Association between Women Veterans' Experiences with VA Outpatient Health Care and Designation as a Women's Health Provider in Primary Care Clinics

BackgroundWomen veterans comprise a small percentage of Department of Veterans Affairs (VA) health care users. Prior research on women veterans' experiences with primary care has focused on VA site differences and not individual provider characteristics. In 2010, the VA established policy requiring the provision of comprehensive women's health care by designated women's health providers (DWHPs). Little is known about the quality of health care delivered by DWHPs and women veterans' experience with care from these providers.MethodsSecondary data were obtained from the VA Survey of Healthcare Experience of Patients (SHEP) using the Consumer Assessment of Healthcare Providers and Systems (CAHPS) patient-centered medical home (PCMH) survey from March 2012 through February 2013, a survey designed to measure patient experience with care and the DWHPs Assessment of Workforce Capacity that discerns between DWHPs versus non-DWHPs.FindingsOf the 28,994 surveys mailed to women veterans, 24,789 were seen by primary care providers and 8,151 women responded to the survey (response rate, 32%). A total of 3,147 providers were evaluated by the SHEP-CAHPS-PCMH survey (40%; n = 1,267 were DWHPs). In a multivariable model, patients seen by DWHPs (relative risk, 1.02; 95% CI, 1.01–1.04) reported higher overall experiences with care compared with patients seen by non-DWHPs.ConclusionsThe main finding is that women veterans' overall experiences with outpatient health care are slightly better for those receiving care from DWHPs compared with those receiving care from non-DWHPs. Our findings have important policy implications for how to continue to improve women veterans' experiences. Our work provides support to increase access to DWHPs at VA primary care clinics.     

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

BackgroundWe examined Veterans Affairs (VA) health care experiences among contemporary women veteran patients receiving care at a VA medical center. Specifically, we examined women veteran patients' satisfaction with VA care along dimensions in line with patient-centered medical home (patient-aligned care teams [PACT] in VA) priorities, and pathways through which women initially accessed VA care.MethodsWe used a mixed methods research design. First, 249 racially diverse women (ages 22–64) who were past-year users of primary care at a VA medical center completed interviewer-administered surveys in 2012 assessing ratings of satisfaction with care in the past year. We then conducted in-depth qualitative interviews of a subset of women surveyed (n = 25) to gain a deeper understanding of perspectives and experiences that shaped satisfaction with care and to explore women's initial pathways to VA care.ResultsRatings of satisfaction with VA care were generally high, with some variation by demographic characteristics. Qualitative interviews revealed perceptions of care centered on the following themes: 1) barriers to care delay needed medical care, while innovative care models facilitate access, 2) women value communication and coordination of care, and 3) personalized context of VA care, including gender sensitive care shapes women's perceptions. Pathways to VA care were characterized by initial delays, often attributable to lack of knowledge or negative perceptions of VA care. Informal social networks were instrumental in helping women to overcome barriers.ConclusionsFindings highlight convergence of women's preferences with PACT priorities of timely access to care, provider communication, and coordination of care, and suggest areas for improvement. Outreach is needed to address gaps in knowledge and negative perceptions. Initiatives to enhance women veterans' social networks may provide an information-sharing resource.     

Association Between Availability and Quality of Health Services in Schools and Reproductive Health Outcomes Among Students: A Multilevel Observational Study

Objectives. We determined the association between availability and quality of school health services and reproductive health outcomes among sexually active students.Methods. We used a 2-stage random sampling cluster design to collect nationally representative data from 9107 students from 96 New Zealand high schools. Students self-reported whether they were sexually active, how often they used condoms or contraception, and their involvement in pregnancy. School administrators completed questionnaires on their school-based health services, including doctor and nursing hours per week, team-based services, and health screening. We conducted analyses using multilevel models controlling for individual variables, with schools treated as random effects.Results. There was an inverse association between hours of nursing and doctor time and pregnancy involvement among sexually active students, with fewer pregnancies among students in schools with more than 10 hours of nursing and doctor time per 100 students. There was no association between doctor visits, team-based services, health screening, and reproductive health outcomes.Conclusions. School health services are associated with fewer pregnancies among students, but only when the availability of doctor and nursing time exceeds 10 hours per 100 students per week.School-based health centers (SBHCs) are health clinics located in schools that provide comprehensive and youth-appropriate health services through their accessible, low-cost, youth-focused services and comprehensive care.1 However, current evidence of the effectiveness of SBHCs in addressing student health outcomes is limited. Kisker and Brown2 suggested that students in schools with health centers had improved access to health care compared with a national sample of students without access to SBHCs, but there were few differences in health risk behaviors, mental health, or pregnancy rates. A study of African American adolescents from 7 Midwestern US high schools found that in schools with SBHCs, students were less likely to smoke cigarettes and marijuana than were students in schools without SBHCs, but there were few differences in alcohol use.3 In terms of sexual and reproductive health outcomes, Kirby et al.4 compared 4 pairs of schools (4 with and 4 without SBHCs) and 2 schools before and after the establishment of school clinics. They found evidence of improved contraceptive and condom use in schools with SBHCs, but inconsistent effects on self-reported pregnancy rates. A recent study of 12 urban California high schools (6 with and 6 without SBHCs) revealed higher rates of contraception use in schools with SBHCs, but only among female students.5Existing studies of school-based health services are limited by the small numbers of schools examined, inclusion of nonrepresentative samples, and use of analytic methods that do not take into account the clustering of students within schools.6,7 A recent study by McNall et al.8 was among the first to appropriately model the clustering of students within schools using multilevel modeling techniques, but the overall study was limited by the small number of schools used as comparisons. There are also few randomized intervention studies because these require group randomization and are difficult to conduct.9 These issues highlight the difficulties in studying group-level interventions such as school-based health services.Previous studies have also largely ignored the variation between schools in the availability and quality of health services provided. For example, some clinics may provide comprehensive and intensive services staffed on-site by a multidisciplinary team of highly trained personnel, whereas other school clinics may provide only limited on-site services with visiting health personnel. Furthermore, provision of contraceptives, condoms, and screening for sexually transmitted infections in many schools remains controversial, thus limiting their availability. It remains unknown how variation in the availability and quality of services affects student health outcomes.To address these shortcomings of the existing literature, we aimed to determine whether school-based health services are associated with better sexual and reproductive health among students. This study is among the first to draw on a large nationally representative sample of students and use multilevel analytical techniques to examine the impact of school-based health services. We examined aspects of school-based health services such as hours of health personnel, doctor visits, and team-based services in relation to student reproductive health outcomes.     

The Association Between Women's Self-Rated Health and Satisfaction with Environmental Services in an Underserved Community in Lebanon

This research evaluated the association between women's self-rated health and a number of socioeconomic and environmental health indicators relating to drinking water services in an underserved Lebanese community. A population-based, cross-sectional survey using interviews was adopted to obtain information from female homemakers of 2,223 households in the town of Bebnine, Lebanon. The questionnaire included indicators on self-rated health, satisfaction with water quality, source of drinking water, occurrence of diarrhea, and socioeconomic variables, such as education, occupation, and perceived economic status. Self-rated health was categorized as poor, fair, and good. Odds ratios for poor and fair compared to good self-rated health values were calculated using multinomial logistic regression. A total of 712 women (32%) reported poor self-rated health. Women who perceived their household income to be worse than others in town were four times as likely to report poor health. Compared to women who were satisfied with drinking water quality, dissatisfied women were 42% more likely to report poor health. Women living in households reporting recent episodes of diarrheal illness had poorer health ratings than those without. The findings suggest a positive relationship between individual perceptions of water quality and self-rated health. Community concerns over their surrounding environment serve as a primary guide for infrastructural development and government policy.     

The Relationship Between Health Status and Utilization of Outpatient Health Care Services

A short, self-administered proxy health status score has been shown to correlate highly with physician’s appraisal based on physical examination. The proxy score has been related to rate of use of ambulatory services by subscribers to two different health insurance plans, one a closed panel group practice plan, and one an open panel largely solo practice. It has been found that health status predicts well those who will not use health care services, but does not predict how much the users will use. Differences between the two health plans in health status-utilization dynamics are noted and discussed.     

妇女孕产期保健服务利用状况及影响因素调查

目的探讨妇女孕产期保健服务的利用状况,对其影响因素进行分析和调查。方法选取2014年3月在我市工作的流动人口育龄妇女为研究对象,其中470人有分娩经历。对这些妇女的产前检查、产后访视服务的利用状况及其影响因素进行分析。结果470例流动人口育龄妇女做过产前检查的共有356例．产前检查率为75．74％;得到产后访视的妇女有342例,产后访视率为72．77％。大专及以上文化程度的妇女产前检查次数为8．72±3．19,产后访视次数为1．12±1．25,明显高于初、高中文化程度妇女的5．86±3．23、0．65±1．12和小学以下文化程度妇女的3．70±2．69、0．29±0．68．差异均具有统计学意义（P＜0．05）。家庭月收入4ooo元以上的妇女产前检查次数为7．78±3．64．产后访视次数为0．98±1．26,明显高于家庭月收入2ooo～3999元妇女的6．22±3．14、0．71±1．23和家庭月收入2000元以下妇女的4．98±3．06、0．49±0．97,差异均具有统计学意义（P＜0．05）。结论文化程度、家庭收入、年龄和是否参加生育保险是影响妇女孕产期保健服务利用状况的重要因素．应加强针对流动人口育龄妇女的孕产期保健管理力度,开展孕产期健康教育,充分发挥计生网络的作用,努力改善流动妇女的孕产期保健状况。     

Older Women's Experiences with Multiple Health Conditions: Daily Challenges and Care Practices

Guided by life-course theory and a trajectory model of chronic illness, we examined the health care practices and management strategies used by 17 older women with multiple chronic conditions. Qualitative analyses revealed that the women played an active role in shaping the course of their illness within their everyday lives. Pain and a decline in energy frequently interfered with completion of daily activities. To compensate, many women reduced and slowed down the pace of activities they performed while emphasizing the importance of maintaining independence and autonomy. Appreciative of support from family members, at times the women received more help and advice than they preferred.     

Managing Mental Health Problems Among Immigrant Women Attending Primary Health Care Services

Researchers in Norway explore treatment options in primary care for immigrant women with mental health problems compared with nonimmigrant women. Three national registers were linked together for 2008. Immigrant women from Sweden, Poland, the Philippines, Thailand, Pakistan, and Russia were selected for analysis and compared with Norwegian women. Using logistic regression, we investigated whether treatment type varied by country of origin. Rates of sickness leave and psychiatric referrals were similar across all groups. Conversational therapy and use of antidepressants and anxiolytics were lower among Filipina, Thai, Pakistani, and Russian women than among Norwegians. Using the broad term “immigrants” masks important differences in treatment and health service use. By closely examining mental health treatment differences by country of origin, gaps in service provision and treatment uptake may be identified and addressed with more success.     

Women's Health Care Centers

Feminist health and holistic health movements predate and contribute to the currenl changes in women's hcalth care. Recentlv, there has been r rivilalization of women's IiealUi centers reflechg three approaches to women's health: (1) centers with an exclusive focus on one health problem, e.g., breast cancer, chemical dependency (2) centers with a predominantly reproductive focus, and (3) centers with a holistic/feminist health care focus. Based on an exploratory survey of women's centers in a large city, this paper identifies differences among them and discusses the potential for misguidance that may occur with the current increase in women's health centers. It also discusses the implications of this growth for social work education and clinical practice.     

Availability and Primary Health Care Orientation of Dementia-Related Services in Rural Saskatchewan,Canada

Community-based services are important for improving outcomes for individuals with dementia and their caregivers. This study examined: (a) availability of rural dementia-related services in the Canadian province of Saskatchewan, and (b) orientation of services toward six key attributes of primary health care (i.e., information/education, accessibility, population orientation, coordinated care, comprehensiveness, quality of care). Data were collected from 71 rural Home Care Assessors via cross-sectional survey. Basic health services were available in most communities (e.g., pharmacists, family physicians, palliative care, adult day programs, home care, long-term care facilities). Dementia-specific services typically were unavailable (e.g., health promotion, counseling, caregiver support groups, transportation, week-end/night respite). Mean scores on the primary health care orientation scales were low (range 12.4 to 17.5/25). Specific services to address needs of rural individuals with dementia and their caregivers are limited in availability and fit with primary health care attributes.     

Clinical Preventive Services for Older Adults: The Interface Between Personal Health Care and Public Health Services

Healthy aging must become a priority objective for both population and personal health services, and will require innovative prevention programming to span those systems. Uptake of essential clinical preventive services is currently suboptimal among adults, owing to a number of system- and office-based care barriers.To achieve maximum health results, prevention must be integrated across community and clinical settings. Many preventive services are portable, deliverable in either clinical or community settings. Capitalizing on that flexibility can improve uptake and health outcomes.Significant reductions in health disparities, mortality, and morbidity, along with decreases in health spending, are achievable through improved collaboration and synergy between population health and personal health systems.BETWEEN 2010 AND 2050, the population of Americans aged 65 years and older is expected to more than double, swelling to nearly 89 million. This “silver tsunami,” composed mostly of Baby Boomers (the first of whom crossed the 65-year line in 2011), will pose serious challenges for our nation’s public health and health care systems, along with state and federal budgets, family finances, and private sector profitability. Healthy aging, too often viewed as a peculiar product of luck or luxury, must become a priority objective for both population and personal health services—and will require innovative prevention programming to span those systems.Chronic illness currently represents an estimated 83% of total US health expenditures and 99% of Medicare spending.1 Increasing rates of costly chronic conditions, many of which are not well managed,2–5 are associated with significant Medicare spending increases.6,7 Each year, more than half of Medicare beneficiaries are treated for 5 or more chronic conditions.6 The average Medicare enrollee sees 2 primary care physicians and 5 specialists working in 4 different practices annually8; those with 5 or more chronic conditions see an average of 14 different physicians a year.9 Care fragmentation results in suboptimal uptake of clinical preventive services (CPS) among US adults3,10: only 33% of women and 40% of men aged 65 years and older are fully up to date with all preventive services recommended for all adults in this age range,11 and less than a quarter of adults aged 50 to 64 years have received all these services.12 Even if adults receive recommended disease screening, a positive finding may not lead to effective treatment: although blood pressure screening in older adults is relatively high, hypertension is controlled in only half of patients.13Preventing chronic diseases and keeping chronically ill older adults healthier are imperatives to drive improvements in health, quality of life, and value in US health spending.14 Population-based primary prevention works to avert disease. It must be reinforced with patient-focused primary prevention and coupled with effective secondary prevention to detect illness as well as tertiary prevention aimed at better managing existing illness and preventing additional disease and disability. To achieve maximum health results, prevention must be integrated across community and clinical settings. Many preventive services are portable—deliverable in either clinical or community settings. Capitalizing on that flexibility can improve uptake and health outcomes.Optimal use of CPS—particularly for cardiovascular conditions—could avert an estimated 50 000 to 100 000 deaths per year among adults younger than 80 years and 25 000 to 40 000 deaths per year among those younger than 65 years.15 Increasing uptake of selected high-value CPS to 90% could produce an additional 1.89 million quality-adjusted life years.16 Outside clinical settings, the Trust for America’s Health has estimated that an investment of $10 per person per year in community-based programs tackling physical inactivity, poor nutrition, and smoking could yield more than $16 billion in medical cost savings annually within 5 years—a return on investment of $5.60 for every $1 spent, without considering the additional gains in worker productivity, reduced absenteeism at work and school, and enhanced quality of life.17 Significant reductions in health disparities, mortality, and morbidity—and attendant decreases in health spending—are achievable through improved collaboration and synergy between population health and personal health systems.18 We discuss essential CPS for older adults, emerging delivery models that encompass health care and community settings to boost uptake, and public health priorities in a changing US health system.     

Violence Against Women and Reproductive Health: Toward Defining a Role for Reproductive Health Care Services

Since a large proportion of U.S. women receive reproductive health care services each year, reproductive health care settings offer an important opportunity to reach women who may be at risk of or experiencing intimate partner violence (IPV). Although screening women for IPV in clinical health care settings has been endorsed by national professional associations and organizations, scientific evidence suggests that opportunities for screening in reproductive health care settings are often missed. This commentary outlines what is known about screening and intervention for IPV in clinical health care settings, and points out areas that need greater attention. The ultimate goal of these recommendations is to increase the involvement of reproductive health care services in sensitive, appropriate, and effective care for women who may be at risk of or affected by IPV.     

福州城市社区产后访视质量调查研究

[目的]研究社区产后保健服务现状,提高保健质量以促进母婴健康。[方法]定量与定性研究相结合,抽取福州市776名产妇问卷调查,并采用了专题小组讨论(产妇12人)和半结构性访谈(9人)。[结果]产后访视率为62.9%。内容询问母子一般情况达98.4%;进行母乳喂养指导为94.7%;对产妇心理情绪状况"关心"的只28.7%,对预防产后抑郁症的保健建议率仅9.9%;产妇对访视满意率不高(33.6%)。[结论]今后既要加快产后访视人员对产褥期保健知识的更新,又要加强规范化管理,实行面对面的质量评估,以提高产后访视保健质量。     

Access to Care and Health Outcomes Among Women Veterans Using Veterans Administration Health Care: Association With Food Insufficiency

Background

Food insecurity has been associated with worse health outcomes in the civilian population. Male veterans of the Gulf Wars have been shown to have a higher prevalence of food insecurity than similarly situated civilians. Women veterans have more risk factors for food insecurity, relative to male veterans, yet little is known about the prevalence of food insecurity in this cohort.