Table 3 Matrix of barriers: themes and participant excerpts by Health Equity Implementation Framework element for HCV-positive, Black VA patients in the Southern USA

1)

VA patients need a medication reminder system to support adherence.

P 6: I’d forget [to take the HCV pill] because I do not take [the pill] at the same time… I wasn’t in the habit of taking it at the same time…So sometimes I would not remember if I took it…I got one of them boxes…You know how they have got the package where you punch them out. The packet does not have that.

2)

Negative clinical encounters occurred when providers did not offer HCV treatment, follow up on results of bloodwork, or explain rationale for decision regarding HCV treatment.

P 1: (from a VA patient who had not received HCV treatment, but tested positive at a recent appointment) [My VA provider] did tell me about this new drug…they had been advertising it on T.V. She asked if I had seen that commercial on T.V. about the drug they are using on Hepatitis C…I said, yes. She said do not believe it because it does not work…why would they advertise something like this on television if it does not work? Why would a doctor say something like this? It made me feel disgruntled…Because I am hearing this and they are saying it cures Hepatitis C in a pill form, and then when I talked to her...She told me something totally different...She could have explained it to me why it does not work, you know.

3)

VA patients lack knowledge of HCV symptoms.

P 4: (When asked what the VA could do to improve HCV treatment) Well, I would like to know exactly what is Hep C and what are the symptoms.

4)

VA patients reported transportation barriers to HCV treatment.

P 10: I think [the VA] should pick people up at their house instead of having them meet at a place because like right now I do not have no transportation and the bus leaves at six o’clock in the morning so I have to get a ride from somebody around five o’clock…I do not like bothering people that time of the morning, you know.

5)

VA patients question trust in some providers.

P 5: I go to the VA doctor, and I guess they know best. I mean, they always want what is best for you, right?

P 6: [I would have a problem] maybe trusting the VA doctors. I guess they really do not treat Veterans like they should and I am just disappointed. I do not know.

6)

VA patients reported some VA providers lacked expertise about HCV treatment.

P 11: They need some more specialist. My Hepatitis C, they should have treated that. [The new HCV treatment] was free, but it just took so long. I had to go through all this red tape because it was so confusing, not just to me but it was confusing to them too. That’s why I say they have got to be better trained, you know.

7)

VA patients reported some VA providers appear to have racial biases.

P 7: Now there was a doctor…he mentioned treatment about Hepatitis C, but he told me if I smoked marijuana I could not get it. I just thought it was old, mean man that did not like the fact that I smoke marijuana…I wasn’t sure that he was going to try to get me treatment for it anyway…I take responsibility for [smoking]…I do not want to make him seem like a bad seller…even though I do not think what he was telling me was right…I have got mixed feelings about it… with all due respect, he’s an old white man and I am down here in the South and I have reservations about that. Not that I do not have trust for the older ones… I just got that impression about this old guy… because I am in the racial South, and if I can remember correctly, he did not really touch me. He just talked to me, and he was kind of grouchy…it’s like he had an attitude, and it could have been some stress from his working. I really do not know, but an old, white man from down here in the South I can easily get the impression that he do not give two cents about black men down here or anywhere. Now that might just be my prejudice, but I do not think so.

8)

VA patients reported stories about lack of follow-up to VA patient after VA patient tested positive for HCV.

P 1: What’s hard is the doctors in [the VA medical center] had never started the treatment, you know, sent it to the [community based outpatient clinic] here…She knew I had this here. I did have bloodwork. Why has not my treatment appeared that you said you were going to prescribe for me? Why have not they come to the clinic yet, and why have not I been told about it?

9)

Negative testimonials from family/friends about racial discrimination at VA made VA patients hesitant to go to VA or trust providers.

P 6: [VA doctors] do not concern themselves with things that are important because they treat you just like I have seen in the black community most people will not go to the VA for medical reasons not because the doctors do not know what they are doing because they are not going to get the service they’ll get at a private practitioner. Well, with the blacks there is a lack of trust because most everybody they know – my dad, he was a World War II Veteran, and they treated him like, you know, like he was nothing. I remember how he was treated…I had not gone to the VA clinic for anything…[because of] I have seen the way they treated him.

10)

Negative VA experiences are generalized to all VA care.

P 6: [The VA provider just sits] down in there and look at your chart. She asks you about your medicines…asks about the doses. She do not check and see if your condition has changed…if you say, oh, it still hurts, she’s going to increase the medicine. They just write a prescription and you can go...I got a cough. They do not look down your throat to see what it is causing the problem…I can be taking Benadryl for a cough and have throat cancer. The services at the VA is piss poor.

11)

VA patients reported there was not enough HCV treatment at local community-based outpatient clinics and they had to travel to larger VA medical centers.

P 6: They should not make appointments that you have to go out of town for…how can you give me a consult to go to [another state] when I can barely get to the clinic here? They need to do something with upgrading the infrastructure here.

12)

HCV stigma in society made VA patients less likely to reach out to share recovery story or get support in obtaining treatment (e.g., transportation).

P 8: I did not tell anybody and nobody asked [about me getting HCV treatment]. I keep to myself. I am not an outgoing person. People like to talk too much…people form opinions about things. ‘He must have been shooting dope or he must be messing with whatever.’ I keep things to myself so that way I will not have that stigma about how I got [HCV].

13)

VA patients reported there are not enough HCV educational materials circulating, especially in rural areas.

P 1: Now, [media] should be something they should do something about. They should advertise that. Let more people know about [HCV]. Is it a disease? they have done a lot about the Zika virus. let us do something about [HCV]… publications, news, radio…However they can get it across to the people and make them aware of this.

P 8: To be honest with you, recently, I am just understanding what Hep C really is…I always felt Hepatitis C was someone using a utensil or something that wasn’t clean or a blood transfusion. Previously, that’s where I felt Hepatitis came from…I wasn’t really aware…I grew up in a rural area. Drugs were not relevant there.