Term Paper: Women Veterans and Hypertension in Houston

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Women Veterans and Hypertension in Houston

Women Veterans and Hypertension

Community Diagnosis: Women Veterans and Hypertension in Houston

HGT Community Health Practicum

Community Diagnosis: Women Veterans and Hypertension in Houston

Ever since the U.S. military transitioned to an all volunteer force in 1973 the proportion female veterans has increased significantly (VA, 2011). While women have historically been excluded from serving in combat positions, such as the infantry, this policy has gone through several revisions in a post-9/11 America. Accordingly, the number of female veterans incurring service-related disabilities qualifying them for life-long medical care through the Veterans Health Administration is also increasing (VHA). The most common disabilities among female veterans, in order of prevalence, are posttraumatic stress disorder (PTSD), lower back pain, migraine, and major depression. Of these, anxiety and depression are significant risk factors for high blood pressure and cardiovascular disease (CVD) (Everson-Rose and Lewis, 2005). Since heart disease is also the number one killer of women in the U.S., a community assessment for hypertension will be conducted on women veterans in Houston, Texas.

Assessment

Target Community Location and Size

The Michael E. DeBakey VA Medical Center (MEDVAMC) in Houston, Texas is the primary health care provider for 130,000 veterans living in Southeastern Texas (VA, 2013a). However, this medical facility provides health care services for veterans living throughout Southeastern Texas, not just in Houston. Outreach clinics have been established in nine other cities throughout this geographic area.

The MEDVAMC is one of four VA medical centers located in Texas (VA, 2010). The other three circumscribe the coastal region from San Antonio northward to Dallas. The area serviced by MEDVAMC is therefore quite large and overlaps with areas serviced by the other three medical centers, in part because not all services are provided at all medical centers. The two main regional VA centers in Texas are located in Waco and Houston, with each offering services to the 1,657,311 veterans that were living in Texas in 2010 (VA, 2012a). The number represented by the Houston Regional office is 734,271, which is 44% of all veterans living in Texas. Nearly 18% of all veterans living within the Houston region therefore rely on MEDVAMC for their health care needs.

The MEDVAMC patient population enrolled between 2011 and 2012 numbered 128,387 and women represented 8% of this population (VA, 2012b). For comparison, the percentage of women veterans nationally is 9.81% (VA, 2013b) and 15.1% are enrolled in VHA (VA, 2012d). These statistics suggest women veterans in the Houston area may be significantly underserved by the Houston VHA.

The average age of female veterans nationally is 49, compared to 64 years of age for male veterans. This age difference is due to the large number of male veterans who served during the Vietnam War Era and the relatively large number of female veterans who served during the second Gulf War [Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF)] (VA, 2011). The age distribution of OEF/OIF female veterans is 77.3% under the age of 40 and 50% under 30 (VA, 2012d). On a national level, 56.2% of OEF/OIF female veterans have obtained health care services at a VA medical facility and of these, 53.5% have sought medical care 11 or more times. At MEDVAMC, OEF/OIF veterans represent 12% of enrolled patients. If national statistics are used as a guide, then 12% of these veterans will be women (Women Veterans Health Care, 2012).

The largest subgroup of women veterans by age is the 45 to 65 age group, which represents 44% of all women veterans (VA, 2012d). Another 14% of women veterans are 65 years of age or older. This subgroup will likely place a greater care burden on the VHA in the near future as they continue to age.

Physical and Social Environment

The Houston area is primarily an urban environment, which experienced rapid growth and industrialization during the latter half of the 20th century (Williams, 2008). The racial makeup of the Houston metropolitan statistical area, which has been defined by the U.S. Census Bureau as the Houston-Sugar Land-Baytown area, is 40% Caucasian, 35% Hispanic, 17% African-American, and 8% other (TDSHS, 2012). The Houston area is therefore an ethnically-diverse and primarily urban community.

From an environmental justice perspective, the Houston area has earned a bad reputation (Williams, 2008). Industrialization, in particular the petrochemical industry, has created a number of environmental hazards that have posed a health risk to residents due to the release of pollutants into the water, soil, and air. These pollutants are released from waste disposal and industrial sites disproportionately located in minority and poorer neighborhoods. This may explain in part the results of a recent health survey conducted on Houston residents, which found that Hispanic, African-American, and Asian residents are more likely to have poor or fair health (Institute for Health Policy, 2011).

Importantly, women veterans are more likely than their civilian peers to be non-White non-Hispanics (VA, 2013b). A significant number of women veterans in Houston may therefore be at risk for developing health problems due to industrial pollutants. In addition, 62% and 57% of African-American and Hispanic Houston residents, respectively, were experiencing economic hardship in 2010 (Institute for Health Policy, 2011). This too is relevant because women veterans nationally are more likely than their male counterparts to be living in poverty (VA, 2013b). In terms of educational achievement, older female veterans (35 and older) have been more successful than their civilian counterparts, but the reverse is true for female veterans below the age of 35 (VA, 2013b).

Health Concern

When compared to male veterans, women veterans are more likely to have a service-connected disability (VA, 2013b). Of the women veterans who seek health care through the VA, the most common service-related disabilities are posttraumatic stress disorder (PTSD; 5.7%), lower back pain (4.9%), migraine (4.8%), and major depression (4.8%) (VA, 2011).

Both PTSD and major depression are significant risk factors for high blood pressure and cardiovascular disease (reviewed by Everson-Rose and Lewis, 2005; Stock and Redberg, 2012). A recent retrospective study revealed that resting blood pressure and heart rate among OEF/OIF male veterans with and without PTSD was significantly higher in veterans with PTSD (Paulus, Argo, and Egge, 2013). Adjusting for age, hypertension diagnosis, diabetes, anxiety, depression, mood disorder, substance abuse, smoking status, and ongoing use of prescription hypertension medications did not alter this finding. The authors of this study also discovered that veterans with PTSD had much higher rates of undiagnosed hypertension (20.5% vs. 2.0%). The overall prevalence of hypertension in the PTSD patients was 34.1%.

The prevalence of hypertension is greater among men between the ages of 20 and 44, but when risk is averaged across all age groups gender is no longer a risk factor (CDC, 2012). Hypertension prevalence is also impacted by race to a large extent. The most susceptible group is African-Americans (43.0-45.7%), with women having a higher risk than men at an earlier age. The next most-susceptible racial group is Caucasians (31.3-33.9%), who are followed by Mexican-Americans (27.8-28.9%).

The residents of Texas and Houston have a prevalence of hypertension of 28% and 30% respectively (Institute for Health Policy, 2011). Nationally, approximately 33% of adults have hypertension (CDC, 2012), which suggests Texas and Houston residents are doing slightly better than average compared to all Americans. The prevalence of hypertension among women veterans is unknown.

Health Resources for Women Veterans

The VHA provides a number of resources to help women navigate the services they offer. At MEBVAMC, a Women Veterans Program Manager is available to help women veterans interested in enrolling in VHA or who might be homeless with or without children (VA, 2012c). The Women Veterans Program Manager can help women veterants discover what option they have both within the VHA system and in their community. Qualifying for coverage through the VA is determined by the existence of a service-related disability, financial need, and a willingness to pay for services when economically advantaged. The services provided through the VHA include all reproductive health services (gynecological, pap smears, mammograms, birth control, and prenatal and postnatal care), mental health, surgical, and nursing home care for qualifying veterans. For VHA non-eligible women veterans and veterans without private or public health insurance, the Women Veterans Program Manager can help find community-based resources, such as Medicaid, food stamps, cash assistance, and the Children's Health Insurance Program.

Diagnosis

Based on the above analysis, the most troubling finding is that OEF/OIF male veterans with PTSD are 10 times more likely to be under-diagnosed for hypertension. While hypertension is more prevalent among younger males, this is not true for African-Americans. This has important implications for OEF/OIF women veterans because they tend to be non-White non-Hispanics and PTSD is the most common service-related disability. The other concerns are women veterans who may be homeless, homeless with children, living in poverty, and living in polluted neighborhoods. This is especially troubling since only 18% of all veterans living within the Houston region rely on the VHA for their health care needs.

Outcomes Identification

The optimum outcome would be to… [END OF PREVIEW]

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