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Comparing and contrasting Veterans’ experiences of access with the SOTA Access Model
2015 Academy Health Annual Mee4ng
June 14, 2015
Authors Christopher J. Koenig San Francisco VA & UC San Francisco
Ann M. Cheney University of California, Riverside & Greater Los Angeles VA
Christopher Miller VA Boston Healthcare System & Harvard University
Trish Wright UAMS & LiNle Rock VA
Kara Zamora San Francisco VA
Regina Stanley LiNle Rock VA
Jeff Pyne LiNle Rock VA & UAMS
Supported by VA HSR&D award CRE 12-‐300 (PI: Pyne)
Access Re-‐Conceptualized
J Gen Med, 2011
Access Re-‐Conceptualized
J Gen Med, 2011
Access to Care
Actual
Perceived
• Observed • Measureable
• Self-‐reported • Experience
Access Re-‐Conceptualized
Access Re-‐Conceptualized SOTA Model Geographical
Temporal
Financial
Cultural
Digital
-‐-‐
-‐-‐
-‐-‐
-‐-‐
Knowledge Gap
How does the SOTA Access model compare with Veterans’
experiences of care?
Study Objectives 1. Elicit rural Veterans’ experiences of
access to mental health. 2. Compare Veterans’ experiences with the
SOTA Access model. 3. Develop a Perceived Access Measure
responsive to Veterans’ experiences.
Methods • Mixed Methods • Quantita4ve & Qualita4ve
• Mul4ple sites • New England, Mid-‐South, West
• N=59 par4cipants (n=75-‐80 an4cipated)
• Military Veterans between 18-‐70 • MH Diagnosis or posi4ve MH screen • Rural, Suburban, Urban areas
Mixed Methods
Data Type Analysis Type
Quan4ta4ve Survey Descrip4ve sta4s4cs
Cultural Domain Analysis Mixed qualita4ve & quan4ta4ve analysis
Semi-‐structured Interviews Qualita4ve content analysis
Analysis #1 Cultural Domain Analysis
Ann M. Cheney, PhD UC Riverside & Greater Los Angeles VA
Cultural Domain Analysis The goals of CDA include: • elici4ng items from an insider perspec4ve
• understanding how people associate item content to larger domain(s)
• interpret rela4onship of items within and across domains
Borga<, 1994
Three-‐step Process
Step 1. Free list exercise
Step 2. Pile sort ac4vity
Step 3. Interpreta4on
phase
Three-‐step Process
Step 1. Free list exercise
Step 2. Pile sort ac4vity
Step 3. Interpreta4on
phase
Master List 1 Legal issues 2 Women veterans can’t seek care 3 Outreach about VA healthcare 4 Concerns about gehng mental healthcare 5 Mental health not asked about 6 Suck it up mentality 7 Transporta4on problems 8 Alcohol & drug use 9 Fear using video teleconferencing 10 Appointments hard to get 11 Civilians not understanding vets 12 Having other priori4es 13 Problems with scheduling 14 Homelessness 15 Too few providers 16 Lack available providers 17 Separa4on from military & transi4on 18 Knowledge of where to go & who contact for mental health services 19 Travel distance 20 Percep4ons mental healthcare 21 Perceived need 22 Anxiety 23 Problems with service connected disability
24 Worry what others think 25 Clinics respond slow 26 Health injury sickness 27 Knowledge of mental health treatments 28 No follow-‐up from providers 29 Veterans abusing system 30 Judgement 31 Racism 32 S4gma 33 Paperwork is daun4ng 34 Wai4ng for appointments 35 Providers changing jobs 36 Not steady employment 37 Finances 38 Friends, family, doctor thinking your crazy 39 Losing rights fought for 40 No follow-‐up from VA 41 Trust 42 Weakness 43 Lack of knowledge & understanding 44 Childcare 45 Fear of losing security clearance 46 Cost of travel
Three-‐step Process
Step 1. Free list exercise
Step 2. Pile sort ac4vity
Step 3. Interpreta4on
phase
Pile Sort Activity
Multi-‐Dimensional Scaling Analysis
Shorter the distance between points, the stronger the conceptual rela4onships.
Weakness (42) Trust (41)
Transporta4on problems (7)
(Stress value= 0.181)
Cluster Analysis
Five Cluster SoluEon
Cultural Barriers (Pink Cluster) • Racism • S4gma • Judgment • Percep4on of mental healthcare • Civilians not understanding Veterans’ experiences • “Suck it up” mentality • Friends, family, doctor thinking your "crazy" • Trust • Worry about what others think • Weakness (example: feeling like a failure or weak) • Anxiety • Alcohol and drug use
Comparisons SOTA Model Cultural Domain Analysis Geographical
Logis4cal Problems Temporal
Financial
Cultural Cultural Barriers
Digital -‐-‐
-‐-‐ Systemic Problems
-‐-‐ -‐-‐
-‐-‐ Mental Health Literacy
-‐-‐ Fear & Abuse of VA
Three-‐step Process
Step 1. Free list exercise
Step 2. Pile sort ac4vity
Step 3. Interpreta4on
phase
Analysis #2 Qualitative Content Analysis
Christopher J. Koenig, PhD San Francisco VA & UC San Francisco
Qualitative Content Analysis The goals of QCA include: • Systema4c descrip4on of text
• Iden4fy trends, paNerns, frequencies, and rela4onships of textual informa4on
• Synthesize codes into paNerns with minimal interpreta4on
Borga<, 1994
Team-‐based Coding Process
Deduc4ve
• SOTA Model • Manual coding • 4 months
Induc4ve
• Emergent codes • Atlas.TI • 6+ months
Domains
• SOTA • Non-‐SOTA
Codes
Experiences of access
Culture
Digital
Logis4cs Processes of Care
VA System
13 codes
Qualitative Content Domains
12 codes 12 codes
6 codes 7 codes
Comparisons SOTA Model Qual Content Analysis Geographical
Logis4cal Problems Temporal
Financial
Cultural Cultural Barriers
Digital Digital
-‐-‐ VA System
-‐-‐ Processes of Care
-‐-‐ -‐-‐
-‐-‐ -‐-‐
Comparisons SOTA Model Cultural Domain Qual Content Geographical
Logis4cal Problems Logis4cs Temporal
Financial
Cultural Cultural Barriers Culture
Digital -‐-‐ Digital
-‐-‐ Systemic Problems VA Systemic
-‐-‐ -‐-‐ Processes of Care
-‐-‐ Mental Health Literacy -‐-‐
-‐-‐ Fear & Abuse of VA -‐-‐
Strengths & Limitations Strengths • Mul4-‐site, in-‐depth interviews with Veterans • Two forms of triangula4on: data and analysis
Weaknesses • Generalizability • No road map for combining findings in mixed and mul4ple method analyses
Conclusions • SOTA model and empirical Veterans’ experiences converge in some areas, but diverge in others
• Veteran data can help determine if some factors are more important than others
• Analyses incorporate Veteran perspec4ve • To refine SOTA model for access • To develop a Perceived Access Measure for system-‐wide implementa4on
Acknowledgments The Full ACCESS Team John Fortney, Jeff Pyne, Jim Burgess, Regina Stanley, Mitzi Moser, Debbie Hodges, Trish Wright, Chris Miller, Karen Seal, Gary Tarantovsky, Kara Zamora, Coleen Hill
Veterans who volunteered as par4cipants United States Department of Veteran Affairs VHA Health Services Research & Development
Ann M. Cheney, PhD Ann.Cheney@ucr.edu UC Riverside & Greater Los Angeles VA
Christopher J. Koenig, PhD Christopher.Koenig@va.gov San Francisco VA & UC San Francisco
FIN
Access Re-‐Conceptualized
Step 1. Free List Exercise Goal Elicit Veterans’ perspec4ves on Perceived Barriers to Care AcEvity “List of all the things you can that make it harder for Veterans to get help for emo4onal-‐ and stress-‐related care.” • N=30 Veterans across 3 sites
Analysis • Result = 238 unique items • Similar items were collapsed • Most frequently and qualita4vely important compiled
Step 2. Pile Sort Activity Goal Understand how Veterans iden4fied barriers to care
AcEvity “Place all the items that you think are similar into piles.” • N=29 Veterans across 3 sites
Analysis • Mul$-‐dimensional scaling exposes underlying rela4ons between items
• Cluster analysis associates items into meaningful groups
Cluster Analysis Cultural Barriers
Fear & Abuse of VA
Mental Health Literacy Systemic Problems
Compe4ng Priori4es & Logis4cal
Step 3. Interpretation Activity Goal Interpret how Veterans understand the rela4onships of barriers to care AcEvity “Why do you think other Veterans put these items together?” • n =15 (an4cipated) Veterans across 3 sites
Analysis • Describe the rela4onships of items within & across clusters • Cri4que clusters
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