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PPO 10-255 – HSR&D Study

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PPO 10-255
Photovoice as an Educational Intervention to Improve Care of OEF/OIF Veterans
Jennifer Gala True PhD
Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
Philadelphia, PA
Funding Period: October 2011 - September 2012

BACKGROUND/RATIONALE:
Veterans returning from deployments in support of Operations Enduring Freedom (OEF) and Iraqi Freedom (OIF) face complex challenges in making the transition to post-deployment life. The VA is uniquely positioned to meet the health care needs of Veterans and support successful reintegration. However, many OEF/OIF Veterans lack a sense of connection with the VA, and in return, VA leadership, providers and staff may have difficulty relating to the deployment and post-deployment experiences of combat Veterans.

Photovoice is an innovative participatory research tool that empowers individuals to convey their experiences, perspectives, and needs through visual images and first person narratives. Establishing feasibility of Photovoice with OEF/OIF Veterans will provide a novel approach to engaging Veterans in their own care, improving patient-provider communication, and sensitizing VA providers and staff to the experiences of returning Veterans.

OBJECTIVE(S):
The primary aim of this pilot project was to establish feasibility of Photovoice with OEF/OIF Veterans. Secondary aims were to explore preliminary effectiveness of Photovoice as an educational intervention to: 1. increase health communication self-efficacy and decrease social anxiety for Veteran participants and 2. positively impact attitudes and knowledge of VA leadership, providers, and staff as relates to the experiences and needs of OEF/OIF Veterans.

METHODS:
Forty OEF/OIF Veterans enrolled in this mixed methods pilot study; 4 withdrew and 7 were lost to follow-up after baseline data had been collected. A total of 29 Veterans completed study participation by collaborating on a Photovoice project focused on answering 4 main questions: 1. How does a deployment impact Veterans' physical, social, and emotional health?; 2. What challenges do Veterans face in making the transition home?; 3. What barriers do Veterans face in seeking care after a deployment?; and 4. Where do Veterans find strength and support to move forward? The sample included Veterans who use VA facilities for their healthcare as well as those who do not.

Veterans were given cameras and asked to take photographs of their daily lives and contribute photos from their personal collections to address the 4 questions described above. Veterans met individually with a member of the study team to review their photographs and describe the meaning behind each image. Veterans contributed over 900 photographs and over 40 hours of narrative data to the project.

Interview transcripts and photographs were coded and analyzed to identify themes and aid in selection of photos and quotes for a Photovoice exhibit. The exhibit was developed in collaboration with Veterans through a series of group meetings.

Effectiveness of Photovoice participation as an intervention to increase self-efficacy and decrease social anxiety is being measured by change in responses to questionnaires administered at baseline and 3- and 9-month follow-up. Follow-up quantitative data is still being collected. Given the additional challenges of enrolling and following Veterans who do not use VA facilities, we found it was infeasible to complete follow-up data collection in a 1-year time-frame.

The impact of attending the Photovoice exhibit on VA providers and staff was assessed through content analysis of written comments.

FINDINGS/RESULTS:
We established feasibility of Photovoice methods with OEF/OIF Veterans through ongoing engagement with 29 Veterans who contributed photos and interviews to the project and collaborated on development of an exhibit installed at a VA Medical Center. Many Veteran participants have elected to continue their involvement in the project through taking part in presentations of findings to VA and non-VA audiences.

Most of the Veterans who did not contribute photos and interviews to the project were struggling with housing instability and/or addiction. We learned valuable lessons about conducting community-engaged research with these special populations, which can be applied to future research studies.

In addition, we identified important themes in Veterans' photos and interviews which are highlighted in the exhibit. Findings related to negative health impacts of deployment, post-deployment challenges, and barriers to care included: the impact of Military Sexual Trauma on post-deployment help-seeking; combat traumas and the role of dissociation in later onset of PTSD; reasons for avoidance of VHA care in general and/or bypassing of particular VA facilities; impact of deployment-related mental health issues on parenting and martial relationships; barriers to accessing mental health care both within and outside VA; pathways to suidality and suicide attempts; pathways to addiction and/or incarceration; and pathways to homelessness. Themes related to sources of support and post-deployment resilience included: positive interactions with VA providers; self-reflection and self-awareness; support from superiors and friends in the military to seek care; positive reinforcement from spouses and other family members; seeking alternative modes of care (e.g., complementary therapies, Veteran-focused events sponsored by non-profit organizations); and 'pet therapy' (e.g., receiving a service animal, adopting a pet).

Analysis of qualitative data demonstrated the impact of the Photovoice exhibit on attitudes and knowledge of VA leadership, providers, and staff, including increased knowledge about the needs of OEF/OIF Veterans, enhanced empathy for and understanding of OEF/OIF Veteran patients, and development of new skills to build rapport with OEF/OIF Veteran patients.

IMPACT:
The success of this pilot project provides a blueprint for conducting community-engaged research with a variety of Veteran populations, as well as opening up numerous pathways for improving care of OEF/OIF Veterans. Findings from the pilot study will inform the design of a multi-site study of Photovoice as an educational intervention for VA providers and other staff to improve OEF/OIF Veterans' experiences of care.

PUBLICATIONS:

Journal Articles

  1. Bugos E, Frasso R, FitzGerald E, True G, Adachi-Mejia AM, Cannuscio C. Practical guidance and ethical considerations for studies using photo-elicitation interviews. Preventing chronic disease. 2014 Oct 30; 11:E189.
  2. Smith RT, True JG. Warring identities: identity conflict and the mental distress of American Veterans of the wars in Iraq and Afghanistan. Society and mental health. 2014 Jan 9; 4(2):147-161.
Magazine/Popular Press Articles

  1. True JG, Patrick R, Console SJ. Wounded warriors and the healing power of stories: how Veterans’ narratives can help us understand. Philadelphia Social Innovations Journal. 2012 May 1; 2012(10):1-3.
  2. True JG. How I learned to be satisfied with only part of the story. Anthropology News. 2012 Apr 1: Opinion: Anthropology in the Public Sector.
HSR&D or QUERI Articles

  1. True JG. Exploring OEF/OIF Veterans’ perceptions of patient-centered care through PhotoVoice. HSR&D Forum. 2015 May 28; 5.
Center Products

  1. True JG. War to Home Exhibit at the Porter College Faculty Gallery, University of California at Santa Cruz. 2014 Apr 10.
  2. True JG. War to Home (Exhibit at the Wilma Theatre, Philadelphia, PA). 2014 Mar 19.
  3. True JG. From war to home: a photovoice exhibit, Philadelphia VA Medical Center Gallery November 13, 2012-February 14, 2013. 2012 Nov 13.
VA Cyberseminars

  1. True JG. Using Photovoice and photo-elicitation methods in VA research: addressing questions around ethics, practice, and measurement [Timely Topics of Interest]. [Cyberseminar]. 2015 Apr 16.
  2. True JG, Pennycuick T, Johnson TI. "More than just a number:" OEF/OIF Veterans’ visions for patient-centered care. [Cyberseminar]. 2014 Aug 21.
  3. Facundo R, True JG. The why and how of patient-centered care: learning from OEF/OIF Veterans. [Cyberseminar]. 2014 Jun 18.
Conference Presentations

  1. True JG. Narrative approaches in teaching and learning about military social work. Paper presented at: Military and Veteran Social Work Annual Conference; 2014 Jun 7; Saint Leo, FL.
  2. True JG. From research to advocacy (and back again): experiences from a photovoice project with Iraq and Afghanistan war Veterans. Presented at: Society for Applied Anthropology Annual Meeting; 2014 Mar 22; Albuquerque, NM.
  3. True JG. From war to home: photos and stories of deployment and homecoming from US Veterans of the wars in Iraq and Afghanistan. Paper presented at: International Society for Traumatic Stress Studies Annual Meeting; 2013 Nov 8; Philadelphia, PA.
  4. Payne J, Sharrow G, True JG. Community-engaged research and problem solving in applied folklore: a brainstorming session to articulate goals and move us forward. Paper presented at: American Folklore Society Annual Meeting; 2013 Oct 27; New Orleans, LA.
  5. True JG. From war to home: an exhibit of OEF/OIF Veterans' photos and stories. Paper presented at: Soldiers Project Annual Conference; 2013 Oct 1; Los Angeles, CA.
  6. True JG, Fritch ES. Understanding and addressing barriers to care for Iraq and Afghan War Veterans: findings from a photovoice study. Poster session presented at: AcademyHealth Annual Research Meeting; 2013 Jun 24; Baltimore, MD.
  7. True JG. An experience-centered approach to combat trauma narratives: exploring the role of disassociation and loss in post-traumatic stress. Paper presented at: American Folklore Society Annual Meeting; 2012 Oct 25; New Orleans, LA.
  8. Smith RT, True JG. Warring identities: American Veterans making sense of postwar identity and health. Paper presented at: Society for Social Studies of Science / European Association for the Study of Science and Technology Annual Meeting; 2012 Oct 19; Copenhagen, Denmark.


DRA: Military and Environmental Exposures, Mental, Cognitive and Behavioral Disorders
DRE: Prevention
Keywords: Attitudes/Beliefs, Health Promotion and Education
MeSH Terms: none