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Veterans' Preferences for Receiving Information About VA Services: Is Getting the Information You Want Related to Increased Health Care Utilization?

Veterans' Preferences for Receiving Information About VA Services: Is Getting the Information You... ABSTRACT Although the current cohort of returning veterans has engaged more fully with care from the Department of Veterans Affairs (VA) than have veterans from previous eras, concern remains regarding low engagement with VA services, particularly for specialty services for diagnoses that can most negatively impact quality of life. This study used the framework of the Andersen Model to examine factors related to VA health care use in Operation Enduring Freedom/Operation Iraqi Freedom veterans. Match between veterans' preferences for source of information about VA programs and veterans' actual sources of information about VA services was examined as an additional predictor of help seeking. The study included 1,161 veterans recruited from the southeast United States. Results suggested that veterans prefer to receive information from VA publications and the web, whereas they actually receive information from VA publications and other veterans. Logistic regression suggested that the number of deployments, income, distance to VA, VA disability rating, self-rated health, and match between preferred source of information and actual source of information were significantly related to the use of VA services since deployment. These results suggest that future outreach efforts should focus on targeting veterans' health needs and preferences for care and source of information. INTRODUCTION Access to and utilization of Department of Veterans Affairs (VA) health care are issues that have garnered significant attention. Recent analyses have suggested that a majority (59%) of veterans serving in support of Operations Iraqi or Enduring Freedom (OIF-OEF) are enrolled in VA care, which represents an increase in use over past service eras.1 For example, only about 20% of deployed Persian Gulf Veterans had enrolled in VA care by the year 2009.2 Although recent policy changes have been enacted to improve access to services for veterans from all eras,3 concerns remain regarding OEF-OIF veterans' low engagement with VA services4 as well as specialty services for diagnoses that can most negatively impact quality of life, such as post-traumatic stress disorder5,6 (PTSD). For example, a 2004 study of returning veterans7 found that out of those veterans who screened positive for PTSD post-deployment, only 23% of OEF veterans and 29% to 40% of OIF veterans had received mental health services in the past year. This study seeks to identify potential factors that might increase OEF-OIF veterans' utilization of VA health care, with a focus on how veterans prefer to receive information about VA programs. Many studies have used the Andersen Model8,9 to describe access to health care.10,11 This framework suggests that health care utilization is related to predisposing factors, such as demographic variables, enabling factors, such as income and health insurance, and need factors, including mental and physical health problems. A study of Vietnam veterans examined the Andersen Model in the prediction of any health care use over the prior 6 months, and indicated that although predisposing and enabling factors including age, income, and combat exposure were significantly related to mental and physical health care use, and that the need variables were most strongly related to health care use.11 A similar study based on the 2001 National Survey of Veterans found that older age, male gender, minority racial status, lower levels of education, unmarried status, combat exposure, lower income, lack of insurance, and overall greater symptom severity were all related to increased help seeking.10 This study also found that need-based variables were the most significant predictors of utilization. Although the model has not been formally tested in OIF-OEF veterans, a recent study of mental health care utilization in returning veterans found that probable need for services, income, combat exposure, and perceptions of VA care were significantly related to use.12 A majority of the research addressing health care utilization in returning veterans has focused on barriers to care such as cost, stigma, and health beliefs, with the intention of identifying targets for intervention for overcoming these barriers.4,13 Relatively recent research has begun to focus additionally on veterans' preferences for care, with an eye toward creating tailored programs and outreach14,15 that might draw patients toward needed care. In a qualitative study of veterans who had an active disability claim for PTSD, veterans reported that acceptance of diagnosis, availability of help, treatment encouraging beliefs, system facilitation, and social network encouragement were the major issues that factored into their treatment seeking.14 In a national sample of OIF-OEF veterans, Sayer et al15 further found that veterans enrolled in VA care were highly interested in receiving information on VA services, particularly information on benefits (83%), occupational assistance (80%), self-help materials (75%), educational classes (62%), and individual therapy (61%). This research also suggested that veterans preferred information about VA services from the VA (57%), on the Internet (53%), or by mail (53%) or e-mail (43%). These studies bring to light the importance of attention to veterans' preferences for care and information, but to date, only limited research has examined the relationship between veterans' health care preferences and actual help-seeking behavior.16 This study uses the framework of the Andersen Model to investigate the potential role of veterans' preferences for receiving information about VA programs in relation to their use of VA programs. In particular, this research examines the match between veterans' preferred method of receiving information (e.g., television, website) and how they actually received this information. The researchers hypothesize that match between preference for and actual receipt of information about VA programs will positively be related to veterans' use of available services, in addition to the factors predicted by the Andersen Model. METHODS Participants Participants included 1,161 OIF-OEF veterans recruited from the VA Veterans Integrated Service Network 6 covering North Carolina and parts of Virginia and West Virginia. Veterans had an average age of 39 years (standard deviation [SD] = 9.9), an average income of $54,500 (SD = 33,000), and an average of 1.6 deployments (SD = 0.9). For further descriptive statistics, see Table I. TABLE I Descriptive Statistics Variable  N  %  Male  959  82.7  Female  196  16.9  Ethnicity   White  818  70.5   African-American  198  17.1   Latino  78  6.7   Other  79  7.1  Married  816  70.3  Unmarried  331  28.5  Dependent Children  727  64.5  No Dependents  412  35.5  Currently Employed  859  74.1  Currently Unemployed  301  25.9  VA Disability Rating   None  612  52.8   0–40%  332  28.5   ≥50%  182  15.79  Current Health Rating   Excellent  135  11.6   Very Good  304  26.2   Good  443  38.2   Fair  205  17.7   Poor  47  4.1  Military Component   Reserves  219  18.9   National Guard  220  19.0   Active Duty  689  59.4  Officer  299  25.7  Enlisted  850  73.3  Military Branch   Army  567  48.9   Navy  249  21.5   Air Force  165  14.2   Marines  154  13.3  Match Between Preferred and Actual Info Source   0  609  52.5   1  205  17.7   2  180  15.5   3  142  12.2   4+  24  2.0  Used VA Services Since Deployment   No  756  65.2   Yes  404  34.8  Variable  N  %  Male  959  82.7  Female  196  16.9  Ethnicity   White  818  70.5   African-American  198  17.1   Latino  78  6.7   Other  79  7.1  Married  816  70.3  Unmarried  331  28.5  Dependent Children  727  64.5  No Dependents  412  35.5  Currently Employed  859  74.1  Currently Unemployed  301  25.9  VA Disability Rating   None  612  52.8   0–40%  332  28.5   ≥50%  182  15.79  Current Health Rating   Excellent  135  11.6   Very Good  304  26.2   Good  443  38.2   Fair  205  17.7   Poor  47  4.1  Military Component   Reserves  219  18.9   National Guard  220  19.0   Active Duty  689  59.4  Officer  299  25.7  Enlisted  850  73.3  Military Branch   Army  567  48.9   Navy  249  21.5   Air Force  165  14.2   Marines  154  13.3  Match Between Preferred and Actual Info Source   0  609  52.5   1  205  17.7   2  180  15.5   3  142  12.2   4+  24  2.0  Used VA Services Since Deployment   No  756  65.2   Yes  404  34.8  View Large TABLE I Descriptive Statistics Variable  N  %  Male  959  82.7  Female  196  16.9  Ethnicity   White  818  70.5   African-American  198  17.1   Latino  78  6.7   Other  79  7.1  Married  816  70.3  Unmarried  331  28.5  Dependent Children  727  64.5  No Dependents  412  35.5  Currently Employed  859  74.1  Currently Unemployed  301  25.9  VA Disability Rating   None  612  52.8   0–40%  332  28.5   ≥50%  182  15.79  Current Health Rating   Excellent  135  11.6   Very Good  304  26.2   Good  443  38.2   Fair  205  17.7   Poor  47  4.1  Military Component   Reserves  219  18.9   National Guard  220  19.0   Active Duty  689  59.4  Officer  299  25.7  Enlisted  850  73.3  Military Branch   Army  567  48.9   Navy  249  21.5   Air Force  165  14.2   Marines  154  13.3  Match Between Preferred and Actual Info Source   0  609  52.5   1  205  17.7   2  180  15.5   3  142  12.2   4+  24  2.0  Used VA Services Since Deployment   No  756  65.2   Yes  404  34.8  Variable  N  %  Male  959  82.7  Female  196  16.9  Ethnicity   White  818  70.5   African-American  198  17.1   Latino  78  6.7   Other  79  7.1  Married  816  70.3  Unmarried  331  28.5  Dependent Children  727  64.5  No Dependents  412  35.5  Currently Employed  859  74.1  Currently Unemployed  301  25.9  VA Disability Rating   None  612  52.8   0–40%  332  28.5   ≥50%  182  15.79  Current Health Rating   Excellent  135  11.6   Very Good  304  26.2   Good  443  38.2   Fair  205  17.7   Poor  47  4.1  Military Component   Reserves  219  18.9   National Guard  220  19.0   Active Duty  689  59.4  Officer  299  25.7  Enlisted  850  73.3  Military Branch   Army  567  48.9   Navy  249  21.5   Air Force  165  14.2   Marines  154  13.3  Match Between Preferred and Actual Info Source   0  609  52.5   1  205  17.7   2  180  15.5   3  142  12.2   4+  24  2.0  Used VA Services Since Deployment   No  756  65.2   Yes  404  34.8  View Large Recruitment and Procedures A list of potential separated active duty personnel, National Guard members and Reservists who had deployed to Iraq or Afghanistan was obtained from the Defense Manpower Data Center. Out of approximately 70,000 eligible veterans in the Veterans Integrated Service Network 6 area, 5,000 were randomly sampled. Out of the 5,000 surveys, 1.4% were uncompleted because of extenuating circumstances, 18.5% were undeliverable, and 80% were successfully delivered. Of the 4,004 surveys that were delivered, 1161 were completed and returned for a final cooperation rate of 29%. A survey contractor was used throughout the study to enhance privacy protections, so no identifying information was obtained by study researchers. A Dillman Total Design Method17 was used, and participants were first sent an alert letter 1 week in advance of the study informing them of the nature and purpose of the research project. Then, they received the survey package that included the survey as well as a cover letter with study contact information, informed consent, and confidentiality information. A follow-up packet was mailed if the veteran had not responded within 5 weeks, and veterans were considered nonresponders if they did not respond within 5 weeks of the second survey mailing. This study was approved by the Durham VA Medical Center Institutional Review Board and the VA Office of Management and Budget. Measures The complete survey consisted of questions regarding demographic information, military history, rating of physical and mental health, and health care service utilization. The selection of items was informed by qualitative needs assessment utilizing six 10 to 12 person focus groups.18 In this study, the outcome variable of interest was binary response to the question, “Since your last deployment, have you used VA for health care services?” Also examined were predisposing factors including gender, ethnicity, marital status, and the number of deployments in addition to the enabling variable of income. Need for services was represented by the level of VA disability, rated on a scale from 0% to 100% disability in increments of 10%, and on self-reported rating of health ranging from excellent to poor. At the conclusion of the survey, veterans were asked to respond to the following question, “People learn about VA programs from different sources. Did you receive any information about VA programs from the following sources?” and asked to indicate yes/no if they had received information from: newspapers, TV, radio, VA information or publications, other government publications, other veterans, discharge counseling, Postdeployment Health Reassessment (PDHRA), veterans' organizations, website, friends/family/coworkers, chaplain/religious leader, command/superiors, family readiness groups, combat stress control/behavioral health contacts, toll-free hotline, Military OneSource, or other. They were then asked, “In the last column above, please indicate how you would prefer to receive information in the future.” For the purposes of this study, a variable was computed that represented a count of the number of matches between the format in which veterans received information about VA programs versus the format in which they would prefer to receive such information. Data Analysis Individual items were initially examined to determine veterans' preferences for information source as well as the number of matches between their preferences for and actual receipt of information. A chi-square test was used to examine the relationship between match and service utilization, and a multivariate logistic regression was used to predict service utilization with demographics, need variables, and match factors included as covariates. RESULTS Results were first analyzed by examining the relative frequencies of how veterans actually received information about VA programs versus how veterans would prefer to receive information about VA programs (Table II). Frequency data indicated that most veterans received information through VA publications, and most veterans also preferred this method of communication. However, relatively few veterans indicated a preference for receiving information from other veterans and from discharge counseling, although the number receiving information in these formats was quite high. TABLE II Frequency Data Comparing Veterans' Receipt of Information Versus Preferences for Information Source Source  Veterans That Received Info This Way (%)  Veterans That Would Prefer to Receive Info This Way (%)  VA Publications  74  37  Other Veterans  69  6  Counseling at Discharge  59  11  Internet  57  33  Source  Veterans That Received Info This Way (%)  Veterans That Would Prefer to Receive Info This Way (%)  VA Publications  74  37  Other Veterans  69  6  Counseling at Discharge  59  11  Internet  57  33  View Large TABLE II Frequency Data Comparing Veterans' Receipt of Information Versus Preferences for Information Source Source  Veterans That Received Info This Way (%)  Veterans That Would Prefer to Receive Info This Way (%)  VA Publications  74  37  Other Veterans  69  6  Counseling at Discharge  59  11  Internet  57  33  Source  Veterans That Received Info This Way (%)  Veterans That Would Prefer to Receive Info This Way (%)  VA Publications  74  37  Other Veterans  69  6  Counseling at Discharge  59  11  Internet  57  33  View Large Preliminary analysis of the relationship between information source match and VA use revealed a significant chi-square, χ2(1) = 3.47, p < 0.05 (1 sided), and indicated that 207 veterans in this study had used VA services since deployment and had at least 1 match between how they preferred to receive information and how they actually received information. An exploratory logistic regression was then performed with gender, racial status, age, marital status, the number of deployments, information source match, employment status, income, distance to closest VA hospital, self-reported health level, and VA disability level as predictors of VA health care use. Although the overall model was significant χ2(6, N = 1070) = 245.88, p < 0.001, a number of the predictors were not, including gender, age, race, marital status, and employment status (p = 0.43–0.89). The model was respecified using only the significant predictors, and the results of this analysis are presented in Table III. Predisposing factors (i.e., number of deployments), enabling factors (i.e., income, distance to VA), need factors (i.e., health rating and VA disability), and matched preferences for receiving information were each associated with VA health care utilization. Odds ratios indicated that an increase in match in information source was related to a 13% increase in the likelihood of help seeking. Health status was the strongest predictor of VA health care use, with a decrease in health status increasing the likelihood of seeking help by 45%. TABLE III Logistic Regression Predicting VA Health Care Utilization Overall Model  −2 Log Likelihood  Nagelkerke R2  χ2  1146.34  28.2  10.00  Variable  B  Wald  Sig  Exp (B)  95% CI  Match  0.13  4.63  0.03  1.13  1.01–1.27  Health  0.37  20.03  0.00  1.45  1.23–1.70  VA Disability  0.18  72.00  0.00  1.20  1.15–1.25  Income  −0.23  54.72  0.00  0.79  0.74–0.84  No. of Deployments  −0.27  8.97  0.00  0.76  0.64–0.91  Distance to VA  −0.20  7.65  0.01  0.82  0.71–0.94  Overall Model  −2 Log Likelihood  Nagelkerke R2  χ2  1146.34  28.2  10.00  Variable  B  Wald  Sig  Exp (B)  95% CI  Match  0.13  4.63  0.03  1.13  1.01–1.27  Health  0.37  20.03  0.00  1.45  1.23–1.70  VA Disability  0.18  72.00  0.00  1.20  1.15–1.25  Income  −0.23  54.72  0.00  0.79  0.74–0.84  No. of Deployments  −0.27  8.97  0.00  0.76  0.64–0.91  Distance to VA  −0.20  7.65  0.01  0.82  0.71–0.94  View Large TABLE III Logistic Regression Predicting VA Health Care Utilization Overall Model  −2 Log Likelihood  Nagelkerke R2  χ2  1146.34  28.2  10.00  Variable  B  Wald  Sig  Exp (B)  95% CI  Match  0.13  4.63  0.03  1.13  1.01–1.27  Health  0.37  20.03  0.00  1.45  1.23–1.70  VA Disability  0.18  72.00  0.00  1.20  1.15–1.25  Income  −0.23  54.72  0.00  0.79  0.74–0.84  No. of Deployments  −0.27  8.97  0.00  0.76  0.64–0.91  Distance to VA  −0.20  7.65  0.01  0.82  0.71–0.94  Overall Model  −2 Log Likelihood  Nagelkerke R2  χ2  1146.34  28.2  10.00  Variable  B  Wald  Sig  Exp (B)  95% CI  Match  0.13  4.63  0.03  1.13  1.01–1.27  Health  0.37  20.03  0.00  1.45  1.23–1.70  VA Disability  0.18  72.00  0.00  1.20  1.15–1.25  Income  −0.23  54.72  0.00  0.79  0.74–0.84  No. of Deployments  −0.27  8.97  0.00  0.76  0.64–0.91  Distance to VA  −0.20  7.65  0.01  0.82  0.71–0.94  View Large DISCUSSION The results of this study both confirm and extend the application of the Andersen Model in a VA health care population. These results suggest that predisposing, enabling, and need factors, including number of deployments, income, distance to VA, health rating, and disability rating, are relevant predictors of VA service utilization. Notably, preferences for care also emerged as a key variable in the prediction of VA help seeking. Results suggest a strong relationship between service utilization and match between how veterans receive information about VA services versus how they would prefer to receive information, such that an increase in match of information source is related to an increase in service use. Although need, represented by disability and self-evaluation of health, was the strongest predictor of service use, these findings suggest that veterans' preferences are an important component that should be considered in the modeling of help-seeking behavior. As stated, the variables representing need for care, including decreased rating of one's health and increased level of disability, both predicted increases in help seeking as expected based on previous research.12 The enabling factors in this study, including income and distance to closest VA, were also significant predictors of service use. Further distance to VA was related to decreased help seeking, confirming that access to care has an important relationship to use of care. Income was predictive of help seeking, but in an unexpected direction. Although income is typically seen as enabling the help-seeking process,8 in this study higher income led to less VA health care use. This is likely because of the higher rates of VA health care utilization by enlisted personnel and those without private insurance.1,19 The predisposing variable of exposure to combat was negatively related to service use in this study, which was surprising, given that combat exposure has been related to increased service use in previous research.10 This discrepancy may be because of sampling. Although veterans in previous studies had a wide range of combat exposure, including many who had seen no combat, all veterans in this study were deployed in the service of OIF/OEF. In light of this sample, it is possible that combat exposure is related to decreased service use because of increased barriers commonly associated with immersion in military culture such as reluctance to acknowledge problems and ask for help. Other predisposing factors, including gender, age, race, marital status, and employment status, were not related to VA health care use in this study. Results from past studies have been variable regarding the significance of similar demographic variables. However, this result is generally consistent with the finding that more treatment-related variables, such as need and preferences for care, have stronger relationships with service utilization than do predisposing variables. Overall, this study demonstrated that the Andersen Model is a relevant conceptualization of help-seeking behavior in the veteran population, with particular contributions from veteran characteristics reflecting need for and access to care. However, this study also suggests an extension of this model to include veterans' preferences for information about VA programs. Several recent articles14,15 have begun to call for attention to veterans' preferences in our attempts to increase VA service utilization, and this study again confirms that preferences are indeed a relevant factor in veterans' use of care. Although many veterans are receiving information in a way in which they prefer, often from VA publications, results from this sample indicate that many veterans are receiving information in ways that they would not prefer (such as from other veterans), and that many veterans would like to receive more information from the web. It appears that one potential way to bridge the gap between veterans and the wide range of VA health care services available to them may be to tailor outreach and advertising campaigns to the preferences for receiving information as well as the most pressing health concerns of returning veterans. This study is limited by a restricted response rate, and consequently, results should be interpreted cautiously. As with preferences for information about care, it appears that veterans in this era have relatively low response rates for paper-and-pencil techniques20 and may respond better to research queries online. Despite this limitation, sample characteristics closely map on to those of larger studies of OIF/OEF veterans4,21 and appear to match closely with figures representing veterans of this era. Future studies might focus on these issues at a national level, and could likely improve cooperation rates by using data collection techniques that might appeal more to returning veterans. In conjunction with other recent studies addressing the critical role of veterans' preferences for care, this study indicates the need for further research on the preferences for the type of care and source of information about care in returning veterans of this era. Targeted marketing and outreach tailored to this cohort's preferences may play a key role in engaging this group of veterans in VA care. REFERENCES 1. Veterans Health Administration, Department of Veterans Affairs Epidemiology Program, Post-Deployment Health Group, Office of Public Health. Analysis of VA Health Care Utilization among Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn Veterans, from 1st Qtr FY 2002 through 2nd Qtr FY 2014 . Washington, DC, 2014. Available at http://www.publichealth.va.gov/docs/epidemiology/healthcare-utilization-report-fy2014-qtr1.pdf; accessed August 4, 2014. 2. U.S. Department of Veterans Affairs Gulf War Era Veterans report: Pre 9/11 . Available at www.va.gov/vetdata/docs/specialreports/gw_pre911_report.pdf; accessed March 1, 2015. 3. U.S. Department of Veterans Affairs Accelerating Access to Care Initiative Fact Sheet . Available at http://www.va.gov/health/docs/052714AcceleratingAccessFactSheet.PDF; accessed August 4, 2014. 4. Elbogen EB, Wagner H, Johnson SC, et al.   Are Iraq and Afghanistan veterans using mental health services? New data from a national random-sample survey. Psychiatr Serv  2013; 64( 2): 134– 41. Google Scholar CrossRef Search ADS PubMed  5. Milliken CS, Auchterlonie JL, Hoge CW Longitudinal assessment of mental health problems among active and reserve component soldiers returning from the Iraq War. JAMA  2007; 298( 18): 2141– 8. Google Scholar CrossRef Search ADS PubMed  6. Seal KH, Maguen S, Cohen B, et al.   VA mental health services utilization in Iraq and Afghanistan veterans in the first year of receiving new mental health diagnoses. J Trauma Stress  2010; 23: 5– 16. Google Scholar PubMed  7. Hoge CW, Castro CA, Messer SC, McGurk D, Cotting DI, Koffman RL Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. N Engl J Med  2004; 351: 13– 22. Google Scholar CrossRef Search ADS PubMed  8. Andersen RM Revisiting the behavioral model and access to medical care: does it matter? J Health Soc Behav  1995; 36: 1– 10. Google Scholar CrossRef Search ADS PubMed  9. Andersen RM Behavioral Model of Families' Use of Health Services. Research Series No. 25 . Chicago, IL, Center for Health Administration Studies, University of Chicago, 1968. 10. Elhai JD, Grubaugh AL, Richardson JD, Egede LE, Creamer M Outpatient medical and mental healthcare utilization models among military veterans: results from the 2001 National Survey of Veterans. J Psychiatr Res  2008; 42: 858– 67. Google Scholar CrossRef Search ADS PubMed  11. Maguen S, Schumm JA, Norris RL, et al.   Predictors or mental and physical health service utilization among Vietnam veterans. Psychol Serv  2007; 4( 3): 168– 80. Google Scholar CrossRef Search ADS   12. Di Leone BAL, Vogt D, Gradus JL, Street AE, Giasson HL, Resick PA Predictors of mental health care use among male and female veterans deployed in support of the wars in Afghanistan and Iraq. Psychol Serv  2013; 10( 2): 145– 51. Google Scholar CrossRef Search ADS PubMed  13. Wells TS, LeardMann CA, Fortuna SO, et al.   A prospective study of depression following combat deployment in support of the wars in Iraq and Afghanistan. Am J of Public Health  2010; 100: 90– 9. Google Scholar CrossRef Search ADS   14. Sayer NA, Friedemann-Sanchez G, Spoont M, et al.   A qualitative study of determinants of PTSD treatment initiation in veterans. Psychiatry  2009; 72: 238– 55. Google Scholar CrossRef Search ADS PubMed  15. Sayer NA, Noorbaloochi S, Frazier P, Carlson K, Gravely A, Murdoch M Reintegration problems and treatment interests among Iraq and Afghanistan combat veterans receiving VA medical care. Psychiatr Serv  2010; 61: 589– 97. Google Scholar CrossRef Search ADS PubMed  16. Crawford EF, Elbogen EB, Wagner HR, et al.   Surveying treatment preferences in U.S. Iraq–Afghanistan veterans with PTSD symptoms: a step toward veteran-centered care. J Trauma Stress  2015; 28( 2): 118– 26. Google Scholar CrossRef Search ADS PubMed  17. Dillman DA Mail and Internet Surveys: The Tailored Design Method , Vol. 2. New York, Wiley, 2000. 18. Straits-Troster K, Gierisch JM, Calhoun PS, Strauss JL, Voils C, Kudler H Living in transition: young veterans' health and the postdeployment shift to family life. In: Treating Young Veterans: Promoting Resilience Through Practice and Advocacy . Edited by Kelly DC, Howe-Barksdale S, Gitelson D New York, Springer, 2011. 19. Shen Y, Hendricks A, Wang F, Gardner J, Kazis LE The impact of private insurance coverage on veterans' use of VA Care: insurance and selection effects. Health Serv Res  2008; 43( 1): 267– 86. Google Scholar PubMed  20. Eisen SV, Schultz MR, Vogt D, et al.   Mental and physical health status and alcohol and drug use following return from deployment to Iraq or Afghanistan. Am J Public Health  2012; 102: S66– 73. Google Scholar CrossRef Search ADS PubMed  21. Calhoun PS, Elter JR, Jones ER, Kudler H, Straits-Troster K Hazardous alcohol use and receipt of risk-reduction counseling among U.S. veterans of the wars in Iraq and Afghanistan. J Clin Psychiatry  2008; 69: 1686– 93. Google Scholar CrossRef Search ADS PubMed  Reprint & Copyright © Association of Military Surgeons of the U.S. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Military Medicine Oxford University Press

Veterans' Preferences for Receiving Information About VA Services: Is Getting the Information You Want Related to Increased Health Care Utilization?

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Oxford University Press
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Reprint & Copyright © Association of Military Surgeons of the U.S.
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0026-4075
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1930-613X
DOI
10.7205/MILMED-D-14-00685
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26837077
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Abstract

ABSTRACT Although the current cohort of returning veterans has engaged more fully with care from the Department of Veterans Affairs (VA) than have veterans from previous eras, concern remains regarding low engagement with VA services, particularly for specialty services for diagnoses that can most negatively impact quality of life. This study used the framework of the Andersen Model to examine factors related to VA health care use in Operation Enduring Freedom/Operation Iraqi Freedom veterans. Match between veterans' preferences for source of information about VA programs and veterans' actual sources of information about VA services was examined as an additional predictor of help seeking. The study included 1,161 veterans recruited from the southeast United States. Results suggested that veterans prefer to receive information from VA publications and the web, whereas they actually receive information from VA publications and other veterans. Logistic regression suggested that the number of deployments, income, distance to VA, VA disability rating, self-rated health, and match between preferred source of information and actual source of information were significantly related to the use of VA services since deployment. These results suggest that future outreach efforts should focus on targeting veterans' health needs and preferences for care and source of information. INTRODUCTION Access to and utilization of Department of Veterans Affairs (VA) health care are issues that have garnered significant attention. Recent analyses have suggested that a majority (59%) of veterans serving in support of Operations Iraqi or Enduring Freedom (OIF-OEF) are enrolled in VA care, which represents an increase in use over past service eras.1 For example, only about 20% of deployed Persian Gulf Veterans had enrolled in VA care by the year 2009.2 Although recent policy changes have been enacted to improve access to services for veterans from all eras,3 concerns remain regarding OEF-OIF veterans' low engagement with VA services4 as well as specialty services for diagnoses that can most negatively impact quality of life, such as post-traumatic stress disorder5,6 (PTSD). For example, a 2004 study of returning veterans7 found that out of those veterans who screened positive for PTSD post-deployment, only 23% of OEF veterans and 29% to 40% of OIF veterans had received mental health services in the past year. This study seeks to identify potential factors that might increase OEF-OIF veterans' utilization of VA health care, with a focus on how veterans prefer to receive information about VA programs. Many studies have used the Andersen Model8,9 to describe access to health care.10,11 This framework suggests that health care utilization is related to predisposing factors, such as demographic variables, enabling factors, such as income and health insurance, and need factors, including mental and physical health problems. A study of Vietnam veterans examined the Andersen Model in the prediction of any health care use over the prior 6 months, and indicated that although predisposing and enabling factors including age, income, and combat exposure were significantly related to mental and physical health care use, and that the need variables were most strongly related to health care use.11 A similar study based on the 2001 National Survey of Veterans found that older age, male gender, minority racial status, lower levels of education, unmarried status, combat exposure, lower income, lack of insurance, and overall greater symptom severity were all related to increased help seeking.10 This study also found that need-based variables were the most significant predictors of utilization. Although the model has not been formally tested in OIF-OEF veterans, a recent study of mental health care utilization in returning veterans found that probable need for services, income, combat exposure, and perceptions of VA care were significantly related to use.12 A majority of the research addressing health care utilization in returning veterans has focused on barriers to care such as cost, stigma, and health beliefs, with the intention of identifying targets for intervention for overcoming these barriers.4,13 Relatively recent research has begun to focus additionally on veterans' preferences for care, with an eye toward creating tailored programs and outreach14,15 that might draw patients toward needed care. In a qualitative study of veterans who had an active disability claim for PTSD, veterans reported that acceptance of diagnosis, availability of help, treatment encouraging beliefs, system facilitation, and social network encouragement were the major issues that factored into their treatment seeking.14 In a national sample of OIF-OEF veterans, Sayer et al15 further found that veterans enrolled in VA care were highly interested in receiving information on VA services, particularly information on benefits (83%), occupational assistance (80%), self-help materials (75%), educational classes (62%), and individual therapy (61%). This research also suggested that veterans preferred information about VA services from the VA (57%), on the Internet (53%), or by mail (53%) or e-mail (43%). These studies bring to light the importance of attention to veterans' preferences for care and information, but to date, only limited research has examined the relationship between veterans' health care preferences and actual help-seeking behavior.16 This study uses the framework of the Andersen Model to investigate the potential role of veterans' preferences for receiving information about VA programs in relation to their use of VA programs. In particular, this research examines the match between veterans' preferred method of receiving information (e.g., television, website) and how they actually received this information. The researchers hypothesize that match between preference for and actual receipt of information about VA programs will positively be related to veterans' use of available services, in addition to the factors predicted by the Andersen Model. METHODS Participants Participants included 1,161 OIF-OEF veterans recruited from the VA Veterans Integrated Service Network 6 covering North Carolina and parts of Virginia and West Virginia. Veterans had an average age of 39 years (standard deviation [SD] = 9.9), an average income of $54,500 (SD = 33,000), and an average of 1.6 deployments (SD = 0.9). For further descriptive statistics, see Table I. TABLE I Descriptive Statistics Variable  N  %  Male  959  82.7  Female  196  16.9  Ethnicity   White  818  70.5   African-American  198  17.1   Latino  78  6.7   Other  79  7.1  Married  816  70.3  Unmarried  331  28.5  Dependent Children  727  64.5  No Dependents  412  35.5  Currently Employed  859  74.1  Currently Unemployed  301  25.9  VA Disability Rating   None  612  52.8   0–40%  332  28.5   ≥50%  182  15.79  Current Health Rating   Excellent  135  11.6   Very Good  304  26.2   Good  443  38.2   Fair  205  17.7   Poor  47  4.1  Military Component   Reserves  219  18.9   National Guard  220  19.0   Active Duty  689  59.4  Officer  299  25.7  Enlisted  850  73.3  Military Branch   Army  567  48.9   Navy  249  21.5   Air Force  165  14.2   Marines  154  13.3  Match Between Preferred and Actual Info Source   0  609  52.5   1  205  17.7   2  180  15.5   3  142  12.2   4+  24  2.0  Used VA Services Since Deployment   No  756  65.2   Yes  404  34.8  Variable  N  %  Male  959  82.7  Female  196  16.9  Ethnicity   White  818  70.5   African-American  198  17.1   Latino  78  6.7   Other  79  7.1  Married  816  70.3  Unmarried  331  28.5  Dependent Children  727  64.5  No Dependents  412  35.5  Currently Employed  859  74.1  Currently Unemployed  301  25.9  VA Disability Rating   None  612  52.8   0–40%  332  28.5   ≥50%  182  15.79  Current Health Rating   Excellent  135  11.6   Very Good  304  26.2   Good  443  38.2   Fair  205  17.7   Poor  47  4.1  Military Component   Reserves  219  18.9   National Guard  220  19.0   Active Duty  689  59.4  Officer  299  25.7  Enlisted  850  73.3  Military Branch   Army  567  48.9   Navy  249  21.5   Air Force  165  14.2   Marines  154  13.3  Match Between Preferred and Actual Info Source   0  609  52.5   1  205  17.7   2  180  15.5   3  142  12.2   4+  24  2.0  Used VA Services Since Deployment   No  756  65.2   Yes  404  34.8  View Large TABLE I Descriptive Statistics Variable  N  %  Male  959  82.7  Female  196  16.9  Ethnicity   White  818  70.5   African-American  198  17.1   Latino  78  6.7   Other  79  7.1  Married  816  70.3  Unmarried  331  28.5  Dependent Children  727  64.5  No Dependents  412  35.5  Currently Employed  859  74.1  Currently Unemployed  301  25.9  VA Disability Rating   None  612  52.8   0–40%  332  28.5   ≥50%  182  15.79  Current Health Rating   Excellent  135  11.6   Very Good  304  26.2   Good  443  38.2   Fair  205  17.7   Poor  47  4.1  Military Component   Reserves  219  18.9   National Guard  220  19.0   Active Duty  689  59.4  Officer  299  25.7  Enlisted  850  73.3  Military Branch   Army  567  48.9   Navy  249  21.5   Air Force  165  14.2   Marines  154  13.3  Match Between Preferred and Actual Info Source   0  609  52.5   1  205  17.7   2  180  15.5   3  142  12.2   4+  24  2.0  Used VA Services Since Deployment   No  756  65.2   Yes  404  34.8  Variable  N  %  Male  959  82.7  Female  196  16.9  Ethnicity   White  818  70.5   African-American  198  17.1   Latino  78  6.7   Other  79  7.1  Married  816  70.3  Unmarried  331  28.5  Dependent Children  727  64.5  No Dependents  412  35.5  Currently Employed  859  74.1  Currently Unemployed  301  25.9  VA Disability Rating   None  612  52.8   0–40%  332  28.5   ≥50%  182  15.79  Current Health Rating   Excellent  135  11.6   Very Good  304  26.2   Good  443  38.2   Fair  205  17.7   Poor  47  4.1  Military Component   Reserves  219  18.9   National Guard  220  19.0   Active Duty  689  59.4  Officer  299  25.7  Enlisted  850  73.3  Military Branch   Army  567  48.9   Navy  249  21.5   Air Force  165  14.2   Marines  154  13.3  Match Between Preferred and Actual Info Source   0  609  52.5   1  205  17.7   2  180  15.5   3  142  12.2   4+  24  2.0  Used VA Services Since Deployment   No  756  65.2   Yes  404  34.8  View Large Recruitment and Procedures A list of potential separated active duty personnel, National Guard members and Reservists who had deployed to Iraq or Afghanistan was obtained from the Defense Manpower Data Center. Out of approximately 70,000 eligible veterans in the Veterans Integrated Service Network 6 area, 5,000 were randomly sampled. Out of the 5,000 surveys, 1.4% were uncompleted because of extenuating circumstances, 18.5% were undeliverable, and 80% were successfully delivered. Of the 4,004 surveys that were delivered, 1161 were completed and returned for a final cooperation rate of 29%. A survey contractor was used throughout the study to enhance privacy protections, so no identifying information was obtained by study researchers. A Dillman Total Design Method17 was used, and participants were first sent an alert letter 1 week in advance of the study informing them of the nature and purpose of the research project. Then, they received the survey package that included the survey as well as a cover letter with study contact information, informed consent, and confidentiality information. A follow-up packet was mailed if the veteran had not responded within 5 weeks, and veterans were considered nonresponders if they did not respond within 5 weeks of the second survey mailing. This study was approved by the Durham VA Medical Center Institutional Review Board and the VA Office of Management and Budget. Measures The complete survey consisted of questions regarding demographic information, military history, rating of physical and mental health, and health care service utilization. The selection of items was informed by qualitative needs assessment utilizing six 10 to 12 person focus groups.18 In this study, the outcome variable of interest was binary response to the question, “Since your last deployment, have you used VA for health care services?” Also examined were predisposing factors including gender, ethnicity, marital status, and the number of deployments in addition to the enabling variable of income. Need for services was represented by the level of VA disability, rated on a scale from 0% to 100% disability in increments of 10%, and on self-reported rating of health ranging from excellent to poor. At the conclusion of the survey, veterans were asked to respond to the following question, “People learn about VA programs from different sources. Did you receive any information about VA programs from the following sources?” and asked to indicate yes/no if they had received information from: newspapers, TV, radio, VA information or publications, other government publications, other veterans, discharge counseling, Postdeployment Health Reassessment (PDHRA), veterans' organizations, website, friends/family/coworkers, chaplain/religious leader, command/superiors, family readiness groups, combat stress control/behavioral health contacts, toll-free hotline, Military OneSource, or other. They were then asked, “In the last column above, please indicate how you would prefer to receive information in the future.” For the purposes of this study, a variable was computed that represented a count of the number of matches between the format in which veterans received information about VA programs versus the format in which they would prefer to receive such information. Data Analysis Individual items were initially examined to determine veterans' preferences for information source as well as the number of matches between their preferences for and actual receipt of information. A chi-square test was used to examine the relationship between match and service utilization, and a multivariate logistic regression was used to predict service utilization with demographics, need variables, and match factors included as covariates. RESULTS Results were first analyzed by examining the relative frequencies of how veterans actually received information about VA programs versus how veterans would prefer to receive information about VA programs (Table II). Frequency data indicated that most veterans received information through VA publications, and most veterans also preferred this method of communication. However, relatively few veterans indicated a preference for receiving information from other veterans and from discharge counseling, although the number receiving information in these formats was quite high. TABLE II Frequency Data Comparing Veterans' Receipt of Information Versus Preferences for Information Source Source  Veterans That Received Info This Way (%)  Veterans That Would Prefer to Receive Info This Way (%)  VA Publications  74  37  Other Veterans  69  6  Counseling at Discharge  59  11  Internet  57  33  Source  Veterans That Received Info This Way (%)  Veterans That Would Prefer to Receive Info This Way (%)  VA Publications  74  37  Other Veterans  69  6  Counseling at Discharge  59  11  Internet  57  33  View Large TABLE II Frequency Data Comparing Veterans' Receipt of Information Versus Preferences for Information Source Source  Veterans That Received Info This Way (%)  Veterans That Would Prefer to Receive Info This Way (%)  VA Publications  74  37  Other Veterans  69  6  Counseling at Discharge  59  11  Internet  57  33  Source  Veterans That Received Info This Way (%)  Veterans That Would Prefer to Receive Info This Way (%)  VA Publications  74  37  Other Veterans  69  6  Counseling at Discharge  59  11  Internet  57  33  View Large Preliminary analysis of the relationship between information source match and VA use revealed a significant chi-square, χ2(1) = 3.47, p < 0.05 (1 sided), and indicated that 207 veterans in this study had used VA services since deployment and had at least 1 match between how they preferred to receive information and how they actually received information. An exploratory logistic regression was then performed with gender, racial status, age, marital status, the number of deployments, information source match, employment status, income, distance to closest VA hospital, self-reported health level, and VA disability level as predictors of VA health care use. Although the overall model was significant χ2(6, N = 1070) = 245.88, p < 0.001, a number of the predictors were not, including gender, age, race, marital status, and employment status (p = 0.43–0.89). The model was respecified using only the significant predictors, and the results of this analysis are presented in Table III. Predisposing factors (i.e., number of deployments), enabling factors (i.e., income, distance to VA), need factors (i.e., health rating and VA disability), and matched preferences for receiving information were each associated with VA health care utilization. Odds ratios indicated that an increase in match in information source was related to a 13% increase in the likelihood of help seeking. Health status was the strongest predictor of VA health care use, with a decrease in health status increasing the likelihood of seeking help by 45%. TABLE III Logistic Regression Predicting VA Health Care Utilization Overall Model  −2 Log Likelihood  Nagelkerke R2  χ2  1146.34  28.2  10.00  Variable  B  Wald  Sig  Exp (B)  95% CI  Match  0.13  4.63  0.03  1.13  1.01–1.27  Health  0.37  20.03  0.00  1.45  1.23–1.70  VA Disability  0.18  72.00  0.00  1.20  1.15–1.25  Income  −0.23  54.72  0.00  0.79  0.74–0.84  No. of Deployments  −0.27  8.97  0.00  0.76  0.64–0.91  Distance to VA  −0.20  7.65  0.01  0.82  0.71–0.94  Overall Model  −2 Log Likelihood  Nagelkerke R2  χ2  1146.34  28.2  10.00  Variable  B  Wald  Sig  Exp (B)  95% CI  Match  0.13  4.63  0.03  1.13  1.01–1.27  Health  0.37  20.03  0.00  1.45  1.23–1.70  VA Disability  0.18  72.00  0.00  1.20  1.15–1.25  Income  −0.23  54.72  0.00  0.79  0.74–0.84  No. of Deployments  −0.27  8.97  0.00  0.76  0.64–0.91  Distance to VA  −0.20  7.65  0.01  0.82  0.71–0.94  View Large TABLE III Logistic Regression Predicting VA Health Care Utilization Overall Model  −2 Log Likelihood  Nagelkerke R2  χ2  1146.34  28.2  10.00  Variable  B  Wald  Sig  Exp (B)  95% CI  Match  0.13  4.63  0.03  1.13  1.01–1.27  Health  0.37  20.03  0.00  1.45  1.23–1.70  VA Disability  0.18  72.00  0.00  1.20  1.15–1.25  Income  −0.23  54.72  0.00  0.79  0.74–0.84  No. of Deployments  −0.27  8.97  0.00  0.76  0.64–0.91  Distance to VA  −0.20  7.65  0.01  0.82  0.71–0.94  Overall Model  −2 Log Likelihood  Nagelkerke R2  χ2  1146.34  28.2  10.00  Variable  B  Wald  Sig  Exp (B)  95% CI  Match  0.13  4.63  0.03  1.13  1.01–1.27  Health  0.37  20.03  0.00  1.45  1.23–1.70  VA Disability  0.18  72.00  0.00  1.20  1.15–1.25  Income  −0.23  54.72  0.00  0.79  0.74–0.84  No. of Deployments  −0.27  8.97  0.00  0.76  0.64–0.91  Distance to VA  −0.20  7.65  0.01  0.82  0.71–0.94  View Large DISCUSSION The results of this study both confirm and extend the application of the Andersen Model in a VA health care population. These results suggest that predisposing, enabling, and need factors, including number of deployments, income, distance to VA, health rating, and disability rating, are relevant predictors of VA service utilization. Notably, preferences for care also emerged as a key variable in the prediction of VA help seeking. Results suggest a strong relationship between service utilization and match between how veterans receive information about VA services versus how they would prefer to receive information, such that an increase in match of information source is related to an increase in service use. Although need, represented by disability and self-evaluation of health, was the strongest predictor of service use, these findings suggest that veterans' preferences are an important component that should be considered in the modeling of help-seeking behavior. As stated, the variables representing need for care, including decreased rating of one's health and increased level of disability, both predicted increases in help seeking as expected based on previous research.12 The enabling factors in this study, including income and distance to closest VA, were also significant predictors of service use. Further distance to VA was related to decreased help seeking, confirming that access to care has an important relationship to use of care. Income was predictive of help seeking, but in an unexpected direction. Although income is typically seen as enabling the help-seeking process,8 in this study higher income led to less VA health care use. This is likely because of the higher rates of VA health care utilization by enlisted personnel and those without private insurance.1,19 The predisposing variable of exposure to combat was negatively related to service use in this study, which was surprising, given that combat exposure has been related to increased service use in previous research.10 This discrepancy may be because of sampling. Although veterans in previous studies had a wide range of combat exposure, including many who had seen no combat, all veterans in this study were deployed in the service of OIF/OEF. In light of this sample, it is possible that combat exposure is related to decreased service use because of increased barriers commonly associated with immersion in military culture such as reluctance to acknowledge problems and ask for help. Other predisposing factors, including gender, age, race, marital status, and employment status, were not related to VA health care use in this study. Results from past studies have been variable regarding the significance of similar demographic variables. However, this result is generally consistent with the finding that more treatment-related variables, such as need and preferences for care, have stronger relationships with service utilization than do predisposing variables. Overall, this study demonstrated that the Andersen Model is a relevant conceptualization of help-seeking behavior in the veteran population, with particular contributions from veteran characteristics reflecting need for and access to care. However, this study also suggests an extension of this model to include veterans' preferences for information about VA programs. Several recent articles14,15 have begun to call for attention to veterans' preferences in our attempts to increase VA service utilization, and this study again confirms that preferences are indeed a relevant factor in veterans' use of care. Although many veterans are receiving information in a way in which they prefer, often from VA publications, results from this sample indicate that many veterans are receiving information in ways that they would not prefer (such as from other veterans), and that many veterans would like to receive more information from the web. It appears that one potential way to bridge the gap between veterans and the wide range of VA health care services available to them may be to tailor outreach and advertising campaigns to the preferences for receiving information as well as the most pressing health concerns of returning veterans. This study is limited by a restricted response rate, and consequently, results should be interpreted cautiously. As with preferences for information about care, it appears that veterans in this era have relatively low response rates for paper-and-pencil techniques20 and may respond better to research queries online. Despite this limitation, sample characteristics closely map on to those of larger studies of OIF/OEF veterans4,21 and appear to match closely with figures representing veterans of this era. Future studies might focus on these issues at a national level, and could likely improve cooperation rates by using data collection techniques that might appeal more to returning veterans. In conjunction with other recent studies addressing the critical role of veterans' preferences for care, this study indicates the need for further research on the preferences for the type of care and source of information about care in returning veterans of this era. Targeted marketing and outreach tailored to this cohort's preferences may play a key role in engaging this group of veterans in VA care. REFERENCES 1. Veterans Health Administration, Department of Veterans Affairs Epidemiology Program, Post-Deployment Health Group, Office of Public Health. Analysis of VA Health Care Utilization among Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn Veterans, from 1st Qtr FY 2002 through 2nd Qtr FY 2014 . Washington, DC, 2014. Available at http://www.publichealth.va.gov/docs/epidemiology/healthcare-utilization-report-fy2014-qtr1.pdf; accessed August 4, 2014. 2. U.S. Department of Veterans Affairs Gulf War Era Veterans report: Pre 9/11 . Available at www.va.gov/vetdata/docs/specialreports/gw_pre911_report.pdf; accessed March 1, 2015. 3. U.S. Department of Veterans Affairs Accelerating Access to Care Initiative Fact Sheet . Available at http://www.va.gov/health/docs/052714AcceleratingAccessFactSheet.PDF; accessed August 4, 2014. 4. Elbogen EB, Wagner H, Johnson SC, et al.   Are Iraq and Afghanistan veterans using mental health services? New data from a national random-sample survey. Psychiatr Serv  2013; 64( 2): 134– 41. Google Scholar CrossRef Search ADS PubMed  5. 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Chicago, IL, Center for Health Administration Studies, University of Chicago, 1968. 10. Elhai JD, Grubaugh AL, Richardson JD, Egede LE, Creamer M Outpatient medical and mental healthcare utilization models among military veterans: results from the 2001 National Survey of Veterans. J Psychiatr Res  2008; 42: 858– 67. Google Scholar CrossRef Search ADS PubMed  11. Maguen S, Schumm JA, Norris RL, et al.   Predictors or mental and physical health service utilization among Vietnam veterans. Psychol Serv  2007; 4( 3): 168– 80. Google Scholar CrossRef Search ADS   12. Di Leone BAL, Vogt D, Gradus JL, Street AE, Giasson HL, Resick PA Predictors of mental health care use among male and female veterans deployed in support of the wars in Afghanistan and Iraq. Psychol Serv  2013; 10( 2): 145– 51. Google Scholar CrossRef Search ADS PubMed  13. Wells TS, LeardMann CA, Fortuna SO, et al.   A prospective study of depression following combat deployment in support of the wars in Iraq and Afghanistan. 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Straits-Troster K, Gierisch JM, Calhoun PS, Strauss JL, Voils C, Kudler H Living in transition: young veterans' health and the postdeployment shift to family life. In: Treating Young Veterans: Promoting Resilience Through Practice and Advocacy . Edited by Kelly DC, Howe-Barksdale S, Gitelson D New York, Springer, 2011. 19. Shen Y, Hendricks A, Wang F, Gardner J, Kazis LE The impact of private insurance coverage on veterans' use of VA Care: insurance and selection effects. Health Serv Res  2008; 43( 1): 267– 86. Google Scholar PubMed  20. Eisen SV, Schultz MR, Vogt D, et al.   Mental and physical health status and alcohol and drug use following return from deployment to Iraq or Afghanistan. Am J Public Health  2012; 102: S66– 73. Google Scholar CrossRef Search ADS PubMed  21. Calhoun PS, Elter JR, Jones ER, Kudler H, Straits-Troster K Hazardous alcohol use and receipt of risk-reduction counseling among U.S. veterans of the wars in Iraq and Afghanistan. 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Journal

Military Medicine – Oxford University Press

Published: Feb 1, 2016

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