Reviewer ’s report  
 
Title:  Experiences with VHA Care: A Qualitative Study of U.S. Women Veterans with Self -
Reported Trauma Histories  
 
Version: 0 Date: 22 Dec 2016 
 
Reviewer:  Suzannah  Creech  
 
Reviewer’s report:  
 
Thank you for the opportunity to review this manuscript. The authors are to be commended for 
this important work and for their rigorous use of qualitative methods in the study design. The 
manuscript is well -written, but still there are opportuniti es to strengthen its impact. Most of these 
opportunities are related to how the study is presented, the time frame in which it occurred, and 
the need for increased specificity on what these data can speak to - given the very specific 
sample and time at whi ch interviews occurred.  
 
 
Introduction  
 
1. Overall, the introduction is very well -written. I really like the way the second paragraph 
frames the problem to be researched. However, that section is broad, so it is important that the 
final paragraph is clear  that this study examines just one subsection of the women veteran 
population that may not have benefited from recent quality improvement.  
 
2. Can the authors provide more up to date numbers on the percent of women Veteran users 
at VHA? Believe it is slig htly higher now - the unique veteran users report from 2014 indicated 
"Female Veterans made up 8.5% of all users in 2014." If the growth rate continued - numbers for 
2016 may actually be close to 10% now.  
 
3. Might the second and the last sentence of the first paragraph be saying the same thing? 
Perhaps the flow would be better if these were consolidated?  
 
4. Third para - I think there is opportunity to strengthen the first sentence. Women veterans 
with sexual trauma and PTSD are not just of interest, but may be one group with substantial 
unmet needs. Without a stronger first sentence the 2nd paragraph may sugg est that study is about 
something else.  
 
5. I am not sure that this is the first qualitative study of gender specific experiences 
receiving VHA healthcare. I guess I am thinking of the Washington, 2007 focus group study. 
Though perhaps it wasn't as specif ic as the current study.  
 
 
Methods  
1. I had no concerns about the qualitative methods employed. These are all quite appropriate 
and represent a rigorous approach to qualitative data analysis.  
 
2. Given that the sample has such specific inclusion criteria - I wonder if some components 
of the introduction might benefit from increased specificity. The intro foreshadows a somewhat 
broader population of women veterans, but the women included had to have applied for service 
connection in the 90's in addition to other very specific criteria. Certainly it is likely that there 
were no OEF/OIF women in the sample?  
 
3. Since the interviews took place in 2011 -2012, but the VHA mandate discussed in the 
intro happened in 2010 - I wonder if these data reflect a time peri od where some but not all 
change had occurred.  However, I am concerned that since so much time has passed the 
interviews don't reflect the current state of VHA care for women. Since change in VA is slow, 
presumably a great deal has occurred in the 5 years  since the interviews occurred? I think it may 
be important that the introduction reflects that this is a snapshot in time as processes were 
changing and the mandate was still being implemented (unless I am misunderstanding and the 
components of the mandat e were implemented immediately on a national scale - though this 
would still be to varying degrees of success). Therefore, these findings may not speak to the state 
of care after full implementation of the mandate. Some of this occurs as the paper goes on but I 
think including further detail on this in the intro will pull everything together.  
 
4. One idea that could help is to include greater detail on some of the interview questions - 
for example, if women were asked to speak not about care in past 10 year s but care in the past 
year… etc.  
 
 
Results:  
 
5. Can the authors please add descriptors to the quotes (i.e. , 50 year old Gulf War I veteran) 
so we have a better sense of who is saying what and so we can be assured there is adequate 
breadth represented. (T hat the same participant isn't quoted each time).  
 
6. I believe it is important that some changes are made to how the study is presented (place 
in time and population) as the first theme described must be understood within the broader 
context and the time at which the interviews occurred. That is within the theme "Many Current 
VHA Service Fall Short" - this was true in 2011 -2012 (hence the need for the mandate) but can 
we conclude it is true now?  
 
7. At the bottom of page 8 the authors begin to speak of quo tes related to vet centers. Most 
readers will not know how Vet Centers differ so I believe this needs further explanation. I think 
it is important that this section is framed more carefully because it occurs in a larger section on 
VHA mental health and I d on't know how much Vet Centers were required to change in the 
context of the 2010 mandate. In addition, with a population that was primarily Vietnam era, 
peacetime, or Gulf War I, I was surprised that enough women in the sample spoke about Vet 
Centers.  
 
Discussion:  
 
1. Continuing earlier comments on the time at which the study was conducted relative to 
VA quality improvement efforts - I think the Oishi finding from 2007 may be out of place in this 
context since that was 4 years prior to the mandate  
 
2. Page 13, first para, it may be important to say more about what chronic PTSD is.  
 
3. Second para, first sentence - I may have missed this but I didn't see anything in the results 
referring specifically to lack of trust in providers. It was more that they d idn't feel comfortable 
with male providers right?  
 
4. Page 15, last para, first sentence - this sentence may be a little too broad for the sample in 
the study - and also since these were emergent themes, I am not sure it is accurate to describe this 
as in in-depth accounting for first person experiences.  
 
 
Conclusions  
 
1. Some of my comments on the intro may be relevant here. Adding increased explanation 
of the time frame of the study will strengthen the overall manuscript and allow the reader to 
better un derstand how and whether these data can reflect on the state of care in 2016 -2017.  
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
Yes 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
Yes 
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
No 
 
Are you able to assess any statistics in the manuscript or would you recommend an 
additional statistical review?  
If an additional statistical review is recommended, please specify what aspects require further 
assessment in your comments to the editors.  
 
I am able to assess the statistics  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Acceptable  
 
Declaration of competing interests  
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