Twenty-one veterans between the ages of 22–85 years old participated in a qualitative interview (Table 1).
Three primary themes emerged across 21 veteran interviews: (1) Veterans described how the landscape of female-specific healthcare at the VA has expanded in recent decades, but still has a long way to go; (2) Veterans valued the way the Boost Program outreach calls communicate to them that the VA cares about them and their unique needs, both as female veterans and as rural veterans; and (3) The Boost Program outreach call works against the perception that the VA does not offer female-specific healthcare services.
Theme 1: veterans described how the landscape of female-specific healthcare at the VA has expanded in recent decades, but still has a long way to go
Overall, veterans reported seeing an increase in the availability of female-specific healthcare services in VA in recent decades. Notably, veterans emphasized the establishment of Women’s Clinics as a landmark expansion of female healthcare services in VA. V016 described how the experience of going to Women’s Clinic departs from going to regular primary care where “The average person was a man, white or black, and old… I just didn’t look like the other vets, so at least when it was other women, so there was similarity even though, I mean, it’s every walk of life, but it’s more comfortable.” At the same time, participants highlighted that in addition to system-level changes, they also observed changes on the individual clinician level, with one participant stating “Since [my new PCP] is a female, I think she takes women more seriously than he [my prior PCP] did” (V010). One participant who lived in a rural community, V011, shared how important it was to her to be able to be seen by a female health practitioner at her local VA outpatient clinic, stating:
“The older I get the more—I feel more comfortable having a women’s health practitioner… Seriously, I have only wanted a women’s health practitioner since, probably, since I had a baby… I went like [3–4] years because, you know, I didn’t want to have the male physicians or male nurse practitioners, or the PA’s that they had, you know, I was not comfortable dealing with them at all. I would either go without healthcare or I would wait until I could get an appointment through my own insurance.”
While participants valued the increase in female-specific healthcare services in recent decades, they generally commented that VA is still lacking in providing comprehensive care for female veterans across varied life stages. Participants noted that while the higher number of nurse practitioners (NP) at VA makes some routine female healthcare available (e.g., pap smears), other forms of routine care such as mammograms, bone density tests, or specialty fertility care are still largely outsourced to non-VA community-based clinicians. Given this, V013 emphasized the need to make all female health care provided within VA (e.g., nutrition, in vitro fertilization, menopause care), stating “I think anything with regard to women’s health should be in the forefront.” V013 added that doing so would be ideal both financially (e.g., instead of reimbursing community-based clinicians) and by providing improved continuity of care for female veterans, concluding: “In addition to us not having to jump through hoops… the [VA clinicians] who are reading the x-rays [from community care clinicians] are getting reimbursed nil – financially it would make more sense.”
Theme 2: veterans valued the way the Boost Program outreach calls communicate to them that the VA cares about them and their unique needs, both as female veterans and as rural veterans
Participants described the outreach calls as communicating to them that the VA cares about their needs as female veterans, with veterans stating: “It’s nice to have someone that actually sounds like they’re taking an interest in what you need” (V006) and to help ensure that “my requests are taken seriously” (V013). Several veterans reported feeling appreciative that someone at the VA was reaching out to them, asking about their experiences, and asking for their feedback. Participants found the outreach call to be beneficial, with V020 stating “I felt supported. I felt the NP knew the system well and could help me. I was reminded my service mattered and my health did too to the VA.” Other participants shared that the outreach calls were helpful for increasing their knowledge about what services are available to female veterans at VA, which in numerous cases they had not known existed or not known they were entitled to.
Participants characterized receiving the initial unscheduled and unexpected call from the Boost NP as a surprise, but generally as a pleasant one. They felt the call signaled to them that the VA cares about female veterans. As one participant shared, “I was actually elated… because it’s the VA’s job to make sure that we’re getting adequate care, so, to get a blind phone call asking where we could improve, that’s just positive” (V013). V004 shared that she appreciated being asked her opinion of her care during the outreach call, and V007 similarly spoke to her appreciation that the VA is making care not only for female veterans a priority, but also for rural veterans. V007 elaborated:
“I was pleasantly surprised that the VA has made care up here for veterans a priority because it is so rural up here and there is not a lot of options. You know, the healthcare up here in general has been really super frustrating… Speaking to [the Boost NP] … felt like a breath of fresh air as I was like, wow, they actually care and are trying to help. It’s awesome the service that’s being provided.”
Participants also emphasized the importance of receiving the outreach call from a clinician, rather than from someone calling only to set up an appointment. As a retired nurse, V015 shared being impressed that a nurse practitioner was making the outreach calls and that follow-through on the care discussed was important to her. V015 explained: “Maybe because I’m a nurse, knowing that the VA cared enough in a sense to have a nurse call and ask the questions if I was receiving what I was needed and so forth. That to me was very important. … It said to me that you guys care. And that was important, it was very important to me.”
For numerous participants, the experience of receiving a call from an NP who could deliver care in real-time during the outreach call (e.g., attend to medical needs and arrange specialty care if needed, refill medications, order routine preventative wellness screenings) came in contrast to prior experiences seeking care. Given this, participants emphasized that the outreach calls can help veterans access needed care sooner rather than later. Veterans shared prior experiences of having difficulty scheduling timely appointments, as V012 shared: “It’s hard to get scheduled, to get in, a lot of times and, I know a lot of times when I needed immediate help I was scheduled 6 weeks out sometimes” (V012). Similarly, V008 reflected:
Sometimes it’s just nice knowing that someone’s kind of taken the time to reach out to you, instead of sometimes you having to be the one constantly trying to reach out and not getting a response or getting help back, so it meant a lot to me because sometimes when I reach out – sometimes you don’t get a call or a response back for months or weeks or days. And so, being able to just get a call was nice, made it easy. Surprising, but I actually liked it.
Relatedly, multiple participants spoke highly of the personalized nature of the Boost NP’s care in contrast to prior experiences of having difficulty accessing care. V007 stated: “So many times in the healthcare field it’s really easy, unfortunately, to feel like a number and not a person. It’s one of the aspects that I really appreciate about this program, is that it is very personalized and individualized for us, for our healthcare, and what we need.” Another participant similarly emphasized the importance of feeling as though the Boost NP took the time to listen, as well as act on, her concerns, stating:
“I feel like she actually cares about the patients, so that was refreshing. There’s other times I feel like, you kind of just get moved through… I appreciate that she took the time to talk to me and actually listen, like, put in referrals and stuff to get me seen, because I was having trouble just getting anyone on the phone even let alone an appointment. So, she helped a lot” (V002).
One participant, V011, concluded: “With [the Boost NP’s] intervention things happened, and so I felt like things were under control”.
Theme 3: the Boost Program outreach call works against the perception that the VA does not offer female-specific healthcare services
Many participants touched on the perception that the VA does not focus on offering female-specific healthcare services. Even with the increase of Women’s Health-trained PCPs throughout the VA, several participants shared not having been informed of the female health services available to them by their VA clinicians. In one example, when asked if her PCP at her local VA outpatient clinic had informed her about what female health services are available to her, V008 responded “No, I’ve never been talked to about it.” Participants also spoke to the challenges of accessing VA care as female veterans with young children. In response to one participant’s, V007, referral to a surgical procedure at the nearest VA medical center over 5 h away from her home, V007 explained that receiving the surgery in her local community through a community care referral would be much more appropriate given her many responsibilities at home. V007 continued that in lieu of a community care referral, the VA should assist with reimbursements for traveling to the medical center. V007 elaborated:
“I don’t know how much money the VA has to be able to do things for people. And I know I am kind of like the odd participant because I’m not an old man. Cause the typical veteran is an old man, right? So, my situation, my circumstances are different because I’m younger and all the kids I have and whatnot. But I’m still a veteran and I can still participate. So maybe just like for the people like me, like the unusual participants… maybe if there are special circumstances like financial hardship or children with disabilities, like gift cards maybe, a free hotel voucher, or a gas card. If we’re going to get denied the care that we want where we live… and we are going to be forced to go out of that area with our family… the VA should be helping to make it happen… Or reimbursement too, if I keep the receipts.”
Beyond availability of services, several veterans also shared experiences of feeling as though they don’t “count” as a veteran or of people assuming that they are not veterans because they are female. One participant, V011, described having had people ask her if she was a veteran when she was clearly in line for a service at a VA clinic. V011 added seeing phrases such as “thank you for your service” being said mostly to male veterans, concluding: “In some ways we can be invisible.” Relatedly, V003 shared that she doesn’t always feel like she “counts” as a veteran because she was discharged early in her military service period. Emphasizing a need for female-specific support groups at VA, V003 stated that the VA needs to establish more programs that offer female veterans ways to connect and feel a sense of belonging with one another.
Recommendations for improving healthcare services for female veterans
Participants generally expressed the view that services for female veterans need to be expanded by the VA. For example, participants emphasized the need for female-specific mental health support groups for various concerns and across different life stages that can include groups for endometriosis, menopause, military sexual trauma, groups for grief, and groups focused on aging (e.g., a senior exercise group for female veterans). Another participant highlighted the need to better disseminate information about female-specific healthcare services that are already available in the VA. V008 reflected:
I guess I never really get that [form of care] from the VA, or, it never crosses my mind to go to them for that. When I have my appointments and stuff it’s never talked about, and that’s been a lot of my health issues in the last year and a surgery I had… when I tried to talk to them about hopefully getting it covered or anything like that, or them doing it, it really didn’t get touched on, and so I ended up having to pay out of pocket for it… I tried to schedule an appointment with them and it just never happened.
Across the board, participants also highlighted the importance of continuously promoting the Boost Program and the services the program provides for female veterans. Recommendations included the distribution of flyers, pamphlets, brochures, and mail-outs, with veterans emphasizing that they would notice any program or service specifically for female veterans.
