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