Health Status of Women Veterans: A Literature Review

We recently conducted a literature review on the health status of women veterans for one of our healthcare clients. Our findings-including summaries and important quotes from the articles we read-are featured here. Our client will use these literature review findings to contextualize a research study they recently conducted on the healthcare systems that support women veterans. We are now working with our client team to compose a journal article that situates their research within the broader conversations happening within this field, as evident in the literature review notes you’ll discover below.

We strongly believe that published research is meant to be shared broadly and publicly-to inspire conversation and the growth of public intellectualism. Get up to date on the latest research about women veterans’ healthcare by exploring our literature review notes below. If you would like to learn more about veteran services, you can learn more here.

Literature Review Findings

Women Veterans are among the fastest-growing segment of new health care users, with as many as 44 percent OEF/OIF Veterans electing to use VHA health care. Today, there are approximately 23 million Veterans overall, of which 2.2 million (10%) are female. According to the Veteran Population Projections Model, whereas the total number of Veterans is projected to decrease by 2040, the percentage of women Veterans is expected to increase to 18% during the same timeframe.

Women have historically been called “invisible Veterans” because until recently their service contributions were under-recognized by both military and civilian communities (Special ReportsWomen Veterans Issues). As such, providers within and outside of VA care continue to face “the challenge of organizing and delivering gender-specific and gender-sensitive services in a system historically focused on treating men” (Yano, Hayes, Wright et al., 2010). With the growing women Veteran population, a focus on women’s health care has become increasingly important within VHA.

Previous research has acknowledged the unique and complex physical, mental, and psychosocial challenges faced by women VA patients as compared to their male Veteran and women civilian counterparts, including struggles related to Post-Traumatic Stress Disorder and Military Sexual Trauma (MST) (Yano et al., 2006; Levander, 2015; MacGregor et al. 2011; Zinzow et al., 2007; Yano, Hayes, Wright et al. 2010). The general population of women VA patients have poorer health status than civilian women, and cite increased bodily pain and decreased emotional and social function, even compared to civilian women who face serious chronic medical conditions (Frayne et al., 2006; Lehavot et al., 2012).

Women Veterans have reported better health outcomes when they have consistent relationships with healthcare providers who know their medical history, emphasize preventative care, encourage behavioral changes to meet their health goals, and understand military culture.

Literature Review Sources, Summaries, & Important Quotes

Bastian LA, Trentalange M, Murphy TE, Brandt C, Bean-Mayberry B, Mailer NC, Wright SM, Gaetano VS, Allore H, Skanderson M, Reyes-Harvey E, Yano EM, Rose D. Haskell S. Association between women veterans’ experiences with VA outpatient health care and designation as a women’s health provider in primary care clinics. Womens Health Issues. 2014 Nov-Dec;24(6):605-12.

  • Summary: Reports on research study based on secondary data 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. “Of 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-CAHPSPCMH survey (40%; n ¼ 1,267 were DWHPs). In a multivariable model, patients seen by Designated Women’s Health Providers (DWHPs) (relative risk, 1.02; 95% CI, 1.01–1.04) reported higher overall experiences with care compared with patients seen by non-DWHPs.”
  • “The main finding is that women veterans’ experiences with outpatient health care are slightly better for DWHPs compare with non-DWHPs.”
  • “In addition to the DWHP status, we found provider class, for example, NPs versus MDs, to be a factor associated with veterans’ better overall experience with outpatient care. Previous studies have examined differences in patient experiences with care by provider type (NP, PA, and MD) in predominantly male populations. Budzi, Lurie, Singh, and Hooker (2010) found that veteran patients were more satisfied with care by NPs compared with PAs and MDs, and these authors highlighted that NPs focus on health promotion, health education, attentiveness, and counseling. Another non-VA study found older patients (>65 years) were more satisfied with NPs (Cipher, Hooker, & Sekscenski, 2006). Although more research is needed to adjust for time spent with the patient and the complexity of the patients cared for by these providers, this may represent an important finding for VA, the largest single provider of health care in the United States in its mission to care for women veterans. To address the potential scarcity of primary care providers in the future, the VA may need to consider hiring more NPs.”
  • “In our study, increasing age of the women veteran is a significant factor associated with better experiences with outpatient care. Many older women veterans have alternative options to VA care (Shen, Hendricks, Zhang, & Kazis, 2003) and may continue to use VA services because they are satisfied with the care they receive. More than one half of new women veterans using care are under age 45 growing from 57% in FY03 to 64% in FY09 (Friedman et al., 2011). Wright and co-workers (2012) suggested that the 21st-century VA needs to become more responsive to younger veterans of both genders.”
  • “Compared with men, women in the active duty military have higher proportions of racial and ethnic minorities (Patten & Parker, 2011), and our finding of non-White race associated with better experiences with care is important in this veteran subgroup who are younger and more often non-White than the average male veteran. This finding should promote further inquiry as it adds to the literature on factors associated with the presence or absence of racial/ethnic disparities (Saha, Freeman, Toure, Tippens, & Weeks, 2007; Quinones et al., 2011).”
  • “In our study, 60% of women veterans received care from DWHPs.”
  • “Compared with non-DWHPs, DWHPs were more likely to be younger, female, less likely to be MDs, and more likely to be NPs.”
  • “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.”
  • “Women are still a minority in the Department of Veterans Affairs (VA), currently accounting for only 6% of VA users (Frayne et al., 2012). However, the number of women veterans using the VA health care system has doubled in the past decade (Frayne et al., 2012).”

Bergmann, AA, Frankel RM, Hamilton AB, Yano EM. Challenges with delivering gender-specific and comprehensive primary care to women veterans. Womens Health Issues. 2015 Jan-Feb; 25 (1): 28-34.

  • Summary: Discusses qualitative interviews with 22 WH-PCPs at a Midwestern VA Medical Center and identifies six themes: “1) Time constraints, 2) importance of staff support, 3) necessity of sufficient space and equipment/supplies, 4) perceptions of discomfort among patients with trauma histories, 5) lack of education/training, and 6) challenges with scheduling/logistics.” Concludes that, because of their multilevel and multifactorial nature, the barriers arising from these themes may require “special policy and practice.”
  • “Because VA health care delivery has historically focused on male veterans’ health care needs, what remains unclear are the barriers and facilitators WH-PCPs encounter in their roles in light of the unique and potentially challenging clinical issues that women veteran patients might present. Furthermore, in the comprehensive care model, WH-PCPs face additional requirements in terms of procedures, staffing, and time (e.g., safety requirement for a chaperone during gender-specific examinations, 1-hour instead of 30-minute visits for women veterans who also need Pap or pelvic examinations to be conducted).”
  • “There were a few WH-PCPs who even avoided or delayed giving or addressing gender-specific care or issues with their women veteran patients owing to these assumptions regarding MST (e.g., patient preferences for provider gender, readiness).”
  • “WH-PCPs seemed to be especially concerned about handling women veterans’ multiple comorbidities under existing time constraints, with most of the participants indicating that 30-minute visits was insufficient, especially if gender-specific care was also needed.”
  • “Enhancements in VA leadership communication and administrative support to WHPCPs and staff may also be necessary to effectively overcome some of these barriers, particularly those related to awareness of longer appointment times, problems with scheduling and/or resources, and support for Pap testing.”
  • “The adequacy of VA space for delivering appropriate care to women veterans (while also sufficiently attending to their privacy needs) has been a problem in the past (S. Government Accounting Office, 1999). Increased attention to this dilemma has led to the development and greater diffusion of WH clinic models (Yano, Goldzweig, Canelo, &Washington, 2006), but little has been reported about changes in space and privacy for women veterans. The continued growth in numbers of women veterans patients seeking care in VA facilities will likely promote decision makers to invest in space and, in particular, to ensure that a sufficient number of rooms are available for WH-PCPsto conduct pelvic examinations and other gender-specific procedures.”

Cordasco KM, Huynh AK, Zephyrin L, Hamilton AB, Lau-Herzberg AE, Kessler CS, Yano EM. Building capacity in VA to provide emergency gynecology services for women. Med Care. 2015 Apr; 53 (4 Supp 1): S81-7.

  • Summary: Discusses an interview study that aimed to understand the facilitators and/or barriers to improving VA emergency departments’ capacity to provide quality gynecology services. The study consisted of semistructured interviews with 14 ED directors/providers, 13 ED nurse managers, and 13 Women Veteran Program Managers in 13 VA facilities. Results pointed to several important factors that affected VA EDs ability to build capacity and improve gynecologic care, including leadership, staff, space, demand, funding, policies, and community.
  • “Leadership, staff, space, demand, funding, policies, and community were noted as important factors influencing VA EDs building capacity and improving emergency gynecologic care for women Veterans. These factors are intertwined and cross multiple organizational levels so that each ED’s capacity is a reflection not only of its own factors, but also those of its local medical center and non-VA community context as well as VA regional and national trends and policies.”
  • “Policies and quality improvement initiatives aimed at building VA’s emergency gynecologic services for women need to be multifactorial and aimed at multiple organizational levels. Policies need to be flexible to account for wide variations across EDs and their medical center and community contexts.”
  • “Over the last decade, the number of women Veterans using Veterans Administration (VA) services has grown exponentially, with nearly 400,000 women using VA services in 2013.1 However, despite this growth, women are still a small proportion (7%) of the VA patient population, and therefore meeting their sex-specific needs is an organizational challenge.”
  • “Women Veterans may have different emergency care needs, and may require different resources and processes of care than male Veterans. For example, approximately 40% of women using VA services are in their childbearing years and may present with gynecologic emergencies”

Cordasco KM, Zuchowski JL, Hamilton AB, Kirsch S, Veet L, Saavedra JO, Altman L, Knapp H, Canning M, Washington DL. Early lessons learned in implementing a women’s health educational and virtual consultation program in VA. Med Care. 2015 Apr; 53 (4 Suppl 1): S88-92.

  • Summary: Reports on a mixed methods research study of a virtual consultation program for VHA primary care providers that focused on women’s health. All interviewees reported that the program was useful in increasing their WH knowledge, and 89% of post-session respondents agreed that the information in the session would influence their patient care. The authors conclude that the consultation program holds promise to improve PCP knowledge of WH and therefore influence patient care.
  • “Women Veterans are a rapidly growing minority among Veterans Health Administration (VA) patients. Although ethically and judicially entitled to receive care equivalent to their male counterparts, achievement of this goal is an organizational challenge.”
  • “VA is committed to the goal of delivering equitable, high-quality, and comprehensive health care to women Veterans.14 Concordantly, VA has invested in numerous initiatives to improve sex-specific and sex-related care provided in primary care settings.”

deKleijn M, Lagro-Janssen A.L.M., Canelo I, and Yano E. Creating a Roadmap for Delivering Gender-sensitive Comprehensive Care for Women Veterans: Results of a National Expert Panel. Med Care. 2015 Apr; 53 (4 Suppl 1): S156-64.

  • Summary: Used expert panel methods with eleven clinicians and social scientists in order to determine what aspects of health care should be tailored to the needs of women Veterans to ensure gender-sensitive care. The panel agreed on 14 recommendations “that broadly encompassed the importance of (1) the design/delivery of services sensitive to trauma histories, (2) adapting to women’s preferences and information needs, and (3) sex awareness and cultural transformation in every facet of VA operations.”
  • “The panel ratings suggest that meeting women Veterans’ needs will require tailoring the orientation, education, and training of the VA workforce to meet clinical care needs (eg, gender incorporated into guideline implementation) and to transform the organization’s culture to be more gender sensitive.”
  • “Improving the gender sensitivity of the VA workforce, given generations caring for men, could prove challenging. Certainly, universal access to same-sex employees is unlikely, as federal hiring practices preclude use of sex as a criterion. The VA has instead focused on proficiency, which is arguably more important as women are not automatically embued with gender sensitivity by virtue of their sex. Establishing women’s health proficiency standards (ie, training, minimum patient volumes) has resulted in placement of designated providers in the vast majority of VA facilities.43”

Dichter ME, Wagner C, Goldberg EB, Iverson KM. Intimate partner violence detection and care in the Veterans Health Administration: Patient and Provider Perspectives. Womens Health Issues. 2015 Jul 27; 25 (5): 555-60.

  • Summary: Describes a study that sought to “identify VHA patients’ and providers’ perspectives on how to facilitate IPV detection and care in VHA.” The research team interviewed 25 female Veteran patients and 15 VHA health care providers, finding barriers to disclosure of IPV to providers, adequate response, and follow-up care.
  • “Extending prior work on barriers and facilitators to IPV screening (Iverson et al., 2013b; Iverson et al., 2014), we focus here on barriers to – and recommendations for – facilitating patient disclosure of IPV and health care provider and system response to disclosures, within the VHA.”
  • Data Analysis: “We used an inductive approach to data analysis, developing a coding scheme and identifying dominant themes through a close reading of the data (Thomas, 2006). Three members of the research team, including the first author, each read over the transcripts and noted common themes related to IPV disclosure and response. The research team together developed a preliminary coding structure based on the identified themes. Two members of the research team then coded each of the transcripts, using NVIVO software, with codes added and refined as appropriate to the data and agreed upon by the research team. The research team then reviewed the coding reports to come to consensus about themes identified in the data. The team selected examples from transcripts that reflected each of the themes described.”
  • “This study provides insights from both patients and providers that can help to inform the implementation of IPV screening and response in VHA and may also be relevant to IPV programs in other health care settings. Findings were both consistent with existing literature on IPV detection and response outside of the VHA setting and also revealed VHA-specific considerations that can inhibit disclosure as well as offer new opportunities for intervention. Results replicate and extend previous work finding that IPV disclosure is rare in the absence of direct inquiry (Gerbert et al., 1999); that lack of time, information, and resources inhibit provider screening (Gerber et al., 2005; Iverson et al., 2013b; Waalen, Goodwin, Spitz, Petersen, & Saltzman, 2000), and that lack of comfort with the provider or not feeling ready to talk about the violence inhibits patient disclosure of IPV (e.g., Iverson et al., 2014). Further extending the literature, results highlight concerns about potential negative consequences of IPV disclosure that were specific to VA system factors and unique to the VA’s integrated health care system. Additionally, VHA patients and providers noted a desire for both in-house resources to address IPV-related needs as well as a more streamlined process for connecting patients with community-based services.”

Kauth MR, Shipherd JC, Lindsay JA, Kirsh S, Knapp H, Matza L. Teleconsultation and training of VHA providers on transgender care: Implementation of a multisite hub system. Telemed J E Health. 2015 Jul 14.

  • Summary: Reports on a new national program piloted by the VHA that seeks to increase clincians’ knowledge of and comfort with treating transgender Veterans. After participating in the 7-month program, evaluation respondents reported that their confidence to treat transgender Veterans had increased significantly.

Lehavot K, Simpson TL. Incorporating lesbian and bisexual women into women veterans’ health priorities. J Gen Intern Med. 2013 Jul; 28 (Suppl 2): S609-14.

  • Summary: Citing a lack of research on lesbian and bisexual women Veterans, this article surveys available data on LB women veterans’ experiences. These include the likelihood of experiencing discrimination and victimization, as well as numerous unique issues in accessing health care, “including fears of insensitive care and difficulty disclosing sexual orientation to Veterans Health Administration (VHA) providers.” Lehavot and Simpson conclude that training, outreach, and research on lesbian and bisexual women Veterans are critical for equitable health care delivery.

Levander, XA, Overland MK. Care of women veterans. Med Clin North Am. 2015 May; 99 (3): 651-62.

  • Summary: Discusses shift in US Veteran population to include more women and the resulting impact on women’s overall health. Argues for a better understanding by providers of the US military culture and the “unique medical, psychiatric, and psychosocial needs of women veterans.”
  • This article seems geared toward civilian providers. It argues for a better understanding by providers of the US military culture and the “unique medical, psychiatric, and psychosocial needs of women veterans.” This may or may not be applicable in the VA setting. Not ALL providers served in the military and may in fact need some additional training regarding the unique service of women Veterans.
  • “In order to open the conversation about the potential impacts of military service on patient health, providers must ask all patients about whether they served in the military, especially as some veterans may not initially volunteer this information.”
  • “With the creation of the Women Veterans Task Force of the Department of Veterans Affairs in 2012, the VA has recognized that women veterans represent a unique patient population with specific medical, psychiatric and psychosocial care needs, and that the VA system will need to change in order to optimally deliver health care to this evolving population.”
  • Regarding care coordination: “All health care providers should recognize the complex needs of women veterans, as this population often receives much of its care outside the VA system. It is estimated that 24% of women veterans use the VA Health Care System, and only 5.1% use the VA exclusively.”

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. Womens Health Issues. 2011 Jul-Aug; 21 (4): 138-44.

  • Summary: Uses qualitative research to explore the structure and development of the VA’s separate/designated mental health services for female Veterans. Interviews with VA mental health administrators and providers demonstrated a wide variety of arrangements for women’s mental health service delivery and suggested the presence of “champions” at most facilities, barriers to viability, and concern about stigmatization surrounding separate services for female Veterans.
  • “Many female veterans have significant mental health conditions (e.g., depression), often at disproportionately higher rates than their male counterparts; experiences such as sexual trauma during military service also disproportionately affect female veterans, necessitating informed treatment options.”
  • “Women from these conflicts [OEF/OIF] are enrolling in VA health care at unprecedented levels compared with previous cohorts.”
  • “Currently, no single recommended model exists for delivery of women’s mental health care in the VA. Preliminary evidence suggests that mental health care arrangements for women in the VA are following similar patterns to women’s primary care service arrangements.”

Maisel NC, Haskell S, Hayes PM, Balasubramanian V, Torgal A, Ananth L, Saechao FF, Iqbal S, Phibbs CS, Frayne SM. Readying the workforce: Evaluation of VHA’s comprehensive women’s health primary care provider initiative. Med Care. 2015 Apr; 53 (4 Supp 1): S39-46.

  • Summary: Reports on an evaluation of early implementation of the VHA’s Designated WH Providers, a national policy established in 2010 that preferentially assigned women patients to providers who are expected to “maintain proficiency in comprehensive WH care.” The evaluation found that 19% of patients seen by a Designated WH Provider were women, compared to 5% for other PCPs, and established women Veterans were more likely to see a Designated WH Provider than new patients.
  • “In particular, VHA policy notes that other means may be used to maintain proficiency if there are not enough women at the site for Designated WH Providers to meet the 10% volume standard. Future evaluations can examine this in greater detail. For example, at community clinics, where Designated WH Providers tend to see fewer women veterans, providers may profit from other opportunities for ongoing proficiency, such as attending the VHA WH Mini-Residency, Continuing Medical Education training, or preceptorship arrangements.”
  • “Although data on how VHA’s proficiency standards and training initiatives translate into quality of care are lacking, recent work suggests that women are more satisfied with Designated WH Providers19 and receive higher rates of screening for breast and cervical cancer from them than from other providers.”20
  • “A substantial proportion of women veterans (48%) saw both Designated WH Providers and Other PCPs. This might put women at risk for fragmentation of care, especially if additionally compounded by receipt of non-VHA care (through VHA’s fee basis system18 or obtained by the woman privately21,22).”

Wagner C, Dichter ME, Mattocks K. Women veterans’ pathways to and perspectives on Veterans Affairs health care. Womens Health Issues 2015; 25 (6) 658-665.

  • Summary: This study used a mixed methods research design to examine women Veteran patients’ experiences with care at a VA medical center. The study found generally high ratings of satisfaction, which varied somewhat by demographics. “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.”
  • Findings 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.
  • “Organizational features of care, including availability of women’s clinics or primary care models tailored to women’s needs, female providers, and gender-specific services (Bean-Mayberry et al., 2003, 2006a, 2006b; Washington, Bean-Mayberry, Mitchell, Riopelle, & Yano, 2011a) are associated with greater satisfaction among women VA users.”
  • “Analysis of the interviews revealed women’s experiences with care to be 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 shapes women’s perceptions of quality.”
  • “Patients valued communication with and between providers and coordination and continuity of care. These values were evident in their descriptions of both positive and negative experiences with VA care.”
  • “In addition to continuity of care across providers and services, women valued continuity of care over time within their relationship with their providers. Women talked about wanting a doctor who knew them and their medical history.”
  • “Women spoke about valuing interpersonal aspects of provider communication, including the manner of the provider as sensitive and taking the time to build a relationship with them and share, as Participant 6 put it, a “personal connection.”
  • Personal Connection:
    • “Patients valued communication with and between providers and coordination and continuity of care. These values were evident in their descriptions of both positive and negative experiences with VA care. Participant 9 described appreciating how her doctors were “all working together.” Likewise, participant 10 liked the team-based approach where all members of her care team communicated with one another and knew her medical history:
    • “Women talked about wanting a doctor who knew them and their medical history. Participant 11 requested a doctor who knew her after having repeatedly to describe her medical history to new residents. Women valued their doctors’ emphasis on preventive care and encouragement of behavioral change to meet their health goals, appreciating that their doctors, as Participant 10 phrased it, “stay on me” about goals like smoking cessation or weight loss.”
    • “Women spoke about valuing interpersonal aspects of provider communication, including the manner of the provider as sensitive and taking the time to build a relationship with them and share, as Participant 6 put it, a “personal connection.”
  • Male Dominated Environment:
    • Women noted feeling “outnumbered by the men” (participant 19) and as though their needs were not prioritized. They described a need for the VA to offer additional gender-sensitive services for women, including women’s support groups and programs. Participants emphasized the importance of recognizing their identities and experiences as veterans and as women, that they should have access to the same level of care as the male veterans and also needed to be respected for their gender-specific concerns. Participant 13 commented: I think they should definitely provide programs for women. They need to remember that we’re veterans as well. Don’t just exclude me from certain things just because I’m a female. This statement reflects participants’ call both for inclusion as part of the larger veteran community and for attention to their unique needs as members of a minority veteran community.”
    • “Within the predominately male VA setting, participants reflected on the value of having a designated women’s health clinic, not only as a source of gender-sensitive services where female providers were available, but also as a separate physical space allocated to women. This was evident in descriptions by women who first encountered the clinic as a welcome contrast to prior negative perceptions of or experiences with VA care. Participant 5, who had recounted initial discomfort with the VA’s predominantly male environment, subsequently learned of and sought care through the women’s health clinic and said of her experience there, “It’s needed, and a shelter.” Participant 12 said of the clinic, “They made sure they hired female doctors, to make it more comfortable, and they’re great.” Several participants noted negative experiences related to lack of gender-sensitive services, including lack of privacy and separate space for women receiving inpatient services, and availability of women-only groups for mental health issues.
  • Knowledge Gaps about VA services:
    • Some participants, all of whom were receiving VA services at the time of the interview, reported initial perceptions that they were ineligible for VA care based on misperceptions or inaccurate information about eligibility requirements, as well as initial negative perceptions of VA care. While this was more salient among older participants, from early military service eras, some younger/more recent (OEF/OIF) era veterans reported delays in initial access to VA care and negative perceptions as a barrier to such access. Participant 14, who served during the post Vietnam era reported: I just thought it [VA care] would be something I would have had to be retired or be active duty to take advantage of. I had no idea. Participant 15, who had likewise served in the post Vietnam era and was married to a veteran, had been told years earlier when she accompanied her husband to a VA Medical Center that she was not a veteran: The young lady that was in there, she said, “Oh no, you ain’t no veteran.” And it was like somebody just crushed me. And I’m telling myself, now I know I was there, I know I was there. But I can’t even describe the hurt that I was feeling. I don’t take rejection too well, and I just thought okay I’m not a veteran. And I held onto that.

Washington DL, Bean-Mayberry B, Mitchell MN, Riopelle D, Yano EM. Tailoring VA primary care of women veterans: Association with patient-related quality and satisfaction. Womens Health Issues 2011; 21 (4S): S112-119.

  • Summary: “Assessed women veterans’ ratings of their VA health care quality, gender-related satisfaction, gender appropriateness, and VA provider skills in treating women, in relation to primary care model at VA sites nationwide.” Found that “Adopter sites received higher adjusted ratings of gender-related satisfaction and perceptions of VA provider skills than non-adopter and small sites. Adopter sites also received higher adjusted ratings of gender appropriateness than small sites. Adjusted ratings of quality of care did not differ by type of site.”
  • VA sites with primary care models tailored to women were rated higher on most dimensions of care. Facilitating establishment of these optimal care models at other sites is one strategy for improving women veterans’ experiences with VA care. Research to identify other features of care associated with quality could inform ongoing VA quality transformation efforts.
  • “VA sites that have put into place primary care delivery arrangements tailored for women with designated providers, teams, or comprehensive women’s health centers, have higher ratings from women veterans on most dimensions of care. As VA reaches out to disenfranchised women veterans, making their health care experience rewarding and satisfying is a vital step toward enhancing the patient-centeredness of their VA care. Facilitating establishment of recommended care models at other sites is one strategy for improving women veterans’ experiences with VA care. Health care settings outside of the VA that aim to increase women’s satisfaction with care should consider similar alterations in their primary care delivery arrangements for women.”

Yano EM, Goldzweig C, Canelo I, Washington DL. Diffusion of innovation in women’s health care delivery: the Department of Veterans Affairs’ adoption of women’s health clinics. Womens Health Issues. 2006 Sep-Oct; 16(5): 226-35.

  • Summary: Reports on 2001 survey of “the senior women’s health clinician at each VA medical center serving > or =400 women veterans (83% response rate) regarding their internal organizational characteristics in relation to factors associated with organizational innovation (centralization, complexity, formalization, interconnectedness, organizational slack, size).” Study found that “WHCs were less likely to have same-gender providers (p < .05), women’s health training programs (p < .01), separate women’s mental health clinics (p < .001), separate space (p < .05), or adequate privacy (p < .05); however, they were less likely to have experienced educational program closures (p < .001) and staffing losses (p < .05) compared to CWHCs.”
  • More research is needed to examine the quality of care associated with these models and to establish the business case for managers faced with small female patient caseloads.
  • “They are among the fastest growing segments of new users of the US Department of Veterans Affairs (VA) health care system, projected to be 10% of the total population of veteran users by 2010 (US Department of Veterans Affairs, 2002). However, in contrast to community health care settings where women are likely to outnumber men, women veterans represent only between 5-7% of the total veteran population using VA health care services.”
  • “In 1982, the US GAO released a report highly critical of VA’s lack of general and gender-specific services and inadequate privacy for women (US GAO, 1982). Another 10 years passed before the GAO reviewed the VA’s progress again, and although some gains were evident, concerns about the availability and privacy of services for women remained.”
  • “Their numerical minority has created logistical challenges in trying to create delivery systems that ensure their equitable access to high-quality, comprehensive health services, especially gender-specific care veterans also have higher physical and mental health burdens than their female nonveteran counterparts, and health burdens comparable to or worse than that of male veterans.”
  • “Women’s health leaders are not particularly well-integrated into local clinical or administrative committees. Women’s health coordinators are more likely to serve as important conduits of information to other providers in WHCs (Women’s Health Clinics) than CWHCs (Comprehensive Women’s Health Centers) (_ .05).”
  • “As women continue to enter the system, VA policymakers may want to foster peer networks, encourage local monitoring of women veterans’ needs, and report gender-specific performance to support further innovation.”
  • “The growth of WHCs in VA generally bodes well for improving the quality of care available to women veterans. Women veterans’ satisfaction with care is higher in women’s clinics than in traditional primary care clinics (Bean-Mayberry et al., 2003). Their use of VA versus non-VA care has also been found to be directly influenced by the scope of clinical services, especially availability of routine gynecologic care within primary care settings which reduces fragmentation of women’s care.”
  • “Despite these advances, barriers to women veterans’ use of VA care remain. Recent research demonstrates significant gaps in women veterans’ knowledge and awareness of VA women’s health care services (Washington et al., 2006) and concerns about the ease of using the VA and the availability of needed services.”
  • “The VA’s adoption of new care models for delivering women’s health care has created a strong foundation for meeting the challenges of a rapidly growing population of eligible users with complex health care needs (Washington et al., 2006).”
  • “The VA’s adoption of women’s health care programs is likely to continue to need a combination of centralized and decentralized diffusion techniques to yield benefits in the long term. Establishing some level of core women’s health expertise appears key, although accomplishing this in smaller sites with less organizational slack will likely require centralized support and oversight. Diffusion theory also suggests that managers could leverage their resources by further supporting the interconnectedness of these clinical programs, fostering collaboration and communication of new ideas to meet the challenges of delivering women’s health care.”

Yano EM, Haskell S, Hayes P. Delivery of gender-sensitive comprehensive primary care to women veterans: implications for VA patient aligned care teams. J Gen Intern Med. 2014 Jul; 29 (Suppl 2): S703-7.

  • Summary: Addresses how PACTs are applied to meet the needs of women Veterans. The article describes how VA primary care delivery has evolved to serve women Veterans, reviews VA policies on gender-sensitive comprehensive primary care for women, and discusses how PACT implementation is challenged by the needs of female Veterans, concluding with recommendations.
  • “While historical differences in military participation meant women veterans were rarely seen in VA healthcare settings, they now represent the fastest growing segment of new VA users. They also have complex healthcare needs, adding gender-specific services and other needs to the spectrum of services that the VA must deliver. These trends are changing the VA landscape, introducing challenges to how VA care is organized, how VA providers need to be trained, and how VA considers implementation of new initiatives, such as PACT.”
  • “Unlike the typically balanced gender mix of practices outside the VA, women veterans represent a numerical minority, at about 7 % of VA users. Their numbers have created proficiency challenges among VA providers and logistical and fiscal challenges to delivering comprehensive PC in gender-sensitive environments that take account of women’s military roles/experiences and complex healthcare needs.3–5 Women VA users have higher mental health burdens than their male counterparts, including high rates of exposure to military sexual trauma, which require trauma sensitive approaches to care and special attention to the safety and security of clinic environments.6–8 Their quality of care has also lagged behind that of men,9 and they typically have to seek multiple visits within and outside the VA to achieve the level of care men achieve through a single on-site visit.10–11”
  • “There is growing awareness of the complexity and constraints of effectively and efficiently delivering PC to women veterans in a healthcare system where they represent a characteristically low volume of patients.”
  • “Careful attention must be paid to the differences in how women access and use PC, the mix of their healthcare needs, and the proficiencies that PC teams must acquire and sustain.”

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. J Gen Intern Med. 2010; 25 (Supp 1): 56-61.

  • Summary: The authors “describe women veterans’ health and health-care use, note how VA care is organized to meet their needs, report gender differences in quality, highlight national plans for women veterans’ quality improvement, and discuss VA women’s health research. [They] then discuss challenges and potential solutions for increasing representation of women veterans in VA research, including steps for implementation research.”
  • “Among women veterans, VA users are more likely than VA nonusers to have low income, no medical insurance, poor health status and social support, and a military service-connected disability.6 Their mental health and chronic disease burdens are comparable to male VA users; top diagnoses include post-traumatic stress disorder (PTSD), hypertension, depression, hyperlipidemia, and chronic low back pain. 8,9”
  • “As women veterans have entered the VA health-care system in increasing numbers, VA managers and providers have struggled with the challenge of organizing and delivering gender-specific and gender-sensitive services in a system historically focused on treating men.”
  • “However, some providers may be unwilling to participate in research because of high caseloads. While clinicians working with men may face similar time pressures, our anecdotal experience suggests that pressures are greater for clinicians who focus their practice on women, perhaps due to more limited clinical backup and administrative support in women’s programs.”

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