Barriers to Veterans Health Administration care in a nationally representative sample of women veterans

Sex differences in unmet needs between male and female older veterans

Aging Veterans face complex needs across multiple domains. However, the needs of older female Veterans and the degree to which unmet needs differ by sex are unknown. We analyzed responses to the HERO CARE survey from 7,955 Veterans aged 55 years and older (weighted N = 490,148), 93.9% males and 6.1% females. We evaluated needs and unmet needs across the following domains: activities of daily living (ADLs), instrumental ADLs (IADLs), health management, and social. We calculated weighted estimates and compared sex differences using age-adjusted prevalence ratios. On average, female Veterans were younger, more were Non-Hispanic Black and unmarried. Females and males reported a similar prevalence of problems across all domains. However, compared to males, female Veterans had a lesser prevalence of missed appointments due to transportation (aPR 0.49; 95% CI: 0.26-0.92), housework unmet needs (aPR: 0.44; 95% CI: 0.20-0.97), and medication management unmet needs (aPR: 0.33; 95% CI: 0.11-0.95) but a higher prevalence of healthcare communication unmet needs (aPR: 2.40; 95% CI: 1.13-5.05) and monitoring health conditions unmet needs (aPR: 2.13, 95% CI: 1.08-4.20). Female Veterans' common experience of unmet needs in communicating with their healthcare teams could result in care that is less aligned with their preferences or needs. As the number of older female Veterans grows, these data and additional work to understand sex-specific unmet needs and ways to address them are essential to providing high-quality care for female Veterans.

Gender Differences in Psychological Outcomes Following Surf versus Hike Therapy among U.S. Service Members

BACKGROUND

Surf and hike therapies have demonstrated effectiveness as adjunct interventions for service members with major depressive disorder (MDD). This study explores gender differences in intervention outcomes following a pragmatic, randomized controlled trial of Surf and Hike Therapy for service members with MDD (N = 96; men, n = 46; women, n = 50).

METHODS

Clinician-administered and self-report measures (depression, anxiety, positive affect, negative affect, resilience, and pain) were completed at preprogram, postprogram, and 3-month follow-up; brief measures (depression/anxiety and positive affect) were completed before and after each session.

RESULTS

Multilevel modeling results showed that anxiety decreased from pre- to postprogram and significantly differed by gender (B = -2.26, p = 0.029), with women reporting greater reductions. The remaining outcomes from pre- to postprogram demonstrated significant improvements that did not differ by gender (ps = 0.218-0.733). There were no gender differences through follow-up (ps = 0.119-0.780). However, within sessions, women reported greater improvements in depression/anxiety (B = -0.93, p = 0.005) and positive affect (B = 3.73, p = 0.001). The change in positive affect scores within sessions was greater for women in Hike Therapy compared to men (p = 0.016).

CONCLUSIONS

Overall, results demonstrate that both genders benefit from adjunctive Surf and Hike Therapies, but women exhibit a better response in terms of longer-term anxiety and immediate psychological outcomes.

Improving suicide prevention for women veterans: Recommendations from VHA suicide prevention coordinators

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.

Myocardial Infarction Across COVID-19 Pandemic Phases: Insights From the Veterans Health Affairs System

Background Cardiovascular procedural treatments were deferred at scale during the COVID-19 pandemic, with unclear impact on patients presenting with non-ST-segment-elevation myocardial infarction (NSTEMI). Methods and Results In a retrospective cohort study of all patients diagnosed with NSTEMI in the US Veterans Affairs Healthcare System from January 1, 2019 to October 30, 2022 (n=67 125), procedural treatments and outcomes were compared between the prepandemic period and 6 unique pandemic phases: (1) acute phase, (2) community spread, (3) first peak, (4) post vaccine, (5) second peak, and (6) recovery. Multivariable regression analysis was performed to assess the association between pandemic phases and 30-day mortality. NSTEMI volumes dropped significantly with the pandemic onset (62.7% of prepandemic peak) and did not revert to prepandemic levels in subsequent phases, even after vaccine availability. Percutaneous coronary intervention and coronary artery bypass grafting volumes declined proportionally. Compared with the prepandemic period, patients with NSTEMI experienced higher 30-day mortality during Phases 2 and 3, even after adjustment for COVID-19-positive status, demographics, baseline comorbidities, and receipt of procedural treatment (adjusted odds ratio for Phases 2 and 3 combined, 1.26 [95% CI, 1.13-1.43], P<0.01). Patients receiving Veterans Affairs-paid community care had a higher adjusted risk of 30-day mortality compared with those at Veterans Affairs hospitals across all 6 pandemic phases. Conclusions Higher mortality after NSTEMI occurred during the initial spread and first peak of the pandemic but resolved before the second, higher peak-suggesting effective adaptation of care delivery but a costly delay to implementation. Investigation into the vulnerabilities of the early pandemic spread are vital to informing future resource-constrained practices.

Predictors of Incident Severe Acute Respiratory Syndrome Coronavirus 2 Positivity in a Veteran Population

OBJECTIVES

We explored factors related to testing positive for severe acute respiratory coronavirus 2 (SARS-CoV-2) to identify populations most at risk for this airborne pathogen.

METHODS

Data were abstracted from the medical record database of the U.S. Department of Veterans Affairs and from public sources. Veterans testing positive were matched in a 1:4 ratio to those at a similar timepoint and local disease burden who remained negative between March 1, 2020, and December 31, 2020. Multivariable logistic regression was used to calculate odds ratios for the association of each potential risk factor with a positive test result.

RESULTS

A total of 24,843 veterans who tested positive for SARS-CoV-2 were matched with 99,324 controls. Cases and controls were similar in age, sex, ethnicity, and rurality, but cases were more likely to be Black, reside in low-income counties, and suffer from dementia. Multivariable analysis demonstrated highest risk for Black veterans, those with dementia or diabetes, and those living in nursing homes or high-poverty areas. Veterans living in counties likely to be more adherent to public health guidelines were at the lowest risk.

CONCLUSIONS

Our results are similar to those from studies of other populations and add to that work by accounting for several important proxies for risk. In particular, this work has implications for the value of infection control measures at the population level in helping to stem widespread outbreaks of this type.

Gender Differences in Psychological Outcomes Following Surf Therapy Sessions among U.S. Service Members

Surf therapy is increasingly being used as an intervention to address various health problems, including psychological symptoms. Although recent research supports the positive impact of surf therapy on psychological outcomes, it is unclear whether these outcomes differ between men and women. This study compared changes in depression/anxiety (Patient Health Questionnaire-4), positive affect (Positive and Negative Affect Schedule), and pain (Numerical Pain Rating Scale) between U.S. service men and women (N = 74) during six weekly surf therapy sessions. Overall, participants reported decreased depression/anxiety (p < 0.001) and increased positive affect (p < 0.001), but no change in pain rating following each session (p = 0.141). Significant gender differences were found in the magnitude of changes in depression/anxiety (B = -1.01, p = 0.008) and positive affect (B = 4.53, p < 0.001) during surf sessions, despite no differences in pre-session scores on either outcome. Women showed greater improvements in depression/anxiety and positive affect compared with men-an important finding, given that surfing and military environments are often socially dominated by men. Future research is needed to replicate these findings in other samples, extend this research to other underrepresented populations, and identify barriers and facilitators of the sustainable implementation of surf therapy across populations.

Factors contributing to veterans' satisfaction with PTSD treatment delivered in person compared to telehealth

INTRODUCTION

Telehealth is an increasingly popular treatment delivery modality for mental healthcare, including evidence-based treatment for complex and intense psychopathologies such as post-traumatic stress disorder (PTSD). Despite the growing telehealth literature, there is a need for more confirmatory research on satisfaction with PTSD telehealth treatment, particularly among veterans, for whom the most rapid and permanent expansion of telehealth services has been implemented through the Department of Veterans Affairs.

METHODS

The current paper integrates data from two concurrent PTSD treatment outcome studies that compared prolonged exposure therapy delivered both in person and via telehealth for veterans (N = 140). Using two different measures of satisfaction (the Charleston Psychiatric Outpatient Satisfaction Scale-Veteran Affairs Version (CPOSS) and the Service Delivery Perception Questionnaire (SDPQ)), we hypothesized that PTSD improvement would predict satisfaction, but that delivery modality (in person vs telehealth) would not.

RESULTS

Results only partially supported the hypotheses, in that PTSD symptom improvement was associated with greater satisfaction, and in-person treatment modality was associated with satisfaction as measured by the CPOSS (but not the SDPQ). Subgroup differences by sex were found, such that male veterans, typically with combat-related trauma, were more satisfied with their PTSD treatment compared to female veterans, who were most frequently seen in this study for military sexual trauma.

DISCUSSION

Altogether, results illustrate a need for additional satisfaction studies with diverse samples and large sample sizes. Future research may benefit from examining satisfaction throughout treatment, identifying predictors of greater PTSD improvement, and further examining demographic subgroups.

"We Have a Long Way to Go:" A Case Study Examination of Older Women Veterans' Experiences in VA Primary Care

Women Veterans are a growing population with complex care needs. While previous research has examined the experiences of women Veterans, little attention has been paid to the specific experiences of older women Veterans. These case studies present the experiences of 2 older women Veterans who have been enrolled in Veterans Affairs (VA) health care for several decades. Results suggest that these older women Veterans have faced gender-specific challenges and barriers throughout their time accessing VA care. The experiences of these participants suggest that they have gender-sensitive needs that are not always addressed by VA primary care and that women’s groups are important mechanisms by which they have gained psychological support in a gender-sensitive environment. These cases suggest that access to gender-sensitive services and women-centered spaces are important for these 2 older women Veterans and should be explored in future research.

An Examination of the Roles of Mental Health Literacy, Treatment-Seeking Stigma, and Perceived Need for Care in Female Veterans' Service Use

OBJECTIVE

Little is known about the role of mental health literacy in military veterans' treatment-seeking stigma and service use, or the impact of these factors on perceived need for mental health care. In addition, most research has focused on mixed-gender samples. This study examined the relationships among mental health literacy, treatment seeking stigma, perceived need for mental health care, and service use in a national, longitudinal study of female veterans.

METHODS

A sample of 171 female veterans were drawn from a larger three-wave prospective national survey conducted between 2014 and 2017.

RESULTS

Path analyses revealed that treatment seeking stigma had a direct negative effect on service use and an indirect effect that was mediated by perceived need for care, such that higher treatment seeking stigma was associated with lower perceived need for mental health care. Mental health literacy had an indirect effect on service use via its inverse association with treatment-seeking stigma. In contrast, mental health literacy was not associated with perceived need.

CONCLUSIONS

Mental health literacy, treatment-seeking stigma, and perceived need for care affect female veterans' service use in unique ways. Further longitudinal research is needed to better understand these pathways in diverse samples.

Mental Health Service Preferences and Utilization Among Women Veterans in Crisis: Perspectives of Veterans Crisis Line Responders

Women military veterans are at increased risk of suicide compared to non-veterans, but little is known about the mental health service preferences and needs of women veterans in crisis. This study used qualitative, secondary source key informant interviews to ascertain the experiences of women veterans in crisis from 54 responders working at the Veterans Crisis Line. Responders indicated that women veterans reported different experiences with Veterans Administration (VA) and non-VA care, though drivers of satisfaction or dissatisfaction were similar. Availability of specialty care, sensitivity to veterans' issues or Military Sexual Trauma, strong provider relationships, and continuity of care contributed to satisfaction; lengthy appointment wait times, limited service options, and insensitivity to veterans' issues contributed to dissatisfaction. Responders suggested that barriers limiting VA access for women veterans are perceived as similar to non-VA care. Findings suggest that caller experiences with providers drive satisfaction with VA and non-VA mental health services.

Exploring the association of care fragmentation and patient ratings of care quality: A mediation analysis of women Veterans' experience with VA care

OBJECTIVE

To examine the relationship between care fragmentation and patient ratings of care quality and identify potentially actionable mediators.

DATA SOURCES/STUDY SETTING

2015 telephone survey of 1395 women Veterans with three or more visits in primary care and/or women's health care in the prior year at 12 Veterans Affairs (VA) medical centers.

STUDY DESIGN

Cross-sectional analysis.

DATA COLLECTION/EXTRACTION METHODS

We operationalized lower care fragmentation as receiving VA-only care versus dual use of VA/non-VA care. Participants rated VA care quality (overall care, women's health care (WH), and primary care (PC)) and three aspects of their patient experience (ease of access to services, provider communication, and gender sensitivity of VA environments). We examined associations between care fragmentation and care ratings and applied the Karlson-Holm-Breen decomposition method to test for mediation by aspects of patients' experience.

PRINCIPAL FINDINGS

Lower care fragmentation was associated with higher ratings of care quality (odds ratios [95% CI] for overall care: 1.57 [1.14;2.17]; WH: 1.65 [1.20;2.27]; PC: 1.41 [1.10;1.82]). Relationships were mediated by patient-rated provider communication and gender sensitivity (26-54 percent and 14-15 percent of total effects, respectively). Ease of access was associated with higher care ratings (odds ratios [95% CI] for overall care: 2.93 [2.25;3.81]; WH: 2.81 [2.15;3.68]; PC: 2.33 [1.63;3.33], in models with the three types of patient care experiences included), but did not mediate the association of care fragmentation and care ratings.

CONCLUSIONS

Potential negative effects of care fragmentation on care quality ratings could be mitigated by attention to quality of patient-provider communication and gender sensitivity of VA environments.

What Do Veterans Want? Understanding Veterans’ Preferences for PTSD Treatment Delivery

Introduction

Home-based delivery of psychotherapy may offer a viable alternative to traditional office-based treatment for post-traumatic stress disorder (PTSD) by overcoming several barriers to care. Little is known about patient perceptions of home-based mental health treatment modalities. This study assessed veterans’ preferences for treatment delivery modalities and how demographic variables and trauma type impact these preferences.

Materials and Methods

Veterans with PTSD (N = 180) participating in a randomized clinical trial completed a clinician-administered PTSD assessment and were asked to identify their modality preference for receiving prolonged exposure: home-based telehealth (HBT), office-based telehealth (OBT), or in-home-in-person (IHIP). Ultimately, modality assignment was randomized, and veterans were not guaranteed their preferred modality. Descriptive statistics were used to examine first choice preference. Chi-square tests determined whether there were significant differences among first choice preferences; additional tests examined if age, sex, and military sexual trauma (MST) history were associated with preferences.

Results

The study includes 135 male veterans and 45 female veterans from all military branches; respondents were 46.30 years old, on average. Veterans were Caucasian (46%), African-American (28%), Asian-American (9%), American Indian or Alaskan Native (3%), Native Hawaiian or Pacific Islander (3%), and 11% identified as another race. Veterans experienced numerous trauma types (e.g., combat, sexual assault), and 29% had experienced MST. Overall, there was no clear preference for one modality: 42% of veterans preferred HBT, 32% preferred IHIP, and 26% preferred OBT. One-sample binomial tests assuming equal proportions were conducted to compare each pair of treatment options. HBT was significantly preferred over OBT (p = 0.01); there were no significant differences between the other pairs. A multinomial regression found that age group significantly predicted veterans’ preferences for HBT compared to OBT (odds ratio [OR] = 10.02, 95% confidence interval [CI]: 1.63, 61.76). Older veterans were significantly more likely to request HBT compared to OBT. Veteran characteristics did not differentiate those who preferred IHIP to OBT. Because there were fewer women (n = 45), additional multinomial regressions were conducted on each sex separately. There was no age group effect among the male veterans. However, compared to female Veterans in the younger age group, older female Veterans were significantly more likely to request HBT over OBT (OR = 10.66, 95% CI: 1.68, 67.58, p = 0.012). MST history did not predict treatment preferences in any analysis.

Conclusions

Fewer than 50% of the sample preferred one method, and each modality was preferred by at least a quarter of all participants, suggesting that one treatment modality does not fit all. Both home-based care options were desirable, highlighting the value of offering a range of options. The use of home-based care can expand access to care, particularly for rural veterans. The current study includes a diverse group of veterans and increases our understanding of how they would like to receive PTSD treatment. The study used a forced choice preference measure and did not examine the strength of preference, which limits conclusions. Future studies should examine the impact of modality preferences on treatment outcomes and engagement.

Disabilities Status, Health Insurance, and Medical Hardship among Veterans

This study aims to examine the health care hardships among veterans and the effects from the measures of disability statuses and health insurance coverage. Patterns and variations for different subgroups are categorized and analyzed. Using the 2014 National Health Interview Survey (NHIS), this study included 2,686 veterans who were active duty in U.S. military in Persian Gulf War in the 1990s and Gulf War-era II since September 2001 or later. The dependent variable, medical hardship, was measured with four dichotomous indicators: problems paying medical bills, currently having medical bills that were being paid over time, currently having medical bills that were unable to be paid at all, and having medical care delayed due to cost. The independent variables were disability status and health care coverage. Covariates included demographics (age, gender, race), socioeconomic status (education, poverty status), along with marital status and self-reported health status. Logistic regressions were employed to predict the likelihood of experiencing health care hardships. Statistical results indicated that health disparities were prevalent in terms of health care hardships. Disabled veterans were more likely to report medical hardships compared to their counterparts with no disability. Having no health insurance coverage further deteriorated the severity of medical hardship. Veterans who self-reported poor health lived in poverty were less educated, and had higher likelihood of experiencing health care hardship. The policy implications can be lined with disabled veterans' programs in terms of outreach activities, community services, and integrated care.

Periodic reflections: a method of guided discussions for documenting implementation phenomena

BACKGROUND

Ethnography has been proposed as a valuable method for understanding how implementation occurs within dynamic healthcare contexts, yet this method can be time-intensive and challenging to operationalize in pragmatic implementation. The current study describes an ethnographically-informed method of guided discussions developed for use by a multi-project national implementation program.

METHODS

The EMPOWER QUERI is conducting three projects to implement innovative care models in VA women's health for high-priority health concerns - prediabetes, cardiovascular risk, and mental health - utilizing the Replicating Effective Programs (REP) implementation strategy enhanced with stakeholder engagement and complexity science. Drawing on tenets of ethnographic research, we developed a lightly-structured method of guided "periodic reflections" to aid in documenting implementation phenomena over time. Reflections are completed as 30-60 min telephone discussions with implementation team members at monthly or bi-monthly intervals, led by a member of the implementation core. Discussion notes are coded to reflect key domains of interest and emergent themes, and can be analyzed singly or in triangulation with other qualitative and quantitative assessments to inform evaluation and implementation activities.

RESULTS

Thirty structured reflections were completed across the three projects during a 15-month period spanning pre-implementation, implementation, and sustainment activities. Reflections provide detailed, near-real-time information on projects' dynamic implementation context, including characteristics of implementation settings and changes in the local or national environment, adaptations to the intervention and implementation plan, and implementation team sensemaking and learning. Reflections also provide an opportunity for implementation teams to engage in recurring reflection and problem-solving.

CONCLUSIONS

To implement new, complex interventions into dynamic organizations, we must better understand the implementation process as it unfolds in real time. Ethnography is well suited to this task, but few approaches exist to aid in integrating ethnographic insights into implementation research. Periodic reflections show potential as a straightforward and low-burden method for documenting events across the life cycle of an implementation effort. They offer an effective means for capturing information on context, unfolding process and sensemaking, unexpected events, and diverse viewpoints, illustrating their value for use as part of an ethnographically-minded implementation approach.

TRIAL REGISTRATION

The two implementation research studies described in this article have been registered as required: Facilitating Cardiovascular Risk Screening and Risk Reduction in Women Veterans (NCT02991534); and Implementation of Tailored Collaborative Care for Women Veterans (NCT02950961).

Enhancing Mental and Physical Health of Women through Engagement and Retention (EMPOWER): a protocol for a program of research

BACKGROUND

The Enhancing Mental and Physical health of Women through Engagement and Retention or EMPOWER program represents a partnership with the US Department of Veterans Health Administration (VA) Health Service Research and Development investigators and the VA Office of Women's Health, National Center for Disease Prevention and Health Promotion, Primary Care-Mental Health Integration Program Office, Women's Mental Health Services, and the Office of Patient Centered Care and Cultural Transformation. EMPOWER includes three projects designed to improve women Veterans' engagement and retention in evidence-based care for high-priority health conditions, i.e., prediabetes, cardiovascular, and mental health.

METHODS/DESIGN

The three proposed projects will be conducted in VA primary care clinics that serve women Veterans including general primary care and women's health clinics. The first project is a 1-year quality improvement project targeting diabetes prevention. Two multi-site research implementation studies will focus on cardiovascular risk prevention and collaborative care to address women Veterans' mental health treatment needs respectively. All projects will use the evidence-based Replicating Effective Programs (REP) implementation strategy, enhanced with multi-stakeholder engagement and complexity theory. Mixed methods implementation evaluations will focus on investigating primary implementation outcomes of adoption, acceptability, feasibility, and reach. Program-wide organizational-, provider-, and patient-level measures and tools will be utilized to enhance synergy, productivity, and impact. Both implementation research studies will use a non-randomized stepped wedge design.

DISCUSSION

EMPOWER represents a coherent program of women's health implementation research and quality improvement that utilizes cross-project implementation strategies and evaluation methodology. The EMPOWER Quality Enhancement Research Initiative (QUERI) will constitute a major milestone for realizing women Veterans' engagement and empowerment in the VA system. EMPOWER QUERI will be conducted in close partnership with key VA operations partners, such as the VA Office of Women's Health, to disseminate and spread the programs nationally.

TRIAL REGISTRATION

The two implementation research studies described in this protocol have been registered as required: Facilitating Cardiovascular Risk Screening and Risk Reduction in Women Veterans: Trial registration NCT02991534 , registered 9 December 2016. Implementation of Tailored Collaborative Care for Women Veterans: Trial registration NCT02950961 , registered 21 October 2016.

Predictors of Mental Health Care Utilization in Veterans With Post-Traumatic Stress Disorder Symptoms and Hazardous Drinking

OBJECTIVES

Describe outpatient mental health service use in a sample of recent combat Veterans with post-traumatic stress disorder (PTSD) symptoms and hazardous alcohol use and investigate predictors of mental health care utilization.

METHODS

In this prospective study, 126 Veterans with full or subthreshold PTSD and hazardous alcohol use completed a baseline assessment and reported mental health service use through a 12-month follow-up period. Logistic regressions were used to identify factors predicting mental health care utilization.

RESULTS

Veterans who were employed were 63% less likely to use outpatient mental health care in the 12 months following baseline. Additionally, for each 1-point increase in negative mental health care beliefs, participants were 70% less likely to use outpatient mental health care. For each 1-point worsening in social support and leisure functioning, participants were 2.2 times more likely to use outpatient mental health care.

CONCLUSIONS

The current study indicates that negative mental health beliefs are barriers to mental health care while unemployment and poor social support/leisure functioning are predictors of mental health care utilization for recent combat Veterans with PTSD symptoms and hazardous alcohol use. Patient and system level interventions for these factors are discussed to guide efforts to improve mental health care among this high-need population.

Evidence-based Treatments for Military-related Posttraumatic Stress Disorder in a Veterans Affairs Setting

Posttraumatic stress disorder (PTSD) can have a significant negative impact on the physical, emotional, and mental health of individuals. This article discusses the prevalence, risk factors, and diagnostic criteria for PTSD. Given the high incidence of PTSD in the Veteran population, much attention has been given to assessment and treatment issues. Treatment options for PTSD, including the 2 most effective treatments, prolonged exposure and cognitive processing therapy, are discussed. Special issues concerning the treatment of Veterans are also reviewed.

Rural Women Veterans' Use and Perception of Mental Health Services

While the total number of veterans in the U.S. is decreasing overall, the number of women veterans is significantly increasing. There are numerous barriers which keep women veterans from accessing mental health care. One barrier which can impact receiving care is living in a rural area. Veterans in rural areas have access to fewer mental health services than do urban residing veterans, and women veterans in general have less access to mental health care than do their male colleagues. Little is known about rural women veterans and their mental health service needs. Women, who have served in the military, have unique problems related to their service compared to their male colleagues including higher rates of post-traumatic stress disorder (PTSD) and military sexual trauma (MST). This qualitative study investigated use of and barriers to receiving mental health care for rural women veterans. In-depth interviews were conducted with ten women veterans who have reported experiencing problems with either MST, PTSD, or combat trauma. All ten women had utilized mental health services during active-duty military service, and post service, in Veterans Administration (VA) community based-outpatient clinics. Several recurring themes in the women's experience were identified. For all of the women interviewed, a sentinel precipitating event led to seeking mental health services. These precipitating events included episodes of chronic sexual harassment and ridicule, traumatic sexual assaults, and difficult combat experiences. Efforts to report mistreatment were unsuccessful or met with punishment. All the women interviewed reported that they would not have sought services without the help of a supportive peer who encouraged seeking care. Barriers to seeking care included feeling like they were not really a combat veteran (in spite of serving in a combat unit in Iraq); feeling stigmatized by providers and other military personnel, being treated as crazy; and a lack of interest from those providing care in hearing their stories. This study may generate positive social change by helping providers approach women veterans in a way that is sympathetic to their experiences.

Women Veterans' Pathways to and Perspectives on Veterans Affairs Health Care

BACKGROUND

We examined Veterans Affairs (VA) health care experiences among contemporary women veteran patients receiving care at a VA medical center. Specifically, we examined women veteran patients' satisfaction with VA care along dimensions in line with patient-centered medical home (patient-aligned care teams [PACT] in VA) priorities, and pathways through which women initially accessed VA care.

METHODS

We used a mixed methods research design. First, 249 racially diverse women (ages 22-64) who were past-year users of primary care at a VA medical center completed interviewer-administered surveys in 2012 assessing ratings of satisfaction with care in the past year. We then conducted in-depth qualitative interviews of a subset of women surveyed (n = 25) to gain a deeper understanding of perspectives and experiences that shaped satisfaction with care and to explore women's initial pathways to VA care.

RESULTS

Ratings of satisfaction with VA care were generally high, with some variation by demographic characteristics. Qualitative interviews revealed perceptions of care centered on the following themes: 1) barriers to care delay needed medical care, while innovative care models facilitate access, 2) women value communication and coordination of care, and 3) personalized context of VA care, including gender sensitive care shapes women's perceptions. Pathways to VA care were characterized by initial delays, often attributable to lack of knowledge or negative perceptions of VA care. Informal social networks were instrumental in helping women to overcome barriers.

CONCLUSIONS

Findings highlight convergence of women's preferences with PACT priorities of timely access to care, provider communication, and coordination of care, and suggest areas for improvement. Outreach is needed to address gaps in knowledge and negative perceptions. Initiatives to enhance women veterans' social networks may provide an information-sharing resource.

Latent classes of PTSD symptoms in Iraq and Afghanistan female veterans

BACKGROUND

Recent studies have used latent class analysis (LCA) to identify subgroups of individuals who share similar patterns of PTSD symptom endorsement; however, further study is needed among female veterans, whose PTSD symptom expression may vary from that of their male counterparts. The current study examined latent PTSD symptom classes in female veterans who returned from recent military service in Iraq and Afghanistan, and explored military and demographic variables associated with distinct PTSD symptom presentations.

METHODS

A retrospective analysis was conducted using existing medical records from female Iraq and Afghanistan veterans who were new users of VA mental health outpatient (MHO) care, had received a PTSD diagnosis anytime during the post-deployment period, and completed the PTSD checklist within 30 days of their first MHO visit (N=2425).

RESULTS

The LCA results identified four latent classes of PTSD symptom profiles in the sample: High Symptom, Intermediate Symptom, Intermediate Symptom with High Emotional Numbing (EN), and Low Symptom. Race/ethnicity, age, time since last deployment, and distance from a VA facility emerged as predictors of PTSD symptom presentation.

LIMITATIONS

The current study was cross-sectional and utilized administrative data. The results may not be generalizable to female veterans from other service eras.

CONCLUSIONS

Longer times between end of last deployment and initiation of MHO services were associated with more symptomatic classes. Exploration of PTSD symptom presentation may enhance our understanding of the service needs of female veterans with PTSD, and suggests potential benefits to engaging veterans in MHO soon after last deployment.

Comparison of outcomes of homeless female and male veterans in transitional housing

Homelessness among female veterans is of national concern, but there have been few studies of how they differ from male veterans or whether they have different outcomes. This study compared 59 female and 1,181 male participants in a multi-site study of three VA-funded transitional housing programs over a 1-year period following completion of an episode of treatment. At baseline, female participants were younger, reported more psychiatric symptoms, had shorter histories of homelessness,were less likely to have substance use disorders, and were less likely to be working than males. After controlling for these baseline differences, there were no overall gender differences in outcomes measures of housing, employment,substance use, physical and mental health, or quality of life. These results suggest homeless female veterans have different characteristics than male veterans, but benefit equally from transitional housing.

Barriers to Psychosocial Services among Homeless Women Veterans

Veterans comprise a disproportionate fraction of the nation's homeless population, with women veterans up to four times more likely to be homeless than non-veteran women. This paper provides a grounded description of barriers to psychosocial services among homeless women veterans. Three focus groups were held in Los Angeles, CA, with a total of 29 homeless women veterans. These women described three primary, proximal (current) barriers: lack of information about services, limited access to services, and lack of coordination across services. Compared to non-veteran homeless women, women veterans potentially face additional challenges of trauma exposure during military service, post-military readjustment issues, and few services specific to women veterans. Understanding their service needs and experiences is critical to the development of relevant and appropriate services that move homeless women veterans away from vulnerability, into safety.

Reducing barriers to mental health and social services for Iraq and Afghanistan veterans: outcomes of an integrated primary care clinic

BACKGROUND

Despite high rates of post-deployment psychosocial problems in Iraq and Afghanistan veterans, mental health and social services are under-utilized.

OBJECTIVE

To evaluate whether a Department of Veterans Affairs (VA) integrated care (IC) clinic (established in April 2007), offering an initial three-part primary care, mental health and social services visit, improved psychosocial services utilization in Iraq and Afghanistan veterans compared to usual care (UC), a standard primary care visit with referral for psychosocial services as needed.

DESIGN

Retrospective cohort study using VA administrative data.

POPULATION

Five hundred and twenty-six Iraq and Afghanistan veterans initiating primary care at a VA medical center between April 1, 2005 and April 31, 2009.

MAIN MEASURES

Multivariable models compared the independent effects of primary care clinic type (IC versus UC) on mental health and social services utilization outcomes.

KEY RESULTS

After 2007, compared to UC, veterans presenting to the IC primary care clinic were significantly more likely to have had a within-30-day mental health evaluation (92% versus 59%, p < 0.001) and social services evaluation [77% (IC) versus 56% (UC), p < 0.001]. This exceeded background system-wide increases in mental health services utilization that occurred in the UC Clinic after 2007 compared to before 2007. In particular, female veterans, younger veterans, and those with positive mental health screens were independently more likely to have had mental health and social service evaluations if seen in the IC versus UC clinic. Among veterans who screened positive for  ≥ 1 mental health disorder(s), there was a median of 1 follow-up specialty mental health visit within the first year in both clinics.

CONCLUSIONS

Among Iraq and Afghanistan veterans new to primary care, an integrated primary care visit further improved the likelihood of an initial mental health and social services evaluation over background increases, but did not improve retention in specialty mental health services.

PTSD Treatment-Seeking Among Rural Latino Combat Veterans: A Review of the Literature

Latino combat soldiers report both higher prevalence and greater overall severity of post-traumatic stress disorder (PTSD) symptoms than non-Hispanic Caucasians. However, these veterans face unique social and cultural barriers to accessing treatment for PTSD that distinguish them from their non-Hispanic white counterparts. Latino veterans who reside in rural settings face additional socio-cultural and structural impediments, in that they are likely to reside far from VA (Veterans Administration) medical facilities, have limited access to public transportation, and hold more conservative views toward mental health treatment than those residing in urban locales. However, little is known about the unique individual, sociocultural, and structural barriers to treatment faced by rural Latino veterans. This paper synthesizes the separate mental health and treatment-seeking literatures pertaining to Latinos, rural populations, and veterans, with the goal of identifying fruitful areas of conceptual overlap, and providing direction for future theory building, research, and targeted interventions.

Comparison of outpatient health care utilization among returning women and men veterans from Afghanistan and Iraq

BACKGROUND

The number of women serving in the United States military increased during Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF), leading to a subsequent surge in new women Veterans seeking health care services from the Veterans Administration (VA). The objective of this study was to examine gender differences among OEF/OIF Veterans in utilization of VA outpatient health care services.

METHODS

Our retrospective cohort consisted of 1,620 OEF/OIF Veterans (240 women and 1380 men) who enrolled for outpatient healthcare at a single VA facility. We collected demographic data and information on military service and VA utilization from VA electronic medical records. To assess gender differences we used two models: use versus nonuse of services (logistic regression) and intensity of use among users (negative binomial regression).

RESULTS

In our sample, women were more likely to be younger, single, and non-white than men. Women were more likely to utilize outpatient care services (odds ratio [OR] = 1.47, 95% confidence interval [CI]:1.09, 1.98), but once care was initiated, frequency of visits over time (intensity) did not differ by gender (incident rate ratio [IRR] = 1.07; 95% CI: 0.90, 1.27).

CONCLUSION

Recently discharged OEF/OIF women Veterans were more likely to seek VA health care than men Veterans. But the intensity of use was similar between women and men VA care users. As more women use VA health care, prospective studies exploring gender differences in types of services utilized, health outcomes, and factors associated with satisfaction will be required.

Effective breast reconstruction in female veterans

BACKGROUND

Despite increasing female veteran numbers, literature regarding reconstruction after breast cancer is lacking. The purpose of this study was to examine breast reconstruction referral rates and reconstruction outcomes at a tertiary Veterans Affairs hospital.

METHODS

Female breast cancer patients (1997-2008) were identified. Demographics, tumor stage, oncologic therapies, reconstructive timings and procedures, and complications were noted.

RESULTS

Eighty-two women underwent mastectomy (46%) or breast conservation (43%). The referral rates to plastic surgery were 61% (mastectomy) and 32% (overall). Reconstruction rates were 42% (mastectomy) and 22% (overall). Sixty-nine percent were suitable candidates and chose immediate (67%) or delayed (33%) reconstruction, with implant-based (44%), autologous (39%), or autologous plus implants (17%). There were complications (28%) but no mortalities. Comorbidities were not correlated with outcomes.

CONCLUSIONS

Breast reconstruction can be effectively delivered within the Veterans Affairs system. It is essential that sufficient Veterans Affairs resources be deployed to address the increasing reconstructive needs of female veterans.

Toward gender-aware health care: evaluation of an intervention to enhance care for female patients in the VA setting

In response to identified deficits in the provision of health care to female patients, we sought to improve healthcare workers' gender awareness- conceptualized as gender-role ideology, sensitivity, and knowledge related to female patients-through the application of a brief computerized educational intervention. This study, conducted in the Veterans Affairs (VA) health-care setting, involved a pretest-posttest equivalent control group design. We evaluated hypotheses using random coefficients regression, a technique that offers a number of advantages relative to repeated-measures ANOVA. Findings revealed significant improvements in sensitivity and knowledge for participants in the treatment condition compared to the control condition. With several exceptions, the intervention was similarly effective across employee groups.

Effects of military trauma exposure on women veterans' use and perceptions of Veterans Health Administration care

BACKGROUND

Few studies have addressed how military trauma exposure, particularly sexual assault and combat exposure, affects women veterans' use and perceptions of Veterans Health Administration (VHA) care.

OBJECTIVE

The aim of the present study was to evaluate the effects of military sexual assault and combat exposure on women veterans' use and perceptions of different aspects of VHA care.

DESIGN

Cross-sectional telephone survey of a national sample of women veterans.

PARTICIPANTS

Women from the VA's National Registry of Women Veterans.

MEASUREMENTS

Sociodemographic characteristics, VHA care utilization, perceptions of care.

RESULTS

Women veterans with histories of military sexual assault reported more use of VHA services, but less satisfaction, poorer perceptions of VHA facilities and staff, and more problems with VHA services compared to women veterans without histories of sexual assault. Combat exposure was related to more problems with VHA staff, although few other differences were observed for women with and without histories of combat exposure.

CONCLUSIONS

Findings provide information on areas that can be targeted with respect to caring for women veterans exposed to military sexual trauma and combat exposure, including improving interactions with VHA staff and the ease of using VHA services.

Diffusion of innovation in women's health care delivery: the Department of Veterans Affairs' adoption of women's health clinics

BACKGROUND

In response to concerns about the availability and quality of women's health services in Department of Veterans Affairs (VA) medical centers in the early 1990s, Congress approved landmark legislation earmarking funds to enhance women's health services. A portion of the appropriation was used to launch Comprehensive Women's Health Centers as exemplars for the development of VA women's health care throughout the system. We report on the diffusion and characteristics of VA women's health clinics (WHCs) 10 years later.

METHODS

In 2001, we surveyed the senior women's health clinician at each VA medical center serving > or =400 women veterans (83% response rate) regarding their internal organizational characteristics in relation to factors associated with organizational innovation (centralization, complexity, formalization, interconnectedness, organizational slack, size). We evaluated the comparability of WHCs (n = 66) with characteristics of the original comprehensive women's health centers (CWHCs; n = 8).

RESULTS

Gender-specific service availability in WHCs was comparable to that of CWHCs with important exceptions in mental health, mammography and osteoporosis management. WHCs were less likely to have same-gender providers (p < .05), women's health training programs (p < .01), separate women's mental health clinics (p < .001), separate space (p < .05), or adequate privacy (p < .05); however, they were less likely to have experienced educational program closures (p < .001) and staffing losses (p < .05) compared to CWHCs.

CONCLUSIONS

Diffusion of comprehensive women's health care is as yet incomplete. More research is needed to examine the quality of care associated with these models and to establish the business case for managers faced with small female patient caseloads.