for WIZARD KIM: Review Paper—Topic Proposal & Reference Page

Perceived Barriers to Care Among Veterans Health Administration Patients With Posttraumatic Stress Disorder

Paige Ouimette Syracuse VA Medical Center and

Syracuse University

Dawne Vogt VA Boston Healthcare System and

Boston University

Michael Wade and Vanessa Tirone Syracuse VA Medical Center and

Syracuse University

Mark A. Greenbaum, Rachel Kimerling, Charlene Laffaye, and Julie E. Fitt

VA Palo Alto Health Care System

Craig S. Rosen VA Palo Alto Health Care System and Stanford University

Despite the availability of specialty posttraumatic stress disorder (PTSD) care within Department of Veterans Affairs (VA) facilities, many VA patients with PTSD do not seek needed PTSD treatment. This study examined institutional and stigma-related barriers to care among a large diverse group of Vietnam and Iraq/Afghanistan veterans who had been diagnosed with PTSD by a VA provider. A total of 490 patients who had not received VA treatment for PTSD in the previous 2 years (31% response rate) were asked about psychological symptoms and reasons for not using care. Stigma related barriers (concerns about social consequences and discomfort with help-seeking) were rated as more salient (rated in the “slightly” to “moderately” problematic range) than institutional factors (not “fitting into” VA care, staff skill and sensitivity, and logistic barriers; rated in the “not at all” to “slightly” problematic range). Regression analyses revealed that younger age and White females were associated with higher ratings on not fitting into VA health care, whereas non-White males were associated with higher ratings on logistic barriers. PTSD symptoms were positively associated with perceived barriers to care, with the most consistent results observed for PTSD avoidance symp- toms. Magnitude of effects was generally small, suggesting the possibility that other factors not assessed in this study may also contribute to perceptions of barriers to care. Future research should attend to the effects of stigma, as well as institutional barriers to care, on VA mental health treatment seeking.

Keywords: PTSD, access barriers, Iraq War, veterans, stigma, Longitudinal Veterans Health Survey

This article was published Online First June 27, 2011. Paige Ouimette, Michael Wade, and Vanessa Tirone,

Center for Integrated Healthcare, Syracuse VA Medical Center, Syracuse University; Dawne Vogt, Women’s Health Sciences Division, National Center for PTSD, VA Boston Healthcare System Division of Psychiatry, Boston Univer- sity; Mark A. Greenbaum, Sierra-Pacific Mental Illness Research, Education and Clinical Center, VA Palo Alto Health Care System; Rachel Kimerling, Charlene Laffaye, and Julie E. Fitt, Dissemination & Training Division, Na- tional Center for PTSD, VA Palo Alto Health Care System; Craig S. Rosen, Dissemination & Training Division, Na- tional Center for PTSD, VA Palo Alto Health Care System, and Department of Psychiatry & Behavioral Sciences, Stan- ford University.

This work is supported by the Center for Integrated Health Care, VA Sierra-Pacific Mental Illness Research, Education and Clinical Center; the VA National Center for Posttraumatic Stress Disorder; the VA Office of Ac- ademic Affiliations; and the VA Palo Alto Health Care System. Gregory Beehler, Larry Lantinga, and Kyle Pos- semato provided comments on this article. Melissa Cohen assisted with manuscript preparation. The opinions ex- pressed are those of the authors and do not reflect the policy of the Department of Veterans Affairs or the United States Government.

Correspondence concerning this article should be ad- dressed to Paige Ouimette, Center for Integrated Healthcare, Syracuse VAMC (116C), 800 Irving Avenue, Syracuse, NY 13210. E-mail: [email protected]

Psychological Services In the public domain 2011, Vol. 8, No. 3, 212–223 DOI: 10.1037/a0024360

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Military service is a time of high risk for exposure to trauma, including combat and sex- ual assault (e.g., Murdoch, Polusny, Hodges, & O’Brian, 2004). Of recent concern is the high prevalence of posttraumatic stress disorder (PTSD) among Operation Enduring Freedom/ Operation Iraqi Freedom (OEF/OIF) active duty personnel (e.g., Kang & Hyams, 2005; Seal, Bertenthal, Miner, Sen, & Marmar, 2007) and this cohort’s apparent underuse of mental health care (APA Presidential Task Force on Military Deployment Services for Youth, Families & Service Members, 2007; Hoge, Auchterlonie, & Milliken, 2006; Hoge et al., 2004). Information on how Department of Veterans Affairs (VA) patients with PTSD perceive VA care is sparse, and such information may assist with service planning and efforts to increase accessibility of PTSD treatment (Sayer, Clothier, Spoont, & Nelson, 2007; Sayer, Spoont, & Nelson, 2004; Wang et al., 2005).

Research on barriers to VA care has in- creased over the past several decades, identify- ing factors that impact service use. Vogt (2011), classified barriers to health care into three broad domains, which may independently and jointly affect service use, including individual back- ground characteristics, institutional factors, and stigma-related beliefs about mental illness and mental health treatment. Studies of barriers to care among individuals with mental health problems identify key factors such as lack of confidence in and perceived need for treatment, stigma-related fears, and beliefs in self-reliance (e.g., Bauer, Williford, McBride, & Shea, 2005; Hoge et al., 2004; Kessler et al., 2001; Leaf, Bruce, & Tischler, 1986; Mansfield, Addis, & Courtenay, 2005; Mojtabai, Olfson, & Me- chanic, 2002). The few studies that have fo- cused on barriers to care reported by individuals with PTSD, suggest that patients with PTSD are less knowledgeable about care options and eli- gibility for service (Davis, Ressler, Schwartz, Stephens, & Bradley, 2008; Sayer et al., 2009), have more stigma-related concerns (Hoge et al., 2004; Sayer et al., 2009), and have more nega- tive perceptions of accessibility and delivery of services and staff interpersonal behavior (Desai, Stefanovics, & Rosenheck, 2005; Sayer et al., 2009) than patients without PTSD. The current study extends previous work on PTSD-related barriers to VA health care by examining insti- tutional and stigma-related barriers to care

among a large, diverse national sample of VA outpatients with PTSD.

A number of different background character- istics may influence perceived barriers to VA care. For example, given that VA was originally designed to serve male veterans and that the patient population is mostly male and older, it might be expected that women and younger veterans would be more uncomfortable seeking care at VA, particularly with respect to percep- tions of “fitting in.” Similarly, OEF/OIF veter- ans may have concerns regarding the extent to which they “fit in” at the VA, given that the current VA patient population is predominantly from the Vietnam era. In addition, some studies suggest that stigma-related concerns may be a more important factor for males than females (e.g., Wang et al., 2005).

The literature on the impact of race or eth- nicity on perceived barriers to care has been mixed. While race and ethnicity have been iden- tified as correlates of attitudes, perceptions, and behaviors related to seeking mental health care in some research (Alvidrez, 1999; Ojeda & McGuire, 2006), other studies have not found an association between race or ethnicity and perceived barriers to care (e.g., Bauer et al., 2005; Pietrzak, Johnson, Goldstein, Malley, & Southwick, 2009; Smith, Dawson, Goldstein, & Grant, 2010). Here, we extend previous work by examining whether age, sex, and racial or ethnic minority status is associated with perceptions of barriers to VA health care. We also examined whether the observed sex effects are moderated by racial or ethnic minority status based on a recent paper suggesting that racial or ethnic differences on perceived barriers to care may vary by sex (Ojeda & Bergstresser, 2008).

It also seems likely that individuals with more severe mental health symptoms might have more difficulty navigating the complexi- ties of accessing VA care, and consequently, may perceive more VA-specific barriers to care than veterans with less severe symptoms (e.g., Davis et al., 2008). Similarly, severity of mental health problems may predict stigma-related concerns as individuals with more severe symp- toms may: (1) be more visible to others, and in turn, elicit more stigmatizing behavior from their social environments, and (2) report more stigma-related concerns because of greater im- mediacy of their symptoms relative to those with less severe symptoms (e.g., Corrigan,

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2004; Greene-Shortridge, Britt, & Castro, 2007; Pyne et al., 2004).

There is also some evidence that specific PTSD symptom clusters may differentially pre- dict barriers to care. In a study of veterans seeking disability claims for PTSD, Sayer et al. (2009) found that trauma-related avoidance symptoms were a key factor in failure to seek PTSD treatment. The current study adds to pre- vious work by examining severity of mental health symptoms as reflected in PTSD severity, as well as specific PTSD symptom clusters, as correlates of barriers to care among VA patients with PTSD.

The Present Study

During, 2006 –2007, a national sample of 490 male and female VA patients with PTSD were assessed regarding their perceptions of barriers to VA care and health symptoms. Using these data, this study expanded on previous work by describing barriers to care in a large sample of Vietnam and Iraq/Afghanistan patients and by examining whether demographics and symptom characteristics were associated with greater per- ceptions of barriers to care. We expected that younger, female, and racial or ethnic minority PTSD patients would endorse more barriers to care, in particular concerns about fitting into the VA. We examined whether race and sex would interact in association with barriers to care. Fi- nally, it was expected that patients with more severe PTSD symptoms, and those with more PTSD avoidance symptoms would perceive greater barriers to care. Given that PTSD is highly comorbid with depression (e.g., Nixon, Resick, & Nishith, 2004), depression was con- trolled for, so that the unique effects of PTSD severity and symptoms on barriers to care could be examined.

Method

Participants and Procedure

The final sample of participants were 490 male and female VHA outpatients between the ages of 18 to 69 who served in the Vietnam era or later period and had been newly diagnosed with PTSD (ICD-9-CM 309.81) during a VA outpatient visit within the last 6 months. Pa- tients were excluded if they had any VA outpa-

tient or inpatient PTSD treatment in the 2 years before that visit. Treatment for PTSD was in- ferred by the absence of a PTSD diagnosis during those 2 years (clinicians are required to code for a PTSD diagnosis for any visit wherein PTSD treatment is received; thus, the absence of a PTSD diagnosis would signify that no treatment for PTSD was delivered, regardless of visit type). Participants completed a mail survey between August 11, 2006 and April 6, 2008, an average of 2.7 months (SD � 1.2, range � 0.8 to 7.6) after being diagnosed. Data were col- lected as part of the Longitudinal Veterans’ Health Study (LVHS; Rosen et al., 2009).

With a HIPAA waiver, recruitment began by identifying potential participants from the na- tional VA administrative database (National Pa- tient Care Database; NPCD). Four strata were created using random sampling: male OEF/OIF patients, female OEF/OIF patients, male pa- tients who served before OEF/OIF, and female patients who served before OEF/OIF. Substrata ensured a representative distribution of age groups and past year VA service use.

A total of 1,609 potential participants (roughly 100 per month) were contacted by mail over a 17-month period using the Dillman method (Dillman, 2000). Potential participants were contacted up to three times by mail plus up to four attempts by phone (leaving one voice mail message if unable to speak directly to the participant on the fourth attempt). Participants received a $10 VA canteen coupon for comple- tion of the survey. The Stanford University IRB oversaw study procedures.

A total of 500 patients (31%) participated in the survey, which is a response rate similar to other recent survey studies of veterans and mil- itary personnel (e.g., the Millennium Cohort Study; Wells et al., 2008; Pietrzak et al., 2009). Five were excluded because their surveys indi- cated pre-Vietnam service, four were excluded because their survey was completed more than 8 months after diagnosis, and one participant asked to be withdrawn. Thus, the final sample of 490 participants included 137 male OEF/OIF patients (19% response rate), 111 female OEF/ OIF patients (33%), 122 male pre-OEF/OIF pa- tients (51%), and 120 (41%) female pre-OEF/ OIF patients.

Mean age of the sample was 41 years (SD � 13.37), 67% (N � 330) were White, and 45% (N � 215) were married. As expected

214 OUIMETTE ET AL.

because of stratification (i.e., groups were sam- pled to have equal numbers), half the sample was female (47%; N � 231), half had served in OEF/OIF (51%; N � 248), and about half of the sample (44%; N � 216) had received at least one session of VA mental health care (no PTSD diagnosis was noted, signifying no PTSD men- tal health care) in the prior 2 years. A total of 203 (41%) and 287 (59%) were diagnosed with a primary and secondary PTSD diagnosis, re- spectively.

To assess the representativeness of the sam- ple, we used data from the NPCD to compare characteristics of LVHS participants and the corresponding populations from which they were drawn (31,684 male OEF/OIF veter- ans, 3,299 female OEF/OIF veterans, 96,683 male prior service period veterans, and 7,916 female prior service period veterans). For each group, we compared the survey sample and total population on age, period of service, marital status, mean income, percent service connec- tion, types and total number of comorbid mental health disorders, mortality risk factors, site of initial clinic visit (i.e., primary care vs. mental health), number of VA visits (of all types) in the prior year, and number of primary care, mental health, and substance abuse visits completed in the 3 months after the index visit (inclusive). Because even minute differences can be statis- tically significant in such large samples, we examined differences in terms of effect sizes. Out of a total of 172 comparisons between the four populations and samples, all the differ- ences were smaller than d � .20 or h � .20, suggesting that any differences are quite small.

Measures

Demographics and military service. Data on participants’ age and sex were culled from the VA NPCD. Survey questions asked partic- ipants to identify their race or ethnicity, marital status, and OEF/OIF service.

Depression. The Center for Epidemiolog- ical Studies Depression Scale (CES-D; Radloff, 1977) is a well-validated measure of the symp- toms of clinical depression (Clark, Mahoney, Clark, & Eriksen, 2002).

Posttraumatic stress disorder. The Im- pact of Events Scale—Revised (IES-R; Weiss & Marmar, 1996) was used to assess severity of PTSD symptom clusters (reexperiencing, avoid-

ance, and hyperarousal) and overall PTSD symptoms. The IES-R is valid and reliable mea- sure of PTSD among veterans (Creamer, Bell, & Failla, 2003).

Barriers to VA health care. Twenty-five items were created to assess perceived access barriers to care using selected items from the Barriers to Help Seeking Scale (Mansfield, Ad- dis, & Courtenay, 2005) and additional items based on a literature review of reasons that men and women identify for not seeking help (e.g., Vogt, 2011). Items are presented in Table 1.

Participants indicated the degree to which each potential barrier hindered their use of health care on a 4-point scale with 1 indicating “not at all,” 2 “slightly,” 3 “moderately,” and 4 “very much.” An exploratory factor analysis with varimax rotation revealed five factors with eigenvalues greater than 1, generally consistent with the conceptual frameworks of Mansfield et al. (2005) and Vogt’s (2011). Factors reflecting institutional barriers were labeled Staff Skill and Sensitivity (SSS; � � .67), Logistical Barriers (LB; � � .62), and Not Fitting In (NFI; � � .66). Factors reflecting stigma-related barriers included Discomfort with Help Seeking (DHS; � � .84), and Concerns about Social Conse- quences (CSC; � � .72).

Data Analytic Plan

Means and standard deviations were calcu- lated to describe the sample. Zero-order corre- lations were used to describe simple associa- tions between variables. Preliminary analyses of scale distributions revealed that three of the five subscales violated assumptions of normality. LB was positively skewed and SSS and NFI followed a Poisson distribution. For data ana- lytic purposes, LB was log transformed. SSS and NFI were analyzed using Poisson regres- sion.

Hierarchical linear regression was used to examine the association between potential de- mographic and health predictors (i.e., demo- graphics, PTSD symptom clusters, and mental health symptom severity) and LB, DHS, and CSC; Poisson regression was used to examine predictors of SSS and NFI. In the model exam- ining age, sex, and racial identity as predictors of barriers to care, main effects were entered on the first step (control variables included mental health treatment in the past 2 years, OEF/OIF

215BARRIERS

status, and marital status). The zero-centered race by gender interaction effect was entered in the next step to examine whether the interaction of race and sex accounted for significant unique variance in the barriers measures.

In models examining PTSD symptoms as a predictor of barriers to care, VA mental health

treatment in the past 2 years, OEF/OIF status, marital status, age, sex, white racial identity, and depression severity were entered in the first step as covariates, followed by PTSD symptoms on the second step. Lastly, in models examining the unique associations of the three PTSD symptom clusters on barriers to care, step 1 entered the same

Table 1 Factor Loadings, Means, and Standard Deviations for the Individual Barriers to Care Items

Factor loadings

1 2 3 4 5 Mean SD

Institutional barriers Staff skill and sensitivity

I don’t trust doctors and nurses.b 0.76 0.17 0.17 0.14 0.09 1.58 0.88 I don’t trust mental health professionals (counselors,

psychotherapists, or psychiatrists).b 0.74 0.11 0.08 0.20 0.20 1.62 0.88 VA or Vet Center staff members were not responsive to my

needs.b 0.39 0.37 0.33 0.03 0.06 1.64 0.95 Logistic barriers

I have real difficulty finding transportation to the VA.b 0.28 0.69 0.10 0.05 0.02 1.32 0.76 The nearest VA clinic or Vet Center is too far away.b �0.04 0.69 0.09 0.17 0.00 1.67 1.00 I don’t know what sort of help is available from the VA.b �0.24 0.51 0.13 0.27 0.31 1.86 0.93 I have to pay more than I can afford to get care at the VA.b 0.18 0.51 �0.10 �0.09 0.05 1.35 0.79 The VA’s hours conflict with my parenting responsibilities.b 0.11 0.28 0.07 �0.09 0.14 1.24 0.65 The VA’s hours conflict with my work schedule.b 0.01 0.03 0.08 0.14 0.02 1.73 1.05 I had to wait too long to get a VA appointment.b 0.19 0.21 0.19 0.08 �0.01 1.95 1.12

Not fitting in The VA is for people who are a different sex than me.b 0.11 0.08 0.78 �0.04 0.09 1.21 0.63 The VA doesn’t feel comfortable for people my age, race,

or sex.b 0.23 0.03 0.77 0.11 0.09 1.39 0.81 The VA is for people who are a very different age than me.b �0.11 0.02 0.61 0.18 0.24 1.49 0.83 VA mental health treatment is only for people whose

problems are more severe or long lasting than mineb 0.02 0.08 0.42 0.47 0.23 1.72 0.99 Stigma-related barriers

Discomfort with help-seeking My problems aren’t a big deal; they will go away in time.a �0.02 0.04 0.20 0.76 �0.10 2.14 0.99 I don’t want to overreact to problems that aren’t serious.a �0.02 0.14 0.11 0.74 0.17 2.49 1.07 I don’t like to get emotional about things.a 0.19 �0.01 0.01 0.67 0.30 2.63 1.09 I don’t like other people telling me what to do.a 0.29 0.00 �0.06 0.52 0.28 2.33 1.12 I don’t like to talk about feelings.a 0.18 0.04 �0.08 0.64 0.43 2.66 1.08 I would think less of myself for needing help.a 0.08 0.07 0.08 0.55 0.46 1.97 1.04 Privacy is important to me, and I don’t want other people to

know about my problems.a 0.15 0.04 �0.04 0.55 0.54 2.72 1.16 Concerns about social consequences

I don’t want to look stupid for not knowing how to figure these problems out.a 0.06 0.14 0.14 0.29 0.77 2.35 1.19

My problems are embarrassing.a �0.05 0.15 0.17 0.27 0.76 2.30 1.14 I’m concerned that other people might find out information

in my VA medical records.b 0.23 0.04 0.26 0.08 0.60 1.87 1.09 I only want to be seen individually, not in a therapy group.b 0.28 �0.20 0.06 0.19 0.50 2.42 1.25

Note. Participants indicated the degree to which each potential barrier hindered their use of health care on a 4-point scale with 1 indicating “not at all,” 2 “slightly,” 3 “moderately,” and 4 “very much.” a Instructions for these items stated “(The following) . . . are some reasons people might have for NOT seeking help with personal problems. Please read each reason and decide how important it would be in keeping you from seeking help.” b Instructions for these items stated, “(The following) . . . are some reasons people might have for NOT seeking help for personal problems from the VA or Vet Center. Please read each reason and decide how important it would be in keeping you from seeking help.”

216 OUIMETTE ET AL.

covariate set used in the model examining PTSD severity, and step 2 entered the three PTSD symp- tom clusters.

Results are displayed in standard deviation units (i.e., a common metric) so that betas can be compared across correlates and outcomes. For SSS and NFI, results are displayed as log rates (ratio of means), whereas LB, DHS, and CSC are shown as standard slopes or differ- ences in means per 1 SD increase in predictors. Cohen’s d was calculated as an index of effect size for statistically significant findings for sub- group analyses and PTSD symptom results.

Results

Description of Perceived Barriers to Care

Table 1 presents factor loadings, means, and standard deviations for the individual items. Table 2 presents the mean and standard deviation for each barrier measure. In regard to institutional barriers, participants average score was in the not at all range in perceptions of barriers associated with SSS and between the not at all and slightly range in perceptions of LB, as well as perceptions of NFI. In regard to stigma related barriers, par- ticipants’ average score for DHS and CSC fell in between the slightly to moderately range.

Correlates of Barriers to Care

Table 3 presents zero order correlations be- tween background characteristics, symptoms,

and barriers to care. Receipt of VA mental health treatment in the prior 2 years was not associated with barriers to care subscales. Being a veteran of OEF/OIF was associated with greater perceptions of not fitting into the VA. Being married was associated with greater dis- comfort with help seeking and greater concern about negative social consequences. Younger age was associated with greater perceptions of not fitting into the VA. Female sex was nega- tively associated with discomfort with help seeking and positively associated with greater perceptions of not fitting into the VA. White racial status was not associated with the barriers to care subscales. Depression and PTSD, as well as each of the PTSD symptom clusters, was associated with higher scores on the five barri- ers measures. Depression and PTSD were sig- nificantly associated, r � .64, p � .001.

Table 4 presents regression analyses examin- ing demographics and military background as correlates of barriers to care. After adjusting for covariates, both age and sex accounted for a significant amount of unique variance in pre- dicting NFI, indicating that older age and male sex were associated with fewer concerns about fitting in. White racial identity, marital status, OEF/OIF status, and prior mental health treat- ment were not significantly associated with per- ceived barriers to care.

The interaction between sex and race was significant for NFI and LB. Follow-up analyses revealed that among white participants, female

Table 2 Unadjusted Means and Standard Deviations of Perceived Barriers to Care Subscales Among VA Patients With PTSD

Males (N � 259�) Females (N � 231�)

Total (N � 490)

White (N � 186)

Non-White (N � 71)

White (N � 144)

Non-White (N � 87)

Variable M (SD) M (SD) M (SD) M (SD) M (SD)

Institutional barriers SSS 1.61 (.71) 1.59 (.66) 1.75 (.79) 1.58 (.70) 1.63 (.84) LB 1.59 (.50) 1.54 (.47) 1.75 (.61) 1.60 (.48) 1.54 (.52) NFI 1.45 (.59) 1.35 (.45) 1.49 (.59) 1.59 (.70) 1.40 (.58)

Stigma-related factors DHS 2.42 (.76) 2.52 (.74) 2.49 (.83) 2.34 (.75) 2.24 (.74) CSC 2.24 (.86) 2.25 (.84) 2.18 (.94) 2.27 (.83) 2.19 (.92)

Note. SSS � Staff skill and sensitivity; LB � Logistic barriers; DHS � Discomfort with help-seeking; NFI � Not fitting in to VA; CSC � Concerns about social consequences. Higher scores indicate more perceived barriers. Items were rated on a 4-point scale with 1 � not at all, 2 � slightly, 3 � moderately, and 4 � very much. � N’s slightly vary for each outcome depending missing data.

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sex was positively associated with scores on NFI, p � .01 (Cohen’s d � .42, indicating a small-medium effect size). Among White fe- male and male participants, adjusted mean scores for NFI were 1.59 and 1.35, respectively. Among non-White participants, there was not a significant association between sex and NFI. In regard to LB, follow-up analyses indicated that among non-White participants, male sex was positively associated with scores on LB, p � .05 (Cohen’s d � .41, indicating a small-medium effect size). Among non-White female and male participants, adjusted mean scores for LB

were 1.75 and 1.54, respectively. Among white participants, there was not a significant associ- ation between sex and LB.

Symptom characteristics. After control- ling for covariates, severity of PTSD symptoms was uniquely associated with four of the five barriers measures (see Table 5, Model 1). An increase in 1 SD on the IES scale was associated with a 9, 14, 11, and 11% increase in score on SSS, LB, DHS, and CSC, Cohen’s d � .15, .13, .25, and .23, respectively, indicating small ef- fect sizes.

After controlling for covariates, severity of PTSD reexperiencing symptoms was negatively associated with DHS (an increase in 1 SD on the IES was associated with a 9% decrease in NFI, Cohen’s d � .19 indicating a small effect size), and PTSD avoidance symptoms was positively associated with SSS, DHS, NFI, and CSC (an increase in 1 SD in IES avoidance was associ- ated with a 9 –13% increase in these barriers scales, Cohen’s d � .21, .29, .11, and .17, respectively, indicating small effect sizes, see Table 5, Model 2). PTSD hyper-arousal symp- toms were not associated with the barriers to care measures.

Discussion

This study examined institutional and stigma- related barriers to care among a large diverse group of Vietnam and Iraq/Afghanistan veter- ans who had been diagnosed with PTSD by a VA provider. To facilitate comparison across different service periods, neither cohort of vet- erans had received PTSD treatment in the 2

Table 3 Zero Order Correlations Among Demographics, Symptoms, and Perceived Barriers to Care

SSS LB NFI DHS CSC

PMHT �.01 .02 .02 �.03 .01 OEF/OIF �.07 .06 .10� .03 �.04 Married .08 .02 �.05 .12�� .10�

Age .03 �.07 �.05��� .06 .06 Females �.02 �.02 .12� �.14�� .00 White �.07 �.07 .01 .05 .04 Reexperiencing .21��� .21��� .12�� .22��� .31���

Avoidance .27��� .19��� .15��� .32��� .32���

Hyperarousal .25��� .22��� .15��� .27��� .34���

PTSD .27��� .23��� .15��� .30��� .35���

Depression .27��� .24��� .17��� .20��� .35���

Note. PMHT � Prior VA mental health treatment (not PTSD treatment); OEF/OIF � Operation Enduring Free- dom/Operation Iraqi Freedom Veteran; SSS � Staff skill and sensitivity; LB � Logistic barriers; DHS � Discomfort with help-seeking; NFI � Not fitting in to VA; CSC � Concerns about social consequences; PTSD � posttrau- matic stress disorder. � p � .05. �� p � .01. ��� p � .001.

Table 4 Regression Analyses Examining Associations Between Barriers to Care and Demographics

Step Predictor

SSS LB NFI DHS CSC

� �2 � t � t � �2 B T

1 PMHT �.02 .19 .04 .39 .04 .42 �.00 �.06 .03 .31 OEF/OIF �.14 3.2 .07 .54 .03 .15 .12 1.20 �.01 �.15 Married .10 3.08 .08 .84 .01 .04 .11 1.43 .17 1.96 Age �.05 1.3 �.05 �.77 .04 4.1� .06 1.18 .03 .47 Females �.03 .29 �.04 �.36 .13 4.7� �.14 �1.9 .06 .75 White racial identity (ID) �.09 2.4 �.11 �1.1 .04 .32 .06 .8 .08 .92

2 White racial ID�females .09 0.7 .56 2.8�� .41 10.8��� .10 .65 .03 .16

Note. PMHT � Prior VA mental health treatment (not PTSD treatment); OEF/OIF � Operation Enduring Freedom/ Operation Iraqi Freedom Veteran; SSS � Staff skill and sensitivity; LB � Logistic barriers; NFI � Not fitting in to VA; DHS � Discomfort with help-seeking; CSC � Concerns about social consequences. � p � .05. �� p � .01. ��� p � .001.

218 OUIMETTE ET AL.

years before the survey (although about half received mental health treatment for a mental health concern other than PTSD, and partici- pants may have received care at Vet Centers). The most salient barriers to care reported by these veterans were those characterized as stigma-related, specifically discomfort with help seeking and concerns about social conse- quences (on average, rated in between slightly to moderately problematic as perceived barriers to care). Perceptions of institutional barriers (skill and sensitivity of VA staff, logistic barri- ers, not fitting in) were less salient (on average, rated in between the not at all to slightly prob- lematic as perceived barriers to care), possibly reflecting the fact that this veteran sample was already enrolled in VA care and had received a diagnosis of PTSD by a VA provider. These data suggest that patients diagnosed with PTSD perceived VA care to be relatively accessible and VA staff to be relatively skillful and sensi- tive to their needs.

After adjusting for military background and other demographics, we found that younger age was associated with greater perceptions of not fitting in. Given that VA predominately serves older veterans (e.g., the average age of patients in primary care is about 70 years of age; Liu et al., 2010), this finding is perhaps not surprising. In addition, we found that the association between female sex and greater perceptions of not fitting in held only for white participants. Given that racial or ethnic minorities, especially African American vet- erans, are overrepresented among VA health

care patients (e.g., Rosenheck & Stolar, 1998; Washington et al., 2002), women who are minorities may feel more comfortable within VA. Thus, younger and White female patients may be at greatest risk for perceiving VA health care to be geared for other veterans. Interestingly, ethnic or racial minority men reported greater perceptions of logistic barri- ers, such as ease of use and availability of services at VA. Together these findings sug- gest that attending to race or ethnicity in understanding barriers to care may be impor- tant for some women and male VA patients with PTSD.

As expected, individuals with more severe PTSD symptoms rated barriers to care as some- what more important than their counterparts with less severe symptomatology. Importantly, PTSD symptoms were associated with more self-reported barriers even when controlling for the effects of depression symptoms, suggesting a unique association between PTSD symptoms and perceived barriers. This finding, which is consistent with other studies demonstrating that those with the highest levels of symptoms may perceive the most barriers to care (e.g., Hoge et al., 2004; Menke & Flynn, 2009), underscores the importance of recognizing and understand- ing the impact that psychopathology (in this case, PTSD) may have on one’s experiences and perceptions with seeking mental health care. As discussed previously, individuals with more severe mental health symptoms may have more difficulty navigating the complexities of accessing VA care (e.g., Davis et al., 2008) and

Table 5 Regression Analyses Examining Associations Between Barriers to Care and PTSD Severity and PTSD Symptom Cluster Severity Scores

SSS LB NFI DHS CSC

� �2 � t � t B �2 � t

Model 1 PTSD .08 5.6� .13 2.1� .07 2.9 .25 4.1��� .23 3.9���

Model 2 Reexperiencing �.07 1.8 .06 .6 �.05 .9 �.19 �2.24� �.07 �.9 Avoidance .11 9.5�� .08 1.2 .09 5.0� .29 4.67��� .17 2.8��

Hyperarousal .05 .7 .01 .1 .03 .4 .17 1.94 .15 1.8

Note. SSS � Staff skill and sensitivity; LB � Logistic barriers; NFI � Not fitting in to VA; DHS � Discomfort with help-seeking; CSC � Concerns about social consequences. VA mental health treatment (not PTSD treatment) in the past 2 years, Operation Enduring Freedom/Operation Iraqi Freedom status, marital status, age, sex, and white racial identity were controlled for in Model 1. Model 2 included the same covariates as Model 1. � p � .05. �� p � .01. ��� p � .001.

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they may perceive more stigma because of the fact that their symptoms are likely more salient both for them and for those around them (e.g., Corrigan, 2004; Greene-Shortridge, Britt & Castro, 2007; Pyne et al., 2004).

Interestingly, it appears that the association between PTSD and perceived barriers to care was mainly through avoidance symptoms. Sayer et al. (2009) found that PTSD avoidance symptoms were associated with reports of bar- riers to care, specifically that veterans avoided PTSD treatment to avoid talking about the trauma and associated painful memories and emotions. Consistent with these findings, here we found that greater severity of PTSD avoid- ance symptoms was associated with greater per- ceptions of institutional and stigma-related bar- riers to care. Avoidance symptoms can lead to interpersonal disconnection and possibly con- tribute to poorer interactions with VA staff as well as feelings of not fitting in at VA. In addition, these symptoms may be associated with perceptions of stigma because by avoiding contact with others and triggers, these veterans do not allow the assimilation of corrective in- formation about how others perceive them.

An unexpected finding was that severity of reexperiencing symptoms was associated with fewer stigma-related concerns in the area of help seeking. Reexperiencing symptoms are the hallmark of PTSD and perhaps the most easily recognized. Patients who have more florid reexperiencing symptoms may be less likely to blame themselves and more likely to accept help.

Study results have numerous implications for future research and clinical care. The find- ing that stigma-related barriers to care were more salient than institutional factors for this sample of veterans with PTSD suggests the importance of additional attention to the role of stigma in mental health service use. In the current study we examined two different di- mensions of mental health stigma. Specifi- cally, we addressed both concerns about be- ing stigmatized by others and one’s own per- sonal discomfort with help-seeking for mental health care. As pointed out by Vogt (2011), the existing military and veteran literature on barriers to care has focused primarily on the former category; additional attention is needed to the role of self stigma in mental health service use.

In addition, the salience of stigma-related concerns suggests that patient-focused or social interventions are clinically indicated. For exam- ple, the finding that one’s own beliefs about help-seeking may serve as a barrier to care suggests the potential utility of interventions targeted at addressing and improving veterans’ comfort levels with help-seeking. Psychoeduca- tion about the potential benefits of treatment by providers and peers may help increase comfort with help-seeking. Alternatively, the finding that concerns about public stigma are an issue may suggest the need for more attention to initiatives that can maximize privacy in the health care setting, such as greater integration of primary and mental health care services (e.g., Funderburk et al., 2010).

Results can also be used to inform outreach efforts for helping veterans initiate and main- tain ongoing treatments. More specifically, the finding that barriers to care differ across subgroups of veterans might suggest the need to tailor outreach efforts to particular sub- groups. For example, the finding that younger veterans and women are more likely to per- ceive that they do not fit in at the VA suggests the importance of initiatives aimed at educat- ing veterans about the increasingly diverse nature of the VA patient population and ser- vices offered specifically for women veterans and younger veterans, such as the OEF/OIF cohort. As Sayer and colleagues (2007) noted, the VA could greatly benefit from the use of tailored treatment-promotion strategies. Re- sults may also be used to inform employee education about veterans who use VA care and the factors that influence their choice to seek different types of VA care. As noted by Murdoch and her colleagues (2006), in- creased knowledge among VA health care staff about the patient population they serve can enhance the quality of the health care interaction. More generally, efforts to educate staff about barriers to care from the perspec- tive of women and OEF/OIF veterans can promote empathy and build trust within the doctor-patient relationship.

Limitations to this study include potential self-selection bias and the use of cross-sectional data. The measure of PTSD used for this study was based on a self-report measure; future work would benefit from the use of structured clinical interviews for PTSD. Another limitation is that

220 OUIMETTE ET AL.

several barrier items asked about Vet Center access or responsiveness and we did not have access to Vet Center diagnostic or visit data. The internal consistency of several barriers sub- scales was modest; further work is needed to develop psychometrically strong barriers mea- sures. Another limitation is that our barriers measure was intended to assess stigma associ- ated with mental health care help seeking (e.g., is a sign of weakness to seek help for mental health problems) but it is possible that these items may also capture rational barriers to care (e.g., sometimes symptoms really are too mild to warrant help-seeking). Distinguishing be- tween the latter two concepts is a direction for future research on the measurement of barriers to care. Strengths of this study included a focus on multiple barrier domains in a contemporary cohort of veterans.

Future research should focus on samples of veterans with PTSD diagnosed by a structured clinical interview, multidimensional measure- ment of barriers to care and studies should ex- amine the impact of barriers on multiple param- eters of service use (e.g., treatment entry, engagement in treatment, length of treatment) over time. It is also important to note that effect sizes for statistically significant findings were generally small, indicating that other factors not assessed in this study may also contribute to perceptions of barriers to care. Thus, future research might benefit from a consideration of other factors that may influence perceptions of institutional barriers and stigma-related con- cerns, including, for example, prior experiences with mental health treatment. In addition, stud- ies that focus on veterans who have not yet enrolled in VA care will be important in ongo- ing efforts to understand factors that impact veterans’ use of VA care.

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Received December 8, 2009 Revision received March 30, 2011

Accepted April 13, 2011 �

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