behavior (Individual Belief)—The emphasis of military culture on self-reliance may promote further isolation, even if health or emotional needs are not being met. As one veteran student said, “We are trained to be self-helped, work with a group. When military people get out, they may even shy away from getting help.” A veteran expressed the idea that “You break your hand, break your bone, whatever, you shrug it off and you drive on and you continue the mission.” An extreme sense of social isolation after active duty was expressed by one veteran who shared, “I used to be [a] very social, outgoing person. Now I’m just in the house and just nothing.” Another veteran student stated, “So being back in school I had to kind of force myself because I knew if I stayed home and did nothing, it was gon’ get worse. So this way I’m forcing myself to be social and interact with people, and it helps some.”
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Limited Access to Affordable and Convenient Health Care (Modifying Factor) —Veterans expressed frustration about not having access to affordable health care. One stated, “With being a veteran, I feel like I shouldn’t have to worry about health care. I put my life on the line for this country to keep going the way that it has and for people to have their freedom. Why should I have to worry about anything?” A veteran with a diagnosis of hypertension commented, “I was prescribed medication, but I haven’t had that medication in probably 2 years, and that’s because I don’t have health insurance now and with that it’s expensive to buy meds.” Regarding healthcare coverage, another veteran commented, “So I was stuck in between my coverage for VA health care and public assistance health care, in which I didn’t really fit into a category for either.” According to focus group participants, appointments at the VA were hard to obtain outside business hours. “It’s just virtually impossible, and that’s what makes it infuriating and frustrating for the young soldiers,” noted one veteran. Another echoed these sentiments, saying, “It would be nice if they did stuff on the weekends, you know, or maybe during the day and it’s so limited.”
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Unmet Basic Needs for Self and Family (Modifying Factor)—For many veterans, basic needs such as housing and employment or providing for their families overshadowed any focus on health needs. One said, “You’re just barely making it by today, especially today’s economy.” Another admitted, “I currently live in transitional housing.” Regarding finding employment, a veteran student stated, “I’d already been injured while I was in the Air Force and then I was injured in an industrial accident at a job I worked here and I was left completely out of my realm of skills, and I was seeking not only new employment but new sustainable employment.” A motivation to improve their own health, however, was to care for themselves and their families. Regarding health priorities, one veteran commented, “My number one priority is, you know, take care of myself health wise. That’s always number one, but like you’ve got family. You’ve got loved ones. That’s priority.” Another veteran noted, “At this point, my priority is definitely finding the means to take care of my family,” while another expressed wanting “to bring something positive and good to the table.”
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Academics Competing with Health Needs (Modifying Factor)—Veteran students took their studies seriously. “I take school as something that’s very important. It’s no joke. I treat it as just like my active-duty job,” noted one veteran. The stress of academic workload, however, often was difficult to manage with other life priorities, with one veteran stating, “Going back to school after so many years can be overwhelming. Now I’ve got a family (wife and kids) and the cares of work and car payments, mortgage, and all that stuff makes it really difficult, and plus I work at night, too, so you know trying to stay awake at night and studying at night because I can’t do it during the day because of the kids and everything. So it’s been, it’s really hard.” Another remarked, “It’s still just difficult and challenging because of the PTSD (posttraumatic stress disorder) issues and some other physical issues, and it’s just very frustrating.”
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Our study identified that timely access to healthcare facilities is only one of several important barriers to health-seeking behavior facing veterans in the community. We identified factors related to individual beliefs, as well as modifying factors that could affect health-seeking behavior. The sense of disconnection to civilian life and to others who have not had similar experiences, as well as the loss of focus on maintaining physical health after active duty adversely affected individual motivation to improve health after return from service. Veterans avoided seeking care because of concern about stigma; frustration about the inconvenience and cost of health care; and competing life priorities, including finding work, housing, and providing for a family while trying to succeed academically. Veterans’ sense of isolation and their extreme self-reliance posed additional barriers.
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Stigma has been identified as a barrier to returning service members seeking care for mental health issues,6,9,29 and the social isolation experienced by veterans may exacerbate mental illness,30 especially for veterans with posttraumatic stress disorder.31 Our work demonstrates that these issues represent barriers to seeking any type of health care. As veterans from recent conflicts return home and veterans from previous conflicts age, accessing non–mental health services, particularly preventive health care and care for the control of chronic diseases, will be increasingly important.
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Our exploratory work could inform future quantitative study on larger groups of veterans to examine their perceived barriers to seeking health care and could be linked to their healthcare utilization patterns. Although some veteran students noted that the focus on academic success competed with healthcare needs, the concentration of veterans on campus affords an opportunity for outreach to an otherwise isolated group. Based on our findings, efforts should be made to increase awareness of health services available, reduce stigma, and improve convenience. Existing models for on-campus mental health and social work services for veterans32 may be extended to general health services, either offered on-site or through partnerships with local healthcare facilities. Attention to the cost of care and extended hours should improve uptake. Another proposed means for reaching isolated veterans is electronic communication.10,33 Our findings suggest that fear of stigma extends even to electronic communication. Such
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fears would have to be overcome for that approach to be successful. Linking veteran students to necessary health services through routine screening of all students at the time of enrollment may reduce the stigma associated with seeking care. In addition, peer support programs could help34 decrease social isolation and extreme self-reliance. National programs targeted to veteran students on college campuses such as the 8 Keys to Success, Veterans Integration to Academic Leadership, or the VetSuccess on Campus programs35 could help school administrations to implement these strategies. Results of ongoing evaluations of existing programs such as the US Army’s Comprehensive Soldier and Family Fitness program,36 aimed at improving the resilience of soldiers, also will be informative in choosing the most effective interventions.
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Our findings suggest that health needs often are subjugated to more immediate priorities such as finding work and stable housing. Efforts to mitigate these issues will involve several steps, including educating health professionals about the unique social needs of returning service members,37 as well as a need to extend health promotion efforts beyond traditional healthcare settings. These findings should provoke further longitudinal research into the overall state of our returning veterans as has been formally recommended.38 Our study is limited by the small sample size; therefore, the veteran student focus group participants may not have been representative of veterans in general. We continued subject recruitment and focus groups until we achieved thematic saturation in our qualitative data collection and analysis, however. The barriers we identified in our study are plausibly generalizable. Further studies such as a survey of a larger veteran population could quantify the relative contribution of each of these barriers.
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We acknowledge that investigator bias regarding views about seeking health care may have influenced the focus group research method and data analysis as ***D is a clinician and ***E is a health educator. Allowing for reflexivity39 in data analysis, all of the transcripts were initially coded independently by the two investigators and then discussed until consensus was reached on each code, thereby permitting resolution of potential biases.
Conclusions
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By engaging veteran students in conversations about health, we identified barriers to healthseeking behavior and priority areas to inform targeted health promotion efforts. The impact of social determinants of health, such as the stress of the transition to student life, the sense of stigma, and often the lack of fulfillment of basic needs such as housing or employment on health-seeking behavior is substantial. Efforts to improve the transition to civilian life; reduce stigma; and offer assistance related to work, housing, and convenient, affordable access to health care may improve health in veteran students.
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Acknowledgments This study was supported by the Louis Stokes Cleveland Veterans Affairs Medical Center Research and Education Foundation and National Institutes of Health (grants MD002265 and TR000439). A.D.M.H. received compensation from the Louis Stokes Cleveland Veterans Affairs Medical Center Research and Education Foundation and has received a Clinical and Translational Science Collaborative–Case Western Reserve University research program committee grant. A.R.S. has received grant support from the National Institutes of Health. D.C.A. has received a grant from the Department of Veterans Affairs VA Quality Scholars Fellowship Program.
References
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1. Chokshi DA. Improving health care for veterans—a watershed moment for the VA. N Engl J Med. 2014; 371:297–299. [PubMed: 24896820] 2. Kizer KW, Jha AK. Restoring trust in VA health care. N Engl J Med. 2014; 371:295–297. [PubMed: 24896816] 3. Luncheon C, Zack M. Health-related quality of life among US veterans and civilians by race and ethnicity. Prev Chronic Dis. 2012; 9:E108. [PubMed: 22652126] 4. Spelman JF, Hunt SC, Seal KH, et al. Post deployment care for returning combat veterans. J Gen Intern Med. 2012; 27:1200–1209. [PubMed: 22648608] 5. Stecker T, Fortney JC, Hamilton F, Ajzen I. An assessment of beliefs about mental health care among veterans who served in Iraq. Psychiatr Serv. 2007; 58:1358–1361. [PubMed: 17914017] 6. Chapman PL, Elnitsky C, Pitts B, et al. Mental health, help seeking, and stigma and barriers to care among 3- and 12-month postdeployed and never deployed U.S. Army Combat Medics. Mil Med. 2014; 179(8 Suppl):55–62. [PubMed: 25102550] 7. Elnitsky CA, Chapman PL, Thurman RM, et al. Gender differences in combat medic mental health services utilization, barriers, and stigma. Mil Med. 2013; 178:775–784. [PubMed: 23820352] 8. Mittal D, Drummond KL, Blevins D, et al. Stigma associated with PTSD: perceptions of treatment seeking combat veterans. Psychiatr Rehabil J. 2013; 36:86–92. [PubMed: 23750758] 9. Blais RK, Renshaw KD. Stigma and demographic correlates of help-seeking intentions in returning service members. J Trauma Stress. 2013; 26:77–85. [PubMed: 23335155] 10. Zinzow HM, Britt TW, McFadden AC, et al. Connecting active duty and returning veterans to mental health treatment: interventions and treatment adaptations that may reduce barriers to care. Clin Psychol Rev. 2012; 32:741–753. [PubMed: 23063627] 11. Interian A, Kline A, Callahan L, et al. Readjustment stressors and early mental health treatment seeking by returning National Guard soldiers with PTSD. Psychiatr Serv. 2012; 63:855–861. [PubMed: 22706956] 12. Seal KH, Bertenthal D, Miner CR, et al. Bringing the war back home: mental health disorders among 103,788 US veterans returning from Iraq and Afghanistan seen at Department of Veterans Affairs facilities. Arch Intern Med. 2007; 167:476–482. [PubMed: 17353495] 13. Seal KH, Shi Y, Cohen G, et al. Association of mental health disorders with prescription opioids and high-risk opioid use in US veterans of Iraq and Afghanistan. JAMA. 2012; 307:940–947. [PubMed: 22396516] 14. Eisen SV, Schultz MR, Vogt D, et al. Mental and physical health status and alcohol and drug use following return from deployment to Iraq or Afghanistan. Am J Public Health. 2012; 102(Suppl 1):S66–S73. [PubMed: 22390605] 15. MacGregor AJ, Han PP, Dougherty AL, et al. Effect of dwell time on the mental health of US military personnel with multiple combat tours. Am J Public Health. 2012; 102(Suppl 1):S55–S59. [PubMed: 22390601] 16. Sayers SL, Farrow VA, Ross J, et al. Family problems among recently returned military veterans referred for a mental health evaluation. J Clin Psychiatry. 2009; 70:163–170. [PubMed: 19210950] 17. Cohen BE, Marmar C, Ren L, et al. Association of cardiovascular risk factors with mental health diagnoses in Iraq and Afghanistan war veterans using VA health care. JAMA. 2009; 302:489–492. [PubMed: 19654382]
South Med J. Author manuscript; available in PMC 2016 August 01.
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Author Manuscript Author Manuscript Author Manuscript Author Manuscript
18. Cohen BE, Gima K, Bertenthal D, et al. Mental health diagnoses and utilization of VA non-mental health medical services among returning Iraq and Afghanistan veterans. J Gen Intern Med. 2010; 25:18–24. [PubMed: 19787409] 19. Barry AE, Whiteman, Shawn D, et al. Student service members/veterans in higher education: a systematic review. J Stud Aff Res Pract. 2014; 51:30–42. 20. Widome R, Laska MN, Gulden A, Fu SS, Lust K. Health risk behaviors of Afghanistan and Iraq war veterans attending college. Am J Health Promot. 2011; 26:101–108. [PubMed: 22040391] 21. Widome R, Littman AJ, Laska MN, et al. Preventing chronic illness in young veterans by promoting healthful behaviors. Prev Chronic Dis. 2012; 9:E19. [PubMed: 22172186] 22. Cuyahoga Community College. About Tri-C. http://www.tri-c.edu/about/Pages/default.aspx. Accessed November 24, 2014 23. Merriam, SB., editor. Qualitative Research in Practice: Examples for Discussion and Analysis. 1st. Jossey-Bass; San Francisco: 2002. Basic interpretive qualitative research; p. 37-39. 24. Kuzel, AJ. Sampling in qualitative inquiry. In: Crabtree, BF.; Miller, WL., editors. Doing Qualitative Research. 2nd. Sage Publications; Thousand Oaks, CA: 1999. p. 33-45. 25. Fereday J, Muir-Cochrane E. Demonstrating rigor using thematic analysis: a hybrid approach of inductive and deductive coding and theme development. Int J Qual Methods. 2006; 5:1–11. 26. Hsieh HF, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res. 2005; 15:1277–1288. [PubMed: 16204405] 27. Champion, VL.; Skinner, CS. Chapter 3: The Health Belief Model in Health Behavior and Health Education: Theory, Research, and Practice. Glanz, K.; Rimer, BK.; Viswanath, K., editors. John Wiley & Sons; San Francisco, CA: 2008. F 28. Kelly GR, Mamon JA, Scott JE. Utility of the health belief model in examining medication compliance among psychiatric outpatients. Soc Sci Med. 1987; 25:1205–1211. [PubMed: 2893455] 29. Keane TM, Docherty JP, Jesse RL, et al. Mental health needs of returning veterans. J Clin Psychiatry. 2013; 74:e20. [PubMed: 24229760] 30. Mistry R, Rosansky J, McGuire J, et al. Social isolation predicts re-hospitalization in a group of older American veterans enrolled in the UPBEAT Program. Unified Psychogeriatric Biopsychosocial Evaluation and Treatment. Int J Geriatr Psychiatry. 2001; 16:950–959. [PubMed: 11607938] 31. Rosen C, Adler E, Tiet Q. Presenting concerns of veterans entering treatment for posttraumatic stress disorder. J Trauma Stress. 2013; 26:640–643. [PubMed: 24123262] 32. 2013 APA Silver Award: On-campus VA mental health and social work services for student veterans: SFVAMC's veterans outreach program at City College of San Francisco. Psychiatr Serv. 2013; 64:e10–e11. [PubMed: 24081420] 33. Sadler AG, Mengeling MA, Torner JC, et al. Feasibility and desirability of web-based mental health screening and individualized education for female OEF/OIF reserve and national guard war veterans. J Trauma Stress. 2013; 26:401–404. [PubMed: 23696367] 34. Whiteman SD, Barry AE, Mroczek DK, et al. The development and implications of peer emotional support for student service members/veterans and civilian college students. J Couns Psychol. 2013; 60:265–278. [PubMed: 23421774] 35. The White House. 8 Keys to success: supporting veterans, military and military families on campus. http://www.whitehouse.gov/blog/2013/08/13/8-keys-success-supporting-veteransmilitary-and-military-families-campus. Published August 13, 2013. Accessed October 29, 2014 36. US Army. Comprehensive soldier and family fitness program. http://csf2.army.mil/ about.html#about. Accessed February 17, 2015 37. Lee J, Sanders KM, Cox M. Honoring those who have served: how can health professionals provide optimal care for members of the military, veterans, and their families? Acad Med. 2014; 89:1198–1200. [PubMed: 24979290]
FPls check citation. Wiley doesn’t list this book and couldn’t find on the Internet. South Med J. Author manuscript; available in PMC 2016 August 01.
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38. Institute of Medicine Committee on the Initial Assessment of Readjustment Needs of Military Personnel, Veterans, and Their Families. Returning Home from Iraq and Afghanistan: Preliminary Assessment of Readjustment Needs of Veterans, Service Members, and Their Families. National Academies Press; Washington, DC: 2010. 39. Mays N, Pope C. Qualitative research in health care. Assessing quality in qualitative research. BMJ. 2000; 320:50–52. [PubMed: 10617534]
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Key Points •
Timely access to healthcare facilities is only one of several important barriers to health-seeking behavior facing veterans in the community.
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Veterans avoided seeking care because of concern about stigma, frustration about the inconvenience and cost of healthcare, and competing life priorities, including finding work, housing, and providing for family while trying to succeed academically. Veterans’ sense of isolation and their extreme selfreliance posed additional barriers.
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By engaging veteran students in conversations about health, we identified barriers to health-seeking behavior and priority areas to inform targeted health promotion efforts.
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Fig.
Factors affecting health-seeking behavior in the student military veteran.
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Appendix: Focus Group Guide
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Prior to starting recording:
First of all, I want to thank you all for agreeing to participate in this focus group. (Facilitator introduces self).
After recording begins:
My research team and I are trying to work toward providing the best health care services to veterans in the community and we wanted to start by hearing from veteran students. Today we will be discussing some of your views about health and accessing health care. I/we are really interested in hearing from you and in learning what you have to say today. There are some specific questions to help guide our discussion, but I really encourage you to share your ideas and opinions as much as you feel comfortable doing so, as the purpose of this group is to make your voice heard to the people who provide health care for veterans. I want to tell you about how this focus group will be organized and will review a few ground rules.
Organization of focus group & ground rules:
As you know, we are audio recording this discussion. In order to preserve confidentiality, we ask that you do not address each other by name. We will not ask you any information that could identify you on the recordings and no identifying information will appear on the transcripts from this focus group. We ask you also to keep what you hear today confidential and not share it with anyone who is not here today. Please respect everyone’s opinions, even if you may disagree with them. Please allow for one person to speak at a time, so that we can clearly hear the conversation on the audio recording. I want to make a comment also about why we are taking notes: we want to make sure that we capture as much as we can about the discussions in addition, and as a back-up to, our audio recordings. Before we begin, do you have any questions for us? As mentioned, there are some specific questions to help lead our discussion but I would like to keep this as open as possible so that you (and not I) are doing most of the talking after this!
Question 1:
We just want to begin with a few introductory comments from all of you so we get a sense of “where you are” in your life these days. Please tell us how long you have been a student, which war you served in, and your branch of service.
Question 2:
Can you tell us about what led to your decision to enroll in community college?
Question 3:
Can you tell us a little about what your priorities are these days, what is important to you? Where does your personal health fit in with your priorities?
Question 4:
Are there any issues related to health that are a concern for you these days? Can you tell me if there are any differences between how you view your health now as compared to when you were on active duty? Are there any specific barriers to improving your health these days?
Question 5:
Now think about making decisions to seek health care. Tell us about some of the reasons why you might choose to seek health care. Now tell us about some of the reasons why you might choose to NOT seek health care- even if you felt that you needed it
Question 6:
A lot of people may come to a health care provider because they think they may be at risk for health problems- either because there may be someone in their family that has certain health problems or because of some behaviors in their own lives that may put them at risk for health problems, or maybe a close friend developed a health problem. Thinking about that…how do you view your personal health status or risk? (try to get at issues of family history, health habits) for chronic diseases (explain …like diabetes, high blood pressure, high cholesterol, obesity)? ***You do not need to talk about the specific risks, but we just are trying to get a sense overall about how you think about your health these days
Question 7:
If you feel your health could be improved, tell us about some things that may motivate you to improve your health?
Question 8:
Can you tell us in general about how you prefer to communicate with others. Text messaging, email, phone, social networking like Facebook or Twitter, in person?
Question 9:
Can you now tell us about how you would prefer to communicate with health care providers about health issues? Text messaging, email, phone, social networking like Facebook or Twitter, in person, reading materials, specific internet sites?
Question 10:
Can you tell us about the places that you may currently obtain medical care? What are your impressions of these places?
Question 11:
What are your current impressions of the Veterans Affairs (VA) healthcare system as a source of care? Access to care? Type of services offered?
Closing script:
Thank you again for participating today in this focus group. Your opinions/contributions are invaluable. Are there any additional questions? I encourage you to contact me if you have any questions after you leave this session.
South Med J. Author manuscript; available in PMC 2016 August 01.
South Med J. Author manuscript; available in PMC 2016 August 01. Published in final edited form as: South Med J. 2015 August ; 108(8): 488–493. doi:10.14423/SMJ.0000000000000326.
Understanding the Health Needs and Barriers to Seeking Health Care of Veteran Students in the Community Anita D. Misra-Hebert, MD, MPH, Laura Santurri, PhD, MPH, Richard DeChant, BA, Brook Watts, MD, MS, Michael Rothberg, MD, MPH, Ashwini R. Sehgal, MD, and David C. Aron, MD, MS
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Center for Value Based Care Research, Medicine Institute, Cleveland Clinic, Cleveland, Ohio, the Department of Health Promotion and Human Performance, Jerry & Vickie Moyes College of Education, Weber State University, Ogden, Utah, Veterans Services and Programs, Cuyahoga Community College, Cleveland, Ohio, the Department of Medicine, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, Ohio, and the Center for Reducing Health Disparities, Case Western Reserve University, Cleveland, Ohio.
Abstract Objectives—Access to care at Veterans Affairs facilities may be limited by long wait times; however, additional barriers may prevent US military veterans from seeking help at all. We sought to understand the health needs of veterans in the community to identify possible barriers to healthseeking behavior.
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Methods—Focus groups were conducted with veteran students at a community college until thematic saturation was reached. Qualitative data analysis involved both an inductive content analysis approach and deductive elements. Results—A total of 17 veteran students participated in 6 separate focus groups. Health needs affecting health-seeking behavior were identified. Themes included lack of motivation to improve health, concern about social exclusion and stigma, social interactions and behavior, limited access to affordable and convenient health care, unmet basic needs for self and family, and academics competing with health needs.
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Conclusions—Veterans face a range of personal, societal, and logistical barriers to accessing care. In addition to decreasing wait times for appointments, efforts to improve the transition to civilian life, reduce stigma, and offer assistance related to work, housing, and convenient access to health care may improve health in veteran students.
Correspondence to Dr Anita D. Misra-Hebert, Department of Internal Medicine, Center for Value Based Care Research, Medicine Institute, Cleveland Clinic, 9500 Euclid Ave, G10, Cleveland, OH 44195. [email protected].. The views expressed are solely those of the authors and do not represent those of the Veterans Health Administration or any other agency. An earlier version of this work was presented at the American Public Health Association meeting, Boston, Massachusetts, on November 6, 2013, and at the Society of General Internal Medicine national meeting, San Diego, California, on April 25, 2014. The remaining authors have no financial relationships to disclose and no conflicts of interest to report.
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Keywords veterans; health promotion; health behavior; health services research Providing high-quality care to US military veterans is a national priority. Although recent focus has been on wait times at Veterans Affairs (VA) facilities,1,2 additional factors may prevent veterans in the community from seeking or accessing care. Veterans have a higher burden of illness than civilians,3 but fewer than one-third of individuals deployed to Iraq or Afghanistan since 2001 have used VA healthcare services.4 Issues of stigma and “not being able to ask for help” have been identified as barriers to seeking treatment.5–11 Mental health concerns,4,12,13 including issues related to substance abuse,14 stress related to multiple deployments,15 and family reintegration problems,16 may increase health risks17 but also may affect health-seeking behavior and use of non–mental health outpatient services.18
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Veterans returning to civilian life often pursue higher education through the GI Bill. Partnerships between VA medical centers and community colleges offer an opportunity for VA medical centers to engage with veteran students and better assess their healthcare needs.19–21 We used one such partnership to conduct focus groups of student veterans. Our goal was to understand veterans’ beliefs regarding their health needs and to explore modifying factors that could affect their health-seeking behavior. We hypothesized that barriers other than the ability to access health care affect health-seeking behavior of veteran students.
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Setting and Participants Our study was conducted at Cuyahoga Community College, Cleveland, Ohio, in collaboration with the US Department of Veterans Services and Programs. Cuyahoga Community College is the largest public community college in Ohio, with 4 main campuses, serving >60,000 students annually.22 The eligible study population included all student veterans of military service (875 students) identified by the community college who were enrolled at Cuyahoga Community College in the 2012 fall semester. Design
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Our study used a basic interpretive, qualitative research design.23 No personal identifiers were collected. The protocol was granted an exemption by the institutional review board and approved by the research and development committee at the Louis Stokes Cleveland Veterans Affairs Medical Center and was approved by the institutional review board at Cuyahoga Community College. Purposeful sampling24 was used for the focus groups. Invitations were initially extended to veterans of the recent conflicts in Iraq or Afghanistan and those veterans of previous conflicts to attend separate focus groups. Male and female veterans also were invited to separate focus groups. Later groups were opened to all veterans.
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An announcement was sent in an electronic newsletter to all veterans enrolled at Cuyahoga Community College during the 2012 fall semester, inviting them to participate. A $25 grocery store gift card was offered as an incentive. Four additional e-mail reminders were sent during the next 6 weeks, with two specifically addressing female veterans to ensure representation of women. All focus groups were conducted on campus, lasted for 90 minutes each, and were completed by early December 2012. The interview guide (Appendix, http:// links.lww.com/SMJ/A31) was created by the principal investigator (***A) with input from co-investigators and revised through an iterative process. It included questions about health attitudes, health risks, health communication, and motivation to improve health or seek health care. Each focus group was facilitated by ***B. The discussions were audio recorded and transcribed verbatim. Data Analysis
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Focus groups were conducted until thematic saturation was reached (ie, no new codes arose from the data). All of the transcripts were coded and data were managed using Microsoft Excel (Microsoft, Redmond, WA). Our analysis involved both deductive and inductive elements.25 An inductive content analysis approach was initially used for coding and thematic development,26 deriving our codes during the analysis without using predetermined categories.26 Two research team members (*** and ***C) coded each transcript independently and met to discuss the codes to reach consensus in developing the codebook through an iterative process. The final codes were organized conceptually to produce major thematic categories of data. The deductive analysis was based upon the health belief model (HBM)27,28 and its components of modifying factors and individual beliefs as they relate to cues to actions pursued by the individual. The HBM has been used to understand compliance behavior in veteran patients.28 In our work, the final thematic categories were grouped into individual beliefs and modifying factors.
Results
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A total of 17 veterans volunteered to participate in 6 focus groups. Participants included veterans from conflicts in Iraq and Afghanistan, as well as those from previous conflicts, female veterans, and those who had sought health care both at the VA and civilian facilities. Participants discussed life priorities, motivations to improve health, and perceptions of health care. Initial coding of transcripts yielded 72 individual codes. From these codes, 12 themes emerged, which were then grouped into 6 major thematic categories. Our final model (Fig.) depicts the factors affecting health-seeking behavior in the student veteran, including the major thematic group categories and whether each thematic group contributes to individual beliefs or modifying factors based upon the HBM. Thematic Groups Lack of Motivation to Improve Health (Individual Belief)—Veterans expressed several beliefs about health. A feeling of “disconnection” after returning from deployment APls insert initials of principal investigator. BPls insert initials of group facilitator. CPls insert research team members’ initials. South Med J. Author manuscript; available in PMC 2016 August 01.
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was prevalent and this affected their sense of overall health and well-being, both emotionally and physically, as well as their desire to seek health care. One veteran stated, “You know, I’m proud to say that I was a professional soldier, and that means complete dedication and also pretty deep conditioning. So once you get out of that, then take a look at yourself and who you’ve become, you know one realizes that one is disconnected from normal life,” and “socially and mentally when I came back I was pretty far out there.”
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Others expressed the lack of motivation to improve health stating, “I just don’t think about it too much, ‘cause if I feel all right, I just keep on going and really don’t think about other things that could be wrong.” Many faced challenges remaining physically fit without a mandated fitness requirement and lack of access to fitness facilities. One veteran explained, “‘cause that whole thing there the military has in place for you, you’re constantly being monitored and all that is gone, and then it’s up to you.” Another lamented, “I used to be very physically fit. I used to love to run, very active. Now this is most of my day is sitting around watching TV. My wife, we’ve been constantly to the point where mentally I was never there. My mind was always off in the war zone somewhere.”
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In this regard, female veterans were perceived to have an advantage. According to one focus group participant, “It seems gender based, too. You know males don’t tend to take care of themselves as well as females do.” Generational differences in veterans of different wars seemed to contribute to the sense of disconnection after returning from active duty. Veterans of conflicts before the Iraq and Afghanistan wars expressed that more recent veterans were different even as the differences related to their health issues. One veteran stated, “I see people with some of the same injuries, but I have no type of connection with them whatsoever,” or as a Persian Gulf war veteran stated, “I just feel such a disconnection when speaking about Afghan-Iraq veterans.” Another veteran commented, “New guys … they don’t tend to care until it’s … they’re in some kind of ailment or some kind of abyss.” Not all of the veterans lacked motivation to improve health. One reported, “I know it sounds crazy, but I read this short story, right? I’m in class and I read the story and it’s about an alcoholic, right? And that story scared the daylight out of me, right? This story scared me like crazy and I was just like ‘Okay, I need to stop,’ so I stopped. So I just completely stopped.”
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Concern about Social Exclusion and Stigma (Individual Belief)—In addition to their personal feeling of disconnection, veterans were concerned that veteran status and stigma may exclude them from employment and thus were hesitant to seek health care for any conditions that may lead to their being excluded. One veteran believed he could not admit to having flashbacks or seek care for them, stating, “I was at work one day and I had a flashback, so I wasn’t comfortable at work to tell anyone, ‘cause if I were to have told anyone what really happened, I would’ve lost my job. So, that’s a good reason not to seek health care.” Another veteran commented, “It's almost like you’re I guess the term would be ‘damaged goods’.” The concern extended to connecting regarding health issues through social media, as one veteran remarked, “It’s difficult too because sometimes you don’t want to get on any social networks because it’s like you don’t want to get there because you might be selling yourself out.” Other veterans noted, “To tell you the truth, I really don’t trust
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social media,” and “all of a sudden now someone catches wind of that and they can use that against you. It’s just ammo.”
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Social Interactions and Behavior (Individual Belief)—The emphasis of military culture on self-reliance may promote further isolation, even if health or emotional needs are not being met. As one veteran student said, “We are trained to be self-helped, work with a group. When military people get out, they may even shy away from getting help.” A veteran expressed the idea that “You break your hand, break your bone, whatever, you shrug it off and you drive on and you continue the mission.” An extreme sense of social isolation after active duty was expressed by one veteran who shared, “I used to be [a] very social, outgoing person. Now I’m just in the house and just nothing.” Another veteran student stated, “So being back in school I had to kind of force myself because I knew if I stayed home and did nothing, it was gon’ get worse. So this way I’m forcing myself to be social and interact with people, and it helps some.”
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Limited Access to Affordable and Convenient Health Care (Modifying Factor) —Veterans expressed frustration about not having access to affordable health care. One stated, “With being a veteran, I feel like I shouldn’t have to worry about health care. I put my life on the line for this country to keep going the way that it has and for people to have their freedom. Why should I have to worry about anything?” A veteran with a diagnosis of hypertension commented, “I was prescribed medication, but I haven’t had that medication in probably 2 years, and that’s because I don’t have health insurance now and with that it’s expensive to buy meds.” Regarding healthcare coverage, another veteran commented, “So I was stuck in between my coverage for VA health care and public assistance health care, in which I didn’t really fit into a category for either.” According to focus group participants, appointments at the VA were hard to obtain outside business hours. “It’s just virtually impossible, and that’s what makes it infuriating and frustrating for the young soldiers,” noted one veteran. Another echoed these sentiments, saying, “It would be nice if they did stuff on the weekends, you know, or maybe during the day and it’s so limited.”
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Unmet Basic Needs for Self and Family (Modifying Factor)—For many veterans, basic needs such as housing and employment or providing for their families overshadowed any focus on health needs. One said, “You’re just barely making it by today, especially today’s economy.” Another admitted, “I currently live in transitional housing.” Regarding finding employment, a veteran student stated, “I’d already been injured while I was in the Air Force and then I was injured in an industrial accident at a job I worked here and I was left completely out of my realm of skills, and I was seeking not only new employment but new sustainable employment.” A motivation to improve their own health, however, was to care for themselves and their families. Regarding health priorities, one veteran commented, “My number one priority is, you know, take care of myself health wise. That’s always number one, but like you’ve got family. You’ve got loved ones. That’s priority.” Another veteran noted, “At this point, my priority is definitely finding the means to take care of my family,” while another expressed wanting “to bring something positive and good to the table.”
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Academics Competing with Health Needs (Modifying Factor)—Veteran students took their studies seriously. “I take school as something that’s very important. It’s no joke. I treat it as just like my active-duty job,” noted one veteran. The stress of academic workload, however, often was difficult to manage with other life priorities, with one veteran stating, “Going back to school after so many years can be overwhelming. Now I’ve got a family (wife and kids) and the cares of work and car payments, mortgage, and all that stuff makes it really difficult, and plus I work at night, too, so you know trying to stay awake at night and studying at night because I can’t do it during the day because of the kids and everything. So it’s been, it’s really hard.” Another remarked, “It’s still just difficult and challenging because of the PTSD (posttraumatic stress disorder) issues and some other physical issues, and it’s just very frustrating.”
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Our study identified that timely access to healthcare facilities is only one of several important barriers to health-seeking behavior facing veterans in the community. We identified factors related to individual beliefs, as well as modifying factors that could affect health-seeking behavior. The sense of disconnection to civilian life and to others who have not had similar experiences, as well as the loss of focus on maintaining physical health after active duty adversely affected individual motivation to improve health after return from service. Veterans avoided seeking care because of concern about stigma; frustration about the inconvenience and cost of health care; and competing life priorities, including finding work, housing, and providing for a family while trying to succeed academically. Veterans’ sense of isolation and their extreme self-reliance posed additional barriers.
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Stigma has been identified as a barrier to returning service members seeking care for mental health issues,6,9,29 and the social isolation experienced by veterans may exacerbate mental illness,30 especially for veterans with posttraumatic stress disorder.31 Our work demonstrates that these issues represent barriers to seeking any type of health care. As veterans from recent conflicts return home and veterans from previous conflicts age, accessing non–mental health services, particularly preventive health care and care for the control of chronic diseases, will be increasingly important.
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Our exploratory work could inform future quantitative study on larger groups of veterans to examine their perceived barriers to seeking health care and could be linked to their healthcare utilization patterns. Although some veteran students noted that the focus on academic success competed with healthcare needs, the concentration of veterans on campus affords an opportunity for outreach to an otherwise isolated group. Based on our findings, efforts should be made to increase awareness of health services available, reduce stigma, and improve convenience. Existing models for on-campus mental health and social work services for veterans32 may be extended to general health services, either offered on-site or through partnerships with local healthcare facilities. Attention to the cost of care and extended hours should improve uptake. Another proposed means for reaching isolated veterans is electronic communication.10,33 Our findings suggest that fear of stigma extends even to electronic communication. Such
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fears would have to be overcome for that approach to be successful. Linking veteran students to necessary health services through routine screening of all students at the time of enrollment may reduce the stigma associated with seeking care. In addition, peer support programs could help34 decrease social isolation and extreme self-reliance. National programs targeted to veteran students on college campuses such as the 8 Keys to Success, Veterans Integration to Academic Leadership, or the VetSuccess on Campus programs35 could help school administrations to implement these strategies. Results of ongoing evaluations of existing programs such as the US Army’s Comprehensive Soldier and Family Fitness program,36 aimed at improving the resilience of soldiers, also will be informative in choosing the most effective interventions.
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Our findings suggest that health needs often are subjugated to more immediate priorities such as finding work and stable housing. Efforts to mitigate these issues will involve several steps, including educating health professionals about the unique social needs of returning service members,37 as well as a need to extend health promotion efforts beyond traditional healthcare settings. These findings should provoke further longitudinal research into the overall state of our returning veterans as has been formally recommended.38 Our study is limited by the small sample size; therefore, the veteran student focus group participants may not have been representative of veterans in general. We continued subject recruitment and focus groups until we achieved thematic saturation in our qualitative data collection and analysis, however. The barriers we identified in our study are plausibly generalizable. Further studies such as a survey of a larger veteran population could quantify the relative contribution of each of these barriers.
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We acknowledge that investigator bias regarding views about seeking health care may have influenced the focus group research method and data analysis as ***D is a clinician and ***E is a health educator. Allowing for reflexivity39 in data analysis, all of the transcripts were initially coded independently by the two investigators and then discussed until consensus was reached on each code, thereby permitting resolution of potential biases.
Conclusions
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By engaging veteran students in conversations about health, we identified barriers to healthseeking behavior and priority areas to inform targeted health promotion efforts. The impact of social determinants of health, such as the stress of the transition to student life, the sense of stigma, and often the lack of fulfillment of basic needs such as housing or employment on health-seeking behavior is substantial. Efforts to improve the transition to civilian life; reduce stigma; and offer assistance related to work, housing, and convenient, affordable access to health care may improve health in veteran students.
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Acknowledgments This study was supported by the Louis Stokes Cleveland Veterans Affairs Medical Center Research and Education Foundation and National Institutes of Health (grants MD002265 and TR000439). A.D.M.H. received compensation from the Louis Stokes Cleveland Veterans Affairs Medical Center Research and Education Foundation and has received a Clinical and Translational Science Collaborative–Case Western Reserve University research program committee grant. A.R.S. has received grant support from the National Institutes of Health. D.C.A. has received a grant from the Department of Veterans Affairs VA Quality Scholars Fellowship Program.
References
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1. Chokshi DA. Improving health care for veterans—a watershed moment for the VA. N Engl J Med. 2014; 371:297–299. [PubMed: 24896820] 2. Kizer KW, Jha AK. Restoring trust in VA health care. N Engl J Med. 2014; 371:295–297. [PubMed: 24896816] 3. Luncheon C, Zack M. Health-related quality of life among US veterans and civilians by race and ethnicity. Prev Chronic Dis. 2012; 9:E108. [PubMed: 22652126] 4. Spelman JF, Hunt SC, Seal KH, et al. Post deployment care for returning combat veterans. J Gen Intern Med. 2012; 27:1200–1209. [PubMed: 22648608] 5. Stecker T, Fortney JC, Hamilton F, Ajzen I. An assessment of beliefs about mental health care among veterans who served in Iraq. Psychiatr Serv. 2007; 58:1358–1361. [PubMed: 17914017] 6. Chapman PL, Elnitsky C, Pitts B, et al. Mental health, help seeking, and stigma and barriers to care among 3- and 12-month postdeployed and never deployed U.S. Army Combat Medics. Mil Med. 2014; 179(8 Suppl):55–62. [PubMed: 25102550] 7. Elnitsky CA, Chapman PL, Thurman RM, et al. Gender differences in combat medic mental health services utilization, barriers, and stigma. Mil Med. 2013; 178:775–784. [PubMed: 23820352] 8. Mittal D, Drummond KL, Blevins D, et al. Stigma associated with PTSD: perceptions of treatment seeking combat veterans. Psychiatr Rehabil J. 2013; 36:86–92. [PubMed: 23750758] 9. Blais RK, Renshaw KD. Stigma and demographic correlates of help-seeking intentions in returning service members. J Trauma Stress. 2013; 26:77–85. [PubMed: 23335155] 10. Zinzow HM, Britt TW, McFadden AC, et al. Connecting active duty and returning veterans to mental health treatment: interventions and treatment adaptations that may reduce barriers to care. Clin Psychol Rev. 2012; 32:741–753. [PubMed: 23063627] 11. Interian A, Kline A, Callahan L, et al. Readjustment stressors and early mental health treatment seeking by returning National Guard soldiers with PTSD. Psychiatr Serv. 2012; 63:855–861. [PubMed: 22706956] 12. Seal KH, Bertenthal D, Miner CR, et al. Bringing the war back home: mental health disorders among 103,788 US veterans returning from Iraq and Afghanistan seen at Department of Veterans Affairs facilities. Arch Intern Med. 2007; 167:476–482. [PubMed: 17353495] 13. Seal KH, Shi Y, Cohen G, et al. Association of mental health disorders with prescription opioids and high-risk opioid use in US veterans of Iraq and Afghanistan. JAMA. 2012; 307:940–947. [PubMed: 22396516] 14. Eisen SV, Schultz MR, Vogt D, et al. Mental and physical health status and alcohol and drug use following return from deployment to Iraq or Afghanistan. Am J Public Health. 2012; 102(Suppl 1):S66–S73. [PubMed: 22390605] 15. MacGregor AJ, Han PP, Dougherty AL, et al. Effect of dwell time on the mental health of US military personnel with multiple combat tours. Am J Public Health. 2012; 102(Suppl 1):S55–S59. [PubMed: 22390601] 16. Sayers SL, Farrow VA, Ross J, et al. Family problems among recently returned military veterans referred for a mental health evaluation. J Clin Psychiatry. 2009; 70:163–170. [PubMed: 19210950] 17. Cohen BE, Marmar C, Ren L, et al. Association of cardiovascular risk factors with mental health diagnoses in Iraq and Afghanistan war veterans using VA health care. JAMA. 2009; 302:489–492. [PubMed: 19654382]
South Med J. Author manuscript; available in PMC 2016 August 01.
Misra-Hebert et al.
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Author Manuscript Author Manuscript Author Manuscript Author Manuscript
18. Cohen BE, Gima K, Bertenthal D, et al. Mental health diagnoses and utilization of VA non-mental health medical services among returning Iraq and Afghanistan veterans. J Gen Intern Med. 2010; 25:18–24. [PubMed: 19787409] 19. Barry AE, Whiteman, Shawn D, et al. Student service members/veterans in higher education: a systematic review. J Stud Aff Res Pract. 2014; 51:30–42. 20. Widome R, Laska MN, Gulden A, Fu SS, Lust K. Health risk behaviors of Afghanistan and Iraq war veterans attending college. Am J Health Promot. 2011; 26:101–108. [PubMed: 22040391] 21. Widome R, Littman AJ, Laska MN, et al. Preventing chronic illness in young veterans by promoting healthful behaviors. Prev Chronic Dis. 2012; 9:E19. [PubMed: 22172186] 22. Cuyahoga Community College. About Tri-C. http://www.tri-c.edu/about/Pages/default.aspx. Accessed November 24, 2014 23. Merriam, SB., editor. Qualitative Research in Practice: Examples for Discussion and Analysis. 1st. Jossey-Bass; San Francisco: 2002. Basic interpretive qualitative research; p. 37-39. 24. Kuzel, AJ. Sampling in qualitative inquiry. In: Crabtree, BF.; Miller, WL., editors. Doing Qualitative Research. 2nd. Sage Publications; Thousand Oaks, CA: 1999. p. 33-45. 25. Fereday J, Muir-Cochrane E. Demonstrating rigor using thematic analysis: a hybrid approach of inductive and deductive coding and theme development. Int J Qual Methods. 2006; 5:1–11. 26. Hsieh HF, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res. 2005; 15:1277–1288. [PubMed: 16204405] 27. Champion, VL.; Skinner, CS. Chapter 3: The Health Belief Model in Health Behavior and Health Education: Theory, Research, and Practice. Glanz, K.; Rimer, BK.; Viswanath, K., editors. John Wiley & Sons; San Francisco, CA: 2008. F 28. Kelly GR, Mamon JA, Scott JE. Utility of the health belief model in examining medication compliance among psychiatric outpatients. Soc Sci Med. 1987; 25:1205–1211. [PubMed: 2893455] 29. Keane TM, Docherty JP, Jesse RL, et al. Mental health needs of returning veterans. J Clin Psychiatry. 2013; 74:e20. [PubMed: 24229760] 30. Mistry R, Rosansky J, McGuire J, et al. Social isolation predicts re-hospitalization in a group of older American veterans enrolled in the UPBEAT Program. Unified Psychogeriatric Biopsychosocial Evaluation and Treatment. Int J Geriatr Psychiatry. 2001; 16:950–959. [PubMed: 11607938] 31. Rosen C, Adler E, Tiet Q. Presenting concerns of veterans entering treatment for posttraumatic stress disorder. J Trauma Stress. 2013; 26:640–643. [PubMed: 24123262] 32. 2013 APA Silver Award: On-campus VA mental health and social work services for student veterans: SFVAMC's veterans outreach program at City College of San Francisco. Psychiatr Serv. 2013; 64:e10–e11. [PubMed: 24081420] 33. Sadler AG, Mengeling MA, Torner JC, et al. Feasibility and desirability of web-based mental health screening and individualized education for female OEF/OIF reserve and national guard war veterans. J Trauma Stress. 2013; 26:401–404. [PubMed: 23696367] 34. Whiteman SD, Barry AE, Mroczek DK, et al. The development and implications of peer emotional support for student service members/veterans and civilian college students. J Couns Psychol. 2013; 60:265–278. [PubMed: 23421774] 35. The White House. 8 Keys to success: supporting veterans, military and military families on campus. http://www.whitehouse.gov/blog/2013/08/13/8-keys-success-supporting-veteransmilitary-and-military-families-campus. Published August 13, 2013. Accessed October 29, 2014 36. US Army. Comprehensive soldier and family fitness program. http://csf2.army.mil/ about.html#about. Accessed February 17, 2015 37. Lee J, Sanders KM, Cox M. Honoring those who have served: how can health professionals provide optimal care for members of the military, veterans, and their families? Acad Med. 2014; 89:1198–1200. [PubMed: 24979290]
FPls check citation. Wiley doesn’t list this book and couldn’t find on the Internet. South Med J. Author manuscript; available in PMC 2016 August 01.
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38. Institute of Medicine Committee on the Initial Assessment of Readjustment Needs of Military Personnel, Veterans, and Their Families. Returning Home from Iraq and Afghanistan: Preliminary Assessment of Readjustment Needs of Veterans, Service Members, and Their Families. National Academies Press; Washington, DC: 2010. 39. Mays N, Pope C. Qualitative research in health care. Assessing quality in qualitative research. BMJ. 2000; 320:50–52. [PubMed: 10617534]
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Key Points •
Timely access to healthcare facilities is only one of several important barriers to health-seeking behavior facing veterans in the community.
•
Veterans avoided seeking care because of concern about stigma, frustration about the inconvenience and cost of healthcare, and competing life priorities, including finding work, housing, and providing for family while trying to succeed academically. Veterans’ sense of isolation and their extreme selfreliance posed additional barriers.
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By engaging veteran students in conversations about health, we identified barriers to health-seeking behavior and priority areas to inform targeted health promotion efforts.
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Fig.
Factors affecting health-seeking behavior in the student military veteran.
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Appendix: Focus Group Guide
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Prior to starting recording:
First of all, I want to thank you all for agreeing to participate in this focus group. (Facilitator introduces self).
After recording begins:
My research team and I are trying to work toward providing the best health care services to veterans in the community and we wanted to start by hearing from veteran students. Today we will be discussing some of your views about health and accessing health care. I/we are really interested in hearing from you and in learning what you have to say today. There are some specific questions to help guide our discussion, but I really encourage you to share your ideas and opinions as much as you feel comfortable doing so, as the purpose of this group is to make your voice heard to the people who provide health care for veterans. I want to tell you about how this focus group will be organized and will review a few ground rules.
Organization of focus group & ground rules:
As you know, we are audio recording this discussion. In order to preserve confidentiality, we ask that you do not address each other by name. We will not ask you any information that could identify you on the recordings and no identifying information will appear on the transcripts from this focus group. We ask you also to keep what you hear today confidential and not share it with anyone who is not here today. Please respect everyone’s opinions, even if you may disagree with them. Please allow for one person to speak at a time, so that we can clearly hear the conversation on the audio recording. I want to make a comment also about why we are taking notes: we want to make sure that we capture as much as we can about the discussions in addition, and as a back-up to, our audio recordings. Before we begin, do you have any questions for us? As mentioned, there are some specific questions to help lead our discussion but I would like to keep this as open as possible so that you (and not I) are doing most of the talking after this!
Question 1:
We just want to begin with a few introductory comments from all of you so we get a sense of “where you are” in your life these days. Please tell us how long you have been a student, which war you served in, and your branch of service.
Question 2:
Can you tell us about what led to your decision to enroll in community college?
Question 3:
Can you tell us a little about what your priorities are these days, what is important to you? Where does your personal health fit in with your priorities?
Question 4:
Are there any issues related to health that are a concern for you these days? Can you tell me if there are any differences between how you view your health now as compared to when you were on active duty? Are there any specific barriers to improving your health these days?
Question 5:
Now think about making decisions to seek health care. Tell us about some of the reasons why you might choose to seek health care. Now tell us about some of the reasons why you might choose to NOT seek health care- even if you felt that you needed it
Question 6:
A lot of people may come to a health care provider because they think they may be at risk for health problems- either because there may be someone in their family that has certain health problems or because of some behaviors in their own lives that may put them at risk for health problems, or maybe a close friend developed a health problem. Thinking about that…how do you view your personal health status or risk? (try to get at issues of family history, health habits) for chronic diseases (explain …like diabetes, high blood pressure, high cholesterol, obesity)? ***You do not need to talk about the specific risks, but we just are trying to get a sense overall about how you think about your health these days
Question 7:
If you feel your health could be improved, tell us about some things that may motivate you to improve your health?
Question 8:
Can you tell us in general about how you prefer to communicate with others. Text messaging, email, phone, social networking like Facebook or Twitter, in person?
Question 9:
Can you now tell us about how you would prefer to communicate with health care providers about health issues? Text messaging, email, phone, social networking like Facebook or Twitter, in person, reading materials, specific internet sites?
Question 10:
Can you tell us about the places that you may currently obtain medical care? What are your impressions of these places?
Question 11:
What are your current impressions of the Veterans Affairs (VA) healthcare system as a source of care? Access to care? Type of services offered?
Closing script:
Thank you again for participating today in this focus group. Your opinions/contributions are invaluable. Are there any additional questions? I encourage you to contact me if you have any questions after you leave this session.
South Med J. Author manuscript; available in PMC 2016 August 01.
