Evidence Review-Social Determinants of Health for Veterans

Abstract

Background: Veterans Health Administration (VHA) is committed to providing high-quality care and addressing health disparities for vulnerable Veterans. To meet these goals, VA policymakers need guidance on how to address social determinants in operations planning and day-to-day clinical care for Veterans.

Method: MEDLINE (OVID), CINAHL, PsycINFO, and Sociological Abstracts were searched from inception to January 2017. Additional articles were suggested by peer reviewers and/or found through search of work associated with US and VA cohorts. Eligible articles compared Veterans vs non-Veterans, and/or Veterans engaged with those not engaged in VA healthcare. Our evidence maps summarized study characteristics, social determinant(s) addressed, and whether health behaviors, health services utilization, and/or health outcomes were examined. Qualitative syntheses and quality assessment were performed for articles on rurality, trauma exposure, and sexual orientation.

Results: We screened 7242 citations and found 131 eligible articles-99 compared Veterans vs non-Veterans, and 40 included engaged vs non-engaged Veterans. Most articles were cross-sectional and addressed socioeconomic factors (e.g., education and income). Fewer articles addressed rurality (N = 20), trauma exposure (N = 17), or sexual orientation (N = 2); none examined gender identity. We found no differences in rural residence between Veterans and non-Veterans, nor between engaged and non-engaged Veterans (moderate strength evidence). There was insufficient evidence for role of rurality in health behaviors, health services utilization, or health outcomes. Trauma exposures, including from events preceding military service, were more prevalent for Veterans vs non-Veterans and for engaged vs non-engaged Veterans (low-strength evidence); exposures were associated with smoking (low-strength evidence).

Discussion: Little published literature exists on some emerging social determinants. We found no differences in rural residence between our groups of interest, but trauma exposure was higher in Veterans (vs non-Veterans) and engaged (vs non-engaged). We recommend consistent measures for social determinants, clear conceptual frameworks, and analytic strategies that account for the complex relationships between social determinants and health.

Keywords: population health; socioeconomic factors; vulnerable populations.

Figure 1

Citation screening and selection of included articles. Asterisk symbol indicates total articles reviewed includ an additional three articles found through an expedited review of MEDLINE citations (N = 354) identified using the same search terms except limited to trials, one article found through review of publications from the VA Epidemiology Program, and two articles recommended by expert reviewers.

Figure 2

Heatmaps of included articles addressing social determinants and various outcomes for Veterans vs. non-Veterans, and for engaged vs. non-engaged Veterans. Articles may have addressed more than one social determinant, included comparisons of Veterans vs. non-Veterans and/or engaged vs. non-engaged Veterans, and may or may not have examined the role of social determinants in health behaviors, services access, and/or various health outcomes. Of 131 total included articles, 99 compared Veterans with non-Veterans, and 40 articles addressed engaged and non-engaged Veterans. SES, socioeconomic status.