Alcohol misuse in the military:Should veterans' healthcare services focus on the longer-term physical, rather than mental, consequences of deployment?
Lead Research Organisation:
King's College London
Department Name: Psychological Medicine
Abstract
There are a number of factors about the UK military which could put them at a greater risk of physical health problems and mortality than the general population. There are very high levels of alcohol use and drinking is an accepted part of military culture. In addition, military personnel are more likely to experience stressful events than the general population, particularly during deployment. Many of these stressful events have previously been found to be associated with mental health problems. The King's Centre for Military Health Research (KCMHR) cohort study was set up to look at a representative sample of UK military personnel, and collected data on mental health, alcohol use and deployment experiences. The study found that 13% of the military are abusing alcohol at a level which is hazardous to their health and overall, levels of alcohol use are much higher than the general population at all ages. Research findings from the general population have shown that both alcohol use and mental health problems are associated with poorer physical health outcomes. Therefore, it is predicted that current and future healthcare use for physical conditions will be high in the UK military population.
Identifying the future healthcare needs of military personnel and veterans is a current priority for the UK government. However, the current datasets that are available to look at use of healthcare services (and the reasons why) do not identify whether or not an individual is in the military. The proposed study will be able to identify military personnel in existing NHS datasets for England, Wales and Scotland that include secondary healthcare records, by linking to the KCMHR cohort data. In NHS hospitals, data is recorded each time someone is admitted to hospital as an inpatient, or has an outpatient visit or visits an accident and emergency department. The reason for the hospital visit is coded using an existing international classification of disease and health related problems (ICD-10). This data is collated from all hospitals and is called Hospital Episode Statistics (HES) in England. In this study, English, Scottish and Welsh data will be linked with the KCMHR cohort study, providing information on approximately 10,000 military personnel. This will offer a unique opportunity to study the health of UK military personnel and will provide data on the health problems for which they most commonly seek help. We will be able to identify whether physical health conditions or accidents and injuries are most common. A further aim for the study will be to look at whether we can predict if an individual is likely to be admitted to, or visit hospital, for a physical health condition or an accident or injury, by using the information from the KCMHR cohort about how much alcohol they drink and whether they have a mental health problem. We will also be able to look at the costs to the NHS resulting from high levels of alcohol use and mental health problems within the military.
It is a high social, health and political priority to identify the future health care needs of the UK military (serving and ex serving), so that the NHS commissioning board have the data they need in order to plan specialised commissioning of health care services. It is also very important to find out more information about the links between alcohol use, mental health problems and physical ill-health in military personnel. This is so we can identify which military personnel are most at risk of having poorer physical health in the future and also so that there is evidence that existing policies regarding the use of alcohol within military settings may need to be changed.
Identifying the future healthcare needs of military personnel and veterans is a current priority for the UK government. However, the current datasets that are available to look at use of healthcare services (and the reasons why) do not identify whether or not an individual is in the military. The proposed study will be able to identify military personnel in existing NHS datasets for England, Wales and Scotland that include secondary healthcare records, by linking to the KCMHR cohort data. In NHS hospitals, data is recorded each time someone is admitted to hospital as an inpatient, or has an outpatient visit or visits an accident and emergency department. The reason for the hospital visit is coded using an existing international classification of disease and health related problems (ICD-10). This data is collated from all hospitals and is called Hospital Episode Statistics (HES) in England. In this study, English, Scottish and Welsh data will be linked with the KCMHR cohort study, providing information on approximately 10,000 military personnel. This will offer a unique opportunity to study the health of UK military personnel and will provide data on the health problems for which they most commonly seek help. We will be able to identify whether physical health conditions or accidents and injuries are most common. A further aim for the study will be to look at whether we can predict if an individual is likely to be admitted to, or visit hospital, for a physical health condition or an accident or injury, by using the information from the KCMHR cohort about how much alcohol they drink and whether they have a mental health problem. We will also be able to look at the costs to the NHS resulting from high levels of alcohol use and mental health problems within the military.
It is a high social, health and political priority to identify the future health care needs of the UK military (serving and ex serving), so that the NHS commissioning board have the data they need in order to plan specialised commissioning of health care services. It is also very important to find out more information about the links between alcohol use, mental health problems and physical ill-health in military personnel. This is so we can identify which military personnel are most at risk of having poorer physical health in the future and also so that there is evidence that existing policies regarding the use of alcohol within military settings may need to be changed.
Planned Impact
INFORMING THE COMMISSIONING OF FUTURE SERVICES: As outlined in the Murrison report "Fighting Fit: a mental health plan for servicemen and veterans", the current and future health care of serving and ex-servicemen and women has become of high social, health and political importance. Commitments on future health care form an important part of the Military Covenant, now written into law. While military healthcare is one of the few areas taken on by the National Commissioning Board, there remains a remarkable dearth of data on need, access, provision and outcome, partly because of difficulties in identifying service personnel and veterans in all the key data sets normally used for such a purpose. The proposed study is an excellent opportunity to utilise KCMHR's experience and knowledge to identify which conditions are most common among service personnel and veterans, providing vital information for NHS Commissioning Board in planning specialised commissioning.
TACKLING ALCOHOL USE WITHIN MILITARY CULTURE: The Government's 2012 Alcohol Strategy highlighted the national issue of binge-drinking, with a focus on approaches to reducing access to alcohol such as setting a minimum unit price in order to decrease the associated harm and costs. The military can be considered as a separate population with different norms regarding the use of alcohol, including higher levels of alcohol misuse. When the Strategy was released, the Secretary of State estimated the annual cost of alcohol-related hospital admissions at £3.5 billion; this cost will likely be greater for military personnel, given evidence of higher consumption levels. The proposed research study can quantify and investigate the links between alcohol use and physical morbidity in military personnel as well as providing economic implications. This evidence will support the MoD in changing policies regarding alcohol use within the military.
IDENTIFYING AT RISK GROUPS WITHIN THE MILITARY: The Military Covenant was developed to readdress disadvantages that military personnel may face compared to other citizens. Whilst this relates to the military as a whole, there may be sub-populations within the military which face greater physical health inequality, such as reservists or personnel of lower ranks. Findings from the current study will inform future health-care commitments in the Covenant by identifying those at greatest need of services.
ADDRESSING THE RISKS OF COMORBID MENTAL HEALTH PROBLEMS AND ALCOHOL MISUSE: One of the questions that this study aims to answer is whether the association between alcohol misuse and later physical morbidity is greater in individuals with a mental health problem. The findings will inform future NICE guidelines, direct clinicians at the newly developing Community Veterans' Mental Health Services in treating co-morbid alcohol misuse in individuals with mental health problems, and provide invaluable information to Public Health England in developing health campaigns for military personnel and veterans.
INFORMING MILITARY CHARITIES AND THE NATIONAL VETERANS MENTAL HEALTH NETWORK: KCMHR's work is already supported by several veterans' charities, including RBL and Combat Stress and these collaborations will provide a ready opportunity for dissemination within these and other charities. RBL and Combat Stress have recently partnered for a three-year programme focussing on the mental health needs of service personnel and veterans, and regularly lobby the MoD and DH. The new National Veterans' Mental Health Network has been set up by DH to develop the provision of future services, drawing on the combined expertise of clinicians, academics, and military charities; also looking to KCMHR to provide the evidence base for the development of services. This study would therefore be conducted at a time when there is optimal opportunity to shape services and when strong scientific evidence can most easily be translated into clinical practice and policy.
TACKLING ALCOHOL USE WITHIN MILITARY CULTURE: The Government's 2012 Alcohol Strategy highlighted the national issue of binge-drinking, with a focus on approaches to reducing access to alcohol such as setting a minimum unit price in order to decrease the associated harm and costs. The military can be considered as a separate population with different norms regarding the use of alcohol, including higher levels of alcohol misuse. When the Strategy was released, the Secretary of State estimated the annual cost of alcohol-related hospital admissions at £3.5 billion; this cost will likely be greater for military personnel, given evidence of higher consumption levels. The proposed research study can quantify and investigate the links between alcohol use and physical morbidity in military personnel as well as providing economic implications. This evidence will support the MoD in changing policies regarding alcohol use within the military.
IDENTIFYING AT RISK GROUPS WITHIN THE MILITARY: The Military Covenant was developed to readdress disadvantages that military personnel may face compared to other citizens. Whilst this relates to the military as a whole, there may be sub-populations within the military which face greater physical health inequality, such as reservists or personnel of lower ranks. Findings from the current study will inform future health-care commitments in the Covenant by identifying those at greatest need of services.
ADDRESSING THE RISKS OF COMORBID MENTAL HEALTH PROBLEMS AND ALCOHOL MISUSE: One of the questions that this study aims to answer is whether the association between alcohol misuse and later physical morbidity is greater in individuals with a mental health problem. The findings will inform future NICE guidelines, direct clinicians at the newly developing Community Veterans' Mental Health Services in treating co-morbid alcohol misuse in individuals with mental health problems, and provide invaluable information to Public Health England in developing health campaigns for military personnel and veterans.
INFORMING MILITARY CHARITIES AND THE NATIONAL VETERANS MENTAL HEALTH NETWORK: KCMHR's work is already supported by several veterans' charities, including RBL and Combat Stress and these collaborations will provide a ready opportunity for dissemination within these and other charities. RBL and Combat Stress have recently partnered for a three-year programme focussing on the mental health needs of service personnel and veterans, and regularly lobby the MoD and DH. The new National Veterans' Mental Health Network has been set up by DH to develop the provision of future services, drawing on the combined expertise of clinicians, academics, and military charities; also looking to KCMHR to provide the evidence base for the development of services. This study would therefore be conducted at a time when there is optimal opportunity to shape services and when strong scientific evidence can most easily be translated into clinical practice and policy.
Publications
Chui Z
(2016)
P09 Developing a framework of non-communicable physical diseases
in Journal of Epidemiology and Community Health
Goodwin L
(2020)
Hospital admissions for non-communicable disease in the UK military and associations with alcohol use and mental health: a data linkage study.
in BMC public health
Goodwin L
(2016)
P10 Using electronic hospital records to identify the most common physical disorders in the UK military: a data linkage study
in Journal of Epidemiology and Community Health
Goodwin, L
(2020)
Hospital admissions for non-communicable disease in the UK military and associations with alcohol use and mental health: A data linkage study
in BMC Public Health
Leightley D
(2017)
Linking electronic healthcare records: Developing a UK-wide dataset for evaluating health outcomes in England, Scotland and Wales
in BMC Medical Informatics and Decision Making
Leightley D
(2018)
Integrating electronic healthcare records of armed forces personnel: Developing a framework for evaluating health outcomes in England, Scotland and Wales.
in International journal of medical informatics
Leightley D
(2017)
Understanding NHS hospital admissions in England, Scotland and Wales: data linkage to the King's College Military Cohort Study IJPDS (2017) Issue 1, Vol 1:273 Proceedings of the IPDLN Conference (August 2016)
in International Journal of Population Data Science
Leightley D
(2016)
P102 Understanding hospital admissions for military personnel in England, Scotland and Wales: a data linkage study
in Journal of Epidemiology and Community Health
| Description | 1) The was the first study to link and analyse English, Welsh and Scottish healthcare records together, with a methodological guide and paper produced for future users of these datasets: This work has identified common variables across all three datasets which can be combined to produce a single dataset representing healthcare use in all three countries. A guide to these variables has been produced, including the variable names within each dataset; the coding required to merge these data will be made publically available. This work showed that admitted patient care (inpatient) records were of the highest quality with diagnosis codes well reported. We additionally identified a number of limitations of all the electronic healthcare records, with poor completeness of records for both outpatient and accident and emergency (A & E) datasets. 2) This is the first representative UK data on the most common non-communicable diseases (NCDs) and accidents and injuries requiring secondary health care: The most prevalent NCDs which required an inpatient stay in this military population were gastrointestinal (GI) disorders and joint disorders, both with a prevalence over 5%. The next most frequent were arthritis/osteoarthritis (2%), prostate and genitourinary disease (2%) and hypertension (2%). The most common accidents and injuries requiring an inpatient event were complications of medical and surgical care, falls, and exposure to inanimate mechanical forces, all with prevalences ranging from 0.7 to 1%. Sequelae of external causes of morbidity and mortality (that is, late effects of a previous hospital event) was the next most common with a prevalence of 0.5% and intentional self-harm was the fifth most common (0.3%) 3) This work provides unique data on the association between mental and physical health in the UK military: Personnel with a mental disorder (post-traumatic stress disorder or a common mental disorder) were more likely to have a hospital admission for gastrointestinal disorders, hypertension and prostate and genitourinary disorders. This study provides strong evidence that Armed Forces personnel with a mental health problem are at risk of developing adverse physical health outcomes. Personnel with a mental disorder were also more likely to be admitted to hospital for intentional self-harm, sequelae of external causes of morbidity and mortality and accidents involving exposure to inanimate mechanical forces. This work highlights the priority to provide good mental healthcare and quick access to services for serving and ex-serving personnel. 4) There was little evidence that alcohol misuse was associated with the top 5 NCDs in this sample, during the timeframe of this study: There were no statistically significant associations between self-reported alcohol misuse and any of the top 5 NCDs in this military population. This goes against previous findings in other populations on the longer term health risks of alcohol. It is plausible that the null finding in this study related to the lag time and to the age of the population. It is quite possible that if we followed these individuals for another 10 to 20 years we may find that the physical health consequences of heavy alcohol use were much stronger. |
| Exploitation Route | 1) This research, which utilised a range of secondary healthcare datasets, provides a good grounding for other academic researchers in using these data. It will enable future researchers to analyse English, Scottish and Welsh electronic healthcare records together, without having to do all of the preliminary work to understand the similarities, nuances and limitations of these data. This information has been publically disseminated through conference presentations and a methodological paper which will be submitted for publication in February 2017. 2) The Department of Health and NHS England were interested in what were the most common NCDs and accidents and injuries in the UK military, when these data were presented at the public engagement event. These findings have alerted them to understand further why particular conditions, such as gastrointestinal disorders, might be so common in this population. These data can also be compared by academics to both UK data for the general population and findings from international military populations, such as the US. 3) This research provides an important message for the Ministry of Defence, Department of Health and NHS England on the longer term risks of having a mental disorder for both serving and ex-serving personnel. These finding are particularly salient given that we have previously established that common mental disorders are more common in serving personnel than the general population and affect around 20% at any one time. This work highlights the priority of providing suitable mental health services for the UK Armed Forces and veterans. 4) The null findings on the links between alcohol misuse and NCDs will be of interest to other academics conducting research on the longer term consequences of alcohol misuse. This study contradicts research in the general population, but is in line with a recent study showing that being physically active may be protective against the health consequences of alcohol use, e.g. for cancer (Perrault et al., 2016), and the Armed Forces are likely to be a physically active occupational group. Further research in this area is required in the UK Armed Forces. |
| Sectors | Aerospace, Defence and Marine,Digital/Communication/Information Technologies (including Software),Healthcare |
| URL | https://www.kcl.ac.uk/kcmhr/research/kcmhr/alcohol.aspx |
| Description | This study has published an open access resource for the first framework for linking national electronic healthcare records in Great Britain.This framework provided an overview of common variables across the three sources of electronic healthcare records which will allow future users to easily link and analyse data across nations. This approach can be used not only by academics, but by those in the public sector (including those managing these electronic data) and by commissioners of healthcare services and by local think tanks. This approach can be used to collate and analyse healthcare data for Great Britain as a whole or to compare outcomes and clinical need across nations. The release of this framework has been acknowledged by staff at the data providers (e.g the Secure Anonymised Information Linkage (SAIL) for Welsh data) as a helpful and much needed resource which can encourage future integration of these national databases. The future impact of the release of this framework will increase the longer that it is available and the applications cover areas relating to health that are much wider than the topic for the current study. |
| First Year Of Impact | 2018 |
| Sector | Digital/Communication/Information Technologies (including Software),Healthcare |
| Impact Types | Policy & public services |
| Description | Public Health Intervention Development Scheme |
| Amount | £187,515 (GBP) |
| Funding ID | MR/N028244/1 |
| Organisation | Medical Research Council (MRC) |
| Sector | Public |
| Country | United Kingdom |
| Start | 05/2016 |
| End | 11/2017 |
| Title | Framework of non-communicable diseases |
| Description | Systematic review conducted in order to develop a new framework of non-communicable diseases(NCDs) (and related ICD-10 codes) which can be applied to electronic healthcare records. This framework defines categories of NCDs and the ICD-10 codes for each category. |
| Type Of Material | Improvements to research infrastructure |
| Year Produced | 2016 |
| Provided To Others? | Yes |
| Impact | This framework has been shared with colleagues working in health economics and will be shared with other researchers at the IOPPN. The publication of this framework in a research paper will lead to further use of this framework. |
| Title | Guide and coding on use of electronic healthcare records |
| Description | This study involved the first analysis of English, Welsh and Scottish healthcare records together and a guide on the use of these datasets has been submitted for publication, with the code for data cleaning provided as an appendix. |
| Type Of Material | Improvements to research infrastructure |
| Year Produced | 2017 |
| Provided To Others? | Yes |
| Impact | This methodological tool and provision of code will allow future researchers in any health field to analyse these national data more efficiently and to understand the complexities and common variables provided in each of the datasets. |
| Description | Collaboration with the Armed Forces and Veterans' Health Policy Team at the Department of Health |
| Organisation | Government of Catalonia |
| Department | Department of Health |
| Country | Spain |
| Sector | Public |
| PI Contribution | The research team presented the findings to the project partner at the steering group meetings and worked with them in providing lay summaries of the research results to inform future health policies. The research team will be accessible to the Armed Forces and Veterans' Health Policy Team to explain and answer any queries as the research is disseminated through peer reviewed academic papers and future press releases. |
| Collaborator Contribution | The Head of the Armed Forces and Veterans' Health Policy Team was a member of the steering group for this study and provided input at all stages and presented at the public engagement event. The project partner provided additional advice on the process when we were applying to gain access to the healthcare records data and they have disseminated the research findings more widely within the Department of Health. |
| Impact | The project partner contributed a presentation including providing feedback on the research findings and putting the results into context in relation to current UK health policies at the public engagement event. The project partner has provided feedback on all academic papers at the preparation stage. |
| Start Year | 2014 |
| Description | Conference presentation (Sweden) |
| Form Of Engagement Activity | A talk or presentation |
| Part Of Official Scheme? | No |
| Geographic Reach | International |
| Primary Audience | Professional Practitioners |
| Results and Impact | Presentation at 18th meeting of the Section of Epidemiology and Social Psychiatry of the European Psychiatric Association, Sweden titled "Using electronic hospital records to identify the most common accidents and injuries in the UK military: a data linkage study" which resulted in interest from the audience due to this being the first data to be reported of this kind. |
| Year(s) Of Engagement Activity | 2016 |
| Description | Conference presentation (Sweden) |
| Form Of Engagement Activity | A talk or presentation |
| Part Of Official Scheme? | No |
| Geographic Reach | International |
| Primary Audience | Professional Practitioners |
| Results and Impact | Presentation at 18th meeting of the Section of Epidemiology and Social Psychiatry of the European Psychiatric Association, Sweden titled "Can we use Outpatient and Accident & Emergency records from Health Episode Statistics for epidemiological research?" which sparked discussion about the use of electronic healthcare records for research and which led to queries from other academics. |
| Year(s) Of Engagement Activity | 2016 |
| Description | Conference presentation (Sweden) |
| Form Of Engagement Activity | A talk or presentation |
| Part Of Official Scheme? | No |
| Geographic Reach | International |
| Primary Audience | Professional Practitioners |
| Results and Impact | Presentation at 18th meeting of the Section of Epidemiology and Social Psychiatry of the European Psychiatric Association, Sweden titled "Non-communicable diseases in the UK military and associations with alcohol use and mental health: A data linkage study" which resulted in interest from the audience due to this being the first data to be reported of this kind. |
| Year(s) Of Engagement Activity | 2016 |
| Description | Internal talk at KCL e-health group |
| Form Of Engagement Activity | A formal working group, expert panel or dialogue |
| Part Of Official Scheme? | No |
| Geographic Reach | Local |
| Primary Audience | Professional Practitioners |
| Results and Impact | Internal working group meeting to discuss the benefits of analysing secondary healthcare records, which sparked discussion and interest in the approach we had used and requests for information regarding the data application. |
| Year(s) Of Engagement Activity | 2019 |
| Description | Invited presentation at the Veterans Health and Wellbeing conference Northern Ireland |
| Form Of Engagement Activity | A talk or presentation |
| Part Of Official Scheme? | No |
| Geographic Reach | National |
| Primary Audience | Policymakers/politicians |
| Results and Impact | Invited presentation on alcohol research in military personnel at the Veterans Health and Wellbeing conference at Ulster University, Northern Ireland. |
| Year(s) Of Engagement Activity | 2016 |
| Description | Lay summary booklet produced |
| Form Of Engagement Activity | A magazine, newsletter or online publication |
| Part Of Official Scheme? | No |
| Geographic Reach | National |
| Primary Audience | Policymakers/politicians |
| Results and Impact | A summary booklet of the research findings was produced which was disseminated at the public engagement event and more widely, and the attendees/readers reported that the findings provided new information to them and would inform future decision making. |
| Year(s) Of Engagement Activity | 2016 |
| Description | Magazine article - piece in ESRC Society Now magazine |
| Form Of Engagement Activity | A magazine, newsletter or online publication |
| Part Of Official Scheme? | No |
| Geographic Reach | National |
| Primary Audience | Professional Practitioners |
| Results and Impact | Magazine article from Society Now 2018 publicising the findings from this ESRC funded study evidencing the strong links between mental and physical health in military personnel. |
| Year(s) Of Engagement Activity | 2018 |
| URL | https://esrc.ukri.org/files/news-events-and-publications/publications/magazines/society-now/society-... |
| Description | Presentation on the data linkage and preliminary findings at IOPPN departmental meeting |
| Form Of Engagement Activity | A talk or presentation |
| Part Of Official Scheme? | No |
| Geographic Reach | Local |
| Primary Audience | Professional Practitioners |
| Results and Impact | Dr Goodwin and Dr Leightley presented at a departmental meeting of 20-30 academics and PhD students in Psychological Medicine at the IOPPN. There was interest in the project findings and the methodology, with discussion focusing around the issues of data linkage. |
| Year(s) Of Engagement Activity | 2016 |
| Description | Presentation to the Forces in Mind Trust charity |
| Form Of Engagement Activity | A talk or presentation |
| Part Of Official Scheme? | No |
| Geographic Reach | Regional |
| Primary Audience | Third sector organisations |
| Results and Impact | Chief Executive of Forces and Mind Trust and other representatives of the charity attended for a briefing of research at King's Centre for Military Health Research. Dr Goodwin presented on the current ESRC funded project and there was interest and questions from the charity following on from the talk. |
| Year(s) Of Engagement Activity | 2015 |
| Description | Press release to publicise academic publication |
| Form Of Engagement Activity | A press release, press conference or response to a media enquiry/interview |
| Part Of Official Scheme? | No |
| Geographic Reach | National |
| Primary Audience | Media (as a channel to the public) |
| Results and Impact | Press release of academic article in BMC Public Health showing the association between mental health and physical health in the UK military, which was also subsequently publicised through twitter. |
| Year(s) Of Engagement Activity | 2020 |
| URL | https://www.liverpool.ac.uk/research/news/articles/mental-health-of-military-personnel-impacts-their... |
| Description | Public engagement event (London) |
| Form Of Engagement Activity | A talk or presentation |
| Part Of Official Scheme? | No |
| Geographic Reach | National |
| Primary Audience | Policymakers/politicians |
| Results and Impact | Public engagement event held in October 2016 at the end of the project to report on the findings to relevant public and third sector representatives. Feedback on the event was excellent and NHS England expressed an interest in the project findings and requested further information to inform their policy making. |
| Year(s) Of Engagement Activity | 2016 |
| Description | Working group meetings including academic, public and third sector representatives |
| Form Of Engagement Activity | A formal working group, expert panel or dialogue |
| Part Of Official Scheme? | No |
| Geographic Reach | Regional |
| Primary Audience | Policymakers/politicians |
| Results and Impact | Presentation and discussion of research methods and preliminary findings at working group meetings, including representatives from the Royal British Legion and the Department of Health. |
| Year(s) Of Engagement Activity | 2015,2016 |