Accessibility and Acceptability of the Department of Veteran Affairs Health Care: Diverse Veterans' Perspectives

Military Medicine, Mar 2004 by Damron-Rodriguez, JoAnn, White-Kazemipour, Whitney, Washington, Donna, Villa, Valentine M, Et al

Objectives: Diverse veteran's perspectives on the accessibility and acceptability of the Department of Veteran Affairs (VA) health services are presented. Methods: The qualitative methodology uses 16 focus groups (N = 178) stratified by war cohort (World War II and Korean Conflict versus Vietnam War and Persian Gulf War) and four ethnic/racial categories (African American, Asian American, European American, Hispanic American). Results: Five themes emerged regarding veterans' health care expectations: (1) better information regarding available services, (2) sense of deserved benefits, (3) concern about welfare stigma, (4) importance of physician attentiveness, and (5) staff respect for patients as veterans. Although veterans' ethnic/racial backgrounds differentiated their military experiences, it was the informants'veteran identity that framed what they expected of VA health services. Conclusions: Accessibility and acceptability of VA health care is related to veterans' perspectives of the nature of their entitlement to service. Provider education and customer service strategies should consider the identified factors to increase access to VA as well as improve veterans' acceptance of the care.

Introduction

Access to health care and the quality of health care services in the United States have been the focus of national attention.1 The Department of Veteran Affairs (VA) health care services, the largest integrated health care system in the nation, has been compelled to increasingly address access and quality of its health care system.

The importance of VA health services access issues has been emphasized in an acknowledgment that only 10% of veterans use VA health services.2 Eligibility requirements including military service-related disability and financial need limit access to a subset of veterans.3 However, only approximately 23% of veterans who meet eligibility requirements choose to use the VA health care,4 leading to a questioning of the accessibility of VA health services as well as their acceptability among veterans.

Accessibility particularly relates to consumers' entry into a system of care. Access requires the availability of services but also includes that "the available services are approachable and that the means to use them is reachable."5 Beyond access, services must be acceptable to the consumers. Even if services are available and accessible, if there is a perception among users that services are not acceptable to a certain group, services will not be fully used.6 Both accessibility and acceptability of a health care service are best understood from the patient's or consumer's perspective.

Increasingly, the consumer's perspective on access to health care and quality of health care services is deemed important.7-9 The VA has moved to systematize quality management,10 and the "new VA" aims to serve as a national laboratory for understanding elements of access and quality.10 The consumer perspective is sought through needs assessments and consumer satisfaction surveys, which identify specific barriers to access and problems related to the use and quality of services. Focus groups, using methodologies geared to market research, have also been used for these purposes by the VA to identify problems related to consumer satisfaction.11

However, consumer approaches, which are based in the identification of specific problems or the rating of a service, may not assist in understanding the meaning of these issues to the consumer. Additionally, these methods tell us little about the perception of nonusers of VA health services. Furthermore, although there are known ethnic/racial differences in the use of VA health services,12,13 little is known about diverse groups' perceptions of the VA. To understand the meaning of the use of a service and how that service is perceived as accessible and acceptable, a qualitative approach could lead to greater insight into the perception of consumers. Such qualitative explorations of meaning can be informed by previous research into the access to VA health services.

Low income and lack of medical insurance are the factors most associated with greater likelihood of VA use.14,15 Previous investigation of VA access has aimed to explain use in terms of financial need and lack of health care alternatives.16 Disparities by ethnicity/race, income, and medical coverage of veterans have been significantly related to the need to use VA health care as a safety net.17

For some eligible veteran nonusers, inconvenient distance from a VA health care center is a barrier for use, but it is perhaps a smaller actual factor than one would assume. In one study of mental health services users, inconvenience vs. convenience of VA health care or similar services accounted for only 8% of variation in usage.18 Another study, which looked at general medical care usage, found that distance is a barrier primarily in densely populated areas, and then it is only one of many factors.19 In fact, there are veterans who travel great distances to get their care from the VA.19