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COVID-19

While the majority of those who have served report they are in very good or excellent health, they have higher rates of cancer, coronary heart disease and other health challenges than those who have not served.

2016 Health of Those Who Have Served - Full Report

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Percentage of adults who have served who reported either binge drinking (four or more [females] or five or more [males] alcoholic beverages on a single occasion in the past 30 days) or heavy drinking (eight or more [females] or 15 or more [males] alcoholic beverages per week)

<h2>Why does this matter?</h2>

Alcohol is the third leading <a href="https://www.niaaa.nih.gov/alcohol-facts-and-statistics">preventable cause of death</a> in the United States behind tobacco and poor diet/physical inactivity. The Centers for Disease Control and Prevention (CDC) <a href="https://www.cdc.gov/alcohol/fact-sheets/alcohol-use.htm">defines</a> excessive drinking as binge drinking, heavy drinking, and any drinking by individuals younger than 21 years or by pregnant women. Excessive drinking comes with many risks, <a href="https://www.cdc.gov/alcohol/fact-sheets/alcohol-use.htm">including</a>:&nbsp;

<ul>
	<li>Unintentional injuries.&nbsp;</li>
	<li>Violence such as homicide, suicide and sexual assault.&nbsp;</li>
	<li>Hypertension, heart disease, stroke and liver disease.&nbsp;</li>
	<li>Cancer of the breasts, mouth, throat, esophagus, liver or colon.</li>
</ul>

Alcohol is the <a href="https://www.samhsa.gov/data/sites/default/files/report_2111/Spotlight-2111.html">most common</a> substance abused by veterans. It has traditionally <a href="https://doi.org/10.3109/09540261.2010.550868">played a part</a> in military culture, both socially and as a way of coping with intense stress. In a 2015 study, more than <a href="https://www.rand.org/pubs/research_briefs/RB9955z7.html">two-thirds</a> of service personnel surveyed perceived military culture to be supportive of drinking.&nbsp;

Every year from 2006 to 2010 there were approximately 88,000 <a href="https://www.cdc.gov/alcohol/fact-sheets/alcohol-use.htm">alcohol-attributable deaths</a>. On average, <a href="https://www.cdc.gov/motorvehiclesafety/impaired_driving/impaired-drv_factsheet.html">29 people</a> die every day in motor vehicle crashes that involve an alcohol-impaired driver. Excessive alcohol use cost the United States a total of <a href="https://www.cdc.gov/features/costsofdrinking/">$249 billion</a> in 2010, which is equivalent to $2.05 for each alcoholic beverage consumed, or $807 per person. A 2009 study revealed that alcohol misuse costs the Department of Defense an estimated <a href="https://doi.org/10.7205/MILMED-D-03-9008">$1.2 billion</a> annually.
 <h2>Who is affected?</h2>

There are several risk factors for excessive drinking among the veteran community, including <a href="https://www.drugabuse.gov/publications/drugfacts/substance-use-military-life">experiencing combat</a> involving violence or trauma, and <a href="https://doi.org/10.1111/ajad.12731">depression</a>.&nbsp;

The <a href="https://www.americashealthrankings.org/explore/health-of-those-who-have-served/measure/ExcessDrink/state/ALL">prevalence</a> of excessive drinking among veterans is higher among:

<ul>
	<li>Males compared with females.</li>
	<li>Younger veterans ages 18-34, who have a prevalence more than double than those ages 50 and older.</li>
	<li>Hawaiian/Pacific Islander, Hispanic, white, American Indian/Alaska Native and multiracial veterans than a and Asian veterans, who have the lowest prevalence. &nbsp;</li>
</ul>
 <h2>What works?</h2>

The CDC recommends that some people not drink, including anyone younger than 21 and women who are pregnant or trying to become pregnant. For those who do drink, choosing to <a href="https://www.cdc.gov/alcohol/fact-sheets/moderate-drinking.htm">use moderation</a> when consuming alcohol can reduce the risk of adverse short and long-term health outcomes. The United States Preventive Services Task Force <a href="https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/alcohol-misuse-screening-and-behavioral-counseling-interventions-in-primary-care">recommends</a> that clinicians screen adults ages 18 and older for unhealthy alcohol use and provide those with nondependent unhealthy alcohol use with brief behavioral counseling interventions.&nbsp;

A variety of <a href="https://www.cdc.gov/alcohol/fact-sheets/prevention.htm">evidence-based strategies</a> have been shown to effectively reduce excessive drinking and related health and social costs:

<ul>
	<li>Increasing alcohol excise taxes.</li>
	<li>Reducing alcohol-outlet density.</li>
	<li>Reducing the days and hours of alcohol sales.</li>
	<li>Holding alcohol retailers liable for injuries or damage done by their intoxicated or underage customers.</li>
</ul>

There are a number of interventions that the U.S. Department of Veterans Affairs <a href="https://www.mentalhealth.va.gov/substance-abuse/treatment.asp">recommends</a> to treat alcohol use disorder, such as therapy and medication. They offer more information on <a href="https://www.mentalhealth.va.gov/substance-abuse/programs.asp">programs and services</a> for veterans, such as a local program locator, as well as numerous other <a href="https://www.mentalhealth.va.gov/substance-abuse/resources.asp">resources</a> for those seeking help.
 <h2>References</h2>

Fuehrlein, Brian S., et al. &ldquo;Trajectories of Alcohol Consumption in U.S. Military Veterans: Results from the National Health and Resilience in Veterans Study: Alcohol Consumption Trajectories in Veterans.&rdquo; The American Journal on Addictions, vol. 27, no. 5, Aug. 2018, pp. 383&ndash;90. DOI.org (Crossref), doi:<a href="https://doi.org/10.1111/ajad.12731">10.1111/ajad.12731</a>.

Harwood, Henrick J., et al. &ldquo;Economic Implications of Reduced Binge Drinking Among the Military Health System&rsquo;s TRICARE Prime Plan Beneficiaries.&rdquo; Military Medicine, vol. 174, no. 7, July 2009, pp. 728&ndash;36. DOI.org (Crossref), doi:<a href="https://doi.org/10.7205/MILMED-D-03-9008">10.7205/MILMED-D-03-9008</a>.

Jones, Edgar, and Nicola T. Fear. &ldquo;Alcohol Use and Misuse within the Military: A Review.&rdquo; International Review of Psychiatry, vol. 23, no. 2, Apr. 2011, pp. 166&ndash;72. DOI.org (Crossref), doi:<a href="https://doi.org/10.3109/09540261.2010.550868">10.3109/09540261.2010.550868</a>.

CDC, Behavioral Risk Factor Surveillance System

Percentage of adults who have served who reported sleeping, on average, fewer than seven hours in a 24-hour period

<h2>Why does this matter?</h2>

Insufficient sleep has been recognized as a <a href="https://www.cdc.gov/sleep/index.html">threat to public health</a>. Many U.S. military personnel are exposed to irregular sleep schedules and poor sleep conditions which may have <a href="https://www.doi.org/10.5665%2Fsleep.5972">lasting effects</a> after service ends. Further, veterans tend to have a higher prevalence of conditions such as muscle pain, traumatic brain injury, smoking, substance abuse, hypertension, depression and post traumatic stress disorder (PTSD) that can be disruptive to healthy sleep or <a href="https://www.doi.org/10.5665%2Fsleep.5972">increase risk</a> of developing a sleep disorder. Sleep and wakefulness disorders are <a href="https://www.doi.org/10.5665%2Fsleep.5972">more common</a> among veterans than the general population, with sleep apnea and insomnia the most prevalent.&nbsp;

Sleep is critical for brain and body <a href="https://www.nhlbi.nih.gov/health-topics/sleep-deprivation-and-deficiency">functions</a> including the immune system, hormonal and metabolic systems, cognition and emotion. Insufficient sleep is associated with <a href="https://doi.org/10.2147/NSS.S134864">chronic diseases</a>, including cancer, depression, diabetes, hypertension and obesity. Insufficient sleep is also associated with <a href="https://www.nhlbi.nih.gov/health-topics/sleep-deprivation-and-deficiency">reduced</a> productivity and quality of life, as well as <a href="https://doi.org/10.15585/mmwr.mm6506a1">increased risk</a> of motor vehicle and other transportation <a href="https://www.cdc.gov/features/dsdrowsydriving/">accidents</a>, industrial accidents and medical errors. A <a href="https://www.rand.org/news/press/2016/11/30.html">2016 report</a> by the Rand Corporation estimated insufficient sleep cost $411 billion in missed work days and reduced productivity.
 <h2>Who is affected?</h2>

Sleep disorders tend to be <a href="https://www.rand.org/pubs/research_reports/RR739.html">more common</a> among veterans that have been deployed to a combat zone, deployed multiple times or were deployed to Iraq or Afghanistan. Other <a href="https://www.rand.org/pubs/research_reports/RR739.html">factors</a> include the type of service, with active duty servicemembers, support and sustainment units, and electronics repair units experiencing more sleep disorders after discharge.&nbsp;

The <a href="http://www.americashealthrankings.org/explore/health-of-those-who-have-served/measure/sleep/state/ALL">prevalence</a> of insufficient sleep is higher among:

<ul>
	<li>White veterans compared with Black veterans.</li>
	<li>Veterans with a higher annual household income than veterans with lower income levels.</li>
</ul>
 <h2>What works?</h2>

Early detection and treatment of sleep disorders is important. Screening questionnaires can effectively <a href="https://www.doi.org/10.1007/s11606-017-4250-4">detect</a> some sleep disorders in veterans, and consulting with a <a href="https://www.sleepapnea.org/why-our-veterans-cant-sleep/">primary care physician</a> is the first step toward receiving proper treatment. The U.S. Department of Veterans Affairs offers cognitive behavioral therapy for the treatment of insomnia online through their <a href="https://www.veterantraining.va.gov/insomnia/index.asp">Path to Better Sleep</a> program. Sleep apnea is commonly <a href="https://www.mayoclinic.org/diseases-conditions/obstructive-sleep-apnea/diagnosis-treatment/drc-20352095">treated</a> with lifestyle changes, minor surgery, or with a continuous positive airway pressure (CPAP) machine. The U.S. Department of Veterans Affairs is researching ways to <a href="https://www.paloalto.va.gov/research_taps.asp">improve CPAP machines</a> for veterans who find they cannot comfortably use them.

The National Institute of Health <a href="https://www.nhlbi.nih.gov/health-topics/sleep-deprivation-and-deficiency">recommends</a> that adults sleep seven to eight hours nightly and follow a sleep schedule. It should be noted that making up for lost sleep through naps may provide short-term boosts of attentiveness, but <a href="https://www.nhlbi.nih.gov/health-topics/sleep-deprivation-and-deficiency#how-much-sleep-is-enough">does not</a> provide the health benefits gained by regular adequate nighttime sleep. The U.S. Army has <a href="https://p3.amedd.army.mil/performance-learning-center/sleep">several guides</a> to achieving quality sleep for current and former military personnel under different conditions. One recommendation from the <a href="https://p3.amedd.army.mil/performance-learning-center/sleep/effective-sleep-strategies">Army</a> and <a href="https://www.sleepfoundation.org/articles/why-electronics-may-stimulate-you-bed">The National Sleep Foundation</a> is to limit use of electronic devices before bedtime to improve sleep quality.
 <h2>References</h2>

Alexander, Melannie, et al. &ldquo;The National Veteran Sleep Disorder Study: Descriptive Epidemiology and Secular Trends, 2000&ndash;2010.&rdquo; Sleep, vol. 39, no. 7, July 2016, pp. 1399&ndash;410, doi:<a href="https://doi.org/10.5665/sleep.5972">10.5665/sleep.5972</a>.

Hughes, Jaime M., et al. &ldquo;Single-Item Measures for Detecting Sleep Problems in United States Military Veterans.&rdquo; Journal of General Internal Medicine, vol. 33, no. 5, May 2018, pp. 698&ndash;704. Springer Link, doi:<a href="https://doi.org/10.1007/s11606-017-4250-4">10.1007/s11606-017-4250-4</a>.

Liu, Yong, et al. &ldquo;Prevalence of Healthy Sleep Duration among Adults &mdash; United States, 2014.&rdquo; MMWR. Morbidity and Mortality Weekly Report, vol. 65, no. 6, Feb. 2016, pp. 137&ndash;41. DOI.org (Crossref), doi:<a href="https://doi.org/10.15585/mmwr.mm6506a1">10.15585/mmwr.mm6506a1</a>.

Medic, Goran, et al. &ldquo;Short- and Long-Term Health Consequences of Sleep Disruption.&rdquo; Nature and Science of Sleep, vol. 9, 2017, pp. 151&ndash;61, doi:<a href="https://doi.org/10.2147/NSS.S134864">10.2147/NSS.S134864</a>.

Troxel, Wendy M. Sleep in the Military: Promoting Healthy Sleep among U.S. Servicemembers. RAND Corporation, 2015. Library of Congress ISBN: <a href="https://www.rand.org/pubs/research_reports/RR739.html">978-0-8330-8851-2</a>.

Percentage of adults who have served with a body mass index of 30.0 or higher based on reported height and weight

<h2>Why does this matter?</h2>

People who have obesity, defined as a body mass index (<a href="https://www.cdc.gov/healthyweight/assessing/bmi/index.html">BMI</a>) of 30 or above, are at <a href="https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/groups-at-higher-risk.html">higher risk</a> of severe illness from coronavirus disease (COVID-19). For more information about COVID-19 see the Centers for Disease Control and Prevention <a href="https://www.cdc.gov/coronavirus/2019-nCoV/index.html">website</a>.

Adults who have obesity, compared with healthy-weight adults, are more likely to have a decreased quality of life and an increased risk of developing <a href="https://www.cdc.gov/obesity/adult/causes.html">serious health conditions</a> including:

<ul>
	<li>Hypertension.</li>
	<li>Type 2 diabetes.</li>
	<li>Heart disease and stroke.</li>
	<li>Sleep apnea and breathing problems.</li>
	<li>Some cancers.</li>
	<li>Mental illness such as depression and anxiety due to <a href="https://www.nationaleatingdisorders.org/weight-stigma">weight stigma</a>.</li>
</ul>

Obesity rates tend to be <a href="https://doi.org/10.7205/MILMED.173.6.544">similar between veterans and non-veterans</a>, though veterans are more likely to be physically active. Several studies have pointed to a pattern of <a href="https://doi.org/10.1038/oby.2011.2">post-service</a> rapid weight gain among veterans recently discharged from military service. Possible explanations include the ending of the military&rsquo;s intense physical activity routines, or overeating to <a href="https://doi.org/10.1016/j.appet.2017.07.011">relieve mental distress</a>. Obesity prevalence among those who have served is a growing <a href="https://doi.org/10.1093/cdn/nzz041.P21-050-19">national security concern</a>.

 
The costs associated with obesity and obesity-related health problems are staggering. One study estimated the medical costs of obesity to be <a href="http://www.doi.org/10.1007/s11606-016-3968-8">$342.2 billion</a> (in 2013 dollars). Beyond direct medical costs, the indirect costs of decreased productivity tied to obesity are estimated at <a href="https://www.doi.org/10.1097/JOM.0000000000000298">$8.65 billion</a> per year.
 <h2>Who is affected?</h2>

Obesity is a complex condition that can affect anyone. <a href="https://www.cdc.gov/obesity/adult/causes.html">Contributing factors</a> include the social and physical environment, genetics, <a href="https://www.nature.com/articles/mp201354">childhood maltreatment</a>, medical history and behaviors such as poor diet and physical inactivity. Recent studies have also found that trauma, including <a href="https://doi.org/10.1089/jwh.2016.6105">military sexual trauma</a> and <a href="https://doi.org/10.1017/S0033291718001514">post traumatic stress disorder</a>, is associated with higher levels of obesity in veterans. The <a href="https://www.americashealthrankings.org/explore/health-of-those-who-have-served/measure/Obesity/state/ALL">prevalence</a> of obesity among veterans is higher among:

<ul>
	<li>Males compared to females.</li>
	<li>Older cohorts of veterans than younger cohorts.</li>
	<li>Black adults and adults who identify as multiracial compared with all other race and ethnicities.</li>
	<li>Those with less than a high school education compared with college graduates; the prevalence of obesity is lowest among college graduates who have served.</li>
</ul>
 <h2>What works?</h2>

<a href="https://www.nhlbi.nih.gov/files/docs/guidelines/ob_gdlns.pdf#page=13">Weight loss is effective</a> at preventing or improving obesity-related chronic diseases. <a href="https://doi.org/10.1007/s11606-016-3960-3">Behavioral interventions</a> are a cost effective way to reduce obesity rates and well suited to help those who have served dealing with mental illnesses. Bariatric surgery, in combination with strong social support, can be an <a href="https://dx.doi.org/10.1007%2Fs40519-017-0425-6">effective method</a> of lowering obesity rates among those who have served with severe obesity.

At the population level, physical environment, health promotion, and food policy and regulations can support healthy behaviors and help prevent obesity. The Community Preventive Services Task Force has compiled a list of <a href="https://www.thecommunityguide.org/topic/obesity">resources</a> for community-level interventions that can lower obesity rates by supporting healthy eating and active living in a variety of settings.
 <h2>References</h2>

Almond, Nathaniel, et al. &ldquo;The Prevalence of Overweight and Obesity among U.S. Military Veterans.&rdquo; Military Medicine, vol. 173, no. 6, June 2008, pp. 544&ndash;49. DOI.org (Crossref), doi:<a href="https://doi.org/10.7205/MILMED.173.6.544">10.7205/MILMED.173.6.544</a>.

Andreyeva, Tatiana, et al. &ldquo;State-Level Estimates of Obesity-Attributable Costs of Absenteeism.&rdquo; Journal of Occupational and Environmental Medicine, vol. 56, no. 11, Nov. 2014, pp. 1120&ndash;1127. journals.lww.com, doi:<a href="https://doi.org/10.1097/JOM.0000000000000298">10.1097/JOM.0000000000000298</a>.

Biener, Adam, et al. &ldquo;The High and Rising Costs of Obesity to the US Health Care System.&rdquo; Journal of General Internal Medicine, vol. 32, no. S1, Apr. 2017, pp. 6&ndash;8. DOI.org (Crossref), doi:<a href="https://doi.org/10.1007/s11606-016-3968-8">10.1007/s11606-016-3968-8</a>.

Danese, A., and M. Tan. &ldquo;Childhood Maltreatment and Obesity: Systematic Review and Meta-Analysis.&rdquo; Molecular Psychiatry, vol. 19, no. 5, May 2014, pp. 544&ndash;54. DOI.org (Crossref), doi:<a href="https://doi.org/10.1038/mp.2013.54">10.1038/mp.2013.54</a>.

Dorflinger, Lindsey M., et al. &ldquo;Night Eating among Veterans with Obesity.&rdquo; Appetite, vol. 117, Oct. 2017, pp. 330&ndash;34. DOI.org (Crossref), doi:<a href="https://doi.org/10.1016/j.appet.2017.07.011">10.1016/j.appet.2017.07.011</a>.

Erickson, Zachary D., et al. &ldquo;A Randomized, Controlled Multisite Study of Behavioral Interventions for Veterans with Mental Illness and Antipsychotic Medication-Associated Obesity.&rdquo; Journal of General Internal Medicine, vol. 32, no. S1, Apr. 2017, pp. 32&ndash;39. DOI.org (Crossref), doi:<a href="https://doi.org/10.1007/s11606-016-3960-3">10.1007/s11606-016-3960-3</a>.

Funk, Luke M., et al. &ldquo;Patient Predictors of Weight Loss Following a Behavioral Weight Management Intervention among US Veterans with Severe Obesity.&rdquo; Eating and Weight Disorders - Studies on Anorexia, Bulimia and Obesity, vol. 23, no. 5, Oct. 2018, pp. 587&ndash;95. DOI.org (Crossref), doi:<a href="https://doi.org/10.1007/s40519-017-0425-6">10.1007/s40519-017-0425-6</a>.

Koepsell, Thomas D., et al. &ldquo;Obesity, Overweight, and Their Life Course Trajectories in Veterans and Non-Veterans.&rdquo; Obesity, vol. 20, no. 2, Feb. 2012, pp. 434&ndash;39. DOI.org (Crossref), doi:<a href="https://doi.org/10.1038/oby.2011.2">10.1038/oby.2011.2</a>.

Lemmens, Valery E. P. P., et al. &ldquo;A Systematic Review of the Evidence Regarding Efficacy of Obesity Prevention Interventions among Adults.&rdquo; Obesity Reviews, vol. 9, no. 5, Sept. 2008, pp. 446&ndash;55, doi:<a href="https://doi.org/10.1111/j.1467-789X.2008.00468.x">10.1111/j.1467-789X.2008.00468.x</a>.

Mason, Susan M., et al. &ldquo;Child Maltreatment&rsquo;s Heavy Toll.&rdquo; American Journal of Preventive Medicine, vol. 50, no. 5, May 2016, pp. 646&ndash;49. DOI.org (Crossref), doi:<a href="https://doi.org/10.1016/j.amepre.2015.11.004">10.1016/j.amepre.2015.11.004</a>.

Mitchell, K. S., et al. &ldquo;A Co-Twin Control Study of the Association between Combat Exposure, PTSD and Obesity in Male Veterans.&rdquo; Psychological Medicine, vol. 48, no. 14, Oct. 2018, pp. 2449&ndash;52. DOI.org (Crossref), doi:<a href="https://doi.org/10.1017/S0033291718001514">10.1017/S0033291718001514</a>.

Pandey, Nivedita, et al. &ldquo;Military Sexual Trauma and Obesity Among Women Veterans.&rdquo; Journal of Women&rsquo;s Health, vol. 27, no. 3, Mar. 2018, pp. 305&ndash;10. DOI.org (Crossref), doi:<a href="https://doi.org/10.1089/jwh.2016.6105">10.1089/jwh.2016.6105</a>.

Shams-White, Marissa, et al. &ldquo;A Comparison of Anthropometric Measures with Bioelectrical Impedance Analysis in the Classification of Overweight and Obesity in U.S. Military Personnel (P21-050-19).&rdquo; Current Developments in Nutrition, vol. 3, no. Supplement_1, June 2019, p. nzz041.P21-050-19. DOI.org (Crossref), doi:<a href="https://doi.org/10.1093/cdn/nzz041.P21-050-19">10.1093/cdn/nzz041.P21-050-19</a>.

Percentage of adults who have served who reported doing no physical activity or exercise other than their regular job in the past 30 days

<h2>Why does this matter?</h2>

Regular physical activity is a vital element of a healthy lifestyle. Only <a href="http://www.cdc.gov/physicalactivity/downloads/trends-in-the-prevalence-of-physical-activity-508.pdf">24% of adults</a> met <a href="https://health.gov/paguidelines/second-edition/pdf/Physical_Activity_Guidelines_2nd_edition.pdf#page=55">physical activity guidelines</a> in 2018, and many adults spent a large portion of their time <a href="https://doi.org/10.1001/jama.2019.3636">being sedentary</a> (sitting). Being physically active and reducing sedentary behavior <a href="https://www.doi.org/10.1136/bmjopen-2012-000828">can benefit health</a>. Regular physical activity (at least 150 minutes a week) is associated with <a href="https://health.gov/paguidelines/second-edition/pdf/Physical_Activity_Guidelines_2nd_edition.pdf#page=32">reduced risk</a> of:

<ul>
	<li>Cardiovascular diseases, such as heart disease and stroke.</li>
	<li>Hypertension.</li>
	<li>Type 2 diabetes.</li>
	<li>Certain cancers, including bladder, breast and colon cancer.</li>
	<li>Dementia.</li>
	<li>Anxiety and depression.</li>
</ul>

A study by the Centers for Disease Control and Prevention (CDC) found that <a href="https://www.doi.org/10.5888/pcd18.170354">8.3%</a> of deaths of non-disabled adults ages 25 and older were attributed to physical inactivity. Costs associated with physical inactivity account for more than 11% of total health care expenditures and are estimated at <a href="https://doi.org/10.1016/j.pcad.2014.08.002">$117 billion</a> annually.
 <h2>Who is affected?</h2>

The <a href="https://www.americashealthrankings.org/explore/health-of-those-who-have-served/measure/physical_inactivity/state/ALL">prevalence</a> of physical inactivity among veterans is higher among:

<ul>
	<li>Women compared with men.&nbsp;</li>
	<li>Those who are ages 50 and older, who have a prevalence nearly three times higher than those ages 18-25.&nbsp;</li>
	<li>Veterans who have less than a high school education; the prevalence decreases as educational attainment increases.</li>
	<li>Those who have an annual household income of less than $25,000; the prevalence decreases with each increasing income group.</li>
	<li>Veterans who <a href="https://doi.org/10.1016/j.socscimed.2015.07.034">experienced</a> depression and more days of functional limitation due to physical or mental health concerns.</li>
</ul>
 <h2>What works?</h2>

Reducing the amount of time spent sitting and increasing physical activity may <a href="https://doi.org/10.1001/jamaoncol.2020.2045">decrease the health risks</a> associated with physical inactivity. Physical activity guidelines specify that adults should <a href="https://health.gov/paguidelines/second-edition/pdf/Physical_Activity_Guidelines_2nd_edition.pdf#page=8">move more and sit less</a> throughout the day. Some physical activity is better than none. Key <a href="https://health.gov/paguidelines/second-edition/pdf/Physical_Activity_Guidelines_2nd_edition.pdf#page=56">guidelines for adults</a> include:

<ul>
	<li>At least 150 minutes of moderate-intensity (or 75 minutes of vigorous-intensity) aerobic physical activity a week, such as running, riding a bike, dancing or swimming.</li>
	<li>Muscle-strengthening activities involving all major muscle groups two or more days a week.</li>
</ul>

One study found that several things were associated with higher levels of physical activity among veterans, <a href="https://doi.org/10.1016/j.socscimed.2015.07.034">including</a> social support and neighborhood aesthetics.&nbsp;

The CDC makes <a href="https://www.cdc.gov/physicalactivity/activepeoplehealthynation/creating-an-active-america.html">several recommendations</a> for community efforts to increase physical activity, including <a href="https://www.cdc.gov/physicalactivity/community-strategies/beactive/index.html">built environment</a> approaches to make it easier for people to walk, run, bike, skate or use wheelchairs to get to where they need to go.
 <h2>References</h2>

Carlson, Susan A., Janet E. Fulton, et al. &ldquo;Inadequate Physical Activity and Health Care Expenditures in the United States.&rdquo; Progress in Cardiovascular Diseases, vol. 57, no. 4, Jan. 2015, pp. 315&ndash;23. ScienceDirect, doi:<a href="https://doi.org/10.1016/j.pcad.2014.08.002">10.1016/j.pcad.2014.08.002</a>.

Carlson, Susan A., E. Kathleen Adams, et al. &ldquo;Percentage of Deaths Associated With Inadequate Physical Activity in the United States.&rdquo; Preventing Chronic Disease, vol. 15, Mar. 2018, p. 170354. DOI.org (Crossref), doi:<a href="https://doi.org/10.5888/pcd18.170354">10.5888/pcd18.170354</a>.

Gilchrist, Susan C., et al. &ldquo;Association of Sedentary Behavior With Cancer Mortality in Middle-Aged and Older US Adults.&rdquo; JAMA Oncology, June 2020. DOI.org (Crossref), doi:<a href="https://doi.org/10.1001/jamaoncol.2020.2045">10.1001/jamaoncol.2020.2045</a>.

Hoerster, Katherine D., et al. &ldquo;Individual and Contextual Correlates of Physical Activity among a Clinical Sample of United States Veterans.&rdquo; Social Science &amp; Medicine, vol. 142, Oct. 2015, pp. 100&ndash;08. DOI.org (Crossref), doi:<a href="https://doi.org/10.1016/j.socscimed.2015.07.034">10.1016/j.socscimed.2015.07.034</a>.

Katzmarzyk, Peter T., and I. Min Lee. &ldquo;Sedentary Behaviour and Life Expectancy in the USA: A Cause-Deleted Life Table Analysis.&rdquo; BMJ Open, vol. 2, no. 4, 2012, doi:<a href="https://doi.org/10.1136/bmjopen-2012-000828">10.1136/bmjopen-2012-000828</a>.

Yang, Lin, et al. &ldquo;Trends in Sedentary Behavior Among the US Population, 2001-2016.&rdquo; JAMA, vol. 321, no. 16, Apr. 2019, p. 1587. DOI.org (Crossref), doi:<a href="https://doi.org/10.1001/jama.2019.3636">10.1001/jama.2019.3636</a>.

Percentage of adults who have served who reported smoking at least 100 cigarettes in their lifetime and currently smoke daily or some days

<h2>Why does this matter?</h2>

Smoking is a behavior that may cause a person&#39;s immune system to not function properly (medically referred to as being immunocompromised). Current and former smokers may be at <a href="https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/groups-at-higher-risk.html">higher risk</a> of severe illness from coronavirus disease (COVID-19). For more information about COVID-19 see the <a href="https://www.cdc.gov/coronavirus/2019-nCoV/index.html">CDC website</a>.&nbsp;

Smoking is the <a href="https://www.cdc.gov/tobacco/data_statistics/fact_sheets/fast_facts/index.htm">leading cause</a> of preventable death and disease in the United States. Cigarette smoking is responsible for more than <a href="https://www.cdc.gov/tobacco/data_statistics/fact_sheets/health_effects/effects_cig_smoking/index.htm">480,000 deaths</a> every year. Smokers live <a href="https://www.cdc.gov/tobacco/data_statistics/fact_sheets/fast_facts/index.htm">10 years</a> less than non-smokers, on average. People who do not smoke are also affected by smoking. Exposure to secondhand smoke is estimated to cause <a href="https://www.cdc.gov/tobacco/data_statistics/fact_sheets/fast_facts/index.htm">41,000 deaths</a> among U.S. adults every year. Smoking damages <a href="https://www.cdc.gov/tobacco/infographics/health-effects/pdfs/he-infographic1.pdf?s_cid=bb-osh-effects-graphic-005">nearly every organ</a> and is associated with:

<ul>
	<li>Heart disease.</li>
	<li>Stroke.</li>
	<li>Respiratory diseases such as chronic obstructive pulmonary disease (COPD).</li>
	<li>Diabetes.</li>
	<li>Multiple types of <a href="https://www.cdc.gov/mmwr/volumes/67/ss/ss6712a1.htm?s_cid=ss6712a1_e#T1_down">cancer.</a></li>
</ul>

Tobacco use has historically been normalized in the military. Data suggest that 38% of current smokers in the military <a href="https://truthinitiative.org/research-resources/targeted-communities/tobacco-use-military">began smoking</a> during military service.&nbsp;

Smoking is <a href="https://www.ncbi.nlm.nih.gov/books/NBK179276/pdf/Bookshelf_NBK179276.pdf#page=41">estimated to cost</a> the U.S. between $132.5 and $175.9 billion for medical expenses as well as $151 billion in lost productivity due to premature death every year. The Veterans Health Administration spent an estimated <a href="https://doi.org/10.1093/ntr/ntu187">$2.7 billion</a> on the health effects of smoking in 2010, which included ambulatory care, prescription drugs, hospitalizations and home health care.
 <h2>Who is affected?</h2>

The <a href="https://www.americashealthrankings.org/explore/health-of-those-who-have-served/measure/smoking/state/ALL">prevalence</a> of cigarette smoking among veterans is higher in:

<ul>
	<li>Men compared with women.</li>
	<li>American Indian/Alaska Native, multiracial, Hawaiian/Pacific Islander, Black, white and Hispanic veterans compared with Asian veterans, who have the lowest prevalence.</li>
	<li>Those without a high school degree than those with higher levels of education; the prevalence decreases with each increase in education level.</li>
	<li>Those with a household income less than $25,000 than all higher income levels; the prevalence decreases with each increase in income level.</li>
	<li>Those who are <a href="https://www.cdc.gov/mmwr/volumes/67/wr/mm6701a2.htm">uninsured</a> than those with health insurance.</li>
</ul>
 <h2>What works?</h2>

<a href="https://www.cdc.gov/tobacco/quit_smoking/how_to_quit/benefits/index.htm">Quitting smoking</a> can have profound benefits on current and long-term health at any age, even among heavy and lifelong smokers. A variety of interventions are <a href="https://www.doi.org/10.7326/M15-0171">effective for smoking prevention and cessation</a>.&nbsp;

For examples of communities preventing and controlling tobacco use, see the Center for Disease Control and Prevention&rsquo;s <a href="https://nccd.cdc.gov/DCH_CHORC/">Community Health Online Resource Center</a>. County Health Rankings &amp; Roadmaps provides a <a href="https://www.countyhealthrankings.org/take-action-to-improve-health/what-works-for-health">list of evidence-based strategies</a> to address health issues such as tobacco control. <a href="https://smokefree.gov/">Smokefree.gov</a> provides free, accurate and evidence-based information as well as professional assistance to support the immediate and long-term needs of smokers trying to quit.&nbsp;

A variety of resources are available to veterans who are <a href="https://www.mentalhealth.va.gov/quit-tobacco/how-to-quit.asp">trying to quit</a>, including:

<ul>
	<li><a href="https://www.mentalhealth.va.gov/quit-tobacco/quit-vet.asp">Quit VET</a>, the Veterans Administration&rsquo;s quitline, which is staffed by trained counselors.</li>
	<li><a href="https://www.mentalhealth.va.gov/quit-tobacco/smokefreevet.asp">SmokefreeVET</a>, which sends out daily text messages of support and encouragement.</li>
	<li><a href="https://www.mentalhealth.va.gov/quit-tobacco/docs/My-Smoking-Workbook-REVISED-2017-final-508.pdf#">My Tobacco Cessation Workbook: A Resource for Veterans</a> is a guide/workbook put out by the U.S. Department of Veterans Affairs to help veterans quit.</li>
</ul>
 <h2>References</h2>

Chaloupka, F. J., et al. &ldquo;Effectiveness of Tax and Price Policies in Tobacco Control.&rdquo; Tobacco Control, vol. 20, no. 3, May 2011, pp. 235&ndash;38. DOI.org (Crossref), doi:<a href="https://doi.org/10.1136/tc.2010.039982">10.1136/tc.2010.039982</a>.

Hu, S. Sean, et al. &ldquo;State-Specific Patterns of Cigarette Smoking, Smokeless Tobacco Use, and E-Cigarette Use Among Adults &mdash; United States, 2016.&rdquo; Preventing Chronic Disease, vol. 16, Feb. 2019, p. 180362. DOI.org (Crossref), doi:<a href="https://doi.org/10.5888/pcd16.180362">10.5888/pcd16.180362</a>.

Jamal, Ahmed, et al. &ldquo;Current Cigarette Smoking Among Adults &mdash; United States, 2016.&rdquo; MMWR. Morbidity and Mortality Weekly Report, vol. 67, no. 2, Jan. 2018, pp. 53&ndash;59. DOI.org (Crossref), doi:<a href="https://doi.org/10.15585/mmwr.mm6702a1">10.15585/mmwr.mm6702a1</a>.

Patnode, Carrie D., et al. &ldquo;Behavioral Counseling and Pharmacotherapy Interventions for Tobacco Cessation in Adults, Including Pregnant Women: A Review of Reviews for the U.S. Preventive Services Task Force.&rdquo; Annals of Internal Medicine, vol. 163, no. 8, Oct. 2015, p. 608. DOI.org (Crossref), doi:<a href="https://doi.org/10.7326/M15-0171">10.7326/M15-0171</a>.

Percentage of adults who have served who use chewing tobacco, snuff, or snus every day or some days

<h2>Why does this matter?</h2>

Smokeless tobacco describes any tobacco product that is <a href="https://veterans.smokefree.gov/smokeless-tobacco/get-the-facts">not burned</a>. This includes products such as chewing tobacco, dip, snuff and snus. Smokeless tobacco contains nicotine, the same addictive agent found in cigarettes, as well as many of the same <a href="https://www.fda.gov/tobacco-products/products-ingredients-components/dip-chew-snuff-snus-smokeless-doesnt-mean-safe">cancer-causing agents</a>.&nbsp;

<a href="https://www.fda.gov/tobacco-products/products-ingredients-components/dip-chew-snuff-snus-smokeless-doesnt-mean-safe">Health issues</a> associated with smokeless tobacco use include:

<ul>
	<li>Nicotine addiction.</li>
	<li>Cancers of the esophagus, mouth and pancreas.</li>
	<li>Diseases of the mouth, such as tooth loss and gum decay.</li>
</ul>

Smokeless tobacco use contributes to substantial expenditures for the Veterans Health Administration (VHA). In 2010, the VHA spent an estimated <a href="https://doi.org/10.1093/ntr/ntu187">$2.7 billion</a> on health services linked to smoking, such as ambulatory care, prescription drugs and hospitalizations.
 <h2>Who is affected?</h2>

The <a href="https://www.americashealthrankings.org/explore/health-of-those-who-have-served/measure/tobacco/state/ALL">prevalence</a> of smokeless tobacco use among veterans is higher in:

<ul>
	<li>Men compared with women.</li>
	<li>Adults ages 18-49 than those ages 50+.</li>
	<li>American Indian and Alaska Native and white adults compared with those who are Hispanic, Asian or Black.</li>
	<li>Adults with less than a high school education compared with adults who have some college education or are college graduates.</li>
</ul>
 <h2>What works?</h2>

Quitting smokeless tobacco use can have profound <a href="https://smokefree.gov/quitting-dip/why-do-you-want-quit-dip">benefits on health</a>. Just quitting cigarettes, quitting smokeless tobacco <a href="https://www.uwhealth.org/health/topic/special/-quitting-smokeless-tobacco/av2497.html">can be difficult</a> due to nicotine addiction. Many interventions have <a href="https://doi.org/10.1002/14651858.CD004306.pub5">been proven to help</a> with quitting. A variety of nicotine replacement therapies, as well as other medications, can <a href="https://www.mentalhealth.va.gov/quit-tobacco/docs/Smokeless_Tobacco_A_Guide_for_Quitting_Workbook_508.pdf#page=14">help</a>. Counseling has also been <a href="https://www.cancer.org/healthy/stay-away-from-tobacco/guide-quitting-smoking/deciding-to-quit-smokeless-tobacco-and-making-a-plan.html">shown to help</a>.&nbsp;

A variety of resources are available to veterans who are trying to quit, including:

<ul>
	<li><a href="https://www.mentalhealth.va.gov/quit-tobacco/quit-vet.asp">Quit VET</a>, the Veterans Administration&rsquo;s quitline, which is staffed by trained counselors.</li>
	<li><a href="https://www.mentalhealth.va.gov/quit-tobacco/smokefreevet.asp">SmokefreeVET</a>, which sends out daily text messages of support and encouragement.</li>
	<li><a href="https://www.mentalhealth.va.gov/quit-tobacco/docs/Smokeless_Tobacco_A_Guide_for_Quitting_Workbook_508.pdf">Smokeless Tobacco: A Veteran&rsquo;s Guide for Quitting</a> is a guide/workbook put out by the U.S. Department of Veterans Affairs to help veterans quit.</li>
</ul>
 <h2>References</h2>

Barnett, P. G., et al. &ldquo;Health Care Expenditures Attributable to Smoking in Military Veterans.&rdquo; Nicotine &amp; Tobacco Research, vol. 17, no. 5, May 2015, pp. 586&ndash;91. DOI.org (Crossref), doi:<a href="https://doi.org/10.1093/ntr/ntu187">10.1093/ntr/ntu187</a>.

Ebbert, Jon O., et al. &ldquo;Interventions for Smokeless Tobacco Use Cessation.&rdquo; Cochrane Database of Systematic Reviews, edited by Cochrane Tobacco Addiction Group, Oct. 2015. DOI.org (Crossref), doi:<a href="https://doi.org/10.1002/14651858.CD004306.pub5">10.1002/14651858.CD004306.pub5</a>.

Percentage of adults who have served who are in the workforce and are either employed for wages or self-employed

<h2>Why does this matter?</h2>

There is a strong relationship between employment status and <a href="https://doi.org/10.1023/A:1025634504740">mental and physical health</a>. A stable, safe and well-paying job makes it easier for people to live in healthier neighborhoods, provide quality child care and education for their families, afford nutritious food and access medical care &mdash; all <a href="https://www.rwjf.org/content/dam/farm/reports/issue_briefs/2013/rwjf403360">critical factors</a> to maintaining good health. While those that have served typically have a <a href="https://s3.amazonaws.com/files.cnas.org/documents/Veteran-Pathways-edited-mvs-final-1-min.pdf?mtime=20200129113555#page=4">lower unemployment rate</a> compared with those who have not served, there is growing research that many veterans are having <a href="https://s3.amazonaws.com/files.cnas.org/documents/Veteran-Pathways-edited-mvs-final-1-min.pdf?mtime=20200129113555#page=4">difficulty finding meaningful work</a> or are underemployed. Those who have served that are unemployed are also <a href="https://doi.org/10.1080/15332985.2016.1229714">more likely</a> to report having more poor mental health days compared with those who have not served.&nbsp;

High unemployment rates increase the <a href="https://doi.org/10.1146/annurev.pu.17.050196.002313">economic burden</a> on states due to decreased revenue from income taxes and increased demand for unemployment insurance and social welfare programs
 <h2>Who is affected?</h2>

The employment rate of those who have served <a href="https://www.bls.gov/careeroutlook/2017/article/veterans.htm#unemployment-and-employment">varies considerably by state</a>. Populations who have served that are more affected by lack of employment include:&nbsp;

<ul>
	<li>Gulf War-era II Veterans, or those who served in the Armed Forces since September 2001, have a <a href="https://www.bls.gov/news.release/vet.nr0.htm">lower employment</a> rate than veterans of other service periods.&nbsp;</li>
	<li>Veterans with a disability related to their service have a<a href="https://www.bls.gov/news.release/vet.nr0.htm"> higher unemployment rate</a> when compared with veterans with no disability.&nbsp;</li>
</ul>
 <h2>What works?</h2>

There are multiple programs available to help veterans find work. The U.S Department of Veterans Affairs has a list of <a href="https://www.va.gov/careers-employment/">resources</a> as well as resources from other <a href="https://www.va.gov/careers-employment/veteran-resources/">organizations</a>. Numerous organizations focused on finding employment for veterans appeared <a href="https://s3.amazonaws.com/files.cnas.org/documents/Veteran-Pathways-edited-mvs-final-1-min.pdf?mtime=20200129113555#page=7">following the financial collapse</a> of 2008 such as <a href="https://www.hiringourheroes.org">Hiring our Heroes</a>, <a href="https://www.veteranjobsmission.com">Veteran Jobs Mission</a>, and <a href="https://www.sba.gov/offices/headquarters/ovbd">The Office of Veterans Business Development</a> from the Small Business Administration.
 <h2>References</h2>

Dooley, D., et al. &ldquo;Health and Unemployment.&rdquo; Annual Review of Public Health, vol. 17, no. 1, Jan. 1996, pp. 449&ndash;65. DOI.org (Crossref), doi:<a href="https://doi.org/10.1146/annurev.pu.17.050196.002313">10.1146/annurev.pu.17.050196.002313</a>.

Dooley, David. &ldquo;Unemployment, Underemployment, and Mental Health: Conceptualizing Employment Status as a Continuum.&rdquo; American Journal of Community Psychology, vol. 32, no. 1&ndash;2, 2003, pp. 9&ndash;20. Wiley Online Library, doi:<a href="https://doi.org/10.1023/A:1025634504740">10.1023/A:1025634504740</a>.

Tran, Thanh V., et al. &ldquo;Differential Association between Unemployment Status and Mental Health among Veterans and Civilians.&rdquo; Social Work in Mental Health, vol. 15, no. 4, Routledge, July 2017, pp. 419&ndash;34. Taylor and Francis+NEJM, doi:<a href="https://doi.org/10.1080/15332985.2016.1229714">10.1080/15332985.2016.1229714</a>.

Percentage of adults who have served who reported not having sufficient money to eat when and what they should, or being concerned that food would run out before they have money to buy more in the past 30 days

<h2>Why does this matter?</h2>

Food insecurity is a <a href="https://www.ers.usda.gov/topics/food-nutrition-assistance/food-security-in-the-us/definitions-of-food-security.aspx">social and economic condition</a> where access to food is limited or uncertain. It differs from hunger in that hunger is a physiological feeling. Every year about <a href="https://www.cbpp.org/research/food-assistance/snap-helps-13-million-low-income-veterans-including-thousands-in-every">1.3 million veterans</a> rely on the Supplemental Nutrition Assistance Program (SNAP) to help put food on their table and about <a href="https://www.feedingamerica.org/hunger-blog/fighting-for-veterans-1">8 million veterans</a> used food banks associated with <a href="https://www.feedingamerica.org/">Feeding America</a> in 2017. Food insecurity has broad effects on health due to the mental and physical stress that it places on the body and it can <a href="https://www.feedingamerica.org/hunger-in-america/food-insecurity">force a person to choose</a> between food and medications. Among veterans, food insecurity is <a href="https://doi.org/10.1017/S136898001400072X">associated with</a> poor general health status, tobacco use and lower average hours of sleep.

Health-related costs attributed to hunger were conservatively estimated at <a href="http://hungerreport.org/2016/wp-content/uploads/2015/11/HR2016-Full-Report-Web.pdf#page=81">$160 billion</a> in 2014. Adding in lost economic productivity, education costs (such as special education support and costs of school dropout) and charity to combat hunger brings the total to <a href="http://hungerreport.org/2016/wp-content/uploads/2015/11/HR2016-Full-Report-Web.pdf#page=81">$178.9 billion</a>.
 <h2>Who is affected?</h2>

Food insecurity is a <a href="https://hungerandhealth.feedingamerica.org/understand-food-insecurity/">complex problem</a> and does not exist in isolation. For veterans, food insecurity is also <a href="https://doi.org/10.1017/S136898001400072X">associated with</a> being unmarried, living in households with more children, having a lower final military pay grade and getting less sleep compared with veterans who were food secure.

Food insecurity is <a href="http://www.americashealthrankings.org/explore/health-of-those-who-have-served/measure/food_insecurity/state/ALL">more prevalent</a> among:

<ul>
	<li>Veterans ages 26-49 compared with veterans that are over the age of 50. Younger veterans tend to have a <a href="https://doi.org/10.1017/S136898001400072X">higher prevalence</a> of food insecurity.</li>
	<li>Black and multiracial veterans compared with white, Asian and Hispanic veterans.&nbsp;</li>
	<li>Veterans with less than a high school education compared with veterans with higher levels of education; college graduates have the lowest prevalence of food insecurity.&nbsp;</li>
	<li>Veterans with an annual household income less than $35,000, who have over nine times the prevalence of food insecurity compared with veterans with an income of $75,000 or more.</li>
</ul>
 <h2>What works?</h2>

Programs that are effective at reducing food insecurity among veterans by providing either cash or food assistance include the U.S Department of Veterans Affairs Medical Center <a href="https://www.feedingamerica.org/about-us/press-room/veterans-affairs">food banks</a> or other veteran oriented <a href="https://feedingsandiego.org/programs/feeding-heroes/">food pantries</a>, <a href="https://www.fns.usda.gov/snap/supplemental-nutrition-assistance-program-snap">Supplemental Nutrition Assistance Program</a> (SNAP), Special Supplemental Nutrition Program for <a href="https://www.cbpp.org/research/food-assistance/wic-works-addressing-the-nutrition-and-health-needs-of-low-income-families">Women, Infants and Children</a> (WIC), and local food banks.&nbsp;

In 2017, SNAP lifted <a href="https://www.rwjf.org/en/library/research/2018/09/snap-supports-children-and-families.html">3.4 million people</a> out of poverty. Despite this success, it is estimated that <a href="https://www.feedingamerica.org/sites/default/files/research/map-the-meal-gap/2016/2016-map-the-meal-gap-all-modules.pdf#page=9">27%</a> of food-insecure individuals live in a household that does not qualify for assistance. <a href="https://www.feedingamerica.org/about-us/press-room/feeding-america-network-member-ceo-testifies-house-committee-regarding-veteran">Policy changes</a> could make accessing nutritional assistance easier for veterans.
 <h2>References</h2>

Widome, Rachel, et al. &ldquo;Food Insecurity among Veterans of the US Wars in Iraq and Afghanistan.&rdquo; Public Health Nutrition, vol. 18, no. 5, Cambridge University Press, Apr. 2015, pp. 844&ndash;49. Cambridge Core, doi:<a href="https://doi.org/10.1017/S136898001400072X">10.1017/S136898001400072X</a>.

CDC, NCHS, National Health Interview Survey, Sample Adult Core

Percentage of adults who have served who have health insurance privately, through their employer, or through the government

<h2>Why does this matter?</h2>

Health insurance helps people receive the preventive and medical care they need to achieve and maintain good health. The U.S. Department of Defense (DoD) and Department of Veterans Affairs (VA<a href="https://www.tricare.mil/about">) provide health insurance</a> benefits for members of the military, veterans and their families, however, access to VA benefits depends on several factors, including <a href="https://www.benefits.va.gov/benefits/character_of_discharge.asp">character of discharge</a>. National data show these benefits are not the leading or primary source of health insurance for those who have served. About <a href="https://www.census.gov/newsroom/blogs/random-samplings/2017/09/health_insurancecov0.html">half of all veterans</a> are covered through Medicare, and employer-sponsored plans are the leading source of coverage for working-age veterans.&nbsp;

The nation&rsquo;s uninsurance rate <a href="http://hrms.urban.org/quicktakes/HRMS-Benchmarks-Well-against-Gallup-Healthways-and-NHIS-on-Changes-in-Health-Insurance-Coverage-between-2013-and-2015.html">dropped significantly</a> after the Affordable Care Act was enacted, <a href="https://www.rwjf.org/en/library/research/2017/04/veterans-saw-broad-coverage-gains-between-2013-and-2015.html">including among veterans</a>, yet nearly <a href="https://www.census.gov/library/stories/2018/09/who-are-the-uninsured.html">28 million</a> people were still uninsured in 2018. Having insurance is particularly important for veterans because they tend to be diagnosed with <a href="https://www.rand.org/pubs/periodicals/health-quarterly/issues/v5/n4/13.html">more health conditions</a>, including <a href="https://www.doi.org/10.1093/milmed/usy410">chronic conditions</a> such as lower back problems, arthritis, anxiety, depression and sleep disorders when compared to their civilian counterparts. In 2016, an <a href="https://www.kff.org/uninsured/fact-sheet/key-facts-about-the-uninsured-population/">analysis found</a> that 45% of uninsured adults reported that they were uninsured because they could not afford health insurance.
 <h2>Who is affected?</h2>

Populations who have served that have a <a href="https://www.americashealthrankings.org/explore/health-of-those-who-have-served/measure/HealthInsurance/state/ALL">higher percentage</a> of insurance include:

<ul>
	<li>Veterans over the age of 50 compared with younger veterans.&nbsp;</li>
	<li>White veterans compared with Hispanic and American Indian/Alaskan Native veterans.</li>
	<li>Veterans who have graduated college, who have a percentage 20% higher than those who did not graduate high school; the percentage increases with each increase in education level attained.</li>
	<li>Veterans with an annual household income of $50,000 or more per year compared with veterans with an income less than $50,000 per year.</li>
</ul>
 <h2>What works?</h2>

Medicaid expansion has <a href="https://www.kff.org/medicaid/issue-brief/the-effects-of-medicaid-expansion-under-the-aca-updated-findings-from-a-literature-review-august-2019/">decreased uninsured rates</a> among low income individuals and vulnerable populations in states that have expanded Medicaid. This has reduced the uninsured veteran population by <a href="https://www.rwjf.org/en/library/research/2017/04/veterans-saw-broad-coverage-gains-between-2013-and-2015.html">nearly 40%</a>. Currently, <a href="https://www.kff.org/uninsured/report/the-uninsured-and-the-aca-a-primer-key-facts-about-health-insurance-and-the-uninsured-amidst-changes-to-the-affordable-care-act/">45% of the uninsured</a> do not have access to health coverage provided by the Affordable Care Act because they live in a state that has not expanded Medicaid, they are not a U.S. citizen, or their income is too high to be eligible for subsidies. Additional states adopting the Medicaid expansion or a policy change to make non-citizens eligible for health coverage could <a href="https://www.kff.org/medicaid/issue-brief/the-effects-of-medicaid-expansion-under-the-aca-updated-findings-from-a-literature-review-august-2019/">decrease the number of uninsured</a> individuals. Increasing awareness of government assistance programs may increase enrollment of eligible individuals. Veterans may be eligible for health benefits that they are unaware of or don&rsquo;t know how to use. Organizations such as the <a href="https://www.woundedwarriorproject.org/programs/career-and-va-benefits-counseling">Wounded Warrior Project</a> can help veterans find and use the benefits they are entitled to.&nbsp;

Increasing the number of people with health insurance is important to improve health outcomes and decrease health care spending, however, a combination of <a href="https://www.rwjf.org/content/dam/farm/reports/issue_briefs/2013/rwjf72446">three strategies</a> &mdash; expanding health insurance coverage, delivering better preventive and chronic care, and focusing on community prevention &mdash; is more effective at saving lives and money than implementing any of these strategies alone.
 <h2>References</h2>

Eibner, Christine, et al. &ldquo;Current and Projected Characteristics and Unique Health Care Needs of the Patient Population Served by the Department of Veterans Affairs.&rdquo; Rand Health Quarterly, vol. 5, no. 4, May 2016, p. 13. PMID: <a href="https://www.ncbi.nlm.nih.gov/pubmed/28083423">28083423</a>.

Schult, Tamara M., et al. &ldquo;The Health Status of Veteran Employees Compared to Civilian Employees in Veterans Health Administration.&rdquo; Military Medicine, vol. 184, no. 7&ndash;8, July 2019, pp. e218&ndash;24. DOI.org (Crossref), doi:<a href="https://doi.org/10.1093/milmed/usy410">10.1093/milmed/usy410</a>.

Percentage of adults ages 50-75 who have served who reported receiving one or more of the recommended colorectal cancer screening tests within the recommended time interval

<h2>Why does this matter?</h2>

There is strong evidence that screening for colorectal cancer <a href="http://dx.doi.org/10.5888/pcd15.180029">reduces mortality</a> by both detecting the cancer early when treatments are more effective and removing abnormal growths. <a href="https://www.cdc.gov/cancer/colorectal/basic_info/what-is-colorectal-cancer.htm">Colorectal cancer</a> is the <a href="https://www.cdc.gov/cancer/colorectal/statistics/index.htm">second-leading</a> cause of cancer deaths and the <a href="https://www.cdc.gov/cancer/colorectal/statistics/index.htm">third most common</a> cancer in both men and women in the United States. According to the American Cancer Society&rsquo;s Cancer Facts &amp; Figures 2019 <a href="https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/annual-cancer-facts-and-figures/2019/cancer-facts-and-figures-2019.pdf#page=15">report</a>, there will be an estimated 145,600 new cases of colorectal cancer and over 51,000 colorectal cancer deaths in 2019.&nbsp;

Past <a href="https://doi.org/10.3816/CCC.2009.n.004">studies</a> have shown that a large proportion of both veterans and <a href="https://www.cdc.gov/mmwr/preview/mmwrhtml/su6102a9.htm?s_cid=su6102a9_w">non-veterans</a> are not up-to-date with screening recommendations. Among veterans with VA care, TRICARE or other military care, recent <a href="http://doi.org/10.1007/s10620-017-4607-x">data</a> show they have a significantly higher rate of colorectal cancer screening than veterans with private health insurance and civilians.

According to the U.S. Preventive Services Task Force (USPSTF), screening for colorectal cancer, which may include fecal sample testing, colonoscopy and/or sigmoidoscopy, is <a href="https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/colorectal-cancer-screening2">recommended</a> for all adults ages 50-75. Screening at earlier ages is recommended for those with particular risk factors or a <a href="https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/colorectal-cancer-facts-and-figures/colorectal-cancer-facts-and-figures-2017-2019.pdf#page=17">family history</a> of colorectal cancer.&nbsp;

Multiple studies have shown that screening for colorectal cancer is <a href="https://doi.org/10.1177/107327481502200219">cost-effective</a> compared to not screening. An estimated <a href="http://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/colorectal-cancer-screening2">20 to 24</a> colorectal cancer deaths can be averted for every 1,000 adults screened.
 <h2>Who is affected?</h2>

Common <a href="https://www.cdc.gov/cancer/colorectal/basic_info/risk_factors.htm">risk factors</a> of colorectal cancer include bowel diseases such as Crohn&rsquo;s, family history of colorectal cancer, lack of physical activity and obesity. The <a href="https://www.americashealthrankings.org/explore/health-of-those-who-have-served/measure/colorectal_cancer_screen/state/ALL">prevalence</a> of colorectal cancer screening among those who have served is higher in:

<ul>
	<li>College graduates compared with those with lower levels of education; the prevalence of colorectal cancer screening increases with each increase in education level.</li>
	<li>Those with an annual household income of $75,000 or more than those with lower levels of income; the prevalence of colorectal cancer screening increases with each increase in income level.</li>
</ul>
 <h2>What works?</h2>

There are numerous strategies for increasing colorectal cancer screening. <a href="https://www.countyhealthrankings.org">County Health Rankings &amp; Roadmaps</a> recommends several, including:

<ul>
	<li>Using <a href="https://www.countyhealthrankings.org/take-action-to-improve-health/what-works-for-health/policies/patient-navigators">patient navigators</a>, also called system navigators, to help guide patients through the medical, insurance and social support systems.</li>
	<li>Providing <a href="https://www.countyhealthrankings.org/take-action-to-improve-health/what-works-for-health/policies/patient-financial-incentives-for-preventive-care">financial incentives</a>, such as payments or vouchers, for preventive care.</li>
</ul>

<a href="https://www.thecommunityguide.org">The Community Guide</a> recommends a multicomponent approach. The guide has several strategies that work best when more than one are used together. These <a href="https://www.thecommunityguide.org/findings/cancer-screening-multicomponent-interventions-colorectal-cancer">strategies include</a>:&nbsp;

<ul>
	<li>Media campaigns to increase awareness.</li>
	<li>Client reminders.</li>
	<li>Cost reduction.</li>
	<li>Removal of barriers in transportation and language.</li>
</ul>

The Centers for Disease Control and Prevention established a <a href="https://www.cdc.gov/cancer/crccp/">Colorectal Cancer Control Program</a> that focuses on increasing screening in targeted groups. The National Colorectal Roundtable has resources for increasing colorectal cancer screening rates in <a href="https://nccrt.org/resource/crc-clinicians-guide/">clinical practice</a> and in <a href="http://nccrt.org/wp-content/uploads/0305.60-Colorectal-Cancer-Manual_FULFILL.pdf">community health centers</a>.&nbsp;
 <h2>References</h2>

DeGroff, Amy, et al. &ldquo;Increasing Colorectal Cancer Screening in Health Care Systems Using Evidence-Based Interventions.&rdquo; Preventing Chronic Disease, vol. 15, Aug. 2018, p. 180029. DOI.org (Crossref), doi:<a href="https://doi.org/10.5888/pcd15.180029">10.5888/pcd15.180029</a>.

Patel, Shaan S., and Meredith L. Kilgore. &ldquo;Cost Effectiveness of Colorectal Cancer Screening Strategies.&rdquo; Cancer Control: Journal of the Moffitt Cancer Center, vol. 22, no. 2, Apr. 2015, pp. 248&ndash;58. PubMed, doi:<a href="https://doi.org/10.1177/107327481502200219">10.1177/107327481502200219</a>.

White, Arica, et al. &ldquo;Cancer Screening Test Use &mdash; United States, 2015.&rdquo; MMWR. Morbidity and Mortality Weekly Report, vol. 66, no. 8, Mar. 2017, pp. 201&ndash;06. DOI.org (Crossref), doi:<a href="https://doi.org/10.15585/mmwr.mm6608a1">10.15585/mmwr.mm6608a1</a>.

Herta H. Chao et al.&nbsp; &quot;Improving Colorectal Cancer Screening and Care in the Veterans Affairs Healthcare System.&quot; Clinical Colorectal Cancer 8, no. 1 (2009): 22-28. <a href="https://doi.org/10.3816/CCC.2009.n.004">https://doi.org/10.3816/CCC.2009.n.004</a>

Folasade P. May et al.&nbsp; &quot;The Association Between Primary Source of Healthcare Coverage and Colorectal Cancer Screening Among US Veterans.&quot; Digestive Diseases and Sciences 62, no. 8 (2017): 1923-1932. <a href="http://doi.org/10.1007/s10620-017-4607-x">http://doi.org/10.1007/s10620-017-4607-x</a>

Percentage of adults ages 50-75 who have served

Percentage of adults who have served who reported visiting a dentist or dental clinic within the past year for any reason

<h2>Why does this matter?</h2>

<a name="_7fhu3ao9jn5q"></a>Oral health is a <a href="https://www.cdc.gov/oralhealth/index.html">vital</a> component of overall health. Oral diseases such as tooth decay, dental caries (cavities), gingivitis and periodontal (gum) disease are common and can <a href="https://www.cdc.gov/oralhealth/basics/index.html">cause</a> pain, tooth loss, oral infection and chronic disease if left untreated. In the United States, <a href="https://www.cdc.gov/oralhealth/basics/adult-oral-health/index.html">one in four</a> adults has untreated cavities and nearly <a href="https://www.cdc.gov/oralhealth/basics/adult-oral-health/index.html">half</a> of adults ages 30 and older have signs of gum disease.

Roughly <a href="https://doi.org/10.1111/jphd.12095">41%</a> of veterans self-report their oral health status as fair or poor. Service members are <a href="https://www.navy.mil/submit/display.asp?story_id=66542">encouraged</a> to maintain good oral hygiene to reduce the risk of developing oral diseases that can cause them to be unfit for duty and adversely affect unit readiness. Oral health readiness is a requirement for deployment of troops: the Department of Defense (DoD) has <a href="https://doi.org/10.7205/MILMED-D-12-00445">four levels</a> of dental readiness with the goal of having 95% of active duty members in the first two levels, or in good enough dental health to be deployable worldwide.

Lack of proper dental care can lead to <a href="https://doi.org/10.7205/MILMED.173.Supplement_1.23">dental emergencies</a> and pose a lethal threat to service members during combat operations. Inadequate use of routine dental health services can result in various dental emergencies and the overuse of the emergency departments as a primary and only source of care. Dental emergencies cost the United States Army an estimated <a href="https://doi.org/10.7205/milmed-d-12-00431">$21.9 million</a> between July 1, 2010 and June 30, 2011.
 <h2>Who is affected?</h2>

Those who have served report significantly <a href="https://www.americashealthrankings.org/explore/health-of-those-who-have-served/measure/dental_visit/state/ALL">higher</a> rates of dental visits than those who have not served, however, there are still barriers to dental care among veterans. The <a href="https://www.americashealthrankings.org/explore/health-of-those-who-have-served/measure/dental_visit/state/ALL">prevalence</a> of dental visits among those who have served is higher in:

<ul>
	<li><a name="_leiurlqn613g"></a> Females than males.</li>
	<li><a name="_lsbtx8kqsan4"></a> Adults ages 18-25 compared with adults ages 26 and older. Older veterans in particular report <a href="https://pubmed.ncbi.nlm.nih.gov/26863706/">difficulties</a> in oral care activities such as bleeding gums, difficulty or pain during brushing and flossing, and forgetting to brush or floss.</li>
	<li><a name="_trmntvcjcfil"></a> Asian adults compared with all other racial and ethnic groups.</li>
	<li><a name="_64k2l3krdjhj"></a> Adults with a college degree, who have a prevalence nearly two times higher than those with less than a high school education; the prevalence increases with each increase in education level.</li>
	<li><a name="_9f2r3kspsvvf"></a> Adults with an annual household income of $75,000 or more, who have a prevalence nearly two times higher than those with an income less than $25,000; the prevalence increases with each increase in income level.</li>
</ul>

<a href="https://www.ruralhealth.va.gov/docs/promise/AccesstoDentalCareCaseStudy.pdf">Rural</a> veterans may face difficulties in accessing dental care such as lack of transportation and inability to afford care. One <a href="https://dx.doi.org/10.1111%2Fjphd.12230">study</a> found that rural veterans were significantly less likely to have had one dental visit in the past year and more likely to have all teeth missing compared to veterans in metropolitan areas.


 <h2>What works?</h2>

Oral health problems are largely <a href="https://www.cdc.gov/oralhealth/conditions/index.html">preventable</a> through routine visits to the dentist and good oral hygiene. The Department of <a href="https://www.va.gov/dental/">Veterans Affairs</a> (VA) provides comprehensive dental care for qualifying veterans. Adults who have served can check their <a href="https://www.va.gov/health-care/about-va-health-benefits/dental-care/">eligibility</a> for dental health coverage. Access to the VA dental services can be limited due to <a href="https://pubmed.ncbi.nlm.nih.gov/31409719/">strict</a> eligibility criteria, however, congress has recently implemented some <a href="https://www.federalregister.gov/documents/2019/12/13/2019-26901/pilot-program-for-dental-health-care-access">pilot initiatives</a> to increase veteran access to dental care by removing <a href="https://www.govinfo.gov/content/pkg/USCODE-2018-title38/html/USCODE-2018-title38-partII-chap17-subchapII-sec1712.htm">restrictions</a> that previously excluded some veterans from dental coverage.&nbsp;

<a name="_aw70pecrix5v"></a>Some organizations that provide dental care to veterans include:

<ul>
	<li><a name="_u8vnm6s0mxvc"></a> Everyone for Veterans (<a href="https://www.everyoneforveterans.org/">E4V</a>) connects veterans to various services including <a href="https://www.ada.org/en/publications/ada-news/2019-archive/march/program-to-help-combat-veterans-receive-free-oral-care-expanding-throughout-nation">dental care</a> options.</li>
	<li><a name="_1expavdw4r28"></a> Donated Dental Services (<a href="https://dentallifeline.org/dds/donated-dental-services-dds-provides-free-dental-veterans/">DDS</a>) provides donated dental services to veterans who may not be covered by the VA.</li>
</ul>
 <h2>References</h2>

Chaffin, Jeffrey, and David Moss. &ldquo;Review of Current U.S. Army Dental Emergency Rates.&rdquo; Military Medicine, vol. 173, no. Supplement_1, Jan. 2008, pp. 23&ndash;26. DOI.org (Crossref), doi:<a href="https://doi.org/10.7205/MILMED.173.Supplement_1.23">10.7205/MILMED.173.Supplement_1.23</a>.

Colthirst, Paul M., et al. &ldquo;Operational Cost Analysis of Dental Emergencies for Deployed U.S. Army Personnel During Operation Iraqi Freedom.&rdquo; Military Medicine, vol. 178, no. 4, Apr. 2013, pp. 427&ndash;31. DOI.org (Crossref), doi:<a href="https://doi.org/10.7205/MILMED-D-12-00431">10.7205/MILMED-D-12-00431</a>.

Honey, James R. &ldquo;The Army Selected Reserve Dental Readiness System: Overview, Assessment, and Recommendations.&rdquo; Military Medicine, vol. 178, no. 6, June 2013, pp. 607&ndash;18. DOI.org (Crossref), doi:<a href="https://doi.org/10.7205/MILMED-D-12-00445">10.7205/MILMED-D-12-00445</a>.

Jennings, Andrea. &ldquo;Assessing Oral Hygiene in Hospitalized Older Veterans.&rdquo; Medsurg Nursing: Official Journal of the Academy of Medical-Surgical Nurses, vol. 24, no. 6, Dec. 2015, pp. 420&ndash;24. PMID: <a href="https://pubmed.ncbi.nlm.nih.gov/26863706/">26863706</a>.

<a name="_i90t648n8c7"></a>Nieto, Valerie, et al. &ldquo;Attitudes and Access Patterns of Michigan Veterans Ineligible for Oral Healthcare Benefits: A Cross-Sectional Study.&rdquo; American Dental Hygienists&rsquo; Association, vol. 93, no. 4, Aug. 2019, p. 6. PMID: <a href="https://pubmed.ncbi.nlm.nih.gov/31409719/">31409719.</a>

<a name="_41khpgsd6ed1"></a>Wiener, R. Constance. &ldquo;Oral Health Perception in Veterans with Self-Identified Disabilities: National Survey of Veterans, 2010: Oral Health Perceptions in Veterans.&rdquo; Journal of Public Health Dentistry, vol. 75, no. 3, Aug. 2015, pp. 245&ndash;52. DOI.org (Crossref), doi:<a href="https://doi.org/10.1111/jphd.12095">10.1111/jphd.12095</a>.

<a name="_3fqya7mjuh3e"></a>Wiener, R. Constance, et al. &ldquo;Rural Veterans&rsquo; Dental Utilization, Behavioral Risk Factor Surveillance Survey, 2014: Rural Veterans&rsquo; Dental Utilization.&rdquo; Journal of Public Health Dentistry, vol. 77, no. 4, Sept. 2017, pp. 383&ndash;92. DOI.org (Crossref), doi:<a href="https://doi.org/10.1111/jphd.12230">10.1111/jphd.12230</a>.

Percentage of adults who have served who reported receiving a flu vaccine in the past 12 months

<h2>Why does this matter?</h2>

Influenza, or the flu, is a <a href="https://www.cdc.gov/flu/about/keyfacts.htm">contagious respiratory illness</a> that is caused by the influenza virus. A flu vaccine is the best <a href="https://www.cdc.gov/flu/prevent/vaccine-benefits.htm">protection</a> against seasonal influenza viruses. Each year in the United States, <a href="https://www.cdc.gov/flu/about/burden/index.html">millions of people</a> get the flu, and thousands of people die from it. The vaccine can <a href="https://www.cdc.gov/flu/vaccines-work/vaccineeffect.htm">prevent</a> people from coming down with the flu and it also helps lessen the degree to which people are sick if they do get it. Veterans tend to be older and have <a href="https://www.ncbi.nlm.nih.gov/pubmed/28083423">higher rates of other chronic diseases</a> compared with the general population which can place them at a greater risk of complications from the flu. According to a 2013 <a href="https://dx.doi.org/10.1186%2F1471-2458-13-1082">study</a>, veterans were more likely to be vaccinated against the flu compared with the general population, however, vaccination rates still fell below the national goal.&nbsp;

Recent studies have estimated the annual economic burden of the flu to be between <a href="https://doi.org/10.1377/hlthaff.2016.0462">$5.79 billion</a> and <a href="https://doi.org/10.1016/j.vaccine.2018.05.057">$11.2 billion</a> in direct medical costs and indirect costs, such as loss of productivity. The estimated annual economic burden of flu in the U.S. Veteran Affairs population is <a href="https://doi.org/10.1371/journal.pone.0169344">$1.2 billion</a> with premature deaths being the largest driver of cost.
 <h2>Who is affected?</h2>

The <a href="https://www.americashealthrankings.org/explore/health-of-those-who-have-served/measure/flu_vaccine/state/ALL">prevalence</a> of flu vaccination among those who have served is higher in:

<ul>
	<li>Females than males.</li>
	<li>Adults who are ages 18-25 than those who are ages 35-49.</li>
	<li>Adults with a college degree than those with lower levels of education; the prevalence of flu vaccination increases with each increase in education level.</li>
	<li>Adults with an annual household income of $50,000 or more, than those with lower household incomes.</li>
</ul>
 <h2>What works?</h2>

For all vaccines, achieving and maintaining high vaccination coverage is critical to sustain progress in reducing the impact of vaccine-preventable diseases. A <a href="https://doi.org/10.1080/10790268.2007.11753908">study</a> found that system wide strategies that incorporate patient and provider education as well as vaccine reminders&nbsp; are correlated with higher rates of influenza vaccination in the Veterans healthcare system.&nbsp;

Improving <a href="https://www.ncbi.nlm.nih.gov/pubmed/28269827">veteran access to care</a> through Veterans Affairs (VA) partnerships with retail pharmacies like Walgreens could also reduce the burden of long distance commuting which can help improve vaccination rates among veterans.
 <h2>References</h2>

Botts, Nathan, et al. &ldquo;Improved Veteran Access to Care through the Veteran Health Information Exchange (VHIE) Retail Immunization Coordination Project.&rdquo; AMIA Annual Symposium Proceedings, vol. 2016, Feb. 2017, pp. 326&ndash;31. PMCID:<a href="https://www.ncbi.nlm.nih.gov/pubmed/28269827">PMC5333250</a>.

Der-Martirosian, Claudia, et al. &ldquo;Comparison of the Use of H1N1 and Seasonal Influenza Vaccinations between Veterans and Non-Veterans in the United States, 2010.&rdquo; BMC Public Health, vol. 13, no. 1, Dec. 2013, p. 1082. DOI.org (Crossref), doi:<a href="https://doi.org/10.1186/1471-2458-13-1082">10.1186/1471-2458-13-1082</a>.

Eibner, Christine, et al. &ldquo;Current and Projected Characteristics and Unique Health Care Needs of the Patient Population Served by the Department of Veterans Affairs.&rdquo; Rand Health Quarterly, vol. 5, no. 4, May 2016, p. 13. PMCID: <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/pmc5158228/">PMC5158228</a>

Ozawa, Sachiko, et al. &ldquo;Modeling The Economic Burden Of Adult Vaccine-Preventable Diseases In The United States.&rdquo; Health Affairs, vol. 35, no. 11, Nov. 2016, pp. 2124&ndash;32. DOI.org (Crossref), doi:<a href="https://doi.org/10.1377/hlthaff.2016.0462">10.1377/hlthaff.2016.0462</a>.

Putri, Wayan C. W. S., et al. &ldquo;Economic Burden of Seasonal Influenza in the United States.&rdquo; Vaccine, vol. 36, no. 27, June 2018, pp. 3960&ndash;66. DOI.org (Crossref), doi:<a href="https://doi.org/10.1016/j.vaccine.2018.05.057">10.1016/j.vaccine.2018.05.057</a>.

Weaver, Frances M., et al. &ldquo;Interventions to Increase Influenza Vaccination Rates in Veterans With Spinal Cord Injuries and Disorders.&rdquo; The Journal of Spinal Cord Medicine, vol. 30, no. 1, Jan. 2007, pp. 10&ndash;19. DOI.org (Crossref), doi:<a href="https://doi.org/10.1080/10790268.2007.11753908">10.1080/10790268.2007.11753908</a>.

Young-Xu, Yinong, et al. &ldquo;The Annual Burden of Seasonal Influenza in the US Veterans Affairs Population.&rdquo; PLOS ONE, edited by Daniela Flavia Hozbor, vol. 12, no. 1, Jan. 2017, p. e0169344. DOI.org (Crossref), doi:<a href="https://doi.org/10.1371/journal.pone.0169344">10.1371/journal.pone.0169344</a>.

Percentage of adults who have served who reported having a personal doctor or health care provider

<h2>Why does this matter?</h2>



Individuals with a dedicated health care provider are better positioned <a href="https://doi.org/10.1377/hlthaff.2010.0025">to receive care</a> that can prevent, detect and manage disease or other health conditions. Having a regular health care provider helps the patient and provider build a stable, long-term relationship that is associated with a number of <a href="https://doi.org/10.1377/hlthaff.2010.0025">benefits</a>, including:

<ul>
	<li>Increased likelihood that patients will receive appropriate preventive care</li>
	<li>Lower health care costs</li>
	<li>Better overall health status</li>
	<li>Fewer emergency room visits for non-urgent or avoidable problems</li>
	<li>Improvements in <a href="https://doi.org/10.3122/jabfm.2010.02.090084">chronic care management</a> for asthma, hypertension and diabetes</li>
</ul>

There is an <a href="http://doi.org/10.22454/FamMed.2018.795504">assumption</a> that veterans receive adequate health care through the Veterans Health Administration (VA). However, <a href="http://doi.org/10.22454/FamMed.2018.795504">over half</a> of veterans do not receive needed care from the VA. While the United States Department of Veterans Affairs (VA) is responsible for providing<a href="http://www.urban.org/sites/default/files/alfresco/publication-pdfs/412577-Uninsured-Veterans-and-Family-Members-Who-Are-They-and-Where-Do-They-Live-.PDF"> health care to veterans</a>, some veterans <a href="http://doi.org/10.7249/RB10006">do not use VA services</a> because they do not meet eligibility criteria, live a great distance from VA facilities, or do not know they <a href="https://www.healthaffairs.org/do/10.1377/hblog20150521.047909/full/">qualify to receive VA care</a>. As such, veterans are more likely to receive care from <a href="http://doi.org/10.7249/RB10006">multiple sources</a>, including the private sector. In some cases, the VA pays for veterans to receive care from non-VA providers. In other cases, veterans opt to receive care entirely from private providers. Moreover, the VA is currently facing <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5158229/">limited</a> medical resources and workforce to care for veterans.
 <h2>Who is affected?</h2>



The percentage of those who have served who have a dedicated health care provider is <a href="https://www.americashealthrankings.org/explore/health-of-those-who-have-served/measure/ded_HC_provider/state/ALL">higher</a> among:&nbsp;

<ul>
	<li>Women than men.</li>
	<li>Those ages 50 or older than younger age groups.</li>
	<li>Those with an annual household income of $75,000 or more than those who earn less than $25,000.</li>
	<li>College graduates than those with less than a high school education.</li>
</ul>


 <h2>What works?</h2>



Strategies for increasing the prevalence of adults with a dedicated health care provider include:

<ul>
	<li>Increasing <a href="https://doi.org/10.1377/hlthaff.2013.0234">primary care capacity</a> by empowering licensed personnel, including nurse practitioners and physician assistants, to provide more care to patients.&nbsp;</li>
	<li>Enacting <a href="https://doi.org/10.1016/j.outlook.2015.08.005">scope-of-practice laws</a> that enable nurse practitioners to perform more primary care functions. Scope-of-practice laws lead to increases in the number of nurse practitioners per capita and higher yearly growth of the nurse practitioner workforce.&nbsp;</li>
	<li><a href="https://doi.org/10.1377/hlthaff.2010.0025">Reorienting</a> health care systems to encourage patients to utilize primary care for new symptoms instead of seeking specialists with low-impact and high-cost procedures which will also encourage capital investment in primary care.&nbsp;&nbsp;</li>
	<li>Reducing <a href="https://www.healthypeople.gov/2020/topics-objectives/topic/access-to-health-services">barriers</a> to care such as lack of health insurance, high cost of care, poor geographic availability of services and lack of culturally competent care.&nbsp;&nbsp;</li>
</ul>

The U.S. Department of Veterans Affairs provides several strategies <a href="https://www.va.gov/QUALITYOFCARE/new-approach/improving-access.asp">such as</a> transportation service, telehealth and special groups to improve veterans&rsquo; access to health care.
 <h2>References</h2>

Bodenheimer, Thomas S., and Mark D. Smith. &ldquo;Primary Care: Proposed Solutions To The Physician Shortage Without Training More Physicians.&rdquo; Health Affairs, vol. 32, no. 11, Nov. 2013, pp. 1881&ndash;86. DOI.org (Crossref), doi:<a href="https://doi.org/10.1377/hlthaff.2013.0234">10.1377/hlthaff.2013.0234</a>.

Friedberg, Mark W., et al. &ldquo;Primary Care: A Critical Review Of The Evidence On Quality And Costs Of Health Care.&rdquo; Health Affairs, vol. 29, no. 5, May 2010, pp. 766&ndash;72. DOI.org (Crossref), doi:<a href="https://doi.org/10.1377/hlthaff.2010.0025">10.1377/hlthaff.2010.0025</a>.

Hussey, Peter S., et al. &ldquo;Resources and Capabilities of the Department of Veterans Affairs to Provide Timely and Accessible Care to Veterans.&rdquo; Rand Health Quarterly, vol. 5, no. 4, May 2016. PubMed Central,<a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5158229/"> https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5158229/</a>.

Tanielian, Terri, et al. Are Private Health Care Providers Ready to Treat Veterans? Evidence from New York State. RAND Corporation, 2018. DOI.org (Crossref), doi:<a href="https://doi.org/10.7249/RB10006">10.7249/RB10006</a>.

Vest, Bonnie M., et al. &ldquo;Addressing Patients&rsquo; Veteran Status: Primary Care Providers&rsquo; Knowledge, Comfort, and Educational Needs.&rdquo; Family Medicine, vol. 50, no. 6, June 2018, pp. 455&ndash;59. DOI.org (Crossref), doi:<a href="https://doi.org/10.22454/FamMed.2018.795504">10.22454/FamMed.2018.795504</a>.

Winters, P., et al. &ldquo;The Role of Usual Source of Care in Cholesterol Treatment.&rdquo; The Journal of the American Board of Family Medicine, vol. 23, no. 2, Mar. 2010, pp. 179&ndash;85. DOI.org (Crossref), doi:<a href="https://doi.org/10.3122/jabfm.2010.02.090084">10.3122/jabfm.2010.02.090084</a>.

Xue, Ying, et al. &ldquo;Impact of State Nurse Practitioner Scope-of-Practice Regulation on Health Care Delivery: Systematic Review.&rdquo; Nursing Outlook, vol. 64, no. 1, Jan. 2016, pp. 71&ndash;85. DOI.org (Crossref), doi:<a href="https://doi.org/10.1016/j.outlook.2015.08.005">10.1016/j.outlook.2015.08.005</a>.

Percentage of adults who have served who reported a time in the past 12 months when they needed to visit a doctor but could not because of cost

<h2>Why does this matter?</h2>

The high cost of health care in the United States is one of the leading factors in avoidance of care, other barriers include <a href="https://www.doi.org/10.1097/MLR.0000000000000922">transportation</a> and <a href="https://www.doi.org/10.1186%2Fs12913-018-3346-9">stigma</a>. Not obtaining health care has long been associated with increased <a href="https://www.doi.org/10.1093/eurpub/cks053">preventable hospitalizations</a> and missed opportunities to <a href="https://www.ncbi.nlm.nih.gov/books/NBK53914/">prevent</a> disease and <a href="https://www.countyhealthrankings.org/take-action-to-improve-health/what-works-for-health/policies/chronic-disease-management-programs">manage</a> chronic conditions, all of which can lead to worse and more expensive health outcomes. Veterans tend to be diagnosed with <a href="https://www.rand.org/pubs/periodicals/health-quarterly/issues/v5/n4/13.html">more health conditions</a>, including chronic conditions, than their civilian counterparts which can make getting the care they need harder and more expensive. Meanwhile, the <a href="https://www.healthsystemtracker.org/chart-collection/much-health-spending-expected-grow/#item-annual-change-in-per-capita-prescription-drug-spending-1970-2018-projected-2019-2027">cost of U.S. health care</a> is projected to continue increasing for the next 30 years. Currently, the average American spends more than <a href="https://www.healthsystemtracker.org/chart-collection/much-health-spending-expected-grow/#item-annual-change-in-per-capita-prescription-drug-spending-1970-2018-projected-2019-2027">$10,000 a year</a> on healthcare.
 <h2>Who is affected?</h2>

Adults who are uninsured or underinsured are more likely to delay or entirely avoid care due to cost compared with adults who are adequately insured. A nationally representative survey from 2018 found that 41% of underinsured adults <a href="https://www.commonwealthfund.org/press-release/2019/underinsured-rate-rose-2014-2018-greatest-growth-among-people-employer-health">delayed care due to cost</a>, compared with 23% of adequately insured adults. Even among insured adults those enrolled in <a href="https://www.cdc.gov/nchs/data/databriefs/db28.pdf">high-deductible health plans</a> are nearly twice as likely to delay or entirely forego care due to cost compared with adults enrolled in traditional health plans.&nbsp;

Populations of veterans who have a higher prevalence of <a href="https://www.americashealthrankings.org/explore/health-of-those-who-have-served/measure/unmet_medical/state/ALL">avoiding care due to cost</a> include:

<ul>
	<li>Women compared with men.</li>
	<li>Veterans ages 26-49 compared with veterans ages 18-25 and 50 and older.</li>
	<li>Multiracial, Hispanic, American Indian / Alaskan Native and Hawaiian / Pacific Islander veterans compared with white veterans.</li>
	<li>Adults with less than a high school education, who have more than twice the prevalence of avoided care due to cost than college graduates.&nbsp;</li>
	<li>Adults with an annual household income less than $25,000, who have nearly five times the prevalence of avoided care due to cost than adults with an annual household income of $75,000 and above.</li>
</ul>
 <h2>What works?</h2>

Among veterans, an increase in the <a href="https://www.doi.org/10.1097/MLR.0000000000000922">reimbursement rate</a> for travel to Bureau of Veterans Affairs Medical Center (VA) clinics was associated with an increase in VA outpatient encounters, indicating that better compensation for travel could help patients access care. A health system cost saving measure is fuller <a href="https://www.doi.org/10.1097/NCM.0000000000000075">use of nurse practitioners</a>. Increasing use of nurse practitioners in VA and non-VA facilities has been shown to decrease costs while having no effect on patient outcomes.&nbsp;

<a href="https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2012.1074">Multidisciplinary interventions</a> that increase the affordability of healthcare by reducing out-of-pocket costs, the need for hospitalizations, or using specialty care may have an impact on reducing the proportion of adults who avoid care due to the cost:

<ul>
	<li><a href="https://www.doi.org/10.3122/jabfm.2011.03.100170">Patient centered care</a> and shared decision making has been shown to reduce cost of care through increased health education and empowering patients to choose cost effective diagnostic tools and treatment options.</li>
</ul>

<a href="https://www.aafp.org/medical-school-residency/choosing-fm/value-scope.html">Primary care management</a> reduces costs by increasing <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6231930/">continuity of care</a> and reducing expensive emergency room and specialty care visits.
 <h2>References</h2>

Bazemore, Andrew, et al. &ldquo;Higher Primary Care Physician Continuity Is Associated With Lower Costs and Hospitalizations.&rdquo; The Annals of Family Medicine, vol. 16, no. 6, Nov. 2018, pp. 492&ndash;97. DOI.org (Crossref), doi:<a href="https://doi.org/10.1370/afm.2308">10.1370/afm.2308</a>.

Bertakis, K. D., and R. Azari. &ldquo;Patient-Centered Care Is Associated with Decreased Health Care Utilization.&rdquo; The Journal of the American Board of Family Medicine, vol. 24, no. 3, May 2011, pp. 229&ndash;39. DOI.org (Crossref), doi:<a href="https://doi.org/10.3122/jabfm.2011.03.100170">10.3122/jabfm.2011.03.100170</a>.

Camacho-Walsh, Mercedes. &ldquo;Strategies for Reducing Hospitalization Costs and Improving Health Care Access for Veterans: The Nurse Practitioner&ndash;Case Manager Collaboration.&rdquo; Professional Case Management, vol. 20, no. 1, Feb. 2015, pp. 43&ndash;49. insights.ovid.com, doi:<a href="https://doi.org/10.1097/NCM.0000000000000075">10.1097/NCM.0000000000000075</a>.

Cheney, Ann M., et al. &ldquo;Veteran-Centered Barriers to VA Mental Healthcare Services Use.&rdquo; BMC Health Services Research, vol. 18, July 2018. PubMed Central, doi:<a href="https://doi.org/10.1186/s12913-018-3346-9">10.1186/s12913-018-3346-9</a>.

Cohen, Robin A. &ldquo;Impact of Type of Insurance Plan on Access and Utilization of Health Care Services for Adults Aged 18-64 Years with Private Health Insurance: United States, 2007-2008.&rdquo; NCHS Data Brief, no. 28, Feb. 2010, pp. 1&ndash;8. PMID: <a href="https://pubmed.ncbi.nlm.nih.gov/20167150/">20167150</a>.

Cosgrove, Delos M., et al. &ldquo;Ten Strategies To Lower Costs, Improve Quality, And Engage Patients: The View From Leading Health System CEOs.&rdquo; Health Affairs, vol. 32, no. 2, Feb. 2013, pp. 321&ndash;27. DOI.org (Crossref), doi:<a href="https://doi.org/10.1377/hlthaff.2012.1074">10.1377/hlthaff.2012.1074</a>.

Eibner, Christine, et al. &ldquo;Current and Projected Characteristics and Unique Health Care Needs of the Patient Population Served by the Department of Veterans Affairs.&rdquo; Rand Health Quarterly, vol. 5, no. 4, May 2016, p. 13. PubMed Central, doi:<a href="https://doi.org/10.7249/RR1165.1">10.7249/RR1165.1</a>.

Medicine, Institute of Medicine (US) Roundtable on Evidence-Based, et al. &ldquo;Missed Prevention Opportunities.&rdquo; The Healthcare Imperative: Lowering Costs and Improving Outcomes: Workshop Series Summary, National Academies Press (US), 2010. www.ncbi.nlm.nih.gov,&nbsp;<a href="http://www.ncbi.nlm.nih.gov/books/NBK53914/">NBK53914</a>.

Nelson, Richard E., et al. &ldquo;The Impact of a Change in the Price of VA Health Care on Utilization of VA and Medicare Services.&rdquo; Medical Care, vol. 56, no. 7, July 2018, pp. 569&ndash;576. journals.lww.com, doi:<a href="https://doi.org/10.1097/MLR.0000000000000922">10.1097/MLR.0000000000000922</a>.

Rosano, Aldo, et al. &ldquo;The Relationship between Avoidable Hospitalization and Accessibility to Primary Care: A Systematic Review.&rdquo; European Journal of Public Health, vol. 23, no. 3, May 2012, pp. 356&ndash;60, doi:<a href="https://doi.org/10.1093/eurpub/cks053">10.1093/eurpub/cks053</a>.

Schult, Tamara M., et al. &ldquo;The Health Status of Veteran Employees Compared to Civilian Employees in Veterans Health Administration.&rdquo; Military Medicine, vol. 184, no. 7&ndash;8, July 2019, pp. e218&ndash;24. DOI.org (Crossref), doi:<a href="https://doi.org/10.1093/milmed/usy410">10.1093/milmed/usy410</a>.

Percentage of adults who have served experiencing mental illness in the past year who reported receiving any mental health treatment in the past 12 months or taking any prescription medications prescribed to treat a mental or emotional condition (excluding treatment for alcohol or drug use)

<h2>Why does this matter?</h2>

While effective treatments exist for most mental disorders, only <a href="https://www.apna.org/files/public/Resources/Expanding_Mental_Health_Care_Services_in_America-The_Pivotal_Role_of_Psychiatric-Mental_Health_Nurses_04_19.pdf#page=3">44%</a> of adults receive the mental health care they need. Moreover, treatments for identified mental health conditions are often <a href="https://www.apna.org/files/public/Resources/Expanding_Mental_Health_Care_Services_in_America-The_Pivotal_Role_of_Psychiatric-Mental_Health_Nurses_04_19.pdf#page=3">delayed for many years</a>. Delaying, avoiding or being unable to access mental health care when needed has been associated with <a href="http://doi.org/10.1016/j.jad.2013.10.002">poor health outcomes</a> among people with depression.&nbsp;

Mental health issues <a href="https://www.mentalhealth.va.gov/explore_by_topic.asp">such as</a> depression, anxiety and post-traumatic disorder are common among veterans. Recent studies have found the utilization of mental health services among veterans with mental disorders is <a href="http://www.doi.org/10.1176/appi.ps.201300056">increasing</a>, but many continue not to receive care, even following a confirmed mental illness diagnosis. Negative beliefs and stigma surrounding mental health treatment may contribute to the avoidance of mental health care among veterans and non-veterans alike. Nearly half of veterans in <a href="https://dx.doi.org/10.1037/mil0000169">one study</a> perceived that they were responsible for dealing with their own mental health problems, and <a href="http://doi.org/10.7205/MILMED-D-15-00495">in another study</a>, some veterans reported believing mental health treatment would not improve symptoms; in both cases, these beliefs were associated with lower utilization of care.
 <h2>Who is affected?</h2>

Populations of those who have served who are less likely to receive mental health treatment include:&nbsp;

<ul>
	<li>African Americans, who are <a href="http://doi.or/10.1097/01.MLR.0000053232.67079.A5">less likely</a> to receive medical service for posttraumatic disorder compared with other racial/ethnic groups. Additionally, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2926126/pdf/nihms226363.pdf">American Indian/Alaskan Native</a> veterans are more likely to delay care compared with white veterans.&nbsp;</li>
	<li>Veterans who live <a href="http://doi.org/10.1002/jts.20493">far from </a>a Veterans Affairs (VA) facility compared with those who live near a facility.&nbsp;</li>
	<li>Veterans <a href="http://doi.org/10.1002/jts.20493">ages 25 and older</a> compared with those younger than 25.</li>
</ul>

<a href="http://doi.org/10.1097/01.MLR.0000053232.67079.A5">Racial disparities</a> are shown in the use of health care services of the VA. However, when other variables, such as health status or financial barriers, <a href="http://doi.org/10.1007/s11126-013-9268-0">are controlled</a>, African Americans are more likely to use VA services compared with whites.
 <h2>What works?</h2>

The U.S. Department of Veterans Affairs provides <a href="https://www.va.gov/health-care/health-needs-conditions/mental-health/">various resources</a> to support veterans&rsquo; mental health. The VA initiated <a href="http://doi.org/10.1176/appi.ps.201900104">a telehealth program</a> that distributes video-enabled tablets to veterans in order to minimize geographic, clinical or social barriers to mental health care. Moreover, the integration of <a href="http://doi.org/10.1016/j.japh.2020.03.011">clinical pharmacy specialists</a> in a mental care team at the VA was found to improve access to care. Clinical pharmacy specialists serve to improve patient-centered care and comprehensive medication management.
 <h2>References</h2>

Ghio, Lucio, et al. &ldquo;Duration of Untreated Illness and Outcomes in Unipolar Depression: A Systematic Review and Meta-Analysis.&rdquo; Journal of Affective Disorders, vol. 152&ndash;154, Jan. 2014, pp. 45&ndash;51. ScienceDirect, doi:<a href="https://doi.org/10.1016/j.jad.2013.10.002">10.1016/j.jad.2013.10.002</a>.

Graziano, Robert, and Eric B. Elbogen. &ldquo;Improving Mental Health Treatment Utilization in Military Veterans: Examining the Effects of Perceived Need for Care and Social Support.&rdquo; Military Psychology, vol. 29, no. 5, June 2017, pp. 359&ndash;69. DOI.org (Crossref), doi:<a href="https://doi.org/10.1037/mil0000169">10.1037/mil0000169</a>.

Jacobs, Josephine C., et al. &ldquo;Increasing Mental Health Care Access, Continuity, and Efficiency for Veterans Through Telehealth With Video Tablets.&rdquo; Psychiatric Services, vol. 70, no. 11, American Psychiatric Publishing, Aug. 2019, pp. 976&ndash;82. ps.psychiatryonline.org (Atypon), doi:<a href="https://doi.org/10.1176/appi.ps.201900104">10.1176/appi.ps.201900104</a>.

Johnson, Emily M., et al. &ldquo;Predictors of Mental Health Care Utilization in Veterans With Post-Traumatic Stress Disorder Symptoms and Hazardous Drinking.&rdquo; Military Medicine, vol. 181, no. 10, Oxford Academic, Oct. 2016, pp. 1200&ndash;06. academic.oup.com, doi:<a href="https://doi.org/10.7205/MILMED-D-15-00495">10.7205/MILMED-D-15-00495</a>.

Johnson, Pamela Jo, et al. &ldquo;Healthcare Disparities for American Indian Veterans in the United States.&rdquo; Medical Care, vol. 48, no. 6, June 2010, pp. 563&ndash;69. PubMed Central, doi:<a href="https://doi.org/10.1097/MLR.0b013e3181d5f9e1">10.1097/MLR.0b013e3181d5f9e1</a>.

Moore, Tera, et al. &ldquo;Increasing Access to Care Using Clinical Pharmacy Specialist Providers in Outpatient Mental Health: Successful Practice Integration within the Department of Veterans Affairs.&rdquo; Journal of the American Pharmacists Association, vol. 0, no. 0, Elsevier, Mar. 2020. www.japha.org, doi:<a href="https://doi.org/10.1016/j.japh.2020.03.011">10.1016/j.japh.2020.03.011</a>.

Mott, Juliette M., et al. &ldquo;Changes in Psychotherapy Utilization Among Veterans With Depression, Anxiety, and PTSD.&rdquo; Psychiatric Services, vol. 65, no. 1, American Psychiatric Publishing, Jan. 2014, pp. 106&ndash;12. ps.psychiatryonline.org (Atypon), doi:<a href="https://doi.org/10.1176/appi.ps.201300056">10.1176/appi.ps.201300056</a>.

Murdoch, Maureen, et al. &ldquo;Racial Disparities in VA Service Connection for Posttraumatic Stress Disorder Disability:&rdquo; Medical Care, vol. 41, no. 4, Apr. 2003, pp. 536&ndash;49. DOI.org (Crossref), doi:<a href="https://doi.org/10.1097/01.MLR.0000053232.67079.A5">10.1097/01.MLR.0000053232.67079.A5</a>.

Seal, Karen H., et al. &ldquo;VA Mental Health Services Utilization in Iraq and Afghanistan Veterans in the First Year of Receiving New Mental Health Diagnoses.&rdquo; Journal of Traumatic Stress, vol. 23, no. 1, 2010, pp. 5&ndash;16. Wiley Online Library, doi:<a href="https://doi.org/10.1002/jts.20493">10.1002/jts.20493</a>.

Tsai, Jack, et al. &ldquo;The Effects of Race and Other Socioeconomic Factors on Health Service Use Among American Military Veterans.&rdquo; Psychiatric Quarterly, vol. 85, no. 1, Mar. 2014, pp. 35&ndash;47. Springer Link, doi:<a href="https://doi.org/10.1007/s11126-013-9268-0">10.1007/s11126-013-9268-0</a>.

SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health

Percentage of adults who have served who reported being told by a health professional that they have some form of arthritis

<h2>Why does this matter?</h2>

Arthritis is a general term that describes more than 100 conditions that result in <a href="https://www.cdc.gov/arthritis/basics/types.html">inflammation</a> or swelling of the joints, and is a major cause of pain and <a href="https://doi.org/10.1016/j.dhjo.2017.04.010">workplace disability</a>. A study found that about <a href="https://dx.doi.org/10.5435%2FJAAOS-20-08-S64">94.4%</a> of arthritis cases among the Army&rsquo;s wounded warriors were attributable to combat <a href="https://dx.doi.org/10.5435%2FJAAOS-20-08-S64">injuries</a>, especially knee injuries, resulting in disabling post-traumatic osteoarthritis. The incidence of <a href="https://doi.org/10.1016/j.arth.2016.03.026">osteoarthritis</a> is increasing among U.S. military service members. Those who have served have a significantly <a href="https://www.americashealthrankings.org/explore/health-of-those-who-have-served/measure/Arthritis/state/ALL">higher rate of arthritis</a> than those who have not served.&nbsp;

About <a href="https://www.cdc.gov/arthritis/pain/index.htm">one in four</a> adults with arthritis experience chronic pain. Back pain and <a href="https://doi.org/10.5435/jaaos-20-08-s23">osteoarthritis</a> are the most common disabilities in the U.S. Army, both conditions combined affect nearly four times more soldiers than post-traumatic stress disorder (PTSD). Osteoarthritis is the most common <a href="https://doi.org/10.5435/00124635-201102001-00002">cause of disability</a> among those who have served who have been medically separated from military service. Carrying heavy loads, long periods of sitting or crouching, and traumatic or overuse injuries incurred during combat are aspects of military service that may predispose those who have served to developing arthritis. &nbsp;Many adults with arthritis also experience <a href="https://www.cdc.gov/arthritis/data_statistics/disabilities-limitations.htm">limitations</a> in activities of daily living &mdash; such as walking, standing, sitting, reaching and grasping objects. Veterans are more likely to report back/neck pain and fracture, bone, and joint injuries as <a href="https://dx.doi.org/10.1371%2Fjournal.pone.0167143">activity-limiting conditions</a> at a younger age compared to non-veterans.

In 2013, the total cost of arthritis, including medical care costs and lost earnings attributable to arthritis was <a href="https://doi.org/10.1002/acr.23425">$303.5 billion</a>.
 <h2>Who is affected?</h2>

<a href="https://www.cdc.gov/arthritis/basics/risk-factors.htm">Risk factors</a> for arthritis include having overweight or obesity, history of joint injury or infection, performing a job that requires a lot of repetitive bending or squatting, and smoking.&nbsp;

The <a href="https://www.americashealthrankings.org/explore/health-of-those-who-have-served/measure/Arthritis/state/ALL">prevalence</a> of arthritis among those who have served is higher in:&nbsp;

<ul>
	<li>Females than males.</li>
	<li>Adults ages 50 and older than younger adults; the prevalence of arthritis increases with each increase in age group level.</li>
	<li>Adults with an annual household income less than $25,000 than those with incomes of $75,000 or more; the prevalence of arthritis increases with each decrease in income level.</li>
	<li>American Indian/Alaska Native adults than Asian adults.</li>
</ul> <h2>What works?</h2>

Maintaining a healthy weight, engaging in regular <a href="https://www.cdc.gov/arthritis/interventions/physical-activity.html">physical activity</a> and avoiding joint injuries are ways to <a href="https://www.cdc.gov/arthritis/basics/risk-factors.htm">reduce risk</a> of developing arthritis. Joint-friendly exercises include walking, biking and swimming. The Veterans Affairs (VA) has some <a href="https://www.healthquality.va.gov/guidelines/CD/OA/VADoDOAPatientSummaryFINAL090214.pdf#page=3">guidelines</a> for managing arthritis including:

<ul>
	<li>Acupuncture.</li>
	<li>Chiropractic and <a href="https://dx.doi.org/10.1089%2Facm.2014.0254">massage</a> therapy.</li>
	<li>Over-the-counter pain relievers (e.g., Tylenol, Ibuprofen, Advil).</li>
	<li>Prescription medications.</li>
	<li>Corticosteroids.</li>
	<li>Hylan/hyaluronate injections.</li>
	<li><a href="https://www.niams.nih.gov/health-topics/joint-replacement-surgery/advanced">Joint replacement therapy.&nbsp;</a></li>
</ul>

The Centers for Disease Control and Prevention propose specific <a href="https://www.cdc.gov/features/arthritis-among-veterans/index.html">programs</a> for veterans living with arthritis including <a href="https://www.cdc.gov/arthritis/interventions/physical-activity.html">physical activity programs</a> and <a href="https://www.cdc.gov/arthritis/interventions/self_manage.htm">self management classes</a>.
 <h2>References</h2>

Cross, Jessica, et al. &ldquo;Battlefield Orthopaedic Injuries Cause the Majority of Long-Term Disabilities.&rdquo; American Academy of Orthopaedic Surgeon, vol. 19, Feb. 2011. DOI.org (Crossref), doi:<a href="https://doi.org/10.5435/00124635-201102001-00002">10.5435/00124635-201102001-00002</a>.

Hinojosa, Ramon, and Melanie Sberna Hinojosa. &ldquo;Activity-Limiting Musculoskeletal Conditions in US Veterans Compared to Non-Veterans: Results from the 2013 National Health Interview Survey.&rdquo; PLOS ONE, vol. 11, no. 12, Public Library of Science, Dec. 2016, p. e0167143. PLoS Journals, DOI.org (Crossref), doi:<a href="https://doi.org/10.1371/journal.pone.0167143">10.1371/journal.pone.0167143</a>.

Juberg, Michael, et al. &ldquo;Pilot Study of Massage in Veterans with Knee Osteoarthritis.&rdquo; The Journal of Alternative and Complementary Medicine, vol. 21, no. 6, Mary Ann Liebert, Inc., publishers, May 2015, pp. 333&ndash;38. DOI.org (Crossref), doi:<a href="https://doi.org/10.1089/acm.2014.0254">10.1089/acm.2014.0254</a>.

Murphy, Louise B., et al. &ldquo;Medical Expenditures and Earnings Losses Among US Adults With Arthritis in 2013.&rdquo; Arthritis Care &amp; Research, vol. 70, no. 6, 2018, pp. 869&ndash;76. Wiley Online Library, DOI.org (Crossref), doi:<a href="https://doi.org/10.1002/acr.23425">10.1002/acr.23425</a>.

Patzkowski, Jeanne C., et al. &ldquo;The Changing Face of Disability in the US Army: The Operation Enduring Freedom and Operation Iraqi Freedom Effect.&rdquo; JAAOS - Journal of the American Academy of Orthopaedic Surgeons, vol. 20, 2012, p. S23. DOI.org (Crossref), doi:<a href="https://doi.org/10.5435/JAAOS-20-08-S23">10.5435/JAAOS-20-08-S23</a>.

Rivera, Jessica C., et al. &ldquo;Posttraumatic Osteoarthritis Caused by Battlefield Injuries: The Primary Source of Disability in Warriors.&rdquo; JAAOS - Journal of the American Academy of Orthopaedic Surgeons, vol. 20, 2012, p. S64. journals.lww.com, DOI.org (Crossref), doi:<a href="https://doi.org/10.5435/JAAOS-20-08-S64">10.5435/JAAOS-20-08-S64</a>.

Showery, James E., et al. &ldquo;The Rising Incidence of Degenerative and Posttraumatic Osteoarthritis of the Knee in the United States Military.&rdquo; The Journal of Arthroplasty, vol. 31, no. 10, Elsevier, Oct. 2016, pp. 2108&ndash;14. DOI.org (Crossref),&nbsp; doi:<a href="https://doi.org/10.1016/j.arth.2016.03.026">10.1016/j.arth.2016.03.026</a>.

Theis, Kristina A., et al. &ldquo;Prevalence and Causes of Work Disability among Working-Age U.S. Adults, 2011&ndash;2013, NHIS.&rdquo; Disability and Health Journal, vol. 11, no. 1, Jan. 2018, pp. 108&ndash;15. ScienceDirect, DOI.org (Crossref), doi:<a href="https://doi.org/10.1016/j.dhjo.2017.04.010">10.1016/j.dhjo.2017.04.010</a>.

Percentage of adults who have served who reported being told by a health professional that they had any form of cancer, skin or otherwise

<h2>Why does this matter?</h2>

Receiving cancer treatment, such as chemotherapy, radiation or immunotherapy, may cause a person&#39;s immune system to not function properly (medically referred to as being immunocompromised). People who are immunocompromised may be at <a href="https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/groups-at-higher-risk.html">higher risk</a> of severe illness from coronavirus disease (COVID-19). For more information about COVID-19 see the Centers for Disease Control and Prevention (CDC) <a href="https://www.cdc.gov/coronavirus/2019-nCoV/index.html">website</a>.

Cancer is the <a href="https://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm">second-leading</a> cause of death in the United States. According to the American Cancer Society&rsquo;s <a href="https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/annual-cancer-facts-and-figures/2020/cancer-facts-and-figures-2020.pdf">Cancer Facts &amp; Figures 2020</a> report, an estimated <a href="https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/annual-cancer-facts-and-figures/2020/cancer-facts-and-figures-2020.pdf#page=3">1.8 million</a> new cancer diagnoses will be made in 2020. The most commonly diagnosed <a href="https://doi.org/10.7205/MILMED-D-16-00371">cancers</a> in the Veterans Affairs health care system are prostate, lung/bronchus and colorectal cancer.&nbsp;

In 2017, the national cost of cancer care was approximately <a href="https://www.cancer.gov/about-cancer/understanding/statistics">$147.3 billion</a>. Assuming the number of newly diagnosed people and the rate of survival remain constant, costs are expected to increase to nearly <a href="http://www.doi.org/10.1093/jnci/djq495">$157.8 billion</a> in 2020. This is in part due to a growing number of aging Americans. In addition, the estimated cost of lost productivity from cancer mortality is projected to be <a href="http://www.doi.org/10.1093/jnci/djn384">$147.6 billion</a> in 2020.
 <h2>Who is affected?</h2>

The biggest risk factor for cancer is advancing age &mdash; <a href="https://www.cancer.gov/about-cancer/causes-prevention/risk/age">half</a> of all new cancer diagnoses occur in adults ages 66 or older. Cigarette and tobacco use is another major risk factor and tobacco use is a common and <a href="https://doi.org/10.1080/14622200802027123">accepted practice</a> within the military, despite its <a href="https://www.cancer.gov/about-cancer/causes-prevention/risk/tobacco">causal ties</a> to cancer. Other cancer risks include <a href="https://www.cancer.gov/about-cancer/causes-prevention/risk/substances">environmental carcinogens</a>, <a href="https://www.cancer.gov/about-cancer/causes-prevention/genetics">genetic factors</a> and viral and bacterial <a href="https://www.cancer.gov/about-cancer/causes-prevention/risk/infectious-agents">infections</a>. The veteran population is unique in that they may be <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6363310/">exposed to</a> cancer-causing chemicals during deployment, such as mustard gas, agent orange and depleted uranium.&nbsp;

The <a href="https://www.americashealthrankings.org/explore/health-of-those-who-have-served/measure/Cancer/state/ALL">prevalence</a> of cancer among veterans is higher in:&nbsp;

<ul>
	<li>Females than males.</li>
	<li>Those ages 50 and older, who have a prevalence more than 11 times higher than those ages 18-25.</li>
	<li>American Indian/Alaska Native, multiracial, white, and Hispanic veterans compared with Asian and Black veterans.&nbsp;</li>
	<li>Veterans who have either less than a high school education or are college graduates, compared with those who are high school graduates or have some college education.</li>
</ul>
 <h2>What works?</h2>

While there is no universal cure for cancer, death rates can be lowered through various means including:&nbsp;

<ul>
	<li>Lifestyle changes: Quitting smoking at any age will lower the risk of developing cancer. Smoking is responsible for approximately <a href="https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/annual-cancer-facts-and-figures/2019/cancer-facts-and-figures-2019.pdf#page=46">30%</a> of cancer deaths. Engaging in more <a href="https://www.cancer.gov/about-cancer/causes-prevention/risk/obesity/physical-activity-fact-sheet#q2">physical activity</a> and reducing <a href="http://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/annual-cancer-facts-and-figures/2020/cancer-facts-and-figures-2020.pdf#page=51">alcohol consumption</a> are also associated with lower risk of certain cancers.&nbsp;</li>
	<li>Vaccination: The human papillomavirus (HPV) vaccine is the first vaccine ever developed to prevent cancer. The CDC reports that <a href="https://www.cdc.gov/vitalsigns/cervical-cancer/">up to 93%</a> of cervical cancers can be prevented through HPV screening and vaccination. Additionally, the hepatitis B vaccine can reduce the risk of <a href="https://www.cdc.gov/vaccines/vpd/hepb/index.html">liver cancer</a>.</li>
	<li>Screening: Routine <a href="https://www.cancer.org/healthy/find-cancer-early/cancer-screening-guidelines/american-cancer-society-guidelines-for-the-early-detection-of-cancer.html">recommended screening</a> for breast, colon and prostate cancer can improve outcomes by detecting cancer in its earlier stages.&nbsp;</li>
	<li>Increasing access to services for prevention, early detection and high-quality cancer treatment may help reduce racial and socioeconomic disparities in cancer deaths.&nbsp;</li>
</ul>

Information on specific screening, counseling and prevention recommendations for cancer are available from the <a href="https://www.uspreventiveservicestaskforce.org/BrowseRec/Search?s=cancer">U.S. Preventive Services Task Force</a>.
 <h2>References</h2>

Bradley, Cathy J., et al. &ldquo;Productivity Costs of Cancer Mortality in the United States: 2000&ndash;2020.&rdquo; JNCI: Journal of the National Cancer Institute, vol. 100, no. 24, Dec. 2008, pp. 1763&ndash;70. DOI.org (Crossref), doi:<a href="https://doi.org/10.1093/jnci/djn384">10.1093/jnci/djn384</a>.

Krefft, Silpa D., et al. &ldquo;Deployment-Related Lung Disorders.&rdquo; Federal Practitioner: For the Health Care Professionals of the VA, DoD, and PHS, vol. 32, no. 6, June 2015, pp. 32&ndash;38. PMCID:<a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6363310/">PMC6363310</a>

Mariotto, A. B., et al. &ldquo;Projections of the Cost of Cancer Care in the United States: 2010-2020.&rdquo; JNCI Journal of the National Cancer Institute, vol. 103, no. 2, Jan. 2011, pp. 117&ndash;28. DOI.org (Crossref), doi:<a href="https://doi.org/10.1093/jnci/djq495">10.1093/jnci/djq495</a>.

Nelson, Jenenne, and Linda Pederson. &ldquo;Military Tobacco Use: A Synthesis of the Literature on Prevalence, Factors Related to Use, and Cessation Interventions.&rdquo; Nicotine &amp; Tobacco Research, vol. 10, no. 5, May 2008, pp. 775&ndash;90. DOI.org (Crossref), doi:<a href="https://doi.org/10.1080/14622200802027123">10.1080/14622200802027123</a>.

Zullig, Leah L., et al. &ldquo;Cancer Incidence Among Patients of the U.S. Veterans Affairs Health Care System: 2010 Update.&rdquo; Military Medicine, vol. 182, no. 7, July 2017, pp. e1883&ndash;91. DOI.org (Crossref), doi:<a href="https://doi.org/10.7205/MILMED-D-16-00371">10.7205/MILMED-D-16-00371</a>.

Percentage of adults who have served who reported being told by a health professional that they have chronic obstructive pulmonary disease (COPD)

<h2>Why does this matter?</h2>

People who have a chronic lung disease such as chronic obstructive pulmonary disease (COPD) are at <a href="https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/groups-at-higher-risk.html">higher risk</a> of severe illness from coronavirus disease (COVID-19). For more information about COVID-19 see the Centers for Disease Control and Prevention <a href="https://www.cdc.gov/coronavirus/2019-nCoV/index.html">website</a>.

<a href="https://www.mayoclinic.org/diseases-conditions/copd/symptoms-causes/syc-20353679">Chronic obstructive pulmonary disease (COPD)</a> is a chronic lung disease that slowly <a href="https://www.healthline.com/health/copd">damages</a> air sacs in the lungs, decreasing airflow and making it difficult to breathe. COPD is <a href="https://www.cdc.gov/copd/basics-about.html">the third leading cause</a> of death in the United States. The symptoms of COPD <a href="https://www.mayoclinic.org/diseases-conditions/copd/symptoms-causes/syc-20353679">include</a> shortness of breath, wheezing, tightness of the chest, needing to clear the throat frequently and a chronic cough. COPD has <a href="https://www.nhlbi.nih.gov/health-topics/copd">no treatment</a>, but its progress and symptoms can be managed. Untreated COPD may lead to other <a href="https://www.mayoclinic.org/diseases-conditions/copd/symptoms-causes/syc-20353679">health complications</a> including respiratory infections, heart disease, lung cancer and depression.&nbsp;

Veterans who have COPD are <a href="https://doi.org/10.2147/COPD.S8047">hospitalized more frequently</a> and have higher rates of co-occurring diabetes, heart failure, heart attack and cancer than those who do not have COPD. <a href="https://doi.org/10.1007/s11606-009-1160-0">Tobacco use in active duty military and veterans</a>, along with exposure to <a href="https://doi.org/10.1093/epirev/mxu009">airborne hazards during deployment</a>, may increase the burden of COPD among those who have served.
 <h2>Who is affected?</h2>

<a href="https://www.nhlbi.nih.gov/health-topics/copd">Risk factors</a> of COPD include cigarette smoking, secondhand smoke, asthma, exposure to smoke from burning fuels and long-term exposure to chemicals. The <a href="https://www.americashealthrankings.org/explore/health-of-those-who-have-served/measure/COPD/state/ALL">prevalence</a> of COPD among those who have served is higher in:

<ul>
	<li>Females compared with males.</li>
	<li>Adults ages 50 and older compared with younger adults.</li>
	<li>Multiracial and American Indian/Alaska Native adults compared with Asian and Hawaiians/Pacific Islander adults who had the lowest prevalence.&nbsp;</li>
	<li>Those with less than a high school education than those with higher levels of education.</li>
	<li>Those with an annual household income of $75,000 or more than those with lower levels of income; the prevalence of COPD increases with each increase in income level.</li>
</ul>
 <h2>What works?</h2>

While COPD has no cure, its progress and symptoms can be <a href="https://doi.org/10.2147/COPD.S79077">treated</a>. One of the main risk factors associated with developing COPD is <a href="https://www.mayoclinic.org/diseases-conditions/copd/symptoms-causes/syc-20353679">smoking</a>. Avoiding or quitting smoking is the best way to prevent COPD and the American Lung Association offers many <a href="http://freedomfromsmoking.org">smoking cessation programs</a> that can aid in preventing COPD. One <a href="https://doi.org/10.37765/ajmc.2020.42394">study</a> found that higher care coordination in hospitals is correlated with better COPD outcomes among those who have served. Another <a href="https://doi.org/10.1378/chest.09-2328">study</a> found that improving specific communication strategies between clinicians and patients can improve COPD outcomes.&nbsp;

Other strategies to prevent and/or manage COPD <a href="https://www.cdc.gov/copd/basics-about.html">include</a>:

<ul>
	<li>Avoiding secondhand smoking at home and work.</li>
	<li>Asking physicians about pulmonary rehabilitation, a personalized COPD management program that improves an individual&rsquo;s lifestyle.</li>
	<li>Taking medications that lessen symptoms such as coughing and wheezing.</li>
	<li>Receiving supplemental oxygen therapy.</li>
</ul>
 <h2>References</h2>

Brown, David W. &ldquo;Smoking Prevalence among US Veterans.&rdquo; Journal of General Internal Medicine, vol. 25, no. 2, Feb. 2010, pp. 147&ndash;49. DOI.org (Crossref), doi:<a href="https://doi.org/10.1007/s11606-009-1160-0">10.1007/s11606-009-1160-0</a>.

&ldquo;Care Coordination for Veterans with COPD: A Positive Deviance Study.&rdquo; The American Journal of Managed Care, vol. 26, no. 2, Feb. 2020, pp. 63&ndash;68. DOI.org (Crossref), doi:<a href="https://doi.org/10.37765/ajmc.2020.42394">10.37765/ajmc.2020.42394</a>.

Dalal, Anand. &ldquo;Burden of COPD in a Government Health Care System: A Retrospective Observational Study Using Data from The US Veterans Affairs Population.&rdquo; International Journal of Chronic Obstructive Pulmonary Disease, Apr. 2010, p. 125. DOI.org (Crossref), doi:<a href="https://doi.org/10.2147/COPD.S8047">10.2147/COPD.S8047</a>.

Falvo, M. J., et al. &ldquo;Airborne Hazards Exposure and Respiratory Health of Iraq and Afghanistan Veterans.&rdquo; Epidemiologic Reviews, vol. 37, no. 1, Jan. 2015, pp. 116&ndash;30. DOI.org (Crossref), doi:<a href="https://doi.org/10.1093/epirev/mxu009">10.1093/epirev/mxu009</a>.

Patel, Jeetvan, et al. &ldquo;COPD Affects Worker Productivity and Health Care Costs.&rdquo; International Journal of Chronic Obstructive Pulmonary Disease, vol. Volume 13, July 2018, pp. 2301&ndash;11. DOI.org (Crossref), doi:<a href="https://doi.org/10.2147/COPD.S163795">10.2147/COPD.S163795</a>.

Pleasants, Roy, et al. &ldquo;Defining and Targeting Health Disparities in Chronic Obstructive Pulmonary Disease.&rdquo; International Journal of Chronic Obstructive Pulmonary Disease, vol. Volume 11, Oct. 2016, pp. 2475&ndash;96. DOI.org (Crossref), doi:<a href="https://doi.org/10.2147/COPD.S79077">10.2147/COPD.S79077</a>.

Ray, Shaunta&rsquo;, et al. &ldquo;The Clinical and Economic Burden of Chronic Obstructive Pulmonary Disease in the USA.&rdquo; ClinicoEconomics and Outcomes Research, June 2013, p. 235. DOI.org (Crossref), doi:<a href="https://doi.org/10.2147/CEOR.S34321">10.2147/CEOR.S34321</a>.

Slatore, Christopher G., et al. &ldquo;Patient-Clinician Communication.&rdquo; Chest, vol. 138, no. 3, Sept. 2010, pp. 628&ndash;34. DOI.org (Crossref), doi:<a href="https://doi.org/10.1378/chest.09-2328">10.1378/chest.09-2328</a>.

Percentage of adults who have served who reported being told by a health professional that they had angina or coronary heart disease

Percentage of adults who have served who reported being told by a health professional that they have a depressive disorder, including depression, major depression, minor depression or dysthymia including depression, major depression, minor depression or dysthymia

<h2>Why does this matter?</h2>

Depression, also called major depressive disorder or clinical depression, is a <a href="https://www.nimh.nih.gov/health/topics/depression/index.shtml">common mood disorder</a>. Symptoms of depression such as persistent sadness or anxiety, decreased energy and difficulty sleeping, can impact all aspects of a person&rsquo;s life, including how they think, feel and handle daily activities. Among veterans, <a href="https://www.nami.org/Blogs/NAMI-Blog/November-2019/5-Ways-You-Can-Support-Veterans-Mental-Health">challenging aspects of the military lifestyle</a>, such as multiple deployments, combat exposure and injuries often lead to mental disorders including depression and posttraumatic disorder (PTSD). Moreover, a transition from military to <a href="http://doi.org/10.2147/AMEP.S89479">civilian life</a> may be stressful. Active members of the U.S. military are up to <a href="http://doi.org/10.1001/jamapsychiatry.2014.28">5 times</a> more likely to have depression compared with civilians.&nbsp;

Depression can negatively affect many aspects of veterans&rsquo; health. If left untreated, depression can increase the risk of drug addiction, insomnia and suicide. In the general population, around 80% of adults with depression report at least <a href="https://www.cdc.gov/nchs/products/databriefs/db303.htm">some difficulty</a> performing work, home or social activities. One <a href="https://content.iospress.com/articles/work/wor01417">study</a> found that depression is associated with a higher prevalence of unemployment among veterans.&nbsp;

There are significant societal costs associated with depression. The economic burden of depression in the U.S. is estimated at <a href="https://www.apa.org/monitor/2017/03/numbers">$2.4 trillion</a>, including individual out-of-pocket cost and private and government insurance spending.
 <h2>Who is affected?</h2>

Depression is a complex disorder that is caused by a combination of genetic, biological, environmental and psychological factors. Common known <a href="https://www.nimh.nih.gov/health/topics/depression/index.shtml">risk factors</a> for depression include a family history of depression, major life changes or stressors and certain medications or illnesses, such as diabetes, cancer or heart disease.

The <a href="https://www.americashealthrankings.org/explore/health-of-those-who-have-served/measure/Depression/state/ALL">prevalence</a> of depression among those who have served is higher in:&nbsp;

<ul>
	<li>Females compared with males.</li>
	<li>American Indian/Alaska Native adults compared with other racial/ethnic groups.</li>
	<li>Lower-income veterans compared with higher-income veterans.&nbsp;</li>
	<li>Those with lower educational attainment compared with higher educational attainment.</li>
</ul>


 <h2>What works?</h2>

Depressive disorders are common and treatable. The U.S. Department of Veterans Affairs provides <a href="https://www.mentalhealth.va.gov/depression/treatment.asp?utm_source=google&amp;utm_medium=cpc&amp;utm_campaign=search-va-depression&amp;utm_content=treatments-and-programs&amp;utm_term=%2Bva%20%2Bdepression&amp;gclid=EAIaIQobChMIufvZ8Jbt6AIVV__jBx3PtwbmEAAYASAAEgKHGPD_BwE">resources</a> on therapies for depression including cognitive-behavioral therapy, acceptance and commitment therapy, and interpersonal psychotherapy. Recently, psychotherapy over <a href="http://doi.org/10.1016/S2215-0366(15)00122-4">telemedicine</a> was found to be effective among older veterans.
 <h2>References</h2>

Cohen, Sara I., et al. &ldquo;Clinical and Demographic Factors Associated with Employment Status in US Military Veterans Returning from Iraq and Afghanistan.&rdquo; Work, vol. 44, no. 2, IOS Press, Jan. 2013, pp. 213&ndash;19. content.iospress.com, doi:<a href="https://doi.org/10.3233/WOR-2012-1417">10.3233/WOR-2012-1417</a>.

Egede, Leonard E., et al. &ldquo;Psychotherapy for Depression in Older Veterans via Telemedicine: A Randomised, Open-Label, Non-Inferiority Trial.&rdquo; The Lancet Psychiatry, vol. 2, no. 8, Aug. 2015, pp. 693&ndash;701. DOI.org (Crossref), doi:<a href="https://doi.org/10.1016/S2215-0366(15)00122-4">10.1016/S2215-0366(15)00122-4</a>.

Kessler, Ronald C., et al. &ldquo;Thirty-Day Prevalence of DSM-IV Mental Disorders Among Nondeployed Soldiers in the US Army: Results From the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS).&rdquo; JAMA Psychiatry, vol. 71, no. 5, American Medical Association, May 2014, pp. 504&ndash;13. jamanetwork.com, doi:<a href="https://doi.org/10.1001/jamapsychiatry.2014.28">10.1001/jamapsychiatry.2014.28</a>.

Olenick, Maria, et al. &ldquo;US Veterans and Their Unique Issues: Enhancing Health Care Professional Awareness.&rdquo; Advances in Medical Education and Practice, Dec. 2015, p. 635. DOI.org (Crossref), doi:<a href="https://doi.org/10.2147/AMEP.S89479">10.2147/AMEP.S89479</a>.

Percentage of adults who have served who reported being told by a health professional that they have diabetes (excluding pre-diabetes and gestational diabetes)

<h2>Why does this matter?</h2>

People who have type 2 diabetes are at <a href="https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/groups-at-higher-risk.html">higher risk</a> of severe illness from coronavirus disease (COVID-19). People who have type 1 or gestational diabetes may also be at higher risk. For more information about COVID-19 see the Centers for Disease Control and Prevention <a href="https://www.cdc.gov/coronavirus/2019-nCoV/index.html">website</a>.

Diabetes is the nation&rsquo;s<a href="https://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm"> seventh-leading</a> cause of death, accounting for more than 79,000 deaths annually. It also <a href="https://www.heart.org/en/health-topics/diabetes/why-diabetes-matters/cardiovascular-disease--diabetes">contributes to deaths from heart disease and stroke</a> which are the leading and fifth-leading causes of death, respectively. There are three major <a href="https://www.cdc.gov/diabetes/basics/quick-facts.html">types of diabetes</a>: type 1, type 2, and gestational. Type 2 diabetes accounts for 90% to 95% of all cases.&nbsp;

Diabetes is a leading cause of <a href="https://www.cdc.gov/diabetes/basics/quick-facts.html">kidney failure</a>, nontraumatic lower-limb amputations and blindness among adults. In 2018, <a href="https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf#page=4">13.0%</a> of all U.S. adults were estimated to have diabetes, with 78% diagnosed and another 22% undiagnosed. In 2018, <a href="https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf#page=8">1.5 million</a> new cases of diabetes were diagnosed among adults.

Around <a href="https://www.research.va.gov/topics/diabetes.cfm">25%</a> of veterans are affected by diabetes. The prevalence of diabetes is <a href="http://doi.org/10.5888/pcd14.170230">higher</a> among veterans compared with the general population.&nbsp;

Direct medical costs and lost productivity attributable to diagnosed diabetes was estimated to be <a href="https://doi.org/10.2337/dci18-0007">$327 billion</a> in 2017. Among people with diagnosed diabetes, direct medical costs are <a href="https://doi.org/10.2337/dci18-0007">twice as high</a> compared with people without diabetes after adjusting for population age and sex differences.
 <h2>Who is affected?</h2>

Type 2 diabetes is a largely preventable progressive disease that is influenced by <a href="https://www.cdc.gov/diabetes/basics/risk-factors.html">risk factors</a> that are amenable to change such as obesity, physical inactivity, high blood pressure, poor diet and <a href="https://www.cdc.gov/tobacco/campaign/tips/diseases/diabetes.html">smoking</a>. Populations of those who have served who are more likely to have diabetes <a href="https://www.americashealthrankings.org/explore/health-of-those-who-have-served/measure/Diabetes/state/ALL">include</a>:

<ul>
	<li>Men compared with women</li>
	<li>American Indian/Alaska Native adults compared with adults of other races and ethnicities&nbsp;</li>
	<li>Adults with less than a high school education compared with adults with higher education levels; the prevalence decreases as educational attainment increases.&nbsp;</li>
	<li>Adults with an annual household income less than $25,000 compared with higher income levels; the prevalence decreases as income levels increase.&nbsp;</li>
	<li>Older adults compared with younger adults</li>
</ul>
 <h2>What works?</h2>

Diabetes is an ideal target for prevention strategies as the onset of type 2 diabetes can be largely prevented through <a href="https://care.diabetesjournals.org/content/29/9/2102">weight loss</a> as well as increasing physical activity and <a href="https://doi.org/10.1146/annurev.publhealth.26.021304.144532">improving dietary choices</a>. <a href="https://doi.org/10.2337/diacare.22.4.623">The National Diabetes Prevention Program,</a> a partnership of public and private organizations working to prevent or delay type 2 diabetes, has been shown to reduce diabetes incidence by <a href="https://doi.org/10.1016/S0140-6736(09)61457-4">58%</a> among those at high risk for the disease and delay onset by about four years. The program provides evidence-based interventions that target healthier lifestyles in communities. The U.S Department of Veterans Affairs offers a similar program, <a href="https://www.research.va.gov/topics/diabetes.cfm">Diabetes Prevention Program, modeled </a>after the National Diabetes Prevention Program. The program provides opportunities to change diet and increase physical activity among veterans. More information on diabetes prevention can be found on the Center for Disease Control and Prevention&rsquo;s <a href="http://www.cdc.gov/diabetes/home/">website</a> as well as through the <a href="http://www.diabetes.org/">American Diabetes Association</a>.&nbsp;

 
Diabetes can be managed through a combination of <a href="https://doi.org/10.1146/annurev.publhealth.26.021304.144532">lifestyle modifications</a> and health care interventions. Moreover, ensuring people with diabetes have access to <a href="https://makeinsulinaffordable.org/the-issue/#fast-facts">affordable insulin</a> can prevent diabetes-related complications and death due to insulin rationing.
 <h2>References</h2>

Association, American Diabetes. &ldquo;Economic Costs of Diabetes in the U.S. in 2017.&rdquo; Diabetes Care, vol. 41, no. 5, American Diabetes Association, May 2018, pp. 917&ndash;28. care.diabetesjournals.org, doi:<a href="https://doi.org/10.2337/dci18-0007">10.2337/dci18-0007</a>.

Diabetes Prevention Program Research Group. &ldquo;10-Year Follow-up of Diabetes Incidence and Weight Loss in the Diabetes Prevention Program Outcomes Study.&rdquo; The Lancet, vol. 374, no. 9702, Nov. 2009, pp. 1677&ndash;86, doi:<a href="https://doi.org/10.1016/S0140-6736(09)61457-4">10.1016/S0140-6736(09)61457-4</a>.

Hamman, Richard F., et al. &ldquo;Effect of Weight Loss With Lifestyle Intervention on Risk of Diabetes.&rdquo; Diabetes Care, vol. 29, no. 9, Sept. 2006, pp. 2102&ndash;07. PubMed Central, doi:<a href="https://doi.org/10.2337/dc06-0560">10.2337/dc06-0560</a>.

Liu, Ying, et al. &ldquo;Prevalence of and Trends in Diabetes Among Veterans, United States, 2005&ndash;2014.&rdquo; Preventing Chronic Disease, vol. 14, 2017. www.cdc.gov, doi:<a href="https://doi.org/10.5888/pcd14.170230">10.5888/pcd14.170230</a>.

Schulze, Matthias B., and Frank B. Hu. &ldquo;Primary Prevention of Diabetes: What Can Be Done and How Much Can Be Prevented?&rdquo; Annual Review of Public Health, vol. 26, no. 1, Apr. 2005, pp. 445&ndash;67. DOI.org (Crossref), doi:<a href="https://doi.org/10.1146/annurev.publhealth.26.021304.144532">10.1146/annurev.publhealth.26.021304.144532</a>.

&ldquo;The Diabetes Prevention Program. Design and Methods for a Clinical Trial in the Prevention of Type 2 Diabetes.&rdquo; Diabetes Care, vol. 22, no. 4, Apr. 1999, pp. 623&ndash;34. PubMed, doi:<a href="https://doi.org/10.2337/diacare.22.4.623">10.2337/diacare.22.4.623</a>.

Percentage of adults who have served who reported their mental health was not good 14 or more days in the past 30 days

<h2>Why does this matter?</h2>

A healthy mental state is essential to overall positive health and well-being. Frequent mental distress is a measure that aims to capture the population experiencing persistent, and likely severe, mental health issues. The cutoff point of <a href="https://doi.org/10.1007/s11136-008-9330-9">14 or more days</a> of self-reported poor mental health is used to capture frequent mental distress. There is a strong relationship between the 14-day period and clinically diagnosed mental disorders, such as depression and anxiety.&nbsp;

In some cases, poor mental health may lead to suicide, the <a href="https://dx.doi.org/10.1186%2F1471-2458-11-374">second</a> leading cause of death among those who have served in the United States military. In 2017, those who have served accounted for <a href="https://www.mentalhealth.va.gov/docs/data-sheets/2019/2019_National_Veteran_Suicide_Prevention_Annual_Report_508.pdf#page=5">18.3%</a> of all suicide deaths even though they represented only 11.3% of the U.S. population. Additionally, veterans who have been deployed during the <a href="https://doi.org/10.1016/j.annepidem.2014.11.020">Iraq and Afghanistan wars</a> between 2001&ndash;2007 had a <a href="https://www.publichealth.va.gov/epidemiology/studies/suicide-risk-death-risk-recent-veterans.asp">41%</a> higher suicide risk compared to the general U.S. population.&nbsp;

When including institutionalized and active-duty military, direct medical spending associated with mental health disorders (including anxiety, depression and dementia) in the United States reached <a href="https://doi.org/10.1377/hlthaff.2015.1659">$201 billion</a> in 2013, surpassing costs for heart disease ($147 billion) and traumatic injury ($143 billion).
 <h2>Who is affected?</h2>

Frequent mental distress is <a href="https://doi.org/10.1093/pubmed/fdt029">associated with</a> smoking, physical inactivity, <a href="https://www.doi.org/10.5888%2Fpcd11.130334">housing insecurity</a>, food insecurity and insufficient sleep. The <a href="https://www.americashealthrankings.org/explore/health-of-those-who-have-served/measure/mental_distress/state/ALL">prevalence</a> of frequent mental distress among those who have served is higher in:

<ul>
	<li>Females than males.</li>
	<li>American Indian/Alaska Native adults than white adults.</li>
	<li>Adults ages 26-34 than adults ages 50 and older.</li>
	<li>Adults with less than a high school education, who have a prevalence nearly three times higher than college graduates.</li>
	<li>Adults with an annual household income less than $25,000 than those with an income of $75,000 or more; the prevalence decreases with each increase in income level.</li>
</ul>

<a href="https://scholarsarchive.jwu.edu/health_fac/18/?utm_source=scholarsarchive.jwu.edu%2Fhealth_fac%2F18&amp;utm_medium=PDF&amp;utm_campaign=PDFCoverPages">Unemployed</a> veterans, who have three times greater odds of reporting frequent mental distress compared to veterans who are employed.
 <h2>What works?</h2>

Although occasional short periods of mental distress may be unavoidable, more prolonged and serious episodes are treatable and may be <a href="https://www.who.int/mental_health/evidence/en/prevention_of_mental_disorders_sr.pdf">preventable</a> through early interventions. Effective early interventions for mental distress prevention among veterans <a href="https://doi.org/10.1016/j.cpr.2012.09.002">include</a>:&nbsp;

<ul>
	<li>Improving early <a href="https://dx.doi.org/10.1007%2Fs11606-011-1849-8">access</a> to the Veteran Affairs (VA) <a href="https://www.ncbi.nlm.nih.gov/books/NBK499499/">mental healthcare services</a> since the rate of suicide is greatest in the <a href="https://www.publichealth.va.gov/epidemiology/studies/suicide-risk-death-risk-recent-veterans.asp">first three years</a> after leaving the military.&nbsp;</li>
	<li>Integrating clinicians into medical and military contexts.</li>
	<li>Reducing stigma associated with seeking treatment by reframing conversations around mental health.</li>
	<li>Preventative interventions such as <a href="https://doi.org/10.7205/MILMED-D-16-00311">Combat Stress Control Treatment</a>, <a href="https://usamrd-w.amedd.army.mil/assets/docs/publications/adler_et_al_2007_report_2007-001_battlemind_procedures.pdf">psychological debriefing</a> and <a href="https://doi.org/10.1016/j.jsams.2018.05.005">resiliency training</a>.&nbsp;</li>
	<li>Use of technological advances such as <a href="https://dx.doi.org/10.1080%2F20008198.2019.1654782">virtual reality exposure therapy</a> and telehealth service delivery. For example, <a href="https://www.vetsprevail.org/">Vetsprevail</a> is a convenient online resource provided by the VA that offers clinical assessments, peer-to-peer support and referrals to in-person mental health care.&nbsp;</li>
</ul>

Continued <a href="https://doi.org/10.1016/j.amepre.2009.01.038">surveillance</a> of frequent mental distress may help identify unmet social and mental health needs and help guide prevention and treatment interventions. The Centers for Disease Control and Prevention has a general <a href="https://www.cdc.gov/mentalhealth/tools-resources/index.htm">resources</a> page for mental health including a mental health services locator.
 <h2>References</h2>

Bruning, John, et al. &ldquo;Medical Cost and Frequent Mental Distress among the Non-Elderly US Adult Population.&rdquo; Journal of Public Health, vol. 36, no. 1, Oxford Academic, Mar. 2014, pp. 134&ndash;39. DOI.org (Crossref), doi:<a href="https://doi.org/10.1093/pubmed/fdt029">10.1093/pubmed/fdt029</a>.

DiBiasio, Eleanor, et al. &ldquo;Correlates of Frequent Mental Distress among Active and Former Military Personnel.&rdquo; Health &amp; Wellness Department Faculty Publications and Research, Jan. 2014,Report. <a href="https://scholarsarchive.jwu.edu/health_fac/18">Report</a>.

Judkins, Jason L., and Devvon L. Bradley. &ldquo;A Review of the Effectiveness of a Combat and Operational Stress Control Restoration Center in Afghanistan.&rdquo; Military Medicine, vol. 182, no. 7, Oxford Academic, July 2017, pp. E1755&ndash;62. DOI.org (Crossref),&nbsp; doi:<a href="https://doi.org/10.7205/MILMED-D-16-00311">10.7205/MILMED-D-16-00311</a>.

Kang, Han K., et al. &ldquo;Suicide Risk among 1.3 Million Veterans Who Were on Active Duty during the Iraq and Afghanistan Wars.&rdquo; Annals of Epidemiology, vol. 25, no. 2, Feb. 2015, pp. 96&ndash;100. ScienceDirect, DOI.org (Crossref),&nbsp; doi:<a href="https://doi.org/10.1016/j.annepidem.2014.11.020">10.1016/j.annepidem.2014.11.020</a>.

Kehle, Shannon M., et al. &ldquo;Interventions to Improve Veterans&rsquo; Access to Care: A Systematic Review of the Literature.&rdquo; Journal of General Internal Medicine, vol. 26, no. 2, Oct. 2011, p. 689. Springer Link, DOI.org (Crossref), doi:<a href="https://doi.org/10.1007/s11606-011-1849-8">10.1007/s11606-011-1849-8</a>.

Kothgassner, Oswald, et al. Full Article: Virtual Reality Exposure Therapy for Posttraumatic Stress Disorder (PTSD): A Meta-Analysis. DOI.org (Crossref),&nbsp; doi: <a href="https://www.tandfonline.com/doi/full/10.1080/20008198.2019.1654782">10.1080/20008198.2019.1654782</a>.&nbsp;

Liu, Yong. &ldquo;Relationships Between Housing and Food Insecurity, Frequent Mental Distress, and Insufficient Sleep Among Adults in 12 US States, 2009.&rdquo; Preventing Chronic Disease, vol. 11, 2014. DOI.org (Crossref),&nbsp; doi:<a href="https://doi.org/10.5888/pcd11.130334">10.5888/pcd11.130334</a>.

Moriarty, David G., et al. &ldquo;Geographic Patterns of Frequent Mental Distress: U.S. Adults, 1993&ndash;2001 and 2003&ndash;2006.&rdquo; American Journal of Preventive Medicine, vol. 36, no. 6, Elsevier, June 2009, pp. 497&ndash;505. DOI.org (Crossref), doi:<a href="https://doi.org/10.1016/j.amepre.2009.01.038">10.1016/j.amepre.2009.01.038</a>.

National Academies of Sciences, Engineering, et al. &ldquo;The Veterans Health Administration&rsquo;s Mental Health Services.&rdquo; Evaluation of the Department of Veterans Affairs Mental Health Services, National Academies Press (US), 2018. www.ncbi.nlm.nih.gov,<a href="https://www.ncbi.nlm.nih.gov/books/NBK499499/">Report</a>.

Nindl, Bradley C., et al. &ldquo;Perspectives on Resilience for Military Readiness and Preparedness: Report of an International Military Physiology Roundtable.&rdquo; Journal of Science and Medicine in Sport, vol. 21, no. 11, Elsevier, Nov. 2018, pp. 1116&ndash;24. DOI.org (Crossref), doi:<a href="https://doi.org/10.1016/j.jsams.2018.05.005">10.1016/j.jsams.2018.05.005</a>.

Roehrig, Charles. &ldquo;Mental Disorders Top The List Of The Most Costly Conditions In The United States: $201 Billion.&rdquo; Health Affairs, vol. 35, no. 6, Health Affairs, June 2016, pp. 1130&ndash;35.&nbsp;DOI.org (Crossref), doi:<a href="https://doi.org/10.1377/hlthaff.2015.1659">10.1377/hlthaff.2015.1659</a>.

Shih, Margaret, and Paul A. Simon. &ldquo;Health-Related Quality of Life among Adults with Serious Psychological Distress and Chronic Medical Conditions.&rdquo; Quality of Life Research, vol. 17, no. 4, May 2008, pp. 521&ndash;28. DOI.org (Crossref), doi:<a href="https://doi.org/10.1007/s11136-008-9330-9">10.1007/s11136-008-9330-9</a>.

Weiner, Janet, et al. &ldquo;Military Veteran Mortality Following a Survived Suicide Attempt.&rdquo; BMC Public Health, vol. 11, no. 1, May 2011, p. 374. BioMed Central, DOI.org (Crossref), doi:<a href="https://doi.org/10.1186/1471-2458-11-374">10.1186/1471-2458-11-374</a>.

Zinzow, Heidi M., et al. &ldquo;Connecting Active Duty and Returning Veterans to Mental Health Treatment: Interventions and Treatment Adaptations That May Reduce Barriers to Care.&rdquo; Clinical Psychology Review, vol. 32, no. 8, Dec. 2012, pp. 741&ndash;53. ScienceDirect, DOI.org (Crossref), doi:<a href="https://doi.org/10.1016/j.cpr.2012.09.002">10.1016/j.cpr.2012.09.002</a>.

Percentage of adults who have served who reported their physical health was not good 14 or more days in the past 30 days 

<h2>Why does this matter?</h2>

Frequent physical distress is based on self-reported poor physical health days. The measure aims to capture the population experiencing persistent and likely severe physical health problems, which may have a significant impact on health-related quality of life and overall wellness. The cutoff point of <a href="https://www.cdc.gov/hrqol/index.htm">14 or more days</a> of poor physical health has been validated by the Centers for Disease Control and Prevention as constituting a substantial level of physical impairment. Frequent physical distress is associated with <a href="https://doi.org/10.1186/s12963-017-0133-5">chronic health conditions</a>, such as diabetes, hypertension and <a href="https://dx.doi.org/10.2147%2FCOPD.S194018">chronic obstructive pulmonary disease</a>. It is also <a href="http://www.doi.org/10.1186/s12963-017-0133-5">associated with</a> smoking, obesity and physical inactivity.&nbsp;

Those who have served have a <a href="https://www.americashealthrankings.org/explore/health-of-those-who-have-served/measure/function_impairment/state/ALL">higher</a> prevalence of frequent physical distress than those who have not served. Veterans who reported multiple chronic illnesses, smoking or physical disabilities such as spinal cord injury had <a href="https://doi.org/10.1038/sc.2008.2">higher odds</a> of reporting frequent physical distress. Another <a href="https://pubmed.ncbi.nlm.nih.gov/14680052/">study</a> found that active duty military personnel were more likely to report 14 or more days of pain and activity limitation within one month than men without military service. Carrying heavy loads, long periods of sitting or crouching, and traumatic or overuse injuries during combat are aspects of military service that may be risk factors for frequent physical distress.
 <h2>Who is affected?</h2>

The <a href="https://www.americashealthrankings.org/explore/health-of-those-who-have-served/measure/function_impairment/state/ALL">prevalence</a> of frequent physical distress among those who have served is higher in:

<ul>
	<li>Females than males.</li>
	<li>Those ages 50 and older compared with those who are younger; the prevalence of frequent physical distress increases with each increase in age group.</li>
	<li>American Indian/Alaska Native adults than adults of other racial/ethnic groups; American Indian/Alaska Native adults have a prevalence more than two times higher than Asian adults.&nbsp;</li>
	<li>Adults with an annual household income below $50,000 than those with higher levels of income; the prevalence of frequent physical distress increases with each decrease in income level.</li>
	<li>Adults with less than a high school education have a prevalence nearly three times higher than college graduates; the prevalence of frequent physical distress increases with each decrease in education level.</li>
</ul>
 <h2>What works?</h2>

Strategies to reduce the prevalence of frequent physical distress include reducing the risk of developing <a href="https://www.cdc.gov/mmwr/volumes/66/ss/ss6616a1.htm">chronic conditions</a> such as cardiovascular disease, cancer, diabetes, obesity and arthritis. This may be done by focusing on evidence-based interventions that curb <a href="https://www.cdc.gov/tobacco/data_statistics/fact_sheets/cessation/quitting/index.htm">smoking</a>, increase <a href="https://www.cdc.gov/physicalactivity/activepeoplehealthynation/creating-an-active-america.html">physical activity</a> and promote <a href="https://www.cdc.gov/obesity/downloads/fandv_2011_web_tag508.pdf">healthy eating</a>.
 <h2>References</h2>

Barrett, Drue H., et al. &ldquo;Health-Related Quality of Life of U.S. Military Personnel: A Population-Based Study.&rdquo; Military Medicine, vol. 168, no. 11, Nov. 2003, pp. 941&ndash;47. PMID: <a href="https://europepmc.org/article/med/14680052">14680052</a>.&nbsp;

Dwyer-Lindgren, Laura, et al. &ldquo;Self-Reported General Health, Physical Distress, Mental Distress, and Activity Limitation by US County, 1995-2012.&rdquo; Population Health Metrics, vol. 15, no. 1, Apr. 2017, p. 16. BioMed Central, doi:<a href="https://doi.org/10.1186/s12963-017-0133-5">10.1186/s12963-017-0133-5</a>.

Gamble, Sonya, et al. &ldquo;Surveillance for Certain Health Behaviors and Conditions Among States and Selected Local Areas &mdash; Behavioral Risk Factor Surveillance System, United States, 2013 and 2014.&rdquo; MMWR. Surveillance Summaries, vol. 66, no. 16, Sept. 2017, pp. 1&ndash;144. DOI.org (Crossref), doi:<a href="https://doi.org/10.15585/mmwr.ss6616a1">10.15585/mmwr.ss6616a1</a>.

Smith, B. M., et al. &ldquo;Health-Related Quality of Life for Veterans with Spinal Cord Injury.&rdquo; Spinal Cord, vol. 46, no. 7, 7, Nature Publishing Group, July 2008, pp. 507&ndash;12. www.nature.com, doi:<a href="https://doi.org/10.1038/sc.2008.2">10.1038/sc.2008.2</a>.

Stellefson, Michael, et al. &ldquo;Risk Factors Associated with Physical and Mental Distress in People Who Report a COPD Diagnosis: Latent Class Analysis of 2016 Behavioral Risk Factor Surveillance System Data.&rdquo; International Journal of Chronic Obstructive Pulmonary Disease, vol. Volume 14, Apr. 2019, pp. 809&ndash;22. DOI.org (Crossref), doi:<a href="https://doi.org/10.2147/COPD.S194018">10.2147/COPD.S194018</a>.

Percentage of adults who have served who reported being limited in any way in any activities because of physical, mental, or emotional problems or have any health problem that requires them to use special equipment, such as a cane, a wheelchair, a spec

Percentage of adults who have served who reported being told by a health professional that they had a heart attack (myocardial infarction)

Percentage of adults who have served who reported that their health is very good or excellent

<h2>Why does this matter?</h2>

Self-reported <a href="https://www.healthypeople.gov/2020/about/foundation-health-measures/General-Health-Status#selfAssessed">health status</a> is a measure of how individuals perceive their health and is used as an <a href="https://doi.org/10.1093/ije/dym236">indicator</a> of a population&rsquo;s health. It is a <a href="https://www.healthypeople.gov/2020/about/foundation-health-measures/General-Health-Status#selfAssessed">subjective measure</a> of <a href="https://doi.org/10.1093/ije/dym236">health-related quality of life</a> and is not limited to certain health conditions or outcomes but instead is influenced by life experiences, the health of others in a person&rsquo;s life, support from family and friends, as well as other factors affecting well-being.

Research shows that those with a high self-reported health status (i.e. excellent or very good) have <a href="https://doi.org/10.1111/j.1525-1497.2005.00291.x">lower rates of mortality</a> from <a href="https://doi.org/10.1111/j.1475-6773.2005.00404.x">all causes</a> than those with a low self-reported health status (i.e. fair or poor). The association between health status and mortality makes this measure a <a href="https://doi.org/10.1093/ije/dym236">good predictor</a> of future mortality rates and future use of health care.

 
Veteran populations who report low health status also <a href="https://www.cdc.gov/nchs/products/databriefs/db101.htm">frequently report</a> having multiple chronic diseases like diabetes, cancer and heart disease. Non-health factors like <a href="https://doi.org/10.1111/j.1525-1497.2006.00373.x">social support</a> and <a href="https://doi.org/10.1080/03630242.2011.641713">financial barriers</a> to accessing care also correlate with lower health status in veterans.
 <h2>Who is affected?</h2>

The prevalence of high health status among veterans is higher in:

<ul>
	<li><a href="https://doi.org/10.1016/j.amepre.2019.10.016">Officers</a> compared with enlisted personnel.</li>
	<li>Those with an annual household <a href="http://dx.doi.org/10.5888/pcd9.110138">income of $50,000 or more</a> compared with those with an income less than $50,000.&nbsp;</li>
	<li>Members that were not deployed to a <a href="https://doi.org/10.1016/j.amepre.2019.10.016">war zone</a> compared with members who were deployed.</li>
	<li>Men <a href="https://doi.org/10.1016/j.amepre.2019.10.016">compared</a> with women.</li>
	<li>Hispanics compared with <a href="http://dx.doi.org/10.5888/pcd9.110138">non-Hispanic white members</a>; <a href="http://dx.doi.org/10.5888/pcd9.110138">American Indian/Alaskan Natives</a> had the lowest prevalence of high health status of any racial/ethnic group.</li>
</ul>
 <h2>What works?</h2>

Better self-reported health status is<a href="http://www.npc.umich.edu/publications/policy_briefs/brief9/"> associated with</a> higher educational attainment regardless of age, gender or race. An additional four years of education reduces the probability of reporting fair or poor health status by<a href="http://www.npc.umich.edu/publications/workingpaper06/paper19/working-paper06-19.pdf#page=5"> 6 percentage points</a>. This is due, in part, to those with<a href="http://www.npc.umich.edu/publications/policy_briefs/brief9/"> higher education</a> suffering from fewer<a href="https://doi.org/10.1007/s00148-012-0429-5"> chronic conditions</a>.

Female veterans facing financial barriers <a href="https://doi.org/10.1080/03630242.2011.641713">report</a> lower health status, indicating the need for policy makers to use new health care delivery tools, such as <a href="https://doi.org/10.1016/j.ypmed.2014.06.017">health information technologies</a>, to improve health care and reduce barriers to high quality care. Due to the low prevalence of high health status among enlisted members and war zone deployed personnel, interventions should be geared towards <a href="https://doi.org/10.1016/j.amepre.2019.10.016">increasing support</a> for these groups during enlistment and after service has ended.
 <h2>References</h2>

Bauer, Amy M., et al. &ldquo;Aligning Health Information Technologies with Effective Service Delivery Models to Improve Chronic Disease Care.&rdquo; Preventive Medicine, vol. 66, Sept. 2014, pp. 167&ndash;72. DOI.org (Crossref), doi:<a href="https://doi.org/10.1016/j.ypmed.2014.06.017">10.1016/j.ypmed.2014.06.017</a>.

Brown, Derek S., et al. &ldquo;Associations Between Health-Related Quality of Life and Mortality in Older Adults.&rdquo; Prevention Science, vol. 16, no. 1, Jan. 2015, pp. 21&ndash;30. Springer Link, doi:<a href="https://doi.org/10.1007/s11121-013-0437-z">10.1007/s11121-013-0437-z</a>.

DeSalvo, Karen B., Nicole Bloser, et al. &ldquo;Mortality Prediction with a Single General Self-Rated Health Question.&rdquo; Journal of General Internal Medicine, vol. 21, no. 3, Mar. 2006, p. 267, doi:<a href="https://doi.org/10.1111/j.1525-1497.2005.00291.x">10.1111/j.1525-1497.2005.00291.x</a>.

DeSalvo, Karen B., Vincent S. Fan, et al. &ldquo;Predicting Mortality and Healthcare Utilization with a Single Question.&rdquo; Health Services Research, vol. 40, no. 4, 2005, pp. 1234&ndash;46. Wiley Online Library, doi:<a href="https://doi.org/10.1111/j.1475-6773.2005.00404.x">10.1111/j.1475-6773.2005.00404.x</a>.

Frayne, Susan M., et al. &ldquo;Health Status among 28,000 Women Veterans: The VA Women&rsquo;s Health Program Evaluation Project.&rdquo; Journal of General Internal Medicine, vol. 21, no. S3, Mar. 2006, pp. S40&ndash;46. DOI.org (Crossref), doi:<a href="https://doi.org/10.1111/j.1525-1497.2006.00373.x">10.1111/j.1525-1497.2006.00373.x</a>.

Lansford, Jennifer E., et al. &ldquo;A Public Health Perspective on School Dropout and Adult Outcomes: A Prospective Study of Risk and Protective Factors From Age 5 to 27 Years.&rdquo; J Adolesc Health, vol. 58, no. 6, June 2016, pp. 652&ndash;58, doi:<a href="https://doi.org/10.1016/j.jadohealth.2016.01.014">10.1016/j.jadohealth.2016.01.014</a>.

Luncheon, C., and M. Zack. &ldquo;Health-Related Quality of Life Among US Veterans and Civilians by Race and Ethnicity.&rdquo; Preventing Chronic Disease, May 2012. DOI.org (Crossref), doi:<a href="https://doi.org/10.5888/pcd9.110138">10.5888/pcd9.110138</a>.

Lundborg, Petter. &ldquo;The Health Returns to Schooling&mdash;What Can We Learn from Twins?&rdquo; Journal of Population Economics, vol. 26, no. 2, 2012, pp. 673&ndash;701, doi:<a href="https://doi.org/10.1007/s00148-012-0429-5">10.1007/s00148-012-0429-5</a>.

Peerson, A., and M. Saunders. &ldquo;Health Literacy Revisited: What Do We Mean and Why Does It Matter?&rdquo; Health Promot Int, vol. 24, no. 3, Sept. 2009, pp. 285&ndash;96, doi:<a href="https://doi.org/10.1093/heapro/dap014">10.1093/heapro/dap014</a>.

Quesnel&ndash;Vall&eacute;e, Am&eacute;lie. &ldquo;Self-Rated Health: Caught in the Crossfire of the Quest for &lsquo;True&rsquo; Health?&rdquo; International Journal of Epidemiology, vol. 36, no. 6, Oxford Academic, Dec. 2007, pp. 1161&ndash;64. academic.oup.com, doi:<a href="https://doi.org/10.1093/ije/dym236">10.1093/ije/dym236</a>.

Shen, Chan, and Usha Sambamoorthi. &ldquo;Associations Between Health-Related Quality of Life and Financial Barriers to Care Among Women Veterans and Women Non-Veterans.&rdquo; Women &amp; Health, vol. 52, no. 1, Feb. 2012, pp. 1&ndash;17. DOI.org (Crossref), doi:<a href="https://doi.org/10.1080/03630242.2011.641713">10.1080/03630242.2011.641713</a>.

Vogt, Dawne S., et al. &ldquo;U.S. Military Veterans&rsquo; Health and Well-Being in the First Year After Service.&rdquo; American Journal of Preventive Medicine, vol. 58, no. 3, Mar. 2020, pp. 352&ndash;60. DOI.org (Crossref), doi:<a href="https://doi.org/10.1016/j.amepre.2019.10.016">10.1016/j.amepre.2019.10.016</a>.

Percentage of adults who have served who reported being told by a health professional that they had a stroke

Percentage of adults who have served who reported having six or more permanent teeth extracted due to tooth decay or gum disease

<h2>Why does this matter?</h2>

<a href="https://www.nidcr.nih.gov/DataStatistics/SurgeonGeneral/Documents/hck1ocv.@www.surgeon.fullrpt.pdf">Extraction of teeth</a> due to disease is associated with poor health and a high rate of <a href="https://doi.org/10.1097/00005650-200308000-00007">teeth retention</a> can indicate access to quality dental care services. Limited access to <a href="https://www.nidcr.nih.gov/DataStatistics/SurgeonGeneral/Documents/hck1ocv.@www.surgeon.fullrpt.pdf">preventive</a> dental and primary care due to geographic, financial or other factors increases the likelihood of using <a href="https://doi.org/10.2105/AJPH.2014.302398">emergency departments</a> for oral health care which may lead to teeth extractions. <a href="http://www.ada.org/~/media/ADA/Public%20Programs/Files/bringing-disease-prevention-to-communities_adh.ashx">Periodontal disease</a>, also known as gum disease, is the most common cause of tooth loss among adults. Among adults ages 45 and older, advanced gum disease resulting in tooth loss was associated with the development of <a href="https://doi.org/10.1111/jgs.14944">dementia</a>, and loss of six or more teeth is associated with increased self-reported prevalence of <a href="https://doi.org/10.1016/j.amepre.2005.07.006">heart disease</a>. In 2000, the Surgeon General <a href="https://www.nidcr.nih.gov/sites/default/files/2017-10/hck1ocv.%40www.surgeon.fullrpt.pdf#page=25">noted</a> that many systemic diseases have an oral component and tooth loss can also impact verbal and nonverbal communication, social interaction and intimacy from loss of self-esteem. These limitations can have long lasting <a href="https://www.nidcr.nih.gov/sites/default/files/2017-10/hck1ocv.%40www.surgeon.fullrpt.pdf#page=31">impacts</a> on marital, educational and career opportunities.

A <a href="https://doi.org/10.1111/jphd.12292">study</a> of data from the Department of Veteran&rsquo;s Affairs (VA) found a high prevalence of dental caries which led to some teeth extractions among dental patients.
 <h2>Who is affected?</h2>

The <a href="https://www.americashealthrankings.org/explore/health-of-those-who-have-served/measure/teeth_extractions/state/ALL">prevalence</a> of teeth extractions among those who have served is higher in:

<ul>
	<li>Males than females.</li>
	<li>Adults ages 50 and older, who have a prevalence nearly 13 times higher compared with adults ages 26-34; the prevalence increases with each increase in age group.</li>
	<li>American Indian/Alaska native adults compared with all other racial and ethnic groups, who have a prevalence more than two times higher than Asian adults.</li>
	<li>Adults with less than a high school education, who have a prevalence more than three times higher than adults with a college degree; the prevalence increases with each decrease in education level.</li>
	<li>Adults with an annual household income less than $25,000, who have a prevalence three times higher than those with an income of $75,000 or more; the prevalence increases with each decrease in income level.</li>
</ul>
 <h2>What works?</h2>

Service members are <a href="https://www.navy.mil/submit/display.asp?story_id=66542">encouraged</a> to maintain good oral hygiene to reduce the risk of developing oral diseases that can lead to emergency dental care such as teeth extractions. The Department of <a href="https://www.va.gov/dental/">Veterans Affairs</a> (VA) provides comprehensive dental care for qualifying veterans. Adults who have served can check their <a href="https://www.va.gov/health-care/about-va-health-benefits/dental-care/">eligibility</a> for some or all of their dental health coverage. Access to the VA dental services can be limited due to <a href="https://pubmed.ncbi.nlm.nih.gov/31409719/">strict</a> eligibility criteria, however, congress has recently implemented some <a href="https://www.federalregister.gov/documents/2019/12/13/2019-26901/pilot-program-for-dental-health-care-access">pilot initiatives</a> to increase access to dental care by removing <a href="https://www.govinfo.gov/content/pkg/USCODE-2018-title38/html/USCODE-2018-title38-partII-chap17-subchapII-sec1712.htm">restrictions</a> that previously excluded some veterans from dental coverage.&nbsp;&nbsp;

Some organizations that provide dental care to veterans include:

<ul>
	<li>Everyone for Veterans (<a href="https://www.everyoneforveterans.org/">E4V</a>) connects veterans to various services including <a href="https://www.ada.org/en/publications/ada-news/2019-archive/march/program-to-help-combat-veterans-receive-free-oral-care-expanding-throughout-nation">dental care</a> options.&nbsp;</li>
	<li>Donated Dental Services (<a href="https://dentallifeline.org/dds/donated-dental-services-dds-provides-free-dental-veterans/">DDS</a>) provides donated dental services to veterans who may not be covered by the VA.</li>
</ul>
 <h2>References</h2>

Jones, Judith A., et al. &ldquo;Tooth Retention as an Indicator of Quality Dental Care: Development of a Risk Adjustment Model.&rdquo; Medical Care, vol. 41, no. 8, Aug. 2003, pp. 937&ndash;949. <a href="https://journals.lww.com/lww-medicalcare/Abstract/2003/08000/Tooth_Retention_as_an_Indicator_of_Quality_Dental.7.aspx">Report</a>.

Jurasic, M. Marianne, et al. &ldquo;Caries Prevalence and Associations with Medications and Medical Comorbidities.&rdquo; Journal of Public Health Dentistry, vol. 79, no. 1, Dec. 2019, pp. 34&ndash;43. DOI.org (Crossref), doi:<a href="https://doi.org/10.1111/jphd.12292">10.1111/jphd.12292</a>.

Lee, Ya-Ling, et al. &ldquo;Periodontal Disease Associated with Higher Risk of Dementia: Population-Based Cohort Study in Taiwan.&rdquo; Journal of the American Geriatrics Society, vol. 65, no. 9, Sept. 2017, pp. 1975&ndash;80. DOI.org (Crossref), doi:<a href="https://doi.org/10.1111/jgs.14944">10.1111/jgs.14944</a>.

Nieto, Valerie, et al. &ldquo;Attitudes and Access Patterns of Michigan Veterans Ineligible for Oral Healthcare Benefits: A Cross-Sectional Study.&rdquo; Journal of Dental Hygiene: JDH, vol. 93, no. 4, Aug. 2019, pp. 6&ndash;13. PMID: <a href="https://pubmed.ncbi.nlm.nih.gov/31409719/">31409719</a>

Okoro, Catherine A., et al. &ldquo;Tooth Loss and Heart Disease.&rdquo; American Journal of Preventive Medicine, vol. 29, no. 5, Dec. 2005, pp. 50&ndash;56. DOI.org (Crossref), doi:<a href="https://doi.org/10.1016/j.amepre.2005.07.006">10.1016/j.amepre.2005.07.006</a>.

Sun, Benjamin C., et al. &ldquo;Emergency Department Visits for Nontraumatic Dental Problems: A Mixed-Methods Study.&rdquo; American Journal of Public Health, vol. 105, no. 5, May 2015, pp. 947&ndash;55. DOI.org (Crossref), doi:<a href="https://doi.org/10.2105/AJPH.2014.302398">10.2105/AJPH.2014.302398</a>.

Surgeon General&rsquo;s Report on Oral Health in America | Data &amp; Statistics | National Institute of Dental and Craniofacial Research. www.nidcr.nih.gov,&nbsp;<a href="https://www.nidcr.nih.gov/research/data-statistics/surgeon-general">Report</a>.

Percentage of adults who have served who reported ever being told by a health professional that they have an anxiety disorder

Percentage of adults who have served who reported having serious, moderate, or mild mental illness in the past year

<h2>Why does this matter?</h2>

People who have a <a href="https://www.ncbi.nlm.nih.gov/books/NBK92254/">mental illness</a> experience patterns of mood, thoughts or behaviors that result in emotional distress or challenges with daily functioning. Mental illnesses <a href="https://www.who.int/mental_health/management/en/">range</a> in severity from mild, occasional symptoms to debilitating impairments that can lead to persistent disability and premature death from chronic disease or suicide. The most common mental illnesses among adults in the United States are <a href="https://adaa.org/about-adaa/press-room/facts-statistics">anxiety disorders and depression</a>.&nbsp;

Among veterans, post-traumatic stress disorder (PTSD) is highly prevalent and of paramount concern. According to one <a href="https://doi.org/10.2105/AJPH.2008.150284">study</a>, lifetime prevalence of PTSD among Vietnam-era veterans was 30.9% for men and 26.9% for women. Certain experiences associated with military service may predispose people who have served to developing mental illness. These include combat exposures, such as traumatic physical injuries or witnessing upsetting events, as well as military sexual trauma. <a href="https://doi.org/10.1016/j.neulet.2019.134294">Traumatic brain injuries</a> sustained during deployments in war zones are associated with chronic mental illness including <a href="https://dx.doi.org/10.1016%2Fj.psc.2013.11.005">anxiety disorder and depression</a>, PTSD and <a href="https://doi.org/10.1016/j.copsyc.2017.08.030">suicidal ideations</a>.&nbsp;&nbsp;&nbsp;

Mental health disorders were one of the&nbsp; most expensive health conditions in the United States costing an estimated <a href="https://doi.org/10.1377/hlthaff.2015.1659">$201 billion</a> in 2013.
 <h2>Who is affected?</h2>

The <a href="https://www.americashealthrankings.org/explore/health-of-those-who-have-served/measure/mental_illness/state/ALL">prevalence</a> of mental illness among those who have served is higher in:

<ul>
	<li>Females, who have a prevalence nearly twice as high as males.</li>
	<li>Adults ages 18-50 than adults ages 50 and older.</li>
	<li>Adults with an annual household income less than $30,000 than those with higher levels of income; the prevalence of mental illness increases with each decrease in income level.</li>
</ul>
 <h2>What works?</h2>

Effective early interventions for mental illness prevention among veterans <a href="https://doi.org/10.1016/j.cpr.2012.09.002">include</a>:&nbsp;

<ul>
	<li>Improving early <a href="https://dx.doi.org/10.1007%2Fs11606-011-1849-8">access</a> to the Veteran Affairs (VA) <a href="https://www.ncbi.nlm.nih.gov/books/NBK499499/">mental healthcare services</a> since the rate of suicide is greatest in the <a href="https://www.publichealth.va.gov/epidemiology/studies/suicide-risk-death-risk-recent-veterans.asp">first three years</a> after leaving the military. In 2018, more than <a href="https://www.research.va.gov/topics/mental_health.cfm">1.7 million veterans</a> received treatment in a Veteran Affairs mental health specialty program.&nbsp;</li>
	<li>Integrating clinicians into medical and military contexts.</li>
	<li>Reducing stigma associated with seeking treatment by reframing conversations around mental health.</li>
	<li>Preventive interventions such as <a href="https://doi.org/10.7205/MILMED-D-16-00311">Combat Stress Control Treatment</a>, <a href="https://usamrd-w.amedd.army.mil/assets/docs/publications/adler_et_al_2007_report_2007-001_battlemind_procedures.pdf">psychological debriefing</a> and <a href="https://doi.org/10.1016/j.jsams.2018.05.005">resiliency training</a>.&nbsp;</li>
	<li>Use of technological advances such as <a href="https://dx.doi.org/10.1080%2F20008198.2019.1654782">virtual reality exposure therapy</a> and telehealth service delivery. For example, <a href="https://www.vetsprevail.org/">Vetsprevail</a> is a convenient online resource provided by the VA that offers clinical assessments, peer-to-peer support and referrals to in-person mental health care.&nbsp;</li>
</ul>

The Centers for Disease Control and Prevention has a general <a href="https://www.cdc.gov/mentalhealth/tools-resources/index.htm">resources</a> page for mental health including a mental health services locator.
 <h2>References</h2>

Dreer, Laura E., et al. &ldquo;Suicide and Traumatic Brain Injury: A Review by Clinical Researchers from the National Institute for Disability and Independent Living Rehabilitation Research (NIDILRR) and Veterans Health Administration Traumatic Brain Injury Model Systems.&rdquo; Current Opinion in Psychology, vol. 22, Aug. 2018, pp. 73&ndash;78. ScienceDirect, doi:<a href="https://doi.org/10.1016/j.copsyc.2017.08.030">10.1016/j.copsyc.2017.08.030</a>.

Elder, Gregory A., et al. &ldquo;Relationship of Traumatic Brain Injury to Chronic Mental Health Problems and Dementia in Military Veterans.&rdquo; Neuroscience Letters, vol. 707, Aug. 2019, p. 134294. ScienceDirect, doi:<a href="https://doi.org/10.1016/j.neulet.2019.134294">10.1016/j.neulet.2019.134294</a>.

Kothgassner, Oswald D., et al. &ldquo;Virtual Reality Exposure Therapy for Posttraumatic Stress Disorder (PTSD): A Meta-Analysis.&rdquo; European Journal of Psychotraumatology, vol. 10, no. 1, Dec. 2019, p. 1654782. doi:<a href="https://doi.org/10.1080/20008198.2019.1654782">10.1080/20008198.2019.1654782</a>.

Health (UK), National Collaborating Centre for Mental. &ldquo;COMMON MENTAL HEALTH DISORDERS.&rdquo; Common Mental Health Disorders: Identification and Pathways to Care, British Psychological Society, 2011. <a href="https://www.ncbi.nlm.nih.gov/books/NBK92254/">Report</a>.

Jorge, Ricardo E., and David B. Arciniegas. &ldquo;Mood Disorders After TBI.&rdquo; Psychiatric Clinics of North America, vol. 37, no. 1, Mar. 2014, pp. 13&ndash;29. ScienceDirect, doi:<a href="https://doi.org/10.1016/j.psc.2013.11.005">10.1016/j.psc.2013.11.005</a>.

Judkins, Jason L., and Devvon L. Bradley. &ldquo;A Review of the Effectiveness of a Combat and Operational Stress Control Restoration Center in Afghanistan.&rdquo; Military Medicine, vol. 182, no. 7, Oxford Academic, July 2017, pp. e1755&ndash;62. academic.oup.com, doi:<a href="https://doi.org/10.7205/MILMED-D-16-00311">10.7205/MILMED-D-16-00311</a>.

Kehle, Shannon M., et al. &ldquo;Interventions to Improve Veterans&rsquo; Access to Care: A Systematic Review of the Literature.&rdquo; Journal of General Internal Medicine, vol. 26, no. 2, Oct. 2011, p. 689. Springer Link, doi:<a href="https://doi.org/10.1007/s11606-011-1849-8">10.1007/s11606-011-1849-8</a>.

National Academies of Sciences, Engineering, et al. &ldquo;The Veterans Health Administration&rsquo;s Mental Health Services.&rdquo; Evaluation of the Department of Veterans Affairs Mental Health Services, National Academies Press (US), 2018. <a href="https://www.ncbi.nlm.nih.gov/books/NBK499499/">Report</a>.

Nindl, Bradley C., et al. &ldquo;Perspectives on Resilience for Military Readiness and Preparedness: Report of an International Military Physiology Roundtable.&rdquo; Journal of Science and Medicine in Sport, vol. 21, no. 11, Elsevier, Nov. 2018, pp. 1116&ndash;24. doi:<a href="https://doi.org/10.1016/j.jsams.2018.05.005">10.1016/j.jsams.2018.05.005</a>.

Roehrig, Charles. &ldquo;Mental Disorders Top The List Of The Most Costly Conditions In The United States: $201 Billion.&rdquo; Health Affairs, vol. 35, no. 6, Health Affairs, June 2016, pp. 1130&ndash;35. doi:<a href="https://doi.org/10.1377/hlthaff.2015.1659">10.1377/hlthaff.2015.1659</a>.

Seal, Karen H., et al. &ldquo;Trends and Risk Factors for Mental Health Diagnoses Among Iraq and Afghanistan Veterans Using Department of Veterans Affairs Health Care, 2002&ndash;2008.&rdquo; American Journal of Public Health, vol. 99, no. 9, American Public Health Association, Sept. 2009, pp. 1651&ndash;58. doi:<a href="https://doi.org/10.2105/AJPH.2008.150284">10.2105/AJPH.2008.150284</a>.

Zinzow, Heidi M., et al. &ldquo;Connecting Active Duty and Returning Veterans to Mental Health Treatment: Interventions and Treatment Adaptations That May Reduce Barriers to Care.&rdquo; Clinical Psychology Review, vol. 32, no. 8, Dec. 2012, pp. 741&ndash;53. ScienceDirect, doi:<a href="https://doi.org/10.1016/j.cpr.2012.09.002">10.1016/j.cpr.2012.09.002</a>.

Percentage of adults who have served who reported being told by a health professional that they had angina or coronary heart disease; a heart attack or myocardial infarction; or a stroke

<h2>Why does this matter?</h2>

Cardiovascular diseases are medical outcomes that decrease the heart&#39;s ability to meet the <a href="https://www.health.harvard.edu/blog/how-does-cardiovascular-disease-increase-the-risk-of-severe-illness-and-death-from-covid-19-2020040219401">demands</a> of the body during some illnesses. People who have serious heart conditions, including heart failure, congenital heart disease, coronary artery disease, cardiomyopathy or pulmonary hypertension,&nbsp;are at <a href="https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/groups-at-higher-risk.html">higher risk</a> of severe illness from coronavirus disease (COVID-19). For more information about COVID-19 see the Centers for Disease Control and Prevention <a href="https://www.cdc.gov/coronavirus/2019-nCoV/index.html">website</a>.&nbsp;

Cardiovascular diseases are the<a href="https://www.nhlbi.nih.gov/health-topics/coronary-heart-disease"> leading cause of death</a> in the United States. Cardiovascular disease refers to a number of <a href="https://www.heart.org/en/health-topics/consumer-healthcare/what-is-cardiovascular-disease">conditions</a> of the heart and blood vessels including coronary artery disease, chest pain, heart attack and stroke. While coronary artery disease frequently has no symptoms, it can restrict the flow of blood to the heart resulting in<a href="https://www.heart.org/en/health-topics/heart-attack/angina-chest-pain"> chest pain</a> and more severely, <a href="https://www.cdc.gov/heartdisease/heart_attack.htm">heart attack</a>. Additionally, individuals with coronary artery disease are at a greater risk of <a href="https://www.doi.org/10.1001/jama.1983.03340210040022">stroke</a> compared with individuals without coronary artery disease.

Veterans report <a href="https://doi.org/10.3122/jabfm.2019.01.180148">higher rates</a> of cardiovascular diseases &mdash; in general and at younger ages &mdash; compared with non-veterans. <a href="https://www.ncbi.nlm.nih.gov/pubmed/25013689">Studies</a> document that veterans have nearly twice the risk of developing heart disease as non-veterans, even after controlling for socioeconomic status, behaviors, body mass index and depressive symptoms. Combat <a href="https://doi.org/10.1161/circulationaha.113.005407">deployment</a> and <a href="https://doi.org/10.1161/CIRCOUTCOMES.119.005563">multiple mental illnesses</a> such as depression, anxiety and <a href="https://doi.org/10.1097/crd.0b013e318265343b">post-traumatic stress disorder</a> put veterans at an even greater risk for cardiovascular diseases. Combat deployers have almost <a href="https://doi.org/10.1161/circulationaha.113.005407">twice the odds</a> of new onset coronary heart disease diagnosis compared to non-combat deployers.&nbsp; Exposure to the Vietnam-era herbicide <a href="https://www.publichealth.va.gov/exposures/agentorange/conditions/ischemicheartdisease.asp">Agent Orange</a> may also elevate the risk of heart attacks.&nbsp;

In 2014-2015 the direct and indirect costs of cardiovascular diseases and strokes totaled approximately<a href="https://www.doi.org/10.1161/CIR.0000000000000659"> $351.2 billion</a>, around 14% of all U.S. health expenditures. Coronary artery disease and other heart diseases were the costliest conditions, accounting for<a href="https://www.doi.org/10.1161/CIR.0000000000000659"> $218.7 billion</a>. Strokes accounted for another<a href="https://www.doi.org/10.1161/CIR.0000000000000659"> $45.5 billion</a> in direct and indirect costs.
 <h2>Why does this matter?</h2>

Many risk factors for<a href="https://www.mayoclinic.org/diseases-conditions/coronary-artery-disease/symptoms-causes/syc-20350613"> coronary artery disease</a>,<a href="https://www.heart.org/en/health-topics/heart-attack/understand-your-risks-to-prevent-a-heart-attack"> heart attack</a> and<a href="https://www.nhlbi.nih.gov/health-topics/stroke"> stroke</a> are the same, including high blood pressure, high cholesterol, obesity, physical inactivity, unhealthy diet, diabetes, smoking, excessive alcohol consumption, high levels of stress and a family history of heart disease or stroke. The <a href="https://www.americashealthrankings.org/explore/health-of-those-who-have-served/measure/CVD/state/ALL">prevalence</a> of cardiovascular disease among those who have served is higher in:

<ul>
	<li>Males than females.</li>
	<li>Adults ages 50 and older, who have a prevalence nearly twelve times higher than adults ages 18-34.</li>
	<li>American Indian/Alaska Native adults compared with all other racial and ethnic groups.</li>
	<li>Adults with an annual household income less than $25,000 than those with higher levels of income; adults with an income of $75,000 or more had the lowest prevalence of cardiovascular disease.</li>
	<li>Adults with less than a high school education than those with higher levels of education.</li>
</ul>
 <h2>What works?</h2>

Lifestyle changes, medicines and medical procedures can help prevent and/or treat cardiovascular diseases. An analysis of National Health and Nutrition Examination Survey data shows an estimated<a href="https://www.doi.org/10.1056/NEJMsa053935"> 44%</a> of the decline in heart disease deaths from 1980 to 2000 was attributable to increases in physical activity, reductions in smoking prevalence and lowering of cholesterol and blood pressure. Interventions that reduce risk factors such as<a href="https://www.healthypeople.gov/2020/topics-objectives/topic/nutrition-and-weight-status/ebrs"> high cholesterol</a>,<a href="https://www.healthypeople.gov/2020/topics-objectives/topic/tobacco-use/ebrs"> smoking</a> and<a href="https://www.healthypeople.gov/2020/topics-objectives/topic/physical-activity/ebrs"> physical inactivity</a> could<a href="https://www.aarp.org/health/conditions-treatments/info-2018/heart-attack-stroke-prevention.html"> prevent as much as 80%</a> of heart attacks and strokes.

The Office of Research and Development of the Veterans Affairs (VA) conducts <a href="https://www.research.va.gov/topics/cardio.cfm">multiple studies</a> to find better interventions to treat veterans with underlying cardiovascular risk factors and disease. The VA&rsquo;s <a href="https://doi.org/10.1001/jamacardio.2017.4843">Community Care Program</a> supplements care with community based medical services which has improved access to treatment and management of cardiovascular disease.

The American Heart Association has created<a href="http://www.heart.org/HEARTORG/Conditions/My-Life-Check---Lifes-Simple-7_UCM_471453_Article.jsp#.Wi7aTkqnGwA"> Life&rsquo;s Simple 7</a>, a tool for individuals to measure their heart health. It includes seven steps to improve heart health.
 <h2>References</h2>

Assari, Shervin. &ldquo;Veterans and Risk of Heart Disease in the United States: A Cohort with 20 Years of Follow Up.&rdquo; International Journal of Preventive Medicine, vol. 5, no. 6, June 2014, pp. 703&ndash;09. PMCID: <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/pmc4085922/">PMC4085922</a>

Barnett, Paul G., et al. &ldquo;Comparison of Accessibility, Cost, and Quality of Elective Coronary Revascularization Between Veterans Affairs and Community Care Hospitals.&rdquo; JAMA Cardiology, vol. 3, no. 2, American Medical Association, Feb. 2018, pp. 133&ndash;41. doi:<a href="https://doi.org/10.1001/jamacardio.2017.4843">10.1001/jamacardio.2017.4843</a>.

Benjamin Emelia J., et al. &ldquo;Heart Disease and Stroke Statistics&mdash;2019 Update: A Report From the American Heart Association.&rdquo; Circulation, vol. 139, no. 10, American Heart Association, Mar. 2019, pp. e56&ndash;528. ahajournals.org (Atypon), doi:<a href="https://doi.org/10.1161/CIR.0000000000000659">10.1161/CIR.0000000000000659</a>.

Crum-Cianflone Nancy F., et al. &ldquo;Impact of Combat Deployment and Posttraumatic Stress Disorder on Newly Reported Coronary Heart Disease Among US Active Duty and Reserve Forces.&rdquo; Circulation, vol. 129, no. 18, American Heart Association, May 2014, pp. 1813&ndash;20. ahajournals.org (Atypon), doi:<a href="https://doi.org/10.1161/CIRCULATIONAHA.113.005407">10.1161/CIRCULATIONAHA.113.005407</a>.

Ford, Earl S., et al. &ldquo;Explaining the Decrease in U.S. Deaths from Coronary Disease, 1980&ndash;2000.&rdquo; New England Journal of Medicine, vol. 356, no. 23, Massachusetts Medical Society, June 2007, pp. 2388&ndash;98. Taylor and Francis+NEJM, doi:<a href="https://doi.org/10.1056/NEJMsa053935">10.1056/NEJMsa053935</a>.

Hinojosa, Ramon. &ldquo;Veterans&rsquo; Likelihood of Reporting Cardiovascular Disease.&rdquo; The Journal of the American Board of Family Medicine, vol. 32, no. 1, American Board of Family Medicine, Jan. 2019, pp. 50&ndash;57. www.jabfm.org, doi:<a href="https://doi.org/10.3122/jabfm.2019.01.180148">10.3122/jabfm.2019.01.180148</a>.

Kannel, William B., et al. &ldquo;Manifestations of Coronary Disease Predisposing to Stroke: The Framingham Study.&rdquo; JAMA, vol. 250, no. 21, American Medical Association, Dec. 1983, pp. 2942&ndash;46. jamanetwork.com, doi:<a href="https://doi.org/10.1001/jama.1983.03340210040022">10.1001/jama.1983.03340210040022</a>.

Vance Mary C., et al. &ldquo;Increased Cardiovascular Disease Risk in Veterans With Mental Illness.&rdquo; Circulation: Cardiovascular Quality and Outcomes, vol. 12, no. 10, American Heart Association, Oct. 2019, p. e005563. ahajournals.org (Atypon), doi:<a href="https://doi.org/10.1161/CIRCOUTCOMES.119.005563">10.1161/CIRCOUTCOMES.119.005563</a>.

Wentworth, Bailey A., et al. &ldquo;Post-Traumatic Stress Disorder: A Fast Track to Premature Cardiovascular Disease?&rdquo; Cardiology in Review, vol. 21, no. 1, Feb. 2013, pp. 16&ndash;22. PubMed, doi:<a href="https://doi.org/10.1097/CRD.0b013e318265343b">10.1097/CRD.0b013e318265343b</a>.

Percentage of adults who have served who reported seriously thinking about killing themselves in the past year

<h2>Why does this matter?</h2>

Recognizing and treating suicidal thoughts is important for <a href="https://www.cdc.gov/violenceprevention/suicide/riskprotectivefactors.html">preventing deaths</a> by suicide. Nationally, for every 10 people who think about dying by suicide <a href="https://www.cdc.gov/violenceprevention/suicide/fastfact.html">one person attempts to die by suicide</a>. The U.S. suicide rate increased <a href="https://www.cdc.gov/vitalsigns/suicide/infographic.html#graphic1">25.4%</a> from 1999 to 2016, with increases occurring in every state, save for Nevada. In 2018, there were an estimated 1.4 million suicide attempts and more than <a href="https://afsp.org/about-suicide/suicide-statistics/">48,000 deaths by suicide</a>, making it the tenth leading cause of death in the United States. Veterans are <a href="https://www.mentalhealth.va.gov/docs/2016suicidedatareport.pdf#page=25">22% more likely</a> to die by suicide than civilians, and it is estimated that <a href="https://www.mentalhealth.va.gov/suicide_prevention/docs/Office-of-Mental-Health-and-Suicide-Prevention-National-Strategy-for-Preventing-Veterans-Suicide.pdf#page=10">20 veterans</a> die by suicide per day. Veterans are more likely to die by suicide using a <a href="https://www.veteranspolicy.org/analysis/2019/12/29/veterans-firearms-and-suicide">firearm</a>, the <a href="https://www.hsph.harvard.edu/means-matter/means-matter/case-fatality/">most lethal</a> method of suicide, compared with non-veterans.
 <h2>Who is affected?</h2>

There are <a href="https://www.doi.org/10.2105%2FAJPH.2015.302737">many risk factors</a> for death by suicide, and veterans are particularly at risk from conditions such as <a href="https://www.ptsd.va.gov/publications/rq_docs/V28N4.pdf">post-traumatic stress disorder</a> (PTSD), <a href="https://www.doi.org/10.1111/sltb.12482">depression</a>, <a href="https://www.hsrd.research.va.gov/research/abstracts.cfm?Project_ID=2141701170">multiple mental health disorders</a>, <a href="https://www.doi.org/10.1080/08995605.2011.590409">substance use disorder</a>, <a href="https://www.doi.org/10.3233/jad-181055">traumatic brain injuries</a>, having been deployed to a <a href="https://www.doi.org/10.4088/pcc.17m02118">combat scenario</a> and having <a href="https://www.veteranspolicy.org/analysis/2019/12/29/veterans-firearms-and-suicide">access to a firearm</a>. Transgender veterans have <a href="https://doi.org/10.1177%2F1745691618812680">twice the risk</a> of dying by suicide when compared to non-transgender veterans.

Among veterans, <a href="https://www.doi.org/10.2105%2FAJPH.2015.302737">males</a> have a higher rate of death by suicide compared with females, though the suicide rate among females has been <a href="https://www.mentalhealth.va.gov/docs/data-sheets/2019/2019_National_Veteran_Suicide_Prevention_Annual_Report_508.pdf#page=17">increasing alarmingly</a> since 2009.
 <h2>What works?</h2>

Deaths by suicide can be reduced through a number of effective strategies including:

<ul>
	<li><a href="http://doi.org/10.1176/appi.ps.201800445">Universal screening</a> at emergency rooms to identify patients at higher risk of suicide. All Department of Veterans Affairs (VA) health centers use <a href="https://www.hsrd.research.va.gov/for_researchers/cyber_seminars/archives/3527-notes.pdf">REACH VET</a> to screen for veterans at high risk for suicide and other adverse outcomes.&nbsp;&nbsp;</li>
	<li><a href="http://doi.org/10.1001/jamapsychiatry.2018.1776">Safety planning</a> at emergency rooms to assist patients already identified as being suicidal. Patients receive a prioritized list of evidence-based coping strategies and sources of support. This intervention also provides telephone follow-ups until the patient receives treatment.</li>
	<li><a href="https://www.sprc.org/resources-programs/cognitive-therapy-suicide-prevention">Cognitive-behavioral therapy</a> to identify suicidal thoughts, images and beliefs before they lead to a suicide attempt.</li>
	<li><a href="https://www.nimh.nih.gov/news/science-news/2016/adding-better-mental-health-care-to-primary-care.shtml">Collaborative care</a>, a team-based approach to suicide prevention, among the patient, their care manager and primary care provider to develop a treatment plan.</li>
	<li><a href="https://www.hsph.harvard.edu/means-matter/recommendations/families/">Reducing access to lethal means</a>, including access to firearms, lethal doses of medications and alcohol to prevent fatal suicide attempts. <a href="https://efsgv.org/lethal-means-safety-counseling/">Lethal means safety counseling</a> has been shown to help <a href="https://www.doi.org/10.1111/sltb.12618">reduce deaths by suicides</a> in veterans that own firearms. This is when a health care professional talks to an individual about how to <a href="https://www.veteranspolicy.org/analysis/2019/12/29/veterans-firearms-and-suicide">reduce their access</a> to dangerous items including firearms when having thoughts of suicide. Evidence from the past two decades shows a strong association between the <a href="https://doi.org/10.1186/2197-1714-1-6">presence of a firearm</a> in the home and an increased risk of suicide for the gun owner and the gun owner&rsquo;s spouse and children. At the community-level, the <a href="http://doi.org/10.1136/injuryprev-2018-042809">Gun Shop Project</a> builds partnership between firearms businesses and public health experts to provide firearm suicide prevention educational materials to firearms retailers, instructors and customers.</li>
</ul>

The VA has established the Veterans <a href="https://www.veteranscrisisline.net">Crisis Line</a> which can be reached at 1-800-273-8255 (1-800-273-TALK) for veterans or family members to call any time. For states, Native settings, colleges and universities, health systems, and organizations that serve populations at risk for suicide, the <a href="http://www.sprc.org/">Suicide Prevention Resource Center (SPRC)</a> has detailed resources for implementing effective suicide prevention in your community. Additionally, the <a href="https://suicidepreventionlifeline.org/">National Suicide Prevention Lifeline</a> is available around the clock for support and resources. <h2>References</h2>

Allchin, Adelyn, et al. &ldquo;Limiting Access to Lethal Means: Applying the Social Ecological Model for Firearm Suicide Prevention.&rdquo; Injury Prevention, vol. 25, no. Suppl 1, BMJ Publishing Group Ltd, Sept. 2019, pp. i44&ndash;48. injuryprevention.bmj.com, doi:<a href="https://doi.org/10.1136/injuryprev-2018-042809">10.1136/injuryprev-2018-042809</a>.

Ammerman, Brooke A., and Mark A. Reger. &ldquo;Evaluation of Prevention Efforts and Risk Factors Among Veteran Suicide Decedents Who Died by Firearm.&rdquo; Suicide and Life-Threatening Behavior, vol. 50, no. 3, 2020, pp. 679&ndash;87. Wiley Online Library, doi:<a href="https://doi.org/10.1111/sltb.12618">10.1111/sltb.12618</a>.

Black, Sandra A., et al. &ldquo;Prevalence and Risk Factors Associated With Suicides of Army Soldiers 2001&ndash;2009.&rdquo; Military Psychology, vol. 23, no. 4, Routledge, July 2011, pp. 433&ndash;51. Taylor and Francis+NEJM, doi:<a href="https://doi.org/10.1080/08995605.2011.590409">10.1080/08995605.2011.590409</a>.

Bullman, Tim, et al. &ldquo;Relative Importance of Posttraumatic Stress Disorder and Depression in Predicting Risk of Suicide among a Cohort of Vietnam Veterans.&rdquo; Suicide and Life-Threatening Behavior, vol. 49, no. 3, 2019, pp. 838&ndash;45. Wiley Online Library, doi:<a href="https://doi.org/10.1111/sltb.12482">10.1111/sltb.12482</a>.

Dunlap, Laura J., et al. &ldquo;Screening and Intervention for Suicide Prevention: A Cost-Effectiveness Analysis of the ED-SAFE Interventions.&rdquo; Psychiatric Services, vol. 70, no. 12, American Psychiatric Publishing, Aug. 2019, pp. 1082&ndash;87. ps.psychiatryonline.org (Atypon), doi:<a href="https://doi.org/10.1176/appi.ps.201800445">10.1176/appi.ps.201800445</a>.

McCarthy, John F., et al. &ldquo;Predictive Modeling and Concentration of the Risk of Suicide: Implications for Preventive Interventions in the US Department of Veterans Affairs.&rdquo; American Journal of Public Health, vol. 105, no. 9, American Public Health Association, June 2015, pp. 1935&ndash;42. ajph.aphapublications.org (Atypon), doi:<a href="https://doi.org/10.2105/AJPH.2015.302737">10.2105/AJPH.2015.302737</a>.

Opoliner, April, et al. &ldquo;Explaining Geographic Patterns of Suicide in the US: The Role of Firearms and Antidepressants.&rdquo; Injury Epidemiology, vol. 1, no. 1, Mar. 2014, p. 6. BioMed Central, doi:<a href="https://doi.org/10.1186/2197-1714-1-6">10.1186/2197-1714-1-6</a>.

Stanley, Barbara, et al. &ldquo;Comparison of the Safety Planning Intervention With Follow-up vs Usual Care of Suicidal Patients Treated in the Emergency Department.&rdquo; JAMA Psychiatry, vol. 75, no. 9, American Medical Association, Sept. 2018, pp. 894&ndash;900, doi:<a href="https://doi.org/10.1001/jamapsychiatry.2018.1776">10.1001/jamapsychiatry.2018.1776</a>.

Thomas, Melissa M., et al. &ldquo;Mental and Physical Health Conditions in US Combat Veterans: Results From the National Health and Resilience in Veterans Study.&rdquo; The Primary Care Companion For CNS Disorders, vol. 19, no. 3, June 2017. DOI.org (Crossref), doi:<a href="https://doi.org/10.4088/PCC.17m02118">10.4088/PCC.17m02118</a>.

Tucker, Raymond P. &ldquo;Suicide in Transgender Veterans: Prevalence, Prevention, and Implications of Current Policy.&rdquo; Perspectives on Psychological Science, vol. 14, no. 3, SAGE Publications Inc, Apr. 2019, pp. 452&ndash;68, doi:<a href="https://doi.org/10.1177/1745691618812680">10.1177/1745691618812680</a>.

Wadhawan, Abhishek, et al. &ldquo;Traumatic Brain Injury and Suicidal Behavior: A Review.&rdquo; Journal of Alzheimer&rsquo;s Disease, vol. 68, no. 4, IOS Press, 2019, pp. 1339&ndash;70, doi:<a href="https://doi.org/10.3233/JAD-181055">10.3233/JAD-181055</a>

Percentage of adults who have served with suicidal thoughts who tried to kill themselves in the past year

Percentage of adults who have not served who reported either binge drinking (four or more [females] or five or more [males] alcoholic beverages on a single occasion in the past 30 days) or heavy drinking (eight or more [females] or 15 or more [males] alcoholic beverages per week)

Percentage of adults who have not served who reported sleeping, on average, fewer than seven hours in a 24-hour period

Percentage of adults who have not served with a body mass index of 30.0 or higher based on reported height and weight

Percentage of adults who have not served who reported doing no physical activity or exercise other than their regular job in the past 30 days

Percentage of adults who have not served who reported smoking at least 100 cigarettes in their lifetime and currently smoke daily or some days

Percentage of adults who have not served who use chewing tobacco, snuff, or snus every day or some days

Percentage of adults who have not served who are in the workforce and are either employed for wages or self-employed

Percentage of adults who have not served who reported not having sufficient money to eat when and what they should, or being concerned that food would run out before they have money to buy more in the past 30 days

Percentage of adults who have not served who have health insurance privately, through their employer, or through the government

Percentage of adults ages 50-75 who have not served who reported receiving one or more of the recommended colorectal cancer screening tests within the recommended time interval

Percentage of adults ages 50-75 who have not served

Percentage of adults who have not served who reported visiting a dentist or dental clinic within the past year for any reason

Percentage of adults who have not served who reported receiving a flu vaccine in the past 12 months

Percentage of adults who have not served who reported having a personal doctor or health care provider

Percentage of adults who have not served who reported a time in the past 12 months when they needed to visit a doctor but could not because of cost

Percentage of adults who have not served experiencing mental illness in the past year who reported receiving any mental health treatment in the past 12 months or taking any prescription medications prescribed to treat a mental or emotional condition (excluding treatment for alcohol or drug use)

Percentage of adults who have not served who reported being told by a health professional that they have some form of arthritis

Percentage of adults who have not served who reported being told by a health professional that they had any form of cancer, skin or otherwise

Percentage of adults who have not served who reported being told by a health professional that they have chronic obstructive pulmonary disease (COPD)

Percentage of adults who have not served who reported being told by a health professional that they had angina or coronary heart disease

Percentage of adults who have not served who reported being told by a health professional that they have a depressive disorder, including depression, major depression, minor depression or dysthymia including depression, major depression, minor depression or dysthymia

Percentage of adults who have not served who reported being told by a health professional that they have diabetes (excluding pre-diabetes and gestational diabetes)

Percentage of adults who have not served who reported their mental health was not good 14 or more days in the past 30 days

Percentage of adults who have not served who reported their physical health was not good 14 or more days in the past 30 days 

Percentage of adults who have served who reported being limited in any way in any activities because of physical, mental, or emotional problems or have any health problem that requires them to use special equipment, such as a cane, a wheelchair, a special needs scooter

Percentage of adults who have not served who reported being told by a health professional that they had a heart attack (myocardial infarction)

Percentage of adults who have not served who reported that their health is very good or excellent

Percentage of adults who have not served who reported being told by a health professional that they had a stroke

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