The health and health care of women veterans

Abstract

The increasing presence of women in the U.S. armed forces, from 2% 30 years ago to 20% of current military recruits, is reshaping the veteran population and, accordingly, the Department of Veterans Affairs' (VA's) research agenda. Compared with male veterans, women have unique needs with respect to gender-specific care, the VA environment, and privacy. Historically, the growing presence of women veterans in VA health care facilities highlighted gaps in women's VA access and quality of care.1, 2 For example, a 1982 General Accounting Office (GAO) study of VA women's health care found widespread deficiencies in the availability and quality of that care.1 A follow-up 1992 GAO study found that despite progress, inadequate attention to gender-specific health problems persisted, and barriers to addressing privacy deficiencies remained.2 A 1993 Congressional hearing, while providing evidence of strong support within VA leadership and Congress to correct these problems, emphasized the long-standing neglect of the health care needs of women veterans, and identified continuing problems.3 Subsequent Congressional legislative action authorized the VA to provide women's health care services and to appoint in 1997 a full-time director for the Women Veterans Health Program.4 Since that time, the configuration and VA availability of health care services for women has expanded considerably.5, 6 Concurrent with these changes, the VA system as a whole has undergone significant transformation to improve quality of care.7, 8 To better enable the VA to meet the specific health care needs of the growing number of women veterans, VA Health Services Research and Development Service (HSR&D) has established the health of women veterans as a research priority.9 Because the VA is a health care delivery system with an internally funded and oriented research program, it has the unique ability to translate cutting edge research into evidence-based improvements in health care practices and system organization that yield improved patient outcomes. The evidence base needed to inform planning for a nationwide system that delivers accessible, high-quality, patient-centered care to the growing number of women veterans includes key information about the system of care, the experiences and unique needs of women veterans who use the system, and the characteristics of the care itself. The articles presented in this issue of Journal of General Internal Medicine (JGIM) offer perspectives on women's military roles and prior women veterans' health research, new insights into the current health and health care of women veterans, and innovative prescriptions for future research directions. This issue begins with a focused historical overview of women in the U.S. military and the impact of military service on women's physical and mental health (Murdoch). Knowledge of women's veteran status and military trauma or exposure history, can assist clinicians, both within and outside the VA, in the diagnosis and management of complex presentations. Two articles in this issue examine the influences on, and barriers to, VA health care use by women veterans. Vogt's study, conducted in 1997, found that limitations in service availability and logistics of receiving care were barriers to VA use for women veterans who were current and former VA health care users. Much in the VA health care system has changed since that time. Washington and colleagues found that in 2004, availability of women's health clinics at VA facilities was strongly associated with VA health care use. However, inconvenience of VA care remained a deterrent to its use. Washington's study, which was a population-based study that included eligible VA-nonusers, also found that for many women veterans, lack of knowledge of VA eligibility and negative perceptions of VA quality of care, were significant barriers to VA use. Wright's study also examines attitudes about VA health care, by assessing gender differences in patient satisfaction with VA inpatient and outpatient care. He found no gender differences on either overall quality perceptions or for most dimensions of outpatient satisfaction; however, women veterans had lower satisfaction scores on 6 of 9 dimensions of inpatient satisfaction. These findings suggest areas for continued focus in improving VA health care quality. VA availability of contraceptive services is the subject of the article by Cope. She found that VA's provision of hormonal and intrauterine contraception is in accordance with community standards. However, compared with larger VA sites, onsite availability of intrauterine device placement was less widely available at VA community-based outpatient clinics. As the VA continues to explore the ideal service delivery arrangements to assure availability of comprehensive care for women, these data underscore the need for ongoing research in this area. Other articles in this issue examine health issues and health care use of women veteran VA health care users. Few gender differences were found for the medical and surgical care examined in 2 of the reports (Tseng, Borrero). Both reports utilized VA administrative data, demonstrating the utility of such databases in assembling cohorts of relatively small populations such as women veterans for study. However, information on potentially relevant covariates, such as disease severity in the surgical study, is often absent from these databases, which may limit somewhat the interpretation of the findings. Three articles examine comorbidity and use of medical and surgical services among women with posttraumatic stress disorder (PTSD), military sexual trauma, and other psychiatric conditions or trauma (Dobie, Yaeger, Johnson). Collectively, they demonstrate greater symptoms and greater use of medical and surgical services among women veterans with PTSD. They suggest that as more women serve in the military, the impact of PTSD on women's physical health presents an important consideration in ongoing planning for VA health care services. Future studies should focus on treatment approaches for PTSD, and their impact on health care utilization. Two articles examine health risk behavior and health status among women veteran VA health care users. Johnson found that obesity is a major health problem in this population, and suggests that reduction in the time spent watching television and avoidance of eating while watching television may represent achievable first steps toward lifestyle change. Frayne's work found that women VA users have worse health status than women in the general population, and that there are strong age cohort effects. These findings have implications for the intensity of VA health care services required to care for women veterans. The women veterans' health research literature review conducted by Goldzweig, together with the original research presented in this JGIM special issue, comprises a comprehensive compendium of the current state of knowledge related to women veterans' health and health care. A detailed listing of the studies she reviewed is available in the form of evidence tables on the JGIM and VA HSR&D websites as a resource to those involved in health care delivery or research of women veterans. This review also identifies gaps in the research literature that informed the VA women's health research agenda-setting process described by Yano. Yano summarizes the VA's current research portfolio related to women's health, identifies infrastructure needs for fostering the conduct of VA women's health research, and describes the national VA women's health research agenda for the future. We present this special issue on VA women's health and health care research in the hopes that it serves as a springboard for future clinical innovations and scientific inquiry. The support of this special issue by VA HSR&D service demonstrates their ongoing commitment to fostering research in this rapidly emerging area, and we were pleased to be able to participate in the oversight of peer review for this assemblage of high-quality articles. A special thank you goes to the many reviewers who willingly gave of their time to make this special issue possible.