BACKGROUND/RATIONALE:
Findings indicate that many OEF/OIF Veterans are not receiving the mental health care they need. Although previous studies have examined background characteristics (e.g., age) and factors specific to the health-care setting (e.g., ease of using VA facilities) that may impact service use, few studies have addressed the effect of stigma, reflected in both personal endorsement of negative attitudes about mental illness and mental health treatment (i.e., self-stigma) and concerns about being stigmatized by others for having a mental health problem (i.e., concerns about public stigma), as potential barriers to mental health treatment. Moreover, results based on studies of barriers to care within prior cohorts are likely to fall short because the current generation of Veterans differs from Veterans who have accessed VA care in the past. Finally, no study has explored gender differences in a wide array of barriers to care, including stigma-related factors, within a national sample of OEF/OIF Veterans. A study of the prevalence and multidimensional nature of barriers to VA care in a population-based sample would fill a critical gap in the literature and complement other HSR&D-funded research.

OBJECTIVE(S):
The primary objective of this project was to examine the gender-specific contribution of stigma to mental health-care use among female and male OEF/OIF Veterans. A secondary objective was to examine VA-specific barriers to care as they relate to VHA service use in this population. These objectives were expressed via two immediate objectives. Immediate Objective 1 was to conduct focus groups with OEF/OIF Veterans to explore the relevance of proposed barrier categories and to use this information to inform the barriers to care measures. Immediate Objective 2 was to administer measures of barriers to care, including stigma-related factors, and assess health-care use within a national sample of female and male OEF/OIF Veterans and use these data to address study hypotheses.

METHODS:
For Phase I, six focus groups were conducted with approximately seven Veterans per group. Analyses of focus group data involved identifying salient barriers to care, including both those that are specific to seeking mental health care in the VA setting and stigma-related factors that may be relevant for use of services in any setting. Mail surveys incorporating barrier measures and addressing mental health-care use in VA and non-VA settings were then administered to a nationally representative sample of OEF/OIF Veterans. Hypotheses regarding gender-specific associations between potential barriers and health-care use were tested using regression analyses and all analyses controlled for social desirability.

FINDINGS/RESULTS:
Analyses of Phase I focus group data revealed a number of potential barriers to mental health-care use. Based on these results, the following three categories of potential barriers were addressed in the Phase II survey: (1) stigma-related factors (separated into self-stigma including discomfort with treatment-seeking, negative beliefs about mental illness, and negative beliefs about mental-health treatment; and concerns about public stigma including concerns about stigma from both loved ones and in the workplace); (2) perceptions of the quality of VA care (including availability of services, ease of use, and staff skill and sensitivity); and (3) attitudes about fit within VHA (including perceived similarity to the VHA patient population, perceived entitlement to VHA care, and Veteran identity).

The role of stigma in this cohort's use of mental health care was examined among the sub-sample of Veterans that met criteria for at least one probable mental health condition based on measures of probable PTSD, depression, and alcohol abuse (188 women; 131 men). Self-stigma was associated with a decreased likelihood of using mental health services for both female and male Veterans. Women who reported more discomfort with treatment-seeking (aOR=.94) and more negative beliefs about mental illness (aOR=.94) were less likely to use mental health care. For men, negative beliefs about treatment (aOR=.92), discomfort with treatment-seeking (aOR=.89), and negative beliefs about mental illness, (aOR=.86) were associated with a lower likelihood of seeking mental health care. Concern about public stigma from either loved ones or in the workplace did not predict use of mental health care for either female or male Veterans.

An examination of the role of perceptions of VA care and fit within the VA setting as barriers to care among Veterans with an identified need for mental health treatment revealed a number of interesting gender-specific results. For women, positive perceptions of availability of care (aOR=1.09), ease of use (aOR=1.05), and provider skill and sensitivity (aOR=1.08) predicted greater likelihood of using VA mental health care. For men, only ease of use (aOR=1.05) predicted use of VA mental health care. Among measures addressing attitudes about fit within VA, only perceptions of greater perceived entitlement to VA care (aOR=1.27) predicted use of VA mental health care for women. For men, greater entitlement to VA care (aOR = 1.36) and perceived similarity to the VA patient population (aOR=1.21) predicted higher likelihood of using VA mental health care.

We expected that men would report more positive perceptions of VA and attitudes about fit within VA than women and that these factors would be stronger predictors of VA mental health service use for women compared to men. These hypotheses were not supported. No differences in perceptions of VA or attitudes about fit were observed in this sample of OEF/OIF Veterans and the interaction between perceptions of fit within VA and gender (aOR=.88) was significant, such that perceptions of fit within VA was a stronger predictor of use of VA mental health services for men (aOR=1.20) compared to women (aOR=1.06). We also expected that men would report more stigma-related barriers to care than women and that stigma would be a stronger predictor of men's use of mental health services. Partially consistent with this hypothesis, men reported more self-stigma (negative beliefs about mental health treatment B=-1.78,p<.01; discomfort with treatment-seeking B=-1.98,p<.05,; negative beliefs about mental illness B=-1.40,p<.05,), but there were no gender differences in reports of concerns about public stigma. Relationships between stigma-related factors and use of mental health services were significantly different for men and women in two cases. Negative beliefs about mental illness was a stronger predictor of use of mental health services for men (aOR=.86) than for women (aOR=.94), and concerns about public stigma from family and friends demonstrated a negative, but nonsignificant, association with mental health service use for men (aOR=.96), and a positive, but nonsignificant, association for women (aOR = 1.03).

IMPACT:
Health problems that are not addressed initially often become chronic health conditions that require more extensive and expensive care. The primary product of this project is information regarding barriers to care for female and male OEF/OIF Veterans that can be used to inform clinical care, outreach efforts, and staff education. Findings underscore the importance of self-stigma in OEF/OIF Veterans' use of mental health services and highlight a number of gender differences in the impact of perceived barriers care on use of mental health treatment in this population.

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. Vogt D, Di Leone BA, Wang JM, Sayer NA, Pineles SL, Litz BT. Endorsed and Anticipated Stigma Inventory (EASI): a tool for assessing beliefs about mental illness and mental health treatment among military personnel and veterans. Psychological Services. 2014 Feb 1; 11(1):105-13. [view]
2. Vogt D. Mental health-related beliefs as a barrier to service use for military personnel and veterans: a review. Psychiatric services (Washington, D.C.). 2011 Feb 1; 62(2):135-42. [view]

Conference Presentations

1. Dutra L, Ouimette P, Southwick S, Vogt DS, Whealin J. Current findings on barriers to VA health care use. Paper presented at: International Society for Traumatic Stress Studies Annual Meeting; 2009 Nov 1; Atlanta, GA. [view]
2. Vogt DS, Dutra L, Scheiderer E, Pineles S. Stigma-related barriers to VA health care use for OEF/OIF veterans. Paper presented at: International Society for Traumatic Stress Studies Annual Meeting; 2009 Nov 1; Atlanta, GA. [view]

DRA: Military and Environmental Exposures, Mental, Cognitive and Behavioral Disorders, Health Systems
DRE: Treatment - Observational
Keywords: Operation Enduring Freedom, Access, Operation Iraqi Freedom
MeSH Terms: none