Abstract
Objective:
We sought to identify key areas to inform the development of Veteran-facing airborne hazard exposure communication materials.
Background:
Military personnel are commonly exposed to environmental and occupational hazards. Airborne hazard exposures may be particularly salient to Veterans because they are common, and the relationship to health concerns is often uncertain. VA offers a toolkit to help providers navigate caring for Veterans with airborne hazard exposure concerns. Veteran-facing materials, which address their concerns, are lacking.
Methods:
Five generative, qualitative focus groups with Veterans with airborne hazard exposure concerns. Focus group discussions covered information needs, how the VA should communicate about environmental exposures when the evidence is unclear, communication preferences, and how they get health information.
Results:
We identified 3 areas important to communicating with Veterans about their airborne hazard exposure concerns. (1) Veterans want personalized, transparent and comprehensive communication. (2) Veterans want to be able to act on the information with tangible next steps. (3) Diverse, multimodal communication strategies are needed to reach the range of Veterans with concerns about airborne hazard exposures.
Conclusions:
In situations of uncertainty, where robust clinical guidance is limited, Veterans want Veteran-centered, transparent, respectful communication that attends to their socially and historically rooted exposure experiences. The information they receive on airborne exposures should be actionable and delivered through a variety of modalities.
Key Words: qualitative, veterans, airborne hazards exposures, patient-centered communication, uncertainty
Military personnel are commonly exposed to environmental and occupational hazards. Approximately 45% of the over 6 million Veterans screened by the U.S. Department of Veterans Affairs (VA) report concerns about toxic exposures.1–3 The types of environmental hazards military personnel are exposed to varies depending on military occupation and deployments.4,5
Airborne hazard concerns are common, particularly for service members who deployed to the Gulf region, where many were exposed to smoke from burn pits and oil well fires, as well as sand, dust, and particulate matter.4,5 These airborne hazards may cause short-term and long-term health effects. In a review of military personnel deployed to Iraq and Afghanistan, 39%–69% reported acute respiratory illnesses during deployment, and higher rates of asthma, obstructive diagnoses and sinusitis after deployment.6 Concerns about cancer caused by exposure to airborne hazards are common, intertwined with fear,7 and were in part the impetus for the “Sergeant First Class Heath Robinson Honoring our Promise to Address Comprehensive Toxics (PACT) Act.”8 The PACT Act, enacted in 2022, is the largest health care and benefits expansion in VA in decades, and is meant to address the needs of Veterans exposed to burn pits and other toxins during their military service.1
Communicating with Veterans about how exposure to airborne hazards and burn pits may impact health and how to treat exposure-related health conditions is important.9 However, this communication can be challenging. There is typically no individual data to quantify the type or scope of environmental exposures, and even when this data exist, it is often difficult to determine if the environmental exposure has or will contribute to disease or disability.5 This uncertainty can leave Veterans and health care providers unsure of the relationship between a Veteran’s health condition and their history of exposure and how to best proceed with care.10,11 These challenges are embedded within a historical context of “institutional betrayal,” a term describing when an institution fails to protect constituents from harm.12 This has been applied to the experiences felt by many Veterans whose military exposure concerns have gone unaddressed.12
VA has engaged in multiple initiatives to overcome these challenges, including extensive efforts to provide: (1) nationwide education to health care professionals on airborne hazards and open burn pits; (2) training on how to communicate about military environmental exposures; and (3) tools to help health care professionals navigate the treatment of airborne hazard and burn-pit related respiratory diseases.13 However, materials are also needed that communicate directly to Veterans about airborne hazards and address common Veteran concerns and questions. To guide the development of Veteran-facing tools that adequately speak to military exposure concerns, we sought to identify key areas to inform Veteran-facing airborne hazard exposure materials development.
METHODS
Design
We conducted a quality improvement effort using qualitative focus groups with Veterans with concerns about airborne hazard exposures. The Focus Group Guide (Table 1) covered: information needs, how the VA should communicate about environmental exposures when the evidence is unclear, communication preferences, and how they get health information. Focus groups offer generative discussions around a topic of interest and are particularly useful for developing health education messages.14
TABLE 1.
Focus Group Guide Topics
| Topic | Questions |
|---|---|
| Information sources | Where is the first place you’d go to for information if you unexpectedly woke up feeling off?Where do you get trusted and reliable health information related to your military experiences? What gives you confidence in them? Are there any sources you are wary of? |
| Navigating airborne hazard concerns | We are creating a health information resource for Veterans who have had airborne hazard exposures to help them navigate VA health care; like a “what to expect” document -What thoughts do you have about that concept? We are still learning a lot about airborne hazards and your doctor may not have all of the answers -What would be helpful when a doctor doesn’t have an immediate answer? What has been helpful to you in navigating the VA surrounding your airborne hazard concerns? |
| Information veterans should know | What advice would you give other Veterans navigating VA for airborne hazard concerns? VA currently has a document to help providers communicate with Veterans about airborne hazard exposure. We are now making a parallel document for Veterans What should we include in that document to be able to connect with Veterans? Are there pitfalls we should avoid when preparing materials for Veterans? Eg, What are the stereotypes about Veterans seeking treatment for military environmental exposure? Next, I’d like to hear your thoughts on the preferred mode and timing of this document What types of VA information have you received in the past? What is the format/product? Eg, print, mailing, website, email How should we distribute these? |
| Other | What else should we know? What haven’t we thought about? |
Participants and Recruitment
Potential participants were identified through the national Veteran-Signals (V-Signals) survey regarding military environmental exposure care administered by the Veterans Experience Office. Veterans were sent the survey because they reported a health concern related to a military environmental exposure (documented in their electronic health record). At the time of our recruitment, May 2024 and June 2024, V-Signals had over 22,000 respondents, with over 10,000 Veterans reporting airborne hazard exposure concerns. From this subset, we contacted 157 Veterans who had responded within the past 6 months and reported they were moderately or very concerned about airborne hazard exposures; 13 of them agreed and were able to participate in one of our virtual focus groups. Recruitment began with non-White, rural and women Veterans to ensure their perspectives were included, and that the findings would be more representative of all Veterans.
Data Collection
Focus groups were recorded using Microsoft Teams, with transcription enabled. Transcripts were reviewed, cleaned, and anonymized for analysis. The first author facilitated the focus groups and wrote descriptive fieldnotes to capture participant interactions, the overall sentiment, and key takeaway points.15
Analysis
Transcripts were reviewed systematically and coded using a rapid analysis template.16 The first transcript was reviewed by 4 team members, and later transcripts by 2–3 team members. Data were organized in the coding template, which captured both general topics (current life, reflections on service, VA communications and health care experiences) and airborne hazard-specific topics (environmental exposure concerns, airborne hazard-specific concerns, sources of health information, what Veterans should know, and perceptions of the PACT Act and their experiences of care). The template had space to record a summary, quotes, and analytic memos for each topic. The templates and field notes were systematically reviewed across the focus groups. This quality improvement effort was conducted to inform the creation of materials that communicate directly to Veterans about airborne hazards and address Veteran concerns and questions. It was reviewed by the VA Bedford Healthcare System Research & Development Committee. They determined this work does not meet the definition of research.
RESULTS
We conducted 5 focus groups with 13 Veterans (Table 2), 11 of whom served after 9/11. We identified 3 areas important to communicating with Veterans about their airborne hazard exposure concerns: (1) communicate about airborne hazards in a personalized way; (2) provide Veterans with actionable information; and (3) ensure these messages reach all Veterans. Each area is further discussed below.
TABLE 2.
Focus Group Participant Demographics
| Demographic | Participants |
|---|---|
| Age | 30–39 (N=1) |
| 40–49 (N=1) | |
| 50–59 (N=7) | |
| 60–69 (N=4) | |
| Sex | Women (N= 8) |
| Men (N=5) | |
| Race | White (N=7) |
| Black (N=5) | |
| Asian (N=1) | |
| Location | Alabama, Colorado, Connecticut, Florida, Kentucky, North Carolina, South Carolina, Texas, Tennessee |
Area 1. How to Communicate With Veterans About Airborne Hazard Exposures: Personalized, Transparent and Comprehensive
A primary focus group question was how to communicate about topics where the evidence is unclear. We asked, “What information would be helpful, in this situation where doctors don’t always have immediate answers?”
The Veterans we spoke with understood this dilemma. They wanted transparent, honest information: “It should all be out there. We don’t like secrets” [White, female, 60s]. Nor did they want their concerns dismissed. One Veteran in her 50s recalled her provider discounting her exposure concerns by saying “[your] blood work is good, all of your functions are well” [Asian, female] and instead attributed to her health complaints to her age.
Veterans wanted communication that proactively broached and acknowledged their exposure concerns. They reported the challenge of raising their exposure concerns themselves because:
“We’re afraid of what people might say, because we’re a very proud people. Veterans are a very proud people, and we don’t want to be labeled… I didn’t like for people to know my business… I’m learning how to be open about my illness, about my condition. Beforehand, I was ashamed, and I didn’t want anybody to know that I would battle through those things, especially as a male.” [Black, male, 50s]
Veterans wanted their providers to ask about their unique military experiences, in the context of their lives. Simply asking about airborne exposures was insufficient: “I only got asked if I was exposed to burn pits—that’s it” [White, female, 60s]. With yet another suggesting a provider specifically ask: “What locations, what cities were you in? What did you handle?” [White, female, 50s]
Veterans understood their exposures in their geographic, social, and historic contexts. One Veteran explained: “Look at the people that have spent 10, 15, 20, 25 years on military installations and the hazards associated with those installations… you find a lot of stuff on military installations that you’re not going to find in the normal world” [White, female, 50s]. A statement that rooted exposures historically, geographically.
Another Veteran similarly noted the socially and historically embedded context of exposures: “A lot of my friends from the boat have died fairly young, and we all talk like, ‘this is kind of weird.’” [Black, male, 30s]
Veterans contextualized their military environmental exposures beyond a specific toxin:
“When I was in Iraq, our water sources were pallets of plastic bottles filled with water sitting out in the sun. 140 degrees weather and that’s what we drink the whole year…. Nobody really knows what to say…” [White, female, 60s]
While our questions were constrained to airborne hazard exposures, many responses did not specify toxins, but instead contextualized their exposures in a setting (military installations), or spoke more broadly using general terms like “stuff,” as described by the Veteran previously. This socially and historically situated understanding of health, informed how they thought about their own, current health.
After acknowledging and understanding Veterans’ concerns, they wanted to be given information on how exposures may impact their health. They were unclear how airborne hazards might manifest in themselves as an individual:
“I would be concerned with what kind of signs should I be looking for in my body. I’m not going to be paranoid, but let me know what kind of things people are experiencing so I can be paying a little more attention to it.” [Black, male, 50s]
Across the focus groups, Veterans shared their desire to understand what symptoms to watch for: “Tell me some symptoms I should be looking out for. Like headaches, dizziness, nosebleeds?” [Black, male, 30s]. Another Veteran similarly remarked, “What kind of exposure are you looking for?… Because I was in so many years ago, does this really pertain to me? Who knows? I don’t know.” [White, female, 60s]
Veterans wanted information about exposures and risks, given in a personalized way, instead of a checklist or form being read to them:
“The most important thing is that… you’re not getting read right from a book…I want somebody to personalize a response to me where they sit here and they take me as person…” [White, male, 60s]
Area 2. What to Communicate to Veterans About Airborne Hazard Exposures: Provide Tangible Next Steps
Veterans shared they wanted clear communication and guidance about actions they should follow to address airborne hazard exposure concerns. Veterans wanted conversations about exposure concerns paired with tangible next steps: “I registered in the registry. I had the testing done. Now what? Am I just supposed to sit around and wait for symptoms to manifest?” [White, female, 50s] While another noted the divergence between having information about exposures, but no follow-up action: “I know of it from the newsletter, so the communication is there, but the execution is not there.” [Asian, female, 50s]
Because of the complexities of bridging personal health while navigating health care and benefits systems, Veterans wanted an advocate or support person to help guide them: “I’d like to get a professional involved and have them help direct me as to where I think where they think I should go.” [White, male, 60s]
Veterans also described wanting their overall health addressed with holistic approaches to counterbalance their military exposures. One Veteran described an experience that made her feel fully cared for:
“Normally, you get a doctor at the VA and they tell you, OK, you have to take… anxiety pills. You have to take all these medications. Painkiller for aches and pains. But they have really come a long way and now they have holistic approaches with meditation, yoga. There are several other things. Acupuncture, which they didn’t have originally and chiropractic treatment.” [White, female, 60s]
Notably, This Veteran Links a Broader Array of Veterans Affairs Treatment Modalities to Her Improved Health.
In addition, the Veterans we spoke with were interested in being made aware of what next steps in research the VA was doing to address military exposures:
“Just put out, ‘This is what we’re researching,’ not necessarily results if there’s not accurate data. But just to say, ‘This is what we’re doing, what we’re researching.’” [White, male, 40s]
Veterans understood that the research was ongoing. This Veteran went on to describe how he does research for his wife’s more well-understood medical conditions, lamenting that for airborne hazard exposures, he wanted to, “…find something that’s an actual semischolarly article.” Further, they wanted to not only know about ongoing studies, but ones they could participate in, as appropriate.
Area 3: Ways to Reach Veterans With Information to Address Concerns About Airborne Exposures
To better understand how to reach Veterans, we asked where focus group participants got their health information. Many were already highly engaged with VA products such as VA websites, listservs and digital tools like VA’s patient portal, and texting software. In addition, they used a range of non-VA sources from Google to PubMed, the Mayo Clinic and WebMD, as well as family members, especially when those family members were nurses or doctors.
Veterans welcomed the prospect of Veteran-facing materials about airborne hazard exposures. For Veteran-facing tools, they suggested it look different from existing provider-facing tools and in contrast to other VA websites so that it was easier to navigate. One focus group participant described frustration looking through VA websites, especially trying to retrieve information they had previously found:
“I get frustrated, because it’s not very intuitive. So, if you don’t make it, if it’s more than 3 clicks, people don’t want to have to go digging too far.” [White, female, 50s]
Focus group participants further noted VA communications reach limited audiences, particularly with information about airborne hazards: “I can’t remember ever seeing an advertisement for the VA, to be honest with you. Like an honest radio or television advertisement” [White, male, 40s], a statement met with strong agreement among other focus group participants.
Veterans reported a range of ways VA could reach other Veterans with airborne exposure concerns, from VA websites, the patient portal, to direct mail, to email, and social media. In-person strategies were also suggested, such as, “Local VA offices, the community areas, the VFW, the American Legion, the county state Veterans Service Officer” [White, female, 50s]. A diversity of community options were suggested ranging from “churches, town hall, city halls… Just common places that really everyone goes” [Black, male, 30s]. Participants also suggested places with higher rates of Veterans, like shooting ranges, or military retail establishments [commissary, BX (base exchange) PX (post exchange), pharmacies].
Focus group participants explained how to reach Veterans would vary, especially by Veteran’s age. One Veteran described how she and her older, military spouse differ: “If he gets it in [the mail] and it says ‘VA,’ he’ll make sure he opens it. He takes his time to read through it, everything” [White, female, 50s]. She went on to say that, “Our young population is drawn in by their eyes first” [White, female, 50s], suggesting that social media, which is heavy on graphics, would be better than receiving a letter in the mail. Another focus group similarly described that, “The problem is, like [White, male, 40s] said, it’s all geared toward older veterans, and we [younger veterans] are kind of forgotten in a sense” [Black, male, 30s].
Veterans felt any communication strategy used should be paired and complementary. For example, a paper mailer needed to be paired with a digital one, like an email or website. Further, the strategy should be multiplicative:
“You’ve gotta do social media campaigns, television advertisements, radio. [You] can’t expect people to come to you. You’ve gotta find them and let them know what’s going on and tell them, ‘Hey the military did something to you that we wanna help you understand.’” [White, male, 40s]
And finally, Veterans suggested modeling a communications campaign on others:
“I don’t know if you guys have seen them yet, but the American Legion has been doing Facebook ads and they have completely rebranded themselves. They’re really focusing towards the youth. They’re doing like skits and what not.” [White, male, 40s]
CONCLUSIONS
Through focus groups with geographically and demographically diverse Veterans, we identified 3 areas important to communicating about airborne hazard exposure concerns. First, Veterans want open, personalized, comprehensive communication. The Veterans we spoke with emphasized the importance of transparent, individualized conversations. Second, Veterans want to be able to act on the information. They want clear, tangible next steps to address their concerns and to know the steps the VA is taking to advance their understanding of military exposures through research. Third, diverse, multimodal strategies are needed to reach the range of Veterans with concerns about airborne hazard exposures.
Historically, Veterans have felt betrayed by VA for not addressing exposure concerns more proactively, especially as it relates to believing Veterans about Gulf War Illness or responding to Agent Orange exposures in Vietnam.12,17 Providers who care for Veterans with military exposures are instructed to display empathy, establish trust, listen and partner with the Veteran.18 These qualities are characteristic of patient-centered communication.19
Patient-centered communication that attends to patients’ needs and preferences may be particularly important for Veterans with airborne hazard exposure concerns, as it is still difficult to ascertain risk based on airborne hazard exposure. Honestly communicating about this uncertainty and seeking to develop a shared understanding of the risk from exposures may be necessary to facilitate trust.20–22 Thus, a patient-centered strategy that validates what they are experiencing, and responding with clear, honest communication is critical to communicating about airborne hazard exposure concerns.23
The Veterans we spoke with wanted a Veteran-facing tool with personalized questions, which is a core feature of patient-centered communication.19 Having personalized information can help Veterans understand what symptoms to look for in themselves, anchored in their military experiences. Veterans bring their own history and experiences into their interactions at VA. Their current health is part of their lifeworld, their experiences of events and problems contextually grounded in their lives.24,25 Patients used their life histories and military service experiences—evidence from their lifeworld—to understand their airborne hazard exposures.26 Moreover, Veterans viewed their exposures through the lens of their military experience, and not in a clinically focused way. It is not uncommon for patients to contextualize their illness experiences within their social and life contexts.27 Asking about their personal histories can help bridge patients’ experiential evidence and evidence-based care. When providers integrate contextual information about patients’ lives, the care and outcomes are better.28
Veterans we spoke with understood that evidence related to airborne exposures was accumulating, and research findings were not static. They understood that research about diagnosing and treating airborne hazards is ongoing; they wanted to be kept updated on what was known. Like all people, Veterans wanted to be treated respectfully; like someone with the capacity to understand health research. Because they understood that VA does not yet have all of the answers, they were interested in both knowing what research VA is conducting and contributing to that research, as appropriate.29
Our findings should be interpreted in the context of the study sample. We spoke with 5 focus groups comprised of 13 Veterans engaged in VA care, in the Fall of 2024. We strategically started recruitment with women and Veterans from minoritized groups to ensure they were included in our sample, and that any subsequent Veteran-facing tool was attuned to the needs of all Veterans. We quickly met our recruiting goal, postulating that these Veterans, in particular, wanted an opportunity for someone to listen to their airborne hazard exposure concerns, unlike the experience of the Veteran in our data who reported her provider dismissing her concerns and instead attributed her symptoms to her age. Moreover, the Veterans we spoke with may be more engaged in VA because they responded to both the V-Signals survey and our invitation to participate in a focus group.
The goal of this quality improvement effort was to understand the communication needs of Veterans with airborne hazard concerns to inform the development of Veteran-facing communication tools for the VA. Veterans were purposely chosen who were seeking care in the VA, and had concerns about military environmental exposure concerns to inform the creation of Veteran-facing tools for the VA. It is not known if the results are generalizable to other Veteran and non-Veteran populations or communication about environmental exposures in other settings. Further, while ensuring the inclusion of women and non-White Veterans is a strength, the sample had a higher percentage of women Veterans than is seen in the total Veteran population. However, given women’s position, particularly in the military, they may be uniquely attuned to the needs of all Veterans.30,31 Further, given the high rates of attrition, it is particularly important to include women when developing Veteran-facing materials.32
Taken together, the Veterans we spoke with wanted a personalized tool that combines individualized information about themselves with information on what is known and not known about airborne hazards. They want to understand what environmental exposures meant for them as individuals and for their health. Veterans want to see reliable information from sources they can trust. Notably, Veterans trust VA to care for their toxic exposures. If VA does not provide this information, they are left in a vacuum where they are vulnerable to misinformation and potentially bad actors might fill in. This presents an opportunity for VA to proactively and transparently address Veterans’ concerns and provide accurate information. By improving attention to Veterans’ communication needs and broader lifeworlds, VA can better meet the needs of Veterans with airborne hazard concerns.
ACKNOWLEDGEMENT
The authors would like to acknowledge the Veterans who have shared their experiences to inform this work, as well as Katharine Bloeser for providing feedback on drafts.
Footnotes
This material is based upon work supported by the Department of Veterans Affairs, Veterans Health Administration, and the Airborne Hazards and Burn Pit Center of Excellence.
The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.
The authors declare no conflict of interest.
Contributor Information
Gemmae M. Fix, Email: Gemmae.Fix@va.gov.
Joshua A. Jordan, Email: joshua.jordan3@va.gov.
Sarah McDannold, Email: sarah.mcdannold@va.gov.
Marla L. Clayman, Email: marla.clayman@va.gov.
Abigail Baim-Lance, Email: abigail.baim-lance@va.gov.
Nicole L. Sullivan, Email: nicole.sullivan4@va.gov.
Katrina T. Webber, Email: katrina.webber2@va.gov.
Lisa M. McAndrew, Email: lisa.mcandrew@va.gov.
Anna M. Barker, Email: anna.barker@va.gov.
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