Gender and the use of Veterans Health Administration homeless services programs among Iraq/Afghanistan Veterans

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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

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• 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.

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Veterans Health Administration (VHA) specialized
homeless services programs
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Operation Enduring Freedom (OEF)
Operation Iraqi Freedom (OIF)
The OEF/OIF Veteran cohort has the largest
proportion of women to serve and to be exposed to
combat of any Veteran era cohort.
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Homelessness
Use of homeless services programs
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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?

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Methods Study population
OEF/OIF Veterans (1.1 million)
Enrolled in VHA system 10/1/01 to 9/30/09
(500,000)

• Nonmissing gender
• Nonmissing separation date
• At least 1 VHA clinical visit
• (445,319)

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Time to first use of a VHA homeless program
Gender
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Primary Outcome Time to
first use of a VHA homeless program
Separation Date
1st visit indicating use of VHA homeless program
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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
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Socio-demographic variables
Rural vs. urban location, geographic region
Rank (officer vs. enlisted)
Age, race/ethnicity, marital status, education
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Clinical variables
Mental health conditions
Service-connected disability rating
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Data Analysis

• Survival analysis
• Cox proportional hazards regression
• Adjusting for socio-demographic clinical
  variables
• ?2 and Wilcoxon rank-sum tests to compare female
  and male Veterans who used a VHA homeless program

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Results
Median duration of follow-up 3.21 years (IQR,
1.74-4.52)

• 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)
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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?

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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
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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?

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Risk of using a VHA homeless program by gender
Study population (445,319)
Female 53,650 (12)
Male 391,667 (88)
Used a VHA homeless program 961 (1.8)
Used a VHA homeless program 6,470 (1.7)
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No difference in risk of using a homeless
program
Female
Male
Hazard ratio for use of a VHA homeless program
Adjusted for age, race/ethnicity, marital
status, education, rank, rural/urban, geographic
region disability rating, mental health diagnoses
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Time to first use of VHA homeless program
Female (n961) Male (n6,470) p-value
Time to first use, years, median (IQR) 1.88 (0.78-3.30) 1.88 (0.82-3.28) 0.53
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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?

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Selected characteristics of Veterans who used a
VHA homeless program
Characteristic Female (n961) Male (n6,470) p-value
Age, median (IQR) 25 (22-30) 24 (22-31) 0.10

Race/ethnicity lt0.001
White 30.4 51.6
Black 46.9 25.6
Hispanic 11.3 12.4
Other 11.4 10.4
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Characteristic Female (n961) Male (n6,470) p-value
Major depression 20.4 14.0 lt0.001
Post-traumatic stress disorder 35.7 42.6 lt0.001
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Characteristic Female (n961) Male (n6,470) p-value
Alcohol use disorder 14.9 27.7 lt0.001
Substance use disorder 10.9 21.2 lt0.001
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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

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What we learned

• About 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

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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

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Stakeholders
Northampton VA Medical Center
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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