The analysis of 2014 APMS data to understand the mental health and wellbeing of veterans: A King's Centre for Military Health Research proposal

King’s Centre for Military Health Research (KCMHR) is a leading department in UK military health research. It consists of highly trained academics whose work contributes to military health policy for reservists, serving personnel and veterans of the armed forces. Several researchers from this department have expressed interest in using the APMS dataset to investigate the following areas:

 To examine whether military veterans are at increased risk of poor employment outcomes (in terms of absenteeism, presenteeism and unemployment) compared to non-veterans and perform a holistic analysis of veteran employment trajectories, including the effect of mental health of post-service employment. (MILITARY EMPLOYMENT STUDY)

 To examine whether military veterans are at an increased risk of developing dementia compared to the general population. (MILITARY DEMENTIA STUDY)

 To examine the mental health of women in the military (MILITARY MENTAL HEALTH-FEMALE STUDY)

 To examine the mental health and health service utilisation of post-national service veterans (MILITARY MENTAL HEALTH-MALE STUDY)

 To examine the factors associated with Domestic Violence and Abuse (DVA) amongst military personnel, including perpetration, victimisation and sociodemographic risk factors as compared to the general population (MILITARY DVA STUDY)

The legal basis for processing falls under GDPR Article 6(1)( e) and GDPR Article 9(2)(j). Processing and dissemination is for research purposes, and also meets the public interest criteria as defined by the ICO for good decision-making by public bodies and securing the best use of public resources.

All studies are of interest to the public due to them providing information on the health and well-being of ex-/serving personnel. There are no moral or ethical issues raised by the proposed dissemination of this data.

King’s College London is the data controller and also processes the data for this study. No other organisations process the data for this purpose.

MILITARY EMPLOYMENT STUDY

Background:

Mental health conditions can have a substantial impact on employment. Such disorders are a major cause of financial loss to the UK economy with estimates in the region of £70 billion per annum being suggested. Mental health disorders may cause both absenteeism and presenteeism with the latter thought to have the bigger impact. Furthermore, as well as poor work performance affecting the lives of those suffering with mental disorders, in rare but tragic cases such as the Germanwings plane crash of 2015, mental health problems amongst those working in safety critical roles can have a much wider impact.

Aim:

To examine whether military veterans are at an increased risk of poor employment outcomes (in terms of absenteeism, presenteeism and unemployment) compared to non-veterans.

MILITARY DEMENTIA STUDY

Background:

Dementia is currently incurable, irreversible and a major cause of disability for the world’s older population. The association between mental health problems, such as post-traumatic stress disorder, depression and dementia has been the focus of research for a considerable time within the general population. Despite this, only limited research attention has been given to explore this potential association in military veterans, who are more likely to develop mental health problems and consist largely of over 65’s.

Aim:

To examine whether military veterans are at an increased risk of developing dementia compared to the general population. As a decline in intellectual and cognitive functioning is a key symptom of developing dementia, this will be used as a proxy measure in the context of the study.

MILITARY MENTAL HEALTH-FEMALE STUDY

Background:

The British Army intend to place women in the ground close combat role. There is a body of data available to assess the impact of combat on the mental health of men, however, due to the comparatively small number of women in the United Kingdom Armed Forces, research in this group is more challenging. KCMHR has gathered data on the mental health of military women and has generated provisional outcomes for women experiencing combat events while deployed; however, an appropriate comparison group is lacking and it is therefore challenging to contextualise and properly interpret such data.

Aim:

The proposed study will compare women participating in the KCMHR cohort with an occupationally matched sample of women from the APMS cohort.

MILITARY MENTAL HEALTH-MALE STUDY

Background:

In 2011, Woodhead et al. [1] published a research article investigating the mental health and health service use of post-national service veterans using the 2007 APMS dataset. This study aims to update the literature on prevalence of mental health disorders amongst veterans using the 2014 APMS dataset. Specifically to investigate:

Aim:

 To examine whether being a veteran is a risk factor for mental health problems and behavioural difficulties

 To examine whether veterans are more likely to have experience adversity, marital instability or have poorer social support than non-veterans

 To examine whether symptomatic veterans are less likely to seek treatment than symptomatic non-veterans

 To examine whether leaving services prematurely (<4 years of military service) adversely affects health and adversity compared to those that served longer.

References:

MILITARY DVA STUDY

There is growing awareness that Domestic Violence and Abuse (DVA), both perpetration and victimisation, is a problem within military populations and DVA in the UK military has been identified as a priority area of concern by the UK Government. US-based studies have suggested that DVA rates are higher among military populations than civilian and that there are unique military risk factors for DVA. Such research has not been undertaken in the UK.

The KCMHR cohort study, established in 2003, is a study of health and wellbeing of UK military personnel. Data has been collected from a randomly selected sample of UK military personnel using a self-completion questionnaire during three phases of collection (2003-2005, 2006-2007 and 2015-2017) on pre-military behaviour, socio-demographics, military experiences, and post-deployment mental health and behaviour problems. Phase 3 of data collection included questions on DVA perpetration and victimisation, adapted from the 2014 UK Adult Psychiatric Morbidity Survey (APMS) questions on Intimate Partner Abuse to measure physical, psychological, and sexual DVA and coercive behaviours (authorised by the APMS team). This will allow King's College for the first time to compare DVA within the sample of UK military personnel to the general UK population.

Aims:

Thus the aims of the project are to use the KCMHR and APMS data sets in order to:

 Compare 12 month prevalence and severity of self-reported DVA (i.e., physical, psychological, and sexual DV and coercive behaviours) perpetration and victimisation among UK military personnel with general population;

 Investigate whether the sociodemographic risk factors for DVA perpetration and victimisation among UK military personnel differ from those in the general population;

 Compare the associations between mental health problems (e.g., PTSD, common mental disorders and alcohol misuse) and DVA among military personnel and the general population;

 Explore whether engagement with support services/service use differs between military personal and general population who reported DVA.

A limited number of military variables were included in APMS 2007, which KCMHR have previously been given access to and used for research projects [1, 2]. For APMS 2014, NATCEN and KCMHR worked together to develop new variables to better understand how military service impacts the mental health and wellbeing of former military personnel now living in the community. Each of the objectives for this work requires access to these additional variables that are not in the standard data extract, specifically:

PTSDarm (have you ever served in the Armed Forces or UK reserved Armed Forces?),

PTSDarmf (in what year did you first serve in the Armed Forces?),

PTSDarmc (Are you currently serving in the Armed Forces?),

PTSDarml (In what year did you last serve in the Armed Forces?),

PTSDarms (was the traumatic event or experience you referred to before…(military/non-military/both)),

RegRes (Are you or were you a regular, reserve or have you served as both a regular and as a reserve?),

Deploy (during your service in the Armed Forces, did you deploy to…).

These variables are required to exclude ‘false positives’ (e.g. persons who say they are from the Armed Forces but give unlikely answers to one of these additional questions) and also allow KCMHR to explore sub-groups within military populations (e.g. those who deployed to Iraq/Afghanistan).

The APMS 2014 data requested consist of personal pseudonymised data in sensitive form. There is no alternative, less intrusive way of achieving this purpose. These variables will not be used to re-identify any individual who took part in the APMS 2014 study.

1. Woodhead, C., Rona, R. J., Iversen, A., MacManus, D., Hotopf, M., Dean, K., ... & Wessely, S. (2011). Mental health and health service use among post-national service veterans: results from the 2007 Adult Psychiatric Morbidity Survey of England. Psychological medicine, 41(2), 363-372.

2. Woodhead, C., Rona, R.J., Iversen, A.C., MacManus, D., Hotopf, M., Dean, K., ... Wessely, S. (2011). Health of national service veterans: an analysis of a community-based sample using data from the 2007 Adult Psychiatric Morbidity Survey of England. Social Psychiatry and Psychiatric Epidemiology, 46 (7), 559-566.

The 2014 APMS data was collected by NATCEN on behalf of NHS Digital. A minimised dataset (having gone through Disclosure Control Procedure advice) is held at UK Data Service for dissemination under direction by NHS Digital, however this does not contain the military specific fields listed in the objective for processing section. Under this agreement, NATCEN, under direction from NHS Digital, will produce and disseminate a bespoke extract of 2014 APMS data which will include the military fields specified to King’s College London. This data consist of personal health care data of a pseudonymised and sensitive nature.

Data will be securely stored on a dedicated server which is regularly audited by MoD data security specialists. All data are stored in an encrypted form using an AES256 encryption algorithm. Only named and vetted King’s College London staff who have signed a confidentiality agreement will have access. All data will be stored on a virtual server managed by King’s College London IT services. The King’s servers are located and backed up both on the Strand campus and Slough premises, on physical servers locked in a secure area so data isn’t compromised. A regular backup schedule is in place.

No data will be linked to patient records. No data will be passed on to other organisations. No attempts will be made to identify participants from the dataset.

The data processing at KCL will only be carried out by substantive employees of KCL or PhD students with a signed contract with KCL. All individuals will be expected to have completed KCL’s GDPR training and NHS Level 1 Data Security Awareness Training and who have confirmed in writing they have read and understood the protocols outlined and referred to in the Data Security and Protection Toolkit.

The data will be held as an encrypted file on KCL’s secure network drive. The encrypted file will be held in an access-controlled area of the network drive and the data will be accessible to authorised study personnel only, by means of a password or a recovery key. All users have their own username and password, and these will never be shared. Access to the data for the study will be cancelled as soon as a user leaves the study, KCL, or if they are absent for a long period.

Data will be stored on servers owned and managed by KCL, within the JISC Southern Data Centre. Only individuals with the administrative rights to those servers will be able to access data stored on them. The only individuals with those administrative rights are KCL’s IT Computer & Storage team. JISC is a United Kingdom not-for-profit company whose role is to support post-16 and higher education, and research, by providing relevant and useful advice, digital resources and network and technology services, while researching and developing new technologies and ways of working.

All organisations party to this agreement must comply with the Data Sharing Framework Contract requirements, including those regarding the use (and purposes of that use) by “Personnel” (as defined within the Data Sharing Framework Contract ie: employees, agents and contractors of the Data Recipient who may have access to that data).

The findings of these studies will be published in international peer reviewed scientific journals and presented at conferences worldwide within one year of receiving the data. Once peer-reviewed and published, it will form a part of newsletters that are shared with the military cohorts involved in longitudinal research, such as the health and well-being survey and ADVANCE study. The newsletter will also be available via the website (www.kcl.ac.uk/kcmhr). The work will be shared with military charities such as Forces In Mind Trust, Combat Stress and Help for Heroes with the hope that this research will have a positive impact on their work with serving and ex-serving personnel.

The work may also be published in a PhD dissertation.

MILITARY EMPLOYMENT STUDY

The project is in the final stages of publishing its 150+ page report, including findings from the APMS dataset. Subsequent to the publication of this report, two academic papers are planned for publication in peer-reviewed journals, one of which will focus on quantitative findings from the APMS dataset.

MILITARY DEMENTIA STUDY

Investigation to address this area of research was paused due to maternity leave during this period. To date, the data for this study has been cleaned and is ready for analysis.

MILITARY MENTAL HEALTH-FEMALE STUDY

This project will begin upon the completion of the "MILITARY MENTAL HEALTH-MALE STUDY".

MILITARY DVA STUDY

Investigation to address this area of research was paused due to maternity leave during this period. Analysis is due to commence late summer 2022.

In order to protect patient confidentiality in publications resulting from analysis of APMS data users must:

• guarantee that any outputs made available to anyone other than those with whom this agreement is made, will meet required standards, including the guarantee, methods and standards contained in the Code of Practice for Official Statistics and the ONS Statistical Disclosure Control for tables produced from surveys;

• apply methods and standards specified in the Microdata Handling and Security Guide to Good Practice for disclosure control for statistical outputs.

MILITARY EMPLOYMENT STUDY

The mental health impacts of unemployment and poor work performance are legion. The UK Government has clearly stated its intent to ensure that as many people as possible are able to work in order to ensure the economy is buoyant and that individuals are able to progress with their, and their families, lives. Furthermore, the military covenant directs that military veterans, whatever their age, should be at ‘no disadvantage’ as a result of their military service and this study will provide an insight into whether veterans are indeed disadvantaged in terms of their post-service employment. The results from this work will be able to inform the planning and delivery of health care services, interventions and policy reform.

MILITARY DEMENTIA STUDY

The prevalence of dementia is increasing with the number of people living with dementia in the UK estimated to reach over 1 million by 2025. With approximately 3-5 million veterans residing in England currently, it is imperative to establish the possible link between mental ill health and dementia in this specific group of elderly in order to identify if there may be a need for specific services for this group. The UK Government has published the military covenant which directs that military veterans, whatever their age, should be at ‘no disadvantage’ as a result of their military service. The results from this work will be able to inform the planning and delivery of health care services, interventions and policy reform.

MILITARY MENTAL HEALTH-FEMALE STUDY

This study will be used to quantify mental health need amongst the spouses/partners of UK military personnel and first responders compared to women in the general population. This will be used to inform support services for these populations and to conduct further research into the causes of poor mental health within these groups.

MILITARY MENTAL HEALTH-MALE STUDY

This study will help develop the ideas originally put forward by Woodhead et al. in 2011 and contribute to the knowledge of veteran specific outcomes in terms of healthcare utilisation and mental health. Developing this understanding and sharing it with military charities will allow them to target their spending on appropriate interventions within those groups most in need.

MILITARY DVA STUDY

The research will provide the first population level information on prevalence of and risk factors for DVA in the UK military compared to the general population, which will inform the need for prevention and support services and the development of evidence-based risk assessment for DVA perpetration and victimisation in this population, and identify potentially modifiable risk factors which can be targeted by interventions to reduce risk of DVA.

This research has the potential to reduce the harm resulting from DVA to serving and ex-serving military personnel and their families, both perpetrators and victims, and the costs associated with it. The findings from this study will provide the first UK evidence to inform expert consensus on good practice in DV prevention and management in this population and a framework for change in practice and policy will be developed along with educational materials to skill the multiagency workforce in how to identify and manage DV in this population.

MILITARY MENTAL HEALTH-MALE STUDY

This project is currently working towards publication, with the paper being prepared for submission to psychological medicine titled “The health of post-national service veterans compared to non-veterans: an analysis of the 2014 Adult Psychiatric Morbidity Survey".

MILITARY EMPLOYMENT STUDY

Outcomes from analysis include:

1. Women were less likely compared to males to go into routine and manual occupation post-service.

2. Demographic factors, in particular age, relationship status, education and childhood adversity, impacted the NS-SEC of occupations ex-Service personnel secured and the type of socioeconomic change experienced. While socioeconomic status increased with age overall, older veterans were more likely to decline in socioeconomic status compared to their status in service after they leave.

3. Military factors such as length of service and deployments were associated with different socioeconomic change. Those having served fewer than 4 years were less likely to go into routine and manual occupations, and ex-Service personnel who had deployed were less likely to experience positive change.

4. Experience of mental health issues was associated with being less likely to experience positive change and more likely to go into routine and manual occupations post service.

MILITARY MENTAL HEALTH-MALE STUDY

Outcomes from this analysis include:

1. Increased rate of musculoskeletal disorders were found among veterans, It is suggested in our paper that NHS services should consider how to identify those at an increased risk of developing musculoskeletal disorders in order to implement appropriate early interventions.

2. Short-term service veterans (<4 years) have an increased risk of homelessness. It is suggested in our paper that interventions may be especially helpful for these individuals who may not be eligible for the same level of support received by those who have served for longer including the Career Transition Partnership (CTP) programme that aims to help those leaving the Armed Forces gain work.