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Gender and the use of Veterans Health Administration homeless services programs among Iraq/Afghanistan
Veterans
Oni J. Blackstock, MD
Yale RWJF Clinical Scholars Program/VA Connecticut Health Care System
Cynthia Brandt, MD MPH, Sally Haskell, MD, Rani Desai, PhD MPH
Yale School of Medicine/VA Connecticut Health Care System
•The authors have no potential conflicts of interest to disclose
•Disclaimer: The views expressed in this presentation are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.
Veterans Health Administration (VHA) specialized homeless
services programs
The OEF/OIF Veteran cohort has the largest proportion of women to serve and to be exposed to combat of any Veteran era cohort.
Operation Enduring Freedom
(OEF)
Operation Iraqi
Freedom (OIF)
Homelessness
Use of homeless services
programs
Research Questions
1. What is the risk of using a VHA homeless program among OEF/OIF Veterans in VHA care?
2. Is there a difference in risk between female and male Veterans?
3. How do the characteristics of female and male Veterans who used a homeless program compare?
Methods: Study population
OEF/OIF Veterans (~1.1 million)
• Nonmissing gender• Nonmissing separation date• At least 1 VHA clinical visit (445,319)
Enrolled in VHA system10/1/01 to 9/30/09
(~500,000)
Time to first use of a VHA
homeless program
Gender
Primary Outcome: Time to first use of a VHA homeless program
Separation Date
1st visit indicating use ofVHA homeless
program
Use of VHA homeless programs identified using program codes
Housing and Urban
Development- VA
Supported Housing
Health Care for
Homeless Veterans
Compensated Work
Therapy/ Transitional Residences
Domiciliary Care for
Homeless Veterans
Grant and Per Diem Program
Socio-demographic variables
Rural vs. urban
location, geographic
region
Rank (officer vs. enlisted)
Age, race/ethnicity
, marital status,
education
Clinical variables
Mental health conditions
Service-connected disability rating
•Survival analysis▫Cox proportional hazards regression▫Adjusting for socio-demographic &
clinical variables•Χ2 and Wilcoxon rank-sum tests to
compare female and male Veterans who used a VHA homeless program
Data Analysis
Results
• Median age, 26 years (IQR, 23 – 37)• 12% female• 62% White, 18% Black, 12% Hispanic, 6% Other• 56% unmarried• 80% high school diploma or less• 22% Post-traumatic stress disorder• 2% - 8% with psychiatric /substance use
disorders
Study population(445,319)
OEF/OIF Veterans (~1.1 million)
Enrolled in VHA system (~500,000)
Median duration of follow-up
3.21 years (IQR, 1.74-4.52)
Research Questions1. What is the risk of using a VHA homeless
program among OEF/OIF Veterans in VHA care?
2. Is there a difference in risk between female and male Veterans?
3. How do the characteristics of female and male Veterans who used a homeless program compare?
Risk of using a VHA homeless program
Study population 445,319
Used a VHA homeless program
7,431 (1.7%)
Median time to first use:
1.88 years(IQR, 0.81-3.29)
IQR, interquartile range
Research Questions1. What is the risk of using a VHA homeless
program among OEF/OIF Veterans in VHA care?
2. Is there a difference in risk between female and male Veterans?
3. How do the characteristics of female and male Veterans who used a homeless program compare?
Study population (445,319)
Used a VHA homeless program
961 (1.8%)
Female 53,650 (12%)
Risk of using a VHA homeless program by gender
Male 391,667
(88%)
Used a VHA homeless program
6,470 (1.7%)
No difference in risk of using a homeless program
*Adjusted for age, race/ethnicity, marital status, education, rank, rural/urban, geographic regiondisability rating, mental health diagnoses
FemaleMale
Hazard ratio for use of a VHA homeless program
Time to first use of VHA homeless program
Female(n=961)
Male(n=6,470)
p-value
Time to first use, years, median (IQR)
1.88(0.78-3.30)
1.88(0.82-3.28)
0.53
Research Questions1. What is the risk of using a VHA homeless
program among OEF/OIF Veterans in VHA care?
2. Is there a difference in risk between female and male Veterans?
3. How do the characteristics of female and male Veterans who used a homeless program compare?
Selected characteristics of Veterans who used a VHA homeless program
CharacteristicFemale(n=961)
Male(n=6,470) p-
value
Age, median (IQR)
25 (22-30) 24 (22-31) 0.10
Race/ethnicity <0.001
White 30.4% 51.6% Black 46.9% 25.6% Hispanic 11.3% 12.4% Other 11.4% 10.4%
Characteristic Female(n=961)
Male(n=6,470) p-
value
Major depression 20.4% 14.0% <0.001
Post-traumatic stress disorder
35.7% 42.6% <0.001
CharacteristicFemale(n=961)
Male(n=6,470) p-
value
Alcohol use disorder 14.9% 27.7% <0.001
Substance use disorder
10.9% 21.2% <0.001
Limitations
• Includes only OEF/OIF Veterans in VHA care
•Does not capture Veterans who accessed only non-VHA-directed homeless services programs
•Lack of data to explore the role of dependents, military sexual trauma, and employment status
What we learnedAbout 1.7% of OEF/OIF Veterans in VHA care
used a VHA homeless program
Overall, female Veterans were as likely as male Veterans to use a VHA homeless program
Differences exist between female and male Veterans who used a homeless program
Females more likely to have depression, less likely to have substance/alcohol use disorder or PTSD
Implications•Determine whether homeless program use
shortly after return represents vulnerability for this group of young Veterans
•Ensure homeless programs are tailored to also meet the needs of female Veterans
•Expand services in areas that may disproportionately affect female Veterans such as depression and programs for families
Stakeholders
Northampton VA
Medical Center
Acknowledgements• Women Veterans Cohort Study
▫ Cynthia Brandt, MD MPH▫ Sally Haskell, MD▫ Rani Desai, PhD MPH▫ Melissa Skanderson, MSW
• Yale RWJF Clinical Scholars Program• Department of Veterans Affairs/VA Connecticut
Healthcare System• OEF/OIF Veterans for their service