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1.  Health Disparities Among Sexual Minority Women Veterans 
Journal of Women's Health  2013;22(7):631-636.
Abstract
Background
Lesbian and bisexual (i.e., sexual minority) identity is more common among women veterans than among male veterans. Unique health issues have been identified among women veterans and among sexual minority women, but little is known about women who are both sexual minorities and veterans. This study aimed to compare demographic and health information from sexual minority women veterans with sexual minority women non-veterans and heterosexual women veterans.
Methods
Behavioral Risk Factor Surveillance Survey data were pooled from ten U.S. states that elected to ask sexual identity during 2010. The analytic sample was comprised of women who identified both their sexual identity and veteran status (n=1,908). Mental health indicators were frequent mental distress, sleep problems, low social/emotional support, and low satisfaction with life. Health risk indicators included current smoking, overweight, and obesity. Physical health status was defined by three components: disability requiring assistive equipment, >14 days of poor physical health in the past 30 days, and activity limitations.
Results
Compared with heterosexual women veterans, sexual minority women veterans had higher odds of mental distress (odds ratio [OR]=3.03, 95% confidence interval [CI]: 1.61–5.70) and smoking (OR=2.31, 95%CI: 1.19–4.48). After adjusting for demographic correlates, sexual minority women veterans had three times the odds of poor physical health (OR=3.01, 95%CI: 1.51–5.99) than their sexual minority non-veteran peers.
Conclusions
Results suggest sexual minority women veterans may experience unique health disparities relevant to provision of care in both Veterans Affairs (VA) and non-VA healthcare systems. Future research requires availability of data that include sexual minority status.
doi:10.1089/jwh.2012.4214
PMCID: PMC3761433  PMID: 23746281
2.  The mental health of UK Gulf war veterans: phase 2 of a two phase cohort study 
BMJ : British Medical Journal  2002;325(7364):576.
Objectives
To examine the prevalence of psychiatric disorders in veterans of the Gulf war with or without unexplained physical disability (a proxy measure of ill health) and in similarly disabled veterans who had not been deployed to the Gulf war (non-Gulf veterans).
Design
Two phase cohort study.
Setting
Current and ex-service UK military personnel.
Participants
Phase 1 consisted of three randomly selected samples of Gulf veterans, veterans of the 1992-7 Bosnia peacekeeping mission, and UK military personnel not deployed to the Gulf war (Era veterans) who had completed a postal health questionnaire. Phase 2 consisted of randomly selected subsamples from phase 1 of Gulf veterans who reported physical disability (n=111) or who did not report disability (n=98) and of Bosnia (n=54) and Era (n=79) veterans who reported physical disability.
Main outcome measure
Psychiatric disorders assessed by the schedule for clinical assessment in neuropsychiatry and classified by the Diagnostic and Statistical Manual of Mental Disorders, fourth edition.
Results
Only 24% (n=27) of the disabled Gulf veterans had a formal psychiatric disorder (depression, anxiety, or alcohol related disorder). The prevalence of psychiatric disorders in non-disabled Gulf veterans was 12%. Disability and psychiatric disorders were weakly associated in the Gulf group when confounding was adjusted for (adjusted odds ratio 2.4, 99% confidence interval 0.8 to 7.2, P=0.04). The prevalence of psychiatric disorders was similar in disabled non-Gulf veterans and disabled Gulf veterans ( 19% v 24%; 1.3, 0.5 to 3.4). All groups had rates for post-traumatic stress disorder of between 1% and 3%.
Conclusions
Most disabled Gulf veterans do not have a formal psychiatric disorder. Post-traumatic stress disorder is not higher in Gulf veterans than in other veterans. Psychiatric disorders do not fully explain self reported ill health in Gulf veterans; alternative explanations for persistent ill health in Gulf veterans are needed.
What is already known on this topicGulf veterans report medically unexplained symptoms more often than non-Gulf veteransThe clinical characteristics of ill health in Gulf veterans are not well known, and factors associated with ill health in Gulf veterans are poorly understoodWhat this study addsMost ill Gulf veterans do not have a formal psychiatric disorderThe rates for post-traumatic stress disorder are lowPsychiatric morbidity is not strongly associated with ill health in Gulf veteransThe rates for somatoform disorders are three times greater in disabled Gulf veterans than they are in disabled non-Gulf veterans
PMCID: PMC124552  PMID: 12228134
3.  Access to Care for Women Veterans: Delayed Healthcare and Unmet Need 
Journal of General Internal Medicine  2011;26(Suppl 2):655-661.
ABSTRACT
BACKGROUND
Timely access to healthcare is essential to ensuring optimal health outcomes, and not surprisingly, is at the heart of healthcare reform efforts. While the Veterans Health Administration (VA) has made improved access a priority, women veterans still underutilize VA healthcare relative to men. Eliminating access disparities requires a better understanding of the barriers to care that women veterans’ experience.
OBJECTIVE
We examined the association of general and veteran-specific barriers on access to healthcare among women veterans.
DESIGN AND PARTICIPANTS
Cross-sectional, population-based national telephone survey of 3,611 women veterans.
MAIN MEASURE
Delayed healthcare or unmet healthcare need in the prior 12 months.
KEY RESULTS
Of women veterans, 19% had delayed healthcare or unmet need, with higher rates in younger age groups (36%, 29%, 16%, 7%, respectively, in 18–34, 35–49, 50–64, and 65-plus age groups; p < 0.001). Among those delaying or going without care, barriers that varied by age group were: unaffordable healthcare (63% of 18–34 versus 12% of 65-plus age groups); inability to take off from work (39% of those <50); and transportation difficulties (36% of 65-plus). Controlling for age, race/ethnicity, regular source of care, and health status, being uninsured (OR = 6.5; confidence interval [CI] 3.0–14.0), knowledge gaps about VA care (OR = 2.1; 95% CI 1.1–4.0), perception that VA providers are not gender-sensitive (OR = 2.4; CI 1.2–4.7), and military sexual assault history (OR = 2.1; CI 1.1–4.0) predicted delaying or foregoing care, whereas VA use and enrollment priority did not.
CONCLUSIONS
Both general and veteran-specific factors impact women veterans’ access to needed services. Many of the identified access barriers are potentially modifiable through expanded VA healthcare and social services. Health reform efforts should address these barriers for VA nonusers. Efforts are also warranted to improve women veterans’ knowledge of availability and affordability of VA healthcare, and to enhance the gender-sensitivity of this care.
doi:10.1007/s11606-011-1772-z
PMCID: PMC3191223  PMID: 21989618
access to care; women veterans; VA healthcare; health services need; health services utilization
4.  Racial/Ethnic Differences in Cardiovascular Risk Factors Among Women Veterans 
Journal of General Internal Medicine  2013;28(Suppl 2):524-528.
ABSTRACT
BACKGROUND
Heart disease is the leading cause of death for women in the United States, accounting for 24.5 % of all deaths among women. Earlier research has demonstrated racial/ethnic differences in prevalence of cardiovascular (CVD) risk factors.
OBJECTIVE
To empirically examine the prevalence of CVD risk factors among a national sample of women Veterans by race/ethnicity, providing the first portrait of women Veterans’ cardiovascular care needs.
DESIGN AND PARTICIPANTS
Cross-sectional, national population-based telephone survey of 3,611 women Veterans.
MEASUREMENTS
Women Veterans were queried about presence of diabetes, hypertension, obesity, tobacco use and physical activity. Four racial/ethnic categories were created: Hispanic, Non-Hispanic White (White), Non-Hispanic Black (Black), and Other. Logistic regressions were conducted for each risk factor to test for racial/ethnic differences, controlling for age (under 40 vs. 40 and over).
KEY RESULTS
Racial/ethnic differences in CVD risk factors persisted after adjusting for age. Black women Veterans were more likely to report a diagnosis of diabetes (OR: 2.58, 95 % CI: 1.07, 6.21) or hypertension (OR: 2.31, 95 % CI: 1.10, 4.83) and be obese (OR: 2.06, 95 % CI: 1.05, 3.91) than White women Veterans. Hispanic women Veterans were more likely than White women Veterans to report diabetes (OR: 4.20, 95 % CI: 1.15, 15.39) and daily smoking (OR: 3.38, 95 % CI: 1.01, 11.30), but less likely to report a hypertension diagnosis (OR 0.21, 95% CI: 0.07, 0.64) or to be obese (OR: 0.39, 95 % CI: 0.18, 0.81).
CONCLUSIONS
Among women Veterans, CVD risks vary by race/ethnicity. Black women Veterans consistently face higher CVD risk compared to White women Veterans, while results are mixed for Hispanic women Veterans.
doi:10.1007/s11606-012-2309-9
PMCID: PMC3695277  PMID: 23807060
cardiovascular disease; risk factors; race; ethnicity; women veterans
5.  Military Sexual Trauma Among Homeless Veterans 
Journal of General Internal Medicine  2013;28(Suppl 2):536-541.
ABSTRACT
BACKGROUND
Military sexual trauma (MST) is the Veteran Health Administration’s (VHA) term for sexual assault and/or sexual harassment that occurs during military service. The experience of MST is associated with a variety of mental health conditions. Preliminary research suggests that MST may be associated with homelessness among female Veterans, although to date MST has not been examined in a national study of both female and male homeless Veterans.
OBJECTIVE
To estimate the prevalence of MST, examine the association between MST and mental health conditions, and describe mental health utilization among homeless women and men.
DESIGN AND PARTICIPANTS
National, cross-sectional study of 126,598 homeless Veterans who used VHA outpatient care in fiscal year 2010.
MAIN MEASURES
All variables were obtained from VHA administrative databases, including MST screening status, ICD-9-CM codes to determine mental health diagnoses, and VHA utilization.
KEY RESULTS
Of homeless Veterans in VHA, 39.7 % of females and 3.3 % of males experienced MST. Homeless Veterans who experienced MST demonstrated a significantly higher likelihood of almost all mental health conditions examined as compared to other homeless women and men, including depression, posttraumatic stress disorder, other anxiety disorders, substance use disorders, bipolar disorders, personality disorders, suicide, and, among men only, schizophrenia and psychotic disorders. Nearly all homeless Veterans had at least one mental health visit and Veterans who experienced MST utilized significantly more mental health visits compared to Veterans who did not experience MST.
CONCLUSIONS
A substantial proportion of homeless Veterans using VHA services have experienced MST, and those who experienced MST had increased odds of mental health diagnoses. Homeless Veterans who had experienced MST had higher intensity of mental health care utilization and high rates of MST-related mental health care. This study highlights the importance of trauma-informed care among homeless Veterans and the success of VHA homeless programs in providing mental health care to homeless Veterans.
doi:10.1007/s11606-013-2341-4
PMCID: PMC3695264  PMID: 23807062
Veterans; homelessness; sexual assault; mental health
6.  Sexual Victimization, Health Status, and VA Healthcare Utilization Among Lesbian and Bisexual OEF/OIF Veterans 
Journal of General Internal Medicine  2013;28(Suppl 2):604-608.
ABSTRACT
Background
Many lesbian and bisexual (LB) women veterans may have been targets of victimization in the military based on their gender and presumed sexual orientation, and yet little is known regarding the health or mental health of LB veterans, nor the degree to which they feel comfortable receiving care in the VA.
Objective
The purpose of this study was to examine the prevalence of mental health and gender-specific conditions, VA healthcare satisfaction and trauma exposure among LB veterans receiving VA care compared with heterosexually-identified women veterans receiving.
Design
Prospective cohort study of Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) women veterans at two large VA facilities.
Participants
Three hundred and sixty five women veterans that completed a baseline survey. Thirty-five veterans (9.6 %) identified as gay or lesbian (4.7 %), or bisexual (4.9 %).
Main Measures
Measures included sexual orientation, military sexual trauma, mental and gender-specific health diagnoses, and VA healthcare utilization and satisfaction.
Key Results
LB OEF/OIF veterans were significantly more likely to have experienced both military and childhood sexual trauma than heterosexual women (MST: 31 % vs. 13 %, p < .001; childhood sexual trauma: 60 % vs. 36 %, p = .01), to be hazardous drinkers (32 % vs. 16 %, p = .03) and rate their current mental health as worse than before deployment (35 % vs. 16 %, p < .001).
Conclusions
Many LB veterans have experienced sexual victimization, both within the military and as children, and struggle with substance abuse and poor mental health. Health care providers working with female Veterans should be aware of high rates of military sexual trauma and childhood abuse and refer women to appropriate VA treatment and support groups for sequelae of these experiences. Future research should focus on expanding this study to include a larger and more diverse sample of lesbian, gay, bisexual, and transgender veterans receiving care at VA facilities across the country.
doi:10.1007/s11606-013-2357-9
PMCID: PMC3695265  PMID: 23807072
lesbian; health services research; Veterans; women
7.  A Review of Epidemiologic Studies of the Health of Gulf War Women Veterans 
Journal of environment and health sciences  2017;3(2):10.15436/2378-6841.17.1551.
Introduction
In the 25 years since the 1990–1991 Gulf War (GW), studies have evaluated Gulf War Illness (GWI), sometimes referred to as medically unexplained multi symptom illness, and other medical and neurological conditions in women GW veterans.
Materials and Methods
In this article, we review epidemiologic studies of the health of women who served in the 1990–1991 GW based upon bibliographic searches in PubMed and CINAHL with relevant search terms through September 2015.
Results
A total of 56 articles were identified in the bibliographic searches. By screening abstracts or full-text articles, a total of 21 relevant studies were identified. Results from some studies, but not all, suggest that GWI is more common in women GW veterans than their male counterparts. Few studies of GW veterans focused on women’s health. A small number of studies suggested excess rates of woman’s health problems, e.g., breast cysts, abnormal Papanicolaou (Pap) smears, yeast infections, and bladder infections. Several studies have identified significantly elevated rates of birth defects and adverse reproductive outcomes among GW veterans. However, findings have varied with different study designs and sample sizes, with some studies showing elevated risks of stillbirths, miscarriages, and/or birth defects and others have not. In some studies, participants reported increased risks of ectopic pregnancies and spontaneous abortions.
Conclusion
Further research is needed to provide a comprehensive picture of the health of women GW veterans and to examine a broad range of women’s health issues including adverse reproductive outcomes. Some deployment-related health problems only become apparent decades later and other conditions may worsen or improve over time. Assessments are needed of current health status, changes in health symptoms and conditions over time, and possible differences in health outcomes associated with specific experiences and exposures during the war. Future studies would be strengthened by assessing GWI symptom patterns that may be specific to women veterans, examine diagnosed medical conditions among women veterans, and evaluate changes in women’s health over time, including changes potentially associated with menopause and age.
PMCID: PMC5635858
Gulf War syndrome; Gulf War veterans; Symptoms; Epidemiology; Women’s health
8.  Health-related quality of life among individuals with long-standing spinal cord injury: a comparative study of veterans and non-veterans 
BMC Public Health  2010;10:6.
Background
Spinal cord-injured (SCI) patients experience poor health-related quality of life (HRQOL) and they usually report lower HRQOL than the general population or population subgroups in Iran and elsewhere. The aim of this study was to compare HRQOL between veterans and non-veterans with SCI in Iran.
Methods
This was a cross-sectional study. HRQOL was measured using the 36-item Short Form Health Survey (SF-36). Thirty-nine male veterans and 63 non-veteran males with SCI were included in the study. Regression analyses were applied to determine the variables affecting physical and mental health-related quality of life among the patients.
Results
The male veterans had a lower HRQOL than the non-veterans with SCI. The differences were significant for all measures except for physical and social functioning. The greatest difference was observed for bodily pain (P = 0.001). The regression analysis results indicated that a longer time since injury was associated (P = 0.01) with better physical health-related quality of life (PCS), while being a veteran (P < 0.001) and having a spinal lesion in the cervical region (P = 0.001) were associated with poorer PCS. Older age (P < 0.001) and higher education (P = 0.01) were associated with better mental health-related quality of life (MCS), while being a veteran and having a spinal lesion in the cervical region (P = 0.02) were associated with poorer MCS.
Conclusion
The study findings showed that veterans with SCI experienced lower HRQOL than their non-veteran counterparts. A qualitative study is recommended to evaluate why HRQOL was lower in veterans than in non-veterans with SCI although veterans had higher incomes as a result of their pensions and increased access to equipment, and medications. To improve quality of life in both veterans and non-veterans with spinal cord injuries, policy changes or implementation of new interventions may be essential so that veterans could receive additional support (e.g. counseling, recreation therapy, vocational therapy, etc.) and non-veterans could meet their basic needs.
doi:10.1186/1471-2458-10-6
PMCID: PMC2819993  PMID: 20047697
9.  Mental Health Disorders and Treatment Seeking Among Veterans in Non-VA Facilities: Results and Implications from the Veterans’ Health Study 
Military behavioral health  2015;3(4):244-254.
We surveyed 700 veterans who were outpatients in a non–Veterans Affairs (VA) multihospital system. Our objective was to assess the prevalence of mental disorders and service use among these veterans. The majority were Vietnam veterans (72.0%), and male (95.9%), and 40.4% reported recently using the VA for care. The prevalence of lifetime post-traumatic stress disorder (PTSD) was 9.6%, lifetime depression 18.4%, and lifetime mental health service use 50.1%. In multivariate analyses, significant factors associated with PTSD, depression, and mental health service use were low self-esteem, use of alcohol/drugs to cope, history of childhood adversity, high combat exposure, and low psychological resilience. VA service use was associated with greater mental health service use and combat exposure. With the exception of alcohol misuse, the mental health status of veterans seen in non-VA facilities appeared to be better than reported in past studies. Because most veterans have access to both VA and non-VA services, these findings have implications for veterans and outcomes research.
doi:10.1080/21635781.2015.1077179
PMCID: PMC4669573  PMID: 26640743
Postdeployment health; post-traumatic stress disorder; depression; alcohol misuse; service use; combat exposure; psychosocial factors; social work
10.  Prevalence and Risk of Homelessness Among US Veterans 
Introduction
Understanding the prevalence of and risk for homelessness among veterans is prerequisite to preventing and ending homelessness among this population. Homeless veterans are at higher risk for chronic disease; understanding the dynamics of homelessness among veterans can contribute to our understanding of their health needs.
Methods
We obtained data on demographic characteristics and veteran status for 130,554 homeless people from 7 jurisdictions that provide homelessness services, and for the population living in poverty and the general population from the American Community Survey for those same jurisdictions. We calculated prevalence of veterans in the homeless, poverty, and general populations, and risk ratios (RR) for veteran status in these populations. Risk for homelessness, as a function of demographic characteristics and veteran status, was estimated by using multivariate regression models.
Results
Veterans were overrepresented in the homeless population, compared with both the general and poverty populations, among both men (RR, 1.3 and 2.1, respectively) and women (RR, 2.1 and 3.0, respectively). Veteran status and black race significantly increased the risk for homelessness for both men and women. Men in the 45- to 54-year-old age group and women in the 18- to 29-year-old age group were at higher risk compared with other ages.
Conclusion
Our findings confirm previous research associating veteran status with higher risk for homelessness and imply that there will be specific health needs among the aging homeless population. This study is a basis for understanding variation in rates of, and risks for, homelessness in general population groups, and inclusion of health data from US Department of Veterans Affairs records can extend these results to identifying links between homelessness and health risks.
PMCID: PMC3337850  PMID: 22280960
11.  Gender Differences in Service Utilization among OEF/OIF Veterans with PTSD after a Brief Cognitive-Behavioral Intervention to Increase Treatment Engagement: A Mixed Methods Study 
Purpose
Women veterans of Iraq and Afghanistan (OEF/OIF) have a moderately higher risk of developing post-traumatic stress disorder (PTSD) than male veterans. However, gender disparities in treatment engagement may prevent women veterans from initiating the care they need. Understanding gender differences in predictors of and barriers to treatment is essential to improving engagement and mental health outcomes. The purpose of this study was to examine gender differences in treatment utilization after a brief, Cognitive-Behavioral Therapy (CBT) intervention among male and female OEF/OIF veterans.
Methods
Participants were randomly assigned to either the intervention or control conditions. Intervention participants received the telephone-based CBT intervention. Participants were 35 female and 238 male OEF/OIF veterans who screened positive for PTSD and had never initiated PTSD treatment. Participants were asked about treatment utilization, beliefs about PTSD treatment, and symptoms at months 1, 3, and 6 months subsequent to the baseline telephone assessment. The PTSD Checklist-Military Version was used to assess PTSD and the Patient’s Health Questionnaire was used to assess symptoms of depression.
Findings
Female veterans who received an intervention were significantly more likely to have attended treatment over the six-month follow-up period than male veterans who received an intervention (χ2 = 7.91, df = 3, OR = 3.93, p = 0.04).
Conclusions
The CBT intervention may be a critical mechanism to engage female veterans in treatment. Further research is needed to understand how to engage male veterans with PTSD in treatment.
doi:10.1016/j.whi.2015.04.008
PMCID: PMC4569511  PMID: 26051022
OEF/OIF veterans; post-traumatic stress disorder; gender differences; treatment engagement
12.  Trends in Financial Barriers to Medical Care for Women Veterans, 2003–2004 and 2009–2010 
Introduction
Women veterans are a fast-growing segment of the veteran population, yet they face many barriers to medical care. The objective of this study was to examine factors that put women veterans at risk for a financial barrier to medical care.
Methods
We conducted repeated cross-sectional analyses of data from the 2003, 2004, 2009, and 2010 Behavioral Risk Factor Surveillance System. We used weighted logistic regression to examine the risk of a financial barrier to medical care as the primary outcome in a multivariate model controlling for factors in health-related domains.
Results
In 2010, there were an estimated 1,719,750 (11.6%) working-aged veterans who needed to see a doctor in the previous 12 months but could not because of cost. For women, 13.4% faced this financial barrier. Over the study period, facing a financial barrier was consistently associated with insurance coverage, physical and mental distress days, and having children in the home. Other associations emerged in particular years, such as binge drinking in 2010. The trends for women veterans relative to men and for younger women veterans relative to older women veterans show reduction in financial barriers to health care.
Conclusion
The Veteran’s Health Administration (VHA) should continue efforts to reduce financial and other barriers, especially among the higher risk groups we identified. This will help meet the VHA’s objectives of providing comprehensive care to all veterans including women.
doi:10.5888/pcd10.130071
PMCID: PMC3809923  PMID: 24157074
13.  Longitudinal Cognitive Trajectories of Women Veterans from the Women’s Health Initiative Memory Study 
The Gerontologist  2015;56(1):115-125.
Purpose of the Study:
A comparison of longitudinal global cognitive functioning in women Veteran and non-Veteran participants in the Women’s Health Initiative (WHI).
Design and Methods:
We studied 7,330 women aged 65–79 at baseline who participated in the WHI Hormone Therapy Trial and its ancillary Memory Study (WHIMS). Global cognitive functioning (Modified Mini-Mental State Examination [3MSE]) in Veterans (n = 279) and non-Veterans (n = 7,051) was compared at baseline and annually for 8 years using generalized linear modeling methods.
Results:
Compared with non-Veterans, Veteran women were older, more likely to be Caucasian, unmarried, and had higher rates of educational and occupational attainment. Results of unadjusted baseline analyses suggest 3MSE scores were similar between groups. Longitudinal analyses, adjusted for age, education, ethnicity, and WHI trial assignment revealed differences in the rate of cognitive decline between groups over time, such that scores decreased more in Veterans relative to non-Veterans. This relative difference was more pronounced among Veterans who were older, had higher educational/occupational attainment and greater baseline prevalence of cardiovascular risk factors (e.g., smoking) and cardiovascular disease (e.g., angina, stroke).
Implications:
Veteran status was associated with higher prevalence of protective factors that may have helped initially preserve cognitive functioning. However, findings ultimately revealed more pronounced cognitive decline among Veteran relative to non-Veteran participants, likely suggesting the presence of risks that may impact neuropathology and the effects of which were initially masked by Veterans’ greater cognitive reserve.
doi:10.1093/geront/gnv663
PMCID: PMC4906317  PMID: 26615021
Women; Veterans; Cognition; Cognitive decline; Risk factors
14.  Pregnancy and Mental Health Among Women Veterans Returning from Iraq and Afghanistan 
Journal of Women's Health  2010;19(12):2159-2166.
Abstract
Background
Veterans of Operations Enduring Freedom and Iraqi Freedom (OEF/OIF) may experience significant stress during military service that can have lingering effects. Little is known about mental health problems or treatment among pregnant OEF/OIF women veterans. The aim of this study was to determine the prevalence of mental health problems among veterans who received pregnancy-related care in the Veterans Health Administration (VHA) system.
Methods
Data from the Defense Manpower Data Center (DMDC) deployment roster of military discharges from October 1, 2001, through April 30, 2008, were used to assemble an administrative cohort of female OEF/OIF veterans enrolled in care at the VHA (n = 43,078). Pregnancy and mental health conditions were quantified according to ICD-9-CM codes and specifications. Mental healthcare use and prenatal care were assessed by analyzing VHA stop codes.
Results
During the study period, 2966 (7%) women received at least one episode of pregnancy-related care, and 32% of veterans with a pregnancy and 21% without a pregnancy received one or more mental health diagnoses (p < 0.0001). Veterans with a pregnancy were twice as likely to have a diagnosis of depression, anxiety, posttraumatic stress disorder (PTSD), bipolar disorder, or schizophrenia as those without a pregnancy.
Conclusions
Women OEF/OIF veterans commonly experience mental health problems after military service. The burden of mental health conditions is higher among women with an identified instance of pregnancy than among those without. Because women do not receive pregnancy care at the VHA, however, little is known about ongoing concomitant prenatal and mental healthcare or about pregnancy outcomes among these women veterans.
doi:10.1089/jwh.2009.1892
PMCID: PMC3052271  PMID: 21039234
15.  Fracture Rates and Bone Density Among Postmenopausal Veteran and Non-Veteran Women From the Women’s Health Initiative 
The Gerontologist  2016;56(Suppl 1):S78-S90.
Purpose of the Study:
Postmenopausal osteoporosis can impact quality-of-life even prefracture. To determine whether osteoporosis should be a greater concern in women Veterans versus non-Veterans, we compared fracture rates and bone mineral density (BMD) for Veterans and non-Veterans using Women’s Health Initiative data.
Design and Methods:
In this cohort study, participants were women aged 50–79 years. Outcomes were hip, central body, and limb fractures occurring during up to 19 years of follow-up and hip, spine, and whole body BMD collected three times over a 6-year period in a participant subsample. Covariates comprised risk factors for fracture, including fall history and other components of the World Health Organization Fracture Risk Assessment Tool (FRAX). Cox Proportional Hazards models were used to examine fracture rates for Veterans compared with non-Veterans.
Results:
Of 161,808 women, 145,521 self-identified as Veteran (n = 3,719) or non-Veteran (n = 141,802). Baseline FRAX scores showed that Veterans had higher 10-year probabilities for any major fracture (13.3 vs 10.2; p < .01) and hip fracture (4.1 vs 2.2; p < .01) compared with non-Veterans. The age-adjusted rate of hip fracture per 1,000 person-years for Veterans was 3.3 versus 2.4 for non-Veterans (p < .01). After adjustment, the hazards ratio for hip fracture was 1.24 (95% confidence interval 1.03–1.49) for Veterans versus non-Veterans. Hazards ratios at other anatomic sites did not differ by Veteran status. Mean BMD at baseline and at Years 3 and 6 also did not differ by Veteran status at any site.
Implications:
Women Veterans had an increased hip fracture rate not explained by differences in well-recognized fracture risk factors.
doi:10.1093/geront/gnv677
PMCID: PMC4759700  PMID: 26768394
Osteoporosis; Cohort; Risk factors; Fracture; Postmenopausal osteoporosis; Veterans
16.  A controlled trial of Partners in Dementia Care: veteran outcomes after six and twelve months 
Introduction
“Partners in Dementia Care” (PDC) tested the effectiveness of a care-coordination program integrating healthcare and community services and supporting veterans with dementia and their caregivers. Delivered via partnerships between Veterans Affairs medical centers and Alzheimer’s Association chapters, PDC targeted both patients and caregivers, distinguishing it from many non-pharmacological interventions. Hypotheses posited PDC would improve five veteran self-reported outcomes: 1) unmet need, 2) embarrassment about memory problems, 3) isolation, 4) relationship strain and 5) depression. Greater impact was expected for more impaired veterans. A unique feature was self-reported research data collected from veterans with dementia.
Methods and Findings
Five matched communities were study sites. Two randomly selected sites received PDC for 12 months; comparison sites received usual care. Three structured telephone interviews were completed every 6 months with veterans who could participate.
Results
Of 508 consenting veterans, 333 (65.6%) completed baseline interviews. Among those who completed baseline interviews, 263 (79.0%) completed 6-month follow-ups and 194 (58.3%) completed 12-month follow-ups. Regression analyses showed PDC veterans had significantly less adverse outcomes than those receiving usual care, particularly for more impaired veterans after 6 months, including reduced relationship strain (B = −0.09; p = 0.05), depression (B = −0.10; p = 0.03), and unmet need (B = −0.28; p = 0.02; and B = −0.52; p = 0.08). PDC veterans also had less embarrassment about memory problems (B = −0.24; p = 0.08). At 12 months, more impaired veterans had further reductions in unmet need (B = −0.96; p < 0.01) and embarrassment (B = −0.05; p = 0.02). Limitations included use of matched comparison sites rather than within-site randomization and lack of consideration for variation within the PDC group in amounts and types of assistance provided.
Conclusions
Partnerships between community and health organizations have the potential to meet the dementia-related needs and improve the psychosocial functioning of persons with dementia.
Trial Registry
NCT00291161
doi:10.1186/alzrt242
PMCID: PMC3978714  PMID: 24764496
17.  Lower prevalence of psychiatric conditions when negative age stereotypes are resisted 
Older military veterans are at greater risk for psychiatric disorders than same-aged non-veterans. However, little is known about factors that may protect older veterans from developing these disorders. We considered whether an association exists between the potentially stress-reducing factor of resistance to negative age stereotypes and lower prevalence of the following outcomes among older veterans: suicidal ideation, anxiety, and posttraumatic stress disorder (PTSD). Participants consisted of 2031 veterans, aged 55 or older, who were drawn from the National Health and Resilience in Veterans Study, a nationally representative survey of American veterans. The prevalence of all three outcomes was found to be significantly lower among participants who fully resisted negative age stereotypes, compared to those who fully accepted them: suicidal ideation, 5.0% vs. 30.1%; anxiety, 3.6% vs. 34.9%; and PTSD, 2.0% vs. 18.5%, respectively. The associations followed a graded linear pattern and persisted after adjustment for relevant covariates, including age, combat experience, personality, and physical health. These findings suggest that developing resistance to negative age stereotypes could provide older individuals with a path to greater mental health.
doi:10.1016/j.socscimed.2014.06.046
PMCID: PMC4372137  PMID: 25189737
Aging; Age stereotypes; Mental health; Stress; Suicide; Anxiety; Posttraumatic stress disorder; Veterans
18.  Psychiatric symptoms of Turkish combat-injured non-professional veterans 
European Journal of Psychotraumatology  2016;7:10.3402/ejpt.v7.29157.
Background
It is well-known that exposure to combat puts individuals at risk for developing adverse psychological problems, including posttraumatic stress disorder (PTSD), depression, anxiety, and health-related behaviour problems and that the presence of combat-related injury increases the risk for psychopathology. Little is known, however, about the consequences of combat among conscripted soldiers fighting against terrorism in their homeland.
Objective
The main aim of the current study was to examine the prevalence of probable PTSD, severity of PTSD symptoms, depression, anxiety, and PTSD-related functional impairment among Turkish combat-injured, non-professional veterans. In addition, investigated were also the possible differences among the symptoms of PTSD, depression, and anxiety of the veterans by the frequency of current cigarette and alcohol use.
Methods
A total of 366 male veterans were assessed by using a demographic information form, which obtained information about injury status and health behaviours, the Posttraumatic Stress Diagnostic Scale (PDS), and the Brief Symptom Inventory (BSI). Symptom frequency and multivariate analysis of variances (MANOVA) were used to analyse the data.
Results
The prevalence of probable PTSD was 46.7% (171) among Turkish veterans while 16.4% experienced severe depression and 18% experienced severe anxiety. “Upset at reminders (65.8%)” was the most common PTSD symptom. “Responsibilities related to home (48.4%)” was the most frequently reported PTSD-related functional impairment. Results indicated that veterans who smoke more than half a pack per day scored significantly higher in severity of PTSD symptoms, depression, and anxiety. Contrary to expectations, there was no significant difference in symptoms of PTSD, depression, and anxiety related to the frequency of current alcohol use.
Conclusion
Turkish non-professional veterans with physical injuries have serious psychiatric problems an average of 13 years after a combat experience. Psychiatric and psychosocial services to Turkish non-professional veterans are a substantial and ongoing need.
doi:10.3402/ejpt.v7.29157
PMCID: PMC4819062  PMID: 27041345
Posttraumatic stress disorders; depression; anxiety; functional impairment; combat; injury; veteran
19.  Post-9/11 Veterans and Their Partners Improve Mental Health Outcomes with a Self-directed Mobile and Web-based Wellness Training Program: A Randomized Controlled Trial 
Background
Veterans with history of deployment in the Global War on Terror face significant and ongoing challenges with high prevalences of adverse psychological, physical, spiritual, and family impacts. Together, these challenges contribute to an emerging public health crisis likely to extend well into the future. Innovative approaches are needed that reach veterans and their family members with strategies they can employ over time in their daily lives to promote improved adjustment and well-being.
Objective
The objective of this study was to evaluate effects of use of a Web-based, self-directed program of instruction in mind- and body-based wellness skills to be employed by Global War on Terror veterans and their significant relationship partners on mental health and wellness outcomes associated with postdeployment readjustment.
Methods
We recruited 160 veteran-partner dyads in 4 regions of the United States (San Diego, CA; Dallas, TX; Fayetteville, NC; and New York, NY) through publicity by the Iraq and Afghanistan Veterans of America to its membership. Dyads were randomly allocated to 1 of 4 study arms: Mission Reconnect (MR) program alone, MR plus the Prevention and Relationship Enhancement Program (PREP) for Strong Bonds weekend program for military couples, PREP alone, and waitlist control. We administered a battery of standardized and investigator-generated instruments assessing mental health outcomes at baseline, 8 weeks, and 16 weeks. Dyads in the MR arms were provided Web-based and mobile app video and audio instruction in a set of mindfulness-related stress reduction and contemplative practices, as well as partner massage for reciprocal use. All participants provided weekly reports on frequency and duration of self-care practices for the first 8 weeks, and at 16 weeks.
Results
During the first 8-week reporting period, veterans and partners assigned to MR arms used some aspect of the program a mean of 20 times per week, totaling nearly 2.5 hours per week, with only modest declines in use at 16 weeks. Significant improvements were seen at 8 and 16 weeks in measures of posttraumatic stress disorder, depression, sleep quality, perceived stress, resilience, self-compassion, and pain for participants assigned to MR arms. In addition, significant reductions in self-reported levels of pain, tension, irritability, anxiety, and depression were associated with use of partner massage.
Conclusions
Both veterans and partners were able to learn and make sustained use of a range of wellness practices taught in the MR program. Home-based, self-directed interventions may be of particular service to veterans who are distant from, averse to, or prohibited by schedule from using professional services. Leveraging the partner relationship may enhance sustained use of self-directed interventions for this population. Use of the MR program appears to be an accessible, low-cost approach that supports well-being and reduces multiple symptoms among post-9/11 veterans and their partners.
Trial Registration
Clinicaltrials.gov NCT01680419; https://clinicaltrials.gov/ct2/show/NCT01680419 (Archived by WebCite at http://www.webcitation.org/6jJuadfzj)
doi:10.2196/jmir.5800
PMCID: PMC5059485  PMID: 27678169
veterans; PTSD; moral injury; mind-body therapies; mindfulness; patient-centered care; compassion; Web-based program; reintegration
20.  Factors Related to Attrition from VA Healthcare Use: Findings from the National Survey of Women Veterans 
Journal of General Internal Medicine  2013;28(Suppl 2):510-516.
ABSTRACT
BACKGROUND
While prior research characterizes women Veterans’ barriers to accessing and using Veterans Health Administration (VA) care, there has been little attention to women who access VA and use services, but then discontinue use. Recent data suggest that among women Veterans, there is a 30 % attrition rate within 3 years of initial VA use.
OBJECTIVES
To compare individual characteristics and perceptions about VA care between women Veteran VA attriters (those who discontinue use) and non-attriters (those who continue use), and to compare recent versus remote attriters.
DESIGN
Cross-sectional, population-based 2008–2009 national telephone survey.
PARTICIPANTS
Six hundred twenty-six attriters and 2,065 non-attriters who responded to the National Survey of Women Veterans.
MAIN MEASURES
Population weighted demographic, military and health characteristics; perceptions about VA healthcare; length of time since last VA use; among attriters, reasons for no longer using VA care.
KEY RESULTS
Fifty-four percent of the weighted VA ever user population reported that they no longer use VA. Forty-five percent of attrition was within the past ten years. Attriters had better overall health (p = 0.007), higher income (p < 0.001), and were more likely to have health insurance (p < 0.001) compared with non-attriters. Attriters had less positive perceptions of VA than non-attriters, with attriters having lower ratings of VA quality and of gender-specific features of VA care (p < 0.001). Women Veterans who discontinued VA use since 2001 did not differ from those with more remote VA use on most measures of VA perceptions. Overall, among attriters, distance to VA sites of care and having alternate insurance coverage were the most common reasons for discontinuing VA use.
CONCLUSIONS
We found high VA attrition despite recent advances in VA care for women Veterans. Women’s attrition from VA could reduce the critical mass of women Veterans in VA and affect current system-wide efforts to provide high-quality care for women Veterans. An understanding of reasons for attrition can inform organizational efforts to re-engage women who have attrited, to retain current users, and potentially to attract new VA patients.
doi:10.1007/s11606-013-2347-y
PMCID: PMC3695263  PMID: 23807058
Veterans; women’s health; access to care; attrition
21.  Health Care Utilization and Health Indicators Among a National Sample of U.S. Veterans in Same-Sex Partnerships 
Military medicine  2013;178(2):207-212.
Objectives
To examine health indicators of same-sex partnered veterans as compared with their opposite-sex partnered veteran and nonveteran peers.
Methods
Same-sex partner status was derived by self-reported same-sex partnerships in data from the 2004 Behavioral Risk Factor Surveillance System. Outcome variables included health risk disparities associated with sexual minority status (e.g., frequent mental distress) and veteran status (e.g., firearm ownership). Stratified multiple logistic regression models were used to examine the association of same-sex partnered veteran status with health indicators.
Results
Same-sex partnered veterans had higher odds of being overweight and keeping firearms in the house compared with same-sex partnered nonveterans. Same-sex partnered veterans were less likely than opposite-sex partnered veterans to be overweight, and they were more than twice as likely to be current smokers when compared with opposite-sex partnered nonveterans.
Conclusions
Findings suggest both that some health disparities patterns identified by same-sex partnership status among the general population also exist among veteran populations, and that some unique distinctions may exist, particularly related to BMI and firearm ownership. Collection of information about sexual minority status within Department of Veterans Affairs data sources is needed to more accurately assess the health of this minority population.
PMCID: PMC3725588  PMID: 23495467
22.  Use of outpatient care in VA and Medicare among disability-eligible and age-eligible veteran patients 
Background
More than half of veterans who use Veterans Health Administration (VA) care are also eligible for Medicare via disability or age, but no prior studies have examined variation in use of outpatient services by Medicare-eligible veterans across health system, type of care or time.
Objectives
To examine differences in use of VA and Medicare outpatient services by disability-eligible or age-eligible veterans among veterans who used VA primary care services and were also eligible for Medicare.
Methods
A retrospective cohort study of 4,704 disability- and 10,816 age-eligible veterans who used VA primary care services in fiscal year (FY) 2000. We tracked their outpatient utilization from FY2001 to FY2004 using VA administrative and Medicare claims data. We examined utilization differences for primary care, specialty care, and mental health outpatient visits using generalized estimating equations.
Results
Among Medicare-eligible veterans who used VA primary care, disability-eligible veterans had more VA primary care visits (p < 0.001) and more VA specialty care visits (p < 0.001) than age-eligible veterans. They were more likely to have mental health visits in VA (p < 0.01) and Medicare-reimbursed visits (p < 0.01). Disability-eligible veterans also had more total (VA+Medicare) visits for primary care (p < 0.01) and specialty care (p < 0.01), controlling for patient characteristics.
Conclusions
Greater use of primary care and specialty care visits by disability-eligible veterans is most likely related to greater health needs not captured by the patient characteristics we employed and eligibility for VA care at no cost. Outpatient care patterns of disability-eligible veterans may foreshadow care patterns of veterans returning from Afghanistan and Iraq wars, who are entering the system in growing numbers. This study provides an important baseline for future research assessing utilizations among returning veterans who use both VA and Medicare systems. Establishing effective care coordination protocols between VA and Medicare providers can help ensure efficient use of taxpayer resources and high quality care for disabled veterans.
doi:10.1186/1472-6963-12-51
PMCID: PMC3359202  PMID: 22390389
Outpatient; Utilization; Primary care; Veterans; Medicare
23.  The study of reproductive outcome and the health of offspring of UK veterans of the Gulf war: methods and description of the study population 
BMC Public Health  2003;3:4.
Background
The aim of this study is to determine whether Gulf war veterans and their partners are at increased risk of adverse reproductive events and whether their children have increased risk of serious health problems. Methods and response to the study are reported here.
Methods
This was a retrospective cohort study of reproduction among UK Gulf war veterans, with a comparison cohort of Armed Service personnel who were not deployed to the Gulf. Reproductive history and details of children's health was collected by means of a validated postal questionnaire. A separate study of non-responders was conducted.
Results
Questionnaires were returned by a total of 25,084 Gulf war veterans (24,379 men) and 19,003 (18,439 men) subjects in the comparison group. After adjusting for undelivered mail the response rate was 53% for Gulf war veterans and 42% for non-Gulf veterans among men, 72% and 60% among women. Data from the non-responder study suggests that failure to respond to the main survey was largely unrelated to reproduction. 11,155 (46%) male Gulf war veterans and 7,769 (42%) male non-Gulf war veterans had conceived, or attempted to conceive, since the Gulf war. They reported 16442 and 11517 pregnancies respectively in that period. For women, 313 (44%) Gulf veterans and 235 (42%) non-Gulf veterans reported 484 and 377 pregnancies respectively conceived since the Gulf war.
Conclusions
This survey enabled collection of information on a range of reproductive outcomes from veterans of the Gulf war and a suitably matched comparison cohort. Although the response rate for men was disappointing, selection bias related to reproduction does not appear to be strong in these data.
doi:10.1186/1471-2458-3-4
PMCID: PMC149233  PMID: 12523940
24.  Suicide and Substance Use among Female Veterans: a Need for Research 
Background
The number of female veterans is increasing. Veterans Administration (VA) enrollment increased over 40% from past eras. However, little research has focused on their mental health. We reviewed literature to examine associations of substance use with suicide in female veterans, identify research gaps, and inform future studies.
Methods
Google Scholar, Pub Med, and PsychINFO were searched using: substance use, female veteran, and suicide. Exclusion criteria (e.g., not discussing U.S. veterans) left 17 articles.
Results
Nine studies examined completed suicide among veterans. In most recent years, rates of deaths were greater for veterans than nonveterans, including females. Completed suicide was associated with past trauma, young age, and a mental disorder. Studies have often not addressed substance use. Three studies examined completed suicide among VA treated veterans without examining substance use as an associated factor. Rates of completed suicides were also higher among veterans than nonveterans, including females. A large proportion of females also had a mental diagnosis. Five studies examined substance use and attempted or completed suicide among VA treated veterans. Veterans in poor mental health had increased odds of suicide mortality; women with a substance use disorder (SUD) had a higher hazard ratio for completed suicide than men with a SUD. Engagement in substance abuse treatment decreased odds of suicide attempt among veterans.
Conclusion
Available data suggest that suicide rates are higher among female veterans than women in the general population. Substance use may increase the likelihood of suicidal behaviors among female veterans, particularly those with a mental diagnosis.
doi:10.1016/j.drugalcdep.2013.11.009
PMCID: PMC3945024  PMID: 24315571
Female Veteran; Suicide; Substance Abuse; Substance Use
25.  Experiences with VHA care: a qualitative study of U.S. women veterans with self-reported trauma histories 
BMC Women's Health  2017;17:38.
Background
Women veterans in the United States, particularly those with posttraumatic stress disorder (PTSD) or a history of military sexual assault, have unique health care needs, but their minority status in the US Veterans Health Administration (VHA) has led to documented healthcare disparities when compared to men. This study’s objective was to obtain a richer understanding of the challenges and successes encountered by women veterans with self-reported service-related trauma histories (particularly those with a history of military sexual assault and/or posttraumatic stress symptomology) receiving VHA care.
Methods
Thirty-seven female Vietnam and post-Vietnam (1975–1998) era veterans were randomly selected from a cohort of PTSD disability benefit applicants to complete semi-structured interviews in 2011–2012. Grounded-theory informed procedures were used to identify interview themes; differences between veterans with and without a history of military sexual assault were examined through constant comparison.
Results
At the time of the interviews, many women believed that VHA was falling short of meeting women veterans’ needs (e.g., lack of women-only mental health programming). Also common, but particularly among those with a military sexual assault history, was the perception that VHA’s environment was unwelcoming; being “surrounded by men” yielded emotions ranging from discomfort and mistrust to severe anxiety. A few veterans reported recent positive changes and offered additional suggestions for improvement.
Conclusions
Findings suggest that while at the time of the interviews gains had been made in the delivery of gender-sensitive outpatient medical care, women veterans with a history of military sexual assault and/or posttraumatic stress symptomology perceived that they were not receiving the same quality of care as male veterans.
doi:10.1186/s12905-017-0395-x
PMCID: PMC5450063  PMID: 28558740
Women; Veterans; Qualitative research; Patient satisfaction; Posttraumatic stress disorder; Military sexual assault

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