- JGIM Supplement Features VA Research on Women Veterans’ Health and Healthcare
This special issue of the Journal of General Internal Medicine (JGIM), titled “Moving Women Veterans’ Health Research Forward,” includes 25 articles and 2 editorials that highlight innovations and new findings related to women Veterans’ health and healthcare, including the diverse needs and experiences of women Veterans and active duty and Reserve/National Guard servicewomen.
Date: September 1, 2022
- Despite Guidelines, Women Veterans More Likely to Receive Unrecommended Psychiatric Medications for PTSD than Men
The primary objectives of this work were to examine PTSD prescribing practices over the last decade (2010–2019) for women and men receiving VA care – and to determine the impact of comorbid diagnoses and demographic characteristics on these practices. Findings showed that across medication classes and years, women were more likely to receive all psychiatric medications of interest. Gender differences were notably larger for medications recommended against using for PTSD, including benzodiazepines and anticonvulsants, after adjustment for psychiatric comorbidity. Benzodiazepine prescriptions decreased in both women and men across the study decade, but the difference between prescribing for women and men persisted. Antidepressants recommended against use for PTSD treatment decreased across time for both men and women, however the adjusted gender gap increased from being slightly lower for women in 2010 to being 27% higher in 2019. Generally, for both women and men, the likelihood of receiving a recommended psychiatric medication was higher when comorbid depressive and anxious disorders were present. To inform tailored intervention strategies, future work is needed to fully understand why women receive more medications that experts recommended against using for the treatment of PTSD.
Date: July 7, 2022
- Medication Risks for Veterans of Child-bearing Age
This study investigated medication use and the role of comorbidity among pregnant Veterans receiving VA care – and where patient education or provider-to-provider communication is needed. Findings showed that, based on prescriptions filled within VA only, women Veterans were prescribed numerous medications during pregnancy and discontinued antidepressants at a substantial rate. The median number of drug classes prescribed during pregnancy was five. Use of SSRI/SNRI antidepressants dropped from 36% preconception to 26% during pregnancy, including new starts, and 15% of pregnant Veterans discontinued SSRI/SNRI treatment. Predictors of discontinuing SSRI/SNRI antidepressants during pregnancy were examined, and only Black race was identified as a predictor. Veterans of childbearing age should receive counseling about medication use before pregnancy. Their non-VA obstetricians and VA providers should share information to optimize outcomes.
Date: March 23, 2022
- Reasons Why Women Veterans Leave or Stay in VA Healthcare
This study sought to characterize women Veterans’ decision-making related to departing from (attriting) or continuing to use VA – and to explore factors that help retain/attract women to the VA healthcare system. Women Veterans described complex reasons why they left or continued using VA, with cost and affordability playing an important role even in considerations of returning to VA after a long hiatus. Personal experiences with VA care were regarded similarly by both attriters and non-attriters and considered greatly influential in their decision to use VA or not. Care experiences that influenced women’s decisions not to continue using VA included: strained patient-provider interactions (e.g., feelings of mistrust); disruptive provider turnover; service-connection compensation/pension claim challenges; billing and care coordination disputes regarding VA-purchased care; burdensome access (i.e., clinic-initiated appointment cancellations and rescheduling problems); inconvenient appointment times; and travel distance to the main medical center. More than one-third of women originally categorized as attriters described subsequently re-entering or planning to re-enter VA care. Suggestions to reduce attrition included increasing outreach, improving access, and continuing to tailor care delivery to women Veterans’ needs.
Date: December 28, 2021
- VA Women’s Health Primary Care Providers More Likely to Experience Burnout than General Primary Care Providers
This study examined differences in burnout and intent to leave practice among VA women’s health (WH) and general primary care providers (PCPs). Findings showed that across the three years of the study, burnout was higher among women’s health PCPs compared to general PCPs (55% vs 47%), even after accounting for provider and practice characteristics, with a similar proportion considering leaving (33% vs. 32%). WH-PCPs who intend to leave their current position are more likely than general PCPs to do so for job-related reasons (e.g., types of work, workload, burnout, boredom). Burnout among women’s health providers was similar at facilities with a comprehensive women’s health clinic and those without one. The study team is currently working collaboratively with WH-PCPs to understand the causes of burnout and develop solutions.
Date: October 7, 2021
- Women Veterans with Premature Cardiovascular Disease Less Likely than Men to Receive Secondary Prevention Therapy
This study sought to evaluate sex-based differences in antiplatelet use, any statin and high-intensity statin (HIS) therapy, and statin adherence among patients with premature and extremely premature atherosclerotic cardiovascular disease (ASCVD). Findings showed that women Veterans with premature (age < 55 years) and extremely premature (age < 40 years) ASCVD were less likely to receive antiplatelet agents or statins than men. Premature ASCVD women, compared with men, were significantly less likely to receive antiplatelets (61% vs. 79%), any statin (58% vs. 75%), or HIS therapy (24% vs. 38%). Women with premature ischemic heart disease were comparatively less statin adherent. Relative to women of other races, Black women were less likely to receive some therapies but also more likely to receive others. There was no heterogeneity observed regarding statin adherence. Overall, both sexes received sub-optimal aspirin and statin therapy and had poor statin adherence.
Date: April 21, 2021
- Need for Systemic, Multi-Level Interventions for Patient-Perpetrated Sexual Harassment in VA Healthcare Settings
This study sought to identify challenges and stakeholder recommendations for addressing patient-perpetrated sexual harassment of women staff and patients at VA facilities. Findings highlight the complexity of addressing patient-perpetrated harassment and underscore the need for systemic, multi-level interventions. Perceived organizational-level challenges included a climate of tolerance for harassment, lack of formal policies, and insufficient leadership support. Perceived staff-level challenges included ambiguity around defining harassment, fear of negatively impacting patient-staff dynamics, and competing priorities. Study participants emphasized the need for greater education and training around harassment. Participants explained that some patients lack awareness and do not realize that their behaviors may be construed as harassing. Findings indicate an urgent need for clear, well-disseminated, action-oriented policies addressing how to report and/or intervene around patient-perpetrated harassment.
Date: February 25, 2021
- Suicide Prevention for Women Veterans
The articles in this supplement highlight the value of a wide range of data sources, from the macro-level surveillance data available through the DoD, VA, and the US National Violent Death Reporting System to the depth of qualitative data of individual experiences with suicide attempts. They also illustrate the complexities of studying gender and suicide, while generating a new understanding of important areas for suicide prevention among women. Articles included suggest that younger age, mental health concerns, experiencing violence, and medical comorbidities may all contribute to suicide risk among women.
Date: February 1, 2021
- VA Mental Health Use During Pregnancy/Postpartum Periods Remained Strong among Women with Prepregnancy Depression, PTSD, and Anxiety Diagnoses
This study examined how prepregnancy psychiatric diagnoses could impact mental health treatment use during pregnancy and postpartum, given there is increased risk of symptom recurrence and/or medication discontinuation during pregnancy. Findings showed that there was a strong correlation between a prepregnancy diagnosis of major depressive disorder (MDD), PTSD, or anxiety and use of mental healthcare during pregnancy and the postpartum period. For women with these pre-pregnancy diagnoses, there was an increase in the use of psychotherapy during pregnancy and postpartum, while the percentage of women using antidepressants only or antidepressants plus therapy decreased during the same time periods; 42% of women reported stopping their antidepressants at the onset of the pregnancy.
Date: November 18, 2020
- VA’s Primary Care-Mental Health Integration Affects Access Differently for Women and Men Veterans
This study of 5.4 million Veterans (including 448,455 women), who received care at one of 396 VA primary care clinics between FY2013 and FY2016, set out to answer the following question: Did VA’s national Primary Care-Mental Health Integration (PC-MHI) initiative improve access to care equally among men and women Veterans? Findings showed that PC-MHI was associated with greater use of all outpatient services among men but with lower use of services (except primary care visits) among women. Both men and women had more primary care visits (+22% and +40%, respectively) and total costs over time, but women had 74% fewer hospitalizations (versus +2% in men) related to mental health integration. Each percentage point increase in the proportion of Veterans who saw an integrated specialist was associated with 38% fewer mental health visits per year for women, but 39% more visits for men. Women Veterans had twice the rates of depression and anxiety and used more mental health and primary care services than men. Also, women Veterans were more likely than men to receive care in hospital-based (vs. community-based) clinics, where average PC-MHI penetration rates are higher and where women-only treatment settings are more commonly located.
Date: October 20, 2020
- Gender Differences in Thought Processes among Veterans who Attempted Suicide
This study sought to better understand gender differences in the development of suicidal behaviors among U.S. Veterans to inform future research and gender-tailored prevention efforts. Findings revealed two gendered narratives of suicide attempts that incorporated the primary themes of self-concept, social power, relationships, coping, and stress. When discussing reasons for their suicide attempts, women described feelings of worthlessness, saying they felt “nonexistent in an existing world,” and that they “don’t deserve to be anything.” Women appeared to internalize negative experiences and evaluations from others into negative assessments of their worth (i.e., ‘I am bad’). In contrast to women, men discussed feeling like the world had let them down and that they no longer had any fight left to obtain the life they want to live. In the moments prior to their attempts, men Veterans recalled thinking, “I’ve had enough,” and, “this is just exhausting and pointless.” These feelings primarily reflected their interpretations of failed actions (i.e., ‘What I did was bad.’) rather than assessments of their worth. Thus, in suicide prevention, women Veterans may benefit from methods to increase self-worth through positive social relationships, while men Veterans may benefit from methods that increase their sense of purpose in life and help them achieve their ideal selves through successful experiences.
Date: September 1, 2020
- Majority of Women Veterans Feel Welcome at VA
Investigators in this study analyzed patient suggestions on how to make the VA healthcare system more welcoming to women. Findings showed that of the study participants, 85% felt welcome within the VA healthcare system. Overall, 490 distinct responses were provided to a question asking for suggestions to make VA more welcoming to women Veterans (260 comments and 230 suggestions). Comments included praise for VA (67%), as well as stories about feeling uncomfortable or harassed in VA (26%). Suggestions included those related to VA staff (31%: e.g., hiring more female staff members), the environment of care (18%: e.g., separate building or entrance for women’s clinics), additional resources for women Veterans (18%: e.g., peer support programs), clinical services for women Veterans (15%; e.g., more women’s providers), changing men Veterans’ behavior toward women Veterans at VA (5%), and making the treatment of women and men the same (5%).
Date: July 1, 2020
- Both PTSD Symptoms and Moral Injury are Associated with Adverse Perinatal Outcomes among Women Veterans
This longitudinal study is the first to examine the impact of PTSD symptoms and moral injury on adverse perinatal outcomes among women who became pregnant in the first three years after separating from military service. Findings showed that after adjusting for age, racial/ethnic minority status, socioeconomic status, and lifetime trauma, both PTSD symptoms and moral injury were associated with adverse perinatal outcomes. Only women with greater PTSD symptoms were more likely to report having postpartum depression/anxiety, and to describe their pregnancy as being more difficult. The new VA/DoD clinical practice guidelines on pregnancy management published in March 2018 incorporate the importance of screening for mental health conditions regularly during pregnancy, as well as the coordination of care between medical and mental health providers to prevent adverse perinatal outcomes. These findings specifically support increased screening for PTSD and moral injury, in order to increase access to treatment for these problems as warranted.
Date: June 1, 2020
- One-third of Reproductive-Age Women Veterans Perceive Gender-based Discrimination in VA Healthcare System
This study examined the prevalence of perceived gender-based discrimination – and factors with which it is associated – among reproductive-aged women Veterans seeking VA healthcare. Findings showed that among 2,294 women Veterans, 34% perceived gender-based discrimination when receiving VA care. However, the mean perceived discrimination score was 8 on a 24-point scale, indicating a relatively low frequency of perceived discrimination in VA among those who do encounter it. Of the women Veterans perceiving gender-based discrimination in VA, odds were higher among women with medical or mental illness, or with a history of military sexual trauma. Odds of perceiving gender-based discrimination were lower among women who received most of their care from the same VA primary care provider – or whose VA had a women’s health clinic. Of note, compared to non-Hispanic White women, Hispanic and non-Hispanic African American women perceived less gender-based discrimination. Efforts to enhance patient experiences to prevent exposure to gender-based discrimination may be needed among women with more health concerns and/or a history of military sexual trauma.
Date: May 1, 2020
- Positive IPV Screen Significantly Associated with Health Outcomes and Healthcare Use among Women Veterans Over 45
This study examined the proportion of women older than childbearing age who screen positive when routinely screened for past-year intimate partner violence (IPV) at VA clinics, as well as associations of a positive screen with health conditions and use of healthcare services. Findings showed that of the study cohort, 255 middle-aged (45-59 years; 9%) and 79 older (60 years and older, 5%) women screened positive for past-year IPV. A positive screen was significantly associated with negative mental and physical health outcomes, as well as increased use of healthcare services. Those screening IPV+ in both the middle-aged and older groups were more likely than those screening IPV- to be diagnosed with each category of mental health condition (i.e., anxiety, PTSD, depression). Middle-aged women screening positive had more than twice the odds of having a diagnosis of depression, anxiety, PTSD, and substance use, and four times the odds of suicidal behaviors or self-harm, while older women screening positive had more than three times the odds of having a depression diagnosis. Middle-aged women screening IPV+ had more than double the rate of psychosocial visits in the subsequent 20 months, and older women had a near doubling. Middle-aged women who screened IPV+ also had increased rates of primary care and ED visits, as well as higher odds of having any inpatient admission. These associations were not seen for the older women. Screening for IPV in middle-aged and older women may improve detection and service delivery in this underserved population.
Date: April 21, 2020
- Women Veterans Significantly More Likely than Male Veterans to Use Any Healthcare Up to One Year Post-Discharge
This study examined gender differences among a national sample of Veterans in the use of VA and non-VA health services during the first 15 months of the transition from military to civilian life. Findings showed that women Veterans were twice as likely as men to use any healthcare (VA or non-VA) immediately post-military and 84% more likely than men to do so a year later – but the use of VA care was comparable between men and women. There was no difference at baseline (within 90 days of separation) and only a 22% increase for women relative to men at one year. Use of the Veterans’ Choice Program was uncommon for both genders. While unstable housing was similar across genders (10% for women and 12% for men), women Veterans with unstable housing at military separation were less likely to use healthcare a year later, especially for the subgroup with mental/behavioral health issues. Sleep problems, anxiety, and depression were associated with healthcare use for both men and women following transition. VA housing assistance services could be gender-tailored for the 10% or 12% of Veterans with unstable housing; this could be implemented via outreach in the first 15 months post-separation. Sleep problems, depression, and anxiety remain drivers of healthcare use; whether expert treatment is provided in the community is unknown and should be assessed.
Date: March 1, 2020
- History of Military Sexual Trauma Common among Older Women Veterans
This study sought to determine the prevalence of military sexual trauma (MST) among older women Veterans – and investigate associations between MST and medical and mental health diagnoses. Findings showed that a history of MST was common among older women Veterans. Positive MST screens were observed in nearly 1 in 5 women aged 55-64, and 1 in 10 aged 65-74. [This is similar to the 23% prevalence found in previous studies in women younger than age 55. Accounting for demographic risk factors, MST was associated with increased odds of a range of medical and mental health diagnoses. Most notably, MST was associated with 7.25 times the odds of PTSD and over two-fold odds of depression and suicidal ideation, as well as increased odds of anxiety, alcohol use disorder, substance use disorder, opioid use disorder, sleep disorders, and chronic pain. Thus, older women Veterans remain at risk for the effects of potentially remote MST. Findings call attention to the need for additional research in this understudied population, and the importance of trauma-informed care approaches for women across the lifespan.
Date: November 11, 2019
- Significant Cost Savings for VA in Allowing for 12-Month Dispensing of Oral Contraceptive Pills
Like most US health plans, VA currently stipulates a 3-month maximum dispensing limit for all medications, including oral contraceptive pills (OCPs). This study sought to determine the expected financial and reproductive health implications for the VA healthcare system in implementing a 12-month dispensing option for oral contraceptive pills. Findings showed that adoption of a 12-month dispensing option for oral contraceptive pills is expected to produce substantial cost savings for VA compared to standard 3-month dispensing, while reducing unintended pregnancies among women Veterans. The 12-month dispensing option resulted in anticipated VA cost savings of $87.12/woman/year compared to 3-month dispensing, or an estimated $2,117,800 total saved annually. Cost savings resulted from an absolute reduction of 24 unintended pregnancies/1,000 women/year with 12-month dispensing, or 583 unintended pregnancies averted annually. Financial gains are a secondary benefit to improving contraceptive access and facilitating women Veterans’ individual abilities to manage their reproductive lives as they see fit.
Date: July 8, 2019
- Women Veterans’ Experience with Research on Intimate Partner Violence
Little is known about successful strategies for recruiting and retaining women who have experienced intimate partner violence (IPV) in research, and their experiences of research participation. This study used data on health, safety, empowerment, and engagement with IPV-related services among women VA patients with self-reported IPV in the 12 months prior to enrollment. Findings showed that direct outreach to women VA patients to participate in research interviews about IPV experience was feasible and effective, and proved more fruitful than reliance on provider or patient self-referral. Of the total cohort (N=169), 92% were recruited via direct outreach by the research team (63% via letter, 29% in-person), compared to provider or patient self-referral (3.6% and 4.1%, respectively). While some women experienced emotional strain during or after study visits, they also expressed value in sharing their experiences, and several found the experience personally beneficial. Participants expressed that disclosure was facilitated by interviewers’ empathic and neutral stance, as well as the relative anonymity and time-limited nature of the research relationship. Women Veterans expressed a desire to help others as a primary motivation for study participation. Given that discussing IPV experiences can prompt motivation for further help-seeking and may bring up difficult emotions, it also is important to provide research participants with information about accessing services and support.
Date: May 6, 2019
- Over-Prescribing of Medication for Insomnia, Particularly among Women Veterans
Zolpidem, a non-benzodiazepine sedative hypnotic, is extensively prescribed in the U.S. for short-term treatment of insomnia. FDA recommends cutting the dose for women in half because women metabolize the same dose of zolpidem more slowly than men; VA’s national Pharmacy Benefits Management service policy is in line with FDA guidelines. This study examined prescribing patterns among all VA patients who received zolpidem from FY2012-FY2016. Findings showed that there was inappropriate prescribing of zolpidem in terms of both guideline-discordant dosage and co-prescribing with benzodiazepines, with female Veterans affected more than male Veterans. In 2016, among Veterans who were prescribed zolpidem, 30% of female Veterans received an inappropriately high guideline-discordant dosage compared to 0.1% of male Veterans. Further, more women than men had overlapping benzodiazepine and zolpidem prescriptions (19% vs. 14%). For both male and female Veterans, having a substance use disorder was associated with an inappropriate high dose. Further, mental health conditions, including anxiety and PTSD, were associated with co-prescribing of zolpidem with benzodiazepines for both male and female Veterans.
Date: March 1, 2019
- Cardiovascular Care and Research for Women Veterans
This review presents important information on five areas of cardiovascular disease (CVD) care for women Veterans: 1) rapidly changing demographics; 2) prevalence of traditional risk factors; 3) prevalence of less traditional risk factors (i.e., homelessness, military sexual trauma, and mental health disorders); 4) treatment and outcomes of CVD; and 5) the current state and future directions of women’s health research. The rapidly growing population of women Veterans represents a specific at-risk population with characteristics that set them apart from their male counterparts as well as civilian women regarding CVD risk factors and CVD recognition, diagnosis, treatment, and possibly outcomes. Significant advancements have been made over the past decade in better characterizing CVD in women Veterans, but there remains a large gender gap and paucity of prospective, randomized, interventional clinical trials.
Date: February 19, 2019
- Women Veterans Who Report Stranger Harassment on VA Grounds More Likely to Delay or Miss Healthcare
This study examined the prevalence of self-reported harassment among women Veterans who use VA healthcare. Findings showed that one in four women Veterans reported inappropriate and/or unwanted comments or behavior by male Veterans on VA grounds. Eight percent said that this usually or always took place at VA. Negative interactions included sexual/derogatory comments and questions about the women’s Veteran identity and right to VA care. Those who reported harassment were less likely to report feeling welcome at VA, and more likely to report feeling unsafe and delaying/missing care. Younger women were more likely to report harassment, as were women Veterans with self-reported fair or poor health status, those with MST and/or other trauma exposures, and those with anxiety. VA Women’s Health Services has responded by establishing a national workgroup, gauging effective harassment reduction programs outside VA, convening an expert panel, piloting interventions, and launching a national culture campaign.
Date: January 24, 2019
- Women’s Health VA Stakeholders Discuss “Ideal” Care
As part of a multisite implementation trial of evidence-based quality improvement for tailoring PACT to women Veterans’ healthcare needs, investigators conducted semi-structured interviews with 86 local leaders. At the conclusion of interviews about women’s primary care, participants were asked to describe their conceptualizations of “ideal care” for women Veterans. Respondents commonly discussed whether women Veterans should have separate primary care services from men; the need for childcare, expanded reproductive health services, resources, and staffing; geographic accessibility; the value of input from women Veterans; physical appearance of facilities; fostering active interest in women’s health across providers and staff; and the relative priority of women’s health at VA. Paths toward ideal care could include projecting and anticipating growth in women’s health programs; building on VA’s pilot program to provide childcare for patients’ children during visits; designing a hiring process to more consistently recruit providers with a strong interest in caring for women; and conducting listening sessions and creating other opportunities that allow senior VA leadership to hear women Veterans’ perspectives and preferences directly.
Date: January 1, 2019
- Women Veterans with Pain More Likely to Use Complementary and Integrative Therapies
This study sought to examine complementary and integrative health (CIH) therapy use by gender among Veterans with chronic musculoskeletal pain, and variations in gender differences by race/ethnicity and age. Findings showed that of Veterans with chronic musculoskeletal pain, more women than men used CIH therapies (36% vs. 26%). Black women, regardless of age, were least likely to use CIH therapies compared to other women. Among men, White and Black Veterans were less likely to use CIH therapies, irrespective of age, than men of Hispanic or other race/ethnicities. Among both women and men, CIH therapies were least likely to be used by younger Black or White Veterans. Given the disparities in CIH therapy use, tailoring CIH therapy engagement to gender, race/ethnicity, and age may increase CIH therapy use among Veterans.
Date: September 1, 2018
- LGBT Women Veterans Report Missing Needed Health Care Due to Concerns about Interacting with Other Veterans
This study sought to examine LGBT women Veterans’ experiences within the VA healthcare system, and whether their experiences impact use of VA care. Findings showed that the majority of women Veterans reported feeling welcome at their VA. However, fewer LGBT women reported feeling welcome and safe at VA compared with non-LGBT women Veterans. After controlling for demographics, health status, and positive trauma screens, LGBT identity was predictive of women Veterans experiencing harassment from male Veterans at VA in the past 12 months, as well as feeling unwelcome or unsafe at VA. LGBT women Veterans were about 3 times more likely than non-LGBT women Veterans to attribute missing needed care in the previous 12 months to concerns about interacting with other Veterans. Study participant descriptions of harassment indicated that male Veterans’ comments and actions were distressing and influenced LGBT women Veteran’s healthcare accessing behavior. Despite VA’s ongoing efforts to educate employees and change the culture toward a more inclusive environment, more targeted work addressing the needs of LGBT women Veterans may be needed.
Date: July 1, 2018
- Evaluating Care Coordination Program for Pregnant Veterans
The VA Maternity Care Coordinator Telephone Care Program (MCC-TCP) was created to support MCCs and includes outlines to guide up to eight calls with Veterans on topics such as VA maternity care benefits, chronic health problems, substance use cessation, and depression and suicide screening. Investigators evaluated the program and assessed its feasibility, as well as facilitators and barriers to its implementation in 11 VA facilities. Findings showed that the VA Maternity Care Coordinator Telephone Care Program was successfully implemented and was perceived by the maternity care coordinators as valuable in meeting the care coordination needs of pregnant Veterans. MCC-TCP implementation barriers included limited information and communication technology tools to support the program – and lack of coordinator time for delivering telephone care. Consistent with prior research, pregnant women Veterans using VA maternity care had a high need for care coordination services due to their substantial burden of physical and mental health problems: 41% had pre-pregnancy chronic physical problem(s); 34% had mental health problem(s), particularly depression (28%) and PTSD/anxiety (21%); and 18% actively or recently smoked. Given the substantial and growing maternity care coordination needs among pregnant Veterans, especially those with chronic medical and mental illness, further investments in programs such as the Maternity Care Coordinator Telephone Care Program should be prioritized.
Date: May 23, 2018
- Most Women Veterans Report Timely Access to Mental Healthcare, Leading to High Satisfaction with VA Care
This study evaluated access to mental healthcare by assessing women Veterans’ perceptions of the timeliness and quality of care. Findings showed that of the 419 women Veterans in this study cohort, 59% reported "always" getting an appointment for mental healthcare as soon as needed, and another 22% reported “usually” getting an appointment as soon as needed. Two problems were negatively associated with timely access to mental healthcare: 1) medical appointments that interfere with other activities, and 2) difficulty getting questions answered between visits. Average ratings of the quality of VA healthcare were high: 8.5 out of 10 regarding VA mental healthcare, 8.7 for VA primary care, and 8.2 for VA healthcare overall. Moreover, 93% of women Veterans reported that they would recommend VA healthcare to other women Veterans. This study highlights opportunities for addressing barriers to timely mental healthcare through practices such as non-traditional clinic hours, open access scheduling, telemedicine, and secure messaging.
Date: April 5, 2018
- Women Veterans Who Experienced Past-Year Intimate Partner Violence Significantly More Susceptible to Housing Instability
This study used VA clinical screening data to assess the relationship between recent experience of intimate partner violence (IPV) and housing instability among women Veterans. Findings showed that female Veteran patients who screened positive for past-year IPV had up to four times the odds of experiencing housing instability. Women Veterans who screened positive for past-year IPV were significantly more likely to have an indicator of housing instability if they identified as Black or African American, previously screened positive for military sexual trauma, had a mental health diagnosis, or a substance use disorder. Women Veterans receiving compensation for a disability incurred during military service – and those who were married – were significantly less likely to have an indicator of housing instability. IPV interventions should assess for both physical and psychological housing needs, and housing interventions should coordinate with IPV programs to address common barriers to resources.
Date: April 1, 2018
- Phone Communication and Care Coordination Associated with Access to Needed Care as Reported by Women Veterans
This study used a survey of women Veterans to examine associations between key care team functions and patient-rated access to needed care (routine and urgent). Findings showed that overall, 74% of study participants reported usually or always being able to see a provider for routine care, and 68% for urgent care. In addition, 62% of patients gave high ratings of care coordination, and 76% gave high ratings of in-person communication. Among women Veterans who called their provider with a healthcare question, 63% usually or always got an answer as soon as needed. Phone communication was strongly associated with better ratings of access to routine and urgent care (absolute increases of 25% and 33%, respectively). Care coordination was also associated with better ratings of access to routine and urgent care (absolute increases of 8% and 13%). Associations with in-person communication were not statistically significant. Results suggest that approaches to improving access that increase reliance on non-VA providers may prove counter-productive if they compromise the team's ability to coordinate care, or diminish their role as a primary point of contact for patients.
Date: March 1, 2018
- Women Veterans Screening Positive for Intimate Partner Violence More Likely to Receive Mental Illness Diagnosis
This cross-sectional study is the first large-scale investigation into the associations between intimate partner violence (IPV) and mental health using IPV clinical screening and mental health diagnosis data from VA medical records. Findings showed that female VA patients who screened positive for past-year IPV were more than twice as likely to have a mental health diagnosis – or more than two mental health diagnoses – compared to those who screened negative. More than half (54%) of the women who screened positive for IPV had a mental health diagnosis, compared with less than one-third (33%) of those who screened negative for IPV. Each category of IPV exposure (psychological, physical, and sexual violence) was significantly associated with having a mental health diagnosis or comorbidity. Associations remained after adjusting for military sexual trauma and combat trauma. IPV assessment and response needs to address all forms of IPV, including psychological violence in the absence of physical or sexual violence, and the particularly strong associations between mental health and experiences of sexual intimate partner violence.
Date: December 1, 2017
- HCV-Related Complications Increasing among Women Veterans
This study examined gender-related differences in the incidence and prevalence of cirrhosis, decompensated cirrhosis, and hepatocellular cancer (HCC) between 2000 and 2013. Findings showed that the incidence and prevalence of hepatitis C virus (HCV) complications was higher in men than in women. However, the rate of increase in the incidence rates of cirrhosis and decompensated cirrhosis among HCV-infected women is similar to the rate of increase in men. In 2000, 3% of women vs. 5% of men had been diagnosed with cirrhosis. By 2013, the prevalence for cirrhosis had risen to 14% and 21% in women vs. men, respectively. In 2000, the prevalence of decompensated cirrhosis was 1.6% in women and 2.4% in men, but increased by 2013 to 7% in women and 12% in men.
Date: November 1, 2017
- Unintended Pregnancy and Contraceptive Use among Women Veterans
This study sought to determine rates of contraceptive use, unmet need for prescription contraception, and unintended pregnancy in a national sample of reproductive-aged women Veterans who receive VA healthcare. Findings showed that while rates of contraceptive use, unmet contraceptive need, and unintended pregnancy among women Veterans served by VA are similar to those in the U.S. population, these rates are sub-optimal in both populations. More than one-third of pregnancies in both populations are unintended, about 10% of women at risk of unintended pregnancy are not using any method of contraception, and nearly 30% are not using prescription contraception. Overall, 62% of women Veterans reported currently using contraception compared to 68% of women in the U.S. population. Among the subset of women at risk for unintended pregnancy, 27% of Veterans were not using prescription contraception compared to 30% in the U.S. population.
Date: August 1, 2017
- Current Diagnosis of PTSD is Risk Factor for Pregnant Women
This analysis evaluated the associations between PTSD and antepartum complications to explore how PTSD’s pathophysiology impacts pregnancy in a large cohort of women Veterans. Findings showed that a current diagnosis of PTSD increases the risk of hypertensive/ischemic placental complications of pregnancy, specifically preeclampsia, and is a risk factor for gestational diabetes. PTSD also was associated with an increased risk of prolonged (>4 day) delivery hospitalization and repeat hospitalization. Authors suggest that pregnancies in women with currently active PTSD should be identified as potentially high-risk, high-need pregnancies.
Date: May 1, 2017
- VA’s Patient Aligned Care Teams’ Challenges in Providing Care for Women Veterans
In this study, investigators conducted interviews with primary care providers and staff in eight VA medical centers to assess provider and staff experiences with PACT, implementation of core medical home features, and facilitators and barriers encountered in providing PACT care to women Veteran patients. Findings showed that providers and staff have generally positive attitudes toward PACT. However, early challenges to the delivery of PACT-principled care persist in both primary care and women’s health clinics. Ongoing barriers to PACT implementation include short staffing, conflicting performance requirements for continuity and same-day access, space constraints, and sharing of support staff across multiple providers. Challenges unique to the care of women Veterans included a higher prevalence of psychosocial needs and the need for specialized training of primary care personnel in gender-specific care. Primary care providers and staff in women’s health clinics are often physically separated from other PACT and medical neighborhood resources or asked to share their support staff with specialists. Primary care providers and staff face unique challenges in the delivery of comprehensive primary care to women Veterans that may require special policy, practice, and management actions if the full benefits of PACT are to be realized for this patient population.
Date: March 1, 2017
- High Prevalence of Intimate Partner Violence among Women Veterans – Up to Age 55 – Using VA Primary Care
This study sought to identify the prevalence of past-year intimate partner violence (IPV) among women Veterans utilizing VA primary care, and to document associated demographic, military, and primary care characteristics. Findings showed that the prevalence of past-year IPV among women Veterans who used VA primary care services was 19%, with higher rates (22% to 26%) among women up to age 55. Most women who experienced IPV identified a VA provider as their usual healthcare provider. Women who were not employed full-time, received public assistance, had been homeless within the past year, or had an annual income of less than $25,000 were more likely to have experienced IPV. Women who identified as lesbian or bisexual also were more likely to report IPV than heterosexual women, as were those who were the parent/guardian of a child younger than 18 years old. Age-adjusted military correlates included service during Vietnam to post-Vietnam eras, less than 10 years of service, and experiences of military sexual trauma (MST). The high prevalence of past-year IPV among women beyond childbearing years, the majority of whom primarily rely on VA as a source of healthcare, reinforces the importance of screening all women for IPV in VA primary care settings.
Date: August 1, 2016
- The Gerontologist Supplement Highlights VA Research on Health Issues Affecting Older Women Veterans
This Supplement includes 13 articles that highlight findings on a range of topics related to women Veterans and aging, such as, menopause, diabetes, cardiovascular disease, chronic pain, and substance use.
Date: February 1, 2016
- Alcohol Misuse among Female Veterans
This study examined the demographic/military, interpersonal violence, and mental health correlates of alcohol misuse among female Veterans seeking VA healthcare. Findings showed that younger age, adulthood physical abuse, military sexual trauma, past-year psychological aggression by an intimate partner, and PTSD and depression symptom severity showed significant associations with alcohol misuse. Two of these associations – younger age and past-year psychological intimate partner violence – remained significant when examined in logistic regression models. Female Veterans at risk for alcohol use disorders may benefit from screening and intervention efforts that take into account exposure to interpersonal violence and mental health symptoms.
Date: December 7, 2015
- Effect of Childhood Physical and Sexual Abuse on Female Veterans’ Health and Healthcare Use
This study sought to investigate whether childhood physical abuse and childhood sexual abuse predict health symptoms and healthcare use. Findings showed that childhood physical abuse was an important contributor to both physical and mental health for female Veterans. After adjusting for age, race, military branch, childhood sexual abuse, and MST, childhood physical abuse was predictive of poorer physical health, greater depressive and PTSD symptoms, and more frequent use of medical healthcare. No significant association was found between childhood sexual abuse and poor physical or mental health, and it was not a predictor for healthcare use. Screening for adverse childhood experiences may facilitate access to appropriate physical and mental health treatment, as well as inform mental health assessment and treatment planning, among female Veterans.
Date: October 1, 2015
- Post-Menopausal Symptoms among Women Veterans with and without Type 2 Diabetes
This study sought to describe the postmenopausal symptom experience in women with type 2 diabetes – and to examine the association between glucose control and symptom severity. Findings showed that, despite higher BMI and increased comorbidities in women Veterans with diabetes compared to those without diabetes, the pattern of menopause symptoms did not differ by group. Symptom severity scores were highest for muscle and joint aches, followed by hot flashes and trouble sleeping, while headaches received the lowest severity scores. Measures of mental health (i.e., anxiety, depressed mood) were similar across groups. Among women Veterans with diabetes, worse glucose control, smoking, and a diagnosis of altered mood demonstrated a positive association with perceived menopause symptom severity, even after adjusting for other covariates. Women without diabetes were younger, of lower BMI, had fewer self-reported comorbid conditions, and reported better physical health.
Date: June 1, 2015
- Prevalence of Alcohol Misuse among Women Veterans High Regardless of Care Setting
This study sought to estimate the prevalence and correlates of alcohol misuse in women Veterans – and to assess the associations between alcohol misuse and mental health use in a group comprising both VA healthcare system users and non-users. Findings showed that women Veterans who did not use VA healthcare had a higher prevalence of alcohol misuse (32%) compared to women Veterans who did use VA healthcare (27%). The prevalence of binge drinking was similar for VA non-users (26%) and VA users (24%). The prevalence of past-year mental healthcare among women Veterans with alcohol misuse was higher for VA users than for non-users: 26% versus 5% for mild alcohol misuse, and 43% versus 17% for moderate-to-severe alcohol misuse. Among VA non-users, 46% of women Veterans with PTSD and 66% of those with sexual assault in the military screened positive for alcohol misuse. Among VA healthcare users, the prevalence of alcohol misuse was notably high among younger women (ages 18-44, 43%), those who served in OEF/OIF (51%), and those with combat exposure (41%).
Date: May 1, 2015
- VA Healthcare for Women Veterans: Medical Care Supplement
The goal of this Supplement is to disseminate new research findings related to the planning, organization, financing, provision, evaluation, and improvement of health services and/or outcomes for women Veterans and women actively serving in the military. In addition to 21 articles, the Supplement features several editorials that describe emerging areas of women’s health research, particularly following the 2014 Veterans Choice Act, as well as a partnered-research initiative that aims to accelerate the implementation of comprehensive care for women Veterans.
Date: April 1, 2015
- Differences between Men and Women Veterans Undergoing Cardiac Catheterization in VA
This study sought to determine whether there were gender differences in clinical characteristics and comorbidities, coronary anatomy and treatment, and procedural complications and long-term outcomes after diagnostic catheterization. Findings showed that female Veterans were younger (57 vs 63 years), with fewer traditional cardiovascular risk factors, but had more obesity, depression, and PTSD than male Veterans. Compared to male Veterans, female Veterans had lower rates of obstructive coronary artery disease (CAD) (23% vs 53%), similar or lower rates of procedural complications, and lower rates of all-cause rehospitalization. Women Veterans had lower mortality at one year, even when adjusted for age, presence of obstructive disease, and multiple comorbidities. Findings suggest that a significant portion of women Veterans treated in VA catheterization labs have chest pain not related to obstructive CAD. This may represent a complex interplay of psychological stressors and somatic disease, but further research is needed.
Date: March 1, 2015
- Women Veterans with PTSD at Significantly Increased Risk of Spontaneous Pre-term Delivery
Using a cohort of deliveries covered by VA from 2000 to 2012, investigators in this study examined the association between PTSD and spontaneous pre-term delivery (before 37 weeks). Findings showed that mothers with active PTSD were at 35% increased odds of having a spontaneous pre-term delivery (two excess pre-term births per 100 deliveries), even after adjusting for psychiatric and medical comorbidities. Thus, PTSD’s health effects may extend, through birth outcomes, into the next generation.
Date: December 1, 2014
- Study Highlights Mental Health Services Important to Women Veterans
Investigators in this study identified a subset of women Veteran primary care users who were potential stakeholders for mental health services, and then quantified their priorities for these services. Treatment for depression, pain management, coping with chronic conditions, sleep problems, weight management, and PTSD emerged as the top six mental healthcare priorities for women. The majority of women Veterans in this study (98%) selected at least one of these services as important, and 80% selected at least three of these six services as important. The majority of women who prioritized each of these six services reported that they had either used this type of service in the past year or were quite a bit or extremely likely to use the service within the next six months, ranging from 62% for weight management to 96% for chronic conditions. Findings suggest that women’s primary care clinics, which are available at many VA healthcare facilities, are a strategic setting to enhance the implementation of women’s health services through primary care-mental health integration.
Date: November 17, 2014
- Women Veterans have Better VA Outpatient Care Experiences with Designated Women’s Health Providers
This operational analysis examined whether women Veterans’ experiences with care were better for patients seen by designated women’s health providers (DWHPs) compared to those seen by non-DWHPs. Findings showed that women Veterans’ overall experiences with outpatient healthcare were slightly better for those receiving care from DWHPs compared to those receiving care from non-DWHPs. Differences in patient experiences were not mitigated after adjusting for variables. Although the majority of DWHPs were physicians (62%), more DWHPs were nurse practitioners (NPs) compared to non-DWHPs (31% vs. 16%). Veterans seeing NPs had significantly better experiences than those seeing MDs (regardless of DWHP status). Provider gender was not independently associated with experiences with care.
Date: November 1, 2014
- Women Veterans, Particularly Black Veterans, Have Worse Risk Factor Control for Cardiovascular Disease than Male Veterans
This study compared gender and racial differences in three risk factors that predispose individuals to cardiovascular disease: diabetes, hypertension, and hyperlipidemia. Findings showed that overall, female Veterans had significantly higher LDL cholesterol levels than male Veterans, despite being almost ten years younger, on average. These differences are similar to gender disparities previously reported both within and outside VHA and represent a clinically significant difference. African-American women Veterans had worse blood pressure control than White women Veterans, and among Veterans with diabetes, male African-Americans had worse control of higher blood pressure, LDL, and HbA1c levels than White males.
Date: September 1, 2014
- Efficacy of Routine Screening Pelvic Examination in Asymptomatic Average-Risk Women
This systematic review evaluated the benefits and harms of the routine screening pelvic examination in asymptomatic, non-pregnant, adult women for indications other than sexually transmitted infection screening, provision of hormonal contraception, and cervical cancer screening. No data supported the use of the routine pelvic examination (excluding cervical cytology) for reduction in morbidity or mortality from any condition. The percentage of women endorsing pain or discomfort during the pelvic exam ranged from 11% to 60% and the percentage of women endorsing fear, embarrassment, or anxiety ranged from 10% to 80%. No studies evaluated mortality or morbidity outcomes of the screening pelvic examination for the diagnosis of other malignancies or other benign gynecologic conditions (i.e., pelvic inflammatory disease).
Date: July 1, 2014
- OEF/OIF Servicewomen Remain Reluctant to Report Military Sexual Assault despite More Knowledge about Reporting Options
This study sought to identify factors associated with officially reporting sexual assault in-military (SAIM), examining demographic, military, and sexual assault characteristics, as well as perceptions and experiences of reporting. Findings showed that 18% of the active duty service members and 12% of the Reserve/National Guard members in this study experienced SAIM. However, despite increased knowledge about how to report SAIM, there was no increase in rates of reporting compared to earlier VA-enrolled samples; the number of servicewomen who knew how to officially report increased from 57% to 65%, but the rates of reporting were similar, 26% vs. 25%. Restricted reporting (law enforcement not informed, command structure not involved) was rated more positively, but unrestricted reporting (law enforcement and command structure notified, criminal investigation initiated) was used more often. Experiences of servicewomen who reported SAIM reinforced concerns of those who did not report, i.e., loss of confidentiality, adverse treatment by peers, no action taken against the perpetrator. Officers were less likely to report than enlisted servicewomen.
Date: July 1, 2014
- Intimate Partner Violence: Current State of Knowledge in Regard to Women Veterans
This article provides an overview of the risk and impact of experiencing intimate partner violence (IPV) among women Veterans, who currently make up 10% of the Veteran population, and who appear particularly likely to report IPV (research has shown prevalence ranges from 24% - 29% of past-year IPV). Investigators also discuss evidence-based treatment for IPV and identify future priorities for research and clinical programming.
Date: February 7, 2014
- Increasing Number of Women Veterans Use VA Maternity Benefits
This study examined the number and cost of inpatient deliveries in VA over a five-year period – from FY2008 to FY2012. Findings showed that the volume of women Veterans using VA maternity benefits increased by 44% – from 12.4 to 17.8 deliveries per 1,000 women Veterans. Also, the number of deliveries increased during each year – from 1,442 delivery claims in FY2008 to 2,730 in FY2012. A majority of women using VA maternity benefits were age 30 and older, resided in urban areas, and had a service-connected disability. Also, 42% were OEF/OIF/OND Veterans. Over the five-year study period, VA paid more than $46 million in delivery claims to community providers for deliveries of women Veterans ($4,993 per Veteran). The rate of C-section delivery was 34%, which is similar to the national average of 32%. Given the sizeable increase in delivery rates, the authors suggest that VA increase its capacity for pregnant Veterans and ensure care coordination systems are in place to address the needs of pregnant Veterans with service-connected disabilities. Coordinating community-based maternity care with ongoing VA care is critical because many women Veterans have complex medical and mental health conditions that may increase their risk of adverse pregnancy outcomes.
Date: January 1, 2014
- Women Veterans who Experience Intimate Partner Violence are at Higher Risk for Some Medical and Mental Health Conditions
This study sought to fill gaps in knowledge by examining demographic and clinical characteristics of women Veterans who have disclosed intimate partner violence (IPV) victimization to a VA healthcare provider. Findings showed that lifetime IPV was documented in about one-quarter (24%) of women Veterans’ medical records and was associated with higher risk of many medical conditions and with increased healthcare use. Women Veterans with documented IPV had higher rates of military sexual trauma, injury/poisoning, mental health disorders, infectious or parasitic diseases, and digestive system disorders. More than 95% of women Veterans with documented IPV had a mental health diagnosis, including: 60% with episodic mood disorders, 57% with neurotic disorders, 48% with PTSD, and 72% with other depression. In addition, 45% reported military sexual trauma. Compared with women who had no documented IPV, those with documented IPV had a higher average number of healthcare encounters per month and were more likely to have visited the emergency department – and to have had a mental health/behavioral health/social work visit during the study period.
Date: August 5, 2013
- Rates of Breast Conserving Surgery Performed in VA for Women Veterans with Breast Cancer Comparable to Private Sector
Previous research suggested a lower rate of breast-conserving surgery (BCS) for the treatment of breast cancer in VA than in the private sector. Combining VA administrative data with VA Centralized Cancer Registry (VACCR) data, this study analyzed utilization rates of BCS among a cohort of women Veterans. Findings showed that, based on procedures performed solely in VA, rates of breast-conserving surgery for women Veterans decreased from 51% in 2000 to 42% in 2006. However, after accounting for procedures conducted in the private sector and paid for by VA, the BCS rate was 60%, which is more in line with private sector data. This suggests that previously reported differences in BCS rates between VA and the private sector may have been caused by the referral of BCS cases to the private sector, but the retention of mastectomies within VA. No statistically significant differences in the use of BCS were found based on age, race, income, marital status, or distance to a VAMC. None of the facility characteristics (including volume) was found to be significantly associated with the use of breast conserving surgery.
Date: July 1, 2013
- Journal Issue Highlights Women Veterans’ Health Issues
The goal of this Supplement is to disseminate new research findings; highlight research that can lead to improvements in care (both within and outside VA); and raise awareness of, stimulate interest in, and increase research about the healthcare of women Veterans and women in the military.
Date: July 1, 2013
- Homelessness More Prevalent among Female Veterans
This review of the literature sought to assess and summarize the body of knowledge on homelessness among female Veterans, in order to inform policy and highlight important gaps in this literature that could be filled by future research. Findings showed that female Veterans now comprise a larger share of the homeless Veteran population than of the overall Veteran population. Homeless female Veterans are characteristically different from their male counterparts, both with respect to demographic and clinical factors. For example, homeless female Veterans are younger, have higher levels of unemployment, and have lower rates of drug or alcohol dependence or abuse, but they have higher rates of mental health problems than homeless male Veterans. Female Veterans are at an increased risk of homelessness relative to the non-Veteran female population. Studies identified factors that may increase the risk of homelessness among women Veterans, including: unemployment, disability, PTSD, sexual assault or harassment during military service, anxiety disorder, poor health status, and older age.
Date: June 26, 2013
- Significant Disparities among Women Veterans with and without Mental Illness in Delaying or Going without Medical Care
This study examined associations of PTSD and depressive symptoms with unmet medical needs and barriers to care among women Veterans. Findings showed that there was a significant degree of disparities reported by women Veterans with and without mental health symptoms in delaying or going without needed medical care. The majority of those who screened positive for both PTSD and depressive symptoms had unmet medical care needs in the prior 12 months (59%) – compared to 30% of women with PTSD symptoms only, 18% of those with depressive symptoms only, and 16% of women with neither set of symptoms. This pattern remained the same after adjustment (e.g., for demographics, insurance, combat exposure). Overall, among women Veterans in this study who reported unmet medical needs (19% of the women surveyed), those with both PTSD and depressive symptoms were more likely than women in the other groups to identify affordability as a reason for going without or delaying care (69%). Being unable to take time off work (31%) was the second most common reason reported among this group. Women with PTSD symptoms (w/ or w/o depression) were less likely than all other groups to have health insurance to cover non-VA care.
Date: May 1, 2013
- More than One in Eight Women Veterans Screen Positive for PTSD and A Significant Segment Does Not Receive Treatment
This study sought to identify PTSD prevalence and mental healthcare use in a representative national sample of women Veterans. Findings showed that more than one in eight women Veterans in this study (13%) screened positive for PTSD, and less than half of this group received mental health treatment (either VA or non-VA). VA healthcare was used by 31% of the women Veterans who screened positive for PTSD and by 11% of women Veterans who screened negative for PTSD. Among women Veterans who screened positive, 49% used mental healthcare services, including 66% of VA users and 41% of non-VA users. Predictors of mental healthcare use included having a diagnosis of depression and utilizing VA healthcare, while lacking a regular healthcare provider and household income below the federal poverty line predicted non-use of mental healthcare. Because the majority of women Veterans utilize non-VA healthcare, and these providers may be unaware of their Veteran status and PTSD risk, the authors suggest that more effective efforts be made to help identify women Veterans with PTSD – and to engage them in care.
Date: February 23, 2013
- Rape and Sex Partnership Adversely Associated with Lower Physical Functioning in Women Veterans
This study sought to determine whether current physical health status in women Veterans is associated with rape in military (RIM) and same-sex partnering. Findings showed that women Veterans who reported a history of rape (during childhood or adolescence, in-military or post-military) and those with same-sex sexual partners at some point in their lives had significantly lower current physical health status compared to women without such histories. Of the participants in the study, 11% reported having women as sex partners (WSW). Women with same-sex partners reported significantly higher lifetime substance use disorder (SUD) and higher rates of rape, both lifetime and in separate time periods, compared to women who reported having sex with men exclusively. Three-quarters (74%) of WSW reported lifetime rape and one-third (35%) reported RIM compared to 48% and 23% in women with men as partners only. Physical health status was lowest for women with a history of chronic pain. Other factors significantly associated with lower physical health status were depression, PTSD, and not having a current SUD.
Date: October 15, 2012
- Higher Rates of Reproductive and Physical Health Problems in OEF/OIF Women Veterans with Mental Illness
OEF/OIF women Veterans with any mental health diagnoses had significantly higher prevalence of nearly all categories of reproductive and physical disease diagnoses compared to women Veterans without mental health diagnoses. Women with mental health diagnoses had approximately two to four times the odds of receiving diagnoses of sexually transmitted infections, cervical dysplasia, dysmenorrhea, and gynecologic pain syndromes, as well as other reproductive and gynecologic health conditions, with prevalence being highest in women with comorbid PTSD and depression. The most striking difference was in sexual dysfunction (a relatively rare outcome), in which women Veterans diagnosed with mental health disorders had 6 to 10 times the odds of receiving this diagnosis than women without mental disorders.
Findings were similar after adjusting for demographics, military service characteristics, and distance to/type of nearest VAMC. The magnitude of the associations of mental and physical health diagnoses were reduced after adjusting for primary care utilization, but most remained significant.
Date: September 1, 2012
- Association between Alcohol Screening Scores and Alcohol-Related Risks among Women Veterans
Among the women Veterans in this study, 24% screened positive for alcohol misuse. Many of these women reported symptoms of alcohol misuse that would not be identified by VA’s current required alcohol screening program because of their lower AUDIT-C scores. Increasing scores on the AUDIT-C reflected increasing prevalence of self-reported alcohol-related risks and consequences. For three out of the five alcohol-related consequences (i.e., tolerance of alcohol, blackouts, feeling the need to cut down on drinking), adjusted prevalence increased at AUDIT-C scores >3. The remaining alcohol-related consequences (i.e., morning drinking, family/friends worried) increased at scores >4, as did self-reported problem drinking and drug use. Associations between health risks (i.e., >2 sexual partners, sexually transmitted diseases, injuries, domestic violence, hepatitis/cirrhosis) and AUDIT-C scores were less consistent, but prevalence generally increased at scores >5.
Date: May 1, 2012
- Women Veterans Report Poorer Health Outcomes Compared to Civilian and Active Duty Women
Veteran women reported consistently poorer health compared with other women, including poorer general health, greater likelihood of health risk behaviors (e.g., smoking), and greater likelihood of chronic conditions and mental health disorders. Veterans were most likely – and active duty least likely – to report frequent poor physical health. Veterans were more likely than civilian and active duty women to be obese or overweight – and to have cardiovascular disease. National Guard or Reserves (NG/R) women also were more likely to be overweight or obese than both civilian and active duty women. Veterans were more likely than civilians to report a history of depressive disorder and more likely than active duty women to report a history of anxiety disorder. NG/R women were more likely than civilian and active duty women to report both depression and anxiety. Tobacco use and lack of exercise were most commonly reported among Veterans and least commonly reported among active duty women. Compared to civilians, Veteran women were more highly educated and had higher incomes. Despite these protective factors, Veteran women reported faring better than civilians on only two indicators – health insurance and receiving clinical breast exams.
Date: May 1, 2012
- Changes in Health Conditions and VA Healthcare Costs among Women Veterans between 2000 and 2008
The number of women Veterans treated in the VA healthcare system increased from 156,305 in 2000 to 266,978 in 2008; 88% of these women were under 65 years of age. The mean costs of care increased from $4,962 per woman Veteran in FY00 to $6,570 in FY08. Gender-specific, cancer, musculoskeletal, and mental health and substance abuse conditions accounted for a greater share of overall costs during the study period. Psychiatric conditions represented the largest share of costs for female VA patients during the study years. There was a modest rise in costs for psychiatric conditions among all female Veteran patients driven by the growing number of women treated for depression and PTSD. From 2000 to 2008, the proportion of women treated for PTSD increased by 133%, while the proportion of women treated for depression increased by 41%.
Date: May 1, 2012
- Journal Issue Targets Veterans’ Sexual Health and Functioning
The International Journal of Sexual Health is the first scientific journal to devote an issue to the sexual health and functioning of military Veterans. Articles in this issue, many authored or co-authored by HSR&D investigators, describe the effects of combat experiences on American Veterans’ sexual functioning, sexual risk behavior, mental health, health status, and relationships. In addition, articles describe the effects of sexual assault on women’s sexual health, and healthcare use among transgender Veterans.
Date: April 1, 2012
- Gender Differences in Healthcare Utilization among Veterans with PTSD
Overall, female OEF/OIF Veterans with PTSD were more likely to have slightly higher mental health, primary care, and emergency care utilization compared to male Veterans with PTSD.
Women Veterans with comorbid PTSD and depression were 12.5 times more likely to have a mental health inpatient hospitalization compared to their female counterparts without depression, and they were twice as likely to have a mental health hospitalization compared to male Veterans with comorbid PTSD and depression. Diagnoses of comorbid PTSD and depression were present in 72% of women and 57% of men. Both men and women with PTSD and alcohol use disorders had more than double the mean number of mental health outpatient visits compared to their counterparts with PTSD but without alcohol use disorders. Comorbid PTSD and alcohol use disorders diagnoses were present in 8% of women and 29% of men. Regardless of gender, Veterans with comorbid PTSD and depression or comorbid PTSD and alcohol use disorders had higher healthcare utilization in all areas, as compared to their counterparts with PTSD but without these comorbid disorders.
Date: February 7, 2012
- Barriers to Healthcare Access for Women Veterans
This study examined the association of general and Veteran-specific barriers on access to healthcare among women Veterans. Findings showed that overall, almost 1 in 5 women Veterans (19%) delayed healthcare or went without needed care in the prior 12 months, including 14% of insured and 55% of uninsured women Veterans. VA healthcare users comprised 21% of those with and 13% of those without delayed healthcare or unmet needs. Younger age groups were associated with a higher prevalence of delayed care or unmet need. Among women Veterans delaying or going without care, barriers that varied by age group were: unaffordable healthcare; inability to take time off work; and transportation difficulties. A higher percentage of women with delayed care or unmet need, compared to those without, were racial/ethnic minorities, lacked a regular source or provider of healthcare, were uninsured, had low income, fair or poor health status, were disabled, and had mental health diagnoses. With respect to Veteran-related factors, women Veterans with delayed care or unmet need were more likely than those without to be OEF/OIF Veterans, in a high-priority group for VA enrollment, and to have experienced military sexual assault.
Date: November 1, 2011
- Updated Literature Review Examines Research and Findings on Women Veterans’ Health
Investigators conducted a systematic review of the scientific literature published from 2004-2008 and summarized major findings, as well as advancements and gaps in comparison to literature from an original synthesis (more research was published in this 5-year review than in the 25-year period of the previous review). High rates of PTSD symptoms and other mental health disorders (e.g., depression) were found among returning OEF/OIF military women. Also, as the number of OIF deployments increases, screening positive for mental health problems appears to increase. Military sexual trauma (MST) combined with combat exposure was associated with doubled rates of new onset PTSD in both women and men, and MST was associated with more readjustment difficulties in civilian life. In addition, the literature suggests the need for repeated PTSD/mental health screening in returning OEF/OIF Veterans. Local organizational culture and quality of leadership support for women’s health were key factors in fostering gender-sensitive VA programs for women Veterans. Within VA healthcare, women Veteran’s satisfaction is positively affected by access to women’s clinics, gynecological services, and overall continuity of care. Women Veterans who do not use VA healthcare lack understanding of VA care and services. Among VA users, women and men had similar outpatient satisfaction ratings; however, women had consistently lower ratings for inpatient care (e.g., physical comfort, courtesy). While successes are evident in the breadth and depth of publications, remaining gaps in the literature include: post-deployment readjustment for women Veterans and their families, and quality of care interventions/outcomes for physical and mental conditions affecting women Veterans.
Date: July 6, 2011
- Growing VA Research Agenda for Women Veterans
This paper reports on the 2010 VA Women’s Health Services Research Conference, as well as the resulting research agenda for moving forward on behalf of women who have served in the military. Recommendations for the future VA women’s health research agenda, resulting from this conference, included, to name a few: Address gaps in women Veterans’ knowledge and use of VA services (e.g., outreach/education, social marketing, telemedicine); Evaluate and improve quality of transitions from military to VA care; Assess gender differences in the presentation and outcomes of chronic diseases; Determine reproductive health needs of women Veterans; Examine the structure and care models that support patient-aligned care teams; Evaluate variations in mental healthcare needs; Assess and reduce the risk of homelessness among women Veterans; Conduct research on post-deployment reintegration and readjustment among women Veterans; and Develop combat exposure measure(s) that reflect women Veterans’ experiences.
Date: July 6, 2011
- Women’s Health Issues Journal Focuses on Women Veterans
This special issue of Women’s Health Issues includes 18 peer-reviewed manuscripts summarizing health services research findings about women Veterans and women in the military, framed in the context of informing evidence-based practice and policy. Highlights include: VA has tailored primary care to women through the use of designated providers or separate women’s clinics. VA’s with these clinics were rated higher on most dimensions of care. These findings are particularly important to VA’s current implementation of patient-aligned care teams (PACTs). More than half of VA facilities now offer one or more mental healthcare services specifically for women Veterans, including services embedded within women’s primary care clinics, designation of women’s healthcare providers within general mental health clinics, and/or separate women’s mental health clinics. Recent data on VA care among men and women Veterans with histories of military sexual trauma (MST) show high satisfaction with care. Authors suggest that VA’s system-wide monitoring of MST-related care may be contributing to these positive results. PTSD among women Veterans is associated with poorer occupational functioning and satisfaction, but not employment status. Symptoms of depression have substantial effects across all components of work-related quality of life, independent of PTSD symptoms. PTSD is the most common psychiatric condition among both women and men with traumatic brain injury (TBI). However, women with TBI are less likely than men to have a PTSD diagnosis, but more likely to have a depression or anxiety disorder diagnosis.
Date: July 6, 2011
- Most Veterans with Military Sexual Trauma Report High Satisfaction with VA Outpatient Care
This study examined the association of military sexual trauma (MST) to patient satisfaction with VA outpatient care. Findings showed that Veterans’ ratings of overall satisfaction with VA outpatient care (regardless of MST status) were high. The proportion of patients reporting very good or excellent overall satisfaction was 79% for male Veterans and 72% for female Veterans. After adjusting for patient characteristics, male and female Veterans’ MST status was not associated with satisfaction ratings of overall VA healthcare. However, female Veterans with a history of MST rated the patient satisfaction dimensions of overall coordination, as well as education and information, less favorably than female Veterans without a history of MST.
Date: July 6, 2011
- Women Veterans with History of Sexual Abuse at Higher Risk for Substance Use Disorder
This study examined the associations between rape history and substance use disorders among women Veterans (age <51 years) who received care at two Midwestern VAMCs. Findings showed that lifetime substance abuse disorder was higher for women Veterans with a history of rape. Two-thirds (62%) of study participants reported lifetime sexual assault, including 11% reporting attempted rape and 51% reporting at least one completed rape. Women with women as sex partners had significantly higher rates of rape and lifetime substance use disorder (73% of women with women as sex partners reported lifetime rape vs. 48% of exclusively heterosexual women). Women with lifetime rape were more likely to report abstinence from drinking (50%) than women with no rape (41%). Women reported the highest rates of rape during childhood and military service (51% and 25%, respectively), and those reporting rape in any period of their lives were significantly more likely to report rape in other periods. For example, women Veterans reporting in-military rape were significantly more likely to report post-military rape (18% vs. 9%).
Date: June 1, 2011
- Women as Resilient to Combat-Related Stress as Men in the First Year Following Return from OEF/OIF Deployment
This study examined gender differences in various dimensions of combat-related stress and associated consequences for post-deployment mental health in a nationally representative sample of male and female OEF/OIF Veterans. Study results suggest that women OEF/OIF service members may be as resilient to combat-related stress as men in the first year following deployment. There were no significant interactions between combat-related stressors and gender in the prediction of post-traumatic stress symptomatology, mental health functioning, or depression. Women reported slightly less exposure than men to most combat-related stressors, but higher exposure to other stressors (i.e., prior life stress, deployment sexual harassment).
There were no differences between men and women in reports of perceived threat in the war zone.
Date: May 30, 2011
- Veterans Reporting a History of Military Sexual Trauma are Treated in a Variety of VA Outpatient Mental Health Settings
This study sought to determine the VA mental health outpatient settings in which patients with military sexual trauma (MST) are most likely to be treated, which might help set priorities for targeted MST-related education and training. Findings showed that more than one-third of female Veterans (36%) and 2% of male Veterans seen in VA outpatient mental healthcare settings during FY08 reported a history of military sexual trauma. Both women and men with MST were more likely to use more than one type of mental health clinic setting, compared to those without MST. A significantly larger proportion of women seen in MST specialty clinics reported MST as compared to all other settings (81% vs. 34%). However, there was a wide range of clinic visit settings for female Veterans with MST, including: MST specialty clinics, PTSD specialty clinics, psychosocial rehabilitation, and substance use disorder clinics. Male Veterans represented a small proportion of patients seen in all clinics, and a larger proportion of men seen in MST specialty clinics reported MST as compared to other settings (56% vs. 2%). These findings indicate that mental health providers who treat women Veterans, even if they work in settings that do not traditionally incorporate interventions focused on traumatic stress, may encounter issues related to MST. Therefore the authors suggest that training in how to respond to sexual trauma disclosure be an important component in all VA mental healthcare settings.
Date: May 1, 2011
- Pregnancy and Mental Health Conditions among Female OEF/OIF Veterans Using VA Healthcare
This study sought to determine the prevalence of mental health problems among 43,078 OEF/OIF women Veterans who received a pregnancy diagnosis in the VA healthcare system over a five-year study period (2003-2008). Although a relatively small proportion of OEF/OIF women Veterans received VA healthcare related to pregnancy (7%), a substantial proportion of these women (32%) received one or more mental health diagnoses compared with 21% of women without a pregnancy-related condition. Compared with all women Veterans enrolled in VA healthcare, Veterans with a pregnancy were twice as likely to have a diagnosis of depression, anxiety, PTSD, bipolar disorder, or schizophrenia than those without a pregnancy.
The most common mental health diagnoses among Veterans with a pregnancy were anxiety (43%), depression (36%), and PTSD (21%), followed by bipolar disorder (3%), and alcohol abuse/dependence (3%). [Sum is greater than 100% due to comorbidity.] Veterans with a pregnancy were significantly more likely to have a service-connected disability than those without a pregnancy. 71% of Veterans with a pregnancy were either never married or no longer married. On average, women Veterans experienced their index pregnancy nearly two years after returning from their last deployment.
Date: December 1, 2010
- Minor Depression Highly Prevalent among Women Veterans with Complex Chronic Illness
This study compared the rates of major and minor depression among women Veterans with chronic conditions (diabetes, heart disease, or hypertension) who received VA care in FY02. Of 13,430 women Veterans with depression, 60% were diagnosed with minor depression and 40% with major depressive disorders. Compared to major depression, minor depression was significantly more likely among women Veterans who were older, and those without any other psychiatric condition or substance use disorders. Results also show that compared to the hypertension only group, women Veterans with diabetes only or diabetes plus hypertension had higher rates of major depression. Moreover, all types of psychiatric conditions and substance use were associated with higher rates of major depression, and 22% of the study population had a substance use disorder. The authors suggest that the generally high rates of depressive disorders among women Veterans with chronic physical illnesses indicate the need for a continuum of care that encompasses both physical and mental illness domains.
Date: August 1, 2010
- Predictors Associated with Homelessness among Women Veterans
Among women Veterans, being unemployed, disabled, or unmarried were the strongest predictors of homelessness. Homeless women Veterans also were significantly more likely than housed women Veterans to have low incomes, to have experienced military sexual assault (53%), to be in fair to poor health, to have diagnosed medical conditions, and to screen positive for anxiety disorder and/or PTSD. Homeless women Veterans were significantly less likely than housed women Veterans to be college graduates or to have health insurance, but were more likely to have used mental health services, VA health care, or been hospitalized in the prior 12 months. Homeless Veterans had an average of four entries into and exits out of homelessness, and the median length of time they spent being homeless (over lifetime) was 2.1 years. Of the homeless women Veterans, 16% had children under the age of 18 living with them in the prior 12 months.
Date: February 1, 2010
- Emerging Issues Related to PTSD for OEF/OIF Women Veterans
The goal of this review was to highlight emerging issues relevant to the development of PTSD among women deployed to Iraq and Afghanistan. Investigators reviewed the literature on topics including: gender differences in combat experiences and in PTSD following combat exposure; sexual assault, sexual harassment, and other interpersonal stressors experienced during deployment; women Veterans’ experiences of pre-military trauma exposure; and unique stressors faced by women Veterans during the homecoming readjustment period. Findings show that combat deployments are not associated with a higher risk of mental health problems for women compared to men. However, women are more likely than men to meet criteria for PTSD following a range of traumatic experiences. In addition, studies published between 2002 and 2007 suggest that more than half of women Veterans experienced pre-military physical or sexual abuse, and there is some evidence that pre-military trauma increases women Veterans’ risk of developing PTSD following combat exposure. Further, concerns about family/relationship disruptions are more strongly associated with post-deployment mental health for female than male service members.
Date: August 24, 2009
- Men and Women Veterans Receive Equal Care for AMI in VA Hospitals
This study sought to describe the clinical characteristics, treatment, and survival in women Veterans compared with men admitted to VA hospitals for AMI between 10/03 and 3/05. Findings show that after adjusting for clinical characteristics, men and women Veterans treated for AMI in VA hospitals had similar levels of care and survival. There were no significant differences in the treatment provided to men and women Veterans, and cardiac catheterization was provided at equal rates (34.9% for men vs. 36.9% for women). Men did have higher mortality rates, but after adjusting for clinical characteristics this difference was no longer significant. In addition, significantly more men were prescribed aspirin and angiotensin-converting enzyme inhibitors, but there were no differences with regard to other platelet inhibitors, beta-blockers, or lipid-lowering medications.
Date: May 1, 2009
- Outpatient Healthcare Use for American Indian and Alaska Native Women Veterans
American Indian and Alaska Native (AIAN) women are among the growing number of female Veterans who now seek VA healthcare. In 2003, VA and the Indian Health Service (IHS) executed a Memorandum of Understanding (MOU) to improve access and health outcomes for AIAN Veterans by encouraging cooperation and resource sharing. In order to inform inter-agency planning and coordination, this study reports on the demographic characteristics and healthcare utilization patterns of AIAN women Veterans at the outset of the MOU agreement. Findings show that regardless of group, the medical needs of female AIAN Veterans were similar to other Veterans, including other female Veterans. On average, Veteran dual-users received two-thirds of their healthcare at VA facilities, while non-Veteran dual-users received most of their healthcare at IHS facilities. The lowest outpatient utilization rate was for IHS-only users. Results also show that three of the most frequent diagnoses were hypertension, diabetes, and depression.
Date: March 1, 2009
- Improving Care for Female Veterans
Findings from this study show significant improvements in sensitivity and knowledge for VA healthcare providers who used a computerized educational program that enhanced gender awareness compared to those who did not.
Date: July 1, 2008