Women veterans have greater mental health (MH) burdens than their male counterparts, in part due to histories of PTSD and military sexual trauma. Different care arrangements have evolved to meet their MH care needs, including separate women's MH clinics and use of designated women's MH providers in general outpatient clinics. However, little is known about how these organizational innovations have emerged, how they have been implemented, or what processes may be needed to achieve sustainability. We sought to explore these care arrangements to inform strategies for developing increasingly gender-sensitive MH care delivery models to serve women veterans' increasing needs.
Our long-term objective is to improve women veterans' access to high-quality gender-sensitive MH care. This project was designed to provide exploratory data from the perspectives of clinical managers and women veterans. To that end, we aimed: Aim #1: To determine the organizational factors associated with implementation and sustainability of VA women's MH services; Aim #2: To better understand women veterans' MH care preferences, use, and experiences related to privacy, gender-sensitivity, as well as accessibility, continuity and coordination of VA MH services; and Aim#3: To explore the MH needs and preferences of OEF/OIF women veterans with respect to gender-sensitive MH care arrangements.
In this mixed methods study, we used Greenhalgh's adapted diffusion of innovations framework to guide our secondary analyses of merged area, organizational and utilization data (Aim #1), telephone-based semi-structured interviews among gender-focused MH clinic managers (Aim #1), in-person semi-structured interviews among women veterans in a local VA clinic setting (Aim #2), and focus groups with OEF/OEF women veteran VA users and non-users (Aim #3). We analyzed transcripts using NVIVO.
Based on 2007 data, we found that one-third of VA facilities (n=67, 34%) employed designated women's MH providers who worked alongside other providers in the general outpatient MH clinic (87%) or delivered care in a women's MH team (11%) also within the general MH clinic. VA's reporting separate women's MH clinics (n=24, 12%) were also commonly embedded within the general MH clinic (61%), but were more likely to represent creation of a separate team (31%) with separate waiting rooms (29%) and exam rooms (30%). Separate women's MH clinics principally delivered sexual trauma or MST group counseling (87%), followed by stress management (67%) and substance abuse treatment (58%). Women veterans were most likely to be assigned to same-gender providers in separate clinics compared to general outpatient MH clinics (61% all/almost assigned to same-gender providers in women's clinics with MH services vs. 46% in separate women's MH clinics vs. 7% in general outpatient MH clinics).
Based on clinic manager interviews, we found that women's MH programs are chiefly informal and focused almost exclusively on military sexual trauma. Some managers expressed skepticism regarding the need for or value of separate services by gender, emphasizing the need to treat "all veterans equally." Many described challenges in tailoring services to such a small population of their patients. Sites with formal women's MH services or providers, however, depicted local processes and a trajectory leading to increase service use after sites had developed gender-specific programs and begun to offer specialized women's MH services. From patient interviews, we learned that most women patients learned of MH services via a women's clinic provider. They described needs for expanded hours, expanded topics for female groups (e.g., weight management, assertiveness, PTSD) and more education on availability of VA MH services for women veterans. Women veterans also expressed a preference for female psychologists for ongoing individual or group therapy, but did not think gender mattered for ongoing medication management with psychiatrists. Per our focus groups, OEF/OIF women veterans learned about the VA about half from colleagues and half from VA or DoD outreach, but noted significant difficulty in learning exactly what VA offers. Perceptions of the value of separate women's programs among OEF/OIF women veterans were mixed, with some expressing preference for them and others being neutral or ambivalent.
The VA Uniform Mental Health Services Benefits Package includes policies on delivering "gender aware" mental health care, recognizing both the changing demographics of the military with nearly 20% of new recruits being women and the high rates of mental health diagnoses among women veterans. Our findings suggest that implementation of these policies may require greater specification and guidance to the field, as well as more research verifying women Veterans' preferences.
- MacGregor C, Hamilton AB, Oishi SM, Yano EM. Description, development, and philosophies of mental health service delivery for female veterans in the VA: a qualitative study. Women's health issues : official publication of the Jacobs Institute of Women's Health. 2011 Jul 1; 21(4 Suppl):S138-44.
- Oishi SM, Rose DE, Washington DL, MacGregor C, Bean-Mayberry B, Yano EM. National variations in VA mental health care for women veterans. Women's health issues : official publication of the Jacobs Institute of Women's Health. 2011 Jul 1; 21(4 Suppl):S130-7.
- Haskell SG, Mattocks K, Goulet JL, Krebs EE, Skanderson M, Leslie D, Justice AC, Yano EM, Brandt C. The burden of illness in the first year home: do male and female VA users differ in health conditions and healthcare utilization. Women's health issues : official publication of the Jacobs Institute of Women's Health. 2011 Jan 1; 21(1):92-7.
- Hamilton A, Oishi S, Klap RS, Yano EM. Implementation of Evidence-Based Treatments for Women Veterans with Multiple Mental Health Conditions: A Study of Existing Practices. Poster session presented at: VA HSR&D / QUERI National Meeting; 2012 Jul 16; National Harbor, MD.
- MacGregor C, Rose DE, Canelo IA, Yano EM. Organizational Arrangements for Women’s Mental Health Care Services in VA. Poster session presented at: VA HSR&D Field-Based Women's Health Meeting; 2010 Jul 15; Arlington, VA.
- Oishi S, Washington DL, Bean-Mayberry BA, Canelo IA, Yano EM. Organizational Features of Outpatient Women’s Mental Health Services in VHA: Findings from the VHA Survey of Women Veterans Health Programs and Practices, 2007. Poster session presented at: VA HSR&D Field-Based Women's Health Meeting; 2010 Jul 15; Arlington, VA.
- MacGregor C, Yano EM, Canelo IA, Miake-Lye I. Availability and implementation of formal women’s mental health services in the Veterans Health Administration: Build it and they will come? Poster session presented at: AcademyHealth Annual Research Meeting; 2009 Jun 28; Chicago, IL.