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Women have been an extreme numerical
minority in VA settings for many years,
settings that once reflected the historical
2 percent cap on their participation in
the military. These settings offered limited
acknowledgment of women veterans' contributions
and the risks they faced while
serving their country.1 As a consequence,
few VA providers have much experience
seeing women patients, and few women veterans
know much about their veteran benefits;
fewer still are aware of the availability
of women's health services in the VA.2
Among those women who use VA care, many
now have the option of being seen in women's
health clinics, their growth rate roughly paralleling
increases in women veteran caseloads.
However, recent evidence suggests that, on
average, these clinics are open roughly halftime—reducing access—and that over 40
percent of these clinics focus on genderspecific
exams only. While comprehensive
women's primary care clinics exist, they are
the exception rather than the rule. As Dr.
Hayes points out, however, changes are
taking place at an unprecedented rate, and
VA researchers are in a unique position to
support and inform the transitions ahead.
VA women's health research has had a relatively
brief but highly dynamic and productive
evolution in recent years. In 2003, in response
to inquiries from policymakers, the VA
Office of Research & Development (ORD)
sponsored establishment of a VA women's
health research agenda. A national planning
group combined an appraisal of VA's research
portfolio with a systematic literature review
and secondary analyses of existing databases
to serve as the foundation for a national
consensus development conference designed
to set evidence-based research priorities.3
Subsequently, following an unexpectedly
high number of submissions,HSR&D funded
a special issue of the Journal of General
Internal Medicine, which came out in 2006,
that focused on women veterans' health and
health care. In the intervening years, the
virtual explosion of women veterans' related
research literature has led to the funding by
VA HSR&D's Evidence Synthesis Program
(ESP) of an updated systematic review,
which is now underway.
VA HSR&D Service has explicitly made
women's health services research a priority
solicitation area for over a decade. While
only a handful of women's health projects
were funded in the early years, this changed
significantly following the establishment of
the VA women's health research agenda.
VA HSR&D has funded a broad range of
research related to this agenda, including:
assessing women veterans' chronic physical
and mental illnesses (Sambamoorthi &
Findlay, East Orange VA); their unmet health
care needs and fragmentation (Washington,
West Los Angeles VA); the quality of breast
cancer care received in VA settings (Luther,
Gainesville VA); determinants of changes in
how VA care is organized (Yano, Sepulveda
VA); resource use and outcomes among
OEF/OIF women veterans compared to men
(Brandt, Haskell & Justice, West Haven VA);
sexual violence and gynecologic health
(Sadler, Iowa City VA); evaluation of MST
screening and treatment (Kimerling, Palo
Alto VA); MST effects of PTSD and behavior
among women Marines (Shipherd, Boston
VA); physical and sexual assault among deployed
women (Sadler, Iowa City VA); and,
stigma and barriers to care (Vogt, Boston
VA), among others.
VA women's health services research now
has the direct attention of national leaders
in VA Central Office, and beyond. While
the spotlight can be bright, this attention
brings with it an unprecedented opportunity
to conduct research that is highly policy relevant
to a waiting audience. VA managers
and clinicians are facing enormous challenges
ahead, as the numbers of women
veterans double. Almost all of the women
veterans' research literature reflects descriptive
or observational studies, leaving an
enormous hole—and opportunity—for
designing and conducting studies of quality
improvement interventions that can help
improve women's health care and address
gender disparities.
Interventions for promoting provider skills,
proficiency, and comfort in treating women
veterans are needed, as are interventions for
improving women veterans' knowledge and
awareness of their VA benefits, and their
entree to VA care. Given the substantial
amount of care that women veterans receive
in the community, via fee basis and contract
care, studies are needed that evaluate the
quality of care delivered. Coordination of
care among multiple providers, especially for
women with comorbid mental health conditions,
is another important research area.
While the VA has mandated inclusion of
women in all VA studies since 1983, I believe
that most "non-compliance" is unlikely
purposeful but instead a function of the difficulties
inherent in recruiting available
women in sufficient numbers. Creation of a
women veterans' practice-based research
network would help remedy this structural
limitation by setting up the infrastructure
for trials in VA medical centers with larger
volumes of female patients. As members of
the VA research community, it is incumbent
on all of us to be mindful of not only the
requirements but also the value of including
women veterans in our research.
The time is ripe for advancing VA women's
health research in ways that we did not even
envision during the agenda-setting process a
few short years ago. I invite you to join the
growing consortium of researchers working
in this arena, and challenge you to consider
innovative ways to integrate women veterans
into your current research.
-
Murdoch M, et al. Women and War:What Physicians
Should Know. Journal of General Internal Medicine
2006; 21(Suppl 3):S5-10.
-
Washington DL, et al. To Use or Not to Use–Women
Veterans' Choices About VA Health Care Use. Journal
of General Internal Medicine 2006; 21(Suppl 3):S11-18.
- Yano EM, et al. Toward a VA Women's Health Research
Agenda: Setting Evidence-Based Priorities to Improve
the Health and Health Care of Women Veterans.
Journal of General Internal Medicine 2006;
21(Suppl 3):S93-101.
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