Introduction We investigated the effect of unmet medical need on the mental health of Republic of Korea (ROK) Armed Forces personnel, as most of the service members work in remote areas and often experience such unmet needs.
Methods This study used secondary data from the 2014 Military Health Survey (MHS), conducted by the ROK School of Military Medicine and designed to collect military health determinants. Descriptive statistics showed the general characteristics of the study populations by variable. We specifically compared the population after stratifying participants by suicide ideation. An analysis of variance was also carried out to compare Kessler Psychological Distress Scale 10 Scores. Additionally, dependent spouses and children of both active-duty service members and retirees are included among those entitled to Military Health System healthcare.
Results Among the 4967 military personnel, 681 (13.7%) individuals reported an experience of unmet medical need within the past 12 months and gave reasons of ‘no time (5.15%)’, ‘long office wait (2.6%)’, ‘no money (0.22%)’, ‘long distance from base (1.19%)’, ‘illness but not very serious (1.65%)’, ‘mistrust in doctors (1.95%)’ and ‘pressure due to performance appraisal (0.95%)’. Regression analysis revealed that unmet medical need was significantly associated with negative mental health (β=1.753, p<0.0001) and increased suicide ideation (OR=2.649, 95% CI 1.84 to 3.82). Also, soldiers reporting unmet medical need due to ‘no money’, ‘no time’ or ‘pressure due to performance appraisal’ were significantly more likely to experience similar negative mental health effects.
Conclusions Our study indicates that unmet medical need is significantly associated with soldiers' mental health decline and suicide ideation, highlighting the importance of providing military personnel with timely, affordable and sufficient medical care.
- unmet medical need
- MENTAL HEALTH
- HEALTH SERVICES ADMINISTRATION & MANAGEMENT
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Military personnel report being unable to address their perceived physical healthcare needs due to their duties or work schedules.
Each country has a different type of healthcare system in accordance with its unique sociocultural environment. These differences among healthcare systems can be associated with the medical use behaviours of personnel.
Among our study participants, 681 (13.7%) and 155 (3.1%) individuals reported experiencing unmet medical needs or had considered suicide in the past 12 months, respectively.
Generally, experience of unmet medical need was negatively associated with the mental health and suicide ideation of military personnel.
The impact of experience of unmet medical need on mental health largely depended upon the specific reasons for the unmet medical need.
With respect to medical care, many socioeconomic factors, such as cost, lack of time off work and lack of medical facilities are associated with the occurrence of unmet medical need.1–4 Unmet medical need describes a situation in which a person desires or requires medical attention, especially to address a preventable or treatable condition, but did not receive medical care.5 This need is often an indicator of limited access to health services and may increase the likelihood of complications in patients due to lack of timely or appropriate treatment.6
In previous studies involving patients with psychiatric disorders, active medical intervention could be provided to help alleviate symptoms, but lack of psychiatric treatment often led to significant changes in clinical outcomes.7 ,8 Psychological stress is a widespread problem, even among non-psychiatric patients, especially in various social environments.9 Thus, unmet medical need with respect to a patient's mental health is relevant to nearly all individuals and the two may be associated. In these studies, unmet medical need exhibited a negative association with quality of life (QOL), which can be improved by addressing an existing unmet medical need.10 ,11
Many countries have different types of healthcare systems in accordance with their unique sociocultural environments, but many provide welfare benefits for their armed forces as well, meaning that the scope of military healthcare services provided to soldiers varies depending on the circumstances of their country. The ‘TRICARE’ programme of the US military provides health insurance coverage to those who are entitled to benefits on the basis of current or past service in the armed services. Most soldiers on active duty are subject to free medical services at both military and civilian hospitals through TRICARE. Additionally, dependent spouses and children of both active-duty service members and retirees are included among those entitled to Military Health System healthcare.12
In contrast to the USA, the UK has a government-sponsored universal healthcare system (the National Health Service), which consists of a series of publicly funded healthcare systems.13 Additionally, primary healthcare in the military context includes general practice, dentistry, occupational medicine and community mental health services within the UK and at defence outposts overseas.
In ROK, the National Health Insurance system was introduced in 1977 and was gradually extended to the self-employed and ultimately to the entire population in July 1989,14 and is equally applicable to the ROK military healthcare system. Under this system, most people pay a proportion of medical fees in accordance with their medical use, but the ROK Armed Forces essentially pay the soldier's proportion of medical fees only at military medical facilities, unless military personnel need to use a private hospital for emergency situations or when the required treatment is not available at military medical facilities. However, if military personnel are injured outside of military missions or if they wish to use a private medical facility, they must pay their proportion of medical fees themselves. Moreover, these medical benefits do not apply to dependent spouses and children of military personnel.15 ,16
In ROK it is mandatory for men over 19 years of age to serve in the military for a certain amount of time. Given this requirement, certain military personnel might have a negative perception of military service, and such characteristics could be associated with medical service utilisation or mental health.
Although many studies have explored possible relationships between unmet medical need and QOL, studies examining associations between unmet medical need and mental health are limited. More specifically, ROK military officers may not be able to address their perceived physical healthcare needs due to their duties or work schedules. They may also decline medical attention as a result of pressure to receive a positive work evaluation, particularly those of higher rank due to their need to show leadership.17 Thus, military personnel may experience unique unmet medical needs that could be associated with their mental health. Because of limited data regarding this relationship and the current state of the ROK Armed Forces, we investigated possible associations between mental health and unmet medical need in ROK military personnel, in the first study of its kind.
This study used data from the 2014 Military Health Survey (MHS) conducted by the ROK School of Military Medicine, which is based on the Korea National Health and Nutrition Examination Survey which is an ongoing surveillance system that monitors trends in health risk factors and the prevalence of major chronic diseases, and provides data for the development and evaluation of health policies and programmes in Korea.18 Similarly, the MHS is composed of general characteristics, health behaviour, injuries and safety consciousness, social support, disease and medical service use, and specific female soldier questionnaires. The MHS questionnaire is composed of 170 items for participants with a rank above E5 and 100 items for those with a rank below E4. Additionally, to represent the entire population of ROK military personnel, the MHS used stratified random sampling. Specifically, the MHS sampling considered the soldier's gender, rank, service type and working area. We used secondary data and raw data obtained from the Korean Military Medical School with the Dean's approval. Because the 2014 MHS was an anonymous, self-administered survey, individual responses cannot be linked to specific personnel or medical records. Information from 8009 military personnel (officers, non-commissioned officers (NCOs) and warrant officers: n=3599; enlisted soldiers: n=4410) was initially included in the data; however, of those included, 3042 personnel had incomplete data for the independent or dependent variables associated with the present research. Thus, in order to determine what to do with the incomplete data, all analyses were performed twice, once with the personnel with incomplete data excluded, and once with those with incomplete data included. Comparison of the main results indicated that the inclusion of personnel with incomplete data did not result in significant differences. Thus, for our present research, the 3042 personnel with incomplete data were excluded from the study but the data are available as an online supplementary file. The final number of records from military personnel used in our study was 4967.
The first dependent variable was the score on the Kessler Psychological Distress Scale 10 (K-10) Index, a self-reporting instrument consisting of 10 items with scores ranging from 10 to 50, designed to measure the level of respondent distress in both clinical and population surveys and is an excellent screening tool for mental health disorders.19 The 2001 Victorian Population Health Survey adopted a set of cut-off scores as a guide for psychological distress screening,20 although K-10 test validation is dependent upon the characteristics of each country in which the instrument is given. For example, although disorders are typically screened by setting the optimal score to 24 points,21 in South Korea, K-10 test validation for the Korean senior population has been proposed to be 20–21 points.22
Military personnel completed the 10 self-administered questions which had 5 possible responses with regard to the previous month's experience: ‘all the time’, ‘most of the time’, ‘some of the time’, ‘a little of the time’ or ‘none of the time’ scoring 5, 4, 3, 2 or 1, respectively. Higher scores were generally indicative of greater degrees of psychological distress.23
The second dependent variable was suicide ideation, which is an important risk factor for suicide attempts and completions; participants with very high K-10 Scores are more likely to report suicidal ideation, thus, K-10 Score could be a clinically useful indicator of the presence of suicidal ideation.24 In the 2014 MHS, suicide ideation was determined by responses to the question: ‘During the past 12 months, have you ever considered suicide?’.
The variable of primary interest was unmet medical need determined by responses to the following question: ‘During the last 12 months, have you ever needed medical care but could not get it?’ with possible responses of ‘yes’, ‘no’ or ‘medical care or tests are never required’ reclassified into as one of seven groups of responses to a specific question: (1) no money to pay for service; (2) no time to go for service; (3) do not believe in doctors; (4) illness not very serious; (5) difficult to make an appointment or long office wait; (6) medical facility is distant from military base; or (7) pressure for performance appraisal.
Other independent variables considered in the analysis were age, gender, education level, marital status, military service, military branch, rank, service classification, length of service, working place, working time, perceived health status, stress about health status, having additional private supplemental health insurance, physical activity, weight fluctuation in the past year, smoking status. ‘Military branch’ was classified into combat branch (infantry, armour, artillery, air defence, intelligence, engineering, information/communication and aviation) or non-combat branch (ordinance, quarter master, transportation, chemical, adjutant general, military police, finance, troop information and education, medical, judge advocate and chaplain). Rank was classified as enlisted soldier (E1–E2), enlisted soldier (E3–E4), non-commissioned officer (E5–E6), non-commissioned officer (E7–E9), warrant officer and company grade officer (W1–O3), and field grade officer (O4–O6). Service classification was grouped as short-term military service which was the basic service period of military service (3 years) or long-term military service beyond that; work place was defined as isolated military area, urban or rural and ‘Having additional private supplemental health insurance’ was classified as either ‘yes’ or ‘no/don't know’.
Descriptive statistics show the general characteristics of the study populations by variable. To compare average K-10 values according to independent variables, analyses of variance were performed. Multiple linear and logistic regression models were used to examine the association between unmet medical need with K-10 Score and suicide ideation, respectively. Additional multiple linear and logistic regression analysis was similarly carried out twice to examine the association between the primary reasons of unmet medical need with K-10 Score and suicide ideation. ORs and 95% CIs were calculated. All analyses were performed using SAS V.9.4 software (SAS Institute, Cary, North Carolina, USA).
The study population consisted of 4967 military personnel of the ROK Armed Forces. Among all participants, 681 (13.7%) and 155 (3.1%) individuals reported experiencing unmet medical needs or had considered suicide in the past 12 months, respectively. Primary reasons for experiencing unmet medical need included ‘no time to go for service’ (37.6%), followed by ‘difficult to make an appointment or long office wait’ (18.9%), ‘do not believe in doctors’ (14.2%) and ‘illness not very serious’ (12.0%). These results, along with demographic information and other survey responses, are summarised in Table 1. The average K-10 Score was significantly higher for individuals with an unmet medical need and in those who had considered suicide. The average K-10 Score was highest for respondents who gave the primary reason of ‘no time to go for service’ for their unmet medical need compared with the other primary reason groups. With respect to rank, the average K-10 Score was highest for the enlisted soldier (E1–E2) group than for the other rank groups. In addition, individuals with a self-perceived health status of ‘poor’ exhibited the highest average K-10 Scores compared with the ‘good’ and ‘moderate’ groups, and women had higher K-10 Scores than male personnel (Table 1).
Regarding the relationship between unmet medical need and mental health, having an experience of unmet medical need was positively associated with risk for negative mental health. Scores were significantly higher for the female group than for the male group. The K-10 Score for rank in the enlisted soldier (E1–E2) group was the higher than in the other rank group. Scores were significantly higher for those with ‘poor’ self-perceived health status compared with those in the ‘good’ and ‘moderate’ groups. The mean K-10 Score was significantly higher for the ‘yes’ than the ‘no/don't know’ group with regard to having additional private supplemental health insurance. Compared with those with an experience of unmet medical need, a greater proportion of personnel had a higher suicide ideation. Also, regarding self-perceived health status, ‘poor’ health status was positively associated with risk for increased suicide ideation. (Table 2, Figures 1 and 2).
Regarding primary reasons for unmet medical need, soldiers who responded ‘no money to pay for service’, ‘medical facility is distant from military base’, ‘illness not very serious’ or ‘do not believe in doctors’ usually had higher K-10 Scores than those in the other primary reason groups (Figure 1). Also, a greater proportion of personnel in the ‘no money to pay for service’, ‘pressure for performance appraisal’, ‘do not believe in doctors’ and ‘no time to go for service’ response groups had a higher rate of suicide ideation than respondents from other primary reason groups (Figure 2).
This study analysed how unmet medical need is associated with the mental health of ROK Armed Forces military personnel. Generally, unmet medical need occurrence was higher for military personnel who had no time to go for medical service and experienced difficulty in making an appointment or long office waits. This finding corroborates those from previous studies that determined that military personnel often experience decreased QOL and eventual mental health-related hospitalisation as a result of unmet medical need.25 In addition, depressive symptoms typically predict greater medical care utilisation,26 although suicide ideation could be reduced by healthcare intervention.27
Unmet medical needs that occurred due to lack of money were found to have the highest negative relationship to both K-10 Scale and suicide ideation. Particularly, when the association between mental health and suicide ideation according to unmet medical need was examined, the most significant reason given was ‘no money to pay for service’ (OR=7.41, 95% CI=1.41 to 39.05). Given that participants with very high K-10 Scores were more likely to report suicidal ideation, unmet medical needs that occur due to lack of money should be considered carefully.
In a previous study, the association between financial hardship and health self-efficacy was explained by unmet medical need due to cost.28 In the UK, the primary care system is better equipped than most other countries, and the UK population has high confidence in their primary care. In addition, there are appropriate controls on the flow of patients, such as judgement and care for patients in primary care. Thus, the unmet medical experience of UK soldiers may not be a healthcare system problem; a UK study of veterans with mental health problems found that many of their issues with healthcare seeking were related to psychological or psychiatric factors.29 However, in the primary healthcare system of the ROK military, one general practitioner at the lowest echelon of the infantry battalion is appointed and is responsible for the care of about 500 military personnel; as such, there is a lack of medical staff appointed for primary care. Unlike the UK, ROK military personnel are able to go directly to a secondary institution without visiting a primary institution first, which can increase waiting times there17 and thus many consider receiving medical treatment in private hospitals. As such, many patients receive treatment by paying for the care that would normally be provided free of charge at military medical facilities in private hospitals; therefore, this problem of the healthcare system in the ROK military could act as a factor for increasing the medical costs of soldiers and could also be associated with psychiatric factors.
The US military provides the majority of healthcare services and costs for military personnel, regardless of the various situations of soldiers, thus, the claimed association of unmet medical need with medical monetary cost does not apply in this case, but the proportion of the national defence and military healthcare budgets is much lower in ROK than USA.30–32 Although the ROK military healthcare system provides basic healthcare service to military personnel, coverage of expenses incurred for this service is limited. For example, if the disease or condition occurs when soldiers are not on official duty, the military healthcare system does not provide health benefits to them; in such cases soldiers must pay for their own medical care. Thus, intervention for military personnel with poor financial resources should be considered when expanding clinic-based health assessments to capture financial hardship and unmet medical need due to cost as potential contributors to low health self-efficacy.
Overall, unmet medical need occurrence and its influence on mental health and suicide ideation were similar with respect to the reason given for lack of care. However, unmet medical need due to ‘no time to go for service’ or ‘pressure for performance appraisal’ and suicide ideation as indicated by the K-10 Scale was more frequent than among other response groups. This relationship could be explained by soldiers whose access to medical facilities may be limited due to long-term outdoor training or whose branch of service discourages them from seeking care. Planning an integrated training approach for combat and medical services corps is important for providing medical services to combat troops in the field. In addition, in smaller field training situations, patient-centred medical assistance should be activated to support deployed groups of personnel. Moreover, heavy workloads can limit time available to use medical facilities during working hours, and unsurprisingly, health problems experienced outside of normal business hours are a leading source of emergency department visits.33 Unmet medical need that occurs due to lack of time has a negative relationship with mental health and suicide ideation, which is exacerbated in certain military personnel as the medical facilities follow a schedule similar to that of combat troops. As a result, only emergency care is often available to these soldiers, leading to unmet medical need. Alternatives to address this unmet medical need could include adapting military medical facility operating hours to the duty hours of the combat unit.
In addition, the greatest difference in the associations of experience of unmet medical needs with K-10 and suicide ideation was unmet medical needs that occur as a result of pressure due to performance appraisal. For that reason, the degree of suicide ideation (OR=5.36, 95% CI 1.88 to 15.30) was relatively greater than the degree of K-10 Scale (β=1.807, p=0.0059).
According to previous studies, work-related pressure is often associated with depression and leads to negative business performance. Because employees are commonly faced with greater demands and less job security, psychological disorders are increasingly caused by work-related stressors.34–37 Furthermore, our results show that unmet medical need is significantly associated with negative mental health and suicide consideration. Previous studies also noted that the stigma connected to mental health problems has been highlighted as a key barrier that prevents serving and ex-serving personnel from seeking help.38
The results of this study also indicate a higher association between psychiatric problems and burdensome events related to job performance or unmet medical evaluation. Our results could be interpreted to suggest that those with more mental health distress perceive it as a barrier to seeking healthcare. However, due to the limitations of the data, we were unable to confirm whether certain military personnel had psychiatric disease or not. Thus, future studies will be needed to determine the association between unmet medical needs and soldiers with psychiatric disorders.
Our study identified factors contributing to unmet medical need occurrence and determined that many of them relate to political and cultural characteristics unique to South Korea, although the study should be considered in the context of its strengths and limitations. First, the data were collected from a survey of ROK Armed Forces personnel that used stratified random sampling. Thus, the survey results potentially represent 600 000 ROK Armed Forces individuals. Second, our study analysed both the unmet medical need occurrence and the primary reasons given by respondents. Third, this study is based on the K-10 Index, an excellent screening tool for mental health disorders39 as well as suicide ideation. Finally, as far as we know, this is the first study to use MHS data to assess unmet medical need in this population. With respect to its limitations, our study is cross-sectional, so we could not identify a causal relationship between unmet medical need and mental health. Second, unmet medical need, mental health, and suicide ideation were measured by a self-reported questionnaire. Third, we were unable to ascertain whether there is actual unmet need, only that the personnel have had a perceived need that they experienced as not being met. Lastly, because of limited data access, we did not review the clinical records of military personnel with insomnia and diagnosed mental health problems. Therefore, we were unable to distinguish these individuals from the other respondents.
Based on this research, it is essential for the military to address factors that promote unmet medical need occurrence for their personnel. Specifically, those who reported lack of time and work evaluation-related pressure experienced the most severe unmet medical need, which in many situations was negatively associated with mental health and suicide ideation.
We identified a distinguishable relationship between unmet medical need and mental health among ROK military personnel and determined the most significant factors that lead to such need in this population. Our results may help minimise negative psychological effects caused by unmet medical need and prevent its occurrence if certain factors, such as healthcare availability and a restructured work evaluation system, are addressed.
Contributors CPT, TKK has received commissioned education at Yonsei University, Seoul, Republic of Korea, designed the study, researched the data, performed statistical analyses and wrote the manuscript. SGL, K-TH, YC, SYL and E-CP contributed to the discussion and reviewed and edited the manuscript. E-CP is the guarantor of this work and as such, takes responsibility for the integrity of the data and the accuracy of the data analysis.
Competing interests The views expressed in this article are those of the authors and do not reflect the official policy or position of the Ministry of National Defense or the Korea government.
Ethics approval The Institutional Review Board (IRB) of the Armed Forces Medical Command (AFMC) provided formal ethics approval for the MHS data sets (IRB approval number AFMC-14-IRB-004).
Provenance and peer review Not commissioned; externally peer reviewed.