Highlights on Post-Deployment Health Research among Women

Highlights on Post-Deployment Health Research among

WomenElizabeth M. Yano, PhD, MSPH

VA Greater Los Angeles HSR&D Center of Excellence

UCLA School of Public Health

Women in the Military• Women now represent:

– 15% active duty– 20% new recruits – 17% reserve/National Guard

• Equalization of hardships/risks– 71% w/1+ combat exposure

• Fastest growing segment of new VA users– Currently 5-7% of VA users, but

>40% OEF/OIF market penetration

• Different sociodemographics– >60% under age 45, minorities

Source: Murdoch, et al., Women and war: What physicians need to know. JGIM, 21:S5-10, 2006.

Purpose of Talk• To review highlights from current

post-deployment health research among women veterans– Both post-deployment health and

women veterans research are top priorities in VA

– Need to inform development and design of programs that improve entry into and delivery of appropriate services

Health & Safety of Women in the Reserves, National Guard & Active Duty

Military• Goal Study antecedent risks of sexual

violence and consequent health outcomes in deployed Reserve/National Guard & Active Duty women

• VA HSR&D and DoD funded companion studies

• Comparison groups are women:– Not deployed– Deployed to combat regions once– Deployed to combat regions more than once– Deployed elsewhere other than combat regionsAnne Sadler, PhD, RN (PI), BM Booth, BL Cook, MA Mengeling,JC Toner; Iowa City VA.

Health & Safety of Women in the Reserves, National Guard & Active Duty

Military:Preliminary Results

• Lack of knowledge about mental health symptoms• Barriers to reporting post-deployment problems• Barriers to care• Unmet or delayed mental health care• Cross-leveling stressors (deployed with other than

home unit)• Couple and parenting readjustment issues• Social isolation• Concern about other soldier’s readjustment

problems

Anne Sadler, PhD, RN (PI), BM Booth, BL Cook, MA Mengeling,JC Toner; Iowa City VA.

Stigma, Gender and Other Barriers to Care for OEF/OIF Veterans

• Goal Explore the unique contribution of stigma-related factors to VA health care seeking

• National sample of female and male OEF/OIF veterans

• Phase 1 (focus groups) completed– Six focus groups with male and female OEF/OIF

veterans (including VA users and non-users)

• Phase 2 (survey) ongoing– Mail survey to a stratified national sample of

1,538 OEF/OIF veteransDawne Vogt, PhD, Principal InvestigatorNational Center for PTSD (Boston VA Healthcare System)

Stigma, Gender and Other Barriers to Care: Preliminary Phase 1

Findings• Reluctance to acknowledge mental health problems due to perceived stigma

• Tendency to want to “tough it out” with respect to mental health problems

• Concerns about impact of using VA on career and confidentiality of records

• General sense VA is for veterans who are older and men with severe mental health problems or physical disabilities

• Women veterans – feel need to “suck it up” to prove worth as service members– feeling out of place in VA, that their service is less respected

because of assumption that they do not experience direct combat

Dawne Vogt, PhD, Principal InvestigatorNational Center for PTSD (Boston VA Healthcare System)

Further Development of the Deployment Risk & Resilience

Inventory (DRRI)• DRRI is a suite of scales used to assess pre-, during

and post-deployment factors for stress-related illnesses– Primarily intended for research but clinical applications

possible

• Goal Revise DRRI to make it broadly applicable to different veteran subgroups (e.g., OEF/OIF veterans, female veterans)

• Phase 1 (focus groups) completed– Six focus groups with diverse population of male and female

OEF/OIF veterans

• Phase 2 (survey) proposal under review– Mail survey to stratified random sample of 1000 OEF/OIF veterans to

validate DRRI-2 scales and develop short formsDawne Vogt, PhD, Principal InvestigatorNational Center for PTSD (Boston VA Healthcare System)

Reintegration and Service Needs of Women Veteran Mothers

• Goal Deepen understanding of concerns and stressors that accompany reintegration into civilian life for OEF/OIF Reserve and Guard women veterans who were or were not mothers of dependent children at deployment– Reintegration issues related to family and to work– Barriers to use of current services and how to

improve these services

• Focus groups and semi-structured interviews of previously deployed OEF/OIF women veterans

Gudrun Lange, PhD (PI) & Karen Quigley, PhD (Co-PI)NJ War Related Illness & Injury Study Center (WRIISC)

Reintegration and Service Needs of Women Veteran Mothers:

Family• Feelings of isolation and having difficult

communicating with family and friends• Not having enough time to “readjust”• Family members’ expectations for them to

return to their former roles and “old selves”• Difficulties bonding with children (differed

depending on age of child, time/distance away)

• Feeling need to “compensate” for being away• Feeling “out of sync” w/children,

partners/familyGudrun Lange, PhD (PI) & Karen Quigley, PhD (Co-PI)NJ War Related Illness & Injury Study Center (WRIISC)


Family• “My husband thought I was going to come

back and straighten it all out…he, you know let them get away with a little bit more…”

• “I felt like I had missed out on so much…I just felt like so detached from everything and everyone. Then as more time went on I’m trying to play catch up, trying to find out what I missed.”Gudrun Lange, PhD (PI) & Karen Quigley, PhD (Co-PI)NJ War Related Illness & Injury Study Center (WRIISC)

Reintegration and Service Needs of Women Veteran Mothers: Work• Employment concerns (with or without children)

– Making more $$ in military than since returning home– Difficulty finding civilian job that pays as well as military

• Going back to school as attractive option (GI bill)• Difficulties in money management

– From having basic needs (housing, food, clothing) taken care of to learning how to budget/manage $$

– Made more difficult by lower earning power– Tensions about (mis)management of $$ while away


Reintegration and Service Needs of Women Veteran Mothers: Work

• “I was making more money deployed than my civilian job. So I ended up having to look for another job.”

• “I came back and needed to look for a new job, and I just had to wait. I just didn’t feel like I could…I wasn’t in the mindset…I just couldn’t get back on my feet…until I got a couple months, and you know I just once I decided in my mind that I was ready to go back to work.”Gudrun Lange, PhD (PI) & Karen Quigley, PhD (Co-PI)NJ War Related Illness & Injury Study Center (WRIISC)


Barriers• Hard time finding supports upon return home• Vocal about need for additional support from

military and VA to help them with reintegration– VA needs to “reach out” to them with supports

within 3-6 months of return home

• Insufficient pre-deployment planning for financial matters, custody arrangements for minor children

• Family support groups and post-deployment briefings of variable quality and helpfulnessGudrun Lange, PhD (PI) & Karen Quigley, PhD (Co-PI)NJ War Related Illness & Injury Study Center (WRIISC)


Barriers• “I signed up the VA forms and got hooked up

because I didn’t have any medical insurance and needed to follow up with that. As far as mental issues, I really didn’t have anybody to help me out with them, so I thought I’d go to the church… just to talk to someone.”

• “You get stared at a lot when you come here [VA].”

• “I think it’s very important that they understand that women are different from men also. That you can’t just throw [everyone] in a group…”


Women at War Survey• Goals

– Identify among men and women deployed to OEF and OIF• Frequency of combat exposure and military

sexual trauma (MST)• Post-deployment adjustment post-exposure• Explore additive effects of both combat and

MST

– Examine gender differences in VA health care use and satisfaction with VA care

Amy Street, PhD, Principal InvestigatorWomen’s Health Sciences Division

Women at War Survey

Amy Street, PhD, Principal InvestigatorWomen’s Health Sciences Division

• Funded by National Center for PTSD• Mail survey of 2000 female and 2000 male

OEF-OIF veterans• Measures:

• Deployment stressors, traumatic brain injury, mental and physical health symptoms, readjustment issues, relationship and family functioning, suicidal behavior

Women Veterans Cohort Study

• Goal To evaluate use, costs and outcomes among female and male OEF/OIF veterans after separation from service– 2-years post-discharge, 2-years after coverage

ends – Compare diagnosis/treatment of stress-related

conditions– Assess trajectories in use, cost, outcomes by

gender over time

• OEF/OIF roster from Defense Manpower Data Center who have enrolled in VA or used VA care

• Multi-site prospective cohort studyCynthia Brandt, MD, MPH (PI) & Sally Haskell, MD (Co-PI)VA Connecticut Healthcare System


• 12% of VA-enrolled OEF/OIF vets are women• OEF/OIF women veterans (vs. men) are:

– Younger (average 2 years)– More likely to be racial-ethnic minorities– Less likely to be married– More likely to be educated beyond high school– More likely to be active duty (vs. NG/R)– More likely to be Air Force, less to be Marines– More likely to be officers

Cynthia Brandt, MD, MPH (PI) & Sally Haskell, MD (Co-PI)VA Connecticut Healthcare System


• Most prevalent conditions among women:– Back problems, joint problems, PTSD,

depression

• Many gender differences, women have:– More depression, less PTSD– More connective tissue and skin disorders– Less hypertension, hyperlipidemia,

diabetes or coronary artery disease– Less alcohol or drug abuse



• Enrollment for prospective cohort in two sites underway– Assessing demographics, deployment

info, combat exposure, traumatic life events, depression, quality of life, social support, stress, sexual behavior, eating behavior, PTSD, alcohol use, smoking, substance abuse, military sexual trauma, pain, satisfaction, utilization, medication, comorbidities, reproductive health history


National Survey of Women Veterans

• Goal Assess health care needs, VA experiences, knowledge/awareness of VA eligibility and services, preferences for care

• Funded by VA Office of Public Health & Environmental Hazards (Women Veterans Health Strategic Health Care Group)– Last such national survey conducted in 1985

• Over 3,500 telephone interviews completed– VA users + non-users; OEF/OIF oversampled

Donna L. Washington, MD, MPH (Principal InvestigatorVA Greater Los Angeles Healthcare System

Post-Deployment Health Research among Women

Veterans: Next Steps• Translate qualitative research findings into

improved programs and delivery models• Important to synthesize findings across

research studies (validation, adaptation)• Relatively small size requires special

attention to their inclusion in VA research– Observational studies, clinical trials, etc.– WV practice-based research network (PBRN)

Source: Yano EM, Hayes P, Wright S, et al. Importance of inclusion of womenveterans in VA quality improvement research. J Gen Intern Med. 2009:[in press].

VA Health Services Research Priorities:

Post-Deployment Health• Outreach, coordination of care, recognition of

unique injuries and problems, including chronic care needs of this new generation of veterans– Improve transitions between acute care, outpatient

care and community needs; evaluate caregiver needs

– Chronic pain, PTSD, neurological disorders, TBI, rehab (vision, hearing, mobility, neurological losses), military sexual trauma

• Treatment effectiveness/quality at veteran and system levels, emotional and cognitive recovery, community reintegration, overall quality of life

Highlights on Post-Deployment Health Research among Women

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