D6 Respond

Research Plan Outline 3:

Exploring the Barriers to Care Amongst US Veterans from the Pacific Islands

Lori Wramp

School of Behavioral Sciences, Liberty University

EDCO 747

Dr. Fred Milacci

June 26, 2026

Author Note

Lori Wramp

I have no known conflict of interest to disclose.

Correspondence concerning this article should be addressed to Lori Wramp. Email: [email protected]

Research Plan Outline:

Exploring the Barriers to Care Amongst US Veterans from the Pacific Islands

Name: Lori Wramp

Stage of Completion: Introduction (Stage 1)

I. Introduction

A. Problem Statement

1. Many US veterans within the Pacific region, including Guam, Commonwealth of Northern Mariana Islands (CNMI), Federated States of Micronesia (FSM), etc., are not seeking medical or mental health care through the Department of Veterans Affairs (VA). Literature regarding barriers to care for rural US veterans does not address the cultural aspect or geographical challenges specifically within the Pacific islands, that is home to thousands of US veterans.

a. Connor, L., Fischer, I. C., Tsai, J., Harpaz-Rotem, I., & Pietrzak, R. H. (2024). Barriers to mental health care in US military veterans. Psychiatric Quarterly, 95, 367–383. https://doi.org/10.1007/s11126-024-10078-7 .

b. Fischer, E. P., Curran, G. M., Fortney, J. C., McSweeney, J. C., Williams, D. K., & Williams, J. S. (2021). Impact of attitudes and rurality on veterans’ use of veterans health administration mental health services. Psychiatric Services (Washington, D.C.), 72(5), 521-529. https://doi.org/10.1176/appi.ps.201900275 .

c. Fischer, E. P., McSweeney, J. C., Wright, P., Cheney, A., Curran, G. M., Henderson, K., & Fortney, J. C. (2016). Overcoming barriers to sustained engagement in mental health care: Perspectives of rural veterans and providers. The Journal of Rural Health., 32(4), 429–438. https://doi.org/10.1111/jrh.12203 .

d. Rohs, C. M., Albright, K. R., Monteith, L. L., Lane, A. D., & Fehling, K. B. (2023). Perspectives of VA healthcare from rural women veterans not enrolled in or using VA healthcare. PloS One, 18(8), e0289885. https://doi.org/10.1371/journal.pone.0289885

2. It is important to explore the reasoning for barriers to care with the US veterans from the Pacific region to determine what changes are needed in the region to provide the medical and mental health care that should be available to those that served our country. Currently there is only one small VA community-based outpatient clinic (CBOC) on Guam to provide both medical and mental health care, but do not include specialists. If a specialist is required for patient needs, then the veteran must travel to Hawaii or the mainland for specialized care and treatment. Most outlying islands only have a Dept. of VA office to address benefits, but do not have a medical or mental health clinic. Most veterans from outlying islands that do seek care through the Dept. of VA will travel to Guam for access to medical/mental health care or for better care than what is available on the smaller islands through civilian doctors, will wait for medical personnel from the Guam CBOC to travel to their island, or will have to travel even further distances such as Hawaii or the mainland, for specialized care.

a. Kenneally, L., Riblet, N., Stevens, S., Rice, K., Scott, R. (2024). Examining the impact of the veterans affairs community care program on mental healthcare in rural veterans: A qualitative study. Health Services Research, 60, e14405. https://doi.org/10.1111/1475-6773.14405

b. US Government Accountability Office (GAO). (2024). Report to congressional committees: Actions needed to improve access to care in the U.S. territories and freely associated states. https://www.gao.gov/products/gao-24-106364 .

c. US Government Accountability Office (GAO). (2018). Report to congressional committees: Opportunities exist for improving veterans’ access to health care services in the pacific islands. https://www.gao.gov/products/gao-18-288 .

d. Miller, K. C. (2023). The PATRIOTS we forget. DAV Magazine (1985), 65(5), 26. https://global-factiva-com.eu1.proxy.openathens.net/ha/default.aspx#./!?&_suid=178003116953406581980059053734 .

3. The problem is that US veterans within the Pacific Islands face multiple barriers to care, for both medical and mental health, which includes geographical and cultural challenges (Whealin et al., 2017; US GAO, 2024; US GAO, 2018). Many veterans choose not to seek medical or mental health care through the Dept. of VA due to the limitations of care that is available on their island, the extensive wait time, lack of specialists available through the VA in this region, or the financial burden that is needed to travel for medical care (Miller, 2023; US GAO, 2024; US GAO, 2018).

B. Purpose

1. The purpose of this phenomenological study is to describe US Veterans in the Pacific region’s experiences choosing to not seek medical or mental health services from the VA.

C. General research questions

1. How do US veterans in the Pacific region describe their experiences using medical and mental health services outside of VA services?

2. How do US veterans in the Pacific region describe their experiences using VA services?

3. How do US veterans in the Pacific region describe their reasoning for deciding to choose (or not choose) alternative medical and mental health care outside of the VA healthcare system?

4. How do US veterans in the Pacific region describe how their culture influences their decision to seek medical and mental health care through the VA healthcare system or alternative care?

D. Research Plan

1. The study will be qualitative, focusing on the experiences and challenges of US veterans within the Pacific region.

2. Sharing the experiences of US veterans within the Pacific region will provide more understanding into the challenges they face seeking medical and mental health care through the Dept. of VA. It will also address the cultural differences that exist between the different islands of the Pacific region and the mainland.

II. Review of Related Literature

A. Theoretical Framework

1. My research will be based on the philosophical assumption of ontology to explore the multiple realities that exist within the Pacific Islands. I wanted to hear the stories and experiences of US veterans across the Pacific region. According to Creswell & Poth (2025), ontological assumptions is exploring the different subjective realities of the participants of the research to understand their realities. Each island has it’s own culture and beliefs; my study will acknowledge and understand the differences and how different perspectives are created amongst the people within this region based on their culture and beliefs.

2. Social constructivism is the most applicable theory for my study because it is a subjective interpretation of experiences from US veterans from various islands within the Pacific region. As Creswell & Poth (2025) indicate, the researcher will ask broad questions so the participant can respond based on their interpretation, knowledge, interactions with others, and experience. The primary goal for my research will be to give a platform for US veterans to talk about their experiences based on their history and culture, exploring similarities and differences amongst the various islands to understand their challenges and beliefs regarding their military service, as well as the veteran’s benefits they earned from that service.

B. Important Thinkers/experts/theorists in this field of study

1. Whealin, J. M., Nelson, D., Kawasaki, M. M., & Mahoney, M. A. (2017). Factors impacting rural pacific island veterans' access to care: A qualitative examination. Psychological Services, 14(3), 279-288. https://doi.org/10.1037/ser0000161 .

a. This article specifically focused on the experiences of US veterans through qualitative research within the Pacific Islands to understand the challenges they face with accessing care through the Dept. of VA.

b. Grounded theory was the approach that was utilized during the interviews to help the researchers understand the struggles and challenges, as well as their beliefs and culture, that veterans experience in the Pacific region.

2. Wittrock, S., Ono, S., Stewart, K., Reisinger, H. S., & Charlton, M. (2015). Unclaimed health care benefits: A mixed-method analysis of rural veterans. The Journal of Rural Health, 31(1), 35-46. https://doi.org/10.1111/jrh.12082

a. This article explored the reasons why rural US veterans do not utilize Dept. of VA medical and mental health benefits.

b. The study was based on US veterans that reside in the Midwest, and does not include data for veterans that reside in the Pacific Islands region.

c. Most participants disclosed they were not aware they were eligible for care through the VA, and many felt that utilizing the care would take away from another veteran that was in need.

3. Stotzer, R. L., Whealin, J. M., & Darden, D. (2012). Social work with veterans in rural communities: Perceptions of stigma as a barrier to accessing mental health care. Advances in Social Work, 13(1), 1-16. https://doi.org/10.18060/1891

a. This study explored stigma, in forms such as self, family, community, military, as a barrier to care for mental health within the rural US veteran population.

b. Although the authors were connected to a university in Hawaii, the study itself does not specifically address stigma within the Pacific Island region.

C. Related Research

1. Monteith, L. L., Kittel, J. A., Holliday, R., Schneider, A. L., Herring-Nathan, E., Krishnamurti, L. S., et al. (2025) Suicidal ideation and non-fatal suicidal self-directed violence prevalence and associations among Veterans residing in U.S. Pacific Island Territories: Guam, American Samoa, and the Northern Mariana Islands. PLoS One 20(6): e0326533. https://doi.org/10.1371/journal.pone.0326533 .

a. This article discussed the prevalence of suicide and suicidal ideations within the population of the US Pacific Island territories.

b. It is important to understand the prevalence of suicide and suicidal ideations that exists within the US Pacific region veteran community because it reflects the need for mental health care that is culturally sensitive.

2. Ball, D. D., Sadler, A. G., Steffen, M. J., Paez, M. B., & Mengeling, M. A. (2024). The impact of patient–provider relationships on choosing between VA and VA‐purchased care: A qualitative study of health care decision‐making among rural veterans. The Journal of Rural Health, 40(3), 430-437. https://doi.org/10.1111/jrh.12804 .

a. This study identified the rationale that US veterans identify when deciding on the type of health care they choose.

b. The study focused on rural veterans that live within the Midwest region of the US that has elected to purchase medical coverage through the Dept. of VA.

c. The study was qualitative research conducted through telephone interviews to explore the barriers to care that rural veterans experience, as well as understanding the reasoning for choosing community care over the use of Dept. of VA medical care.

d. The results indicated that rural US veterans are willing to travel further distances to receive quality care with stable providers they were able to connect with.

3. Ramalingam, N. S., Barnes, C., Patzel, M., Kenzie, E. S., Ono, S. S., & Davis, M. M. (2024). “It’s like finding your way through the labyrinth”: A qualitative study of veterans’ experiences accessing healthcare: Veterans’ experiences accessing healthcare. Journal of General Internal Medicine : JGIM, 39(4), 596-602. https://doi.org/10.1007/s11606-023-08442-7 .

a. This study explored the opinions and beliefs about the VA healthcare system of rural US veterans within one region of the mainland.

b. According to the article, the area studied serves almost 195,000 US veterans in mostly rurally populated areas, which has access to six VA medical centers, 20 community-based outpatient clinics, one mobile clinic, and two tertiary sites that provides services to veterans.

III. Methods

A. Design (approach) and Rationale

1. This study will be utilizing a phenomenological approach because it is the best way to explore the lived experiences of US veterans from the Pacific Islands.

2. The purpose of the research is to explore the barriers to care and to understand why they choose not to seek medical or mental health care through the Department of Veterans Affairs (VA). Exploring the patterns that develop through interviews will provide insight into their decisions and will allow me, as the researcher, to learn more about the cultural differences that may create barriers to care within the Pacific region.

B. Site

1. The primary meeting site will be at The Hootch – Sagan Kotturan CHamoru in Tumon, Guam. In addition, use of the mayor’s offices on each island will be utilized.

2. It is part of the cultural center, but Veterans use one building as a regular meeting location, overlooking Tumon Bay, Guam.

3. US veterans from the Pacific region, as well as veterans from mainland US that live on Guam, are welcome during regular meetings, held every Wednesday night. Many veterans from other Pacific islands have moved to Guam and are active within the veteran group, Got Your Six71.

4. The site is a cultural center dedicated to preserving and promoting the traditions of Guam's indigenous people through immersive exhibits, demonstrations, and workshops.

C. Participants

1. Creswell and Poth (2025) recommend having between five to 25 participants within a phenomenological qualitative study. This study will include two US veterans chosen through criterion sampling from each Pacific island to represent the various island cultures. Each participant must be a US veteran living on one of the ten identified islands that can receive medical and mental health care through the VA healthcare system. There are ten specific islands that will be included in the study, for a total of 20 US veterans.

a. Compacts of Free Assocation (COFA) provides a treaty between Pacific Island nations with the US that allows islanders to move to the mainland US or territories to pursue work, military service, education, healthcare, etc. in exchange for giving the US rights to the land, ocean, and airspace throughout the Pacific region (Tupuola, 2025).

b. Islands across the Pacific region included for the study are the Commonwealth of Northern Mariana Islands (CNMI), Freely Associated States (FAS), and Federated States of Micronesia (FSM). The following islands are included: Guam, Saipan (CNMI), Rota (CNMI), Tinian (CNMI), Chuuk (FSM), Pohnpei (FSM), Kosrae (FSM), Palau (FAS), Yap (FSM), and Marshall Islands (FAS).

2. Interviewed participants will be US veterans that complete an online or paper questionnaire and indicate they would be interested in partaking in an interview with the researcher. Questionnaires will be sorted according to island and those that are interested in being interviewed will be contacted by phone and email.

3. The age range for the majority of US veterans that will be selected for this study will be between 35 to 80 years old, and must have cultural ties to one of the Pacific islands selected for the study. Female and male US veterans will be included in the study.

4. By using purposeful sampling suggested by fellow peer Kimtrese Slaughter (personal communication, June 2026), researcher will select two US veterans from each island, it will provide insight into the cultural differences that exist between the Pacific island nations, as well as cultural differences between the Pacific region and the US mainland.

D. Role of Researcher or Personal biography

1. Lori Wramp

2. VA Mental Health Counselor

3. I graduated from Liberty University with a MA in Clinical Mental Health Counseling in May 2025. I continued my education through Liberty University and achieved a MA in Human Services Counseling, Military Resilience in August 2025. I am currently in the doctoral program through Liberty University for a Doctor of Education in Community Care and Counseling with a focus on Traumatology.

4. My role will be as an outside phenomenological researcher as I am a Caucasian female that did not serve in the US military. My experience within these populations includes being a veteran spouse that has lived the military lifestyle, both Active Duty and the Reserve Component. I was born and raised in the states, moved to Guam 10 years ago for my husband’s professional advancement and decided to make Guam our permanent home. I have no historical, cultural, or familial connection to Guam or any of the other Pacific islands.

5. As the researcher, I will need to be cognizant of my biases based on my lived experience with my husband which is a US veteran. I will also need to recognize bias and my personal feelings that may exist due to the cultural differences between the island nations and the US mainland.

E. Data Collection

1. Questionnaires will be disbursed online and on paper to US veterans living on the various Pacific islands.

a. Paper questionnaires will be widely distributed on Guam at locations frequented by US veterans, for ease of accessibility.

b. A QR code will also be created and disbursed via posters to businesses and organizations to reach US veterans that live on the various islands within the Pacific region.

2. Initial contact would include a brief recorded telephone/Facetime interview between participant and researcher based on their response to one question on the questionnaire regarding interest in a face-to-face interview with researcher. The initial phone interview will be approximately 30 minutes.

a. Verbal consent must be obtained at the start of the interview to video record the session.

b. Informed consent must also be obtained to disclose the purpose of the study, the option to withdraw at any time, and to discuss confidentiality (Creswell & Poth, 2025).

3. Individual face-to-face interviews will also be conducted at the Mayor’s offices on each Pacific island to provide a safe, familiar, and neutral environment for the US veteran. There will be one interview for each participant, lasting approximately 90-120 minutes in length. The interview will explore the veteran’s experiences: using VA services or using alternative services, exploring their reasoning for choosing VA services or alternatives, and exploring how culture plays a role in their decision making.

a. Thorough informed consent will be provided before the start of the interview, requiring signature from participants. In addition, explanation of the participant’s right to withdraw from research will be discussed, as well as providing a form that requires signature informing the participant they can withdraw their consent at any time (Creswell & Poth, 2025).

b. Additional consent must be obtained to record the private interviews.

4. One group discussion will also be conducted on each of the Pacific islands between the researcher and participants. Utilizing a group discussion will allow for additional feedback from the US veterans about their experiences, as well as provide clarification and supplemental input that can provide more understanding and depth into the phenomenon (Aguas, 2022).

a. According to Aguas (2022), “Group interviews facilitated understanding of the human social dynamic among the research participants, and promoted discussion of diverse perspectives with the researcher as an active and neutral participant” (p. 9).

b. Discussions will be held on the same day at the Mayor’s office to allow for accessibility for the US veterans to participate. Due to geographical and transportation challenges, conducting both the interview and group discussion on the same day at the same location is preferred.

c. The discussion will be 90-120 minutes in length, with a 30 minute break in between sessions. Lunch will be provided for all participants.

d. Prior to the start of the group discussions, informed consent and purpose of the study will be discussed and forms will be distributed requesting signatures for consent (Creswell & Poth, 2025). In addition, written consent must be given by each participant agreeing to be recorded for research purposes.

5. Additional research will also be conducted by the researcher to explore the culture of each island to have a better understanding of the participant’s beliefs, values, language, family, and history. Researcher will explore historical sites, cultural sites, documents, and have discussions with historians, anthropologists, and sociologists to further understand the cultural significance to decision-making and rationale of the participants to explain the essence of the phenomenon (Creswell & Poth, 2025).

F. Data Analysis

1. Horizontalization

a. This process is examining the interview transcriptions to identify key phrases or statements that explain the phenomenon that was experienced by each participant (Creswell & Poth, 2025). Commonality may be evident based on participant’s responses to their lived experience.

b. The researcher will read though the participant’s responses using the interview transcription, highlighting and taking note of common phrases, statements, or words that provide meaning into the lived experiences that explain the phenomenon (Creswell & Poth, 2025).

c. This process will allow the researcher to establish patterns and commonality amongst the participants to explain their experiences and essence of the phenomenon (Creswell & Poth, 2025).

2. Bracketing

a. Using bracketing throughout the research process will help me as the researcher to check my own biases, values, and prejudices by removing them from the equation to focus on the experience of the participant and remove any preconceived notions.

b. Considering I am considered an outside phenomenological researcher for this dissertation, there are cultural differences that will be obvious to the participant. I do not want tension to exist that could create resistance or closed mindedness that could interfere with the data collection process.

c. As the researcher, I do not want my opinions, values, beliefs, and biases to interfere with the process so I will explore these privately through memoing prior to and after each interview.

G. Trustworthiness

1. Member checking

a. This is a process where the researcher will share the research findings with the participants of the study and discuss the outcomes and interpretations for accuracy and understanding (Vella, 2024).

b. It provides credibility because it allows the participants to verify their input and validates their experiences through their stories. Credibility for the researcher is also important as it allows the participants to know the information that is being shared is factual and accurate (Vella, 2024).

c. This will be completed months after the interview, but prior to the dissertation completion and defense to allow for editing, if required, and to include additional information from the participant that may be relevant to the study.

2. Preservation of the lived experience

a. This is a process where the researcher will preserve the experience that is being told by the participant by preserving the original words and descriptions, as well as maintaining the context that was shared by the participant (Tavakol & Sandars, 2025).

b. It is important because it shows the researcher and research is trustworthy and represents factual information and experience by the participants. It also provides credibility to the researcher by providing honest and factual representation of the shared experiences by participants.

3. Memoing

a. Per the peer recommendation by Abraham De La Cruz (personal communication, June 2026), recording the interviewer’s personal feelings and experience before and after each participant interview will be included.

b. Recording the researcher’s feelings and thoughts prior to and after each interview will help to learn patterns that may exist, but also to conceptualize a theory that explains the phenomenon and veteran’s experiences (Creswell & Poth, 2025).

c. According to Creswell & Poth (2025), memoing creates an audit trail and “tracks the development of ideas through the process” which provides credibility to the data analysis process and results (p. 223).

H. Ethical Considerations

1. Cultural differences could pose a threat to obtaining participants that would be willing to be interviewed. Researcher will engage multiple US military veterans support groups to gain support and endorsement to bridge the cultural gaps that will be prevalent.

2. Trust issues could also pose a threat to obtaining participants that would be willing to be interviewed due to “broken promises” and negative feelings toward the Dept. of Veterans Affairs, specifically from higher levels within the organization. Researcher will engage support groups and various organizational representatives that will support and endorse the research to promote organizational and governmental change within the Pacifc Islands region.

3. Due to sensitive topic and the possibility of participants discussing their military experiences, participants could become distressed and interview could lead to unintentional harm to participants resulting in psychological distress or dissociative reactions (Creswell & Poth, 2025). Provide resources for mental health professionals that are local to the participants or are available through telehealth services for welfare concerns.

4. Confidentiality of participants will be protected by means of using pseudonyms to identify participants within the study. All data will be stored on a password-protected external hard drive that is connected to a password-protected laptop that is only accessible to the researcher. All data will be deleted and/or shredded seven years after the completion of the study.

References

Aguas, P. (2022). Fusing approaches in educational research: Data collection and data analysis in phenomenological research. Qualitative Report, 27(1), 1-20. https://doi.org/10.46743/2160-3715/2022.5027

Ball, D. D., Sadler, A. G., Steffen, M. J., Paez, M. B., & Mengeling, M. A. (2024). The impact of patient–provider relationships on choosing between VA and VA‐purchased care: A qualitative study of health care decision‐making among rural veterans. The Journal of Rural Health, 40(3), 430-437. https://doi.org/10.1111/jrh.12804 .

Connor, L., Fischer, I. C., Tsai, J., Harpaz-Rotem, I., & Pietrzak, R. H. (2024). Barriers to mental health care in US military veterans. Psychiatric Quarterly, 95, 367–383. https://doi.org/10.1007/s11126-024-10078-7 .

Creswell. J. W. & Poth, C. N. (2025). Qualitative inquiry & research design: Choosing among five approaches (5th ed.). Sage Publications.

Fischer, E. P., Curran, G. M., Fortney, J. C., McSweeney, J. C., Williams, D. K., & Williams, J. S. (2021). Impact of attitudes and rurality on veterans’ use of veterans health administration mental health services. Psychiatric Services (Washington, D.C.), 72(5), 521-529. https://doi.org/10.1176/appi.ps.201900275 .

Fischer, E. P., McSweeney, J. C., Wright, P., Cheney, A., Curran, G. M., Henderson, K., & Fortney, J. C. (2016). Overcoming barriers to sustained engagement in mental health care: Perspectives of rural veterans and providers. The Journal of Rural Health., 32(4), 429–438. https://doi.org/10.1111/jrh.12203 .

Kenneally, L., Riblet, N., Stevens, S., Rice, K., Scott, R. (2024). Examining the impact of the veterans affairs community care program on mental healthcare in rural veterans: A qualitative study. Health Services Research, 60, e14405. https://doi.org/10.1111/1475-6773.14405 .

Miller, K. C. (2023). The PATRIOTS we forget. DAV Magazine (1985), 65(5), 26. https://global-factiva-com.eu1.proxy.openathens.net/ha/default.aspx#./!?&_suid=178003116953406581980059053734 .

Monteith, L. L., Kittel, J. A., Holliday, R., Schneider, A. L., Herring-Nathan, E., Krishnamurti, L. S., et al. (2025) Suicidal ideation and non-fatal suicidal self-directed violence prevalence and associations among Veterans residing in U.S. Pacific Island Territories: Guam, American Samoa, and the Northern Mariana Islands. PLoS One 20(6): e0326533. https://doi.org/10.1371/journal.pone.0326533 .

Ramalingam, N. S., Barnes, C., Patzel, M., Kenzie, E. S., Ono, S. S., & Davis, M. M. (2024). “It’s like finding your way through the labyrinth”: A qualitative study of veterans’ experiences accessing healthcare: Veterans’ experiences accessing healthcare. Journal of General Internal Medicine : JGIM, 39(4), 596-602. https://doi.org/10.1007/s11606-023-08442-7 .

Rohs, C. M., Albright, K. R., Monteith, L. L., Lane, A. D., & Fehling, K. B. (2023). Perspectives of VA healthcare from rural women veterans not enrolled in or using VA healthcare. PloS One, 18(8), e0289885. https://doi.org/10.1371/journal.pone.0289885 .

Stotzer, R. L., Whealin, J. M., & Darden, D. (2012). Social work with veterans in rural communities: Perceptions of stigma as a barrier to accessing mental health care. Advances in Social Work, 13(1), 1-16. https://doi.org/10.18060/1891 .

Tavakol, M., & Sandars, J. (2025). Twelve tips for using phenomenology as a qualitative research approach in health professions education. Medical Teacher, 47(9), 1441–1446. https://doi.org/10.1080/0142159X.2025.2478871

Tupuola, J. (2025). The compacts of free association. Congressional Research Service. https://www.congress.gov/crs_external_products/IF/PDF/IF12194/IF12194.46.pdf

US Government Accountability Office (GAO). (2024). Report to congressional committees: Actions needed to improve access to care in the U.S. territories and freely associated states. https://www.gao.gov/products/gao-24-106364 .

US Government Accountability Office (GAO). (2018). Report to congressional committees: Opportunities exist for improving veterans’ access to health care services in the pacific islands. https://www.gao.gov/products/gao-18-288 .

Vella, J. (2024). In pursuit of credibility: Evaluating the divergence between member-checking and hermeneutic phenomenology. Research in Social and Administrative Pharmacy, 20(7), 665-669. https://doi.org/10.1016/j.sapharm.2024.04.001

Whealin, J. M., Nelson, D., Kawasaki, M. M., & Mahoney, M. A. (2017). Factors impacting rural pacific island veterans' access to care: A qualitative examination. Psychological Services, 14(3), 279-288. https://doi.org/10.1037/ser0000161 .

Wittrock, S., Ono, S., Stewart, K., Reisinger, H. S., & Charlton, M. (2015). Unclaimed health care benefits: A mixed-method analysis of rural veterans . The Journal of Rural Health, 31(1), 35-46. https://doi.org/10.1111/jrh.12082

Appendix A Interview Questions/Guide

To start the conversational interview, an icebreaker will be used to encourage the interviewee to show the love of their island. The researcher will ask the participant to name three places that a tourist should visit on the island and why.

Although a few of these questions will be asked on the questionnaire, it is important to provide a safe space for the participant to explain how they made their decision and what their reasoning was for their decision. Allowing them to have a voice and explain their rationale provides more understanding into the phenomenon and their personal experiences (Creswell & Poth, 2025).

1. What current medical and mental health services do you receive through the VA or alternative services?

2. How soon after you were discharged or retired from the military did you seek services?

3. If you waited to seek services, what was your reasoning for choosing to wait?

4. What VA services are available on your island?

5. How do you describe your experience using medical and mental health services outside of VA services?

6. How do you describe your experience using VA services?

7. What was your reasoning for deciding to choose (or not choose) alternative medical and mental health care outside of the VA healthcare system? How did you come to that decision?

8. How do you describe how your culture influences your decision to seek medical and mental health care through the VA healthcare system or alternative?

9. What factors do you feel influenced your decision to seek (or not to seek) medical and mental health care through the VA?

Appendix B: Other Data Collection Procedures

Questionnaires will be the initial way to gather demographic information from participants, as well as garner interest from those that would be willing to be interviewed. First interviews will be conducted via phone or Facetime for a brief introduction to the study and to determine if candidate has experienced the phenomenon that is being studied, as well as receive confirmation they are willing to participate in a face-to-face interview with researcher. Follow-up interviews will be conducted face-to-face where researcher will travel to each of the islands identified for the study. In addition, group discussions with participants and researcher on each island will allow veterans to provide additional information about their experiences, the phenomenon, and their culture that was not discussed during the interview. Additional research will be conducted by the researcher to explore the island culture and way of life to understand the essence of the phenomenon and the differences between the Pacific island cultures.

Appendix C Timeline and Budget

· August through December 2026—Finish degree coursework, leaving only dissertation classes left for completion ($6,000, Federal loans)

· January 2027 through August 2028 ---Enroll in dissertation courses sometime during this period (EDCO 770 & EDCO 900) ($3,000); only research and dissertation preparation will be performed during this time due to relocation to states and limited accessibility to participants for interview process

· Fall 2028---Relocate back to Guam; Enroll in dissertation course EDCO 988 for Spring 2029 semester (relocation budget – unknown; class - $1,000)

· January 2029---Get assignment of chair & committee; Submit research plan to the Institutional Review Board (IRB) for approval ($5,000); complete research/interviews

· Spring 2029---Complete and transcribe interviews, finish conducting research; start writing proposal and make necessary edits

· Fall 2029—Prepare and defend proposal

· Spring 2030—Complete dissertation defense

· May 2030---Graduate from Liberty University with my EdD in Community Care & Counseling, with an emphasis on Traumatology

Appendix D Consent Form

Consent

Title of the Project: Exploring the Barriers to Care Amongst US Veterans from the Pacific Islands

Principal Investigator: Lori Wramp, Doctoral Candidate, School of Behavioral Sciences, Liberty University

Key Information about the Research Study

You are invited to participate in a research study. To participate, you must be a US veteran, currently eligible for VA medical and mental health benefits (does not have to be enrolled) and living on one of the 10 Pacific Island nations selected for the study.

Things you should know:

· The purpose of the study is to explore the reasoning for barriers to care with the US veterans from the Pacific region to determine what changes are needed in the region to provide the medical and mental health care that should be available to those that served our country. If you choose to participate, you will be asked to participate in one confidential questionnaire, one introductory phone call, one face-to-face interview, and one group session. The interview will take approximately 90-120 minutes.

· Risks or discomforts from this research include distress from disclosing war experiences and disabilities that would have resulted from military service, as well as disclosing personal medical experiences with civilian or Dept. of VA medical personnel.

· Participants will not receive a direct benefit to participate in this study.

· Taking part in this research project is voluntary. You do not have to participate, and you can stop at any time.

Please read this entire form and ask questions before deciding whether to participate in this research.

What is the study about, and why is it being done?

The purpose of the study is to explore the reasoning for barriers to care with the US veterans from the Pacific region to determine what changes are needed in the region to provide the medical and mental health care that should be available to those that served our country.

What will happen if you take part in this study?

If you agree to be in this study, I will ask you to do the following:

1. Participate in a confidential questionnaire, either online or on paper, that will take no more than 30 minutes to complete.

2. Participate in a brief, audio recorded phone interview that will last no more than 30 minutes.

3. Participate in one face-to-face in-depth, confidential interview at the mayor’s office that will take no more than 120 minutes (2 hours) to complete. This interview will be video recorded.

4. Participate in one group discussion that will take no more than 120 minutes (2 hours) and will be video recorded.

5. Review of participant interview transcript and research results will be requested near the end of the study, prior to the conclusion and dissertation defense. The length of time to completion will vary depending on participant’s availability.

How could you or others benefit from this study?

Participants should not expect a direct benefit from participating in this study.

What risks might you experience from being in this study?

The expected risks from participating in this study are minimal, which means they are equal to the risks you would encounter in everyday life. The risks involved in this study include the possibility of psychological stress from being asked to recall and discuss traumatic events to include distressing memories, flashbacks, reminders of events, feelings of anxiety, depressive symptoms, and/or panic symptoms. The likelihood of these risks occurring are slim, but individuals with a previous diagnosis of post-traumatic stress disorder (PTSD) will be more at risk due to the nature of the study. To reduce risk, I will monitor the participant, discontinue the interview if needed, and provide referral information for counseling services or medical services, as well as provide community resources that could be utilized for additional support.

I am a mandatory reporter. During this study, if I receive information about child abuse, child neglect, elder abuse, or intent to harm self or others, I will be required to report it to the appropriate authorities.

How will personal information be protected?

The records of this study will be kept private. Published reports will not include any information that will make it possible to identify a subject. Research records will be stored securely, and only the researcher will have access to the records.

· Participant responses will be kept confidential by replacing names with pseudonyms chosen by the participant.

· Interviews will be conducted in a location where others will not easily overhear the conversation.

· Confidentiality cannot be guaranteed in group discussion settings. While discouraged, other group members may share what was discussed with persons outside of the group.

· Data collected from you may be used in future research studies and/or shared with other researchers. If data collected from you is reused or shared, any information that could identify you, if applicable, will be removed beforehand.

· Data will be stored on a password-protected external hard drive connected to a password protected laptop. The researcher, her dissertation chair, and committee will have access to the data. After seven years, all electronic records will be deleted, and all hardcopy records will be shredded.

· Recordings will be stored on a password-protected external hard drive connected to a password protected laptop. The researcher, her dissertation chair, and committee will have access to the recordings. After seven years, the recordings will be deleted.

Is study participation voluntary?

Participation in this study is voluntary. Your decision whether to participate will not affect your current or future relations with Liberty University or the Dept. of Veterans Affairs. If you decide to participate, you are free not to answer any question or withdraw at any time without affecting those relationships.

What should you do if you decide to withdraw from the study?

If you choose to withdraw from the study, please contact the researcher at the email address/phone number in the next paragraph. Should you withdraw, data collected from you, apart from group discussion data, will be destroyed immediately and not included in this study. Group discussion data will not be destroyed, but your contributions to the group will not be included in the study if you choose to withdraw.

Whom do you contact if you have questions or concerns about the study?

The researcher conducting this study is Lori Wramp. You may ask any questions you have now. If you have questions later, you are encouraged to contact me at (671) 489-3771 or [email protected]. You may also contact the researcher’s faculty sponsor, [name], at [email].

Whom do you contact if you have questions about your rights as a research participant?

If you have any questions or concerns regarding this study and want to talk to someone other than the researcher, you are encouraged to contact the IRB. Our physical address is Institutional Review Board, 1971 University Blvd., Green Hall Ste. 2845, Lynchburg, VA, 24515; our phone number is 434-592-5530, and our email address is [email protected] .

Disclaimer: The Institutional Review Board (IRB) ensures that human subjects research will be conducted ethically as defined and required by federal regulations. The topics covered and viewpoints expressed or alluded to by student and faculty researchers are those of the researchers and do not necessarily reflect the official policies or positions of Liberty University.

Your Consent

By signing this document, you are agreeing to be in this study. Make sure you understand what the study is about before you sign. You will be given a copy of this document for your records. The researcher will keep a copy with the study records. If you have any questions about the study after you sign this document, you can contact the study team using the information provided above.

I have read and understood the above information. I have asked questions and have received answers. I consent to participate in the study.

The researcher has my permission to audio-record/video-record me as part of my participation in this study.

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Printed Subject Name

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Signature & Date