2\. QUESTIONNAIRE DESIGN

The 2001 National Survey of Veterans (NSV 2001) was designed to collect
information that will help the U.S. Department of Veterans Affairs (VA)
respond to many of its policy, planning, and budgetary challenges. This
survey information is crucial to the VA for program and benefit
planning. To ensure that the NSV 2001 would be useful to a large,
diverse group of stakeholders, we examined the 1992 NSV instrument and
reviewed results of the 1992 National Survey of Veterans Utilization
Study before the questionnaire design phase. (Westat conducted the
Utilization Study in 1999 to determine the data and information required
by various stakeholders within VA to manage the policies, programs, and
services that support the veteran population.) We then assessed the
feasibility of meeting those information needs and set priorities among
the needs. Finally, we integrated the results of the Utilization Study
into the design of the proposed NSV 2001 instrument and sampling
methodology. This chapter provides an overview of the 1992 NSV, presents
recommendations from the 1992 NSV Utilization Study, describes how these
findings were integrated into the NSV 2001, and details the content of
this most recent version of the NSV.

# 2.1 1992 National Survey of Veterans

The VA conducted the 1992 NSV to obtain information necessary for
planning and budgeting VA programs and services for veterans in general,
as well as for certain subgroups of veterans. It also studied
characteristics of the veteran population. The survey was designed to
collect data that would enable the VA to follow changing trends in the
veteran population, compare characteristics of veterans who use VA
programs versus those who do not, and provide a current data resource
for policy analyses. In addition, the data provided information needed
for major initiatives that have a direct effect on veterans, such as
benefit eligibility reform and health care benefit reform.

To the extent permitted by changing data needs, the 1992 NSV questions
were tailored to match questions in previous VA surveys to allow for
trend analysis. However, new information needs, new directions and
initiatives within VA, and a rapidly developing national agenda
necessitated a number

of changes to the survey. These changes were reflected in each major
stage of the instrument's development. Principal factors driving the
design changes over time were:

The need for more detailed information on veterans' health status,
medical facilities usage, and health insurance coverage;

New financial eligibility guidelines for certain VA programs;

Legislation expanding the definition of military service experience
eligible for veterans benefits; and

The need to represent certain subgroups in the veteran population
through:

-   A random cross section of the veterans drawn from a household survey
    (RDD Sample); and

-   A random sample from VA files of VA medical facilities users and
    veterans receiving compensation for service-connected disabilities
    (List Sample).

Another major factor driving the 1992 survey design was results of a
pretest showing the feasibility of collecting certain information by
telephone. This led to the decision to use a telephone survey as the
data collection method and to use computer-assisted telephone
interviewing (CATI) to conduct the interviews. The wording and structure
of the survey instrument accommodated this mode of data collection. This
mode required for instance, that questions be easy to comprehend on the
phone, that lists of choices be kept as short as possible without unduly
limiting likely responses, and that questionnaire administration time
meet a target of 45 minutes on average.

# 2.2 1992 National Survey of Veterans Utilization Study

As the primary means for generating key information for the VA's
planning process, the NSV needs to answer central questions about the
VA's "clients"--veterans of the U.S. uniformed services. These questions
include:

Who are the VA's clients?

How many veterans are eligible for VA benefits? What characteristics
make them eligible?

What are veterans' needs? How do they perceive their needs?

How do veterans act on their needs and their perceived needs?

How many eligible veterans actually use their VA benefits?

How easy is it for them to access VA services?

What are their preferences for receiving services?

How are their needs likely to change in the near term?

Westat conducted the 1992 National Survey of Veterans Utilization Study
in 1999 to identify and articulate the uses to which stakeholders both
inside and outside the VA put previous NSV results and their anticipated
information needs from a future NSV.[^1] We conducted 51 interviews with
a diverse group of 102 individuals and found that while the 1992 survey
included answers to some of the above questions, it had serious gaps and
did not provide some important information to VA planners.

One important topic covered in the interviews was use of the 1992 NSV
final report and survey data set. Of the 51 stakeholder interviews, 36
indicated at least some use of the written NSV report, while only 18
indicated any use of the database of survey responses. All 18 database
users indicated they were also users of the final report. Fifteen of
those interviewed indicated using neither the report nor the database.
Their reasons included:

The report or database was not directly relevant to their needs.

Certain subpopulations were not sufficiently represented in the data set
(e.g., female, minority, and homeless veterans).

The database was expensive to access (users had to access the database
through a link with the Austin data center).

The database was difficult to use.

Even those who reported high initial use reported less use over time
because the data were no longer current or because other, more current,
sources of information existed (e.g., hospital utilization data in other
Veterans Health Administration \[VHA\] databases).

The interviews also asked about specific topics from the 1992 NSV. None
was identified as a candidate to be excluded from a future study. Those
interviewed suggested improvements or modifications for all but one
topic area (Respondent Information). Two topic areas (Health and
Activity Limitations, and Health Insurance) were targeted for major
changes. Suggested improvements to the Health Insurance section called
for more extensive information about other types of insurance coverage
and satisfaction with various insurance policy services.

In addition to specific topics, users also made suggestions and requests
about enhancements to the survey database. Many users requested the
ability to find the residence location for persons in the sample to
support analyses of geographic distribution of veterans and access to
services. Other requests included a requirement to link survey responses
to the actual use patterns of veterans as identified in current VA
databases. The 1992 database users also strongly supported having access
to the survey database on a CD-ROM.

Both internal and external VA stakeholders requested more detailed
information on service patterns for special subpopulations to ensure
fairness of service delivery and to meet special needs. Stakeholders
wanted more information on minority, female, and homeless veterans, as
well as other special subpopulations, such as veterans exposed to Agent
Orange in Vietnam or veterans who served in the Gulf War. Others
interviewed commented on the use of different sampling strategies (e.g.,
combining a List Sample of those receiving services with an RDD Sample).

The general pattern of the interviews showed that current users of the
information would likely continue to use the results provided by another
NSV. Many persons throughout the VA indicated an interest in national
survey data if the data also addressed their specific program and
mission responsibilities. Many in the latter group offered specific
suggestions for items and for characteristics of the report or database
that would encourage their increased use.

A primary finding was strong support for a survey effort to collect data
that would allow analysts to distinguish between those veterans who do
or do not currently use VA programs. Many of those interviewed noted an
increased need for information that could be used to plan, manage, and
evaluate programs. Although many of the organizations have their own
survey efforts focused on their program offerings, all VA organizations
indicated a desire for information on veterans who do not use VA
programs as a part of their overall planning, policy, and evaluation
efforts.

Based on the 1992 NSV Utilization Study, we made several structural and
content changes to the survey instrument to address the VA's needs and
to increase the usability of the next NSV data set and report.

# 2.3 Structural and Content Revisions to the NSV

The 1992 NSV Utilization Study provided the framework for setting
priorities among topics and items for the next NSV. As the fifth
national survey in a series, it was important that the NSV 2001 address
emerging issues while maintaining comparability in some areas with past
surveys. However, to keep the questionnaire to a reasonable length, we
had to shorten or remove some topics. We chose priority topics and items
by focusing on the planning information needs identified in the
Utilization Study. We reduced the number of items used to measure
service use -- most notably in the area of health care -- and we cut
items on awareness of specific types of benefits. We also eliminated
items that did not address planning questions and items that were or
could be available from other sources.

Compared to the previous version, the NSV 2001 has a more direct focus
on nonusers. It also addresses veterans' future plans for using
education, training, and burial benefits. We added new items that assess
veterans' communication preferences. We also expanded race and ethnicity
categories to permit more accurate classification of veterans.
Additionally, we expanded the set of items that measured combat exposure
to better identify women's combat exposure and permit more detailed
projections of future health care needs.

The most significant structural change to the NSV 2001 survey is the
modular structure of the instrument. This modular approach allowed us to
collect information about multiple program usage (and nonusage) among
veterans while minimizing respondent burden by letting them skip
questions about services they had not used. Grouping the questions by
benefit area also simplified the respondents' cognitive burden by asking
them to think about only one topic at a time. In addition, the parallel
structure of the modules allowed respondents to "learn" the interview
and anticipate questions, reducing perceived respondent burden and
interview length. Questions in the new NSV include the following:

Introduction;

Military Background;

Health Background;

Benefit-specific modules:

-   Health care

-   Disability

-   Mortgage Loan

-   Life Insurance

-   Education and Training

-   Burial

    Communication; and

    Sociodemographic Information

These modules are described in detail in the following paragraphs. The
NSV 2001 extended questionnaire (with CATI programming specifications)
appears in Appendix C.

**Introduction.** The Introduction module identified Westat as the data
collection contractor and named the study sponsor (U.S. Department of
Veterans Affairs). Here we outlined the general study objective,
informed the respondent that participation was voluntary, and provided
the respondent an option to receive the Privacy Act Statement. The
Introduction module disclosed U.S. Office of Management and Budget (OMB)
clearance, provided the study's OMB clearance number, and provided VA
contact and address information.

**Military Background.** This module collected respondent gender and
date of birth, along with information on military service, including
component (reserves or active), branch of service, active duty start and
release dates, service era, type of discharge, geographic locations of
service, and combat and other military experiences (exposure to
hazards/agents, prisoner of war). This module was used to establish the
basis of veteran eligibility (e.g., type of service, length of service,
locations) for specific veteran entitlements, services, and benefits.

The Military Background module was very similar to the Eligibility and
Description of Military Service sections of the 1992 NSV. Periods of
service were revised so as to be comparable with Census 2000, and the
set of items identifying combat exposure was expanded to ensure more
accurate assessment of female veterans' combat exposure and to permit
more detailed projections of future need. The items used to expand the
set of combat items were adapted from the combat intensity scale
developed and used by the U.S. Centers for Disease Control and
Prevention (CDC).

**Health Background.** The Health Background module collected general
information on health status and whether current health was a limiting
factor in performing selected daily activities (e.g., climbing stairs,
pushing a vacuum). This module included the VSF12 (a 12-item scale
providing measures of mental and physical well-being). It identified
veterans who were disabled and who had a service-connected disability,
and collected the veteran's service-connected disability rating. The
module asked veterans about the effects of their health problems on
their ability to perform daily activities (e.g., walking, bathing,
shopping, getting dressed, eating), and whether or not the veteran had
received medical treatment in the past year for a list of specific
health conditions (e.g., high blood pressure, stroke, heart trouble,
cancer, drug abuse/alcoholism, post-traumatic stress disorder). It also
collected information about the veteran's current health insurance plans
or programs, including Medicare (Part A, Part B), Medicare managed care,
HMO, Medigap/Medicare supplemental health insurance, Medicaid
(Medi-Cal), CHAMPUS, TRICARE, other government health care programs, or
private health insurance.

**Health Care.** The Health Care benefits module collected information
on the veteran's use of VA and non-VA health care services (number of
visits) within the past 12 months, including emergency room use,
outpatient care, and inpatient care (number of overnights hospitalized).
It asked how services were paid for (e.g., VA, CHAMPUS/TRICARE, HMO,
Medicare, private health insurance) and where veterans obtained their
prescription medications. This module also contained items that asked
about receipt of medical care due to exposure (while in the military) to
environmental hazards, in-home health care, prosthetics, psychological
counseling, therapy, and alcohol or drug treatment. Finally, it
collected information on reasons why the veteran did not use VA health
care benefits (within the past 12 months, or ever).

**Disability.** The Disability module applied to veterans who indicated
(in the Health Background module) that they had either a disabling
condition or a service-connected disability. It collected information on
application for disability benefits, reasons for not applying, and
status of most recent claim. It also collected information on receipt of
disability payments from the VA, including type of payment
(service-connected disability compensation, nonservice-connected
disability pension), receipt of aid and attendance or housebound
benefits, and how these payments helped in meeting financial needs.
Items in this module asked about other (non-VA) sources of monetary
disability benefits, use (or nonuse) of VA and non-VA vocational
rehabilitation services, how well the veteran understood VA disability
entitlements, and perceived ease in obtaining benefits.

**Mortgage Loan.** The Mortgage Loan module collected information on use
of VA or non-VA loan programs to purchase a home, make home
improvements, or refinance a home loan. It also asked reasons for not
using the VA home loan program.

**Life Insurance.** The Life Insurance module collected information on
VA life insurance coverage, whether the veteran was currently covered by
VA life insurance, main reasons for not using VA life insurance, and
life insurance coverage from other sources. It also asked how well the
veteran understood VA life insurance entitlements.

**Education and Training.** The Education and Training module collected
information on use or nonuse of VA and non-VA education and training
benefits. (This module did not include vocational rehabilitation
benefits, which were addressed in the Disability Module). It contained
items that asked for what purpose the VA educational benefit was used
(college/university coursework leading to a degree, correspondence
courses, flight training, teacher certification, or business, technical,
or vocational training), how important the VA educational benefits were
in meeting the veteran's educational goals or preparing the veteran for
a better job, and how likely the veteran would be to use VA educational
benefits in the future.

**Burial.** The Burial benefits module asked veterans whether they had
heard of specific burial benefit programs (VA headstones and markers,
burial in a national or state veteran's cemetery, Presidential Memorial
Certificates for next of kin). It also collected information on veteran
burial plans and preferences, reasons for wanting/not wanting to be
buried in a veteran's cemetery, whether they intended to use a
VA-provided headstone or marker, how well the veteran understood veteran
burial benefits, and how difficult the veteran thought it would be to
obtain information about veteran burial benefits.

**Communication.** The Communication module collected information on
where veterans "think they would go" to obtain information about VA
benefits. It asked how much the veteran knew about veteran benefits, how
satisfied the veteran was with the ability to get information about
veteran benefits, whether the veteran has needed any information about
benefits in the past year, and whether the veteran had access to the
Internet.

This module was a new feature of the revised NSV questionnaire. It
collected general information about respondents' recent need for VA
benefit information, preferred sources and media for VA benefit
information, Internet access, and recent Internet use.

Questions in the communication section were adapted from the 1992 NSV
and from materials used by the Centers for Medicare and Medicaid
Services (formerly known as the Health Care Financing Administration) in
its market research projects. Information in this module will help VA
researchers identify effective media for reaching users and nonusers,
and track changes in communication preferences.

**Sociodemographic Information.** The Sociodemographic Information
module collected information on employment status (working, retired,
disabled, looking for work), operation of a small business (including
Federal Employer Identification Number), race/ethnicity, education,
marital status, number of dependents, income (total combined family
income), income sources, assets, market value of primary residence,
amount of mortgage on primary residence, zip code, Social Security
number, and interest in participation in future VA studies. If the
veteran expressed an interest in participating in future surveys, his or
her full name and address were collected.

The Sociodemographic Information module is similar to several sections
of the 1992 NSV questionnaire (the Demographics and Income and the
Respondent Information sections). Several items were revised based on
discussions with VA staff and a desire to ensure comparability with
Census 2000. Taken together with the information on Military Background,
this information will be useful for:

Assessing program eligibility;

Analyzing current use;

Projecting future use;

Identifying emerging needs;

Identifying subpopulations with special needs; and

Modeling the effects of changes in program eligibility criteria.

[^1]: See 1992 National Survey of Veterans Utilization Study (Westat,
    1999), for more detailed information about study methodology and
    results.