ABSTRACT
Purpose
American Indian and Alaska Native (AI/AN) women use VA healthcare and reside in rural areas at higher proportions than other women Veterans. To support an investigation of ways to improve healthcare access and outcomes among rural AI/AN women Veterans, we conducted listening sessions on healthcare experiences, needs, and preferences.
Methods
We conducted in‐person, group interview‐style listening sessions using a qualitative descriptive approach. Our sample was based on states with relatively high numbers of AI/AN women Veterans. Specific sites were identified in consultation with the VA Office of Tribal Government Relations. Eleven listening sessions were conducted in eight states. Sessions were audio‐recorded, transcribed, coded, and analyzed with a thematic content approach.
Findings
Participants reported intentional decisions about choosing VA care for health conditions they considered a direct result of military service. Examples of reasons Veterans avoided using VA included preferences for culturally based treatment services and provider cultural awareness. The relative proximity of Indian Health Service/Tribal Health Program (IHS/THP) clinics compared to VA clinics was noted in decisions for primary and acute care needs.
Conclusions
Aspects of women’s prior military service were directly connected with present‐day health concerns and choices about where to seek care. Results suggest AI/AN women actively select VA care for military‐related conditions and use IHS/THPs for other health concerns. Healthcare systems should recognize this dual use as a Veteran‐driven pattern and continue to strengthen care coordination across VA and IHS/THPs, building on existing efforts to support information sharing and continuity of care.
Keywords: access to care, care coordination, indigenous health, veteran health, women’s health
1. Introduction
The population of American Indian and Alaska Native (AI/AN) Veterans, including growing numbers of women Veterans, has a unique standing with respect to the US government and associated benefits. Historical treaties and subsequent policies have established federal responsibilities to provide sovereign tribal nations with land, education, and healthcare following colonization and removal of Native people from their original homelands [1]. The federal government plays a central role in the landscape of health service delivery for AI/AN Veterans, particularly in rural areas. The Indian Health Service (IHS) is the agency responsible for providing healthcare to enrolled tribal members along with Tribal Health Programs (THPs), which are directly managed by tribal nations [2, 3]. Most IHS/THPs are concentrated in rural areas where reservations and other tribal lands are located.
Access to healthcare for AI/AN women Veterans is shaped by multiple federal and tribal systems. Eligible AI/AN Veterans have access to healthcare benefits through the Department of Veterans Affairs (VA), primarily the Veterans Health Administration (VHA). IHS/THPs offer women’s healthcare across the life course, although services vary by site depending on staffing, infrastructure/equipment available, and funding. VA services for women Veterans, including AI/AN women, were extremely limited until initiatives in the mid‐1980s to increase women‐specific healthcare. Expansions in access to mammography, obstetrics and gynecological care, and other health services for women Veterans culminated in the mid‐2000s with comprehensive women’s healthcare delivery programs requiring every facility to employ a Women Veterans Program Manager to ensure women received care that meets their needs [4]. However, the availability of specific services varies by site. AI/AN Veterans may be eligible for healthcare benefits through multiple programs, including IHS/THPs and VHA, as well as other sources (e.g., employee health insurance, Medicare, or Medicaid), although access to certain services is often limited in rural areas. These overlapping systems are particularly salient for AI/AN women Veterans, whose healthcare needs often span primary care, reproductive health, and chronic disease management across settings.
Previous research, including findings from mixed‐gender samples and women‐specific studies, has shown that many AI/AN Veterans are dual users of VA and IHS/THPs, often selectively using specialty services from each system [5, 6]. VA and IHS have built a partnership through a memorandum of understanding (MOU), established in 2003 and revised in 2021, that continues to support sharing resources to improve healthcare for AI/AN Veterans [7]. Multisystem healthcare use has been associated with care delays, duplication, increased healthcare costs, and potentially poorer outcomes [8, 9, 10]. Research is limited regarding how and why AI/AN Veterans receive care from multiple healthcare systems, especially amid recent benefit enhancements such as the VA Maintaining Internal Systems and Strengthening Integrated Outside Networks Act of 2018 (MISSION Act) and the Sergeant First Class Heath Robinson Honoring our Promise to Address Comprehensive Toxics Act (PACT Act), enacted in 2022 and expanded in 2024.
AI/AN women serve in the military at higher proportions than other groups and are more likely than other women Veterans to return to rural areas following service [11, 12]. AI/AN populations face some of the nation’s greatest health challenges, including the highest rates of diabetes and hypertension, as well as cancer disparities [13, 14], compounded in rural areas. The literature on AI/AN women Veterans’ health and healthcare is limited, with qualitative studies in particular remaining scarce, leaving gaps in understanding of their experiences, access, and use [15]. AI/AN women experience a higher prevalence of multiple chronic conditions, with the greatest burden among those living in rural communities [11]. Evidence suggests they are more likely to use VA services and to experience conditions such as post‐traumatic stress disorder (PTSD), chronic pain, diabetes, and pregnancy complications related to hypertension or diabetes [11, 12, 13, 14].
Understanding the healthcare experiences, needs, preferences, and priorities of AI/AN women Veterans and how they choose to use VA care alongside other systems is essential for identifying opportunities for improvement. We conducted listening sessions with the overall, broad research question: “What are AI/AN women Veterans’ healthcare experiences, needs, and preferences as they relate to VHA, IHS/THP, and other healthcare?” This approach was used to assess whether efforts should prioritize improving VA care delivery, enhancing specific services, or strengthening care coordination across systems.
2. Methods
We conducted in‐person, group interview‐style listening sessions using a qualitative descriptive approach to understand AI/AN women Veterans’ healthcare experiences, needs, preferences, and priorities. In many contemporary AI/AN contexts, listening sessions are informal, participant‐driven discussions in which community members share perspectives with leaders; unlike focus groups, listening sessions emphasize open, wide‐ranging comments rather than moderator‐directed questioning. We intentionally framed data collection as listening sessions to build trust and emphasize participants’ perspectives, recognizing that Veterans may view researchers as representatives of the VA, which could influence how and what information they shared.
We constructed our sample by identifying states with either the largest absolute number or the highest proportion of AI/AN women Veterans (see Figure 1). Within selected states, sites were chosen to facilitate the recruitment and participation of rural women Veterans. Rurality was defined following VHA Office of Rural Health guidelines that use the U.S. Department of Agriculture’s Rural‐Urban Commuting Area (RUCA) Codes. RUCA codes use population density and commute information to assign rurality scores, such that RUCA 1.0 and 1.1 are designated as urban, 10.0 highly rural, and all other RUCA codes (2−9, 10.1−10.3) are rural [16]. State served as the site identifier for each listening session, with specific sites identified in consultation with the VA Office of Tribal Government Relations (OTGR). The goal was to recruit 8–10 participants per session to support diversity of perspectives and facilitate group discussion. This study was reviewed by the University of Iowa and designated as a quality improvement study, which did not meet the regulatory definition of human subjects research as defined under 45 CFR 46.
FIGURE 1.
Location of listening sessions. The map shows states highlighted in blue where listening sessions were held with AI/AN women Veterans. These states were selected based on high absolute numbers or proportions of AI/AN women Veterans.
Initial recruitment relied on mailed outreach to rural and highly rural women Veterans; recruitment was later conducted in partnership with OTGR and local tribal and Veteran organizations, which disseminated session information through established community networks, physical postings, and social media. Sessions were hosted in community‐based settings (e.g., Veteran organization headquarters, community centers). Eligibility was intentionally broad: any self‐identified Native American, AI/AN, or Indigenous woman Veteran was eligible, regardless of VA enrollment or tribal citizenship. Participants received $50.00 via direct deposit for their time and travel.
We used a privacy‐focused approach to collecting participant demographic information. Participants were invited to complete a brief demographic survey at the start of each listening session; no names, addresses, or other identifying information were collected. Information needed for purposes of compensation was collected separately and was not linked to study data. Participants could use pseudonyms during sessions if they preferred. Participants were not asked to report tribal affiliation or tribal enrollment status. This decision reflected both the focus of the study and a commitment to minimizing the collection of sensitive information that was not essential to research questions. Participants frequently shared aspects of their cultural identity, and some participants described tribal affiliations when relevant to their experiences.
We used a semi‐structured data collection approach with prompts focusing on healthcare access and use while allowing participants to introduce additional topics. Our research question was intentionally broad to allow for the exploration of a range of experiential and contextual factors guiding healthcare decision‐making and use. Questions were informed by previous research regarding VHA‐IHS/THP dual use and addressed experiences with VA, IHS, and other healthcare providers. Sessions were led by a qualitative researcher (MKG) with a PhD in Cultural Anthropology and experience conducting research with Indigenous communities. A second team member (MM) attended each session to take notes and ask follow‐up questions as needed. Both facilitators were non‐AI/AN women and non‐Veterans. In most sessions, an OTGR representative, a local VA Native Rural Health Navigator, and/or a VA Women’s Health Representative were present to provide logistical assistance and answer questions about VA benefits. Sessions lasted 1–2 h (mean 1.75 h).
Listening sessions were audio‐recorded after receiving verbal consent from all participants and transcribed. Transcripts were imported into the MAXQDA 2025 software for coding and analysis. Two PhD‐trained qualitative researchers (MKG, DDB) developed a preliminary codebook using deductive codes based on the listening session guide. Both independently coded one transcript and compared results to ensure consistency. The codebook was revised iteratively to refine definitions and incorporate inductive codes. Any discrepancies in coding were resolved through discussion. The team then identified connections across transcripts and derived themes.
3. Results
We conducted 11 listening sessions at eight sites (see Figure 1) with 54 attendees, 46 of whom contributed to the discussion (see Table 1). Sites were selected to facilitate participation among AI/AN women Veterans living in rural areas and included locations on reservation lands, near reservations, and in urban areas. One urban site was chosen to coincide with a large regional powwow that drew AI/AN participants from surrounding rural areas. The other urban site acted as a shopping and social services “hub” for outlying rural communities. Participants represented a range of geographic contexts; some reported traveling 1–2 h to attend.
TABLE 1.
Site and session characteristics.
Session sites
Participants
State/session number
Attended (N = 54)
Verbally participated (N = 46)
Completed anonymous optional demographic survey (N = 43)
Alaska 1
3
3
3
Alaska 2
2
2
2
Arizona
10
8
7
California
2
2
2
Colorado 1
1
1
1
Colorado 2
2
2
2
Montana
7
6
6
Oklahoma
6
6
5
South Dakota
14
9
8
Texas 1
1
1
1
Texas 2
6
6
6
Table 2 presents characteristics of participants who completed the optional demographic survey. The average age was 53 years (range: 30−91). Most participants served in enlisted ranks (n = 34, 80%), and in the Army (n = 24, 56%). The sample was evenly split between those who served pre‐9/11 and post‐9/11; five participants served in both eras. More than half (n = 27, 62%) had used VA healthcare.
TABLE 2.
Participant characteristics.
Total
Participant age
Mean = 53 (range 30–91)
Branch of service
a
Army
24
Navy
7
Air Force
9
Marines
4
Military rank
Enlisted
34
Noncommissioned officer
9
Service period
a
Pre‐9/11
24
Post‐9/11
20
No answer
4
Ever deployed during service
Yes
19
No
23
No answer
1
Ever deployed to a combat zone during service
Yes
14
No
29
Enrolled in VA healthcare
Yes
28
No
13
Don’t know
1
No answer
1
Ever used VA healthcare
Yes
27
No
16
Used VA healthcare in the past year
Yes
24
No
19
No answer
0
Total survey respondents
43
We identified four main themes from the listening session transcripts regarding VA healthcare access and use: (1) factors affecting VA enrollment; (2) factors affecting healthcare use/where to seek care; (3) benefits/advantages to VA care; and (4) areas for improvement in VA care. Each main theme included several subthemes, described below.
3.1. Factors Affecting Enrollment in VA Healthcare
Multiple factors contributed to whether participants decided to enroll in VA care immediately following their military service or later. Most participants had a gap between leaving the military and seeking enrollment, either because they felt they did not need to use VA health benefits or because they were not sure they qualified. Aspects of prior military service influenced participants’ choices about enrolling in VA healthcare. Memories of increased scrutiny because they were women, or experiences of sexual harassment or sexual assault while serving in the military (i.e., military sexual trauma [MST]), left some participants wanting to avoid anything having to do with the military, including the VA:
“I think a lot of that stigma [of being a woman]…like I said, I haven’t gone to the VA. I think I would feel that pressure, like that shame or guilt, or carry that pain of what I’ve experienced while I was in battalion, in camp, going to the VA and seeing somebody in uniform. It’s just, you know, khaki uniform, the shiny shoes, whatever I’ve dealt with before. I feel like I would be standoffish, probably not completely honest about the health care that, you know, like, “it burns when I pee,” like with a UTI. No man’s gonna understand that. Even, whether or not they’re a medical provider, or they might be professionals, or whatever the case may be, there’s just some things that you don’t want to share with a provider that’s very militant.” Participant A, Alaska Session 1
Participants also reported that knowledge of historical discriminatory medical practices by the US government, such as involuntary sterilization of AI/AN women by IHS providers up until the 1970s [17, 18], and a lack of trust in the US government in general, added to their hesitation to use VA healthcare. Additionally, relatives’ experiences with VA healthcare both positively and negatively influenced perspectives on VA healthcare. While one participant reported a negative association with the VA because “family members I loved went there and died,” other women recounted stories of accompanying relatives to the VA and being impressed by the quality of care or being encouraged by relatives to use VA healthcare.
Across sites, AI/AN women Veterans described variable experiences with the support of liaisons between VA and Veterans, such as County Veteran Service Officers, Tribal Veteran Representatives, and others. Some women described how these representatives, either in volunteer positions or paid by state Veteran organizations or the VA, were critical to them successfully enrolling for benefits and keeping them informed.
“I got this Vet Rep during the pandemic and he’s helped me out a lot. He’s from the state of Colorado, and he’s helped me navigate quite a few different things and so, um, I depend on him…That’s where I
get
all my information. I get it from him.” Participant A, Colorado Session 2
However, many other participants had negative experiences with Veteran representatives, including being told inaccurate or misleading information that caused them to mistakenly believe they were ineligible or led them to decide not to pursue enrollment.
“Honestly, I’ve never used the VA. …When I first got back, I don’t remember who the VSO was, it was a long time ago. I did all the paperwork and everything, and he took it, and then he said, “we’ll be in touch.” But I never heard back on anything. And then, a few years ago, I did it again. And, they said, because I never [heard from] the VSO, or used the VA when I first got back, that they probably won’t accept any of my health issues now. So, I’ve never bothered after that…So for me, it was my encounters with the VSOs when I first came back that really didn’t encourage me, or even give me information about what the VA was. I had to hear about it from my uncles who served.” Participant G, South Dakota Session
Some participants described receiving incorrect or conflicting information about their VA eligibility because of their entitlement to IHS benefits. The two types of federal government health benefits are administered by separate government agencies and have distinct criteria to qualify for receiving them.
“So back in 2022, my husband and I went to the VA, we served, let’s go sign up. We didn’t know, we had no clue about nothing, how to sign up for benefits, nothing, so we got all our paperwork together, we went to the VA here. Took us probably about a half hour to fill out our paperwork, because, you know, cross your T ’s, and dot your I’s, and so we get in there, the lady looks at our paperwork and she’s like, “You guys are better off at IHS.” And gives us our paperwork. We’re like, “What?! Just, that’s it?!” So we got up and we walked out, we left. And we were mad, because we were like, what the heck, we served our country, we should be able to utilize these services. What does that have to do with IHS?” Participant C, Montana Session
3.2. Factors Affecting Healthcare Use/Where to Seek Care
AI/AN women Veterans eligible for both VA and IHS/THP healthcare discussed how they made intentional decisions about which services to use for different health concerns. Following on from discussions of VA enrollment above, one element that factored into initiating VA healthcare was the relatively high burden of paperwork compared to seeking care at IHS/THPs, where typically showing proof of tribal citizenship in the form of an ID card or CDIB document would be sufficient.
“I don’t know how many years it’s been, but I tried before. So much paperwork. I was like, screw that. IHS is so convenient, and [I use] traditional practice for mental health. So I figured, hey, if the white man’s way can’t do it, I’ll just stick with the [name of tribe] way, so it helps.” Participant C, Arizona Session
For many rural women participants, the distance to care also played a role in where they sought healthcare, especially in the case of acute illness or other urgent needs. Particularly for women with small children, IHS/THP was an easier choice for acute care related to illness so that “I can be seen where my family is seen” (TX‐2D). Participants living on or near reservations often felt IHS/THP facilities were closer and easier to get appointments quickly than VA clinics as well.
“Maybe if they [VA] were closer, because I live in [rural town]. It’s, it’s a long ways to have to go to an appointment. You know, and for me, it’s a scheduling thing, it’s hard for me to take off work, it’s hard for me to take that time.” Participant D, Oklahoma Session
“It’s a day trip to go to the VA.” Participant C, Texas Session 2
However, some participants discussed making the decision to travel long distances for specific healthcare needs they felt the VA was more skilled at handling. One participant told a story of an urgent situation where her struggles with PTSD and chronic pain led her to drive to the VA hospital despite the risks entailed in traveling in her condition:
“You do that travel. I get injections in my neck and my lower back. I went [to get the injection], but afterwards, I woke up and my arms were tingling all the way down to my hands. So I called the VA. It’s a three‐hour drive from here to [VA hospital]. I’m panicking because my side starts shaking, and it just like start tingling on this side of my face. And I am telling the doctor, I’m like, ″I don’t know what’s going on.” Participant C, South Dakota Session
3.3. Benefits/Advantages to VA Healthcare
Many participants who were dual users of VA and IHS felt that VA was the best choice for care for service‐related conditions, including everything from mental health to musculoskeletal concerns. Participants reported intentionally deciding to use VA for these service‐related conditions not only because the costs were sometimes covered, but also because they believed it was the responsibility of VA to treat the injuries and conditions acquired in the military.
Yeah, yeah, I feel like, for the things I have compensation for, then I think that it is right to be seen at the VA and it’s appropriate, so I do go there…And it’s interesting because I have something that I acquired in the military that is women’s health related. It hasn’t progressed into a worse situation, so I’ll have to make that decision down the road if it does get worse, if I want to keep my mindset of you know, this is what I acquired in the military, I want to keep it at the VA, so they can handle their situation. Or, am I gonna go to my primary care at my Native health facility? Participant C, Alaska Session 1
AI/AN women Veterans praised the care given to them by the VA in cases of complex surgeries related to the toll military service took on their bodies, including care for knees, shoulder, and spine concerns.
Participants also felt that VA mental/behavioral health services could provide better mental healthcare when it came to addressing specific conditions like PTSD, MST, or general processing of military experiences. Some women preferred mental health services at VA because they felt they had a greater degree of privacy and confidentiality than at IHS/THP. The availability of mental healthcare at local IHS/THP facilities also varied widely across our sites. For some participants, VA was the only option for mental health available. Participants emphasized the importance of VA providing mental health services, even suggesting that VA providers should incorporate mental health screenings at every appointment.
“You’re always concerned about your privacy [at IHS]. If it gets out I know where it’s getting out from. If it is, then it’s a problem.” Participant C, Texas Session 2
“I believe mental health is always going to be [the most important]. I truly believe if you’re going to go and get a physical, and they’re going to check your body, they should do a mental health check. You know, mental health is just as important as physical health and it’s overlooked often. And a lot of times, I believe it, it goes unheard.” Participant A, Alaska Session 2
Notably, some AI/AN women Veterans described being highly satisfied with the women’s healthcare they received from VA, while others expressed that they did not know what types of women’s health were available. Both awareness of women’s health services and availability of services appeared to vary by site.
“I have a history of miscarriages…And since I’ve been meeting with the VA here, she’s been on the ball with getting me appointments and actually sat down and telling me possibilities of reasons why I may be having multiple miscarriages. I’ve never had answers before, and so her validating that, it really was very, really made me feel heard, and seen, and valued.” Participant K, Montana Session
3.4. Areas for Improvement in VA Healthcare
AI/AN women Veterans who used VA provided recommendations that would improve their ease of access to care, as well as suggestions for building trust and increasing their likelihood of using VA healthcare. Participants sought greater ease of communication, including the ability to make appointments and connect more directly with specific care services rather than using a single phone number for all services. Improvements to care coordination were a priority for participants who were dual users of VA and IHS/THP. Many of these dual users reported difficulties with ensuring all of their providers knew about updates to their health conditions and went to great measures to keep their providers informed, going so far as to take copies of medical records with them to all appointments.
“To be honest with you, I carry most of my medical records with me, if I’m going to visit another doctor…I just find it easier to carry the operative reports around so they don’t think I’m BS‐ing them. So I don’t have to go into this, ‘Oh we need [to request] your medical records,’ thing. Nope, I got ‘em right here.” Participant A, Colorado Session 2
Participants also suggested greater attention to health conditions that are known to disproportionately affect AI/AN people, such as diabetes, cardiovascular disease, and mental health concerns. Addressing these risks as part of routine health management was a priority for AI/AN women Veterans.
Listening session participants also thought that having more female providers, women’s‐specific spaces, or even specific days or times where only women Veterans would be seen in the clinic would be helpful for building trust and comfort with VA. The need for representation of both women Veterans in general and AI/AN women Veterans more specifically was a frequent recommendation. Participants suggested that recognizing the needs of women Veterans as well as the cultural specificities of AI/AN women Veterans would help improve access to VA care as well as awareness of VA services.
“I feel like the VA representation should have more acknowledgement to say, you know, there is healing in identity, there’s healing in ceremonial ways. As [tribal members], we’re warrior people, we come from strong lines of warrior people. We were mighty, but we were few, but we’re here because of that, and that’s something I think we should continue to acknowledge and that my prayer is that the VA would also see that.” Participant I, Montana Session
“I think probably more on social media, you know, the commercials that we all see, you know, things like that that. We’re so used to being put to the wayside, unfortunately, and even to see a commercial that has a Native person in it, it’s like, “Wow look!” and it will hit Facebook like fire. Just like that, and it actually sounds very goofy just to say that, but it’s the truth, that we are not acknowledged, we’re not represented well, we’re not given the opportunity to be representatives of Native people, period. Social media‐wise, to see that the VA is actually reaching out to, not only just a race of people, but to women. In our culture, women, it used to be before we were colonized that we were the ones in charge, it was a very matriarchal society. So to even see that we are being acknowledged. In that manner, in social media.” Participant B, Colorado Session 2
4. Discussion
Consistent with prior research documenting dual use among AI/AN Veterans, our findings suggest that AI/AN women Veterans often choose VA for military‐related conditions (e.g., PTSD, physical and mental health concerns related to MST, service‐related injuries) while relying on IHS or other providers for acute and other types of care [5, 9, 19, 20]. Our findings extend this work by showing that while healthcare need drives care‐seeking, decisions about where to seek care are shaped by personal comfort level, travel burden, administrative complexity, and out‐of‐pocket costs. Rather than reflecting fragmentation, this pattern highlights how AI/AN women Veterans navigate multiple systems to meet health needs within the constraints of rural and reservation‐based settings.
The emphasis on VA mental health as a particular strength in our findings aligns with existing evidence that Veterans often perceive VA providers as having a greater understanding of military culture and experience in treating service‐related conditions, such as PTSD [21, 22, 23, 24]. Our findings reinforce this evidence in the context of AI/AN women Veterans; further, they suggest these perceptions contribute to the selective use of VA for specific types of care. Recent programs that tailor telemental health services specifically to the needs and cultural values of AI/AN Veterans lend additional strength to VA mental health for this group [25, 26]. At the same time, experiences in the military have lasting effects for AI/AN women Veterans, including an impact on their willingness to use VA healthcare, indicating a continuing need to address sex‐ and race‐based discrimination, harassment, and assault in the military [27, 28].
Participants were interested in a range of women’s health services, although awareness of available services varied across sites. While VA policy requires the availability of comprehensive women’s health services, including designated Women Veterans Program Managers and, in many facilities, women’s health clinics, participants’ experiences suggest that the visibility and communication of these resources may lag behind policy intent. Similar gaps between policy and patient awareness have been documented in prior studies of women Veterans’ healthcare access, particularly in rural settings [29, 30, 31]. Increasing visibility of women’s health services, expanding women‐specific spaces, and ensuring access to culturally competent female providers where possible may help improve engagement and trust among AI/AN women Veterans.
Our findings also suggest that dual use of VA and IHS/THPs can function as a successful, Veteran‐driven strategy when both systems are accessible. This is consistent with the intent of the VHA‐IHS Memorandum of Understanding and recent federal policy efforts, including the VA MISSION Act, which emphasize coordination and resource sharing rather than exclusive reliance on a single system [7, 32]. However, participants’ accounts highlight persistent challenges related to geographic distance, staffing shortages, and limited facility resources in rural and reservation‐based settings. Reducing barriers that have been widely documented in research on IHS/THPs, including better records sharing, would likely improve health outcomes through timely, comprehensive attention to health conditions.
Tribal Veteran Coordinators, Veteran Service Officers, and other outreach representatives can be valuable resources to support VA enrollment and receiving entitled benefits [33, 34]. On the other hand, misinformation or negative interactions can be a barrier to enrollment and utilization. Strengthening ties between VA and these representatives to ensure accurate and up‐to‐date information could potentially increase AI/AN women Veterans’ enrollment and use of VA. Expanding recent innovations for supporting AI/AN Veteran access and use, such as the Rural Native Veteran Health Care Navigator program that currently operates in Northern Arizona and Northern California, could also increase AI/AN women Veterans’ use of VA and improve health outcomes [35, 36].
It is important to note that, while we found similarities in the experiences and needs of across listening sessions, the AI/AN women Veteran participants also reflected considerable variation in culture and experience. Availability of services in each area for VA and IHS/THP facilities also differed significantly across sessions. Tribal nations view women and women’s military service in different ways, and other cultural values, beliefs, and practices shape the experiences of women in the military and as Veterans. Additional research is needed to understand how tribal and regional differences might influence AI/AN women Veterans’ experiences and decisions about healthcare.
4.1. Limitations
This qualitative study presents insights into AI/AN women Veterans’ healthcare needs and experiences, but has some limitations. Participation was voluntary, and women with different healthcare experiences may be underrepresented; few participants discussed using private insurance and nongovernmental healthcare providers, limiting comparisons to VA and IHS care. While discussions across sessions reflected a range of experiences, no participants were under the age of 30, and younger women Veterans are not represented. Session size varied (range: 1–14 participants), with sessions of one or two participants functioning more like individual interviews; these sessions could not benefit from group interaction that has an impact on the depth and breadth of discussion. This study focused on rural and reservation‐based settings and does not include urban AI/AN women Veterans. Barriers such as distance, limited services, and reliance on multiple systems most likely reflect the rural context and may differ in urban settings. Despite these limitations, this paper addresses a gap in the literature on contemporary AI/AN women Veterans’ healthcare experiences and provides a foundation for future studies on particular health conditions (e.g., menopause, cardiovascular disease) and the impacts of regional, tribal, or cultural differences.
5. Conclusions
AI/AN women Veterans make intentional, context‐dependent decisions about when to use VA care and when to rely on IHS/THPs or other providers. Recognizing dual use as a Veteran‐driven strategy highlights the importance of care coordination, accurate information, and culturally responsive outreach. Strengthening partnerships among VA, IHS/THPs, and Veteran Service Organizations aligns with federal policy goals and has the potential to improve access, continuity, and quality of care for AI/AN women Veterans.
Funding
This work is based on a project supported by the Department of Veterans Affairs, Veterans Health Administration, Office of Rural Health, Veterans Rural Health Resource Center—Iowa City (NOMAD PROJ04117, PI: Mengeling).
Disclosures
The views expressed in this manuscript are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the US government.
Conflicts of Interest
The authors declare no conflicts of interest.
Acknowledgments
The authors wish to thank all of the Native women Veterans who participated in the listening sessions, as well as the caregivers and others who supported their transportation to and participation in the sessions. We appreciate the consultation and collaboration of the VA Office of Tribal Government Relations in this work. We are also very grateful for the generous collaboration of local tribal organizations, community Veteran organizations, and Tribal Veteran liaisons, service officers, and representatives who invited us onto their land, hosted our sessions in their spaces, and provided logistical support.
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