Women's Health Research in HSR&D

March 2018

Approximately 2.2 million female Veterans currently comprise about 10% of the U.S. Veteran population. As female Veterans are the fastest growing population served by VA, those numbers are expected to double in the next 10 years.¹ With more women serving in combat facing positions during OIF/OEF/OND than previous operations, both incidence and prevalence rates of female Veterans with combat-related health problems such as PTSD and physical trauma have increased.² Additionally, those and other factors, including military sexual trauma (MST) and comorbid mental health issues can affect reproductive and gynecological health.³ In many instances women Veterans delay or avoid seeking care at higher rates than male Veterans⁴ or struggle with psychosocial barriers not applicable to Veteran men.⁵ To address the healthcare needs associated with both current and future women Veterans, VA's Health Services Research & Development Service (HSR&D) supports VA’s comprehensive women's health research agenda.⁶

In honor of Women’s History Month,⁷ the following featured HSR&D studies address health issues specific to women Veterans.

• Examining Contraceptive Use and Unmet Need Among Women Veterans
• Metabolic Effects of Medications for Serious Mental Illness in Female Veterans
• Web and Shared Decision Making for Reserve/National Guard Women's PTSD Care
• Military Sexual Trauma Screening: Examining Patient Satisfaction and Preferences

Examining Contraceptive Use and Unmet Need Among Women Veterans

Unintended pregnancy is prevalent in the U.S. population and is associated with significant adverse health and social consequences. Contraceptive counseling, a highly effective way to prevent unintended pregnancy, is an integral component of primary care for women of reproductive age. The number of female Veterans of reproductive age is rapidly increasing, yet little is known about contraceptive care or outcomes among the growing population of women Veterans who receive health care within the VA Healthcare System. This study sought to determine rates of contraceptive use, unmet need for prescription contraception, and unintended pregnancy in a national sample of female Veterans of reproductive age who use VA for primary care.

Approximately 2,300 VA-using women aged 18-44 completed telephone surveys regarding contraceptive use, pregnancy history, and experiences with VA reproductive healthcare. Researchers also conducted qualitative interviews with a subgroup of 195 participants.

Findings were:

• Greater than 62% of women Veterans were using contraception in the month prior to completing the survey.
• Of those, approximately 35% were using highly effective methods such as sterilization or intrauterine device, 17% moderately effective method such as the pill, and 10% less effective such as condoms or withdrawal.
• Among the more than 1,100 at risk for unintended pregnancy, approximately 89% were using contraception. The remaining 11% demonstrate unmet contraceptive need.
• The annual pregnancy rate was 67 per 1,000 women, and the unintended pregnancy rate was 26 per 1,000 women. Thus, 37% of pregnancies were reported as unintended.
• Similar to the general US population, over a third of pregnancies were unintended; about 10% of those at risk for unintended pregnancy were not using any sort of birth control, and nearly 30% used no prescription contraception.

Implications: As the first published data on rates of contraceptive use, unmet contraceptive need, and unintended pregnancy among women VA users, this study provides a comprehensive picture of the current state of contraceptive care in VA and has yielded a rich dataset that can be further used to answer research questions about women Veterans' reproductive healthcare experiences and outcomes within VA. Findings suggest that additional efforts are needed to help women Veterans reduce their risk of unintended pregnancy.

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Metabolic Effects of Medications for Serious Mental Illness in Female Veterans

Antipsychotic and mood stabilizer medications for serious mental illnesses (SMI) such as schizophrenia and bipolar disorder are widely prescribed in VA.  Weight gain and other metabolic effects of these medications have been implicated in the high rates of obesity and cardiovascular disease among people living with SMI.  Women are more susceptible to weight gain from these medications and report more distress than men.  Since weight gain is linked to medication nonadherence, women may experience disproportionate adverse effects yet little research has addressed these complex inter-relationships. This study sought to understand the perspective of female Veterans with SMI and VA mental health prescribers on how knowledge, attitudes, and experiences regarding weight gain influence medication selection, adherence, and female patients’ physical and mental health.

Qualitative interviews were conducted with 30 female Veterans with SMI and 18 mental health prescribers.

Findings were:

• Female Veterans described considerable concern about weight gain with resulting psychological and physical distress.
• Both groups emphasized that multiple factors along with medications, including age, medical conditions, lifestyle, and environment complicate weight management.
• Many Veterans expressed a willingness to accept weight gain as a trade-off for medications' positive effects, which was echoed by prescribers. However, both described a stressful struggle with that trade-off, including difficulty identifying effective weight management strategies.
• Both groups also described using mostly reactive rather than proactive approaches to weight management, often employed in response to (sometimes significant) weight gain, at a time when weight is difficult to lose.
• Women expressed resolve by trying many different weight-loss strategies, yet endured significant frustration, making motivation difficult to maintain
• Prescribers expressed concern regarding time and limited resources to substantially help Veterans.

Implications: Understanding how certain side effects of antipsychotic and mood stabilizer medications that are of particular concern to women (e.g., weight gain) influence prescribing choices and outcomes of treatment will facilitate more informed shared decision-making by women Veterans and VA clinicians regarding the risks and benefits of these treatments. Ultimately, this will enable VA to better address the unique physical and mental health treatment needs of female Veterans with SMI. 

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Web and Shared Decision Making for Reserve/National Guard Women's PTSD Care

Women Reserve and National Guard (RNG) OEF/OIF/OND war Veterans are a fast growing group of new VA users. Although PTSD is highly prevalent in this group of Veterans, most do not seek care. This gap between need for VA PTSD care and pursuit thereof indicates persistent barriers to Veteran engagement in mental health (MH). This study sought to identify and alleviate these barriers and support post-deployment adjustment to mediate the severity of additional MH conditions associated with PTSD.

The study consisted of four phases: 1) Recently returned OEF/OIF/OND RNG female Veterans who screened positive for PTSD (PTSD+) were interviewed to evaluate their preferences, barriers, and facilitators to pursuing VA MH services and evidence-based psychotherapy (EBP) for PTSD; 2) With this information, investigators refined the WEB-ED, a web-based interface that screens for post-deployment readjustment and MH concerns; 3) The revised interface was used to assess Veteran satisfaction with it, and to identify and recruit participants to be randomly assigned to either the standard of care outreach or a nurse care manager (NCM); 4) Follow-up assessments at 6 and 12 months compared the efficacy of the two approaches in promoting initiation of VA MH services.

Findings were:

• In phase 1, nearly 75% of servicewomen interviewed had no EBP treatment. Barriers described included shame, time constraints, perceptions of poor staffing, and career and access concerns. 80% reported they had received no education or shared decision making (SDM) for PTSD treatment options.
• In phase 2, using the refined WEB-ED, half of approximately 2,500 servicewomen screened positive for PTSD. Many screened positive for other post-deployment MH conditions including depression, substance and prescription drug misuse, anger, and family issues. 80% expressed satisfaction with WEB-ED and said they would recommend it to peers. 60% indicated that they would seek MH care as a direct result of WEB-ED, and nearly 70% gained new information.
• During phase 3, PTSD+ participants receiving standard of care outreach described feeling disengaged and overwhelmed, resulting in lower participation than those screening negative for PTSD but positive for other MH conditions. They reported fear of reliving traumas, disbelief in therapy, and privacy concerns. Those receiving the NCM intervention indicated high satisfaction with the new information, conciseness, and support for the doctor-patient communication it contained.
• In phase 4 follow-up assessments, approximately 60% of participants obtained MH treatment, the majority (85%) through VA. Half of those received EBP in the form of cognitive processing therapies and prolonged exposure therapy.

Implications: This study provides valuable insights into barriers and facilitators regarding female RNG Veterans who may delay or not access MH and PTSD treatment. PTSD+ Veterans with low patient-activation scores require additional support for engaging in needed MH care that this study’s methods addressed. Focusing on these high-risk populations and providing Veteran-centered approaches, this study demonstrated the efficacy of relatively inexpensive interventions that can be implemented within existing models of care and indicated clear implications for expansion to other Veteran populations. Participants reported high satisfaction with WEB-ED, SDM, and EBP. Next steps include engaging providers with PTSD decision aid/SDM use and refining interventions to further focus on the Veteran-provider partnership.

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Military Sexual Trauma Screening: Examining Patient Satisfaction and Preferences

VA has implemented a universal military sexual trauma (MST) screening program and extensive treatment resources targeting MST-related health conditions. Existing research has evaluated VHA's MST Screening Program from an organizational perspective, but there have been few efforts to understand patients’ perspectives on this process. This study sought to ascertain Veterans' attitudes, preferences, and satisfaction regarding MST screening conversations, and to understand associations between MST screening satisfaction, willingness to disclose an MST history, and health outcomes. 

The study team conducted semi-structured qualitative interviews with 55 Veterans whose medical records indicated a recent conversation with a VA healthcare provider about MST. Participants included Veterans who had experienced MST and those who had not.

Findings were:

• Most conversations about MST occurred in primary care or mental health settings. Veterans were most often screened by a physician, nurse, or mental health provider who they had recently met.
• Around 1 in 4 Veterans spontaneously disclosed their MST experiences to a provider without the provider initiating the conversation.
• Overall Veterans were generally quite satisfied with their conversations about MST.
• Veterans who had not experienced MST were not offended by MST screening. In fact, many expressed support for the program.
• Reasons for high satisfaction included a relatively brief screening process, providers’ use of clear language, no perceived pressure to extensively discuss MST experiences, and specific aspects of providers’ manner (e.g., “understanding,” listened carefully).
• Veterans with poorer satisfaction noted providers’ perfunctory manner (e.g., lack of acknowledgement of disclosure) and Veterans’ general discomfort with discussing MST experiences.

Implications: Despite provider concerns that Veterans may feel uncomfortable discussing MST, most Veterans were comfortable with their screening experiences. These findings may help providers feel more comfortable raising this important but sensitive topic. Provider trainings specific to MST screening should focus on strategies that are consistent with Veteran preference and with best practices for screening for histories of interpersonal violence.

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