Researchers led by Andrea L. Nevedal of the VA Center for Clinical Management Research at VA Ann Arbor Healthcare System and colleagues, including senior author Donna M. Zulman of VA Palo Alto and Stanford University, interviewed 25 veterans between July and October 2024. All participants had endorsed at least one social risk, such as food insecurity or financial strain, in a national survey administered across the Department of Veterans Affairs between March and June 2024, and all had agreed to a follow-up interview. Rather than asking a simple yes-or-no question about comfort with screening, the team structured their semi-structured interviews around the Theoretical Framework of Acceptability, a rigorous model that describes seven distinct determinants of whether patients judge a health care intervention to be acceptable: affective attitude, burden, ethicality, intervention coherence, opportunity costs, perceived effectiveness, and self-efficacy. The analysis used rapid directed content analysis, an approach designed to distill themes quickly while preserving fidelity to the guiding framework.

The headline finding is strikingly positive. Veterans in the study found social risk and needs screening to be acceptable, and many framed it in terms of duty and reciprocity. The ethicality determinant aligned with a core value the researchers describe as serving those who served: veterans viewed the VA’s interest in housing, food, and financial stability as consistent with the institution’s mission, provided staff explain how such questions belong in health care at all. That conditional is crucial. Veterans told the researchers they feel comfortable disclosing needs only when staff make clear that screening is an integral part of VA health care rather than an administrative intrusion. Without that framing, the same questions could feel invasive or bureaucratic.

Perceived burden, one of the framework’s seven determinants, was low, but again with a condition attached: screening must not interfere with the goals veterans bring to a health care visit. This is a technical point with real implementation consequences. When a patient arrives for a diabetes management appointment or a mental health session, additional questionnaires compete for limited visit time. The study suggests that screening tools embedded seamlessly into existing workflows, rather than layered on top of them, preserve the goodwill that makes disclosure possible. Similarly, veterans’ affective attitudes toward screening were dependent on what happened afterward. Screening that leads to resource receipt generates positive emotional responses; screening that leads nowhere risks breeding cynicism.

One of the most consequential findings concerns information risk. Opportunity costs did not outweigh screening benefits in the aggregate, but veterans worried that sensitive information could be used against them. This concern has particular resonance in the VA context, where disability compensation and eligibility are tied to documented conditions and histories. Patients who fear that disclosing food insecurity or financial strain might somehow jeopardize benefits have a rational incentive to underreport, and underreporting would quietly dismantle the entire screening enterprise. The study’s implication is that trust-building measures, including transparent explanations of how data are stored, who sees them, and how they relate to clinical care, are not optional extras but structural requirements for valid screening programs.

Intervention coherence, the degree to which patients understand how an intervention works, emerged as another area ripe for improvement. Veterans wanted clarification on how social risks actually impact health. This may sound like a communication detail, but the science behind it is substantive. A large body of literature links social determinants such as housing instability, food insecurity, and social isolation to measurable outcomes including cardiovascular disease, hospital utilization, and mortality, and organizations from the National Academies of Sciences, Engineering, and Medicine to the American College of Physicians and the American Heart Association have issued position statements urging clinical integration of social care. The Joint Commission has even established a National Patient Safety Goal aimed at improving health care equity. Veterans asking how a missed meal connects to a chronic disease diagnosis are asking a question the field has spent a decade learning to answer, and clinics that can answer it credibly are more likely to earn honest responses.

Perceived effectiveness was the final hinge. Veterans anticipated that screening would be worthwhile if the VA provided timely and appropriate resources in response to disclosed needs. Prior research has documented exactly why this matters. A systematic review in Health Equity found that social needs screening and interventions in clinical settings show variable effects on utilization, cost, and clinical outcomes, and commentators in JAMA Network Open have warned that screening is increasing faster than the infrastructure to act on results. A screening program that identifies needs without referral capacity is not merely ineffective; it can actively erode the patient trust that the VA study identifies as the foundation of acceptability. Prior qualitative work with primary care patients and caregivers, including studies in American Journal of Preventive Medicine and Journal of the American Board of Family Medicine, has reached consistent conclusions across populations: patients accept social screening when it comes with a credible pathway to help.

The study’s practical recommendations distill into three design principles. First, explain the purpose of screening and its relevance to health, so veterans understand why a clinician is asking about rent alongside blood pressure. Second, offer appropriate resources in response to disclosed needs, closing the loop between identification and action. Third, designate a point of contact and provide multiple avenues to access support, a recommendation aimed at the self-efficacy determinant of the framework. When patients know who to talk to and can reach help by phone, in person, or digitally, the psychological cost of acting on a disclosed need drops. Related VA programs, such as the Assessing Circumstances and Offering Resources for Needs, or ACORN, screening and referral initiative described in earlier work in the same journal, suggest the health system is already building toward these mechanisms.

Methodologically, the study is notable for its disciplined use of theory. By anchoring each interview and each analytic code to a named determinant of acceptability, the researchers converted a diffuse question, do patients like this?, into a structured map of the cognitive and emotional responses that determine program viability. The team applied purposeful sampling and information-power principles to guide sample size, and followed consensus-based standards for rigor in rapid qualitative analysis. The authors note the limits inherent in the design: participants were veterans who had already endorsed social risks on a national survey, meaning the findings speak most directly to the population screening programs are intended to reach, and anonymized quotations rather than full datasets were shared to protect confidentiality. The study was approved by the VA Central Institutional Review Board, and the views expressed are those of the authors, not necessarily the Department of Veterans Affairs.

The broader significance of this work extends well beyond the VA. Health systems nationwide are now embedding social risk screening into electronic health records, quality measures, and even accreditation standards, sometimes faster than evidence about patient receptivity can accumulate. This study supplies that evidence from a population that is often assumed to be guarded about personal hardship, and the verdict is encouraging: veterans welcome these conversations when they are explained honestly, embedded respectfully, and answered with real help. The title phrase the researchers borrowed from a participant, that screening would be a burden off my back, captures the essential insight. Patients do not experience questions about social hardship as the burden; the hardship itself is the burden, and a health system that asks, listens, and responds can genuinely lift it.

Subject of Research: Veterans' acceptability of social risk and needs screening in the Veterans Affairs health system

Article Title: “It Would be a Burden off My Back”: Veterans’ Perceptions of Social Risk and Needs Screening Acceptability

Article References: “It Would be a Burden off My Back”: Veterans’ Perceptions of Social Risk and Needs Screening Acceptability. (n.d.). https://doi.org/10.1007/s11606-026-10805-9

Image Credits: AI Generated

DOI: 10.1007/s11606-026-10805-9

Keywords: veterans, social risk screening, social determinants of health, health-related social needs, Veterans Affairs, qualitative research, acceptability, food insecurity, patient-centered care, health equity, Theoretical Framework of Acceptability, Journal of General Internal Medicine