Health Services Research & Development

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FORUM - Translating research into quality health care for Veterans

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Research Highlight

As health care systems increasingly recognize the need to engage more deeply with the individuals they serve, the Veterans Healthcare Administration (VHA) has the advantage of a defined target population. One appealing approach for VHA clinicians and researchers is to work with Veterans groups, particularly Veterans Service Organizations (VSOs) such as the American Legion.

Researchers at Milwaukee's Clement J. Zablocki VA Medical Center (ZVAMC) have engaged VSOs in research activities since 2005. Because this collaboration has been in place longer than many others, its history may be of interest to others in the field. Following the precepts of community-engaged research, we first visited the leadership of various VSOs to gain support for our efforts to work with their membership. While three VSOs had substantial presence in the Milwaukee area (American Legion, Veterans of Foreign Wars (VFW), and Vietnam Veterans of America (VVA)), the VFW became our first partner when the organization's leadership signaled its interest following introductions by a key contact at the ZVAMC.

While many VSOs have sophisticated state and national organizations with full-time professional administrators, the primary organization unit is a local one, most often referred to as a post. These units meet regularly, typically monthly, to conduct business; for example, a post might distribute funds to Veterans in need, organize care packages to deployed active duty forces, and sustain long term programs like an honor guard, Boy Scout Troop, or youth sports team. We wrote to post leaders and asked to visit the posts to talk about how members could take an active role in research regarding the care of chronic disease.

Most posts welcomed the opportunity to have a VA physician attend a meeting. The resulting discussions generally led to positive interest in health promotion and an expressed interest in participating in research in this area. Despite encouraging post members to view the choice of topics as a collaborative process, they tended to defer to researchers regarding the focus of health promotion research efforts. These initial discussions then led to VA HSR&D-funded research efforts that employed the post infrastructure to provide peer support for improved hypertension self-management.

In addition to contributing to research findings, these projects also provide valuable lessons about working with VSO posts. First, we learned that we needed more time to develop a relationship where VSO members felt empowered to provide direction to physicians. This finding may reflect an older population trained to obey doctors' orders, and further screened by membership in VSOs, which have military style command structure. Second, we learned how powerful peer pressure could be—a substantial majority of all post members with hypertension consented to participate in the randomized trial we designed. Since post members served both as interventionists and recruiters for the research project, we considered there might be ethical issues regarding coercion. Post members believed that once the post had decided to participate in a project, typically by majority vote, individual members should participate, though they acknowledged members should not be directly coerced. They expressed no ethical concerns that peer pressure might influence free choice. We discuss these findings in more detail in published work.1 Third, we witnessed spread of the intervention from post to post, and across organizations, as many VFW members are also members of the Legion, the VVA, or the DAV. Fourth, we found that posts vary widely in their ability to engage effectively in complex research activity. In general, posts with more resources were both more willing and also more able to participate.2 This finding raises concern that our efforts to target Veterans in their community settings is of disproportionate benefit to the communities with the greatest existing resources.

In 2008, word of mouth brought us into contact with the leadership of DryHootch of America (DH), an organization of Vietnam Veterans formed in 2005 with the mission of "helping Veterans who survived the war, survive the peace." The organization's mental health focus was a clear departure from our prior experience, but the shared interest in self-management and peer support encouraged us to work together. A small initial grant led to participation by Zeno Franco, Ph.D., a psychologist with VA experience and a trauma psychology research interest. In contrast to the initial experience with older VSOs, the DH partnership was driven by the participating Veterans from the outset. Perhaps because of this less traditional relationship, or because DH is a small and dynamic organization, interactions have sometimes been more complex. Dr. Franco and DH member Mark Flower recently described some of the challenges this collaboration has encountered.3 Dr. Franco leads a $750,000 foundation-funded grant and has helped DH leaders reach out to the Substance Abuse and Mental Health Services Administration (SAMHSA) and other grantors—efforts that have led to over a million dollars in additional funding.

1. Whittle, J. et al. "Ethical Challenges in a Randomized Controlled Trial of Peer Education among Veterans' Service Organizations," Journal of Empirical Research on Human Research Ethics 2010; (4):43-51.

2. Patterson, L. et al. "Location and Organizational Features: What Type of Veteran Communities Participate in Health Programs," Progress in Community Health Partnerships 2012 Summer; 6(2):141-52.

3. Franco, Z.E. et al. "Professional Ethics and Virtue Ethics in Community-Engaged Healthcare Training," p. 211-29, in Mitchell D.E., and R.K. Ream eds. Professional Responsibility: The Fundamental Issue in Education and Health Care Reform. Advances in Medical Education, Vol 4. Springer International Publishing Switzerland, 2015.