Ethnicity and Veteran Identity as Determinants of VA Ambulatory Care Use
Nancy D. Harada PhD MPA
VA Greater Los Angeles Healthcare System, West LA
West Los Angeles, CA
Funding Period: July 1997 - June 2001

BACKGROUND/RATIONALE:
Despite VA's mandate to shift resources towards ambulatory care, there are no studies that address ambulatory care access and utilization for minority veterans. This study draws upon the expertise of the Department of Veterans Affairs, the University of California, Los Angeles, and leaders of the minority veteran community to understand racial/ethnic differences in VA ambulatory care and use, and reasons why these racial/ethnic differences exist.

OBJECTIVE(S):
The veteran Identity Program draws upon the expertise of the Department of Veterans Affairs, the University of California, Los Angeles, and leaders of the minority veteran community to understand racial/ethnic differences in utilization of VA ambulatory care, and reasons why these racial/ethnic variations exist. Specific objectives are: (1) to establish baseline levels of ambulatory care utilization between minority veteran groups, (2) to identify sociodemographic, health related, and military service predictors of ambulatory care utilization and how these predictors vary between racial/ethnic groups, (3) to understand how factors related to ethnicity and veteran identity influence utilization of ambulatory care services and how these factors vary between racial/ethnic groups, (4) to assess the health and functioning of minority veterans, and (5) to apply these findings to prescribe program and practitioner interventions to improve access of minority veterans to ambulatory care.

METHODS:
This 4-year study uses a triangulated methodology consisting of secondary data analysis, focus groups and a telephone survey. Secondary analyses of data from the 1992 National Survey of Veterans were first conducted to determine baseline levels of utilization and health status for racial/ethnic groups and to identify sociodemographic, health-related, and military service predictors of VA ambulatory care utilization based on the Behavioral Model of Health Care Utilization. Because these data do not include detailed information on ethnicity and veteran identity, focus groups were conducted to explore relationships between race/ethnicity, the military experience, and health services use. The focus group information was used to inform the development of a telephone survey which was administered to 3,227 veterans in the Veterans Integrated Service Network 22, covering Southern California and Southern Nevada.

FINDINGS/RESULTS:
Black veterans report worse health status across all key indicators as compared to non-Hispanic White veterans. The Black disadvantage for health remains regardless of war cohort, socioeconomic status, disease prevalence, and mental health. Black and Hispanic veterans are more likely to report VA only use as compared with non-Hispanic White and Asian/Pacific Islander veterans. Black and Hispanic veterans are also more likely than other groups to report dual use of VA and non-VA ambulatory care, and least likely to be non-VA only ambulatory care users. Black and Hispanic veterans were 1.9 and 2.5 times respectively more likely than non-Hispanic Whites to have been unable to get needed care. Preferences for, use of, and satisfaction with VA ambulatory care are significantly influenced by race/ethnicity and veteran identity factors, including membership in veterans' organizations and veteran influence on daily life.

IMPACT:
The results of the research will be used to develop specific strategies and interventions to improve access and utilization of ambulatory care services for minority veterans.

PUBLICATIONS:

Journal Articles

1. Washington DL, Villa V, Brown A, Damron-Rodriguez J, Harada N. Racial/ethnic variations in veterans' ambulatory care use. American Journal of Public Health. 2005; 95(12): 2231-7.
2. Damron-Rodriguez J, White-Kazemipour W, Washington D, Villa VM, Dhanani S, Harada ND. Accessibility and acceptability of the Department of Veteran Affairs health care: diverse veterans' perspectives. Military Medicine. 2004; 169(3): 243-50.
3. Huynh-Hohnbaum AT, Damron-Rodriguez J, Washington DL, Villa V, Harada N. Exploring the Diversity of Women Veteran's Identity to Improve the Delivery of Veteran's Health Services. Affilia: Journal of Women and Social Work. 2003; 18(2): 165-176.
4. Villa VM, Harada ND, Washington D, Damron-Rodriguez J. The health and functional status of US veterans aged 65+: implications for VA health programs serving an elderly, diverse veteran population. American Journal of Medical Quality. 2003; 18(3): 108-16.
5. Villa VM, Harada ND, Washington D, Damron-Rodriguez J. Health and functioning among four war eras of U.S. veterans: examining the impact of war cohort membership, socioeconomic status, mental health, and disease prevalence. Military Medicine. 2002; 167(9): 783-9.
6. Harada ND, Villa VM, Andersen R. Satisfaction with VA and non-VA outpatient care among veterans. American Journal of Medical Quality. 2002; 17(4): 155-64.
7. Harada ND, Villa VM, Damron-Rodriguez J, Washington D, Makinodan T, Dhanani S, Shon H, Liu H, Andersen R. The influence of military service on outpatient care use among racial/ethnic groups in Department of Veterans Affairs medical centers. Military Medicine. 2002; 167(7): 525-31.
8. Dhanani S, Damron-Rodriguez J, Leung M, Villa V, Washington DL, Makinodan T, Harada N. Community-based strategies for focus group recruitment of minority veterans. Military Medicine. 2002; 167(6): 501-5.
9. Washington DL, Harada ND, Villa VM, Damron-Rodriguez J, Dhanani S, Shon H, Makinodan T. Racial variations in Department of Veterans Affairs ambulatory care use and unmet health care needs. Military Medicine. 2002; 167(3): 235-41.
10. Harada ND, Damron-Rodriguez J, Villa VM, Washington DL, Dhanani S, Shon H, Chattopadhyay M, Fishbein H, Lee M, Makinodan T, Andersen R. Veteran identity and race/ethnicity: influences on VA outpatient care utilization. Medical Care. 2002; 40(1 Suppl): I117-28.

DRA: Health Services and Systems, Special (Underserved, High Risk) Populations
DRE: Resource Use and Cost
Keywords: Access, Minority, Primary care
MeSH Terms: Cross-Cultural Comparison, Databases, Ethnic Groups, Focus Groups, Health Care Surveys, Health Policy, Health Services Accessibility