CLINICAL ARTICLE
Critical questions: Advancing the health of female Veterans
Lisa Muirhead DNP, APRN, ANP-BC, FAANP,
Priscilla Hall PhD, CNM,
Cedrella Jones-Taylor MD,
Gari D. Clifford DPhil (Oxon), MA (Oxon), MSc (Soton), BSc (Hons),
Tasha Felton-Williams DNP, WNP, APRN,
Kathy Williams RN, MA,
Corresponding Author
Lisa Muirhead DNP, APRN, ANP-BC, FAANP
(Assistant Professor, VANAP Co-Director)
Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia
Correspondence
Lisa Muirhead, DNP, APRN, ANP-BC, FAANP, Assistant Professor, Clinical, NHWSN Director, VA Nursing Academic Partnership (VANAP) Program Emory University, Nell Hodgson Woodruff School of Nursing, 1520 Clifton Rd NE, Atlanta, GA 30322. Tel: 404-727-6544; Fax: 404-727-8514;
E-mail: [email protected]
Search for more papers by this authorPriscilla Hall PhD, CNM
(Assistant Professor)
Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia
Search for more papers by this authorCedrella Jones-Taylor MD
(Assistant Chief, Assistant Clinical Professor)
Primary Care, Atlanta VA Medical Center, Emory University School of Medicine, Decatur, Georgia
Search for more papers by this authorGari D. Clifford DPhil (Oxon), MA (Oxon), MSc (Soton), BSc (Hons)
(Associate Professor)
Department of Biomedical Informatics, Georgia Institute of Technology, Emory University, Atlanta, Georgia
Department of Biomedical Engineering, Georgia Institute of Technology, Emory University, Atlanta, Georgia
Search for more papers by this authorTasha Felton-Williams DNP, WNP, APRN
(Womens Veteran Program Manager)
Atlanta VA Medical Center, Decatur, Georgia
Search for more papers by this authorKathy Williams RN, MA
(Associate Nurse Executive, Primary Care)
Atlanta VA Medical Center, Decatur, Georgia
Search for more papers by this authorLisa Muirhead DNP, APRN, ANP-BC, FAANP,
Priscilla Hall PhD, CNM,
Cedrella Jones-Taylor MD,
Gari D. Clifford DPhil (Oxon), MA (Oxon), MSc (Soton), BSc (Hons),
Tasha Felton-Williams DNP, WNP, APRN,
Kathy Williams RN, MA,
Corresponding Author
Lisa Muirhead DNP, APRN, ANP-BC, FAANP
(Assistant Professor, VANAP Co-Director)
Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia
Correspondence
Lisa Muirhead, DNP, APRN, ANP-BC, FAANP, Assistant Professor, Clinical, NHWSN Director, VA Nursing Academic Partnership (VANAP) Program Emory University, Nell Hodgson Woodruff School of Nursing, 1520 Clifton Rd NE, Atlanta, GA 30322. Tel: 404-727-6544; Fax: 404-727-8514;
E-mail: [email protected]
Search for more papers by this authorPriscilla Hall PhD, CNM
(Assistant Professor)
Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia
Search for more papers by this authorCedrella Jones-Taylor MD
(Assistant Chief, Assistant Clinical Professor)
Primary Care, Atlanta VA Medical Center, Emory University School of Medicine, Decatur, Georgia
Search for more papers by this authorGari D. Clifford DPhil (Oxon), MA (Oxon), MSc (Soton), BSc (Hons)
(Associate Professor)
Department of Biomedical Informatics, Georgia Institute of Technology, Emory University, Atlanta, Georgia
Department of Biomedical Engineering, Georgia Institute of Technology, Emory University, Atlanta, Georgia
Search for more papers by this authorTasha Felton-Williams DNP, WNP, APRN
(Womens Veteran Program Manager)
Atlanta VA Medical Center, Decatur, Georgia
Search for more papers by this authorKathy Williams RN, MA
(Associate Nurse Executive, Primary Care)
Atlanta VA Medical Center, Decatur, Georgia
Search for more papers by this authorFirst published: 21 July 2017
Disclosures: Each author contributed to the intellectual content and their respective expertise related to the health of female Veterans and the development of the manuscript.
Abstract
Purpose
Women are the fastest growing Veteran population in the United States and many receive all or part of their health care outside of the Department of Veterans Affairs (VA). The purpose of this article is to review the healthcare issues of women Veterans and discuss implications for care.
Data sources
Review of selected literature, VA resources and guidelines, and expert opinion.
Conclusions
Few providers are aware of the impact military service has on the health of women and fail to ask the all-important question, “Have you served in the military?” Recognizing women's military service can reveal important information that can answer perplexing clinical questions, aid in designing comprehensive plans of care, and enable women to receive the assistance needed to address complex physical and psychosocial issues to improve the quality of their lives.
Implications for practice
There are gender disparities related to physical health conditions, mental health issues, environmental exposures, and socioeconomic factors that contribute to female Veterans’ vulnerabilities. Many of the health conditions, if recognized in a timely manner, can be ameliorated and shift the health trajectory of this population. Clinicians play a critical role in identifying health risk and helping female Veterans start the sometimes arduous journey toward wellness. Discovering and acknowledging women's military history is critical in ensuring quality care and appropriate decision making.
References
- Adler-Baeder, F., Pittman, J. F., & Taylor, L. (2006). The prevalence of marital transitions in military families. Journal of Divorce & Remarriage, 44(1-2), 91–106. Retrieved from https://doi.org/10.1300/J087v44n01_05
10.1300/J087v44n01_05 Google Scholar
- Agency for Health Care Quality and Research. (2012). Five major steps to intervention (the "5 A's"). Rockville, MD. Retrieved from http://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/tobacco/5steps.html
- Almond, N., Kahwati, L., Kinsinger, L., & Porterfield, D. (2008). Prevalence of overweight and obesity among U.S. military Veterans. Military Medicine, 173(6), 544–549.
- Alschuler, K., & Otis, J. (2014). An examination of the impact of clinically significant levels of posttraumatic stress disorder symptomatology on the classification of pain as mild, moderate, or severe in a sample of Veterans with chronic pain. Psychological Services, 11(3), 273–280. Retrieved from https://doi.org/10.1037/a0036201
- Andersen, L. B., Melvaer, L. B., Videbech, P., Lamont, R. F., & Joergensen, J. S. (2012). Risk factors for developing post-traumatic stress disorder following childbirth: A systematic review. Acta Obstetrica Gynecolica Scandinavica, 91(11), 1261–1272. Retrieved from https://doi.org/10.1111/j.1600-0412.2012.01476.x
- Bahraini, N. H., Breshears, R. E., Hernandez, T. D., Schneider, A. L., Forster, J. E., & Brenner, L. A. (2014). Traumatic brain injury and posttraumatic stress disorder. Psychiatric Clinics of North America, 37(1), 55–75. Retrieved from https://doi.org/10.1016/j.psc.2013.11.002
- Barnett, P. G., Hamlett-Berry, K., Sung, H. Y., & Max, W. (2015). Health care expenditures attributable to smoking in military Veterans. Nicotine & Tobacco Research, 17(5), 586–591. Retrieved from https://doi.org/10.1093/ntr/ntu187
- Birgisson, N. E., Zhao, Q., Secura, G. M., Madden, T., & Peipert, J. F. (2015). Preventing unintended pregnancy: The contraceptive CHOICE project in review. Journal of Women's Health, 24(5), 349–353. Retrieved from https://doi.org/10.1089/jwh.2015.5191
- Bond, E. F. (2004). Women's physical and mental health sequellae of wartime service. Nursing Clinics of North America, 39(1), 53–68. Retrieved from https://doi.org/10.1016/j.cnur.2003.11.004
- Brickell, T. A., Lippa, S., French, L. M., Kennedy, J., Bailie, J., & Lange, R. T. (2017). Female service members and symptom reporting following combat and non-combat related mild traumatic brain injury. Journal of Neurotrauma, 34(2), 300–312. https://doi.org/10.1089/neu.2016.4403
- Briscione, M. A., Michopoulos, V., Jovanovic, T., & Norrholm, S. D. (2017). Neuroendocrine underpinnings of increased risk for posttraumatic stress disorder in women. Vitamins and Hormones, 103, 53–83.
- Buescher, P. A., Roth, M. S., Williams, D., & Goforth, C. M. (1991). An evaluation of the impact of maternity care coordination on Medicaid birth outcomes in North Carolina. American Journal of Public Health, 81(12), 1625–1629.
- Callegari, L. S., Zhao, X., Nelson, K. M., & Borrero, S. (2015). Contraceptive adherence among women Veterans with mental illness and substance use disorder. Contraception, 91(5), 386–392. Retrieved from https://doi.org/10.1016/j.contraception.2015.01.013
- Chan, C., Chan, Y., Au, A., & Cheung, G. (2010). Reliability and validity of the extended-hurt, insult, threaten, scream screening tool in detecting intimate partner violence in hospital emergency departments in Hong Kong. Hong Kong Journal of Emergency Medicine, 17, 109–117. Retrieved from https://doi.org/10.1016.s11606-013-2534x
- Chang, J. J., Pien, G. W., Duntley, S. P., & Macones, G. A. (2010). Sleep deprivation during pregnancy and maternal and fetal outcomes: Is there a relationship? Sleep Medicine Review, 14(2), 107–114. Retrieved from https://doi.org/10.1016/j.smrv.2009.05.001
- Creech, S. K., & Borsari, B. (2014). Alcohol use, military sexual trauma, expectancies, and coping skills in women veterans presenting to primary care. Addictive Behaviors, 39, 379–385.
- Dalager, N. A., Kang, H. K., & Thomas, T. L. (1995). Cancer mortality patterns among women who served in the military: The Vietnam experience. Journal of Occupational and Environmental Medicine, 37(3), 298–305.
- Defense Advisory Committee on Women in the Services. (2015). Defense advisory committee on women in the services. Retrieved from http://dacowits.defense.gov/Portals/48/Documents/Reports/2015/AnnualReport/2015DACOWITSAnnualReport_Final.pdf
- DeKleijn, M., Lagro-Janssen, A., Canelo, I., & Yano, M. (2015). Creating a roadmap for delivering gender-sensitive comprehensive care for women Veterans: Results of a national expert panel. Medical Care, 53(4 Suppl. 1), S156–S164. Retrieved from https://doi.org/10.1097/MLR.0000000000000307
- Denneson, L. M., Corson, K., & Dobscha, S. K. (2011). Complementary and alternative medicine use among veterans with chronic non-cancer pain. Journal of Rehabilitation Research and Development, 48(9), 1119–1128.
- Department of Veterans Affairs/Department of Defense. (2010). Clinical practice guideline for the management of opioid therapy for chronic pain. Retrieved from https://www.va.gov/PAINMANAGEMENT/docs/CPG_opioidtherapy_fulltext.pdf
- Erbes, C. R., Stinson, R., Kuhn, E., Polusny, M., Urban, J., & Hoffman, J. (2014). Access, utilization, and interest in mHealth application among Veterans receiving outpatient care for PTSD. Military Medicine, 179(11), 1218–1222.
- Foster, S. N., Brock, M. S., Hansen, S., Collen, J. F., Walter, R., O'Connor, P., … Mysliwiec, V. (2016). Sleep disorders related to deployment in active duty service members and Veterans. Current Pulmonology Reports, 5(2), 101–110. Retrieved from https://doi.org/10.1007/s13665-016-0147-7
- Frayne, S. M., Phibbs, C. S., Saechao, F., Maisel, N. C., Friedman, S. A., Finlay, A., & Haskell, S. (2014). Sourcebook: Women veterans in the veterans health administration. Volume 3. Sociodemographics, utilization, costs of care and health profile. Women's health evaluation initiative. Washington, DC: Department of Veterans Affairs.
- Frayne, S. M., Skinner, K. M., Sullivan, L. M., Tripp, T. J., Hankin, C. S., Kressin, N. R., & Miller, D. R. (1999). Medical profile of women veterans administration outpatients who report a history of sexual assault occurring while in the military. Journal of Women's Health & Gender-Based Medicine, 8(6), 835–845. Retrieved from https://doi.org/10.1089/152460999319156
- Ganzini, L., Denneson, L., Press, N., Bair, M., Helmer, D., Poat, J., & Dobscha, S. (2013). Trust is the basis for effective suicide risk screening and assessment in Veterans. Journal of General Internal Medicine, 28, 1215–1221. Retrieved from https://doi.org/10.1007/s11606-013-2412-6
- Goyal, V., Borrero, S., & Schwarz, E. B. (2012). Unintended pregnancy and contraception among active-duty servicewomen and Veterans. American Journal of Obstetrics and Gynecology, 206(6), 463–469. Retrieved from https://doi.org/10.1016/j.ajog.2011.11.018
- Grubaugh, A. L., Monnier, J., Magruder, K. M., Knapp, R. G., & Frueh, B. C. (2006). Female Veterans seeking medical care at Veterans Affairs primary care clinics: Psychiatric and medical illness burden and service use. Women & Health, 43(3), 41–62. Retrieved from https://doi.org/10.1300/J013v43n03_03
- Hamilton, A. B., Poza, I., & Washington, D. L. (2011). “Homelessness and trauma go hand-in-hand”: Pathways to homelessness among women veterans. Women's Health Issues, 21(4 Suppl.), S203–S209. Retrieved from https://doi.org/10.1016/j.whi.2011.04.005
- Haskell, S. G., Gordon, K. S., Mattocks, K., Duggal, M., Erdos, J., Justice, A., & Brandt, C. A. (2010). Gender differences in rates of depression, PTSD, pain, obesity, and military sexual trauma among Connecticut War Veterans of Iraq and Afghanistan. Journal of Womens Health, 19(2), 267–271. Retrieved from https://doi.org/10.1089/jwh.2008.1262
- Haskell, S. G., Heapy, A., Reid, M. C., Papas, R. K., & Kerns, R. D. (2006). The prevalence and age-related characteristics of pain in a sample of women veterans receiving primary care. Journal of Women's Health, 15(7), 862–869.
- Haskell, S. G., Ning, Y., Krebs, E., Goulet, J., Mattocks, K., Kerns, R., & Brandt, C. (2012). Prevalence of painful musculoskeletal conditions in female and male Veterans in 7 years after return from deployment in Operation Enduring Freedom/Operation Iraqi Freedom. Clinical Journal of Pain, 28(2), 163–167. Retrieved from https://doi.org/10.1097/AJP.0b013e318223d951
- Higgins, D. M., Buta, E., Dorflinger, L., Masheb, R., Ruser, C., Goulet, J. L., & Heapy, A. A. (2016). Prevalence and correlates of painful conditions and multimorbidity in national sample of overweight/obese Veterans. Journal of Rehabilitation Research and Development, 53(1), 71–82.
- Hoggatt, K. J., Jamison, A. L., Lehavot, K., Cucciare, M. A., Timko, C., & Simpson, T. L. (2015a). Alcohol and drug misuse, abuse, and dependence in women Veterans. Epidemiologic Reviews, 37, 23–37. Retrieved from https://doi.org/10.1093/epirev/mxu010
- Hoggatt, K. J., Williams, E. C., Der-Martirosian, C., Yano, E. M., & Washington, D. L. (2015b). National prevalence and correlates of alcohol misuse in women Veterans. Journal of Substance Abuse Treatment, 52, 10–16. Retrieved from https://doi.org/10.1016/j.jsat.2014.12.003
- Iverson, K. M., Hendricks, A. M., Kimerling, R., Krengel, M., Meterko, M., Stolzmann, K. L., & Lew, H. L. (2011). Psychiatric diagnoses and neurobehavioral symptom severity among OEF/OIF VA patients with deployment-related traumatic brain injury: A gender comparison. Women's Health Issues, 21(4 Suppl.), S210–S217. Retrieved from https://doi.org/10.1016/j.whi.2011.04.019
- Iverson, K., King, M. W., Resick, O. A., Megan, R., Gerber, R., Kimerling, R., & Vogt, D. (2013). Clinical utility of an intimate partner violence screening tool for female VA patients. Journal of General Internal Medicine, 28(10), 1288–1293.
- Katon, J., Mattocks, K., Zephyrin, L., Reiber, G., Yano, E. M., Callegari, L., & Haskell, S. (2014). Gestational diabetes and hypertensive disorders of pregnancy among women Veterans deployed in service of operations in Afghanistan and Iraq. Journal of Women's Health, 23(10), 792–800. Retrieved from https://doi.org/10.1089/jwh.2013.4681
- Kelley, M. L., Herzog-Simmer, P. A., & Harris, M. A. (1994). Effects of military-induced separation on the parenting stress and family functioning of deploying mothers. Military Psychology, 6(2), 125–138.
10.1207/s15327876mp0602_4 Google Scholar
- Lehavot, K., & Simpson, T. L. (2013). Incorporating lesbian and bisexual women into women veterans' health priorities. Journal of General Internal Medicine, 28(Suppl. 2), S609–S614. Retrieved from https://doi.org/10.1007/s11606-012-2291-2
- Mattocks, K. (2015a). Mental health care screening and care coordination during pregnancy and postpartum for women Veterans. Journal of Womens Health, 24(1), 1–2. Retrieved from https://doi.org/10.1089/jwh.2014.1517
- Mattocks, K. M. (2015b). Care coordination for women Veterans: Bridging the gap between systems of care. Medical Care, 53(4 Suppl. 1), S8–S9. Retrieved from https://doi.org/10.1097/mlr.0000000000000339
- Mattocks, K. M., Frayne, S., Phibbs, C. S., Yano, E. M., Zephyrin, L., Shryock, H., … Bastian, L. A. (2014). Five-year trends in women Veterans' use of VA maternity benefits, 2008–2012. Women's Health Issues, 24(1), e37–e42. Retrieved from https://doi.org/10.1016/j.whi.2013.10.002
- Mattocks, K. M., Haskell, S. G., Krebs, E. E., Justice, A. C., Yano, E. M., & Brandt, C. (2012). Women at war: Understanding how women Veterans cope with combat and military sexual trauma. Social Science and Medicine, 74(4), 537–545. Retrieved from https://doi.org/10.1016/j.socscimed.2011.10.039
- Mission, J. F., Marshall, N. E., & Caughey, A. B. (2013). Obesity in pregnancy: A big problem and getting bigger. Obstetric & Gynecological Survey, 68(5), 389–399. Retrieved from https://doi.org/10.1097/OGX.0b013e31828738ce
- Mulhall, E. (2009). Women warriors: Supporting she who has borne the battle. Retrieved from http://media.iava.org/IAVA_WomenWarriors_2009.pdf
- Murdoch, M., Bradley, A., Mather, S. H., Klein, R. E., Turner, C. L., & Yano, E. M. (2006). Women and war: What physicians should know. Journal of General Internal Medicine, 21(Suppl. 3), S5–S10. Retrieved from https://doi.org/10.1111/j.1525-1497.2006.00368.x
- National Academies of Sciences, Engineering, and Medicine. (2016). Veterans and agent orange: Update 2014. Washington, DC: The National Academies Press.
- Nayar, P., Nguyen, A. T., Ojha, D., Schmid, K. K., Apenteng, B., & Woodbridge, P. (2013). Transitions in dual care for veterans: Non-federal physician perspectives. Journal of Community Health, 38(2), 225–237. Retrieved from https://doi.org/10.1007/s10900-012-9604-6
- Pearlstein, T. (2015). Depression during pregnancy. Best Practice & Research: Clinical Obstetrics & Gynaecology, 29(5), 754–764. Retrieved from https://doi.org/10.1016/j.bpobgyn.2015.04.004
- Resnick, E. M., Mallampalli, M., & Carter, C. L. (2012). Current challenges in female veterans' health. Journal of Women's Health, 21(9), 895–900.
- Rivera, J. C., & Johnson, A. E. (2014). Female veterans of Operations Enduring and Iraqi Freedom: Status and future directions. Military Medicine, 179(2), 133–136.
- Saunders, J. B., Aasland, O. G., Babor, T. F., De la Fuente, J., & Grant, M. (1993). Development of the alcohol use disorders identification test (AUDIT): WHO collaborative project on early detection of persons with harmful alcohol consumption–II. Addiction, 88(6), 791–804).
- Shivakumar, G., Anderson, E. H., & Suris, A. M. (2015). Managing posttraumatic stress disorder and major depression in women Veterans during the perinatal period. Journal of Womens Health, 24(1), 18–22. Retrieved from https://doi.org/10.1089/jwh.2013.4664
- Street, A. E., Vogt, D., & Dutra, L. (2009). A new generation of women Veterans: Stressors faced by women deployed to Iraq and Afghanistan. Clinical Psychology Review, 29(8), 685–694. Retrieved from https://doi.org/10.1016/j.cpr.2009.08.007
- Suris, A., & Lind, L. (2008). Military sexual trauma: A review of prevalence and associated health consequences in Veterans. Trauma Violence Abuse, 9(4), 250–269. Retrieved from https://doi.org/10.1177/1524838008324419
- The Joint Economic Committee. (2007). Helping military moms balance family and longer deployments. Washington, DC. Retrieved from https://www.jec.senate.gov/archive/Documents/Reports/MilitaryMoms05.11.07Final.pdf on August 16, 2016.
- U.S. Department of Veterans Affairs. (n.d.-a). Polytrauma/TBI system of care. Retrieved from https://www.polytrauma.va.gov/understanding-
- U.S. Department of Veteran Affairs. (n.d.-b). Burn pits. Retrieved from https://www.publichealth.va.gov/exposures/burnpits/index.asp
- U.S. Department of Veterans Affairs. (2015a). Report on data from the airborne hazards and open burn pit (AH&OBP) registry, Retrieved from http://www.publichealth.va.gov/docs/exposures/va-ahobp-registry-data-report-june2015.pdf
- U.S. Department of Veterans Affairs. (2015b). Military sexual trauma. Retrieved from http://www.mentalhealth.va.gov/docs/mst_general_factsheet.pdf
- U.S. Department of Veterans Affairs. (2016a). Profile of women veterans: 2014. Retrieved from https://www.va.gov/vetdata/docs/SpecialReports/Women_Veterans_2014.pdf on August 16, 2016.
- U.S. Department of Veterans Affairs. (2016b). Suicide among Veterans and other Americans 2001-2014. Retrieved from https://www.mentalhealth.va.gov/docs/2016suicidedatareport.pdf
- U.S. Department of Veterans Affairs. (2017). National center for PTSD. Retrieved from https://www.ptsd.va.gov.
- U.S. Department of Veterans Affairs, National Center for Veterans Analysis and Statistics. (2014). Veterans population projections model. Retrieved from https://www.va.gov/vetdata/docs/Demographics/New_Vetpop_Model/VetPop2014Document.pdf
- Washington, D. L., Davis, T. D., Der-Martirosian, C., & Yano, E. M. (2013). PTSD risk and mental health care engagement in a multi-war era community sample of women Veterans. Journal of General Internal Medicine, 28(7), 894–900 https://doi.org/10.1007/s11606-012-2303
- Washington, D. L., Farmer, M. M., Mor, S. S., Canning, M., & Yano, E. M. (2015). Assessment of the healthcare needs and barriers to VA use experienced by women veterans: Findings from the national survey of women Veterans. Medical Care, 53, S23–S31.
- Wentworth, B. A., Stein, M. B., Redwine, L. S., Xue, Y., Taub, P. R., Clopton, P., … Maisel, A. S. (2013). Post-traumatic stress disorder: A fast track to premature cardiovascular disease? Cardiology in Review, 21, 16–22.
- Yano, E. M., Bair, M. J., Carrasquillo, O., Krein, S. L., & Rubenstein, L. V. (2014). Patient aligned care teams (PACT): VA's journey to implement patient-centered medical homes. Journal of General Internal Medicine, 29(Suppl. 2), S547–S549. Retrieved from https://doi.org/10.1007/s11606-014-2835-8
- Zephyrin, L. C. (2016). Reproductive health management for the care of women veterans. Obstetrics and Gynecology, 127(2), 383–392. Retrieved from https://doi.org/10.1097/aog.0000000000001252
- Zinzow, H. M., Grubaugh, A. L., Monnier, J., Suffoletta-Maierle, S., & Frueh, B. C. (2007). Trauma among female Veterans: A critical review. Trauma Violence & Abuse, 8(4), 384–400. Retrieved from https://doi.org/10.1177/1524838007307295
