Health Related Behavior Study 2018 – Conclusions, Findings and Implications for Politics for the Active Servicemen

The HRBS is the U.S. Department of Defense’s (DoD) flagship study of the health, health-related behaviors and well-being of military personnel. The HRBS has been conducted regularly for more than 30 years and covers areas that may affect military readiness or the ability to meet the demands of military life.

The Department of Defense Office of Health and Human Services commissioned the RAND Corporation to review and conduct the 2018 HRBS survey among active and reserve military personnel. This summary discusses the results from the active component.

This summary presents high-level findings on the broad themes of the HRBS and the policy implications of key findings. They present estimates of changes since the 2015 HRBS, where available; these are based on regression estimates, as the results of the two studies are not directly comparable due to significant changes in methodology.

The HRBS results are also compared to the Health Promotion 2020 (HP2020) goals set by the U.S. Department of Health and Human Services for the entire U.S. population. Because military personnel are very different from the general population (e.g., military personnel are more likely to be young and male than the general population), these comparisons are presented for interest only. It also suggests ways to improve future versions of the HRBS.

Main findings

Disease Prevention and Health Support

The HRBS examined body weight, physical activity, annual health checks, and sleep.

• 33.3 percent (confidence interval [CI]: 32.1-34.5) of service members aged 20 years or older reported that their height and weight met federal guidelines for normal weight (HP2020 target for the general population was 33.9 percent or more); 15.1 percent (CI: 14.2-15.9) were classified as obese (HP2020 target was 30.5 percent or less).
• Members of the active component met or exceeded HP2020 goals for moderate physical activity (MPA), vigorous physical activity (VPA), and weight training.
• 70.3% (CI: 69.1-71.4) reported having had a routine physical examination in the past 12 months, which is not in accordance with the current Army standard of requiring all personnel to have an annual physical examination.
• 33.3% (CI: 32.2-34.3) met HP2020 guidelines for adequate sleep, and 13.1% (CI: 12.3-13.9) reported using over-the-counter or prescription sleep medication at least once a week in the past 30 days.
• For staying awake in the past 30 days, 16.5% (CI: 15.5-17.5) reported using energy drinks at least three times a week, 1.2% (CI: 0.9-1.4) reported using OTC drugs at least three times a week, and 1.7% (CI: 1.4-2.0) reported using prescription drugs at least three times a week.

Substance and Drug Use

The HRBS examined the use of alcohol, tobacco and nicotine products, marijuana and synthetic cannabis, other drugs, and prescription drugs.

• 34 percent (CI: 32.9-35.2) of HRBS participants were binge drinkers, defined as men who had five or more drinks on a single occasion in the past 30 days or women who had four or more drinks in the past 30 days, and 9.8% (CI: 9.0-10.6) were heavy drinkers, defined as binge drinkers at least once a week in the past 30 days. In the 2018 National Survey on Drug Use and Health (NSDUH), 26.5% of U.S. adults aged 18 years and older were binge drinkers and 8.9% were heavy drinkers.
• 6.2% (CI: 5.6-6.9) experienced serious consequences of their alcohol use in the past 12 months (such as a fight), 4.9% (CI: 4.3-5.5) reported drinking and driving or high-risk driving (as a drunk driver or passenger in a vehicle), and 5.7% (CI: 5.1-6.3) reported decreased productivity at work due to drinking and driving.
• 28.2% (CI: 27.1-29.4) thought that the military culture encourages alcohol consumption (e.g., if you don’t drink, it is difficult to fit into a command).
• 37.8% (CI: 36.6-39.0) reported current use of tobacco or nicotine products. According to the National Health Interview Survey, 19.3% of the population currently uses tobacco, although this estimate is not directly comparable to the HRBS.
• 16.2% (CI: 15.2-17.3) reported using e-cigarettes. According to the 2017 Behavioral Risk Factor Surveillance System, 4.6% of US adults currently smoke e-cigarettes.
• 1.3% (CI: 0.9-1.7) reported using drugs (e.g., using an OTC cough or cold medicine to get high, using OTC anabolic steroids, using marijuana or synthetic cannabis, or using drugs such as cocaine or amphetamines) in the past 12 months; 0.5% (CI: 0.3-0.7) reported using drugs in the past 30 days.
• Respondents in the active part of the HRBS survey reported using fewer stimulants, sedatives, and painkillers in the past 12 months than civilians, as well as lower rates of drug abuse.

Mental Health and Well-Being

The HRBS examined mental health, social and emotional factors related to mental health, perceived unmet care needs, barriers to using mental health services, and concern that mental health care would interfere with a military career.

• 9.6% (CI: 8.7-10.4) reported severe psychological distress in the past 30 days, and 10.4% (CI: 9.6-11.1) reported symptoms in the past 30 days indicating probable post-traumatic stress disorder. Between 2.9% and 5.2% of the population reported severe psychological distress in the past 30 days, and 3.5% met criteria for PTSD in the past 12 months.
• 49.1% (CI: 47.9-50.3) reported choleric or aggressive behavior in the past 30 days.
• 9.6% (CI: 9.0-10.2) reported having had unwanted sexual intercourse since joining the military, and 2.5% (CI: 2.1-2.9) reported having had such intercourse in the past 12 months. It is important to remember that the Workplace and Gender Relations Survey of Active Duty Military (WGRA) and the HRBS measure different concepts. The WGRA measures sexual violence. The HRBS measures unwanted sexual contact, which is a broader concept. The HRBS defines unwanted sexual contact as “someone who touches you sexually, has sex with you, or attempts to have sex with you without your consent or your ability to give it.” By sexual contact we mean any sexual contact and any oral, anal, or vaginal penetration.” Therefore, the results between the two studies are not comparable.
• 5.3% (CI: 4.8-5.8) reported being physically abused since joining the military; 1.1% (CI: 0.8-1.4) reported being abused in the past 12 months. Among the population aged 12 years and older, 1.7% reported having experienced physical violence in the past 12 months.
• 8.3% (CI: 7.5-9.0) of the employed population reported having had suicidal thoughts in the past 12 months, 2.7% (CI: 2.3-3.2) had made suicide plans, and 1.2% (CI: 0.9-1.6) had attempted suicide. Among adults aged 18 years or older, 4.3% had suicidal thoughts in the past 12 months, 1.3% had suicide plans, and 0.6% reported having attempted suicide.
• 25.5% (CI: 24.4-26.5) reported using mental health services in the past 12 months; this rate is about 10 percentage points higher than that of the same age population.
• Those in the active component were more likely to consult a mental health professional (18.2%, CI: 17.2-19.1) than a general practitioner (13.4%, CI: 12.6-14.3). In contrast, the general population is more likely to consult a general practitioner for mental health services. Active component members who sought mental health services consulted a general practitioner an average of 11.9 times in the past 12 months (CI: 11.0-12.9).
• 8.5% (CI: 7.8-9.1) of military personnel reported using medication for mental health problems in the past 12 months; 12.2% of U.S. adults aged 18 years or older used medication.
• 6.8% (CI: 6.2-7.5) of military personnel reported needing mental health services but not receiving them in the past 12 months. The most common reason for not receiving services was that they did not understand their need, which is consistent with civilian results.
• 34.2% (CI: 33.1-35.4) of all active duty respondents felt that seeking mental health services would be detrimental to their military career.

Disabilities and Physical Health

The HRBS survey asked about chronic health conditions, physical symptoms, pain, mild brain injury and post-concussion symptoms, and perceived health.

• 40.3% (CI: 39.1-41.5) of active component members reported having at least one chronic condition diagnosed by a physician. The most common conditions were bone, joint, or muscle injuries (including arthritis) and back pain.
  The most common physical symptoms that active component members reported suffering in the past 30 days were body aches, including headaches (29.4%, CI: 28.3-30.5), sleep disturbances (20.2%, CI: 19.2-21.3), and fatigue or lack of energy (18.4%, CI: 17.5-19.4).
• 6.1% (CI: 5.4-6.7) of the active component had a positive MBCT.
• 52.3% (CI: 51.1-53.6) reported very good or excellent health.
  On average, workers reported 0.62 days (CI: 0.54-0.70) and 2.19 days (CI: 2.03-2.35) of reduced productivity due to a mental or physical symptom in the previous 30 days.

Sexual behavior and Sexual health

The HRBS examined sexual risk behavior, sexually transmitted infections and unintended pregnancies, contraceptive use and availability, and human immunodeficiency virus (HIV) testing in the past 12 months.

• 19.3% (CI: 18.3-20.4) reported having had more than one sexual partner in the past 12 months, 34.9% (CI: 33.7-36.0) did not use condoms with new sexual partners, and 21.8% (CI: 20.7-22.9) were at high risk for HIV infection.
• 3.4% (CI: 2.9-3.8) reported having contracted sexually transmitted infections in the last 12 months.
• 5.5% (CI: 4.4-6.5) of female soldiers reported having had an unwanted pregnancy in the past year; 2.4% (CI: 1.0-2.9) of male soldiers reported having caused such a pregnancy. The proportion of unintended pregnancies during deployment was less than 0.1%.
• 16.8% (CI: 15.9-17.7) of military personnel reported not using contraception at last vaginal intercourse. Among military personnel at risk of unintended pregnancy, only 77.0% (CI: 75.0-79.1) used contraception at last intercourse, which is below the HP2020 target (91.6%).
• 25.4% (CI: 24.4-26.4) reported using highly effective contraception at last vaginal intercourse.
  Most female soldiers did not receive contraceptive counseling prior to deployment. Men (14.5%, CI: 12.7-16.3) were less likely than women (39.0%, CI: 34.7-43.4) to receive such advice.
• 75.8% (CI: 74.7-76.9) of military personnel reported having been tested for HIV in the past 12 months, including 78.6% (CI: 71.0-86.2) of male military personnel who had sex with men. Among those in the HIV risk group (male military personnel who had sex with one or more men in the past 12 months, military personnel who had vaginal or anal sex with more than one partner in the past 12 months, and military personnel with a history of sexually transmitted infections in the past 12 months), 81.2% (CI: 78.9-83.5) reported having been tested for HIV in the past 12 months.

Sexual Orientation

The HRBS assessed the proportion of military personnel who are lesbian, gay, or bisexual (LGB) and identified key information on the behavior and health status of LGB military personnel.

• 3.4% (CI: 2.8-4.0) of military personnel and 9.9% (CI: 8.7-11.0) of military personnel reported having had one or more same-sex partners in the past 12 months.
• 6.3% (CI: 5.8-6.9%) of military personnel reported being homosexual, including 4.1% (CI: 3.5-4.6%) of men and 17.6% (CI: 16.0-19.2) of women.
• LGB service members were more likely than others to drink or use hard alcohol, illicit drugs, and smokeless tobacco.
• LGB individuals were more likely than others to have had sex with a new partner without a condom in the past 12 months, to have had more than one sexual partner, and to have had a sexually transmitted disease. They were also more likely to have been tested for HIV in the past six months.
• LGB people were more likely than others to suffer from severe psychological problems, probably PTSD, suicidal thoughts, suicide attempts, and angry and aggressive behaviors. LGB service users were more likely to use mental health services, take medication for mental health problems, and report unmet care needs.
• LGB individuals were more likely than non-LGB individuals to report unwanted sexual contact and physical violence.
• There were no significant differences between LGB and non-LGB members in routine physical health assessments, amount of exercise or sleep, use of prescription medications, and prevalence of chronic illness.

Experiences During Deployment

The HRBS examined frequency and duration of deployments (combat and non-combat), combat trauma experiences, and deployment experiences and health.

• 60.4% (CI: 59.2-61.7) of military personnel reported being deployed at least once.
  27.3% (CI: 26.0-28.7) of all soldiers who reported being deployed did not report being deployed in combat.
• 54.3% (CI: 52.9-55.7) of all servicemen who reported being deployed had not been deployed in the past 12 months.
  36.2% (CI: 34.9-37.5) of all military personnel who reported being deployed also reported having had one or more traumatic combat experiences. The most common traumatic experience reported was feeling that someone had been killed in combat (22.3%, CI: 21.2-23.3); the least common experience was being wounded in combat (3.0%, CI: 2.6-3.5).
• Members who had been deployed in the past 12 months were more likely to report drinking and smoking while intoxicated or in an advanced mental state. They were more likely to report moderate psychological distress, but not post-traumatic stress disorder.

Impact of policy on troop readiness, health, and well-being

Desease Prevention and Health Support

Sleep health remains a major health concern for military members: most active duty service members reported not getting enough sleep, and many described their sleep as poor. The defense forces and Coast Guard must educate service members about normal sleep requirements and the consequences of inadequate sleep on performance and health.

All military personnel are required to undergo an annual medical checkup, but many did not report having one in the previous year. Increasing the proportion of those who meet this requirement could increase the ability to address individual health problems and the overall health of troops.

Substance and Drug Abuse

Alcohol abuse remains a persistent and serious threat to military readiness. It has been associated with accidents, sexual and physical assault and victimization, relationship violence, and physical and mental health problems, including suicide. The MOD and Coast Guard must better understand the culture and climate of alcohol consumption and work to implement evidence-based approaches to prevent excessive consumption.

Reducing the use of tobacco and nicotine products is a priority, given the likely long-term health effects of their use. Intervention and prevention measures will likely need to build on existing evidence-based approaches for civilians, with particular attention to beliefs about e-cigarettes as a substitute for combustible cigarettes.

Mental Health and Emotional Well-being

Serious mental health problems are prevalent among military personnel and continue to pose a significant threat to military readiness. Studies have linked severe mental distress to a range of problems, including reduced work capacity. Perhaps the greatest obstacle to addressing this problem is the widespread perception that mental health treatment is unnecessary and potentially detrimental to the careers of military personnel.

The MOD and Coast Guard should assess the impact of stricter confidentiality standards in the mental health field and alternative treatment options, including informal treatment, as well as more formal treatment options. Future research should also examine the reasons military personnel seek mental health services outside the military health system and the impact of civilian and military mental health services on military personnel.

Despite the significant investment that has been made in understanding and preventing suicide in the military, further action is needed to address the problem. The increase in the number of suicides highlights the urgency of identifying the precursors to suicide and improving prevention.

Physical health and functional capacity

The Ministry of Defense and the Coast Guard should investigate the causes of absences and associated absenteeism, as eliminating them can be an effective way to reduce productivity losses.

Pain is a widespread condition in the military, and the MoD and Coast Guard should continue to work to reduce pain (e.g., by reducing musculoskeletal and overuse injuries) and to address pain in the service by increasing access to quality pain care, including universal non-pharmacological approaches.

Sexual Behavior and Sexual Health

The MOD and Coast Guard should consider ways to increase the proportion of personnel receiving contraceptive counseling prior to deployment. Service providers should make it clear in their outreach activities (e.g., information campaigns, digital applications) that contraceptive counseling guidelines apply to both men and women.

Similar activities for service providers should expand the offer of contraceptive counseling to men. Service providers and military personnel may need additional training on the benefits of the most effective contraceptive methods and on the new military contraceptive guidelines.

To combat rising STD rates, defense forces and Coast Guardsmen should consider regular STD testing and ensure that condoms are readily available through the TRICARE program and to service members at all duty stations at no or reduced cost.

These programs can increase condom use and reduce the incidence of STIs without promoting sexual activity or increasing the number of sexual partners. Improving the regular medical screening process and targeting of at-risk individuals could lead to annual HIV testing and better prevention for this group.

Sexual Orientation

Broadly targeted health promotion activities carried out by the MoD and Coast Guard should include LGB-specific aspects when necessary, as they are part of the service. Addressing health inequalities among LGB people is unlikely to require the development of LGB-specific programs or policies.

Defense forces and coast guards should also take into account the specific mental health needs of LGB personnel. Campaigns to reduce stigma associated with the use of mental health services should include messages and images relevant to LGB personnel and should be tested for acceptability and perceived effectiveness.

Sexual health disparities between LGB and non-LGB populations could be reduced through training of military health care providers. Inaccurate assumptions about bisexual personnel based on the sex of their current sexual partners may lead to inappropriate or inaccurate STI prevention counseling.

Findings for future versions of the HRBS

Review of the use of survey incentives

Although the HRBS is now fully web-based, response rate remains an issue. Existing studies have shown that incentives can increase response rates. DoD policy allows federal contractors to reimburse deemed federal employees for participating in the survey. The next version of the HRBS should explore the use of targeted incentives to increase participation by groups with low response rates.

Shorten the survey and focus on its content

Although the 2018 HRGS survey was shorter in length than the 2015 version, it was still long, which may be boring to respondents, especially if they have recently answered similar questions in other surveys. The MoD could examine the degree of overlap between the HRBS and other data already collected.

For example, some of the content of the periodic check overlaps with elements of the HRBS. The MoD should consider whether an overlap is necessary, perhaps by first examining whether there is a difference between the periodic check and the confidential HRBS database.

Another approach would be the use of modules. The modules could be, for example, on smoking or musculoskeletal injuries. In this approach, not all employees would receive all items in the questionnaire, but certain modules would be selected.

Investigate the use of a panel of employees to monitor risk behaviors over time

To complement the HRBS, defense forces could consider creating a panel of military personnel to collect data on specific health indicators and health-related behaviors in real time. Expert panels are groups of individuals who agree to participate in surveys for a set period of time and are renewed periodically.

Panels require ongoing maintenance to ensure their continuous representation of the population of interest and are not effective in estimating the prevalence of rare outcomes. However, they can reduce the overall frequency of HRBS and thus improve its response rate.

Summary

HRBS data provide information on health outcomes and health-related behaviors in several areas that affect troop well-being and readiness. HRBS will face some challenges in the future – declining response rates, duplication of content, and competition for resources – but will continue to be an important source of information for trend monitoring, policy development, and program decision making.

Methodology

RAND conducted the 2018 HRBS survey of active and reserve members of the U.S. Air Force, Army, Navy, Marine Corps, and Coast Guard from October 2018 through March 2019. The 2018 HRBS was a confidential online survey that allowed researchers to address reminders to nonrespondents and reduce survey burden by linking responses to administrative data.

The sample was selected using a random sampling strategy, stratified by grade, class, and gender. The overall weighted response rate was 9.6%, resulting in a final analysis sample of 17,166 responses. Missing data were treated by imputation, a statistical procedure that uses available data to estimate missing values.

To represent the working population, RAND researchers weighted responses to account for oversampling of service members in some strata. Point estimates and 95% CIs are presented in this research note. 2] Point estimates and 95% CI are presented in this research note. 3] In this research note.

RAND researchers controlled for differences in each outcome between levels of the main factors or by subgroups-branch of service, grade, gender, race/ethnicity, and age group-using a two-step procedure based on the Rao-Scott chi-square test to find overall differences between levels of a factor, and if the overall test was statistically significant, then a two-sample t-test to examine any possible pairwise comparisons between factor levels (e.g., males and females).

Readers interested in these differences should refer to the HRBS 2018 active component final report. This summary is one of eight active component summaries; each of the other seven corresponds to a different chapter of the full report. A similar set of eight summaries covers the reserve component results.

Limitations & Restrictions

The response rate to the survey is low. Although the low response rate does not automatically imply that the survey data are biased, it does increase the possibility of bias. As with any self-report survey, socially desirable bias is possible, especially for sensitive questions and topics. For some groups, which represent a small percentage of the total defense population, survey estimates may be inaccurate and should be interpreted with caution.