"We Have a Long Way to Go:" A Case Study Examination of Older Women Veterans' Experiences in VA Primary Care.

Women Veterans are a growing population with complex care needs. While previous research has examined the experiences of women Veterans, little attention has been paid to the specific experiences of older women Veterans. These case studies present the experiences of 2 older women Veterans who have been enrolled in Veterans Affairs (VA) health care for several decades. Results suggest that these older women Veterans have faced gender-specific challenges and barriers throughout their time accessing VA care. The experiences of these participants suggest that they have gender-sensitive needs that are not always addressed by VA primary care and that women's groups are important mechanisms by which they have gained psychological support in a gender-sensitive environment. These cases suggest that access to gender-sensitive services and women-centered spaces are important for these 2 older women Veterans and should be explored in future research.

What do we already know about this topic?

We know that women Veterans have significant health disparities and face unique challenges in accessing primary care when compared with their male counterparts.

How does your research contribute to the field?

This research contributes to the field by presenting the experiences of 2 older women Veterans and investigating the challenges that this unique and understudied population faces when accessing Veterans Affairs (VA) care.

What are your research’s implications toward theory, practice, or policy?

The perspectives provided by these cases support continuing efforts to advance gender-sensitive services and women-centered spaces for older women Veterans in VA care.

Introduction

Women now constitute the fastest growing segment of eligible Veterans Affairs (VA) health care users,[1] with their proportion of the Veteran population projected to double from the current 9% to 18% by 2045.[2] Due to the growth of the women Veteran population, the VA has identified understanding the health needs of women Veterans as a priority area. To address women Veteran’s health care needs, the VA has made efforts to designate funding to this area of research[1] and launch initiatives to provide patient-centered, holistic care for women Veterans.[3] The VA now encourages the development of specialized women’s health programs to address disparities in this population, and a majority of VA sites include a women’s health program or center.[4] Despite these efforts, women Veterans’ quality of VA care continues to lag behind that of male Veterans,[5,6] suggesting that the needs of women Veterans are not yet fully understood and addressed in VA care.

A substantial body of research has examined the perspectives and health outcomes of women Veterans. Studies of women Veterans aged 18 years or older show that women Veterans have significant psychological and physical health disparities when compared with the civilian population. Women Veterans are more likely to report worse physical and mental health,[7] including higher rates of post-traumatic stress disorder and depressive symptoms,[8] and are more likely to experience trauma, intimate partner violence, and sexual assault than non-Veteran women.[9-11] Women in the military are at very high risk for sexual victimization[12]; 1 in 10 women Veterans experience military sexual trauma (MST), or repeated, threatening sexual harassment or sexual assault during military service.[13] The high rates of trauma exposure as well as mental and physical health comorbidities associated with this population require special attention to the safety of clinic environments,[14] which can make it difficult for women Veterans to access quality health care in VA clinics where these approaches are not present.[3] Although examining the impact of sexual assault and MST experiences has been a focus in the development of comprehensive, gender-sensitive VA women’s health care, there are still considerable challenges to addressing these trauma experiences.[15] Women Veterans receiving care outside of the VA may be less likely to receive trauma-sensitive care, and to have military experiences such as MST addressed in routine care.[15] The failure of health care systems to provide trauma-sensitive care that addresses the gender-sensitive needs of women Veterans, such as sexual assault and MST, may contribute to secondary victimization, or an exacerbation of trauma experienced during military service.[12] Given the high rates of trauma among this population, including MST, care that is trauma sensitive is an integral component of gender-sensitive comprehensive care for women Veterans in the VA.[16]

In addition to health disparities, women Veterans face unique challenges in accessing primary care when compared with their male counterparts. These include a perceived lack of gender-sensitive care,[17-21] which includes gender-specific services, attention to prevalent issues among women such as sexual trauma, and care that reflects the preferences of women.[3] Women must access an array of VA and non-VA providers to achieve the same basic level of care which male Veterans can achieve with 1 primary care visit.[22] Many women Veterans choose to receive care in civilian health care systems because they view the VA primarily as a resource for men.[23]

As these challenges indicate, the availability of women’s health services impacts women Veterans’ experiences when accessing health care and affects the decision of whether to use VA or civilian services.[24] One study assessing the experiences of women in VA care found that women’s negative experiences were primarily driven by a lack of gender-sensitive treatments and services, and many women were unable to access the women-centered mental health treatment settings they wanted.[25] Furthermore, women perceived the VA’s environment to be unwelcoming, and that being in a health care setting with men resulted in discomfort, mistrust, and severe anxiety, especially for women with a military sexual assault history.[25] These findings suggest that lack of access to gender-sensitive services can affect women Veterans’ satisfaction with VA care.

When women Veterans do have access to primary care that provides gender-sensitive services—such as women’s clinics tailored to general and gender-specific health needs, female providers if preferred, and women-centered mental health services—they report greater satisfaction with their care provider.[26] In addition, women Veterans who receive care in specialized women’s clinics are more satisfied with their care than their civilian counterparts in traditional primary care clinics.[17] Participants in a study focusing on the perspectives of women Veterans repeatedly emphasized their desire for gender-sensitive care, medical equipment designed for women, and physicians who understand women’s issues.[23]

Despite a growing literature examining the experiences and health care needs of women Veterans, less attention has been paid to the experiences of older Veteran women accessing VA care. Studies show that older women Veterans have worse self-reported health, physical decline, and mental health conditions than their civilian counterparts. Veteran women aged 80 years or older reported significantly lower perceived health, life satisfaction, social support, and quality of life than non-Veteran women of similar age.[6] Older women Veterans have been shown to experience greater declines in the level of physical activity as compared with non-Veteran women.[27] In addition, older women Veterans have a higher prevalence of mental health disorders and are more likely to experience interpersonal violence than non-Veteran women.[6] Because of these health disparities, accessing quality health care is imperative for this population.

While findings suggest that gender-sensitive primary care services benefit women Veterans of varying ages, additional research is needed to further examine the perspectives of older women Veterans and their experiences accessing VA care. In this case study, we explore the perspectives of 2 older women Veterans who receive primary and mental health care in a VA women’s clinic to examine how access to gender-sensitive health services shaped their experiences within VA care.

Methods

Setting and Participants

The data presented in this case study are part of a larger qualitative study, in which we conducted semi-structured interviews with older Veterans to elicit their perspectives on measuring functional status in primary care. We recruited patients from 3 primary care clinics at 1 large, urban VA medical center. Clinic settings included a mixed-gender primary care clinic, a geriatrics primary care clinic for Veterans aged 65 years and older, and a women’s primary care clinic. All care settings used a Patient Aligned Care Team model of primary care, which focuses on team-based care, patient access, care management, and patient-centered communication.[14] We identified patients aged 65 years and older who received care in 1 of these clinics and had seen their primary care provider in the past year, and used stratified purposeful sampling to select participants based on their functional status.[28] All participants provided written informed consent. The local institutional review board provided written consent and approval for this study.

Data Collection

Between March 2016 and October 2016, a medical anthropologist and research assistant trained in qualitative methods conducted in-person semi-structured interviews with 33 participants, 15 of whom were women. During these interviews, participants were asked open-ended questions about their daily routine, functional status, and primary care visits. Participants gave written consent before each interview, and interviews were audio recorded and professionally transcribed. Each interview lasted approximately 60 minutes. While these interviews were originally designed to assess perspectives on the measurement of functional status, access to gender-sensitive care emerged as a prominent theme among many of the 15 women participants when discussing their experiences in primary care. Two of these women stood out due to their emphasis on how their experiences receiving care at the VA were influenced by gender. To further explore their unique perspectives, we selected the experiences of these 2 women to highlight in a case study examination.

Analytic Approach

The case study is a method for presenting qualitative information, allowing individual examples to be explained and understood in relation to a broader population being studied.[29] By allowing in-depth, multifaceted explorations of complex issues and experiences,[30] this approach can be used to explain, describe, or explore events or phenomena as they occur in everyday life.[31] We chose to use a case study approach to closely examine the detailed, gender-specific experiences of 2 older women Veterans. Through this approach, we connect their experiences to previous research in this population to gain a deeper understanding of the gender-specific barriers that affect these women Veterans in VA health care.

We used Atlas.ti (Version 8, Berlin, Scientific Software Development) to manage qualitative data and facilitate data analysis. The cases were then analyzed using inductive thematic analysis, a qualitative method for identifying, analyzing, and reporting patterns and themes within data.[32] First, 2 members of the study team independently reviewed 5 transcripts and developed codes to identify key concepts related to the larger study goals of understanding older women Veteran’s experiences in primary care. We then refined codes through serial review of transcripts and developed relevant themes. During this iterative process, we met to discuss findings after each set of 3 independently coded transcripts. We resolved disagreements about the presence, scope, or definition of codes and presence of themes through discussion and consensus. Of the 15 women Veteran interview transcripts that were coded, 2 women were selected as cases for our analysis because they illustrated gender-specific challenges and barriers when accessing VA primary care. These interview transcripts were then closely read and analyzed by several members of the study team a second time to explore themes related to these older women’s gender-specific experiences in VA care.

Results

In our 2 case analyses, we begin with a description of the research participants and relevant demographic information, followed by the themes that emerged from the analysis of their experiences. Through our analytic approach, we identified 3 important themes: (1) the availability of women’s health care services influenced the experiences of these 2 women throughout their time accessing VA care, (2) these women have gender-sensitive needs that have not always been addressed by VA primary care, and (3) women’s groups have and continue to play an important role in providing psychological support and services to these older women Veterans. We then explored how these themes relate to previous research. To protect the anonymity of our participants, we have altered some identifying information.

The Case of Ms. X: Addressing the Gender-Sensitive Needs of Women Veterans

“I don’t want to look behind me and see that my legacy was that I was the only female. That would just crush me,” said Ms. X, a 74-year-old African American Veteran who served in a management position for Veterans’ organizations. She now acts as a national advocate for women’s health issues and Veterans with disabilities, mentoring women in her organizations and encouraging them to pursue leadership roles.

Ms. X highly values her role as a proponent for women’s involvement and support in the military, and during the interview emphasized that women Veterans have important gender-specific needs. Ms. X began accessing VA services in 1995, at a time when the first VA women’s clinics were established to address gendered gaps in care.[3] She spoke of her struggle to access mental health support that met her needs as a woman Veteran: “When I first came out of combat, they put me in a group with all males which was just fine, but we didn’t have the same issues,” she said.

Like this [research] study . . . unless we let you guys know what’s going on, sometimes you don’t know. It’s like the PTSD for the women, how would you know? Female vs. male . . . we have certain issues that maybe they don’t have.

Here, Ms. X emphasizes that it is important for researchers and providers to know that men and women Veterans can have different problems surrounding mental health. Ms. X’s story illustrates feelings of exclusion when placed in a mental health support group with male participants due to a perceived lack of understanding or acknowledgment of her psychological needs as a woman. To address her own mental health and that of her female peers, she worked with another woman Veteran to create a support group specifically for women at the clinic they attended. Even when participating in a support group catered to women, Ms. X acknowledged that not all women Veterans have the same issues: “You’re in an all-female group, but sexual trauma is a bit different than dead bodies, so we need to look at that.” Ms. X’s perspective suggests that gender-specific services and women-centered spaces have improved her psychological health by providing a safe environment in which her needs as a woman Veteran are addressed.

In addition to the barriers in accessing gender-sensitive psychological care, Ms. X discussed instances in which her identity as both a woman and a Veteran was challenged during her visits to the VA medical center. She described waiting in a VA pharmacy for her medication and staff calling her “Mr. [LAST NAME]” when reading her prescription, assuming she was male because of her Veteran status. She explained that these situations bother her because they dissociate her gender identity and military status: “Women are in the military. They’ve been in for some time. I don’t see why the VA is doing this, so things like that really perturb me.” This experience illustrates how a lack of gender sensitivity can affect women Veterans’ perception of VA services.

Ms. X’s story illustrates the challenges she has faced in VA primary care and mental health services because of her status as a woman Veteran with experiences that may be improved with broad training in gender-sensitive care for providers and staff in VA settings. As Ms. X herself stated, “ . . . I do think we’ve come a long way, but we have a long way to go as far as bringing the standards up for female Veterans.”

The Case of Ms. Y: The Importance of Women-Centered Spaces in VA Care

“Well, I’m definitely a feminist, but I was a feminist before there was feminism,” said Ms. Y, a 73-year-old white and Asian woman, who worked for 20 years as a US Army Intelligence Officer. Divorced twice, she now lives alone in a large, sprawling retirement community and works part-time as a caregiver and companion to older residents in her community. Since 2004, she has received a variety of health services from a VA women’s clinic including primary care and mental health services.

Ms. Y disclosed that, like an estimated one third of women Veterans, she has experienced intimate partner violence.[11,33] Ms. Y’s first husband was physically violent and her second husband was psychologically abusive, which resulted in a hostile divorce. According to Ms. Y, this psychological trauma led her to seek out the mental health services provided by a VA women’s clinic, which aided her healing process. “The VA women’s center was a huge part of me moving on,” she told us. “I stayed in this area because of the women’s center. Because I’ve really, really, needed what it offered.” For many years, she attended VA women’s groups such as “Seeking Safety,” a present-focused group that teaches coping skills targeted to individuals who have experienced trauma and/or addiction.[34]

The case of Ms. Y illustrates the importance of women-centered spaces for both primary and mental health services in VA care. When asked why she enjoys women’s groups, Ms. Y explained the following:

One of the things I loved about the women’s center was that there weren’t any men. Just because . . . in our country, in our society, men just don’t go through much of a learning process about what it is to be a woman in America.

Here, she acknowledges that women have a unique societal experience due to their marginalized gender identity, which men might not be able to understand. She goes on to say the following: “I think that one of the things I liked about the women’s center was it was no men with the, you know, male privilege and all that.” Her perspective suggests that women-centered spaces are important in providing a safe, gender-sensitive environment for her primary care and mental health treatment as a woman Veteran.

Discussion

The cases of Ms. X and Ms. Y illustrate the perspectives of older Veteran women who have accessed VA for several decades, providing unique narratives that explore the impact of gender-sensitive services within VA care. Their perspectives emphasize the importance of providing gender-sensitive services and women-centered spaces for the growing population of women Veterans. The experiences of Ms. X and Ms. Y suggest that these older Veteran women have faced gender-specific challenges and barriers when accessing VA care over time.

The experiences of these 2 women share important similarities. Like many women Veterans, Ms. X and Ms. Y indicated that their experiences accessing VA care are affected by the availability of women’s health care services, and that their identity as women is an important consideration when planning for health care.[24] In both cases, participants expressed that their identity as women embodies significant meaning; Ms. X spoke of the importance of her leadership role at the VA as the first woman in this position, while Ms. Y emphasized her identity as a feminist and discussed gendered societal issues, such as male privilege and the obstacles faced by women in their everyday lives. Ms. X and Ms. Y made the decision to attend a VA women’s clinic to gain access to gender-sensitive care and services, indicating the value they place on health care spaces that consider and acknowledge their unique challenges as women and as Veterans. Both women recounted positive experiences with their clinic’s gender-sensitive mental health services and care, reflecting the tendency for women Veterans to report greater satisfaction with women’s clinics or primary care models tailored to women’s needs.[26]

The experiences of Ms. X and Ms. Y emphasize the importance of women’s groups in providing psychological support and services to women Veterans. Many women Veterans desire women-centered mental health treatment settings and providers that understand women’s issues.[25] In case 1, Ms. X was initially put into a male-dominated mental health support group, so she worked with another woman Veteran to create a support group specifically for women at the clinic they attended. Her agency and determination to create a safe environment in which women Veterans could access psychological support illustrates the importance of providing women-centered spaces to women Veterans, as well as the high demand for such resources.

Similarly, the experience of Ms. Y illustrates the benefits that gender-sensitive mental health spaces can provide to women Veterans. The women-centered support groups that she attended aided her psychological healing process to such an extent that she decided to remain in the area with her clinic rather than move away. Ms. Y’s positive experience accessing mental health services suggests gender-sensitive services and women-centered spaces greatly improved her life after experiencing trauma. Because women Veterans are more likely to experience trauma, intimate partner violence, and sexual assault than non-Veteran women,[9-11] it is imperative that their mental health is addressed in VA care through gender-sensitive services.

In addition to providing support for the benefits of gender-sensitive care, the cases of Ms. X and Ms. Y illustrate the harmful effects that can occur if the challenges faced by women Veterans are not addressed in VA care. When Ms. X was assigned to a mental health support group with male participants, she expressed feelings of exclusion and a perceived lack of understanding of her psychological needs as a woman Veteran. In addition, when Ms. X was mistaken for a male Veteran at a VA pharmacy, she felt that her dual identity as a Veteran and as a woman was not acknowledged. These findings are consistent with previous research, which has shown that many women Veterans view the VA primarily as a resource for men[23] and report that being in a health care setting without women-centered spaces exacerbated feelings of discomfort, mistrust, and severe anxiety, especially for women with a military sexual assault history.[25]

The perspectives of Ms. X and Ms. Y suggest that these 2 older Veteran women have faced barriers accessing VA care over time. The experiences of these participants suggest that their unique needs as women Veterans have not always been addressed by VA primary care, and that women’s groups are important mechanisms by which they have gained psychological support in a gender-sensitive environment. Additional research is needed to further explore the significance and impact of gender-sensitive care in VA settings for older women Veterans.

Conclusion

The perspectives of Ms. X and Ms. Y suggest that these 2 women Veterans highly value health care spaces that consider and acknowledge their gender-specific challenges, and that mental health services are important mechanisms by which these women have gained psychological support in a gender-sensitive environment. Their experiences align with previous research that has examined the challenges and barriers that face women Veterans of all ages when accessing VA care. Additional research is needed to further examine the impact of gender in VA care for older women Veterans and explore how women’s groups can provide a way to overcome barriers in accessing psychological support for women Veterans across the lifespan.