BACKGROUND/RATIONALE:
Despite substantial efforts by the VA to improve the reintegration process of returning veterans, only limited attention has been given to the unique needs of cultural subgroups in the OEF/OIF/OND population. One step to address OEF/OIF health disparity issues was to learn about and address the unique needs of Veterans and families living in the U.S. Virgin Islands (US VI). The US VI includes 3 islands -- St. Croix, St. Thomas, St. Johns. Despite the high numbers of US VI service members who have been deployed to Iraq and Afghanistan, we could find no post-deployment health information or published research on patient education and community reintegration needs of this unique subgroup of Veterans. Because the US VI is geographically isolated, it is often overlooked and is one of the most underserved areas in the VA healthcare system. The US Virgin Islands is unique from other islands in the Caribbean. For example 81% of the US VI population is of West Indian background and the majority of citizens speak English.

OBJECTIVE(S):
Objectives
Our specific aims were the following:
1. Conduct an implementation project in the US Virgin Islands (US VI) to refine and adapt our methods by creating printed and web-based health information that are written in the English language, at a low literacy level and tailored for a unique cultural group.

2. Use the lessons learned in Puerto Rico and the US Virgin Islands, to plan and develop a service-directed project to address the diverse informational needs of predominant cultural subgroups in VISN8.

METHODS:
Theoretical Framework: We used the Centers for Disease Control and Prevention CDCynergy Model, a framework that guides implementation research to improve health information, implementation and evaluation. We used the RE-AIM framework to guide the summative and formative evaluations.

For Aim #1, we did the following:
(1) We conducted a needs assessment that included: a) critical review of documents (research literature and government and VA reports), b) review of online resources for OEF/OIF/OND Veterans and their families, c) communications with stakeholders in US VI and across the VA, and d) a focus group with 9 Veterans and a focus group with 7 healthcare professionals in the US VI.
(2) We developed and then evaluated our Post-Deployment Readjustment Guidebook for US VI Veterans and their families.
(3) We disseminated our post-deployment guidebook in printed and web-based formats.
(4) We conducted a promotional campaign
(5) We conducted formative evaluations by using a dissemination tracking tool and phone calls with stakeholders to learn about barriers and facilitations. We conducted a summative evaluation by analyzing responses on postcard surveys from 13 respondents and responses from 24 Veterans and 4 professionals in two focus groups.

For Aim #2, we collaborated with stakeholders in the US VI and throughout the VA to plan a future SDP project to address the diverse informational needs of predominant cultural subgroups in VISN8.


FINDINGS/RESULTS:
The needs assessment found that the major health care and social problems were mental health issues, violence, substance abuse, and unemployment. Barriers to receiving care were the "culture of privacy" and stigma that existed on the islands that interfered with Veterans enrolling for and accessing care. Other barriers were the lack of services and customer service issues in the two VA CBOCs in the US VI. Another barrier identified was the challenge of traveling via airplanes to the main medical center in Puerto Rico to receive many needed services. Transportation issues, financial concerns, and perception that the care in Puerto Rico was not culturally relevant were additional barriers. Healthcare professionals also identified a lack of educational materials to help with post-deployment readjustment. Facilitators were the strong network of VA and community professionals who provided services to the OEF/OIF/OND population and the perception that the VA was trying to improve services in the US VI.

Base on the needs assessment, we created and printed the " Post-Deployment Readjustment Guide for US Virgin Islands Veterans and their Families." The guidebook includes 18 factsheets; a list of local, national and online resources; and a tear-out document that Veterans can give to their employers to help with post-deployment work experiences. We disseminated 950 books to Veterans and their families at Veteran Service Organization and National Guard events and through professionals in the VA and the University of the Virgin Islands. In addition, the guidebook was available in an online format on the VA CHS website.

The promotional campaign was conducted to increase awareness of our guidebook, expand outreach efforts, and improve knowledge of post-deployment issues and VA services in the US VI. The campaign included two radio broadcasts, presentations at events for Veterans, town meetings with VA and community professionals, and publications in local newspapers and on VHA Facebook.

The summative evaluation included the postcard surveys and the final focus groups with Veterans and professionals. Only 13 of the 950 persons who received the guidebook returned their postcard surveys. All 13 postcard respondents listed that the guidebook was helpful and that they would recommend the book to another Veteran or family member. The final focus group respondents were overwhelmingly positive about the book and gave examples of how the book had helped Veterans and family members readjust post-deployment. The focus group respondents suggested that the book should have additional local resources with addresses and phone numbers and new topics.


IMPACT:
The deliverable is a guidebook for OEF/OIF/OND Veterans and family members living in the US VI that is available in printed and web-based formats. According to focus group and postcard survey respondents, the guidebook improved post-deployment readjustment, motivated Veterans to obtain VA care, and led to effective family communication. The project improved VA healthcare in the US VI by providing a resource that providers and professionals can use for patient and family education. Additionally, the project provides a model that can be used throughout the VA to develop, promote, evaluate, and implement family education for persons of diverse culturally backgrounds.

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External Links for this Project

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PUBLICATIONS:

Conference Presentations

1. Midolo JP, Freytes IM, Wing KL, Uphold CR. Needs Assessment of Returning OEF/OIF Veterans in the United States Virgin Islands. Poster session presented at: VA Research in the Southeast RFPs to Outcomes: Translating Research to Practice Conference; 2010 Jul 21; Orlando, FL. [view]
2. del Valle LE, Freytes IM, Midolo JP, Collison B, Wing K, Uphold CR. Printed and Web-Based OEF/OIF/OND Culturally- Relevant Family Education Materials. Paper presented at: VA Caribbean Healthcare System Annual Research Day; 2015 May 22; San Juan, Puerto Rico. [view]
3. Uphold CR, Midolo JP, Freytes IM, del Valle L, Wing KL, Knauff LE, Findley KE. Unmet Needs of OEF/OIF/OND Veterans and Their Families Living in the U.S. Virgin Islands. Paper presented at: VA HSR&D National Meeting; 2012 Jul 19; National Harbor, MD. [view]

DRA: Military and Environmental Exposures, Health Systems Science
DRE: Prevention
Keywords: Education (patient), Operation Enduring Freedom, Operation Iraqi Freedom
MeSH Terms: none