Health Equity in the Veterans Health Administration From Veterans’ Perspectives by Race and Sex

Author:

Lee Natalie S.12,Keddem Shimrit345,Sorrentino Anneliese E.3,Jenkins Kevin Ahmaad35,Long Judith A.356

Affiliation:

1. Division of General Internal Medicine, The Ohio State University Wexner Medical Center, Columbus

2. Center for the Advancement of Team Science, Analytics, and Systems Thinking in Health Services and Implementation Science Research, The Ohio State University, Columbus

3. Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania

4. Department of Family Medicine and Community Health, University of Pennsylvania Perelman School of Medicine, Philadelphia

5. Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia

6. Division of General Internal Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia

Abstract

ImportanceAdvancing equitable patient-centered care in the Veterans Health Administration (VHA) requires understanding the differential experiences of unique patient groups.ObjectiveTo inform a comprehensive strategy for improving VHA health equity through the comparative qualitative analysis of care experiences at the VHA among veterans of Black and White race and male and female sex.Design, Setting, and ParticipantsThis qualitative study used a technique termed freelisting, an anthropologic technique eliciting responses in list form, at an urban academic VHA medical center from August 2, 2021, to February 9, 2022. Participants included veterans with chronic hypertension. The length of individual lists, item order in those lists, and item frequency across lists were used to calculate a salience score for each item, allowing comparison of salient words and topics within and across different groups. Participants were asked about current perceptions of VHA care, challenges in the past year, virtual care, suggestions for change, and experiences of racism. Data were analyzed from February 10 through September 30, 2022.Main Outcomes and MeasuresThe Smith salience index, which measures the frequency and rank of each word or phrase, was calculated for each group.ResultsResponses from 49 veterans (12 Black men, 12 Black women, 12 White men, and 13 White women) were compared by race (24 Black and 25 White) and sex (24 men and 25 women). The mean (SD) age was 64.5 (9.2) years. Some positive items were salient across race and sex, including “good medical care” and telehealth as a “comfortable/great option,” as were some negative items, including “long waits/delays in getting care,” “transportation/traffic challenges,” and “anxiety/stress/fear.” Reporting “no impact” of racism on experiences of VHA health care was salient across race and sex; however, reports of race-related unprofessional treatment and active avoidance of race-related conflict differed by race (present among Black and not White participants). Experiences of interpersonal interactions also diverged. “Impersonal/cursory” telehealth experiences and the need for “more personal/attentive” care were salient among women and Black participants, but not men or White participants, who associated VHA care with courtesy and respect.Conclusions and RelevanceIn this qualitative freelist study of veteran experiences, divergent experiences of interpersonal care by race and sex provided insights for improving equitable, patient-centered VHA care. Future research and interventions could focus on identifying differences across broader categories both within and beyond race and sex and bolstering efforts to improve respect and personalized care to diverse veteran populations.

Publisher

American Medical Association (AMA)

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