Highlights on Post-Deployment Health Research among Women

1. Highlights on Post-Deployment Health Research among Women Elizabeth M. Yano, PhD, MSPH VA Greater Los Angeles HSR&D Center of Excellence UCLA School of Public Health

2. Women in the Military • Women now represent: • 15% active duty • 20% new recruits • 17% reserve/National Guard • Equalization of hardships/risks • 71% w/1+ combat exposure • Fastest growing segment of new VA users • Currently 5-7% of VA users, but >40% OEF/OIF market penetration • Different sociodemographics • >60% under age 45,  minorities Source: Murdoch, et al., Women and war: What physicians need to know. JGIM, 21:S5-10, 2006.

3. Purpose of Talk • To review highlights from current post-deployment health research among women veterans • Both post-deployment health and women veterans research are top priorities in VA • Need to inform development and design of programs that improve entry into and delivery of appropriate services

4. Health & Safety of Women in the Reserves, National Guard & Active Duty Military • Goal  Study antecedent risks of sexual violence and consequent health outcomes in deployed Reserve/National Guard & Active Duty women • VA HSR&D and DoD funded companion studies • Comparison groups are women: • Not deployed • Deployed to combat regions once • Deployed to combat regions more than once • Deployed elsewhere other than combat regions Anne Sadler, PhD, RN (PI), BM Booth, BL Cook, MA Mengeling, JC Toner; Iowa City VA.

5. Health & Safety of Women in the Reserves, National Guard & Active Duty Military:Preliminary Results • Lack of knowledge about mental health symptoms • Barriers to reporting post-deployment problems • Barriers to care • Unmet or delayed mental health care • Cross-leveling stressors (deployed with other than home unit) • Couple and parenting readjustment issues • Social isolation • Concern about other soldier’s readjustment problems Anne Sadler, PhD, RN (PI), BM Booth, BL Cook, MA Mengeling, JC Toner; Iowa City VA.

6. Stigma, Gender and Other Barriers to Care for OEF/OIF Veterans • Goal  Explore the unique contribution of stigma-related factors to VA health care seeking • National sample of female and male OEF/OIF veterans • Phase 1 (focus groups) completed • Six focus groups with male and female OEF/OIF veterans (including VA users and non-users) • Phase 2 (survey) ongoing • Mail survey to a stratified national sample of 1,538 OEF/OIF veterans Dawne Vogt, PhD, Principal Investigator National Center for PTSD (Boston VA Healthcare System)

7. Stigma, Gender and Other Barriers to Care: Preliminary Phase 1 Findings • Reluctance to acknowledge mental health problems due to perceived stigma • Tendency to want to “tough it out” with respect to mental health problems • Concerns about impact of using VA on career and confidentiality of records • General sense VA is for veterans who are older and men with severe mental health problems or physical disabilities • Women veterans • feel need to “suck it up” to prove worth as service members • feeling out of place in VA, that their service is less respected because of assumption that they do not experience direct combat Dawne Vogt, PhD, Principal Investigator National Center for PTSD (Boston VA Healthcare System)

8. Further Development of the Deployment Risk & Resilience Inventory (DRRI) • DRRI is a suite of scales used to assess pre-, during and post-deployment factors for stress-related illnesses • Primarily intended for research but clinical applications possible • Goal  Revise DRRI to make it broadly applicable to different veteran subgroups (e.g., OEF/OIF veterans, female veterans) • Phase 1 (focus groups) completed • Six focus groups with diverse population of male and female OEF/OIF veterans • Phase 2 (survey) proposal under review • Mail survey to stratified random sample of 1000 OEF/OIF veterans to validate DRRI-2 scales and develop short forms Dawne Vogt, PhD, Principal Investigator National Center for PTSD (Boston VA Healthcare System)

9. Reintegration and Service Needs of Women Veteran Mothers • Goal  Deepen understanding of concerns and stressors that accompany reintegration into civilian life for OEF/OIF Reserve and Guard women veterans who were or were not mothers of dependent children at deployment • Reintegration issues related to family and to work • Barriers to use of current services and how to improve these services • Focus groups and semi-structured interviews of previously deployed OEF/OIF women veterans Gudrun Lange, PhD (PI) & Karen Quigley, PhD (Co-PI) NJ War Related Illness & Injury Study Center (WRIISC)

10. Reintegration and Service Needs of Women Veteran Mothers: Family • Feelings of isolation and having difficult communicating with family and friends • Not having enough time to “readjust” • Family members’ expectations for them to return to their former roles and “old selves” • Difficulties bonding with children (differed depending on age of child, time/distance away) • Feeling need to “compensate” for being away • Feeling “out of sync” w/children, partners/family Gudrun Lange, PhD (PI) & Karen Quigley, PhD (Co-PI) NJ War Related Illness & Injury Study Center (WRIISC)

11. Reintegration and Service Needs of Women Veteran Mothers: Family • “My husband thought I was going to come back and straighten it all out…he, you know let them get away with a little bit more…” • “I felt like I had missed out on so much…I just felt like so detached from everything and everyone. Then as more time went on I’m trying to play catch up, trying to find out what I missed.” Gudrun Lange, PhD (PI) & Karen Quigley, PhD (Co-PI) NJ War Related Illness & Injury Study Center (WRIISC)

12. Reintegration and Service Needs of Women Veteran Mothers: Work • Employment concerns (with or without children) • Making more $$ in military than since returning home • Difficulty finding civilian job that pays as well as military • Going back to school as attractive option (GI bill) • Difficulties in money management • From having basic needs (housing, food, clothing) taken care of to learning how to budget/manage $$ • Made more difficult by lower earning power • Tensions about (mis)management of $$ while away Gudrun Lange, PhD (PI) & Karen Quigley, PhD (Co-PI) NJ War Related Illness & Injury Study Center (WRIISC)

13. Reintegration and Service Needs of Women Veteran Mothers: Work • “I was making more money deployed than my civilian job. So I ended up having to look for another job.” • “I came back and needed to look for a new job, and I just had to wait. I just didn’t feel like I could…I wasn’t in the mindset…I just couldn’t get back on my feet…until I got a couple months, and you know I just once I decided in my mind that I was ready to go back to work.” Gudrun Lange, PhD (PI) & Karen Quigley, PhD (Co-PI) NJ War Related Illness & Injury Study Center (WRIISC)

14. Reintegration and Service Needs of Women Veteran Mothers: Barriers • Hard time finding supports upon return home • Vocal about need for additional support from military and VA to help them with reintegration • VA needs to “reach out” to them with supports within 3-6 months of return home • Insufficient pre-deployment planning for financial matters, custody arrangements for minor children • Family support groups and post-deployment briefings of variable quality and helpfulness Gudrun Lange, PhD (PI) & Karen Quigley, PhD (Co-PI) NJ War Related Illness & Injury Study Center (WRIISC)

15. Reintegration and Service Needs of Women Veteran Mothers: Barriers • “I signed up the VA forms and got hooked up because I didn’t have any medical insurance and needed to follow up with that. As far as mental issues, I really didn’t have anybody to help me out with them, so I thought I’d go to the church… just to talk to someone.” • “You get stared at a lot when you come here [VA].” • “I think it’s very important that they understand that women are different from men also. That you can’t just throw [everyone] in a group…” Gudrun Lange, PhD (PI) & Karen Quigley, PhD (Co-PI) NJ War Related Illness & Injury Study Center (WRIISC)

16. Women at War Survey • Goals  • Identify among men and women deployed to OEF and OIF • Frequency of combat exposure and military sexual trauma (MST) • Post-deployment adjustment post-exposure • Explore additive effects of both combat and MST • Examine gender differences in VA health care use and satisfaction with VA care Amy Street, PhD, Principal Investigator Women’s Health Sciences Division

17. Women at War Survey • Funded by National Center for PTSD • Mail survey of 2000 female and 2000 male OEF-OIF veterans • Measures: • Deployment stressors, traumatic brain injury, mental and physical health symptoms, readjustment issues, relationship and family functioning, suicidal behavior Amy Street, PhD, Principal Investigator Women’s Health Sciences Division

18. Women Veterans Cohort Study • Goal  To evaluate use, costs and outcomes among female and male OEF/OIF veterans after separation from service • 2-years post-discharge, 2-years after coverage ends • Compare diagnosis/treatment of stress-related conditions • Assess trajectories in use, cost, outcomes by gender over time • OEF/OIF roster from Defense Manpower Data Center who have enrolled in VA or used VA care • Multi-site prospective cohort study Cynthia Brandt, MD, MPH (PI) & Sally Haskell, MD (Co-PI) VA Connecticut Healthcare System

19. Women Veterans Cohort Study • 12% of VA-enrolled OEF/OIF vets are women • OEF/OIF women veterans (vs. men) are: • Younger (average 2 years) • More likely to be racial-ethnic minorities • Less likely to be married • More likely to be educated beyond high school • More likely to be active duty (vs. NG/R) • More likely to be Air Force, less to be Marines • More likely to be officers Cynthia Brandt, MD, MPH (PI) & Sally Haskell, MD (Co-PI) VA Connecticut Healthcare System

20. Women Veterans Cohort Study • Most prevalent conditions among women: • Back problems, joint problems, PTSD, depression • Many gender differences, women have: • More depression, less PTSD • More connective tissue and skin disorders • Less hypertension, hyperlipidemia, diabetes or coronary artery disease • Less alcohol or drug abuse Cynthia Brandt, MD, MPH (PI) & Sally Haskell, MD (Co-PI) VA Connecticut Healthcare System

21. Women Veterans Cohort Study • Enrollment for prospective cohort in two sites underway • Assessing demographics, deployment info, combat exposure, traumatic life events, depression, quality of life, social support, stress, sexual behavior, eating behavior, PTSD, alcohol use, smoking, substance abuse, military sexual trauma, pain, satisfaction, utilization, medication, comorbidities, reproductive health history Cynthia Brandt, MD, MPH (PI) & Sally Haskell, MD (Co-PI) VA Connecticut Healthcare System

22. National Survey of Women Veterans • Goal  Assess health care needs, VA experiences, knowledge/awareness of VA eligibility and services, preferences for care • Funded by VA Office of Public Health & Environmental Hazards (Women Veterans Health Strategic Health Care Group) • Last such national survey conducted in 1985 • Over 3,500 telephone interviews completed • VA users + non-users; OEF/OIF oversampled Donna L. Washington, MD, MPH (Principal Investigator VA Greater Los Angeles Healthcare System

23. Post-Deployment Health Research among Women Veterans: Next Steps • Translate qualitative research findings into improved programs and delivery models • Important to synthesize findings across research studies (validation, adaptation) • Relatively small size requires special attention to their inclusion in VA research • Observational studies, clinical trials, etc. • WV practice-based research network (PBRN) Source: Yano EM, Hayes P, Wright S, et al. Importance of inclusion of women veterans in VA quality improvement research. J Gen Intern Med. 2009:[in press].

24. VA Health Services Research Priorities:Post-Deployment Health • Outreach, coordination of care, recognition of unique injuries and problems, including chronic care needs of this new generation of veterans • Improve transitions between acute care, outpatient care and community needs; evaluate caregiver needs • Chronic pain, PTSD, neurological disorders, TBI, rehab (vision, hearing, mobility, neurological losses), military sexual trauma • Treatment effectiveness/quality at veteran and system levels, emotional and cognitive recovery, community reintegration, overall quality of life