Justification A_WomensHealthBarriers Survey (comments (v8))

Women Veterans Health Care Barriers Survey
OMB FORM 2900-0795

A. JUSTIFICATION

1. Explain the circumstances that make the collection of information necessary. Identify legal or administrative requirements that necessitate the collection of information.

Legal authority for this data collection is in response to the Caregivers and Veterans Omnibus Health Services Act of 2010, Public Law 111-163, Sec. 201-Women Veterans Health Care Matters, which requires VA to conduct an independent comprehensive study of the barriers to the provision of comprehensive health care for women Veterans. Women Veterans comprise one of the fastest growing subpopulations of Veterans. Today, there are more than 1.8 million living women Veterans, more than 500,000 of whom have enrolled in the VA Health Care System. Over the last decade, the number of women Veterans using VA health care has nearly doubled. VA is responding by improving access and services for women. The study will help us better understand barriers women Veterans face accessing VA care, the comprehensiveness of care, and improve our understanding of the long-term consequences of military deployment. The data collected will allow VA to plan and provide better health care for women Veterans and to support reports to Congress about the status of women Veterans’ health care.

2. Indicate how, by whom, and for what purposes the information is to be used; indicate actual use the agency has made of the information received from current collection.

This national survey is being conducted on behalf of the VHA Women’s Health Services, which is responsible for national program planning and VA health care delivery to women Veterans. The audience for this research is also comprised of clinicians, administrators and policymakers at VA sites who are responsible for the delivery and quality of VA care and women’s health care. The planned research will provide this audience with data on patterns and determinants of women Veterans’ VA health care use, and it will also allow investigators to better define components of potential interventions to improve access and quality of VA women’s health care. Collection of this data will allow these stakeholders to identify barriers to VA use, unmet need for health care, and health care delivery preferences (i.e., the features of current VA women’s health delivery model that facilitates versus hinders access to VA care). The survey results will be of interest to VHA leaders, providers and policymakers.

3. Describe whether, and to what extent, the collection of information involves the use of automated, electronic, mechanical, or other technological collection techniques or other forms of information technology, e.g. permitting electronic submission of responses, and the basis for the decision for adopting this means of collection. Also describe any consideration of using information technology to reduce burden.

We considered three methodologies for surveying participants: mail survey, phone survey and web-based survey. After comparing the relative advantages and disadvantages of these methods in terms of participants’ convenience, privacy, data validity, logistics and cost, we chose a telephone survey approach for this project. Accordingly, improved information technology will not decrease the burden on the public.

Participants will be mailed a pre-notification letter. The pre-notification letter will provide the participants several weeks’ notice that they will be contacted to participate in the survey. The letter will contain contact information for a point of contact (POC) whom they could contact to ask questions or obtain more information about the survey. A FAQ sheet will be provided as well.

The survey will be administered over the phone by highly trained, professional interviewers, employing Computer-Assisted Telephone Interviewing (CATI) software.

Use of this technology will reduce interviewing time because very little time is lost between respondents’ answers and the recording of the same. By doing so, this state-of-the-art technology reduces respondent burden and inconvenience. The CATI system allows a computer to perform a number of functions otherwise prone to error when done manually by interviewers, including:

• Providing correct question sequence;

• Automatically executing skip patterns based on prior question answers (which decreases overall burden on respondents);

• Recalling answers to prior questions and displaying the information in the text of later questions;

• Providing random rotation of specified questions or response categories (to avoid bias);

• Ensuring that questions cannot be skipped by the interviewer (i.e., an entry is made to every question, even if the entry is “no response”); and

• Rejecting invalid responses or data entries.

Survey responses from the CATI database will be converted into a Statistical Analysis System (SAS) file and analyzed using SAS on a server within the Altarum Secure Network (ASN) to ensure data quality, SAS programs will be written to perform data checks. Range and internal consistency edit checks will be performed to determine the reasonableness of the data.

4. Describe efforts to identify duplication. Show specifically why any similar information already available cannot be used or modified for use for the purposes described in Item 2 above.

We have conducted a thorough search and literature review of the research concerning women veterans and have concluded there are no other surveys of this type specifically aimed at national variations in women Veterans’ health and health care use across all military cohorts. Currently funded VA research on women Veterans targets specific health conditions or selected cohorts only. The survey will collect data for all 21 Veterans Integrated Service Networks (VISNs), supporting assessment and comparison across regions.

5. If the collection of information impacts small businesses or other small entities, describe any methods used to minimize burden.

The collection of information involves randomly selected women Veterans in their residences, not small businesses or other small entities.

We do not anticipate that any small businesses or other small entities will be impacted by the information collection.

6. Describe the consequences to Federal program or policy activities if the collection is not conducted or is conducted less frequently as well as any technical or legal obstacles to reducing burden.

If this data were not collected, the VA would not be responsive to the requirements of PL 111-163 Section 201. This is a one-time data collection via phone survey.

7. Explain any special circumstances that would cause an information collection to be conducted more often than quarterly or require respondents to prepare written responses to a collection of information in fewer than 30 days after receipt of it; submit more than an original and two copies of any document; retain records, other than health, medical, government contract, grant-in-aid, or tax records for more than three years; in connection with a statistical survey that is not designed to produce valid and reliable results that can be generalized to the universe of study and require the use of a statistical data classification that has not been reviewed and approved by OMB.

There are no such special circumstances.

8. a. If applicable, provide a copy and identify the date and page number of publication in the Federal Register of the sponsor’s notice, required by 5 CFR 1320.8(d), soliciting comments on the information collection prior to submission to OMB. Summarize public comments received in response to that notice and describe actions taken by the sponsor in responses to these comments. Specifically address comments received on cost and hour burden.

The notice of Proposed Information Collection Activity was published in the Federal Register on January 23, 2013 (Volume 78, Number 15, Page 4983). VA received 5 comments in response to this notice.

Comment On: VA-2013-VACO-0001-0001; FR Doc. #2013-01232 (1-23-2013)

1. Commenter Name: Aileen Diane Mullaney, Veteran (1-23-2013)
   Ms. Mullaney made notation of her exposure to toxins while serving. Her comment was more of
   a complaint about the government and deplorable treatment of female soldiers. VA has offered Ms. Mullaney a response with additional contact information to explore possible claims and treatment.
   

2. Commenter Name: Cacilia Kim, Sr. Staff Attorney, California Women’s Law Center
   (2-21-2013)

Ms. Kim had contacted the VHA OMB liaison January 21, 2013 to clarify what the prior Women Veterans health study was in entitled. She was in possession of a copy and wanted to be sure it was accurate. In this comment, Ms. Kim proposed the question: Is this the survey that Public Law 111-163 refers to as the “previous study.”  If so, is the methodology used in the previous study (the one attached) going to be the same methodology used to implement the current survey?  I ask because the justification you gave me for the methodology, although helpful, are very vague and I’m trying to understand in greater detail the methodology that will be used in the current survey.

VHA Response: VHA provided Ms. Kim with information regarding the National Survey of Women Veterans (NSWV), conducted from 2008-2009 and directed by Dr. Donna Washington, as the “previous study” referenced by Public Law 111-163. Ms. Kim was informed that details of the methods and findings of the NSWV study can be found in the following two articles: Washington DL, Sun S, Canning M. Creating a sampling frame for population-based veteran research: Converge and overlap of VA and non-VA databases. J Rehabil Res Dev. 2010;47(8):763-71.

Washington DL, Bean-Mayberry B, Riopelle D, Yano EM. Access to Care for Women Veterans: Delayed Healthcare and Unmet Need. J Gen Intern Med. 2011;26 (Suppl 2):655-61 (See attachment-Public Comments–ROCIS)

3. Commenter Name: Cacilia Kim, Sr. Staff Attorney, California Women’s Law Center
   (3-25-2013)

4. Commenter Name: Cacilia Kim, Sr. Staff Attorney, California Women’s Law Center
   Previous (3-25-2013) comment was refiled again on 5-25-2013.

The comments Ms. Kim provided were on behalf of a diverse, statewide coalition of individuals and organizations that work on behalf of women Veterans in California. The 13 page document offered VHA assistance and direction with categories that includes: I. Practical Utility of the Survey; II. Accuracy of Burden on Female Veterans; III; Ways to Enhance the Quality, Utility and Clarity of the Information Collected; IV. Minimize the Burden on Women Veteran Survey Participants; and V. Study Results Should Be Made Public. This document was posted by Ms. Kim on behalf of her list of colleagues:

Mary Ellen Salzano

Founder

California Statewide Collaborative for our Military and Families

Melissa Tyner

Senior Staff Attorney Homeless Veterans Project
Inner City Law Center

Elizabeth Kristen

Director, Gender Equity & LGBT Rights Program

Senior Staff Attorney

Legal Aid Society – Employment Law Center

Tara Jones

President

National Women Veterans Association of America

Amy N. Fairweather, Esq. Policy Director

Swords to Plowshares

Irene Cruz

Director

Women Veterans Strategic Alliance

Paula J. Caplan, Ph.D.

Clinical and Research Psychologist, Women’s Advocate, Veterans Advocate and Head of

The Welcome Johnny and Jane Home Project and The Welcome Johnny and Jane Home

Coalition (whenjohnnyandjanecomemarching.weebly.com) Author of triple award-winning book, When Jonny and Jane Come Marching Home: How All of Us Can Help Veterans

VHA Response: VHA provided Ms. Kim with information a broad description of the Women Veterans Healthcare Barriers Survey. VHA addressed the following topics in detail for Ms. Kim and colleagues: Survey Development; Survey Administration; Survey Data Analysis; Optimizing Care for Women Veterans: Complimentary Research Policy and Program Development. (See attachment-Public Comments–ROCIS)

5. Commenter Name: Glenna Tinney, Military Advocacy Program Coordinator, Battered Women’s Project (3-25-2013)

Ms. Tinney provided several comments on this data collection effort. These are just a few that Ms. Tinney reflects upon:

1. survey methodology and instrument as currently defined have limitations that will not provide the kind of comprehensive and specific information that is needed

2. a phone survey to landlines only will significantly limit which women veterans will be able to participate.

3. proposed survey does not have the breadth and scope to truly understand the complex and

multi-dimensional issues that impact the barriers that interfere with women veterans seeking healthcare.

4. The survey includes questions about military sexual trauma (MST), but it does not ask about other types of trauma such as domestic violence.

VHA Response: VHA provided Ms.Kinney with background information about the Caregivers and Veterans Omnibus Health Services Act of 2010 that mandates this data collection. VHA expounded on the topic of land lines; post-survey data analysis; survey instrument development; sexual assault as a potential barrier; child care support; utilization of mental healthcare; domestic violence and other forms of trauma. (See attachment-Public Comments–ROCIS)

6. Commenter Name: Lisa M. Maatz Director, Public Policy and Government Relations
   American Association of University Women (AAUW) (3-25-2013)
   Lisa Maatz submitted the comment on behalf of the more than 150,000 members and supporters of the American Association of University Women (AAUW), sharing AAUW’s comments and suggestions on the Veterans Health Administration’s proposed information collection.

   1. Needs of Sexual Assault and Harassment Victims

   2. Work/Life Balance: VA providing childcare options for eligible veterans to facilitate access to quality health care services.

   3. Inclusion of Women in Studies & Research (PTSD)

VHA Response: VHA addressed each concern for Ms. Maatz. VHA expounded on its efforts in VA and Women’s Health Services assuring the provision of healthcare support. VHA addressed each topic for the Needs of Sexual Assault and Harassment Victims; Work/Life Balance: VA providing childcare options for eligible veterans to facilitate access to quality health care services and inclusion of Women in Studies & Research (PTSD) (See attachment-Public Comments–ROCIS)

b. Describe efforts to consult with persons outside the agency to obtain their views on the availability of data, frequency of collection, clarity of instructions and recordkeeping, disclosure or reporting format, and on the data elements to be recorded, disclosed or reported. Explain any circumstances which preclude consultation every three years with representatives of those from whom information is to be obtained.

Outside consultation is conducted with the public through the 60- and 30-day Federal Register notices. This is a one-time survey.

9. Explain any decision to provide any payment or gift to respondents, other than remuneration of contractors or grantees.

No payment or gift is provided to respondents.

10. Describe any assurance of privacy to the extent permitted by law, provided to respondents and the basis for the assurance in statute, regulation, or agency policy.

Security Requirements. The HITECH Act substantially expands the scope of the HIPAA Privacy

and Security Rule by applying most of the rules’ provisions to business associates. Section

13401 of the Act requires individuals and entities acting as “business associates” of HIPAA

covered entities to comply with the HIPAA Security Rule provisions on:

• Administrative safeguards (45 C.F.R. § 164.308)

• Physical safeguards (45 C.F.R. § 164.310)

• Technical safeguards (45 C.F.R. § 164.312)

• Policies and documentation (45 C.F.R. § 164.316),

11. Provide additional justification for any questions of a sensitive nature (Information that, with a reasonable degree of medical certainty, is likely to have a serious adverse effect on an individual's mental or physical health if revealed to him or her), such as sexual behavior and attitudes, religious beliefs, and other matters that are commonly considered private; include specific uses to be made of the information, the explanation to be given to persons from whom the information is requested, and any steps to be taken to obtain their consent.

Survey respondents are asked questions concerning their utilization of mental health care and questions about unwanted sexual attention, intimidation or assault. These questions are a relatively small portion of the overall survey questionnaire. Prior to asking these specific questions, the interviewer informs the respondent of the potentially sensitive nature of the questions and explains that any question or series of questions that cause discomfort to the respondent may be skipped. This study will be conducted using only female interviewers.

12. Estimate of the hour burden of the collection of information:

a. The total number of respondents for the study is 8,400. This total is divided evenly between women who are currently using VA health care services and women who are not (i.e., 4,200 in each of the two groups). The survey questionnaire asks additional questions of the current users, taking approximately 45 minutes to administer. Respondents who are not current users receive a shorter questionnaire version taking approximately 35-40 minutes to administer. Thus the average burden is 40 minutes. The number of respondents, frequency of responses, annual hour burden, and explanation for each form is reported as follows:



VA Telephone Survey	No. of respondents	x No. of responses	Equals	x No. of minutes	Equals	÷	Number of Hours
						by 60=
Script	8,400	1	8,400	40	336,000		5600



b. If this request for approval covers more than one form, provide separate hour burden estimates for each form and aggregate the hour burdens in Item 13 of OMB 83-I.

This request covers only one form/telephonic script.

c. Provide estimates of annual cost to respondents for the hour burdens for collections of information. The cost of contracting out or paying outside parties for information collection activities should not be included here. Instead, this cost should be included in Item 14.

VA does not require any additional recordkeeping. The cost to the respondents for completing these forms is $_84,000___ ($15 per hour x no. of burden hours).

13. Provide an estimate of the total annual cost burden to respondents or recordkeepers resulting from the collection of information. (Do not include the cost of any hour burden shown in Items 12 and 14).

There is no anticipated recordkeeping burden.

14. Provide estimates of total project cost to the Federal Government. Also, provide a description of the method used to estimate cost, which should include quantification of hours, operation expenses (such as equipment, overhead, printing, and support staff), and any other expense that would not have been incurred without this collection of information. Agencies also may aggregate cost estimates from Items 12, 13, and 14 in a single table.

This is a three-year project and the cost summary below reflects the entire three-year period of performance.

15. Explain the reason for any burden hour changes or adjustments reported in items 13 or 14 of the OMB form 83-1.

This is a new collection and all burden hours are considered a program increase.

16. For collections of information whose results will be published, outline plans for tabulation and publication. Address any complex analytical techniques that will be used. Provide the time schedule for the entire project, including beginning and ending dates of the collection of information, completion of report, publication dates, and other actions.

VA intends to publish a data report for the government. The contractor will produce a report of findings to the government and this report will also be summarized in a power point briefing to VA Executives. The contract for this project started in February 2012. We estimate that actual data collection will begin in late 2013, and will last approximately six months. All required reports to be delivered to the government were projected to be completed before February 2015.

17. If seeking approval to omit the expiration date for OMB approval of the information collection, explain the reasons that display would be inappropriate.

VA seeks to minimize the cost to itself of collecting, processing and using the information by not displaying the expiration date. VA seeks an exemption that waives the displaying of the expiration date on this VA Form (i.e., the survey instrument). The VA Form may be reproduced by the respondents, contractors and VA field facilities and then stocked. If VA is required to display an expiration date, it would result in unnecessary waste of existing stock of the forms. Inclusion of the expiration date would place an unnecessary burden on the respondent (since they would find it necessary to obtain a newer version, while VA would have accepted the old one).

18. Explain each exception to the certification statement identified in “Certification for Paperwork Reduction Act Submissions,” of OMB 83-I.

There are no exceptions.

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