The Impact of Demographic Differences on Native Veterans’ Outpatient Service Utilization


“Many Native veterans—including American Indian/Alaska Native (AIAN) and Native Hawaiian/Pacific Islanders (NHPI)—have served in the United States Armed Forces. Most of these veterans are eligible for medical care from the Department of Veterans Affairs (VA), but research examining the determinants of their service use is needed to inform policy and allocate appropriate resources for these unique groups. In a retrospective cohort study, we examined the impact of Native veterans’ personal demographics on their outpatient utilization of VA-based primary care and mental health services. AIAN (n = 37,687) and NHPI (n = 46,582) veterans were compared with a non-Native reference (N = 262,212) using logistic and binomial regression. AIAN and NHPIs were more likely to be female, report military sexual trauma, and utilize the VA for posttraumatic stress disorder, traumatic brain injury, depression, addiction, anxiety, hypertension, and diabetes care. More AIAN and urban NHPI veterans served in Iraq and Afghanistan, and Native women reported more military sexual trauma than their non-Native counterparts. Primary care and mental health services were associated with race, number of diagnoses, and disability ratings. For mental health services, service era, military sexual trauma, and marital status were related to service utilization. Native veterans’ medical need was elevated for primary and mental health care. Rural residence was associated with less mental health use. The findings underscore the need for additional specialized services in rural areas, more targeted outreach to Operation Enduring Freedom/Operation Iraqi Freedom Native veterans, and additional care directed toward Native women’s health care needs.”


For Practice

American Indian and Alaska Native (AIAN) and National Hawaiian/Pacific Islanders (NHPI) veterans should continue utilizing VA primary care and mental health services. Their family members should encourage them to seek relevant services. In particular, veterans who have experienced military sexual trauma should continue reporting their experience and seek necessary mental health services. Military family advocates should consider calling for an increased number of clinics and services in rural areas, as well as cultural competency training for providers working with Native populations. To better serve AIAN/NHPI veterans, clinicians and providers should recognize the importance of understanding and respecting different cultures. Clinicians and providers should attend cultural competency training(s) that specifically address Native American populations, especially Native American veterans and military families. Attending such cultural competency trainings might help clinicians and providers better promote, deliver, and personalize care for these groups.

For Policy

The Department of Veterans Affairs (VA) might increase specialty services and cultural competency trainings for staff and providers who serve populations of color, including AIANs and NHPIs. Given that care can be coordinated across doctors and offices, the VA might consider making cultural competency trainings mandatory for all staff and providers, especially those serving rural areas. To ensure that existing programs are best meeting the needs of AIAN veterans, the VA could re-evaluate its programs to determine areas of improvement and success. After evaluating the programs, the VA might expand its outreach programs, such as the Tribal Veterans Representative Program. To encourage AIAN/NHPI veterans to enroll in and utilize VA programs, the VA might implement new strategies, such as targeted transition programs or resources for AIAN/NPHI service members. Since this study found that AIAN/NHPI veterans are more likely to have served in Iraq or Afghanistan, the VA might continue its efforts to increase accessibility of health services to AIAN/NHPI veterans upon their return. The VA could also increase the number of outpatient clinics in rural areas, including reservations, islands, and other remote areas. Additionally, the VA might consider raising the travel reimbursement rate for these populations and offering alternative health delivery systems (i.e. telehealth). Lastly, the VA might create specialized treatment options for issues related to military sexual trauma (MST) in AIAN/NPHI veterans, especially for female AIAN/NHPI veterans. Specialized treatment options offer to AIAN/NHPI veterans who have experienced MST might include immediate crisis counseling, support groups, and behavioral treatments, such as biofeedback procedures and desensitization techniques.

For Future Research

A limitation of the study is that the data only included veterans who sought care at the VA during 2011. It is not clear how non-AIAN/NHPI and AIAN/NHPI veterans compare in samples of veterans that have not sought or enrolled in VA care. Another limitation of the data used is that provider entries vary and as a result, missing data was common. This study is limited by only considering the utilization of VA services. Since nearly half of AIAN/NHPI veterans solely use the Indian Health Service, future researchers should include utilization of the Indian Health Service. Including the Indian Health Service in future studies might help researchers better understand why 46% of AIAN/NHPI veterans only utilize the Indian Health Service. More research is needed on AIAN and NHPI service members and the high likelihood of experiencing mental health problems and military sexual trauma. AIAN/NHPI veterans also access primary care and mental health services more than non-Native service members. Future studies should investigate additional factors related to AIAN/NHPI veteran outcomes, such as age, preexisting medical and mental health conditions, substance use, or family support and culture. It might be beneficial to evaluate the efficacy of existing programs (i.e. Tribal Veterans Representative Program) to improve and create new programs or services for AIAN/NHPI veterans and military families.

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