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On the Front Lines of Women’s Health

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“We now have an evidence base that practitioners can use to transform care for women veterans, and the VA is adopting our research at an unprecedented clip.”
— Dr. Elizabeth Yano

WHEN ELIZABETH (BECKY) YANO, MSPH ’87, PhD ’96, BEGAN HER TRAINING in epidemiology, biostatistics and health policy, the idea that she might use her Fielding School education to spearhead a transformation in how the nation’s largest integrated health system provides care for its female patients was the furthest thing from her mind.

To better meet the needs of its women veterans, the VA has moved toward gender-sensitive clinic environments and has trained approximately 5,000 primary care physicians to specialize in women’s health.

But after Yano arrived at the VA Greater Los Angeles Healthcare System (VAGLAHS) in 1989 for what was intended to be a short stint — to help evaluate the VA’s first primary care demonstration project — she discovered that the Veterans Health Administration, which serves more than 9 million veterans through care provided at more than 1,200 facilities across the country, was an institution with a great interest in using research to implement policy changes. “Once I saw the kind of impact I could have, I never left,” Yano says.

For much of the last two decades, Yano, an adjunct professor in FSPH’s Department of Health Policy and Management, has led a research enterprise that has sought to identify and address gaps in knowledge about women veterans’ health and health care needs in ways that improve the quality of care they receive, as well as their satisfaction with the patient experience in the VA system.

When Yano got started, women represented barely more than 2 percent of the VA user population and their health needs were vastly understudied, she says. But the population of women veterans has grown rapidly: Today women account for nearly 10 percent of the total veteran population, and represent approximately 20 percent of new recruits. For the VA, this has added to the urgency of meeting gender-specific care needs, many of which have been elucidated by the work Yano has led.

Unique health concerns for women veterans include high overall rates of military sexual trauma, Yano notes — both in-service sexual assaults and sexual harassment. “This is a predictor of post-traumatic stress disorder, anxiety, depression and unemployment, and is one of the reasons women veterans have greater mental health burdens than male veterans,” Yano says. Women veterans experience elevated levels of chronic pain, in part as a result of a history of ill-fitting equipment designed for larger men, she adds. With women increasingly entering the VA system at childbearing age, there is a growing demand for reproductive health services. The historic predominance of men in the VA system has also limited the exposure of VA doctors to female patients. In response, the VA has provided clinical retraining to approximately 5,000 primary care physicians so that they can specialize in women’s health.

Yano has helped to address these and other needs of women veterans since as early as 2001, when she secured funding from the Department of Veterans Affairs’ Office of the Under Secretary for Health to pursue the first national survey of how women’s health services were organized at the VA. Three years later she was asked to lead the effort to develop a national VA women’s health research agenda.

“They wanted me to convene a group and come back with something in a couple of weeks,” Yano recalls. “I said this needs to be driven not by what 10 of us personally think is important, but by the epidemiology. So I put together an action plan and asked for funding to analyze the big data and conduct a systematic review of what was already known, as well as to learn what researchers’ needs were so that we could design an agenda to fit those needs. To my surprise, they said yes.” The resulting agenda included ambitious recommendations for building a research infrastructure for women’s health. Once again, Yano was asked to write a proposal for what was needed; she did, and was again granted approval to move forward.
 
Not long ago, women represented barely more than 2 percent of the VAuser population. today, approximately 20 percent of new recruits are women.
Today, in addition to her role at VAGLAHS as director of the Center for the Study of Healthcare Innovation, Implementation and Policy, which develops and tests innovative models aiming to improve VA care, Yano is director of the national VA’s Women’s Health Research Network (WHRN), which she co-founded in 2010 to promote studies focusing on the needs of women veterans. The WHRN includes the Women’s Health Research Consortium, consisting of more than 300 clinicians and investigators who receive education and training, technical support in research methods, mentorship, and dissemination support; and a Women’s Health Practice-Based Research Network, which provides an infrastructure for multisite studies and interventions. Yano also directs the national Women Veterans Healthcare CREATE Initiative, a $5 million program using research to accelerate implementation of comprehensive care for women veterans in VA settings. She has led or co-led more than a dozen national VA organizational survey studies, has provided a number of federal briefings, and has authored or co-authored 90 articles on women veterans research, many with mentees who are now VA investigators themselves. Among her many honors, Yano is a recipient of the VA Under Secretary for Health Award for Outstanding Achievement in Health Services Research and the FSPH Lifetime Achievement Alumni Hall of Fame Award. “The VA system was set up to address the needs of male veterans, but women now represent 15 percent of the active duty in the U.S. military and are in increasingly dangerous occupations,” says Shurhonda Love, assistant legislative director for Disabled American Veterans, which honored Yano this year with a Special Recognition Award for her work on behalf of the nation’s women veterans. “When you consider that women represent a younger cohort, we have many women veterans who will be getting care in the VA for a long period of time, and it’s extremely important to understand their gender-specific needs. Dr. Yano’s research is providing evidence on the issues women veterans have faced for many years, which helps us to advocate more effectively. Her leadership and dedication to her work have made a huge difference for women veterans now, and for those who will serve down the road.” 

The Women’s Health Practice-Based Research Network, which involved four sites when it was funded in 2010, has grown to 60 sites across the country with plans to expand even further over the next two years. Yano explains that in addition to increasing the participation of women veterans in multisite studies and quality improvement projects, this infrastructure has been integral to the VA’s ability to test and implement evidence-based quality improvement (EBQI) initiatives, which expedite the incorporation of scientific findings into clinical settings through partnerships involving researchers and clinic administrators and staff.

This rapid adoption of findings is illustrated by the CREATE-funded research to tailor the VA’s patient-centered medical home model — in which patients work in partnership with members of a health care team, each of whom has a defined role, to ensure coordinated, patient-centered care — in ways that promote gender-sensitive care for women veterans. “Before we even finished the trial, the approach we were testing was adopted for use with the VA’s lowest-performing facilities, and we’re now evaluating how well improving and tailoring care to women veterans works in twice the number of VA facilities as we did for the previous trial,” Yano says. 

Among the co-investigators on the original study is Dr. Emmeline Chuang, assistant professor in FSPH’s Department of Health Policy and Management. Chuang interviewed providers and staff who see women veterans across eight regions of the U.S. to learn more about their work experience and how that influenced the delivery of care. “Part of what’s exciting about this intervention is that it focuses on building local capacity,” Chuang says. “The idea is to empower providers and staff to pilot-test and refine changes designed to improve performance so that they can sustain these ongoing quality improvement efforts after the intervention ends.”

In addition to teaching in FSPH’s Executive Masters of Public Health program offered by the Department of Health Policy and Management, Yano has been invited by Chuang to deliver guest lectures to her students on topics that include implementation science and organizational research. Yano also serves on the dissertation committees of several Fielding School PhD candidates. Among them is Julian Brunner, who, while completing his FSPH dissertation on the use of electronic health records in primary care settings, has been working on Yano’s VA team, publishing several peer-reviewed articles on topics related to health care for women veterans. “Traditionally as a researcher you publish papers and hope to capture the attention of people who make decisions,” Brunner says. “What draws me to the work we’re doing at the VA is that the research is designed with input from the policymakers, guaranteeing that it will be relevant and have real-world impact.”

The Women’s Health Research Network headed by Yano remains as robust as ever, with 15 career development awardees around the country and another 15 young investigators soon to be awarded or readying their applications, allowing Yano to continue thinking in ambitious terms about an overarching research agenda for women veterans at the VA. High on her priority list is the ongoing effort to use the evidence-based quality improvement approach to spread promising practices across the more than 1,200 sites where the VA provides care. “We need to ensure that every woman veteran is treated with the same dignity by providers who are proficient and prepared to deliver comprehensive services,” she says. “Within that context, we need to work on improving trauma-sensitive environments and trauma-sensitive care delivery. There are still providers who see a woman veteran and assume she is the spouse of a male veteran. There are still those who see a woman who is missing a leg and can’t believe that it was from combat. The VA has done a lot of work to bring people along, but we have a lot more work to do.” 

Thanks to the foundation laid by Yano and her colleagues, the VA is well positioned to continue moving forward. Yano notes that the volume of research and published papers on the health and health care of military women and women veterans has grown exponentially since the 2004 VA women’s health research agenda recommendations were made. “We now have an evidence base that practitioners can use to transform care for women veterans,” Yano says, “and the VA is adopting our research at an unprecedented clip.”