Background Despite all local authorities in England signing up to the Armed Forces Covenant, only a small proportion of Joint Strategic Needs Assessments (JSNAs) include detailed consideration of the health of the local ex-military population. This article supports improvements to JSNAs by systematically reviewing published research for evidence of differences in health between the ex-military population and the general public.
Methods Systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology for qualitative synthesis of mixed study designs. SCOPUS, PubMed and Google Scholar were searched for published research on health outcomes among UK ex-military populations. All study designs were included.
Results 43 studies met the inclusion criteria. Rates of mental illness and hearing loss are higher among ex-military populations compared with the general public, while rates of cancer among ex-military personnel born after 1960 are lower. Despite high rates of hazardous drinking among serving personnel, rates of alcohol-related harm among ex-military populations are no higher than the general public. There is a subpopulation at increased risk of a range of adverse outcomes. This group is variously identified as younger, male, less educated, more likely to have served in a combat role and/or left service early.
Conclusions This review found evidence of areas of increased and reduced disease burden among ex-military populations. More detailed information on the make-up of the local ex-service population would support more meaningful needs assessments. The Ministry of Defence and local authorities and service providers should work together to support early identification and targeted support for those at the highest risk of adverse outcomes.
- systematic review
- health needs assessment
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The ex-military population appears less healthy than the general public in some respects, such as mental health and hearing impairments.
There are areas where former members of the Armed Forces appear healthier than the general public, such as cancer rates among those born after 1960.
There is a subpopulation of ex-military personnel at increased risk of a range of adverse outcomes.
These people are typically young, male, less highly educated, served in a combat role and/or left service early.
The Ministry of Defence, local authorities, and providers of health and other services should work together to identify those service leavers at highest risk of adverse outcomes.
More detailed information on local ex-military populations, such as breakdowns by service, rank and length of service, would allow more meaningful assessments of health needs.
The Armed Forces Covenant is the UK’s commitment to making sure that people who serve in its Armed Forces and their families face no disadvantage in the provision of public services, and in some circumstances receive special consideration.1 This includes commitments on access to healthcare, as well as support in a number of the wider determinants of health, including education, family well-being, housing, employment and financial assistance.2 All local authorities in England have signed up to the Armed Forces Covenant, as have NHS England and Public Health England.
However, a review of 150 local authorities’ joint strategic needs assessments (JSNAs) in 2015 for the Forces in Mind Trust found that only 40% included a reference to the health needs of former members of the Armed Forces. Of those JSNAs that do mention the ex-military population, only 18% contained more than a brief mention of people who have served in the Armed Forces as a vulnerable group, often in the context of alcohol-related harm. Only a handful had a fuller discussion of the full range of health needs among the local ex-military population.3
Health needs assessments depend on published evidence of the burden of disease in specific populations. This paper summarises published evidence on whether and how the health of people who have served in the UK’s Armed Forces differs from the general public. As well as evidence on illness, it includes evidence on the wider determinants of health. It updates a previous review carried out by the Liverpool Public Health Observatory.4 The review was carried out as part of a health needs assessment for the ex-military population of Tameside. It supports wider efforts to improve health needs assessments of ex-military populations by local authorities, and is intended to inform the commissioning of healthcare and other public services.
This study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology for qualitative synthesis of mixed study designs.5
SCOPUS, PubMed and Google scholar were searched for original research or review articles published from 2013 onwards using the search terms [“(military OR veteran*) AND health”] in title abstract or keywords. The search was carried out on 18 August 2017. Inclusion criteria were studies of health outcomes in UK ex-military populations from 1 January 2013 to 18 August 2017. Original research and review articles published in English were included. To get as broad an overview of the published literature as possible, all study designs were included. Journal subject areas were limited to Medicine, Nursing, Health, Social Sciences, Psychology and Neurosciences.
Abstracts were reviewed for relevance against the inclusion criteria. Further studies were identified by snowball searching of references of included studies. Studies in the grey literature were identified by manual searching of the websites of key organisations (King’s Centre for Military Health Research, Ministry of Defence, Royal British Legion, Forces in Mind Trust) and Google searches.
For each study, the author(s), publication year, research methodology and key findings were extracted. Systematic assessment of study design quality and assessment of publication bias were not feasible, owing to the wide range of study designs included in the review.
The literature search identified 428 publications. After review of abstracts, 36 relevant studies were identified in the research literature. Seven further studies were identified in the grey literature. Forty-three studies in total met the search criteria. Figure 1 illustrates the flow of studies through the process.
Table 1 presents a breakdown of studies by research design. The most common study designs found were cohort studies and cross-sectional surveys, with smaller numbers of systematic and non-systematic reviews and descriptive epidemiological studies.
Table 2 describes the distribution of evidence across the various areas of health included in this review. By far, the most common area of health studied was mental health. There was also a significant overlap in the studies on mental health and alcohol and substance misuse, reflecting their common comorbidity.
Table 3 provides a list of the studies included in the qualitative synthesis.
Health and burden of disease
A study by the Ministry of Defence found that 74.3% of working-age ex-military rated their health as ‘good’ or ‘very good’, compared with 77.7% of the general population, and 40.1% of working-age ex-military report a long-term condition, compared with 35.4% of the general population (Table 3, study 1).6 These differences were not statistically significant, but this might have been caused by lack of statistical power. The overall similarities may also hide differences in specific areas of health or in subgroups of ex-military personnel. Previous needs assessments (studies 2 and 3) have found evidence of differences in specific areas of health between ex-military personnel and the wider public.3 4 This review found further evidence of differences in specific health needs and variations in health within the ex-service population. These studies are summarised below.
People who have served in the UK’s Armed Forces have higher rates of mental illness than the general population (studies 4 and 5).7 8 The most common conditions are depression, anxiety, panic and adjustment disorder. Post-traumatic stress disorder does not appear to be more common among former members of the Armed Forces than in the general public, although it is more common in reservists than in regulars (studies 6 and 7).9 10 There is also evidence from qualitative research that members of the Armed Forces experiencing depression may delay getting help and present differently (study 8).11
Overall suicide rates are similar to the general population (studies 9 and 10), but men leaving the Armed Forces before age 25 have a risk of suicide two to three times higher than the general population, while older ex-military men have a lower risk of suicide than the general population (study 10).12 13 Rates of self-harm appear to be lower than the general population (study 11).14
The risk of mental illness appears to be higher among those who left service early (studies 5, 11 and 12),8 15 16 served in a combat role (studies 13 and 14),17 18 were exposed to improvised explosive devices (study 15),19 were evacuated because of an injury (study 16)20 and among reservists (studies 17 and 18).21 22 Cumulative time spent on deployment is associated with an increased risk of post-traumatic stress disorder and psychological distress (study 18).22 However, longer service is associated with rates of mental illness similar to the general population (study 5).8 The loss of social networks in the transition from military to civilian life may also contribute to risk of mental illness (study 19).23
Alcohol and substance misuse
Study 20 (along with earlier studies) found evidence of high rates of alcohol use and hazardous drinking in serving members of the Armed Forces.24 25 Despite this, studies 21 and 22 found no evidence of differences between people who served in the military and the general public in alcoholic liver disease, alcohol-related deaths or severity of alcohol-related problems.26 27 However, younger service leavers and those who leave service early appear to be at higher risk of alcohol-related harms (studies 21 and 23).26 28 There is also evidence that people who have served in the Armed Forces may take longer before seeking help and may stay longer in hospital (study 22).27
Alcohol misuse among former members of the Armed Forces is associated with a wide range of mental illness (study 24) and changes in the degree of hazardous drinking are associated with changes in severity of psychiatric symptoms (study 20).24 29
Overall cancer incidence is similar between people who have served in the Armed Forces and the general public, but former members of the Armed Forces born from 1960 onwards appear to be at lower risk than the general public (studies 25 and 26).30 31 Rates of smoking-related cancers are higher in people who served in the Armed Forces, although this has declined over time and those born from 1960 onwards have a lower risk of lung cancer than the general public (study 27).32 People born in 1960–1964 who served in the Armed Forces also appear to have an increased risk of bladder and pancreatic cancer (study 28).31
Study 28 found that men who served in the military who were born before 1959 appear to be at higher risk of cardiovascular disease than the general public.33 Men born from 1960 onwards and women who served in the Armed Forces experience similar rates of cardiovascular disease to the general population.33 This may be linked to higher rates of smoking: the pattern of risk among the ex-military population is similar to that for smoking-related cancer, and military personnel are more physically active than the general public (study 29) and have similar or lower rates of obesity (study 30).34 35
Neurological and sensory conditions
Men who have served in the Armed Forces appear to be at higher risk of motor neuron disease (study 31) but not multiple sclerosis (study 26) compared with men who have not served in the Armed Forces.31 36 A range of possible explanations for this increased risk has been suggested, including smoking, alcohol, trauma, toxins and vigorous physical activity. An association between motor neuron disease and trauma has been found in both people who have served in the Armed Forces and those who have not (study 31).36
Study 1 found that younger former members of the Armed Forces are two to three times more likely to report problems hearing than people of the same age who have not served in the Armed Forces.6
Musculoskeletal disorders are the most common reason for medical discharge from the Armed Forces, accounting for 60% of medical discharges for regular members of the Armed Forces between 2010/2011 and 2014/2015.37 Study 1 found evidence of increased rates of musculoskeletal illness among ex-military personnel in some English regions but not others.6
People who serve in the Armed Forces are at increased risk of physical injury compared with the general public, both during training and while on deployment. Studies 33 and 34 found evidence that those injured on operations between 2003 and 2012 are surviving increasingly severe injuries, as a result of improvements in battlefield trauma care.38–40 Study 35 found that injuries caused by improvised explosive devices are associated with complications that are rare in civilian casualties.41 42
At-risk or vulnerable groups
While people who have left the Armed Forces appear not to differ from the general population in terms of most aspects of health, a small proportion find the transition from military to civilian life difficult. Study 12 found that this is more likely for people who leave service early, who often leave at short notice, have little time to plan for the transition to civilian life and tend to have lower levels of education and qualification.16 Study 36 found that poor transition is associated with a higher risk of mental illness, suicide, alcohol misuse, homelessness and unemployment.43
The literature review found little evidence on the health needs of the families of those who have served in the UK’s Armed Forces. Study 37 found that military parents report low levels of serious illness in their children, but this is an imperfect measure.44 Limited international literature (study 38) suggests that children of service personnel may have a higher risk of behavioural problems and mental illness, particularly where the serving parent had a diagnosis of post-traumatic stress disorder.45
Wider determinants of health
Income and employment
Study 1 found that those who have served in the Armed Forces have similar rates of employment to the general public.6 However, study 39 found qualitative evidence that those who need to use the benefits system may face particular challenges in claiming benefits and looking for work caused by a lack of familiarity with civilian welfare systems and lack of understanding of military skills and qualifications on the part of some benefits advisers.46
Study 1 found that former members of the Armed Forces are less likely to hold a degree-level qualification than the general public.6 Study 40 found that education levels among non-officer infantry recruits were particularly low.47 Study 1 also found that people who served in the Armed Forces are more likely to have gained qualifications through work. This may be a protective aspect of military service. In other respects education levels in the ex-military population is similar to the general public (study 3).6
Estimates of the proportion of people that are homeless who have served in the UK’s Armed Forces vary from 5% to 25%, but high-quality evidence is lacking. Homeless former members of the Armed Forces appear similar to other homeless people, but may be older on average.4 6 An earlier needs assessment (study 3) found evidence that homeless people who have served in the Armed Forces are more likely to have slept rough, and are more likely to have served in the Army than the Navy or Royal Air Force.4
Crime and imprisonment
Overall, rates of offending are lower among the ex-military population than the general public (study 1), but studies 41 and 42 found evidence of increased violent offending among men under 30 years old and those who were deployed in a combat role.48 49
Study 43 found that people approximately 5% of the prison population have served in the Armed Forces.50 This is similar to the proportion of the overall population,6 suggesting that people who have left the Armed Forces are not more likely to be imprisoned. Imprisoned former members of the Armed Forces appear more likely to have qualifications, and to have worked full time before imprisonment, and less likely to have substance misuse problems than the general prison population.50
While general health appears similar between ex-military and non-military populations, there is evidence of differences in the burden of specific conditions between ex-military personnel and the general public. These include mental health, musculoskeletal conditions and hearing. Despite evidence of high levels of hazardous drinking among serving military personnel, there is no evidence of greater levels of alcohol-related illness among former members of the Armed Forces as a whole. There are also areas where the health of the ex-military population is better than the general public, such as cancer among younger veterans, and rates of self-harm and suicide among those with longer service careers.
The evidence found in this review suggests that it is difficult to generalise about the health of people who have served in the Armed Forces. Factors such as the branch of the Armed Forces in which a person serves, profession and rank, length of service, gender, levels of education, whether they left service early or served in a combat role are important in determining risk of a range of adverse health outcomes. These risk factors appear to cluster, suggesting a small proportion of leavers, typically those who are younger, male, with lower educational achievement and exposure to combat, are at higher risk for a number of linked adverse outcomes, such as homelessness, unemployment, mental illness, substance misuse, violent offending and suicide. There is also evidence that these people may present later and differently to civilians with similar problems, and so may not receive the help that they need.
Strengths and limitations
The literature review covers a wide range of health needs and provides evidence covering many of the wider determinants of health. It provides a basis for the assessment of health needs among ex-military populations. However, like all literature reviews, it is limited by what research is publicly available. There are relatively few large-scale, methodologically rigorous epidemiological studies that provide comparisons between ex-military personnel and the general public. Because of this, a wide range of study designs are included here. This has prevented the use of a systematic framework for assessing study quality, or the assessment of publication bias. As a result, there remains a risk that the conclusions here are subject to methodological and publication biases.
There are also at least two noticeable gaps in the research literature. First, there is an important evidence gap around the health of close family members of military personnel, particularly partners and children. The lack of robust evidence on the health needs of military families limits the ability of local authorities and commissioners and providers of health and social care services to meet their obligations to military families under the Armed Forces Covenant.
Second, this review found limited evidence on the barriers that former members of the Armed Forces may face in accessing healthcare and other services. Such barriers may include aspects of the civilian care system itself, such as failure to note military service in medical records, or lack of understanding on the likely needs of ex-military personnel among healthcare staff. Features of military life such as a culture of ‘not going sick’ leading to delays in seeking care may also contribute. There may also be complex interactions between military culture and civilian healthcare, such as expectations about waiting times for healthcare derived from military service creating unrealistic expectations of civilian healthcare and other services. Again, the lack of evidence may be limiting the ability of healthcare providers to meet the needs of ex-military patients.
Implications for policy-makers and service providers
Studies included in this review identify a number of factors that influence risk among ex-military personnel. For this information to be useful, data on ex-military population must be available that provide a more nuanced description of the local ex-military population. This could include breakdowns of population by age, armed service, rank and length of service. This would allow local authorities and providers of health and other services to the ex-military population to develop a more accurate picture of the likely level of need locally.
A common feature of studies included in this review is that, while former members of the Armed Forces fare well in general, there is a subpopulation who are at higher risk of a range of linked adverse outcomes. Studies variously identify this group as early service leavers, younger, male, less highly educated and more likely to have served in a combat role. The Ministry of Defence, local authorities, and providers of health and other services should work together to identify these service leavers early and provide targeted support. Service providers may consider incorporating this evidence into training programmes for staff to raise awareness of the likely health needs of ex-military service users.
I would like to thank Gideon Smith for his support and encouragement in conducting this review as part of a health needs assessment for the ex-military population of Tameside.
Contributors SLS designed the study, carried out the literature search, performed the analysis and drafted the manuscript.
Funding The author has not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient consent Not required.
Ethics approval No ethical approval was required for this literature review.
Provenance and peer review Not commissioned; internally peer reviewed.
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