Factors Associated with Delayed Care Among Women Veterans Actively Engaged in Primary Care.

Background: Delaying needed medical care contributes to greater health risks and higher long-term medical costs. Women Veterans with complex medical and mental health needs face increased barriers to timely care access. Objectives: In a sample of women Veterans with recent engagement in Veterans Administration (VA) primary care, we aimed to compare characteristics of women Veterans who delayed care in the past 6 months with those who did not and examine factors associated with self-reported delayed care. Our study aims to inform interventions focused on eliminating health care access disparities among women Veterans. Materials and Methods: An innovation to improve women Veterans' engagement and retention in evidence-based health care for cardiovascular (CV) risk reduction (CV Toolkit) was implemented across five primary care sites within the VA. Women Veterans who were exposed to at least one CV Toolkit component participated in a mailed survey (n = 253). We used multivariate logistic regression to model factors associated with delaying care, including trust in VA providers, positive mental health screening (i.e., positive screen for either depression or anxiety), traumatic experience, self-rated health, and age. Results: Women with any mental health symptoms (odds ratio [OR] 2.42, 95% confidence interval [CI]: 1.23-4.74) and women who had experienced a traumatic event (OR 2.61, 95%CI: 1.11-6.14) were significantly more likely to report delaying care. Conclusions: Our study identified high rates of delayed care-over one-third of respondents-among women Veterans with recent primary care engagement. Mental health symptoms were the most common reported reason for delay among those who delayed care. Clinical Trial registration: NCT02991534.

Ask and Ask Again: Repeated Screening for Smoking Increases Likelihood of Prescription for Cessation Treatment Among Women Veterans.

BACKGROUND: Preventive screening at the point of care can increase desired clinical outcomes. However, the impact of repeated screening for tobacco use on receiving smoking cessation treatment among women Veteran population has not been documented. OBJECTIVE: To examine screening for tobacco use using clinical reminders and the association between the number of screenings and prescription for cessation treatment. DESIGN: A retrospective analysis using data from a 5-year implementation trial for cardiovascular risk identification conducted between December 2016 and March 2020. SUBJECTS: Women patients who had at least one primary care visit with a women's health provider during the study period at five primary care clinics in the Veterans Affairs (VA) Healthcare System. MEASURES: The outcome is prescription of pharmacotherapy or referral to behavioral counseling for smoking cessation on or after the screening date. The exposure is the number of screenings for tobacco use from the trial and the annual VA national clinical reminders during the study period. RESULTS: Of 6009 eligible patients, 5788 (96.3%) were screened at least once for tobacco use over five calendar years, and 2784 of those screened (48.1%) were reported as current and former smokers. Among current and former smokers, 709 (25.5%) received a prescription and/or referral for smoking cessation. In the adjusted model, the average predicted probability of prescription and/or referral for smoking cessation was 13.7% among current and former smokers screened once over 5 years, 18.6% among screened twice, 26.5% among screened thrice, 32.9% among screened four times, and 41.7% among screened five or six times. CONCLUSIONS: Repeated screening was associated with higher predicted probabilities of being prescribed smoking cessation treatment.

Use of alcohol as a sleep aid, unhealthy drinking behaviors, and sleeping pill use among women veterans.

OBJECTIVES: Sleep complaints, such as insomnia and sleep disturbances caused by posttraumatic stress disorder (PTSD), are more common among women veterans than nonveteran women. Alcohol use among some women may be partially motivated by the desire to improve sleep. This study evaluated rates of alcohol use as a sleep aid among women veterans and explored the relationship between alcohol use to aid sleep and drinking frequency and sleeping pill use. DESIGN AND SETTING: National cross-sectional population-based residential mail survey on sleep and other symptoms. PARTICIPANTS: Random sample of women veteran VA users who completed a postal survey (N = 1533). INTERVENTIONS: None. MEASUREMENTS: The survey included demographics, Insomnia Severity Index, Primary Care PTSD screen, and items on alcohol use frequency (days/week), use of prescription or over-the-counter sleep medications, and use of alcohol as a sleep aid (yes/no for each item) over the past month. RESULTS: A total of 14.3% of respondents endorsed using alcohol to aid sleep. Logistic regression models showed more severe insomnia (odds ratio [OR] = 1.03; 95% confidence interval [CI]: 1.01-1.06) and PTSD (OR = 2.11; 95% CI: 1.49-2.97) were associated with increased odds of using alcohol to aid sleep. Alcohol use to aid sleep was associated with increased odds of daily drinking (OR = 8.46; 95% CI: 4.00-17.87) and prescription (OR = 1.79; 95% CI: 1.34-2.38) and over-the-counter sleep aid use (OR = 1.54; 95% CI: 1.12-2.11). CONCLUSIONS: Insomnia and PTSD may increase risk for using alcohol as a sleep aid, which may increase risk for unhealthy drinking and for mixing alcohol with sleep medications. Findings highlight the need for alcohol use screening in the context of insomnia and for delivery of cognitive-behavioral therapy for insomnia to women veterans with insomnia.

Timely access to mental health care among women veterans.

Using survey data on (N = 419) patients at Department of Veterans Affairs (VA) clinics we analyzed women veterans' reports of timely access to VA mental health care. We evaluated problems that patients might face in obtaining care, and examined subjective ratings of VA care as a function of timely access to mental health care. We found that 59% of participants reported "always" getting an appointment for mental health care as soon as needed. In adjusted analyses, two problems were negatively associated with timely access to mental health care: (a) medical appointments that interfere with other activities, and (b) difficulty getting questions answered between visits. Average subjective ratings of VA ranged from 8.2-8.6 out of 10, and 93% of participants would recommend VA care. Subjective ratings of VA were higher among women who reported timely access to mental health care. Findings suggest that overall experience of care is associated with timely access to mental health care, and that such access may be amenable to improvements related to clinic hours or mechanisms for answering patient questions between visits. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Mental Health Screening Results Associated with Women Veterans' Ratings of Provider Communication, Trust, and Care Quality.

BACKGROUND: Identifying factors influencing patient experience and communication with their providers is crucial for tailoring comprehensive primary care for women veterans within the Veterans Health Administration. In particular, the impact of mental health (MH) conditions that are highly prevalent among women veterans is unknown. METHODS: From January to March 2015, we conducted a cross-sectional survey of women veterans with three or more primary care and/or women's health visits in the prior year at 12 Veterans Health Administration sites. Patient measures included ratings of provider communication, trust in provider, and care quality; demographics, health status, health care use; and brief screeners for symptoms of depression, anxiety, and posttraumatic stress disorder. We used multivariate models to analyze associations of patient ratings and characteristics. RESULTS: Among the 1,395 participants, overall communication ratings were high, but significant variations were observed among women screening positive for MH conditions. In multivariate models, high communication ratings were less likely among women screening positive for multiple MH conditions compared with patients screening negative (odds ratio, 0.43; p < .001). High trust in their provider and high care ratings were significantly less likely among women with positive MH screens. Controlling for communication, the effect of MH on trust and care ratings became less significant, whereas the effect of communication remained highly significant. CONCLUSIONS: Women veterans screening positive for MH conditions were less likely to give high ratings for provider communication, trust, and care quality. Given the high prevalence of MH comorbidity among women veterans, it is important to raise provider awareness about these differences, and to enhance communication with patients with MH symptoms in primary care.

Estimated Prevalence of Insomnia among Women Veterans: Results of a Postal Survey.

OBJECTIVES: Insomnia is a significant public health concern known to particularly impact women and the veteran population; however, rates of insomnia disorder among women veterans are not known. METHOD: Women veterans who had received health care at VA Greater Los Angeles Healthcare System between 2008 and 2010 and resided within 25 miles of the facility were sent a postal survey assessing sleep, demographics, and other related patient characteristics. RESULTS: A total of 660 women (43.1% of potential responders) returned the postal survey and provided sufficient information for insomnia diagnosis. On average, women reported 6.2 hours of sleep per night. The prevalence of insomnia, determined according to diagnostic criteria from the International Classification of Sleep Disorders-2, was 52.3%. Women with insomnia reported more severely disturbed sleep, and more pain, menopausal symptoms, stress/worries, and nightmares compared with women without insomnia. There was a quadratic relationship between age and insomnia with women in their mid-40s, most likely to have insomnia. CONCLUSIONS: This survey study found that insomnia symptoms were endorsed by more than one-half of the women veterans in this sample of VA users, highlighting the critical need for enhanced clinical identification and intervention. Further research is needed to establish national rates of insomnia among women veterans and to improve access to evidence-based treatment of insomnia disorder.

Factors Associated With Accepting Assistance for Smoking Cessation Among Military Veterans.

INTRODUCTION: Cigarette smoking remains a significant health risk for Veterans. Increased understanding of factors that influence the tobacco cessation referral process within Veterans Affairs medical facilities is useful for enhancing utilization of smoking cessation treatment. The present study examined the association of demographic and health variables with whether smokers accepted referral for medication and/or tobacco cessation clinic. METHODS: Electronic medical record data (2011-2013) were obtained for a sample of US military Veterans who accepted cessation assistance from their health care provider. Demographic and diagnostic variables were examined to identify predictors of the types of assistance accepted (medication only, clinic referral only, or both). RESULTS: The sample includes 2941 Veterans, 10.3% female, 19.9% African American, 10.7% Hispanic, and 57.9% non-Hispanic white. Veterans averaged of 50.69 years of age (SD = 14.01), 31.5% had a substance use disorder diagnosis and 54.1% had a psychiatric diagnosis. Demographic and diagnostic information was compared across types of assistance accepted. Significant differences were found between those who accepted medications only and those who accepted either clinic referral or both medication and clinic referral. Veterans in the latter two categories were younger and more likely to have a psychiatric diagnosis than those accepting medication only. Women Veterans were significantly more likely than men to accept clinic referral plus medication. However, in contrast to men, almost none of the variables examined were associated with the type of assistance accepted by women. CONCLUSION: These findings indicate significant gender differences in influences on accepting assistance for smoking cessation among Veterans. IMPLICATIONS: Existing research identifies factors associated with unassisted quitting. However, little is known regarding the referral process, which is critical in connecting smokers with treatment. The present work is unique in employing electronic medical record data to examine factors associated with accepting different types of smoking cessation treatment referrals. This study represents an initial effort to elucidate the smoking cessation treatment referral process. These findings highlight the need to examine sex specific influences on smoking cessation treatment utilization and the importance of focusing on smokers with psychiatric disorders.

Acceptability of Medication and Nonmedication Treatment for Insomnia Among Female Veterans: Effects of Age, Insomnia Severity, and Psychiatric Symptoms.

PURPOSE: Female veterans are at high risk for sleep problems, and there is a need to provide effective treatment for this population who experience insomnia. This study's primary goal was to compare the acceptability of medication versus nonmedication treatments for insomnia among female veterans. In addition, we examined the role of patient age, severity of sleep disturbance, and psychiatric symptoms on acceptability of each treatment approach and on the differences in acceptability between these approaches. METHODS: A large nationwide postal survey was sent to a random sample of 4000 female veterans who had received health care at a Veterans Administration (VA) facility in the previous 6 months (May 29, 2012-November 28, 2012). A total of 1559 completed surveys were returned. Survey items used for the current analyses included: demographic characteristics, sleep quality, psychiatric symptoms, military service experience, and acceptability of medication and nonmedication treatments for insomnia. For analysis, only ratings of "very acceptable" were used to indicate an interest in the treatment approach (vs ratings of "not at all acceptable," "a little acceptable," "somewhat acceptable," and "no opinion/don׳t know"). FINDINGS: In the final sample of 1538 women with complete data, 57.7% rated nonmedication treatment as very acceptable while only 33.5% rated medication treatment as very acceptable. This difference was statistically significant for the group as a whole and when examining subgroups of patients based on age, sleep quality, psychiatric symptoms, and military experience. The percentage of respondents rating medication treatment as very acceptable was higher for women who were younger, had more severe sleep disturbances, had more psychiatric symptoms, who were not combat exposed, and who had experienced military sexual trauma. By contrast, the percentage of respondents rating nonmedication treatment as very acceptable differed only by age (younger women were more likely to find nonmedication treatment acceptable) and difficulty falling asleep. IMPLICATIONS: Female veterans are more likely to find nonmedication insomnia treatment acceptable compared with medication treatment. Thus, it is important to match these patients with effective behavioral interventions such as cognitive behavioral therapy for insomnia. Efforts to educate providers about these preferences and about the efficacy of cognitive behavioral therapy for insomnia may serve to connect female veterans who have insomnia to the treatment they prefer. These findings also suggest that older female veterans may be less likely to find either approach as acceptable as their younger counterparts.

Social facilitation expectancies for smoking: psychometric properties of a new measure.

OBJECTIVE: Expectancies about social outcomes for smoking are relevant to college student smokers, who frequently report "social smoking." A new measure, the Social Facilitation Expectancies (SFE) scale, was developed to assess these beliefs. PARTICIPANTS: The SFE was administered to undergraduate college student smokers (N = 1,096; study completed in May 2011). METHODS: Items were scored on a 5-point scale with a summed total score. The sample was randomly split and principle axis factoring and confirmatory factor analysis applied to determine scale structure. The structure was tested across sex and smoking groups and validation analyses were conducted. RESULTS: A 9-item, 1-factor scale was replicated within each group. Higher SFE scores were observed among those with greater smoking experience and higher scores were associated with greater endorsement of other smoking-related beliefs. CONCLUSIONS: These preliminary findings provide support for the sound psychometric properties of this measure for use with young adult college students.

Cigarette smoking initiation during college predicts future alcohol involvement: a matched-samples study.

OBJECTIVE: Little is known about the relationship between cigarette smoking initiation and subsequent alcohol involvement. To address this question, the present study compared alcohol use between students who initiated smoking during college and a matched sample of never-smoking students. We hypothesized greater increases in alcohol involvement among smoking initiators, mediated by exposure to cigarette use situations. METHOD: Included in the present study were 104 Chinese American and Korean American undergraduates who at baseline (freshman year) reported never having smoked a cigarette. Subjects were drawn from 433 participants in a naturalistic longitudinal study of tobacco use who were assessed annually each year in college. Cigarette smoking status was assessed annually as part of a structured interview. Initiators and never-smokers were matched on gender, ethnicity, baseline alcohol use, parental smoking status, and behavioral undercontrol. RESULTS: As predicted, participants who initiated smoking during college reported significantly greater increases in the number of past-30-day total drinks consumed (p < .001) and reported greater prevalence of heavy drinking episodes (p < .05). The effect of smoking initiation on the change in the number of past-30-day drinks at the final assessment was partially mediated by exposure to smoking (p < .05). Exploratory analyses indicated that greater recent smoking significantly predicted increased alcohol consumption over and above the effect of exposure. CONCLUSIONS: Students who initiate smoking during college appear at risk for increased alcohol involvement. Part of this risk is explained by environmental contextual factors, specifically exposure to situations involving other smokers that also may result in greater exposure to alcohol use.

Psychometric characteristics of the Pittsburgh Sleep Quality Index in English speaking non-Hispanic whites and English and Spanish speaking Hispanics of Mexican descent.

STUDY OBJECTIVES: The current study investigated the factor structure of the Pittsburgh Sleep Quality Index (PSQI) among English speaking non-Hispanic whites (NHW) and English and Spanish speaking Hispanics of Mexican descent (HMD). DESIGN: The PSQI was administered during a telephone interview. In order to test the factor structure of the PSQI structure across ethnic/language groups, multiple group confirmatory analysis with covariates (MIMIC) was employed. The 1- and 3-factor versions of the PSQI previously reported in the literature were examined. SETTING: San Diego County. PARTICIPANTS: Community-dwelling English speaking, NHW (n = 1,698) and English (n = 654) and Spanish (n = 792) speaking HMD. MEASUREMENT AND RESULTS: A single-factor scoring model fit across language/ethnic groups; however, a 3-factor model provided a better than the 1-factor model in all language/ethnic groups. The subscale sleep medications loaded poorly and was removed from all models. CONCLUSION: Across groups, a 3-factor model of the PSQI more reliably assessed sleep quality than a single-factor global score. Results indicate that the 3-factor structure of the PSQI was uniform across English speaking NHW and English and Spanish speaking HMD.

A prospective study of the Acquired Preparedness Model: the effects of impulsivity and expectancies on smoking initiation in college students.

This study reports on a prospective test of the Acquired Preparedness Model, which posits that impulsivity influences cigarette smoking through the formation of more positive and fewer negative expectancies about smoking effects. College freshman never-smokers (n = 400; 45% male) completed a baseline interview and quarterly online follow-up assessments for 15 months after baseline. Structural equation modeling indicated that the effects of the impulsivity components of sensation seeking and negative urgency on risk of smoking initiation were mediated by expectancies for positive and negative reinforcement from smoking, respectively. Expectancies about negative consequences from smoking predicted initiation but did not mediate the effects of sensation seeking or negative urgency. Findings are consistent with the Acquired Preparedness Model and suggest that heightened impulsivity is associated with heightened expectancies for reinforcement from smoking, and thus with greater risk for smoking initiation.

A prospective study of the effects of the DRD2/ANKK1 TaqIA polymorphism and impulsivity on smoking initiation.

This study tested whether DRD2/ANKK1 TaqIA genotype predicted smoking initiation and subsequent use, and effects were mediated by sensation seeking and negative urgency. Between 2009 and 2012, college never smokers (n = 387) completed six assessments over 15 months; those who reported smoking were classified as initiators. Logistic regression indicated that the A1 allele was associated with initiation (p = .003). This effect was partially mediated by sensation seeking and negative urgency. Effects were stronger in Asian Americans. Findings have implications for improving prevention by including elements focused on urges to seek positive or negative reinforcement. Limitations and future directions are discussed.

Progression to problem drinking among Mexican American and White European first-year college students: a multiple group analysis.

OBJECTIVE: Problem drinking during college is a well-known phenomenon. However, predictors of progression to problematic drinking, particularly among ethnic minorities such as Mexican Americans, have received limited research attention. METHOD: The current study compared the rates and predictors of problem drinking progression from the first to the second year of college among four groups: Mexican American men, Mexican American women, White European men, and White European women (N = 215). At baseline, participants were all first-year college students who scored as nonproblem drinkers on the Young Adult Alcohol Problems Screening Test (YAAPST). Participants were classified as progressors or stable nondrinkers/nonproblem drinkers based on YAAPST scores 12 months later. Hypothesized predictors of progression included behavioral undercontrol, negative emotionality, alcohol use expectancies, and cultural orientation (Mexican American sample only). Differences were anticipated between gender and ethnic groups in both progression rates and predictors of progression. RESULTS: Twenty-nine percent of the sample progressed to problematic drinking; however, no differences emerged by gender or ethnicity. For the full sample, higher behavioral undercontrol and higher negative emotionality significantly predicted progression. Differences in predictors were not found across gender and ethnic subgroups. CONCLUSIONS: The hypothesis that rates of progression to problem drinking would differ among the four gender and ethnic groups was not supported. Thus, although White European men are most often identified as at high risk for alcohol use problems, the present findings indicate that women and Mexican American students also should be targeted for prevention and/or intervention.

Do expectancies for reinforcement from smoking change after smoking initiation?

Expectancies are important predictors of smoking behavior. Recent research suggests that expectancies are not stable and vary across internal and external states and levels of cigarette consumption. Expectancies may also vary between individuals as a function of temperamental characteristics such as behavioral undercontrol (BU). Although pre-initiation expectancies have been linked to subsequent smoking behaviors, no study has assessed the effect of smoking initiation on expectancies. The present study was designed to test the hypotheses that both positive (PRE) and negative (NRE) reinforcement expectancies would increase following initiation, and that these changes would be moderated by BU. College students were interviewed 12-15 months apart. Those who initiated smoking between assessments (n = 69) were included in the present study. Linear mixed models showed a significant increase in PRE but not NRE from pre- to postinitiation. The relationship between NRE and time was moderated by BU, such that higher BU was associated with significantly larger post-initiation increases in NRE. Findings suggest that PRE and NRE change significantly following experience with smoking. Furthermore, undercontrolled, impulsive individuals may be particularly vulnerable to smoking with the intention of alleviating aversive states.