Satisfaction of the Use of Telehealth and Access to Care for Veterans During the COVID-19 Pandemic

Introduction

In March of 2020, the World Health Organization declared COVID-19 a pandemic. In the weeks that followed, measures aimed at reducing the spread of the virus (such as quarantining and social distancing) became the norm across the globe.¹ In response, many health care providers shifted to the use of telehealth service to continue to provide care at a distance, while minimizing the spread of COVID-19.²

Telehealth refers to the use of information and communication technology (such as telephones, videoconferencing, Web-based applications, and more) to provide health care services to individuals.³ While telehealth has been available as a means for providing care for years, its use has been somewhat limited in the past.^4,5 However, some studies did demonstrate an increase in the use of telehealth in recent years before the pandemic.^4,6 Telehealth offers several advantages, including lower cost, convenience, and more access for people traditionally limited due to distance or disability.¹ As a result, telehealth has historically been used as a means of providing cost-effective health care where access may be limited, such as with people who reside in rural communities.^3,6 In the United States, certain policies (such as authorizing reimbursements for telehealth services, improving broadband access to underserved communities, and more) have been implemented to make it easier to adopt telehealth services.^2,7 While these changes are aimed at making telehealth more widely available, challenges have remained in the perception and acceptance of telehealth care.

One such population that could greatly benefit from the use and availability of telehealth services is those who have served in the U.S. military. In 2010, Tuerk et al.,⁸ called for the expansion of telehealth medicine in the Veterans Health Administration. Authors argued that the Department of Veterans Affairs (VA) offered an ideal environment for telehealth intervention and research. While telehealth services within the VA have expanded, several limitations must be noted. Little is known about the perceived satisfaction of telehealth care in the general veteran population. The majority of research available is limited to specific programs or populations of veterans (i.e., aging or rural Veterans).^9,10 In addition, many Veterans, particularly those who are younger, choose to receive care outside of the VA or are not eligible for VA care. Research must examine the use of telehealth care beyond care provided within the VA. The forced shift to telehealth care services as a result of the pandemic exposed many veterans to the use of this type of care and thus provides a unique opportunity for examining perceptions of that care in the Veteran population.

Veterans represent a population that may be particularly vulnerable to the impacts of the pandemic. Because of the military’s role (to fight and win wars), Veterans are at increased risk of developing physical¹¹ and mental health¹² challenges that require. These include musculoskeletal injuries^13,14 (e.g., back and knee pain), obesity,¹⁵ traumatic brain injuries,¹⁶ posttraumatic stress disorder,^12,17 depression,¹² and more. Furthermore, current research suggests that traumatic stress is associated with changes in the immune system,¹⁸ which contribute to risk of severe infections¹⁹ and physical illnesses.²⁰ Due to this increased risk of infection, and risk of medical comorbidities, Veterans may be particularly vulnerable to infection and may benefit from continuing to receive care through telehealth services.²¹

Despite the increased need of health care services among Veterans, prior studies have shown that many Veterans do not seek care,¹² and those that do seek care often drop out prematurely.^22,23 There are many factors that may contribute to this low rate of treatment utilization. One of the most often endorsed reasons for not seeking treatment is Veterans’ preference toward self-reliance (“I can solve this issue on my own”) over treatment, which may be rooted in military cultural beliefs, which value strength, courage, self-sufficiency, and resiliency.^24,25 Additionally, many Veterans often express concerns related to stigma (e.g., concern that others may perceive them as weak, or concern about how a diagnosis label will impact their relationships with others and career opportunities) as a barrier to treatment.^22,23,26 Furthermore, certain factors, such as clinic location, travel time, clinic hours, and previous experiences with treatment can serve as either facilitators or barriers to treatment.²⁶ For example, when Veterans find that accessing treatment is easy or convenient, they are more likely to engage in treatment and when prior experiences are positive, they may have positive beliefs about treatment, which will encourage them to continue seeking services. With regard to telehealth, issues related to privacy concerns and beliefs that it is ineffective, among many others, contribute to low utilization of such care in the general population before the pandemic.⁵ Given the recent increased use of telehealth services, the purpose of this study was to examine Veteran’s satisfaction with the use of telehealth care during the COVID-19 pandemic as well as the impact of the pandemic on access to care.

Materials and Methods

Procedures

Cross-sectional survey data from a convenience sample were used to examine the research questions around use of telehealth and access to care for Veterans during the COVID-19 pandemic. Two participant recruitment strategies were utilized for data collection. First, participants from previous research studies who agreed to future contact from the research team were invited to complete the survey. Second, Veterans receiving care at a national Veteran behavioral health organization were also invited to participate. All data were collected online through an online survey tool from the end of June 2020 through August 2020. The survey took ∼30 min to complete. All data collection procedures were approved by the [blinded for review] Institutional Review Board.

Measures

Use of telehealth

Participants were asked several questions regarding their past and current use of telehealth services. Veterans were asked to indicate whether they had used telehealth services to access physical or mental health care before the start of the pandemic and whether they were currently utilizing telehealth and for what kind of care. Participants were also asked to indicate their level of interest in using telehealth care before the pandemic.

Satisfaction with telehealth

Participants who received care through telehealth services were asked to indicate their satisfaction with such care. Six telehealth satisfaction questions were answered with response choice options of strongly disagree, disagree, agree, and strongly agree. Example of questions include “My therapist was comfortable and confident using the technology,” “I feel my experience with telehealth was valuable and helpful” and “I would recommend telehealth to a friend.” Telehealth satisfaction items can be viewed in Table 2.

Access to care

Participants were asked to indicate whether the COVID-19 pandemic had made them unable to receive any of the following services: physical health care, mental health care, physical therapy, massage therapy, medical prescriptions, acupuncture, and audiology care. Participants were asked to respond yes, no, or do not use. Only participants who utilized the service were included in the analysis.

Results

Sample

The sample consisted of 404 participants who have served in the U.S. Armed Forces. The age of participants ranged from 25 to 94 with a mean age of 54 years (standard deviation [SD] ±15.89). The sample was 64% White, 12% Black/African American, and 16% Hispanic or Latino. Over a quarter of the sample (27%) was female and 72% male. Over half the sample (58%) indicated being married and 64% had a 4-year or postgraduate degree. The majority of the sample were veterans who previously served (94%) with an average service time of 11 years (SD ±9.20). Sample characteristics are displayed in Table 1.

Telehealth Care

Before the start of the COVID-19 pandemic, 72% of veterans in the sample had never used telehealth services to access physical health care and 76% had never used telehealth services to access mental health care. Participants were asked before the pandemic, how interested they had been using telehealth to access care. For physical health care, 46% reported no interest in accessing care through telehealth with 58% reporting no interest for mental health care. Only 15% of the participants were very interested in utilizing telehealth care for either service before the pandemic.

Since the start of the COVID-19 pandemic, 62% of veterans in the sample reported they had received some type of care through telehealth services. Twenty-eight percent received physical health care, 30% mental health care, and 39% both physical and mental health care through telehealth. Those who received care through telehealth were asked to indicate their satisfaction with that care.

Overall, veterans were satisfied with the care they received through telehealth. Table 2. Eighty-six percent reported their therapist was comfortable and confident with using the technology. Veterans overwhelmingly reported feeling their experience with telehealth care was valuable and helpful (82%). Most indicated the technology was well explained (77%) and that issues were resolved quickly and easily (67%). Three-fourths reported they would use telehealth in future if coming to the office was inconvenient (75%) and would recommend telehealth to a friend (75%). There were no statistically significant differences in satisfaction with telehealth care with regard to gender, race/ethnicity, or age.

Access to Care

Participants were asked to indicate whether COVID-19 has made them unable to access certain services. Only those participants who reported using a service were included in calculations regarding access. The biggest limitation access to a service was found in those who utilize massage therapy, where 64% of those who use the service reported inability to receive this type of care. Approximately half of participates who use dental care (53%), routine checkups (50%), acupuncture (50%), and physical therapy (48%) reported no longer being able to access these services due to COVID-19. Access to audiology and hearing care was also limited, with 46% of those utilizing that service reporting barriers. Participants also reported limited access to physical health care (37%), mental health care (25%), and medical prescriptions (10%). Access to care results can be viewed in Table 3.

Discussion

Findings demonstrated a large increase in the use of telehealth services in veterans for both physical and mental health care as a result of the COVID-19 pandemic. The majority of veterans in the sample had not previously used telehealth care before the pandemic. Furthermore, only a small fraction of the sample had indicated being very interested in the use of telehealth care before March 2020.

Overall, results show positive views of telehealth care from veterans in the sample. Satisfaction in telehealth services was overwhelming, with strong majorities indicating the use was valuable that they would use telehealth again in the future and would recommend care through telehealth to a friend. A recent study on satisfaction with telehealth services in veterans who received care from the VA found similar results.²⁷ These findings are also consistent with studies examining user satisfaction with telehealth care in a variety of populations.^28–30

Findings represent a large positive shift in perceptions of the use of telehealth care in Veterans postpandemic. This shift is important as the use of telehealth care has long been viewed as an opportunity to increase access to care and overcome barriers to care in the Veteran population.⁸ This is particularly true for older, rural Veterans, who represent the major population of Veterans that use of telehealth care has been aimed toward due to their often complex medical issues and limited access to health care facilities.¹⁰ However, changing culture and perceptions around physical and mental health care in the Veteran population is a significant challenge. As the pandemic forced practitioners to alter methods of the delivery of health care, more Veterans were exposed to the use of telehealth care. Therefore, the high rates of satisfaction in this sample present an incredible opportunity for the expansion of telehealth services for veterans for all demographics, facilities, and type of care. As Veterans are a population with physical and health care needs as well as significant cultural and systematic barriers to care, the expansion of telehealth services could significantly aid in meeting the health care needs of Veterans.

While study findings demonstrated high rates of satisfaction in telehealth care in Veterans, about one-sixth of the sample indicated they were not satisfied with telehealth services. Results are limited as such expanding on the experience of this group was beyond the scope of the current study. Differences in satisfaction were not explained by demographic characteristics. Possible explanations could include preference for in-person care, difficulties with technology, or privacy concerns. Further research should examine challenges and solutions in the use of telehealth care with this group.

This research also explored barriers to services for veterans during the COVID-19 pandemic. The largest barriers were visible in types of care that could not be transitioned to telehealth services. These included massage therapy, acupuncture, physical therapy, and hearing care. These are incredibly important findings as many veterans use a number of services to support their well-being beyond that of traditional mental and physical health care. Musculoskeletal issues³¹ and hearing loss³² are the most frequent disability claims by Veterans who receive care at the VA. Results demonstrated limited access to such care for Veterans during the pandemic. It is essential when considering the health care needs of Veterans that practitioners and policy makers understand the holistic nature of the services needed by the veteran population. These results also have important implications for understanding the limitations of telehealth care in meeting all Veteran care needs.

It is important to note that despite the expansion of telehealth care, a significant portion of veterans still indicated barriers to receiving physical and mental health care. This finding indicates that more research is needed to understand what limitations are keeping veterans from accessing telehealth care and increasing awareness on the availability of such services. Findings also demonstrated significant barriers to services of dental care and routine checkups. While these services are not unique to veteran care, it will be important to reengage the veteran population in general health care. The prolonged lack of access to the aforementioned services may have had significant impacts on the well-being of the Veteran population. Working to minimize the long-term effects of this lack of access will be important to Veteran care postpandemic.

As with all research, several limitations must be acknowledged. The cross-sectional design and use of nonprobability sampling may limit the generalizability of the results, although it should be noted that the study population does closely mirror the general U.S. Veteran population. The sample was relatively small (around 400), which could also limit the representativeness of the results. Data were collected during summer 2020, a time where the pandemic’s first major wave had slowed. Additionally, different areas of the country had distinct restrictions. Both factors could influence veteran access to care.

Conclusions

Findings have important implications for the use of telehealth care in the Veteran population. Veterans in the sample were overwhelmingly satisfied with the telehealth care they received with most indicating they would use the service again in the future. The transition to telehealth care during the pandemic increased exposure to the services to many veterans. This provides a great opportunity to continue to expand telehealth care to meet the health care needs of veterans. Notably, veterans reported significant barriers to needed care that could not be provided through telehealth services, such as services that address musculoskeletal pain and hearing care. Veteran needs often expand beyond that of traditional physical and mental health care. Finally, it is important to recognize that despite the expansion of telehealth services, a significant number of Veterans still reported barriers to receiving physical and mental health care during the pandemic. Addressing these barriers, expanding the reach of telehealth services, and increasing awareness will be essential to the continued use of telehealth services in the veteran population.

Authors’ Contributions

S.K. contributed to the conception and design of the work, data collection, data analysis and interpretation, drafting of the article, revisions of the article, and final approval of the published article. W.A.R. contributed to the drafting of the article, critical revision of the article, and final approval of the published article. C.A.C. contributed to the conception and design of the work, data collection, interpretation of findings, and final approval of the published article.

Disclosure Statement

Authors have no disclosures to report.

Funding Information

The work from the article was not funded.