Gender differences in barriers to mental healthcare for UK military veterans: a preliminary investigation

'I never thought of myself as a veteran': written reflections on veteran identity by ex-servicewomen in Wales

INTRODUCTION

Although over 2 50 000 women in England and Wales have served in the armed forces, veteran research has historically focused on men, with only 2% of international studies including women. This study examines how veteran identity, defined as the significance of military service to one's self-concept, shapes ex-servicewomen's connection to the veteran community.

METHODS

Qualitative written reflections were collected from 21 ex-servicewomen. Participants reflected on their perception of what constitutes a veteran, and whether the term 'veteran' formed part of their identity. The researchers employed reflexive thematic analysis, using NVivo V.14.

RESULTS

Participants generally understood the official UK government definition of a veteran. Additionally, women's understanding of the meaning of the term veteran was related to someone having served in the military, having shared core values relating to military service and preconceived associations of the term veteran with men, older age and particular conflicts. In relation to their own veteran identity, results indicate that while some participants experienced a sense of pride and belonging tied to their veteran identity, others struggled with feelings of unworthiness, especially if they had shorter service periods or non-combat roles. Many participants also described a delayed identification with veteran status due to stereotypical perceptions and negative in-service experiences.

CONCLUSIONS

This study aligns with previous evidence that ex-servicewomen struggle to identify with the term veteran. Both stereotypical societal perceptions of who a veteran is, often older men with combat experience and longer terms of service, and negative military experiences were factors related to women's non-identification or delayed identification with their veteran identity. This study underscores the importance of peer support opportunities for ex-servicewomen. For some, engaging with other ex-servicewomen and participating in the veteran community was a factor in developing connection to being a veteran, which they previously had not identified with.

Personalising veteran healthcare: recognising barriers to access for minority and under-represented groups of veterans

Veterans are not a demographically homogenous group, yet minority groups continue to be under-represented in research and report feeling less able to access clinical services to seek support. While veteran-specific healthcare has responded to the needs of the majority, the success of veteran mental health services is contingent on serving the whole veteran population. Key to the personalisation of healthcare is the question of access and a need to address specific inequalities and barriers to help-seeking behaviour. In this paper, we explore the issues of access to veteran healthcare at three levels: those barriers common to all veterans; those common to all minority groups of veterans; and those relevant to specific minority groups of veterans. Stigma, military attitudes and culture (eg, stoicism), and access to services and professionals with veteran-specific knowledge are universal barriers across veteran groups. Minority groups report a heightening of these barriers, alongside being 'othered' in veteran care settings, a lack of representation of them or their experiences in service descriptions and advertising, a lack of professional cultural competencies on specific issue, and the veteran environment potentially being retraumatising. Finally, barriers specific to individual groups are discussed. Attending to these is essential in developing holistic approaches to personalised healthcare that meets the needs of all veterans.

UK female veterans' physical health: perceived impact of military service and experiences of accessing healthcare. Findings of a qualitative study

INTRODUCTION

Women make up almost 14% of the UK's veteran population; however, little is known about female veterans' physical health and experiences of accessing healthcare after military service. As part of a qualitative study to understand female veterans' experiences of statutory and charitable support, participants were asked if they felt anything about their military service had impacted their physical health as civilians. They were also asked about their experiences with accessing healthcare and any associated challenges. The aim of this paper is to outline participants' responses to inform the development of further research.

METHODS

85 women who had served in the British Armed Forces took part in semistructured interviews conducted via Microsoft Teams between June and December 2022. Reflexive thematic analysis of interview transcripts was conducted to identify, analyse and report repeated patterns in responses to questions.

RESULTS

Participants reported a range of physical health consequences that they attributed to military service. These included injuries sustained during training and deployment, 'wear and tear' through training and the impact of sometimes unsuitable clothing. They reported chronic pain, tendonitis, arthritis, slipped discs, broken bones and hearing loss. Some described their lives as severely restricted as a result. Challenges to accessing healthcare included perceived stigma associated with help-seeking, inconsistency around the transfer of medical records and a widespread lack of veteran awareness among civilian healthcare professionals.

CONCLUSIONS

There is a distinct lack of research in the UK against which to compare these findings; thus, further research is required in all areas of female veterans' physical health and experiences of accessing healthcare. Research should begin by establishing the nature and prevalence of health conditions among female and male veterans to identify the unique needs of both and tailor support accordingly.

Female military service members and veterans: Understanding treatment seeking behavior and previous suicide risk among suicide decedents

To examine the differences in treatment seeking behaviors, previous suicidal thoughts, previous suicide attempts, and disclosure of suicidal thoughts among female service members (SM)/Veteran suicide decedents who used a firearm and those who used another method. Data was acquired from the National Violent Death Reporting System which is maintained and monitored by the Center for Disease Control and Prevention. Data included in the present study were from suicide deaths that occurred between 2003-2018. Female SM/Veterans who died by firearm suicide had lower proportions of current mental health or substance use treatment, lifetime mental health or substance use treatment, and previous suicide attempts compared to those who used another method. Female SM/Veterans who die by firearm suicide are less likely to encounter mental health services than those who use another method. Conversations on secure firearm storage need to occur outside of the health care setting.

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

PURPOSE

Structural 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.

METHODS

Currently 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.

RESULTS

Overall, 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.

CONCLUSIONS

Findings 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.

Women veteran transition mental health and well-being support group programs: A scoping review

BACKGROUND

The military is a male-dominated environment and culture in which women veterans can experience significant institutional prejudice. Transition can be confusing and isolating for women veterans. Group programs are an important source of transition support. However, we know little about the specific group program needs of women veterans.

OBJECTIVES

To examine mental health and well-being support group programs delivered to women veterans, to understand what they value and find most helpful.

ELIGIBILITY CRITERIA

Women military veterans (all types); empirical studies using any design; published between 1990 and 2022; group programs focused on transition issues (such as housing, employment, education, physical health, mental health).

SOURCES OF EVIDENCE

Peer-reviewed journals and theses.

CHARTING METHODS

Six databases searched: Medline (via Ovid SP), PsycINFO (via Ovid SP), EmCare (via Ovid SP), CINAHL, Scopus, and ProQuest.

RESULTS

There was significant heterogeneity across 35 included studies in type of groups, program content and structure, length of sessions, measurement of impact, follow-up, and so forth. Most programs were delivered face to face. Physical health and preventative healthcare were important topics for women veterans, particularly reproductive health, mental health, and chronic pain. Groups that included physical activity, creative arts, and alternative therapies were beneficial to women's physical and mental health. Strengths-based women-only groups, facilitated by women, that created safe spaces for women veterans to share their experiences, enhanced self-expression, agency, and self-empowerment. This was particularly important for women who had experience military sexual trauma.

CONCLUSION

This review found a small but diverse range of group programs available for women veterans. Many program evaluations were of moderate or low quality and lacked sufficient information to determine whether benefits were sustained over time. No studies involved Australian women veterans. Despite these concerns, this review highlighted several useful lessons that could help inform improved design, delivery, and evaluation of group programs for women veterans.

Digital Therapeutic Intervention for Women in the UK Armed Forces Who Consume Alcohol at a Hazardous or Harmful Level: Protocol for a Randomized Controlled Trial

BACKGROUND

Alcohol misuse is common in the United Kingdom Armed Forces (UKAF), with prevalence significantly higher than in the general population. To date, digital health initiatives to support alcohol misuse have focused on male individuals, who represent approximately 89% of the UKAF. However, female veterans drink disproportionally more than female members of the public.

OBJECTIVE

This 2-arm participant-blinded (single-blinded) confirmatory randomized controlled trial (RCT) aims to assess the efficacy of a brief alcohol intervention (DrinksRation) in reducing weekly self-reported alcohol consumption between baseline and a 3-month follow-up (day 84) among women who have served in the UKAF.

METHODS

In this 2-arm single-blinded RCT, a smartphone app that includes interactive user-focused features tailored toward the needs of female veterans and designed to enhance participants' motivations to reduce the amount of alcohol they consume is compared with the UK Chief Medical Officer guidance on alcohol consumption. The trial will be conducted among women who have served at least 1 day of paid service in the UKAF. Recruitment, consent, and data collection will be carried out automatically through the DrinksRation app or the BeAlcoholSmart platform. The primary outcome is change in self-reported weekly alcohol consumption between baseline (day 0) and the 3-month follow-up (day 84) measured using the Timeline Follow Back for alcohol consumption. The secondary outcome is the change in the Alcohol Use Disorders Identification Test score measured at baseline and 3-month follow-up between the control and intervention groups. The process evaluation measures include (1) app use and (2) usability ratings as measured by the mHealth App Usability Questionnaire.

RESULTS

RCT recruitment will begin in January 2024 and last for 5 months. We aim to complete all data collection, including interviews, by May 2024.

CONCLUSIONS

This study will assess whether a smartphone app tailored to the needs of women who have served in the UKAF is efficacious in reducing self-reported alcohol consumption. If successful, the digital therapeutics platform could be used not only to support women who have served in the UKAF but also for other conditions and disorders.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05970484; https://www.clinicaltrials.gov/study/NCT05970484.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/51531.

'Treat everyone like they're a man': Stakeholder perspectives on the provision of health and social care support for female veterans in the UK

International research suggests that female veterans may experience gender-specific barriers to accessing veteran-specific care. This is the first UK study to report an exploratory qualitative investigation of the provision of health and social care support for female veterans and whether this support meets their needs. The research team carried out 13 virtual semi-structured interviews between October and November 2020, with representatives from statutory and third sector organisations that provide support to UK female veterans. Ethical approval was obtained from the Anglia Ruskin University School of Education and Social Care Research Ethics Committee. The authors identified four overarching themes and nine sub-themes in a thematic analysis following the framework outlined by Braun and Clarke (2006). The findings of this study suggest that practitioners from statutory and third sector organisations perceive the UK veteran support sector as male-dominated and male-targeted, with a lack of consideration for female veterans' needs. Participants reported a lack of engagement with veteran-specific services by female veterans and suggested that women either do not identify with the 'veteran' label or do not feel comfortable accessing male-dominated veteran-specific services. The need for specific services for female veterans split participant opinion, with most of those who were female veterans themselves highlighting the importance of 'safe spaces' for women, particularly those who had experienced gender-based violence during military service. Others felt that the veteran support sector currently lacked evidence of women's unique support needs, and an examination of current provision was required. The authors recommend a thorough assessment of UK female veterans' health and social care needs, alongside development of training and guidance for health and social care professionals, to ensure that veteran services are adequately developed, tailored and targeted with women's needs in mind.

Engaging veterans in the research process: a practical guide

Aims: Provide guidance for engaging military veterans in various research teams to help overcome veterans' lack of trust in research. Methods: We draw from our combined experience to present four case studies of veteran research on sensitive topics to illustrate successful engagement with veterans. Results: For each case example, we describe veterans' contributions at different phases of research. We then share practical guidance for realizing benefits and overcoming challenges of engaging veterans in research at each phase. In our experience, successful engagement has built trust by aligning research with participants' own experience as veterans. Conclusion: Investigators wishing to engage veterans in research may benefit from the lessons presented through these case studies.