“Sleep is not getting the attention it deserves”: A qualitative study of patient and provider views on sleep management in the Veterans Health Administration

Abstract

Background:

Unique characteristics and service exposures of the post-9/11 cohort of U.S. Veterans can influence their sleep health and associated comorbidities. The objectives were to learn about men and women post-9/11 Veterans’ and ‘front line’ VA providers’ knowledge about sleep and experiences with Veterans Health Administration (VA) sleep management.

Research Design:

One sample included post-9/11 Veterans who received VA care (n=23; 60% women; Mage: 45 years). To complement those views, primary care and mental health providers were recruited from VA medical centers (n=27). Semi-structured qualitative interviews were conducted via Microsoft Teams. Questions pertained to sleep knowledge, care practices, and perceived barriers to sleep-related VA care. Interview data were synthesized with content analysis and inductive coding to characterize major themes.

Results:

Four main themes emerged: 1) Sleep is viewed as foundational but Veterans and providers often have limited related knowledge and more routine education is needed. 2) Men and women have distinct sleep management needs. Relative to men, women are more likely to advocate for sleep assessment, and for behavioral vs. pharmacological treatment. 3) Sleep management practices vary considerably between clinics and providers. 4) Veterans and their providers each experience unique barriers to sleep management.

Conclusions:

Post-9/11 Veterans and providers view sleep as critical. Yet, VA sleep management needs to be more uniform. Providers are motivated to assess sleep but require standardized education and low-burden opportunities to incorporate sleep into their practice, perhaps with mental health screening. Ultimately, more specialized care is required to meet the responsibility of Veterans’ sleep health.

INTRODUCTION

Due to the demands and traumas of U.S. military service, Veterans have a significantly greater risk of sleep deficiency and of developing a sleep disorder.^1,2 Chronic conditions that are characterized by sleep deficiency or that are comorbid with sleep disorders are also burdensome to the Veteran population.^3,4 Despite Veterans’ vulnerability to sleep problems, sleep is inconsistently screened, potentially undiagnosed, or misdiagnosed, and thereby undertreated^2,5–8 – representing a concerning gap in VA care. Improving sleep management may be particularly advantageous among the most recent cohort of Veterans (i.e., who served in Iraq and Afghanistan conflicts and were discharged post-9/11) to reduce long-term health effects of sleep deficiency.^9–11 As the proportion of Veterans who are women or members of other minority groups increases,¹² and those individuals have a distinct risk for sleep disorders,^13,14 providing comprehensive sleep-related primary and secondary prevention (e.g., sleep hygiene education, offering a sleep study to those who are already high-risk for sleep apnea, peer support groups for individuals with insomnia) could particularly benefit this distinct cohort of patients.

Younger Veterans increasingly access frontline VA services – primary care and mental health¹⁵ – and these settings present ideal opportunities to assess and triage patients with sleep deficiency (e.g., during new patient evaluations and annual visits). Addressing sleep problems with the comprehensive, integrative care approach that informs these settings is congruent with curbing the widespread effects of sleep deficiency.³ Most Veterans also report that primary care and mental health clinics are preferable settings for initial sleep management, compared to a specialty referral to sleep medicine,¹⁶ where the average wait time for an appointment can be 40 days.⁵ Thus, for many Veterans, screening and treating sleep in these high-volume frontline clinics may be a favorable pathway. Yet, efforts to manage sleep still appear to be insufficient to meet Veterans’ needs.^8,17 In one study, 50% of Veterans followed in VA primary care met the criteria for a sleep disorder,^16,17 yet >75% of them had never discussed sleep with their provider,¹⁶ a gap that may be greater for women.¹⁸ Importantly, several past studies about sleep have offered the perspective of VA providers,^17,19–21 but largely focused on insomnia, and no study reflected providers’ views of sleep management differences in men compared to women. Identifying the barriers to evidence-based sleep management in frontline settings – primary care and mental health – would help to optimize sleep assessment and triage in the VA.

Two decades ago, an Institute of Medicine report first promoted awareness of the magnitude of sleep deficiency among Veterans.²² Subsequent, mounting evidence for the health-related effects of Veterans’ sleep deficiency, recently led the VA to disseminate clinical practice guidelines for sleep disorder screening, insomnia and obstructive sleep apnea (OSA) management, and implementation of evidence-based sleep treatments.²³ Yet, these expanded practices were largely based on healthcare data from all Veterans.^3,11 The post-9/11 Veteran cohort differs from these previous groups in the service-related experiences that could contribute to sleep problems after military separation,^10,24–26 in the proportion using VA care,^15,27 and in their demographic characteristics.^4,28 Thus, the goals of qualitative investigation were (1) to assess sleep-related experiences and knowledge, and (2) to identify barriers to the provision of quality sleep care, among men and women post-9/11 Veterans and VA primary care and mental health providers.

METHODS

Participants

A convenience sample of post-9/11 Veterans served by the VA and VA providers were contacted by email to offer information about the study, the researchers’ motivation to conduct the study, and to schedule the interviews at a time that was agreeable for each participant. Veterans were recruited from those who had previously participated in the survey portion of the Women Veterans Cohort Study (WVCS). WVCS is a nationally representative, prospective investigation of gender differences in health risk factors and in healthcare utilization among men and women Veterans who participated in conflicts in Iraq and Afghanistan and were discharged from service after October 1, 2001 (i.e., post-9/11¹²). For Veterans, recruitment and enrollment occurred August 2023-October 2023.

For providers, before beginning recruitment, the principal investigator received approval to recruit from the Associate Chief of Staff for Research and Development at each VA location. Eligible providers were initially identified based on listservs provided by Department Chairs, and recruitment was complemented by snowballing. Primary care and mental health providers (including physicians and other allied health professionals [i.e., psychologists and nurse practitioners]) were recruited from 6 VA facilities in the Northeast United States (i.e., VISN 1 of the Veterans Health Administration). Recruitment and enrollment occurred September 2022-March 2023.

Procedures

The study design included sociodemographic questionnaires and semi-qualitative interviews. Interviews were focused on sleep-related knowledge, education, management, and perceptions of barriers and facilitators to sleep assessment and care within the VA. Two separate interview guides were developed based on the relevant literature and in consultation with the research team (see Supplemental Digital Content 1). The guides were then iteratively refined based on initial interviews with the groups of patients and providers. Field notes were not used. Sessions were conducted by a female, PhD-trained psychologist who trained in VA primary care and cardiology, and advanced mixed methods, and with and no military experience (AEG). The interviewer led the remote study sessions from a VA office, using the Microsoft Teams application, and no one else was present for any session besides the participants and researcher. The interviewer had no relationship with the participants prior to study commencement. Repeat interviews were not conducted.

First, participants completed questions about their sociodemographic characteristics and professional background. Next, semi-structured interviews were conducted, a format which allowed participants greater extemporaneity in discussing the topics. The interviews were scheduled for about 50 minutes for Veterans and 25 minutes for providers. All sessions were digitally recorded to capture verbatim content and automatically transcribed. Transcribed interviews were then checked for accuracy. This study is reported according to the COnsolidated criteria for REporting Qualitative research Checklist (COREQ; see Supplemental Digital Content 2).²⁹

Statistical Analysis

Qualitative analyses were managed with ATLAS.ti (Scientific Software GmbH, Berlin, Germany) and conducted January 2024-May 2024. Veteran and provider interviews were analyzed separately, due to the distinct lived experiences of each group. Two investigators who primarily work with qualitative research methods independently reviewed the transcripts (VM, LW). A conventional content analysis approach and use of inductive coding (i.e., no a priori codes) were used to note the primary themes, and to develop an initial coding scheme with broad categories, including sleep assessment, clinical considerations, screening measures, knowledge about sleep, mental health and other comorbidity, sleep treatment, patient perspective, gender differences, barriers, and facilitators to sleep management. After the codes were iteratively determined, the two investigators independently read and coded each of the 23 Veteran and 27 provider interviews, which were labeled with de-identified codes (e.g., V1 for Veteran 1 or P1 for Provider 1). Themes were derived from the data over time rather than having an a priori list. If necessary, the investigators conferred to achieve consensus about the underlying themes. It was determined that the study reached saturation (i.e., when no new themes emerged during interviews) based on a saturation grid,³⁰ which was constructed separately for patients and providers. Points of data saturation were also discussed by the authorship group. Transcripts were not returned to participants for comments or corrections and participants did not provide feedback on the findings. A secure password-protected VA server was used to store all files. Recordings were destroyed upon verification. The VA Connecticut Institutional Review Board approved these procedures.

RESULTS

Characteristics of Veteran Participants

Of the 70 Veterans who were originally contacted, interviews were completed by 23 (33%; Table 1). The average age was 45 years (range:34-56), 43% were male, 13% were non-White race, 26% were Hispanic. About half had a graduate education, a similar proportion were married, 82% were employed, and 48% had an annual income of at least $75,000. Regarding military service, 39% served in the Army, 43% had participated in active duty, and 48% participated in at least 6 VA healthcare visits the prior year. For this group, the interview duration was 45 minutes on average (35 to 61 minutes).

Table 1.

Demographic characteristics of men and women post-9/11 Veterans, n=23.

Age (y)	45.4 ± 6.2
Gender
Male	10 (43.4)
Female	13 (56.6)
Race
Asian	1 (4.3)
Black	3 (13.0)
White	19 (82.6)
Ethnicity
Hispanic	6 (26.1)
Education
Graduate degree	10 (43.4)
Married	14 (60.9)
Employed	18 (78.3)
Income
≥$75,000	13 (56.6)
Service branch
Air Force	6 (26.1)
Army	10 (43.4)
Marines	3 (13.0)
Navy	4 (17.4)
Component
Active	10 (43.4)
Civilian Government Employee	1 (4.3)
National Guard	8 (34.8)
Reserves	4 (17.4)
Recent VA healthcare utilization
No visits	1 (4.3)
1 visit	1 (4.3)
2-3 visits	5 (21.7)
4-5 visits	3 (13.0)
6 or more	13 (56.6)

Notes. Data are presented as n (%) and mean±SD. Healthcare utilization was based on number of visits in the last 12 months.

Characteristics of Providers

Of the 60 recruited VA providers, 27 were interviewed (45%; Table 2). The average age was 44 years (range:30-74), 35% were male, and 22% were non-White. The VA with the most participants was VA Connecticut (22%) and states without any participants were Maine and New Hampshire. Overall, 43% of providers worked in mental health and about 46% were physicians. Within the primary care and mental health clinics, the average number of years in practice was 12.6 (4 months to 49 years), while the average duration of VA service was 8.8 years (4 months to 36 years). Overall, interviews were about 29 minutes (24 to 32 minutes).

Table 2.

Demographic characteristics of VA primary care and mental health providers, n=27.

Age (y)	44.3±11.5
Gender
Male	10 (37.0)
Female	17 (63.0)
Race
Asian	6 (2.2)
Black	0 (0)
White	21 (77.8)
Ethnicity
Hispanic	2 (7.4)
Professional training
MD	9 (33.3)
Nurse/APRN	7 (25.9)
Psychologist	11 (40.7)
Years worked in the VA	8.8±11.4
Years worked in their profession	12.6±8.9
VA location
Boston VA	3 (1.1)
VACWM	8 (29.6)
VACHS	6 (22.2)
Providence VA	5 (18.5)
WRJ VA	5 (18.5)

Notes. Data are presented as n (%) and mean±SD. Abbreviations. APRN, Advanced practice registered nurse; VACWM, VA Central Western Massachusetts; VA, Veterans Affairs Medical Center; VACHS, VA Connecticut Healthcare System; WRJ, White River Junction VA

Qualitative results

Theme 1. Sleep is important, but Veterans and VA providers have limited knowledge of it.

All Veterans recognized the importance of sleep. As one Veteran noted, “Sleep is kind of fundamental, and it’s a building block for every day… if I have great sleep, I can wake up and battle whatever is out there for me.”[V3] Providers also overwhelmingly affirmed that managing sleep is valuable for the best patient care, but that appreciation of sleep has only increased recently. As one provider stated pointedly, “The biggest concern of people coming in is sleep.”[P17] Then another explained, “I don’t know if I would go to the extent that it was not paid attention to it all, but [sleep] wasn’t given much attention…in the last decade, I think it is something more of us are incorporating into our work.”[P3] Furthermore, only one provider had heard of VA/Department of Defense (DoD) guidelines for insomnia and OSA.^23,31 Among potential health subareas, patients and providers were attuned to the interactions of sleep with mental health, stress, chronic pain, and cardiovascular health. One Veteran stated: “If I am super stressed out, I am not going to sleep whatsoever. And then it goes hand in hand: bad sleep, more stress…more stress, bad sleep.”[V6] And from a provider’s perspective, “sleep disorders that go untreated have repercussions on cardiovascular health, it’s a reason for patients’ blood pressure to be elevated and increases the risk of strokes and heart attacks.”[P7]

Despite the professed importance of sleep, the interviewed Veterans and providers expressed limited related knowledge. One Veteran reported, “[I don’t know] very much, to be honest. I’ve never been educated on that.”[P22] A few Veterans had more knowledge because of personal experience. “I’ve had Afib [i.e., atrial fibrillation] before that, but I didn’t know what it was… And then the doctor came in. He had Afib also and was explaining to me that not sleeping can make heart issues worse because you’re not breathing. Your body’s not getting the oxygen it needs.”[P10] Few providers recalled sleep-related education during their training; if so, it was limited. One provider reported, “I remember one or two lectures in medical school about sleep; during residency, this focused on sleep apnea and a little bit about sleep hygiene…but not so much.”[P16] In recognition of these knowledge gaps and to bridge them, some providers – often psychologists – described seeking additional education on their own, out of interest in better serving their patients. Most providers suggested that increasing sleep-related knowledge, potentially with required continuing education, would not take significant time or VA resources.

Theme 2. Men and women Veterans often have unique needs for sleep management.

Differences in men’s and women’s’ sleep problems can arise from the consequences of military service, social roles, and normal aging. As a provider explained, “I have seen more of a pattern of safety-related sleep concerns with women, and a lot of that comes from experiences of military sexual trauma.”[P24] Another female Veteran reported, “Women are natural caregivers. I support my family’s sleep at a personal health cost. A lot of female Vets do too. They trudge along on their own to do whatever it is they have to do and just manage [poor sleep].”[V5] Another stated, “I’m in menopause, and it has been a nightmare. I have cramps at night; there’s going to the restroom, and then I’m hot and drenched in sweat.” Providers were mixed about whether women are more likely to raise sleep concerns, “Women either experience more sleep issues or are just more freely willing to engage in conversation about it…how this affects their lives, relationships, and mood. Men want their medication refilled and don’t want to discuss anything else.”[P16] Conversely, women may bring up other health issues, and thus, discussing sleep may not occur. A provider explained, “I talk about sleep less with my female patients, mostly because we are talking about other things.”[P9]

Men and women Veterans also often held divergent views about sleep medications. While most of the men interviewed favored medication use, women largely described avoiding medications due to the belief that medications cannot address their sleep problems or negative experiences with medications, including sleep medications. One woman reported, “I really don’t trust sleep aids or want to get involved with them.”[V16] This theme also aligned with providers’ experiences, with one explaining, “I run across two kinds of patients. They either want every medication known to man, or they don’t want any.”[V18] At the same time, the primary care providers interviewed tend to use medications as a first-line treatment for sleep concerns but also described exercising caution. As a provider noted, “I think that sleep medications do help some Veterans with sleep problems. And with others, it’s not helpful at all or even counterproductive… I consider medication to be a secondary intervention after CBT-I [i.e., cognitive behavioral therapy for insomnia].”[P24] Providers also thought Veterans require better information about sleep medication use. Per one, “A lot of the Veterans I work with don’t necessarily have a good working knowledge of what these medications are or what side effects might happen.”[P10]

Theme 3. Sleep assessment and management practices are highly variable.

Among the Veterans interviewed, opinions were divided about who is responsible for bringing up the topic of sleep. For example, one Veteran said, “The provider should ask [about sleep] because not many people recognize that something could be a problem unless it’s brought to their attention that it is a problem. Sometimes people don’t take note of it because they dealt with for so many years, so it’s just normal for them.”[V17] Conversely, another Veteran reported, “If I didn’t bring up my concerns, it wouldn’t have been addressed.”[V18] Providers endorsed this view, reporting, “Usually I’m asking because there’s something in the history or our conversation that makes me think sleep might be an issue… If they don’t bring it up or if I don’t see any triggers, then I would not necessarily ask them in the review.”[P9] There was also substantial variability in sleep assessment based on where a professional practiced (less frequently assessed in primary care vs. more frequently in mental health) and by profession (less frequently assessed by physicians vs. more often among psychologists).

Providers reported that screening inconsistencies also arise from simply forgetting to mention sleep. As a provider said, “[It would be helpful] if there was a little bit more reminding of primary care providers and triage nurses to assess a little bit more thoroughly than they do now.”[P21] Providers are also aware of the variability in sleep assessment and often do not know who is responsible for assessing sleep in a clinical setting and how that is accomplished. Several providers described developing their own practices without a known standardized approach. As a provider explained, “Every one of us does things differently. I know that people use scales for certain things. We don’t use a scale, but we talk about their hours of sleep, whether they feel rested when they get up.”[P5] Many suggested that the complexity of sleep issues led their colleagues to avoid discussing sleep altogether. Finally, both Veterans and providers were receptive to the idea of adding a brief, annual sleep screening to accompany other mental health screeners, and incrementally testing this approach in select settings (e.g., the Women’s Clinic).

Theme 4. Veteran-, provider-, and system-level barriers to VA sleep management.

Among Veterans, expectations for addressing sleep are one barrier to sleep-related care, with one stating, “I think there’s a cultural component of wanting a magic pill or simple fix in America.”[V22] Veterans’ comorbid mental health symptoms and substance use are a second barrier, as multimorbidity presents a challenge to determine if sleep problems are attributable to other conditions and which condition to treat first. Providers agreed, with one stating, “A lot of folks who have depression and anxiety seem to have trouble sleeping. It’s hard to parse out or separate a sleep disorder from a diagnosed mental health condition. Maybe sleep has taken second fiddle.”[P21] As a third barrier, certain generational and social factors affect the time needed for sleep management care. As a provider explained, “For younger Veterans, scheduling time for any healthcare or a sleep study is difficult…they might not be able to take that time off from their job or find care for kids.”[P14]

Providers’ barriers included a lack of time or knowledge for routine sleep assessment and a paucity of sleep specialists, which affects the timing and availability of sleep medicine and CBT-I appointments. As one explained, “Providers are absolutely swamped. It’s not surprising that sleep, while undoubtedly important, may be further down the line from basic things like suicide prevention, getting people in the door, establishing safety risks, and all that kind of stuff. Let’s acknowledge that the staffing, workload, and staff morale issues are all playing into it, and that sleep is not getting the attention it deserves.”[P19] Providers agreed that adding clinical reminders could exacerbate burnout, particularly in primary care. Finally, providers suggested that when sleep is assessed, the focus is often limited to OSA, with infrequent consideration of insomnia or restless legs syndrome. The most universal systemic barrier for patients and providers was the belief that the VA does not prioritize sleep. A Veteran reported, “Sleep is important, it’s paramount. I think the VA needs to wake up and smell the roses.”[V5] A provider agreed with this stating, “there’s so many competing VA and healthcare concerns and screenings. So how do you fit sleep into all of that?”[P6]

DISCUSSION

This is the only known qualitative investigation of general sleep knowledge and the barriers to related care among men and women post-9/11 Veterans, and VA providers with varied training. These distinct but complementary perspectives extend earlier qualitative evidence from either source,^{17,20,32–37} and which often focused on insomnia or OSA exclusively.^20,36–39 In contrast with those reports, the present interviews concerned sleep management in general, included a timely focus on potential differences in sleep management by sex, and the samples of Veterans and providers were larger than most past studies in order to reflect diverse viewpoints. All interviewees –Veterans and providers – agreed that sleep health is important. Despite this belief, interviewees agreed that sleep knowledge is low among post-9/11 Veterans and their providers. Sleep education programs may be a valuable next step. Leveraging the VA’s Whole Health model^40,41 (i.e., working with a transdisciplinary team to create a personalized health plan based on one’s values, needs, and goals) to specifically reference sleep as a “Building Block of Health and Well-being” could be helpful to offer related patient-centered education. For VA providers, increased sleep training could be included in continuing education, other expected professional development, and in-services.

Our findings align with earlier reports on patient-, provider-, and system-level barriers to sleep management, including the time limitations of both groups, and inadequate impetus or resources for sleep assessment and triage,^{17,19,20,32,33} which have also been long-time issues in U.S. healthcare at large.^6,20 Another identified barrier to routine sleep management was a lack of sleep specialists in VA, a concern that is discordant with the VA/DoD clinical practice guidelines for managing OSA and insomnia.³¹ Just one interviewed VA provider could explain the guidelines, suggesting gaps in their subsequent dissemination and implementation. In contrast with these clinical recommendations, too often, sleep is only assessed when a patient brings it to a provider’s attention. Veterans are concerned that this variability negatively affects the entirety of their healthcare, and providers overwhelmingly, mutually believe that this problem adversely affects Veterans’ health. Indeed, as sleep is comorbid with other prevalent conditions in Veterans (e.g., PTSD and chronic pain^40,41) and the growing recognition that sleep is influential in cardiovascular risk,^42,43 prioritizing sleep health could also improve the acute management of comorbidities affected by poor sleep; thus, aiding long-term disease prevention.

Men and women each present with unique sleep concerns and needs for related care – e.g., women are less likely to be diagnosed with OSA,⁴² and have a greater risk of insomnia than men ⁴³ – but previous qualitative studies of sleep and VA sleep management have largely included older, male Veterans.^36–39 To fill that gap, over half of the Veteran participants were women, and responses differed by group. Based on their impressions, men and women may each benefit from better education about the suitable staging and complementary use of pharmacologic and behavioral therapies to ensure the appropriate use of each. While interviewed providers reported caution about using sleep medications as a first-line treatment, these data are discordant with an investigation of VA electronic health record data from >5 million patients, revealing that patients were 24x more likely to receive a sleep medication before behavioral therapy for sleep.⁴⁴ Moreover, patients who were younger and women were more likely to receive CBT-I than medication, preferences also reported by women in this study. Women post-9/11 Veterans also have other differences in healthcare utilization preferences (e.g., greater use of VA and non-VA providers vs. men¹²), which may influence their sleep care. Finally, women Veterans appear to manage sleep differently than men or non-Veterans. In another study, women who were Veterans were more likely to use alcohol as a sleep aid than non-Veterans.⁴⁵ Thus, more uniform sleep assessment, education, and management may benefit men and women Veterans in different ways.

In this investigation of VA sleep management, the views of Veterans and providers were often complementary, and pointed towards clear opportunities to test and implement more uniform clinical care for sleep. Thus, we have several clinical recommendations. First, to reduce burden, it could be advantageous to trial combining a brief sleep screener (e.g., the National Institutes of Health’s PROMIS Sleep Disturbance and Sleep-Related Impairment short forms) with other mandatory, annual screeners (e.g., depression and anxiety) and to use a similar, stepwise screening process as for mental health questions. Second, clinicians could provide a brief sleep screener before their encounter, in the waiting room or through MyHealthyVet, so the provider has initial data available. Third, VAs could prioritize increasing access to behavioral sleep treatment, by expanding services in primary care or creating dedicated behavioral sleep health clinics. There are excellent, validated treatments for sleep, including CBT-I, supported by VA/DoD clinical practice recommendations with the highest evidence base,³¹ and VA has made greater strides to improve CBT-I access. Yet, in another study of 1300 VA providers who were trained in behavioral sleep medicine, only 700 providers appeared to be offering this care.⁴⁴ It appears there are unrealized chances to bridge Veterans’ need for sleep care with available guidelines, and providers who already have relevant expertise. Finally, VA could consider creating sleep medicine clinics – with either a behavioral or general sleep medicine focus – in larger CBOCs. We expect that demand would support these measures in each case and acknowledge that careful staging would be important to absorb the associated caseload.

This study had several limitations. The first relates to generalizability. We included post-9/11 Veterans and VA providers from the Northeast U.S., and Veterans were not selected based on their history of sleep disorders or receipt of sleep medicine care per se. Veterans who participated may have disproportionately represented those who value sleep health, and the interviewed providers may have been those who are more cognizant of sleep management in their clinical practice. Thus, these points merit a broader geographical inquiry into VA sleep management from joint patient and provider perspectives. Second, sleep medicine providers were not interviewed for this study, representing an important future direction for qualitative research to improve VA sleep management. Third, while the interview was anonymous, the video format may have inadvertently prevented some Veterans or providers from being completely transparent about their experiences. Fourth, although there was a desire to focus on sleep management among post-9/11 Veterans, providers may have answered questions while reflecting on the Veteran population at large, particularly if their views are consistent among Veterans from different service eras.

Despite the professed importance of sleep, and a growing awareness of sleep health, many men and women who were interviewed needed to learn that sleep should be discussed at all, and related clinical practices remain at the discretion of each VA provider. Neither Veterans served by VA or providers who practice in VA ‘frontlines’ believe that sleep is a sufficient priority in the healthcare system. Yet, these stakeholders offered multiple solutions to these disparities and gaps in care, including improved implementation of recent clinical guidelines.²³ With a changing population of Veterans and opportunities to provide healthcare tailored to men and women, there is a resounding call for better sleep assessment and management. Doing so could benefit the health and well-being of each group and those who care for them after service.

Supplementary Material

Supplemental Digital Content 1

Supplemental Digital Content 1 – Interview Guides

Supplemental Digital Content 2

Supplemental Digital Content 2 – COREQ Checklist