Evolving Comprehensive VA Women’s Health Care: Patient Characteristics, Needs, and Preferences

Understanding rural-urban differences in veterans' internet access, use and patient preferences for telemedicine

BACKGROUND

The expansion of telemedicine (e.g., telephone or video) in the Veterans Health Administration (VA) raises concerns for health care disparities between rural and urban veterans. Factors impeding telemedicine use (e.g., broadband, digital literacy, age) disproportionally affect rural veterans.

PURPOSE

To examine veteran-reported broadband access, internet use, familiarity with, and preferences for telemedicine stratified by residential rurality.

METHODS

Three hundred fifty veterans with a VA primary care visit in March 2022 completed a 30-min computer-assisted telephone interview. The sampling design stratified veterans by residential rurality (i.e., rural or urban) and how primary care was delivered (i.e., in-person or by video). Counts and weighted percentages are reported.

FINDINGS

After accounting for survey weights, 96.2% of respondents had in-home internet access and 89.5% reported functional connection speeds. However, rural- compared to urban-residing veterans were less likely to experience a telemedicine visit in the past year (74.1% vs. 85.2%; p = 0.02). When comparing telemedicine to in-person visits, rural versus urban-residing veterans rated them not as good (45.3% vs. 36.8%), just as good (51.1% vs. 53.1%), or better (3.5% vs. 10.0%) (p = 0.05). To make telemedicine visits easier, veterans, regardless of where they lived, recommended technology training (46.4%), help accessing the internet (26.1%), or provision of an internet-enabled device (25.9%).

CONCLUSIONS

Though rural-residing veterans were less likely to experience a telemedicine visit, the same actionable facilitators to improve telemedicine access were reported regardless of residential rurality. Importantly, technology training was most often recommended. Policy makers, patient advocates, and other stakeholders should consider novel initiatives to provide training resources.

Patient inequities in affording surgical resident operative autonomy at Veterans Affairs teaching hospitals, does it extend to female patients?

BACKGROUND

Examining surgical resident operative autonomy within the Veterans Affairs (VA) System, we previously showed residents were afforded autonomy more frequently on Black patients. We hypothesized that, compared to males, female surgical patients receive less attending involvement and more resident autonomy during surgery.

METHODS

Retrospective review of all general/vascular surgeries performed at teaching VA hospitals from 2004 to 2019. Operative procedures are coded at the time of surgery as attending primary surgeon (AP), attending with resident (AR), or resident primary surgeon--attending not scrubbed (RP). The primary outcome was the difference in supervision rates between patient sexes.

RESULTS

618,578 operations were examined-24.9% AP, 68.9% AR, and 6.2% RP. Overall, 5.9% of cases were performed on women. The rate of RP cases was higher in males compared to females (6.3% vs 5.3%, p < 0.001).

CONCLUSION

Female veterans are less likely to have residents operate on them autonomously. Reasons for this require further characterization.

Care Outcomes for Chiropractic Outpatient Veterans (COCOV): a qualitative study with veteran stakeholders from a pilot trial of multimodal chiropractic care

BACKGROUND

Low back pain (LBP) is common among military veterans seeking treatment in Department of Veterans Affairs (VA) healthcare facilities. As chiropractic services within VA expand, well-designed pragmatic trials and implementation studies are needed to assess clinical effectiveness and program uptake. This study evaluated veteran stakeholder perceptions of the feasibility and acceptability of care delivery and research processes in a pilot trial of multimodal chiropractic care for chronic LBP.

METHODS

The qualitative study was completed within a mixed-method, single-arm, pragmatic, pilot clinical trial of chiropractic care for LBP conducted in VA chiropractic clinics. Study coordinators completed semi-structured, in person or telephone interviews with veterans near the end of the 10-week trial. Interviews were audiorecorded and transcribed verbatim. Qualitative content analysis using a directed approach explored salient themes related to trial implementation and delivery of chiropractic services.

RESULTS

Of 40 participants, 24 completed interviews (60% response; 67% male gender; mean age 51.7 years). Overall, participants considered the trial protocol and procedures feasible and reported that the chiropractic care and recruitment methods were acceptable. Findings were organized into 4 domains, 10 themes, and 21 subthemes. Chiropractic service delivery domain encompassed 3 themes/8 subthemes: scheduling process (limited clinic hours, scheduling future appointments, attendance barriers); treatment frequency (treatment sufficient for LBP complaint, more/less frequent treatments); and chiropractic clinic considerations (hire more chiropractors, including female chiropractors; chiropractic clinic environment; patient-centered treatment visits). Outcome measures domain comprised 3 themes/4 subthemes: questionnaire burden (low burden vs. time-consuming or repetitive); relevance (items relevant for LBP study); and timing and individualization of measures (questionnaire timing relative to symptoms, personalized approach to outcomes measures). The online data collection domain included 2 themes/4 subthemes: user concerns (little difficulty vs. form challenges, required computer skills); and technology issues (computer/internet access, junk mail). Clinical trial planning domain included 2 themes/5 subthemes: participant recruitment (altruistic service by veterans, awareness of chiropractic availability, financial compensation); and communication methods (preferences, potential barriers).

CONCLUSIONS

This qualitative study highlighted veteran stakeholders' perceptions of VA-based chiropractic services and offered important suggestions for conducting a full-scale, veteran-focused, randomized trial of multimodal chiropractic care for chronic LBP in this clinical setting.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03254719.

Experiencing Sexual Assault and/or Stalking-Related Behavior is Associated with Binge Drinking and Substance Use Consequences in Deployed U.S. Servicewomen

BACKGROUND

Being deployed is a risk factor for poor postdeployment mental health outcomes in U.S. servicewomen, including harmful drinking. However, to our knowledge, no studies have examined deployment-related sexual assault and exposure to stalking-related behavior in relation to binge drinking and substance use consequences in this population.

METHODS

A community sample of post-9/11 servicewomen from the Midwest, including both veterans and those actively serving (N = 991), completed computer-assisted telephone interviews after deployment. Logistic regression models examined associations between deployment-related sexual assault (attempted or completed) and stalking-related behavior (e.g., being left unwanted things, having property vandalized), and the likelihood of reporting binge drinking and substance use consequences after controlling for covariates.

RESULTS

U.S. servicewomen experiencing deployment-related sexual assault and/or stalking-related behavior were more likely to report binge drinking in the past 4 weeks and at least one negative consequence of substance use in the past year. Also, 21.56% of the sample reported experiencing any deployment-related sexual assault and/or stalking-related behavior, 17.34% reported any stalking-related behavior and no sexual assault, 2.42% reported both sexual assault and stalking-related behavior, and 1.80% reported sexual assault and no stalking-related behavior. The most commonly endorsed behaviors were being followed or spied on (9.09%), receiving unsolicited correspondence (8.34%-8.74%), and having someone show up at places you were (6.90%).

CONCLUSIONS

U.S. servicewomen experiencing sexual assault and/or stalking-related behavior during deployment may be at higher risk for binge drinking and experiencing negative consequence of substance use when compared with their peers not reporting these stressors.

The Focus They Deserve: Improving Women Veterans' Health Care Access

PURPOSE

Veterans Health Administration (VHA) initiatives aim to provide veterans timely access to quality health care. The focus of this analysis was provider and staff perspectives on women veterans' access in the context of national efforts to improve veterans' access to care.

METHODS

We completed 21 site visits at Veterans Health Administration medical facilities to evaluate the implementation of a national access initiative. Qualitative data collection included semistructured interviews (n = 127), focus groups (n = 81), and observations with local leadership, administrators, providers, and support staff across primary and specialty care services at each facility. Deductive and inductive content analysis was used to identify barriers, facilitators, and contextual factors affecting implementation of initiatives and women veterans' access.

RESULTS

Participants identified barriers to women veterans' access and strategies used to improve access. Barriers included a limited availability of providers trained in women's health and gender-specific care services (e.g., women's specialty care), inefficient referral and coordination with community providers, and psychosocial factors (e.g., childcare). Participants also identified issues related to childcare and perceived harassment in medical facility settings as distinct access issues for women veterans. Strategies focused on increasing internal capacity to provide on-site women's comprehensive care and specialty services by streamlining provider training and credentialing, contracting providers, using telehealth, and improving access to community providers to fill gaps in women's services. Participants also highlighted efforts to improve gender-sensitive care delivery.

CONCLUSIONS

Although some issues affect all veterans, problems with community care referrals may disproportionately affect women veterans' access owing to a necessary reliance on community care for a range of gender-specific services.

Experiences of Perceived Gender-based Discrimination Among Women Veterans: Data From the ECUUN Study

BACKGROUND

Experiences of discrimination are associated with poor health behaviors and outcomes. Understanding discrimination in health care informs interventions to improve health care experiences.

OBJECTIVE

Describe the prevalence of, and variables associated with, perceived gender-based discrimination in the Veterans Affairs (VA) Healthcare System among women Veterans.

DESIGN

A cross-sectional, telephone-based survey of a random national sample of young female Veterans.

PARTICIPANTS

Female VA primary care patients aged 18-45 years.

MAIN MEASURES

The primary outcome was perceived gender-based discrimination in VA health care. Logistic and linear regression models were used to determine associations between any perceived discrimination and cumulative perceived discrimination with patient and health service characteristics.

KEY RESULTS

Among 2294 women Veterans, 33.7% perceived gender-based discrimination in VA. Perceiving gender-based discrimination was associated with medical illness [adjusted odds ratio (aOR)=1.67, 95% confidence interval (CI)=1.34, 2.08], mental illness (aOR=2.06, 95% CI=1.57, 2.69), and military sexual trauma (aOR=2.65, 95% CI=2.11, 3.32). Receiving most health care from the same VA provider (aOR=0.73, 95% CI=0.57, 0.94) and receiving care at a VA site with a women's health clinic (aOR=0.76, 95% CI=0.61, 0.95) were associated with reduced odds of any perceived gender-based discrimination. Among those who perceived gender-based discrimination (n=733), perceived discrimination scores were higher among women with increased age, medical illness, or history of military sexual trauma and lower among those who saw the same VA provider for most medical care.

CONCLUSIONS

One third of women Veterans perceived gender-based discrimination in VA. Obtaining most medical care from the same VA provider and having a women's health clinic at one's VA were associated with less perceived discrimination.

Recommendations for the Evaluation of Cross-System Care Coordination from the VA State-of-the-art Working Group on VA/Non-VA Care

In response to widespread concerns regarding Veterans' access to VA care, Congress enacted the Veterans Access, Choice and Accountability Act of 2014, which required VA to establish the Veterans Choice Program (VCP). Since the inception of VCP, more than two million Veterans have received care from community providers, representing approximately 25% of Veterans enrolled in VA care. However, expanded access to non-VA care has created challenges in care coordination between VA and community health systems. In March 2018, the VA Health Services Research & Development Service hosted a VA State of the Art conference (SOTA) focused on care coordination. The SOTA convened VA researchers, program directors, clinicians, and policy makers to identify knowledge gaps regarding care coordination within the VA and between VA and community systems of care. This article provides a summary and synthesis of relevant literature and provides recommendations generated from the SOTA about how to evaluate cross-system care coordination. Care coordination is typically evaluated using health outcomes including hospital readmissions and death; however, in cross-system evaluations of care coordination, measures such as access, cost, Veteran/patient and provider satisfaction (including with cross-system communication), comparable quality metrics, context (urban vs. rural), and patient complexity (medical and mental health conditions) need to be included to fully evaluate care coordination effectiveness. Future research should examine the role of multiple individuals coordinating VA and non-VA care, and how these coordinators work together to optimize coordination.

Patient Activation and Mental Health Care Experiences Among Women Veterans

We utilized a nationally representative survey of women veteran primary care users to examine associations between patient activation and mental health care experiences. A dose-response relationship was observed, with odds of high quality ratings significantly greater at each successive level of patient activation. Higher activation levels were also significantly associated with preference concordant care for gender-related preferences (use of female providers, women-only settings, and women-only groups as often as desired). Results add to the growing literature documenting better health care experiences among more activated patients, and suggest that patient activation may play an important role in promoting engagement with mental health care.

An Evidence Map of the Women Veterans' Health Research Literature (2008-2015)

BACKGROUND

Women comprise a growing proportion of Veterans seeking care at Veterans Affairs (VA) healthcare facilities. VA initiatives have accelerated changes in services for female Veterans, yet the corresponding literature has not been systematically reviewed since 2008. In 2015, VA Women's Health Services and the VA Women's Health Research Network requested an updated literature review to facilitate policy and research planning.

METHODS

The Minneapolis VA Evidence-based Synthesis Program performed a systematic search of research related to female Veterans' health published from 2008 through 2015. We extracted study characteristics including healthcare topic, design, sample size and proportion female, research setting, and funding source. We created an evidence map by organizing and presenting results within and across healthcare topics, and describing patterns, strengths, and gaps.

RESULTS

We identified 2276 abstracts and assessed each for relevance. We excluded 1092 abstracts and reviewed 1184 full-text articles; 750 were excluded. Of 440 included articles, 208 (47%) were related to mental health, particularly post-traumatic stress disorder (71 articles), military sexual trauma (37 articles), and substance abuse (20 articles). The number of articles addressing VA priority topic areas increased over time, including reproductive health, healthcare organization and delivery, access and utilization, and post-deployment health. Three or fewer articles addressed each of the common chronic diseases: diabetes, hypertension, depression, or anxiety. Nearly 400 articles (90%) used an observational design. Eight articles (2%) described randomized trials.

CONCLUSIONS

Our evidence map summarizes patterns, progress, and growth in the female Veterans' health and healthcare literature. Observational studies in mental health make up the majority of research. A focus on primary care delivery over clinical topics in primary care and a lack of sex-specific results for studies that include men and women have contributed to research gaps in addressing common chronic diseases. Interventional research using randomized trials is needed.

A Health Profile of Senior-Aged Women Veterans: A Latent Class Analysis of Condition Clusters

Background and Objectives

This study characterizes the multiple morbidities experienced by senior-aged women Veterans so that the Veterans Health Administration (VHA) and other health care systems may be better prepared to meet the health care needs of this growing cohort.

Research Design and Methods

Using the VHA’s Corporate Data Warehouse, we conducted a retrospective observational study of the 38,597 female veteran patients who were at least 65 years old and received care in the VHA during 2013 and 2014. We use a latent class analysis model to cluster diagnoses associated with inpatient and outpatient events over the years.

Results

The senior-aged women Veterans are characterized by six major classes of disease clusters. We defined these classes as: Healthy (16.24% of the cohort); Ophthalmological Disorders (13.84%); Musculoskeletal Disorders (14.22%); At Risk for Cardiovascular Disease (37.53%); Diabetic with Comorbidities (9.05%); and Multimorbid (9.12%). The patterns and prevalence of these condition classes vary by race, age, and marital status.

Discussion and Implications

Each of the six clusters can be used to develop clinical practice guidelines that are appropriate for senior-aged women Veterans. Consistent with past literature, the most common conditions in this cohort are hypertension and hyperlipidemia; together they form the most common class, “At Risk of Cardiovascular Disease (CVD)”. Results also show evidence of race-related disparities, with Blacks being more likely to be in the highest risk classes. Also, members of the cohort who are currently married having improved chances of being in the healthy class. And finally, we see a “healthy survivor” effect with the oldest women in our cohort having low overall rates of disease.

Lifetime Sexual Assault and Sexually Transmitted Infections Among Women Veterans

OBJECTIVE

Women veterans report a high prevalence of sexual assault. Unfortunately, there are limited data on the reproductive health sequelae faced by these women. Our objective was to evaluate the association between completed lifetime sexual assault (LSA) and sexually transmitted infections (STIs) among a cohort of women veterans, adjusting for sexual risk behaviors.

MATERIALS AND METHODS

We conducted a retrospective study among women veterans aged 51 years or younger who enrolled for care at two Veterans Administration (VA) healthcare sites between 2000 and 2008. Participants completed a telephone interview assessing reproductive health and sexual violence history. We compared the frequencies of past STI diagnoses among those who had and had not experienced LSA. We used logistic regression to assess the effect of sexual assault with history of an STI diagnosis after adjusting for age, sexual risk behaviors, and substance abuse treatment.

RESULTS

Among 996 women veterans, a history of STIs was reported by 32%, including a lifetime history of gonorrhea (5%), chlamydia (15%), genital herpes infection (8%), and human papillomavirus infection (15%), not mutually exclusive; 51% reported LSA. Women with a history of LSA were significantly more likely to report a history of STIs (unadjusted odds ratio [OR] 1.91, 95% confidence interval [CI] 1.45-2.50; adjusted OR 1.49, 95% CI 1.07-2.08).

CONCLUSIONS

Women veterans who have experienced LSA are at increased risk for lifetime STI diagnoses. To adequately address the reproductive health needs of the growing population of women veterans, STI risk assessments should include queries of military service and LSA histories.

Hysterectomy risk in premenopausal-aged military veterans: associations with sexual assault and gynecologic symptoms

BACKGROUND

Several gynecological conditions associated with hysterectomy, including abnormal bleeding and pelvic pain, have been observed at increased rates in women who have experienced sexual assault. Previous findings have suggested that one of the unique health care needs for female military veterans may be an increased prevalence of hysterectomy and that this increase may partially be due to their higher risk of sexual assault history and posttraumatic stress disorder (PTSD). Although associations between trauma, PTSD, and gynecological symptoms have been identified, little work has been done to date to directly examine the relationship between sexual assault, PTSD, and hysterectomy within the rapidly growing female veteran population.

OBJECTIVES

The objective of the study was to assess the prevalence of hysterectomy in premenopausal-aged female veterans, compare with general population prevalence, and examine associations between hysterectomy and sexual assault, PTSD, and gynecological symptoms in this veteran population.

STUDY DESIGN

We performed a computer-assisted telephone interview between July 2005 and August 2008 of 1004 female Veterans Affairs (VA)-enrolled veterans ≤ 52 years old from 2 Midwestern US Veterans Affairs medical centers and associated community-based outreach clinics. Within the veteran study population, associations between hysterectomy and sexual assault, PTSD, and gynecological symptoms were assessed with bivariate analyses using χ(2), Wilcoxon-Mann-Whitney, and Student t tests; multivariate logistic regression analyses were used to look for independent associations. Hysterectomy prevalence and ages were compared with large civilian populations represented in the Behavioral Risk Factor Surveillance System and American College of Surgeons National Surgical Quality Improvement Program databases from similar timeframes using χ(2) and Student t tests.

RESULTS

Prevalence of hysterectomy was significantly higher (16.8% vs 13.3%, P = .0002), and mean age at hysterectomy was significantly lower (35 vs 43 years old, P < .0001) in this VA-enrolled sample of female veterans compared with civilian population-based data sets. Sixty-two percent of subjects had experienced attempted or completed sexual assault in their lifetimes. A history of completed lifetime sexual assault with vaginal penetration (LSA-V) was a significant risk factor for hysterectomy (age-adjusted odds ratio, 1.85), with those experiencing their first LSA-V in childhood or in military at particular risk. A history of PTSD was also associated with hysterectomy (age-adjusted odds ratio, 1.83), even when controlling for LSA-V. These associations were no longer significant when controlling for the increased rates of gynecological pain, abnormal gynecological bleeding, and pelvic inflammatory disease seen in those veterans with a history of LSA-V.

CONCLUSION

Premenopausal-aged veterans may be at higher overall risk for hysterectomy, and for hysterectomy at younger ages, than their civilian counterparts. Veterans who have experienced completed sexual assault with vaginal penetration in childhood or in military and those with a history of PTSD may be at particularly high risk for hysterectomy, potentially related to their higher risk of gynecological symptoms. If confirmed in future studies, these findings have important implications for women's health care providers and policy makers within both the VA and civilian health care systems related to primary and secondary prevention, costs, and the potential for increased chronic disease and mortality.

Challenges with delivering gender-specific and comprehensive primary care to women veterans

BACKGROUND

The growing presence of women veterans in Veterans Administration (VA) settings has prompted the need for greater attention to clinical proficiency related to women's health (WH) primary care needs. Instead of making appointments for multiple visits or referring patients to a WH clinic or alternate site for gender-specific care, a comprehensive primary care model now allows for women veteran patients be seen by primary care providers (PCPs) who have WH training/experience and can see patients for both primary and WH care in the context of a single visit. However, little is currently known about the barriers and facilitators WH-PCPs face in using this approach to incorporate gender-specific services into women veterans' primary care services.

METHODS

We conducted qualitative in-depth interviews with 22 WH-PCPs at one Midwestern VA Medical Center. All participants were members of one of four outpatient primary care clinics within the main medical center, one off-site satellite clinic, or two off-site community-based outpatient clinics.

RESULTS

Inductive thematic analysis identified six themes: 1) Time constraints, 2) importance of staff support, 3) necessity of sufficient space and equipment/supplies, 4) perceptions of discomfort among patients with trauma histories, 5) lack of education/training, and 6) challenges with scheduling/logistics.

CONCLUSION

Although adequate staff was a key facilitator, the findings suggest that there may be barriers that undermine the ability of VA WH-PCPs to provide high-quality, comprehensive primary and gender-specific care. The nature of these barriers is multifactorial and multilevel in nature, and may therefore require special policy and practice action.

Adverse Childhood Experiences, Military Service, and Adult Health

INTRODUCTION

Prevalence of adverse childhood experiences (ACE) and associations with adult health may vary by gender and military service. This study compares the gender-specific prevalence of ACE by military service and determines the associations of ACE with adult health risk factors and health-related quality of life (HRQOL).

METHODS

This 2014 analysis used data from the 2011 and 2012 CDC Behavioral Risk Factor Surveillance System. Total ACE was operationalized as the number of reported ACE. Associations of total ACE with adult health risk factors were estimated using general linear models; associations with HRQOL were estimated using negative binomial regression. All analyses adjusted for age and race/ethnicity.

RESULTS

Those with military service had more total ACE than civilians. Higher ACE was associated with poorer HRQOL among women (physical health, military service, relative risk [RR]=1.20, 95% CI=1.09, 1.33; civilians, RR=1.18, 95% CI=1.17, 1.20; mental health, military service, RR=1.21, 95% CI=1.12, 1.32; civilians, RR=1.25, 95% CI=1.23, 1.26). Among men, these associations were somewhat attenuated in those with military service relative to civilians (physical health, military service, RR=1.13, 95% CI=1.09, 1.18; civilians, RR=1.20, 95% CI=1.17, 1.24; mental health, military service, RR=1.21, 95% CI=1.16, 1.27; civilians, RR=1.30, 95% CI=1.27, 1.34).

CONCLUSIONS

Relative to civilians, men and women with military service report more ACE, but associations of ACE with adult HRQOL are weaker among men with military service relative to civilians. There is a need to implement and disseminate evidence-based programs to prevent ACE and for research on the long-term health consequences of ACE in military populations.

Strategies for transforming reproductive healthcare delivery in an integrated healthcare system: a national model with system-wide implications

PURPOSE OF REVIEW

As the number of women serving in the US military has grown, so too has the number of women using the US Department of Veterans Affairs Healthcare System (VA). This poses tremendous opportunity to integrate reproductive health services across a national healthcare system. This review summarizes the approaches used to assess, rapidly design, and integrate VA's first National Reproductive Health Program.

RECENT FINDINGS

Compared with the civilian population, women Veterans have poorer health status including increased likelihood of medical comorbidities and mental health conditions. Given these complex health needs, a health systems approach that integrates reproductive health with other needs is essential in this vulnerable population.

SUMMARY

Delivery of high-quality reproductive healthcare must incorporate a systems perspective. Promoting major organizational and cultural change in a national system has required use of an evidence-based strategic framework, which has relied on several key tenets including the following: understanding the population of women Veterans served, developing research-clinical partnerships, building interdisciplinary initiatives for system-wide integration of reproductive healthcare, and developing innovative tools for enhancing care delivery. This approach can serve as a model for other healthcare systems committed to developing an integrated system of reproductive healthcare and addressing reproductive health conditions in women with complex needs.

Prenatal Care for Women Veterans Who Use Department of Veterans Affairs Health Care

OBJECTIVE

The number of women Veterans of childbearing age enrolling in Department of Veterans Affairs (VA) health care is increasing. Our objective was to describe characteristics of women veterans and resumption of VA care after delivery by use of VA prenatal benefits.

STUDY DESIGN

We used data from the National Survey of Women Veterans, a population-based survey. VA-eligible women veterans with at least one live birth who had ever used VA and were younger than 45 years when VA prenatal benefits became available were categorized based on self-reported receipt of VA prenatal benefits. Characteristics of by use of VA prenatal benefits were compared using χ2 tests with Rao-Scott adjustment. All analyses used sampling weights.

RESULTS

In our analytic sample, of those who potentially had the opportunity to use VA prenatal benefits, 25% used these benefits and 75% did not. Compared with women veterans not using VA prenatal benefits, those who did were more likely to be 18 to 24 years old (39.9% vs. 3.7%; p=.03), and more likely to have self-reported diagnosed depression (62.5% vs. 24.5%; p=.02) and current depression or posttraumatic stress disorder (PTSD) symptoms (depression, 46.1% vs. 8% [p=.02]; PTSD, 52.5% vs. 14.8% [p=.02]). Compared with women veterans not using VA prenatal benefits, those who did were more likely to resume VA use after delivery (p<.001).

CONCLUSION

Pregnant women veterans who use VA prenatal benefits are a high-risk group. Among those who opt not to use these benefits, pregnancy is an important point of attrition from VA health care, raising concerns regarding retention of women veterans within VA and continuity of care.

Access to mental health care among women Veterans: is VA meeting women's needs?

BACKGROUND

Patient-centered access to mental health describes the fit between patient needs and resources of the system. To date, little data are available to guide implementation of services to women veterans, an underrepresented minority within Department of Veteran Affairs (VA) health care. The current study examines access to mental health care among women veterans, and identifies gender-related indicators of perceived access to mental health care.

METHODS

A population-based sample of 6287 women veterans using VA primary care services participated in a survey of past year perceived need for mental health care, mental health utilization, and gender-related mental health care experiences. Subjective rating of how well mental health care met their needs was used as an indicator of perceived access.

RESULTS

Half of all women reported perceived mental health need; 84.3% of those women received care. Nearly all mental health users (90.9%) used VA services, although only about half (48.8%) reported that their mental health care met their needs completely or very well. Gender related experiences (availability of female providers, women-only treatment settings, women-only treatment groups, and gender-related comfort) were each associated with 2-fold increased odds of perceived access, and associations remained after adjusting for ease of getting care.

CONCLUSIONS

Women VA users demonstrate very good objective access to mental health services. Desire for, and access to specialized mental health services for women varies across the population and are important aspects of shared decision making in referral and treatment planning for women using VA primary care.

Surveying treatment preferences in U.S. Iraq-Afghanistan Veterans with PTSD symptoms: a step toward veteran-centered care

This study examined health care barriers and preferences among a self-selected sample of returning U.S. veterans drawn from a representative, randomly selected frame surveyed about posttraumatic stress disorder (PTSD) symptomatology and mental health utilization in the prior year. Comparisons between treated (n = 160) and untreated (n = 119) veterans reporting PTSD symptoms were conducted for measures of barriers and preferences, along with logistic models regressing mental health utilization on clusters derived from these measures. Reported barriers corroborated prior research findings as negative beliefs about treatment and stigma were strongly endorsed, but only privacy concerns were associated with lower service utilization (B = -0.408, SE = 0.142; p = .004). The most endorsed preference (91.0%) was for assistance with benefits, trailed by help for physical problems, and particular PTSD symptoms. Help-seeking veterans reported stronger preferences for multiple interventions, and desire for services for families (B = 0.468, SE = 0.219; p = .033) and specific PTSD symptoms (B = 0.659, SE = 0.302; p = .029) were associated with increased utilization. Outcomes of the study suggested PTSD severity drove help-seeking in this cohort. Results also support the integration of medical and mental health services, as well as coordination of health and benefits services. Finally, the study suggested that outreach about privacy protections and treatment options could well improve engagement in treatment.

Association between women veterans' experiences with VA outpatient health care and designation as a women's health provider in primary care clinics

BACKGROUND

Women veterans comprise a small percentage of Department of Veterans Affairs (VA) health care users. Prior research on women veterans' experiences with primary care has focused on VA site differences and not individual provider characteristics. In 2010, the VA established policy requiring the provision of comprehensive women's health care by designated women's health providers (DWHPs). Little is known about the quality of health care delivered by DWHPs and women veterans' experience with care from these providers.

METHODS

Secondary data were obtained from the VA Survey of Healthcare Experience of Patients (SHEP) using the Consumer Assessment of Healthcare Providers and Systems (CAHPS) patient-centered medical home (PCMH) survey from March 2012 through February 2013, a survey designed to measure patient experience with care and the DWHPs Assessment of Workforce Capacity that discerns between DWHPs versus non-DWHPs.

FINDINGS

Of the 28,994 surveys mailed to women veterans, 24,789 were seen by primary care providers and 8,151 women responded to the survey (response rate, 32%). A total of 3,147 providers were evaluated by the SHEP-CAHPS-PCMH survey (40%; n = 1,267 were DWHPs). In a multivariable model, patients seen by DWHPs (relative risk, 1.02; 95% CI, 1.01-1.04) reported higher overall experiences with care compared with patients seen by non-DWHPs.

CONCLUSIONS

The main finding is that women veterans' overall experiences with outpatient health care are slightly better for those receiving care from DWHPs compared with those receiving care from non-DWHPs. Our findings have important policy implications for how to continue to improve women veterans' experiences. Our work provides support to increase access to DWHPs at VA primary care clinics.

Anticipating the traumatic brain injury-related health care needs of women veterans after the Department of Defense change in combat assignment policy

BACKGROUND

Female service members' presence in combat zones during Operation Enduring Freedom and Operation Iraqi Freedom is unprecedented both in terms of the number of women deployed and the nature of their involvement. In light of changing Department of Defense policy governing the deployment of women in combat zones, this article intends to set the groundwork for estimating future combat-related injuries and subsequent Veterans Health Administration (VHA) utilization while focusing on traumatic brain injury (TBI).

METHODS

The article summarizes and presents the results of a study that examines veterans who present to VHA for TBI evaluation. For a national sample of veterans, a dataset including information on post-screening utilization, diagnoses, and location of care was constructed. The dataset included self-reported health symptoms and other information obtained from a standardized national VHA post-screening clinical evaluation, the comprehensive TBI evaluation (CTBIE).

FINDINGS

Both women and men utilize high levels of VHA health care after a CTBIE. However, there are gender differences in the volume and types of services used, with women utilizing different services than their male counterparts and incurring higher costs, including higher overall and outpatient costs.

CONCLUSION

As women veterans seek more of their health care from the VHA, there will be a need for more coordinated care to identify and manage deployment-related TBI and common comorbidities such as posttraumatic stress disorder, depression, and chronic pain. Deployment-connected injuries are likely to rise because of the rescinding of the ban on women in combat. This in turn has critical implications for VHA strategic planning and budgeting.

Contraceptive provision in the VA healthcare system to women who report military sexual trauma

BACKGROUND

Women Veterans who suffered military sexual trauma (MST) may be at high risk for unintended pregnancy and benefit from contraceptive services. The objective of this study is to compare documented provision of contraceptives to women Veterans using the Department of Veterans Affairs (VA) health system who report or deny MST.

METHODS

This retrospective cohort study included women Veterans aged 18-45 years who served in Operation Enduring or Iraqi Freedom and had at least one visit to a VA medical center between 2002 and 2010. Data were obtained from VA administrative and clinical databases. Chi-squared tests and logistic regression were conducted to evaluate the association between MST, ascertained by routine clinical screening, and first documented receipt of hormonal or long-acting contraception.

RESULTS

Of 68,466 women Veterans, 13% reported, 59% denied and 28% had missing data for the MST screen. Among the entire study cohort, 30% of women had documented receipt of a contraceptive method. Women reporting MST were significantly more likely than those denying MST to receive a method of contraception (adjusted odds ratio [aOR] 1.12, 95% confidence interval [CI] 1.07-1.18) including an intrauterine device (odds ratio [OR] 1.29, 95% CI 1.17-1.41) or contraceptive injection (OR 1.17, 95% CI 1.05-1.29). Women who were younger, unmarried, seen at a women's health clinic, or who had more than one visit were more likely to receive contraception.

CONCLUSIONS

A minority of women Veterans of reproductive age receive contraceptive services from the VA. Women Veterans who report MST, and particularly those who seek care at VA women's health clinics, are more likely to receive contraception.

Self-reported infertility among male and female veterans serving during Operation Enduring Freedom/Operation Iraqi Freedom

BACKGROUND

Infertility is associated with psychosocial distress and is a growing public health concern. Our objective was to report the prevalence of lifetime history of infertility among men and women Veterans.

METHODS

We used data from the U.S. Department of Veterans Affairs National Health Study for a New Generation of U.S. Veterans, a nationally representative survey of Veterans serving during Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF). The primary dependent variables were self-reported lifetime history of infertility among Veterans and their partners, defined as trying unsuccessfully to become pregnant for at least 12 months, and seeking medical help for infertility. Multiple logistic regression was used to determine whether gender was associated with lifetime history of infertility or seeking medical help for infertility, after adjusting for sociodemographic and military characteristics. All analyses were weighted to account for the complex survey design and nonresponse.

RESULTS

Among the 20,370 Veterans (16,056 men; 4,314 women) in our final analytic sample, the prevalence of lifetime history of infertility was 15.8% for women and 13.8% for men. After adjusting for age, ever married, education, race/ethnicity, component, branch of service, and deployment to OEF/OIF, compared with men, women Veterans had similar odds of lifetime history of infertility (odds ratio [OR] 1.07; 95% confidence interval [CI] 0.94, 1.20), but increased odds of seeking medical help for infertility (OR 1.35; 95% CI 1.06, 1.72).

CONCLUSIONS

Women Veterans are more likely than their male counterparts to seek care for infertility, and given their increasing numbers, the demand for infertility evaluation and care within Veterans' Affairs may increase.

Caregiving experiences and health conditions of women veteran and non-veteran caregivers

BACKGROUND

Unique experiences, for example, trauma, of women veteran caregivers may create differences in the caregiving experience and may be associated with health concerns. We examined caregiving factors and health concerns in women veteran caregivers compared to non-veteran women (civilian) caregivers, and identified variables associated with being a woman veteran caregiver.

METHODS

We conducted secondary data analyses using data from a multistate survey to examine sociodemographics, the caregiver experience (relationship to recipient, duration as caregiver, hours of care provided, area help is needed, and greatest difficulty faced as a caregiver); emotional support; life satisfaction; lifestyle behaviors; general, physical, and mental health; and chronic conditions in women informal caregivers.

FINDINGS

Of women caregivers, more veteran caregivers provided activities of daily living (ADL) help (33%) than non-veteran caregivers (21%; p = .02). There were no differences in years as a caregiver, hours of care provided, or the relationship to the recipient. Poor sleep and poor mental health were experienced by more women veteran caregivers (vs. non-veteran), but physical health, general health, and chronic condition prevalence did not differ. Women veteran caregivers had twofold greater odds of being Black, never married, college educated, and providing ADL assistance. Odds of obesity were lower for women veteran caregivers relative to other women caregivers.

CONCLUSIONS

Women veteran caregivers experience health concerns, including sleeplessness, poor mental health, and some chronic conditions. Our cohort were young women, yet had concerns that may be exacerbated by being a veteran and assuming a caregiver role. Comprehensive services to support their needs as veteran patients and as caregivers are needed.

Feasibility and desirability of web-based mental health screening and individualized education for female OEF/OIF reserve and national guard war veterans

Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Reserve and National Guard (RNG) service members have an increased risk for postdeployment mental health (MH) and readjustment problems, yet most do not access needed care. It is unknown if RNG servicewomen experiencing postdeployment readjustment symptoms are aware these may signify treatable MH concerns or if this knowledge activates care-seeking. The aims of this proof-of-concept study were to determine the feasibility of web-based MH screening for postdeployment MH symptoms to inform individualized psychoeducation, and to assess user perceptions about the online instrument and process, MH care access, and VA and other MH care. A midwestern sample (N = 131) of recently deployed (past 24 months) OEF/OIF RNG Army and Air Force servicewomen participated. High rates of combat experiences (95%) and military sexual trauma (50%) were reported. Positive screens for key symptoms of MH problems were prevalent. One third (31%) of satisfaction survey completers indicated online information reduced discomfort with seeking MH care; 42% reported they would subsequently seek MH assessment. Participants interviewed by telephone indicated that stigma and limited knowledge about women-specific services were key reasons servicewomen do not use MH care. This study demonstrated web-based screenings with individualized psychoeducation are implementable and favorable to RNG servicewomen.

Reproductive and other health outcomes in Iraq and Afghanistan women veterans using VA health care: association with mental health diagnoses

BACKGROUND

An increasing number of women serve in the military and are exposed to trauma during service that can lead to mental health problems. Understanding how these mental health problems affect reproductive and physical health outcomes will inform interventions to improve care for women veterans.

METHODS

We analyzed national Department of Veterans Affairs (VA) data from women Iraq and Afghanistan veterans who were new users of VA healthcare from October 7, 2001, through December 31, 2010 (n = 71,504). We used ICD-9 codes to categorize veterans into five groups by mental health diagnoses (MH Dx): Those with no MH Dx, posttraumatic stress disorder (PTSD), depression, comorbid PTSD and depression, and a MH Dx other than PTSD and depression. We determined the association between mental health category and reproductive and other physical health outcomes defined by ICD-9 codes. Categories included sexually transmitted infections, other infections (e.g., urinary tract infections), pain-related conditions (e.g., dysmenorrhea and dsypareunia), and other conditions (e.g., polycystic ovarian syndrome, infertility, sexual dysfunction). Models were adjusted for sociodemographic and military service factors.

RESULTS

There were 31,481 patients (44%) who received at least one mental health diagnosis. Women veterans with any mental health diagnosis had significantly higher prevalences of nearly all categories of reproductive and physical disease diagnoses (p < .0001 for adjusted prevalences). There was a trend of increasing prevalence of disease outcomes in women with PTSD, depression, and comorbid PTSD and depression (p for trend <.0001 for all outcomes).

CONCLUSIONS

Iraq and Afghanistan women veterans with mental health diagnoses had significantly greater prevalences of several important reproductive and physical health diagnoses. These results provide support for VA initiatives to address mental and physical health concerns and improve comprehensive care for women veterans.

Physical health status of female veterans: contributions of sex partnership and in-military rape

OBJECTIVE

The aim of this study was to determine whether current physical health status in female veterans is associated with rape during military service and same-sex partnership.

METHODS

Retrospective computer-assisted telephone interviews of 1004 Midwestern US female veterans identified from Veterans Affairs electronic records were conducted. Data included rape history including rape in military, sex partnership history, demographics, and medical history including chronic pain, mental health (depression and posttraumatic stress disorder [PTSD]), and the physical health component of the Short-Form 12-item interview (PCS-12).

RESULTS

Physical health in this sample was lower than norm values [PCS-12: mean (standard deviation) = 43 [12]; norm: mean (standard deviation) = 50 [10]). Fifty-one percent of the participants reported rape in their lifetime, 25% reported rape in military, 11% reported history of women as sex partners, and 71% reported history of chronic pain. Multiple regression analysis indicated that physical health (PCS-12) was associated with chronic pain history (β = -.40, p < .001), rape in military (β = -.09, p = .002), and current PTSD (β = .07, p = .03), adjusting for demographic data. Mediational analysis indicated that chronic pain history significantly mediated relationships of women who have sex with women, childhood rape, PTSD, depression, and current substance use disorder with PCS-12.

CONCLUSIONS

Both rape and sex partnership are adversely associated with lower physical functioning in female veterans. Clinicians evaluating the physical health of this population should therefore consider obtaining detailed sexual histories, and a multidisciplinary team is needed to address mental health issues in female veterans.

Health indicators for military, veteran, and civilian women

BACKGROUND

Women who have served in the military are a rapidly growing population. No previous studies have compared directly their health status to that of civilians.

PURPOSE

To provide estimates of several leading U.S. health indicators by military service status among women.

METHODS

Data were obtained from the 2010 Behavioral Risk Factor Surveillance Survey, a U.S. population-based study. Health outcomes were compared by military status using multivariable logistic regression among the female participants (274,399 civilians, 4221 veterans, 661 active duty, and 995 National Guard or Reserves [NG/R]). Data were analyzed in August 2011.

RESULTS

Veterans reported poorer general health and greater incidence of health risk behaviors, mental health conditions, and chronic health conditions than civilian women. Active duty women reported better access to health care, better physical health, less engagement in health risk behaviors, and greater likelihood of having had a recent Pap than civilian women. Women from the NG/R were comparable to civilians across most health domains, although they had a greater likelihood of being overweight or obese and reporting a depressive and anxiety disorder.

CONCLUSIONS

Compared with civilian women, NG/R women rated their health and access to health care similarly and active duty women rated theirs better on several domains, but veterans consistently reported poorer health.