The SOTA Access Model (Fortney et al, 2011) provides a systematic view of the barriers and facilitators of veterans’ access to health care services. The strength of the model synthesizes scholarship and expert panel knowledge of access to health care in the 21st Century. However, what is not currently known is how the conceptual model may or may not empirically coincide with veterans’ lived experiences of access to VA services. This presentation uses two methods -- Cultural Domain Analysis and Qualitative Content Analysis -- to compare the SOTA Access Model with military veterans' actual experiences. The overall goal is to help ground the original conceptual model using empirical data.
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Comparing and contrasting Veterans’ experiences of access with the SOTA Access Model
1. Comparing
and
contrasting
Veterans’
experiences
of
access
with
the
SOTA
Access
Model
2015
Academy
Health
Annual
Mee4ng
June
14,
2015
2. 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)
7. Knowledge
Gap
How
does
the
SOTA
Access
model
compare
with
Veterans’
experiences
of
care?
8. 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.
9. 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
10. Mixed
Methods
Data
Type
Analysis
Type
Quan4ta4ve
Survey
Descrip4ve
sta4s4cs
Cultural
Domain
Analysis
Mixed
qualita4ve
&
quan4ta4ve
analysis
Semi-‐structured
Interviews
Qualita4ve
content
analysis
11. Analysis
#1
Cultural
Domain
Analysis
Ann
M.
Cheney,
PhD
UC
Riverside
&
Greater
Los
Angeles
VA
12. 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
13. Three-‐step
Process
Step
1.
Free
list
exercise
Step
2.
Pile
sort
ac4vity
Step
3.
Interpreta4on
phase
14. Three-‐step
Process
Step
1.
Free
list
exercise
Step
2.
Pile
sort
ac4vity
Step
3.
Interpreta4on
phase
15. 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
16. Three-‐step
Process
Step
1.
Free
list
exercise
Step
2.
Pile
sort
ac4vity
Step
3.
Interpreta4on
phase
20. 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
21. Comparisons
SOTA
Model
Cultural
Domain
Analysis
Geographical
Logis4cal
Problems
Temporal
Financial
Cultural
Cultural
Barriers
Digital
-‐-‐
-‐-‐
Systemic
Problems
-‐-‐
-‐-‐
-‐-‐
Mental
Health
Literacy
-‐-‐
Fear
&
Abuse
of
VA
22. Three-‐step
Process
Step
1.
Free
list
exercise
Step
2.
Pile
sort
ac4vity
Step
3.
Interpreta4on
phase
23. Analysis
#2
Qualitative
Content
Analysis
Christopher
J.
Koenig,
PhD
San
Francisco
VA
&
UC
San
Francisco
24. 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
25. Team-‐based
Coding
Process
Deduc4ve
• SOTA
Model
• Manual
coding
• 4
months
Induc4ve
• Emergent
codes
• Atlas.TI
• 6+
months
Domains
• SOTA
• Non-‐SOTA
Codes
26. Experiences
of
access
Culture
Digital
Logis4cs
Processes
of
Care
VA
System
13
codes
Qualitative
Content
Domains
12
codes
12
codes
6
codes
7
codes
27. Comparisons
SOTA
Model
Qual
Content
Analysis
Geographical
Logis4cal
Problems
Temporal
Financial
Cultural
Cultural
Barriers
Digital
Digital
-‐-‐
VA
System
-‐-‐
Processes
of
Care
-‐-‐
-‐-‐
-‐-‐
-‐-‐
28. 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
-‐-‐
29. 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
30. 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
31. 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
32. 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
35. 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
36. 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
37. Cluster
Analysis
Cultural
Barriers
Fear
&
Abuse
of
VA
Mental
Health
Literacy
Systemic
Problems
Compe4ng
Priori4es
&
Logis4cal
38. 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