A Needs Assessment of Women Veterans in Western Pennsylvania: Final Report to Adagio Health

Women make up an increasingly large share of the U.S. veteran population, and their numbers continue to grow while the overall number of veterans is on the decline. Yet programs designed to support veterans' health and well-being have largely focused on men. Women's military experiences and postservice needs often differ from those of men, and women veterans also differ in significant ways from their nonveteran counterparts. Few studies have explored these variations, and this has translated to potentially missed opportunities to improve support for women during and after their transition from military to civilian life.

With a mission to “meet the health, wellness, and nutrition” needs of diverse communities, regardless of income, with a focus on women, Adagio Health provides health, wellness, and nutrition services in 62 counties in Pennsylvania and seven counties in West Virginia. Adagio Health's Title X services encompass a 23-county service area, primarily in Western Pennsylvania. Since launching the Women Veterans Initiative in 2018, Adagio Health has been collecting data on the characteristics and needs of its women veteran patients, enhancing staffing and training to provide culturally sensitive care, and engaging in partnerships and outreach efforts to increase awareness of women veterans' experiences and community-level support for their needs. To identify opportunities to expand and enhance these efforts, we quantitatively and qualitatively assessed the needs of women veterans in Adagio Health's service area, centered in Western Pennsylvania, and the organization's women veteran patients. The assessment provides a clearer picture of this often-underserved population, available programs and resources, gaps in support, barriers to access, and areas to prioritize as Adagio Health and other veteran-serving organizations work to provide the best support possible for the health and well-being of women who served.

Approach to Characterizing Women Veterans and Their Needs

Few studies have focused specifically on the health and well-being of women veterans, but there is some evidence that veteran women fare worse than veteran men and nonveteran women in such areas as physical health, mental health, trauma and violence exposure, alcohol or substance use, and social support. Women veterans' reproductive health outcomes are even less studied. Although the U.S. Department of Veterans Affairs (VA) has significantly expanded its services for women veterans, gaps in support remain, and many women veterans have reported feeling unwelcome at VA facilities. For women veterans who are ineligible for VA care or who face barriers to accessing VA services—including those who live far from VA facilities or who face transportation limitations and caregiving demands—it can be difficult to find community-based providers who are versed in veteran culture and understand the unique challenges that veterans face during and after their transition from military to civilian life. High risk of posttraumatic stress disorder (PTSD), depression, and suicide, along with a greater likelihood of having experienced military sexual trauma (MST) and intimate partner violence, can further complicate women veterans' treatment needs.

Our assessment of the needs of women veterans in Adagio Health's service area drew on national and regional survey data and patient data from Adagio Health. We supplemented this information with a review of the literature on women veterans' experiences, needs, and outcomes, along with documentation related to policies addressing women veterans' needs and Adagio Health's own services, resources, providers, and other sources of support for women veterans. Interviews with women veterans and stakeholders from veteran-serving organizations, advocacy groups, VA organizations, and others provided additional insights and context for our findings.

Women Veterans in the Adagio Health Service Area and the Care They Received

The Adagio Health service area includes more than 15,000 women veterans in 23 counties (U.S. Census Bureau, undated). Women veterans in the service area closely resemble women veterans nationally. They are more likely to be middle-aged (35–54 years old) than their nonveteran counterparts and more likely to be White, divorced, and living without a spouse or partner. They are also more likely to have completed some college. Overall, veteran and nonveteran women in the service area had similar employment statuses, household incomes, and housing situations, but the veteran women in the Adagio Health service area were less likely to have private health insurance.

In terms of health and well-being, younger women veterans (20–39 years old) in the service area tended to have more self-care, vision, and ambulatory difficulties than their nonveteran counterparts in the same age group. Older women veterans (ages 40–64) more often faced independent living and cognitive difficulties. Women veterans in the Adagio Health service area were less likely than women veterans nationally to have a service-connected disability rating (see Table 1). Veterans who have a disability resulting from their military service are eligible for VA disability compensation benefits; higher disability ratings indicate more-severe conditions. Monthly compensation rates depend on the disability rating and whether there is a dependent spouse, child, or parent.

Rating	Women Veterans in the Adagio Health Service Area	Women Veterans Nationally
0 percent	0.8%	1.1%
10 or 20 percent	5.3%	5.8%
30 or 40 percent	3.9%	4.6%
50 or 60 percent	2.3%	4.0%
70, 80, 90, or 100 percent	6.6%	10.6%
Not reported	0.4%	1.3%
No rating	80.8%	72.6%

SOURCE: Features data from the five-year American Community Survey (ACS) data file (2016 though 2020) from U.S. Census Bureau, undated. NOTE: Some percentages do not sum to 100 because of rounding. p = 0.004.

The 890 women veterans who received care through Adagio Health between January 2018 and April 2022 differed somewhat from the nonveteran women in its service area. Specifically, they tended to be older and higher earning than their nonveteran counterparts and were more likely to be White and married. However, the two groups had similar family sizes. The types of care that veteran and nonveteran women received were similar; most patients were seen for reproductive health and family planning (see Table 2). Veteran and nonveteran women who were Adagio Health patients had similar numbers of visits with providers regardless of age, but veteran women across all age groups were more likely to have telehealth appointments, and veteran women age 50 and older were more likely to be patients of Adagio Health's Breast and Cervical Cancer Early Detection Program (BCCEDP). Around 38 percent of veteran women patients had private insurance, compared with about 31 percent of nonveteran women patients. Veteran women patients were also less likely to be covered by a Medicaid managed care organization.

	Veteran Women	Nonveteran Women
Patient Type
Reproductive health and family planning	93.6%	93.7%
BCCEDP (for age 50+)*	24.6%	20.4%
Prenatal	3.4%	3.6%
Behavioral health	0.0%	0.2%
Visit Type
Annual visit, new patient	27.9%	24.3%
Annual visit, established patient	47.8%	50.4%
Problem visit, new patient	21.1%	18.4%
Problem visit, established patient	57.8%	60.1%
Telehealth visit**	9.0%	6.5%

SOURCE: Features data from the five-year ACS data file (2016 though 2020) from U.S. Census Bureau, undated.

*p = 0.005.

**p = 0.004.

Adagio Health now prescreens all patients for mental and behavioral health indicators, and the frequency of these screenings increased to every visit partway through the study period. Nonetheless, it is notable that 10.2 percent of veteran women patients had a positive prescreen for a behavioral health issue, compared with 6.5 percent nonveteran women patients (see Figure 1). Providers administer follow-up screenings to patients with positive scores on the initial prescreen. Overall, similar percentages of veteran women patients and nonveteran women patients screened positive, indicating symptoms of depression, PTSD, substance use, or other mental and behavioral health conditions.

Any positive SBIRT prescreen

Veteran women: 10.2%

Nonveteran women: 6.5%

Any positive CAGE-AID

Veteran women: 20.8%

Nonveteran women: 17.9%

Any positive PHQ-9

Veteran women: 22.4%

Nonveteran women: 20.8%

SOURCE: Features data from the five-year ACS data file (2016 though 2020) from U.S. Census Bureau, undated.

NOTE: Adagio Health providers prescreen patients using the Screening, Brief Intervention, and Referral to Treatment (SBIRT) approach, which consists of six prescreening questions (Agerwala and McCance-Katz, 2012). For follow-up screenings, providers use the nine-question Patient Health Questionnaire–9 (PHQ-9), which assesses depression severity, and the Cut down, Annoyed, Guilty, and Eye-opener Adapted to Include Drugs (CAGE-AID) tool, which assesses substance use. p = 0.001 for any positive SBIRT prescreen; not significant (n.s.) for any positive CAGE-AID questionnaire or PHQ-9.

In terms of routine physical health screenings, veteran women patients had worse average blood pressure readings across visits than their nonveteran counterparts, but the two groups had similar body mass index scores.

Resources and Gaps in Support for Women Veterans in the Adagio Health Service Area

We identified a wide array of local and national resources that are theoretically available to women veterans in Western Pennsylvania, including 214 that were physically located in the Adagio Health service area. All 214 regional resources are either exclusively for veterans and their family members or programs and organizations that serve broader populations but also offer veteran-specific services. Not surprisingly, the regional resources are concentrated in counties with larger urban centers and higher concentrations of women veterans. These trends indicate the possibility of resource and transportation barriers for women veterans living in rural areas. It is also unclear whether there is enough capacity to meet demand for these services. The 214 regional resources in the Adagio Health service area include 80 mental health treatment facilities and 71 substance use treatment facilities that offer specialized treatment for veterans. A subset of these facilities provide treatment for PTSD, trauma, and co-occurring disorders and offer virtual treatment options. Notably, nearly half of the substance use treatment facilities provide services for pregnant and postpartum women, as well as transportation assistance. Of the remaining 63 regional resources, 26 provide referrals and information rather than direct services. For example, PAServes and PA VetConnect refer veterans, service members, and their families to a variety of services and supports. Several national veteran-serving organizations also have a presence in Western Pennsylvania and offer a wide variety of services.

We also identified 133 national online resources; 25 experiences, trips, or gifts that are available to a limited number of veterans; and 31 VA facilities, services, and benefits. The national online resources most often provide employment and career development assistance, individual and family support, help for mental health and substance use, education guidance, and wellness and social enrichment opportunities.

Our interviews with women veterans and other stakeholders highlighted several challenges that women veterans in the Adagio Health service area face in navigating services and benefits and accessing the support they need. Interviewees noted that these challenges are often interconnected. For example, women veterans who are unable to access adequate care for mental health conditions can find it difficult to find and maintain steady employment. This is consistent with literature describing how untreated trauma can also have serious implications for women veterans' well-being, cognitive functioning, and risk of intimate or partner violence, all of which can compound the challenge of initiating and following through with treatment. Poor social support can also exacerbate mental health problems, particularly for those with complex trauma histories (Scoglio et al., 2022). On a 2020 Wounded Warrior Project survey of women veteran members, 80 percent of respondents scored as “lonely” on a validated scale (Wounded Warrior Project, 2021). And in a needs assessment of veterans in southwestern Pennsylvania, only around half of respondents said that they felt connected to their community (Kuzminski and Carter, 2015).

Women veterans also reported feeling that their veteran status was less valued than that of men, and that perception left them unsure whether VA benefits were for them. They shared examples of the types of programs that would have been useful as they transitioned from military service to civilian life; often, these services were available, but women veterans were not aware of them at the time. They also emphasized the importance of providers' familiarity with veterans' experiences—and specifically women veterans' experiences. Some of the stakeholders recommended that providers ask about women veteran patients' time in uniform to better understand their respective military experiences, medical history, and gender-specific needs in addition to screening for military-related trauma or exposures. Other interviewees mistrusted VA care because they viewed it as an extension of the military, which was the source of their trauma, or because veteran men had made them feel uncomfortable at VA facilities or they received insensitive treatment from VA providers. Nonetheless, a substantial majority of women veterans we interviewed expressed high levels of satisfaction with the care they received from VA.

Interviewees echoed research findings that transportation and caregiving demands are significant barriers to accessing services. For example, despite the availability of housing resources for veterans, many of these programs do not accommodate veterans with children and other dependents living in the veteran's household, such as elderly parents. In one case (VA dental health care), stricter eligibility requirements posed a barrier to accessing treatment. Interviewees also noted that services that were available often had limited capacity to assist all veterans who needed them or to address the needs of women veterans specifically.

Opportunities to Address Challenges and Improve Support for Women Veterans

Since launching its Women Veterans Initiative in 2018, Adagio Health has made strides in addressing the challenges faced by this population in accessing support. However, opportunities remain to further improve care and support for Adagio Health's women veteran patients and to extend the reach of the Women Veterans Initiative. Our assessment of the needs of women veterans in Adagio Health's service area and its women veteran patients pointed to the following recommendations to further enhance the Women Veterans Initiative.

Develop Strong Relationships with Women Veteran Patients

For women veterans, prior negative experiences with care, including others' lack of recognition of their veteran status, can prevent them from seeking care or engaging with needed services and supports. This means that it is paramount to develop respectful and trusting relationships with these patients. Adagio Health has already taken initial steps in this direction with the hiring of a veteran care navigator but should consider how to strengthen engagement with women veteran patients through higher-quantity and -quality contacts with them.

Collaborate with Agencies and Organizations to Develop Partnerships and Referral Pathways

Women veterans' inability to connect with needed services and supports can be exacerbated by a lack of knowledge of available resources and trust issues. Adagio Health has made strides in establishing relationships with regional veteran-serving organizations. However, because women veterans do not always receive necessary referrals, Adagio Health should consider ways to continue to strengthen its network of partner agencies and organizations, including VA, and to deepen its relationships with them using the inventory to identify potential additional partnership opportunities.

Expand Services to Better Meet Needs of Women Veterans

Despite having high rates of PTSD, depression, and MST, women veterans often do not engage in behavioral health treatment or receive evidence-based mental health treatment. Adagio Health has grown its behavioral health care capabilities by adding screening, behavioral health specialists, and new locations for behavioral health services. To expand its capacity for behavioral health care, Adagio Health can seek funding to expand further into underserved areas. To enhance its MST-related capabilities, Adagio Health can utilize VA resources, such as the Community Provider toolkit and the Beyond MST application for survivors of MST. Women veterans also have reproductive health care needs, including infertility services, that can go unaddressed with VA care. Adagio Health could focus on expanding access for women veterans in nearby states that have more access issues for reproductive health care and increase its own capabilities for providing and referring for infertility care.

Provide Multiple Channels to Ensure That Women Veterans Are Aware of Available Services and Supports

Women veterans noted that their lack awareness of services and supports posed additional challenges during their transitions from military service to civilian life—a situation that was compounded by feelings that they were not real veterans. Adagio Health has undertaken a variety of outreach activities to increase awareness and reach more women veterans. Our findings indicated that further developing this multipronged approach could help enhance the efforts. This might include amplifying efforts to share information about benefit eligibility and available services and programs during visits, expanding its presence at community events and on social media, undertaking direct mail campaigns, and other activities that market how Adagio Health provides specialized care for women veterans.

Address Women Veterans' Feelings of Isolation and Lack of Social Support

A lack of social support can lead to feelings of isolation and exacerbate mental health problems. Women veteran patients might benefit from more-focused efforts to connect them with peer support, social enrichment, recreational activities, and other opportunities to interact with other women veterans and get involved in their communities. Adagio Health could further promote its wellness retreats to its women veteran patients and develop other opportunities both internally and externally to support women veterans. The inventory includes various regional and national online resources that focus on social support and enrichment as possibilities for supporting women veteran patients.

Partner with Agencies and Organizations to Address Unmet Needs and Reduce Barriers to Accessing Health Care and Other Services

Women veterans often encounter concrete barriers to accessing services, such as a lack of transportation and child care demands. Adagio Health could work to further develop strategic partnerships to address specific unmet needs while helping its women veteran patients overcome access barriers. For example, there might be opportunities to partner with agencies and organizations that provide transportation services, child care, family housing, and workforce development programs, as well as access to dental care, which is subject to stricter VA eligibility criteria than other health care services. The inventory can be a resource for finding new potential partners for addressing unmet needs and access barriers once they are identified.

Expand Trauma-Informed Approaches to Care

Although a history of trauma and intimate partner violence is common among women veterans, they do not always have access to trauma-informed, evidence-based care. Adagio Health provides veteran engagement training to providers and staff, but there are still opportunities to improve the identification of women veterans with trauma histories through routine screenings and to ensure seamless care transitions to strengthen trust when women veterans see new providers. Expanding its existing efforts to actively promote Adagio Health's status as a provider of trauma-informed care can help further signal its ongoing commitment to serving women veterans with respect and sensitivity.

Considerations for Women Veteran Service Providers

Efforts to meet the needs of women veterans in Western Pennsylvania should take into account the following considerations drawn from our quantitative and qualitative needs assessment:

• Recognize the interconnectedness of the issues and challenges that women veterans face.
• Individualize and tailor assistance for women veterans in ways that address their unique needs that differ from those of veteran men and nonveteran women.
• Be intentional in reaching women veterans; it takes a great deal of effort and time to build trusted relationships with underserved populations.
• Use systematic, ongoing data collection to help identify unmet needs and gauge the progress of improvement efforts.
• Explore additional opportunities to solicit input and feedback from women veterans. Response rates on surveys can be low, but even limited data can help gauge patient satisfaction and inform improvements to available services and supports.

With these approaches, Adagio Health can continue increasing its capacities and capabilities for supporting its women veteran patients and making progress toward its goal of advancing the health and well-being of its women veteran patients.