Women are a growing segment of the United States military and Veteran populations. Currently, women make up 20% of new recruits, and it is estimated that women Veterans will comprise 10% of the Veteran population by 2018. In response to this rapidly changing demographic, VA established women's health as a research priority in the early 1990s. VA's Office of Research and Development (ORD) has continued to build on that priority goal by creating the VA Women's Health Research Planning Group, which worked to develop a comprehensive research agenda for women Veterans. The Planning Group first held a Women's Health Research agenda-setting conference in November 2004. In 2010, VA HSR&D and the Women Veterans Health Strategic Healthcare Group co-sponsored a major conference that brought together investigators interested in pursuing research on women Veterans, and women serving in our military, with leaders in women's healthcare delivery and policy within and outside the VA (e.g., DoD, NIH, IOM) to review progress and to further advance the research agenda.

VA HSR&D continues to contribute to the growing body of research being conducted to improve the health and healthcare of women Veterans in an array of areas, such as mental health, reproductive health, and chronic disease. The following four recently completed studies examine the role of accessibility, practice structure, mental healthcare, and reintegration concerns for women Veterans.

Keywords: Women, veterans, care, access, quality, usage, mental health, ambulatory, reintegration, OEF, OIF

1. Women Veterans' Use of Ambulatory Care Differs with Chronic and Mental Health Conditions

Completed in August 2009, this study examined several aspects of women Veterans' use of ambulatory care services. (Study no.: IAE 06-083. Donna L. Washington, MD, PhD.)

Questions

For women Veterans, what impact does a chronic medical or mental health condition have on ambulatory care use when considered in the context of distance from a VA facility offering women's care services?

Results

Based on data from 2, 174 women Veterans who participated in the Woman Veterans Ambulatory Care Use project of 2004, results showed that women Veterans have high levels of physical and mental health concerns that impact their overall ambulatory care use.

• 66% have one or more diagnosed medical conditions, 32% have mental health conditions, and 26% have both medical and mental health conditions.
• 10.9% of respondents screened positive for post-traumatic stress disorder (PTSD), and among those screening positive, 27% used mental healthcare services in the prior 12 months.
• African-American and Hispanic Veterans were less likely than Whites to receive mental healthcare.
• Screening positive for an anxiety disorder, being low income, using VA healthcare, and having a service-connected disability are all predictive measures of mental healthcare use of any kind.
• The median distance to the closest VA site was 8.5 miles. For 39% of women Veterans, the nearest VA site did not offer mental healthcare, and for 58% the nearest VA site did not offer women's healthcare.
• For women Veterans with mental health conditions and for those with no chronic conditions, greater distance predicted greater use of women's healthcare outside of the VA.

Implications

The authors found that when sites with formal women's mental health services or providers do implement local processes, it can lead toward increased service use. Findings also showed that geographic barriers to meeting women Veterans' chronic illness care needs do exist, and among those with mental health diagnoses, the lack of access to a nearby VA women's health service was a predictor of the use of non-VA services.

Publication Note: This study resulted in the following journal articles:

• Integration of Women Veterans into VA Quality Improvement Research Efforts: What Researchers Need to Know. Journal of General Internal Medicine, January 2010.
• Women Veterans' Perceptions and Decisionmaking about Veterans Affairs Healthcare. Military Medicine, August 2007.

2. Looking at Patterns of Care among Women Veterans with Comorbid Cardiovascular and Mental Health Diagnoses

This study sought to examine primary care treatment patterns among women Veterans who are diagnosed with both a cardiovascular concern (heart disease, hypertension, diabetes) and a major depressive disorder (MDD). (Study no.: IAE 05-255. Ranjana Banerjea, PhD.)

Questions

What is the pattern of treatment among women Veterans diagnosed with both a cardiovascular concern and major depression? Does that treatment pattern benefit from integrating mental health services with primary care?

Results

Among a majority of women identified with one of three (diabetes, heart disease, hypertension) cardiovascular concerns (CVC) and major depression, results showed:

• A large number of women Veterans suffered from a depressive disorder accompanied by a chronic, cardiovascular condition.
• Major depression that was not associated with CVC but with a broader range of diagnoses did not impact the process of care among women Veterans with CVC.
• Over a two-year period, 45% of women in this study with a diabetes diagnosis had serious mental illness including major depression.
• Women-specific primary care practice structure was associated with greater recognition of depression among women Veterans.

Implications

The authors suggest that women Veterans suffering from both a depressive disorder and a chronic illness can be treated together at women's clinics with primary care services or integrated primary care services that have special women's clinics. Further, they point toward higher rates of diagnoses and treatment as suggesting beneficial effects of such integrated services for women.

Publication Note: This study resulted in the following publications:

• Mental Illness and Substance Use Disorders Among Women Veterans with Diabetes. Women's Health Issues, November 2009.
• Chronic Illness with Complexities: Mental Illness and Substance Use Among Veteran Clinic Users with Diabetes. American Journal of Drug and Alcohol Abuse. January 2007.

3. Understanding Practice Structure and Care Quality for Women Veterans

This study sought to build on previous findings by improving the understanding of how the VA healthcare system has changed its organization in response to the recent influx of women Veterans. (Study no.: IAE 07-170. Elizabeth M. Yano, PhD, MSPH.)

Questions

How has the VA healthcare system adapted, over time, in response to a recent, rapid influx of women Veterans?

Results

Using organizational survey data administered in 2001 and again in 2006-2007, results showed access to basic services remains quite good. Access to care through contracted clinics is high. Onsite availability of women's health services over the 6-year period examined did not increase, however.

Implications

Given the increases in women Veterans' use of the VA healthcare system, the authors suggest that many VA facilities are still working toward increasing onsite delivery of care to women Veterans. Further, they suggest that these findings represent opportunities to inform the design of implementation plans that address concerns within the context of a given facility.

Publication Note: This study resulted in the following publications:

• How are Veterans Health Administration (VA) Facilities Adapting to Their Changing Demographics? Journal of General Internal Medicine. June 2009

4. Understanding Reintegration and Service Needs for Women Veteran Mothers

This study sought to deepen the understanding of the concerns and stressors that accompany reintegration into civilian life for women Veterans of Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF). (Study no.: SHP 08-186. Gudrun Lange, Ph.D.)

Questions

What specific concerns and stressors accompany reintegration into civilian life for OEF/OIF women Veterans? What major themes are associated with reintegration in relation to specific sectors of life (work, family, and access to services)? Do women Veteran mothers have specific concerns that are not shared by women Veterans who are not mothers?

Results

Investigators conducted three separate focus groups consisting of previously deployed OEF/OIF women Veterans both with and without dependent children. Overall, women had a hard time finding supports upon return home, and women in all three focus groups were vocal about the need for additional reintegration support.

Major themes related to readjustment and family shared by both mothers and non-mothers included:

• Feeling isolated,
• Having difficulties in communicating with family and friends,
• Not having enough time to "readjust" when they returned home, and
• Unreasonable expectations of family members for them to return to their former roles and "old selves."

Employment concerns were expressed equally by women with and without children, and included:

• Financial issues due to disparity in pay (military vs. non-military) and or lack of job availability;
• Difficulty finding a civilian job that would pay as well as their military job; and
• Difficulties in money management after deployment because military structure is designed to meet basic needs (housing, food, clothing), and the removal of this structure in civilian life contributed to tension surrounding financial management.

Issues pertaining uniquely to women with dependent children included:

• Difficulties bonding with children and resuming the role as primary parent or disciplinarian,
• Feeling out of sync with children and partners/family members, and
• Feeling that they had "missed so much."

Implications

That combat deployments of long duration and unpredictable length are problematic has been well-established. However, reintegration presents women Veterans with a specific set of unique needs. The knowledge derived from this pilot study did result in the initiation of one intervention targeted toward those needs—a monthly two—hour readjustment support group-and the authors expect that additional study data will provide a basis for designing future reintegration interventions.