Prevalence of Intimate Partner Violence among Women Veterans who Utilize Veterans Health Administration Primary Care.

OBJECTIVES: The objectives of this study were to identify the prevalence of past-year intimate partner violence (IPV) among women Veterans utilizing Veterans Health Administration (VHA) primary care, and to document associated demographic, military, and primary care characteristics. DESIGN: This was a retrospective cohort design, where participants completed a telephone survey in 2012 (84% participation rate); responses were linked to VHA administrative data for utilization in the year prior to the survey. PARTICIPANTS: A national stratified random sample of 6,287 women Veteran VHA primary care users participated in the study. MAIN MEASURES: Past-year IPV was assessed using the HARK screening tool. Self-report items and scales assessed demographic and military characteristics. Primary care characteristics were assessed via self-report and VHA administrative data. KEY RESULTS: The prevalence of past-year IPV among women Veterans was 18.5% (se = 0.5%), with higher rates (22.2% - 25.5%) among women up to age 55. Other demographic correlates included indicators of economic hardship, lesbian or bisexual orientation, and being a parent/guardian of a child less than 18 years old. Military correlates included service during Vietnam to post-Vietnam eras, less than 10 years of service, and experiences of Military Sexual Trauma (MST). Most (77.3%, se = 1.2%) women who experienced IPV identified a VHA provider as their usual provider. Compared with women who did not report past-year IPV, women who reported IPV had more primary care visits, yet experienced lower continuity of care across providers. CONCLUSIONS: The high prevalence of past-year IPV among women beyond childbearing years, the majority of whom primarily rely on VHA as a source of health care, reinforces the importance of screening all women for IPV in VHA primary care settings. Key considerations for service implementation include sensitivity with respect to sexual orientation, race/ethnicity, and other aspects of diversity, as well as care coordination and linkages with social services and MST-related care.

Patient Activation and Mental Health Care Experiences Among Women Veterans.

We utilized a nationally representative survey of women veteran primary care users to examine associations between patient activation and mental health care experiences. A dose-response relationship was observed, with odds of high quality ratings significantly greater at each successive level of patient activation. Higher activation levels were also significantly associated with preference concordant care for gender-related preferences (use of female providers, women-only settings, and women-only groups as often as desired). Results add to the growing literature documenting better health care experiences among more activated patients, and suggest that patient activation may play an important role in promoting engagement with mental health care.

Access to mental health care among women Veterans: is VA meeting women's needs?

BACKGROUND: Patient-centered access to mental health describes the fit between patient needs and resources of the system. To date, little data are available to guide implementation of services to women veterans, an underrepresented minority within Department of Veteran Affairs (VA) health care. The current study examines access to mental health care among women veterans, and identifies gender-related indicators of perceived access to mental health care. METHODS: A population-based sample of 6287 women veterans using VA primary care services participated in a survey of past year perceived need for mental health care, mental health utilization, and gender-related mental health care experiences. Subjective rating of how well mental health care met their needs was used as an indicator of perceived access. RESULTS: Half of all women reported perceived mental health need; 84.3% of those women received care. Nearly all mental health users (90.9%) used VA services, although only about half (48.8%) reported that their mental health care met their needs completely or very well. Gender related experiences (availability of female providers, women-only treatment settings, women-only treatment groups, and gender-related comfort) were each associated with 2-fold increased odds of perceived access, and associations remained after adjusting for ease of getting care. CONCLUSIONS: Women VA users demonstrate very good objective access to mental health services. Desire for, and access to specialized mental health services for women varies across the population and are important aspects of shared decision making in referral and treatment planning for women using VA primary care.

Military sexual trauma among homeless veterans.

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.

Medical care needs of returning veterans with PTSD: their other burden.

BACKGROUND: There has been considerable focus on the burden of mental illness (including post-traumatic stress disorder, PTSD) in returning Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans, but little attention to the burden of medical illness in those with PTSD. OBJECTIVES: (1) Determine whether the burden of medical illness is higher in women and men OEF/OIF veterans with PTSD than in those with No Mental Health Conditions (MHC). (2) Identify conditions common in those with PTSD. DESIGN: Cross-sectional study using existing databases (Fiscal Year 2006-2007). SETTING: Veterans Health Administration (VHA) patients nationally. PATIENTS: All 90,558 OEF/OIF veterans using VHA outpatient care nationally, categorized into strata: PTSD, Stress-Related Disorders, Other MHCs, and No MHC. MEASUREMENTS: (1) Count of medical conditions; (2) specific medical conditions (from ICD9 codes, using Agency for Health Research and Quality's Clinical Classifications software framework). MAIN RESULTS: The median number of medical conditions for women was 7.0 versus 4.5 for those with PTSD versus No MHC (p<0.001), and for men was 5.0 versus 4.0 (p<0.001). For PTSD patients, the most frequent conditions among women were lumbosacral spine disorders, headache, and lower extremity joint disorders, and among men were lumbosacral spine disorders, lower extremity joint disorders, and hearing problems. These high frequency conditions were more common in those with PTSD than in those with No MHC. CONCLUSIONS: Burden of medical illness is greater in women and men OEF/OIF veteran VHA users with PTSD than in those with No MHC. Health delivery systems serving them should align clinical program development with their medical care needs.

Veterans Health Administration mental health treatment settings of patients who report military sexual trauma.

The comprehensive Veterans Health Administration (VHA) policies on military sexual trauma (MST) include provider education and training at each VHA facility. No published data exist that indicate the settings in which VHA mental health patients with MST are treated. Such information could help set priorities for targeted MST-related education and training. The major aim of this article was to describe the VHA mental health outpatient settings in which patients with MST are most likely to be treated. National data from 79,903 female and 889,998 male veteran patients with at least one face-to-face outpatient mental health encounter at any VHA facility in fiscal year 2008 were analyzed. Among all veterans in VHA outpatient mental health care, 35.8% of women and 2.4% of men reported MST. The proportion of MST-positive patients ranged from 25.9% to 81.0% of women and from 1.5% to 56.1% of men across 9 major clinic setting categories. Proportions of women with MST were substantial across specialty MST clinics, specialty posttraumatic stress disorder clinics, psychosocial rehabilitation, and substance use disorder clinics, reflecting a wide range of settings. These settings should be prioritized for MST-related provider education and training. By contrast, male MST patients represented only a small proportion of patients in all clinics, with the exception of MST specialty clinics. Tailored conceptualizations of trauma-informed care are proposed for settings that encounter MST patients, even if these settings do not directly focus on the treatment of traumatic stress.

Military-related sexual trauma among Veterans Health Administration patients returning from Afghanistan and Iraq.

We examined military-related sexual trauma among deployed Operation Enduring Freedom and Operation Iraqi Freedom veterans. Of 125 729 veterans who received Veterans Health Administration primary care or mental health services, 15.1% of the women and 0.7% of the men reported military sexual trauma when screened. Military sexual trauma was associated with increased odds of a mental disorder diagnosis, including posttraumatic stress disorder, other anxiety disorders, depression, and substance use disorders. Sexual trauma is an important postdeployment mental health issue in this population.

Unemployment among women: examining the relationship of physical and psychological intimate partner violence and posttraumatic stress disorder.

Prior research has demonstrated that intimate partner violence (IPV) is associated with employment instability among poor women. The current study assesses the broader relationship between IPV and women's workforce participation in a population-based sample of 6,698 California women. We examined past-year IPV by analyzing specific effects of physical violence, psychological violence, and posttraumatic stress disorder (PTSD) symptoms as predictors of unemployment. Results indicated substantial rates of unemployment among women who reported IPV, with rates of 20% among women who experienced psychological violence, 18% among women who experienced physical violence, and 19% among women with PTSD symptoms. When the relationship was adjusted for demographic characteristics and educational attainment, PTSD (adjusted odds ratio [AOR] = 1.60; 95% confidence interval [CI] = 1.22, 2.09) and psychological violence (AOR = 1.78; 95% CI = 1.36, 2.32), but not physical violence, were associated with unemployment. Implications for supported employment programs and workplace responses to IPV are discussed.

The relationship between child abuse and adult obesity among california women.

BACKGROUND: Despite clinical studies suggesting that child abuse is associated with adult obesity, very few studies have been conducted with large community or state-based samples. This study examines the relationship between child abuse and adult obesity, relative to other risk factors such as demographics, food insecurity, inadequate fruit and vegetable consumption, and physical inactivity, in a representative sample of California women. METHODS: Data are from the California Women's Health Survey, a state-based, random-digit-dial annual probability survey of California women. Participants included 11,115 nonpregnant women aged 18 or older, who provided complete data for all study variables. The telephone interview included assessment of child abuse (abstracted from the Traumatic Stress Schedule), food insecurity, perceived stress, physical activity, fruit and vegetable consumption, height, and weight. Data were collected in 2002, 2003, and 2004, and analyzed in 2006. RESULTS: Obese (body mass index [BMI] of 30 or higher) women were significantly more likely to report exposure to child abuse (odds ratio [OR]=1.32, 95% confidence interval [CI]=1.23-1.42). In a multivariate model adjusted for age, race/ethnicity, education, food insecurity, inadequate fruit and vegetable consumption, physical inactivity, and perceived stress, women exposed to child abuse remained significantly more likely to be obese than unexposed women (adjusted OR=1.27, 95% CI=1.13-1.40). The population-attributable fraction of obesity associated with any type of abuse was 4.5% (95% CI=2.28-6.55). CONCLUSIONS: Exposure to child abuse is associated with adult obesity among California women, even accounting for other relevant variables. This supports the notion that child abuse and its sequelae may be important targets for public health intervention, particularly in subpopulations where the prevalence of child abuse is known to be high.

Intimate partner violence and housing instability.

BACKGROUND: The mental and physical health consequences of intimate partner violence (IPV) have been well established, yet little is known about the impact of violence on a woman's ability to obtain and maintain housing. This cross-sectional study examines the relationship between recent IPV and housing instability among a representative sample of California women. It is expected that women who have experienced IPV will be at increased risk for housing instability as evidenced by: (1) late rent or mortgage, (2) frequent moves because of difficulty obtaining affordable housing, and/or (3) without their own housing. METHODS: Data were taken from the 2003 California Women's Health Survey, a population-based, random-digit-dial, annual probability survey of adult California women (N=3619). Logistic regressions were used to predict housing instability in the past 12 months, adjusting for the following covariates; age, race/ethnicity, education, poverty status, marital status, children in the household, and past year IPV. RESULTS: In the multivariate model, age, race/ethnicity, marital status, poverty, and IPV were significant predictors of housing instability. After adjusting for all covariates, women who experienced IPV in the last year had almost four times the odds of reporting housing instability than women who did not experience IPV (adjusted odds ratio=3.98, 95% confidence interval: 2.94-5.39). CONCLUSIONS: This study found that IPV was associated with housing instability among California women. Future prospective studies are needed to learn more about the nature and direction of the relationship between IPV and housing instability and the possible associated negative health consequences.

Epidemiology and consequences of women's revictimization.

This study uses Kraemer's approach for nonrandom comorbidity to identify the parameters of revictimization among women, using a diverse, population-based sample. Participants (n = 11,056) are from the California Women's Health Survey. Women were asked about childhood and adult violence and current symptoms of posttraumatic stress disorder (PTSD), depression, and anxiety. Logistic regressions adjusted for age, ethnicity, education, and poverty indicate that women who experienced childhood physical or sexual abuse were 5.8 (95% confidence interval, 5.2-6.4) times more likely to experience adult physical or sexual victimization. Revictimization affected 12% of women, and these women were substantially more likely to report current symptoms of anxiety, depression, and PTSD than women exposed to violence only in childhood or only as an adult. Revictimization is a methodologically distinct concept and is a potent risk factor for adult mental health problems. Prevention should target women exposed to both physical and sexual assault.

Military Sexual Trauma Among Recent Veterans: Correlates of Sexual Assault and Sexual Harassment.

INTRODUCTION: Military sexual trauma (MST) includes sexual harassment or sexual assault that occurs during military service and is of increasing public health concern. The population prevalence of MST among female and male veterans who served during Operations Enduring Freedom and Iraqi Freedom (OEF/OIF) has not been estimated to our knowledge. The purpose of this study is to assess the population prevalence and identify military correlates of MST, sexual harassment, and sexual assault among OEF/OIF veterans. METHODS: MST was assessed in the 2009-2011 National Health Study for a New Generation of U.S. Veterans, a survey of 60,000 veterans who served during the OEF/OIF eras (response rate, 34%, n=20,563). Weighted prevalence estimates and AORs of MST, sexual harassment, and sexual assault among women and men were calculated. Gender-stratified logistic regression models controlled for military and demographic characteristics. Data analyses were conducted in 2013-2014. RESULTS: Approximately 41% of women and 4% of men reported experiencing MST. Deployed men had lower risk for MST compared with non-deployed men, though no difference was found among women. However, veterans reporting combat exposure during deployment had increased risk for MST compared with those without, while controlling for OEF/OIF deployment. Among women, Marines and Navy veterans had increased risk for MST compared with Air Force veterans. MST was significantly higher among veterans who reported using Veterans Affairs healthcare services. CONCLUSIONS: These prevalence estimates underscore the importance of public awareness and continued investigation of the public health impact of MST.

Utilization and intensity of outpatient care related to military sexual trauma for veterans from Afghanistan and Iraq.

Little research has examined factors associated with the utilization of outpatient health care services related to sexual assault experiences. The Veterans Health Administration provides free outpatient treatment services to veterans who report military sexual trauma (MST); this system provides a unique opportunity to examine factors related to the utilization of mental health and non-mental health outpatient services by patients with sexual trauma. The current study examined sociodemographic, military service factors, and primary diagnoses related to utilization and utilization intensity of MST-related care among 4,458 Operation Enduring Freedom/Operation Iraqi Freedom Veterans in a 1-year period after reporting an experience of MST. Of the veterans who reported MST, 75.9% received MST-related care. The most notable factor that influenced receipt and intensity of MST-related care was gender, where male veterans used less care than female veterans. These results have important treatment implications for both veteran and civilian sexual trauma survivors.

Military sexual trauma and patient perceptions of Veteran Health Administration health care quality.

BACKGROUND: Although sexual trauma is associated with poorer patient perceptions of health care quality, few studies have investigated this relationship in settings with comprehensive policies surrounding detection and treatment of sexual trauma, such as the Veterans Health Administration (VHA). We examined the association of military sexual trauma (MST) with patient satisfaction with VHA outpatient care among men and women. METHODS: This is a cross-sectional study of a national representative sample of 164,632 VHA outpatients (5,758 women and 158,884 men) from fiscal year 2007. Measures included MST status, patients' ratings of overall satisfaction with VHA care in the last 2 months, and nine other dimensions of patient satisfaction. We assessed bivariate and multivariate associations between MST and overall satisfaction and each dimension of patient satisfaction. Multivariate models were adjusted for demographic characteristics, health status, and medical utilization. All analyses were stratified by gender. FINDINGS: The proportion of patients reporting very good or excellent overall satisfaction was 78.5% for men and 72.3% for women. Findings showed that, once confounding was controlled, men and women veterans' MST status was not associated with satisfaction ratings of VHA health care overall. However, women veterans with a history of MST rated the dimensions of overall coordination and education and information less favorably than women veterans without an MST history. Post hoc analysis of individual items in these domains suggested that areas of improvement might include greater attention to provider-patient communication, including communication across multiple providers. There was no association between men's MST status and subdomains of health care satisfaction. CONCLUSION: Patient ratings of overall satisfaction of VHA care are high. Opportunities exist, however, to educate providers on the special coordination needs of female veterans with histories of MST. These female veterans might benefit from care coordination. When investigating satisfaction in patients with histories of sexual trauma, our findings suggest the importance of adjusting analyses for important patient characteristics.

Adherence to recent screening mammography among Latinas: findings from the California Women's Health Survey.

OBJECTIVES: Latinas are less likely than other racial/ethnic groups to engage in mammography rescreening, but little research has examined why Latinas overdue for screening have not had a mammogram recently. This study investigates the factors that affect adherence to screening mammography guidelines among previously screened Latinas. METHODS: Data are from a population-based, random-digit-dial annual probability survey of California women. Participants included 1298 Latinas aged > or =40 who ever had a mammogram. Multivariate logistic regression was used to examine what factors differentiate adherence to recent screening (having a mammogram < or =2 years ago) from being overdue for screening (having a last mammogram >2 years ago). Perceived barriers to screening were also examined among women overdue for a mammogram. Relationships between self-reported perceived barriers to screening and the identified differentiating factors were assessed using chi-square tests. RESULTS: Adherence to recent mammography was reported by 83.9% of previously screened Latinas. When controlling for significant covariates, factors associated with adherence to recent screening included being aged 50-64, having a college education, preferring to interview in Spanish, having health insurance, and reporting a usual source of care (p < 0.05). Lack of affordability was the most frequently cited perceived barrier to screening among Latinas overdue for screening. Age, education, health insurance, and usual source of care were significantly associated with specific perceived barriers to screening mammography. CONCLUSIONS: Results underscore the impact that affordability of, knowledge about, and convenience in obtaining mammograms have on adherence to recent screening. Strategies to improve mammography adherence among Latinas may need to consider that solely improving access to insurance or a regular source of healthcare, although important, may not be sufficient to improve rates of Latinas' screening mammography adherence.

Lifetime interpersonal violence and self-reported chlamydia trachomatis diagnosis among California women.

OBJECTIVE: To examine the relationship between cumulative exposure to various types of interpersonal violence throughout the life span and self-reported history of Chlamydia trachomatis (CT) diagnosis in a population-based sample of California women. METHODS: This was a cross-sectional analysis of a population-based survey of California women aged 18-44 years (n = 3521). Participants reported their experience of multiple types of interpersonal violence: physical or sexual abuse in childhood or adulthood and intimate partner violence (IPV) in the past 12 months. Current posttraumatic stress disorder (PTSD) and depressive symptoms were also reported. Separate logistic regression models assessed the association between experiencing each type of interpersonal violence, as well as women's cumulative exposure to violence, and past CT diagnosis, adjusting for age, race/ethnicity, and poverty, as well as mental health problems. RESULTS: Six percent of women reported a past diagnosis of CT, and 40.8% reported experiencing at least one type of interpersonal violence in their lifetime. All types of violence were significantly associated with higher odds of having a past CT diagnosis even after controlling for sociodemographics. Women who reported experiencing four or more types of violence experiences had over five times the odds of reporting a lifetime CT diagnosis compared with women who never experienced interpersonal violence (adjusted odds ratio = 5.71, 95% CI 3.27-9.58). Current PTSD and depressive symptoms did not significantly affect the relationship between a woman's cumulative experience of violence and her risk of past CT diagnosis. CONCLUSIONS: There is a robust association between experiencing multiple forms of violence and having been diagnosed with CT. Women who seek treatment for sexually transmitted diseases (STDs), such as CT, should be assessed for their lifetime history of violence, especially violence in their current intimate relationships. Sexual risk reduction counseling may also be important for women who have a history of risky sexual behaviors and who are likely to be reinfected.

Women's childhood and adult adverse experiences, mental health, and binge drinking: the California Women's Health Survey.

BACKGROUND: This study examined sociodemographic, physical and mental health, and adult and childhood adverse experiences associated with binge drinking in a representative sample of women in the State of California. MATERIALS AND METHODS: Data were from the 2003 to 2004 (response rates of 72% and 74%, respectively) California Women's Health Survey (CWHS), a population-based, random-digit-dial annual probability survey sponsored by the California Department of Health Services. The sample was 6,942 women aged 18 years or older. RESULTS: The prevalence of binge drinking was 9.3%. Poor physical health, and poorer mental health (i.e., symptoms of PTSD, anxiety, and depression, feeling overwhelmed by stress), were associated with binge drinking when demographics were controlled, as were adverse experiences in adulthood (intimate partner violence, having been physically or sexually assaulted, or having experienced the death of someone close) and in childhood (living with someone abusing substances or mentally ill, or with a mother vicimized by violence, or having been physically or sexually assaulted). When adult mental health and adverse experiences were also controlled, having lived as a child with someone who abused substances or was mentally ill was associated with binge drinking. Associations between childhood adverse experiences and binge drinking could not be explained by women's poorer mental health status in adulthood. CONCLUSION: Identifying characteristics of women who engage in binge drinking is a key step in prevention and intervention efforts. Binge drinking programs should consider comprehensive approaches that address women's mental health symptoms as well as circumstances in the childhood home.

Self-selection bias in sleep and psychophysiological studies of posttraumatic stress disorder.

Psychobiological studies of posttraumatic stress disorder (PTSD) often challenge participants to assess the dynamics of systems evolved to organize responses to extreme events. Informed consent insures that volunteers have every opportunity to preevaluate the conditions of the research experience and decline if made uncomfortable by them. Notwithstanding their necessity, these protections set the stage for self-selection phenomena that may bias study outcomes. This study compared prospectively obtained psychometric data from 196 participants and 1229 nonparticipants in sleep and psychophysiological studies of PTSD. Lower subjective nightmare severity was endorsed by persons who later agreed to participate in a study of baseline sleep, an observation consistent with the low nightmare frequencies observed in most laboratories studies of sleep in PTSD.