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

Seven years have passed since the VA Office of Research and Development put forward the VA women’s health research agenda (2004), spanning biomedical/laboratory, clinical sciences, rehabilitation, and health services research (). With that effort also came the first VA journal supplement to be focused on women Veterans’ health and health care research (). That supplement was composed of 14 papers examining their health status; influences on and barriers to VA care; gender differences in patient satisfaction, medical, and surgical care; obesity and television viewing; contraceptive availability; health effects of military sexual trauma (MST); and comorbidity and use of services among women veterans with posttraumatic stress disorder (PTSD) and other psychiatric conditions. In that supplement, VA researchers also published the first systematic review of the women veterans literature (), an exploration of the history of women and war (), and a summary of the VA’s initial research agenda (). The impact of this body of work was substantial, because it provided a time-limited publishing target and consolidated “home” for high-quality research, while also drawing heightened attention to this burgeoning field of inquiry. The agenda-setting efforts and special issue together sparked remarkable growth in the number of investigators pursuing research on women veterans and women in the military.

In the intervening years since the last agenda, significant research planning ensued, especially within the VA Health Services Research and Development (HSR&D) Service. An updated research solicitation focused on identified gaps, resulting in a growing research portfolio. To further accelerate progress on this agenda, in 2010 the VA HSR&D Service funded the VA Women’s Health Research Consortium, whose mission is to provide technical consultation, education/training, and mentorship support to catalyze the efforts of the now substantial group of researchers focused on women Veterans’ health (). Building on the value of the previous VA special issue to researchers, providers and policymakers alike, VA HSR&D incorporated dissemination support in the form of another VA supplement—this special issue of Women’s Health Issues—as a function of the consortium.

Therefore, we are very pleased to provide the readership of Women’s Health Issues with a collection of 18 peer-reviewed manuscripts summarizing health services research findings about women veterans and women in the military, framed in the context of informing evidence-based practice and policy. These papers are accompanied by commentaries from VA HSR&D Service (Lipson and Eisen) and from our clinical leadership partner in the Women Veterans Health Strategic Health Care Group, the department overseeing VA women’s health care nationally (Hayes), as well as an editorial from Dr. Anne Markus, Editor-in-Chief of the journal and long-standing advocate for high-quality women’s health research.

The first three papers in this issue provide a foundation for accelerating VA’s investment in women’s health research. Yano et al. present a new VA women’s health services research agenda, updating and focusing the 2004 agenda based on the substantial knowledge gained in the intervening years and crystallized in the 2010 national women’s health services research conference. Bean-Mayberry et al. present results of an updated systematic review, which demonstrates that more research has been published in the 5 years since the 2004 agenda (2004–2008) than the previous 25 years combined. Although the evidence base has grown, and intervention research studies are beginning to dot the landscape, the vast majority of the literature is still descriptive and observational in nature. Although observational work continues to be important, the VA HSR&D Service has underscored the need for investigators to pursue research capable of generating actionable practice and policy changes. Results of a national needs assessment suggest that VA women’s health researchers would benefit from additional training in this regard. Rohrer et al. thus provide an intervention development primer focused on the steps to accomplish this transition for research focused on women veterans.

One of the last agenda’s priorities was a call for research to better understand the characteristics and experiences of the population of women veterans. Three papers in this issue add to an improved portrait of women veterans seen in VA settings. Friedman et al. reflect on the changing demographics of women veterans who use the VA health care system by characterizing those new to the system, highlighting their retention and health care needs. Using recently released data from the National Survey of Women Veterans, Washington documents the performance advantages of VA practices that have tailored primary care to women through use of designated providers or separate women’s clinics. These VA’s were rated higher on most dimensions of care, including VA provider skill and gender appropriateness; these findings are particularly salient to the VA’s current implementation of patient-centered medical homes (referred to as “Patient Aligned Care Teams” or PACTs in the VA). Work by Mengeling et al. follows with an important regional analysis of women veterans’ needs and preferences for care that considers implications of level of VA reliance (sole vs. dual use) in the context of an unusually large, rural population (55% of sample).

To date, mental health research predominates the literature on women veterans and women in the military, with emphasis on PTSD and psychological sequelae of MST (, ). Little is known, however, about how the VA women’s mental health care is organized. In this issue, we present two papers that examine these issues, one from a national survey of VA facilities (Oishi et al.) and another from in-depth interviews of mental health clinic managers (MacGregor et al.). Oishi et al. note that a little over half of VA facilities offer one or more mental health care arrangements specifically for women. These include mental health services embedded within women’s primary care clinics, designation of women’s health providers within general mental health clinics, and/or separate women’s mental health clinics. MacGregor et al. dive into the details of these two latter arrangements, reflecting on diversity of opinion in the field regarding the need for and consequences of adapting mental health programs specifically for women. Data from both studies precede VA’s release of key national mental and women’s health policy guidance, and provide insights into the challenges individual facilities may face in achieving the VA’s stated aims. Kimerling et al. examine perceptions of VA care among women and men with histories of MST, and report high satisfaction with VA care, in contrast with older VA data (1997) and findings from outside the VA, where exposure to sexual trauma is associated with poor satisfaction with care. The authors posit that VA’s system-wide monitoring of MST-related care may be a contributing factor to these positive results. Pierce et al. examine the effects of combat exposure in the early days of Operation Iraqi Freedom on Air Force women’s physical health, finding that Reserve/National Guard forces (vs. active duty) and those in-theater (vs. service elsewhere) report greater physical health impairments following deployment. Sternke’s work to review our ability to reliably and validly measure combat exposure among women follows, providing insights into the strengths and challenges of current measures. Roles following military service are also important. Although many women veterans thrive in the workplace and call upon strengths that they gained from military service, some do not. This is particularly true in the specific cohort of women in Schnurr and Lunney’s study, which uses results from their VA randomized trial of prolonged exposure therapy among women veterans to examine the relationship between PTSD and occupational outcomes. They find that severity of PTSD is associated with poorer occupational functioning and satisfaction, but not employment status, and that symptoms of depression have substantial effects across all components of work-related quality of life, independent of PTSD symptoms. Their results provide further insights into the path to meaningful recovery for women veterans impacted by PTSD and related problems.

One of the other 2004 VA research priorities included the need to increase knowledge of women veterans’ chronic disease care needs and risk factors, in general and in connection with mental health burdens. Relatively little prior work on women veterans has examined cardiovascular disease, the leading killer of women. Consequently, Vimalananda’s work noting less aggressive lipid-lowering therapy among women veterans is timely, especially given the VA’s recent initiative requiring VA network directors to select an area with documented gender disparities upon which to focus for quality improvement. Because improved lipids management is the disparity that most network directors have chosen, her findings may provide an actionable target. Farmer et al. examined another modifiable cardiovascular risk factor, finding that women veterans smoke more than men, despite being more likely to report being advised to quit and equally likely to be offered medications or other treatment. Because organizational factors (e.g., presence of women’s clinics) did not eliminate gender differences, their work demonstrates the need for effective gender-focused smoking cessation programs. Dichter’s paper demonstrates that intimate partner violence is a predictor of several important cardiovascular risk factors. Using a unique database that contains both veterans and non-veterans, they show that one third of women veterans experience intimate partner violence in their lifetimes, which is substantially higher than the rate seen in non-veterans. Their work provides important considerations for health care providers within and outside the VA. Moving from cardiovascular disease to cancer, Yee’s paper identifies women with mental illness as a subgroup at risk for failure to receive recommended breast cancer screening.

We are pleased to also present two articles on high-priority special populations of women veterans, namely homeless women veterans and those with traumatic brain injury (TBI). Hamilton et al. report on the results of a series of focus groups among homeless women veterans in Los Angeles County, discerning their care needs and preferences, and the pathways that brought them to homelessness. This paper contributes important insights for VA’s efforts to prevent and reduce homelessness among the most vulnerable women veterans. Iverson et al. present population-based data on women veterans’ exposures and experience with deployment-related TBI, the current wars’ signature injury. They find that PTSD is the most common psychiatric condition among both women and men with TBI, although women with TBI are less likely than men to have a PTSD diagnosis, but more likely than men to have a depression or anxiety disorder diagnosis. Women also are more likely to report severe neurobehavioral symptoms.

We believe that the potential for advancing evidence-based practice and policy as a result of the VA’s investment in women’s health services research is unprecedented. We benefit from particularly strong research–clinical partnerships with leaders in VA Central Office (e.g., Women Veterans Health Strategic Health Care Group, Office of Mental Health Services, Office of Patient Care Services, Office of Quality and Performance, Office of Academic Affiliations) who are deeply committed to advancing care for women veterans, and who see research as part of the pathway toward achieving this objective. We also have wonderful partners on the frontlines of patient care, including providers, staff, and managers, offering their energy, their insights, and their experience as a platform for ongoing quality improvement research. And now, with the groundswell of enthusiasm among researchers committed to women veterans’ research, the VA Women’s Health Research Consortium has its work cut out for it, as we design programs to keep up with demand. Finally, with the VA HSR&D’s investment in promoting multisite research through the inaugural sites of the VA Women’s Health Practice Based Research Network, we hope that this new infrastructure eliminates the rest of the barriers that researchers have faced (). The Practice Based Research Network is designed to facilitate recruitment of sufficient numbers of women, foster the design and testing of interventions focused on solving women’s health-related issues, and increasingly ensure their inclusion in a wider array of VA research (). We envision growth of this network over the coming years, building on the enthusiasm and energy generated by those in the field who share the commitment to those who have served—our women veterans. We welcome you in this journey, and hope this special issue inspires you to take action in research, clinical care, management, and/or policymaking on behalf of women veterans.

The views expressed in the manuscript are solely those of the authors, and do not necessarily represent the views of the U.S. Department of Veterans Affairs or the United States government.