VA Women Research Articles

Oral Emergency Contraception Provision in the Veterans Health Administration: a Retrospective Cohort Study

ABSTRACTBackgroundIn the USA, oral emergency contraception (EC) use to prevent unintended pregnancy is increasing. Oral EC methods include levonorgestrel (LNG) and ulipristal acetate (UPA), with increased UPA efficacy over LNG in high BMI users and those beyond 3 days post intercourse. The Veterans Health Administration (VHA) provides oral EC at low or no cost, yet prescription-level Veteran data are lacking.ObjectiveTo describe oral EC provision in VHA, including method type and Veteran user and prescriber characteristics.DesignA retrospective cohort study using VHA administrative data.ParticipantsAll VHA oral EC prescriptions from January 1, 2016, to December 31, 2020.Main MeasuresWe linked Veteran-level sociodemographic and military characteristics and provider-level data with each prescription to identify variables associated with oral EC method.Key ResultsA total of 4280 EC prescriptions (85% LNG) occurred for 3120 unique Veterans over 5 years. While prescriptions remained low annually, the proportion of UPA prescriptions increased from 12 to 19%. Compared to LNG users, UPA users were older (34% vs 25% over age 35 years, p <0.001); more likely to identify as white (57% vs 46%) and non-Hispanic (84% vs 79%) (p <0.001); and more likely to have a BMI ≥ 25 (76% vs 67%, p <0.001). UPA prescriptions originated most frequently from VA Medical Centers (87%) and women’s health clinics (76%) compared to community-based or other clinic types. In multivariable regression models, race, ethnicity, BMI ≥30, and prescriber facility type of a VA Medical Center or a women’s clinic location were predictive of UPA prescription.ConclusionsOral EC provision in VHA remains low, but UPA use is increasing. LNG prescription occurs frequently in high BMI Veterans who would benefit from increased efficacy of UPA. Interventions to expand oral EC access in VHA are essential to ensure Veterans’ ability to avert unwanted pregnancies.

Effects of Cesarean Section and Vaginal Delivery on Abdominal Muscles and Fasciae.

Background and objectives: Possible disorders after delivery may interfere with the quality of life. The aim of this study was to ascertain whether abdominal muscles and fasciae differ in women depending on whether they experienced transverse cesarean section (CS) or vaginal delivery (VA) in comparison with healthy nulliparous (NU). Materials and methods: The thicknesses of abdominal muscles and fasciae were evaluated by ultrasound in 13 CS, 10 VA, and 13 NU women (we examined rectus abdominis (RA); external oblique (EO); internal oblique (IO); transversus abdominis (TrA); total abdominal muscles (TAM = EO + IO + TrA); inter-rectus distance (IRD); thickness of linea alba (TLA); rectus sheath (RS), which includes anterior fascia of RS and posterior fascia of RS (P-RS); loose connective tissue between sublayers of P-RS (LCT); abdominal perimuscular fasciae (APF), which includes anterior fascia of EO, fasciae between EO, IO, and TrA, and posterior fascia of TrA). Data on pain intensity, duration, and location were collected. Results: Compared with NU women, CS women had wider IRD (p = 0.004), thinner left RA (p = 0.020), thicker right RS (p = 0.035) and APF (left: p = 0.001; right: p = 0.001), and IO dissymmetry (p = 0.009). VA women had thinner RA (left: p = 0.008, right: p = 0.043) and left TAM (p = 0.024), mainly due to left IO (p = 0.027) and RA dissymmetry (p = 0.035). However, CS women had thicker LCT (left: p = 0.036, right: p < 0.001), APF (left: p = 0.014; right: p = 0.007), and right IO (p = 0.028) than VA women. There were significant correlations between pain duration and the affected fasciae/muscles in CS women. Conclusions: CS women showed significant alterations in both abdominal fasciae and muscle thicknesses, whereas VA women showed alterations mainly in muscles. Thinner RA and/or dissymmetric IO, wider IRD, and thicker LCT and APF after CS may cause muscle deficits and alteration of fascial gliding, which may induce scar, abdominal, low back, and/or pelvic pain.

Personalized Support for Progress (PSP) in a VA Women's Wellness Clinic

Personalized Support for Progress (PSP) in a VA Women's Wellness Clinic

Periodic reflections: a method of guided discussions for documenting implementation phenomena

BackgroundEthnography has been proposed as a valuable method for understanding how implementation occurs within dynamic healthcare contexts, yet this method can be time-intensive and challenging to operationalize in pragmatic implementation. The current study describes an ethnographically-informed method of guided discussions developed for use by a multi-project national implementation program.MethodsThe EMPOWER QUERI is conducting three projects to implement innovative care models in VA women’s health for high-priority health concerns – prediabetes, cardiovascular risk, and mental health – utilizing the Replicating Effective Programs (REP) implementation strategy enhanced with stakeholder engagement and complexity science. Drawing on tenets of ethnographic research, we developed a lightly-structured method of guided “periodic reflections” to aid in documenting implementation phenomena over time. Reflections are completed as 30–60 min telephone discussions with implementation team members at monthly or bi-monthly intervals, led by a member of the implementation core. Discussion notes are coded to reflect key domains of interest and emergent themes, and can be analyzed singly or in triangulation with other qualitative and quantitative assessments to inform evaluation and implementation activities.ResultsThirty structured reflections were completed across the three projects during a 15-month period spanning pre-implementation, implementation, and sustainment activities. Reflections provide detailed, near-real-time information on projects’ dynamic implementation context, including characteristics of implementation settings and changes in the local or national environment, adaptations to the intervention and implementation plan, and implementation team sensemaking and learning. Reflections also provide an opportunity for implementation teams to engage in recurring reflection and problem-solving.ConclusionsTo implement new, complex interventions into dynamic organizations, we must better understand the implementation process as it unfolds in real time. Ethnography is well suited to this task, but few approaches exist to aid in integrating ethnographic insights into implementation research. Periodic reflections show potential as a straightforward and low-burden method for documenting events across the life cycle of an implementation effort.They offer an effective means for capturing information on context, unfolding process and sensemaking, unexpected events, and diverse viewpoints, illustrating their value for use as part of an ethnographically-minded implementation approach.Trial registrationThe two implementation research studies described in this article have been registered as required: Facilitating Cardiovascular Risk Screening and Risk Reduction in Women Veterans (NCT02991534); and Implementation of Tailored Collaborative Care for Women Veterans (NCT02950961).

Practice-based research networks add value to evidence-based quality improvement

BackgroundEvidence-Based Quality Improvement (EBQI) is a systematic, multilevel approach to implementing research evidence into clinical settings. Little is known about EBQI effectiveness in the context of Practice-Based Research Networks (PBRNs), which are themselves designed to foster practice-based change. We evaluated EBQI implementation in a PBRN setting to determine the extent to which the PBRN infrastructure added value. MethodsWe conducted a four-site cluster randomized trial of an EBQI approach to tailoring an evidence-based gender awareness curriculum in the VA Women’s Health PBRN (WH-PBRN). After curriculum implementation, site teams identified impacts of the WH-PBRN context on EBQI processes using qualitative methods, including a formal review of project call minutes, post-project debriefing calls, and structured site team input. WH-PBRN site feedback was mapped to the Replicating Effective Programs implementation phases: pre-condition, pre-implementation, implementation, and maintenance/evolution. ResultsThe pre-condition phase benefited from the existing WH-PBRN research-clinician relationships to facilitate stakeholder engagement and build project buy-in at local sites. During pre-implementation, differences across WH-PBRN sites offered variations in local tailoring of EBQI elements. The WH-PBRN Coordinating Center helped resolve process complexities stemming from local resource differences and the sharing of mid-project adaptations during implementation. Local efforts were amplified in the maintenance phase by WH-PBRN dissemination of findings. ConclusionsThe PBRN strengthened multi-site EBQI activities across all implementation phases. ImplicationsPBRNs contribute to the uptake of evidence into everyday practice, and may serve as an important component of the future implementation of evidence-based initiatives. Level of evidence: V.

Engaging multilevel stakeholders in an implementation trial of evidence-based quality improvement in VA women's health primary care.

The Veterans Health Administration (VHA) has undertaken primary care transformation based on patient-centered medical home (PCMH) tenets. VHA PCMH models are designed for the predominantly male Veteran population, and require tailoring to meet women Veterans' needs. We used evidence-based quality improvement (EBQI), a stakeholder-driven implementation strategy, in a cluster randomized controlled trial across 12 sites (eight EBQI, four control) that are members of a Practice-Based Research Network. EBQI involves engaging multilevel, inter-professional leaders and staff as stakeholders in reviewing evidence and setting QI priorities. The goal of this analysis was to examine processes of engaging stakeholders in early implementation of EBQI to tailor VHA's medical home for women. Four inter-professional regional stakeholder planning meetings were conducted; these meetings engaged stakeholders by providing regional data about gender disparities in Veterans' care experiences. Subsequent to each meeting, qualitative interviews were conducted with 87 key stakeholders (leaders and staff). Stakeholders were asked to describe QI efforts and the use of data to change aspects of care, including women's health care. Interview transcripts were summarized and coded using a hybrid deductive/inductive analytic approach. The presentation of regional-level data about gender disparities resulted in heightened awareness and stakeholder buy-in and decision-making related to women's health-focused QI. Interviews revealed that stakeholders were familiar with QI, with regional and facility leaders aware of inter-disciplinary committees and efforts to foster organizational change, including PCMH transformation. These efforts did not typically focus on women's health, though some informal efforts had been undertaken. Barriers to engaging in QI included lack of communication across clinical service lines, fluidity in staffing, and lack of protected time. Inter-professional, multilevel stakeholders need to be engaged in implementation early, with data and discussion that convey the importance and relevance of a new initiative. Stakeholder perspectives on institutional norms (e.g., gender norms) and readiness for population-specific QI are useful drivers of clinical initiatives designed to transform care for clinical subpopulations.

Associations between provider designation and female-specific cancer screening in women Veterans.

In 2010, the Department of Veterans Affairs Healthcare System (VA) implemented policy to provide Comprehensive Primary Care (for acute, chronic, and female-specific care) from designated Women's Health providers (DWHPs) at all VA sites. However, since that time no comparisons of quality measures have been available to assess the level of care for women Veterans assigned to these providers. To evaluate the associations between cervical and breast cancer screening rates among age-appropriate women Veterans and designation of primary-care provider (DWHP vs. non-DWHP). Cross-sectional analyses using the fiscal year 2012 data on VA women's health providers, administrative files, and patient-specific quality measures. The sample included 37,128 women Veterans aged 21 through 69 years. Variables included patient demographic and clinical factors (ie, age, race, ethnicity, mental health diagnoses, obesity, and site), and provider factors (ie, DWHP status, sex, and panel size). Screening measures were defined by age-appropriate subgroups using VA national guidelines. Female-specific cancer screening rates were higher among patients assigned to DWHPs (cervical cytology 94.4% vs. 91.9%, P<0.0001; mammography 86.3% vs. 83.3%, P<0.0001). In multivariable models with adjustment for patient and provider characteristics, patients assigned to DWHPs had higher odds of cervical cancer screening (odds ratio, 1.26; 95% confidence interval, 1.07-1.47; P<0.0001) and breast cancer screening (odds ratio, 1.24; 95% CI, 1.10-1.39; P<0.0001). As the proportion of women Veterans increases, assignment to DWHPs may raise rate of female-specific cancer screening within VA. Separate evaluation of sex neutral measures is needed to determine whether other measures accrue benefits for patients with DWHPs.

Leading the Nation in Women’s Health: The Important Role of Research

Article history: Received 20 April 2011; Accepted 20 April 2011 Over the past two decades, the Veterans Health Administration (VHA) has supported numerous initiatives to remedy gaps in services available to women veterans. Finding deficits in the VHA’ sw omen’s health care delivery in the early 1990s, reports from the U.S. Government Accounting Office spurred the initial move to upgrade the care provided to women veterans. Unfortunately, much of the country continued to marginalize women’s services in VHA, providing only a “pap” clinic and part-time (and often “collateral duty”) Women Veteran Coordinators to meet all of the needs of women veterans. Nonetheless, there were pockets of true excellence, facilities that engaged in a process of intensive development of comprehensive women’ sh ealth centers (BeanMayberry et al., 2007; Yano, Goldzeig, 2006). In 2008, my office, which oversees delivery of VA health care to women veterans nationally, launched an initiative to take this early work to the next level, transforming VA’s women’s health delivery system into an ational leader in women’s health. Our goal is to provide “the best care anywhere” for women veterans (Longman, 2005). A solid foundation of research is essential to this vision. The U.S. Department of Veterans Affairs has already produced an impressive body of work that has helped to guide changes in strategies for the provision of care for women veterans (BeanMayberry, et al., 2010; Goldzweig, Balekian, Rolon, Tano, & Shekelle, 2006). However, still more research is needed; this current Special Issue of Women’s Health Issues takes another important step forward in filling remaining gaps, while also identifying new areas of research needing attention. As more and more women are entering and serving in military roles, many of which of which expose them to combat, we are challenged to understand and treat the effects of military service on women’s lives. Examining all of the possible effects of military service includes, of course, not only careful assessment of negative effects and vulnerabilities, but also of positive outcomes based on hard-won opportunities to serve their country, strengths, and resilience, and other factors that may have had less attention overall. Nationally, our population of women veterans is rapidly expanding, from the group of pioneering womenwho comprised only 3.5% of the military during World War II, to 4% during the Vietnam Era, and to approximately 11% in 1991, during Gulf War I. Today, women comprise 15% of active duty military and 17% of the National Guard and Reserve forces (Women’s Research and Education Institute, 2008). Thus, we need to plan for the many women “in the pipeline” who will be seeking health care from the VA in the next few years and beyond. The characteristics of the women veteran population and subpopulations (e.g., by period of service or era, among racial-ethnic minorities, education, marital status) are changing as well, requiring ongoing research to support our strategic planning and readiness in the face of their long-term preventive, reproductive, chronic

Systematic Review of Women Veterans’ Health: Update on Successes and Gaps

Objective We assessed the state of women veterans’ health research by conducting a systematic review of scientific literature published from 2004 to 2008, updating a prior review spanning the history of this literature to 2004. Methods We identified articles by searching scientific databases and contacting experts. Relevant articles were independently evaluated by two physician reviewers. We categorized 195 articles by study design, funding source, period of military service, research topic, and health condition. Results More research was published during this 5-year review ( n = 195) than in the 25 years beforehand ( n = 182). The 195 studies included five trials, but only one randomized trial, a study that examined treatment outcomes for women with posttraumatic stress disorder (PTSD). The large number of articles focused on Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) soldiers’ health issues ( n = 23) reflects the growing participation of women in these conflicts. High rates of positive PTSD symptoms (range, 10%–19%) and other mental health disorders were found among OEF/OIF returning military women. The recent post-deployment literature underscores the need for repeated PTSD/mental health screening in returning veterans, and points to continuity of care needs for psychiatric and gynecological problems which occur in the field. The psychiatric and access/utilization literature confirmed the positive relationship between military sexual trauma and PTSD and the associated negative health effects. Conclusion Although most VA women’s health research remains observational, methods are evolving toward an analytical focus. Even though successes are evident in the breadth and depth of publications, remaining gaps in the literature include post-deployment readjustment for veterans/families, and quality-of-care interventions/outcomes for physical and mental conditions.

Using Research to Transform Care for Women Veterans: Advancing the Research Agenda and Enhancing Research–Clinical Partnerships

The purpose of this paper is to report on the outcomes of the 2010 VA Women's Health Services Research Conference, which brought together investigators interested in pursuing research on women veterans and women in the military with leaders in women's health care delivery and policy within and outside the VA, to significantly advance the state and future direction of VA women's health research and its potential impacts on practice and policy. Building on priorities assembled in the previous VA research agenda (2004) and the research conducted in the intervening six years, we used an array of approaches to foster research-clinical partnerships that integrated the state-of-the-science with the informational and strategic needs of senior policy and practice leaders. With demonstrated leadership commitment and support, broad field-based participation, strong interagency collaboration and a push to accelerate the move from observational to interventional and implementation research, the Conference provided a vital venue for establishing the foundation for a new research agenda. In this paper, we provide the historical evolution of the emergence of women veterans' health services research and an overview of the research in the intervening years since the first VA women's health research agenda. We then present the resulting VA Women's Health Research Agenda priorities and supporting activities designed to transform care for women veterans in six broad areas of study, including access to care and rural health; primary care and prevention; mental health; post deployment health; complex chronic conditions, aging and long-term care; and reproductive health.

Health and Health Care of Women Veterans and Women in the Military: Research Informing Evidence-Based Practice and Policy

VA Greater Los Angeles HSR&D Center of Excellence for the Study of Healthcare Provider Behavior, Sepulveda, California VA Women’s Health Research Network, Los Angeles, California and Palo Alto, California Department of Health Services, UCLA School of Public Health, Los Angeles, California Center for Health Care Evaluation, VA Palo Alto Health Care System, Palo Alto, California Division of General Medical Disciplines, Stanford University, Stanford, California

The Prevalence and Age-Related Characteristics of Pain in a Sample of Women Veterans Receiving Primary Care

Women veterans are a growing but understudied population believed to be at increased risk for pain problems. Because of risk factors and clinical observations, we hypothesized that women veterans might have a high prevalence of pain and, thus, sought to determine the prevalence of (and age-related variations in) pain and to characterize several key pain dimensions in a sample of women veterans. Women with routine appointments at the VA Connecticut Women's Health Center were recruited for study. Participants completed a 59-item questionnaire that provided information about their demographic, clinical, and pain status, as well as use of health services. Of 236 women approached, 213 (89%) completed the questionnaire. The mean age was 52 years, and most (78%) reported an ongoing pain problem. For those reporting pain, the mean duration of pain was 6 years, average pain intensity was 6.3 (range 1-10), and commonly endorsed pain sites included lower extremity (68%), low back (63%), and shoulder (48%). The most frequently endorsed treatment (by 80%) was analgesic medication use. Across the four age categories (20-35, 36-50, 51-65, and > or =66 years), pain prevalences were 64%, 89%, 83%, and 69%, respectively. Although pain intensity levels did not vary across age groups, older women (> or =66) reported using fewer pain treatments, including analgesic medications. Finally, those with (vs. those without) pain reported a greater number of medical and mental health visits in the preceding year. This study documented a significantly high prevalence of pain among a sample of women veterans receiving primary care in a VA women's health clinic.

The health and health care of women veterans

The health and health care of women veterans

Improving health care for women veterans

Improving health care for women veterans

The state of women veterans' health research. Results of a systematic literature review.

Assess the state of women veterans' health research. Systematic review of studies that pertained specifically to or included explicit information about women veterans. A narrative synthesis of studies in 4 domains/topics was conducted: Stress of military life; Health and performance of military/VA women; Health services research/quality of care; and Psychiatric conditions. We identified 182 studies. Of these, 2 were randomized-controlled trials (RCTs) and the remainder used observational designs. Forty-five percent of studies were VA funded. We identified 77 studies pertaining to the stress of military life, of which 21 reported on sexual harassment or assault. Rates of harassment ranged from 55% to 79% and rates of sexual assault from 4.2% to 7.3% in active duty military women and 11% to 48% among women veterans. Forty-two studies concerned the health and performance of military/VA women, with 21 studies evaluating sexual assault and posttraumatic stress disorder (PTSD) and their effect on health. Fifty-nine studies assessed various aspects of health services research. Eight studies assessed quality of care and 5, patient satisfaction. Twenty-five studies assessed utilization and health care organization, and findings include that women veterans use the VA less than men, that gender-specific reasons for seeking care were common among female military and veteran personnel, that provision of gender-specific care increased women veterans' use of VA, and that virtually all VAs have available on-site basic women's health services. Fifty studies were classified as psychiatric; 31 of these were about the risk, prevalence, and treatment of PTSD. Most research on VA women's health is descriptive in nature and has concerned PTSD, sexual harassment and assault, the utilization and organization of care, and various psychiatric conditions. Experimental studies and studies of the quality of care are rare.

Toward a VA women’s health research agenda: Setting evidence-based priorities to improve the health and health care of women veterans

The expansion of women in the military is reshaping the veteran population, with women now constituting the fastest growing segment of eligible VA health care users. In recognition of the changing demographics and special health care needs of women, the VA Office of Research & Development recently sponsored the first national VA Women's Health Research Agenda-setting conference to map research priorities to the needs of women veterans and position VA as a national leader in Women's Health Research. This paper summarizes the process and outcomes of this effort, outlining VA's research priorities for biomedical, clinical, rehabilitation, and health services research.

The best of JGIM

The best of JGIM

Comparing the Health Status of Male and Female Veterans Who Use VA Health Care: Results from the VA Women's Health Project

ABSTRACT Background: In recent years the number of women serving in the military has increased substantially, resulting in more demand for VA services by women veterans. This paper describes the characteristics and health status of women veterans who use VA ambulatory services. Methods: Respondents in the VA Women's Health Project (n = 719) represent a randomly selected subsample from all women who had an ambulatory visit between July 1, 1994 and June 30, 1995 at a large tertiary care VA facility in the Boston area. Summary statistics on eight dimensions of health status (using the SF-36) for women veterans who use VA ambulatory care are provided. Comparisons are made between women veterans and men veterans who use VA services. Results: Women veterans reported consistently low scores on health status across multiple dimensions, reflecting considerable health needs. Among veterans using VA services, women were younger, better educated, and less likely to be married than male veterans. Women veterans who use VA ambulatory services scored lower on every scale except physical functioning and general health perceptions when compared to male VA users.There were more pronounced differences for women on scales measuring emotional health. Conclusions: Health status among women veterans is moderate to poor. Important differences in health status are observed between men and women who use VA services which have implications for improving health care to women veterans at VA facilities. These findings strongly indicate that increased mental health services need to be available for women veterans seeking VA health care.