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FORUM - Translating research into quality health care for Veterans

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Research Highlight

In 2001, the Institute of Medicine identified patient centeredness as a priority area for improving the quality and equity of health care. Defined as "providing care that is respectful of and representative to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions," this emphasis on the agency and autonomy of patients signaled a sea change in medicine.1 Within VHA, the formation of the Office of Patient Centered Care and Cultural Transformation, the national roll-out of Patient Aligned Care Teams, and more recently, VA's Blueprint for Excellence have all brought a focus on patient centeredness. These efforts recognize the importance not only of the quality of care Veterans receive, but also Veterans' experiences and perceptions of that care and the environment in which it is delivered. Gaining a deep and productive understanding of Veterans' perspectives on patient-centered care requires innovative approaches that highlight collaboration, dialogue, and prioritization of Veterans' voices.

PhotoVoice is a community-engaged research approach that entails giving cameras to individuals to document and convey the conditions, resources, and unmet needs around a specific problem facing their community, as well as identify potential solutions. 2 This approach repositions 'research participants' as collaborators and co-owners of research data who are key partners in the development and dissemination of findings. This approach also incorporates elements of advocacy and social action, and creates opportunities for dialogue between research partners, policymakers, and other key stakeholders. PhotoVoice encompasses key principles of participatory action and patient-oriented research, and aligns with VHA's goal of increasing Veteran engagement in developing processes and policies to enhance patient-centered care and patient experiences at VA facilities.

With VA HSR&D funding, my research team and I undertook a PhotoVoice collaboration with OEF/OIF Veterans to explore and convey their experiences of deployment, homecoming, and engaging in VA health care. The collaboration places an emphasis on identifying barriers to care and ways to ameliorate those barriers. Through outreach via community-based organizations and student Veteran groups, we ensured participation of Veterans who avoid or abandon VA health care as well as those who rely on VA for health care services. Twenty-nine Veterans from all four major branches of service contributed over 300 photos to the project and described the meaning behind each photo. Through analysis of photos and interview transcripts, we identified common themes around how OEF/OIF Veterans define patient-centered care, the impact of negative health care encounters on a Veteran's decision to seek or continue treatment, and suggestions for how VA health care providers and staff can build trusting relationships with Veteran patients. We also developed an exhibit of Veterans' photo-narratives, entitled From War to Home, which has been traveling for the past three years, including installations at five VA Medical Centers so far.

Veterans' photo-narratives highlighted the role of military cultural identity—including norms of stoicism and self-reliance—in shaping how they think about health, illness, and help-seeking. Veterans' stories revealed the challenges they faced in initiating treatment, getting to an appointment, and making themselves vulnerable to care providers. Their stories emphasized the importance of encountering healing environments, respectful staff, and providers who asked questions about their experiences, needs, and goals— and listened to their responses.

Veterans' stories conveyed how essential it is that VA staff and providers avoid making assumptions about an individual Veteran's military service or current circumstances, but rather, get to know each Veteran as an individual. In particular, Veterans want to feel that they are "more than just a number" or a collection of symptoms; as one Veteran noted, "I need my provider to treat me as a person, instead of just thinking 'this medication goes with this symptom.'" Study findings on barriers to mental health care, including Veterans' photo-narratives, were published in a recent issue of the journal Qualitative Health Research.3

Our PhotoVoice collaboration produced compelling, personal, and rich photo-narratives that engage Veterans and their families, health care providers and staff, and the general civilian public on a deep and visceral level. As the exhibit travels, we are developing new venues for featuring Veterans' stories and perspectives through a website (, photo book, and multi-media presentations with Veterans as expert speakers. Audiences for these events value the opportunity to hear directly from Veterans, while the Veterans who share their stories through From War to Home exhibits and events find the experience cathartic. The conversations about how VA can meet Veterans' visions for patient-centered care are just getting started.

1. Committee on Quality of Health Care in America, Institute of Medicine. (2001) Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC; National Academy Press.

2. Wang, C. C., and Burris, M. A. "PhotoVoice: Concept, Methodology, and Use for Participatory Needs Assessment," Health Education & Behavior; 24, 369–87.

3. True, G., Rigg, K., and Butler, A. "Understanding Barriers to Mental Health Care for Recent War Veterans through PhotoVoice," Qualitative Health Research, published online December 8, 2014.

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