Introduction

Women represent a growing proportion of the U.S. military, with about one-sixth of Service Members and one-tenth of Veterans being female [1, 2]. Women in the military are at a significantly higher risk for suicide and are at greater likelihood of using firearms, which are a particularly lethal method of suicide. The suicide rate of female Veterans is nearly twice the suicide rate of non-Veteran females [3], and female Service Members are two to five times more likely than civilian women to take their own lives, a rate which has been increasing at twice the pace of male Service Members [4]. There are several unique considerations for the female military population. Previous research reported that up to 72% of female Veterans experience depression [5], up to 35% experience post-traumatic stress disorder (PTSD) [5], and one in three have experienced military sexual trauma (MST) [6]. Female Veterans may also face barriers in accessing care including wait times (women do not have comprehensive care at all VA hospitals), lack of knowledge about health care services, privacy, and overall quality of VA care [7]. The transition from active duty to civilian life can result in increased interpersonal conflict, behavioral health issues, social isolation, and low unemployment [7].

To better understand female Service Members and Veterans at risk for suicide, this paper investigates the following social determinants of health: disability status, substance use/misuse, social support, homelessness, physical and mental health, barriers to treatment, housing status, food access, and feelings of loneliness and isolation. Research into Veteran suicide has been predominately focused on understanding the experiences of male Veterans or all Veterans. Gaps exist in the literature regarding understanding the contributing factors of female Veteran suicide. This paper will include findings from a large-scale Veterans survey in Arizona to better understand the social determinants of health that are linked with suicidality.

Materials & Methods

Participants

The Arizona Veteran Survey was first conducted statewide in 2017, with a second iteration in 2019. Service Members, Veterans, family members, and community members were invited to take the survey via an online link or a paper-based option, with questions tailored to each group. From August 2019 through March 2020, the 2019 survey received over 1,100 submissions from female Veterans and Service Members (SMV) (n = 1,134). The sample of female SMV respondents was 4.4% American Indian/Alaskan Native, 2.2% Asian, 9.9% Black or African American, 82.7% White or Caucasian, 0.8% Native Hawaiian or Other Pacific Islander, and 13.9% Hispanic or Latino. Additionally, 1.1% of the sample was 18–24 years old, 9.0% was 25–34 years old, 14.6% was 35–44 years old, 21.0% was 45–54 years old, 32.2% was 55–64 years old, and 22.1% was 65 or older. Of the survey respondents, there were 60 female Service Member respondents and 1,074 female Veteran respondents. Table 1 overviews the respondent demographics to key survey questions.

Table 1 Respondent Demographics
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Measures

Table 2 provides the measures used to assess each risk factor, how these responses were coded and categorized, and the source of the measure (when applicable).

Table 2 Measures Used to Assess Common Risk Factors
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Statistical Approach

Data collected from the 2019 Arizona Veteran Survey was organized and cleaned by the biostatistics team at a large research institution. Response data was cross-tabulated and analyzed for statistical significance using a chi-square test with a p-value of p < 0.05. The chi-squared statistic represents the inverse of the right-tailed probability of the chi-squared distribution. Dependent variables were separated into two groups, having symptoms of depression vs. no symptoms of depression. Comparisons of the dependent variables were made to determine if there was a significant association between the independent variable and dependent variable.

Results

Participant Descriptives

A total of 1,134 female Service Members and Veterans completed the survey. Cases were analyzed using listwise deletion. Of the participants that responded to at least one suicidality question (N = 1,114), 191 respondents reported having at least one symptom of suicidality in the past year (17%); including suicidal ideation (15%; n = 168), suicide attempts (2.8%; n = 32), and/or calling a crisis line for help (4.6%; n = 51). Table 3 displays the summary of responses as well as the response rate by question.

Table 3 Summary of Responses
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Chi-Squared Associations between Variables and Suicidality

As can be seen by the chi-squared analysis in Table 4, there is a significant relation between experiencing symptoms of depression in the last two weeks, and suicidality in the last two weeks (1, n = 1,037) = 67.40, p < 0.001. There is also a significant relation between having a medical disability and suicidality in the last two weeks (1, n = 610) = 7.61, p < 0.01. Having any social support was not significantly associated with suicidality in the last two weeks (1, n = 1,114) = 0.04, not significant. Furthermore, having Veteran social support was also not significantly associated with suicidality in the last two weeks (1, n = 1,114) = 0.15, not significant. Experiencing homelessness at any time in one’s life was significantly associated with suicidality in the last two weeks (1, n = 1,011) = 17.24, p < 0.001. There was a significant association between having any barrier to receiving mental health treatment and suicidality in the last two weeks (1, n = 1,114) = 33.92, p < 0.001. Having poor physical health was significantly associated with suicidality in the last two weeks (1, n = 1,047) = 9.15, p < 0.01. Having a current unstable housing situation was significantly associated with reporting experiencing suicidality in the last two weeks (1, n = 1,012) = 37.33, p < 0.001. Financial insecurity (i.e., struggling with paying for basic needs) was also significantly associated with suicidality in the last two weeks (1, n = 1,007) = 41.88, p < 0.001. Moreover, reporting food insecurity over the past twelve months was significantly associated with suicidality in the last two weeks (1, n = 1,007) = 67.40, p < 0.001. We also found a significant relation with experiencing loneliness or isolation and suicidality in the last two weeks (1, n = 992) = 67.40, p < 0.001. Substance use was not associated with suicidality in the last two weeks (1, n = 920) = 0.80, not significant. Finally, poly-substance use was significantly associated with suicidality in the last two weeks (1, n = 929) = 68.76, p < 0.001.

Table 4 Statistical Analysis
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Chi-Squared Tests to Show Associations between Variables and Suicidality

The findings of our study support the broader research literature regarding the challenges faced by military Veteran women. Although consistent with other research findings, several associations were identified and the significance of suicide risk in this sample was notable. Of particular concern, there are a significant number of respondents having thoughts of suicide 33%, (n = 170, N = 523), with 41% (n = 212, N = 523) knowing other Service Members and Veterans who have these same thoughts. Additionally, suicide attempts were reported by 11% (n = 30, N = 264) of respondents and 61% (n = 160, N = 264) of respondents know other military Service Members or Veterans who have attempted suicide. Nearly half of the respondents 43% (n = 397, N = 933) know at least one person who has died by suicide. Skip rates for suicidality questions are included in Table 4.

These results indicate that a substantial proportion of female Service Member and Veteran respondents are at a considerable risk for suicide. Furthermore, multiple social determinants are found to be significantly associated with their suicidality. Chi-squared tests indicate female Service Members and Veterans most likely to report suicidality, are those experiencing disability (p < 0.01), poor physical health (p < 0.01), homelessness (p < 0.001), barriers to mental health treatment (p < 0.001), housing instability (p < 0.001), financial insecurity (p < 0.001), food insecurity (p < 0.001), and feelings of loneliness or isolation (p < 0.001). The following factors were not associated with female Veteran suicidality: social support, substance use, and Veteran social support. This could be related to inclusion and exclusion criteria.

Discussion

Veterans exhibit a significantly higher suicide risk when compared with the U.S. general population [17]. The majority of previous studies have focused on understanding the compounding factors of male Veteran suicide or general Veteran suicide. However, as the number of female military members grows and suicide disparities persist, it is important to identify specific risk factors for female Veteran suicidality. The findings from the Arizona Veteran Survey analyze several social determinants of health and their impact on suicidality for female Veterans and Service Members.

Suicide in the United States is a public health crisis, with Service Members and Veterans experiencing disproportionate rates of suicide. Specifically, female Service Members and Veterans are at an elevated risk for suicide compared to the civilian female population. It is critical to expand the evidence base of the unique risk factors and disparities experienced by female Service Members and Veterans in order to understand how these factors contribute to suicidality. The findings from this survey provide insight into the experiences of the surveyed female Veteran population in Arizona, as well as female Veteran and Service Member suicide in the United States. Suicide is preventable, and efforts to reduce deaths by suicide among female Service Members and Veterans may be strengthened by using tailored approaches that specifically address the needs of this population.

A comprehensive, public health-driven approach to suicide prevention requires addressing a broad spectrum of social determinants of health, including access to care, economic supports, safe environments, and connectedness [18]. Upstream suicide prevention includes providing social services, such as housing, financial aid, or food assistance, to ideally prevent a mental health crisis before it occurs. Military Veterans are at high risk for suicide and therefore it is crucial that this population is proactively engaged and connected to services in a culturally relevant manner. In terms of barriers to care, many Veterans have a negative view of seeking out care. Veterans feel that it is a sign of weakness, not useful, or that care providers do not understand their needs [19, 20].

Limitations

Our analysis has limitations related to distribution and format. The survey relies on self-reporting by respondents. However, the use of self-reporting in survey-based research in the field is both accepted and common [21]. Additionally, this survey was only administered to respondents in Arizona and results may not be generalizable to other populations. The survey was primarily distributed electronically and may not be fully representative of the Arizona female military population. The survey questions did not fully address factors such as military sexual assault, trauma, and other factors that may contribute to suicidality.

Conclusion

These findings may suggest prioritizing integrated programming to offer services and upstream approaches outside of the VA. The Veterans Health Administration has previously identified suicide prevention as a top priority and has subsequently invested significant resources in developing evidence-based programs such as peer supports, gatekeeper training, and Caring Contacts [22,23,24]. The authors of this paper have used survey results to develop upstream approaches to female Veteran suicide prevention in Arizona such as a program that was developed through a statewide collaboration between Veteran serving governmental partners and a non-profit serving Veterans, Service Members, and Family Members in order to prevent suicide among Service Members, Veterans, and their families [25]. At the national level, the President’s Roadmap to Empower Veterans and End a National Tragedy of Suicide (PREVENTS) [26] lays the groundwork for a public health approach to suicide prevention and calls for cross-sector collaboration including federal, state, and local governments, community-based organizations, health care delivery systems, employers, academic institutions, and faith-based communities. Future efforts should continue to expand upon an upstream approach to suicide prevention that seeks to prevent a mental health crisis before it occurs and ultimately prevent additional deaths by suicide.