AG Sadler, Iowa City Veterans Affairs Medical Center; BM Booth, Department of Psychiatry, The University of Arkansas for Medical Sciences, Little Rock Veterans Affairs Medical Center; HSR&D Field Program for Mental Health Research, Little Rock, Arkansas; BN Doebbeling, Iowa City Veterans Affairs Medical Center, The Departments of Internal Medicine, Epidemiology, and Public Health, The University of Iowa, Iowa City, Iowa

Objectives: Sexually assaulted women report poorer health status and markedly higher outpatient expenditures than women who have not experienced sexual violence. Women surviving childhood sexual abuse are twice as likely to experience rape and physical assault in adulthood. The goal of this study was to determine if there were differences in health care utilization between women veterans who during military service experienced: one rape or physical assault; more than one occurrence of rape and/or physical assault; or no violence, while controlling for pre-military trauma. We used Aday and Andersen’s behavioral model of access to care to determine the relative importance of trauma on health care utilization.

Methods: A national cross-sectional survey of 558 women veterans serving in Vietnam or subsequent eras was conducted. Socioeconomic information, trauma history, access to care, outpatient health-care utilization, and the Medical Outcomes Study ShortForm-36 (SF-36) assessment of health-related quality of life were obtained by structured interview. The stratified sampling design was analyzed using STATA. Multiple regression models were used to examine the data in the context of the Aday and Anderson theoretical model. Predisposing factors included age and marital status, race, and college education. Enabling factors included private insurance, annual income, service connected-disability, and full time employment. Need variables included pre-enlistment trauma history, post-military violence, chronic medical problems, SF-36 physical (PCS) and mental component summary (MCS) scores, and current prescription medication utilization for mental health disorders. The dependent variable was the log of the number of physician visits made by participants during the year prior to interview.

Results: Women who experienced repeated episodes of violence during military service made significantly more outpatient physician visits in the preceding year than singly or non-traumatized peers (16 vs. 9 and 8 visits, respectively; p< .05). Multiply traumatized women more often reported a history of childhood violence (p < .001), post-military violence (p < .001), and substantial adverse effects in their current physical and emotional health (p< .01), educational attainment (p < .05) and economic achievement (p < .05).

In a regression model including military trauma as the only need variable, multiple trauma was significantly associated with health care utilization (p < .01 ). In a second model including all need variables, military trauma did not remain significantly associated with utilization. The total proportion of the variance explained was 40%, of which the SF-36 PCS accounted for the highest unique proportion of the variance (14%).

Conclusions: Repeated violence is associated with impaired health status, increased health services utilization, and adverse socioeconomic effects. Trauma and impaired health status appear to significantly affect women’s perceived need for and utilization of health care.

Impact: DVA clinicians must recognize the severe and chronic negative health effects of violence and routinely screen women for lifetime histories of trauma. Given the greater health status impairment and utilization by women with multiple victimizations, prompt recognition and intervention to prevent repeated violence is imperative.