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Correspondence to: Bevanne Bean-Mayberry, MD, MHS, VA GLA HSR&D Center for Study of Healthcare Provider Behavior, VA Sepulveda, 16111 Plummer St (152), Sepulveda, CA 91343. Phone: 818-895-9449; fax: 818-895-5838.
VA Greater Los Angeles Health Services Research & Development Center of Excellence, Sepulveda, CaliforniaVA Greater Los Angeles Healthcare System, Los Angeles, CaliforniaDepartment of Medicine, UCLA David Geffen School of Medicine, Los Angeles, California
VA Greater Los Angeles Health Services Research & Development Center of Excellence, Sepulveda, CaliforniaVA Greater Los Angeles Healthcare System, Los Angeles, CaliforniaDepartment of Health Services, UCLA School of Public Health, Los Angeles, California
VA Greater Los Angeles Health Services Research & Development Center of Excellence, Sepulveda, CaliforniaVA Greater Los Angeles Healthcare System, Los Angeles, CaliforniaDepartment of Medicine, UCLA David Geffen School of Medicine, Los Angeles, California
VA Greater Los Angeles Health Services Research & Development Center of Excellence, Sepulveda, CaliforniaVA Greater Los Angeles Healthcare System, Los Angeles, California
VA Greater Los Angeles Health Services Research & Development Center of Excellence, Sepulveda, CaliforniaVA Greater Los Angeles Healthcare System, Los Angeles, CaliforniaDepartment of Medicine, UCLA David Geffen School of Medicine, Los Angeles, CaliforniaEvidence Synthesis Program—West Los Angeles VA Medical Center, Los Angeles, California
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.
Background
Women are playing an ever increasing role in the U.S. military, representing about 15% of active military personnel, 17% of reserve and National Guard forces, and 20% of new military recruits (
). Concurrently, women are one of the fastest growing groups of new users in the Department of Veterans Affairs (VA) Healthcare System, with particularly high rates of utilization among veterans of Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF). Of the more than 100,000 OEF/OIF women veterans, over 44% have enrolled for health care (
). Thus, women veterans represent an integral part of the veteran community.
Women’s military experiences and responses to their military experiences are often distinct from those of men, and these differences can affect both their health status and their health care needs as active duty personnel and as veterans. This issue, together with the rise in the number of women veterans in the VA system, calls for increased understanding of women veteran health issues and knowledge gaps to guide VA care and VA research efforts. The body of research literature dedicated to women veterans and women’s military health and health care has significantly grown and expanded in scope since the publication of the first systematic review of women veterans research (
). We update that review by examining the literature on women veterans’ health and health care from 2004 to 2008. In this paper, we summarize major findings since 2004, and the advancements and gaps in comparison with the literature from the original syntheses from 1978 to 2004.
Methods
Search Strategy
We searched MEDLINE/PubMed, PsycINFO, WorldCat, and Web of Science for potentially relevant articles related to women veteran and military health published between January 2004 and September 2008. For each database search, we used the medical subject heading terms women and veterans to search for relevant literature. We supplemented this search by contacting other sources with expertise in women veteran and military health. The Department of Defense Health Affairs Division provided access to bibliographical reports on general deployment and mental health issues in OEF/OIF military personnel from 2002 through 2007 (
). We received additional articles from experts in the field and reviewed bibliographies from articles identified through our search. This study was approved as non-human subjects research by the VA Greater Los Angeles Institutional Review Board.
Study Selection
All titles identified through our search were screened for relevance by members of our team. Each article deemed potentially relevant was reviewed by two physicians with backgrounds in women’s health, working independently (B.B., F.B., C.H.) using a standardized screening form. Disagreements in ratings were reconciled through team consensus. To be included, articles had to relate to U.S. veterans or military personnel, and meet at least one of the following criteria: a) Include women veterans, compare men and women, or analyze women separately; b) involve active duty military and involve a health condition or functional status that requires medical intervention; and/or c) the topic is relevant to VA health care delivery to women. In articles containing both men and women veterans but not focused on a gender comparison, the results had to contain gender-specific statistical testing to be included (e.g., Chi-square, odds ratio, or p-value related to gender/sex). An article was excluded if it was defined as a nonsystematic review, editorial, commentary, or an unclear publication type.
Data Abstraction
After the initial screening process, articles meeting inclusion criteria were further evaluated and abstracted using a structured abstract form to collect year(s) of study or sampling timeframe; purpose of study; outcomes; study population; identification as women-focused or women as a subset population, or neither; summary of methods; and main findings. Sample sizes of women were included in the abstracted data and evidence tables because sampling in the VA system has been a major debate for studies involving or including women veterans and health care. For the few clinical trials identified, we used Jadad criteria for quality assessment (
). For descriptive studies, which were by far the largest number of studies, no simple standardized assessment of quality exists; therefore, a quality assessment protocol was not included in this review.
Data Synthesis
We identified five key focus areas by using high priority areas identified in the 2004 literature synthesis (
) and the VA Health Services Research and Development Service funding priorities: 1) Deployment and post-deployment health, 2) organizational research, 3) quality of care, 4) access to care and utilization, and 5) psychiatric conditions. We then summarized the findings in each area and highlighted their significance.
Results
Yield
Our search identified 675 titles of potential relevance. Of these titles, 118 were duplicate references to a study, 151 were rejected as not being relevant to the topic, and 26 could not be retrieved (Figure 1). Of the remaining 380 articles that were evaluated as full-text articles by at least two physician reviewers independently, 154 were rejected because they did not meet our inclusion criteria; 48 did not relate to U.S. veterans or military personnel and 106 failed to meet at least one of the following other criteria. Thirty-one articles were excluded because the study design was not appropriate (i.e., nonsystematic reviews, editorials or commentaries, or unclear design). Further, data abstraction was performed on the remaining 195 articles, and all were categorized into the following 5 areas, which were not mutually exclusive: Deployment and post-deployment health issues (n = 33), organizational research (n = 7), quality of care (n = 54), access and utilization (n = 48), and psychiatric conditions (n = 85).
The inclusion criteria for the updated review incorporated the main criterion from the baseline review (criterion a) that focused on studies which include women veterans, compare men and women, or analyze women separately and added two additional criteria (b and c) described previously within Study Selection. Figure 2 shows the cross walk between the categories for the baseline and updated review and provides an explanatory rationale.
), the majority of articles discussed were observational (n = 169) or descriptive studies (n = 13). Nearly half of the research articles focused on psychiatric issues. Although eight studies were qualitative, only five studies were identified as experimental studies or clinical trials. Of these five, three focused on women veterans or military personnel with a PTSD diagnosis or symptoms (
). These trials highlight key advances in methods by including the first VA multisite, randomized, controlled trial of women veterans, and a moderately large mental health patient sample (n = 284;
Overall, 33 articles covered deployment and post-deployment health issues, with the majority of studies (n = 23) addressing health issues specific to OEF/OIF veterans (Table 1, Row 1). The OEF/OIF topics focused on mental health screenings, PTSD, general deployment health issues. The remaining articles consisted of deployment studies in non-OEF/OIF cohorts (Table 1, Row 2).
Table 1Research on Deployment and Post-Deployment Factors Related to Women Veterans Health Care (n = 33)
Group refers to the additional references in this systematic review that are related to the overall topic or specific subtopic listed in the second column of the table.
Study Characteristics
Selected Findings
1
OEF and OIF veteran cohorts (n = 23) Mental health screenings (a) MST and PTSD (b) Access, general deployment and other (c)
56–865,674 persons
Surveys of military or veteran persons before, during and/or after deployment
New onset and persistent symptoms of post-traumatic stress disorder self reported after deployment and combat exposures: Prospective population based US military cohort study.
Getting beyond “Don’t ask; don’t tell”: An evaluation of US Veterans Administration postdeployment mental health screening of veterans returning from Iraq and Afghanistan.
American Journal of Public Health.2008; 98: 714-720
Bringing the war back home: Mental health disorders among 103,788 US veterans returning from Iraq and Afghanistan seen at Department of Veterans Affairs facilities.
MST combined with combat exposure was associated with doubled rates of new onset PTSD in women and men, and was associated with more readjustment difficulties in civilian life.
Demographics of and diagnoses in Operation Enduring Freedom and Operation Iraqi Freedom personnel who were psychiatrically evacuated from the theater of operations.
Getting beyond “Don’t ask; don’t tell”: An evaluation of US Veterans Administration postdeployment mental health screening of veterans returning from Iraq and Afghanistan.
American Journal of Public Health.2008; 98: 714-720
Bringing the war back home: Mental health disorders among 103,788 US veterans returning from Iraq and Afghanistan seen at Department of Veterans Affairs facilities.
New onset and persistent symptoms of post-traumatic stress disorder self reported after deployment and combat exposures: Prospective population based US military cohort study.
Demographics of and diagnoses in Operation Enduring Freedom and Operation Iraqi Freedom personnel who were psychiatrically evacuated from the theater of operations.
Getting beyond “Don’t ask; don’t tell”: An evaluation of US Veterans Administration postdeployment mental health screening of veterans returning from Iraq and Afghanistan.
American Journal of Public Health.2008; 98: 714-720
Military populations showed better health status scores than the general U.S. or VA population and deployment was not associated with decreased overall health.
World War II never ended in my house: Interviews of 12 Office of Strategic Services Veterans of Wartime Espionage on the 50th anniversary of WW II psychobiology of posttraumatic stress disorders: A decade of progress. Vol. 1071. Blackwell Publishing,
Malden, MA2006
Abbreviations: MST, military sexual trauma; OEF, Operation Enduring Freedom; OIF, Operation Iraqi Freedom; PTSD, posttraumatic stress disorder.
∗ Group refers to the additional references in this systematic review that are related to the overall topic or specific subtopic listed in the second column of the table.
Of the 23 studies addressing issues specific to OEF/OIF veterans, the majority (Table 1, Row 1, Group a) focused on mental health screening before, during, or after deployment. Four themes were prominent: 1) High rates of positive screens for PTSD symptoms (range, 10%–19%) or other mental health disorders occur among OEF/OIF returning military women; 2) women in the military who recently returned from OEF/OIF deployments are disproportionately affected by PTSD symptoms, depression, and other mental health issues or are more likely referred for mental health care compared with recently deployed men; 3) younger age and separated or divorced marital status tend to place all military members at risk for more mental health symptoms; and 4) a greater number of OIF deployments seems to be associated with screening positive for mental health problems. Separately, military sexual trauma (MST) combined with combat exposure was associated with doubled rates of new-onset PTSD among women and men, and MST was associated with more readjustment difficulties to civilian life (Table 1, Row 1, Group b). Another key finding was that psychiatric diagnoses were common for both OEF and OIF evacuations for men and women, and recurrent gynecological needs in the field were not uncommon, suggesting the need for Department of Defense and VA to ensure that military personnel evacuated from the field for mental or physical health issues receive ongoing care (Table 1, Row 1, Group c).
Other Veteran Cohorts
The remaining 10 deployment and mental health articles are not specific to the OEF/OIF cohorts (Table 1, Row 2), a number of which discussed deployment stressors and/or social support among other cohorts of veterans (e.g., Vietnam). Key findings were that longer and first-time deployments were associated with increased distress in soldiers deployed to Bosnia, and gender-specific active duty problems involved problems with pregnancy or urinary tract infections.
The OEF/OIF studies reflect the growing participation of women in the recent conflicts. More than half of the OEF/OIF articles underscore the need to screen for PTSD and other mental health symptoms among recently returning soldiers. Additionally, women and men with assault histories before combat had doubling rates of new-onset PTSD symptoms. Finally, military readiness for women includes field access to gynecological services and possibly family support during pregnancy. These issues will remain important for both Department of Defense and VA in post-deployment health care settings.
Organizational Research
These seven studies examined organizational characteristics of clinics delivering services to women in national or regional samples of VA sites for primary care (Table 2, Rows 1–2). Studies focused on VA establishment of women’s health clinics, emergency department availability of women’s health expertise, availability of gynecological services in VA settings, and determinants of availability of contraception (hormonal and intrauterine device). One other organizational study examined the influence of the practice environment (e.g., variable organizational support) on delivery of care for MST. Of note, the integration of gynecologists in VA settings or creation of separate gynecology or women’s clinics in VA were associated with improved availability of intrauterine devices, advanced gynecologic services, and after-hours emergency gynecologic services. Furthermore, the local organizational culture and quality of leadership support for women’s health were key factors in fostering gender-sensitive programs.
Table 2Research on Organizational Factors Related to Women Veterans Health Care (n = 7)
Group refers to the additional references in this systematic review that are related to the overall topic or specific subtopic listed in the second column of the table.
Study Characteristics
Selected Findings
1
VA organization of women’s care (n = 6)
8–155 facilities
National surveys evaluating organizational influences on service availability, quality of care
VA comprehensive women’s health centers comparable to DHHS women’s health centers of excellence.
Survey of MST providers in one VA regional network
Individual, facility, and regional MST practice environment (e.g., workload, burnout) highly correlated with organizational support for MST care delivery.
Military sexual trauma services for women veterans in the Veterans Health Administration: The patient-care practice environment and perceived organizational support.
Abbreviations: DHHS, U.S. Department of Health and Human Services; MST, military sexual trauma; VA, U.S. Department of Veterans Affairs; VAMC, VA Medical Center.
∗ Group refers to the additional references in this systematic review that are related to the overall topic or specific subtopic listed in the second column of the table.
The quality-of-care literature on women veterans included 54 studies that covered patient perceptions of quality and satisfaction (Table 3, Row 1), general quality of care processes and outcomes (Table 3, Row 2), surgical outcomes (Table 3, Row 3), prescribing outcomes (Table 3, Row 4), gender-specific and reproductive care (Table 3 Row 5), and other quality of care issues (Table 3, Row 6), including two clinical trials.
Table 3Research on Quality of Care Factors Related to Women Veterans Health Care (n = 54)
Group refers to the additional references in this systematic review that are related to the overall topic or specific subtopic listed in the second column of the table.
Study Characteristics
Selected Findings
1
Patient perceptions of quality and satisfaction (n = 9)
51–133,562 persons
Focus groups and national, regional and local surveys evaluating patient perceptions and satisfaction among women veterans, and women in military setting
Lack of knowledge and gaps about VA prevalent among women veteran non-users.
Surgical outcomes in women patients or diseases predominant in women
Women in VA vs. private sector showed equal or better outcomes for gender-specific surgeries, general surgery procedures, breast surgery outcomes, and gastric bypass surgery.
Comparison of risk-adjusted 30-day postoperative mortality and morbidity in Department of Veterans Affairs hospitals and selected university medical centers: General surgical operations in women.
Journal of the American College of Surgeons.2007; 204: 1127-1136
Comparison of risk-adjusted 30-day postoperative mortality and morbidity in Department of Veterans Affairs hospitals and selected university medical centers: Vascular surgical operations in women.
Journal of American College of Surgeons.2007; 204: 1137-1146
Abbreviations: LDL, low-density lipoprotein; VA, U.S. Department of Veterans Affairs.
∗ Group refers to the additional references in this systematic review that are related to the overall topic or specific subtopic listed in the second column of the table.
The literature on patient perceptions of quality and satisfaction reflects efforts to better understand women veterans’ knowledge, attitudes, and experiences with VA services. Overall, the satisfaction data are mixed, especially among women VA users with mental health problems who have reported both higher and lower satisfaction in outpatient care. Women veterans who do not use the VA lack understanding of VA care and services. In the VA, women veteran satisfaction is positively affected by access to women’s clinics, gynecological services, and overall continuity of care. Among VA users, women and men had similar outpatient satisfaction ratings; however, women had consistently lower ratings for inpatient care (e.g., physical comfort, courtesy).
The general quality of care studies indicate that women in VA may have some comparable outcomes with men; however, overall improvement is needed for lipid (low-density lipoprotein cholesterol) control, hypertension control, and preventive immunizations (Table 3, Row 2).
Surgical outcomes indicate that women in VA settings have equal or lower surgical morbidity and mortality outcomes compared with the private sector for general and vascular procedures (Table 3, Row 3). Prescribing outcomes indicate that VA (compared with settings outside the VA) has consistently lower or comparable rates of inappropriate prescription drugs in the elderly, but women in the VA (compared with men) are consistently more likely to be prescribed inappropriate drugs regardless of the criteria used (Table 3, Row 4). The articles on gender-specific and reproductive care covered a broad range of topics, including urological issues related to postponed voiding, contraception needs, hormone therapy discontinuation, and adverse pregnancy outcomes in a small veteran sample (Table 3, Row 5).
We identified two clinical trials in the quality of care literature. The first, an educational intervention, evaluated gender role stereotypes, knowledge of, and sensitivity to women veterans (Vogt, Barry, & King et al., 2008). Older age, direct patient contact, and years of VA employment predicted greater gender awareness and significant improvements in sensitivity and knowledge, but no significant improvement in gender role stereotypes. The other randomized trial compared rates of mammography among women assigned with two types of interventions, but neither was superior to the mammography rate among the control group (
Forty-eight articles focused on access to care and utilization of services. Twelve articles focused on determinants of access (Table 4, Row 1), 14 on gender-related issues in access (Table 4, Row 2), 6 on sexual trauma patients and utilization (Table 4, Row 3), and 11 on PTSD or other mental health issues and utilization (Table 4, Row 4). Five additional studies focused on access and utilization among specific cohorts of veterans related to periods of military service. Overall, women with mental health diagnoses, positive screening tests, or trauma tended to use more health care services than women without positive screens or than male veterans. In a few areas, findings were mixed, cautioning us to remain aware of patients who may underutilize health care because of specific mental health issues.
Table 4Research on Access and Utilization Factors Related to Women Veterans Health Care (n = 48)
Group refers to the additional references in this systematic review that are related to the overall topic or specific subtopic listed in the second column of the table.
Study Characteristics
Selected Findings
1
Determinants of access (n = 12)
51–1,468,417 persons
National, regional surveys and one focus group evaluating patient use, ratings and perceptions of care, and administrative datasets analyzed for inpatient or outpatient VA utilization
Barriers to care included knowledge gaps, incorrect assumptions about services to women, and difficulty using VA care.
Emergency gynecologic and mental health services are high during day hours, but after hours VA care is linked to presence of a separate women’s clinic and lower community managed care penetration.
National, multisite, or clinic samples of mixed-gender or female-only veteran samples
Veterans with sexual trauma history experienced more difficulties with their emotions, more use of VA services, and more psychological impairment compared with veterans with other trauma.
Age differences in posttraumatic stress disorder, psychiatric disorders, and healthcare service use among veterans in Veterans Affairs primary care clinics.
American Journal of Geriatric Psychiatry.2007; 15: 660-672
Abbreviations: PTSD, posttraumatic stress disorder; VA, U.S. Department of Veterans Affairs.
∗ Group refers to the additional references in this systematic review that are related to the overall topic or specific subtopic listed in the second column of the table.
The 85 publications covering mental health and psychiatric issues fell into five broad categories: PTSD (n = 42), substance abuse and treatment (n = 5), trauma (n = 18), general mental health (n = 13), and other (n = 7).
Three PTSD clinical trials (Table 5, Row 1, Group a) focused on treatment advances, including structured group psychotherapy and self-defense training (improved PTSD symptoms and self-efficacy at 3 and 6 months), prolonged exposure therapy (reduction of PTSD symptoms and PTSD diagnostic criteria), and olanzapine therapy for non–combat-related PTSD (no between-group differences but a large placebo effect). PTSD screening and symptoms (Table 5, Row 1 Group b) included seven articles spanning disability benefits, gender differences in perceived threat, and the importance of availability of specialized treatment programs for women who come to the VA for PTSD treatment.
Table 5Research on Psychiatric Conditions Related to Women Veterans Health Care (n = 85)
Group refers to the additional references in this systematic review that are related to the overall topic or specific subtopic listed in the second column of the table.
Study Characteristics
Selected Findings
1
PTSD (n = 42) Clinical trials (a) Screening and symptoms (b) Determinants of diagnosis (c) Quality of life (d) Comorbid disorders (e)
10–1,599 persons
Clinical treatment interventions, behavioral intervention, surveys, and interviews of active duty, veteran, and veteran registry participants
Prolonged exposure was associated with greater reduction of PTSD symptoms and a lower likelihood of meeting diagnosis criteria after therapy was completed.
Factors predicting/associated with PTSD symptoms clusters in women veterans included pain, childhood sexual/physical maltreatment, childhood sexual assault, or adult sexual assault.
Spontaneous reports of emotional upset and health care utilization among veterans with posttraumatic stress disorder after receiving a potentially upsetting survey.
American Journal of Orthopsychiatry.2005; 75: 142-151
New onset and persistent symptoms of post-traumatic stress disorder self reported after deployment and combat exposures: Prospective population based US military cohort study.
Age differences in posttraumatic stress disorder, psychiatric disorders, and healthcare service use among veterans in Veterans Affairs primary care clinics.
American Journal of Geriatric Psychiatry.2007; 15: 660-672
Relative impact of adverse events and screened symptoms of posttraumatic stress disorder and depression among active duty soldiers seeking mental health care.
The co-occurrence of childhood sexual abuse, adult sexual assault, intimate partner violence, and sexual harassment: A mediational model of posttraumatic stress disorder and physical health outcomes.
Journal of Consulting and Clinical Psychology.2008; 76: 194-207
National VA database analyses, national military samples, military hospital, and VA domiciliary samples for inpatient treatment
Although male gender was associated with alcohol-related consequences and binge drinking, females who consumed alcohol had twice the rate of drinking above established guidelines for safety.
Administrative database analyses, multisite and clinic sampling, and a convenience sample of women veterans in both mental health and women’s health in a hospital setting
Positive MST screens among men and women were associated with greater odds of nearly all mental health comorbidities including PTSD.
Anxiety level is elevated in women with a sexual trauma history for any invasive examination (breast, pelvic, rectal) when the clinician is male and associated with more urgent care utilization.
Prevalence of in-service and post-service sexual assault among combat and noncombat veterans applying for department of veterans affairs posttraumatic stress disorder disability benefits.
National VA database and clinical registry analyses, Large Survey of Veterans, Millennium Cohort Sample, specific cohorts of active-duty and veteran samples
General screening data showed that women in military compared with men had higher prevalence of panic attacks, anxiety, and depression compared with men, but not alcohol abuse.
Air Force women showed increased levels of family stress and conflicts compared with community samples, and children of deployed Air Force mothers had risks for behavioral and emotional adjustment problems.
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