Gender Differences in Veterans’ Perceptions of Harassment on Veterans Health Administration Grounds

Does a Welcoming Environment Influence Women Veterans' Primary Care Experiences?

BACKGROUND

A welcoming environment may influence patient care experiences, and it may be particularly relevant for underrepresented groups, such as women veterans at Veterans Health Administration (VA) facilities where they represent only 8-10% of patients. Challenges to ensuring a welcoming environment for women veterans may include unwelcome comments from male veterans and staff or volunteers and feeling unsafe inside or outside VA facilities. We assessed associations between reports of gender-related environment of care problems and patient-reported outcomes.

PROCEDURES

We merged national patient-reported outcomes from women veterans (n = 4,961) using Consumer Assessment of Health Plans & Systems Patient Centered Medical Home (CAHPS-PCMH) survey composite measures with Women Veteran Program Managers' reports of gender-related environment of care problems (n = 127, 2016-2017) at VA facilities. We performed multilevel bivariate logistic regressions to assess associations between Women Veteran Program Managers' reports of large/extreme problems and likelihood of women veterans' optimal ratings of primary care experiences (access, coordination, comprehensiveness, provider communication, and overall rating of primary care provider). We adjusted for patient-, site-, and area-level characteristics, and clustering of patients within VA facilities, and we applied design weights to address nonresponse bias in the patient data. Response rates were 40% for women veterans and 90% for Women Veteran Program Managers.

MAIN FINDINGS

Few (<15%) Women Veteran Program Managers reported large/extreme environment of care problems. Women veterans obtaining care at those sites were less likely to rate provider communication and comprehensiveness (psychosocial health assessed) as optimal.

PRINCIPAL CONCLUSIONS

Ensuring a welcoming environment may improve women veterans' primary care experiences.

Rural Veterans with HIV and Alcohol Use Disorder receive less video telehealth than urban Veterans

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.

"You want people to listen to you": Patient experiences of women's healthcare within the Veterans Health Administration

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.

Barriers and Facilitators to Behavioral Healthcare for Women Veterans: a Mixed-Methods Analysis of the Current Landscape

Women veterans have historically faced barriers to behavioral health treatment, particularly through the VA. In conjunction, there have been changes in behavioral healthcare delivery resulting from efforts to improve care for women veterans and the COVID-19 pandemic (e.g., widespread telehealth implementation). The current study draws on a quantitative and qualitative study centering current perspectives of women veterans in their choices to seek or not seek behavioral healthcare in VA and non-VA settings through interviewing 18 women recruited from a larger survey study on veteran behavioral health (n = 83 women, n = 882 men) on their experiences with behavioral health care access and satisfaction, including barriers and facilitators to seeking care. Quantitative findings are descriptively reported from the larger study, which outlined screening for behavioral health problems, behavioral health utilization, treatment modality preferences, and barriers/facilitators to care. While women in the survey sample screened for various behavioral health disorders, rates of treatment seeking remained relatively low. Women reported positive and negative experiences with telehealth and endorsed many barriers to treatment seeking in interviews not captured by survey findings, including lack of women-specific care (e.g., care for military sexual trauma, women-only groups), reports of stranger harassment at the VA, and lack of female providers. Women veterans continue to face barriers to behavioral healthcare; however, ongoing efforts to improve care access and quality, including the implementation of telehealth, show promise in reducing these obstacles. Continued efforts are needed to ensure diverse treatment modalities continue to reach women veterans as this population grows.

Overview of Efforts to Increase Women Enrollment in the Veterans Affairs Million Veteran Program

Background

Ensuring enhanced delivery of care to women Veterans is a top Veterans Affairs (VA) priority; however, women are historically underrepresented in research that informs evidence-based health care. A primary barrier to women's participation is the inability to engage with research in person due to a number of documented challenges. The VA Million Veteran Program (MVP) is committed to increasing access for women Veterans to participate in research, thereby better understanding conditions specific to this population and how disease manifests differently in women compared to men. The goal of this work is to describe the results of the MVP Women's Campaign, an effort designed to increase outreach to and awareness of remote enrollment options for women Veterans.

Materials and Methods

The MVP Women's Campaign launched two phases between March 2021 and April 2022: the Multimedia Phase leveraged a variety of strategic multichannel communication tactics and the Email Phase focused on direct email communication to women Veterans. The effect of the Multimedia Phase was determined using t-tests and chi-square tests, as well as logistic regression models to compare demographic subgroups. The Email Phase was evaluated using comparisons of the enrollment rate across demographic groups through a multivariate adjusted logistic regression model.

Results

Overall, 4694 women Veterans enrolled during the MVP Women's Campaign (54% during the Multimedia Phase and 46% during the Email Phase). For the Multimedia Phase, the percentage of older women online enrollees increased, along with women from the southwest and western regions of the United States. Differences for women Veteran online enrollment across different ethnicity and race groups were not observed. During the Email Phase, the enrollment rate increased with age. Compared to White women Veterans, Blacks, Asians, and Native Americans were significantly less likely to enroll while Veterans with multiple races were more likely to enroll.

Conclusion

The MVP Women's Campaign is the first large-scale outreach effort focusing on recruitment of women Veterans into MVP. The combination of print and digital outreach tactics and direct email recruitment resulted in over a fivefold increase in women Veteran enrollees during a 7-month period. Attention to messaging and communication channels, combined with a better understanding of effective recruitment methods for certain Veteran populations, allows MVP the opportunity to advance health and health care not only for women Veterans, but beyond. Lessons learned will be applied to increase other populations in MVP such as Blacks, Hispanics, Asians, Native Americans, younger Veterans, and Veterans with certain health conditions.

Protecting the assessor: sexual harassment in neuropsychology and related training issues

Objective: Despite a growing body of literature on sexual harassment and inappropriate patient sexual behavior towards clinicians within the broader fields of psychology and medicine, literature, guidance, and supervision frameworks specific to neuropsychology are lacking. This gap in the literature is significant, given that neuropsychology is a specialty field faced with vulnerabilities to sexual harassment, and neuropsychologists may weigh unique factors into their decision-making of whether and/or when to respond. This decision-making may be further complicated for trainees. Method: A review of the literature addressing sexual harassment by patients in neuropsychology was completed. In this paper, we summarize the relevant literature on sexual harassment within psychology and academic medicine and provide a framework for discussing sexual harassment in neuropsychology supervision. Results: Research suggests high rates of inappropriate sexual behavior and/or sexual harassment from patients towards trainees, especially amongst trainees who identify as female and/or hold marginalized identities. Trainees report inadequate training in how to deal with sexual harassment by patients and there are perceived barriers for discussing the topic in supervision. Further, most professional organizations do not have formal policies regarding how to handle incidents. Conclusions: As of this writing, guidance and/or position statements from prominent neuropsychological associations could not be found. Research and guidance specific to neuropsychology is needed to help clinicians navigate these challenging clinical situations, provide effective supervision on the topic to trainees, and normalize discussion and reporting of sexual harassment.

Expert Recommendations for Designing Reporting Systems to Address Patient-Perpetrated Sexual Harassment in Healthcare Settings

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.

Getting Connected: a Retrospective Cohort Investigation of Video-to-Home Telehealth for Mental Health Care Utilization Among Women Veterans

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.

Factors associated with sexual violence among waitresses working in Bahir Dar City, Ethiopia: a mixed-method study

Background

When a worker is abused, threatened, or assaulted while at work, it poses an explicit or implicit threat to his/her safety, well-being, or health. However, the magnitude and understanding of the problem and its associated factors have received little attention in low and middle-income countries, including Ethiopia. Thus, this study aimed to ascertain the magnitude, perceptions, and associated factors of workplace sexual violence among waitresses in Bahir Dar, Ethiopia.

Methods

Parallel sampling was used in a facility-based convergent mixed-methods study. A multistage sampling technique was used to select study participants. Four hundred six waitresses provided quantitative information. To collect data, a pretested structured interview administered questionnaire was used. Qualitative data from ten in-depth interviews and six focus group discussions were also collected using a semi-structured questionnaire. The data were cleaned before being entered into Epidata version 7 and exported to STATA version 15 for analysis. Using odds ratios with a 95% confidence interval and a P value of less than 0.05, binary logistic regression was used to identify independent predictors. Thematic analysis was performed using ATLAS ti version 8.4.25 after the recorded audios were transcribed.

Results

The overall prevalence of workplace sexual violence was 45.9% (95% CI 41, 50.8). Waitresses who had heard about sexual violence and workplace sexual violence, had witnessed family violence as a child, had a family who valued their honor over their children’s safety and health, and lacked employment opportunities were more likely to experience workplace sexual violence. Waitresses who worked in emotionally supportive work environments and were educated were less likely to experience workplace sexual violence.

Conclusions

Many of the waitresses in this study had experienced workplace sexual violence. Its awareness, witnessing family violence as a child, growing up in a family that prioritized their honor over their children’s safety and health, and lack of employment opportunities exacerbated it. In contrast, emotionally supportive work environments and education have protected them. This implies that organizations, both governmental and non-governmental, civic organizations, and other responsible bodies must pay attention to the identified factors. Additionally, Ethiopian hospitality workplaces should develop policies to protect women.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12905-022-01806-x.

Managers' and Leaders' Perceptions of Sexual and Gender-Based Public Harassment in the Veterans Health Administration

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.

Patient-centered behavioral services for women veterans with mental health conditions

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.

Staff and Patient Perspectives on Bystander Intervention Training to Address Patient-Initiated Sexual Harassment in Veterans Affairs Healthcare Settings

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.

Challenges to Addressing Patient-Perpetrated Sexual Harassment in Veterans Affairs Healthcare Settings

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.

Women Veterans' Experiences of Harassment and Perceptions of Veterans Affairs Health Care Settings During a National Anti-Harassment Campaign

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.

Fallen Between the Cracks: Protecting Research Staff From Participant-Perpetrated Harassment

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.

Perception and experiences of sexual harassment among women working in hospitality workplaces of Bahir Dar city, Northwest Ethiopia: a qualitative study

BACKGROUND

Workplace sexual harassment is a public health problem that depends on gender, context, and perceived ideology. Although studies have documented the prevalence and consequences of workplace sexual harassment worldwide, victims' perceptions and experiences are still poorly understood in low and middle-income countries, particularly Ethiopia. Female workers in the hospitality industry, including hotels, bars, restaurants, fast-food restaurants, and cafeterias, are particularly affected. Hence, this study aimed to explore sexual harassment perceptions and experiences among women working in these workplaces.

METHODS

An exploratory qualitative study was conducted from 1 January to 30 August 2019. Data were collected from female employees and key informants from several hospitality workplaces in Bahir Dar City. Data were collected through focus group discussions, in-depth interviews, and key-informant interviews. Women who experienced sexual harassment were selected using the snowball method, and key informants were recruited purposefully. Six focus group discussions, ten in-depth interviews, and thirteen key informant interviews were conducted. Data were analysed using the ATLAS ti version 8.4.24.

RESULTS

In this study, most participants perceived that sexual harassment is pressuring, threatening, touching, abducting sexual advances, and experiencing verbal, physical, and non-verbal types. Similarly, the perceived risk factors were related to the organisations, the customers, and the victims, with the consequences being work-related, health-related, financial-related, and family-related.

CONCLUSIONS

Workplace sexual harassment in hospitality workplaces is poorly understood, but many women experience it. A variety of factors also caused it, and it influenced both organisations and people. Public awareness programs, pre-service preparation, in-service training, prevention, and psychosocial support are needed. Similarly, policies and strategies for the organisations should be developed and implemented.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Mobilizing embedded research and operations partnerships to address harassment of women Veterans at VA medical facilities

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.

Evaluating Bystander Intervention Training to Address Patient Harassment at the Veterans Health Administration

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.