Predictors of Veterans Affairs Health Service Utilization by Women Veterans during Pregnancy

BackgroundResearchers have examined predictors of Veterans Affairs (VA) service use by women veterans in general, but less is known about predictors of VA service use by pregnant veterans. This study examined characteristics associated with planned and actual VA service use by pregnant veterans.MethodsThis study includes data from 510 pregnant veterans enrolled in the Center for Maternal and Infant Outcomes Research in Translation Study. Women veterans completed phone interviews during their first trimester and at 3 months postpartum. The Center for Maternal and Infant Outcomes Research in Translation surveys assessed medical and mental health conditions, VA health care use, trauma history, and pregnancy complications. We conducted bivariate and multivariable logistic regression models assessing planned and actual use of VA services during pregnancy.ResultsLifetime post-traumatic stress disorder (odds ratio [OR], 1.73; 95% confidence interval [CI], 1.11–2.69) and history of military sexual trauma (OR, 1.85; 95% CI, 1.19–2.87) were significantly associated with planned VA service use in multivariable models. Lifetime diagnoses of anxiety (OR, 1.78; C.I., 1.15–2.75) were associated with an increased likelihood of actual VA use during pregnancy, whereas Hispanic ethnicity (OR, 0.59; 95% CI, 0.36–0.96), younger age (OR, 0.95; 95% CI, 0.91–0.99), and access to private health insurance (OR, 0.55; 95% CI, 0.37–0.84) were associated with a decreased likelihood of actual VA service use during pregnancy.ConclusionsResults emphasize the association between high-risk mental health characteristics and specific demographic characteristics with VA service use among pregnant veterans. Study findings highlight a continued need for women's health care at the VA, as well as the availability of VA providers knowledgeable about perinatal health issues, and informed community providers regarding women veterans' health.     

Reproductive and Other Health Outcomes in Iraq and Afghanistan Women Veterans Using VA Health Care: Association with Mental Health Diagnoses

BackgroundAn increasing number of women serve in the military and are exposed to trauma during service that can lead to mental health problems. Understanding how these mental health problems affect reproductive and physical health outcomes will inform interventions to improve care for women veterans.MethodsWe analyzed national Department of Veterans Affairs (VA) data from women Iraq and Afghanistan veterans who were new users of VA healthcare from October 7, 2001, through December 31, 2010 (n = 71,504). We used ICD-9 codes to categorize veterans into five groups by mental health diagnoses (MH Dx): Those with no MH Dx, posttraumatic stress disorder (PTSD), depression, comorbid PTSD and depression, and a MH Dx other than PTSD and depression. We determined the association between mental health category and reproductive and other physical health outcomes defined by ICD-9 codes. Categories included sexually transmitted infections, other infections (e.g., urinary tract infections), pain-related conditions (e.g., dysmenorrhea and dsypareunia), and other conditions (e.g., polycystic ovarian syndrome, infertility, sexual dysfunction). Models were adjusted for sociodemographic and military service factors.ResultsThere were 31,481 patients (44%) who received at least one mental health diagnosis. Women veterans with any mental health diagnosis had significantly higher prevalences of nearly all categories of reproductive and physical disease diagnoses (p < .0001 for adjusted prevalences). There was a trend of increasing prevalence of disease outcomes in women with PTSD, depression, and comorbid PTSD and depression (p for trend <.0001 for all outcomes).ConclusionsIraq and Afghanistan women veterans with mental health diagnoses had significantly greater prevalences of several important reproductive and physical health diagnoses. These results provide support for VA initiatives to address mental and physical health concerns and improve comprehensive care for women veterans.     

Military Sexual Trauma and Adverse Mental and Physical Health and Clinical Comorbidity in Women Veterans

IntroductionMilitary sexual trauma (MST)—exposure to sexual harassment or assault during military service—is a major health priority for the Veterans Health Administration (VHA). We examined the health correlates of MST in the largest sample of U.S. women veterans studied to date.MethodsUsing national VHA electronic medical record data, we identified 502,199 women veterans who enrolled in the VHA between January 1, 2000, and December 31, 2017, had at least one VHA visit, and were screened for MST (exclusive of those who declined to answer the screening). We conducted logistic regression analyses to examine associations of a positive MST screen with various mental and physical health conditions—defined by administrative diagnostic codes—and comorbidity of mental and/or physical health conditions. Models were adjusted for demographic and military service characteristics, along with duration in the VHA.ResultsApproximately 26% (n = 130,738) of women veterans screened positive for MST. In fully adjusted models, a positive MST screen was associated with greater risk of having all mental and physical health conditions examined, except cancer-related conditions, ranging from 9% greater odds of rheumatic disease to 5.4 times greater odds of post-traumatic stress disorder. MST was also associated with greater comorbidity, including greater odds of having ≥2 mental health conditions (odds ratio [OR], 3.28; 99% confidence interval [CI], 3.20–3.37), having ≥2 physical health conditions (OR, 1.26; 99% CI, 1.22–1.29), and having ≥1 mental health condition and ≥1 physical health condition (OR, 2.05; 99% CI, 2.00–2.11).ConclusionsFindings suggest that MST is common in women veterans and may play a role in the clinical complexity arising from comorbid conditions.     

Characterization and Comparison of Physical and Mental Health Profiles and Department of Veterans Affairs Health Care Utilization Patterns among Operation Iraqi Freedom/Operation Enduring Freedom Women Veterans in Puerto Rico versus the United States

BackgroundResearch on the physical and mental health profiles and patterns of health care use among women veterans receiving health care from the Department of Veterans Affairs (VA) on the island of Puerto Rico is lacking.MethodsThis cross-sectional study examines differences in physical and mental health conditions, and patterns of VA health care use, between women veterans of the Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) era who were using VA facilities in Puerto Rico (n = 897) and those using U.S.-based VA facilities (n = 117,216) from 2002 to 2015.ResultsResults of fully adjusted logistic regression models revealed that OIF/OEF women in Puerto Rico had heightened risk for global pain-related disorders (i.e., any pain) (adjusted odds ratio [AOR], 1.45; 95% confidence interval [CI], 1.22–1.71), back pain (AOR, 1.83; 95% CI, 1.56–2.14), diabetes (AOR, 1.42; 95% CI, 1.03–1.95), hyperlipidemia (AOR, 3.34; 95% CI, 2.80–3.98), major depression (AOR, 1.78; 95% CI, 1.53–2.06), and bipolar depression (AOR, 1.66; 95% CI, 1.34–2.04). They also evidenced greater risk for a host of reproductive health conditions and had higher average annual use of VA health care than their U.S. counterparts.ConclusionsOIF/OEF women receiving VA health care in Puerto Rico evidenced a greater burden of physical illness, depression, and heightened use of VA health care services relative to their U.S. counterparts. Providers’ increased awareness of the physical and mental health care needs of this population is warranted. Research efforts that help to identify efficient and effective strategies to provide culturally tailored and/or personalized health care for this population could also be useful.     

What Drives Women Veterans’ Trust in VA Healthcare Providers?

IntroductionLittle is known about women veterans’ trust in Veterans Affairs (VA) health care and what factors promote trust in VA providers. We examined provider behaviors and characteristics of women veterans associated with trust in their VA providers.MethodsWe used a 2015 survey of women veterans who were routine users of primary care at 12 VA medical centers (n = 1,395). Patient trust in their VA provider was measured on a seven-item scale. We used multiple logistic regression to examine associations of patient-provider communication and gender appropriateness with complete trust in VA provider (100 [complete trust] vs. <100 [less than complete trust]), controlling for patient characteristics.ResultsOn average, 39.7% of women veterans reported complete trust in their VA providers. Those with complete trust reported greater patient-provider communication and gender appropriateness of VA services than those with less-than-complete trust (all ps ≤ .001). In multiple logistic regression models, higher ratings of provider communication (adjusted odds ratio, 2.37), gender-appropriate care (adjusted odds ratio, 1.93), and trauma-sensitive communication (adjusted odds ratios, 1.79–6.08) were associated with a higher likelihood of reporting complete trust in their VA provider.ConclusionsWomen veterans reported high levels of trust in their VA providers. Provider communication, gender-appropriate care, and trauma-sensitive communication were associated with greater patient trust. Although it is important to highlight the steps already taken by VA to increase the quality of care for women veterans, current findings suggest that women veterans’ trust may be further increased by interventions to improve trauma-informed care by VA providers.     

Military Sexual Assault and Homeless Women Veterans: Clinical Correlates and Treatment Preferences

BackgroundBoth homeless women and women who have experienced military sexual assault (MSA) are at high risk of serious psychological sequelae. However, little is known about the combined impact of MSA and current homelessness on psychological distress, or about distinctive treatment preferences among homeless female veterans affected by MSA.MethodsThis observational study compared clinical symptoms, pre-military experiences, and treatment preferences among 509 female veterans with and without MSA who enrolled in 11 VA Homeless Women Veterans Programs.ResultsOver one third of participants (41.1%) reported MSA. In multivariate analyses, homeless female veterans who reported MSA endorsed greater severity of PTSD and other psychiatric symptoms. Those who had experienced MSA were more likely to report interest in treatment, and treatment focused on safety was reported as especially attractive.ConclusionsAmong homeless female veterans, MSA is associated with greater mental health symptoms and greater interest in safety-focused treatment. Services targeting the needs of homeless MSA survivors should be encouraged.     

Gynecological Health Complaints Among College Women With Sexual Victimization Histories: Examination of Depression and Anxiety as Potential Mediators

PurposeThe study's purpose was to examine the relation between sexual victimization history and gynecological health complaints among college women. A further aim was to explore whether anxiety and depression are mediators of this relation, as well as to examine the size of these indirect relations among individuals with different types of victimization histories (childhood sexual abuse, adolescent/adult sexual assault, combined childhood sexual abuse/adolescent/adult sexual assault).MethodsA sample of 1,759 undergraduate cisgender women attending a large Southeastern U.S. university completed online measures of lifetime sexual victimization history, current anxiety and depression, and current gynecological health complaints (dysmenorrhea, dyspareunia, vaginal discharge, pain during urination, and pelvic pain). Mediation analyses with bootstrapping were conducted to explore the relations among study variables.ResultsCollege women with a history of sexual victimization were significantly more likely to report experiencing the gynecological health complaints in the past month than women with no sexual victimization history (all ps < .05). There was a significant indirect path from sexual victimization to gynecological health complaints through both anxiety and depression for all three victimization types (βs = 0.12–0.26). The indirect paths were stronger for women with combined childhood sexual abuse/adolescent/adult sexual assault histories as compared with the other two types of victimization history.ConclusionsHealth care providers working with college women should implement a trauma-informed approach to addressing gynecological health complaints that recognizes that sexual victimization survivors are at an increased risk for these issues. Further, anxiety and depression represent possible mechanisms of risk for gynecological health complaints among survivors.     

Women Veterans’ Attrition from the VA Health Care System

PurposePatient attrition from the Veterans Health Administration (VA) health care system could undercut its mission to ensure care for eligible veterans. Attrition of women veterans could exacerbate their minority status and impede systemic efforts to provide high-quality care. We obtained women veterans’ perspectives on why they left or continued to use VA health care.MethodsA sampling frame of new women veteran VA patients was stratified by those who discontinued (attriters) and those who continued (non-attriters) using VA care. Semistructured interviews were conducted from 2017 to 2018. Transcribed interviews were coded for women's decision-making, contexts, and recommendations related to health care use.ResultsFifty-one women veterans (25 attriters and 26 non-attriters) completed interviews. Reasons for attrition included challenging patient care experiences (e.g., provider turnover, claim processing challenges) and the availability of private health insurance. Personal experiences with VA care (e.g., gender-specific care) were impactful in women's decision to use VA. The affordability of VA care was influential for both groups to stay connected to services. More than one-third of women originally categorized as attriters described subsequently reentering or planning to reenter VA care. Suggestions to decrease attrition included increasing outreach, improving access, and continuing to tailor care delivery to women veterans' needs.ConclusionsUnderstanding the drivers of patients’ decisions to use or not use the VA is critical for the development of strategies to improve retention of current patients and optimize health outcomes for veterans. Women veterans described complex reasons why they left or continued using VA, with cost/affordability playing an important role even in considerations of returning to VA after a long hiatus.     

Women Veterans’ Experiences with Perceived Gender Bias in U.S. Department of Veterans Affairs Specialty Care

BackgroundIn the past decade, the U.S. Department of Veterans Affairs (VA) has responded to a dramatic increase in women veterans seeking care by expanding Women's Health training to more than 5,000 women's health primary care providers and changing the culture of the VA to be more inclusive of women veterans. These initiatives have resulted in increased patient satisfaction and quality of care, but have focused mostly on primary care settings. Less is known about women's experiences in specialty care within VA. This qualitative study sought to examine women veterans' experiences with VA specialty care providers, with a focus on cardiovascular, musculoskeletal, and mental health care settings.MethodsSemistructured interviews were conducted with 80 women veterans who served during the Iraq and Afghanistan conflicts at four VA facilities nationwide. Interviews focused on understanding women veterans’ experiences with VA specialty care providers, including their perceptions of gender bias.ResultsFour major themes emerged from interviews, including that 1) women did not feel that VA specialty care providers listened to them or took their symptoms seriously, 2) women were told their health conditions or symptoms were attributable to hormonal fluctuations, 3) women noted differences in care based on whether the VA specialty provider was male or female, and 4) women provided recommendations for how gender-sensitive specialty care might be improved.ConclusionsThis study is the first to highlight the perceived gender bias experienced by women veterans in VA specialty care. Women felt that their symptoms were disregarded or diminished by their specialty care providers. Although women veterans report positive experiences within women's health clinics and the primary care setting, their negative experiences in VA specialty care suggest that some providers may harbor unintentional or unconscious gender biases.     

Experiencing Sexual Assault and/or Stalking-Related Behavior is Associated with Binge Drinking and Substance Use Consequences in Deployed U.S. Servicewomen

BackgroundBeing deployed is a risk factor for poor postdeployment mental health outcomes in U.S. servicewomen, including harmful drinking. However, to our knowledge, no studies have examined deployment-related sexual assault and exposure to stalking-related behavior in relation to binge drinking and substance use consequences in this population.MethodsA community sample of post-9/11 servicewomen from the Midwest, including both veterans and those actively serving (N = 991), completed computer-assisted telephone interviews after deployment. Logistic regression models examined associations between deployment-related sexual assault (attempted or completed) and stalking-related behavior (e.g., being left unwanted things, having property vandalized), and the likelihood of reporting binge drinking and substance use consequences after controlling for covariates.ResultsU.S. servicewomen experiencing deployment-related sexual assault and/or stalking-related behavior were more likely to report binge drinking in the past 4 weeks and at least one negative consequence of substance use in the past year. Also, 21.56% of the sample reported experiencing any deployment-related sexual assault and/or stalking-related behavior, 17.34% reported any stalking-related behavior and no sexual assault, 2.42% reported both sexual assault and stalking-related behavior, and 1.80% reported sexual assault and no stalking-related behavior. The most commonly endorsed behaviors were being followed or spied on (9.09%), receiving unsolicited correspondence (8.34%–8.74%), and having someone show up at places you were (6.90%).ConclusionsU.S. servicewomen experiencing sexual assault and/or stalking-related behavior during deployment may be at higher risk for binge drinking and experiencing negative consequence of substance use when compared with their peers not reporting these stressors.     

Primary Care Providers' Perspectives on Providing Care to Women Veterans with Histories of Sexual Trauma

BackgroundOne in four women Veterans who use the Veterans Health Administration (VA) screen positive for military sexual trauma and may need trauma-sensitive care and coordination. VA primary care providers (PCPs), women veterans' main source of care, need to be well-versed in trauma-sensitive approaches to care. Women veterans' numerical minority in the VA can make provider exposure to female patients inconsistent, which may impede PCP experience in providing appropriate care. To inform strategies for improving trauma-sensitive primary care, we sought to better understand PCPs’ current approaches to providing care to women veterans with sexual trauma histories.MethodsWe conducted semistructured telephone interviews with PCPs (n = 28) practicing in VA primary care clinics. Participants were asked about their experiences delivering trauma-sensitive care as well as best practices. Interviews were recorded, transcribed, and analyzed for major themes regarding barriers to and facilitators of trauma-sensitive care.ResultsParticipants expressed challenges delivering care to women with sexual trauma histories, including 1) insufficient time, 2) lack of perceived proficiency and/or personal comfort (with general physical examinations as well as gender-specific care such as Pap, breast, and pelvic examinations), and 3) difficulties with fostering positive patient–provider relationships. Access to mental health resources was noted as a key facilitator of providing trauma-sensitive care. Participants also shared existing (and potential) best practices and recommendations, such as paying special attention to patient behavioral cues related to comfort.ConclusionsPCPs delivering care to women in VA facilities may benefit from an increased awareness of best practices to facilitate the delivery of trauma-sensitive care.     

Female veterans seeking medical care at Veterans Affairs primary care clinics: psychiatric and medical illness burden and service use

OBJECTIVE: To examine rates of medical and psychiatric disorders among 187 female veterans recruited at four Veterans Affairs Medical Centers (VAMCs), the recognition of such disorders by VAMC care providers, and the use of relevant medical and mental health services by women both within and outside of the VA setting. METHODS: We used a cross-sectional, epidemiological design incorporating self-report measures, structured interviews, and chart reviews to obtain relevant information for analyses. RESULTS: Forty-four percent (43.9%) of women met criteria for at least one psychiatric disorder; 34.0% of these women met criteria for two or more additional psychiatric diagnoses, and concordance rates between interview and chart diagnoses were low. Ninety-five percent (95.2%) of women had a medical condition noted in their charts; 86.6% had two or more additional medical conditions, and a significant number of women had both medical and psychiatric diagnoses. Forty-four percent (43.9%) of women with an identified mental health condition received specialized mental health care by the VA in the past year. CONCLUSIONS: Findings from this study suggest that female veterans treated in VAMCs had significant medical and psychiatric problems, and these women might not be getting their health care needs adequately met through the VA health care system. In light of our findings, we discuss relevant implications and future directions for research.     

Implementing and Evaluating a Telephone-Based Centralized Maternity Care Coordination Program for Pregnant Veterans in the Department of Veterans Affairs

PurposeThe purpose of this study was to develop and evaluate a comprehensive, telephonic maternity care coordination (MCC) program for all pregnant veterans enrolled for care at New England Department of Veterans Affairs (VA) facilities that comprise the Veterans Integrated Service Network 1.Research DesignTelephone interviews were conducted with postpartum women veterans who had participated in the MCC program during their pregnancies. The program evaluation instrument assessed satisfaction and use of MCC services, prenatal education classes, and infant and maternal outcomes (e.g., newborn birthweight, insurance status, maternal depression) using both closed-ended and open-ended questions.ResultsA substantial majority (95%) of women enrolled in the MCC program expressed satisfaction with the services they received in the program. Women were most satisfied with help understanding VA maternity benefits and acquiring VA services and equipment, such as breast pumps and pregnancy-related medications. More than one-third of women noted their infants had experienced health problems since delivery, including neonatal intensive care unit hospitalizations. A majority of women planned to return to VA care in the future.ConclusionsOur findings suggest that MCC services play an important role for women veterans as they navigate both VA and non-VA care systems. MCC staff members coordinated maternity, medical, and mental health care services for women veterans. Additionally, by maintaining contact with the veteran during the postpartum period, MCC staff were able to assess the health of the mother and the infant, and refer women and their infants to medical and psychosocial services in the community as needed.     

Veterans Health Administration Screening for Military Sexual Trauma May Not Capture Over Half of Cases Among Midlife Women Veterans

BackgroundApproximately 1 in 3 women veterans endorse military sexual trauma (MST) during Veterans Health Administration (VHA) screening. Higher rates have been reported in anonymous surveys.ObjectiveWe compared MST identified by VHA screening to survey-reported MST within the same sample and identified participant characteristics associated with discordant responses.MethodsCross-sectional data were drawn from an observational study of women veterans aged 45–64 enrolled in VHA care in Northern California, with data from mail- and web-based surveys linked to VHA electronic health records (EHRs). Between March 2019 and May 2020, participants reported sociodemographic characteristics, current depressive (Patient Health Questionnaire-9) and posttraumatic stress (PTSD checklist for DSM-5) symptoms, and MST (using standard VHA screening questions) in a survey; depression and posttraumatic stress disorder diagnoses (ICD-10 codes) and documented MST were identified from EHRs. Associations between sociodemographic characteristics, mental health symptoms and diagnoses, and discordant MST reports (EHR-documented MST vs. MST reported on survey, not in EHR) were examined with multivariable logistic regression.ResultsIn this sample of midlife women veterans (n = 202; mean age 56, SD = 5), 40% had EHR-documented MST, and 74% reported MST on the survey. Sociodemographic characteristics, mental health symptoms, and diagnosed depression were not associated with discordant MST responses. Women with an EHR-documented PTSD diagnosis had fivefold higher odds of having EHR-documented MST (vs. survey only; odds ratio 5.2; 95% confidence interval 2.3–11.9).ConclusionsVHA screening may not capture more than half of women who reported MST on the survey. VHA screening may underestimate true rates of MST, which could lead to a gap in recognition and care for women veterans.     

Correlates of African American sexual assault survivors’ medical care seeking

ABSTRACT

African American women are at higher risk for sexual assault than other racial/ethnic groups and have an overall high prevalence of lifetime sexual assault. Despite elevated risk and prevalence, African American survivors are often reluctant to use services in the aftermath of sexual assault. Yet, little research has focused exclusively on African American women’s sexual assault experiences including their experiences of medical care seeking. A mail survey study was conducted in Chicago (2010–2011) to understand better African American women’s sexual assault experiences in relationship to post-assault medical care seeking in a large community sample (N = 836). Multivariable regression analyses examined whether demographics, assault characteristics, trauma history, and post-assault psychosocial factors were related to medical care seeking. Results revealed unique correlates of immediate and long-term help-seeking from a variety of medical/health sources. Being of older age and lower income, perceived life threat, and delayed disclosure were related to less medical care seeking. Survivors who were assaulted by strangers, experienced interpersonal and contextual traumas, and who received tangible aid and mixed social reactions were related to medical care seeking. Implications for research and clinical practice with this population are provided.     

Comparing the health status of male and female veterans who use VA health care: results from the VA Women's Health Project

BACKGROUND: In recent years the number of women serving in the military has increased substantially, resulting in more demand for VA services by women veterans. This paper describes the characteristics and health status of women veterans who use VA ambulatory services. METHODS: Respondents in the VA Women's Health Project (n = 719) represent a randomly selected subsample from all women who had an ambulatory visit between July 1, 1994 and June 30, 1995 at a large tertiary care VA facility in the Boston area. Summary statistics on eight dimensions of health status (using the SF-36) for women veterans who use VA ambulatory care are provided. Comparisons are made between women veterans and men veterans who use VA services. RESULTS: Women veterans reported consistently low scores on health status across multiple dimensions, reflecting considerable health needs. Among veterans using VA services, women were younger, better educated, and less likely to be married than male veterans. Women veterans who use VA ambulatory services scored lower on every scale except physical functioning and general health perceptions when compared to male VA users. There were more pronounced differences for women on scales measuring emotional health. CONCLUSIONS: Health status among women veterans is moderate to poor. Important differences in health status are observed between men and women who use VA services which have implications for improving health care to women veterans at VA facilities. These findings strongly indicate that increased mental health services need to be available for women veterans seeking VA health care.