Community Diagnosis: Women Veterans and Hypertension in Houston

Introduction

Ever since the U.S. military transitioned to an all-volunteer force in 1973, the proportion of female veterans has increased significantly (VA, 2011). While women have historically been excluded from serving in combat positions such as the infantry, this policy underwent several revisions in post-9/11 America. Accordingly, the number of female veterans incurring service-related disabilities that qualify them for lifelong medical care through the Veterans Health Administration (VHA) is also increasing. 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 was conducted on women veterans in Houston, Texas.

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.

Target Community Location and Size

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 who 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 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 45–65 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 that experienced rapid growth and industrialization during the latter half of the twentieth century (Williams, 2008). The racial makeup of the Houston metropolitan statistical area — 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 poor reputation (Williams, 2008). Industrialization, in particular the petrochemical industry, has created a number of environmental hazards that pose health risks 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 lower-income 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 report 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 is also 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 (age 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).