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Gender Differences in Newly Separated Veterans’ Use of Healthcare
Laurel A. Copeland, PhD; Erin P. Finley, PhD; Dawne Vogt, PhD; Daniel F. Perkins, PhD; and Yael I. Nillni, PhD
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Gender Differences in Newly Separated Veterans’ Use of Healthcare

Laurel A. Copeland, PhD; Erin P. Finley, PhD; Dawne Vogt, PhD; Daniel F. Perkins, PhD; and Yael I. Nillni, PhD
A survey of veterans leaving the military in 2016 found that women may be underserved by the Veterans Health Administration and may need housing assistance.

Objectives: The Veterans Health Administration (VHA) is adapting to a new model of care in the wake of the Veterans Choice Act of 2014. A longitudinal study, The Veterans Metrics Initiative, captured multiple domains of psychosocial health and healthcare use as veterans moved through the first 15 months of transition from military to civilian life. This study examined gender differences and clinical, social, and lifestyle correlates in healthcare use.

Study Design: The multiwave web-based survey collected self-reported measures from a national sample of newly separated military veterans.

Methods: Multivariable analysis weighted to represent the sampling frame and account for attrition at follow-up examined the association between gender and self-reported healthcare utilization overall and in the VHA.

Results: In fall 2016, veterans within approximately 90 days post military separation provided baseline data and completed a follow-up survey a year later, representing a cohort of 49,865. Sleep problems, anxiety, and depression were associated with healthcare use for both men and women following transition. Women were twice as likely as men to use healthcare in general but equally likely to use VHA care. For women veterans, unstable housing at separation was associated with less healthcare use a year later, especially for the subgroup with mental/behavioral health issues.

Conclusions: US veterans separating from military service need expert care, both in the VHA and elsewhere, for anxiety, depression, and sleep disturbance. Women veterans may be underserved by the VHA and may benefit from housing assistance programs to enable ongoing healthcare use.

Am J Manag Care. 2020;26(3):97-104.
Takeaway Points

The Veterans Health Administration (VHA) may need to further enhance how care is provided to women veterans to attract them to VHA services. Women veterans appeared to reduce healthcare use when they had concerns about losing their housing. The VHA may need to make housing assistance programs more well-known or widespread.
  • Women veterans’ healthcare is likely to involve non-VHA care.
  • The coordination of care management must be possible across healthcare systems.
  • Evidence-based therapy training should be available to non-VHA and VHA providers alike.
The United States’ post-9/11 operations in the Middle East have greatly affected well-being among US service members, including women veterans—who now comprise 1 in 6 post-9/11 veterans. Depression, anxiety, and posttraumatic stress disorder (PTSD), as well as pain from physically demanding deployments, drive veterans to seek healthcare.1 Upon separation from the military, most are eligible for care in the Veterans Health Administration (VHA) for 5 years per the National Defense Authorization Act of 2008. VHA healthcare, formerly dominated by Vietnam-era or older male veterans, has increasingly needed to adapt to younger patients and to women’s healthcare needs.2

Barriers to healthcare include cost, transportation, stigma, and intra- and interpersonal factors.3-6 Veterans may undervalue seeking help for problems, feel that help-seeking is counter to their military cultural values, or distrust the healthcare system.7,8 The VHA seeks to improve access by increasing options for VHA-paid care in community settings through the highly publicized Veterans Choice Program (VCP) and increased capacity for women’s healthcare.9 Congress enacted the Veterans Access, Choice, and Accountability Act of 2014 to improve access to VHA-mediated care, making it easier for veterans to get appointments through the VHA, with providers outside the VHA, paid for by the VHA. Although the precipitous rollout of Veterans Choice has not been trouble-free,10 VCP is widely used.

Women’s transition into civilian life has specific features. Villagran et al found that less use of healthcare correlated with declines in health during women’s transition out of the military.11 Another study of 283 post-9/11 veterans reported high rates of psychosocial risk factors among the women.12 VHA data from 5 million veterans connected psychosocial factors and Gulf War service with obesity for both genders.13,14 The purpose of this study was to examine gender differences in the use of VHA and non-VHA health services during the first 15 months of the transition from military to civilian life.


This study was approved by the institutional review boards at VA Boston Healthcare System for the mailed outreach and at ICF International (Fairfax, Virginia) for the survey processes. Veterans separating from active-duty military service (including Reserve/National Guard activated 180 days or more) in fall 2016 were identified through the VHA/Department of Defense Identity Repository and invited by a letter, with $5 cash enclosed, to access a web-based survey managed by ICF. The baseline survey closed when incentive funds were exhausted. Of 48,965 veterans invited, 9566 self-enrolled, completed the survey, and received $20 gift cards. In November 2017, all baseline participants were invited to respond to a follow-up survey ($35 incentive); the survey closed when incentive funds were depleted (n = 7201) (Figure). Weights adjusting for nonresponse relative to the sampling frame were generated based on gender, rank/pay grade, and branch, and for differential dropout at follow-up.

The primary aims of the parent study are to examine trajectories of well-being during the transition period, identify veteran-utilized transition and reintegration programs, decompose programs into their common components, and analyze the association of program components with trajectories of well-being.15 The 6-wave longitudinal study collects data semiannually (2016-2019), and coding to identify common program components is underway. Program characterization and decomposition takes many months, after which the primary aims may be addressed. Secondary analyses such as this one permit investigation into the veterans’ transition process as it unfolds.


Veterans reported age, gender, race/ethnicity, marital status (married or living with a domestic partner, single, divorced, widowed), parental status, and single-parent status.

The survey asked about healthcare use. For baseline, the look-back period was since separation from the military, about 90 days. At follow-up, the look-back period was 6 months. Items asked about use of any kind of healthcare, use of the VCP, use of VHA hospitals, and use of VHA clinics; these last 2 questions were combined to measure any VHA care. The utilization measures had an ordinal response scale ranging from 0 (never) to 5 (≥4 times a week), which was collapsed to indicate none versus any.

Respondents reported whether they were working, looking for work, or in school and whether they were concerned that their housing situation was unstable. Social support was assessed by the Medical Outcomes Study Social Support scale, which has demonstrated good psychometrics; the 8 ordinal-response items queried how often various kinds of support were available from relatives and friends.16 Problems with sleep quality were assessed by endorsing “sleep problem or disorder” as one of their “ongoing physical or mental/emotional health conditions, illnesses, or disabilities” or reporting they “had gotten quality sleep” never/rarely/sometimes as opposed to often/most or all of the time. Veterans completed scales to assess probable depression per the Patient Health Questionnaire,17 probable anxiety per the Generalized Anxiety Disorder core measure,18 and PTSD. Veterans who endorsed experiencing a traumatic event were given the 5-item Primary Care PTSD Screen for DSM-5 assessing symptoms experienced in the past month. Respondents were considered positive for PTSD if they scored 3 or more, a level associated with PTSD based on diagnostic interview.19 Respondents reporting no traumas were considered negative for PTSD.

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