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Overview of VA research on

Health Equity


Health care is distributed unevenly in the United States and minority populations often receive less care than others, or care of lesser quality.

The majority of Veterans today are predominantly male and white, with the largest cohort having served during the Vietnam War. According to a 2018 report prepared by the National Center for Veterans Analysis and Statistics, minority Veterans made up about 22 percent of the total Veteran population in 2016. The two largest groups in that year were African-Americans (11 percent) and Hispanics (7 percent). Women made up 8.7 percent of the Veteran population in 2017, and 34.4 percent of those women were minorities. The two largest groups were African-Americans (19.5 percent) and Hispanics (8.3 percent).

The report projects that the overall Veteran population will decrease from 18.6 million in 2016 to 12.9 million in 2040. Over this time, however, the percentage of minority Veterans will increase from 23 to 34 percent. 

One implication of this trend and others is that American Veterans are increasingly from populations the federal government considers to be "potentially vulnerable patient populations." Veterans from these groups are at risk of receiving lower-quality medical care or for having worse medical outcomes than patients who are white.

Members of minority communities typically have higher rates of chronic illnesses, such as diabetes and high blood pressure. According to the Centers for Disease Control and Prevention (CDC), 43 percent of adult blacks had high blood pressure during the period 2011–2014, compared with 34.5 percent of whites. CDC also reported in 2017 that 7.4 percent of adult white Americans had diabetes during the period 2013–2015, compared with 12.7 percent of blacks, 12.1 percent of Hispanics, and 8.0 percent of Asian-Americans.

Minorities also have higher rates of many cancers. CDC reports, also in 2017, that among male Americans, black men currently have the highest rates of cancer in 2014, followed by white, Hispanic, American Indian/Alaska Native, and Asian/Pacific Islander men. Among women, white women have the highest rates of cancer, followed by black, Hispanic, Asian/Pacific Islander, and American Indian/Alaska Native women.

There are no simple reasons for these disparities, and no simple solutions. Health care access is important, but it is not the only factor. Income, education, social context and support, life experience, perceived discrimination, and patient-level preferences may also contribute. Provider and health care system factors may also play a role.

As the nation's largest health care system, VA offers a unique opportunity to understand the complex reasons why health care disparities may occur. VA also offers an ideal setting in which to develop and evaluate patient-centered and culturally sensitive approaches to care.

In a 2014 article, three senior VA investigators reviewed the Veteran Health Administration's efforts relating to health equity research. In a section entitled "what we have learned so far," the authors cited three significant contributions VA research has made in this area.

First, providing access to health care doesn't, in itself, guarantee equal health outcomes. Second, the causes of health disparities in VA defy simple explanations, because the "usual suspects" of costs or overt bias are likely less important than other factors, such as gaps in health literacy and health activation; lack of cultural competence or unconscious bias among providers; stigma and other obstacles to accessing care, lack of trust in the health care system; and limited access to the community resources, networks, and social capital that support healthy living and appropriate medical care. And third, general improvement in the quality of care sometimes reduces disparities, but not always.

The authors suggest that partnerships between VA and Veterans can provide essential new insights into ways to eliminate health care disparities and ways to transfer new approaches into treatment settings where they are most needed.


Selected Major Accomplishments

  • 2001: Founded the Center for Health Equity Research and Promotion (CHERP) in Philadelphia and Pittsburgh.
  • 2004: Established the Health Equity and Rural Outreach Innovation Center (HEROIC) in Charleston, South Carolina
  • 2006: VA researchers at CHERP published a conceptual framework to guide future health disparities research
  • 2007: Completed a systematic review of the existing evidence on health care disparities within VA
  • 2011: Published a systematic review of interventions to improve minority health care and racial and ethnic disparities
  • 2013:
    • Established the VHA Office of Health Equity
    • CHERP became a VA Center of Innovation (COIN)
    • HEROIC became a VA Center of Innovation (COIN)
  • 2014: American Journal of Public Health (AJPH) published the VA Health Equity Supplement on health disparities in VA and among Veterans
  • 2015: Published a health disparities evidence brief that evaluatedgaps in morbidity/mortality outcomes for major health conditions
  • 2016:
  • 2017:
    • Found that hemoglobin A1c may not be an accurate measure to identify diabetes in African-Americans with the gene for sickle cell disease
    • Medical Care Supplement on the state of the science and VA Health Equity Research Office of Health Equity-QUERI Partnered Evaluation Initiative funded to examine health conditions, mortality, and healthcare quality in vulnerable population groups in the VA healthcare system.
  • 2018: Evidence review and map identified death rate disparities among racial and ethnic groups within VHA

New, Ongoing, and Published Research

VA researchers improve the lives of Veterans by identifying disparities in health care between populations of Veterans, understanding the factors that may underlie these differences, and developing and testing ways to reduce and eliminate them.

One of the nation's premier research sites for such work is the Center for Health Equity Research and Promotion (CHERP), supported mainly by VA's Health Services Research and Development (HSR&D) service. CHERP has investigators at both the Pittsburgh and Philadelphia VA medical centers.

For more information on health equity, visit our Homelessness, Rural Health, and Women's Health topic pages.


➤ Conceptual framework for disparities research

In 2007, the Evidence-Based Synthesis Program, sponsored by HSR&D, systematically reviewed existing evidence on disparities between different races and ethnicities within VA to determine the clinical areas in which these disparities were present and to describe what was known about their likely causes.

Researchers with the CHERP created a conceptual framework that outlined three phases of health disparities research: detection, understanding, and reduction and elimination.

Detection means acquiring the knowledge that disparities exist, typically discovered through epidemiological studies of large patient populations.

Understanding why disparities exist is complex, and explanations usually include many factors. Some factors can be based on patient beliefs or their biology, or on differences in demographic characteristics. Other factors may be provider-related, such as implicit bias or cultural sensitivity, and communication with different groups of patients. Still other factors can include policies and practices of the medical center or the health care system itself. Finally, a host of social determinants and environmental factors outside of the health care system may come into play.

Once disparities are identified, and researchers have some understanding of what may be driving them, interventions are designed and tested to reduce or eliminate the problem.

2016 State of the Science conference—In 2016, CHERP and VA's Health Equity and Rural Outreach Innovation Center (HEROIC) co-hosted a conference that brought together 100 research investigators and partners to address strategies to improve health equity for minority Veterans; homeless Veterans; and lesbian, gay, bisexual, and transsexual (LGBT) Veterans.

In 2017, the journal Medical Care published a special supplement devoted to research growing out of that conference. The supplement included a systematic review of interventions to reduce disparities in at-risk Veteran populations and a discussion of the role implementation science can play in advancing health equity research.

Evidence-based literature review—In a study published in 2018, whose methodology was described in detail in a 2017 article, VA Evidence-based Synthesis Program (ESP) researchers reviewed 361 previous studies to identify knowledge gaps on health disparities within VA. Of the 351 studies included in the review, more than half focused on health care disparities based on race or ethnicity. The second and third most common topics were disparities related to sex and mental health condition. Very few studies focused on sexual or gender identity or homelessness.

Understanding where data is lacking, according to the research team, can help VA further address health care disparities. The 2018 study focused on mortality, and identified disparities that have persisted for African-American Veterans in the areas of stage 4 chronic kidney disease, colon cancer, diabetes, HIV, rectal cancer, and stroke; for American Indian and Alaska Native Veterans undergoing noncardiac major surgery; and for Hispanic Veterans with HIV or traumatic brain injury. The authors concluded, however, that VA's equal access health care system has reduced many racial and ethnic mortality disparities present in the private sector.


➤ Office of Health Equity

In 2011, the Veterans Health Administration (VHA) chartered a health care equality workgroup. The purpose of the workgroup was to determine how VA could achieve a more equitable health care delivery system.

The workgroup's recommendations supported a dedicated national-level office to champion equitable health care for all Veterans. As a result, the Office of Health Equity (OHE) was established in 2012 to support VHA's vision to provide appropriate individualized health care to every Veteran in a way that eliminates disparate health outcomes and assures health equity.

In October 2016, OHE released the first-ever National Veterans Health Equity report, which details patterns and provides comparative rates of health conditions for Veterans by race and ethnicity, gender, age, geography, and mental health status during fiscal year 2013. Among the report's findings were that all racial and ethnic minority groups had greater use of mental health/substance use disorder services compared with white Veteran patients.

Another finding was that despite their younger average age, female Veterans have higher or similar rates of most diagnosed conditions than male Veterans. Mental health and substance use disorder conditions are far more common in women than in men (46 percent vs. 23 percent.)

Overall, the report found that the distribution of diagnosed conditions between rural and urban Veterans are largely similar, with rural Veterans having higher diagnosed rates of conditions including diabetes and chronic obstructive pulmonary disease (COPD), while urban Veterans have higher diagnosed rates of conditions including HIV and hepatitis C.

The Office of Health Equity is conducting a partnered evaluation initiative that will use a population health approach to examine the distribution of diagnosed health conditions, mortality, and health care quality across the entire VA health care system, as defined by Veterans' membership, or non-membership, in vulnerable population groups. The initiative's investigators will also evaluate whether characteristics of the health care delivery settings, such as geography, and the types of care Veterans use, such as telehealth, influence the quality of care Veterans receive.


➤ Identifying and understanding disparities in patient experiences

Despite efforts to address the problem of racial and ethnic health disparities in the United States, experts acknowledge significant barriers to good health still exist, according to a 2012 report by the Institute of Medicine. For example, as a group, African-Americans typically have worse health outcomes than whites. There are many factors contributing to poorer outcomes—among them are socioeconomic disadvantage, residential segregation, and reduced access to health care. VA investigators have been instrumental in helping to identify the complex reasons for health disparities among Veterans.

Patient centered medical home and disparities—VA's Patient Centered Medical Home (PCMH) model of care is a patient-driven, team-based approach that aims to deliver efficient, comprehensive, and continuous care through active communication and the coordination of health care services. The model is widely promoted as a way to achieve better patient outcomes. A study published in 2017, led by researchers at VA's Greater Los Angeles Health Care System, attempted to determine whether the benefits of the PCMH model extend equally to all races and ethnic groups.

From 2010 through 2014, the research team found that greater medical home implementation at local VA facilities was associated with better control of high blood pressure and diabetes for white patients. However, they noted that there were significant disparities in control for racial and ethnic groups such as African-American and Hispanic Veterans. They also found that Veterans residing in economically challenged areas and those under age 65 experienced worse outcomes.

To promote health equity, the team suggested that more research needs to be done to identify the underlying reasons for poor control of high blood pressure and diabetes in different ethnic groups. They also suggested monitoring health outcomes by race and ethnicity. To combat poor outcomes, the researchers recommended the use of tailored strategies to target health disparities that exist within discrete ethnic groups.

One example of a targeted ethnic-group intervention is the use of peer-to-peer "storytelling" in a group of African-American Veterans who had poorly controlled hypertension.

African-Americans not using CPAP therapy to full advantage—VA researchers at the Jesse Brown VA Medical Center in Chicago have begun a study to determine the link between the use of continuous positive airway pressure (CPAP) therapy and blood pressure levels in African-American Veterans. CPAP machines help Veterans with sleep apnea breathe better when they sleep.

Previous studies have found that African-American patients do not use CPAP therapy to full advantage compared to other races. Other surveys have found that when CPAP adherence was comparable between blacks and whites, African-Americans' blood pressure actually responded better. The team hopes that the study will help lay a foundation for more targeted treatment of sleep apnea in this high-risk population.

Sickle cell trait may confound blood sugar readings among African-Americans—Hemoglobin A1c (HbA1c) is a common biomarker used to measure blood sugar levels over time. A 2017 study by researchers from the Providence VA Medical Center and Brown University found that HbA1c may not be an accurate measure of blood sugar in African-Americans who carry the gene for sickle cell trait. Researchers say using HbA1c could lead to an underestimation of blood sugar control among that population.

Sickle cell trait is a genetic variant of hemoglobin, a protein in blood cells, which is found in 8 to 10 percent of African-Americans. It occurs in people with only one copy of the gene—those with two copies are considered to have sickle cell disease, a group of related blood disorders. Using standard clinical cutoffs for HbA1c would have resulted in identifying 40 percent fewer potential cases of prediabetes and 48 percent fewer potential cases of diabetes in people with sickle cell trait—giving patients and their clinicians a false sense of security.

Equal access to care—A 2015 study of VA care led by investigators from the Memphis VA Medical Center suggested that when patients have equal access to care, not only do health differences disappear, but blacks fare better than whites in several important health outcomes. Researchers view VA's equal-access health system as an ideal setting in which to study such issues, since it eliminates or minimizes many of the barriers to care commonly faced by minorities in the private sector.

The team looked at the mortality rates of more than 2.5 million white Veterans and more than 547,000 black Veterans through VA's electronic health record system. They found that the annual mortality of white men was about 32 per 1,000, versus about 23 per 1,000 for black men. Most of the patients were men with an average age of 60 years.

Blacks in the study were 38 percent less likely than whites to develop heart disease, the leading cause of death in the U.S. The authors suggest that blacks may have certain genetic characteristics that actually make them healthier than whites in some ways.

No racial disparities in VA kidney transplant evaluations—In contrast to what has been found in some private sector studies, VA patients who need a kidney transplant are unlikely to face racial disparities in the evaluation process, according to a 2016 study by researchers based at VA and university sites in Pittsburgh; Nashville, Tennessee; Portland, Oregon; and Iowa City, Iowa.

The study included 602 patients who were evaluated for a transplant at one of four VA transplant centers. Candidates for transplant must go through a lengthy process to evaluate their overall health and likelihood of becoming a successful transplant recipient. The researchers found that race did not have an effect on the time Veterans spent being evaluated for a transplant—from their initial appointment at a transplant center to being accepted and placed on a waitlist. The median "time to acceptance" was 133 days for African-Americans, 116 days for whites, and 99 days for other minorities. The differences were not considered statistically significant.

These results suggest that specific characteristics of the VA health care system or its patient population may help reduce disparities in transplantation. The work has influenced a project funded by the National Institutes of Health to test VA's centralized approach to kidney transplant evaluation in a non-VA setting.

Perceived barriers to kidney transplantation in African-Americans—Researchers from the Ralph H. Johnson VA Medical Center in Charleston, South Carolina, and the Medical University of South Carolina asked 27 African-American kidney recipients about their perspectives on the challenges, barriers, and educational needs related to kidney transplants from living donors.

According to the study, published in 2015, the reasons African-Americans seek and receive fewer live-donor kidney transplants include concerns for the donor, a general lack of knowledge about the process— including risks, costs, and the impact on future health—and the difficulty of approaching potential donors.

Participants thought that an educational program led by an African-American peer who had received a kidney from a living donor would increase the number of transplant-eligible patients who asked friends and family if they would donate a kidney. They also said teaching potential recipients how to ask others if they might be willing to donate kidneys to them would be helpful.

Differing perceptions of care among Veterans with mental health disorders—In a large study of Veterans with mental health and substance abuse disorders, a team of CHERP investigators found racial and ethnic differences in the way Veterans gained access to health care, their communication with providers, the courtesy they received, and the comprehensiveness of the care they received.

The study of nearly 66,000 Veterans who were part of a patient-centered medical home found that racial and ethnic minorities reported less overall satisfaction with their health care.

African-American and Hispanic Veterans said they had more negative experiences in obtaining access to health care than whites. However, black Veterans reported fewer communication problems than white Veterans. Hispanic Veterans said they had fewer positive experiences with office staff helpfulness and courtesy than white Veterans. Hispanic Veterans also reported less comprehensiveness of care—being asked about mental health concerns—than whites, while black Veterans reported more positive experiences in this area.

Disparities in health care trust and satisfaction—A 2015 study, conducted by CHERP researchers, tried to gain insight into why a recent VA hospital report card revealed lower levels of satisfaction with health care for blacks compared to whites.

The team conducted telephone interviews with 30 black and 31 white Veterans who had recently visited one of three VA medical centers. They found that blacks reported less trust and confidence in their VA providers and the VA health care system and were less satisfied with their communication with their VA health care providers.

Blacks also reported less satisfaction with their outpatient care, but not with their inpatient care. The researchers conducted a larger national study involving 25 VA sites with 750 black, Hispanic, and white Veterans to gain further insight into the issue and to guide new interventions to reduce this disparity.

In 2018, the first results of this study were reported. Interviews with 1,222 Veterans found that patient satisfaction with VA health care was comparable to or better than satisfaction within other health care systems, and that there were no clear patterns of differences in satisfaction by race, ethnicity, or gender, although some differences were noted. The survey interviews were conducted from June 2013 through January 2015.

Prostate cancer—Several VA research teams have recently looked at issues related to black Veterans and prostate cancer. A number of research studies have determined that blacks are at higher risk for prostate cancer than whites. They tend to be about three years younger, on average, when they are diagnosed, their tumors appear to be faster growing, and they are up to three times as likely to die from the cancer.

A 2015 study by researchers with VA and the University of California, Los Angeles, looked at more than 1,200 California Veterans with prostate cancer. The team found no significant difference in tumor burden or the amount of cancer tissue present, treatment choice, or survival outcomes between whites and blacks who were cared for by VA.

Another 2015 study, conducted by researchers with VA's New York Harbor Healthcare System and the State University of New York Downstate Medical Center, looked at data on nearly 1,800 men. They found there was little difference in the aggressiveness of prostate tumor growth in black men and white men, and little to suggest that prostate cancer takes a more aggressive course in black men.

A 2016 study by a research team from the Michael E. DeBakey VA Medical Center in Houston, Baylor College of Medicine, and research organizations in China and India identified a gene that can cause more active prostate cancer in African-American men than in European-American men. The finding suggests that genetic factors can contribute, at least in part, to the higher incidence of prostate cancer among African-American men compared with men of other ethnic groups.

Internet access disparities—Telehealth interventions over the internet have been shown to be effective at helping Veterans quit smoking. But racial and sociodemographic disparities may limit the ability of some groups to take advantage of these treatments. A 2016 study found that Veterans who were black, older, less educated, had longer travel times to the nearest VA facility, or had increased nicotine dependence were less likely to access the internet on a daily basis. These results highlight the importance of improving accessibility to eHealth interventions for low-income, minority, and socially disadvantaged Veteran populations.


➤ Interventions to reduce disparities

Personal stories engage, but do not affect overall results, for high blood pressure management interventions—African-American Veterans felt more engaged when viewing interventions about high blood pressure management that included personal stories from other Veterans, compared with information-only interventions. The study, published in 2016, included 618 African-American Veterans with uncontrolled hypertension from three VA medical centers.

One group was shown a DVD of information about high blood pressure, while another was shown a DVD featuring other African-American Veterans telling stories about successfully managing their high blood pressure. The Veterans who watched real patients tell their stories were more emotionally engaged and reported intentions to change their behavior than the other group, showing that personal stories may be an effective tool to teach patients how to manage their condition.

In 2017, however, a follow-up to the study was published. It found that when researchers followed the Veterans in both groups for six months, no statistically significant change in blood pressure was found between the two groups. Therefore, the researchers concluded, there was no significant overall storytelling intervention effect.

Arthritis pain study—Arthritis is a painful, disabling condition that disproportionately affects African-Americans. Existing arthritis treatments yield only small to moderate improvements in pain and are not effective at reducing racial disparity in arthritis pain.

A VA study led by researchers at the Corporal Michael J. Crescenz VA Medical Center in Philadelphia and the VA Pittsburgh Healthcare System is testing a patient-centered non-invasive psychological intervention to improve pain outcomes and reduce disparities in African-American and white Veterans with knee arthritis. The intervention is designed to help Veterans develop a positive mindset, the health benefits of which are well documented.

Gout—Researchers at the Birmingham VA Medical Center in Alabama are currently conducting a clinical trial of a new intervention related to gout management for African-American Veterans. Gout is more common in African-Americans than whites, and African-Americans are more likely to have worse outcomes and take their medications less regularly. The team will test compliance with medication regimens following an intervention consisting of video recordings, or "storytelling," of patients with gout explaining their illness and the use of urate-lowering medications. The study is expected to be completed in 2020.

Cultural competence training—VA uses cultural competence techniques (the ability to understand a patient's diverse values, beliefs, and behaviors and customize treatment to meet the patient's social, cultural, and linguistic needs) to reduce disparities in care delivery among different populations.

A study now underway led by researchers at the VA Portland Health Care System is looking at the differences in patient communications between health care providers well-trained in cultural competence techniques and those poorly trained, as well as patients' perceptions of providers who are both well and poorly trained. The study will also attempt to understand the contribution cultural competence makes in the quality and equity of diabetes care at the four VA medical centers that will be studied.

The study is expected to be completed in 2020.


➤ Other vulnerable populations

Majority of lesbian, gay, and transgender Veterans satisfied with VA care—There are an estimated 700,000 people in the United States who identify as transgender (people who express a gender identity that differs from their identified sex at birth).

Researchers at the VA Puget Sound Health Care System conducted an online survey of 298 transgender Veterans living in the United States. In that study, published in 2017, they found that 56 percent of the study participants had used VA medical care since their discharge from the military. This rate is similar to VA health care usage by all Veterans.

Of those transgender Veterans who used VA for health care, 79 percent were satisfied with the care they received, including 69 percent of those who used VA mental health care. The results also showed that transgender men were more likely to be dissatisfied with mental health care than transgender women (people who identify as women, but were assigned a male gender at birth). Eighty-five percent of the study participants were transgender women.

A 2018 study, led by researchers at the Michael E. DeBakey VA Medical Center in Houston, of 218 lesbian, gay, and transgender Veterans, including 151 users of VA health care, found that most of those who used VA for care were older and more ethnically diverse, had less income, and were less open about their sexual or gender identity than nonusers. Most Veterans felt welcome at their facility and were comfortable about disclosing their sexual orientation and gender identity with their VA provider, although these levels were lower among transgender patients.

The two groups did not differ in their levels of depression, anxiety, alcohol use, or tobacco use, although VA users had more physical limitations and chronic medical conditions, in addition to lower health literacy, than nonusers.

Differences between rural and urban transgender Veterans—A study by VA researchers nationwide, completed in 2017, looked at health differences between transgender Veterans living in urban areas and those living in rural areas. The investigators explored the relationship between urban or rural status and lifetime diagnoses of mood disorder, alcohol dependence disorder, illicit substance use disorder, tobacco use, posttraumatic stress disorder (PTSD), HIV, and suicide ideation or attempts for transgender Veterans who used VA health care.

They found that transgender Veterans living in rural towns had increased odds of tobacco use disorder and PTSD compared with their urban transgender peers, however, the place where they lived was not significantly associated with other medical conditions.

An earlier 2017 study at several VA medical centers found that there were few health differences between LGBT Veterans who lived in rural or small towns and urban and suburban Veterans in a sample of 252 LGBT Veterans. The only difference the team found was that rural and small town gay male Veterans evidenced more depression and less community identity than their suburban and urban counterparts.

Eating, drinking behaviors differ by sexual orientation—Evidence suggests that gay men have higher rates of disordered eating than heterosexual men. A 2016 study conducted by the VA Boston Healthcare System looked at 642 male Veterans and found that the 24 gay and bisexual men in the study had significantly greater eating disorder symptoms and food addiction compared with heterosexual men, highlighting the importance of prevention, assessment, and treatment efforts targeted to this population.

In addition, another 2016 study led by researchers at the VA Puget Sound Health Care System in Seattle found, in an online questionnaire, that younger lesbian and bisexual women were more likely to screen positive for alcohol misuse and had more severe alcohol misuse than their heterosexual counterparts. They suggest that prevention and treatment efforts focused specifically on sexual minority women Veterans may be needed.

Social, racial, and mental health disparities in transgender Veterans—In 2014, two VA researchers from the James H. Quillen VA Medical Center in Mountain Home, Tennessee, and VA's Office of Health Equity identified 5,135 transgender Veterans receiving care from VHA. Of that number, 387 were black. They reviewed their health care records and found that black transgender Veterans were generally more socially disadvantaged than white transgender Veterans, and that several mental health conditions and physical illnesses occurred more frequently in blacks, including alcohol misuse, congestive heart failure, and HIV/AIDS.

A further study of the same cohort found that medical and mental health disparities exist in VA for clinically diagnosed transgender Veterans, compared with a matched group of Veterans without that diagnosis.

The researchers found that transgender Veterans were significantly more likely to suffer from all 10 of the mental health conditions the study examined, including depression, suicidal thoughts or intentions, serious mental illness, and PTSD. They also had a much higher prevalence of 16 of 17 medical diagnoses studied, with HIV infection accounting for the largest disparity.

According to the investigators, these findings will have significant implications for policy, health care screening, and service delivery in VA, and possibly for other health care systems as well.

Home-based primary care improves access to long-term care for American Indian Veterans—Home based primary care (HBPC) is a model of non-institutional long-term care used by VA to provide ongoing care to homebound persons. The program allows individual VA medical centers to tailor their model to fit the population and region.

For rural American Indian Veterans, HBPC is a way to receive long-term care once clinic-based care is no longer realistic.

In 2015, a team led by researchers from the VA Greater Los Angeles Healthcare System interviewed VA leaders and staff from 14 VA medical centers on their HBPC programs for American Indians.

They found that 12 had programs specifically aimed at American Indians in reservation communities, and they observed six different successful models of home-based care, all of which were driven by patient-centered care that allowed Veterans to determine their provider of choice based on convenience, cost, and availability of service. They also found "a real learning curve" for facilities to learn to work with tribal governments, and that trust was the key to establishing working relationships and creating successful HBPC programs.


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Selected Scientific Articles by Our Researchers

Mortality disparities in racial/ethnic minority groups in the Veterans Health Administration: an evidence review and map. Peterson K, Anderson J, Boundy E, Ferguson L, McCleery E, Waldtrip K. The review identified mortality disparities that have persisted mainly for black Veterans in several clinical areas. However, because most mortality disparities were supported by single studies with imprecise findings, strong conclusions about this evidence could not be drawn. Am J Public Health. 2018 Mar;108(3):e1-e11.

Lesbian, gay, and transgender Veterans' experiences in the Veterans Health Administration: positive signs and room for improvement. Kauth MR, Barrera TL, Latini DM. Positive experiences of lesbian, gay, and transgender VHA users in the study provide supportive evidence that VHA staff training efforts to raise awareness and competency have been successful. Psychol Serv. 2018 Jan 25. (Epub ahead of print.)

Hormone therapy, gender affirmation surgery, and their association with recent suicidal ideation and depression symptoms in transgender Veterans. Tucker RP, Testa RJ, Simpson TL, Shipherd JC, Blosnich JR, Lehavot K. Transition-related medical interventions can have a protective effect on symptoms of depression and suicidal ideation in transgender Veterans. Psychol Med. 2018 Jan 14;1-8.

Current and military-specific gender minority stress factors and their relationship with suicide ideation in transgender Veterans. Tucker RP, Testa RJ, Reger MA, Simpson TL, Shipherd JC, Lehavot K. Attempts to reduce both the experience and impact of stressors related to gender identity during and after military service may be an important avenue for suicide prevention. Suicide Life Threat Behav. 2018 Jan 12. (Epub ahead of print.)

Racial, ethnic, and gender equity in Veteran satisfaction with health care in the Veterans Affairs Health Care System. Zickmund SL, Burkitt KH, Gao S, Stone RA, Jones AL, Hausmann LRM, Switzer GE, Borrero S, Rodriguez KL, Fine MJ. Multisite interviews of a diverse sample of Veterans at primarily minority-serving sites showed generally high levels of health care satisfaction, with few qualitative differences by race, ethnicity, or gender. J Gen Intern Med. 2018 Jan 8. (Epub ahead of print).

Rationale and design of the Staying Positive with Arthritis (SPA) Study: a randomized controlled trial testing the impact of a positive psychology intervention on racial disparities in pain. Hausmann LRM, Ibrahim SA, Kwoh CK, Youk A, Obrosky DS, Weiner DK, Vina E, Gallagher RM, Mauro GT, Parks A. Description of a randomized controlled trial in which 180 African-American and 180 white primary care patients with chronic pain from knee osteoarthritis will be randomized to a six-week program of either positive skill-building activities or neutral control activities. Contemp Clin Trials. 2018 Jan;64:243-53.

Will Veterans answer sexual orientation and gender identity questions? Ruben MA, Blosnich JR, Dichter ME, Luscri, L, Shipherd, JC. Veterans are just as likely as non-Veterans to complete sexual orientation and gender identity items in survey research. Med Care. 2017 Sep;55 Suppl 9 Suppl 2:S85-S89.

Creating a toolkit to reduce disparities in patient engagement. Keddem S, Agha AZ, Long JA, Werner RM, Shea JA. Information on a toolkit consisting of patient engagement practices and resources. Med Care. 2017 Sep;55 Suppl 9 Suppl 2:S59-S69.

African-American Veterans storytelling: a multisite randomized trial to improve hypertension. Houston TK, Fix GM, Shimada SL, Long JA, Gordon HS, Pope C, Volkman J, Allison JJ, DeLaughter K, Orner M, Bokhour BG. At three VA facilities, African-American Veterans with uncontrolled hypertension received either a storytelling DVD or an instructional DVD. There was no significant overall difference between the two groups. Med Care. 2017 Sep;55 Suppl 9 Suppl 2:S50-S58.

Transgender Veterans' satisfaction with care and unmet health needs. Lehavot K, Katon JG, Simpson TL, Shipherd JC. Although the majority of transgender Veterans are satisfied with VA health care, certain subgroups are less likely to be satisfied with care. Med Care. 2017 Sep;55 Suppl 9 Suppl 2:S90-S96.

Exploring rural disparities in medical diagnoses among Veterans with transgender-related diagnoses utilizing Veterans Health Administration care. Bukowski A, Blosnich J, Shipherd JC, Kauth MR, Brown GR, Gordon AJ. Veterans with transgender-related diagnoses residing in small or isolated rural towns had increased odds of tobacco use disorder and PTSD compared with their urban transgender peers. Med Care. 2017 Sep;55 Suppl 9 Suppl 2:S97-S103.

Health disparities in Veterans: a map of the evidence. Kondo K, Low A, Everson T, Gordon CD, Veazie S, Lozier CC, Freeman M, Motu'apaka M, Mendelson A, Friesen M, Paynter R, Friesen C, Anderson J, Boundy E, Saha S, Quinones A, Kansagara D. Evidence maps provide a "lay of the land" and identify important gaps in knowledge about health disparities experienced by different Veterans populations. Med Care. 2017 Sep;55 Suppl 9 Suppl 2:S9-S15.

Barriers and facilitators to implementation of VA home-based primary care on American Indian reservations: a qualitative multi-case study. Kramer BJ, Cote SD, Lee DI, Creekmur B, Saliba D. Implementation of VA's home-based primary care program was facilitated by key individuals who were able to build trust in faith in VA health care among American Indian communities. Implement Sci. 2017 Sep 2;12(1):109.

New evidence reflecting VA's commitment to achieve health and health care equity for all Veterans. Ibrahim SA, Egede LE, Fine MJ. The VA health care system is committed to providing equitable health care to optimize the health of the growing population of potentially vulnerable Veterans it serves. Med Care. 2017 Sep;55 Suppl 9 Suppl 2:S1-S3.

Has the Department of Veterans Affairs found a way to avoid racial disparities in the evaluation process for kidney transportation? Freeman MA, Pleis JR, Bornemann KR, Crosswell E, Dew MA, Chang CH, Switzer GE, Langone A, Mittal-Henkle A, Saha S, Ramkumar M, Adams Flohr J, Thomas CP, Myaskovsky L. The VA National Transplant System did not exhibit the racial disparities in evaluation for kidney transplants as have been found in non-VA transplant centers. Transplantation. 2017 Jun;101(6)1191-1199.

Racial and ethnic disparities persist at Veterans Health Administration patient-centered medical homes. Washington DL, Steers WN, Huynh AK, Frayne SM, Uchendu US, Riopelle D, Yano EM, Saechao FS, Hoggatt KJ. Health care innovations such as patient-centered medical homes should incorporate tailored strategies that account for determinants of racial or ethnic variations. Health Aff (Millwood). 2017 Jun 1:36(6):1086-1094.

Health differences among Lesbian, Gay, and Transgender Veterans by rural/small town and suburban/urban setting. Kauth MR, Barrera TL, Denton FN, Latini DM. Suburban/urban and rural/small town lesbian, gay, and transgender Veterans evidenced few health differences. LGBT Health. 2017 Jun;4(3):194-201.

Association of sickle cell trait with hemoglobin A1c in African-Americans. Lacy ME, Wellenius GA, Sumner AE, Correa A, Camethon MR, Liem RI, Wilson JG, Sacks DB, Jacobs DR Jr, Carson AP, Luo X, Gjelsvik A, Reiner AP, Naik RP, Liu S, Musani SK, Eaton CB, Wu WC. Hb1Ac may systematically underestimate past glycemia in black patients with sickle cell trait and may require further evaluation. JAMA, 2017 Feb 7;317(5)507-515.

Advancing LGBT healthcare policies and clinical care within a large academic healthcare system: a case study. A look at the steps the VA Boston Healthcare System took to increase cultural competency in dealing with LGBT Veterans at the organizational, structural, and clinical level. J Homosex. 2017;64(10):1411-1431.

Mental health of transgender Veterans of the Iraq and Afghanistan conflicts who experienced military sexual trauma. Lindsay JA, Keo-Meier C, Hudson S, Walder A, Martin LA, Kauth MR. Transgender Veterans who had experienced military sexual trauma had higher rates of PTSD, depression, bipolar disorder, and personality disorder. J Trauma Stress. 2016 Dec;29(6):563-567.

MNX1 is oncogenically upregulated in African-American prostate cancer. Zhang L, Wang J, Wang Y, Zhang Y, Castro P, Shao L, Sreekumar A, Putluri N, Guha N, Deepak S, Padmanaban A, Creighton CJ, Ittmann M. MNX1 is a novel targetable oncogene increased in AA prostate cancer that is associated with aggressive disease. Cancer Res. 2016 Nov 1; 76(21):6290-6298.

Examining weight and eating behavior by sexual orientation in a sample of male veterans. Bankoff SM, Richards LK, Bartlett B, Wolf EJ, Mitchell KS. Sexual minority male Veterans may be more likely to experience eating disorder and food addiction symptoms compared to heterosexual male Veterans. Compr Psychiatry, 2016 Jul:68:134-9.

Mental health and medical health disparities in 5135 transgender Veterans receiving healthcare in the Veterans Health Administration. Brown GR, Jones KT. Transgender Veterans were found to have global disparities in psychiatric and medical diagnoses compared to matched non-transgender Veterans. LGBT Health, 2016 Apr;3(2):122-31.

Association of alcohol misuse with sexual identity and sexual behavior in women Veterans. Lehavot K, Williams EC, Millard SP, Bradley KA, Simpson TL. Younger sexual minority women were more likely to screen positive for alcohol misuse and had more severe alcohol misuse than their heterosexual counterparts. Subst Use Misuse. 2016 Jan 28;51(2):216-29.

Health equity research in the Veterans Health Administration: we've come far but aren't there yet. Atkins D, Kilbourne A, Lipson L. Working with Veterans, VA can continue to provide essential new insights into how to eliminate health care disparities and how to transfer new approaches into treatment settings where they are needed most. Am J Public Health. 2014 September:104(Suppl 4): S525-S526.


Health Equity Fact Sheet

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VA and other U.S. Government Online Resources

Office of Health Equity, U.S. Department of Veterans Affairs

Center for Minority Veterans, U.S. Department of Veterans Affairs

Center for Women Veterans, U.S. Department of Veterans Affairs

Center for Disease Prevention and Health Interventions for Diverse Populations, U.S. Department of Veterans Affairs

VA Center Working to Improve Health EquityVAntage Point blog, U.S. Department of Veterans Affairs

Health Equity, Centers for Disease Control and Prevention

Office of Minority Health , U.S. Department of Health and Human Services

Health Disparities, Health Services Research Information Center, U.S. National Library of Medicine, National Institutes of Health


Health Disparities, National Library of Medicine, MedlinePlus

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