Veterans & Retirees; Is Government Keeping its Promise
This study aimed at exploring the experiences and perceptions of Veterans belonging to Lousiana and Mississippi about three variables; the accessibility of organization; the accessibility of benefits and availability and adequacy of the facilities being provided by government through VA. The respondents were also asked to suggest whether there is a need for improvement and what should VA do to provide benefits and facilities to the Veterans in a better ways.
For this purpose the researcher conducted an online survey targeting 100 Veterans from Mississippi and another 100 from Louisiana. The researcher also conducted an extensive review of the literature focusing on the problems of Veterans as well Government policies and VA structure and healthcare facilities.
Although majority of the Veterans did not give negative response but a great number of responses show that there are problems to access benefits and organization through which veterans can apply for benefits. Veterans perceive that VA is not spending money provided by government in the most efficient manner. The Veterans from Mississippi and Louisiana also suggested that VA should build more VA Medical Centers and also create awareness about the benefits the Government has announced as a great number of Veterans are not aware about these benefits. Veterans also face difficulties in finding organization through which they can apply for the benefits.
Table of Contents
Executive Summary 2
Chapter-1 Problem Statement 7
Introduction 7
Problem Statement 9
Purpose of the Study 11
Research Questions 11
Research Objectives 12
Operationalization of Variables 12
Study Significance 13
Limitations 15
Chapter-II Literature Review 16
Theoretical Framework 16
Impression Management 18
Patient Expectations 20
Service Quality 22
History of Government Benefits for Veterans 23
History of the Veterans Administration 24
Characteristics of the Veterans Health Administration (VHA) 26
Veterans Integrated Service Network (VISN) 27
History and Structure of the VA Service Line 28
Past United States Veterans' Benefits 30
Treating Veterans with Care 31
Veterans Health Administration 32
Common Problems Facing Veterans 33
Veterans Health Problems 36
PTSD: History and Definition 37
Trauma and PTSD Defined 37
Symptom logy 40
Homelessness 41
Risk Factors 42
Post-Traumatic Stress Disorder 46
Depression 47
Drug Abuse 47
Traumatic Brain Injury 48
Housing Problems 48
Veterans and Education 49
Veterans and Unemployment 50
Chapter-III Research Methodology 54
Introduction 54
Research Design 54
Grounded Theory Research 54
Sample 55
Instrument Development 55
Sampling Design 58
Data Collection 60
Data Analysis 60
Chapter-IV Findings 61
Description of the Sample 61
Survey Question-1 what is your Gender? 61
Survey Question-2 What category best describes your current age? 63
Survey Question-3 What is your discharge status? 64
Survey Question-4 What was your Pay Grade/Rank upon discharge? 65
Survey Question-5 What was your branch of Service in the Armed Forces? 66
Survey Question-6 What was your branch of Service in the Armed Forces? 67
Survey Question-7 Is the Veterans Administration doing everything possible to ensure that your needs are met and benefits available? 68
Survey Question-9 Can the U.S. Government improve on both the medical and educational benefits? 70
Survey Question-10 Can the U.S. Government improve on both the medical and educational benefits? 71
Survey Question-11 How easy is it to access the service organizations in your state to help you apply for your benefits? 72
Survey Question-12 Can the Veterans Administration do more to help you receive all your entitled military benefits? 73
Summary 74
Availability 74
Accessibility of the Benefits 75
Adequacy 76
Chapter-V Conclusion 77
Purpose of the Study 78
Summary of the Survey Results 78
Conclusion 79
Recommendations 81
References 83
Chapter-1 Problem Statement
Introduction
Many service veterans served during an active wartime, thus increasing the likelihood of needing VA services. Approximately 25.2 million veterans of the United States uniformed services were living the United States and Puerto Rico and the end of 2000. According to 2000 census of Veteran Population in the United States and Puerto Rico, civilian veterans over the age of 18 living in California was totaled at 2,569,340 accounting for 10% of the general California population over the age of 18. Recent reports document substantial mental and physical health distress and adjustment difficulties among military personnel returning from combat operation in Iraq and Afghanistan. Problems with depression, PTSD, and alcohol and substance misuse are common, particularly among National Guard and Army Reserve Personnel (U.S. Department of Health and Human Services, 2008). As of September 2008, 342,624 veterans were receiving compensation for PTSD diagnosis related treatments (National Center for Veterans Analysis and Statistics, 2008).
The study "Veternas and Retires; Is Government Keeping its promise" is a quantitative exploratory study about the adequacy of Government benefits for Veterans and Retirees as well as the effectiveness of Veterans Administration's in providing health care services. This issue is especially compelling considering the nation's social contract with its veterans -- "to care for him who shall have borne the battle and for his widow and his orphan" (Lincoln, 1865). Recent political discourse in the United States clearly indicates that this social contract remains very much intact. But the social contract is only as good as the ability of the various public and private health plans to adequately take into account the diverse needs and circumstances of the nation's million veterans.
And, as eligibility and coverage policies of non-veteran programs change, it becomes equally important to adjust accordingly veteran eligibility and coverage policies. The dissertation will focus on the adequacy, availability and accessibility of the services and benefits, Government has promised to provide the Veterans and Retirees.
The concept of access is not one dimensional. In attempting to define and operationalize the term "access," Penchansky and Thomas (1981) note that there are a number of dimensions that comprise this multifaceted concept: availability, accessibility, accommodation, affordability, and acceptability. Availability refers to the actual supply of resources obtainable in the community (e.g., the number of physicians, hospitals, clinics, specialists, etc.). Accessibility refers to "the relationship between the location of supply and the location of clients, taking account of client transportation resources and travel time, distance and cost" (p. 128). The third dimension, accommodation, centers on how the supply of health care and other services is delivered to the client and how amenable the pattern of delivery is to the individual seeking care. An example of accommodation is hours of operation (e.g., care available after-hours or weekends or 24-hour walk-in service). Affordability focuses on the customer's financial ability to pay (either out-of-pocket or via insurance or both) for care. The final dimension, acceptability, is "the relationship of clients' attitudes about personal and practice characteristics of providers to the actual characteristics of existing providers" (p. 129). Additionally, this aspect of access refers to providers' attitudes toward client characteristics.
The Department of Veterans[footnoteRef:1] Affairs (VA) is one of the fourteen federal government agencies in the United States. The predecessor to the VA was established in 1930 to provide healthcare services, benefits, and veterans' services to honorably discharged military veterans. [1: Veteran is any member of the U.S. armed services who has served at least 181 days of active duty, and who is discharged under conditions other that dishonorable, or who is discharged under a medical condition (34 CFR Part 645.6)]
Following WWII in 1946, there was eminent need for expanded healthcare in the country. At that time, a veterans' healthcare system was established more formally under the Veterans Administration's new Department of Medicine and Surgery. In 1988, the Veterans Administration, also known as the Veterans Affairs (VA), was assigned cabinet status, which formally came into effect in 1989. The Department of Veterans Affairs consists of the Veterans Benefit Administration (VBA), the Veterans Health Administration (VHA), and the National Cemetery Administration (NCA).
The Veterans Health Administration is the largest healthcare system in the United States (Evans, 2005) and provides medical care to a large population of American veterans of the armed forces which over 5 million men and women. Some of the organization's objectives are to improve safety, healthcare quality, efficiency, access, satisfaction, and responsiveness (Perlin, 2005).
The number of VHA hospitals around the nation has increased from 54 in 1930 to 159 in 2006 (Oliver, 2007; Veterans Health Administration, 2005). The system operates in over 1,400 sites. Because the VHA is an integrated, publicly financed healthcare system, public scrutiny of quality care and resource management is inevitable. In the early 1990's, critics perceived the VHA's services as poor with limited access, but by 2000, the organization experienced a remarkable turnaround as a result of systems reform that was initiated in 1995 (Longman, 2007; Oliver, 2007; Perlin, 2005).
Problem Statement
The Veterans Administration (VA) was established in 1930 and became the second largest cabinet department March 15, 1989. It provides healthcare, compensation, insurance, vocational rehabilitation, and burial assistance to veterans and their families (Department of Veterans Affairs, 206).
VA requested $36.6 billion to provide medical care to 5,819,000 patients in 2008. Veterans returning from operation Iraqi Freedom and operation Enduring Freedom (OIF/OEF) are estimated to be 263,000 of the 5,819,000 patients (Nicholson, 2007). $38.9 billion is estimated to be received in FY 08 rather than $36.9 billion.
The 2006-2011 strategic plans for the Department of Veterans Affairs (VA) outline the government's commitment to veterans. A goal of the VA is to "deliver world-class service to veterans and their families through effective communication and management of people, technology, business processes, and financial resources" (Department of Veterans Affair, October, 2006).
The VA had significant quality issues until Dr. Kenneth Kizer was appointed Under Secretary for Health in 1994. Dr. Kizer "decentralized the VA's cumbersome health bureaucracy and held original mangers more accountable. Patients records were transferred to a system-wide computer network" (Waller, 2006). The VA has become a healthcar model (Longman, 2005; Waller, 2006).
In 2007, the VA received a higher patient satisfaction score (83) than private healthcare (77) in the survey conducted by the American Customer Satisfaction Index (ACSI). However, the VA's score is down 1.2% for inpatients and up 1.2% for outpatients from 2006. Private healthcare satisfaction scores increased 4.1% in 2007 (American Customer Satisfaction Index, 2007; Nicholson, 2007; Withrow, 2006). These scores demonstrate the level of satisfaction patients have with the quality of care they receive and highlight the need for healthcare organizations to understand the expectations of patients.
For over forty years, Veterans are using healthcare services and other benefits. What is not known is how satisfied the Veterans are with these services. Satisfaction is an important measure of the quality of service and its crucial in the evaluation of Veterans Health care and other services. Consumer satisfaction is viewed as an important guage of potential problems in the delivery of VA services and is linked to consumers seeking services, compliance with treatment, and health outcomes (Litt, 1998).
The development of the research problem for the study was influenced by the theory of quality of healthcare (Donabedian, 2003), which stresses that patient satisfaction is a significant component of quality of healthcare (Donabedian, 2003). Examining whether there is a correlation between patient satisfaction and provider type is important so that VA can make plans towards healthcare quality improvement.
Despite five open enrollment periods, over 4 million Medicare beneficiaries have not enrolled with Medicare's prescription drug benefit and have no drug coverage of any kind (Henry J. Kaiser Family Foundation, 2010). The Centers for Medicare and Medicaid Services (CMS) and numerous health plan sponsors have spent millions of dollars promoting the benefit (Justice, 2005), which goes by the title, Part D. One group of researchers estimated that 1.5 million of these uncovered seniors would not only benefit medically from reliable access to prescription drugs, but also financially, due to lower drug costs (Heiss, McFadden, & winter, 2006). There have been suggestions in the literature that indicate why seniors would forgo enrollment, against their self-interest. Researchers have documented that many Medicare beneficiaries know little about Medicare, are easily confused, and have difficulty asking for help.
Satisfaction is an important measure of the quality of service and its crucial in the evaluation of Veterans Health care and other services. Consumer satisfaction is viewed as an important guage of potential problems in the delivery of VA services and is linked to consumers seeking services, compliance with treatment, and health outcomes (Litt, 1998).
Although the overall veteran population has been declining, VA health care enrollees have been increasing and the portion of the veteran patients aged 65 and older is projected to increase by 41% in the next 10 years (VHA Office of Policy and Planning, 2002). Thus, we can expect the number of veterans enrolled in the VA who will potentially use additional health services under Medicare to increase.
Purpose of the Study
The purpose of this research is to evaluate Veteran's satisfaction with services provided by Government through VA. The focus of the study will be on the overall experiences and perceptions of the Veterans from Mississippi and Louisiana. This study will describe how the Veterans Administration is using its financial and technical tools to provide better services to its Veteran population. It will outline what the current VA system looks like and how all the changes will benefit management and its ability to provide better services. First a short history will give a brief overview of how the VA was originally started. It will describe the how the VA hospital system has evolved from its earliest beginnings.
Research Questions
The mission of the VA is to provide healthcare services to the Veterans. To accomplish this goal, the VHA set thirteen Veterans Health Service Standards (VHSS) which will be discussed later, to provide all Veteran Integrated Service Networks (VISN) and facilities the resources to ensure that, "the highest quality of care and services are made available to veterans, and by extension, their families and/or significant others" (Veteran Health Administration 2006a)
Research Objectives
The following were the objectives of the research:
1. To measure whether the Government is keeping its promise by providing Efficient and better services and benefits toward Veterans?
2. To examine the Veterans about the benefits provided to them
3. To explore the difficulties Veterans are facing in accessing benefits
4. To relate Veterans satisfaction to federal policy for Veterans.
The central questions that guided this study included the following:
1. Are Veterans satisfied with the benefits Government providing through VA?
2. Are Veterans aware of the organizations that assist them to apply for benefits?
3. Is there a need for VA to improve services?
Operationalization of Variables
This research is a quantitative study exploring the availability and accessibility of VA healthcare and other services, with special focus on perceptions and experiences of Veterans from Mississippi and Louisiana. A review of the literature indicates that a quantitative research method should be used when the research does not fully understand the service, the characteristics of the veterans, or their problems, expectations, and needs (Steiber and Krowinski, 1990). It is also helpful to use quantitative methods when management is primarily interesting obtaining information useful in determining how to improve the service (Steiber and Krowinski 1990).
The dependent variable in this study was the perceptions of quality from Veterans about the benefits being provided to them by government. Online survey instrument was used to examine the perceptions of Veterans regarding availability, accessibility and adequacy of the healthcare and other benefits offered to Veterans.
The independent variables in this study were the Veteran's prior experiences with the VA services in Louisiana and Mississippi.
Study Significance
The veterans' opinion about the accessibility of services and benefits are significant. Government and VA want to know patients' perceptions about the benefits being provided to them. The Study's Significance
There were several items that made the study significant. This quantitative study provided a unique perspective on the experience of Veterans, identified their complaints regarding accessibility, availability and adequacy. As well as obtained their suggestion to improve services.
Till to date there are not any published robust quantitative studies that examine the Veterans experiences and perceptions about the overall services being offered by the Government. Since the benefits announced since Veterans Administration launched in 1989, researchers have published papers that have examined some aspects related to veterans. These studies were largely quantitative in nature and scrutinized narrowly focused facets of the problem within no particular paradigm. The dissertation study distinctively examined the overall experience of Veterans about the Services. The study was significant because the results provided a more grounded starting point for further investigation into this unique problem.
The study of veterans experiences and perceptions about Government benefits and whether the Government is keeping its promise in providing benefits to Veterans and Retirees will help the Government to assess the flaws of their policies. The study will also be helpful providing information to Veterans Administration about veterans' knowledge of VA services, perceptions about the quality of the VA, and the influence of these factors upon veterans' which will lead to improvement in providing care. The objective that eligible veterans know about VA care and are able to make an informed appraisal about the quality of that service option is a reasonable goal. This study examines the extent to which lack of information about services and poor evaluations of VA health care quality represent barriers to service utilization.
A key contribution this work makes to the general health services literature is that the analyses provide an insight into the extent that predisposing, enabling, and need characteristics predict service use and the provider source that veterans use for their health care needs.
Limitations
Veteran's patients may not define satisfaction as these in the non-veteran sectors because of their military experiences, expectation of care, and service deliver by the VA systems. There may be the possibility of the halo effect such as respondents' positive response bias due to respondents' research participation. The halo effect is defined as the "generalization from the perception of one outstanding personality trait to an overly favorable evaluation of the whole personality (National Quality Care, 2006), or providing positive but bias responses based on respondents' familiarity with the study or a similar situation (Speziale, 2003). Due to confidentiality and information protection restriction in the VA system, each survey respondent could not be linked to his or her service provider.
Another limitation of the present study was the use of Veterans' perceptions as an indicator for quality. As regards healthcare "Patients often don't have the technical competence to judge the quality of medical care; therefore, they rely on different criteria than do professionals in assessing quality" (Carson, Carson, and Roe, 1998, 36).
Chapter-II Literature Review
This quantitative study explored the phenomenon of veterans' perceptions and experiences towards benefits being provided to them through Veterans Administration. This chapter provides additional information to understand the theoretical framework used in the study, a review of related literature on the barriers to access benefits, and suggestion to improve these benefits and organization access. To provide a context for the expected participant themes, a review of health behavior theories used in the study is provided. As little research has been devoted to understanding Veterans perceptions toward Benefits Government being provide them, the literature review provides significant information and prior research related to difficulties Veteran face and difficulties they have to deal with in accessing the Heath care and other benefits. Based on the work of others, the researcher suspected that exploration of the research questions would uncover themes related to common barriers, such as the lack of knowledge of the new benefit, lack of accessibility to organization that assist Veterans to apply for the benefits and improvement suggestion for VA.
Theoretical Framework
As this study focuses on Veterans perception and experiences about adequacy of benefits and services offered by VA therefore the study will be based on the theory of customer satisfaction and service marketing. The evolution of servie marketing is divided into three stages. Prior to 1980, researchers discussed the need for service marketing as opposed to goods marketing. The earliest publication is dated 1953 and there were 120 publication during that time period. Literature during the following five years, 1980-1995, demonstrated the service industries need to understand customers' expectations, and interest in service marketing increased (Brown, Fisk, & Bitner, 1996; Fisk, Brown, & Bitner, 1995).
Since 1986 the service marketing field has expanded to include other avenues such as relationship marketing and service recovery. During this time 1,127 publications on service marketing were produc3d (Brown, 1996; Fisk, 1995). Since November 1992, 3,386 publications on services marketing have been produced.
Services are different from goods because:
1. They are intangible. They can not be held in their hand or seen. Products are produced and later puschased. However, a service is performed and consumed at the same time.
2. The service is easily hanged (heterogeneity). Services change with the delivery of the service. It changes based upon the customer and the way the service is performed and received.
3. Services can not be saved (perishability). Services can not be developed and put on hold. They must be used immediately (Bebko, 2000; Gronroos, 1990; Payne, 1993; Zeithaml & Bitner, 1996, 2000; Zeithaml, 1985).
Lovelock (1996) acknowledged the attributes described above. He adds the following differences to those attributes: differences due to the nature of the product, involvement of customers in production, people are part of the product, difficulty in quality control, hard to evaluate, no inventory, time factor, and distribution.
The increased research on service demonstrates acknowledgement of the importance of the service industry and understanding the needs of the customer. It further demonstrates the need to understand the unique properties which make a service different from goods. Incorporating this knowledge into corporate plans will serve as a catalyst to meet customers' expectations.
Impression Management
The study of impression management is important to an organization's success in meeting the expectation of the customer. Impression management is using behaviors to effect impressions (Becker & Martin, 1995; Bolino, 1999; Cady, 2001; Lewis & Neighbors, 2005). Tedeschi and Riess (1981) describe impression management as "any behavior by a person that has the purpose of controlling of manipulating the attributes and impressions formed of that person by others" (p.3).
Schlienker (1980) defines impression management as "the conscious or unconscious attempt to control images that are projected in real or imagined social interactions" (p.6). Providing the service customers expect will control the image that is provided to the customer.
Understanding self and impression management is presented in the seminal writings of (Burke, 1945; Goffman, 1981). The basis of the worold as a theater or stage in which everyone plays a role provides framework for the theory of impression management. Communication delivers messages based upon impressions, images, and frame work of the participants. It is a complicated system which is important to understand in order to successfully communicate.
Impression are formed by perceptions. The first step is forming positive impression is to learn what the customer/person feels is important (Dimitrius & Mazzarella, 2000)
The second step is to develop the impression as the customer receives of the organization. Schneider and Bowen (1995) state employees are impression managers because the interaction they have with the customer influences the customer's view of the service quality.
Changing actions to form a positive impression can appear manipulative. However, it can be used positively to provide information to others which would assist them (Tedeschi, Linkskold, & Rosenfeld, 1995).
Customers serach for "evidence of service" in every encounter with the company. The attitude of the service workers, the physical plant, and the process influences the impression of service. Impressions are formed by the encounter and the image the customer has of the company (Zeithaml & Bitner, 1996).
Impressions or images of businesses are built through a variety of communication techniques (Gray & Balmer, 1998). Mathukrishman and Chattopadhyay (2007) state that it is difficult to change an initial impression. Mohamad and Gardner (2004) sate "as agents of their respective organizations, employees engage in impression management on behalf and to the benefit of their employer" (p.132). Elsback and Sutton (1998) define impression management as an action "purposefully designed and carried out to influence and audience's perceptions of an organization" (p.68).
Berry and Parasuraman (1991) promote the need for image management to help the company demonstrate a positive image to a customer at the point of contact. The company must understand that the company's image is branded by the perceptions.
Perception, reputatkon, and image are important to the success of any organization. Baird (2000) states that healthcare organizations can only change their reputation through positive communication and excellent customer service.
Impressions can be managed through public relations, advertising, and training those involved. We must be aware of the company's image and make appropriate changes to instill a positive image (Bromley, 1993).
Patient Expectations
The country allocates nearly 15% of its annual production to healthcare. Therefore, healthcare is of vital interest to the entire country (Hutton & Richardson, 1995b). Baby boomers are redefining the healthcare market because they have access to information, they are assertive, and they are demanding control (Chyna, 2000; Lanser, 2003a). O'Malley (1997) states the most important customer in healthcare is the patient because he or she are the reason the healthcare institution operates.
Numerous communication devices have empowered patients to research and make decisions on their healthcare. Vast amounts of information are available about the healthcare facility, treatment choices, and service providers. Healthcare facility managers must continue to identify the expectations of the patient and use this information to improve his or her facility's care and patient satisfaction (Bevolo, 2004; Burt, 2006; Cohen, 2005; Macstravic, 2005; Vance, 2006).
Understanding customer's perceptions and expectations is paramount to providing outstanding service. Failure to meet these expectations is detrimental to business growth (Berry, 1995; Berry & Parasuraman, 1997).
Researchers have found that the physical environment is strongly linked with customer satisfaction (Hutton, & Richardson, 1995a). The environment provides a first impression of the healthcare experience and influences the customer's expectations. If patients are satisfied with the environment, they will more that likely to be satisfied with the entire healthcare experience (Fottler, Ford, Roberts, 2000).
Servie encounters, evidence of service, image, and prices are the primary factors that influence customer perceptions of service. When the customer interacts with the service firm, the most vivid impression of service occurs. Services are intangible; therefore, customers are searching for evidence of service in every interaction they have with an organization (Zeithaml & Bitner, 1996)
Zeithaml and Bitner (1996) state, "Ultimately consumers judge the quality of services on their perceptions of the technical outcome provided and on how that outcome was delivered" (p.117). "In all types of services, understanding and managing the service encounters that take place between customers and service personnel or other elements are central to creating satisfied customers who are willing to enter into long-term relationship with the service provider" (Lovelock, 1996, p.67).
Shelton (2000) found that "understanding and managing patient expectations must form the foundation on which all satisfaction enhancement efforts proceed. After all, it is the patients' ongoing process of comparing what was expected to what was received that drives their perceptions of service quality and value received" (p.3).
A review by the Picker Institute stated that patients expect good clinical outcome and are usually satisfied with the technical quality of care. However, patients are disappointed with the personal aspects of their treatment. Customers are demanding and expecting more from the organization. Consumers' expectations must be met and exceeded if organizations hope to stay competitive. The traditional model of care is being replace with a customer-focused model, which is organized around the needs of the patient. (Lanser, 2000).
Service Quality
Patient satisfaction has emerged as an important component and measure of the quality of care over the past decade. It is now a focal concern of quality assurance and an expected outcome of care. Patient service quality and quality improvement must be based on patient satisfaction data (Ford, Bach, & Fottler, 1997).
Understanding the expectations of the patient must result in implementing actions to improve service quality. Quality measure are used to quantify service quality, enhance programs, provide information on expectations, and patient satisfaction levels.
In 1950, top management and workers in Japan joined together to improve quality. W.Edwards deming began teaching quality improvement classes in Japan in 1950. Dr. Joseph M. Juran began teaching classes on management's role in quality improvement in 1954 (Deming, 1982a).
Deming (1982b) taught statistical measures to determine methods to improve quality. Charts and graphs plotting the process provide information on improvement opportunities. He established "Shewhart Cycle" for quality improvement. The four parts of the cycle are: "Plan-Do-Check-Act" (Walton, 1991, p.21). Deming (1982a) states the Shewhart Cycle is called the Deming Cycle in Japan.
Jurna (1989) established three processes to manage quality: "Quality planning, quality control, and quality improvement" (p.20). He defines quality as "product performance and freedom from deficiencies" (Jurna, 1988, p.4).
Phillip Crosby introduced the term "making quality certain." He described it as "Getting people to do better all the worthwhile things they ought to be doing anyway" (Crossby, 1979, p.3). He further states that for this to be successful the program must be built with four pillars-"management participation and attitude, professional quality management, original programs, and recognition" (Crosby, 1979, p.8).
History of Government Benefits for Veterans
The first national law, enacted in 1776 for the benefit of veterans of the American Revolution, was based on the principle of disability and granted half pay for life or during disability to persons rendered incapable of earning a living by disabilities incurred while in service. The first departure from that principle occurred shortly after in 1778, when congres voted to give half pay for limited period after the war for all officers servicing to the end of the war. That grant, which subsequently became subject of considerable controversy, was, however, intended to allay discontent and insure adherence to the revolutionary and consequently might be regarded as a special reward rather than as a relief measure (Pizzaro, Silver, & Prause, 2006).
Pension legislation for the benefit of the veterans of the War of 1812 and the war with Mexico developed along similar lines, starting with provision for the disabled and ending with service pensions for all veterans and their widows. This development was relatively show and the amount of pensioners was never large enough to pose a problem. It was the corresponding development of pension measures on a larger scale following the Civil War that brought to light the deviciencies of the nation's pension policy. This information is related to the gradual decline in the amount of aid that was given to veterans of war (Pizzaro, 2006). Following the Civil War, World War I, and World War II, relief benefits were typically predicted not upon any recognized obligation of the Government but upon the condition of the Federal Treasure; therefore, veterans were and continue to be subject to unpredictable benefits.
American involvement in World War II was at its peak in June 1944, at which time Congress passed the Servicemen's Readjustment Act, popularly known as the GI Bill. This provided veterans with the first comprehensive set of programs to help them readjust to civilian life. It also attempted to compensate for opportunities they might have missed while in the military service. Under the GI Bill, veterans could receive benefits to continue their education and supplement it with job training (Starr, 1973). Many veterans also received living allowances under this bill, in addition to tuition grants paid to the school of their choice. The bill provided employment counseling and job placement service. It also provided veterans wit guaranteed loans to help them purchase homes, farms, or business.(Starr)
History of the Veterans Administration
Medical care for veterans had its earliest origins in legislation passed in 1798 (Stevens). Merchant seamen were provided with hospital care because the United States was in need of seamen in order to man the ships necessary to trade with the rest of the world. It was vital to the interests of the United States to keep goods flowing. The merchant seamen had to be protected because without them there would not be a viable economic future for the new nation.
The original intent of the War Risk Insurance Act of 1914 (PL 63-193) was to create a mechanism to allow ship owners carrying cargo during the war in Europe to obtain insurance from the federal government. It was not until 1917 that life insurance for merchant seamen was introduced. (Stevens).
The VA hospital system as we know it today was created as a result of him pressing social and economic issues of the time (Stevens).
The seed for what would later become the Veterans Administration Hospital System can be traced back to the year 1812 when a Naval Home was established to care for disabled naval veterans in Philadelphia, Pennsylvania. Two other hospitals were later established in Washington, DC: the Soldier Home in 1853 and Saint Elizabeth's Hospital in 1855 (USDVA, VA History).
In 1989 Congress recognized the importance of veteran's healthcare policy. The VA became a Cabinet level agency and the name was changed to the Department of Veterans Affairs. The title of the Administrator also changed. He became the Under Secretary for Health. He has been the head of the Veterans Health and Research Administration, which was renamed the Veterans Health Administration (USDVA, VA History).
In the 1990s, there was consistent negative feedback from Congress and veterans about poor healthcare quality by the VHA system (Perlin, 2006a). The criticism prompted the need for revitalization of the system. At that time following the Vietnam War, there was decline in the veteran population and an increased number of aging veterans. Critics were skeptical about the future performance of the VHA (Oliver, 2007). Time for policy change in the system had emerged as Congress mounted pressure on the VHA to change its way of doing business or replaced entirely.
Characteristics of the Veterans Health Administration (VHA)
In 2004, Jim Nicholson was appointed to serve as the principal advocate for the nation's veterans. As the Secretary of Veterans Affairs, Nicholson challenged the United States citizens to remain committed to Abraham Lincoln's charge to the nation that states, "To care for him who shall have borne the battle, and for his widow and his orphan" (Veterans Health Administration, 2004). On one occasion, Nicholson advised that the nation must deliver excellent health care to the veterans and "while wars have beginnings and ends, caring for those who fought for them never ends" (Veterans Affairs, 2005). On another occasion, while admonishing the veterans and charging the VHA personnel to adhere to quality healthcare delivery, Nicholson stressed that, "Those who have served our country in uniform deserve nothing but the best that can be done; it is that simple" (Veterans Affairs, 2007).
The number of Veterans Health Administration hospitals around the nation increased from 54 in 1930 to 159 in 2006 (Veterans Health Administration, 2006). The system operates in over 1,400 sites that include 900 ambulatory care and community based outpatient clinics, 136 nursing homes, 43 residential rehabilitation facilities, 206 health care centers, 88 comprehensive home-care programs, and 23 spinal cord injury centers (Oliver, 2007).
The patient population served by the VHA is all adult and 93% male and 7% female (Veterans Health Administration, 2006). Research shows that in 2006, of 8 million veterans that enrolled for healthcare benefits, 6 million were served (Veterans Health Administration, 2007). In 2005, the VA healthcare facilities served over 57.5 million individuals in the outpatient clinics, and 587,000 in the inpatient settings.
Veterans Integrated Service Network (VISN)
In order to accomplish the organization's objectives and to meet the veterans' needs at a local level, in 1995, as the Under Secretary for Health, Kizer developed a plan to reorganize the field management structure of the VHA. The plan decentralized 4 regions, 33 networks, and 159 independent VA medical centers and replaced these with 21 Veterans Integrated Service Networks (VISNs) that report to the Under Secretary for Health (Veterans Health Administration, 2006b).
Each VISN is responsible for its own budgeting and planning of veterans' healthcare delivery within a particular geographic area, headed by a director who reports to the Chief Network Officer in the office of the Under Secretary. The budget for an individual VISN reflects the proportion of the number of VHA consumers who are served in the area that the VISN manages. For example, the state of Florida that has a higher number of retired veterans receives higher funding than other states with lower veteran populations.
Medical care for veterans had its earliest origins in legislation passed in 1798 (Stevens). Merchant seamen were provided with hospital care because the United States was in need of seamen in order to man the ships necessary to trade with the rest of the world. It was vital to the interests of the United States to keep good flowing. The merchant seamen had to be protected because without them there would not be a viable economic future for the new nation.
The original intent of the War Risk Insurance Act of 1914 (PL 63-193) was to create a mechanism to allow ship owners carrying cargo during the war in Europe to obtain insurance from the federal government. It was not unti9ll 1917 that life insurance for merchant seaman was introduced (Stevans).
The VA hospital system as we know it today was created as a result of the pressing social and economic issues of the times (Stevens).
History and Structure of the VA Service Line
"With malice toward none, with charity for all, with firmness in the right as God gives us to see the light, let us strive on to finish the work were are in; to bind up the nation's wounds; to care for him who shall have borne the battle, and for his widow and his orphan-to do all which may achieve and cherish a just and lasting peace, among ourselves, and with all nations."[footnoteRef:2]. This quote from Abraham Lincoln lay the very foundation for the Department of Veterans Affairs (VA) to be born. Today, the VA's primary mission is to give support to military members and their families who have protected our country in war and in peace. [2: March 4, 1865-Lincoln's Second Inaugural Address]
The Department of Veterans Affairs has "VA facilities in all 50 states, its territories, and the District of Columbia and provides services and benefits through 10 major business lines. The services they provide to veterans and their families are accomplished through 173 medical centers, 527 ambulatory and community based outpatient clinics, 206 veteran centers, 57 regional offices, over 24 military discharge centers, and 119 national cemeteries"[footnoteRef:3]. These medical centers that assist with the mission of the VA are constructed under VISN's, or Veterans Integrated Service Networks. [3: The VA Workface -- A Snapshot of VA Employees," Workforce and Succession Planning, Office of Human Resource Management, web page, http://vaww.va.gov/vaworkforceplanning/snapshot.htm.p.1-2]
The Service Line at the VA hospitals is usually responsible for the overall structure and organization of the hospitals. Although the Service Line may have Nurses and other medical staff than fall within the organizational structure, it does not have direct ties to patient care. It does however have a responsibility to the veteran to provide the basic amenities that care providers must utilize in order to treat the veteran's needs.
Many consider the 1944 G.I. Bill of Rights a revolutionary piece of legislation, but careful research show an evolutionary process that occurred in the United States beginning with the 1776 Revolutionary War and extending past World War 1 and New Deal legislations in the twentieth century. At the heart of this process is the war veteran's struggle for survival during the tenuous transition from civilian soldier back to a civilian again. For many, the transition proved to be difficult and lacked any governmental support. Sometimes, government benefits offered little relief too late. In other instances, benefits provided to some veterans hampered later efforts at compensation.
Each war produced veterans' organizations. The Society of the Cincinnati and Saint Tammany fraternities emerged in the Revolutionary War period. The Society aided officers and Saint Tammany assisted enlisted men.
The veteran compensation program after World War II enabled veterans to reenter society not as a burden but as viable economic assets. The educational benefits of the G.I Bill provide far-reaching social benefits that enhanced United Society. Over ten million World War II veterans who elected this provision delayed his or her reentry into the workplace, this relieving some of the stress of releasing so many veterans back into the job market.
The University of Houston's Veteran Village housed veterans seeking an education, and it eventually contained a veteran grocery store and day care facility. The multiple facilities lacked many amenities, but student veterans embraced what the university offered and amended any deficiencies with ingenuity and skill.
Overall, the 1944 G.I Bill of Rights unifies veterans' benefits. For the first time in this nation's history all veterans were treated equally and without discrimination. The education provisions in the bill gave the veteran what he or she needed most: the skills needed to advance in society. In return, the nation benefited from the experience and determination that veterans brought to University campuses.
Past United States Veterans' Benefits
Before 1950, the United States had fought four major wars: the Revolutionary War, the Civil War, World War I, and World War II. While not insignificant, the smaller amount of soldiers needed in the war of 1812, Mexican War, and the Cuban-Spanish-American War readjusted into American society with minimal disruption. (1) In contrast, the Revolutionary War harnessed some 232, 000 men out of an available pool reserve of 700,000 men of fighting age; in the Civil War, an amazing 2,213,365 (U.S. Government Printing Office, 1931) out of a possible 5,635,000 men served in the armies of the North and South combined; World War I called up about 4,000,000 out of 20,000,000 men to fight for democracy; (Wecter, 1944) and World II mobilized 16,000,000 million soldiers from the total population of 139.9 million in 1945 (Michael Bennet, 1996). Most war veterans experienced some hardships after being discharged from active duty as they confronted the various social and economic events in civilian society. Each group of veterans affected governmental policy, and governmental benefits hastened their emotional and physical return to civilian life. Historically, such benefits as pensions, healthcare, employment and education distributed by the United States government grow slowly from the Revolutionary War to World War I, but veterans' benefits after these earlier wars lay the groundwork for the vast social benefits program that the 1944 Selective Servicemen's Readjustment Act provided World War II veterans.
Treating Veterans with Care
One of the strategic tools that the VHA utilizes to improve patient satisfaction is Treating Veterans with Care process. Because the patients' concerns are important and deserve attention this study was conducted to explore their concerns.
The renovated VHA system has recently gained public recognition for patient care improvement. Some researchers describe the VHA as being the best healthcare provider in the nation (Asch, 2004; CBS Evening News, 2006; Gual, 2005; Jha, 2003; Kerr, 2004; Krugman, 2006; Longman, 2005; Oliver, 2007; Peterson, 2001; U.S. News and; Veteran Affairs, 2007; Veterans Health Administration 2006c; World Report, 2005). In 2006, the VHA received a $100,000 award for innovation in government service (Harvard University, 2006).
Studies show that VA patients receive better care including preventive and acute care than adult patient in non-VA healthcare facilities in the nation (Leslie & Rosenheck, 2003; Peterson, 2003; Pizziferri, 2005). In 2003, a study conducted by the New England Journal of Medicine used 11 measures of quality indicators to compare care in the VHA facilities with that of the fee-for-service Medicare. The study found that care in the VHA facilities was significantly better in all 11 measures of quality care (Jha, Perlin, Kizer, & Dudley, 2003).
Studies show that VA patients receive better care including preventive and acute care than adult patients in non-VA healthcare facilities in the nation (Leslie & Rosencheck, 2003; Longman, 2005).
Veterans Health Administration
The health care system provided by the Department of veterans Affairs (VA) is one of the largest public health care systems in the U.S. Its primary goal is to serve all veterans in the field of health care services. Within VA medical care system, every veteran is assigned to a health care enrollment priority group based on their compensable service-connected health condition and annual financial assessment. The Veterans' Health Care Eligibility Reform Act of 1996 established a national enrollment system to manage inpatient and outpatient care for veterans. There is no monthly premium required to use VA care for all veterans. Veterans from priority group 1 to priority group 6 are veterans who are not required to make co-payments for their VA medical care. So these veterans will have cost-free health care from VA.Group 7 veterans either have zero-rated service-connected disable conditions or have income or net worth above the statutory threshold and agree to pay specified co-payments...
The United States has the most comprehensive system of assistance for veterans of any nation in the world (VHA 1999). The mission of the VA is to provide medical care to veterans, research and education, and to serve as backup for the Department of Defense (Kizer, 1998). The Veterans Milliminum Health Care and Benefits Act (1999) require that the VA improves its healthcare system by establishing an expanded program of extended care services for veterans. The VA is required to operate and maintain extended care programs, such as VA nursing homes, home-based primary care, adult day healthcare, domiciliary care, respite care, and community-based nursing home care. In fiscal year 2000, the VA spends almost two billion dollars of its healthcare budget to provide nursing home care to veterans (GAO, 2001).
Kane, Kane and Ladd (1998) state, "The VA has a substantial capability for directly providing and purchasing long-term care for veterans who are eligible based on their service history" (51). Public Law 88-450 was enacted in 1964 for the purpose of establishing a community nursing home (CNH) program in the Veterans Administration. The CNH program is targeted at veterans making the transition from an inpatient setting to less intensive or restorative levels of care. CNH care is provided to veterans via contracts with licensed community nursing facilities meeting VA standards for high quality patient care (VHA 2004).
In April 1999, Kenneth Kizer issued a report entitled Long-Term Care within the Veterans Health Administration that recommended twenty four measures to enhance the VA's services to veterans in need of long-term care. The overall conclusion of this report was the long-term care must remain an integral part of the veterans' healthcare system.
A recent study (Stroupe, 2005) of 1375 patients, demonstrated that the odds of non-VA use decreased by 11% as satisfaction increased. If further found that as satisfaction increased, the odds of non-VA use decreased by 15% for patients 65 and older buth were not significantly lower for patients younger thatn 65.
Members of a post of the American Legion were the subjects for this study. The American Legion, chatered by Congress in 1919, is the largest veterans' service organization. It is influential in establishing care standards for veterans.
Common Problems Facing Veterans
Recent research has found that Vietnam veterans diagnosed with chronic combat related post-traumatic stress disorder (PTSD) die from high-risk behavioral causes, particularly those behaviors related to substance use, at a rate significantly greater than that of the normal population (Drescher, Rosen, Burling, & Foy, 2003). A follow-up study by Schafer (2008) found that 45% of PTSD veteran deaths were due to behavioral causes. This is striking when compared with the mortality rate of 8% due to behavioral causes in the normal population. Of particular note were those deaths from Hepatitis C (21.5% vs. 0.2%), blood diseases (1.5% vs. 0.5%), and alcohol and drug use (24% vs. 1%). An examination of these causes of death, as well as that which influences their acquisition and maintenance, suggests that the high rate of death due to behavioral causes seen in this population could be decreased with appropriate intervention.
The prevalence rates of Hepatitis C (HCV) and Human Immunodeficiency Virus (HIV) infection in the veteran population are significantly greater than that of the general population (Brau et al., 2002; Desai, Rosenheck, & Agnello, 2003). Estimates of HCV infection among veterans range from 7% - 44% (Cheung, 2000; Cheung, Hanson, Maganti, Keeffe, & Matsui, 2002; Desai et al.; Roselle, Danko, Kralovic, Simbarti, & Kizer, 2002). Estimates of HIV infection are also wide-ranging, with findings of positive HIV infection from 1.8% among treatment seeking homeless veterans (Cheung et al.) to as high as 37% among a random sample of veterans from the National Survey of Veterans (Hoff, Beam-Goulet, & Rosenheck, 1997). Despite the wide range of HCV and HIV prevalence rates, the rate of HCV and HIV infection among veterans is considerably higher than that of the normal population. In comparison, prevalence rates of HCV in the normal population are estimated to be 1.8% (Centers for Disease Control and Prevention, 2006) and 0.6% for HIV (UNICEF, n.d.). In addition, co-morbidity of the two diseases is common (Backus, Boothroyd, & Deyton, 2005; Cheung et al.). When examining veterans with PTSD, rates of HIV and HCV infection are even higher (Backus.; Hoff; Lim, Cronkite, Goldstein, & Cheung, 2006; Nguyen., 2002).
The rates of co morbidity of substance use disorders (SUDs) and PTSD among veterans is also alarmingly high, with prevalence rates for co morbid SUDs ranging from 37-92% in veterans with PTSD (Boudewyns, Albrecht, Talbert, & Hyer, 1991; Eisen, 2004; Roszell, McFall, & Malas, 1991) and co morbid PTSD rates of 46% among veterans with SUDs (McFall, Mackay, & Donovan, 1991). In fact, research has demonstrated that SUDs are the most frequently co-occurring disorders among veterans with PTSD (Faustman & White, 1989; Hryvniak, 1989). Although higher rates of alcohol abuse or dependence are found among veterans with PTSD, rates of drug abuse or dependence also remain very high (Hryvniak). Lifetime alcohol dependence rates range from 31-85% and lifetime drug dependence rates range from 4-60% (Eisen et al.; McFall, Mackay, & Donovan, 1992; Rozell et al.; Sutker, Uddo, Brailey, Vasterling, & Errera, 1994).
Significant interrelationships can be found between HCV and HIV infection and substance use disorders. Those veterans who have a history of intravenous drug use or alcohol abuse and/or dependence are at risk for acquiring HCV and HIV (Backus, 2005; Brau et al., 2002). Substance use may also serve to worsen HIV disease progression in veterans. Drinking is associated with poor virologic control, hepatic co morbidity, anemia (Conigliaro, Gordon, McGinnis, Rabeneck, & Justice, 2003), and decreased medication compliance in HIV positive veterans (Braithwaite, 2005). Those HCV positive veterans with substance use disorders or active psychiatric disorders are less likely to be eligible for treatment and experience more adverse effects resulting in premature discontinuation of treatment (Bini, 2005; Ho et al. 2001; Huckans, Blackwell, Harms, & Hauser, 2006).
Substance use has also been linked to other health risks, such as violence, suicidality, and chronic health problems in populations of veterans with PTSD (McFall et al., 1991; McFall, Fontana, Raskin, & Rosenheck, 1999; Prince, Risk, Haden, Lewis, & Spitaznagel, 2004; Tate, Norman, McQuaid, & Brown, 2007). Violence, suicide, and health problems are common causes of mortality among veterans diagnosed with PTSD with veterans with PTSD dying at higher rates from violence and suicide than the general population (suicide, 5% vs. 1%; homicide, 3% vs. 0.5%) and dying from heart disease at a rate of 20% (Schafer, 2008).
Veterans Health Problems
A substantial proportion of Gulf War veterans have reported various health problems following their service. The condition affecting Gulf War veterans appear to be complex, involves diverse symptoms associated with multiple organs and physiological systems. They present a difficult scientific and administrative challenge for federal agencies responsible for addressing them. The traditional scientific consensus in the years since the war indicated that psychiatric illness, combat experiences, or other deployment-related stressors are the likeliest reason for the Gulf War ailments. However, many veterans were unconvinced that wartime stress can adequately explain the symptoms they suffered. This is because the war only had four days of ground combat and most of the veterans were never in combat area. The Department of veterans Affairs (VA) has been under increasing pressure from veterans to de-emphasize the view that stress and trauma were chief drivers of Gulf War illness. Due to the growing complains from Gulf War veterans, the Clinton administration passed a law in 1998 to conduct an expansive research of Gulf War symptoms. In accordance with this law, Congress and VA established the Research Advisory Committee on Gulf War veterans' illness in 2002. One of the prominent findings by this federal panel is a conclusion based on recent epidemiologic studies showing that there is a "probable link" between toxic chemical exposure such as sarin gas and the mysterious ailments that struck Gulf war veterans. This conclusion departs from the past consensus and provides an essential opposite of the stress explanation for Gulf war illness.
PTSD: History and Definition
Trauma and its effects have been referred to throughout history in such works as the Iliad and the Bible (Webber, Mascari, Dubi, & Gentry, 2003). However it has only been recently that there has been a large-scale scientific study of the effects of trauma on the brain and body (van der Kolk & MacFarlane, 2007). The psychiatric history of PTSD, as opposed to trauma in general, originates in the psychological and medical treatment given to the soldiers of World War I (Joyce & Berger, 2007). The initial symptoms of mental breakdown were originally attributed to "weakness and cowardice" (Webber et al., 2003, p. 17). During World War I, these symptoms were given the names shell shock, and in World War II, combat fatigue (Joyce & Berger, 2007). It was not until 1980, however, after the recognition that many Vietnam veterans had developed symptoms similar to those experienced by victims of rape and domestic violence -- such as intrusion, and numbing -- that PTSD became an official diagnosis and was entered into the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, or DSMIII (American Psychiatric Association [APA], 1980).
Trauma and PTSD Defined
Herman (1992) defines trauma as "an affliction of the powerless" (p. 33). Trauma is an event during which the beliefs and "ordinary systems of care" (p. 33) upon which people rely become overwhelmed, rendering the individual helpless. However, whether it is natural disasters or atrocities committed by humans, experiencing trauma is an essential aspect of the human condition (van der Kolk & MacFarlane, 2007). Whatever the event, it is an individual's subjective assessment of an event that determines whether the experience becomes traumatic. Most persons exposed to a traumatic event cope well and are able to go on with their lives without becoming haunted by the memories, or other symptoms of their traumatic experience (van der Kolk & MacFarlane, 2007). This does not mean, however, that the event goes unnoticed or that these individuals have not been affected.
Immediately after a traumatic event, many individuals become preoccupied with their experience and suffer from intrusive memories, one of the symptoms that comprise the symptom picture of PTSD. Such intrusions either help an individual learn from their experience and allow them to construct "restorative actions" (i.e., accommodation) (van der Kolk & MacFarlane, 2007, p. 8), or to gradually accept what has happened and readjust their expectations. Either way, the passage of time alters the way the brain processes the traumatic information: "either it is integrated into memory and stored as an unfortunate event belonging to the past, or the sensations and emotions belonging to the event start leading a life of their own" (van der Kolk & MacFarlane, 2007, p. 8). When this occurs and the traumatic memories are not integrated into one's memory schema, and the replaying of the event leads to increasing levels of distress, alterations in physiology, anxiety, and the memories become further etched into the brain as fixed experiences, as opposed to ordinary memories which are subject to change, PTSD has developed (Solomon & Heide, 2005). Integration of these traumatic memories is therefore crucial for the health of the individual, and it is one of the core issues in the treatment of the disorder.
PTSD and OIF/OEF. The wars in Iraq and Afghanistan are distinct from the previous wars mentioned for several reasons. First, OIF/OEF is the most sustained combat operations since the Vietnam War (Litz, 2007). Second, most of the epidemiological studies of wars and veterans have been conducted years after the soldiers' return (Litz, 2007). This is not the case with OIF/OEF. Thus, one aim of research being undertaken as the war is ongoing is an increase in understanding of the risk and resilience of veterans exposed to combat (Litz, 2007). Third, 37% of OIF/OEF soldiers have been deployed multiple times. Given that it has been shown that repeated exposure to threatening events is associated with high risk of developing PTSD, this then becomes a significant fact when considering the study of PTSD. As a result, there is good reason to be concerned for the mental health of these veterans (Litz, 2007).
Hoge . (2004), in one of the earliest comprehensive studies of OIF (n = 2530) and OEF (n = 3671) veterans, conducted anonymous assessments of Army and Marine combat troops using the PTSD checklist (PCL) 1 week pre-deployment and 4 months post-deployment. The authors found that the prevalence of PTSD to be 9% pre-deployment, with post-deployment rates significantly higher at 12% for OEF troops and 18% for OIF troops. In addition, the authors found a strong correlation between combat experiences (e.g., being shot at, handling dead bodies, or knowing someone who was killed) and rate of PTSD. For example, in Iraq veterans the rate of PTSD increased linearly with the number of firefights experienced: 4.5% for no firefights, 9.3% for one to two, 12.7% for three to five, and19.3% for more than five. In another finding, of those veterans who met the criteria for PTSD, only 38% to 45% expressed interest in receiving help, with only 23% to 40% actually receiving professional help in the last year. Hoge et al. conclude by stating that concern about stigma was "disproportionately greatest" (p. 17) among those soldiers most in need of mental health services. Such findings, the authors point out, have immediate public health implications and should be addressed by the military in the form of outreach, education, and changes in the form of health care delivery.
Schell and Marshall (2008) interviewed 1,965 previously deployed OIF/OEF veterans via telephone to determine the prevalence of PTSD and to assess for utilization of mental health care. Schell and Marshall found that "significant numbers of previously deployed personnel currently suffer from PTSD and major depression" (p. 103). Nineteen percent of respondents met criteria for either PTSD or depression, and 31% met criteria for PTSD, TBI, or depression, with these latter three conditions "tending to co-occur" (Schell & Marshall, 2008, p. 96). Risk factors for PTSD included status as a member of the National Guard or reserve, female, and Hispanic ethnicity, more lengthy deployment, and more extensive combat exposure. Regarding utilization of health services, of those individuals who reported having a need for services, only 30% reported having received adequate treatment (i.e., at least eight sessions of psychotherapy or a minimal course of medication), 18% reported receiving minimally adequate psychotherapy, and 22% reported receiving a minimally adequate course of pharmacotherapy. Finally, 40% of individuals who needed care believed that seeking care could harm their career. Schell and Marshall conclude by stating that their results document "a large -- and largely unmet -- need" (2008, p. 108) for psychological care for combat veterans.
Symptom logy
A vast literature on combat trauma, crimes, rape, and imprisonment has shown that the symptoms of PTSD are phasic in nature, with periods of hyper arousal and hyper-reactivity to stimuli coexisting and alternating with avoidance and psychic numbing (van der Kolk, 1994; Keane, 1995). These responses to overwhelming and terrifying experiences are so consistent regardless of the stimuli (i.e., kind of trauma) that this biphasic reaction appears to be the most common way that traumatic symptoms manifest (van der Kolk, 1994).
Individuals with PTSD find themselves at the mercy of these symptoms as they experience an almost never-ending pattern of chronic hyper arousal to trigger stimuli, followed by emotional numbing. A stimulus, whether directly related to the trauma or not, might cause an individual to experience flashbacks, nightmares, or intrusive memories as is experienced by many soldiers with PTSD.
Homelessness
Homelessness among Military Veterans is a serious problem in the United States of America (Los Angeles Housing Services Authority, 2009). It is estimated that 400,000 veterans will experience homelessness during the course of the year (National Coalition for Homeless Veterans, 2009). Veterans are over represented in the homeless population (U.S. Conference of Mayors, 2008). In fact, one third of all homeless individuals in the United States are military veterans, 97% of these homeless veterans were males (U.S. Department of Veterans Affairs, 2009).
There is no one single risk factor that accounts for veteran homelessness. The (California Department of Veteran Affairs, 2009) reported that personal and structural factors were the reasons for veteran homelessness. The VA found that personal factors such as mental illness, substance abuse, co-occurring disorders, physical disabilities, and lack of social support increased the risk of homelessness. Structural factors such as poverty, housing, employment, certain military vocations, safety net resources, and multiple deployments to combat zones led to homelessness. Both these factors contribute to veteran homelessness (California Department of Veterans Affairs, 2009).
Many veterans who are homeless also have a major mental illness. The VA estimates that 45% of homeless veterans suffered from a mental illness (U.S. Department of Veterans Affairs (2009). This was also supported by Nyamathi et al. (2004), who reported that 48% of homeless veterans suffered from a mental illness. O'toole, Conde-Martel, Gibbon, Hanusa, and Fine (2003) found that 59% of homeless veterans reported that they needed mental health services. In addition, Dedert et al. (2009) found that mental illness was prevalent among veterans who served in combat post September 11, 2001. Goldstein, Luther, Jacoby, Haas, and Gordon (2008), however, found that there was great heterogeneity regarding the type of mental illness that the veterans reported.
Risk Factors
There is no one single risk factor that accounts for veteran homelessness. The California Department of Veteran Affairs (2009) reported that personal and structural factors were the reasons for veteran homelessness. The Veteran Affairs (VA) found that personal factors such as mental illness, substance abuse, co-occurring disorders, physical disabilities, and lack of social support increased the risk of homelessness. Structural factors such as poverty, housing, employment, certain military vocations, safety net resources, and multiple deployments to combat zones led to homelessness. Both these factors contribute to veteran homelessness (California Department of Veterans Affairs, 2009).
Research has shown that mental illness is a risk factor for homelessness. The U.S. Department of Veterans Affairs (2009) estimated that 45% of homeless veterans suffered from a mental illness. Nyamathi et al. (2004), in a sample of 331 homeless veterans, found that 48% of homeless veterans suffered from a mental illness. The most common reported illnesses were Post Traumatic Stress Disorder (PTSD) and depression.
The study found that mental illness impairs the veterans' ability to be gainfully employed or to sustain a household. This was also supported by Ramchand, Karney, Osilla, Burns, and Calderone (2008) who focused on Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) veterans. The researchers found that 19% of veterans reported experiencing symptoms of Traumatic Brain Injury (TBI) and 18.5% experienced symptoms of PTSD and depression. The veterans who suffered from TBI, PTSD, or depression reported that witnessing the death of a fellow soldier made them unproductive members in the community. The veterans reported that they could not hold a job or have a good relationship with family members. These caused them to be homeless.
Substance abuse is also a risk factor for homelessness among veterans. The U.S. Department of Veterans Affairs (2009) reported that more than 70% of homeless veterans have an alcohol and drug abuse problem. The VA (2009) found that substance abuse drained financial resources, eroded supportive social relationships, and made exiting from homelessness extremely difficult. Benda and Belcher (2006) supported these findings. Using a sample of 370 homeless veterans living in domiciliary care, the research found that 83.7% of the sample had problems with alcohol, drugs, or both. Substance abuse led them to commit crimes.
Veterans with co-occurring disorder are also at high risk for homelessness. The Department of Veterans Affairs (2009) found that veterans diagnosed with mental health and substance use disorders were more likely to commit crimes that led to their incarceration and eventually their homelessness. Benda, Rodell, and Rodell (2003) also focused on veterans with co-occurring disorder. The study found that close to half of the veterans in the study committed crimes that caused them to become incarcerated and then homeless.
In addition, Veterans with physical illness are at risk of homelessness. The Department of Veterans Affairs (2009) found that 1 out of 10 homeless veterans are considered disabled and many suffer from a physical illness that impairs their ability to be gainfully employed. For veterans returning from Iraq and Afghanistan, physical illness was often caused by combat injuries (Fairweather, 2006). The study found that the most common combat injury were amputations. These amputations caused psychological distress and prevented the veterans living a normal life which involved holding a job and paying for housing.
Veterans who lack social support are at risk of homelessness. Backus (2008) found that lack of social support predisposed veterans to homelessness. The researcher reported that veterans' loss of interpersonal connections forced them to isolate themselves. The loss of friends, family, and community affiliations led to social isolation. This led them to become homeless. The author claimed that because of isolation, veterans failed to receive the needed resources and support such as money, transportation, public assistance or a room in which to live in. Social isolation also precluded veterans from receiving intangible support such as encouragement, empathy and understanding (Backus, 2008).
Veterans living in poverty are also at risk of homelessness. In a study of 27 U.S., poverty was cited as the primary cause of homelessness among veterans (U.S. Conference of Mayors, 2008). The National Alliance to End Homelessness (2007) found that veterans who were homeless receive low or no income. Even those homeless veterans who were working lacked an adequate income to pay for available housing. Fairweather (2006) found that veterans returning from OIF/OEF also faced significant problems with income and employment. The researcher found that the unemployment rate for veterans returning from Iraq and Afghanistan was 15%. The report stated that veterans with limited education found it difficult to transfer military skills into civilian work. In addition, returning veterans found that their former civilian jobs no longer existed. Certain military vocations have no comparable vocations in civilian life; for example being trained as an infantry soldier (National Coalition for Homeless Veterans, 2009). When these veterans are discharged from military service they lack the skills to be employed in civilian life. Mares and Rosenhech (2004) examined the relationship between active military service and veteran homelessness. Using a sample of 631 homeless veterans, the researchers discovered veterans' re-entry into the civilian world triggered homelessness for several reasons. The first, military occupations and training failed to transfer into civilian jobs. Additionally, the loss of free housing, food and structured life lead to veteran homelessness. Another study by Higate (2000), focusing on the transitory lifestyle of military service and homelessness, discovered that lacking a fixed residence during their military tenure accustomed veterans to homelessness. Drawing from a study of seventeen homeless veterans, the researcher found that lack of Permanent housing accounted for the lifestyle of homeless veterans (Higate, 2000).
Fairweather (2006) reported that veterans who have multiple deployments to combat zones are at high risk of homelessness. Fairweather found that veterans with multiple deployments developed mental illness at high rates. The study found that the most common mental illness developed was PTSD. Markee (2003) also suggested that veterans experience homelessness at high rates when veterans are involved in war with other countries. The researcher reported that it was evident during World War I, World War II, and the Vietnam War. Markee reported that the toll of war on mental health caused the veteran to become homeless.
Mental Illness in Operation Iraqi Freedom and Operation Enduring Freedom Veterans Over 1.6 million U.S. veterans served in combat during Operation Iraqi Freedom (OIF) or Operation Enduring Freedom (OEF), or both (Milliken, Auchterlonie, & Hoge, 2007). Research has shown that veterans in combat in Iraq and Afghanistan have a high risk of developing mental illnesses, including post-traumatic stress disorder (PTSD), major depression, and substance abuse (Hoge, Auchterlonie, & Milliken, 2006). For example, among a sample of 289,328 Iraq and Afghanistan veterans, Seal et al. (2009) reported that over one third of veterans were diagnosed with a mental illness. Of those, more than half were diagnosed with two or more mental illnesses (Seal et al., 2009). PTSD was the most common diagnosis, followed by depression (Seal et al., 2009). In another study, using a sample of 356 veterans who served in combat post-September 11, 2001, Dedert et al. (2009) found that 30% of veterans suffered from PTSD, 20% from major depressive disorder, 6% from substance misuse, and 10% from other Axis Me psychiatric disorders. Further, Ramchand et al. (2008), using a sample of 1,965 veterans, found that veterans exposed to combat zones coupled with multiple deployments to combat zones were more likely to have a mental illness.
Post-Traumatic Stress Disorder
Veterans returning from combat zones in Iraq and Afghanistan experience high rates of PTSD (Hoge et al., 2004; Tuerk, Grubaugh, Hamner, & Foa, 2009). For example, Seal et al. (2009) using a sample of 289,328 veterans found that 21.8% of veterans returning from Iraq and Afghanistan has PTSD.
Veterans suffering from PTSD experience a range of symptoms, including sleep disturbances and nightmares, emotional numbing and instability, feelings of fear and anxiety, hyper-vigilance, impaired concentration, flashbacks, and depression (American Psychiatric Association, 2000). A study using a sample of 435 OIF and OEF veterans examined the relationship between PTSD and suicide (Jakupcak et al., 2009). The researchers found that veterans with PTSD are 5.7 times greater to commit suicide than non-PTSD veterans. Denkin (2004) using data from 480 veterans examined the association between PTSD and the social and family problems that veterans face. The researcher found that PTSD impairs veterans' abilities to function in family and social life, has a debilitating effect on relationships with family and friends, and often leads to marital problems and divorce.
Depression
Depression is prevalent among veterans who served in Iraq and Afghanistan (Marx et al., 2009; Visco, 2009). For example, Marx et al. (2009), using a sample of 268 veterans, found that one third of veterans returning from Iraq and Afghanistan had depression. In another study using a sample of 200 active-duty Air Force members, Visco (2009) found that veterans with multiple deployments to combat zones suffered from depression. In fact, veterans with two or more deployments were more likely to suffer from depression.
Further, veterans who have depression are at a high risk for suicide (Zivin et al., 2007). Using data from 807,694 veterans diagnosed with depression, Zivin et al. (2007) found that 21% of the depressed veterans committed suicide. Zivin et al. (2007) also found that younger veterans returning from wars in Iraq and Afghanistan were at higher risk of suicide. Additionally, the 2008 National Survey on Drug Use and Health Report data on veterans found that veterans aged 21 to 39 were at higher risk of committing suicide (Substance Abuse and Mental Health Services Administration, 2008).
Drug Abuse
Veterans involved in OIF and OEF also have a high prevalence of substance abuse (National Coalition for Homeless Veterans, 2009; Substance Abuse and Mental Health Services Administration, [SAMHSA], 2007). For example, SAMHSA (2007) found that one third of veterans returning from Iraq and Afghanistan met the criteria for substance abuse.
Veterans exposed to combat often abuse substances and experience drag-related problems, including mental health and health problems (National Coalition for Homeless Veterans, 2009; U.S. Department of Veterans Affairs, 2009). The most common health problem caused by drug abuse was hepatitis (U.S. Department of Veterans Affairs, 2009).
Traumatic Brain Injury
Traumatic brain injury (TBI) is the signature wound of the Iraq and Afghanistan wars (Ramchand et al., 2008). The Center of Excellence for Psychological Health and Traumatic Brain Injury estimated that of the 1.8 million troops who have served in OIF and OEF, up to 360,000 veterans have experienced a TBI (U.S. Department of Defense, 2009). In another study, using a sample of 2,525 OIF and OEF veterans, Hoge et al. (2008) also found a high prevalence of TBI among veterans; one quarter of veterans from Iraq and Afghanistan had a TBI.
Veterans with a TBI often suffer from memory, information processing, attention, and concentration problems (Gironda et al., 2009). Further, the risk for PTSD is high among veterans with a TBI (Bryant, 2001; Gironda et al., 2009; Rattok, Boake, & Bontke, 1996). In addition, Bryant (2001) reported that veterans with a TBI are often unable to maintain employment and healthy family relationships.
Housing Problems
Housing is an important issue among people with mental illness who are in recovery (Walker & Seasons, 2002). It plays an important role in stabilizing the psychological well-being of persons with mental illness. Besides providing shelter and privacy, Walker and Seasons (2002) also pointed out that a house provides a space whereby the individual may establish relationships, independence, and develop self-identity. These are important factors for recovery. Ridgway and Zipple ( 1990) argued that in order for a house to be perceived as a home, it has to be congenial to the person's taste.
Traditionally, the model for housing assistance to homeless individuals with mental illness was in the form of Supportive Housing. This was an arrangement whereby individuals were placed in a residential setting according to the person's disability. It functioned with a rigid hierarchical "staff-patient" structure and standards. In the past 2 decades, however, a newer and more efficient model had been developed to assist homeless individuals with mental illness. This was Supported Housing (Parkinson, Nelson, & Horgan, 1999). This model gave individuals with mental illness the option of choosing the location of their housing in the community. In addition, this model of housing also offered a wide range of community-based treatment and support services designed to help individuals with mental illness maximize their potential for independent living in the community.
Veterans and Education
Government is also providing education benefits for Veterans. For this purpose the GI bill was introduced. Named the Service Member's Readjustment Act of 1944, it was enacted to support the returning World War II soldiers' transition from military to civilian life. Lawmakers were concerned that the returning soldiers would face high unemployment as the economy moved from wartime to peacetime production (Thelin, 2004). Returning soldiers could attend college tuition free for a maximum of 48 months. For 90 days of service, they received one year of education. In addition, they received one month of education for each month of active duty and a subsistence allowance (Thelin, 2004).
Many returning soldiers took advantage of the educational provisions of the GI Bill. By 1950, more than 16% of the veterans had pursued education under the legislation. Although the benefits were granted for the attendance at both public and private institutions, it appears that state -- funded institutions were in the best position to finance the increases in capacities necessary to accommodate the additional students.
In 1946, President Harry Truman created the Commission on Higher Education to review higher education in the United States and produce a report recommending how institutions could best serve democracy. Truman's vision included the expansion of instruction for minorities and individuals from low-income families (Thelin, 2004). The report called for a general reduction in tuition costs at public institutions as well as the development of scholarship and fellowship programs (President's Commission on Higher Education, 1947).
Veterans and Unemployment
Unemployment rates among veterans are chronically higher than among nonveterans (Savych, Klerman & Loughran, 2008; Employment Situation of Veterans, 2009). As of 2009, the unemployment rate of the youngest male veterans, those aged 18-25, was 21.6%. This is compared to 19.1% for their non-veteran counterparts (Employment Situation of Veterans, 2009). This is a difference of 2.5%. Statistical significance is debated regarding the unemployment rate of veterans as a whole compared to non-veterans of the same age cohort. Savych, Klerman & Loughran (2008) determined that since the rate of unemployment among veterans is chronically higher than that of non-veterans year-over-year, it is difficult to deny that there is a significance or trend to the higher unemployment rate. This is in contrast to the Employment Situation of Veterans (2007; 2009) which finds every other year (when data are collected), that the differences are not statistically significant. However, there are subgroups of veterans where unemployment rates have shown to be significantly higher than non-veterans groups, such as among female veterans (Foster & Vince, 2009; Walker, 2010), disabled veterans (Cohany, 1990; Madaus, Miller & Vance, 2009) and those with mental disorders such as post-traumatic stress disorder (Zatzick., 1997a; Zatzick et al., 1997b; Galovski & Lyons, 2004).
Unemployment rates also differ among veterans by age group (Employment Situation of Veterans, 2009). In 2009, in addition to an unemployment rate of 21.6% for male veterans aged 18-25, those veterans aged 26-34 had an unemployment rate of 11.2%, those aged 35-44 had an unemployment rate of 7.3%, male veterans aged 45-54 had an unemployment rate of 8.5%, those aged 55-64 had an unemployment rate of 7.2% and veterans aged 65 and over had an unemployment rate of 6.6% (Employment Situation of Veterans, 2009). This range in unemployment by age provides insight to the idea that each group has its own challenges and own needs. Understanding the relationship of participation in the program and the overall employment success of veterans of varying demographics may contribute to improving the TAP program for certain populations, making it more useful during and following transition to the civilian world. (Depending on the findings of this study, it may be determined that it would be beneficial to consider expanding services.)
In the civilian sector, research has been completed on transitional and training programs in other areas. These programs include ?Welfare-to-Work? As well as other government training programs which have reported the effects as minimal (Greenberg. 2001; Greenberg et al., 2005) and even counterintuitive, suggesting that these programs can be detrimental to some participants (Wolpert, 1990). In the Greenberg et al. studies (2001; 2005), they found that participants in the ?Welfare-to-Work? program initially attained sufficient skills to gain employment. However, those skills faded after a few years, and the long-term effects of the training deteriorated if the skills were not focused on ?human-capital. Wolpert (1990) was interested in a program that was similar to TAP. This program, the Career Transition Program (CTP), sought to prepare Air Force retirees for job and life satisfaction after retirement. However, he found that those who participated in the program reported being less satisfied after retirement than those who did not take part. He found that those who attended CTP took longer to find a job after separation, had a lower average income, and their career expectations were less likely to be met than those who did not attend.
After researching the Transition Assistance Program, it was determined that the effectiveness of TAP has not been thoroughly studied, so effectiveness of the program has not yet been established. Since its inception in 1991 via the passage of the National Defense Authorization Act for Fiscal Year 1991, the U.S. government has only attempted to study the effectiveness of the program twice, once in 1992 (U.S. Department of Labor/Veterans' Employment and Training, 2005) and in 1995 (Human Resources Research Organization/U.S. Army Research Institute for the Behavioral and Social Sciences, 1995). The Department of Labor/Veterans' Employment and Training study concluded that there is not a statistical difference between the employability of those who participated in TAP workshops and those who did not. However, they did find that participants found jobs 3-7 weeks sooner than those who did not participate. In the second study, The Human Resources Research Organization/U.S. Army Research Institute for the Behavioral and Social Sciences determined that participants stated that they felt more prepared for their job searches and were likelier to have higher earnings, but because this was a self-report study and the information could not be verified, these data are not fully reliable. In addition, Bascetta (2002) concedes that the data collected were not useful for the purpose of determining the effectiveness of TAP. Unfortunately, data collected for the study were used only for monitoring purposes, not evaluation. This is especially true of the employment aspect of the workshop.
TAP consists of a mix of both mandatory and voluntary workshops. The employment component of TAP is voluntary, and per the Current Population Survey, August 2007: Veterans Supplement, the attendance rate at the employment workshops was below 50%; therefore, there is room for improvement. If it is found that there is a significant positive statistical difference between the employment success of those who attended TAP workshops and those who did not, it may provide support to make employment workshops mandatory upon separation. It is important to increase our knowledge regarding the value of this program in order to understand the impact that the workshops may have on the employment outcome and success of soldiers once they separate from the military.
Chapter-III Research Methodology
Introduction
This chapter will discuss and outline the methodology utilized to obtain quantitative data through survey. An account of the research approach, sample development, collection of data and collection instruments and data analysis for this study is also provided.
Research Design
In order to assess the perceptions of the Veterans whether Veterans Administration providing adequate healthcare and other services and what are the experiences of the Veterans about federal benefits being providing to them and to improve situation there is a need to anticipate and understand the perceptions and experiences of the Veterans towards the benefits being provided to them.
To investigate the experiences and perceptions of the Veterans, a quantitative research design was implemented to investigate certain variables which may impact the flow from federal level to the individual veterans. The method consisted of a survey of randomly selected veterans from Missicippi and Louisiana Veterans. The survey provided the quantitative data.
Grounded Theory Research
To further investigate Veterans' experience regarding welfare and benefits being provided by the VA, grounded theory research was utilized. Grounded theory (GT) as defined by Glaser and Strauss (1967) involves conducting research that focuses on the interpretive process of the study data by analyzing the meaning of the data obtained from the respondents in the study. GT is well suited for this study because the purpose of this study is to understand what are the barriers in the accessing the health care and other facilities by Veterans.
Sample
The target population of the research study, Veterans and Retirees. 200 individuals participated in the survey of which 100 participants were from Louisiana and 100 from Mississippi. The sample population was between the age of 18 and 60, living in Louisiana and Mississippi. To obtain a statistical sample for this study with a five percent (5%) margin of error, 95% confidence level and a 50% response rate, a minimum of 200 participants were required for this survey.
To obtain a total of 200 or greater participants for this study, 2, 00 participants were randomly selected from the population. The email of the participants were loaded into a Microsoft Excel 2003 spreadsheet and a randomization formula was applied to the data resulting in one thousand (2,00) randomly selected participants. The randomly selected participants were invited to participate in an online survey. Invitation requests to participate in the survey were sent to the participants' email address.
Instrument Development
To obtain information on the variables identified, an online survey was selected as the research instrument to collect quantitative data about Veterans experience on the federal benefits being given to them through VA (Appendix A). The online survey instrument was selected because the survey was cost-effective to create and implement, and was more time efficient.
After reviewing various online survey organizations, Zoomerang.com was selected to host the online survey. Zoomerang.com provided the researcher with the ability to customize and design the survey by choosing question type, options for answering questions, colours and layout of survey. A specific link for the survey was created and given to potential respondents to quickly access the survey. Responses could be viewed in real time and the option to close or extend the availability of the survey could be selected. Lastly, the data which was collected could be viewed in graphs and charts, and filtered for additional views. Another reason why this online survey company was used for this study's research is because Zoomerang.com had been used by different researchers and the administration at this university as well as individual researchers. The researcher provided instructions on the use of this program to all the participants.
The design of a survey, whether distributed by mail or online, is important. However, because of the technical environment of online surveys, researchers recommend the following guidelines should be reviewed and incorporated in the design of online surveys (a) support by multiple browsers, (2) prevent multiple submissions by one participant, (3) present questions in a logical order, (4) allow the respondent to save responses and return to survey to complete, (5) ability to use closed and open-ended questions, and (6) provide feedback of appreciation upon completion (Andrews, Nonnecke & Preece, 2003; Kehoe & Pitkow, 1996). The online survey developed for this study incorporated these guidelines.
Design layout for online surveys range from one question per web page requiring the participant to click on a button to move to the next question, to all questions posted on one web page requiring the participant to use the right scroll bar to move to additional questions (Peytchey, et al., 2006). Peytchey, et al. (2006) conducted research comparing the one question per page online survey to all questions on one page and concluded the following:
1. The researchers found no significant difference in the time required to respond to either version.
2. However, the one thing the researchers did observe was that the participants who completed the survey with one question per page indicated in the feedback section that the survey was long and took too much time.
3. Since there was no significant difference in the amount of time required to complete the survey, the researchers determined that moving from page to page gave the participants the perception that it took too long to complete.
Based on this information, the survey for this study was a one page consisting 12 questions. Since the Veterans are characterized with a short attention span (Howe & Strauss, 2000; Elam, Stratton, & Gibson, 2007; Oblinger & Oblinger, 2005), the total number of questions on the survey was limited to twelve (12) questions.
The 1st five questions were demographic questions. The questions involved such demographics as gender, age, ethnicity, class level, living location and major. All five questions were located on one page. The participant was required to use the scroll bar to see and respond to questions six. The questions were aimed at obtaining the demographic characteristics of the sample population i.e. age, gender, department, discharge date and Grad/Rank of the Veterans. The participants were required to enter this information so as to insure the respondent was a Veteran...
The rest seven questions asked the respondents about the quality of services provided by VA as well as their perceptions about whether the funds provided to VA are being used efficiently or not. The last questions asked to the Veterans Administration do more to help you receive all your entitled military benefits?
Kaczmirek (2005) indicates that there are three (3) essential recommendations that should guide the design and the process of conducting and implementing a web survey as follows: (a) be user friendly, (b) be trustworthy and (c) be explicit. User friendly online surveys refer to the electronic component of the survey. Online surveys should be easy to access and easy to navigate, as well as, answers to questions should be easy to select or insert. The recommendation of the online survey being trustworthy involves issues such as privacy of data, and contact information for additional information about the survey. Being explicit involves providing the participants with information regarding the reason for the survey, providing clear directions about the survey and the length of time it will take the participant to complete the survey. All three (3) recommendations were incorporated in the survey and communication requesting the randomly selected Veteran's participation.
As online surveys have appeared on the web, researchers also recognized the need for principles and standards for web-based survey design and implementation (Crawford, McCabe, & Pope, 2005; Archer, 2003; Dillman & Bowker, 2002; Solomon, 2001; Dillman, Tortora & Bowker, 1999). Initially, online surveys were designed by Information Technology employees who were experienced in software programming and implementation. However, software developers have now developed programs for online organizations to provide user friendly survey programs for non-programming individuals.
Even though software programs and web sites have been created for the non-programming individual, the subject of standards is still relevant. As technology advances, the subject of standards needs to include the areas of hardware, operating systems, web browsers and now wireless fidelity (Wi-Fi) and mobile access. Therefore, web-based survey standards should fall into four categories: (a) screen design, (b) questionnaire development, (c) respondent communications, and (d) processing models (Cawford, McCabe & Pope, 2005).
Sampling Design
The researcher used purposeful sampling. This type of sampling was chosen because of the research questions that drove the study. Only veterans who have been using VA services from Louisiana and Mississippi were able to provide the in-depth answers sought. Purposeful sampling was most appropriate because it narrowly identified and selected those participants who could provide quantitative, information-rich data (Creswell, 1998). Purposeful sampling supported the intention of the study: to develop a more in-depth understanding of the benefits being provided to the Veteran. The researcher used a combination purposeful sampling approach to achieve the best result.
The researcher first used convenience sampling to identify potential participants drawn from a two states. Convenience sampling had limited generalizability to a larger population, but for an exploratory study, such as this, generalizability was not the primary concern (Mertens, 2005). To recruit participants, the researcher posted flyers in various locations frequented by veterans (VA Medical Centers, clinics, community agencies, drug stores, and houses of worship) Hundreds of emails were sent to friends and acquaintances asking if they knew of veterans eligible for the study.
Convenience sampling generated one additional participant by supporting snowball sampling. As is common with snowball sampling, the researcher asked all potential participants, identified through convenience sampling, to nominate other potential study participants. Specifically, the researcher asked for referrals to additional potential participants who fit the participation criteria and were likely to have information-rich experiences with the phenomenon (Creswell, 1998). The researcher asked potential participants to pass on the researcher's contact information to other potential participants.
Criterion sampling was applied to all potential participants through the use of an exclusion questionnaire. With criterion sampling, "it is essential that all participants experience the phenomenon being studied" (Creswell, 1998, p. 118). This sampling method identified the target group from the potential participants. Veterans living in Mississippi and Louisiana who have been using benefits being provided by the government were of interest in the study. The selected participants had the ability to answer the research questions.
Data Collection
The response objective of this research was to obtain a minimum of 100 responses which would provide a five percent (5%) margin of error at a 95% confidence level. Initially, an email invitation to participate in the survey was sent to the 150 randomly selected consumers.
Data Analysis
An online survey was selected for this study because this design provides a quantitative view of the attitudes or opinions of the Consumers. Upon closing the online survey, the data from the participants was downloaded into a Microsoft Excel spreadsheet.
The data in the spreadsheet was analyzed with statistical formulas in Excel in order to interpret the data and compare the data to other research. The analysis involved the demographic data and the responses to the questions.
Chapter-IV Findings
The purpose of this quantitative study was to explore Veterans experiences about the services and benefits being offered to them through VA. Three variables, availability, accessibility and adequacy were examined. For this purpose researcher conducted an online survey. This chapter will present a detailed discussion on survey results
Description of the Sample
The study participants were a diverse collection of individuals. They varied in age from 21 to 51 and presented a wide-range of demographics. The number of male participants was greater than the female participants. As regards service field mostly belonged to Army. Please see Table 1 to 5 for a summary of participant attributes.
Survey Question-1 what is your Gender?
First question of the survey was related to the gender of the participants. The results (Table-1) shows that majority of the participants were male (78%) and remaining 44 (22%).
While looking in details, from both Mississippi and Louisiana majority of the participants of the study were Male i.e. 83 from Mississippi and 73 from Louisiana while there. However the number of female participants from Louisiana was greater as compared to Mississippi. Similarly number of Male participants was greater from Mississippi as compared to male participants from Louisiana.
Table 1-Gender Vise Divisions of Respondents
Gender
Mississippi
Louisiana
Total
Percentage
Male
83
73
78%
Female
17
27
44
22%
Total
Survey Question-2 What category best describes your current age?
In question 2, respondent to describe to what age group they belong to. They were given five age groups. The results of the study show a diverse population regarding age. Majority belongs to the age group of 31-40 (31%) followed by 23.5% belonging to the age group above 51.
There was an almost equal percentage of the participants belonging to age group of 23-30 (21%) and 41-50 (19.5%) however the number of participants younger that 22 were only 5%.
Comparing the results of Mississippi and Louisiana, there is not any major difference as both have equal ratios as regards age group of veterans.
The results confirm that majority of the veterans are young or middle aged. The number of veterans below the age of 21 and above the age of 51 is minor.
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