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

Abstract

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.

Introduction

The deferral of needed medical care contributes to greater health risks, a decline in health status,¹ and higher long-term medical costs.² Over the past decade, the Veterans Health Administration (VHA) has made significant investments in improving access to high-quality care for women Veterans—the fastest-growing segment of VHA users.^3,4 Although the VHA has seen a steady increase in women Veterans' use of both outpatient and mental health specialty services,⁴ women Veterans continue to experience access barriers.^5,6 Prior research has focused on health care utilization among women Veterans with little to no engagement with VHA services^7,8 and women Veterans who discontinued use of VHA services.⁹ Less is known about factors directly associated with recent care delay among patients who are established and active users of VHA primary care. Understanding care delay among this population may point to gaps in care access, coordination, and quality that persist in the absence of initial enrollment barriers.

The Andersen model of health services use¹⁰ theorizes health care utilization as a function of predisposing characteristics, enabling factors, and need. Predisposing characteristics associated with delayed care include female gender and younger age.^8,11 Positive perceptions of VA providers and care environments, including high ratings of communication with providers and perceived patient-centered care, have been shown to facilitate women Veterans' care engagement,^12,13 while distance to VA facilities, an inability to take time off work, and lack of health insurance are known barriers to women Veterans attempting to access VHA care.^7,14 Delaying medical care is also associated with poorer physical health, including cardiovascular (CV) risk which is the leading cause of death among women,¹⁵ and mental health status¹⁶; however, studies of the effects of trauma and mental health status on care utilization have produced mixed results. While post-traumatic stress disorder (PTSD) symptomology, cumulative experiences of trauma, and multiple mental health diagnoses predict increased utilization of VHA services among women Veterans,^17,18 experiences of sexual assault and having a depressive disorder diagnosis are associated with women Veterans' reduced access to care.¹⁹

In this study, we examined self-reported delayed care among a sample of women Veterans with recent engagement in VA primary care. We aimed to (1) compare characteristics of female VHA users who delayed care in the past 6 months with those who did not and (2) examine associations between hypothesized factors of health care utilization and self-reported delayed health care. Based on existing literature and Andersen's framework, we hypothesized that delayed care would be associated with younger age, lower ratings of VHA care, a shorter length of time utilizing VHA, and poorer physical and mental health symptoms. Our model thus included domains related to predisposing characteristics (demographics), enabling factors (patient–provider relationship), and need (self-reported health, CV risk, mental health, and patient-reported trauma). Given increasing rates of adverse mental health symptoms and delayed care among U.S. civilians as a result of the coronavirus disease 2019 (COVID-19) pandemic,^20,21 understanding the relationship between mental health and care utilization is valuable for providers who serve both Veterans and non-Veteran populations.

Materials and Methods

Data and study population

This study offers a secondary analysis of data from a quality improvement initiative to improve women Veterans' engagement and retention in evidence-based health care for CV risk reduction—the CV Toolkit²²—which was implemented across five VA primary care sites in June 2017 to March 2020.²³ In the parent study, all women Veterans who were seen at least once by their primary care providers at one of the five primary care clinics were eligible to participate in the intervention, which consisted of three components: a CV self-screener for the patient, discussion of CV risk factors with primary care providers with template documentation, and referral to a gender-tailored facilitated group for goal setting. Because CV disease is the leading cause of death among women, yet women have a limited understanding of their own CV risk,^15,24 the CV Toolkit was designed to help patients and providers assess risk for CV disease. Although participants did not have to be at risk for CV disease, most had at least one CV risk factor. Women Veterans who received one component of the CV Toolkit intervention and had a valid mailing address in the electronic medical record (n = 1197) were invited to participate in a mailed survey. Eligible participants received a packet containing an information sheet, which included the informed consent process, the survey that had been developed before implementation, and a stamped return envelope. Survey responses were kept in a secure filing cabinet and were cleaned and validated by six members of the research team, including four authors (K.S.C., M.M.F., C.C., and L.J.) and two research assistants. While the survey was not the primary outcome for the parent study, it was included as part of the original study design.²³ To address response bias, we followed all required protocols, including sending multiple mailed reminders.

Measures

All measures were drawn from self-reported survey results and have been validated for use within VA populations.

Dependent variable: delaying care

The dependent variable was responses (yes/no) to the single item, “Over the past 6 months, did you ever delay, put off, or go without any type of care that you felt you needed, or that was recommended to you by a VA provider?”⁷ based on Veterans' perceived experiences of delay.

Independent variables

Patient–provider relationship

Respondents' relationship with VHA health care was measured by their length of time receiving VA care (range: <2–20+ years), recoded to <10 years versus 10 or more years. Trust in VA provider was measured using the last item of the PCAS-7 scale.²⁵ We recoded responses—measured on a scale of 0 (low) to 10 (high)—to low levels of trust (8 or lower) versus high (9 or 10) after reviewing the distribution of scores and testing two specifications in the model. We used the Consumer Assessment of Healthcare Providers and Systems (CAHPS) communication six-question subscale to assess respondents' ratings of communication with their VA providers in the past 12 months.²⁶ Responses were assessed on a scale of never, sometimes, usually, or always. Our communication indicator was a perfect score (“always” response on all six questions) versus all others.

Health measures and trauma

We assessed health risk according to physical and mental health. Fair or poor self-rated physical health was assessed on a five-point Likert scale and recoded as fair/poor versus good/very good/excellent. We created a measure for 3 or more CV risk factors (vs. 0–2) from a count of 12 self-reported CV risks (including peripheral artery disease, chronic kidney disease, diabetes, high blood pressure, high cholesterol, depression, autoimmune disease, overweight/obese, prediabetes, heart attack, stroke, and abdominal aortic aneurysm) based on coding precedent,²⁴ and included this measure due to the high prevalence of CV risk among women Veterans. Fair or poor self-rated mental health was assessed on a five-point Likert scale and recoded as fair/poor versus good/very good/excellent. Screens for anxiety (Generalized Anxiety Disorder-2 [GAD-2])²⁷ and depressive symptoms (Patient Health Questionnaire-2 [PHQ-2]),²⁸ commonly used in VA populations,^29,30 were included as indicators of mental health symptoms in the past 2 weeks. A screen was considered positive (coded with a value 1) for a score of 3 or higher.^27,28 Hereinafter, participants are referred to as having a positive mental health screen if either or both screens were positive. Exposure to traumatic events during the patient's lifetime was assessed via the first item from the Primary Care PTSD Screen for DSM-5 (PC-PTSD-5).³¹ Patients responded yes or no to the question “Sometimes things happen to people that are unusually or especially frightening, horrible, or traumatic. For example, a serious accident or fire, a physical or sexual assault or abuse, an earthquake or flood, a war, seeing someone be killed or seriously injured, having a loved one die through homicide or suicide. Have you ever experienced this kind of event?” Given the unique impact of sexual trauma on health and health care involvement among women veterans, we also included the question “Has anyone ever had sex or attempted to have sex with you after you said or showed that you did not want them to, or without your consent?” (yes/no), drawn from the Women's Overall Mental Health Assessment of Needs (WOMAN) study.³²

Demographics

Demographic characteristics included age, race, ethnicity, education, employment status, and care-giving responsibilities. Age was a continuous variable and recoded as a binary variable (> = 65 vs. <65). Race was a series of five nonmutually exclusive binary variables (American Indian or Alaska Native, Asian, White, Black or African American, Other), and ethnicity was coded Hispanic/Latina/Chicana versus not. Respondents' employment status was coded as full or part-time employment versus unemployment, and educational status was recoded to Bachelor's degree or higher versus less than Bachelor's degree. Having care-giving responsibilities (yes/no) was defined as providing nonpaid care for at least one child or adult on a regular basis.

Given the disruptions to medical care access spurred by the COVID-19 pandemic, we included a binary variable to identify whether we received respondents' surveys after March 31, 2020, when nationwide lockdown measures were put in place. This date was selected to account for variations in the timing of VA primary care clinic transitions from in-person to Telehealth visits (telephone and/or video connection) throughout the month of March at participating VA sites, as well as postal delays that may have affected receipt of surveys.

Analysis

We compared characteristics of women Veterans who reported delaying care in the past 6 months with those who did not. In bivariate analyses, we used t-tests for continuous measures and chi-square tests for categorical variables. We fit a multivariate logistic regression model based on domains theorized to affect health care utilization in existing literature and the Andersen model of health care utilization, including demographics (predisposing characteristics), patient–provider relationship (enabling factors), health, and patient-reported traumatic experience (need). We also included care-giving responsibilities in the model based on findings from prior studies.⁷ The model specification was guided by the Andersen model, and we tested the inclusion of variables that were significantly associated with delayed care in bivariate analyses. We retained a limited number of predictors (one or two) within each domain in the final model to account for the small sample size and to limit the risk of collinearity between variables representing closely related concepts. We conducted a sensitivity analysis excluding trauma experience to test whether the response to trauma was related to the pandemic rather than the trauma the study intended to measure.

We conducted an additional analysis of reasons for delaying care among women who responded “yes” to delaying care in the past 6 months (our dependent variable). Respondents who responded “yes” were given the opportunity to select all applicable reasons from a list of eight possible reasons for delaying care (transportation, distance to/from the clinic, getting time off work, VA hours, caregiving responsibilities, physical health/illness, mental health/illness, other); those who selected “other” were offered space for a brief comment. We analyzed the hand-written comments for “other” responses and identified 12 total reasons for delayed care, presented for descriptive purposes.

We used STATA statistical software version 15.0.³³ This multisite study was approved by the VA Central Institutional Review Board (IRB), as well as the local Research and Development Committee at each health system site.

Results

We received 253 completed surveys between October 2017 and August 2020 (21.6% overall response rate). Among 253 respondents, the mean age was 59.2 years; 63.2% were White, 26.9% Black, 13.4% Hispanic, and 46% had a Bachelor's degree or higher (Table 1). Sixty-two percent had received VA health care for 10 or more years. Thirty-two percent gave a low rating of trust (≤8) in their VA provider, and 45.5% gave low communication ratings. Thirty percent of respondents reported fair/poor overall health, and more than half of respondents (58.5%) had three or more CV risk factors. Thirty-three percent reported fair/poor mental health, while 33.6% had a positive mental health screen. Finally, 69.6% of respondents reported ever experiencing a traumatic event, while 41.1% reported ever experiencing nonconsensual sex.

Table 1.

Demographic and Health Characteristics of Participants by Delayed Care (n = 253)

	Delayed care^a			Full sample
	Yes (N/%)	No (N/%)	p	N
Participant characteristics	89 (35.2)	159 (62.8)		253
Age 65+	20 (22.5)	64 (40.3)	0.005	85 (33.6)
Age (M, SD)	55.23 (SD: 12.21)	61.44 (SD: 11.58)	<0.001	59.2 (SD: 12.18)
Race
American Indian or Alaska Native	5 (5.6)	5 (3.1)	0.356	10 (3.9)
Asian	3 (3.4)	6 (3.8)	0.860	9 (3.6)
Black	25 (28.1)	43 (27.0)	0.893	68 (26.9)
White	56 (62.9)	102 (64.2)	0.770	160 (63.2)
Other	7 (7.9)	8 (5.0)	0.382	15 (5.9)
Ethnicity (Hispanic, Latina, Chicana)	12 (13.5)	20 (12.6)	0.947	34 (13.4)
Education (BA or higher)	36 (40.5)	78 (49.1)	0.172	116 (45.9)
Employment Status (Employed)	34 (38.2)	68 (42.8)	0.477	102 (40.3)
Care-giving responsibilities (provided regular nonpaid care for ≥1 child/adult)	29 (32.6)	27 (16.9)	0.008	56 (22.1)
Survey receipt (received after March 31, 2020)	28 (31.5)	30 (18.9)	0.026	59 (23.3)
Patient–provider relationship
Received VA health care 10+ years	53 (59.6)	102 (64.2)	0.435	157 (62.1)
Low trust (rated 8 or lower)	40 (44.9)	41 (25.8)	0.003	82 (32.4)
Low communication (did not choose “always” on all six communication items)	52 (58.4)	61 (38.4)	0.004	115 (45.5)
Health status
Fair/poor health	42 (47.2)	33 (20.8)	<0.001	77 (30.4)
3+ CV risk factors	64 (71.9)	82 (51.6)	0.002	148 (58.5)
Fair/poor mental health	43 (48.3)	38 (23.9)	<0.001	83 (32.8)
Mental health positive screen (depression/anxiety)	51 (57.3)	33 (20.8)	<0.001	85 (33.6)
Experience of a traumatic event	78 (87.6)	96 (60.4)	<0.001	176 (69.6)
Experience of nonconsensual sex	49 (55.1)	53 (33.3)	0.001	104 (41.1)

p-values are from t-tests for quantitative measures and χ² tests for categorical measures.

Missing responses not shown.

CV, cardiovascular; M, mean; SD, standard deviation; VA, Veterans Administration.

Over one-third (35.2%) of respondents reported delaying care in the past 6 months. In bivariate analyses (Table 1), women who reported delaying care (n = 89, 35.2%) were more likely than those who did not delay care to report low ratings of trust in VA providers (44.9% vs. 25.8%, p = 0.003) and low ratings of communication with VA providers (58.4% vs. 38.4%, p = 0.004). Women who reported fair/poor overall health (47.2% vs. 20.8%, p < 0.001), had three or more CV risk factors (71.9% vs. 51.6%, p = 0.002), had fair/poor mental health (48.3% vs. 23.9%, p < 0.001), or a positive mental health screen (57.3% vs. 20.8%, p < 0.001) were more likely to delay care compared to their counterparts. Delaying care was more frequent among women with past experiences of trauma (87.6% vs. 60.4%, p < 0.001) and nonconsensual sex (55.1% vs. 33.3%, p = 0.001) compared to women who did not report these experiences.

In addition, women with caregiving responsibilities (32.6% vs. 17.0%, p = 0.008) and women whose surveys were received after the COVID-19-related disruptions to medical care, including state or local lockdowns, were more likely to delay care (31.5% vs. 18.9%, p = 0.026) compared to those whose surveys were received before March 31, 2020. Race, ethnicity, education, employment status, and length of receipt of VA care were not significantly associated with delaying care in bivariate analyses.

In the final multivariate logistic model (Table 2), women with a positive mental health screen (odds ratio [OR] 2.42, 95% confidence interval [CI]: 1.23–4.74) and women who reported experiencing a traumatic event (OR 2.61, 95%CI: 1.11–6.14) were significantly more likely to report delaying care. Low ratings of trust in VA providers, poor self-rated health, CV risk factors, age, care-giving responsibilities, and whether their surveys were received after COVID-19-related disruptions to medical care were not significantly associated with delayed care.

Table 2.

Logistic Regression of Factors Associated with Delayed Care

	OR	95% CI	p
Low provider trust (Ref: high)	1.87	0.97–3.63	0.063
Poor/fair health	1.77	0.88–3.57	0.108
3+ CV risk factors (Ref: <3)	1.78	0.89–3.53	0.102
Mental health symptoms (Ref: none)	2.42	1.23–4.74	0.010
Traumatic experience (Ref: none)	2.61	1.11–6.14	0.028
Age (Ref: <65 years)	0.58	0.28–1.17	0.129
Care-giving responsibilities (Ref: none)	1.90	0.92–3.94	0.083
Survey receipt (Ref: before March 31, 2020)	1.52	0.72–3.19	0.271

Sample of 253 who were exposed to the CV Toolkit intervention.

CI, confidence interval; OR, odds ratio; Ref, reference.

As a sensitivity analysis we tested a multivariate regression model that excluded experiences of trauma and a multivariate regression model that excluded positive mental health screen to isolate the effects of COVID-19-related disruptions (Supplementary Appendix Table S1). COVID-19-related disruptions to medical care access were not significantly associated with delaying care in either model. Additional bivariate analyses showed that women whose surveys were received after COVID-19-related disruptions were more likely to have experienced trauma and more likely to give low trust ratings to VA providers (Supplementary Appendix Table S2), but these women were not significantly different on other health measures from women whose surveys were received before such disruptions. The multivariate regression results were similar in the model excluding patients whose survey was received after March 2020.

Among women who reported delayed care, the most common reasons given (Table 3) included mental/emotional health issues (53.9%), physical health issues or illness (32.6%), getting time off work (28.1%), and distance to a VA facility (28.1%). Other commonly mentioned reasons for delaying care included transportation (22.5%), VA hours or VA-related scheduling conflicts (19.1%), and caregiving responsibilities (11.2%). About 3.4% voluntarily mentioned the COVID-19 pandemic as a reason for delayed care.

Table 3.

Reasons^a for Delayed Care Among Those Who Delayed (N = 89)

	N (%)
Transportation	20 (22.5)
Distance to/from clinic	25 (28.1)
Getting time off work	25 (28.1)
VA hours/scheduling conflict	17 (19.1)
Personal scheduling conflict	3 (3.4)
Caregiving responsibilities	10 (11.2)
Physical health	29 (32.6)
Mental health	48 (53.9)
Negative perceptions of VA setting/care	3 (3.4)
Care avoidance or refusal	4 (4.5)
COVID-19	3 (3.4)^b
Weather	2 (2.2)

Respondents could select more than one reason.

COVID-19 response represents 10.7% of responses received after March 31, 2020 among respondents who delayed care.

COVID-19, coronavirus disease 2019.

Discussion

Our study identified high rates of delayed care—over one-third of respondents—among women Veterans with recent primary care engagement. These rates were particularly surprising given the high levels of education and length of tenure receiving VHA care among women in our sample and are substantially higher than previously reported rates among women Veteran VHA users (19%).⁷ These rates are also higher than those found among all Veterans (29%) and the general American population (17%).³⁴ Among those who reported delaying care, the most common participant-selected reason for delayed care was mental health symptoms; this association was also supported in our regression models.

The relationship between traumatic experience, mental health conditions, and health care utilization among women Veterans is not clearly defined. While past experience of military sexual trauma (MST), PTSD symptomology, and lifetime exposure to sexual assault have been associated with increased use of medical and mental health services among Veterans,^35,36 mental health symptoms and experiences of trauma may also act as barriers to care, whether as a result of patient-level factors (i.e., perceived stigma, negative perceptions of VA care, or avoidance behaviors for self-protection) or system-level factors, such as fragmented health care delivery.^37
–39 Our findings highlight the need for further research that disentangles risks and barriers to care access among women Veterans with a positive mental health screen and/or trauma experiences who are already connected to care. For example, negative perceptions of care may delay or prevent care engagement even when access is high, both among Veterans seeking general mental health services⁴⁰ and among Veterans seeking MST-specific care.⁴¹ Differential effects by gender depending on type of trauma (e.g., combat, sexual, other) and period of occurrence (e.g., childhood, adulthood, military life)^42,43 may also impact care seeking in ways that are not well understood.

Our analysis of patient reasons for delaying care also points to significant structural barriers, including transportation, distance to clinics, getting time off work, and scheduling conflicts. Increasing access to care through telehealth modalities may be particularly valuable for patients impacted by such barriers, including older and rural Veterans.^44,45 Although we received 23% of surveys from respondents after COVID-19-related disruptions to medical care took effect, we did not see a statistically significant relationship between this indicator and delaying care in multivariate analyses. Yet, women Veterans whose responses were received during this period were more likely to report trauma experiences, suggesting that societal factors affecting care access, while not significant in the multivariate logistic regression, may have indirectly impacted care utilization. Policy initiatives that address structural barriers may help reduce delaying care for women Veterans. For example, the Title V Deborah Sampson Act (or “Megabus” bill) passed by Congress in 2021 includes provisions for childcare assistance for Veterans receiving health care through the VHA.⁴⁶ A recent analysis of focus group and survey data with a sample of 2000 Veterans found that 75% reported needed childcare assistance, while 58% reported missing or cancelling appointments due to challenges finding childcare.⁴⁶ Such policy initiatives may significantly improve care access for women Veterans who are active and established VHA users.

While trust, communication, and other aspects of the patient–provider relationship are widely recognized to impact care utilization both in the Veteran and civilian population,^47,48 our study did not find a significant association between women Veterans' trust in VA providers and delaying care, possibly because of the high levels of trust in our sample. In a sensitivity analysis (Supplementary Appendix Table S1), we found that past experience of trauma and the presence of a positive mental health screen moderated the impact of trust on delayed care; however, it is possible that these insignificant findings were due to our small sample size. In previous research, the presence of mental health conditions among women Veterans⁴⁵ or PTSD symptomology in a mixed-gender sample of Veterans⁴⁶ was associated with lower trust in providers. Given the high rates of trauma among Veterans, trauma-informed care is recommended to improve patients' relationships with providers,^49,50 which may in turn improve care quality.

Our sample was representative of women Veteran VHA users in age and disability⁴: a majority was over age 55 and two-thirds had a service-connected disability. Our sample also mirrored racial-ethnic distributions of women Veteran VHA users; and we did not find any significant associations between race (White vs. Black) and delaying care. However, we were not powered to identify findings using comparisons of other race or ethnicity and delayed care. This result of no White versus Black race difference is important because both non-VA and some VA data report persistent disparities in clinical outcomes among minority Veterans, particularly in hypertension, CV care, and diabetes.^{41

–52} However, VA has several specific studies that have found no race differences for White versus Black comparisons in primary care measures, prevention, and other outcomes.^53
–55 Further research is needed to examine how racial/ethnic disparities among women Veterans impact health care access and unmet need.

Limitations

Our study has several limitations. First, our dependent variable does not account for the length of delay and does not specify what type of care was delayed. In addition, factors associated with delay are also often associated with the need for care; further research is needed to confirm whether associations we observed are specific to delayed care. Second, our measures for assessing mental health symptoms are drawn from the GAD-2 and PHQ-2 screeners. While both have established psychometric properties and provide an indication of need for further assessment and possible presence of an anxiety and/or depressive disorder, they are not sufficient for diagnosis. Determining the relationship between diagnoses of anxiety or depression and delaying or going without care may be an important area for further research. An additional consideration regarding the use of these measures is temporality, as they assess symptoms in the past 2 weeks while we assessed delayed care in the past 6 months. While anxiety and depressive symptoms may persist over time, we are unable to test a prospective relationship between symptoms and delayed care. Likewise, our methods for assessing trauma, while based on established screening and survey materials, are not a substitute for a clinical interview that may help to clarify responses. Further research is needed to understand the impact that trauma type and timing (childhood vs. adulthood) may have on care seeking and utilization among Veterans. Third, our study was unable to determine the clinical impact of care that was delayed; prospective follow-up or linking to the electronic record was not approved for this study. Fourth, in the patient survey, reasons for delayed care were only asked of respondents reporting delayed care. Therefore, measures specific to structural barriers (e.g., transportation, time off work) were not included in the model. Thus, it is unknown how structural barriers interact with model factors. Fifth, our study was limited by a low response rate. Due to IRB protocol, we were unable to compare demographic characteristics and health care utilization of respondents and nonrespondents. Our inability to assess for response bias may impact the generalizability of our findings. Finally, given our focus on VHA users, our findings have limited generalizability for the civilian population, but remain important for Veterans nationally.

Implications for Practice and Policy

Our study highlights the need for additional measures that examine the multifaceted nature of delays in care to inform future novel interventions to improve care experiences—including care coordination and quality of care—for women Veterans. Our data suggest that health systems or providers may need to disentangle delays in care related to patient-reported traumatic experiences along with presence of mental and physical symptoms and underscore the value of a trauma-informed approach from the health system so that patients feel safe and cared for even when symptoms are heightened. Such approaches may benefit from mixed methods research to understand how trauma experiences may intersect with social determinants of health and care experiences.

The VA is in a prime position to provide expertise and guidance on the effects of trauma on health care utilization for system users and nonusers. Both the evidence-based knowledge acquired from post-traumatic stress disorder treatment for men and women Veterans and the innovative programming that has occurred for trauma-sensitive care and polytrauma provide a fertile ground for understanding short-, intermediate-, and long-term impact of trauma and allow for exploratory studies to disentangle gender-based effects. No other system has the combination of this multitude of factors to disentangle the possible effects with breadth and depth. Civilian health systems can learn from VA patient and system level experiences to provide more specific care for patients experiencing trauma.

The barriers identified in this study are not limited to Veterans: depression, anxiety, and traumatic experiences also impact care access among non-Veteran men and women.^56,57 Non-VA data consistently show that trauma (measured by adverse childhood events) adversely impacts the health status of Americans and is significantly associated with risky health behaviors, poor mental health, and chronic conditions leading to significant morbidity and mortality, including a dose–response relationship between the number of traumatic experiences and the leading causes of death.^58
–60 Trauma is a prevalent problem across patients in our health systems nationally. The VA has the opportunity to leverage skills and expertise with Veterans to understand how trauma may play out differently by gender in patients that already have access to care in a designated health system. This new knowledge will provide deeper understanding of both gender-based differences with trauma and potential mediators of trauma on CV risks and outcomes.⁶¹

Conclusions

Women's engagement in care remains a critical component of achieving optimal outcomes in chronic mental and CV conditions across VA facilities and outside of VHA. Supporting innovations to increase access to mental health and trauma-informed care may help reduce barriers to health care among women Veterans and other engaged health care users who delay the medical care they need.

Footnotes

Acknowledgments

The authors thank Jackie Lewis, Heman Saifu, Annie Sumberg, and Dr. Julian Brunner for providing administrative and technical support.

Authors' Contributions

K.S.C.: Conceptualization (lead); writing—original draft (lead); formal analysis (lead); writing—review and editing (equal); software (lead); formal analysis (co-lead).

B.B.-M.: Conceptualization (supporting); Methodology (lead); Writing—original draft (supporting); Writing—review and editing (equal).

C.A.S.: Conceptualization (supporting); Writing—review and editing (equal).

C.C.: Conceptualization (supporting); Methodology (lead); formal analysis (co-lead); software (supporting); validation (lead); Writing—original draft (supporting); Writing—review and editing (equal).

L.J.: Project Administration (lead); Data curation (lead); Writing—review and editing (supporting).

C.T.T.: Conceptualization (supporting); Methodology (supporting); formal analysis (supporting); validation (lead); Writing—review and editing (equal).

E.P.F.: Conceptualization (supporting); Supervision (supporting); Methodology (supporting); Writing—review and editing (supporting).

A.H.: Conceptualization (supporting); Supervision (lead); Methodology (supporting); Writing—review and editing (supporting).

M.M.F.: Conceptualization (supporting); Methodology (lead); Writing—original draft (supporting); formal analysis (co-lead); Writing—review and editing (equal).

Disclaimer

The content and views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the U.S. Department of Veterans Affairs or the U.S. Government.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

This study was supported by VA Quality Enhancement Research Initiative (QUERI) project QUE 15-272: “The Enhancing Mental and Physical Health of Women through Engagement and Retention” (EMPOWER 1.0). A.H. was supported by a VA HSR&D Research Career Scientist Award (Project No. RCS 21-135). These funding agencies were not involved in the research or authorship of the article.

Supplementary Material

Supplementary Appendix Table S1

Supplementary Appendix Table S2

References

Villagran

, Ledford

, Canzona

. Women's health identities in the transition from military member to service veteran. J Health Commun, 2015; 20(10):1125–1132; doi: 10.1080/10810730.2015.1018619

Chan

, Cheadle

, Reiber

, et al. Health care utilization and its costs for depressed Veterans with and without comorbid PTSD symptoms. Psychiatric Services, 2009; 60(12):1612–1617; doi: 10.1176/ps.2009.60.12.1612

Frayne

, Phibbs

, Friedman

, et al. Sourcebook: Women Veterans in the Veterans Health Administration. Volume 2. Sociodemographics and Use of VHA and Non-VA care (fee). Washington, DC: Women's Health Evaluation Initiative, Women's Health Services, Veterans Health Administration, Department of Veterans Affairs;. 2012.

Frayne

, Phibbs

, Saechao

, et al. Sourcebook: Women Veterans in the Veterans Health Administration. Volume 4: Longitudinal Trends in Sociodemographics, Utilization, Health Profile, and Geographic Distribution. Washington, DC: Women's Health Evaluation Initiative, Women's Health Services, Veterans Health Administration, Department of Veterans Affairs;. 2018.

Department of Veterans Affairs Veterans Health Administration. Study of Barriers for Women Veterans to VA Healthcare. Available from: https://www.womenshealth.va.gov/docs/Womens%20Health%20Services_Barriers%20to%20Care%20Final%20Report_April2015.pdf [Last accessed: April 4, 2023 ].

Klap

, Darling

, Hamilton

, et al. Prevalence of stranger harassment of women Veterans at Veterans affairs medical centers and impacts on delayed and missed care. Womens Health Issues, 2019; 29(2):107–115; doi: 10.1016/j.whi.2018.12.002

Washington

, Bean-Mayberry

, Riopelle

, et al. Access to care for women veterans: Delayed healthcare and unmet need. JGIM, 2011; 26(Suppl 2):655–661; doi: 10.1007/s11606-011-1772-z

Washington

, Farmer

, Mor

, et al. Assessment of healthcare needs and barriers to VA use experienced by women veterans. Med Care, 2015; 53(4):S23–S28.

Hamilton

, Frayne

, Cordasco

, et al. Factors related to attrition from VA healthcare use: Findings from the national survey of women veterans. J Gen Intern Med, 2013; 28(Suppl 2):510–516; doi: 10.1007/s11606-013-2347-y

10.

Andersen

, Newman

. Societal and individual determinants of medical care utilization in the United States. Milbank Mem Fund Q Health Soc, 1973; 51(1):95–124; doi: 10.1111/j.1468-0009.2005.00428.x

11.

Diamant

, Hays

, Morales

, et al. Delays and unmet need for health care among adult primary care patients in a restructured urban public health system. Am J Public Health, 2004; 94(5):783–789; doi: 10.2105/ajph.94.5.783

12.

Wagner

, Dichter

, Mattocks

. Women veterans' pathways to and perspectives on Veterans Affairs health care. Womens Health Issues, 2015; 25(6):658–665; doi: 10.1016/j.whi.2015.06.009

13.

Kehle-Forbes

, Harwood

, Spoont

, et al. Experiences with VHA care: A qualitative study of U.S. women veterans with self-reported trauma histories. BMC Womens Health, 2017; 17–38.

14.

Ouimette

, Wolfe

, Daley

, et al. Use of VA health care services by women veterans: Findings from a national sample. Women Health, 2003; 38(2):77–91; doi: 10.1300/J013v38n02_06

15.

Mosca

, Barrett-Connor

, Wenger

. Sex/gender differences in cardiovascular disease prevention: What a difference a decade makes. Circulation, 2011; 124:2145–2154.

16.

Chang

, Zulman

, Nelson

, et al. Use of general primary care, specialized primary care, and other Veterans Affairs services among high-risk veterans. JAMA Netw Open, 2020; 3(6):e208120; doi: 10.1001/jamanetworkopen.2020.8120

17.

Ryan

, McGrath

, Creech

. Predicting utilization of healthcare services in the veterans health administration by returning women veterans: The role of trauma exposure and symptoms of posttraumatic stress. Psychol Services, 2015; 12(4):412–419; doi: 10.1037/ser0000057

18.

Sadler

, Booth

, Mengeling

, et al. Life span and repeated violence against women during military service: Effects on health status and outpatient utilization. J Womens Health, 2004; 13(7):799–811; doi: 10.1089/jwh.2004.13.799

19.

Srivastava

, Butler

, Shroyer

, et al. Impact of depressive disorder on access and quality of care in veterans with prevalent cardiovascular disease. Am J Cardiol, 2018; 121(12):1629–1633; doi: 10.1016/j.amjcard.2018.02.048

20.

Czeisler MÉ. Delay or avoidance of medical care because of COVID-19–related concerns—United States, June 2020. MMWR Morb Mortal Wkly Rep, 2020; 69; doi: 10.15585/mmwr.mm6936a4

21.

Czeisler

MÉ

, Lane

, Wiley

, et al. Follow-up survey of U.S. adult reports of mental health, substance use, and suicidal ideation during the COVID-19 pandemic, September 2020. JAMA Netw Open, 2021; 4(2):e2037665; doi: 10.1001/jamanetworkopen.2020.37665

22.

Bean-Mayberry

, Moreau

, Hamilton

, et al. Cardiovascular risk screening among women veterans: Identifying provider and patient barriers and facilitators to develop a clinical toolkit. Womens Health Issues, 2022; 32(3):284–292; doi: 10.1016/j.whi.2021.12.003

23.

Hamilton

, Farmer

, Moin

, et al. Enhancing Mental and Physical Health of Women through Engagement and Retention (EMPOWER): A protocol for a program of research. Implement Sci, 2017; 12(1):127; doi: 10.1186/s13012-017-0658-9

24.

Mosca

, Mochari

, Christian

, et al. National Study of Women's Awareness, Preventive Action, and Barriers to Cardiovascular Health. Circulation, 2006; 113:525–534.

25.

Safran

, Kosinski

, Tarlov

, et al. The Primary Care Assessment Survey: Tests of data quality and measurement performance. Med Care, 1998; 36:728–739; doi: 10.1097/00005650-199805000-00012

26.

Agency for Healthcare Research and Quality. CAHPS Clinician and Group Survey 3.0 Measures; June 2017. Available from: https://www.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/cg/about/measures-cg30-2309.pdf [Last accessed: August 28, 2023 ].

27.

Kroenke

, Spitzer

, Williams

, et al. Anxiety disorders in primary care: Prevalence, impairment, comorbidity, and detection. Ann Intern Med, 2007; 146:317–325; doi: 10.7326/0003-4819-146-5-200703060-00004

28.

Kroenke

, Spitzer

, Williams

. The Patient Health Questionnaire-2: Validity of a two-item depression screener. Med Care, 2003; 41:1284–1292; doi: 10.1097/01.MLR.0000093487.78664.3C

29.

Levey

, Gelernter

, Polimanti

, et al. Reproducible genetic risk loci for anxiety: Results from ∼200,000 participants in the Million Veteran Program. Am J Psychiatry, 2020; 177(3):223–232; doi: 10.1176/appi.ajp.2019.19030256

30.

Sherbourne

, Asch

, Shugarman

, et al. Early identification of co-occurring pain, depression and anxiety. J Gen Intern Med, 2009; 24:620–625; doi: 10.1007/s11606-009-0956-2

31.

Prins

, Bovin

, Kimerling

, et al. The Primary Care PTSD Screen for DSM-5 (PC-PTSD-5): Development and evaluation within a Veteran primary care sample. J Gen Inter Med, 2016; 31(10):1206–1211; doi: 10.1007/s11606-016-3703-5

32.

Gaska

, Kimerling

. Patterns of adverse experiences and health outcomes among women veterans. Am J Prev Med, 2018; 55(6):803–811.

33.

StataCorp. Stata Statistical Software: Release 16. College Station, TX: StataCorp LLC; 2019.

34.

Lee

, Begley

. Delays in seeking health care: Comparison of Veterans and the general population. J Public Health Manag Pract, 2017; 23(2):160–168; doi: 10.1097/PHH.0000000000000420

35.

Brignone

, Gundlapalli

, Blais

, et al. Increased health care utilization and costs among veterans with a positive screen for military sexual trauma. Med Care, 2017; 55(9): S70–S77; doi: 10.1097/MLR.0000000000000767

36.

Vander Weg

, Sadler

, Abrams

, et al. Lifetime history of sexual assault and emergency department service use among women veterans. Womens Health Issues, 2020; 30(5):374–383; doi: 10.1016/j.whi.2020.05.003

37.

Possemato

, Wray

, Johnson

, et al. Facilitators and barriers to seeking mental health care among primary care veterans with posttraumatic stress disorder. J Trauma Stress, 2018; 31(5):742–752; doi: 10.1002/jts.22327

38.

Nugent

, Riviere

, Sipos

, et al. Mental health service utilization and perceived barriers to receiving care in deployed soldiers. Mil Med, 2020; 185(5–6):e625–e631; doi: 10.1093/milmed/usaa019

39.

Trivedi

, Post

, Sun

, et al. Prevalence, comorbidity, and prognosis of mental health among US veterans. Am J Public Health, 2015; 105(12):2564–2569; doi: 10.2105/AJPH.2015.302836

40.

Wray

, Pikoff

, King

, et al. Veterans' mental health beliefs: Facilitators and barriers to primary care-mental health use. Fam Syst Health, 2016; 34(4):404–413; doi: 10.1037/fsh0000231

41.

McLean

, Turchik

, Kimerling

. Mental health beliefs, access, and engagement with military sexual trauma-related mental health care. J Gen Intern Med, 2022; 37(Suppl 3):742–750; doi: 10.1007/s11606-022-07590-6

42.

Morgan

, Aronson

, Perkins

, et al. The interaction of exposure to adverse childhood and combat experiences on the current mental health of new post-9/11 veterans. J Community Psychol, 2021:1–17; doi: 10.1002/jcop.22523

43.

Aronson

, Perkins

, Morgan

, et al. The impact of adverse childhood experiences (ACEs) and combat exposure on mental health conditions among new post-9/11 veterans. Psychol Trauma, 2020; 12(7):698–706; doi: 10.1037/tra0000614

44.

Lum

, Nearing

, Pimentel

, et al. Anywhere to anywhere: Use of telehealth to increase health care access for older, rural veterans. Public Policy Aging Rep, 2020; 30(1):12–18; doi: 10.1093/ppar/prz030

45.

Gajarawala

, Pelkowski

. Telehealth benefits and barriers. J Nurse Pract, 2021; 17(2):218–221; doi: 10.1016/j.nurpra.2020.09.013

46.

Shepherd-Banigan

, Cannedy

, Rodriguez

, et al. Evaluation of Veteran Preferences for VA Provided Childcare Assistance to Enable Access to Medical Care. Washington, DC: Women's Health Services, Veterans Health Administration, Department of Veterans Affairs; 2022.

47.

Gordon

, Pugach

, Berbaum

, et al. Examining patients' trust in physicians and the VA healthcare system in a prospective cohort followed for six-months after an exacerbation of heart failure. Patient Educ Couns, 2014; 97(2):173–179; doi: 10.1016/j.pec.2014.07.022

48.

Musa

, Schulz

, Harris

, et al. Trust in the health care system and the use of preventive health services by older black and white adults. Am J Public Health, 2009; 99(7):1293–1299; doi: 10.2105/AJPH.2007.123927

49.

Chanfreau-Coffinier

, Gordon

, Schweizer

, et al. Mental health screening results associated with women veterans' ratings of provider communication, trust, and care quality. Womens Health Issues, 2018; 28(5):430–438; doi: 10.1016/j.whi.2018.05.004

50.

Kopacz

, Ames

, Koenig

. Association between trust and mental, social, and physical health outcomes in veterans and active duty service members with combat-related PTSD symptomatology. Front Psychiatr, 2018; 9:408; doi: 10.3389/fpsyt.2018.00408

51.

Trivedi

, Grebla

, Wright

, et al. Despite improved quality of care in the Veterans Affairs health system, racial disparity persists for important clinical outcomes. Health Aff, 2011; 30(4):707–715; doi: 10.1377/hlthaff.2011.0074

52.

Peterson

, Anderson

, Boundy

, et al. Mortality disparities in racial/ethnic minority groups in the Veterans Health Administration: An evidence review and map. Am J Pub Health, 2018; 108(3):e1–e11; doi: 10.2105/AJPH.2017.304246

53.

Bean-Mayberry

, Chang

C-C

, Scholle

. Lack of a race effect in primary care ratings among women veterans. JGIM, 2006; 21(10):1105–1108; doi: 10.1111/j.1525-1497.2006.00517

54.

Bean-Mayberry

, Basitan

, Trentalange

, et al. Associations between provider designation and female-specific cancer screening in women veterans. Med Care, 2015; 53(4):S47–S54; doi: 10.1097/MLR.0000000000000323

55.

Saha

, Freeman

, Toure

, et al. Racial and ethnic disparities in the VA Healthcare System: A systematic review. JGIM, 2008; 32(5):654–671.

56.

Smith

KLW

, Matheson

, Moineddin

, et al. Gender differences in mental health service utilization among respondents reporting depression in a national health survey. Health, 2013; 5(10):1561–1571; doi: 10.4236/health.2013.510212

57.

Horenstein

, Heimberg

. Anxiety disorders and healthcare utilization: A systematic review. Clin Psychol Rev, 2020; 81:101894; doi: 10.1016/j.cpr.2020.101894

58.

Felitti

, Anda

, Nordenberg

, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. Am J Prev Med, 1998; 14(4):245–258; doi: 10.1016/s0749-3797(98)00017-8

59.

Merrick

, Ford

, Ports

, et al. Vital signs: Estimated proportion of adult health problems attributable to adverse childhood experiences and implications for prevention—25 States, 2015–2017. MMWR Morb Mortal Wkly Rep, 2019; 68(44):999–1005; doi: 10.15585/mmwr.mm6844e1

60.

Centers for Disease Control & Prevention. About the CDC-Kaiser ACE Study; April 2021. Available from: https://www.cdc.gov/violenceprevention/aces/about.html [Last accessed: August 28, 2023 ].

61.

Ebrahimi

, Lynch

, Beckham

, et al. Association of posttraumatic stress disorder and incident ischemic heart disease in women veterans. JAMA Cardiol, 2021; 6(6):642–651; doi: 10.1001/jamacardio.2021.0227

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