Recent reviews of health disparities in the VA healthcare system showed that significant racial disparities persist across all sections in the VA, which affect health care costs, quality of care, patient satisfaction, and the health of veterans. Patient-provider communication has been identified as one of the key mediators for racial health disparities in physical and mental health. Yet, the views and experiences of ethnic minority veterans regarding health communications, especially in mental health, remain understudied. The lack of research in this area perpetuates a critical gap in our understanding of how ethnic minority groups understand and experience treatment decision-making. It also limits the VA's efforts to provide quality and culturally competent mental health services to ethnic minority groups, a fast growing veteran population. This study seeks to investigate the processes, facilitators, and barriers to mental health treatment decisions for African-American veterans with the goals of informing future efforts to improve mental health communication and reduce health disparities in the VA.
The specific aims of the revised study are fourfold.
In Aim 1, we will examine how African-Americans describe their understanding and process of mental health treatment decisions;and assess their preferred methods for making these decisions, which may or may not include shared decision- making.
In Aim 2, we will specifically investigate how African American veterans with mental illness define and conceptualize shared decision-making as a model of decision making.
In Aim 3, we will use mixed methods to compare how decisions are made among White (data from a previous study) and African American veterans with mental illness.
In Aim 4, we will develop preliminary models for an intervention aimed at improving shared decision-making and reducing mental health disparities among African-American veterans. To accomplish Aim 1 of the study, we will conduct qualitative interviews with 45 African- American veterans receiving outpatient psychiatric care at the Richard L. Roudebush VAMC. The interviews will focus on participants'views, experiences, and preferences for treatment decisions with their psychiatric treatment providers (prescribers: psychiatrists and nurse practitioners). To achieve Aim 2, the qualitative interview will include questions that explore participants'conceptualization of shared decision-making. To complete Aim 3, participants will complete self-report measures that assess patient-provider working alliance, attitudes towards medication, and activation. The quantitative data will help to triangulate our findings by providing systematic information on factors that affect patient provider relationship and communication. We will also compare our findings to a previous study on shared decision-making with 41 White veterans and their psychiatric treatment providers (Marianne Matthias, PI).
In Aim 4, we will collect preliminary data from the interviews to inform the design of an intervention that we will develop and assess in future studies. The qualitative data will be coded and analyzed using an inductive approach informed by grounded theory. Statistical analyses of the self-report measures will provide summaries of patient characteristics and comparative data between African-American and White veterans.

Public Health Relevance

Research studies on health disparities and shared decision-making in the VA mental health services are lacking. The proposed project is a mixed methods study that will investigate processes, facilitators, and barriers to mental health treatment decisions among 45 African- American Veterans with mental illness. It will also examine their views and experiences of shared decision-making and compare them to those of 41 White Veterans. Findings from this study will contribute to the VA's efforts to improve health communication for Veterans and reduce health disparities. The results of this study could impact African-American Veterans' mental health and the way in which clinicians attempt to engage African-American patients in mental health care decisions. This study will also fill major gaps in our understanding of the processes of shared decision-making in mental health and among minority groups.

National Institute of Health (NIH)
Veterans Affairs (VA)
Veterans Administration (I21)
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HSR-2 Determinants of Patient Response to Care (HSR2)
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Rlr VA Medical Center
United States
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