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Zerach G. Constellations of posttraumatic stress symptoms and posttraumatic growth among Israeli female combat veterans: A latent profile analysis approach. J Clin Psychol 2024; 80:1377-1390. [PMID: 38401144 DOI: 10.1002/jclp.23671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Revised: 02/08/2024] [Accepted: 02/13/2024] [Indexed: 02/26/2024]
Abstract
OBJECTIVES Posttraumatic stress disorder symptoms (PTSS) and posttraumatic growth (PTG) are possible reactions to exposure to potentially traumatic events (PTEs) during military service. However, knowledge about patterns of both PTSS and PTG among female combat veterans is sparse. This study examines constellations of PTSS and PTG among Israeli female combat veterans, as well as military-related exposure and positive psychological correlates of these constellations. METHODS A volunteer sample of Israeli women combat veterans (n = 885) responded to self-report questionnaires in a cross-sectional design study. RESULTS Latent profile analysis (LPA) was used to identify four profiles characterized by unique constellations of PTSS and PTG: moderate PTSS and high PTG (33%), moderate PTSS and moderate PTG (30%), low PTSS and high PTG (30%), and low PTSS and PTG (5.5%). Higher levels of combat experiences were associated with higher odds of inclusion in the moderate PTSS and high PTG and moderate PTSS and moderate PTG profiles. Moreover, compared to the other classes, both low PTSS and high PTG and moderate PTSS and high PTG classes were associated with higher levels of satisfaction with life and happiness psychological outcomes. CONCLUSION The study's findings offer an overview of the complex pattern of associations between PTSS, PTG, and associated predictors and outcomes. Clinicians treating female veterans should be aware of the varying reactions to military service challenges, including the presence of moderate to high levels of PTG reactions in addition to PTSS.
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Affiliation(s)
- Gadi Zerach
- Department of Psychology, Ariel University, Ariel, Israel
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Hein TC, Austin K, Grau PP, Keith JA, Claes NJ, Bowersox NW. Predictors of non-fatal suicide attempts among Veterans Health Administration (VHA) patients who experienced military sexual trauma. Suicide Life Threat Behav 2024; 54:263-274. [PMID: 38421037 DOI: 10.1111/sltb.13038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 11/10/2023] [Accepted: 12/22/2023] [Indexed: 03/02/2024]
Abstract
OBJECTIVE Military sexual trauma (MST) has been identified as a risk factor for suicidal behavior. To inform suicide prevention efforts within the Veterans Health Administration (VHA), this study evaluates predictors of non-fatal suicide attempts (NFSAs) among VHA patients who experienced MST. METHODS For VHA patients in fiscal year (FY) 2019 who previously screened positive for a history of MST, documented NFSAs were assessed. Using multivariable logistic regression, demographic, clinical, and VHA care utilization predictors of NFSAs were assessed. RESULTS Of the 212,215 VHA patients who screened positive for MST prior to FY 2019 and for whom complete race, service connection, and rurality information was available, 1742 (0.8%) had a documented NFSA in FY 2019. In multivariable logistic regression analyses, total physical and mental health morbidities were not associated with NFSA risk. Predictors of a documented NFSA included specific mental health diagnoses [adjusted odds ratio (aOR) range: 1.28-1.94], receipt of psychotropic medication prescriptions (aOR range: 1.23-2.69) and having a prior year emergency department visit (aOR = 1.32) or inpatient psychiatric admission (aOR = 2.15). CONCLUSIONS Among VHA patients who experienced MST, specific mental health conditions may increase risk of NFSAs, even after adjustment for overall mental health morbidity. Additionally, indicators of severity of mental health difficulties such as receipt of psychotropic medication prescriptions and inpatient psychiatric admissions are also associated with increased risk above and beyond risk associated with diagnoses. Findings highlight targets for suicide prevention initiatives among this vulnerable group within VHA and may help identify patients who would benefit from additional support.
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Affiliation(s)
- Tyler C Hein
- Department of Veterans Affairs, Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC), Office of Mental Health and Suicide Prevention (11MHSP), Ann Arbor, Michigan, USA
- TRAILS, a Project of Tides Center, Ann Arbor, Michigan, USA
| | - Karen Austin
- Department of Veterans Affairs, Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC), Office of Mental Health and Suicide Prevention (11MHSP), Ann Arbor, Michigan, USA
| | - Peter P Grau
- Department of Veterans Affairs, Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC), Office of Mental Health and Suicide Prevention (11MHSP), Ann Arbor, Michigan, USA
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
- VA Center for Clinical Management Research (CCMR), Ann Arbor, Michigan, USA
| | - Jessica A Keith
- Department of Veterans Affairs, Military Sexual Trauma Support Team, Office of Mental Health and Suicide Prevention (11MHSP), Washington, DC, USA
- College of Medicine, University of Central Florida, Orlando, Florida, USA
| | - Nathan J Claes
- Department of Veterans Affairs, Military Sexual Trauma Support Team, Office of Mental Health and Suicide Prevention (11MHSP), Washington, DC, USA
| | - Nicholas W Bowersox
- Department of Veterans Affairs, Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC), Office of Mental Health and Suicide Prevention (11MHSP), Ann Arbor, Michigan, USA
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
- VA Center for Clinical Management Research (CCMR), Ann Arbor, Michigan, USA
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3
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Gianoli MO, Meisler AW, Gordon R. Examining bias in the award of Veterans Affairs (VA) disability benefits for posttraumatic stress disorder in women veterans: Analysis of evaluation reports and VA decisions. J Trauma Stress 2024. [PMID: 38462544 DOI: 10.1002/jts.23034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 02/15/2024] [Accepted: 02/15/2024] [Indexed: 03/12/2024]
Abstract
Studies have raised concerns about possible inequities in the U.S. Department of Veterans Affairs (VA)'s awards of disability for posttraumatic stress disorder (PTSD) to women. However, the diagnoses and opinions made by disability examiners have not been studied. A sample of 270 initial PTSD examination reports and corresponding VA decisions were studied. Compared to men, women veterans were as likely to be diagnosed with a service-related mental disorder, χ2 (1, N = 270) = 2.31, p = .129, odds ratio (OR) = 1.79, 95% CI [0.84, 3.80], and be granted service-connection, χ2 (1, N = 270) = 0.49, p = .483, OR = 1.28, 95% CI [0.65, 2.51]. Women veterans were considered to have more psychiatric symptoms, Z = -2.05, p = .041, r = .16, and more psychiatric impairment, Z = -2.48, p = .013, r = .20, but the percentage of disability awarded by the VA did not differ, χ2 (1, N = 270) = 0.49, p = .483; OR = 1.28, 95% CI [0.65, 2.51]. Secondary analyses implicate the role of military sexual trauma and premilitary trauma in explaining sex differences in symptoms and impairment. The findings indicate that neither opinions by examiners nor corresponding decisions by the VA regarding service connection reflect a negative bias toward women veterans. Results indicate that unbiased examinations lead to equitable VA claims decisions for women veterans. Future studies of the VA PTSD disability program nationally, including examination procedures and VA policies and implementation, will promote equity for women veterans in the PTSD claims process.
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Affiliation(s)
- Mayumi O Gianoli
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA
- Department of Psychiatry, University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Andrew W Meisler
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA
- Department of Psychiatry, University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Rebecca Gordon
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
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Kalvesmaki AF, Trevino AY, Charron E, Kroll-Desrosiers A, Peterson K, Pugh MJ. The Impact of Resilience on Employment Among Post-9/11 Veterans With and Without Military Sexual Trauma Exposure. Mil Med 2024; 189:e493-e501. [PMID: 37464907 DOI: 10.1093/milmed/usad267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 05/10/2023] [Accepted: 07/05/2023] [Indexed: 07/20/2023] Open
Abstract
INTRODUCTION Successful employment is a functional outcome of high importance for veterans after military discharge. There is a significant rising concern regarding exposure to military sexual trauma (MST) and related mental health outcomes that can impair functional outcomes, such as employment. Although resilience training is a key component of preparing for military service, to date the impact of resilience on employment outcomes for veterans with exposure to MST has yet to be examined. We sought to examine the relationship between resilience and employment in a national sample of post-9/11 veterans with and without MST exposure. MATERIALS AND METHODS A national survey was conducted between October 2021 and January 2022 to respond to the 2021 National Defense Authorization Act mandate to identify factors affecting post-9/11 women veteran's unemployment. Of veterans, 1,185 completed the survey. Of these, 565 (47.6%) were post-9/11 veterans. The survey collected data on demographics and employment; MST, adult sexual trauma (AST, outside of military), and childhood sexual trauma (CST) exposure; resilience (Response to Stressful Experiences Scale); Post Traumatic Stress Disorder (PTSD) Checklist (PCL-5); and depression (Patient Health Questionnaire-2). Multivariable logistic regression models identified gender-specific associations of resilience with employment among those exposed and not exposed to MST, adjusting for AST, CST, PTSD, and depression. Significance was set at P < .05. RESULTS Of 322 women and 243 men post-9/11 veterans, 86.5% were employed. MST exposure (MST[+]) was reported by 31.4% (n = 101) of women and 16.9% (n = 41) of men. MST(+) women veterans were more likely to report CST (35.6% vs. 14.5%; P < .001), AST (68.3% vs. 17.2%; P < .001), and both CST and AST (19.8% vs. 7.2%; P < .001) than MST(-) women. MST(+) men were more likely to report AST (65.9% vs. 7.9%; P < .001), and both CST and AST (14.6% vs. 1.0%; P < .001) than MST(-) men. Levels of self-reported resilience were similar for MST(+) women and men and their MST(-) counterparts (women: 11.1 vs. 11.0; men: 11.5 vs. 12.0). For MST(+) women, each unit increase in resilience was associated with a 36% increase in odds of employment (OR: 1.36, 95% CI, 1.08-1.71); resilience was not associated with increased odds of employment among MST(-) women. Among MST(+) men veterans, each unit increase in resilience was associated with an 83% increase in odds of employment (aOR: 1.83, 95% CI, 1.13-2.98), and like women veterans, resilience was not associated with employment among MST(-) men. CONCLUSIONS Among MST(+) women and men post-9/11 veterans, higher resilience was associated with increased odds of employment, whereas resilience was not associated with employment in MST(-) veterans. These findings suggest that resiliency during and after military service is a key component for potentially improving long-term outcomes. Improving resilience using evidence-based approaches among post-9/11 veterans exposed to MST may be an important avenue for increasing successful functional outcomes such as employment. Moreover, MST(+) women and men veterans may benefit from trauma-informed care as a substantial proportion of these individuals also report exposure to CST, AST, PTSD, and depression.
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Affiliation(s)
- Andrea F Kalvesmaki
- Informatics Decision-Enhancement, and Analytic Sciences (IDEAS) Center of Innovation, VA Salt Lake City Health Care System, Salt Lake City, UT 84148, USA
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT 84132, USA
| | - Amira Y Trevino
- Department of Educational Psychology, University of Utah College of Education, Salt Lake City, UT 84112, USA
| | - Elizabeth Charron
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT 84132, USA
- Hudson College of Public Health, University of Oklahoma Health Sciences Center, Schusterman Center, Tulsa, OK 74135, USA
| | - Aimee Kroll-Desrosiers
- VA Central Western Massachusetts Healthcare System, 421 North Main Street, Leeds, MA 01053, USA
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA 01605, USA
| | - Kelly Peterson
- Informatics Decision-Enhancement, and Analytic Sciences (IDEAS) Center of Innovation, VA Salt Lake City Health Care System, Salt Lake City, UT 84148, USA
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT 84132, USA
| | - Mary Jo Pugh
- Informatics Decision-Enhancement, and Analytic Sciences (IDEAS) Center of Innovation, VA Salt Lake City Health Care System, Salt Lake City, UT 84148, USA
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT 84132, USA
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Braun TD, Bhuptani PH, O’Keefe B, Abrantes AM, Marsh E, Holzhauer CG. Mindful self-compassion for veteran women with a history of military sexual trauma: feasibility, acceptability, potential benefits, and considerations. Eur J Psychotraumatol 2024; 15:2301205. [PMID: 38349003 PMCID: PMC10866049 DOI: 10.1080/20008066.2023.2301205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 12/08/2023] [Indexed: 02/15/2024] Open
Abstract
Background: Military sexual trauma (MST) is reported by up to 74% of women veterans in the United States and is a driver of poor behavioural and physical health. Self-compassion is a transdiagnostic, protective factor linked with improved posttraumatic stress disorder (PTSD), depression, and health behaviours. Thus, Mindful Self-Compassion training (MSC) may help ameliorate MST-related impacts. However, MSC can also temporarily increase distress (i.e. backdraft). Delivering it with elective trauma-informed yoga (TIY), which regulates acute distress, may help address this issue.Objective: This VA quality improvement project examined feasibility, acceptability, and reported benefits and challenges of a manualized 8-week MSC including within non-randomized subgroups: MSC (n = 4) and MSC+ elective TIY classes (MSC+; n = 4).Methods: Nine women veterans with a history of MST at a Vet Center in the Northeastern U.S.A. enrolled; eight completed, excluding one MSC+ participant. Measures included attrition (n = 9), attendance (n = 8), weekly (n = 8) and posttreatment acceptability (n = 6), validated symptom severity assessments (n = 7), and an exit interview (n = 8).Results: Among completers, MSC attendance was excellent (89%) and higher among in MSC+ vs. MSC (94% vs. 84% sessions completed). On average across the two groups, depressive and PTSD symptom severity decreased by 21% and 30%, respectively. In exit interviews, participants across groups described improved coping with distress and psychiatric symptoms, reduced stress, and improved self-care and health behaviours. Although women in both groups reported backdraft during the programme, MSC+ also reported healthier coping and improved emotional processing.Conclusion: The results of this programme evaluation infer MSC may be feasible, acceptable, and beneficial for women survivors of MST in one Vet Center in the Northeastern USA. Further, temporary elevations in MSC-related distress may be ameliorated with adjunctive TIY. Given requests of women veterans in the USA. for additional complementary and integrative health treatment options, formal research on these approaches is warranted.
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Affiliation(s)
- Tosca D. Braun
- Alpert Medical School of Brown University, Providence, RI, USA
- Butler Hospital, Providence, RI, USA
- VA Central Western Massachusetts, Leeds, MA, USA
| | - Prachi H. Bhuptani
- Alpert Medical School of Brown University, Providence, RI, USA
- Rhode Island Hospital, Providence, RI, USA
| | | | - Ana M. Abrantes
- Alpert Medical School of Brown University, Providence, RI, USA
- Butler Hospital, Providence, RI, USA
| | | | - Cathryn Glanton Holzhauer
- VA Central Western Massachusetts, Leeds, MA, USA
- University of Connecticut School of Medicine, Farmington, CT, USA
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Hargrave AS, Danan ER, Than CT, Gibson CJ, Yano EM. Factors Associated with Military Sexual Trauma (MST) Disclosure During VA Screening Among Women Veterans. J Gen Intern Med 2023; 38:3188-3197. [PMID: 37291361 PMCID: PMC10651589 DOI: 10.1007/s11606-023-08257-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 05/24/2023] [Indexed: 06/10/2023]
Abstract
BACKGROUND Capturing military sexual trauma (MST) exposure is critical for Veterans' health equity. For many, it improves access to VA services and allows for appropriate care. OBJECTIVE Identify factors associated with nondisclosure of MST in VA screening among women. DESIGN Cross-sectional telephone survey linked with VA electronic health record (EHR) data. PARTICIPANTS Women Veterans using primary care or women's health services at 12 VA facilities in nine states. MAIN MEASURES Survey self-reported MST (sexual assault and/or harassment during military service), socio-demographics and experiences with VA care, as well as EHR MST results. Responses were categorized as "no MST" (no survey or EHR MST), "MST captured by EHR and survey," and "MST not captured by EHR" (survey MST but no EHR MST). We used stepped multivariable logistic regression to examine "MST not captured by EHR" as a function of socio-demographics, patient experiences, and screening method (survey vs. EHR). KEY RESULTS Among 1287 women (mean age 50, SD 15), 35% were positive for MST by EHR and 61% were positive by survey. Approximately 38% had "no MST," 34% "MST captured by EHR and survey," and 26% "MST not captured by EHR". In fully adjusted models, odds of "MST not captured by EHR" were higher among Black and Latina women compared to white women (Black: OR = 1.6, 1.2-2.2; Latina: OR = 1.9, 1.0-3.6). Women who endorsed only sexual harassment in the survey (vs. sexual harassment and sexual assault) had fivefold higher odds of "MST not captured by EHR" (OR = 4.9, 3.2-7.3). Women who were screened for MST in the EHR more than once had lower odds of not being captured (OR = 0.3, 0.2-0.4). CONCLUSIONS VA screening for MST may disproportionately under capture patients from historically minoritized ethnic/racial groups, creating inequitable access to resources. Efforts to mitigate screening disparities could include re-screening and reinforcing that MST includes sexual harassment.
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Affiliation(s)
- Anita S Hargrave
- Department of Internal Medicine, University of California San Francisco (UCSF), San Francisco, CA, USA.
- San Francisco VA Health Care System, San Francisco, CA, USA.
| | - Elisheva R Danan
- Division of General Internal Medicine, Minneapolis VA Medical Center: Minneapolis VA Health Care System, Minneapolis, MN, USA
- Department of Internal Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Claire T Than
- Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Carolyn J Gibson
- San Francisco VA Health Care System, San Francisco, CA, USA
- Department of Psychiatry & Behavioral Sciences, San Francisco, CA, USA
| | - Elizabeth M Yano
- Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Department of Health Policy & Management, UCLA Fielding School of Public Health, Los Angeles, CA, USA
- Department of Medicine, UCLA Geffen School of Medicine, Los Angeles, CA, USA
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Webermann AR, Merians AN, Gross GM, Portnoy GA, Rosen MI, Pietrzak RH. Military Sexual Trauma and its Association with Mental Health Among Sexual Minority and Heterosexual Veterans in the United States. LGBT Health 2023; 10:S61-S69. [PMID: 37754922 DOI: 10.1089/lgbt.2023.0074] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/28/2023] Open
Abstract
Purpose: The purpose of this study was to examine the prevalence of military sexual trauma (MST) by sexual orientation, characteristics of sexual minority (SM) and heterosexual veterans who have experienced MST, and associations between sexual orientation and mental health symptoms among veterans who have experienced MST. Methods: Data were analyzed from a nationally representative web-based survey of 4069 U.S. veterans (4.9% SM), which assessed sociodemographic (e.g., age, sexual orientation) and military (e.g., branch) characteristics, and lifetime and current mental health symptoms. Bivariate analyses compared sociodemographic and military characteristics and mental health symptoms among veterans who have experienced MST by sexual orientation. Multivariable logistic regressions examined associations between sexual orientation and mental health symptoms among veterans who have experienced MST, while controlling for differences in sociodemographic characteristics and non-MST traumatic events. Results: The prevalence of MST (7.5% of weighted sample) was higher among SM veterans compared to heterosexual veterans, with bisexual/pansexual/queer veterans endorsing the highest prevalence (22.7%), followed by gay/lesbian (17.0%) and heterosexual (6.5%) veterans. SM veterans who experienced MST were more likely than heterosexual veterans to screen positive for lifetime and current posttraumatic stress disorder (odds ratio [OR] = 3.06 and 3.38, respectively), and current drug use disorder (OR = 3.53). Conclusions: This study adds to growing evidence that mental health symptoms associated with MST disproportionately impact SM veterans relative to heterosexual veterans. Approaches to reducing barriers and tailoring MST-related care to SM veterans, including through addressing cumulative effects of minority stress, are discussed.
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Affiliation(s)
- Aliya R Webermann
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA
| | - Addie N Merians
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA
| | - Georgina M Gross
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA
- Northeast Program Evaluation Center, VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Galina A Portnoy
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA
| | - Marc I Rosen
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA
| | - Robert H Pietrzak
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA
- National Center for PTSD, West Haven, Connecticut, USA
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Rohs CM, Albright KR, Monteith LL, Lane AD, Fehling KB. Perspectives of VA healthcare from rural women veterans not enrolled in or using VA healthcare. PLoS One 2023; 18:e0289885. [PMID: 37578986 PMCID: PMC10424869 DOI: 10.1371/journal.pone.0289885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 07/28/2023] [Indexed: 08/16/2023] Open
Abstract
PURPOSE Women Veterans have unique healthcare needs and often experience comorbid health conditions. Despite this, many women Veterans are not enrolled in the Veterans Health Administration (VHA) and do not use VHA services. Underutilization of VHA services may be particularly prevalent among rural women Veterans, who may experience unique barriers to using VHA care. Nonetheless, knowledge of rural women Veterans and their experiences remains limited. We sought to understand rural women Veterans' perceptions and needs related to VHA healthcare, including barriers to enrolling in and using VHA services, and perspectives on how to communicate with rural women Veterans about VHA services. METHODS Rural women Veterans were recruited through community engagement with established partners and a mass mailing to rural women Veterans not enrolled in or using VHA healthcare. Ten virtual focus groups were conducted with a total of twenty-nine rural women Veterans (27 not enrolled in VHA care and 2 who had not used VHA care in the past 5 years) in 2021. A thematic inductive analytic approach was used to analyze focus group transcripts. FINDINGS Primary themes regarding rural women Veterans' perceptions of barriers to enrollment and use of VHA healthcare included: (1) poor communication about eligibility and the process of enrollment; (2) belief that VHA does not offer sufficient women's healthcare services; and (3) inconvenience of accessing VHA facilities. CONCLUSION Although VHA has substantially expanded healthcare services for women Veterans, awareness of such services and the nuances of eligibility and enrollment remains an impediment to enrolling in and using VHA healthcare among rural women Veterans. Recommended strategies include targeted communication with rural women Veterans not enrolled in VHA care to increase their awareness of the enrollment process, eligibility, and expansion of women's healthcare services. Creative strategies to address access and transportation barriers in rural locations are also needed.
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Affiliation(s)
- Carly M. Rohs
- Seattle-Denver Center for Innovation (COIN), Rocky Mountain Regional VA Medical Center, Aurora, Colorado, United States of America
- VA Rocky Mountain Mental Illness, Research, Education and Clinical Center (MIRECC) for Suicide Prevention, Aurora, Colorado, United States of America
| | - Karen R. Albright
- Seattle-Denver Center for Innovation (COIN), Rocky Mountain Regional VA Medical Center, Aurora, Colorado, United States of America
- Division of General Internal Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States of America
| | - Lindsey L. Monteith
- VA Rocky Mountain Mental Illness, Research, Education and Clinical Center (MIRECC) for Suicide Prevention, Aurora, Colorado, United States of America
- Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States of America
| | - Amber D. Lane
- Seattle-Denver Center for Innovation (COIN), Rocky Mountain Regional VA Medical Center, Aurora, Colorado, United States of America
| | - Kelty B. Fehling
- Seattle-Denver Center for Innovation (COIN), Rocky Mountain Regional VA Medical Center, Aurora, Colorado, United States of America
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Webermann AR, Relyea MR, Portnoy GA, Martino S, Brandt CA, Haskell SG. The Role of Unit and Interpersonal Support in Military Sexual Trauma and Posttraumatic Stress Disorder Symptoms. JOURNAL OF INTERPERSONAL VIOLENCE 2023; 38:9514-9535. [PMID: 37005795 DOI: 10.1177/08862605231165764] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/19/2023]
Abstract
Military sexual trauma (MST) is strongly associated with posttraumatic stress disorder (PTSD). Among many potential factors explaining this association are unit and interpersonal support, which have been explored in few studies with veterans who have experienced MST. This project examines unit and interpersonal support as moderators and/or mediators of PTSD symptoms among post-9/11 Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn veterans who experienced MST. MST, unit support, and interpersonal support variables were collected at Time 1 (T1; N = 1,150, 51.4% women), and PTSD symptoms 1 year later at Time 2 (T2; N = 825; 52.3% women). Given gender differences in endorsed MST, models with the full sample (men and women) and women only were examined, while controlling for covariates related to PTSD, and a path model was examined among women veterans. Mediation was supported in the full model and women-only models, with the combination of both mediators demonstrating the strongest mediation effects (full-model: β = .06, 95% confidence interval [CI] [0.03, 0.10], p < .001; women-only model: β = .07, [0.03, 0.14], p = .002). Among the women-only model, MST was negatively associated with unit support (β = -.23, [-0.33, -0.13], p < .001) and interpersonal support (β = -.16, [-0.27, -0.06], p = .002) and both support types were negatively associated with PTSD symptoms (unit support: β = -.13, [-0.24, -0.03], p = .014; interpersonal support: β = -.25, [-0.35, -0.15], p < .001). Moderation was not supported in the full model nor in the women-only model. Experiencing MST is associated with receiving less unit and/or interpersonal support, which in turn is associated with greater PTSD symptoms. More work is needed to understand and improve the impact of unit and community responses to MST on service members who experience MST.
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Affiliation(s)
- Aliya R Webermann
- VA Connecticut Healthcare System, West Haven, USA
- Yale University School of Medicine, New Haven, CT, USA
| | - Mark R Relyea
- VA Connecticut Healthcare System, West Haven, USA
- Yale University School of Medicine, New Haven, CT, USA
| | - Galina A Portnoy
- VA Connecticut Healthcare System, West Haven, USA
- Yale University School of Medicine, New Haven, CT, USA
| | - Steve Martino
- VA Connecticut Healthcare System, West Haven, USA
- Yale University School of Medicine, New Haven, CT, USA
| | - Cynthia A Brandt
- VA Connecticut Healthcare System, West Haven, USA
- Yale University School of Medicine, New Haven, CT, USA
| | - Sally G Haskell
- VA Connecticut Healthcare System, West Haven, USA
- Yale University School of Medicine, New Haven, CT, USA
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Esopenko C, de Souza N, Wilde EA, Dams-O'Connor K, Teng E, Menefee DS. Characterizing the Influence of Exposure to Military Sexual Trauma and Intimate Partner Violence on Mental Health Outcomes among Female Veterans. JOURNAL OF INTERPERSONAL VIOLENCE 2023; 38:8476-8499. [PMID: 36866584 DOI: 10.1177/08862605231156193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Military sexual trauma (MST) has deleterious long-term psychological consequences. Among female U.S. military members, MST is associated with increased risk for future interpersonal victimization, such as experiencing intimate partner violence (IPV). Few studies have investigated the implications of the cumulative effects of IPV and MST on psychological functioning. This study examined rates of co-exposure to MST, IPV, and their cumulative impact on psychological symptoms. Data were collected from 308 female Veterans (FVets; age: M = 42, SD = 10.4) enrolled in an inpatient trauma-focused treatment program in a Veterans Administration (VA) hospital. Data were collected at program admission on symptoms of posttraumatic stress disorder (PTSD), depression, and current suicidal ideation. Lifetime trauma exposure was assessed using semi-structured interviews that identified adverse childhood events (ACEs) and combat theater deployment as well as MST and IPV. Group differences on psychological symptoms were examined among those exposed to MST, IPV, MST + IPV, and compared to FVets with ACEs or combat exposure, but no other adulthood interpersonal trauma (NAIT). Half of the sample (51%) reported experiencing both MST and IPV, approximately 29% reported MST, 10% reported IPV, and 10% reported NAIT. FVets in the MST + IPV group had worse PTSD and depression symptoms than either the MST or IPV groups. The NAIT group had the lowest scores on these measures. There were no group differences in current suicidal ideation; however, 53.5% reported at least one previous suicide attempt. FVets in this sample reported significant lifetime exposure to MST and IPV, with the majority having experienced MST + IPV. Exposure to MST + IPV was associated with greater PTSD and depression symptom severity, yet an overwhelming proportion reported current and past suicidal ideation regardless of trauma exposure history. These results demonstrate the importance of assessing for lifetime interpersonal trauma history when developing and providing mental and medical health interventions for FVets.
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Affiliation(s)
| | | | - Elisabeth A Wilde
- George E. Wahlen Veterans Affairs Medical Center, Salt Lake City, UT, USA
- University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Kristen Dams-O'Connor
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ellen Teng
- Michael E. DeBakey VA Medical Center, Houston, TX, USA
- Baylor College of Medicine, Houston, TX, USA
- Veterans Integrated System Network (VISN) 16 Mental Illness Research and Clinical Care Center (MIRECC), Houston, TX, USA
| | - Deleene S Menefee
- Michael E. DeBakey VA Medical Center, Houston, TX, USA
- Baylor College of Medicine, Houston, TX, USA
- Veterans Integrated System Network (VISN) 16 Mental Illness Research and Clinical Care Center (MIRECC), Houston, TX, USA
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11
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Webermann AR, Nester MS, Gianoli MO, Black AC, Rosen MI, Mattocks KM, Portnoy GA. Compensation and Pension Exams for Military Sexual Trauma-Related Posttraumatic Stress Disorder: Examiner Perspectives, Clinical Impacts on Veterans, and Strategies. Womens Health Issues 2023; 33:428-434. [PMID: 37003918 DOI: 10.1016/j.whi.2023.02.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 02/06/2023] [Accepted: 02/24/2023] [Indexed: 04/01/2023]
Abstract
BACKGROUND It is estimated that in one in three women veterans experience military sexual trauma (MST), which is strongly associated with posttraumatic stress disorder (PTSD). A 2018 report indicated the Veterans Benefits Administration (VBA) processed approximately 12,000 disability claims annually for PTSD related to MST, most of which are filed by women. Part of the VBA adjudication process involves reviewing information from a Compensation and Pension (C&P) exam, a forensic diagnostic evaluation that helps determine the relationship among military service, diagnoses, and current psychosocial functioning. The quality and outcome of these exams may affect veteran well-being and use of Veterans Health Administration (VHA) mental health care, but no work has looked at examiner perspectives of MST C&P exams and their potential clinical impacts on veteran claimants. METHODS Thirteen clinicians ("examiners") who conduct MST C&P exams through VHA were interviewed. Data were analyzed using rapid qualitative methods. RESULTS Examiners described MST exams as more clinically and diagnostically complex than non-MST PTSD exams. Examiners noted that assessing "markers" of MST (indication that MST occurred) could make veterans feel disbelieved; others raised concerns related to malingered PTSD symptoms. Examiners identified unique challenges for veterans who underreport MST (e.g., men and lesbian, gay, bisexual, transgender, and queer [LGBTQ+] veterans), and saw evaluations as a conduit to psychotherapy referrals and utilization of VHA mental health care. Last, examiners used strategies to convey respect and minimize retraumatization, including a standardized process and validating the difficulty of the process. CONCLUSIONS Examiners' responses offer insight into a process entered by thousands of veterans annually with PTSD. Strengthening the MST C&P process is a unique opportunity to enhance trust in the VBA claims process and increase likelihood of using VHA mental health care, especially for women veterans.
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Affiliation(s)
- Aliya R Webermann
- VA Connecticut Healthcare System, West Haven, Connecticut; Yale School of Medicine, New Haven, Connecticut.
| | - M Shae Nester
- University of North Carolina at Greensboro, Greensboro, North Carolina
| | - Mayumi O Gianoli
- VA Connecticut Healthcare System, West Haven, Connecticut; Yale School of Medicine, New Haven, Connecticut; University of Connecticut School of Medicine, Farmington, Connecticut
| | - Anne C Black
- VA Connecticut Healthcare System, West Haven, Connecticut; Yale School of Medicine, New Haven, Connecticut
| | - Marc I Rosen
- VA Connecticut Healthcare System, West Haven, Connecticut; Yale School of Medicine, New Haven, Connecticut
| | - Kristin M Mattocks
- VA Central Western Massachusetts Healthcare System, Leeds, Massachusetts; University of Massachusetts Chan Medical School, Worcester, Massachusetts
| | - Galina A Portnoy
- VA Connecticut Healthcare System, West Haven, Connecticut; Yale School of Medicine, New Haven, Connecticut
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12
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Monteith LL, Kittel JA, Schneider AL, Miller CN, Holliday R, Katon JG, Brenner LA, Hoffmire CA. Military Sexual Trauma Among Women Veterans Using Veterans Health Administration Reproductive Health Care: Screening Challenges and Associations with Post-Military Suicidal Ideation and Suicide Attempts. JOURNAL OF INTERPERSONAL VIOLENCE 2023; 38:7578-7601. [PMID: 36695157 PMCID: PMC10175204 DOI: 10.1177/08862605221145725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Abstract
Military sexual trauma (MST) is highly prevalent among women veterans. Research among MST survivors has focused on individuals receiving care in specific settings, such as mental health services. There is a dearth of knowledge regarding MST prevalence and associations in other settings commonly accessed by women veterans, including reproductive healthcare settings. We examined MST prevalence (overall, by MST type and extent of underreporting) and associations with suicidal ideation and suicide attempts, among women veterans accessing Veterans Health Administration (VHA) reproductive health care. Our sample included 352 post-9/11 women veterans who used VHA reproductive health care in Fiscal Year (FY) 2018 and participated in a cross-sectional survey. Approximately 68.7% screened positive for MST, including 44.9% who reported experiencing military sexual assault. Notably, 30.8% reported MST on the survey, but had a negative MST screen for their most recent MST screen in their VHA medical record. Both military sexual harassment and assault were associated with increased prevalence of experiencing suicidal ideation following military service; however, a significant association among military sexual harassment, past-month suicidal ideation, and post-military suicide attempts was not detected. Military sexual assault was uniquely associated with past-month suicidal ideation and post-military suicide attempts. As MST and underreporting are highly prevalent among women veterans using VHA reproductive health care, rescreening for MST within this population is essential. A trauma-informed approach is recommended irrespective of prior MST screening results and may facilitate suicide prevention in this population. Addressing barriers to MST disclosure and preventing MST and its sequelae remain critical.
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Affiliation(s)
- Lindsey L. Monteith
- VA Rocky Mountain Mental Illness Research, Education and Clinical Center (MIRECC) for Suicide Prevention, Aurora, CO, USA
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Julie A. Kittel
- VA Rocky Mountain Mental Illness Research, Education and Clinical Center (MIRECC) for Suicide Prevention, Aurora, CO, USA
| | - Alexandra L. Schneider
- VA Rocky Mountain Mental Illness Research, Education and Clinical Center (MIRECC) for Suicide Prevention, Aurora, CO, USA
| | - Christin N. Miller
- VA Rocky Mountain Mental Illness Research, Education and Clinical Center (MIRECC) for Suicide Prevention, Aurora, CO, USA
| | - Ryan Holliday
- VA Rocky Mountain Mental Illness Research, Education and Clinical Center (MIRECC) for Suicide Prevention, Aurora, CO, USA
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | | | - Lisa A. Brenner
- VA Rocky Mountain Mental Illness Research, Education and Clinical Center (MIRECC) for Suicide Prevention, Aurora, CO, USA
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Claire A. Hoffmire
- VA Rocky Mountain Mental Illness Research, Education and Clinical Center (MIRECC) for Suicide Prevention, Aurora, CO, USA
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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13
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Women Veterans' Descriptions of Interactions With Civilian Health Care Providers: A Qualitative Inquiry. ANS Adv Nurs Sci 2023:00012272-990000000-00061. [PMID: 36928280 DOI: 10.1097/ans.0000000000000492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
Women veterans often obtain care for unique gender- and military-related health issues from civilian health care settings. There is a gap in the literature surrounding woman veterans' perspectives about the care they receive. The purpose of this study was to apply the Interaction Model of Client Health Behavior framework to study the patient-provider interaction described by women veterans. A qualitative descriptive methodology, using directed content analysis, was employed. Six themes were identified. Consistent screening, provider knowledge about service roles and experiences of women veterans, and familiarity with military-related health conditions support holistic care. Further research in this area is warranted.
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Diez-Canseco F, Toyama M, Hidalgo-Padilla L, Bird VJ. Systematic Review of Policies and Interventions to Prevent Sexual Harassment in the Workplace in Order to Prevent Depression. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:13278. [PMID: 36293858 PMCID: PMC9603480 DOI: 10.3390/ijerph192013278] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 09/23/2022] [Accepted: 09/26/2022] [Indexed: 06/10/2023]
Abstract
BACKGROUND Sexual harassment in the workplace (SHWP) is highly prevalent and has a negative impact, including depression, on its victims, as well as a negative economic impact resulting from absenteeism and low productivity at work. This paper aims to outline the available evidence regarding the prevention of depressive symptoms among workers through policies and interventions that are effective in preventing SHWP. METHODS We conducted two systematic reviews. The first focused on the association of depression and SHWP, and the second on policies and interventions to prevent SHWP. We conducted a meta-analysis and a narrative synthesis, respectively. We identified 1831 and 6107 articles for the first and second review. After screening, 24 and 16 articles were included, respectively. RESULTS Meta-analysis results show a prevalence of depression of 26%, as well as a 2.69 increased risk of depression among workers who experience SHWP. Variables such as number of harassment experiences and exposure to harassment from coworkers and other people increase this risk. CONCLUSIONS There is limited evidence regarding the effectiveness of policies and training to prevent SHWP, mostly focused on improvements in workers' knowledge and attitudes about SHWP. However, there is no available evidence regarding its potential impact on preventing depression.
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Affiliation(s)
- Francisco Diez-Canseco
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima 15074, Peru
| | - Mauricio Toyama
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima 15074, Peru
| | - Liliana Hidalgo-Padilla
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima 15074, Peru
| | - Victoria J. Bird
- Unit for Social and Community Psychiatry, Wolfson Institute of Population Health, Queen Mary University of London, London E13 8SP, UK
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15
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Sheahan KL, Goldstein KM, Than CT, Bean-Mayberry B, Chanfreau CC, Gerber MR, Rose DE, Brunner J, Canelo IA, Darling Mshs JE, Haskell S, Hamilton AB, Yano EM. Women Veterans' Healthcare Needs, Utilization, and Preferences in Veterans Affairs Primary Care Settings. J Gen Intern Med 2022; 37:791-798. [PMID: 36042076 PMCID: PMC9481772 DOI: 10.1007/s11606-022-07585-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 04/01/2022] [Indexed: 10/25/2022]
Abstract
BACKGROUND The Veterans Health Administration (VA) is the largest integrated health system in the US and provides access to comprehensive primary care. Women Veterans are the fastest growing segment of new VA users, yet little is known about the characteristics of those who routinely access VA primary care in general or by age group. OBJECTIVE Describe healthcare needs, utilization, and preferences of women Veterans who routinely use VA primary care. PARTICIPANTS 1,391 women Veterans with 3+ primary care visits within the previous year in 12 VA medical centers (including General Primary Care Clinics, General Primary Care Clinics with designated space for women, and Comprehensive Women's Health Centers) in nine states. METHODS Cross-sectional survey (45% response rate) of sociodemographic characteristics, health status (including chronic disease, mental health, pain, and trauma exposure), utilization, care preferences, and satisfaction. Select utilization data were extracted from administrative data. Analyses were weighted to the population of routine users and adjusted for non-response in total and by age group. KEY RESULTS While 43% had health coverage only through VA, 62% received all primary care in VA. In the prior year, 56% used VA mental healthcare and 78% used VA specialty care. Common physical health issues included hypertension (42%), elevated cholesterol (39%), pain (35%), and diabetes (16%). Many screened positive for PTSD (41%), anxiety (32%), and depression (27%). Chronic physical and mental health burdens varied by age. Two-thirds (62%) had experienced military sexual trauma. Respondents reported satisfaction with VA women's healthcare and preference for female providers. CONCLUSIONS Women Veterans who routinely utilize VA primary care have significant multimorbid physical and mental health conditions and trauma histories. Meeting women Veterans' needs across the lifespan will require continued investment in woman-centered primary care, including integrated mental healthcare and emphasis on trauma-informed, age-specific care, guided by women's provider preferences.
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Affiliation(s)
- Kate L Sheahan
- JSI, Inc., 2733 Crystal Dr 4th floor, Arlington, VA, 22202, USA.
| | - Karen M Goldstein
- JSI, Inc., 2733 Crystal Dr 4th floor, Arlington, VA, 22202, USA
- Division of General Internal Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Claire T Than
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Bevanne Bean-Mayberry
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Department of Medicine, University of California, Los Angeles (UCLA) Geffen School of Medicine, Los Angeles, CA, USA
| | - Catherine C Chanfreau
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Veterans Affairs Informatics and Computing Infrastructure (VINCI), Salt Lake City, UT, USA
| | - Megan R Gerber
- Albany Stratton VA Medical Center, Albany, NY, USA
- Division of General Internal Medicine, Albany Medical College, Albany, NY, USA
| | - Danielle E Rose
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Julian Brunner
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Ismelda A Canelo
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Jill E Darling Mshs
- Center for Economic and Social Research (CESR), University of Southern California, Los Angeles, CA, USA
| | - Sally Haskell
- Pain Research, Informatics, Multi-morbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT, USA
- Division of General Internal Medicine, Department of Medicine, Yale University School of Medicine, West Haven, CT, USA
- Office of Women's Health, Veterans Health Administration, Washington, DC, USA
| | - Alison B Hamilton
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Department of Psychiatry and Biobehavioral Sciences, UCLA Geffen School of Medicine, Los Angeles, CA, USA
| | - Elizabeth M Yano
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Department of Medicine, University of California, Los Angeles (UCLA) Geffen School of Medicine, Los Angeles, CA, USA
- Department of Health Policy & Management, UCLA Fielding School of Public Health, Los Angeles, CA, USA
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