"It's Like Finding Your Way Through the Labyrinth": a Qualitative Study of Veterans' Experiences Accessing Healthcare

BACKGROUND

The 2014 Veterans Choice Act and subsequent 2018 Veteran's Affairs (VA) Maintaining Systems and Strengthening Integrated Outside Networks Act (MISSION Act) are legislation which clarified Veteran access to healthcare provided by non-VA clinicians (community care). These policies are of particular importance to Veterans living in rural areas, who tend to live farther from VA medical facilities than urban Veterans.

OBJECTIVE

To understand Veterans' experiences of the MISSION Act and how it impacted their access to primary care to inform future interventions with a focus on reaching rural Veterans.

DESIGN

Qualitative descriptive design.

PARTICIPANTS

United States (US) Veterans in Northwestern states engaged in VA and/or community care.

APPROACH

Semi-structured interviews were conducted with a purposive sample of Veterans between August 2020 and September 2021. Interview domains focused on barriers and facilitators of healthcare access. Transcripts were analyzed using thematic analysis.

KEY RESULTS

We interviewed 28 Veterans; 52% utilized community care as their primary source of care and 36% were from rural or frontier areas. Three main themes emerged: (1) Veterans described their healthcare experiences as positive but also frustrating (billing and prior authorization were noted as top frustrations); (2) Veterans with medical complexities, living far from healthcare services, and/or seeking women's healthcare services experienced additional frustration due to increased touch points with VA systems and processes; and (3) financial resources and/or knowledge of the VA system insulated Veterans from frustration with healthcare navigation.

CONCLUSIONS

Despite provisions in the MISSION Act, Veteran participants described persistent barriers to healthcare access. Patient characteristics that required increased interaction with VA processes exacerbated these barriers, while financial resources and VA system knowledge mitigated them. Interventions to improve care coordination or address access barriers across VA and community care settings could improve access and reduce health inequities for Veterans-especially those with medical complexities, those living far from healthcare services, or those seeking women's healthcare.

Dissemination in Extension: Health Specialists' Information Sources and Channels for Health Promotion Programming

In the National Cooperative Extension System (herein: Extension), state-level specialists serve as key intermediaries between research, educators, and the community members they serve. There is a need to understand information seeking and sharing practices (i.e., dissemination) among specialists to increase the adoption of evidence-based health promotion programs. Specialists (N = 94) across 47 states were identified and invited to participate in this mixed methods study. A one-way ANOVA with Bonferroni corrections was used to analyze survey data. Data collected through semi-structured interviews were analyzed using an immersion crystallization approach. Forty-seven health specialists completed the survey representing 31 eligible states (65%) and were predominately female (89%), Caucasian (70%), had a doctorate (62%), and were employed within Extension for 10.2 + 9.7 years. The information sources used most frequently were academic journals and other specialists, and most used email and online meetings to communicate. Qualitative findings support the use of other specialists as a primary source of information and indicate specialists' desire for an on-demand, bi-directional, online national repository of Extension programs. This repository would facilitate the dissemination of evidence-based programming across the system and reduce program duplication as well as information burden on county-based educators.

Intervention Characteristics Considered in Health Educators' Adoption Decision-Making Process

It is well known that perceptions of intervention characteristics (e.g., cost, source, evidence strength and quality) are a critical link from dissemination to implementation. What is less known is the process by which researchers understand the characteristics most valued by key intermediaries (i.e., real-world decision-makers), particularly in the federal system of Cooperative Extension. In Extension, university-based specialists are available to assist county-based agents in program selection, delivery, and evaluation. For this work, a sequential explanatory mixed-methods design was used to conduct surveys and semi-structured interviews, informed by the Diffusion of Innovations theory and Consolidated Framework for Implementation Research. Educators and specialists were recruited across 47 states to identify characteristics of health promotion interventions that facilitate the adoption decision-making process. Analysis of intervention attribute importance survey data was conducted through a one-way ANOVA with Bonferroni post hoc test to determine individual variable differences between responses. Interviews underwent a conventional content analysis. In total, 121 educators and 47 specialists from 33 states completed the survey. Eighteen educators and 10 specialists completed interviews. Educators and specialists valued components such as the community need for the intervention, and potential reach compared with other components including previous delivery settings and external funding of the intervention (p < .05). Qualitative data indicated divergence between educators and specialists; educators valued understanding the intervention cost (time and training) and specialists valued the evidence base and external funding available. Intervention developers should communicate information valued by different stakeholders to improve the adoption of evidence-based interventions.

Recommendations for strengthening the role of embedded researchers to accelerate implementation in health systems: Findings from a state-of-the-art (SOTA) conference workgroup

BACKGROUND

Traditional research approaches do not promote timely implementation of evidence-based innovations (EBIs) to benefit patients. Embedding research within health systems can accelerate EBI implementation by blending rigorous methods with practical considerations in real-world settings. A state-of-the-art (SOTA) conference was convened in February 2019 with five workgroups that addressed five facets of embedded research and its potential to impact healthcare. This article reports on results from the workgroup focused on how embedded research programs can be implemented into heath systems for greatest impact.

METHODS

Based on a pre-conference survey, participants indicating interest in accelerating implementation were invited to participate in the SOTA workgroup. Workgroup participants (N = 26) developed recommendations using consensus-building methods. Ideas were grouped by thematic clusters and voted on to identify top recommendations. A summary was presented to the full SOTA membership. Following the conference, the workgroup facilitators (LJD, CDH, NR) summarized workgroup findings, member-checked with workgroup members, and were used to develop recommendations.

RESULTS

The workgroup developed 12 recommendations to optimize impact of embedded researchers within health systems. The group highlighted the tension between "ROI vs. R01" goals-where health systems focus on achieving return on their investments (ROI) while embedded researchers focus on obtaining research funding (R01). Recommendations are targeted to three key stakeholder groups: researchers, funders, and health systems. Consensus for an ideal foundation to support optimal embedded research is one that (1) maximizes learning; (2) aligns goals across all 3 stakeholders; and (3) implements EBIs in a consistent and timely fashion.

CONCLUSIONS

Four cases illustrate a variety of ways that embedded research can be structured and conducted within systems, by demonstrating key embedded research values to enable collaborations with academic affiliates to generate actionable knowledge and meaningfully accelerate implementation of EBIs to benefit patients.

IMPLICATIONS

Embedded research approaches have potential for transforming health systems and impacting patient health. Accelerating embedded research should be a focused priority for funding agencies to maximize a collective return on investment.

Cooperative Extension Gets Moving, but How? Exploration of Extension Health Educators' Sources and Channels for Information-Seeking Practices

PURPOSE

The Cooperative Extension System (Extension) has implemented concerted efforts toward health promotion in communities across the nation by acting as an intermediary between communities and universities. Little is known about how these intermediaries communicate and learn about existing evidence-based programming. This study serves to explore this gap by learning about information sources and channels used within Extension.

DESIGN

Sequential explanatory mixed methods approach.

SETTING

National Cooperative Extension System.

PARTICIPANTS

Extension community-based health educators.

METHODS

A nationally distributed survey with follow-up semistructured interviews. Survey results were analyzed using a Kruskal-Wallis 1-way analysis of variance test paired with Bonferroni post hoc. Transcripts were analyzed by conventional content analysis.

RESULTS

One hundred twenty-one Extension educators from 33 states responded to the survey, and 18 of 20 invited participants completed the interviews. Educators' information seeking existed in 2 forms: (1) information sources for learning about programming and (2) channels by which this information is communicated. Extension educators reported contacting health specialists and other educators. Extension educators also reported using technological means of communication such as e-mail and Internet to reach information sources such as peers, specialists, academic journals, and so on.

CONCLUSION

Extension state specialists were preferred as primary sources for intervention information, and technology was acknowledged as an easy contact channel. This study identifies county-based health educators' information structures and justifies the need for future research on the role of specialists in communication efforts for educators.

Walk This Way: Our Perspective on Challenges and Opportunities for Extension Statewide Walking Promotion Programs

Evidence-based walking programs exist and some have been tailored specifically for the national Cooperative Extension System; however, program outcomes and translational challenges and successes are underreported. This has presented a challenge to scaling the best-fit intervention for walking promotion within this national system. Here, we describe existing open-access walking programs as well as implications for improving the fit and sustainability of this intervention type within the system. Our experience provides suggestions for pragmatic data collection, infrastructure to support pragmatic data collection, and novel ways to disseminate best practices, as well as considerations for de-implementing what is not working.

Informing the development and uptake of a weight management intervention for preconception: a mixed-methods investigation of patient and provider perceptions

Background

It is recommended for women to have a healthy body mass index before conception. However, there is limited research on appropriate preconception interventions for weight loss. Furthermore, there is a lack of knowledge on providers’ willingness to refer to particular behavioral interventions and the degree to which patients would attend those interventions.

Methods

A cross-section of 67 patients and 21 providers completed surveys related to their demographics and willingness to refer/attend a number of interventions for weight loss. A case study of three patients from the target audience was used to elicit detailed feedback on preconception weight status and weight loss intervention.

Results

Overall, patients were willing to attend a variety of interventions, regardless of BMI category. Focus group participants shared that weight loss prior to conception would be beneficial for them and their child, but cited barriers such as time, location, and the way providers encourage weight loss. Providers were willing to refer to a number of behavioral interventions, and were less willing to prescribe weight loss medications than other intervention options.

Conclusions

A number of intervention strategies may be well received by both patients and providers in preconception care to assist with weight loss prior to conception. Future research is needed on intervention effects and sustainability.

Electronic supplementary material

The online version of this article (doi:10.1186/s40608-017-0144-6) contains supplementary material, which is available to authorized users.