UK Veterans Research Articles

Developing a nationwide dataset of UK veterans seeking help from sector charities

Abstract Background The assistance to military veterans and their families in the UK is provided by both the NHS and over 1800 military charities. These charities count services using different definitions and reporting systems, so to date a national registry of service usage does not exist. The aim of the MONARCH study is to build a standardised registry of service usage data for the military charity sector, in order to identify patterns of use, gain insight on possible risk factors, and guide the allocation of resources. Methods Data is anonymised and a unique identifier is generated by adopting a Secure Hashing Algorithm, allowing both privacy protection and avoiding double counts. Data is standardised, and linked with an automated process to create an aggregated dataset. The dataset describes the population, using both a-priori and machine learning approaches (K-means clustering) to unveil different usage patterns. In addition, it will be linked to an online interactive dashboard. Results To date 5 national charities have shared data, for a total of 42,509 veterans with 128,423 needs. The mean age of beneficiaries was 60.1 years (SD 20.5), and 90% were male. 65% were receiving some other form of statutory benefit, 5% was homeless and 1% was imprisoned. 65% of the needs recorded concerned social wellbeing. 40% of veterans were helped at least in two different years. The k-means clustering approach based on the number of accesses, number of needs and repetition of need returned 4 subgroups of use that were identical to those created using a priori knowledge. Conclusions The dataset is the most comprehensive source of charity usage data in the UK to date. Service usage is generally homogenous among subgroups, but some differences were highlighted indicating that younger, non-officer veterans may be more at risk of presenting with more complex needs. These first useful insights can help allocate resources to build an effective preventive strategy for more complex cases. Key messages • The MONARCH dataset is the first comprehensive nationwide registry in the UK of military charity data. • The understanding of usage patterns can lead to the design of targeted preventive strategies.

Developing a nationwide registry of UK veterans seeking help from sector charities—a machine learning approach to stratification

Abstract The assistance to veterans in the UK is provided by the National Health Service and over 1800 military charities. These charities count services using different definitions and reporting systems, so to date a national registry of service usage does not exist. The aim of the Map Of Need Aggregation ResearCH study is to build a standardized registry of service usage data for the military charity sector. Data are completely anonymized by adopting a Secure Hashing Algorithm. A unique anonymous identifier is generated allowing both privacy protection and avoiding double counts. Data are standardized and linked with an automated process to create an aggregated dataset. The dataset describes the population, using both a priori and machine learning approaches. To date a total of 42 509 veterans with 128 423 needs are included. The mean age was 60.1 years, and 90% were male. 65% were receiving other benefits, 5% were homeless and 1% were in prison. 65% of the needs recorded concerned social wellbeing. 40% of veterans received assistance in at least two different years. The k-means clustering approach returned 4 subgroups of use that were identical to those created using a priori knowledge. The dataset is the most comprehensive source of veteran charity usage data in the UK to date. Service usage is generally homogenous among subgroups, but some differences were highlighted indicating that younger, non-officer veterans may be more at risk of presenting with more complex needs. These first useful insights can help allocate resources to build an effective preventive strategy for more complex cases.

Reflecting on JMVFH’s most popular article of 2017: ‘Living alongside military PTSD: A qualitative study of female partners’ experiences with UK Veterans’

Reflecting on <i>JMVFH</i>’s most popular article of 2017: ‘Living alongside military PTSD: A qualitative study of female partners’ experiences with UK Veterans’

Living alongside military PTSD: A qualitative study of female partners’ experiences with UK Veterans

Introduction: An increased risk of emotional burden in partners of military Veterans with mental health difficulties has been observed. This study aimed to explore the experiences and needs of female partners of Veterans seeking help. Methods: Our sample of eight female partners was drawn from a population of help-seeking Veterans who had received treatment for PTSD. Qualitative data were collected using a semi-structured interview schedule. Results: Super-ordinate themes of challenges faced, desired type of support, and barriers to support were each described by a set of sub-themes. Challenges faced were described with the themes of inequality in relationship, loss of congruence with own identity, volatile environment, and emotional distress and isolation. Desired type of support was described by the themes of practical focus on improving, sharing with fellow experts, and support tailored to the partner. Barriers to support were described by the themes feeling restricted by practical barriers and ambivalence about the involvement of others. Discussion: Interventions to support partners of Veterans with mental health difficulties need to address their individual needs, focus on practical techniques, and consider practical limitations.

Veterans in Care Homes: An International Scoping Review to Inform UK Policy and Practice

Context: In contrast to the mental and physical health needs of veterans, veterans’ social care needs remain relatively neglected by policymakers and researchers. Objective: To inform UK veterans policy and practice by drawing together the expectedly limited international research base on veterans in care homes. Method: An international scoping review of peer-reviewed and grey research literature was conducted, informed by Levac et al.’s (2010) six-stage process. Findings: Thirty-three papers were found to meet the inclusion/exclusion criteria. The papers’ contents typically fell into one or more of the following themes: social connection, care preferences and autonomy, and military-related physical and mental health needs. Limitations: Very little (n = 1) UK-situated research was found, with the majority of retrieved papers (n = 24) being US-based, impeding transferability and relevancy of the findings to a UK context. Implications: Veterans’ social care needs were found to be a largely underexplored area of research, especially in the UK. There is a pressing need for UK veterans’ policymakers to redress existing imbalances in the focus of policy and research by raising the status and importance of the social care needs of UK veterans, as has been achieved on the mental and physical health fronts.

Using Passive and Active Data to Predict Post-Traumatic Stress Disorder Symptoms and Cannabis Use in Recently Discharged UK Veterans: A Protocol for the MAVERICK Feasibility Study.

Post-traumatic stress disorder (PTSD) and comorbid cannabis use disorder (CUD) is a growing concern amongst UK veterans. Co-occurrence of problematic cannabis use, and PTSD is associated with greater PTSD symptom severity, decreased likelihood of cannabis use cessation, worse clinical outcomes, and increased societal burden. Despite increased screening efforts among veterans, there are no effective strategies for predicting risk for PTSD and problematic drug use escalation before these conditions develop, worsen, or become chronic. This feasibility study employs a 4-week (28 day) longitudinal design (daily data collection), multiple passive data collection features via a bespoke study smartphone app called MAVERICK, and active data collection via wearable technology to predict clinically meaningful escalations in cannabis use and PTSD symptoms in UK veterans. Questionnaire data will be collected between 06:00 and 10:00 each day. Passive data will be collected continuously in the background. The study will begin recruitment in June 2023 and will require 18 months to complete. Study results are expected to be published in January 2024. This trial will provide information on the feasibility and utility of a smartphone app (MAVERICK) to collect both active and passive data to predict PTSD symptoms and cannabis use in a UK veteran population. If the smartphone app is deemed feasible and acceptable to users, it has the potential to provide an effective measurement tool to mitigate risk of PTSD and problematic cannabis use among veterans.

Cardiovascular and lifestyle risk factors of mild cognitive impairment in UK veterans and non-veterans.

The link between poor cardiovascular health (CVH), lifestyle and mild cognitive impairment (MCI) has been well established in the general population. However, there is limited research exploring these associations in ageing UK veterans. This study explored the risk of MCI and its association with nine CVH and lifestyle risk factors (including diabetes, heart disease, high cholesterol, high blood pressure, obesity, stroke, physical inactivity, the frequency of alcohol consumption and smoking) in UK veterans and non-veterans. This prospective cohort study comprised data from the PROTECT study between 2014 and 2022. Participants comprised of UK military veterans and non-veterans aged ≥50 years at baseline. Veteran status was defined using the Military Service History Questionnaire. CVH and lifestyle risk factors were defined using a combination of self-report measures, medication history or physical measurements. MCI was defined as the presence of subjective and objective cognitive impairment. Based on a sample of 9378 veterans (n = 488) and non-veterans (n = 8890), the findings showed the risk of MCI significantly reduced in veterans with obesity, those who frequently consumed alcohol and were physically inactive compared to non-veterans. The risk of MCI significantly increased in veterans with diabetes (hazards ratio [HR] = 2.22, 95% confidence interval [CI] 1.04-4.75, P ≤ 0.05) or high cholesterol (HR = 3.11, 95% CI 1.64-5.87, P ≤ 0.05) compared to veterans without. This study identified CVH and lifestyle factors of MCI in UK veterans and non-veterans. Further work is needed to understand these associations and the underpinning mechanisms which could determine intervention strategies to reduce the risk of MCI.

Combat-Genital Injury in UK Male Military Veterans: A Pilot and Feasibility Study Exploring Long-Term Psychosocial and Sexual Experiences and Support Needs

During the most recent conflicts in Iraq and Afghanistan, genital injuries were reported among male personnel at rates higher than previous conflicts. To date, research has focused predominantly on immediate medical management with limited published research exploring the long-term psychosocial and sexual impacts of combat-genital injury. This pilot study, therefore, aimed to explore the psychosocial and sexual health outcomes, experiences and support needs of military veterans who sustained combat-genital injuries and to assess the feasibility of conducting further research on this topic. A cross-sectional online survey design was used, comprising open and closed questions. Recruited through opportunity and snowball sampling, 11 eligible male UK veterans who had sustained a combat-genital injury completed the survey between March and July 2021. The results indicate that participants experienced long-term challenges related to their genital injury including low self-esteem, sexual function difficulties, and fertility concerns. The findings provide preliminary evidence of unmet long-term psychosocial, sexual, and fertility support needs among UK veterans with combat-genital injury. Further research is required to better understand the psychosexual wellbeing of combat veterans who have sustained physical injuries more broadly and to determine how best to provide psychosexual support to those who may benefit.

Factors associated with well-being among treatment-seeking UK Veterans: A cross-sectional study

LAY SUMMARY Veterans seeking treatment for mental health problems are likely to face more than one problem. Well-being is a concept that does not rely on any mental health diagnosis or difficulty and may offer a broader way to capture mental health. In this study, 428 UK Armed Forces Veterans seeking treatment for mental health difficulties at a UK-based charity completed a survey asking about mental health and well-being. Overall, treatment-seeking Veteran well-being was associated with symptoms of anxiety and depression, physical health, problems with anger, moral injury, posttraumatic stress disorder (PTSD), and complex PTSD. Sleep problems, alcohol misuse, and loneliness were also linked with well-being scores. These associations suggest that well-being may capture Veteran health in a way that is separate from any single diagnosis, meaning outcomes for Veterans with complex needs who require a range of support can be compared. These results also highlight the relevance of positive mental health, as opposed to mental ill health.

Restore and Rebuild (R&R): a protocol for a phase 2, randomised control trial to compare R&R as a treatment for moral injury-related mental health difficulties in UK military veterans to treatment as usual

BackgroundExposure to potentially morally injurious events is increasingly recognised as a concern across a range of occupational groups, including UK military veterans. Moral injury-related mental health difficulties can be challenging...

The positive impact of legal advice and services on the mental wellbeing of UK veterans

ABSTRACT Law has been recognised as a significant social determinant of health, however, micro-level legal advice interventions are underexplored. The dearth of research concerning the experience of British veterans highlights the need for uniquely tailored support services. This need is emphasised by the pervasiveness of mental health issues amongst this population. We investigate the feasibility of remotely delivered legal advice as a social intervention for supporting the mental wellbeing of UK veterans. This is based on the Warwick-Edinburgh Mental Wellbeing Scale results from 67 participants, who completed a pre and post legal intervention survey. Average WEMWBS results were higher post-intervention, particularly in participants with pre-identified mental health issues. The difference in overall scores pre and post intervention is statistically significant (p = 0.034). A correlation matrix identifies two variables, with one contributing to 59% variance (LV2). These are identified as “Affective” (LV2), and “Cognitive” (LV1). The difference between LV2 results pre and post intervention was significant (p = 0.016). Findings highlight the importance of individualised interventions for veterans. Free, remotely delivered, tailored legal advice and support shows feasibility as a social intervention due to its ability to encourage emotional disclosure, something which the veteran population can struggle with.

Shorter communications: Exploring the impact of a brief smartphone-based alcohol intervention app (DrinksRation) on the quality of life of UK military veterans

Alcohol misuse – defined as consuming more than 14 units of alcohol per week - is a well-established problem among veterans. This study investigated the change in quality of life among help-seeking UK veterans who completed a 28-day brief alcohol intervention delivered via a digital smartphone application (called DrinksRation) and have previously sought clinical help for a mental health disorder. This study was a secondary outcome analysis of data collected during a randomised control trial. In total, 123 UK veterans participated in the study and were randomly allocated to either the intervention or control arm. Participants completed self-report questionnaires regarding their alcohol use and quality of life (WHOQOL-BREF) at baseline, day 28 (end of intervention), day 84, and day 168. At the primary endpoint (day 84), we found significantly greater improvements in the intervention arm compared to the control arm for psychological quality of life (Cohen's d = 0.47), and environmental quality of life (d = 0.34). However, we observed no statistically significant differences between the intervention and control arm for social relationships and physical quality of life. Further, for day 168 we found no significant differences. Findings suggest that DrinksRation can increase quality of life among help-seeking veterans who have previously sought help for a mental health disorder, but the increases were modest and restricted to certain domains. Additional treatment may be needed for long-term and sustained improvements in quality of life.

Who am I? A qualitative exploration of the identities of spouses/partners of UK Armed Forces Veterans

LAY SUMMARY Military life can negatively affect partner health/well-being and their sense of identity during and after service. To date, most research has focused on the identities of personnel post-transition, with little examining partner identities. Using interviews with 37 current and former partners (31 female, 6 male) from the UK Veterans Family Study, the identities of Veteran partners were explored. Participants discussed military identity and culture, role-based identities, and loss of personal identity. Identities could be taken on or given to partners from within the military community and were often underpinned by military life and culture during and after service. Long-term impacts on self-esteem and confidence were reported, as were pride and resilience. Employment post-transition allowed restoration of personal identity but was sometimes at the cost of the community provided by being in the armed forces. Findings show the difficulties some Veteran partners experienced in maintaining personal identity during and after a Veteran’s service. Future research should concentrate on short- and long-term effects of identity loss/change among military and Veteran partners to inform and improve current and future strategies supporting families.

Veterans in crisis: Describing the complexity of presentations to a mainstream UK Veterans’ mental health service

LAY SUMMARY Armed forces Veterans often delay seeking help for mental health problems until a crisis point is reached. However, the clinical presentation of UK Veterans in mental health crisis is poorly understood. This study explored the presenting demographics, mental health problems, and factors that contributed to the current mental health crisis of UK Veterans who were referred to a Veterans’ crisis service, delivered as part of the mainstream health system. It showed that Veterans in crisis were similar in age and gender to the wider population at higher risk of crisis. Veterans presented with a broad range of symptoms of mental ill health and factors that were driving their current crises. Findings suggest that crisis services that address a broad range of symptoms and factors may be best positioned to address Veterans’ needs. It also suggests that these services need to ensure they are responsive to the needs of the whole Veteran population, including younger Veterans and women.

Validation of a complex needs indicator for veterans in the UK using a composite indicators’ method

ObjectiveTo construct an indicator for assessing the complexity of UK veterans’ needs. Study designCross-sectional, secondary analysis. MethodsThe study applied principal component (PCA) analysis as the method to determine the weights of different needs based on their interactions with each other, the effectiveness of the model was evaluated using bootstrapping. The dataset on UK veterans’ support provided by the “Soldiers, Sailors, Airmen and Families Associations” (SSAFA) (N = 35,208) was considered. The grant applications for different categories of support were used as indicators of different needs. The dimensions of breadth (number of different needs) and depth (number of grant applications to address the need) were incorporated in the assessment of complexity. ResultsThe complex needs indicator for the current sample was validated. The majority of cases had a complexity score of 1 or less. ConclusionsThe research suggested and tested an assessment method for the complexity of veterans’ needs, that may be positively associated with higher risk of adverse health outcomes. This indicator can be used by decision-makers for risk stratification of the veteran population, thus supporting the allocation of resources in a more effective way.

Exploring Reasons for Non-Engagement From a Peer-Led Diversionary Intervention for Veterans in Police Custody.

UK veterans with complex needs arrested in police custody can access support through pre-charge diversion into treatment and ancillary services. We consider why veterans in police custody disengaged from a peer-led criminal justice diversionary support service in one UK region that adopted a continuous case management approach. Seven hundred and fifty-seven veterans were assessed to have high levels of comorbid health needs and socio-economic harms, with one-quarter (26.7%, n = 202) subsequently disengaging from the service. A logistic regression model using Multivariate Imputation by Chained Equations identified that veterans of a younger age, no-fixed-abode, a history of incarceration, and those from a Royal Navy background were likelier to disengage from the intervention. We conclude that this peer-based diversionary model has some efficacy in maintaining the engagement of a highly complex, comorbid segment of criminally-justice-exposed UK military veterans. The perceived benefits of an integrated peer-based model predicated on continuous case-management techniques are discussed.

Is lifetime traumatic brain injury a risk factor for mild cognitive impairment in veterans compared to non-veterans?

ABSTRACT Background: Traumatic brain injury (TBI) is prevalent in veterans and may occur at any stages of their life (before, during, or after military service). This is of particular concern, as previous evidence in the general population has identified TBI as a strong risk factor for mild cognitive impairment (MCI), a known precursor of dementia. Objectives: This study aimed to investigate whether exposure to at least one TBI across the lifetime was a risk factor for MCI in ageing UK veterans compared to non-veterans. Method: This cross-sectional study comprised of data from PROTECT, a cohort study comprising UK veterans and non-veterans aged ≥ 50 years at baseline. Veteran and TBI status were self-reported using the Military Service History Questionnaire (MSHQ) and the Brain Injury Screening Questionnaire (BISQ), respectively. MCI was the outcome of interest, and was defined as subjective cognitive impairment and objective cognitive impairment. Results: The sample population comprised of veterans (n = 701) and non-veterans (n = 12,389). TBI was a significant risk factor for MCI in the overall sample (OR = 1.21, 95% CI 1.11–1.31) compared to individuals without TBI. The prevalence of TBI was significantly higher in veterans compared to non-veterans (69.9% vs 59.5%, p < .001). There was no significant difference in the risk of MCI between veterans with TBI and non-veterans with TBI (OR = 1.19, 95% CI 0.98–1.45). Conclusion: TBI remains an important risk factor for MCI, irrespective of veteran status. The clinical implications indicate the need for early intervention for MCI prevention after TBI.

Identifying the risk factors associated with food insecurity in the UK veteran population: a nationwide survey.

There has been limited focus placed on exploring food insecurity within the UK-ex-Armed Forces population. The present study aims to build on initial work by investigating the prevalence and associated factors of food insecurity within UK veterans and their families and their current health status. 881 veterans (or a family member) who previously served in the Royal Navy and Royal Marines, Army and the Royal Air Force completed an online survey to explore health status, food insecurity and receipt of benefits. In total, 16.9% of survey respondents were part of food-insecure households, with 12% of these also experiencing some element of hunger. Working age, non-officer rank at the time of service discharge, not being married, living in rented accommodation, having at least one medical condition and in receipt of other benefits were significant risk factors associated with food insecurity. Understanding the specific risk factors associated with food insecurity is vital to develop personalised interventions and policies, such as income support programmes and affordable housing initiatives. However, more work is needed to further explore the factors associated with food insecurity, particularly in the long term.

Associations between sleep difficulties and health outcomes in treatment-seeking veterans.

Sleep disturbance in UK Armed Forces personnel appears to be frequent due to factors such as hostile sleeping environments and can persist even once they have transitioned into civilian life. Despite this, there is currently very limited literature surrounding the prevalence and associated factors of insomnia disorder among UK veterans. This study aimed to expand knowledge of the prevalence and associated demographic, military, health and functional outcomes with probable insomnia disorder within a clinical sample of veterans. Treatment-seeking veterans from a national UK mental health charity were invited to complete a questionnaire including socio-demographic, military, health and well-being questions. Of the sample, 489 (43%) completed the questionnaire. Seventy per cent of the sample reported having probable insomnia disorder. Having probable insomnia disorder was significantly associated with being younger and having physical health problems. Moreover, unadjusted models found associations between probable insomnia disorder and common mental health difficulties, obsessive-compulsive disorder and complex post-traumatic stress disorder. The results suggest that many UK veterans with physical and mental health difficulties experience co-morbid insomnia disorder. Therefore, it is important that clinical services are aware of this prevalence and use targeted interventions to reduce the frequency of insomnia disorder in this population.

Gender differences in structural and attitudinal barriers to mental healthcare in UK Armed Forces personnel and veterans with self-reported mental health problems

PurposeStructural and attitudinal barriers often hinder treatment-seeking for mental health problems among members of the Armed Forces. However, little is known about potential gender differences in structural and attitudinal barriers among members of the UK Armed Forces. The current study aimed to explore how men and women differ in terms of these barriers to care among a sample of UK Armed Forces personnel and veterans with self-reported mental health problems.MethodsCurrently serving and ex-serving members of the UK Armed Forces who self-reported a mental health problem were invited to participate in a semi-structured phone interview on mental health and treatment-seeking. The final sample included 1448 participants (1229 men and 219 women). All participants reported on their current mental health, public stigma, self-stigma, and barriers to mental healthcare.ResultsOverall, men and women reported similar levels of both structural and attitudinal barriers, with no significant differences detected. The highest scores for both men and women were observed in attitudinal barriers relating to self-stigma domains, which encapsulate internalised attitudes and beliefs about mental illness and treatment.ConclusionsFindings suggest that anti-stigma campaigns can be targeted simultaneously at both men and women within the Armed Forces. In particular, targeting self-stigma may be beneficial for health promotion campaigns.