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Women Veterans are the fastest growing segment of new users of the VA healthcare system. Nearly 20 percent of Active Duty service members and over 20 percent of National Guard and Reserve members are women. VA projects a 32 percent increase in the number of women Veterans served in VA healthcare facilities by 2029. VA must meet the challenges of delivering timely, high quality, comprehensive care to this growing population of women Veterans in a sensitive and safe environment.
To meet this challenge, we must first understand the unique needs of women Veterans. Women Veterans are, on average, a decade younger than their male counterparts, and are much more racially and ethnically diverse. While they are younger on average, women Veterans face substantial physical and mental healthcare needs when compared to their male counterparts (among those relying on VA care), including comparable chronic disease burdens, and greater prevalence of musculoskeletal conditions and mental health challenges. Some women Veterans’ mental health needs stem from higher rates of military sexual trauma (assault, abuse, and/or harassment during military service), which is associated with higher rates of PTSD, depression, and anxiety. Women Veterans have expressed trust concerns in VA care environments, making trauma-informed and trauma-sensitive care a must.
Women Veterans also have social determinants of health that warrant particular attention; they are more likely to be unemployed and to live in poverty, and they lack adequate social supports. These challenges complicate care delivery and self-management. In addition, recent research highlights emerging cardiovascular risks for women Veterans, including PTSD and gender disparities in cardiovascular care.
Women Veterans have gender-specific healthcare needs, including gender-specific preventative care (e.g., breast and cervical cancer screening) and reproductive care across the life course (ranging from menstrual disorders, sexual health, pregnancy and maternity care to menopause). Gender-neutral conditions also deserve attention, especially those more common among women (e.g., osteoporosis), and those with distinct clinical presentations or treatment needs among women (e.g., heart disease).
Given women Veterans’ historical numerical minority in VA, we also must pay close attention to the potential for gender disparities in access, utilization, quality, and patient experience to ensure VA is a welcoming, high-quality healthcare resource; this need extends from military discharge to later life issues (e.g., long term care and palliative care), and everything in between.
Research has been critical to informing VA Office of Women’s Health policy in every area. VA research on pregnancy risks and maternity care needs informed development of VA’s national Maternity Care Coordination Program, with trained Maternity Care Coordinators at every VA, in addition to stronger links to community care obstetricians-gynecologists as needed. Research examining Veteran-specific factors in maternal morbidity has informed our plans to extend maternity care coordination for a full 12 months postpartum, while we examine the best team configuration for managing maternity care in VA.
VA research on infertility has similarly informed evidence-based policy development and the array of services we provide. For example, women Veterans with service-connected conditions that cause infertility may now be eligible for in vitro fertilization (IVF) or other forms of assisted reproductive technology services. Other fertility-related services for women Veterans include infertility assessments and counseling, genetic counseling and testing, imaging services, hormonal or surgical therapies, and a host of other services. VA research helps us understand that women Veterans with histories of military sexual trauma (MST), combat trauma, or PTSD are two to three times more likely to have chronic pelvic pain, informing care models and services to meet their needs.
The research-policy intersection is apparent in our work on VA culture change and ending harassment. This journey grew from VA HSR&D’s critical experiment in changing how VA researchers partner with operations leaders to design studies capable of accelerating research impacts on top health system priorities. The resulting Collaborative Research to Enhance and Advance Transformation and Excellence (CREATE) Initiative led to five studies co-designed with leading VA women’s health researchers. Each of these studies enabled us to use research evidence to accelerate delivery of comprehensive care for women Veterans.
These studies include seminal work on drivers of attrition among women Veterans new to VA, factors that hasten or hinder delivery of comprehensive women’s healthcare, and women Veterans’ community care experiences and needs. The findings from this work informed how we approach our national Women Veterans’ Call Center; support local provision of enhanced women’s healthcare services and access to designated women’s health primary care providers; and support care coordination for women relying on VA and VA-paid community care. Of the five studies, two were trials. One of those trials served as the foundation for how we virtually support providers delivering care in community clinics at a distance from the resources of our large VA medical centers. The second focused on an evidence-based quality improvement (EBQI) approach to gender-tailoring VA’s patient-centered medical home model (Patient Aligned Care Teams or PACTs) to meet women Veterans’ needs.
While each study has informed practice and policy changes, including our Office’s adoption of EBQI for national implementation, our research-operations partnership ensured constant attention to how women Veterans use VA and what their experiences are like once engaged in care. This framing led to inclusion of a question on whether women Veterans had ever experienced harassment when they came to VA for care, and if so, what did they experience. The results were quite concerning – one in four women Veterans reported being harassed on their way to see their VA provider by men Veterans, and those harassment experiences led to delayed and missed care. Well before publication of a scientific paper, the partnership enabled us to learn these results and begin addressing them.
The research team quickly assessed what worked outside VA to combat harassment, and developed VA adaptations with input from Veterans and VA employees. We launched a National Culture Campaign in a matter of months instead of years.
That Campaign continues and has been augmented with additional programs, like Stand Up to Stop Harassment Now!, and a Secretary-level team focused on ending harassment for Veterans and staff members alike. Ongoing evaluation of the Campaign’s progress is provided through our Office’s partnership with the VA Women’s Health Research Network, which conducts annual surveys of women receiving VA care. The partnered work that followed positioned us to bring research evidence to bear on Congressional inquiries once the scientific papers on stranger harassment were published.
Given our longstanding partnerships with VA health services researchers across the system, we can now consider where additional research is needed to improve care for our nation’s women Veterans. For example, we will continue the work of making women’s healthcare needs more visible in VA, implementing women’s healthcare services, and filling gaps in capacity. We remain focused on implementation and innovations, including enhancements in virtual care offerings, which will be further informed by results from the EMPOWER 2.0 QUERI Program. We are also focused on meeting Veteran family needs, through expansion of newborn care and implementing Veteran childcare assistance at every site. Differential effects of military service on women Veterans’ lives is also a priority, as questions of occupational and toxic exposures including and beyond burn pits arise, especially with passage of The Sergeant First Class Heath Robinson Honoring our Promise to Address Comprehensive Toxics (PACT) Act. We are also aware of gender differences in suicide risk and behavior, requiring gender-tailored approaches to screening and intervention. These gender differences shine a spotlight on the transition from active duty to Veteran status and what we can learn from women Veterans making this transition. Continued attention to care approaches that are sensitive to the spectrum of gender identities and sexual orientations is also essential.
Throughout, our quest to deliver comprehensive women’s healthcare devoid of disparities in access and quality, in safe, secure, and welcoming environments has never wavered. Our many partnerships with VA researchers in these priority areas will continue to ensure we deliver the best care everywhere.
- Yano EM. “A Partnered Research Initiative to Accelerate Implementation of Comprehensive Care for Women Veterans: The VA Women’s Health CREATE,” Medical Care 2015; 53(4 Suppl 1):S10-14.
- Dyer KE, et al. “Mobilizing Embedded Research and Operations Partnerships to Address Harassment of Women Veterans at VA Medical Facilities,” Healthcare (Amsterdam) 2021; 8 Suppl 1:100513.
- Klap R, et al. “Prevalence of Stranger Harassment of Women Veterans at VA Medical Centers and Impacts on Delayed and Missed Care,” Women’s Health Issues 2019; 29(2):107-15.