Abstract

“The Veterans Affairs (VA) healthcare system is dedicated to providing high-quality mental health services to all veterans, including the nearly 40% of enrolled veterans living in rural areas. Family education programs regarding mental illness and post-traumatic stress disorder, mandated for delivery in all VA medical centers and some community-based outpatient clinics (CBOCs), have been developed and provided primarily in large, urban medical centers. This qualitative investigation involved interviews with CBOC providers and veterans and families who live in rural areas and/ or seek care in CBOCs to ascertain their perceptions of the benefits, feasibility, structural and cultural barriers, and logistical preferences regarding family education. The perspectives and concerns that emerged in these interviews were combined with expert knowledge to identify the resources and considerations a VAMC would want to address when translating and implementing similar programming into CBOCs. Although institutional, logistic, and attitudinal challenges were described, all three stakeholder groups endorsed the need for family education, did not see the barriers as insurmountable, and provided creative solutions. Administrators and CBOC clinicians may benefit by anticipating and problem solving around the key issues raised when developing family programming.”

Implications

For Practice

In this study, researchers focused on provider and veteran family member perceptions of potential barriers to the implementation of family education programs for rural populations, as well as veterans’ perceptions of family participation in such programs. Providers will need to consider veteran and family member concerns about family involvement in order to effectively publicize and promote family programs. Findings from this study reinforce the importance of the Department of Veterans Affairs (VA) and other organizations undergoing a careful implementation process when translating current programs into new settings. CBOC providers expressed a need for additional training and a way to consult with experienced program providers before and during early implementation of new programs, including the VA best-practice Support and Family Education (SAFE) program. Providers also cited that time constraints reduced their ability to meet all of the components of the required services package. CBOC administrators should work with providers to offer complete training and support for family service programs, as well as creative solutions for consultation and time management. Rural clinicians and administrators can also make use of the SAFE program Implementation Toolkit, a synthesized and organized collection of the suggestions from stakeholders and SAFE providers, available on the SAFE program website www.ouhsc.edu/safeprogram. Other obstacles to care are travelling long distances to VA medical centers, a lack of childcare, and the expense and time required to travel to the VA. VA administrators should work with veterans to make travel to these locations less arduous by exploring provisions for travel expenses and childcare.

For Policy

Both veterans and their family members need to be made aware of the benefits of participation in family education programs, so policies focused on increasing visibility and access to these programs in veteran populations could be particularly beneficial. VA administrators may need to consider policies that encourage or require providers to inform veterans and family members of CBOC family services, as well as the potential benefits of participation. Otherwise, many veterans and their families may never hear about the services available to them. Family members and veterans in this study frequently mentioned needs relating to young children, including the importance of programs to help children understand and cope with parents with PTSD and other mental disorders and the lack of CBOC childcare provision. Since the lack of childcare serves as a significant barrier to participation in family programs, policy makers should direct federal and state funding toward supporting childcare programs within CBOCs. Alternatively, setting up contracts with existing accredited childcare agencies may be a viable alternative for the VA to pursue, rather than establishing VA childcare programs. These concerns are likely to grow as veterans return from Iraq and Afghanistan; these veterans will constitute a greater percentage of CBOC patients, and veterans of these conflicts are younger on average than the overall veteran population and therefore more likely to have minor children at home.

For Future Research

As the majority of the participants in this study were Vietnam-era veterans and families from rural areas in only two states, the findings from this study are not representative of the veteran population at large. Researchers should include a more nationally representative and diverse sample of veterans in future studies to increase generalizability of findings, including veterans from more recent conflict eras. Veterans returning from Iraq and Afghanistan have been more difficult to engage in care, and many of them are from rural areas as well, making them more likely to use CBOCs. Research including these veterans is especially important as they are a growing population with diverse medical needs. This study was also limited to veterans currently obtaining mental health services at VA locations, and so does not account for the experiences and concerns of veterans and their family memebers who are receiving mental health care at locations other than the VA. Future research can ensure that family education programs are successfully tailored to meet the needs of the veteran population and their families.