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Sheinfil AZ, Day G, Walder A, Hogan J, Giordano TP, Lindsay J, Ecker A. Rural Veterans with HIV and Alcohol Use Disorder receive less video telehealth than urban Veterans. J Rural Health 2024; 40:419-429. [PMID: 37759376 PMCID: PMC10965503 DOI: 10.1111/jrh.12799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 09/08/2023] [Accepted: 09/20/2023] [Indexed: 09/29/2023]
Abstract
PURPOSE Alcohol use disorder (AUD) is highly prevalent among Veterans with HIV. Rural Veterans with HIV are at especially high risk for not receiving appropriate treatment. This retrospective cohort cross-sectional study aimed to investigate patterns of mental health treatment utilization across delivery modality among Veterans diagnosed with HIV and AUD. It was hypothesized that rural Veterans with HIV and AUD would receive a lower rate of mental health treatment delivered via video telehealth than urban Veterans with HIV and AUD. METHODS A national Veterans Health Association administrative database was used to identify a cohort of Veterans diagnosed with HIV and AUD (N = 2,075). Geocoding was used to categorize rural Veterans (n = 246) and urban Veterans (n = 1,829). Negative binomial regression models tested associations between rurality and mental health treatment delivered via face-to-face, audio-only, and video telehealth modalities. FINDINGS Results demonstrated that rural Veterans with HIV and AUD received fewer mental health treatment sessions delivered via telehealth than urban Veterans with HIV and AUD (incidence rate ratio = 0.62; 95% confidence intervals [0.44, 0.87]; P < .01). No differences were found in terms of treatment delivered face-to-face or by audio-only. CONCLUSIONS Rural Veterans with HIV and AUD represent a vulnerable subpopulation of Veterans who may most benefit from video telehealth. Efforts to increase access and improve the uptake of evidence-based mental health treatment delivered via video telehealth are needed.
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Affiliation(s)
- Alan Z Sheinfil
- VA South Central Mental Illness Research, Education and Clinical Center, Michael E. DeBakey VA Medical Center, Houston, Texas, USA
- Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, USA
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, Texas, USA
| | - Giselle Day
- VA South Central Mental Illness Research, Education and Clinical Center, Michael E. DeBakey VA Medical Center, Houston, Texas, USA
- Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, USA
| | - Annette Walder
- VA South Central Mental Illness Research, Education and Clinical Center, Michael E. DeBakey VA Medical Center, Houston, Texas, USA
- Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, USA
| | - Julianna Hogan
- VA South Central Mental Illness Research, Education and Clinical Center, Michael E. DeBakey VA Medical Center, Houston, Texas, USA
- Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, USA
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, Texas, USA
| | - Thomas P. Giordano
- Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, USA
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Jan Lindsay
- VA South Central Mental Illness Research, Education and Clinical Center, Michael E. DeBakey VA Medical Center, Houston, Texas, USA
- Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, USA
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, Texas, USA
- Rice University’s Baker Institute for Public Policy, Houston, Texas, USA
| | - Anthony Ecker
- VA South Central Mental Illness Research, Education and Clinical Center, Michael E. DeBakey VA Medical Center, Houston, Texas, USA
- Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, USA
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, Texas, USA
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Ferguson JM, Goldstein KM, Zullig LL, Zulman DM. Gender Differences in Adoption and Frequency of Virtual Primary Care Among Men and Women Veterans. J Womens Health (Larchmt) 2024; 33:749-757. [PMID: 38629443 DOI: 10.1089/jwh.2023.0781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/18/2024] Open
Abstract
Background: Women Veterans have unique health care utilization patterns; however, video-based primary care utilization among and between women and men has not been well examined. Methods: In a retrospective cohort study, we calculated gender-stratified video visit adoption (i.e., likelihood) and frequency (i.e., rate of use among users) between April 1, 2020, and March 31, 2022, by demographic and clinical characteristics known to impact health care utilization. Results: Among 5,389,139 Veterans (9.2% women), 32% of women and 18.6% of men had a video-based primary care visit over the 2-year study period. Gender interacted with Veteran characteristics and the likelihood of any video care. Men often had associations stronger in magnitude (both positive and negative) than women, including by age, rurality, history of housing instability, mental health conditions, and marital status. The direction of effect never diverged by gender. A positive association among women always coincided with a positive association among men, and vice versa, across all characteristics assessed. Only the risk ratio for video care use comparing Veterans of Black race with White race was stronger among women. In contrast to the video care adoption differences by gender, we found few differences in the frequency of video-based care by gender. Conclusions: The findings suggest there are fewer disparities by demographic and clinical characteristics in any video care use among women compared with men and little to no disparities in the frequency of video care use by gender. Understanding the variation in video care utilization by gender could help improve acceptance, appropriate utilization, and uptake of video-based visits for all.
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Affiliation(s)
- Jacqueline M Ferguson
- Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, Menlo Park, California, USA
| | - Karen M Goldstein
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
- Division of General Internal Medicine, Duke University, Durham, North Carolina, USA
| | - Leah L Zullig
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
- Department of Population Health Sciences, Durham, North Carolina, USA
| | - Donna M Zulman
- Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, Menlo Park, California, USA
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California, USA
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Yano EM, Than C, Brunner J, Canelo IA, Meredith LS, Rubenstein LV, Hamilton AB. Impact of Evidence-Based Quality Improvement on Tailoring VA's Patient-Centered Medical Home Model to Women Veterans' Needs. J Gen Intern Med 2024; 39:1349-1359. [PMID: 38424344 PMCID: PMC11169220 DOI: 10.1007/s11606-024-08647-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Accepted: 01/22/2024] [Indexed: 03/02/2024]
Abstract
BACKGROUND Women Veterans' numerical minority, high rates of military sexual trauma, and gender-specific healthcare needs have complicated implementation of comprehensive primary care (PC) under VA's patient-centered medical home model, Patient Aligned Care Teams (PACT). OBJECTIVE We deployed an evidence-based quality improvement (EBQI) approach to tailor PACT to meet women Veterans' needs and studied its effects on women's health (WH) care readiness, team-based care, and burnout. DESIGN We evaluated EBQI effectiveness in a cluster randomized trial with unbalanced random allocation of 12 VAMCs (8 EBQI vs. 4 control). Clinicians/staff completed web-based surveys at baseline (2014) and 24 months (2016). We adjusted for individual-level covariates (e.g., years at VA) and weighted for non-response in difference-in-difference analyses for readiness and team-based care overall and by teamlet type (mixed-gender PC-PACTs vs. women-only WH-PACTs), as well as post-only burnout comparisons. PARTICIPANTS We surveyed all clinicians/staff in general PC and WH clinics. INTERVENTION EBQI involved structured engagement of multilevel, multidisciplinary stakeholders at network, VAMC, and clinic levels toward network-specific QI roadmaps. The research team provided QI training, formative feedback, and external practice facilitation, and support for cross-site collaboration calls to VAMC-level QI teams, which developed roadmap-linked projects adapted to local contexts. MAIN MEASURES WH care readiness (confidence providing WH care, self-efficacy implementing PACT for women, barriers to providing care for women, gender sensitivity); team-based care (change-readiness, communication, decision-making, PACT-related QI, functioning); burnout. KEY RESULTS Overall, EBQI had mixed effects which varied substantively by type of PACT. In PC-PACTs, EBQI increased self-efficacy implementing PACT for women and gender sensitivity, even as it lowered confidence. In contrast, in WH-PACTs, EBQI improved change-readiness, team-based communication, and functioning, and was associated with lower burnout. CONCLUSIONS EBQI effectiveness varied, with WH-PACTs experiencing broader benefits and PC-PACTs improving basic WH care readiness. Lower confidence delivering WH care by PC-PACT members warrants further study. TRIAL REGISTRATION The data in this paper represent results from a cluster randomized controlled trial registered in ClinicalTrials.gov (NCT02039856).
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Affiliation(s)
- Elizabeth M Yano
- VA Los Angeles HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, 16111 Plummer Street (Mailcode 152), Sepulveda, CA, 91343, USA.
- Department of Health Policy and Management, UCLA Fielding School of Public Health, 650 Charles E. Young Drive South, Los Angeles, CA, 90095, USA.
- Department of Medicine, UCLA Geffen School of Medicine, 855 Tiverton Drive, Los Angeles, CA, 90024, USA.
| | - Claire Than
- National Precision Oncology Program, Veterans Health Administration, Washington, DC, USA
| | - Julian Brunner
- VA Los Angeles HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, 16111 Plummer Street (Mailcode 152), Sepulveda, CA, 91343, USA
| | - Ismelda A Canelo
- VA Los Angeles HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, 16111 Plummer Street (Mailcode 152), Sepulveda, CA, 91343, USA
| | - Lisa S Meredith
- RAND Corporation, 1776 Main Street, Santa Monica, CA, 90401-3208, USA
| | - Lisa V Rubenstein
- Department of Medicine, UCLA Geffen School of Medicine, 855 Tiverton Drive, Los Angeles, CA, 90024, USA
- RAND Corporation, 1776 Main Street, Santa Monica, CA, 90401-3208, USA
| | - Alison B Hamilton
- VA Los Angeles HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, 16111 Plummer Street (Mailcode 152), Sepulveda, CA, 91343, USA
- Department of Psychiatry and Biobehavioral Sciences, UCLA Geffen School of Medicine, 757 Westwood Plaza, Los Angeles, CA, 90095, USA
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Mog AC, Benson SK, Sriskantharajah V, Kelly PA, Gray KE, Callegari LS, Moy EM, Katon JG. "You want people to listen to you": Patient experiences of women's healthcare within the Veterans Health Administration. Health Serv Res 2024. [PMID: 38804072 DOI: 10.1111/1475-6773.14324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2024] Open
Abstract
OBJECTIVE To identify constructs that are critical in shaping Veterans' experiences with Veterans Health Administration (VA) women's healthcare, including any which have been underexplored or are not included in current VA surveys of patient experience. DATA SOURCES AND STUDY SETTING From June 2022 to January 2023, we conducted 28 semi-structured interviews with a diverse, national sample of Veterans who use VA women's healthcare. STUDY DESIGN Using VA data, we divided Veteran VA-users identified as female into four groups stratified by age (dichotomized at age 45) and race/ethnicity (non-Hispanic White vs. all other). We enrolled Veterans continuously from each recruitment strata until thematic saturation was reached. DATA COLLECTION/EXTRACTION METHODS For this qualitative study, we asked Veterans about past VA healthcare experiences. Interview questions were guided by a priori domains identified from review of the literature, including trust, safety, respect, privacy, communication and discrimination. Analysis occurred concurrently with interviews, using inductive and deductive content analysis. PRINCIPAL FINDINGS We identified five themes influencing Veterans' experiences of VA women's healthcare: feeling valued and supported, bodily autonomy, discrimination, past military experiences and trauma, and accessible care. Each emergent theme was associated with multiple of the a priori domains we asked about in the interview guide. CONCLUSIONS Our findings underscore the need for a measure of patient experience tailored to VA women's healthcare. Existing patient experience measures used within VA fail to address several aspects of experience highlighted by our study, including bodily autonomy, the influence of past military experiences and trauma on healthcare, and discrimination. Understanding distinct factors that influence women and gender-diverse Veterans' experiences with VA care is critical to advance efforts by VA to measure and improve the quality and equity of care for all Veterans.
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Affiliation(s)
- Ashley C Mog
- Seattle-Denver Center of Innovation (COIN), VA Puget Sound Health Care System, Seattle, Washington, USA
| | - Samantha K Benson
- Seattle-Denver Center of Innovation (COIN), VA Puget Sound Health Care System, Seattle, Washington, USA
| | - Vyshnika Sriskantharajah
- Seattle-Denver Center of Innovation (COIN), VA Puget Sound Health Care System, Seattle, Washington, USA
| | - P Adam Kelly
- Southeast Louisiana Veterans Health Care System, New Orleans, Louisiana, USA
- Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Kristen E Gray
- Seattle-Denver Center of Innovation (COIN), VA Puget Sound Health Care System, Seattle, Washington, USA
- Department of Health Services, University of Washington School of Public Health, Seattle, Washington, USA
| | - Lisa S Callegari
- Seattle-Denver Center of Innovation (COIN), VA Puget Sound Health Care System, Seattle, Washington, USA
- Department of Obstetrics and Gynecology, University of Washington School of Medicine, Seattle, Washington, USA
| | - Ernest M Moy
- Office of Health Equity, Veterans Health Administration, Washington, District of Columbia, USA
| | - Jodie G Katon
- VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
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Clair KS, Bean-Mayberry B, Schweizer CA, Chanfreau C, Jackson L, Than CT, Finley EP, Hamilton A, Farmer MM. Factors Associated with Delayed Care Among Women Veterans Actively Engaged in Primary Care. J Womens Health (Larchmt) 2024; 33:604-612. [PMID: 38386795 DOI: 10.1089/jwh.2023.0227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2024] Open
Abstract
Background: Delaying needed medical care contributes to greater health risks and higher long-term medical costs. Women Veterans with complex medical and mental health needs face increased barriers to timely care access. Objectives: In a sample of women Veterans with recent engagement in Veterans Administration (VA) primary care, we aimed to compare characteristics of women Veterans who delayed care in the past 6 months with those who did not and examine factors associated with self-reported delayed care. Our study aims to inform interventions focused on eliminating health care access disparities among women Veterans. Materials and Methods: An innovation to improve women Veterans' engagement and retention in evidence-based health care for cardiovascular (CV) risk reduction (CV Toolkit) was implemented across five primary care sites within the VA. Women Veterans who were exposed to at least one CV Toolkit component participated in a mailed survey (n = 253). We used multivariate logistic regression to model factors associated with delaying care, including trust in VA providers, positive mental health screening (i.e., positive screen for either depression or anxiety), traumatic experience, self-rated health, and age. Results: Women with any mental health symptoms (odds ratio [OR] 2.42, 95% confidence interval [CI]: 1.23-4.74) and women who had experienced a traumatic event (OR 2.61, 95%CI: 1.11-6.14) were significantly more likely to report delaying care. Conclusions: Our study identified high rates of delayed care-over one-third of respondents-among women Veterans with recent primary care engagement. Mental health symptoms were the most common reported reason for delay among those who delayed care. Clinical Trial registration: NCT02991534.
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Affiliation(s)
- Kimberly S Clair
- VA Health Service Research and Development, Center for the Study of Healthcare Innovation, Implementation, and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Bevanne Bean-Mayberry
- VA Health Service Research and Development, Center for the Study of Healthcare Innovation, Implementation, and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
- Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, California, USA
| | - C Amanda Schweizer
- VA Health Service Research and Development, Center for the Study of Healthcare Innovation, Implementation, and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Catherine Chanfreau
- VA Informatics and Computing Infrastructure (VINCI), VA Salt Lake City Healthcare System, Salt Lake City, Utah, USA
| | - LaShawnta Jackson
- VA Health Service Research and Development, Center for the Study of Healthcare Innovation, Implementation, and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Claire T Than
- VA Health Service Research and Development, Center for the Study of Healthcare Innovation, Implementation, and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Erin P Finley
- VA Health Service Research and Development, Center for the Study of Healthcare Innovation, Implementation, and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
- Department of Medicine, Joe R. and Teresa Lozano Long School of Medicine, University of Texas Health Science Center, San Antonio, Texas, USA
| | - Alison Hamilton
- VA Health Service Research and Development, Center for the Study of Healthcare Innovation, Implementation, and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, Jane and Terry Semel Institute for Neuroscience and Human Behavior, UCLA, Los Angeles, California, USA
| | - Melissa M Farmer
- VA Health Service Research and Development, Center for the Study of Healthcare Innovation, Implementation, and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
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Gebhardt HM, Norr AM, Markman JD, Reger MA. Experience and impact of inappropriate patient sexual behaviors within a large VA healthcare system. J Hosp Med 2024; 19:394-398. [PMID: 38439164 DOI: 10.1002/jhm.13313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 01/26/2024] [Accepted: 02/11/2024] [Indexed: 03/06/2024]
Abstract
Inappropriate patient sexual behaviors (IPSBs) can negatively impact work performance, job satisfaction, and the psychological well-being of clinicians and staff. Although the Veterans Health Administration (VHA) is the largest integrated healthcare system in the United States, the rate of IPSBs in VHA hospitals is unknown. The unique demographic and cultural characteristics of military populations may be associated with IPSBs. To evaluate the extent and impact of IPSBs within a large VA healthcare system (VAHS), a survey was disseminated to all staff. Among the 32% of staff who responded (N = 1359), over half (n = 789; 58.1%) of participants reported at least one instance of IPSB during the past year; this included 67.9% (n = 644) of staff who identified as women and 33.4% (n = 126) of staff who identified as men. There was a significantly greater impact of IPSBs for women, as compared to men, on psychological well-being (X2 1 = 60.4, p < .001, odds ratio [OR] = 4.55, 95% confidence interval [CI]: [3.08, 6.79]), work satisfaction (X2 1 = 43.0, p < .001, OR = 3.51, 95% CI: [2.40, 5.18]), and workplace practices (X2 1 = 48.9, p < .001, OR = 4.02, 95% CI: [2.69, 6.11]). The results of this project highlight the need for overcoming barriers to reducing the pervasiveness and impact of these experiences.
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Affiliation(s)
| | - Aaron M Norr
- VA Puget Sound Healthcare System, Seattle Division, Seattle, USA
| | - Jesse D Markman
- VA Puget Sound Healthcare System, Seattle Division, Seattle, USA
| | - Mark A Reger
- VA Puget Sound Healthcare System, Seattle Division, Seattle, USA
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Holder N, Ranney RM, Bernhard PA, Holliday R, Vogt D, Hoffmire CA, Blosnich JR, Schneiderman AI, Maguen S. Which veterans with PTSD are most likely to report being told of their diagnosis? J Psychiatr Res 2024; 170:158-166. [PMID: 38147692 DOI: 10.1016/j.jpsychires.2023.12.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 12/11/2023] [Accepted: 12/13/2023] [Indexed: 12/28/2023]
Abstract
Veterans who do not know about their posttraumatic stress disorder (PTSD) diagnosis experience a fundamental barrier to accessing effective treatment. Little is known about the characteristics that influence veterans' PTSD diagnosis knowledge (i.e., report of being told they have a PTSD diagnosis by a healthcare provider). Veterans who met probable and provisional criteria for PTSD on the self-report PTSD checklist for DSM-5 were identified from the Comparative Health Assessment Interview Research Study (n = 2335). Weighted logistic regression was performed to identify demographic variables, clinical characteristics, and social determinants of health (e.g., economic instability, homelessness, healthcare coverage) associated with PTSD diagnosis knowledge among post-9/11 veterans. Approximately 62% of veterans with probable and provisional PTSD had PTSD diagnosis knowledge. Predictors with the strongest associations included another mental health diagnosis (OR = 6.10, CI95:4.58,8.12) and having Veterans Affairs (VA) healthcare coverage (OR = 2.63, CI95:1.97,3.51). Veterans with combat or sexual trauma were more likely to have PTSD diagnosis knowledge than those with different trauma types. Results suggest veterans with VA healthcare coverage and military-related trauma are more likely to be informed by a healthcare professional about a PTSD diagnosis. Further research is needed to improve PTSD diagnosis knowledge for those with non-military-related trauma and those without VA healthcare coverage.
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Affiliation(s)
- Nicholas Holder
- San Francisco Veterans Affairs Health Care System, United States; University of California, San Francisco School of Medicine, United States.
| | - Rachel M Ranney
- San Francisco Veterans Affairs Health Care System, United States; University of California, San Francisco School of Medicine, United States; Sierra Pacific Mental Illness Research, Education, and Clinical Center, United States
| | - Paul A Bernhard
- Health Outcomes Military Exposures Epidemiology Program, Patient Care Services, U.S. Department of Veterans Affairs, United States
| | - Ryan Holliday
- Department of Veterans Affairs Rocky Mountain Mental Illness Research, Education, and Clinical Center for Suicide Prevention, United States; University of Colorado Anschutz Medical Campus, Department of Psychiatry, United States
| | - Dawne Vogt
- Women's Health Sciences Division, National Center for Posttraumatic Stress Disorder, VA Boston Healthcare System, United States; Boston University School of Medicine, United States
| | - Claire A Hoffmire
- Department of Veterans Affairs Rocky Mountain Mental Illness Research, Education, and Clinical Center for Suicide Prevention, United States; University of Colorado Anschutz Medical Campus, Department of Physical Medicine and Rehabilitation, United States
| | - John R Blosnich
- Suzanne Dworak-Peck School of Social Work, University of Southern California, United States; Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, United States
| | - Aaron I Schneiderman
- Health Outcomes Military Exposures Epidemiology Program, Patient Care Services, U.S. Department of Veterans Affairs, United States
| | - Shira Maguen
- San Francisco Veterans Affairs Health Care System, United States; University of California, San Francisco School of Medicine, United States; Sierra Pacific Mental Illness Research, Education, and Clinical Center, United States
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Orshak J, Ondoma C, Johnson HM, Lauver D. Women Veterans' Barriers to Care-Seeking for Cardiovascular Disease Prevention. Nurs Res 2024; 73:26-36. [PMID: 38064302 DOI: 10.1097/nnr.0000000000000684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
BACKGROUND Women veterans have a high prevalence of traditional and nontraditional risks for cardiovascular disease (CVD) including obesity and posttraumatic stress disorder. Experts from the U.S. Department of Veterans Affairs have called for actions to improve the cardiovascular health of this population. One approach is to assess women veterans' barriers to care-seeking for CVD prevention, to inform future intervention research. OBJECTIVE The objective of this study was to describe women veterans' barriers to care-seeking for CVD prevention, guided by the theory of care-seeking behavior and concept awareness. METHODS Using a cross-sectional, descriptive design, a national sample of 245 women veterans participated in an online survey about barriers to care-seeking. Participants provided narrative responses to open-ended items, endorsements to closed-ended items, and rankings of their top five barriers. Researchers conducted poststratification weighting of numerical data to reflect the women veteran population. RESULTS Narrative responses described unaffordable and inaccessible services, feeling harassed or not respected in healthcare settings, and lack of awareness of risks for CVD. Frequently endorsed barriers were unaffordable and inaccessible services. Frequently ranked barriers were feeling not respected in healthcare settings and clinicians not recommending CVD prevention. DISCUSSION Findings support concepts in theory of care-seeking behavior and concept awareness. Understanding women veterans' barriers to care-seeking for CVD prevention can inform clinicians and researchers as they address these barriers.
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9
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Krishnamurti LS, Denneson LM, Agha A, Beyer N, Mitchell S, Dichter ME. Improving suicide prevention for women veterans: Recommendations from VHA suicide prevention coordinators. Gen Hosp Psychiatry 2023; 84:67-72. [PMID: 37393650 DOI: 10.1016/j.genhosppsych.2023.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 05/24/2023] [Accepted: 05/25/2023] [Indexed: 07/04/2023]
Abstract
OBJECTIVE Women are a minority veteran subpopulation experiencing particular risk for suicide and facing distinct challenges in accessing Veterans Health Administration (VHA) care. As part of efforts to enhance suicide prevention, the VHA established Suicide Prevention Coordinators (SPC) as clinicians who work exclusively to connect high-risk veterans to the scope of VHA's services. To understand the experiences of women veterans with suicide risk who access care, this study presents findings from qualitative interviews with SPCs regarding the care needs, preferences, and concerns of women veterans who utilize VHA for enhanced suicide-related care. METHODS We conducted qualitative interviews with 20 SPCs from 13 VAMCs around the United States. We specifically asked SPCs to share perspectives on women veterans' barriers to accessing care and their recommendations to improve suicide prevention for this subpopulation. We conducted a thematic content analysis to extract key themes. RESULTS SPCs revealed that women veterans opt to avoid VHA due to prior negative experiences, often related to provider sensitivity to women's issues. Safety was another key concern, specifically related to feeling unwelcome or intimidated in the male dominated veteran community. Key provider recommendations include increasing the availability of gender-sensitive providers and making changes to the physical spaces of the VHA to better facilitate women veterans' access to care. CONCLUSIONS SPCs underscored the importance of comfort and relatability between women patients and providers, especially in relation to enhanced care for suicide risk. This study presents important evidence in support of enhancing suicide prevention by better engaging women veterans in care that is more inclusive and more sensitive to their experiences and identity, in and outside VHA.
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Affiliation(s)
- Lauren S Krishnamurti
- U.S. Department of Veterans Affairs, Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, United States of America.
| | - Lauren M Denneson
- U.S. Department of Veterans Affairs, VA Portland Health Care System, Portland, OR, United States of America; Oregon Health and Science University School of Medicine, Portland, OR, United States of America
| | - Aneeza Agha
- U.S. Department of Veterans Affairs, Center for Health Equity Research and Promotion, Crescenz VA Medical Center, Philadelphia, PA, United States of America
| | - Nicole Beyer
- U.S. Department of Veterans Affairs, Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, United States of America
| | - Shannon Mitchell
- U.S. Department of Veterans Affairs, Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, United States of America
| | - Melissa E Dichter
- U.S. Department of Veterans Affairs, Center for Health Equity Research and Promotion, Crescenz VA Medical Center, Philadelphia, PA, United States of America; Temple University School of Social Work, Philadelphia, PA, United States of America
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Rohs CM, Albright KR, Monteith LL, Lane AD, Fehling KB. Perspectives of VA healthcare from rural women veterans not enrolled in or using VA healthcare. PLoS One 2023; 18:e0289885. [PMID: 37578986 PMCID: PMC10424869 DOI: 10.1371/journal.pone.0289885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 07/28/2023] [Indexed: 08/16/2023] Open
Abstract
PURPOSE Women Veterans have unique healthcare needs and often experience comorbid health conditions. Despite this, many women Veterans are not enrolled in the Veterans Health Administration (VHA) and do not use VHA services. Underutilization of VHA services may be particularly prevalent among rural women Veterans, who may experience unique barriers to using VHA care. Nonetheless, knowledge of rural women Veterans and their experiences remains limited. We sought to understand rural women Veterans' perceptions and needs related to VHA healthcare, including barriers to enrolling in and using VHA services, and perspectives on how to communicate with rural women Veterans about VHA services. METHODS Rural women Veterans were recruited through community engagement with established partners and a mass mailing to rural women Veterans not enrolled in or using VHA healthcare. Ten virtual focus groups were conducted with a total of twenty-nine rural women Veterans (27 not enrolled in VHA care and 2 who had not used VHA care in the past 5 years) in 2021. A thematic inductive analytic approach was used to analyze focus group transcripts. FINDINGS Primary themes regarding rural women Veterans' perceptions of barriers to enrollment and use of VHA healthcare included: (1) poor communication about eligibility and the process of enrollment; (2) belief that VHA does not offer sufficient women's healthcare services; and (3) inconvenience of accessing VHA facilities. CONCLUSION Although VHA has substantially expanded healthcare services for women Veterans, awareness of such services and the nuances of eligibility and enrollment remains an impediment to enrolling in and using VHA healthcare among rural women Veterans. Recommended strategies include targeted communication with rural women Veterans not enrolled in VHA care to increase their awareness of the enrollment process, eligibility, and expansion of women's healthcare services. Creative strategies to address access and transportation barriers in rural locations are also needed.
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Affiliation(s)
- Carly M. Rohs
- Seattle-Denver Center for Innovation (COIN), Rocky Mountain Regional VA Medical Center, Aurora, Colorado, United States of America
- VA Rocky Mountain Mental Illness, Research, Education and Clinical Center (MIRECC) for Suicide Prevention, Aurora, Colorado, United States of America
| | - Karen R. Albright
- Seattle-Denver Center for Innovation (COIN), Rocky Mountain Regional VA Medical Center, Aurora, Colorado, United States of America
- Division of General Internal Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States of America
| | - Lindsey L. Monteith
- VA Rocky Mountain Mental Illness, Research, Education and Clinical Center (MIRECC) for Suicide Prevention, Aurora, Colorado, United States of America
- Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States of America
| | - Amber D. Lane
- Seattle-Denver Center for Innovation (COIN), Rocky Mountain Regional VA Medical Center, Aurora, Colorado, United States of America
| | - Kelty B. Fehling
- Seattle-Denver Center for Innovation (COIN), Rocky Mountain Regional VA Medical Center, Aurora, Colorado, United States of America
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11
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Goldstein KM, Bosworth HB, Gierisch JM. Can Right-Sizing the Use of Virtual Care Improve Access to Equitable, Patient-Centered Care for Women Veterans? J Gen Intern Med 2023:10.1007/s11606-023-08113-7. [PMID: 36920681 PMCID: PMC10015126 DOI: 10.1007/s11606-023-08113-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 02/24/2023] [Indexed: 03/16/2023]
Affiliation(s)
- Karen M Goldstein
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC, USA.
- Division of General Internal Medicine, Duke University School of Medicine, Durham, NC, USA.
| | - Hayden B Bosworth
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC, USA
- Division of General Internal Medicine, Duke University School of Medicine, Durham, NC, USA
- Duke University School of Nursing, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Jennifer M Gierisch
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC, USA
- Division of General Internal Medicine, Duke University School of Medicine, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
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12
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Hamilton AB, Finley EP, Bean-Mayberry B, Lang A, Haskell SG, Moin T, Farmer MM. Enhancing Mental and Physical Health of Women through Engagement and Retention (EMPOWER) 2.0 QUERI: study protocol for a cluster-randomized hybrid type 3 effectiveness-implementation trial. Implement Sci Commun 2023; 4:23. [PMID: 36890587 PMCID: PMC9994412 DOI: 10.1186/s43058-022-00389-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 12/22/2022] [Indexed: 03/10/2023] Open
Abstract
BACKGROUND Women Veterans are the fastest-growing segment of Veterans Health Administration (VA) users. The VA has invested heavily in delivering care for women Veterans that is effective, comprehensive, and gender-tailored. However, gender disparities persist in cardiovascular (CV) and diabetes risk factor control, and the rate of perinatal depression among women Veterans is higher than that among civilian women. Challenges such as distance, rurality, negative perception of VA, discrimination (e.g., toward sexual and/or gender minority individuals), and harassment on VA grounds can further impede women's regular use of VA care. Enhancing Mental and Physical Health of Women through Engagement and Retention (EMPOWER) 2.0 builds on work to date by expanding access to evidence-based, telehealth preventive and mental health services for women Veterans with high-priority health conditions in rural and urban-isolation areas. METHODS EMPOWER 2.0 will evaluate two implementation strategies, Replicating Effective Practices (REP) and Evidence-Based Quality Improvement (EBQI), in supporting the implementation and sustainment of three evidence-based interventions (Virtual Diabetes Prevention Program; Telephone Lifestyle Coaching Program; and Reach Out, Stay Strong Essentials) focused on preventive and mental health care for women Veterans. We will conduct a mixed-methods implementation evaluation using a cluster-randomized hybrid type 3 effectiveness-implementation trial design to compare the effectiveness of REP and EBQI on improved access to and rates of engagement in telehealth preventive lifestyle and mental health services. Other outcomes of interest include (a) VA performance metrics for telehealth care delivery and related clinical outcomes; (b) progression along the Stages of Implementation Completion; (c) adaptation, sensemaking, and experiences of implementation among multilevel stakeholders; and (d) cost and return on investment. We will also generate implementation playbooks for program partners to support scale-up and spread of these and future evidence-based women's health programs and policies. DISCUSSION EMPOWER 2.0 provides a model for mixed-methods hybrid type 3 effectiveness-implementation trial design incorporating evaluation of performance metrics, implementation progress, stakeholder experience, and cost and return on investment, with the ultimate goal of improving access to evidence-based preventive and mental telehealth services for women Veterans with high-priority health conditions. TRIAL REGISTRATION ClinicalTrials.gov, NCT05050266 . Registered on 20 September 2021.
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Affiliation(s)
- Alison B Hamilton
- Veterans Affairs Health Services Research and Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA.
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA.
| | - Erin P Finley
- Veterans Affairs Health Services Research and Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Departments of Medicine and Psychiatry and Behavioral Sciences, University of Texas Health Science Center, San Antonio, TX, USA
| | - Bevanne Bean-Mayberry
- Veterans Affairs Health Services Research and Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Division of General Internal Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Ariel Lang
- VA San Diego Healthcare System, San Diego, CA, USA
- Department of Psychiatry, University of California San Diego, San Diego, CA, USA
| | - Sally G Haskell
- VA HSR&D Pain Research, Informatics, Multi-morbidities, and Education Center, VA Connecticut Healthcare System, West Haven, CT, USA
- Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, CT, USA
| | - Tannaz Moin
- Veterans Affairs Health Services Research and Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Division of General Internal Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
- Division of Endocrinology, Diabetes & Metabolism, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Melissa M Farmer
- Veterans Affairs Health Services Research and Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
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Orshak JJ, Lauver DR. Developing and Evaluating Survey Items About Women Veterans’ Care-seeking for Cardiovascular Disease Prevention. JOURNAL OF VETERANS STUDIES 2023. [DOI: 10.21061/jvs.v9i1.319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
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Krishnamurti LS, Agha A, Denneson LM, Montgomery AE, Chhatre S, Dichter ME. Gender Differences in Connecting Veterans to Care Through the Veterans Crisis Line: A Mixed Methods Evaluation of Referrals to Suicide Prevention Coordinators. Med Care 2023; 61:50-53. [PMID: 36477620 DOI: 10.1097/mlr.0000000000001789] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Suicide is a major public health crisis within the US military veteran community, with distinct gender differences in suicide risk and behavior. The Veterans Crisis Line (VCL) is a component of the Veterans Health Administration (VHA) suicide prevention program; through VCL, veterans may be referred to a VHA Suicide Prevention Coordinator (SPC) to arrange follow-up care. Research shows that engagement with an SPC is a strong protective factor in reducing veteran suicide risk. METHODS We evaluated SPC referral acceptance and assessed correlates of SPC referral decline using VCL administrative data for contacts: (1) made between January 1, 2018, through December 31, 2019; (2) by veterans contacting VCL on their own behalf; (3) with gender identified; and (4) current thoughts of suicide. Then, among a subsample of 200 veterans, evenly distributed by gender, we examined data from call synopsis notes to identify reasons given for veterans declining an SPC referral. RESULTS We found it was generally callers rated as lower risk by responders, and callers with loneliness as a reason for contacting VCL, who more frequently declined the SPC referral. An analysis of reasons given for declining SPC referral found that concerns with/about Veterans Affairs care were a key concern, particularly among women veterans articulating specific negative care experiences. Other reasons for referral decline included managing the veteran's needs directly on the call or via alternative resources. CONCLUSION The VCL as an intervention provides an important opportunity to re-engage vulnerable veterans into care, one that may be more challenging for women veterans.
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Affiliation(s)
- Lauren S Krishnamurti
- US Department of Veterans Affairs, Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh
| | - Aneeza Agha
- US Department of Veterans Affairs, Center for Health Equity Research and Promotion, Crescenz VA Medical Center, Philadelphia, PA
| | - Lauren M Denneson
- US Department of Veterans Affairs, VA Portland Health Care System
- Oregon Health and Science University School of Medicine, Portland, OR
| | - Ann E Montgomery
- Birmingham VA Health Care System & National Center on Homelessness among Veterans
- School of Public Health, University of Alabama at Birmingham, Birmingham, AL
| | | | - Melissa E Dichter
- US Department of Veterans Affairs, Center for Health Equity Research and Promotion, Crescenz VA Medical Center, Philadelphia, PA
- Temple University School of Social Work, Philadelphia, PA
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15
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Fenwick KM, Dyer KE, Klap R, Oishi K, Moreau JL, Yano EM, Bean-Mayberry B, Sadler AG, Hamilton AB. Expert Recommendations for Designing Reporting Systems to Address Patient-Perpetrated Sexual Harassment in Healthcare Settings. J Gen Intern Med 2022; 37:3723-3730. [PMID: 35266124 PMCID: PMC9585114 DOI: 10.1007/s11606-022-07467-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 02/08/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Patient-perpetrated sexual harassment toward staff and patients is prevalent in Veterans Affairs and other healthcare settings. However, many healthcare facilities do not have adequate systems for reporting patient-perpetrated harassment, and there is limited evidence to guide administrators in developing them. OBJECTIVE To identify expert recommendations for designing effective systems for reporting patient-perpetrated sexual harassment of staff and patients in Veterans Affairs and other healthcare settings. DESIGN We conducted qualitative interviews with subject matter experts in sexual harassment prevention and intervention during 2019. PARTICIPANTS We used snowball sampling to recruit subject matter experts. Participants included researchers, clinicians, and administrators from Veterans Affairs/other healthcare, academic, military, and non-profit settings (n = 33). APPROACH We interviewed participants via telephone using a semi-structured guide and analyzed interview data using a constant comparative approach. KEY RESULTS Expert recommendations for designing reporting systems to address patient-perpetrated sexual harassment focused on fostering trust, encouraging reporting, and deterring harassment. Recommendations included the following: (1) promote a climate in which harassment is not tolerated; (2) take proportional, corrective actions in response to reports; (3) minimize adverse outcomes for reporting parties; (4) facilitate and simplify reporting processes; and (5) hold the reporting system accountable. Specific strategies related to each recommendation were also identified. CONCLUSIONS This qualitative study generated initial recommendations to guide healthcare administrators and policy makers in assessing, developing, and improving systems for reporting patient-perpetrated sexual harassment toward staff and other patients. Results indicate that proactive, careful design and ongoing evaluation are essential for ensuring that reporting systems have their intended effects and mitigating the risks of inadequate systems. Additional research is needed to evaluate strategies that effectively address patient-perpetrated harassment while balancing patients' clinical needs.
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Affiliation(s)
- Karissa M. Fenwick
- HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, CA USA
| | - Karen E. Dyer
- HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, CA USA
| | - Ruth Klap
- HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, CA USA
| | - Kristina Oishi
- HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, CA USA
| | - Jessica L. Moreau
- HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, CA USA
| | - Elizabeth M. Yano
- HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, CA USA
- Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, CA USA
- Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, CA USA
| | - Bevanne Bean-Mayberry
- HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, CA USA
- Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, CA USA
| | - Anne G. Sadler
- VA Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Healthcare System, Iowa City, IA USA
- Department of Psychiatry, University of Iowa Carver College of Medicine, Iowa City, IA USA
| | - Alison B. Hamilton
- HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, CA USA
- Department of Psychiatry and Biobehavioral Sciences, UCLA David Geffen School of Medicine, Jane & Terry Semel Institute for Neuroscience & Human Behavior, Los Angeles, CA USA
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Monteith LL, Holliday R, Dichter ME, Hoffmire CA. Preventing Suicide Among Women Veterans: Gender-Sensitive, Trauma-Informed Conceptualization. CURRENT TREATMENT OPTIONS IN PSYCHIATRY 2022; 9:186-201. [PMID: 35730002 PMCID: PMC9198614 DOI: 10.1007/s40501-022-00266-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Accepted: 05/20/2022] [Indexed: 11/26/2022]
Abstract
Purpose of Review There is growing concern regarding suicide among women veterans, who have experienced an increase in suicide rates that has exceeded that reported for other US adult populations. Recent research has bolstered understanding of correlates of suicide risk specific to women veterans. Yet most existing suicide prevention initiatives take a gender-neutral, rather than gender-sensitive, approach. We offer clinical considerations and suggestions for suicide prevention tailored to the needs, preferences, and experiences of women veterans. Discussion is framed around the White House strategy for preventing suicide among military service members and veterans. Recent Findings Considering high rates of trauma exposure among women veterans, we propose that a trauma-informed lens is essential for taking a gender-sensitive approach to suicide prevention with this population. Nonetheless, research to inform evidence-based assessment and intervention remains largely focused on veteran men or gender-neutral. Integral next steps for research are posited. Summary Extant research provides an initial foundation for beginning to understand and address suicide among women veterans in a gender-sensitive, trauma-informed manner. Additional research that is specific to women veterans or that examines gender differences is critical to ensure women veterans receive optimal, evidence-based care to prevent suicide.
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Getting Connected: a Retrospective Cohort Investigation of Video-to-Home Telehealth for Mental Health Care Utilization Among Women Veterans. J Gen Intern Med 2022; 37:778-785. [PMID: 36042096 PMCID: PMC9427431 DOI: 10.1007/s11606-022-07594-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 04/01/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND Increasingly, women are serving in the military and seeking care at the Veterans Health Administration (VHA). Women veterans face unique challenges and barriers in seeking mental health (MH) care within VHA. VA Video Connect (VVC), which facilitates video-based teleconferencing between patients and providers, can reduce barriers while maintaining clinical effectiveness. OBJECTIVE Primary aims were to examine gender differences in VVC use, describe changes in VVC use over time (including pre-COVID and 6 months following the beginning of COVID), and determine whether changes over time differed by gender. DESIGN A retrospective cohort investigation of video-to-home telehealth for MH care utilization among veterans having at least 1 MH visit from October 2019 to September 2020. PARTICIPANTS Veterans (236,268 women; 1,318,024 men). INTERVENTIONS (IF APPLICABLE) VVC involves face-to-face, synchronous, video-based teleconferencing between patients and providers, enabling care at home or another private location. MAIN MEASURES Percentage of MH encounters delivered via VA Video Connect. KEY RESULTS Women veterans were more likely than men to have at least 1 VVC encounter and had a greater percentage of MH care delivered via VVC in FY20. There was an increase in the percentage of MH encounters that were VVC over FY20, and this increase was greater for women than men. Women veterans who were younger than 55 (compared to those 55 and older), lived in urban areas (compared to those in rural areas), or were Asian (compared to other races) had a greater percentage of MH encounters that were VVC since the start of the pandemic, controlling for the mean percentage of VVC MH encounters in the 6 months pre-pandemic. CONCLUSIONS VVC use for MH care is greater in women veterans compared to male veterans and may reduce gender-specific access barriers. Future research and VVC implementation efforts should emphasize maximizing patient choice and satisfaction.
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Carlson GC, Than CT, Rose D, Brunner J, Chanfreau-Coffinier C, Canelo IA, Klap R, Bean-Mayberry B, Agrawal A, Hamilton AB, Gerber MR, Yano EM. What Drives Women Veterans' Trust in VA Healthcare Providers? Womens Health Issues 2022; 32:499-508. [PMID: 35367107 PMCID: PMC9522916 DOI: 10.1016/j.whi.2022.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 02/01/2022] [Accepted: 02/10/2022] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Little is known about women veterans' trust in Veterans Affairs (VA) health care and what factors promote trust in VA providers. We examined provider behaviors and characteristics of women veterans associated with trust in their VA providers. METHODS We used a 2015 survey of women veterans who were routine users of primary care at 12 VA medical centers (n = 1,395). Patient trust in their VA provider was measured on a seven-item scale. We used multiple logistic regression to examine associations of patient-provider communication and gender appropriateness with complete trust in VA provider (100 [complete trust] vs. <100 [less than complete trust]), controlling for patient characteristics. RESULTS On average, 39.7% of women veterans reported complete trust in their VA providers. Those with complete trust reported greater patient-provider communication and gender appropriateness of VA services than those with less-than-complete trust (all ps ≤ .001). In multiple logistic regression models, higher ratings of provider communication (adjusted odds ratio, 2.37), gender-appropriate care (adjusted odds ratio, 1.93), and trauma-sensitive communication (adjusted odds ratios, 1.79-6.08) were associated with a higher likelihood of reporting complete trust in their VA provider. CONCLUSIONS Women veterans reported high levels of trust in their VA providers. Provider communication, gender-appropriate care, and trauma-sensitive communication were associated with greater patient trust. Although it is important to highlight the steps already taken by VA to increase the quality of care for women veterans, current findings suggest that women veterans' trust may be further increased by interventions to improve trauma-informed care by VA providers.
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Affiliation(s)
- Gwendolyn C Carlson
- Department of Mental Health, VA Greater Los Angeles Healthcare System, North Hills, California; VA Los Angeles HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, North Hills, California; Department of Psychiatry and Biobehavioral Sciences, UCLA Geffen School of Medicine, Los Angeles, California.
| | - Claire T Than
- VA Los Angeles HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, North Hills, California
| | - Danielle Rose
- VA Los Angeles HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, North Hills, California
| | - Julian Brunner
- VA Los Angeles HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, North Hills, California
| | - Catherine Chanfreau-Coffinier
- VA Los Angeles HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, North Hills, California; VA Informatics and Computing Infrastructure (VINCI), Salt Lake City VA Healthcare System, Salt Lake City, Utah
| | - Ismelda A Canelo
- VA Los Angeles HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, North Hills, California
| | - Ruth Klap
- VA Los Angeles HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, North Hills, California; Department of Psychiatry and Biobehavioral Sciences, UCLA Geffen School of Medicine, Los Angeles, California
| | - Bevanne Bean-Mayberry
- VA Los Angeles HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, North Hills, California; Department of Medicine, UCLA Geffen School of Medicine, Los Angeles, California
| | - Alpna Agrawal
- Department of Mental Health, VA Greater Los Angeles Healthcare System, North Hills, California; VA Los Angeles HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, North Hills, California; Department of Psychiatry and Biobehavioral Sciences, UCLA Geffen School of Medicine, Los Angeles, California
| | - Alison B Hamilton
- VA Los Angeles HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, North Hills, California; Department of Psychiatry and Biobehavioral Sciences, UCLA Geffen School of Medicine, Los Angeles, California
| | - Megan R Gerber
- Albany Medical College, Albany Stratton VA Medical Center, Albany, New York
| | - Elizabeth M Yano
- VA Los Angeles HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, North Hills, California; Department of Medicine, UCLA Geffen School of Medicine, Los Angeles, California; Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, California
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Differences in Burnout and Intent to Leave Between Women's Health and General Primary Care Providers in the Veterans Health Administration. J Gen Intern Med 2022; 37:2382-2389. [PMID: 34618305 PMCID: PMC9360298 DOI: 10.1007/s11606-021-07133-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 09/02/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Although they are a minority of patients served by the Veterans Health Administration (VHA), women Veterans comprise a fast-growing segment of these patients and have unique clinical needs. Women's health primary care providers (WH-PCPs) are specially trained and designated to provide care for women Veterans. Prior work has demonstrated that WH-PCPs deliver better preventative care and have more satisfied patients than PCPs without the WH designation. However, due to unique clinical demands or other factors, WH-PCPs may experience more burnout and intent to leave practice than general PCPs in the VHA. OBJECTIVE To examine differences in burnout and intent to leave practice among WH and general PCPs in the VHA. DESIGN Multi-level logistic regression analysis of three cross-sectional waves of PCPs within the VHA using the national All Employee Survey and practice data (2017-2019). We modeled outcomes of burnout and intent to leave practice as a function of WH provider designation, gender, and other demographics and practice characteristics, such as support staff ratio, panel size, and setting. PARTICIPANTS A total of 7903 primary care providers (5152 general PCPs and 2751 WH-PCPs; response rates: 63.9%, 65.7%, and 67.5% in 2017, 2018, and 2019, respectively). MAIN MEASURES Burnout and intent to leave practice. KEY RESULTS WH-PCPs were more burned out than general PCPs (unadjusted: 55.0% vs. 46.9%, p<0.001; adjusted: OR=1.29, 95% confidence interval [CI] 1.10-1.55) but did not have a higher intention to leave (unadjusted: 33.4% vs. 32.1%, p=0.27; adjusted: OR=1.07, CI 0.81-1.41). WH-PCPs with intentions to leave were more likely to select the response option of "job-related (e.g., type of work, workload, burnout, boredom)" as their primary reason to leave. CONCLUSIONS Burnout is higher among WH-PCPs compared to general PCPs, even after accounting for provider and practice characteristics. More research on causes of and solutions for these differences in burnout is needed.
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Scheuner MT, Huynh AK, Chanfreau-Coffinier C, Lerner B, Gable AR, Lee M, Simon A, Coeshott R, Hamilton AB, Patterson OV, DuVall S, Russell MM. Demographic Differences Among US Department of Veterans Affairs Patients Referred for Genetic Consultation to a Centralized VA Telehealth Program, VA Medical Centers, or the Community. JAMA Netw Open 2022; 5:e226687. [PMID: 35404460 PMCID: PMC9002339 DOI: 10.1001/jamanetworkopen.2022.6687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
IMPORTANCE Telehealth enables access to genetics clinicians, but impact on care coordination is unknown. OBJECTIVE To assess care coordination and equity of genetic care delivered by centralized telehealth and traditional genetic care models. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study included patients referred for genetic consultation from 2010 to 2017 with 2 years of follow-up in the US Department of Veterans Affairs (VA) health care system. Patients were excluded if they were referred for research, cytogenetic, or infectious disease testing, or if their care model could not be determined. EXPOSURES Genetic care models, which included VA-telehealth (ie, a centralized team of genetic counselors serving VA facilities nationwide), VA-traditional (ie, a regional service by clinical geneticists and genetic counselors), and non-VA care (ie, community care purchased by the VA). MAIN OUTCOMES AND MEASURES Multivariate regression models were used to assess associations between patient and consultation characteristics and the type of genetic care model referral; consultation completion; and having 0, 1, or 2 or more cancer surveillance (eg, colonoscopy) and risk-reducing procedures (eg, bilateral mastectomy) within 2 years following referral. RESULTS In this study, 24 778 patients with genetics referrals were identified, including 12 671 women (51.1%), 13 193 patients aged 50 years or older (53.2%), 15 639 White patients (63.1%), and 15 438 patients with cancer-related referrals (62.3%). The VA-telehealth model received 14 580 of the 24 778 consultations (58.8%). Asian patients, American Indian or Alaskan Native patients, and Hawaiian or Pacific Islander patients were less likely to be referred to VA-telehealth than White patients (OR, 0.54; 95% CI, 0.35-0.84) compared with the VA-traditional model. Completing consultations was less likely with non-VA care than the VA-traditional model (OR, 0.45; 95% CI, 0.35-0.57); there were no differences in completing consultations between the VA models. Black patients were less likely to complete consultations than White patients (OR, 0.84; 95% CI, 0.76-0.93), but only if referred to the VA-telehealth model. Patients were more likely to have multiple cancer preventive procedures if they completed their consultations (OR, 1.55; 95% CI, 1.40-1.72) but only if their consultations were completed with the VA-traditional model. CONCLUSIONS AND RELEVANCE In this cross-sectional study, the VA-telehealth model was associated with improved access to genetics clinicians but also with exacerbated health care disparities and hindered care coordination. Addressing structural barriers and the needs and preferences of vulnerable subpopulations may complement the centralized telehealth approach, improve care coordination, and help mitigate health care disparities.
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Affiliation(s)
- Maren T. Scheuner
- San Francisco Veterans Affairs Health Care System, San Francisco, California
- University of California, San Francisco, School of Medicine, San Francisco
| | - Alexis K. Huynh
- Center for the Study of Healthcare Innovation, Implementation, and Policy, Veterans Affairs Greater Los Angeles Health Care System, Los Angeles, California
| | | | - Barbara Lerner
- Veterans Affairs Boston Health Care System, Boston, Massachusetts
| | - Alicia R. Gable
- Center for the Study of Healthcare Innovation, Implementation, and Policy, Veterans Affairs Greater Los Angeles Health Care System, Los Angeles, California
| | - Martin Lee
- Center for the Study of Healthcare Innovation, Implementation, and Policy, Veterans Affairs Greater Los Angeles Health Care System, Los Angeles, California
- University of California Los Angeles Fielding School of Public Health, Los Angeles
| | - Alissa Simon
- Center for the Study of Healthcare Innovation, Implementation, and Policy, Veterans Affairs Greater Los Angeles Health Care System, Los Angeles, California
| | - Randall Coeshott
- San Francisco Veterans Affairs Health Care System, San Francisco, California
| | - Alison B. Hamilton
- Center for the Study of Healthcare Innovation, Implementation, and Policy, Veterans Affairs Greater Los Angeles Health Care System, Los Angeles, California
- David Geffen School of Medicine at University of California Los Angeles, Los Angeles
| | - Olga V. Patterson
- Veterans Affairs Informatics and Computing Infrastructure, Salt Lake City, Utah
- Division of Epidemiology, University of Utah, Salt Lake City
| | - Scott DuVall
- Veterans Affairs Informatics and Computing Infrastructure, Salt Lake City, Utah
- Division of Epidemiology, University of Utah, Salt Lake City
| | - Marcia M. Russell
- Center for the Study of Healthcare Innovation, Implementation, and Policy, Veterans Affairs Greater Los Angeles Health Care System, Los Angeles, California
- David Geffen School of Medicine at University of California Los Angeles, Los Angeles
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21
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Cannedy S, Dyer KE, Oishi A, Fenwick KM, Olmos-Ochoa TT, Luger TM, Gideonse TK, Cheney AM, Canelo I, Yano EM, Hamilton AB. Managers' and Leaders' Perceptions of Sexual and Gender-Based Public Harassment in the Veterans Health Administration. Womens Health Issues 2022; 32:395-401. [PMID: 35277335 DOI: 10.1016/j.whi.2022.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 01/10/2022] [Accepted: 01/27/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE Managers and leaders have a critical role to play in sexual and gender-based harassment prevention within organizations. Although the Veterans Health Administration has committed to eliminating harassment through national directives and training programs, it is unclear how aware local-level managers and leaders are about public harassment at their facilities and how they perceive sexual and gender-based harassment. We examined middle managers' and leaders' views about whether harassment is perceived as a problem locally, and what policies and procedures (if any) are in place to address public harassment. METHODS We conducted 69 semistructured telephone interviews with middle managers and facility leaders before implementation of an evidence-based quality improvement project designed to improve delivery of comprehensive women's health care. Transcripts were coded using the constant comparative method and analyzed for overarching themes. RESULTS Perceptions of the prevalence of sexual and gender-based public harassment varied among middle managers and leaders. A little more than one-half of respondents were unaware of facility-level policies and procedures to address public harassment between patients. To decrease patient-to-patient harassment, both groups generally supported the creation of separate clinical spaces for women. However, middle managers also stated that education was needed to change patient harassing behavior, which they tied to male military culture. CONCLUSIONS Aligning divergent perspectives of what constitutes sexual and gender-based harassment and how to address it is a necessary step towards tackling harassment at the local level. Managers and leaders should continue to assess environments of care and share findings widely among employees and leadership to improve awareness and inform a unified response.
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Affiliation(s)
- Shay Cannedy
- Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Health Services Research and Development (HSR&D), Los Angeles, California.
| | - Karen E Dyer
- Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Health Services Research and Development (HSR&D), Los Angeles, California
| | - Anneka Oishi
- Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Health Services Research and Development (HSR&D), Los Angeles, California
| | - Karissa M Fenwick
- Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Health Services Research and Development (HSR&D), Los Angeles, California
| | - Tanya T Olmos-Ochoa
- Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Health Services Research and Development (HSR&D), Los Angeles, California
| | | | - Theodore K Gideonse
- Department of Health, Society, and Behavior, UCI Program in Public Health, Irvine, California
| | - Ann M Cheney
- Department of Social Medicine, Population, and Public Health, UC Riverside School of Medicine, Riverside, California
| | - Ismelda Canelo
- Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Health Services Research and Development (HSR&D), Los Angeles, California
| | - Elizabeth M Yano
- Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Health Services Research and Development (HSR&D), Los Angeles, California; Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, California; Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, California
| | - Alison B Hamilton
- Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Health Services Research and Development (HSR&D), Los Angeles, California; Department of Psychiatry and Biobehavioral Sciences, UCLA David Geffen School of Medicine, Jane & Terry Semel Institute for Neuroscience & Human Behavior, Los Angeles, California
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22
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Hoffmire CA, Brenner LA, Katon J, Gaeddert LA, Miller CN, Schneider AL, Monteith LL. Women Veterans' Perspectives on Suicide Prevention in Reproductive Health Care Settings: An Acceptable, Desired, Unmet Opportunity. Womens Health Issues 2022; 32:418-425. [PMID: 35272885 DOI: 10.1016/j.whi.2022.01.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 01/07/2022] [Accepted: 01/12/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Women veterans of reproductive age experience a suicide rate more than double their civilian peers. Developing effective suicide prevention strategies for women veterans requires identifying settings frequented by women veterans where acceptable prevention initiatives can be implemented. Reproductive healthcare (RHC) settings may provide such an opportunity. METHODS We conducted semi-structured interviews with 21 cisgender women veterans of reproductive age using RHC services provided or paid for by the Department of Veterans Affairs (VA) to understand their beliefs, attitudes, and preferences regarding suicide risk assessment and prevention within these settings. Interview analysis was inductive and used a thematic analysis framework. RESULTS Four major themes emerged from the interviews: 1) positive patient-provider relationships in RHC settings are important; 2) some women veterans prefer women providers for RHC and suicide risk screening; 3) women veterans' experiences with VA suicide risk screening and assessment vary; and 4) suicide risk screening and prevention in RHC settings is a desired and acceptable, yet unmet opportunity. CONCLUSIONS Findings from this novel study suggest that VA RHC settings may present a viable milieu for implementing upstream, gender-sensitive, veteran-centric suicide prevention strategies. Future research is needed with VA RHC providers to determine their needs for successfully implementing such strategies.
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Affiliation(s)
- Claire A Hoffmire
- Rocky Mountain Mental Illness, Research, Education and Clinical Center (MIRECC) for Suicide Prevention, Rocky Mountain Regional VAMC, Aurora, Colorado; Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, Colorado.
| | - Lisa A Brenner
- Rocky Mountain Mental Illness, Research, Education and Clinical Center (MIRECC) for Suicide Prevention, Rocky Mountain Regional VAMC, Aurora, Colorado; Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, Colorado; Department of Psychiatry, University of Colorado Anschutz Medical Campus, Aurora, Colorado; Department of Neurology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Jodie Katon
- Health Services Research and Development Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington; Department of Health Services, University of Washington, Seattle, Washington
| | - Laurel A Gaeddert
- Rocky Mountain Mental Illness, Research, Education and Clinical Center (MIRECC) for Suicide Prevention, Rocky Mountain Regional VAMC, Aurora, Colorado
| | - Christin N Miller
- Rocky Mountain Mental Illness, Research, Education and Clinical Center (MIRECC) for Suicide Prevention, Rocky Mountain Regional VAMC, Aurora, Colorado
| | - Alexandra L Schneider
- Rocky Mountain Mental Illness, Research, Education and Clinical Center (MIRECC) for Suicide Prevention, Rocky Mountain Regional VAMC, Aurora, Colorado
| | - Lindsey L Monteith
- Rocky Mountain Mental Illness, Research, Education and Clinical Center (MIRECC) for Suicide Prevention, Rocky Mountain Regional VAMC, Aurora, Colorado; Department of Psychiatry, University of Colorado Anschutz Medical Campus, Aurora, Colorado
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23
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Chrystal JG, Frayne S, Dyer KE, Moreau JL, Gammage CE, Saechao F, Berg E, Washington DL, Yano EM, Hamilton AB. Women Veterans' Attrition from the VA Health Care System. Womens Health Issues 2022; 32:182-193. [PMID: 34972600 DOI: 10.1016/j.whi.2021.11.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 11/17/2021] [Accepted: 11/23/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE Patient attrition from the Veterans Health Administration (VA) health care system could undercut its mission to ensure care for eligible veterans. Attrition of women veterans could exacerbate their minority status and impede systemic efforts to provide high-quality care. We obtained women veterans' perspectives on why they left or continued to use VA health care. METHODS A sampling frame of new women veteran VA patients was stratified by those who discontinued (attriters) and those who continued (non-attriters) using VA care. Semistructured interviews were conducted from 2017 to 2018. Transcribed interviews were coded for women's decision-making, contexts, and recommendations related to health care use. RESULTS Fifty-one women veterans (25 attriters and 26 non-attriters) completed interviews. Reasons for attrition included challenging patient care experiences (e.g., provider turnover, claim processing challenges) and the availability of private health insurance. Personal experiences with VA care (e.g., gender-specific care) were impactful in women's decision to use VA. The affordability of VA care was influential for both groups to stay connected to services. More than one-third of women originally categorized as attriters described subsequently reentering or planning to reenter VA care. Suggestions to decrease attrition included increasing outreach, improving access, and continuing to tailor care delivery to women veterans' needs. CONCLUSIONS Understanding the drivers of patients' decisions to use or not use the VA is critical for the development of strategies to improve retention of current patients and optimize health outcomes for veterans. Women veterans described complex reasons why they left or continued using VA, with cost/affordability playing an important role even in considerations of returning to VA after a long hiatus.
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Affiliation(s)
- Joya G Chrystal
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Health Services Research and Development (HSR&D), Los Angeles, California.
| | - Susan Frayne
- VA HSR&D Center for Innovation to Implementation (Ci2i), VA Palo Alto Healthcare System, Menlo Park, California; Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California
| | - Karen E Dyer
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Health Services Research and Development (HSR&D), Los Angeles, California
| | - Jessica L Moreau
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Health Services Research and Development (HSR&D), Los Angeles, California
| | - Cynthia E Gammage
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Health Services Research and Development (HSR&D), Los Angeles, California
| | - Fay Saechao
- VA HSR&D Center for Innovation to Implementation (Ci2i), VA Palo Alto Healthcare System, Menlo Park, California
| | - Eric Berg
- VA HSR&D Center for Innovation to Implementation (Ci2i), VA Palo Alto Healthcare System, Menlo Park, California
| | - Donna L Washington
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Health Services Research and Development (HSR&D), Los Angeles, California; Division of General Internal Medicine and Health Services Research, UCLA, Los Angeles, California
| | - Elizabeth M Yano
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Health Services Research and Development (HSR&D), Los Angeles, California; Department of Health Policy & Management, UCLA Fielding School of Public Health, Los Angeles, California
| | - Alison B Hamilton
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Health Services Research and Development (HSR&D), Los Angeles, California; Department of Psychiatry and Biobehavioral Sciences, UCLA Geffen School of Medicine, Semel Institute/NPI, Los Angeles, California
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24
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Cucciare MA, Mengeling MA, Han X, Kennedy K, Torner J, Sadler AG. Experiencing Sexual Assault and/or Stalking-Related Behavior is Associated with Binge Drinking and Substance Use Consequences in Deployed U.S. Servicewomen. Womens Health Issues 2022; 32:402-410. [PMID: 34991954 DOI: 10.1016/j.whi.2021.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 11/23/2021] [Accepted: 12/03/2021] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Michael A Cucciare
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, Arizona; VA South Central Mental Illness Research, Education and Clinical Center, Central Arkansas Veterans Healthcare System, North Little Rock, Arkansas; Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Affairs Healthcare System, North Little Rock, Arkansas.
| | - Michelle A Mengeling
- Center for Access and Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, Iowa; VA Office of Rural Health, Veterans Rural Health Resource Center-Iowa City, Iowa City VA Health Care System, Iowa City, Iowa; Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Xiaotong Han
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, Arizona; VA South Central Mental Illness Research, Education and Clinical Center, Central Arkansas Veterans Healthcare System, North Little Rock, Arkansas; Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Affairs Healthcare System, North Little Rock, Arkansas
| | - Kristina Kennedy
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, Arizona
| | - James Torner
- Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, Iowa
| | - Anne G Sadler
- Center for Access and Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, Iowa; Department of Psychiatry, University of Iowa Carver College of Medicine, Iowa City, Iowa
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25
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Castillo F, Peracca S, Oh DH, Twigg AR. The Utilization and Impact of Live Interactive and Store-and-Forward Teledermatology in a Veterans Affairs Medical Center During the COVID-19 Pandemic. Telemed J E Health 2021; 28:1186-1192. [PMID: 34919470 DOI: 10.1089/tmj.2021.0275] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Introduction: Teledermatology has emerged as a promising method of continuing dermatologic care during the coronavirus 2019 (COVID-19) pandemic, including in the Department of Veterans Affairs (VA). Analysis of the utilization and impact of teledermatology within the San Francisco Veterans Affairs Health Care System (SFVAHCS) may elucidate the ways that teledermatology programs can continue to be optimized. Methods: We conducted a retrospective analysis of live interactive encounters, Veterans Affairs Video Connect (VVC), store-and-forward telehealth (SFT), and face-to-face (FTF) consultations, performed within the SFVAHCS from March 2020 to December 2020. To assess utilization, we analyzed numbers of encounters throughout 2020. To assess impact, we analyzed primary diagnoses for each encounter and rates of recommendations for medications and lesion biopsies. Additionally, we assessed diagnostic accuracy associated with each teledermatology type by measuring concordance between teledermatologists' clinical diagnoses and histopathological diagnoses. Results: Two thousand two hundred fifty FTF, 347 VVC, and 470 SFT encounters were conducted from March to December 2020. More female patients utilized VVC, and patients who utilized VVC were younger than SFT and FTF users (p < 0.01). SFT was utilized more by patients from rural areas (p < 0.01). Diagnoses addressed were significantly different between VVC and SFT. A majority of VVC encounters involved referrals for inflammatory conditions; primary diagnoses associated with SFT consultations were most frequently neoplasms. Comparison of VVC and SFT outcomes showed that more VVC visits resulted in a medication recommendation, while more SFT consultations resulted in a biopsy recommendation. Conclusions: Teledermatology contributed to meeting patient needs throughout 2020 and created an impact on clinical management. Patient characteristics, diagnoses, and type of impact associated with encounters varied between SFT and VVC. This analysis provides insight into teledermatology utilization within the VA system and can contribute to efforts to improve the quality of teledermatology care for veterans.
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Affiliation(s)
- Francine Castillo
- Department of Dermatology, University of California, San Francisco School of Medicine, San Francisco, California, USA
| | - Sara Peracca
- Dermatology Research Unit, San Francisco VA Health Care System, San Francisco, California, USA
| | - Dennis H Oh
- Department of Dermatology, University of California, San Francisco School of Medicine, San Francisco, California, USA.,Dermatology Research Unit, San Francisco VA Health Care System, San Francisco, California, USA
| | - Amanda R Twigg
- Department of Dermatology, University of California, San Francisco School of Medicine, San Francisco, California, USA.,Dermatology Research Unit, San Francisco VA Health Care System, San Francisco, California, USA
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Ali J, Davis AF, Burgess DJ, Rhon DI, Vining R, Young‐McCaughan S, Green S, Kerns RD. Justice and equity in pragmatic clinical trials: Considerations for pain research within integrated health systems. Learn Health Syst 2021; 6:e10291. [PMID: 35434355 PMCID: PMC9006531 DOI: 10.1002/lrh2.10291] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 08/23/2021] [Accepted: 09/12/2021] [Indexed: 12/12/2022] Open
Abstract
Introduction Methods Results Conclusions
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Affiliation(s)
- Joseph Ali
- Department of International Health Johns Hopkins Bloomberg School of Public Health Baltimore Maryland USA
- Johns Hopkins Berman Institute of Bioethics Baltimore Maryland USA
| | - Alison F. Davis
- Pain Management Collaboratory, Department of Psychiatry Yale University School of Medicine New Haven Connecticut USA
| | - Diana J. Burgess
- VA HSR&D Center for Care Delivery and Outcomes Research, Minneapolis VA Medical Center Minneapolis Minnesota USA
- Department of Medicine University of Minnesota Medical School Minneapolis Minnesota USA
| | - Daniel I. Rhon
- Brooke Army Medical Center and Uniformed Services University of the Health Sciences Fort Sam Houston Texas USA
| | - Robert Vining
- Palmer Center for Chiropractic Research, Palmer College of Chiropractic Davenport Iowa USA
| | - Stacey Young‐McCaughan
- The University of Texas Health Science Center Houston Texas USA
- South Texas Veterans Health Care System San Antonio Texas USA
| | - Sean Green
- Pain Management Collaboratory, Department of Psychiatry Yale University School of Medicine New Haven Connecticut USA
| | - Robert D. Kerns
- Departments of Psychiatry, Neurology, and Psychology Yale University New Haven Connecticut USA
- VA Connecticut Healthcare System Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center West Haven Connecticut USA
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27
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Fletcher TL, Amspoker AB, Wassef M, Hogan JB, Helm A, Jackson C, Jacobs A, Shammet R, Speicher S, Lindsay JA, Cloitre M. Increasing access to care for trauma-exposed rural veterans: A mixed methods outcome evaluation of a web-based skills training program with telehealth-delivered coaching. J Rural Health 2021; 38:740-747. [PMID: 34648188 DOI: 10.1111/jrh.12628] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
PURPOSE While rural veterans with trauma exposure report high rates of posttraumatic stress disorder (PTSD), depression, and functional impairment, utilization of health services is low. This pilot study used mixed qualitative and quantitative methods to evaluate the potential benefits of a transdiagnostic web-based skills training program paired with telehealth-delivered coaching to address a range of symptoms and functional difficulties. The study directed substantial outreach efforts to women veterans who had experienced military sexual trauma given their growing representation in the Veterans Healthcare Administration (VHA) and identified need for services. METHODS Participants were 32 trauma-exposed veterans enrolled in rural-serving VHA facilities who screened positive for either PTSD or depression. Symptoms of PTSD, depression, emotion regulation, and interpersonal problems were assessed at baseline, midpoint, posttreatment, and 3-month follow-up. Veterans completed exit interviews to identify benefits and limitations of the program. RESULTS Intent-to-treat analyses revealed significant symptom reduction for all outcomes, with large to moderate effect sizes at 3-month follow-up. Outcomes did not differ by gender or military sexual trauma status. Veterans' rating of the therapeutic alliance was high and interview responses indicated that the presence of the coach was critical to success in the program. CONCLUSION This remotely delivered transdiagnostic intervention provided significant benefits across a range of symptoms and functional outcomes and was viewed positively by veterans. The results indicate that further research (ie, a randomized controlled trial) is warranted. Attention to the role of the coach as a means by which to increase engagement and retention in technology-delivered interventions is warranted.
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Affiliation(s)
- Terri L Fletcher
- VA HSR&D Houston Center of Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, USA.,Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, Texas, USA.,VA South Central Mental Illness Research, Education and Clinical Center, Houston, Texas, USA
| | - Amber B Amspoker
- VA HSR&D Houston Center of Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, USA.,VA South Central Mental Illness Research, Education and Clinical Center, Houston, Texas, USA.,Baylor College of Medicine, Department of Medicine, Houston, Texas, USA
| | - Miryam Wassef
- VA HSR&D Houston Center of Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, USA.,VA South Central Mental Illness Research, Education and Clinical Center, Houston, Texas, USA
| | - Julianna B Hogan
- VA HSR&D Houston Center of Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, USA.,Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, Texas, USA.,VA South Central Mental Illness Research, Education and Clinical Center, Houston, Texas, USA
| | - Ashley Helm
- VA HSR&D Houston Center of Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, USA.,VA South Central Mental Illness Research, Education and Clinical Center, Houston, Texas, USA
| | | | - Adam Jacobs
- National Center for PTSD Dissemination and Training Division, VA Palo Alto Health Care System, Palo Alto, California, USA
| | - Rayan Shammet
- National Center for PTSD Dissemination and Training Division, VA Palo Alto Health Care System, Palo Alto, California, USA
| | - Sarah Speicher
- National Center for PTSD Dissemination and Training Division, VA Palo Alto Health Care System, Palo Alto, California, USA
| | - Jan A Lindsay
- VA HSR&D Houston Center of Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, USA.,VA South Central Mental Illness Research, Education and Clinical Center, Houston, Texas, USA.,Baylor College of Medicine, Department of Medicine, Houston, Texas, USA
| | - Marylène Cloitre
- National Center for PTSD Dissemination and Training Division, VA Palo Alto Health Care System, Palo Alto, California, USA.,Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California, USA
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Pebole MM, VanVoorhees EE, Chaudhry N, Goldstein KM, Thompson J, Parker R, Caron KM, Hall KS. Patient-centered behavioral services for women veterans with mental health conditions. Transl Behav Med 2021; 11:1676-1681. [PMID: 34080638 DOI: 10.1093/tbm/ibab057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
The Veterans Health Administration (VHA) is undergoing a transformational shift from disease-focused care to a Whole Health model that emphasizes physical, mental, emotional, and spiritual health and well-being. As this shift is occurring, women veterans using VHA services face challenges navigating a system that has historically served a primarily male demographic, without consistent consensus on which services require specialization by gender. A quality improvement project was conducted to solicit feedback on VHA behavioral and wellness programs from women veterans enrolled in VHA mental healthcare services. A multi-disciplinary work group of clinical researchers and healthcare providers developed a needs assessment survey to assess patient needs and preferences for behavioral health services. A convenience sample of female veterans using VHA mental healthcare services within a comprehensive Women's Health Clinic were invited to complete this anonymous survey. 107 women Veterans 18-65+ years old (65.3% African American; 5.9% LatinX; 54.2% aged under 55) completed the survey. Over 50% of patients endorsed relationships, physical activity, sleep/nightmares, pain management, anger, or spiritual/moral pain as top wellness priorities. Programatic preferences included location (located at the main VA Hospital) and gender composition (female only group formats). Schedule conflicts were the most frequently cited barriers. Results from this quality improvement project highlight considerations for tailoring the content and delivery of behavioral services for women veterans with mental health conditions.
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Affiliation(s)
- Michelle M Pebole
- Department of Kinesiology and Community Health, University of Illinois at Urbana Champaign, Champaign, IL, USA.,Geriatric Research, Education, and Clinical Center, Durham Veterans Affairs Healthcare System, Durham, NC, USA
| | - Elizabeth E VanVoorhees
- Durham Veterans Affairs Medical Center, Durham, NC, USA.,Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | | | - Karen M Goldstein
- Durham Veterans Affairs Medical Center, Durham, NC, USA.,Department of Medicine, Duke University, Durham, NC, USA
| | - Jillian Thompson
- Physical Medicine and Rehabilitation Service, Durham Veterans Affairs Healthcare System, Durham, NC, USA
| | - Ryan Parker
- Chaplain Service, Durham Veterans Affairs Healthcare System, Durham, NC, USA
| | - Kelly M Caron
- Durham Veterans Affairs Medical Center, Durham, NC, USA
| | - Katherine S Hall
- Geriatric Research, Education, and Clinical Center, Durham Veterans Affairs Healthcare System, Durham, NC, USA.,Department of Medicine, Duke University, Durham, NC, USA
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Fenwick KM, Potter SJ, Klap R, Dyer KE, Relyea MR, Yano EM, Luger TM, Bergman AA, Chrystal JG, Hamilton AB. Staff and Patient Perspectives on Bystander Intervention Training to Address Patient-Initiated Sexual Harassment in Veterans Affairs Healthcare Settings. Womens Health Issues 2021; 31:576-585. [PMID: 34452824 DOI: 10.1016/j.whi.2021.07.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 06/14/2021] [Accepted: 07/22/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION One in four women veteran patients experience public harassment by men veterans at Veterans Affairs (VA) health care facilities. Bystander intervention training-teaching bystanders to identify harassment, assess appropriate responses, and safely intervene before, during, or after an event-is a popular strategy for addressing harassment in military and education settings. We explored staff and veteran patient perspectives on bystander intervention training to address harassment of women veterans in VA health care settings. METHODS We conducted 24 staff interviews and 15 veteran patient discussion groups (eight men's groups and seven women's groups) at four VA Medical Centers. We analyzed transcripts using the constant comparative method. RESULTS Participants expressed divergent views about bystander intervention training to address harassment of women veteran patients at VA. Most participants supported training staff in bystander intervention, but support for training patients was mixed. Participants identified potential benefits of bystander intervention, including staff and patient empowerment and improvements to organizational culture. They also identified potential concerns, including provocation of conflict between patients, lack of buy-in among the VA community, and difficulty in identifying intervention-appropriate situations. Finally, participants offered recommendations for tailoring training content and format to the VA context. CONCLUSIONS Bystander intervention training has the potential to raise collective responsibility for addressing harassment of women in VA and other health care contexts. However, our results illustrate divergent stakeholder views that underscore the importance of engaging and educating stakeholders, securing buy-in, and tailoring bystander intervention programs to local contexts before implementation.
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Affiliation(s)
- Karissa M Fenwick
- HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, California.
| | - Sharyn J Potter
- Department of Women's and Gender Studies, Prevention Innovations Research Center, University of New Hampshire, Durham, New Hampshire
| | - Ruth Klap
- HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, California; Department of Psychiatry and Biobehavioral Sciences, UCLA David Geffen School of Medicine, Jane & Terry Semel Institute for Neuroscience & Human Behavior, Los Angeles, California
| | - Karen E Dyer
- HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Mark R Relyea
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut; Yale School of Medicine, New Haven, Connecticut
| | - Elizabeth M Yano
- HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, California; Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, California; Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, California
| | - Tana M Luger
- HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, California; Covenant Health Network, Phoenix, Arizona
| | - Alicia A Bergman
- HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Joya G Chrystal
- HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Alison B Hamilton
- HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, California; Department of Psychiatry and Biobehavioral Sciences, UCLA David Geffen School of Medicine, Jane & Terry Semel Institute for Neuroscience & Human Behavior, Los Angeles, California
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Challenges to Addressing Patient-Perpetrated Sexual Harassment in Veterans Affairs Healthcare Settings. J Gen Intern Med 2021; 36:2332-2338. [PMID: 33634380 PMCID: PMC8342739 DOI: 10.1007/s11606-020-06390-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 12/03/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Patient-perpetrated sexual harassment adversely affects healthcare organizations, staff, and other patients, yet few institutions have clear policies to address it. Understanding the challenges to addressing patient-perpetrated harassment can inform development of institutional guidelines and interventions. OBJECTIVE To identify challenges and stakeholder-driven recommendations for addressing patient-perpetrated sexual harassment of women staff and patients at Veterans Health Administration (VA) facilities. DESIGN We conducted qualitative interviews with 24 staff, clinicians, and administrators across four VA healthcare facilities. PARTICIPANTS We used snowball sampling to identify stakeholders with expertise in overseeing care environments, providing care to women patients, and/or managing disruptive patient behavior. APPROACH We interviewed participants in-person or via phone using a semi-structured guide. Two members of the research team analyzed the interview data using the constant comparative method. KEY RESULTS Participants identified challenges to addressing patient-perpetrated harassment of women staff and patients that were interrelated and spanned multiple levels. Perceived organizational-level challenges included a climate of tolerance for harassment, lack of formal policies, and insufficient leadership support. At the staff level, perceived challenges included ambiguity around defining harassment, fear of negatively impacting patient-staff dynamics, and competing priorities. Finally, participants identified patient-level challenges, including patient characteristics such as age, cognitive impairment, and psychiatric diagnoses that complicated assessments of intentionality and culpability. Participant recommendations focused on development and implementation of policies, reporting systems, public norms campaigns, staff and patient education, and bystander intervention training. CONCLUSIONS VA offers unique opportunities for studying patient-perpetrated harassment of women staff and patients due to its majority-male patient population, culture informed by military gender norms, and commitment to reducing harassment at its facilities. Our findings highlight the complexity of addressing patient-perpetrated harassment and underscore the need for systemic, multilevel interventions.
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Fenwick KM, Golden RE, Frayne SM, Hamilton AB, Yano EM, Carney DV, Klap R. Women Veterans' Experiences of Harassment and Perceptions of Veterans Affairs Health Care Settings During a National Anti-Harassment Campaign. Womens Health Issues 2021; 31:567-575. [PMID: 34238668 DOI: 10.1016/j.whi.2021.06.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 06/08/2021] [Accepted: 06/11/2021] [Indexed: 11/19/2022]
Abstract
PURPOSE In 2017, Veterans Health Administration (VA) launched a social marketing and training campaign to address harassment of women veterans at VA health care facilities. We assessed women veterans' experiences of harassment, reported perpetrators of harassment, and perceptions of VA in 2017 (before campaign launch) and 2018 (1 year after campaign implementation). METHODS We administered surveys to women veterans attending primary care appointments (2017, n = 1,300; 2018, n = 1,711). Participants reported whether they experienced sexual harassment (e.g., catcalls) and gender harassment (e.g., questioning women's veteran status) from patients and/or staff at VA in the past 6 months. They also indicated whether they felt welcome, felt safe, and believed the VA is working to address harassment. We compared variables in 2017 versus 2018 with χ2 analyses, adjusting for facility-level clustering. RESULTS There were no significant differences in percentages of participants reporting sexual harassment (20% vs. 17%) or gender harassment (11% vs. 11%) in 2017 versus 2018. Men veterans were the most frequently named perpetrators, but participants also reported harassment from staff. Participant beliefs that VA is working to address harassment significantly improved from 2017 to 2018 (52% vs. 57%; p = .05). CONCLUSIONS One year after campaign launch, women veterans continued to experience harassment while accessing VA health care services. Findings confirm that ongoing efforts to address and monitor both staff- and patient-perpetrated harassment are essential. Results have implications for future anti-harassment intervention design and implementation and highlight additional opportunities for investigation.
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Affiliation(s)
- Karissa M Fenwick
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, California.
| | - Rachel E Golden
- VA HSR&D Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, California
| | - Susan M Frayne
- VA HSR&D Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, California; Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Alison B Hamilton
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, California; Department of Psychiatry and Biobehavioral Sciences, UCLA David Geffen School of Medicine, Jane & Terry Semel Institute for Neuroscience & Human Behavior, Los Angeles, California
| | - Elizabeth M Yano
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, California; Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, California; Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, California
| | - Diane V Carney
- VA HSR&D Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, California
| | - Ruth Klap
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, California; Department of Psychiatry and Biobehavioral Sciences, UCLA David Geffen School of Medicine, Jane & Terry Semel Institute for Neuroscience & Human Behavior, Los Angeles, California
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Goodwin CL, Driver JA, Shipherd JC, Yeterian JD, Mori DL. Fallen Between the Cracks: Protecting Research Staff From Participant-Perpetrated Harassment. J Empir Res Hum Res Ethics 2021; 16:389-395. [PMID: 34180742 DOI: 10.1177/15562646211028010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
There has been a call to identify populations who are at-risk for harassment. At our institution, participant-perpetrated harassment led to the development of an institution-wide program called Cultivating Respect in Research Environments (CuRRE). In this article, we describe the proactive and multipronged approach used to promote and implement the CuRRE program. We describe a policy created to set guidelines and expectations for research participants and discuss the educational and skills-based trainings delivered to principal investigators and research staff members. Research staff members completed anonymous surveys before and after the training. Over half of the attendees reported having been harassed by a participant/patient. Attendees responded favorably to the training; they felt more confident and better equipped to address participant-perpetrated harassment at the conclusion of the training. Given the dearth of literature in this area, we offer our experiences to encourage others to address this issue within their own research environment and institution.
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Affiliation(s)
- Christina L Goodwin
- 20025VA Boston Healthcare System, Boston, MA, USA.,1811Harvard Medical School, Boston, MA, USA.,12259Boston University School of Medicine, Boston, MA, USA
| | - Jane A Driver
- 1811Harvard Medical School, Boston, MA, USA.,New England Geriatric Research Education and Clinical Center, VA Boston Healthcare System, Boston, MA, USA.,Division of Aging, 1861Brigham and Women's Hospital, Boston, MA, USA
| | - Jillian C Shipherd
- 12259Boston University School of Medicine, Boston, MA, USA.,LGBTQ+ Health Program Office of Patient Care Services, 8267Department of Veterans Affairs, Washington, DC, USA.,National Center for PTSD, Women's Health Sciences Division, VA Boston Healthcare System, Boston, MA, USA
| | - Julie D Yeterian
- 20025VA Boston Healthcare System, Boston, MA, USA.,12259Boston University School of Medicine, Boston, MA, USA
| | - DeAnna L Mori
- 20025VA Boston Healthcare System, Boston, MA, USA.,12259Boston University School of Medicine, Boston, MA, USA
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Jones AL, Fine MJ, Taber PA, Hausmann LR, Burkitt KH, Stone RA, Zickmund SL. National Media Coverage of the Veterans Affairs Waitlist Scandal: Effects on Veterans' Distrust of the VA Health Care System. Med Care 2021; 59:S322-S326. [PMID: 33976083 PMCID: PMC8121177 DOI: 10.1097/mlr.0000000000001551] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND On April 23, 2014, US media outlets broadcast reports of excessive wait times and "secret" waitlists at some Veterans Affairs (VA) hospitals, precipitating legislation to increase Veterans' access to private sector health care. OBJECTIVE The aims were to assess changes in Veterans' distrust in the VA health care system before and after the media coverage and explore sex and racial/ethnic differences in the temporal patterns. METHODS Veterans completed semistructured interviews on health care satisfaction from June 2013 to January 2015, including a validated scale of health system distrust (range: 1-5). We used linear splines with knots at 90-day intervals to assess changes in distrust before and after April 23, 2014 ("day 0") in linear mixed models. To explore sex and racial/ethnic differences in temporal patterns, we stratified models by sex and tested for interactions of race/ethnicity with time. RESULTS For women (n=600), distrust scores (mean=2.09) increased by 0.45 in days 0-90 (P<0.01), then decreased by 0.45 in days 90-180 (P<0.01). Among men (n=575), distrust scores (mean=2.05) increased by 0.18 in days 0-90 (P=0.059). Distrust levels were significantly higher for Black versus White women (time adjusted mean difference=0.21) and for Black and Hispanic versus White men (differences=0.26 and 0.18). However, the temporal patterns did not vary by race/ethnicity for women or men (interaction P=0.85 and 0.21, respectively). CONCLUSIONS Health system distrust increased in women following media coverage of VA access problems and was higher in Black/Hispanic versus White Veterans at all time periods. Such perceptions could influence Veteran decisions to seek health care in the community rather than VA.
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Affiliation(s)
- Audrey L. Jones
- VA Salt Lake City Health Care System, Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center
- Department of Internal Medicine, Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, UT
| | - Michael J. Fine
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion
- Department of Medicine, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Peter A. Taber
- Department of Biomedical Informatics, University of Utah School of Medicine, Salt Lake City, UT
| | - Leslie R.M. Hausmann
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion
- Department of Medicine, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Kelly H. Burkitt
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion
| | - Roslyn A. Stone
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion
| | - Susan L. Zickmund
- VA Salt Lake City Health Care System, Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center
- Department of Internal Medicine, Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, UT
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Barriers to PTSD treatment-seeking by women veterans who experienced military sexual trauma decades ago: The role of institutional betrayal. Nurs Outlook 2021; 69:458-470. [PMID: 33863545 DOI: 10.1016/j.outlook.2021.02.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 02/03/2021] [Accepted: 02/05/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND While some barriers to PTSD treatment engagement among veterans are well-identified, e.g., stigma, little is known about the barriers to VA PTSD treatment-seeking among women veterans who experienced military sexual trauma (MST) decades ago. PURPOSE To explore the barriers to PTSD treatment-seeking of women veterans with PTSD related to MST experienced prior to 2000. METHOD Data were collected from women veterans (n = 14) who had experienced MST and sought VA PTSD treatment. Data analyses utilized a constructivist grounded theory approach. FINDINGS The context of the MST experience, including the military environment at the time, the era in which they experienced MST and the response of others to their reporting or disclosure of MST created decades-long barriers to PTSD treatment-seeking. DISCUSSION Understanding institutional betrayal as a barrier to PTSD treatment-seeking among women veterans who experienced MST decades ago is necessary to develop effective targeted outreach and programs for this population.
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Johnson LL, Muehler T, Stacy MA. Veterans' satisfaction and perspectives on helpfulness of the Veterans Crisis Line. Suicide Life Threat Behav 2021; 51:263-273. [PMID: 33876480 DOI: 10.1111/sltb.12702] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Crisis hotlines are an important part of a public health approach to suicide prevention. The Veterans Crisis Line (VCL) provides hotline services to Veterans. There is a paucity of research concerning the effectiveness of the VCL. The current work describes efforts to establish groundwork for VCL effectiveness research. METHODS 155 VCL users who were referred to a Veterans Affairs Medical Center Suicide Prevention Team completed interviews including open-ended and closed-ended questions. Outcomes are reported for suicidal participants, non-suicidal participants, and those who had emergency intervention. Thematic analysis was used for open-ended questions. RESULTS Eighty-seven percent of interviewees expressed satisfaction with the VCL, 81.9% reported that the VCL was helpful, and 72.9% said that the VCL helped keep them safe. Of those with suicidal thoughts, 82.6% said the contact helped stop them from killing themselves. Themes are described concerning user identified reasons for VCL contact, most and least helpful aspects of the contact, and suggestions for improvement. DISCUSSION This project demonstrates that this group of people who used the VCL overwhelmingly finds the service to be helpful and a barrier to suicide. Further, implications of user feedback for application to VCL operations and future research are discussed.
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Affiliation(s)
- Lora L Johnson
- Department of Veterans Affairs, Robley Rex VA Medical Center, Louisville, KY, USA
| | - Tanner Muehler
- Department of Veterans Affairs, Robley Rex VA Medical Center, Louisville, KY, USA.,Eastern Kentucky University, Richmond, KY, USA
| | - Meaghan A Stacy
- Department of Veterans Affairs, Veterans Crisis Line, National Care Coordination and Field Operations Team, Canandaigua, NY, USA.,Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA
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The Focus They Deserve: Improving Women Veterans' Health Care Access. Womens Health Issues 2021; 31:399-407. [PMID: 33582001 DOI: 10.1016/j.whi.2020.12.011] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Revised: 12/18/2020] [Accepted: 12/24/2020] [Indexed: 11/23/2022]
Abstract
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.
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Monteith LL, Holliday R, Hoffmire CA, Bahraini NH. Female Veterans' Willingness to Seek Veterans Health Administration and Non-Veterans Health Administration Services for Suicidal Thoughts and Mental Health Concerns. Med Care 2021; 59:S23-S30. [PMID: 33438879 DOI: 10.1097/mlr.0000000000001480] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND The extent to which female veterans are willing to seek Veterans Health Administration (VHA) and non-VHA care when they are suicidal or experiencing mental health (MH) concerns is unknown. OBJECTIVES The objectives of this study were to: (1) examine whether current, past, and never VHA using female veterans' willingness to seek VHA care differs from their willingness to seek non-VHA care if suicidal or experiencing MH symptoms; (2) examine if VHA use, military sexual trauma, and suicidal ideation and attempt are associated with female veterans' willingness to use VHA and non-VHA care when experiencing suicidal thoughts or MH symptoms. RESEARCH DESIGN A cross-sectional anonymous survey. SUBJECTS Four hundred thirty nine female veterans, including current, past, and never VHA users were included. MEASURES General Help-Seeking Questionnaire, Self-Injurious Thoughts and Behaviors Interview, and the VA Military Sexual Trauma Screening Questions. RESULTS Current VHA users reported more willingness to use VHA than non-VHA care; conversely, past and never VHA users reported less willingness to use VHA care relative to non-VHA care. Military sexual assault and none or past VHA use were associated with lower willingness to use VHA care if suicidal or experiencing MH symptoms. In contrast, those with none or past VHA use reported greater willingness to use non-VHA care if suicidal or experiencing MH symptoms, while prior suicide attempt was associated with lower willingness. CONCLUSIONS Ensuring that acceptable and effective suicide prevention services are available to female veterans in both VHA and community settings is critical. Increasing help-seeking intentions among female veterans who have attempted suicide or experienced military sexual assault is also essential.
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Affiliation(s)
- Lindsey L Monteith
- Rocky Mountain Mental Illness Research, Education and Clinical Center for Suicide Prevention
- Departments of Psychiatry
| | - Ryan Holliday
- Rocky Mountain Mental Illness Research, Education and Clinical Center for Suicide Prevention
- Departments of Psychiatry
| | - Claire A Hoffmire
- Rocky Mountain Mental Illness Research, Education and Clinical Center for Suicide Prevention
- Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Nazanin H Bahraini
- Rocky Mountain Mental Illness Research, Education and Clinical Center for Suicide Prevention
- Departments of Psychiatry
- Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, CO
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Dyer KE, Hamilton AB, Yano EM, Moreau JL, Frayne SM, Carney DV, Golden RE, Klap R. Mobilizing embedded research and operations partnerships to address harassment of women Veterans at VA medical facilities. HEALTHCARE-THE JOURNAL OF DELIVERY SCIENCE AND INNOVATION 2021; 8 Suppl 1:100513. [PMID: 33514498 DOI: 10.1016/j.hjdsi.2020.100513] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 09/17/2020] [Accepted: 12/19/2020] [Indexed: 01/07/2023]
Abstract
Key insights: A: Addressing a complex problem like harassment in VA medical facilities requires committed, engaged collaboration at multiple levels of the organization. B: Timely feedback of initial research findings to operations partners enabled rapid and more responsive development of new programs and policies. C: Our research-clinical partnership has enabled us to pursue targeted change from the outset, while incorporating real-time findings from embedded researchers working to develop a comprehensive understanding of the problem.
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Affiliation(s)
- Karen E Dyer
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA.
| | - Alison B Hamilton
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA; Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Elizabeth M Yano
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA; Department of Health Policy and Management, Fielding School of Public Health, University of California Los Angeles, Los Angeles, CA, USA; Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Jessica L Moreau
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Susan M Frayne
- VA HSR&D Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, CA, USA; Division of Primary Care & Population Health, Stanford University, Stanford, CA, USA
| | - Diane V Carney
- VA HSR&D Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, CA, USA
| | - Rachel E Golden
- VA HSR&D Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, CA, USA
| | - Ruth Klap
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA; Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
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Leung LB, Rubenstein LV, Post EP, Trivedi RB, Hamilton AB, Yoon J, Jaske E, Yano EM. Association of Veterans Affairs Primary Care Mental Health Integration With Care Access Among Men and Women Veterans. JAMA Netw Open 2020; 3:e2020955. [PMID: 33079197 PMCID: PMC7576407 DOI: 10.1001/jamanetworkopen.2020.20955] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
IMPORTANCE Women veterans increasingly seek care yet continue to face barriers in the Veterans Health Administration (VA), which predominantly cares for men. Evidence-based collaborative care models can improve patient access to treatment of depression, which is experienced at higher rates by women. While the VA has implemented these care models nationally, it is not known whether access improvements occur equitably across genders in primary care. OBJECTIVE To examine whether the VA's national Primary Care-Mental Health Integration (PC-MHI) initiative (beginning 2007) expanded realized access to mental health care similarly for men and women. DESIGN, SETTING, AND PARTICIPANTS This cohort study included 5 377 093 million primary care patients assigned to 396 VA clinics that provided integrated mental health services nationally between October 2013 and September 2016. Data analysis occurred between May 2017 and July 2020. EXPOSURES Clinic PC-MHI penetration, calculated as the proportion of clinic patients who saw an integrated specialist per fiscal year. MAIN OUTCOMES AND MEASURES Estimates of mean VA health care utilization (mental health, primary care, other specialty care, telephone, hospitalizations) and median total costs for men and women. Multilevel models adjusted for year, clinic, patient characteristics, and interactions between patient-defined gender and clinic PC-MHI penetration. RESULTS This study examined 5 377 093 veterans (448 455 [8.3%] women; 3 744 140 [69.6%] White) with a mean (SD) baseline age 62.0 (16.6) years. Each percentage-point increase in the proportion of clinic patients who saw an integrated specialist was associated with 38% fewer mental health visits per year for women (incidence rate ratio [IRR], 0.62; 95% CI, 0.60-0.65), but 39% more visits for men (IRR, 1.39; 95% CI, 1.34-1.44; P < .001). Both men and women had more primary care visits (men: IRR, 1.40; 95% CI, 1.36-1.45; women: IRR, 1.22; 95% CI, 1.17-1.28; P < .001) and total costs (men: β [SE], 2.23 [0.10]; women: β [SE], 1.24 [0.15]; P = .06), but women had 74% fewer hospitalizations than men related to clinics with mental health integration (IRR, 0.26; 95% CI, 0.19-0.36 vs IRR, 1.02; 95% CI, 0.83-1.24; P < .001). CONCLUSIONS AND RELEVANCE While greater outpatient service use for men was observed in this study, PC-MHI was associated with a decrease in mental health specialty visits (and hospitalizations) for women veterans, potentially signifying a shift of services to primary care. With increasing patient choice for where veterans receive care, the VA must tailor medical care to the needs of rising numbers of women patients. Differences in health care utilization by gender highlight the importance of anticipating policy impacts on and tailoring services for patients in the numerical minority in the VA and other health systems.
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Affiliation(s)
- Lucinda B. Leung
- Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles
| | - Lisa V. Rubenstein
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles
- Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles
- RAND Corporation, Santa Monica, California
| | - Edward P. Post
- Center for Clinical Management Research, VA Ann Arbor Health Care System, Ann Arbor, Michigan
- Department of Medicine, University of Michigan Medical School, Ann Arbor
| | - Ranak B. Trivedi
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California
- VA Palo Alto Health Care System, Menlo Park, California
| | - Alison B. Hamilton
- Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California
- Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles
| | - Jean Yoon
- VA Palo Alto Health Care System, Menlo Park, California
- Department of General Internal Medicine, University of California, San Francisco
| | - Erin Jaske
- VA Puget Sound Health Care System, Seattle, Washington
| | - Elizabeth M. Yano
- Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California
- Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles
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Holliday R, Wiblin J, Holder N, Gerard GR, Matarazzo BB, Monteith LL. Preventing Suicidal Self-Directed Violence Among Survivors of Military Sexual Trauma: Understanding Risk and Applying Evidence-Based Principles. Psychiatr Ann 2020. [DOI: 10.3928/00485713-20200908-01] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Relyea MR, Portnoy GA, Klap R, Yano EM, Fodor A, Keith JA, Driver JA, Brandt CA, Haskell SG, Adams L. Evaluating Bystander Intervention Training to Address Patient Harassment at the Veterans Health Administration. Womens Health Issues 2020; 30:320-329. [PMID: 32830008 DOI: 10.1016/j.whi.2020.06.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 06/15/2020] [Accepted: 06/19/2020] [Indexed: 01/15/2023]
Abstract
PURPOSE One in four women veteran patients report experiencing sexual and gender harassment when attending the Veterans Health Administration (VA) for health care. Bystander intervention-training community members how to intervene when witnessing inappropriate behaviors-is a common approach for addressing harassment in school and military settings. We evaluated implementation of a VA harassment awareness and bystander intervention training that teaches health care staff how to identify and intervene in the harassment of women veteran patients. METHODS Participants included 180 VA staff, including both providers and administrative staff from one VA state health care system, who participated in harassment training during the first year of implementation. Pretest and post-test evaluation surveys included questions on acceptability of training length and relevance, staff experiences with harassment, perceptions of the training, and four short-term attitudinal outcomes: awareness of harassment, barriers to intervening, self-efficacy for intervening, and intentions to intervene. RESULTS At pretest, most staff reported witnessing harassment, yet fewer than one-half had intervened. By post-test, staff reported significantly decreased barriers to intervening and increased awareness, self-efficacy, and intentions to intervene. Belief that harassment is a problem increased from 42.4% to 75.0%. The majority of staff found the training relevant and appropriate in length. Staff felt the most useful aspects of the training were learning how to intervene, group discussion, effective facilitation, and information on harassment. CONCLUSIONS We found that a bystander approach was acceptable to health care staff and efficacious on short-term outcomes. Bystander intervention may be a promising strategy to address harassment among patients in medical facilities.
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Affiliation(s)
- Mark R Relyea
- VA Connecticut Healthcare System, West Haven, Connecticut; Yale School of Medicine, New Haven, Connecticut.
| | - Galina A Portnoy
- VA Connecticut Healthcare System, West Haven, Connecticut; Yale School of Medicine, New Haven, Connecticut
| | - Ruth Klap
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California; VA Women's Health Research Network (WHRN), VA Greater Los Angeles Healthcare System, Los Angeles, California; Department of Psychiatry and Biobehavioral Sciences, UCLA Geffen School of Medicine, Los Angeles, California
| | - Elizabeth M Yano
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California; VA Women's Health Research Network (WHRN), VA Greater Los Angeles Healthcare System, Los Angeles, California; Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, California; Women's Health Services, Office of Patient Care Services, Veterans Health Administration, Washington, DC
| | - Angie Fodor
- Department of Medicine, UCLA Geffen School of Medicine, Los Angeles, CA
| | - Jessica A Keith
- Bay Pines VA Healthcare System, Bay Pines, Florida; University of Central Florida College of Medicine, Orlando, FL
| | - Jane A Driver
- New England Geriatric Research and Clinical Center, VA Boston Healthcare System and Harvard Medical School, Boston, Massachusetts
| | - Cynthia A Brandt
- VA Connecticut Healthcare System, West Haven, Connecticut; Yale School of Medicine, New Haven, Connecticut
| | - Sally G Haskell
- VA Connecticut Healthcare System, West Haven, Connecticut; Yale School of Medicine, New Haven, Connecticut
| | - Lynette Adams
- VA Connecticut Healthcare System, West Haven, Connecticut; Yale School of Medicine, New Haven, Connecticut; Women's Health Services, Office of Patient Care Services, Veterans Health Administration, Washington, DC
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Women Veterans' Perspectives on How to Make Veterans Affairs Healthcare Settings More Welcoming to Women. Womens Health Issues 2020; 30:299-305. [DOI: 10.1016/j.whi.2020.03.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 03/04/2020] [Accepted: 03/17/2020] [Indexed: 02/06/2023]
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Experiences of Perceived Gender-based Discrimination Among Women Veterans: Data From the ECUUN Study. Med Care 2020; 58:483-490. [PMID: 32000171 DOI: 10.1097/mlr.0000000000001304] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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Mattocks K, Casares J, Brown A, Bean-Mayberry B, Goldstein KM, Driscoll M, Haskell S, Bastian L, Brandt C. Women Veterans’ Experiences with Perceived Gender Bias in U.S. Department of Veterans Affairs Specialty Care. Womens Health Issues 2020; 30:113-119. [DOI: 10.1016/j.whi.2019.10.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 09/20/2019] [Accepted: 10/07/2019] [Indexed: 12/20/2022]
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Holliday R, Smith NB, Holder N, Gross GM, Monteith LL, Maguen S, Hoff RA, Harpaz-Rotem I. Comparing the effectiveness of VA residential PTSD treatment for veterans who do and do not report a history of MST: A national investigation. J Psychiatr Res 2020; 122:42-47. [PMID: 31923834 DOI: 10.1016/j.jpsychires.2019.12.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 12/13/2019] [Accepted: 12/19/2019] [Indexed: 11/15/2022]
Abstract
The Department of Veterans Affairs (VA) has implemented initiatives to promote veterans' recovery from the health sequelae of military sexual trauma (MST), including posttraumatic stress disorder (PTSD). MST can impact emotion regulation, interpersonal functioning, and perceptions of trust and safety, as well as increase risk for psychiatric comorbidity, which may impede PTSD treatment.. VA PTSD Residential Rehabilitation Treatment Programs (RRTPs) may facilitate the therapeutic process by offering increased structure, support, and adjunctive services. Limited research has examined the effect of MST on PTSD RRTP outcomes. Utilizing data from 7918 men and women veterans participating in a VA PTSD RRTP, the impact of the experience of MST on rates of program completion and changes in PTSD symptoms during and after treatment were examined. Rates of program completion were similar between those who did and did not report experiencing MST. Multilevel modeling was utilized to examine the impact of MST on PTSD symptoms after accounting for gender, age, race/ethnicity, and program completion. MST survivors endorsed more severe PTSD symptoms at admission; however, PTSD symptom severity scores were similar to those who did not report experiencing MST by discharge. Additionally, MST survivors had larger initial reductions in PTSD symptoms, followed by a greater recurrence of PTSD symptoms over time, compared to those who did not report experiencing MST. MST survivors appear able to participate in and benefit from PTSD RRTPs. Nonetheless, the increased recurrence of PTSD symptoms following discharge from residential treatment indicates the need for strategies to maintain post-treatment gains among MST survivors.
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Affiliation(s)
- Ryan Holliday
- Rocky Mountain Mental Illness Research, Education and Clinical Center for Suicide Prevention, USA; University of Colorado Anschutz Medical Campus, USA
| | - Noelle B Smith
- VA Northeast Program Evaluation Center, USA; Yale University School of Medicine, USA.
| | - Nicholas Holder
- San Francisco Veterans Affairs Health Care System, USA; Sierra Pacific Mental Illness Research, Education and Clinical Center, USA; University of California San Francisco, School of Medicine, USA
| | - Georgina M Gross
- VA Northeast Program Evaluation Center, USA; Yale University School of Medicine, USA; VA Connecticut Healthcare System, USA
| | - Lindsey L Monteith
- Rocky Mountain Mental Illness Research, Education and Clinical Center for Suicide Prevention, USA; University of Colorado Anschutz Medical Campus, USA
| | - Shira Maguen
- San Francisco Veterans Affairs Health Care System, USA; Sierra Pacific Mental Illness Research, Education and Clinical Center, USA; University of California San Francisco, School of Medicine, USA
| | - Rani A Hoff
- VA Northeast Program Evaluation Center, USA; Yale University School of Medicine, USA; VA National Center for PTSD, VA Connecticut Healthcare System, USA
| | - Ilan Harpaz-Rotem
- VA Northeast Program Evaluation Center, USA; Yale University School of Medicine, USA; VA National Center for PTSD, VA Connecticut Healthcare System, USA
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Than C, Chuang E, Washington DL, Needleman J, Canelo I, Meredith LS, Yano EM. Understanding Gender Sensitivity of the Health Care Workforce at the Veterans Health Administration. Womens Health Issues 2020; 30:120-127. [PMID: 32094056 DOI: 10.1016/j.whi.2020.01.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 12/23/2019] [Accepted: 01/06/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Gender sensitivity of providers and staff has assumed increasing importance in closing historical gender disparities in health care quality and outcomes. The Department of Veterans Affairs (VA) has implemented several initiatives intended to improve gender sensitivity of its health care workforce. The current study examines practice- and individual-level characteristics associated with gender sensitivity of primary care providers (PCPs) and staff. METHODS We surveyed PCPs and staff (nurses, medical assistants, and clerks) at 12 VA medical centers (VAMCs) (n = 256 of 649; response rate, 39%). Gender sensitivity was measured using a 10-item scale adapted from the Gender Awareness Inventory-VA. We used weighted multivariate regression with maximum likelihood estimation to identify individual- and practice-level characteristics associated with gender sensitivity of PCPs and staff. RESULTS PCPs and staff had similar gender sensitivity but differed in most characteristics associated with that gender sensitivity. Among PCPs, women's health training and positive communication with others in the clinic were associated with greater gender sensitivity. For staff, prior work experience caring for women, working in Women's Health Patient-Aligned Care Teams, and rural location were associated with greater gender sensitivity, whereas more years of VA service was associated with lower gender sensitivity. Working at VA medical centers with a higher volume of women veteran patients was associated with greater gender sensitivity for both PCPs and staff. CONCLUSIONS Women's health training and experience in working with other women's health professionals are strongly correlated with greater gender sensitivity in the clinical workforce.
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Affiliation(s)
- Claire Than
- VA Health Services Research & Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California; Department of Health Policy and Management, Fielding School of Public Health, University of California Los Angeles (UCLA), Los Angeles, California
| | - Emmeline Chuang
- Department of Health Policy and Management, Fielding School of Public Health, University of California Los Angeles (UCLA), Los Angeles, California
| | - Donna L Washington
- VA Health Services Research & Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California; Department of Medicine, Geffen School of Medicine, UCLA, Los Angeles, California
| | - Jack Needleman
- Department of Health Policy and Management, Fielding School of Public Health, University of California Los Angeles (UCLA), Los Angeles, California
| | - Ismelda Canelo
- VA Health Services Research & Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California
| | | | - Elizabeth M Yano
- VA Health Services Research & Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California; Department of Health Policy and Management, Fielding School of Public Health, University of California Los Angeles (UCLA), Los Angeles, California.
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Boykin DM, Keegan F, Thompson KE, Voelkel E, Lindsay JA, Fletcher TL. Video to Home Delivery of Evidence-Based Psychotherapy to Veterans With Posttraumatic Stress Disorder. Front Psychiatry 2019; 10:893. [PMID: 31920747 PMCID: PMC6915196 DOI: 10.3389/fpsyt.2019.00893] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 11/13/2019] [Indexed: 11/13/2022] Open
Abstract
Background: The Veterans Health Administration (VHA) has pioneered the implementation of video to home (VTH) technology to increase access to mental health treatments for Veterans facing barriers to receiving in-person care, particularly for posttraumatic stress disorder (PTSD). Randomized controlled trials have established the noninferiority of evidence-based psychotherapies (EBPs) for PTSD delivered through VTH, compared to in-person delivery. Less is known about the use of VTH to deliver EBPs for PTSD in routine clinical practice. Objective: We examined the provision of EBPs for PTSD delivered via VTH at a large Southwestern VHA PTSD outpatient clinic. Methods: Data were obtained from chart review of the electronic medical records of Veterans receiving at least one session of Cognitive Processing Therapy or Prolonged Exposure via VTH in the VHA PTSD clinic during the study time frame. Results: Fourteen providers (including six psychology trainees) delivered EBPs for PTSD via VTH between 2016 and 2018. Providers treated 74 Veterans (33.8% women) from diverse sociocultural backgrounds who ranged in age from 25 to 79. Each provider treated about 3.08 (± 2.18) Veterans using VTH, not including one provider who saw more than 30. A hybrid approach, in which VTH-delivery was coupled with in-person delivery, was used with 70.3% of Veterans across treatment (including sessions completed before initiation and after termination of the EBP). This demonstrates the versatility of VTH for meeting individual patient needs. Most EBP sessions (85.4%) were conducted over VTH. Despite Veterans attending an average of 6.85 (± 4.88) EBP sessions, 50% terminated before session 7. This dropout rate is consistent with national and local EBP completion averages within the VHA. Veterans receiving Cognitive Processing Therapy via VTH were more likely to complete treatment than those receiving Prolonged Exposure. No other patient factors predicted attrition. Conclusions: This study highlights the use of VTH as "tool in the toolbox" that expands the scope of practice for providers and increases opportunities for Veterans to receive EBPs for PTSD. We describe other potential advantages of using VTH to deliver EBPs for PTSD.
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Affiliation(s)
- Derrecka M. Boykin
- VA South Central Mental Illness Research, Education and Clinical Center, Houston, TX, United States
- Houston VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, United States
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, United States
| | - Fallon Keegan
- Department of Psychology, University of North Texas, Denton, TX, United States
| | - Karin E. Thompson
- VA South Central Mental Illness Research, Education and Clinical Center, Houston, TX, United States
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, United States
- Michael E. DeBakey VA Medical Center, Houston, TX, United States
| | - Emily Voelkel
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, United States
- Michael E. DeBakey VA Medical Center, Houston, TX, United States
| | - Jan A. Lindsay
- VA South Central Mental Illness Research, Education and Clinical Center, Houston, TX, United States
- Houston VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, United States
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, United States
| | - Terri L. Fletcher
- VA South Central Mental Illness Research, Education and Clinical Center, Houston, TX, United States
- Houston VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, United States
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, United States
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Dyer KE, Potter SJ, Hamilton AB, Luger TM, Bergman AA, Yano EM, Klap R. Gender Differences in Veterans’ Perceptions of Harassment on Veterans Health Administration Grounds. Womens Health Issues 2019; 29 Suppl 1:S83-S93. [DOI: 10.1016/j.whi.2019.04.016] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 04/27/2019] [Accepted: 04/30/2019] [Indexed: 10/26/2022]
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