Abstract
Introduction and Background

Budget request for FY2011 and FY2012, Statement of The Honorable Eric K. Shinseki, House Committee on Veterans Affairs.
Topic | Funded Research Studies |
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Needs assessments (health care needs, barriers to access, continuity, chronic care needs) | Updated systematic review of research on military women and women veterans Chronic physical and mental illness care in women veterans Assessment of the health care needs and barriers to VA use by women veterans Determinants of women veterans’ ambulatory care use and unmet need The quality of locoregional breast cancer treatment for breast cancer in VA |
Evaluations of Models of care | Impact of practice structure on the quality of care for women veterans Changes in women’s health care delivery Re-engineering systems for the primary care treatment of PTSD Implementation and sustainability of VA women’s mental health clinics |
Mental health care needs | Gender differences in mental health treatment needs and service use Barriers and facilitators to PTSD treatment seeking Examining the diagnostic and clinical utility of the PTSD checklist Relationship and PTSD study: Detection of intimate partner violence PTSD focused cognitive behavioral therapy for partner violence: A pilot study Evaluation of military sexual trauma screening and treatment Military sexual trauma effect on PTSD and health behavior: A longitudinal study of Marines Evaluating the VA’s assessment of military sexual trauma in veterans Sexual violence and women veterans’ gynecological health Alcohol misuse and risk of postsurgical complications and mortality |
Returning veterans’ and deployed women’s needs | Stigma, gender and other barriers to VA use among OEF/OIF veterans Soldier to civilian: Randomized trial of an intervention to promote post-deployment reintegration Community reintegration problems and treatment preference among OEF/OIF veterans Online interventions for female OEF/OIF Reserve/National Guard women veterans Women Veterans Cohort Study (OEF/OIF) Predicting post-deployment mental health substance abuse and service needs Gender and medical needs of OEF/OIF veterans with PTSD and comorbid substance abuse Understanding pain of gastrointestinal origin in women that serve in OEF/OIF Physical and sexual assault in deployed women: risks, outcomes and services Urogenital symptoms, depression and PTSD in OEF/OIF women veterans Combat, sexual assault, and posttraumatic stress in OEF/OIF military women Further development and validation of the DRRI Validation of modified DRRI scales in a national sample of OEF/OIF veterans |
Reproductive health | Paternal environmental exposures and reproductive outcomes: A comparison Pilot study of the reintegration and service needs of women veteran mothers |
Infrastructure development | VA Women’s Health Research Consortium VA Women Veterans’ Practice Based Research Network |
U.S. Department of Veterans Affairs. VA R&D Women’s Health. (2011, March 31). Available: http://www.research.va.gov. Accessed April 4, 2011.
Methods
Conference Design
Theory-Based Domain | Conference Design Element |
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Leadership commitment/support | Introductory remarks by senior officials in patient care, women’s health and research Virtually every VA Office represented ∗ VA Office of the Under Secretary for Health, Office of Patient Care Services, Office of Quality & Performance, Office of Mental Health Services, Office of Academic Affiliations, Office of Public Health & Environmental Hazards, Office of Rural Health, Office of Research & Development, in addition to key program offices and centers such as the Center for Women Veterans, the Homeless Program, the National Center for PTSD, among others. |
Broad field-based participation | Nearly 100 MD and PhD researchers, representing 45 VA facilities and spanning 27 states Represented approximately two thirds of the >150 investigators expressing interest in conducting VA women’s health research |
Knowledge production | Invited plenary presentations on state of the state: Women’s Health Evaluation Initiative Systematic Literature Review Update National Survey of Women Veterans State of VA Women’s Mental Health Research Thematically organized scientific presentations based on competitive abstracts Research spanned high-priority topics in mental health, post-deployment/reintegration, access, prevention, screening, treatment, gender differences, methods |
Integration of VA strategic planning and operational needs | Introductory remarks on VA transformational initiatives Leadership panel response to current state of knowledge Workshop on patient-centered medical homes for women veterans † The VA has initiated implementation of patient-centered medical homes nationwide as one of many transformation initiatives outlined by the Secretary of the U.S. Department of Veterans Affairs. The VA also recently completed a new VHA Handbook on Health Care Services for Women Veterans (VHA Handbook 1330.01, May 21, 2010), which encompasses comparable restructuring and redesign efforts. VA leaders/managers participation in agenda-setting breakout sessions alongside researchers |
Focus attention on interagency collaboration | Invited representatives from policy, practice, and research within and outside VA Workshop on opportunities for VA–DoD research collaboration Attendance from high-level policy/research organizations (e.g., Institute of Medicine; U.S. Departments of Veterans Affairs, Defense, Health & Human Services [NIH, NIMH, AHRQ], and Labor; National Committee for Quality Assurance; Society for Women’s Health Research; Congressional staff) ‡ Attendees included high-level representatives from the Institute of Medicine Board on Select Populations (which encompasses military and veterans), the U.S. Department of Health & Human Services (e.g., NIH Office of Research on Women’s Health, NIMH Board on Women’s Health Research, AHRQ), the U.S. Department of Defense (e.g., Congressionally Directed Medical Research Program, Tripler Army Medical Center), the U.S. Department of Labor (DOL), the National Committee for Quality Assurance, the Society for Women’s Health Research (SWHR), the RAND Center for Military Research, Veteran Service Organization (VSO) representatives, and Congressional staffers. |
Accelerate move from observational to interventional and implementation research | Workshop on intervention design, multisite studies, implementation research and PBRNs Invited talks and agenda recommendations from experts in conducting multisite interventional research through PBRNs and implementation research leaders from within and outside the VA |
Scientific Data Sources ∗ Overviews of the state of VA women’s health research were presented by leading VA investigators: Women’s Health Evaluation Initiative (Susan Frayne, MD, MPH, Principal Investigator [PI], VA Palo Alto); Evidence Synthesis (Bevanne Bean-Mayberry, MD, MHS, PI, VA Greater Los Angeles); National Survey of Women Veterans (Donna Washington, MD, MPH, PI, VA Greater Los Angeles); and the state of VA women’s mental health research (Paula Schnurr, PhD, National Center for PTSD, White River Junction VA). | Selected Findings |
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Overview of the Women's Health Evaluation Initiative | Women represent 3%–8% of veteran outpatients at most VA facilities (fiscal year 2008). |
Secondary analyses of national VA databases | Number of women veterans using VA has doubled over past decade. |
Funded by Women Veterans Health Strategic Health Care Group | Age distribution no longer bimodal (reflects infusion of OEF/OIF, anticipate large cohort of elderly women). |
Support for strategic planning | Women have more diagnosed mental health conditions than men. |
High prevalence of cardiovascular risk factors (e.g., hypertension, hyperlipidemia, obesity), depression, and musculoskeletal disorders. | |
Updated Systematic Literature Review Update of 2004 systematic review (reflects 191 articles between 2004–2008) Funded by VA Evidence Synthesis Program under the direction of the HSR&D Service | More observational and less descriptive. Reflects increase in VA funding. Majority of literature on mental health, followed by quality/satisfaction, access/use, deployment/post-deployment, and organizational studies. Strengths in PTSD treatment outcomes, access to care (barriers, perceptions, use) and organizational determinants of quality. Gaps in clinical and intervention studies for chronic mental/physical conditions, transitions from military to civilian life, impact of military duty, and effects on families. |
Overview of Findings from National Survey of Women Veterans last national survey of female veterans conducted in 1985 (25 years ago) | Younger women veteran cohorts more likely to be racial–ethnic minorities, with greater VA use in past 12 months. |
Funded by Women Veterans Health Strategic Health Care Group | VA users have more chronic medical conditions, higher prevalence of mental health diagnoses (e.g., PTSD, anxiety) compared with nonusers. |
Gaps in knowledge of eligibility and VA services remain. | |
State of VA Women’s Mental Health Research | Majority of VA HSR&D–funded projects in women’s health focus on mental health. |
Synthesis of funded research (including selected VA, DoD and other studies) | Substantial mental health burdens among women Veterans. Military sexual trauma prevalent, increases risk of comorbid problems. |
Move to interventions accelerating (e.g., long-term health outcomes of women’s service during Vietnam War, Women Veterans Cohort Study, online interventions for female OEF/OIF Reserve and National Guard veterans). | |
Prominence of mental health conditions reflects need as well as cross-cutting effects on physical health and health behaviors. | |
Scientific sessions addressing women veterans’ needs, perceptions and barriers | Lack of close proximity to VA women’s health services deters use of VA. Unmet need higher among young, low-income, and poor health status; younger have problems with affordability/time off work, older with transportation. |
Lack awareness of VA reproductive services. | |
OEF/OIF veterans with PTSD and/or substance use disorders have high rates of musculoskeletal, digestive, nervous system, and other problems. | |
Challenges to family reintegration substantial. | |
Scientific sessions on clinical issues in caring for women veterans: Prevention, screening, and treatment | Women’s health mini-residencies improved provider comfort in delivering care. Mental health conditions associated with less cancer screening. |
Traumas convey excess risk of irritable bowel syndrome, which is itself underdiagnosed in VA. | |
Significant alcohol use while on antidepressants. | |
Scientific sessions on combat, sexual, and nonmilitary trauma | High rates of PTSD and depression. |
Significant combat and trauma exposure. | |
High rates of harassment, sexual assault. | |
High rates of intimate partner violence. | |
Combat exposure and military sexual harassment associated with greater suicidal ideation, attempts. | |
Women with military sexual trauma have poorer ratings of coordination of care; prefer separate waiting rooms, choice of male/female provider. | |
Scientific sessions on gender differences in health and health care for deployed military personnel and veterans | Women veterans smoke more, although more likely to be offered treatment. Less likely to be screened for depression (use of designated providers in mental health clinics helps). |
Higher prevalence of musculoskeletal conditions. | |
Less combat exposure, but more likely to result in PTSD and more likely to seek health care. | |
Lower BMI among OEF/OIF women veterans. | |
Women with traumatic brain injury experience more severe neurobehavioral symptoms. |
Results
State of Women Veterans Health and Health Care Research
VA Women’s Health Research Agenda
Main Topic | Research Priorities | Supporting Activities |
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Access to care and rural health | Address gaps in women Veterans’ knowledge and use of VA services (e.g., outreach/education, social marketing, telemedicine interventions). Evaluate and improve quality of transitions from military to VA care. Evaluate care provided at VA community-based outpatient clinics (e.g., availability, provision of women’s health services). Evaluate care delivered to women Veterans through fee-basis or contract arrangements; compare quality with VA providers. Assess impact of transportation issues and need for child care arrangements and flexible clinic hours on access and use. Assess factors related to women veterans’ trust of VA and other providers and clinic environments (e.g., safety, privacy, secure messaging). Need data on urban/rural differences in women Veteran population distribution, demographics, medical conditions, access and quality. | Consider development of a rural health registry. Increase conduct of implementation research (i.e., studies of strategies for implementing research into routine practice). |
Primary care and prevention | Evaluate VA comprehensive women’s primary care models (e.g., patient satisfaction, patient ratings of care, chronic disease quality, prevention performance, provider proficiency). Evaluate and improve primary care-specialist, primary care-hospital and primary care-emergency department communication and coordination of care. Conduct research on breast and cervical cancer screening and care (e.g., mammography compliance, follow-up of abnormal screens). Conduct studies of women Veterans’ sexual health, sleep issues, menopausal management, obesity/weight management (quality of care, determine need for gender-sensitive programs). Develop and test informatics tools to support primary care providers’ achievement of comprehensive, guideline-concordant care. Assess gender differences in symptom reporting. Assess VA care for women veterans using Healthy People 2020 priorities as benchmark. | Determine strategies for increasing protected time of clinician researchers. Develop repository/report of funding opportunities. Develop pilot funding mechanisms for quality improvement studies. Increase quality of data capture. Foster collaboration with CDC, DoD, and VA National Center for Health Promotion & Disease Prevention. |
Mental health | Need for research on how to integrate treatment of women with complex presentations (e.g., combinations of depression, PTSD, pain, substance use disorders and personality disorder). Examine structure and care models that support the patient-centered medical home. Understand similarities/differences between male and female Veterans with military sexual trauma, including barriers, needs and outcomes. Understand impact of mental health on sexual health and reproductive health over the lifetime. Determine barriers to caring for women who attempt/complete suicide. Identify risk factors for suicide among women Veterans. Evaluate variations in mental health care needs, use and outcomes of subgroups of women Veterans (e.g., racial–ethnic minorities). Improve PTSD screening instruments for use with women Veterans. Study effectiveness of integration of alternate mental health coping mechanisms (e.g., community support groups, spiritual/religious support). Conduct research on intimate partner violence, disordered eating, binge drinking, and other topics understudied among women Veterans. Test interventions to engage and retain women Veterans in mental health care. Evaluate effectiveness of group therapy by gender, by military cohort, by type of trauma (as well as with same-gender providers). Evaluate effectiveness of gender-specific approaches to interventions (e.g., smoking cessation). Evaluate effectiveness of peer support interventions to improve use. | Build capacity for more protected research time for clinician investigators. Increase data sharing opportunities (within VA, between VA and DoD, etc.). Increase partnerships with National Center for PTSD and VA Women’s Mental Health Support Team. Enhance collaboration with university partners where expertise complements VA capabilities. Increase research dissemination through use of a clearinghouse. Develop sourcebook of mental health measures. Increase emphasis on implementation research. Promote VA and DoD collaborations. Use VA women Veterans practice-based research network to gain access to larger numbers of women veterans. |
Post deployment health | Conduct research on post-deployment reintegration and readjustment among women Veterans. Evaluate determinants of use of VA health care by era, branch of service and participation in Reserves and National Guard. Evaluate functional status, quality of life, and resilience post-deployment, in addition to physical and mental health. Improve care coordination after post-deployment screenings. Evaluate polytrauma care needs and service delivery among women Veterans. Evaluate impacts of multiple deployments on women Veterans and their families. Develop combat exposure measure(s) that reflect women Veterans’ experiences. Evaluate interventions designed to smooth transitions between the military and VA health care systems (e.g., transfer of medical record information, communication of community resources before discharge). Test interventions supporting appropriate care-seeking. | Increase collaboration among researchers interested in post-deployment health at VA, DoD, NIH, and other agencies. Improve access to large population cohorts of OEF/OIF Veterans. Promote integration of veteran status in databases outside VA. Increase effective communication about VA research to Veterans Service Organizations as well as the general public. |
Complex chronic conditions/aging and long-term care | Understand the aging issues of women Veterans (e.g., menopause, osteoporosis, arthritis, diabetes, heart failure, chronic pain, substance use, incontinence, dementia), including needs, use, and preferences. Assess gender differences in presentation and outcomes of chronic disease among Veterans; reduce gender disparities in care delivery. Assess and improve osteoporosis screening/management. Investigate the unique long-term care needs of women Veterans (i.e., to what extent should long-term care services be tailored to women’s needs?). Assess and reduce risks of homelessness among women Veterans. Understand the natural progression of mental health issues as women Veterans age (e.g., long-term follow-up of women with PTSD). Evaluate access to and use and quality of home-based primary care and nursing home care (community living center options) for women. Evaluate needs and care for disabled women Veterans. Evaluate provider proficiency in gender-based differences in aging. Assess impacts of caregiver burdens on women Veterans’ health. Evaluate and improve VA emergency care for women Veterans. Evaluate and improve palliative care interventions adapted to women Veterans’ needs and preferences. | Engage women Veterans on research advisory boards. Increase collaboration to enhance growth in this research area (increase number of investigators and studies). Foster multisite research to ensure adequate numbers of women for geriatric research. |
Reproductive health | Determine reproductive health needs of women Veterans (e.g., reproductive technologies, infertility needs, hysterectomy rates, contraceptive needs, preconception care). Understand impacts of military exposure on pregnancy outcomes. Track reproductive health care needs of military women and women Veterans across the lifespan (see Complex chronic conditions/aging and long-term care). Investigate best models of specialty reproductive care (e.g., supporting transitions between VA and community providers). Assess costs of reproductive health services among women Veterans. Evaluate VA implementation of the new pregnancy and newborn care legislation. Evaluate workforce development and integration (e.g., obstetrics-gynecology, family practice, nurse practitioners, nurse midwives). Examine impacts of first experiences with reproductive health services (e.g., on perceptions of care, on later use). Examine relationships between reproductive health and mental health (e.g., care coordination, impact of medications on pregnancy). Evaluate variations in screening for sexually transmitted diseases. Evaluate impacts of potential reversal of “Don’t Ask Don’t Tell” policies on VA care. Study needs and level of demand for care among transgendered Veterans. | Create a reproductive health research work group to enhance collaboration, foster interdisciplinary teamwork, and increase portfolio area. Explore value of creation of a birth outcomes registry. Engage other national organizations (e.g., American College of Obstetrics & Gynecology, Association of Women’s Health, Obstetric & Neonatal Nurses, National Institute for Child Health & Human Development). Improve collaboration with affiliated centers (e.g., NIH Cancer Centers). |
Discussion
Acknowledgments
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Biography
Article info
Publication history
Footnotes
Funding Source: This paper is based on work supported by the U.S. Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, Health Services Research & Development (HSR&D) Service and the Women Veterans Health Strategic Health Care Group under the Office of Public Health & Environmental Hazards (now under the VA Office of Patient Care Services) (Project No. CSF 10-179). The project was also supported by VA Women's Health Research Consortium also funded by VA HSR&D Service (Project No. SDR 10-120). Dr. Yano's time was covered by a VA HSR&D Research Career Scientist award (Project No. RCS 05-195).