oversight

Gender Issues: Medical Support for Female Soldiers Deployed to Bosnia

Published by the Government Accountability Office on 1999-03-10.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

                  United States General Accounting Office

GAO               Report to the Ranking Minority Member,
                  Subcommittee on Readiness and
                  Management Support, Committee on
                  Armed Services, U.S. Senate

March 1999
                  GENDER ISSUES

                  Medical Support for
                  Female Soldiers
                  Deployed to Bosnia




GAO/NSIAD-99-58
             United States
GAO          General Accounting Office
             Washington, D.C. 20548                                                                                   Leter




             National Security and
             International Affairs Division                                                                           Leter




             B-281815

             March 10, 1999

             The Honorable Charles S. Robb
             Ranking Minority Member
             Subcommittee on Readiness
              and Management Support
             Committee on Armed Services
             United States Senate

             Dear Senator Robb:

             At your request, we are reviewing various issues pertaining to the
             treatment of men and women in the armed services. This report addresses
             your question concerning whether adequate medical services were
             available to servicemembers deployed to the field. In this report, we have
             focused on female-specific medical services and health-related issues for
             Army personnel serving in the ongoing U.S. peace operation in Bosnia.
             Specifically, we (1) determined the availability of data collected on female
             soldiers’ health care needs in Bosnia and (2) obtained the views of health
             care officials and female soldiers on female-specific medical services and
             health-related issues in Bosnia.



Background   U.S. military forces initially deployed to Bosnia in December 1995 as part of
             a multinational effort to monitor and enforce implementation of the Dayton
             Agreement peace accords.1 Most of the deployed soldiers live and work in
             base camps in the vicinity of Tuzla. Each camp has a small medical clinic,
             usually staffed by at least one doctor and other medical personnel, that
             provides health care services to the camp population. In addition, an Army
             hospital has been established at one of the base camps to provide a higher
             level of health care.2 The hospital is better equipped than the clinics and
             has a relatively large medical staff. Soldiers who cannot be treated in the
             theater of operations are evacuated to a military hospital in Germany.

             The size of the U.S. force in Bosnia and the proportion of female soldiers
             there have fluctuated over time as units and individuals rotate. As of


             1Theagreement provided the structure and mandates for an international operation intended to
             promote an enduring peace in Bosnia and stability in the region.

             2
              At the time of our review, the hospital was located in a site known as Blue Factory at Guardian Base.
             In October 1998, Guardian Base was closed and the hospital was moved to another base.




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                   October 1998, 6,871 U.S. soldiers were serving in Bosnia, with female
                   soldiers numbering 960 (14 percent). Another 1,318 soldiers, including
                   476 female soldiers (36 percent), were deployed to Croatia and Hungary to
                   support the Bosnia operation.

                   We obtained information on women’s views primarily through a
                   questionnaire of 234 female soldiers who had recently served in Bosnia.3
                   We included a wide variety of women in our review. The women were
                   assigned to eight different units and represented three pay grade groups
                   (E-1s to E-4s, E-5s to E-9s, and officers); they had been deployed for
                   varying lengths of time (almost all had served sometime in 1998); and they
                   had served in 12 different base camps. To supplement the survey results
                   and obtain a more complete picture of female-specific health issues in
                   Bosnia, we conducted group interviews with 80 women who participated in
                   our survey. Because our survey participants were not randomly selected,
                   the survey results cannot be projected to a larger population.



Results in Brief   Outpatient health care data is collected from medical treatment facilities in
                   Bosnia, but this data has limited value for assessing the health care needs
                   of deployed female soldiers. First, data collected on non-female-specific
                   health problems is not broken out by gender. Second, while data on
                   gynecological visits is collected, this data does not show the specific
                   reasons for each visit. Consequently, the types and extent of women’s
                   health care needs, including female-specific needs, cannot be quantified.
                   Collecting this data would enable the Army to study the everyday aspects
                   of the gynecological health of military women, especially in field
                   conditions, and to identify and correct any shortfalls in medical services
                   provided to deployed women.

                   Health care officials, including primary care providers who staffed the base
                   camp clinics and the hospital, told us that the Army’s health service support
                   system in Bosnia was capable of meeting the female-specific health care
                   needs of women. For example, they said very few women had been
                   evacuated to the military hospital in Germany for female-specific health
                   problems. About two-thirds of the women we surveyed who reported


                   3
                    A small number of these female soldiers had served in a base camp across the border in Croatia. Army
                   officials said the soldiers at this base camp supported the U.S. operation in Bosnia, served under similar
                   deployment conditions, and were provided medical care through the same health service support sys-
                   tem.




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                        having gynecological problems said all or most or their female-specific
                        health care needs were met while in Bosnia, while the other one-third said
                        only a few or none of their female-specific health care needs were met.
                        Female soldiers expressed some concerns about the Army’s medical
                        services and other health-related issues in Bosnia. A frequent complaint
                        was the lack of information on these subjects provided to women before
                        they deployed. Women said they would have benefited from more
                        information on how to prepare for an impending deployment, for example,
                        information on the availability of female-specific medications and supplies,
                        on the health care system that would serve them during the deployment,
                        and on best practices for staying healthy. Women also expressed concerns
                        about the quality of medical support provided to them and about the
                        privacy and confidentiality of care at the clinics, which were described as
                        very small and lacking interior walls and doors to shield individuals being
                        examined.



Collected Outpatient    The great majority of health problems—including female-specific health
                        problems—are resolved on an outpatient basis and do not require
Data Has Limitations    hospitalization. In Bosnia, information on soldiers’ outpatient visits is
for Assessing Women’s   gathered through a data collection system that countries participating in
                        the peace operation have adopted. Medical treatment facilities report
Health Care Needs       weekly on their number and types of new outpatient visits. Health officials
                        use the collected data to monitor trends in the incidence of disease and
                        non-battle-related injury.

                        The data collection system was not designed to capture the gender of
                        soldiers making outpatient visits. Thus, for non-female-specific categories
                        of disease and injury, the data does not show how many men and women
                        made outpatient visits. In the absence of gender-specific data, the total
                        number of outpatient visits by women, the relative number of visits made
                        by men and women, and the proportion of gynecological visits to women’s
                        overall visits cannot be determined. Studies from prior deployments
                        showed that female-specific health care needs accounted for a minimum of
                        14 percent and a maximum of 26 percent of women’s health care needs.
                        (See app. II for discussion of this research.)

                        Gynecological problems are reported as one category of outpatient visits.
                        In 1997, according to an analysis conducted by Army health officials,
                        1.9 percent of the 38,786 reported outpatient visits by soldiers deployed to
                        Bosnia were for gynecological problems—equating to approximately
                        740 gynecological visits during the year, or a weekly average of 14. The



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                          data collected on gynecological outpatient visits, however, does not
                          indicate the specific reasons for each visit. For example, the data does not
                          indicate how many visits were for health services such as obtaining birth
                          control refill prescriptions or for specific medical problems such as pelvic
                          pain or menstrual difficulties.



Health Care Officials     Army officials have characterized the U.S. operation in Bosnia as “one of
                          the healthiest deployments in recent history,” with low rates of disease and
Said Female Soldiers      non-battle-related injury. A 1998 Army health assessment attributed these
Received Satisfactory     low rates partly to an emphasis on preventative medicine and the
                          deployment of a healthy, fit force.4 Health officials we interviewed,
Level of Care in Bosnia   including 14 doctors and 9 physician assistants who had served in Bosnia
                          as primary care medical providers, agreed with this overall assessment. In
                          addition, on the basis of their personal experience, these officials did not
                          perceive an unusually high incidence of female-specific health problems.
                          At camps where combat units were primarily assigned, few women were
                          present and medical providers saw very small numbers of female-specific
                          health problems.5

                          According to health care officials, the combined capabilities of the base
                          camp clinics and the in-theater Army hospital provided a satisfactory level
                          of care to female soldiers. Almost all women who sought care for female-
                          specific problems were treated either at the clinics or the hospital, and very
                          few had to be evacuated to Germany. The former commander of the Army
                          hospital in Bosnia said only one such evacuation had been necessary
                          during her recent 6-month deployment. This case involved a woman who
                          needed a follow-up diagnostic procedure for an abnormal Pap smear. The
                          equipment for this procedure was not available at the Army’s hospital in
                          Bosnia. Other health care officials recalled similarly small numbers of
                          evacuations for female-specific problems. 6 Data provided by one Army


                          4
                           Other positive factors, according to the assessment, were (1) a relatively friendly host nation populace,
                          (2) mild environmental conditions, (3) limited opportunity for transmission of food-related pathogens,
                          (4) almost exclusive use of bottled water for drinking, and (5) limits on motor vehicle use and alcohol
                          consumption.

                          5Fewfemale soldiers were assigned to these camps because women are barred from holding ground
                          combat positions.

                          6
                           Not included in these anecdotes were women who were evacuated because they tested positive for
                          pregnancy. Such evacuations, unless they involved an abnormal pregnancy, were accomplished
                          through administrative channels rather than through the medical system.




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unit shows that of the 229 female soldiers it sent to Bosnia during a
10-month time span, only 4 (1.7 percent) were evacuated for a female-
specific health problem and all 4 returned to duty in Bosnia.

Medical providers who staffed the base camp clinics said their mission was
to stabilize and evacuate soldiers with acute conditions and treat minor
health problems. With respect to female-specific conditions, the providers
said they could treat relatively simple problems such as yeast infections
and urinary tract infections. They could also test for pregnancy and
dispense birth control. The clinics, however, were not equipped to
diagnose and treat all female-specific conditions. For instance, providers
said they did not have microscopes or a laboratory. However, they
generally believed that the equipment they had at the clinics was
appropriate for the level of care they provided. They also said they could
obtain needed supplies, including medicine.

Medical providers at the base camp clinics described varying approaches
for treating female-specific problems. Some providers said they had tried
to treat certain conditions before deciding to send women to the Army’s in-
theater hospital for laboratory tests. Other providers said they had referred
women to the hospital if laboratory tests were needed. Some providers
said they had performed pelvic exams at the clinics; others said they had
not (either because of the lack of privacy or laboratory support). Providers
said it was easy to refer a soldier to the Army’s in-theater hospital if
necessary.

Soldiers referred to the hospital for nonurgent health care problems were
typically placed on a convoy leaving the base camp.7 The soldiers would
arrive at the hospital, receive treatment, and then return to their base camp
by convoy later that day. Although a gynecologist was not on the hospital
staff, a physician certified in family medicine was available to treat female-
specific health problems. For problems requiring pelvic exams, the
hospital had a private room with a door. It also had a laboratory and
ultrasound equipment (which is used to diagnose a wide variety of pelvic
problems). The hospital also performed Pap smears.




7
    Emergency cases could be evacuated by ground ambulance or helicopter.




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Women Expressed             Our survey of female soldiers indicated that gynecological problems were
                            common for this group of women. Of the 234 women taking our survey,
Some Concerns About         121 (52 percent) reported they had at least one such problem while
Female-Specific             deployed,8 though many of these women had not sought medical care for
                            their problems. Of the 121 women reporting that they had gynecological
Medical Services and        problems, almost two-thirds said all or most of their female-specific health
Other Health-Related        care needs had been met in Bosnia, and one-third said only a few or none of
Issues                      their needs had been met. In our survey and group interviews, several
                            common themes emerged as concerns women had about female-specific
                            medical services and other health-related issues related to deployment in
                            Bosnia. Particular concerns were expressed about predeployment
                            information provided to women on female health and hygiene, the quality
                            of medical support provided for women, and the privacy and
                            confidentiality of care at the base camp clinics. In is unclear to what extent
                            some of the concerns were unique to female-specific health care or were
                            symptomatic of the medical care overall in Bosnia. (See app. I for more
                            detailed information on the views expressed to us by these women.)


Predeployment Information   Women in our group interviews emphasized the lack of unit predeployment
on Female Health and        training on female health and hygiene more than any other issue. They told
                            us they would have benefited from having been better informed about how
Hygiene
                            to prepare for an impending deployment. Some emphasized the need to
                            prepare younger female soldiers with no previous deployment experience.
                            About one-fourth of our survey respondents reported that their unit had
                            been their primary source of information on female-specific health care
                            and hygiene practices in the field. In contrast, about half said they either
                            had not received this type of information prior to deployment or had
                            obtained it through informal conversation with their peers. One unit we
                            visited had deployed more than 200 women, but unit medical officials said
                            information on female-specific health care and hygiene was not part of
                            soldier readiness preparations.

                            Participants in our group interviews suggested that women with previous
                            deployment experience and medical credentials conduct unit
                            predeployment briefings. Some suggested topics for these briefings were
                            (1) birth control and sexually transmitted diseases; (2) female hygiene in

                            8
                             Not all 234 women taking our survey responded to our questions about whether they experienced
                            gynecological problems while in Bosnia. The proportion of respondents who reported experiencing
                            these problems was higher than 52 percent. (See app. I for further discussion of these survey results.)




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                             field settings, including advice about avoiding urinary tract infections and
                             yeast infections; (3) female-specific health care services available in-
                             theater and ways to obtain these services; (4) guidance on packing
                             sufficient supplies of medications and feminine hygiene products; and
                             (5) tips for staying healthy.

                             Strategies for preparing female soldiers for deployment also are suggested
                             in an Army handbook developed for military leaders. While the handbook
                             states that responsibility for personal readiness ultimately falls on the
                             soldiers themselves, it suggests that units coordinate a training session for
                             female soldiers with a community health nurse or a representative of the
                             local hospital’s department of obstetrics and gynecology. According to the
                             handbook, these health officials can teach women how to prepare
                             themselves for the field and how to maintain their health during
                             deployment.


Quality of Medical Support   The types of gynecological problems women reported experiencing were
                             common problems, such as pelvic cramping or pain and menstrual
                             difficulties. Those who had sought care for gynecological problems
                             typically went to the medical treatment facility serving their base camp.
                             Although some women had positive experiences when seeking care there,
                             others expressed various concerns about the medical support. For
                             instance, about half of the survey respondents who had sought
                             gynecological care while in Bosnia were only mildly confident or not
                             confident at all in the medical provider’s abilities.

                             Women cited various reasons for not seeking care for gynecological
                             problems. The most common reason was that the women had not
                             considered the problems severe or important enough to warrant medical
                             care. Others cited a lack of confidence in the medical providers. When we
                             explored this lack of confidence issue during group interviews, some
                             participants said the medical providers at their base camp did not appear to
                             be well-qualified to provide female-specific care and did not take their
                             health concerns seriously. One woman, for instance, said her company
                             commander had to intervene with the medical provider at the clinic to
                             secure a referral to the Army hospital. Some women noted on their surveys
                             that they would prefer to see a gynecologist for their female-specific
                             problems but that a gynecologist was not available.

                             The Army has recently taken some steps aimed at evaluating and improving
                             medical support for deployed women. In 1997, a team was chartered to



                             Page 7                                           GAO/NSIAD-99-58 Gender Issues
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                              identify the quantity and quality of well women’s services available to
                              active duty women in garrison, prior to deployment, and during
                              deployment. The team is to recommend standards of care necessary to
                              ensure medical readiness for deployment. The results of that effort were
                              undergoing review within the Army. Additionally, the Army has designed a
                              new medical equipment set for providing primary care to female soldiers.
                              The set, to be provided to deployable medical companies, includes the
                              capability of providing gynecological exams and related laboratory tests
                              and provides common medications such as birth control pills and
                              antibiotics. The set is to be tested in 1999 and fielded in 2000.


Privacy and Confidentiality   In the view of many women we interviewed, the small base camp clinics
                              did not offer sufficient privacy to soldiers being examined. Women also
                              had concerns that their medical problems would not be kept confidential
                              by staff at the clinics. Our survey showed that one-fourth of respondents
                              who had sought care were moderately dissatisfied or very dissatisfied with
                              the level of privacy afforded them while receiving care; almost one-third of
                              respondents who had sought care were moderately uncomfortable or very
                              uncomfortable talking with the medical provider about private matters.
                              During the group interviews, some women told us they had been concerned
                              that if they sought care at the clinic, word of their visit would leak out and
                              spread around camp.


Other Health-Related Issues   Some aspects of the deployment received favorable comment regarding
                              their contribution to personal health and hygiene. For example, all but one
                              of the survey respondents reported that a shower or clean water for
                              bathing had been available daily. In addition, more than half of the
                              respondents cited military stores located at the base camps as their
                              primary source of feminine hygiene products.

                              However, one-fifth of the respondents reported that they had problems
                              obtaining adequate supplies of feminine hygiene products at some time
                              during their deployment. Several respondents, in their write-in comments
                              to the survey, criticized the limited selection of feminine hygiene products
                              at the base camp stores. One wrote, “There was a lack of feminine hygiene
                              products. They always ran out. They had no variety.” Another wrote,
                              “Many times a form of feminine hygiene product was available, but it was
                              . . . most often a generic brand unfamiliar to the soldier.”




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                 More than half of the survey respondents reported that there were times
                 during the deployment when they had encountered obstacles to urinating.
                 Of the women encountering obstacles, about 20 percent said this problem
                 had occurred on a daily basis. The most frequently cited cause was
                 extended travel time on convoys. When leaving their base camp,
                 U.S. soldiers in Bosnia are required to travel by convoy to enhance force
                 protection. During our group interviews, women said these convoys could
                 last several hours without a stop to urinate. In a write-in comment to the
                 survey, one soldier stated, “The drive from Taszar [Hungary] to Bosnia was
                 12 hours without urinating and very painful.” Real or perceived obstacles
                 to urinating can become a medical problem for women if they decrease
                 their fluid intake and dehydrate themselves.

                 Overall, more than four-fifths of our survey respondents said they had
                 access to their preferred method of birth control during the deployment.
                 However, a number of women taking birth control pills were concerned
                 about the limited selection available for refill prescriptions at the base
                 camp clinics and were troubled because they had to change to another
                 brand. One woman, for instance, said she had to change prescriptions
                 three times while in Bosnia. Another said she had switched prescriptions
                 while deployed, then switched back when she returned home. Birth
                 control pills, in addition to preventing pregnancy, may be used to regulate a
                 woman's menstrual cycle.



Conclusions      The biggest concern raised by many women we interviewed was the lack of
                 predeployment information provided to deploying women on female health
                 and hygiene. Our survey data indicates that about half the respondents
                 either had not received this type of information prior to deploying to
                 Bosnia or had obtained it on their own through informal conversations with
                 their peers. Female soldiers told us it would have been helpful to receive a
                 briefing on these issues before they deployed. Some women were
                 particularly concerned that younger soldiers with no deployment
                 experience did not receive the information they needed from their unit.



Recommendation   We recommend that the Secretary of the Army take steps to improve the
                 preparation of female soldiers for deployment by requiring units to provide
                 information on female-specific health care and hygiene. Included should
                 be information on the health services available to them once deployed.




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Agency Comments   In written comments on a draft of this report, the Department of Defense
                  agreed with our findings and recommendation. The Department stated that
                  adequate preparation of all servicemembers for deployment is a critical
                  element in successfully completing the assigned mission. It further noted
                  that our recommendation to improve preparation of female soldiers for
                  deployment will be adopted. Specifically, the Department said military
                  units will provide information to their female members on female-specific
                  field health care and hygiene issues as well as information on scope and
                  access to deployed health services as part of routine deployment
                  preparations. The Department’s comments are reprinted in their entirety in
                  appendix IV.


                  Our scope and methodology are discussed in appendix III.

                  We are sending copies of this report to interested congressional
                  committees, the Secretaries of Defense and the Army, and the Director of
                  the Office of Management and Budget. We will make copies available to
                  other parties on request.

                  If you or your staff have questions concerning this report, please call me at
                  (202) 512-5140. The major contributors to this report are listed in
                  appendix V.

                  Sincerely yours,




                  Mark E. Gebicke
                  Director, Military Operations
                   and Capabilities Issues




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Page 11    GAO/NSIAD-99-58 Gender Issues
Contents



Letter                                                                                            1


Appendix I                                                                                       14
Views of Female
Soldiers Deployed to
Bosnia

Appendix II                                                                                      26
Prior Research on
Health Care Needs of
Deployed Women

Appendix III                                                                                     31
Scope and
Methodology

Appendix IV                                                                                      34
Comments From the
Department of Defense

Appendix V                                                                                       35
Major Contributors to
This Report

Figures                 Figure I.1: In the 3 months prior to deployment, what was your primary
                          source of information on female-specific health care and hygiene
                          practices in field conditions?                                       15
                        Figure I.2: Which topics on female-specific health and hygiene were
                          addressed in the information you received prior to deployment?       16
                        Figure I.3: Which of the following gynecological problems did you
                          experience while deployed to Bosnia?                                 18




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Contents




Figure I.4: To what extent did the health services in Bosnia meet your
  overall female-specific health care needs?                              19
Figure I.5: What were the reasons you did not seek care for
  gynecological problems?                                                 21
Figure I.6: While you were deployed to Bosnia, what was your
  primary source of feminine hygiene products?                            23
Figure I.7: What caused you to postpone urinating or prevented
  you from urinating?                                                     24




Page 13                                         GAO/NSIAD-99-58 Gender Issues
Appendix I

Views of Female Soldiers Deployed to Bosnia                                                                                          AppeIx
                                                                                                                                          ndi




                        This appendix discusses women’s views of female-specific medical services
                        and other health-related issues in Bosnia. We obtained information on
                        women’s views primarily through a questionnaire of 234 female soldiers
                        who had recently served in Bosnia.1 The number of respondents to each
                        question varied because (1) some survey respondents were told to skip
                        certain questions based on their answers to other questions and (2) some
                        participants chose not to answer certain questions. The women were
                        assigned to eight different units and represented three pay grade groups
                        (E-1s to E-4s, E-5s to E-9s, and officers); they had been deployed for
                        varying lengths of time (almost all had served sometime in 1998); and they
                        had served in 12 different base camps. To supplement the survey results
                        and obtain a more complete picture of female-specific health issues related
                        to deployment in Bosnia, we conducted group interviews with 80 women
                        who participated in our survey. Because our survey participants were not
                        randomly selected, the survey results cannot be projected to a larger
                        population.

                        During our review, women expressed some concerns about female-specific
                        medical services and other health-related issues. Particular concerns were
                        expressed about predeployment information on female health and hygiene,
                        the quality of medical support provided for women, and the privacy and
                        confidentiality of care at the base camps. In addition, women expressed
                        concerns about feminine hygiene supplies, obstacles to urinating, and the
                        unavailability of birth control pill prescriptions.



Predeployment           More than three-fourths of the survey respondents felt they were either
                        very prepared (43 percent) or moderately prepared (35 percent) for the
Information on Female   Bosnia deployment with respect to female-specific health care and hygiene.
Health and Hygiene      Other women said they were only mildly prepared (15 percent) or not
                        prepared at all (7 percent). Nevertheless, many women expressed
                        concerns about their units’ efforts to prepare female soldiers for this aspect
                        of deployment

                        In our survey, we asked women to review the preparations they made prior
                        to deploying to Bosnia and to recall their primary source of information on


                        1
                         A small number of these female soldiers had served in a base camp across the border in Croatia. Army
                        officials said the soldiers at this base camp supported the U.S. operation in Bosnia, served under similar
                        deployment conditions, and were provided medical care through the same health service support
                        system.




                        Page 14                                                            GAO/NSIAD-99-58 Gender Issues
Appendix I
Views of Female Soldiers Deployed to Bosnia




female-specific health care and hygiene practices in field conditions. While
61 (27 percent) women said they had received this information primarily
through unit training or information sessions,2 115 (51 percent) said they
either had not received this type of information from any source prior to
deployment or had obtained information through informal conversations
with peers (see fig. I.1).



Figure I.1: In the 3 months prior to deployment, what was your primary source of
information on female-specific health care and hygiene practices in field conditions?




Note: This question was asked to all survey participants and was answered by 226 respondents.
Source: Our analysis of survey responses.


The 61 women who said they had received information from their units
prior to deployment indicated that the most common topics covered were
sexually transmitted diseases, guidance on packing feminine hygiene
supplies and medications, and birth control. Fewer women said their units



2
 Three of these 61 respondents marked more than one answer to this question, indicating that they had
important sources of information other than unit training or information sessions.




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Appendix I
Views of Female Soldiers Deployed to Bosnia




had provided information on preventing urinary tract infections and vaginal
infections (see fig I.2).



Figure I.2: Which topics on female-specific health and hygiene were addressed in
the information you received prior to deployment?




Note: This figure shows responses from the 61 women in our survey who reported that their units had
been their primary source of predeployment information on female health and hygiene.
Source: Our analysis of survey responses.


We also asked all survey participants about any female-specific medical
conditions that were not resolved prior to deployment. A small group of
women—25 (11 percent) respondents—reported they had an unresolved
female-specific medical problem. Of these 25 women, 11 said the problem
concerned an abnormal Pap smear. We do not know what the other
unresolved problems were.



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                  Appendix I
                  Views of Female Soldiers Deployed to Bosnia




Medical Support   We asked all survey participants what types of female-specific health
                  problems they had experienced while deployed to Bosnia and whether they
                  had sought medical care for these problems. We listed seven possible
                  gynecological problems and asked the women to indicate, for each,
                  whether they (1) did not have the problem, (2) had the problem but did not
                  seek care, or (3) had the problem and sought care.3 The most commonly
                  experienced problems were pelvic cramping or pain and menstrual
                  difficulties (see fig. I.3).




                  3
                   Respondents were also asked if they experienced other gynecological problems that were not among
                  the seven listed.




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Appendix I
Views of Female Soldiers Deployed to Bosnia




Figure I.3: Which of the following gynecological problems did you experience while
deployed to Bosnia?




Note: The items in this question were asked to all survey participants and were answered by 211 to
217 respondents.
Source: Our analysis of survey responses.


In a subsequent question about what they did to correct such problems, 95
(44 percent) respondents said they had none of the problems, 71
(33 percent) had one or more problems but had not sought care, and 49
(23 percent) had sought care for at least one of these problems.4 Thus,
more than half of the respondents—120 (56 percent) of 215 women—

4
 Another 14 women indicated in the previous question that they had sought care for one of the specific
gynecological problems listed but were not consistent in their answers to this question.




Page 18                                                          GAO/NSIAD-99-58 Gender Issues
Appendix I
Views of Female Soldiers Deployed to Bosnia




reported that they had experienced a gynecological problem in Bosnia.5
For women who said they had at least one gynecological problem, almost
two-thirds said that all or most of their female-specific health care needs
had been met in Bosnia, and one-third said only a few or none of their
needs had been met (see fig. I.4).



Figure I.4: To what extent did the health services in Bosnia meet your overall female-
specific health care needs?




Note: This question was answered by 121 survey respondents who reported experiencing a
gynecological problem while in Bosnia.
Source: Our analysis of survey responses.


Of the approximately 60 women who said they had sought care for at least
one gynecological problem,6 more than 80 percent went to the medical
treatment facility serving their base camp. We asked the women who had
sought care to rate five aspects of that care: (1) confidence in the medical


5One  respondent indicated in the previous question that she had experienced a gynecological problem,
but in this question she did not report having a problem. When this respondent is added, a total of 121
women reported experiencing gynecological problems.
6
 These survey respondents included the 49 women who said they sought care for at least one
gynecological problem while in Bosnia as well as 14 other women who indicated in the previous
question that they sought care for one of the specific problems listed. Between 55 and 57 of these
women answered each of our survey questions concerning the medical care they received.




Page 19                                                          GAO/NSIAD-99-58 Gender Issues
Appendix I
Views of Female Soldiers Deployed to Bosnia




provider, (2) appropriateness of the gynecological services received,
(3) timeliness of care, (4) comfort level talking about private matters, and
(5) satisfaction with privacy while receiving care. The last two aspects—
comfort level talking about private matters and satisfaction with privacy—
are discussed in the next section of this appendix. The survey responses
for the other three aspects showed the following:

• Half the respondents were only mildly confident (32 percent) or not
  confident at all (18 percent) in the medical provider’s abilities, and half
  were very confident (16 percent) or moderately confident (35 percent)
  in the provider’s abilities.7
• Considering their particular needs, 61 percent thought the gynecological
  services they had received were either highly or generally appropriate,
  23 percent thought the services were neither appropriate nor
  inappropriate, and 16 percent thought the services were either generally
  or highly inappropriate.
• With respect to timeliness of care received, 73 percent said they had
  received prompt or very prompt care, 22 percent said there had been
  some delay, and 6 percent said it had taken much too long to receive
  care.8

Women who reported in the survey that they had not sought care for one or
more gynecological problems were asked to provide reasons. The most
prevalent reason cited by the 93 respondents9 was they did not feel the
problems had been severe or important enough to warrant medical
attention, and the second most prevalent reason was that the respondent
had lacked confidence in the medical provider (see fig. I.5).




7
    Percentages do not add to 100 due to rounding.
8Percentages    do not add to 100 due to rounding.
9
 The 93 respondents included women who did not seek care for any gynecological problems, as
discussed earlier in the appendix, as well as women who sought care for some problems but not for
other problems.




Page 20                                                         GAO/NSIAD-99-58 Gender Issues
Appendix I
Views of Female Soldiers Deployed to Bosnia




Figure I.5: What were the reasons you did not seek care for gynecological
problems?




Note: This figure shows responses from the 93 women in our survey who reported that they had not
sought care for one or more of the gynecological problems they experienced.
Source: Our analysis of survey responses.


When asked whether they would have sought care if stationed at their
home installation, 56 (60 percent) of these 93 respondents said they would
have sought care, and 37 (40 percent) said they would not have. Isolating
those respondents who reported that they did not seek care for any of the
gynecological problems they had in Bosnia, we found that 36 (54 percent)




Page 21                                                       GAO/NSIAD-99-58 Gender Issues
                   Appendix I
                   Views of Female Soldiers Deployed to Bosnia




                   of 67 respondents would have sought care if they were back home, and
                   31 (46 percent) would not have sought care.10



Privacy and        Women cited concerns about the privacy and confidentiality of care
                   provided at the base camp clinics. Our survey showed that of the
Confidentiality    approximately 60 women who said they had sought medical care for one or
                   more gynecological problems, 44 percent were very comfortable or
                   moderately comfortable talking with their medical provider about private
                   matters, 23 percent were neither comfortable nor uncomfortable, and
                   33 percent were moderately uncomfortable or very uncomfortable. In
                   addition, 51 percent were very satisfied or moderately satisfied with their
                   level of privacy while receiving care, 21 percent were neither satisfied nor
                   dissatisfied, and 28 percent were moderately dissatisfied or very
                   dissatisfied.

                   During our group interviews, some women expressed concerns about a
                   lack of both visual and auditory privacy in the small base camp clinics. For
                   instance, they said that examining rooms lacked doors and that curtains or
                   other dividers used to screen off the examining rooms did not always close
                   completely. Furthermore, discussions in the clinics could easily be
                   overheard by others. Women also were concerned about what they
                   perceived to be a lack of patient confidentiality. They told us that word
                   would leak out if they sought care and that the information about their
                   problem, or an exaggerated version of the problem, would soon spread
                   around camp. Medic staff, rather than doctors or physician assistants,
                   were more often blamed for these breaches of confidentiality.



Feminine Hygiene   Some aspects of the Bosnia deployment received favorable comment
                   regarding their contribution to good personal health and hygiene. For
Supplies           example, all but one of the survey respondents (more than 99 percent) said
                   they had daily access to showers or clean water for bathing. The survey
                   indicated, however, that some women had experienced problems obtaining
                   feminine hygiene products such as tampons and sanitary pads. Of the
                   survey respondents, 45 (20 percent) said there had been times during the
                   deployment when they had not been able to obtain adequate supplies of

                   10
                     Of the 71 respondents who reported earlier in the survey that they had not sought care for any
                   gynecological problems, 2 did not answer this question and 2 answered that this question was not
                   applicable to them, leaving a total of 67 respondents.




                   Page 22                                                         GAO/NSIAD-99-58 Gender Issues
                         Appendix I
                         Views of Female Soldiers Deployed to Bosnia




                         these products, while 182 (80 percent) said they had not had such
                         problems. When asked about their primary source of feminine hygiene
                         products, 124 (56 percent) respondents cited base camp stores
                         see fig. I.6).11 A number of women indicated in the survey that they had
                         been dissatisfied with the limited selection of feminine hygiene products at
                         the base camp stores and complained that the stores had run out of
                         supplies of these products.



                         Figure I.6: While you were deployed to Bosnia, what was your primary source of
                         feminine hygiene products?




                         Notes: This question was asked to all survey participants and answered by 222 respondents.
                         Percentages do not add to 100 due to rounding.
                         Source: Our analysis of survey responses.




Obstacles to Urinating   A majority of women taking our survey said there were times during the
                         deployment when they had encountered obstacles to urinating.
                         Specifically, 126 (55 percent) of 230 respondents said this had happened to


                         11
                          Nine of these 124 respondents entered more than one response to this question, indicating that they
                         had important sources of feminine hygiene products in addition to base camp stores.




                         Page 23                                                         GAO/NSIAD-99-58 Gender Issues
Appendix I
Views of Female Soldiers Deployed to Bosnia




them, and 104 (45 percent) said it had not happened. Of those women who
experienced this problem, 61 (50 percent) of 123 respondents said it had
occurred at least 2 to 3 days a week, including 25 women (20 percent) who
had experienced the problem daily.12 By a large margin, the top obstacle to
urinating was extended travel time on convoys (see fig. I.7). When leaving
their base camp, U.S. soldiers in Bosnia are required to travel by convoy to
enhance force protection. During our group interviews, women said these
convoys could last several hours without a stop to urinate.



Figure I.7: What caused you to postpone urinating or prevented you from urinating?




Note: This figure shows responses from 123 women in our survey who reported that they had
encountered obstacles to urinating during their deployment.
Source: Our analysis of survey responses.



12
  Of the 126 respondents who reported that that were times when they felt they had to postpone
urinating, 3 did not answer this question, leaving a total of 123 respondents.




Page 24                                                         GAO/NSIAD-99-58 Gender Issues
                          Appendix I
                          Views of Female Soldiers Deployed to Bosnia




Unavailability of Birth   Of 189 survey respondents, 156 (83 percent) said they had access to their
                          preferred method of birth control during deployment, and 33 (17 percent)
Control Pills             said they had not. Of those who said they had not had access, the most
                          frequent form of birth control not available was birth control pills.
                          Specifically, 13 (62 percent) of 21 respondents said birth control pills had
                          not been available to them.13 According to women we surveyed and
                          interviewed, the primary problem concerning birth control pills was the
                          limited selection for refill prescriptions at their base camp clinics. Several
                          women said their brand had not been available and that they had to change
                          prescriptions, sometimes more than once, after they deployed. Other
                          women avoided this problem by bringing a long-term supply of pills with
                          them.




                          13
                           Of the 33 respondents who reported that they had not had access to their preferred birth control
                          method during deployment, 12 did not answer this question, leaving a total of 21 respondents.




                          Page 25                                                          GAO/NSIAD-99-58 Gender Issues
Appendix II

Prior Research on Health Care Needs of
Deployed Women                                                                                                           ApIpexndi




               Prior to the Persian Gulf War, very little research was published on
               women’s health experiences while deployed or on the effectiveness of the
               health service support system in meeting women’s medical needs. The Gulf
               War generated greater interest in these issues because of the large number
               of women—more than 40,000—who deployed. In three separate studies,
               Army doctors reviewed patient records from the war to assess women’s
               health care needs.1 In at least one study, Air Force women were surveyed
               about their health experiences during the Gulf War, including gynecological
               health care needs.2 In addition, our office studied the deployment of
               women to the Persian Gulf and addressed concerns that had been raised
               about the impact of austere deployment conditions on women’s health.3
               Some research has been conducted on other deployments as well. An
               Army study, for instance, reviewed the morbidity of women deployed to
               Korea and at a U.S. installation,4 and Navy researchers have studied
               women’s health experiences while deployed aboard ships.5

               In fiscal years 1994 and 1995, Congress appropriated a total of $80 million
               for additional research on defense women’s health issues. More than
               100 studies were funded under this program, covering a broad array of
               subjects. The Institute of Medicine prepared a report in 1995 that served as
               guidance for the research program. The Institute’s report noted “very little
               is being done to study the everyday aspects of gynecologic or reproductive
               health of military women, especially in field conditions” and “health
               services research should be conducted to study the accessibility and
               availability of women’s health services in field operations and ways that


               1
                J.F. Hines, Ambulatory Health Care Needs of Women Deployed With a Heavy Armored Division During
               the Persian Gulf War, Military Medicine, 157, 5:219, 1992; G. Markenson, Female Health Care During
               Operation Desert Storm: The Eighth Evacuation Hospital Experience, Military Medicine, 157, 11:610,
               1992; and J.T. Hanna, An Analysis of Gynecological Problems Presented to an Evacuation Hospital
               During Operation Desert Storm, Military Medicine, 157, 5:222, 1992.
               2
                A.S. Robbins, Availability, Accessibility, and Adequacy of Health Care Provided to USAF Active Duty
               Women In-Theater During Operation Desert Shield/Storm, Armstrong Lab, Brooks Air Force Base,
               Texas (Oct. 1995).
               3
                   Women in the Military: Deployment in the Persian Gulf War (GAO/NSIAD-93-93, July 13, 1993).
               4J.D.
                   Gunzenhauser, Comparative Morbidity Study of Active Duty Women Serving in Korea and Fort
               Lewis, Madigan Army Medical Center, Tacoma, Washington (May 1997).
               5
                 S. Nice, Sex Differences in Health Care Requirements Aboard U.S. Navy Ships, Naval Health Research
               Center (Report No. 90-2, Mar. 20, 1990); S. Nice, Sex Differences and Occupational Influences on Health
               Care Utilization Aboard U.S. Navy Ships, Military Psychology, 6(2), 109-123, 1994; R.G. Burr, Health
               Care Satisfaction: A Comparison of U.S. Navy Women With Men Aboard Ships, Naval Health Research
               Center (Report No. 96-28, Oct. 1996); and M.J. Schwerin, Shipboard Women’s Health Care: Provider
               Perceptions, Military Medicine, 162, 10:666, 1997.




               Page 26                                                           GAO/NSIAD-99-58 Gender Issues
Appendix II
Prior Research on Health Care Needs of
Deployed Women




these might be improved.” In 1998, the Department of Defense hired a
contractor to assess the overall results of the research program and
determine what research gaps remain.

According to the various published studies, men and women tend to
experience similar types of illnesses and disorders while deployed,
although there may be some gender differences for particular diagnoses. A
study of sick call data at an Army division deployed to the Persian Gulf War
evaluated gender disparities for seven major clinical diagnoses, which
together accounted for 67 percent of all the sick call visits. 6 The study
found that women and men were statistically similar for three diagnoses—
acute gastrointestinal, respiratory, and dental disorders. Men were more
likely to be diagnosed with dermatological and orthopedic disorders, and
women were more likely to be diagnosed with psychiatric and optometry
disorders. A study comparing the morbidity of male and female
servicemembers deployed to Korea did not reproduce these results. This
study found that women had higher rates of dermatological disorders than
men did and that psychiatric and ophthalmic conditions represented only a
small proportion of all clinic visits. A study of women’s health aboard Navy
ships found that, for both genders, about half of all sick call visits were for
illnesses or disorders, another one-fourth were for injuries, and the
remaining one-fourth were for health services (such as physical
examinations).

The studies have consistently shown that, following patterns in the civilian
sector and at peacetime garrisons, deployed women tend to visit medical
providers for sick call more often than men. A Navy researcher concluded
that it is the frequency, not the types, of health problems that distinguishes
the health of men and women. That study found that the monthly sick call
rate for women aboard ships was 1.79 times greater than for men. A
subsequent study found a similar female-to-male ratio of shipboard
sick-call rates—1.66 to 1. When the data was adjusted for age, however, the
ratio decreased to 1.44 to 1 because the women aboard the ships were
younger on average than the men and younger people tend to make sick
call visits more often. Additionally, when visits for female-specific
conditions were excluded, the female-to-male ratio decreased to 1.21 to 1.
The study of servicemembers deployed to Korea and at a U.S. installation
found that gender was a much more significant factor on morbidity than


6
 J.f. Hines, A Comparison of Clinical Diagnoses Among Male and Female Soldiers Deployed During the
Persian Gulf War, Military Medicine, 158, 2:099, 1993.




Page 27                                                        GAO/NSIAD-99-58 Gender Issues
Appendix II
Prior Research on Health Care Needs of
Deployed Women




were the effects of deployment. Women in Korea visited clinics at twice
the rate of men and self-reported significantly worse health status. In an
Army combat division deployed to the Persian Gulf, women made up
approximately 6 percent of the total force but accounted for nearly
18 percent of all sick call visits to five support battalion medical units.
These medical units, however, were located in areas behind the front lines
where most women served (women are excluded from front-line ground
combat positions). Thus, the analysis may have been skewed because the
female-to-male ratio was higher in the rear, giving women comparatively
greater access to health care. Several reasons for women’s higher health
care usage have been postulated, but there does not yet appear to be a
consensus among researchers.

A number of the published studies calculated the proportion of
female-specific health care needs as a percentage of women’s overall health
needs during deployment. In these studies, female-specific needs
accounted for a minimum of 14 percent and a maximum of 26 percent of
women's health needs. According to Army studies of the Gulf War, the
most common gynecological diagnoses were vaginitis (mostly yeast
infections), abnormal bleeding, pelvic pain, desire for birth control pills,
and pregnancy. A gynecologist who reviewed these studies stated that the
most common gynecological complaints women experienced during the
Gulf War are also the most common seen in private practice.7 A Navy study
on gynecological care aboard one ship found that routine care, including
Pap smears and birth control pill refills, accounted for 30 percent of visits,
followed by sexually transmitted diseases (14 percent), menstrual
abnormality (13 percent), vaginitis (10 percent), urinary tract problems
(9 percent), and pregnancy-related issues (9 percent).

Female-specific health needs, while common, do not generally represent
severe problems during deployments. Most gynecological conditions have
been handled on an outpatient basis. During the Gulf War, gynecological
hospital admissions accounted for a small percentage of total hospital
admissions. (This percentage would have been even smaller had
U.S. forces experienced the combat casualties that were predicted prior to
the start of hostilities.) For instance, of 577 gynecological patient visits to
one Army hospital in the Persian Gulf, only 9 patients were admitted. Of
86 women admitted to another Army hospital, 10 (12 percent) had


7
  D.S. Lyon, Medical Care of Women Deployed During Desert Storm, Southern Medical Journal, Vol. 89,
No. 2 (Feb. 1996).




Page 28                                                         GAO/NSIAD-99-58 Gender Issues
Appendix II
Prior Research on Health Care Needs of
Deployed Women




gynecological-related diagnoses. A third Army hospital recorded
17 gynecological-related admissions, accounting for 3 percent of all
admissions.

Various studies also have found that the great majority of female-specific
health needs can be addressed by a medical provider other than a
obstetrical/gynecological specialist. One researcher stated that a provider
armed with a basic knowledge of gynecology and a modicum of equipment,
laboratory, and pharmacy support would be sufficient to evaluate most
female-specific complaints.

The published research indicates that most women surveyed report that
they get the health care they need. An Air Force survey of women deployed
to the Persian Gulf showed that women gave high overall ratings for
availability, accessibility, and adequacy of health care during the
deployment. However, there have been some troubling survey findings
with respect to gynecological care. The Air Force survey showed the
following:

• A substantial percentage (66 percent) of those with gynecological
  conditions during deployment said their illnesses persisted after the
  deployment.
• Of the women with gynecological conditions, 74 percent reported
  seeking medical care during the deployment. However, 89 percent said
  they would have sought care had they been back in the United States.
  Reasons for not seeking care included (1) they did not think their
  conditions were serious enough, (2) they had no confidence in the
  medical providers, or (3) they would have had to wait too long to
  receive care. Nearly half the women were embarrassed about their
  gynecological problems.
• Nearly 40 percent of the respondents had to see a medical provider two
  or three times for a condition.
• Women gave their highest negative rankings to providers’ efforts to
  explain the women’s symptoms.

A Navy survey of women and men aboard ships found that a majority of
women were satisfied with their health care during sick call visits, but they
reported less satisfaction than men with their general health care, health
care providers or consultations, the quality of service at sick call visits, and
the extent to which sick call visits met their needs. Women also reported
lower distress relief and lower levels of rapport with health care providers.




Page 29                                            GAO/NSIAD-99-58 Gender Issues
Appendix II
Prior Research on Health Care Needs of
Deployed Women




While they did not describe their general health less favorably than men,
women reported significantly more symptoms of distress.




Page 30                                         GAO/NSIAD-99-58 Gender Issues
Appendix III

Scope and Methodology                                                                          AIpIexndi




               To review medical services available to servicemembers deployed to the
               field, we focused on female-specific medical services and health-related
               issues for Army personnel who had deployed recently to Bosnia. We
               focused on female-specific health care because it constituted up to
               one-fourth of women's health care needs in prior deployments. We
               selected the U.S. deployment to Bosnia because it is a major, ongoing
               operation. At more than 3 years old, it is also a relatively mature operation
               and no longer can be said to represent austere field conditions. During the
               course of our review, we were told that the health and hygiene conditions
               today are greatly improved from the first months of the operation when
               there was very little infrastructure support. Currently, a contractor
               provides base support, and amenities have been added to increase the
               comfort level of U.S. forces deployed there.

               To determine the availability of data collected on female soldiers’ health
               care needs in Bosnia, we met with or contacted cognizant Army officials to
               discuss the outpatient data collection system. We obtained an analysis of
               disease and non-battle-related injury data that was conducted by Army
               health officials responsible for gathering the data. We also obtained a 1998
               Army health assessment of the Bosnia deployment that considered various
               health measures and a briefing on a mental health study of soldiers in
               Bosnia that was conducted by Army officials in Germany.

               To obtain the views of health care officials on female-specific medical
               services, we interviewed health officials and medical staff responsible for
               providing care to soldiers deployed to Bosnia. Among those interviewed
               were the Commander and Deputy Chief for Clinical Services, 67th Combat
               Support Hospital, Wurzburg, Germany; Commander, 396th Combat Support
               Hospital, U.S. Army Reserve; Command Surgeon, 1st Armored Division,
               Bad Kreuznach, Germany; and Commander, 261st Area Support Medical
               Battalion, Fort Hood, Texas. We also interviewed officials in the Office of
               the Command Surgeon, U.S. Army Europe; the Europe Regional Medical
               Command; and the Office of the Command Surgeon, V Corps, Heidelberg,
               Germany; the 2nd Armored Cavalry Regiment, Fort Polk, Louisiana; the
               U.S. Army Surgeon General's Office, Baileys Crossroads, Virginia; and the
               U.S. Army Medical Command, Fort Sam Houston, Texas. We interviewed
               23 medical providers who served in Bosnia—14 doctors and 9 physician
               assistants. Almost all of these medical personnel served in primary care
               positions, either at the base camps or in the hospital. We also met with a
               small number of combat medics who staffed the base camp clinics.




               Page 31                                          GAO/NSIAD-99-58 Gender Issues
Appendix III
Scope and Methodology




To obtain the perspective of women who deployed to Bosnia, we
conducted a survey of 234 female soldiers. Of the 234 soldiers surveyed,
144 (62 percent) were assigned to the 2nd Armored Cavalry Regiment, Fort
Polk, Louisiana, and 90 (38 percent) were assigned to the following units in
Germany: 130th Engineering Brigade, Hanau; 22nd Signal Brigade,
Darmstadt; 18th Corps Support Battalion (3rd Corps Support Command),
Hanau; 127th Maintenance Support Battalion, Hanau; 501st Military
Intelligence Battalion, Dexheim; Headquarters, 1st Armored Division, Bad
Kreuznach; and 527th Military Police Company, Wiesbaden. In Germany,
the U.S. Army’s V Corps selected units for us to visit. The units identified
and provided female soldiers to participate in our survey. We visited each
of the selected units to administer the survey. Because our survey
participants were not randomly selected, the results cannot be projected to
a larger population.

Of the 234 survey participants, 158 (68 percent) were in the E-1 to E-4 pay
grade group, 54 (23 percent) were in the E-5 to E-9 pay grade group, and 21
(9 percent) were officers.1 The average length of deployment for the
survey participants was 7.3 months, and their average age was 25.6 years.
Most of the women served sometime in 1998, although a few served earlier
tours. We asked those who had deployed more than once to provide
information concerning their most recent deployment. We did not
determine how many of the survey participants were on their first
deployment when they served in Bosnia. The great majority of survey
participants served at one of the three following base camps: Tuzla Main,
74 (32 percent); Guardian Base/Blue Factory, 64 (28 percent); and
Comanche, 34 (15 percent). Another 44 participants (19 percent) served at
nine other base camps in Bosnia, and 16 (7 percent) served in Croatia2 in
support of the U.S. peace operation in Bosnia.

To obtain a more complete picture of female soldiers’ views, we
interviewed 80 of the 234 soldiers surveyed. These interviews were
conducted in small groups of 2 to 13 people. For each interview, we
grouped the comments into overall themes. Likewise, we grouped the
write-in comments to the survey into overall themes.

To supplement our work in Bosnia, we conducted a literature search for
research on women's health issues during deployments. We also reviewed

1One    woman did not identify her pay grade group.
2
    Two women did not identify their primary base camp.




Page 32                                                   GAO/NSIAD-99-58 Gender Issues
Appendix III
Scope and Methodology




Department of Defense research programs, contacted officials responsible
for overseeing defense women's health research, and interviewed selected
researchers.

We performed our work between May and December 1998 in accordance
with generally accepted government auditing standards.




Page 33                                       GAO/NSIAD-99-58 Gender Issues
Appendix IV

Comments From the Department of Defense                    ApV
                                                             Ienxdi




              Page 34          GAO/NSIAD-99-58 Gender Issues
Appendix V

Major Contributors to This Report                                       ApV
                                                                          enxdi




National Security and   Carol Schuster
                        Bill Beusse
International Affairs   Thomas Gosling
Division, Washington,   Carole Coffey
                        Suzanne Lofhjelm
D.C.                    Jack Edwards



Los Angeles Field       Cheryl Gordon

Office




(703268)                Page 35            GAO/NSIAD-99-58 Gender ]Issues
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