Enhancing Primary Care and Mental Health Integration for Women Veterans with Complex Healthcare Needs Using Evidence-Based Quality Improvement.

BACKGROUND: Women Veterans with co-morbid medical and mental health conditions face persistent barriers accessing high-quality health care. Evidence-based quality improvement (EBQI) offers a systematic approach to implementing new care models that can address care gaps for women Veterans. OBJECTIVE: This study examines factors associated with the successful deployment of EBQI within integrated health systems to improve primary care for women Veterans with complex mental health needs. DESIGN: Following a 12-site (8 EBQI, 4 control) cluster randomized study to evaluate EBQI effectiveness, we conducted an in-depth case study analysis of one women's health clinic that used EBQI to improve integrated primary care-mental health services for women Veterans. PARTICIPANTS: Our study sample included providers, program managers, and clinic staff at a women Veteran's health clinic that, at the time of the study, had one Primary Care and Mental Health Integration team and one women's health primary care provider serving 800 women. We analyzed interviews conducted 12 months, 24 months, and 4 years post-implementation and call summaries between the clinic and support team. MAIN MEASURES: We conducted qualitative thematic analysis of interview and call summary data to identify EBQI elements, clinic characteristics, and reported challenges and successes within project development and execution. KEY RESULTS: The clinic harnessed core EBQI elements (multi-level stakeholder engagement, data-driven progress-monitoring, PDSA cycles, sharing results) to accomplish pre-defined project goals, strengthen inter-disciplinary partnerships, and bolster team confidence. Clinic characteristics that facilitated implementation success included prior QI experience and an organizational culture responsive to innovation, while lack of pre-existing guidelines and limited access to centralized databases posed implementation challenges. CONCLUSIONS: Successful practice transformation emerges through the interaction of evidence-based methods and site-specific characteristics. Examining how clinic characteristics support or impede EBQI adaptation can facilitate efforts to improve care within integrated health systems.

Impact of Evidence-Based Quality Improvement on Tailoring VA's Patient-Centered Medical Home Model to Women Veterans' Needs.

BACKGROUND: Women Veterans' numerical minority, high rates of military sexual trauma, and gender-specific healthcare needs have complicated implementation of comprehensive primary care (PC) under VA's patient-centered medical home model, Patient Aligned Care Teams (PACT). OBJECTIVE: We deployed an evidence-based quality improvement (EBQI) approach to tailor PACT to meet women Veterans' needs and studied its effects on women's health (WH) care readiness, team-based care, and burnout. DESIGN: We evaluated EBQI effectiveness in a cluster randomized trial with unbalanced random allocation of 12 VAMCs (8 EBQI vs. 4 control). Clinicians/staff completed web-based surveys at baseline (2014) and 24 months (2016). We adjusted for individual-level covariates (e.g., years at VA) and weighted for non-response in difference-in-difference analyses for readiness and team-based care overall and by teamlet type (mixed-gender PC-PACTs vs. women-only WH-PACTs), as well as post-only burnout comparisons. PARTICIPANTS: We surveyed all clinicians/staff in general PC and WH clinics. INTERVENTION: EBQI involved structured engagement of multilevel, multidisciplinary stakeholders at network, VAMC, and clinic levels toward network-specific QI roadmaps. The research team provided QI training, formative feedback, and external practice facilitation, and support for cross-site collaboration calls to VAMC-level QI teams, which developed roadmap-linked projects adapted to local contexts. MAIN MEASURES: WH care readiness (confidence providing WH care, self-efficacy implementing PACT for women, barriers to providing care for women, gender sensitivity); team-based care (change-readiness, communication, decision-making, PACT-related QI, functioning); burnout. KEY RESULTS: Overall, EBQI had mixed effects which varied substantively by type of PACT. In PC-PACTs, EBQI increased self-efficacy implementing PACT for women and gender sensitivity, even as it lowered confidence. In contrast, in WH-PACTs, EBQI improved change-readiness, team-based communication, and functioning, and was associated with lower burnout. CONCLUSIONS: EBQI effectiveness varied, with WH-PACTs experiencing broader benefits and PC-PACTs improving basic WH care readiness. Lower confidence delivering WH care by PC-PACT members warrants further study. TRIAL REGISTRATION: The data in this paper represent results from a cluster randomized controlled trial registered in ClinicalTrials.gov (NCT02039856).

Coping with disruptive patients: Perspectives of primary care employees.

BACKGROUND: The impact of patient aggression on primary health care employees is underexplored, yet imperative to address, given high rates of burnout. OBJECTIVE: We qualitatively explore perceptions of patient aggression among staff in women's health primary care at the Veterans Health Administration (VA). Our objective is to identify coping strategies that staf devised in response to aggressive behavior. METHODS: We conducted semi-structured interviews with 60 VA women's health primary care employees in 2021 and 2022. Informed by the Job Demands-Resources theoretical model, we used rapid qualitative analysis to identify themes related to patient aggression and employee coping strategies. RESULTS: Disruptive behaviors reported by participants included verbal and physical aggression. Staff cited disruptive patient behavior as emotionally draining and perceived a lack of consequences for low-level aggression. Respondents used coping strategies in response to patient aggression at three time points: before, during, and after a negative interaction. At each point, support from team members emerged as a dominant coping mechanism, as well as rapport-building with patients. CONCLUSION: Patient aggression can negatively impact the work experiences of primary care employees. At VA, women's health primary care staff have devised multiple strategies to cope with these interactions. However, the ability to effectively prevent and manage patient aggression is limited by the lack of meaningful repercussions for aggression at the organizational level, which has important implications for employee well-being and retention. Retention of women's health employees in VA is critical given the need for a highly specialized workforce to address the complex health needs of women veterans.

Improving primary care team functioning through evidence based quality improvement: A comparative case study.

BACKGROUND: Provision of team-based primary care (PC) is associated with improved care quality, but limited empirical evidence guides practices on how to optimize team functioning. We examined how evidence-based quality improvement (EBQI) was used to change PC team processes. EBQI activities were supported by research-clinical partnerships and included multilevel stakeholder engagement, external facilitation, technical support, formative feedback, QI training, local QI development and across-site collaboration to share proven practices. METHODS: We used a comparative case study in two VA medical centers (Sites A and B) that engaged in EBQI between 2014 and 2016. We analyzed multiple qualitative data sources: baseline and follow-up interviews with key stakeholders and provider team ("teamlet") members (n = 64), and EBQI meeting notes, reports, and supporting materials. RESULTS: Site A's QI project entailed engaging in structured daily huddles using a huddle checklist and developing a protocol clarifying team member roles and responsibilities; Site B initiated weekly virtual team meetings that spanned two practice locations. Respondents from both sites perceived these projects as improving team structure and staffing, team communications, role clarity, staff voice and personhood, accountability, and ultimately, overall team functioning over time. CONCLUSION: EBQI enabled local QI teams and other stakeholders to develop and implement innovations to improve PC team processes and characteristics in ways that improved teamlet members' perceptions of team functioning. IMPLICATIONS: EBQI's multi-level approach may empower staff and facilitate innovation by and within teams, making it an effective implementation strategy for addressing unique practice-based challenges and supporting improvements in team functioning across varied clinical settings. LEVEL OF EVIDENCE: VI.

Challenges to Engaging Women Veterans in Quality Improvement From Patient Care to Policy: Women's Health Managers' Perspectives.

INTRODUCTION: Patients are uniquely positioned to identify issues and to provide innovative solutions to problems impacting their care. Yet, patient engagement in quality improvement (QI) and health care governance remains limited and underexplored. In the Veterans Health Administration, the work of women's health managers (WHMs) includes engaging women veterans, a numerical minority with unique health care needs, in QI. We aimed to understand the extent to which WHMs engage women veterans along a continuum, highlight challenges to engagement, and identify potential strategies to facilitate multilevel patient engagement. METHODS: Data were generated from a multisite evaluation to improve delivery of comprehensive women's health care in Veterans Health Administration primary care sites. We conducted 39 semistructured interviews with WHMs across 21 sites. Guided by Carman et al.'s patient engagement framework, we analyzed the interviews using rapid-qualitative and content analysis methods. RESULTS: When effectively engaged, women veterans were important champions and partners in QI activities to improve the structure and delivery of care. However, most WHMs engaged women veterans in mainly informal or passive ways-that is, solicited feedback through comment cards, surveys, focus groups, and townhall meetings-and did not report pursuing more in-depth or long-term forms of engagement. WHMs also identified a variety of facilitators and challenges to engaging women veterans in QI. CONCLUSIONS: There may be unanticipated benefits to health care policy from engaging patients in QI, especially for patients with unique health care needs who represent a minority within the health care system. However, managers require training and workflow integration of patient engagement tasks to increase their efficiency and allow for meaningful patient engagement.

Association Between Availability of Women's Health Services and Women Veterans' Care Experiences.

INTRODUCTION: Few studies have focused on determinants of women's ratings of care experiences in primary care. We assessed associations between availability of women's health services and women veterans' ratings of care experiences. METHODS: In a cross-sectional analysis, we linked Fiscal Year (FY) 2017 (October 1, 2016, to September 30, 2017) survey data from 126 Veterans Health Administration (VA) primary care leaders to 4,254 women veterans' ratings of care from VA's Survey of Healthcare Experiences of Patients-Patient Centered Medical Home (FY 2017). The dependent variables were ratings of optimal access (appointments, information), care coordination, comprehensiveness (behavioral health assessment), patient-provider communication, and primary care provider. Key independent variables were number of women's health services 1) routinely available all weekday hours (compared with some hours or not available) and 2) available in VA general primary care vs. other arrangements. In multilevel logistic regression models, we adjusted for patient-, facility-, and area-level characteristics. RESULTS: A greater number of women's health services routinely available in VA primary care was associated with a higher likelihood of optimal ratings of care coordination (adjusted odds ratio [AOR], 1.06; 95% confidence interval [CI], 1.01-1.10), provider communication (AOR, 1.08; 95% CI, 1.002-1.16), and primary care provider (AOR, 1.07; 95% CI, 1.02-1.13). A greater number of services available in VA primary care was associated with a lower likelihood of optimal ratings for access (AOR, 0.94; 95% CI, 0.88-0.99). CONCLUSION: For the most part, routine availability of women's health services in VA primary care clinics enhanced women's healthcare experiences. These empirical findings offer healthcare leaders evidence-based approaches for improving women's care experiences.

Women Veterans' Healthcare Needs, Utilization, and Preferences in Veterans Affairs Primary Care Settings.

BACKGROUND: The Veterans Health Administration (VA) is the largest integrated health system in the US and provides access to comprehensive primary care. Women Veterans are the fastest growing segment of new VA users, yet little is known about the characteristics of those who routinely access VA primary care in general or by age group. OBJECTIVE: Describe healthcare needs, utilization, and preferences of women Veterans who routinely use VA primary care. PARTICIPANTS: 1,391 women Veterans with 3+ primary care visits within the previous year in 12 VA medical centers (including General Primary Care Clinics, General Primary Care Clinics with designated space for women, and Comprehensive Women's Health Centers) in nine states. METHODS: Cross-sectional survey (45% response rate) of sociodemographic characteristics, health status (including chronic disease, mental health, pain, and trauma exposure), utilization, care preferences, and satisfaction. Select utilization data were extracted from administrative data. Analyses were weighted to the population of routine users and adjusted for non-response in total and by age group. KEY RESULTS: While 43% had health coverage only through VA, 62% received all primary care in VA. In the prior year, 56% used VA mental healthcare and 78% used VA specialty care. Common physical health issues included hypertension (42%), elevated cholesterol (39%), pain (35%), and diabetes (16%). Many screened positive for PTSD (41%), anxiety (32%), and depression (27%). Chronic physical and mental health burdens varied by age. Two-thirds (62%) had experienced military sexual trauma. Respondents reported satisfaction with VA women's healthcare and preference for female providers. CONCLUSIONS: Women Veterans who routinely utilize VA primary care have significant multimorbid physical and mental health conditions and trauma histories. Meeting women Veterans' needs across the lifespan will require continued investment in woman-centered primary care, including integrated mental healthcare and emphasis on trauma-informed, age-specific care, guided by women's provider preferences.

What Drives Women Veterans' Trust in VA Healthcare Providers?

INTRODUCTION: Little is known about women veterans' trust in Veterans Affairs (VA) health care and what factors promote trust in VA providers. We examined provider behaviors and characteristics of women veterans associated with trust in their VA providers. METHODS: We used a 2015 survey of women veterans who were routine users of primary care at 12 VA medical centers (n = 1,395). Patient trust in their VA provider was measured on a seven-item scale. We used multiple logistic regression to examine associations of patient-provider communication and gender appropriateness with complete trust in VA provider (100 [complete trust] vs. <100 [less than complete trust]), controlling for patient characteristics. RESULTS: On average, 39.7% of women veterans reported complete trust in their VA providers. Those with complete trust reported greater patient-provider communication and gender appropriateness of VA services than those with less-than-complete trust (all ps ≤ .001). In multiple logistic regression models, higher ratings of provider communication (adjusted odds ratio, 2.37), gender-appropriate care (adjusted odds ratio, 1.93), and trauma-sensitive communication (adjusted odds ratios, 1.79-6.08) were associated with a higher likelihood of reporting complete trust in their VA provider. CONCLUSIONS: Women veterans reported high levels of trust in their VA providers. Provider communication, gender-appropriate care, and trauma-sensitive communication were associated with greater patient trust. Although it is important to highlight the steps already taken by VA to increase the quality of care for women veterans, current findings suggest that women veterans' trust may be further increased by interventions to improve trauma-informed care by VA providers.

Managers' and Leaders' Perceptions of Sexual and Gender-Based Public Harassment in the Veterans Health Administration.

PURPOSE: Managers and leaders have a critical role to play in sexual and gender-based harassment prevention within organizations. Although the Veterans Health Administration has committed to eliminating harassment through national directives and training programs, it is unclear how aware local-level managers and leaders are about public harassment at their facilities and how they perceive sexual and gender-based harassment. We examined middle managers' and leaders' views about whether harassment is perceived as a problem locally, and what policies and procedures (if any) are in place to address public harassment. METHODS: We conducted 69 semistructured telephone interviews with middle managers and facility leaders before implementation of an evidence-based quality improvement project designed to improve delivery of comprehensive women's health care. Transcripts were coded using the constant comparative method and analyzed for overarching themes. RESULTS: Perceptions of the prevalence of sexual and gender-based public harassment varied among middle managers and leaders. A little more than one-half of respondents were unaware of facility-level policies and procedures to address public harassment between patients. To decrease patient-to-patient harassment, both groups generally supported the creation of separate clinical spaces for women. However, middle managers also stated that education was needed to change patient harassing behavior, which they tied to male military culture. CONCLUSIONS: Aligning divergent perspectives of what constitutes sexual and gender-based harassment and how to address it is a necessary step towards tackling harassment at the local level. Managers and leaders should continue to assess environments of care and share findings widely among employees and leadership to improve awareness and inform a unified response.

The Relationship Between Sexual Assault History and Cervical Cancer Screening Completion Among Women Veterans in the Veterans Health Administration.

Background: Sexual assault affects one in three U.S. women and may have lifelong consequences for women's health, including potential barriers to completing cervical cancer screening and more than twofold higher cervical cancer risk. The objective of this study was to determine whether a history of sexual assault is associated with reduced cervical cancer screening completion among women Veterans. Materials and Methods: We analyzed data from a 2015 survey of women Veterans who use primary care or women's health services at 12 Veterans Health Administration facilities (VA's) in nine states. We linked survey responses with VA electronic health record data and used logistic regression to examine the association of lifetime sexual assault with cervical cancer screening completion within a guideline-concordant interval. Results: The sample included 1049 women, of whom 616 (58.7%) reported lifetime sexual assault. Women with a history of sexual assault were more likely to report a high level of distress related to pelvic examinations, and to report ever delaying a gynecologic examination due to distress. However, in the final adjusted model, lifetime sexual assault was not significantly associated with reduced odds of cervical cancer screening completion (OR 1.35, 95% CI 0.93-1.97). Conclusions: Contrary to our expectations, sexual assault was not significantly associated with gaps in cervical cancer screening completion. Three- to five-year screening intervals may provide sufficient time to complete screening, despite barriers. Trauma-sensitive care practices promoted in the VA may allow women to overcome the distress and discomfort of pelvic examinations to complete needed screening. ClinicalTrials.gov (#NCT02039856).

Discontinuity of Women Veterans' Care in Patient-Centered Medical Homes: Does Workforce Gender Sensitivity Matter?

BACKGROUND: Prior research has found that 25% of women veterans who are new to the Department of Veterans Affairs (VA) health care system discontinue services within 3 years of initial use. Although it has been suggested that providing more gender-sensitive care might improve women veterans' health care experiences, no study has yet documented an empirical relationship between clinic and provider factors associated with the provision of gender-sensitive care and women veterans' care discontinuity. METHODS: Surveys of primary care providers (n = 82) and staff members (n = 108) from 12 VA medical centers were linked to administrative data for women veteran patients with at least one primary care visit in 2014 and 2015 (n = 9,958). Patient care discontinuity was operationalized as having no additional primary care visit within 3 years after the patient's baseline visit. Key indicators of gender-sensitive comprehensive primary care included type of medical home (women's health-focused vs. general primary care), workforce gender sensitivity, team functioning, perceived quality of provider/staff communication, leadership support for medical home implementation, and other structural components of care delivery (e.g., chaperone availability). We used logistic regression to assess the association between these indicators and women's care discontinuity, measuring discontinuity for both new and continuing VA users and controlling for patient characteristics. RESULTS: Eleven percent of women patients discontinued primary care within 3 years. Poor workforce gender sensitivity (lowest quartile vs. top three quartiles) was significantly associated with higher odds of discontinuity (odds ratio, 1.26; 95% confidence interval, 1.01-1.57); other indicators were not associated with discontinuity. CONCLUSIONS: This study is the first to document a relationship between workforce gender sensitivity and women veterans' care continuity. This finding underscores the need for additional attention to enhancing workforce gender sensitivity in VA.

Dynamic waitlisted design for evaluating a randomized trial of evidence-based quality improvement of comprehensive women's health care implementation in low-performing VA facilities.

BACKGROUND: Women's Health Services (WHS) in the Veterans Health Administration (VA) has long partnered with VA researchers to evaluate how VA care is organized for women veterans. This partnership has yielded substantial evidence of (1) variations in women veterans' access to comprehensive healthcare services that contribute to disparities in quality and patient experience and (2) the positive impacts of gender-specific care models for women veterans' quality and satisfaction. In an effort to provide support specifically to sites that were low-performing in women's health, WHS and the VA Quality Enhancement Research Initiative co-funded an effort to roll out and evaluate evidence-based quality improvement (EBQI), an implementation strategy with demonstrated effectiveness in a prior cluster randomized trial in women's health clinics. METHODS: We will identify 21 low-performing VA facilities through a combination of practice data, VA quality metrics (by gender), and other indicators. In partnership with WHS, an EBQI contractor will deliver the EBQI "package"-local consensus development and priority setting using stakeholder panels, multilevel stakeholder engagement, practice facilitation, local EBQI team training, and formative feedback-to participating sites. We propose a dynamic wait-listed design to evaluate the WHS plans for seven EBQI launches per year over 3 years. The goal is to evaluate (1) barriers and facilitators to achieving delivery of comprehensive women's health care in low-performing VA facilities; (2) effectiveness of EBQI in supporting low-performing VA facilities to achieve improved practice features (e.g., level of comprehensive services available, care coordination arrangements, Patient Aligned Care Team (PACT) features implemented, environment of care improvements), provider/staff attitudes (e.g., improved gender awareness, women's health knowledge and practice), quality of care, and patient experience; and (3) contextual factors, local implementation processes, and organizational changes over time. DISCUSSION: Access to comprehensive women's health care reduces fragmentation of care, improves patient satisfaction, and results in better patient outcomes. We hypothesize that EBQI implementation will result in changes in leadership awareness and buy-in, multilevel engagement in problem-solving, an enhanced culture of quality improvement, structural changes in care, improved provider/staff attitudes, and better quality and patient experience. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03238417. Registered 3 August 2017. Retrospectively registered, https://clinicaltrials.gov/ct2/show/study/NCT03238417.

The role of healthcare system hassles in delaying or forgoing care.

BACKGROUND: Several factors besides appointment availability can influence access to care. Among these factors are the diverse challenges that patients may experience in navigating the healthcare system. However, the relationship between these challenges or "hassles" and delaying or forgoing care has not been assessed. METHODS: We examined the relationship between healthcare system hassles and delaying or forgoing needed care. We used data from a 2016 Veterans Affairs (VA) survey of women veterans (N = 821) who were active users of primary care (3+ primary care visits in the past year) at any of 12 VA medical centers. The main independent variable was a measure of 16 healthcare system hassles, encompassing a wide range of clinically-relevant aspects of patient experience, such as uncertainty about when/how to take a medication or difficulty getting questions answered between appointments. The outcome was a self-reported measure of delaying or forgoing needed care. We used logistic regression to estimate this outcome as a function of hassles, adjusting for age, comorbidities, and health care utilization. Survey weights accounted for within-site clustering, nonproportional sampling, and nonresponse. RESULTS: Overall, 26% of participants reported 0 hassles, and 39% reported 4 or more. Reporting 4 or more hassles (vs. 0) was associated with a roughly 5-fold increase in the predicted probability of delaying or forgoing care. CONCLUSION: Addressing healthcare system hassles could yield unexpected benefits to realized access.

Understanding Gender Sensitivity of the Health Care Workforce at the Veterans Health Administration.

BACKGROUND: Gender sensitivity of providers and staff has assumed increasing importance in closing historical gender disparities in health care quality and outcomes. The Department of Veterans Affairs (VA) has implemented several initiatives intended to improve gender sensitivity of its health care workforce. The current study examines practice- and individual-level characteristics associated with gender sensitivity of primary care providers (PCPs) and staff. METHODS: We surveyed PCPs and staff (nurses, medical assistants, and clerks) at 12 VA medical centers (VAMCs) (n = 256 of 649; response rate, 39%). Gender sensitivity was measured using a 10-item scale adapted from the Gender Awareness Inventory-VA. We used weighted multivariate regression with maximum likelihood estimation to identify individual- and practice-level characteristics associated with gender sensitivity of PCPs and staff. RESULTS: PCPs and staff had similar gender sensitivity but differed in most characteristics associated with that gender sensitivity. Among PCPs, women's health training and positive communication with others in the clinic were associated with greater gender sensitivity. For staff, prior work experience caring for women, working in Women's Health Patient-Aligned Care Teams, and rural location were associated with greater gender sensitivity, whereas more years of VA service was associated with lower gender sensitivity. Working at VA medical centers with a higher volume of women veteran patients was associated with greater gender sensitivity for both PCPs and staff. CONCLUSIONS: Women's health training and experience in working with other women's health professionals are strongly correlated with greater gender sensitivity in the clinical workforce.

Exploring the association of care fragmentation and patient ratings of care quality: A mediation analysis of women Veterans' experience with VA care.

OBJECTIVE: To examine the relationship between care fragmentation and patient ratings of care quality and identify potentially actionable mediators. DATA SOURCES/STUDY SETTING: 2015 telephone survey of 1395 women Veterans with three or more visits in primary care and/or women's health care in the prior year at 12 Veterans Affairs (VA) medical centers. STUDY DESIGN: Cross-sectional analysis. DATA COLLECTION/EXTRACTION METHODS: We operationalized lower care fragmentation as receiving VA-only care versus dual use of VA/non-VA care. Participants rated VA care quality (overall care, women's health care (WH), and primary care (PC)) and three aspects of their patient experience (ease of access to services, provider communication, and gender sensitivity of VA environments). We examined associations between care fragmentation and care ratings and applied the Karlson-Holm-Breen decomposition method to test for mediation by aspects of patients' experience. PRINCIPAL FINDINGS: Lower care fragmentation was associated with higher ratings of care quality (odds ratios [95% CI] for overall care: 1.57 [1.14;2.17]; WH: 1.65 [1.20;2.27]; PC: 1.41 [1.10;1.82]). Relationships were mediated by patient-rated provider communication and gender sensitivity (26-54 percent and 14-15 percent of total effects, respectively). Ease of access was associated with higher care ratings (odds ratios [95% CI] for overall care: 2.93 [2.25;3.81]; WH: 2.81 [2.15;3.68]; PC: 2.33 [1.63;3.33], in models with the three types of patient care experiences included), but did not mediate the association of care fragmentation and care ratings. CONCLUSIONS: Potential negative effects of care fragmentation on care quality ratings could be mitigated by attention to quality of patient-provider communication and gender sensitivity of VA environments.

Prevalence of Stranger Harassment of Women Veterans at Veterans Affairs Medical Centers and Impacts on Delayed and Missed Care.

BACKGROUND: Harassment of servicewomen during military service has been well-documented, but harassment of women veterans in Veterans Affairs (VA) health care settings has not been studied systematically. We assessed the prevalence and impacts of harassment among women veterans who use VA health care. METHODS: From January to March 2015, we conducted computer-assisted telephone interviews of randomly sampled women veterans with three or more primary care and/or women's health visits at 1 of 12 VA medical centers. We asked if patients had experienced inappropriate/unwanted comments or behavior from male veterans at VA in the past year. We measured sociodemographics, health status, perceptions of VA care, delayed/unmet health care need, and care preferences. All analyses were weighted to account for the disproportionate sample design and nonresponse. Brief, open-ended descriptions of harassment were transcribed and coded. RESULTS: Approximately one in four women veterans (25.2%; n = 1,395, response rate 45%) reported inappropriate/unwanted comments or behavior by male veterans on VA grounds. Site prevalence ranged from 10% to 42%. Incident descriptions were wide-ranging (e.g., catcalls, sexual/derogatory remarks, propositioning, stalking, and denigration of veteran status). Reports of harassment were more common among women with histories of military sexual trauma; other trauma exposures (e.g., combat, childhood); positive screens for anxiety, depression, and/or posttraumatic stress disorder; and fair/poor health. Those who reported harassment were significantly less likely to report feeling welcome at VA, and more likely to report not feeling safe, and delaying/missing care. CONCLUSIONS: One-quarter of women veteran VA users experienced harassment in VA health care settings; these experiences negatively impacted women's health care experiences and use.

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.

Access to Care and Health Outcomes Among Women Veterans Using Veterans Administration Health Care: Association With Food Insufficiency.

BACKGROUND: Food insecurity has been associated with worse health outcomes in the civilian population. Male veterans of the Gulf Wars have been shown to have a higher prevalence of food insecurity than similarly situated civilians. Women veterans have more risk factors for food insecurity, relative to male veterans, yet little is known about the prevalence of food insecurity in this cohort. METHODS: We used the Women Veterans' Health Utilization and Experience Survey for this analysis. Our study population consisted of women veterans who had at least three primary care or women's health visits to 1 of 12 Veteran's Health Administration health care facilities from December 2013 to November 2014. Multiple logistic regression was used to examine the relationship between food insufficiency (an inadequate amount of food intake owing to a lack of money or resources), delayed/missed care, anxiety, depression, and self-reported fair to poor health, controlling for race/ethnicity, marital status, and employment status. RESULTS: The prevalence of food insufficiency among women veterans was 27.6%. Being food insufficient was associated with 16.4, 15.4, 14.9, and 12.1 percentage point increases in the probability of delayed/missed care, screening positive for anxiety, screening positive for depression, and reporting fair to poor health, respectively (p < .05). CONCLUSIONS: The prevalence of food insufficiency in this cohort was associated with delayed access to health care and worse health outcomes. Interventions addressing Veterans Administration access and health outcomes will need to examine the potential role of food insufficiency.