Outlook: Newsletter of the Society of Behavorial Medicine

Summer 2024

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Decreasing the Military-Civilian Gap: Cultural Competence is Key to Addressing Military and Veteran Behavioral Health

Jennifer Fillo, PhD; Jordan M. Ellis, PhD - Co-Chairs of SBM Military & Veteran Health SIG

Despite the past nearly 23 years of heightened military activity, Americans have fewer ties to the military than ever before. This “military-civilian gap” contributes to misunderstanding, negative stereotypes, and feelings of isolation. Greater cultural competence among researchers, clinicians, and policy makers is critical for narrowing this gap and mitigating its effects on behavioral health. Our first article in this series addressed similarities and differences in the military and veteran experience across individuals. In the current installment, we highlight top behavioral health concerns and clarify key terminology relevant to this population.

Military and Veteran Behavioral Health

Ensuring the health and performance of nearly 2.86 million service members is a tall task. Most threats to operational readiness are associated with health-related behaviors1-3, including:

  • Nearly one-third of service members sleep five or fewer hours per night.
  • More than one-third of service members report binge drinking in the past 30 days.
  • More than one-third of service members report using tobacco in some form.
  • Two-thirds meet criteria for overweight or obesity, a 68% increase since 2002.

These issues continue and can worsen after leaving service. Indeed, US military veterans report higher rates of nearly all health conditions compared to civilians, including cancers, heart disease, stroke, respiratory problems, arthritis, overweight/obesity, kidney disease, and diabetes.4 Furthermore, substance use and related disorders are higher among veterans than age-matched civilians, particularly alcohol and tobacco use.5. Promoting positive health behaviors is important for primary, secondary, and tertiary prevention related to these conditions.

Interactions with Civilian Healthcare Systems

In order to promote behavioral health in these populations, it is critical to understand the ways in which service members and veterans interact with civilian healthcare systems. Their care is not constrained to the Department of Defense (DoD) and Veterans Health Administration (VHA). While serving, military personnel may seek care through civilian providers due to capacity constraints, eligibility limitations, and concerns about potential negative effects of seeking care on their career. Among former military, the ability to seek VHA services depends on service- and discharge-related eligibility requirements. Even among eligible veterans, less than half actually use their VHA benefits.6 Furthermore, the VA Choice Act (2014) and VA MISSION Act (2018) have increased veterans’ ability to seek care outside the VHA system.7 Despite increasing rates of civilian healthcare utilization, civilian providers do not consistently ask patients about military service history and indicate need for greater education in understanding and identifying service-connected conditions.8,9

Using Correct Terminology

Whether you are engaged in clinical work, research/survey design, or developing policy, military cultural competence is critical. An important first step in better supporting this community is using the right terminology when referencing aspects of the military experience. What may seem like small details can go a long way in communicating understanding and building rapport. It will also ensure that certain individuals are not incorrectly included or excluded from policies, programs, and/or study eligibility.

Branch. The US Armed Forces is comprised of six branches, each of which uses a specific term to refer to their personnel, regardless of gender:

  • Army: “soldier”
  • Navy: “sailor”
  • Air Force: “airman”
  • Marines: “marine”
  • Space Force: “guardian”
  • Coast Guard: “coast guardsman” 

It is important to use the correct term when referring to each branch. For example, whereas the Army comprises the largest proportion of the US Armed Forces, it is not appropriate to refer to military personnel generically as “soldiers.” In cases where branch is unknown or when working with personnel of multiple branches, “service member” should be used.

Component. Each branch of the US Armed Forces is comprised of up to three components: active duty, reserve, and National Guard. All branches have an active duty component, all but the Space Force have reserve components, and only the Army and Air Force have National Guard components. The use of the term “active duty” when trying to refer to all individuals currently serving—in any component— excludes the 38% of US Armed Forces serving in reserve and National Guard components. Reserve and National Guard components play a critical role in military activities. In addition to responding to various domestic emergencies (e.g., natural disasters, COVID pandemic, border crisis, civil unrest), reserve and National Guard service members have seen unprecedented rates of deployment in overseas operations since 9/11.

Conclusion

There is a great need to design, evaluate, and disseminate prevention and intervention programs among military service members and veterans. Whereas the DoD and VHA systems specifically focus on these individuals, they also seek care in civilian healthcare settings and intersect with broader civilian communities. Cultural competence is critical for researchers’, clinicians’, and policy makers’ ability to effectively target behavioral health issues in these populations. And the US Armed Forces could certainly benefit from the expertise of those trained to target health risk behaviors upstream in diverse communities.

References

  1. 2018 Department of Defense Health Related Behaviors Survey (HRBS): Results for the active component (RAND Corporation) (2021).
  2. Troxel WM, Shih RA, Pedersen E, et al. Sleep in the military: Promoting healthy sleep among U.S. service members. RAND Corporation; 2015.
  3. Smith TJ, Marriott BP, Dotson L, et al. Overweight and obesity in military personnel: Sociodemographic predictors. Obesity. Jul 2012;20(7):1534-1538. doi:10.1038/oby.2012.25
  4. Betancourt JA, Granados PS, Pacheco GJ, et al. Exploring health outcomes for U.S. veterans compared to non-veterans from 2003 to 2019. Healthcare. May 18 2021;9(5):604. doi:10.3390/healthcare9050604
  5. Teeters JB, Lancaster CL, Brown DG, Back SE. Substance use disorders in military veterans: Prevalence and treatment challenges. Substance Abuse and Rehabilitation. 2017;8:69-77. doi:10.2147/SAR.S116720
  6. VA utilization profile FY 2017 (US Department of Veterans Affairs) (2020).
  7. Rose L, Aouad M, Graham L, Schoemaker L, Wagner T. Association of expanded health care networks with utilization among Veterans Affairs enrollees. JAMA Network Open. 2021;4(10):e2131141. doi:10.1001/jamanetworkopen.2021.31141
  8. Vest BM, Kulak JA, Homish GG. Caring for veterans in US civilian primary care: Qualitative interviews with primary care providers. Family practice. 2019;36(3):343-350. doi:10.1093/fampra/cmy078
  9. Vest BM, Kulak J, Hall VM, Homish GG. Addressing patients’ veteran status: Primary care providers’ knowledge, comfort, and educational needs. Family Medicine. 2018;50(6):455-459. doi:10.22454/FamMed.2018.795504