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

Background  

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

Association Between Availability of Women's Health Services and Women Veterans' Care Experiences

IntroductionFew studies have focused on determinants of women's ratings of care experiences in primary care. We assessed associations between availability of women's health services and women veterans' ratings of care experiences.MethodsIn a cross-sectional analysis, we linked Fiscal Year (FY) 2017 (October 1, 2016, to September 30, 2017) survey data from 126 Veterans Health Administration (VA) primary care leaders to 4,254 women veterans' ratings of care from VA's Survey of Healthcare Experiences of Patients-Patient Centered Medical Home (FY 2017). The dependent variables were ratings of optimal access (appointments, information), care coordination, comprehensiveness (behavioral health assessment), patient–provider communication, and primary care provider. Key independent variables were number of women's health services 1) routinely available all weekday hours (compared with some hours or not available) and 2) available in VA general primary care vs. other arrangements. In multilevel logistic regression models, we adjusted for patient-, facility-, and area-level characteristics.ResultsA greater number of women's health services routinely available in VA primary care was associated with a higher likelihood of optimal ratings of care coordination (adjusted odds ratio [AOR], 1.06; 95% confidence interval [CI], 1.01–1.10), provider communication (AOR, 1.08; 95% CI, 1.002–1.16), and primary care provider (AOR, 1.07; 95% CI, 1.02–1.13). A greater number of services available in VA primary care was associated with a lower likelihood of optimal ratings for access (AOR, 0.94; 95% CI, 0.88–0.99).ConclusionFor the most part, routine availability of women's health services in VA primary care clinics enhanced women's healthcare experiences. These empirical findings offer healthcare leaders evidence-based approaches for improving women's care experiences.     

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.     

Gender Differences in Response to Acceptance and Commitment Therapy Among Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn Veterans

BackgroundMost of our knowledge base regarding treatment response among veterans comes from predominantly male samples. Evidence suggests, however, that women and men use different coping strategies, which may impact how effective treatments are for people of different genders. The purpose of this investigation was to examine gender differences in response to acceptance and commitment therapy, an empirically supported transdiagnostic psychotherapy.MethodsData were drawn from a multisite, randomized, controlled trial of acceptance and commitment therapy as compared with a psychotherapy control, namely, present-centered therapy (PCT), in veterans with emotional distress who served in Operations Enduring Freedom, Iraqi Freedom, or New Dawn (OEF/OIF/OND). Although the original trial did not find a difference between acceptance and commitment therapy and present-centered therapy, we were interested in examining whether gender differences may have been obscured in the original analyses. This secondary analysis included 117 participants for whom at least one post-baseline data point was available and examined the role of gender in treatment response.ResultsGender differences were not observed on the primary outcome of general distress, but were observed in post-traumatic stress disorder symptoms (p < .01).ConclusionsThese preliminary results suggest the possibility of gender differences in psychotherapy response and should motivate additional study of gender-specific care.     

Health Disparities Among Women by Sexual Orientation Identity and Same-Sex or Different-Sex Cohabiting Partnership Status

BackgroundThe objective of this study was to compare health outcomes by sexual orientation identity and cohabiting partnership status (defined as whether heterosexual, lesbian, and bisexual women were non-partnered, partnered in a cohabiting same-sex relationship, or partnered in a cohabiting different-sex relationship).MethodsWe used data on heterosexual (n = 95,289) and sexual minority (n = 2,600) women aged 18 years and older from the 2013–2018 National Health Interview Survey. We estimated adjusted odds ratios (AORs) with 95% confidence intervals (CIs) from multivariable logistic regression models comparing health outcomes by sexual orientation identity and cohabiting partnership status while controlling for sociodemographic characteristics.ResultsCompared with heterosexual women in a different-sex relationship, nonpartnered women generally reported worse health outcomes regardless of sexual orientation. Lesbian women with a same-sex partner were more likely to report poor/fair health (AOR, 1.61; 95% CI, 1.09–2.37), current cigarette smoking (AOR, 1.48; 95% CI, 1.14–1.94), and binge drinking (AOR, 1.63; 95% CI, 1.19–2.23) compared with heterosexual women with a different-sex partner. Bisexual women with a different-sex partner were more likely to report poor/fair health (AOR, 1.91; 95% CI, 1.23–2.97), severe psychological distress (AOR, 2.86; 95% CI, 1.78–4.59), current cigarette smoking (AOR, 1.38; 95% CI, 1.01–1.88), and binge drinking (AOR, 1.66; 95% CI, 1.18–2.32) compared with heterosexual women with a different-sex partner.ConclusionMore research is needed to identify the processes in which heterosexual and sexual minority women partner and cohabitate with members of the same or different sex—and whether or how this influences their health. Meanwhile, health care providers should be mindful that families are diverse, and acknowledging this diversity could be a first step toward achieving health equity for all women regardless of sexual orientation.     

Getting beyond "Don't ask; don't tell": an evaluation of US Veterans Administration postdeployment mental health screening of veterans returning from Iraq and Afghanistan

Objectives. We sought to evaluate outcomes of the Veterans Administration (VA) Afghan and Iraq Post-Deployment Screen for mental health symptoms.Methods. Veterans Administration clinicians were encouraged to refer Iraq or Afghanistan veterans who screened positive for posttraumatic stress disorder, depression, or high-risk alcohol use to a VA mental health clinic. Multivariate methods were used to determine predictors of screening, the proportions who screened positive for particular mental health problems, and predictors of VA mental health clinic attendance.Results. Among 750 Iraq and Afghanistan veterans who were referred to a VA medical center and 5 associated community clinics, 338 underwent postdeployment screening; 233 (69%) screened positive for mental health problems. Having been seen in primary care (adjusted odd ratio [AOR]=13.3; 95% confidence interval [CI]=8.31, 21.3) and at a VA community clinic (AOR=3.28; 95% CI=2.03, 5.28) predicted screening. African American veterans were less likely to have been screened than were White veterans (AOR=0.45; 95% CI=0.22, 0.91). Of 233 veterans who screened positive, 170 (73%) completed a mental health follow-up visit.Conclusions. A substantial proportion of veterans met screening criteria for co-occurring mental health problems, suggesting that the VA screens may help overcome a “don’t ask, don’t tell” climate that surrounds stigmatized mental illness. Based on data from 1 VA facility, VA postdeployment screening increases mental health clinic attendance among Iraq and Afghanistan veterans.High levels of exposure to combat have characterized the conflicts principally in Iraq and Afghanistan—Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF). Improvised explosive devices and frequent, unexpected mortar attacks have brought the “front line” to most OIF and OEF military service personnel.1 In the Vietnam and Persian Gulf wars, level of combat exposure was strongly associated with posttraumatic stress disorder (PTSD), depression, and substance use disorders.2^,3 Similarly, an epidemic of mental health disorders is emerging among veterans of OIF and OEF.4^,5 Early intervention with evidence-based mental health treatment has been shown to prevent chronic mental illness and associated disability.6 Mental health screening of combat veterans has the potential to increase early detection of symptoms and early intervention.Since World War I, the US military has conducted mass mental health screening primarily to exclude psychologically vulnerable recruits from service, yet these programs have failed to reduce the incidence of psychological casualties.7 This experience, coupled with high rates of psychiatric disorders in the aftermath of the Vietnam and Persian Gulf wars, shifted the focus of screening to the detection of mental health symptoms during and after deployment.8 Recent reports have indicated that service members are more likely to report mental health problems 3 to 4 months after returning from deployment, and delayed presentations of mental health disorders have been documented years after military service.9^,10 Accordingly, in June 2004, the Veterans Administration (VA) issued a national directive to initiate the Afghan and Iraq Post-Deployment Screen.11 The screen consists of brief, previously validated instruments to detect symptoms of PTSD, depression, and high-risk alcohol use among veterans of OIF and OEF who seek VA healthcare. Veterans Administration clinicians are expected to complete the screen and to assess whether veterans who meet screening criteria for depression and high-risk alcohol use require a mental health referral. Veterans Administration clinicians are encouraged to refer patients who meet screening criteria for PTSD for further mental health assessment and treatment.Clinicians at 1 VA medical center and its affiliated community-based clinics were encouraged to refer Iraq and Afghanistan veterans who met screening criteria for PTSD, depression, or high-risk drinking for follow-up mental health assessment. Based on data from this facility, we sought to determine (1) the frequency and predictors of implementation of the VA postdeployment screen; (2) the proportion of veterans with positive screens for PTSD, depression, or high-risk alcohol use; and (3) the proportion of veterans who were seen in a VA mental health clinic within 90 days of screening and beyond.     

Health risk behaviors of Afghanistan and Iraq war veterans attending college

PURPOSE. The population of military veterans attending college is rapidly growing as veterans return from Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF). We sought to describe patterns of student veterans' health-related behaviors and how they might differ from their nonveteran peers. DESIGN. We analyzed data from the 2008 Boynton College Student Health Survey (CSHS). SETTING. CSHS participants completed an anonymous online survey. SUBJECTS. The CSHS sampled students (n = 8651) attending public, private, 2-year, and 4-year postsecondary educational institutions in Minnesota. MEASURES. The CSHS included items on substance use (including alcohol and tobacco), safety, nutrition, and physical activity. ANALYSIS. We described demographics of OEF/OIF veteran, non-OEF/OIF veteran, and nonveteran students and used Poisson regression to compute adjusted relative risks (ARRs) with 95% confidence intervals (CIs) to characterize associations between veteran status and health behaviors. RESULTS. After controlling for demographics, veteran students reported more safety-, tobacco-, and alcohol-related risk behaviors compared to nonveteran students. For instance, compared to the nonveteran reference group, the ARR for past year smokeless tobacco use and physical fighting among for OEF/OIF veterans was 1.76 (95% CI = 1.31-2.35) and 1.48 (95% CI = 1.22-1.79) respectively. Veteran and nonveteran students display similar weight-related behaviors, though OEF/OIF veteran students were more likely to engage in strengthening exercises. CONCLUSIONS. There are specific health risk behaviors that are particularly relevant for veterans attending postsecondary institutions. As veterans enroll in postsecondary education, there is a unique window of opportunity for health promotion in this population.     

Prenatal Care for Women Veterans Who Use Department of Veterans Affairs Health Care

ObjectiveThe number of women Veterans of childbearing age enrolling in Department of Veterans Affairs (VA) health care is increasing. Our objective was to describe characteristics of women veterans and resumption of VA care after delivery by use of VA prenatal benefits.Study designWe used data from the National Survey of Women Veterans, a population-based survey. VA-eligible women veterans with at least one live birth who had ever used VA and were younger than 45 years when VA prenatal benefits became available were categorized based on self-reported receipt of VA prenatal benefits. Characteristics of by use of VA prenatal benefits were compared using χ² tests with Rao–Scott adjustment. All analyses used sampling weights.ResultsIn our analytic sample, of those who potentially had the opportunity to use VA prenatal benefits, 25% used these benefits and 75% did not. Compared with women veterans not using VA prenatal benefits, those who did were more likely to be 18 to 24 years old (39.9% vs. 3.7%; p = .03), and more likely to have self-reported diagnosed depression (62.5% vs. 24.5%; p = .02) and current depression or posttraumatic stress disorder (PTSD) symptoms (depression, 46.1% vs. 8% [p = .02]; PTSD, 52.5% vs. 14.8% [p = .02]). Compared with women veterans not using VA prenatal benefits, those who did were more likely to resume VA use after delivery (p < .001).ConclusionPregnant women veterans who use VA prenatal benefits are a high-risk group. Among those who opt not to use these benefits, pregnancy is an important point of attrition from VA health care, raising concerns regarding retention of women veterans within VA and continuity of care.     

Effects of Repeated Deployment to Iraq and Afghanistan on the Health of New Jersey Army National Guard Troops: Implications for Military Readiness

Objectives. We assessed the effects of prior military service in Iraq or Afghanistan on the health of New Jersey Army National Guard members preparing for deployment to Iraq.Methods. We analyzed anonymous, self-administered predeployment surveys from 2543 National Guard members deployed to Iraq in 2008. We used bivariate and multivariate analyses to measure the effects of prior service in Afghanistan (Operation Enduring Freedom [OEF]) or Iraq (Operation Iraqi Freedom [OIF]) on mental and physical health.Results. Nearly 25% of respondents reported at least 1 previous OEF or OIF deployment. Previously deployed soldiers were more than 3 times as likely as soldiers with no previous deployments to screen positive for posttraumatic stress disorder (adjusted odds ratio [AOR] = 3.69; 95% confidence interval [CI] = 2.59, 5.24) and major depression (AOR = 3.07; 95% CI = 1.81, 5.19), more than twice as likely to report chronic pain (AOR = 2.20; 95% CI = 1.78, 2.72) and more than 90% more likely to score below the general population norm on physical functioning (AOR = 1.94; 95% CI = 1.51, 2.48).Conclusions. Repeated OEF and OIF deployments may adversely affect the military readiness of New Jersey National Guard combat soldiers.The mental and physical health consequences of service in Afghanistan (Operation Enduring Freedom [OEF]) and Iraq (Operation Iraqi Freedom [OIF]) have been well documented. Studies report rates of posttraumatic stress disorder (PTSD) among returning soldiers ranging from 4%¹ to 31%² and rates of depression ranging from 3%³ to 25%,⁴ with rates varying by diagnostic criteria, military population, deployment location, and time since deployment. Traumatic brain injury has been identified in 19% of returning troops.⁵ Those experiencing multiple deployments are most at risk, with the Office of the US Army Surgeon General⁶ reporting mental health problems in 11.9% of those with 1 deployment, 18.5% with 2 deployments, and 27.2% with 3 or 4 deployments. National Guard and Reserve troops are more vulnerable than active-duty troops, with 35.5% of Guard and Reserve troops at mental health risk 6 months after deployment compared with 27.1% of active-duty soldiers.⁷ With respect to physical health, the OEF and OIF conflicts have produced the highest ratio of wounded to killed of any previous military operation (approximately 7:1), with over 33 170 wounded in action as of October 2008.⁸ Orthopedic injuries are the most common class of injury⁹ and pain one of the most frequently reported symptoms.^10,11Although the adverse health consequences of service in OEF and OIF have focused public attention on the medical needs of returning veterans, concern has also centered on the military readiness of our fighting force, given the unprecedented pattern of repeat deployments unique to this particular conflict. Of all soldiers deployed to Iraq since 2003, approximately 38% have been deployed more than once and 10% have been deployed 3 times or more.¹² The Department of Defense and state National Guard authorities conduct extensive pre- and postdeployment screenings to ensure that only “healthy and medically prepared”¹³ soldiers are deployed to combat. However, because most studies of veterans of OEF and OIF to date have focused on postdeployment populations, we have little information about the effectiveness of military programs in screening seriously impaired soldiers out of the eligibility pool for future deployment. Postdeployment studies, moreover, are likely to include many medically compromised soldiers who were subsequently disqualified from, or voluntarily left, active military service before being recalled to duty. In the absence of large-scale predeployment health studies, we have no information on the effect of multiple deployments on the fitness of soldiers returning to combat. The 1 published study identified by the authors to date that examined predeployment health status⁷ included a small sample of combat veterans (n = 173) with mixed histories of previous service: some had served in Afghanistan, some in conflicts other than OEF and OIF, but none in Iraq, even though, until recently, Iraq war veterans experienced substantially greater combat stress than veterans from Afghanistan.¹⁴We explored the effects of multiple deployments on the mental and physical health of New Jersey Army National Guard troops preparing for deployment to Iraq. Specifically, we (1) compared the health status of soldiers with previous OEF and OIF deployments with that of soldiers experiencing their first deployment, (2) examined associations between deployment status and health after controlling for possible confounding factors, and (3) compared the present survey with New Jersey''s predeployment health assessment on identification rates of key mental health problems.     

Post-traumatic stress disorder, depression, and health-related quality of life in OEF/OIF veterans

Purpose  

Comorbid post-traumatic stress disorder (PTSD) and depression are often associated with negative physical and mental health outcomes in Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) combat veterans. The current study examines the individual contributions of these two disorders on health-related quality of life (HRQoL) in an OEF/OIF cohort. The study hypothesizes that PTSD and depression will each significantly predict lower physical and mental HRQoL even when controlling for overlapping symptoms: anhedonia, concentration, and insomnia.     

Gender Differences in Service Utilization among OEF/OIF Veterans with Posttraumatic Stress Disorder after a Brief Cognitive–Behavioral Intervention to Increase Treatment Engagement: A Mixed Methods Study

PurposeWomen veterans who served in Iraq and Afghanistan (Operation Enduring Freedom and Operation Iraqi Freedom [OEF/OIF]) have a moderately higher risk of developing posttraumatic stress disorder (PTSD) than male veterans. However, gender disparities in treatment engagement may prevent women veterans from initiating the care they need. Understanding gender differences in predictors of and barriers to treatment is essential to improving engagement and mental health outcomes. The purpose of this study was to examine gender differences in treatment utilization after a brief, cognitive–behavioral therapy (CBT) intervention among male and female OEF/OIF veterans.MethodsParticipants were assigned randomly to either the intervention or control conditions. Intervention participants received the telephone-based CBT intervention. Participants were 35 female and 238 male OEF/OIF veterans who screened positive for PTSD and had never initiated PTSD treatment. Participants were asked about treatment utilization, beliefs about PTSD treatment, and symptoms at months 1, 3, and 6 months subsequent to the baseline telephone assessment. The PTSD Checklist—Military Version was used to assess PTSD and the Patient's Health Questionnaire was used to assess symptoms of depression.FindingsFemale veterans who received an intervention were significantly more likely to have attended treatment over the 6-month follow-up period than male veterans who received an intervention (χ² = 7.91; df = 3; odds ratio, 3.93; p = .04).ConclusionsThe CBT intervention may be a critical mechanism to engage female veterans in treatment. Further research is needed to understand how to engage male veterans with PTSD in treatment.     

Characteristics and Health Care Preferences Associated with Cardiovascular Disease Risk among Women Veterans

BackgroundWomen veterans are at increased risk for cardiovascular disease (CVD), but little is known about comorbidities and healthcare preferences associated with CVD risk in this population.MethodsWe describe the prevalence of CVD-relevant health behaviors, mental health symptoms, and health care use characteristics and preferences among participants of the National Survey of Women Veterans (conducted 2008–2009).FindingsFifty-four percent of respondents were at risk for CVD (defined as a diagnosis of hypertension, diabetes, current tobacco use, or obesity without CVD). In unadjusted analysis, ORs for being at risk for CVD were greater among those interested in gender-specific clinical settings (OR, 2.0; 95% CI, 1.2–3.4) and gender-specific weight loss programs (OR, 1.8; 95% CI, 1.1–2.9). ORs were also greater for women who were physically inactive (OR, 1.9; 95% CI, 1.1–3.3), with current symptoms of depression (OR, 2.5; 95% CI, 1.1–6.1), anxiety (OR, 2.1; 95% CI, 1.2–3.6), and posttraumatic stress disorder (OR, 2.4; 95% CI, 1.2–4.8). Adjusting for age, race/ethnicity, marital status, education level, employment, and source of health care use, the ORs for CVD risk were higher for women with current posttraumatic stress disorder symptoms (2.5; 95% CI, 1.1–5.3) and gender-specific health care preferences (2.0; 95% CI, 1.1–3.4), and gender-specific weight loss programs (1.9; 95% CI, 1.1–3.2).ConclusionsRisk for CVD was common and preferences for gender-specific care and posttraumatic stress disorder were associated with being at risk for CVD. Women's health clinics may be a good location for targeted CVD prevention interventions for women veterans both in and outside the Veterans Health Administration.     

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.     

Women Veterans’ Experiences of Harassment and Perceptions of Veterans Affairs Health Care Settings During a National Anti-Harassment Campaign

PurposeIn 2017, Veterans Health Administration (VA) launched a social marketing and training campaign to address harassment of women veterans at VA health care facilities. We assessed women veterans’ experiences of harassment, reported perpetrators of harassment, and perceptions of VA in 2017 (before campaign launch) and 2018 (1 year after campaign implementation).MethodsWe administered surveys to women veterans attending primary care appointments (2017, n = 1,300; 2018, n = 1,711). Participants reported whether they experienced sexual harassment (e.g., catcalls) and gender harassment (e.g., questioning women's veteran status) from patients and/or staff at VA in the past 6 months. They also indicated whether they felt welcome, felt safe, and believed the VA is working to address harassment. We compared variables in 2017 versus 2018 with χ² analyses, adjusting for facility-level clustering.ResultsThere were no significant differences in percentages of participants reporting sexual harassment (20% vs. 17%) or gender harassment (11% vs. 11%) in 2017 versus 2018. Men veterans were the most frequently named perpetrators, but participants also reported harassment from staff. Participant beliefs that VA is working to address harassment significantly improved from 2017 to 2018 (52% vs. 57%; p = .05).ConclusionsOne year after campaign launch, women veterans continued to experience harassment while accessing VA health care services. Findings confirm that ongoing efforts to address and monitor both staff- and patient-perpetrated harassment are essential. Results have implications for future anti-harassment intervention design and implementation and highlight additional opportunities for investigation.     

Public health impact and cost-effectiveness of implementing a ‘pre-vaccination screening' strategy with the dengue vaccine in Puerto Rico

BackgroundThe World Health Organization (WHO) recommended ‘pre-vaccination screening’ as its preferred implementation strategy when using the licensed dengue vaccine (CYD-TDV; Dengvaxia, Sanofi), so that only individuals with previous dengue infection are vaccinated. The US Centers for Disease Control and Prevention (CDC) recommended use of CYD-TDV to prevent dengue in children with previous laboratory-confirmed dengue infection in regions where dengue is endemic. Here, we evaluate the public health impact and cost-effectiveness of a ‘pre-vaccination screening’ strategy in Puerto Rico.MethodsThe current analysis builds upon a previously published transmission model used to assess the benefits/risks associated with dengue vaccination. For ‘pre-vaccination screening’, three alternative testing methods were assessed: one using an immunoglobulin G (IgG) enzyme-linked immunosorbent assay (ELISA) dengue serotest, another with dengue serotesting using a rapid diagnostic test (RDT), and one using both sequentially (as recommended in Puerto Rico). The time horizon considered was 10 years.ResultsIn Puerto Rico, the disability-adjusted life years (DALYs) averted for ‘pre-vaccination screening’ with an ELISA-based program, RDT-based program, and both sequentially would be a median 1,192 (95% CI: 716–2,232), 2,812 (95% CI: 1,579–5,019), and 1,017 (95% CI: 561–1,738), respectively. These benefits would arise from the reduction in cases: median 24,961 (95% CI: 17,480–36,782), 58,273 (95% CI: 40,729–84,796), 20,775 (95% CI: 14,637–30,374) fewer cases, respectively. The cost per DALY averted from a payer perspective would be US$12,518 (95 %CI: US$4,749–26,922), US$10,047 (95% CI: US$3,350–23,852), and US$12,334 (95% CI: US$4,965–26,444), respectively. All three strategies would be cost saving from a societal perspective.ConclusionsOur study supports the WHO and CDC ‘pre-vaccination screening’ guidance for CYD-TDV implementation. In Puerto Rico, regardless of the testing strategy and even with a relatively low rate of testing, it would be cost-effective from a payer perspective and cost saving from a societal perspective.