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Women Veterans’ Reproductive Health Preferences and Experiences: A Focus Group Analysis
Women's Health Issues 21-2 (2011) 124–129
www.whijournal.com
Original article
Women Veterans’ Reproductive Health Preferences and Experiences: A Focus Group Analysis Kristin M. Mattocks, PhD a,b,*, Cara Nikolajski, MPH c,d, Sally Haskell, MD a,b, Cynthia Brandt, MD a,e, Jennifer McCall-Hosenfeld, MD f, Elizabeth Yano, PhD g,h, Tan Pham, MPH a,b, Sonya Borrero, MD c,d,i a
Yale University School of Medicine, Department of Internal Medicine, New Haven, Connecticut VA Connecticut Healthcare System, West Haven, Connecticut Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania d Center for Research on Health Care, University of Pittsburgh, Pennsylvania e Yale University School of Medicine, Yale Center for Medical Informatics, New Haven, Connecticut f PennState Milton S. Hershey Medical Center, Hershey, Pennsylvania g VA HSR&D Center of Excellence for the Study of Healthcare Provider Behavior, VA Greater Los Angeles Healthcare System, Sepulveda, California h Department of Health Services, UCLA School of Public Health, Los Angeles, California i General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania b c
Article history: Received 1 July 2010; Received in revised form 10 September 2010; Accepted 8 November 2010
a b s t r a c t Objective: Although women veterans are seeking care at the Veterans Administration (VA) in record numbers, there is little information regarding women veterans’ experiences and preferences for reproductive health care services. We sought to characterize women veterans’ experiences with, and preferences for, reproductive health services in the VA. Methods: We conducted five focus groups with a total of 25 participants using a semistructured interview guide to elicit women veterans’ experiences and preferences with reproductive health care. Women veterans’ utilizing VA health care at two VA facilities who responded to advertisements were selected on a first-come basis to participate in the study. We analyzed transcripts of these audiorecorded sessions using the constant comparative method of grounded theory. Results: Five main themes emerged from the focus group discussions: 1) Women veterans prefer VA women’s clinics for comprehensive medical care; 2) Women veterans have had both positive and negative reproductive health experiences in the VA; 3) Women veterans experience knowledge gaps regarding VA coverage for reproductive health services; 4) Women veterans believe the VA should provide additional coverage for advanced infertility care and for newborns; and 5) Perceived gender discrimination shapes how women veterans view the VA. Conclusion: As the VA continues to tailor its services to women veterans, attention should be given to women’s reproductive health care needs. Copyright Ó 2011 by the Jacobs Institute of Women’s Health. Published by Elsevier Inc.
Introduction Many of those who have historically sought Veterans Health Administration (VA) care have been men, with many of the VA’s
The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs. Funded by VA Office of Public Health and Environmental Hazards, Women Veterans Health Strategic Healthcare Group. * Correspondence to: Kristin M. Mattocks, PhD, VA Connecticut Healthcare System, 950 Campbell Avenue, 11-ACSLG, West Haven, CT 06516. Phone: 413548-6777; fax: 203-937-4926. E-mail address: [email protected] (K.M. Mattocks).
services being particularly tailored to the needs of older male veterans (e.g., World War II, Korean War, and Vietnam War veterans). However, women veterans are seeking care at VA facilities in record numbers. Recent estimates suggest that nearly 50% of women who have served in Iraq (Operation Iraqi Freedom [OIF]) and/or Afghanistan (Operation Enduring Freedom [OEF]) have enrolled in VA health care (Kang, 2008). This market penetration is in sharp contrast to previous cohorts, where an average of 11% of eligible women used the VA for care (Yano, Washington, Goldzweig, Caffery, & Turner, 2003). The surge among OEF/OIF women veterans has changed the demographic and thus clinical needs of women veterans seen in VA settings. Specifically, many OEF/OIF women veterans accessing VA care
1049-3867/$ - see front matter Copyright Ó 2011 by the Jacobs Institute of Women’s Health. Published by Elsevier Inc. doi:10.1016/j.whi.2010.11.002
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are under the age of 40 and therefore of childbearing age (Under Secretary for Health Workgroup, 2008), and it is unclear whether their major health concerns mirror those of other women veterans seeking care in the VA, let alone those of male veterans who still predominate the system (Kang, 2008). Over the past decade, the VA has greatly expanded services available to women veterans (United States General Accounting Office, 1999). In 1992, legislation authorized new and expanded services for women veterans, including counseling for sexual trauma and reproductive health care, including Pap smears, mammography, contraceptive services, and treatment of menopause-related symptoms. By 1996, services were further expanded to include maternity and infertility benefits. To accommodate service expansion and improve attention to privacy needs, the VA increased provision of women’s health services in gender-specific primary care models (i.e., women’s health clinics), present in about 54% of VA facilities (Seelig, Yano, Bean-Mayberry, Lanto, & Washington, 2008; Yano, Goldzweig, Canelo, & Washington, 2006; Yano et al., 2003). Separate gynecology clinics have also been established (Seelig et al., 2008). Given the experience and training necessary to deliver quality women’s health services, however, VA managers continue to struggle with the value of delivering gender-specific care in-house versus through community providers. This concern is especially salient for the delivery of reproductive health services. To inform further development of suitable care arrangements, we sought to characterize women veterans’ experiences with and expectations of reproductive health care in the VA, using a series of focus groups from 2 geographically distinct VA sites. Materials and Methods Participants and Recruitment We conducted five focus groups with 25 women veterans who receive care at VA facilities in Pittsburgh, Pennsylvania, and West Haven, Connecticut. Both VA facilities had comprehensive women’s health programs that provide medical care for women veterans (i.e., one-stop shopping programs outside of traditional primary care or gynecology clinics). We used multiple strategies to recruit women to participate. In West Haven, we used flyers in the Women’s Clinic lobby, and recontacted women who were participants in another ongoing women’s health study (Haskell et al., 2009). In Pittsburgh, we posted flyers in general primary care, women’s health primary care, and gynecology clinics, and asked clinicians in these clinics to refer potential participants. We also mailed informational letters and study flyers to female patients seen by the principal investigator, and mailed study flyers to women receiving visit reminder notices or new patient packets from the women’s health primary care clinic. Women were considered eligible for the study if they were between the ages of 18 and 50; were enrolled within the VA Healthcare System; and self-identified as Black/African-American or White. Women responding to study advertisements study were screened for eligibility over the phone. In an effort to keep groups racially homogenous, we limited the study to Black/ African and White women because there were too few women of other races/ethnicities at either site to form a focus group. We excluded non-English speakers. We invited eligible women to participate, and sent follow-up letters confirming the date, time, and location of the focus group session. Reminder telephone calls were placed the night before scheduled focus groups. Participants received a $40 gift card, in addition to provision of a meal at each
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session. Our final sample size of 24 women veterans was determined by thematic saturation, the point at which no new themes emerged from successive interviews (Malterud, 2001; Patton, 2002). The research protocol was approved by the Institutional Review Boards at VA Pittsburgh and VA Connecticut. Instrument We developed a 10-item, semistructured interview guide designed to elicit use of, experiences with, and knowledge about reproductive health services in the VA. For this study, reproductive health care included services such as cancer screening and mammography. Focus group methods, which use an inductive approach, have been advocated for evaluating topics that have received little prior investigation (Poses & Isen, 1998). Participants also completed a brief demographic questionnaire at the conclusion of the focus groups. Focus Groups Two experienced moderators (K.M. and C.N.) conducted five focus groups, stratified by participant race. In general, focus groups should occur in nonthreatening environments with a group of individuals who share certain characteristics to allow for a good group dynamic and greater self-disclosure (Borrero et al., 2009; Krueger & Casey, 2000). Focus groups were conducted in private conference rooms in each VA facility. Focus groups lasted an average of 45 minutes, were audiorecorded, and professionally transcribed. Participants were asked to describe the kinds of health services that had received at the VA, with a specific focus on the types of reproductive health services they received. Participants were also asked to detail any problems they had experienced with reproductive health care services, and what additional reproductive health services the VA should provide. Analysis After checking transcriptions for accuracy of content, two members of the research team (K.M. and C.N.) analyzed the transcripts according to concepts of grounded theory (Britten, 1995; Glaser, 1967). We used open coding, where each coder independently reviewed the transcripts line by line, creating code definitions as concepts emerged inductively from the data. Coders met to compare codes, resolve discrepancies, and review the code structure. Codes were then refined until a final coding structure was achieved. A total of 25 codes capturing major concepts in the data were then applied to all of the transcripts. We then used axial coding, combining codes into broader categories to better define emerging themes that characterized women’s perceptions of VA reproductive health care services. Because no unique themes arose across the racially homogenous focus groups, we chose to report the major themes for all participants combined. We used Atlas.Ti for data management and retrieval (Muhr, 2004). Results Twenty-five women participated in five focus groups. The median sample age was 39 years (range, 29–49), with 70% of participants Caucasian and 30% African American. All had at least a high school degree or GED, 36% had some college education, 23% had a college degree, and 18% had a graduate or professional
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degree. Thirty-three percent were single, 31% were married, and 36% were divorced or separated. Forty-five percent of the participants were uninsured, 37% had private insurance, and 18% had insurance for military personnel or veterans. Five main themes emerged from the focus group discussions: 1) Women veterans prefer VA women’s clinics for comprehensive medical care; 2) Women veterans had both positive and negative reproductive health experiences in the VA; 3) Women veterans experience knowledge gaps regarding VA coverage for reproductive health services; 4) Women veterans believe the VA should provide additional coverage for advanced infertility care and for newborns; and 5) Perceived gender discrimination shapes how women veterans view the VA. We describe each theme, providing representative quotations to illustrate these themes and dissenting views when present (Waitzkin, 1990). Women Veterans Prefer VA Women’s Clinics for Comprehensive Medical Care We found that women preferred VA women’s clinics for comprehensive medical care, including their reproductive health needs. Participants stated that they were able to receive the majority of their care within the women’s clinics, and felt that the staff in these clinics had the knowledge and skills to address most of their medical needs: “They are excellent. I mean, for me. Since the Women’s Clinic has been there and it’s like our own entity, there is not a problem. They jump through hoops.” Many expressed an appreciation for team-based approaches to their care, with physicians, nurse practitioners, and other medical staff working together to address each woman veteran’s needs: “There is always someone there to help someone else. I mean, they work together as a team a whole lot down there and I really commend them. I can’t complain about the women’s clinic.” In fact, even though several participants had private health insurance that allowed them to seek care elsewhere, they still preferred to receive their care in the VA women’s clinics. Many women felt that the VA women’s clinics were better suited to understand and assist with problems associated with military service, whereas other women experienced a more welcoming environment in the VA as compared to non-VA care: “Doctors on the outside [of the VA] are cold. That’s why I come here because I also have insurance for the outside and the one time where I did decide to see an outside doctor, I did not like it. I did not like how cold she was. She didn’t ask any questions, she had no personality. She was just treating me like I was an object. I’ll never go back out again.” Although women were generally satisfied with VA women’s clinics once they had arrived, many women recalled their initial reservations about coming to the VA. Women cited persistent rumors among veterans regarding VA care, and many participants believed these ongoing rumors prohibited other women veterans from seeking care at the VA: “Honestly, I didn’t want to come to the VA because from what I heard, this is lousy care, you know. That’s what I’ve always heard, so when the guy told me I had to come to the VA, I was like ‘No, I don’t want to go there.’ But I’m glad I did because I was not aware of the women’s health clinic.” Despite feeling comfortable receiving care within the walls of the VA women’s clinics, several women noted that they occasionally felt out of place in the larger VA system. Noting that most VA patients are male and that many of them have significant physical and mental health problems arising from their military service, several women worried that their own health problems
may not be serious enough to warrant VA care: “I came to the VA and it was like ‘I’m on a movie set of Born on the Fourth of July!’ Guys wearing bandanas and I was just like, ‘Wow, am I one of these people?’ But I’m not broken. Maybe I really shouldn’t be coming here. You know? I am seeing someone for [posttraumatic stress disorder] and I even said to my doctor the other day, ‘Listen I’m not having nightmares anymore so I don’t want to take someone else’s slot.” Women Veterans had Both Positive and Negative Reproductive Health Experiences in the VA Women veterans reported both positive and negative experiences with VA reproductive health care. Participants varied in the types of reproductive health care services they utilized at the VA, although nearly all received annual Pap smears and routine preventive care. When participants required services that were not provided in the VA, such as infertility services, pregnancy care, or mammography, they were given referrals to fee basis or contract providers outside the VA. Participants were generally satisfied with the range and quality of reproductive health services they received from the VA, whether the reproductive health services were provided within the VA or from fee or contract providers: “I got to commend them. They be on your about your mammogram. Every year faithfully they call me, ‘It’s time for your mammogram,’ and they’ll hunt you down until they get your appointment. That to me shows that they really care.” Participants were generally satisfied with the competence of VA women’s health providers. Several participants discussed their efforts to try to conceive a child, and were pleased with the assistance that the VA had given them in this regard: “I got my fibroid tumors removed here at the VA which was the best surgery. Now the VA is doing everything they possibly can for me to conceive because I am in my 40s and I haven’t yet conceived.” Another woman concurred, speaking of the ease at which she was able to receive a referral for infertility care provided by a private fertility clinic: “I came to the women’s clinic and they said, ‘What do you want?’ I said I want to have a baby. He said, okay let me see. He said oh, yeah, we can pay for that. So he sent me over to the fertility clinic.” However, some participants also expressed concerns about the amount of care provided in the women’s clinics by medical residents. Much of this concern was focused on participant’s perceptions that the VA remains a major training facility for medical residents and interns, causing occasionally poor service delivery: “I did have a problem with an intern giving me a pap smear, only because you could tell he never did it before. He was looking at the clampy things and he was kind of like fumbling and he just kind of picked one and he goes ‘It [the size] doesn’t matter, right?” Another woman echoed this sentiment: “That’s because this is like a training facility. Every time I come in for a Pap, I have a new physician and I have to go back and tell them all of my information all over again and that is pretty frustrating!” Women reported having mixed experiences in terms of appointment availability. Some women were pleased with the flexible system of appointments, including the ability to arrange a walk-in appointment for urgent care issues: “If you don’t have an appointment and need to see them, they let you be a walk-in. Even if the walk-in is from certain hours at least you do have the opportunity to be a walk-in.” Other participants, particularly those who did not live close to the VA, found appointment scheduling difficult, and were reluctant to take the amount of
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time off from work necessary to receive routine gynecological care: “I got to take a day off from work because the VA Women’s Clinic is only open like on Tuesday mornings or something. Like some insane schedule thing because I’ve got to drive a hour down and sit there, have my exam and drive an hour back to work. So I’ve got to at least take a half a day off from work.” Other participants were frustrated by appointment schedules, as they thought the VA did not respect their work and family commitments: “They just give you random appointments. Like you work and I feel like they think we are all like 90-year-old men veterans and we can just come whenever.” A few participants commented on the culture of the clinic. Some women felt that the focus is on poor health habits, and noted that the women’s clinics waiting rooms were filled with admonitions regarding risky sex, alcohol and drug use, and smoking: When I started back in 2000, 2001 the questionnaire you filled out had everything to do with did you take drugs? Were you HIV infected? Do you have hepatitis? Do you drink too much? Have you been sexually assaulted? But I just remember thinking, ‘Is this all they think we are? That women are down on their luck and they all have drinking problems and they’re all abusing drugs? That just wasn’t what I expected for going into any women’s clinic. I kind of expect them to ask about babies and your period and stuff. Not the last time I was drug abusing. Furthermore, most participants expressed a belief that the VA had expanded the range of contraceptive options available to women veterans over the years. Women who had been receiving reproductive health care in the VA for many years recalled feeling pressure to choose among a limited set of contraceptive options, none of which were ideal: “I’ve been coming to the VA for years for contraception and they were very limited on a lot of things that they would offer you because they didn’t have much. But in the past couple of years, it’s been different. You get a little bit more of an option now.” However, some women expressed frustration that their opinions and preferences were not fully considered when contraceptive options were presented. Participants felt that providers made decisions without regard for patient preferences, and some patients went further to suggest that providers pressured patients to choose one contraceptive option over another: “I have Mirena and these people put it in. Pressured me to put it in, actually. I really didn’t want it but they kinda talked me into it and I was really sorry after that.” Some patients acknowledged that they had learned it was important to communicate their preferences clearly to providers in order to ensure that treatment decisions were in line with their own preferences, rather than that of the provider: “You have to be your biggest advocate because if you’re not, sometimes they go with what they’ve been doing but that may not be right for your current situation.”
Women Veterans Experience Knowledge Gaps Regarding VA Coverage for Reproductive Health Services Although most participants were aware that the VA provided reproductive health services, including routine breast and gynecological cancer screening and contraception management, several women were not: “I didn’t even know that we got Pap smears here. I just thought it was primary care. Not even like female health.”
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Some women commented that information concerning available reproductive health services was difficult to find in the VA, and that this type of information should be made more widely available to patients: “If they could come out with a pamphlet or something saying that the VA does fertility issues, the VA does birth control issues, the VA does pregnancy issues, like prenatal issues. You know, they could just give you a booklet or something that says, this is what we do, this is what we don’t do, and this is who you need to contact to find out who does.” Some participants had heard that the VA did not provide any infertility or pregnancy care, and were surprised when fellow group members disclosed that they had received infertility or pregnancy care from the VA: “I didn’t know and I still don’t know to the extent reproductive health is covered. It was my understanding when I read the booklet that having children was not covered by the VA.” Some participants were also not aware that their ability to access reproductive health services was not dependent on their service-connected disability status: “Does it depend on the percentage of disability you have? So does 10% cover you through your pregnancy but once you give birth, your kid’s not covered? Or if you’re 100%, do they cover you and your child until your child is 18, or how does that work? That would be a good thing to know.”
Women Veterans Believe the VA Should Provide Additional Coverage for Advanced Infertility Care and for Newborns Although participants expressed general satisfaction with the range of reproductive health care services available to them in the VA, some women thought the VA could go further to assist women in becoming pregnant. Several participants had utilized infertility services provided by the VA, including infertility medications and artificial insemination, yet were denied VA coverage for assisted reproductive technologies, including in vitro fertilization. Participants expressed beliefs that the VA should provide more extensive infertility coverage, including in vitro fertilization, to assist women who are having difficulties becoming pregnant: You know, I can essentially say that I gave my reproductive years to the Marine Corps. And those are the years you can serve. We serve during our fertile years and we sacrifice. Now there’s some women who can manage to have a family and, and a career but a lot more women give up the career because it’s just not manageable to have children (in the military). You know, you do sacrifice and you say, “Well, mission first before a family mission,” type of thing and the more I think about I think, you know, the VA probably should address that part of womanhood and have that understanding. Participants also expressed dissatisfaction that the VA does not extend health care coverage to newborns of women veterans. To what extent the VA should provide coverage to older children of women veterans was unclear, but participants did believe that the VA should have an obligation to extend health coverage for some period of time to newborn children. I’m just saying that the child maybe should be covered for 6 months to a year after that. At least for the shots or any complications. That’s the only thing that I would say to have at least a neonatal kind of situation covered. You know, we could have girl getting off active duty and gets pregnant right away and they haven’t gotten established or whatever.
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Perceived Gender Discrimination Shapes how Women Veterans View the VA The final major theme that emerged from the discussion related to the broader VA environment in which women received health care. Major subthemes included 1) perceived differential treatment of women versus men by VA staff, and 2) perceived differential access to VA resources for women versus men. Women veterans’ experiences outside VA women’s clinics were very different and impacted their overall perception of the VA. Perceived differential treatment by VA staff Women reported they felt the treatment they received from VA staff was less respectful than that provided to male veterans: “You are treated like a second class citizen.” Participants believed that some of this inferior treatment was related to ongoing stereotypes regarding women’s roles in the military: “They say women don’t go to war. Well, guess what, this is a new era now. We are on the front lines just like they are. Why don’t we get the same treatment?” Women were frustrated that the differential treatment they experienced in the military was still present when accessing health services in the VA: “I felt like I was segregated my whole career in the military and I didn’t appreciate that happening at the VA. The doctor that I saw was anemic at best and didn’t give me any information and I didn’t feel was interested in my health at all.” Another participant echoed these sentiments while recounting her own experiences at the VA: “You know what, I don’t know if it is specifically reproductive health, but the VA is really trying to become a little more women focused, but I think it’s still kinda discriminatory, like here it’s mainly male focused. Like I go in that clinic with all these old men, and there’s a men’s room right in the urology clinic waiting room! Like there’s no ladies!” Perceived differential access to VA resources Participants felt that they did not have access to the same breadth of choice in VA benefits that male veterans enjoyed: “Everything that a male gets offered here, a female should get offered. We make the same, sometimes more, sacrifices as a male does. Any type of benefit that a male gets here, a female should get, too.” Participants cited several examples, including access to eyeglasses and orthotics, where they believed that male veterans had a wider range of choices available to them than female veterans. For example, one participant complained that male veterans were able to choose among many more eyeglasses than female veterans: “You know, how come we are limited? How come the guys have 150 different pairs, and we have 3?” Similarly, another participant noted the differences in access to orthotics: “And then, if you get orthopedic shoes, you know the men can get everything from golf shoes to athletic shoes. We get these olderdI don’t know if my grandfather would wear the shoes they offer us. They are horrible!” Discussion The views described by participants shed light on the experiences of women veterans seeking reproductive health care services at the VA. We found that women veterans in our study had generally positive experiences with reproductive health care in the VA. Participants noted substantial improvements in the range and quality of reproductive health services available to them over time. However, participants expressed frustration over the relative lack of information available to them regarding
what reproductive health care services were available, particularly in the areas of infertility and prenatal care. Participants also believed the VA had an obligation to women veterans to provide more extensive coverage for advanced reproductive health care technologies, as well as care for newborn infants. Last, participants also described the gender discrimination they had experienced while receiving services at the VA and noted how this perceived discrimination impacted their comfort as a woman seeking VA health care services. The perspectives offered by the participants in this study highlight both the importance of understanding women’s reproductive health care needs as well as opportunities for the VA to provide comprehensive services to women veterans in a safe and comfortable environment. The finding that women veterans were unaware of the range of reproductive health services available to them suggests that the VA must ensure that its patients and providers are aware of the range of reproductive health care services offered available to women veterans. This may be particularly important for patients who seek care in VA facilities without a designated women’s health clinic or designated women’s health providers, where knowledge of the range of reproductive health services available to women may be more limited. Perceived gender discrimination emerged as another important theme regarding women veteran’s ongoing care at the VA. Research suggests that discrimination in health care is not uncommon (Blanchard & Lurie, 2004), although most studies have focused on racial/ethnic discrimination (Krieger & Sidney, 1996; Lillie-Blanton, Brodie, Rowland, Altman, & McIntosh, 2000; Williams, Neighbors, & Jackson, 2003) in care. Gender discrimination has been shown to be associated with suboptimal mental health, including depression, stress, and anxiety (Landrine, Klonoff, Gibbs, Manning, & Lund, 1995; Stuber, Galea, Ahern, Blaney, & Fuller, 2003). Although the current study did not rigorously examine whether perceived discrimination led to poor health outcomes or health care utilization, in other studies these experiences led some women to avoid care (Dailey, Kasl, & Jones, 2008), potentially jeopardizing their health. Although women did not feel that gender discrimination impacted their care in the women’s clinics, many women felt uncomfortable receiving care in clinics other than the women’s clinics. Further attention should be given to this important finding in future studies of women receiving care in the VA system. Women identified the need for expanded access to advanced infertility services, such as in vitro fertilization, and for coverage for newborn care. Participants argued that because they gave up many years of their reproductive years for military service, this sacrifice could be rectified through provision of infertility services and newborn care. Although newborn care would represent a major shift in VA policy, these findings may be worthy of consideration as more women veterans of reproductive age seek VA services. It is important to consider the limitations of the study. Our study population was limited to a convenience sample of women veterans in care in Pittsburgh, Pennsylvania, and West Haven, Connecticut, both of which have women’s health programs in place. Thus, our these findings cannot be extended to the experience of women in VA’s without women’s health programs, and may not fully characterize the experiences of all women veterans in VA care. This study also had several strengths. Given the dearth of information about women veterans’ experiences with reproductive health care, the inductive nature of qualitative research commends it to examine these important questions
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regarding women’s perceptions of reproductive health services in the VA. We also recruited a sample that was diverse in terms of potentially relevant characteristics, including race and age. Despite this diversity, participants shared common views on their experiences regarding reproductive health care in the VA and what additional services should be offered to women veterans. In conclusion, creating a health care environment that successfully allows women veterans to realize comprehensive, person-centered care for all health care needs, including reproductive health care, is an important element of providing highquality care for women veterans. The overall number of women veterans is growing, and ensuring that all of their health needs are met in a comfortable environment is crucial. Close attention should also be paid to staff-level training and VA-wide policies that target discriminatory practices that impact women veterans. Raising awareness of women veterans’ health needs and drafting policy recommendations at the national level to ensure women veterans are receiving comprehensive, personcentered care that is free of discriminatory practices will help to create an environment where women veterans are comfortable receiving care for all their health needs. Acknowledgments
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Author Descriptions
Dr. Kristin Mattocks had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Kristin M. Mattocks is an investigator at Yale University School of Medicine and VA Connecticut Healthcare System. She has conducted numerous qualitative and quantitative studies on women veteran’s healthcare utilization in both VA and non-VA settings.
References
Cara Nikolajski is a research coordinator for the VA Pittsburgh Healthcare System and the University of Pittsburgh’s Department of Medicine. She has extensive experience facilitating and analyzing focus groups and interviews for numerous research studies.
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Sally Haskell is an Associate Professor of Medicine in Yale University School of Medicine. She is the Acting Director of Comprehensive Women’s Health for the Women Veterans Health Strategic Healthcare Group in VA Central Office and a coprincipal investigator of the VA HSR and D funded Women Veterans Cohort Study. She has published numerous papers on women Veteran’s health issues.
Cynthia Brandt is an Associate Professor at Yale School of Medicine and investigator at VA Connecticut Healthcare System whose research focuses on informatics and health services research.
Jennifer McCall-Hosenfeld is a general internist and BIRCWH (Building Interdisciplinary Skills in Women’s Health) Scholar (5 K12 HD05582-03). Her research explores women trauma survivors in primary care. Her previous experience includes a Special Fellowship in the Health Issues of Women Veterans.
Elizabeth Yano is Co-Director and a Research Career Scientist at the VA Greater Los Angeles HSR&D Center of Excellence and Adjunct Professor of Health Services at the UCLA School of Public Health. Her work focuses organizational influences on quality.
Tan Pham is a research associate for the VA Connecticut Healthcare System and the Yale University's Department of Internal Medicine.
Sonya Borrero is an investigator at the Center for Health Equity Research and Promotion (VA Pittsburgh Healthcare System), and the University of Pittsburgh's School of Medicine. She has conducted numerous qualitative and quantitative studies focusing on disparities in reproductive health care.
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Original article
Women Veterans’ Reproductive Health Preferences and Experiences: A Focus Group Analysis Kristin M. Mattocks, PhD a,b,*, Cara Nikolajski, MPH c,d, Sally Haskell, MD a,b, Cynthia Brandt, MD a,e, Jennifer McCall-Hosenfeld, MD f, Elizabeth Yano, PhD g,h, Tan Pham, MPH a,b, Sonya Borrero, MD c,d,i a
Yale University School of Medicine, Department of Internal Medicine, New Haven, Connecticut VA Connecticut Healthcare System, West Haven, Connecticut Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania d Center for Research on Health Care, University of Pittsburgh, Pennsylvania e Yale University School of Medicine, Yale Center for Medical Informatics, New Haven, Connecticut f PennState Milton S. Hershey Medical Center, Hershey, Pennsylvania g VA HSR&D Center of Excellence for the Study of Healthcare Provider Behavior, VA Greater Los Angeles Healthcare System, Sepulveda, California h Department of Health Services, UCLA School of Public Health, Los Angeles, California i General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania b c
Article history: Received 1 July 2010; Received in revised form 10 September 2010; Accepted 8 November 2010
a b s t r a c t Objective: Although women veterans are seeking care at the Veterans Administration (VA) in record numbers, there is little information regarding women veterans’ experiences and preferences for reproductive health care services. We sought to characterize women veterans’ experiences with, and preferences for, reproductive health services in the VA. Methods: We conducted five focus groups with a total of 25 participants using a semistructured interview guide to elicit women veterans’ experiences and preferences with reproductive health care. Women veterans’ utilizing VA health care at two VA facilities who responded to advertisements were selected on a first-come basis to participate in the study. We analyzed transcripts of these audiorecorded sessions using the constant comparative method of grounded theory. Results: Five main themes emerged from the focus group discussions: 1) Women veterans prefer VA women’s clinics for comprehensive medical care; 2) Women veterans have had both positive and negative reproductive health experiences in the VA; 3) Women veterans experience knowledge gaps regarding VA coverage for reproductive health services; 4) Women veterans believe the VA should provide additional coverage for advanced infertility care and for newborns; and 5) Perceived gender discrimination shapes how women veterans view the VA. Conclusion: As the VA continues to tailor its services to women veterans, attention should be given to women’s reproductive health care needs. Copyright Ó 2011 by the Jacobs Institute of Women’s Health. Published by Elsevier Inc.
Introduction Many of those who have historically sought Veterans Health Administration (VA) care have been men, with many of the VA’s
The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs. Funded by VA Office of Public Health and Environmental Hazards, Women Veterans Health Strategic Healthcare Group. * Correspondence to: Kristin M. Mattocks, PhD, VA Connecticut Healthcare System, 950 Campbell Avenue, 11-ACSLG, West Haven, CT 06516. Phone: 413548-6777; fax: 203-937-4926. E-mail address: [email protected] (K.M. Mattocks).
services being particularly tailored to the needs of older male veterans (e.g., World War II, Korean War, and Vietnam War veterans). However, women veterans are seeking care at VA facilities in record numbers. Recent estimates suggest that nearly 50% of women who have served in Iraq (Operation Iraqi Freedom [OIF]) and/or Afghanistan (Operation Enduring Freedom [OEF]) have enrolled in VA health care (Kang, 2008). This market penetration is in sharp contrast to previous cohorts, where an average of 11% of eligible women used the VA for care (Yano, Washington, Goldzweig, Caffery, & Turner, 2003). The surge among OEF/OIF women veterans has changed the demographic and thus clinical needs of women veterans seen in VA settings. Specifically, many OEF/OIF women veterans accessing VA care
1049-3867/$ - see front matter Copyright Ó 2011 by the Jacobs Institute of Women’s Health. Published by Elsevier Inc. doi:10.1016/j.whi.2010.11.002
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are under the age of 40 and therefore of childbearing age (Under Secretary for Health Workgroup, 2008), and it is unclear whether their major health concerns mirror those of other women veterans seeking care in the VA, let alone those of male veterans who still predominate the system (Kang, 2008). Over the past decade, the VA has greatly expanded services available to women veterans (United States General Accounting Office, 1999). In 1992, legislation authorized new and expanded services for women veterans, including counseling for sexual trauma and reproductive health care, including Pap smears, mammography, contraceptive services, and treatment of menopause-related symptoms. By 1996, services were further expanded to include maternity and infertility benefits. To accommodate service expansion and improve attention to privacy needs, the VA increased provision of women’s health services in gender-specific primary care models (i.e., women’s health clinics), present in about 54% of VA facilities (Seelig, Yano, Bean-Mayberry, Lanto, & Washington, 2008; Yano, Goldzweig, Canelo, & Washington, 2006; Yano et al., 2003). Separate gynecology clinics have also been established (Seelig et al., 2008). Given the experience and training necessary to deliver quality women’s health services, however, VA managers continue to struggle with the value of delivering gender-specific care in-house versus through community providers. This concern is especially salient for the delivery of reproductive health services. To inform further development of suitable care arrangements, we sought to characterize women veterans’ experiences with and expectations of reproductive health care in the VA, using a series of focus groups from 2 geographically distinct VA sites. Materials and Methods Participants and Recruitment We conducted five focus groups with 25 women veterans who receive care at VA facilities in Pittsburgh, Pennsylvania, and West Haven, Connecticut. Both VA facilities had comprehensive women’s health programs that provide medical care for women veterans (i.e., one-stop shopping programs outside of traditional primary care or gynecology clinics). We used multiple strategies to recruit women to participate. In West Haven, we used flyers in the Women’s Clinic lobby, and recontacted women who were participants in another ongoing women’s health study (Haskell et al., 2009). In Pittsburgh, we posted flyers in general primary care, women’s health primary care, and gynecology clinics, and asked clinicians in these clinics to refer potential participants. We also mailed informational letters and study flyers to female patients seen by the principal investigator, and mailed study flyers to women receiving visit reminder notices or new patient packets from the women’s health primary care clinic. Women were considered eligible for the study if they were between the ages of 18 and 50; were enrolled within the VA Healthcare System; and self-identified as Black/African-American or White. Women responding to study advertisements study were screened for eligibility over the phone. In an effort to keep groups racially homogenous, we limited the study to Black/ African and White women because there were too few women of other races/ethnicities at either site to form a focus group. We excluded non-English speakers. We invited eligible women to participate, and sent follow-up letters confirming the date, time, and location of the focus group session. Reminder telephone calls were placed the night before scheduled focus groups. Participants received a $40 gift card, in addition to provision of a meal at each
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session. Our final sample size of 24 women veterans was determined by thematic saturation, the point at which no new themes emerged from successive interviews (Malterud, 2001; Patton, 2002). The research protocol was approved by the Institutional Review Boards at VA Pittsburgh and VA Connecticut. Instrument We developed a 10-item, semistructured interview guide designed to elicit use of, experiences with, and knowledge about reproductive health services in the VA. For this study, reproductive health care included services such as cancer screening and mammography. Focus group methods, which use an inductive approach, have been advocated for evaluating topics that have received little prior investigation (Poses & Isen, 1998). Participants also completed a brief demographic questionnaire at the conclusion of the focus groups. Focus Groups Two experienced moderators (K.M. and C.N.) conducted five focus groups, stratified by participant race. In general, focus groups should occur in nonthreatening environments with a group of individuals who share certain characteristics to allow for a good group dynamic and greater self-disclosure (Borrero et al., 2009; Krueger & Casey, 2000). Focus groups were conducted in private conference rooms in each VA facility. Focus groups lasted an average of 45 minutes, were audiorecorded, and professionally transcribed. Participants were asked to describe the kinds of health services that had received at the VA, with a specific focus on the types of reproductive health services they received. Participants were also asked to detail any problems they had experienced with reproductive health care services, and what additional reproductive health services the VA should provide. Analysis After checking transcriptions for accuracy of content, two members of the research team (K.M. and C.N.) analyzed the transcripts according to concepts of grounded theory (Britten, 1995; Glaser, 1967). We used open coding, where each coder independently reviewed the transcripts line by line, creating code definitions as concepts emerged inductively from the data. Coders met to compare codes, resolve discrepancies, and review the code structure. Codes were then refined until a final coding structure was achieved. A total of 25 codes capturing major concepts in the data were then applied to all of the transcripts. We then used axial coding, combining codes into broader categories to better define emerging themes that characterized women’s perceptions of VA reproductive health care services. Because no unique themes arose across the racially homogenous focus groups, we chose to report the major themes for all participants combined. We used Atlas.Ti for data management and retrieval (Muhr, 2004). Results Twenty-five women participated in five focus groups. The median sample age was 39 years (range, 29–49), with 70% of participants Caucasian and 30% African American. All had at least a high school degree or GED, 36% had some college education, 23% had a college degree, and 18% had a graduate or professional
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degree. Thirty-three percent were single, 31% were married, and 36% were divorced or separated. Forty-five percent of the participants were uninsured, 37% had private insurance, and 18% had insurance for military personnel or veterans. Five main themes emerged from the focus group discussions: 1) Women veterans prefer VA women’s clinics for comprehensive medical care; 2) Women veterans had both positive and negative reproductive health experiences in the VA; 3) Women veterans experience knowledge gaps regarding VA coverage for reproductive health services; 4) Women veterans believe the VA should provide additional coverage for advanced infertility care and for newborns; and 5) Perceived gender discrimination shapes how women veterans view the VA. We describe each theme, providing representative quotations to illustrate these themes and dissenting views when present (Waitzkin, 1990). Women Veterans Prefer VA Women’s Clinics for Comprehensive Medical Care We found that women preferred VA women’s clinics for comprehensive medical care, including their reproductive health needs. Participants stated that they were able to receive the majority of their care within the women’s clinics, and felt that the staff in these clinics had the knowledge and skills to address most of their medical needs: “They are excellent. I mean, for me. Since the Women’s Clinic has been there and it’s like our own entity, there is not a problem. They jump through hoops.” Many expressed an appreciation for team-based approaches to their care, with physicians, nurse practitioners, and other medical staff working together to address each woman veteran’s needs: “There is always someone there to help someone else. I mean, they work together as a team a whole lot down there and I really commend them. I can’t complain about the women’s clinic.” In fact, even though several participants had private health insurance that allowed them to seek care elsewhere, they still preferred to receive their care in the VA women’s clinics. Many women felt that the VA women’s clinics were better suited to understand and assist with problems associated with military service, whereas other women experienced a more welcoming environment in the VA as compared to non-VA care: “Doctors on the outside [of the VA] are cold. That’s why I come here because I also have insurance for the outside and the one time where I did decide to see an outside doctor, I did not like it. I did not like how cold she was. She didn’t ask any questions, she had no personality. She was just treating me like I was an object. I’ll never go back out again.” Although women were generally satisfied with VA women’s clinics once they had arrived, many women recalled their initial reservations about coming to the VA. Women cited persistent rumors among veterans regarding VA care, and many participants believed these ongoing rumors prohibited other women veterans from seeking care at the VA: “Honestly, I didn’t want to come to the VA because from what I heard, this is lousy care, you know. That’s what I’ve always heard, so when the guy told me I had to come to the VA, I was like ‘No, I don’t want to go there.’ But I’m glad I did because I was not aware of the women’s health clinic.” Despite feeling comfortable receiving care within the walls of the VA women’s clinics, several women noted that they occasionally felt out of place in the larger VA system. Noting that most VA patients are male and that many of them have significant physical and mental health problems arising from their military service, several women worried that their own health problems
may not be serious enough to warrant VA care: “I came to the VA and it was like ‘I’m on a movie set of Born on the Fourth of July!’ Guys wearing bandanas and I was just like, ‘Wow, am I one of these people?’ But I’m not broken. Maybe I really shouldn’t be coming here. You know? I am seeing someone for [posttraumatic stress disorder] and I even said to my doctor the other day, ‘Listen I’m not having nightmares anymore so I don’t want to take someone else’s slot.” Women Veterans had Both Positive and Negative Reproductive Health Experiences in the VA Women veterans reported both positive and negative experiences with VA reproductive health care. Participants varied in the types of reproductive health care services they utilized at the VA, although nearly all received annual Pap smears and routine preventive care. When participants required services that were not provided in the VA, such as infertility services, pregnancy care, or mammography, they were given referrals to fee basis or contract providers outside the VA. Participants were generally satisfied with the range and quality of reproductive health services they received from the VA, whether the reproductive health services were provided within the VA or from fee or contract providers: “I got to commend them. They be on your about your mammogram. Every year faithfully they call me, ‘It’s time for your mammogram,’ and they’ll hunt you down until they get your appointment. That to me shows that they really care.” Participants were generally satisfied with the competence of VA women’s health providers. Several participants discussed their efforts to try to conceive a child, and were pleased with the assistance that the VA had given them in this regard: “I got my fibroid tumors removed here at the VA which was the best surgery. Now the VA is doing everything they possibly can for me to conceive because I am in my 40s and I haven’t yet conceived.” Another woman concurred, speaking of the ease at which she was able to receive a referral for infertility care provided by a private fertility clinic: “I came to the women’s clinic and they said, ‘What do you want?’ I said I want to have a baby. He said, okay let me see. He said oh, yeah, we can pay for that. So he sent me over to the fertility clinic.” However, some participants also expressed concerns about the amount of care provided in the women’s clinics by medical residents. Much of this concern was focused on participant’s perceptions that the VA remains a major training facility for medical residents and interns, causing occasionally poor service delivery: “I did have a problem with an intern giving me a pap smear, only because you could tell he never did it before. He was looking at the clampy things and he was kind of like fumbling and he just kind of picked one and he goes ‘It [the size] doesn’t matter, right?” Another woman echoed this sentiment: “That’s because this is like a training facility. Every time I come in for a Pap, I have a new physician and I have to go back and tell them all of my information all over again and that is pretty frustrating!” Women reported having mixed experiences in terms of appointment availability. Some women were pleased with the flexible system of appointments, including the ability to arrange a walk-in appointment for urgent care issues: “If you don’t have an appointment and need to see them, they let you be a walk-in. Even if the walk-in is from certain hours at least you do have the opportunity to be a walk-in.” Other participants, particularly those who did not live close to the VA, found appointment scheduling difficult, and were reluctant to take the amount of
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time off from work necessary to receive routine gynecological care: “I got to take a day off from work because the VA Women’s Clinic is only open like on Tuesday mornings or something. Like some insane schedule thing because I’ve got to drive a hour down and sit there, have my exam and drive an hour back to work. So I’ve got to at least take a half a day off from work.” Other participants were frustrated by appointment schedules, as they thought the VA did not respect their work and family commitments: “They just give you random appointments. Like you work and I feel like they think we are all like 90-year-old men veterans and we can just come whenever.” A few participants commented on the culture of the clinic. Some women felt that the focus is on poor health habits, and noted that the women’s clinics waiting rooms were filled with admonitions regarding risky sex, alcohol and drug use, and smoking: When I started back in 2000, 2001 the questionnaire you filled out had everything to do with did you take drugs? Were you HIV infected? Do you have hepatitis? Do you drink too much? Have you been sexually assaulted? But I just remember thinking, ‘Is this all they think we are? That women are down on their luck and they all have drinking problems and they’re all abusing drugs? That just wasn’t what I expected for going into any women’s clinic. I kind of expect them to ask about babies and your period and stuff. Not the last time I was drug abusing. Furthermore, most participants expressed a belief that the VA had expanded the range of contraceptive options available to women veterans over the years. Women who had been receiving reproductive health care in the VA for many years recalled feeling pressure to choose among a limited set of contraceptive options, none of which were ideal: “I’ve been coming to the VA for years for contraception and they were very limited on a lot of things that they would offer you because they didn’t have much. But in the past couple of years, it’s been different. You get a little bit more of an option now.” However, some women expressed frustration that their opinions and preferences were not fully considered when contraceptive options were presented. Participants felt that providers made decisions without regard for patient preferences, and some patients went further to suggest that providers pressured patients to choose one contraceptive option over another: “I have Mirena and these people put it in. Pressured me to put it in, actually. I really didn’t want it but they kinda talked me into it and I was really sorry after that.” Some patients acknowledged that they had learned it was important to communicate their preferences clearly to providers in order to ensure that treatment decisions were in line with their own preferences, rather than that of the provider: “You have to be your biggest advocate because if you’re not, sometimes they go with what they’ve been doing but that may not be right for your current situation.”
Women Veterans Experience Knowledge Gaps Regarding VA Coverage for Reproductive Health Services Although most participants were aware that the VA provided reproductive health services, including routine breast and gynecological cancer screening and contraception management, several women were not: “I didn’t even know that we got Pap smears here. I just thought it was primary care. Not even like female health.”
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Some women commented that information concerning available reproductive health services was difficult to find in the VA, and that this type of information should be made more widely available to patients: “If they could come out with a pamphlet or something saying that the VA does fertility issues, the VA does birth control issues, the VA does pregnancy issues, like prenatal issues. You know, they could just give you a booklet or something that says, this is what we do, this is what we don’t do, and this is who you need to contact to find out who does.” Some participants had heard that the VA did not provide any infertility or pregnancy care, and were surprised when fellow group members disclosed that they had received infertility or pregnancy care from the VA: “I didn’t know and I still don’t know to the extent reproductive health is covered. It was my understanding when I read the booklet that having children was not covered by the VA.” Some participants were also not aware that their ability to access reproductive health services was not dependent on their service-connected disability status: “Does it depend on the percentage of disability you have? So does 10% cover you through your pregnancy but once you give birth, your kid’s not covered? Or if you’re 100%, do they cover you and your child until your child is 18, or how does that work? That would be a good thing to know.”
Women Veterans Believe the VA Should Provide Additional Coverage for Advanced Infertility Care and for Newborns Although participants expressed general satisfaction with the range of reproductive health care services available to them in the VA, some women thought the VA could go further to assist women in becoming pregnant. Several participants had utilized infertility services provided by the VA, including infertility medications and artificial insemination, yet were denied VA coverage for assisted reproductive technologies, including in vitro fertilization. Participants expressed beliefs that the VA should provide more extensive infertility coverage, including in vitro fertilization, to assist women who are having difficulties becoming pregnant: You know, I can essentially say that I gave my reproductive years to the Marine Corps. And those are the years you can serve. We serve during our fertile years and we sacrifice. Now there’s some women who can manage to have a family and, and a career but a lot more women give up the career because it’s just not manageable to have children (in the military). You know, you do sacrifice and you say, “Well, mission first before a family mission,” type of thing and the more I think about I think, you know, the VA probably should address that part of womanhood and have that understanding. Participants also expressed dissatisfaction that the VA does not extend health care coverage to newborns of women veterans. To what extent the VA should provide coverage to older children of women veterans was unclear, but participants did believe that the VA should have an obligation to extend health coverage for some period of time to newborn children. I’m just saying that the child maybe should be covered for 6 months to a year after that. At least for the shots or any complications. That’s the only thing that I would say to have at least a neonatal kind of situation covered. You know, we could have girl getting off active duty and gets pregnant right away and they haven’t gotten established or whatever.
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Perceived Gender Discrimination Shapes how Women Veterans View the VA The final major theme that emerged from the discussion related to the broader VA environment in which women received health care. Major subthemes included 1) perceived differential treatment of women versus men by VA staff, and 2) perceived differential access to VA resources for women versus men. Women veterans’ experiences outside VA women’s clinics were very different and impacted their overall perception of the VA. Perceived differential treatment by VA staff Women reported they felt the treatment they received from VA staff was less respectful than that provided to male veterans: “You are treated like a second class citizen.” Participants believed that some of this inferior treatment was related to ongoing stereotypes regarding women’s roles in the military: “They say women don’t go to war. Well, guess what, this is a new era now. We are on the front lines just like they are. Why don’t we get the same treatment?” Women were frustrated that the differential treatment they experienced in the military was still present when accessing health services in the VA: “I felt like I was segregated my whole career in the military and I didn’t appreciate that happening at the VA. The doctor that I saw was anemic at best and didn’t give me any information and I didn’t feel was interested in my health at all.” Another participant echoed these sentiments while recounting her own experiences at the VA: “You know what, I don’t know if it is specifically reproductive health, but the VA is really trying to become a little more women focused, but I think it’s still kinda discriminatory, like here it’s mainly male focused. Like I go in that clinic with all these old men, and there’s a men’s room right in the urology clinic waiting room! Like there’s no ladies!” Perceived differential access to VA resources Participants felt that they did not have access to the same breadth of choice in VA benefits that male veterans enjoyed: “Everything that a male gets offered here, a female should get offered. We make the same, sometimes more, sacrifices as a male does. Any type of benefit that a male gets here, a female should get, too.” Participants cited several examples, including access to eyeglasses and orthotics, where they believed that male veterans had a wider range of choices available to them than female veterans. For example, one participant complained that male veterans were able to choose among many more eyeglasses than female veterans: “You know, how come we are limited? How come the guys have 150 different pairs, and we have 3?” Similarly, another participant noted the differences in access to orthotics: “And then, if you get orthopedic shoes, you know the men can get everything from golf shoes to athletic shoes. We get these olderdI don’t know if my grandfather would wear the shoes they offer us. They are horrible!” Discussion The views described by participants shed light on the experiences of women veterans seeking reproductive health care services at the VA. We found that women veterans in our study had generally positive experiences with reproductive health care in the VA. Participants noted substantial improvements in the range and quality of reproductive health services available to them over time. However, participants expressed frustration over the relative lack of information available to them regarding
what reproductive health care services were available, particularly in the areas of infertility and prenatal care. Participants also believed the VA had an obligation to women veterans to provide more extensive coverage for advanced reproductive health care technologies, as well as care for newborn infants. Last, participants also described the gender discrimination they had experienced while receiving services at the VA and noted how this perceived discrimination impacted their comfort as a woman seeking VA health care services. The perspectives offered by the participants in this study highlight both the importance of understanding women’s reproductive health care needs as well as opportunities for the VA to provide comprehensive services to women veterans in a safe and comfortable environment. The finding that women veterans were unaware of the range of reproductive health services available to them suggests that the VA must ensure that its patients and providers are aware of the range of reproductive health care services offered available to women veterans. This may be particularly important for patients who seek care in VA facilities without a designated women’s health clinic or designated women’s health providers, where knowledge of the range of reproductive health services available to women may be more limited. Perceived gender discrimination emerged as another important theme regarding women veteran’s ongoing care at the VA. Research suggests that discrimination in health care is not uncommon (Blanchard & Lurie, 2004), although most studies have focused on racial/ethnic discrimination (Krieger & Sidney, 1996; Lillie-Blanton, Brodie, Rowland, Altman, & McIntosh, 2000; Williams, Neighbors, & Jackson, 2003) in care. Gender discrimination has been shown to be associated with suboptimal mental health, including depression, stress, and anxiety (Landrine, Klonoff, Gibbs, Manning, & Lund, 1995; Stuber, Galea, Ahern, Blaney, & Fuller, 2003). Although the current study did not rigorously examine whether perceived discrimination led to poor health outcomes or health care utilization, in other studies these experiences led some women to avoid care (Dailey, Kasl, & Jones, 2008), potentially jeopardizing their health. Although women did not feel that gender discrimination impacted their care in the women’s clinics, many women felt uncomfortable receiving care in clinics other than the women’s clinics. Further attention should be given to this important finding in future studies of women receiving care in the VA system. Women identified the need for expanded access to advanced infertility services, such as in vitro fertilization, and for coverage for newborn care. Participants argued that because they gave up many years of their reproductive years for military service, this sacrifice could be rectified through provision of infertility services and newborn care. Although newborn care would represent a major shift in VA policy, these findings may be worthy of consideration as more women veterans of reproductive age seek VA services. It is important to consider the limitations of the study. Our study population was limited to a convenience sample of women veterans in care in Pittsburgh, Pennsylvania, and West Haven, Connecticut, both of which have women’s health programs in place. Thus, our these findings cannot be extended to the experience of women in VA’s without women’s health programs, and may not fully characterize the experiences of all women veterans in VA care. This study also had several strengths. Given the dearth of information about women veterans’ experiences with reproductive health care, the inductive nature of qualitative research commends it to examine these important questions
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regarding women’s perceptions of reproductive health services in the VA. We also recruited a sample that was diverse in terms of potentially relevant characteristics, including race and age. Despite this diversity, participants shared common views on their experiences regarding reproductive health care in the VA and what additional services should be offered to women veterans. In conclusion, creating a health care environment that successfully allows women veterans to realize comprehensive, person-centered care for all health care needs, including reproductive health care, is an important element of providing highquality care for women veterans. The overall number of women veterans is growing, and ensuring that all of their health needs are met in a comfortable environment is crucial. Close attention should also be paid to staff-level training and VA-wide policies that target discriminatory practices that impact women veterans. Raising awareness of women veterans’ health needs and drafting policy recommendations at the national level to ensure women veterans are receiving comprehensive, personcentered care that is free of discriminatory practices will help to create an environment where women veterans are comfortable receiving care for all their health needs. Acknowledgments
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Author Descriptions
Dr. Kristin Mattocks had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Kristin M. Mattocks is an investigator at Yale University School of Medicine and VA Connecticut Healthcare System. She has conducted numerous qualitative and quantitative studies on women veteran’s healthcare utilization in both VA and non-VA settings.
References
Cara Nikolajski is a research coordinator for the VA Pittsburgh Healthcare System and the University of Pittsburgh’s Department of Medicine. She has extensive experience facilitating and analyzing focus groups and interviews for numerous research studies.
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Sally Haskell is an Associate Professor of Medicine in Yale University School of Medicine. She is the Acting Director of Comprehensive Women’s Health for the Women Veterans Health Strategic Healthcare Group in VA Central Office and a coprincipal investigator of the VA HSR and D funded Women Veterans Cohort Study. She has published numerous papers on women Veteran’s health issues.
Cynthia Brandt is an Associate Professor at Yale School of Medicine and investigator at VA Connecticut Healthcare System whose research focuses on informatics and health services research.
Jennifer McCall-Hosenfeld is a general internist and BIRCWH (Building Interdisciplinary Skills in Women’s Health) Scholar (5 K12 HD05582-03). Her research explores women trauma survivors in primary care. Her previous experience includes a Special Fellowship in the Health Issues of Women Veterans.
Elizabeth Yano is Co-Director and a Research Career Scientist at the VA Greater Los Angeles HSR&D Center of Excellence and Adjunct Professor of Health Services at the UCLA School of Public Health. Her work focuses organizational influences on quality.
Tan Pham is a research associate for the VA Connecticut Healthcare System and the Yale University's Department of Internal Medicine.
Sonya Borrero is an investigator at the Center for Health Equity Research and Promotion (VA Pittsburgh Healthcare System), and the University of Pittsburgh's School of Medicine. She has conducted numerous qualitative and quantitative studies focusing on disparities in reproductive health care.