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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
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, 369â€“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.