Women are a fast growing segment of the veteran population. However, their numerical minority within the VA, coupled with their gender-specific and often complex co-morbid health care needs, has created challenges to designing delivery systems that ensure their equitable access to high quality, gender-appropriate care. Little is known about how geographic barriers to VA use impacts women veterans' health services use, particularly for women veterans with chronic medical and mental health conditions.
Our objectives were to: (1) examine the influence of having chronic medical or mental health conditions on ambulatory care use, specific services used, and the presence of unmet health care need; (2) investigate the influence of distance to VA women's health and mental health services on VA use, for women veterans overall and by category of chronic conditions; and (3) investigate in a national sample gender differences in barriers to VA use.
We conducted statistical analyses of merged secondary data from existing data sources. The Women Veterans' Ambulatory Care Use dataset provided socio-demographic, health and ambulatory care use characteristics of 2,174 women veterans residing in southern California and southern Nevada. VA administrative data provided facility and clinical setting of VA use. The 2001 National Survey of Veterans provided national data on health care use by male and female veterans. Data were weighted to represent population estimates.
Women veterans had high levels of physical and mental health disease burden, with 66.5% having one or more diagnosed medical conditions, 32.2% having mental health conditions, 26.1% having both, and 27.4% having neither. Overall, 10.9% of respondents screened positive for post-traumatic stress disorder (PTSD) (26.0% of VA users, 9.7% of VA nonusers; p<0.0001). Among those screening positive, 27.3% 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 all predicted mental healthcare use.
The median distance to the closest VA site was 8.5 miles (interquartile range 8.1). For 39.8% of women veterans, the nearest VA site did not offer mental health care, and for 58.7% the nearest VA site did not offer women's health care. Greater distance predicted use of women's health care outside of the VA for women veterans with mental health conditions and for those with no chronic conditions. Adjusting for age, chronic conditions, and VA priority group, for each 10 mile increase in distance to VA women's health services, the relative risk ratio favoring no use of women's health services versus VA use was 1.16 (95% C.I. 1.03-1.3), and the relative risk ratio favoring use of women's health services in non-VA settings was 1.15 (95% C.I. 1.1-1.2).
Our findings reveal important geographic barriers to meeting women veterans' chronic illness care needs. Lack of close proximity to VA women's health services predicted use of women's health care outside of the VA, particularly among those with mental health comorbidity. Concentration of services at a limited number of sites also led to preferential VAMC over CBOC use. Next steps should identify strategies for assuring that designated primary care providers with appropriate women's health expertise are available in geographically dispersed VA sites.
- Washington DL, Davis TD, Der-Martirosian C, Yano EM. PTSD risk and mental health care engagement in a multi-war era community sample of women veterans. Journal of general internal medicine. 2013 Jul 1; 28(7):894-900.
- Yano EM, Hayes P, Wright S, Schnurr PP, Lipson L, Bean-Mayberry B, Washington DL. Integration of women veterans into VA quality improvement research efforts: what researchers need to know. Journal of general internal medicine. 2010 Jan 1; 25 Suppl 1:56-61.
- Washington DL, Kleimann S, Michelini AN, Kleimann KM, Canning M. Women veterans' perceptions and decision-making about Veterans Affairs health care. Military medicine. 2007 Aug 1; 172(8):812-7.
HSR&D or QUERI Publications
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- Washington DL, Sun S, Lee ML, Mitchell MN, Canning M, Yano EM. Geographic Distance as a Barrier to VA Women's Health Care Use. Poster session presented at: AcademyHealth Annual Research Meeting; 2013 Jun 24; Baltimore, MD.
- Washington DL. Access to care for Women Veterans. Taking action: Responding to health care needs of women Veterans. Paper presented at: American Public Health Association Annual Meeting and Exposition; 2012 Oct 30; San Francisco, CA.
- Washington DL. Women Veterans Research. Paper presented at: CalVet Women Veterans Conference; 2010 Sep 11; Los Angeles, CA.
- Washington DL. Women Veteran Research. Paper presented at: Disabled American Veterans Annual Convention; 2010 Aug 2; Atlanta, GA.
- Washington DL, Yano EM. VA and Community Mental Healthcare Use by Women Veterans Who Screen Positive For Post-traumatic Stress Disorder. Presented at: VA HSR&D National Meeting; 2008 Feb 13; Baltimore, MD.