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

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

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

This executive summary presents high-level findings across the broad HRBS topic areas and policy implications of key findings. The reserve component results are compared to the U.S. Department of Health and Human Services Healthy People 2020 (HP2020) goals for the general U.S. population and the active component results.

Because the military population differs significantly from the general population (e.g., military personnel are more likely to be young and male than the general population), the HP2020 comparisons are presented for interest only. It also suggests ways to improve future versions of the HRBS.

Main results

Health and disease prevention

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

• Among reservists, 31.4% (confidence interval [CI]: 30.2-32.5) were of normal weight according to body mass index (BMI) and 19.0% (CI: 18.1-20.0) were obese. Among reservists, obesity rates were lower than the population (31.4%) and the HP2020 target (30.5% or less).
• Reservists met or exceeded HP2020 goals for moderate physical activity, vigorous physical activity, and strength training.
• 71.6% (CI: 70.4-72.7) reported having had a periodic review in the past 12 months, which is not the current Army standard for annual reviews.
• 8.0% (CI: 7.2-8.9) did not have health insurance. This is lower than the HP2020 goal of 100% of the population being insured, but is comparable to the 8.5% of the population that is uninsured.
• 45.4% (CI: 44.2-46.6) met HP2020 guidelines for adequate sleep, and 10.4% (CI: 9.7-11.1) reported using over-the-counter or prescription sleep medications at least once a week in the past 30 days.
• For staying awake in the past 30 days, 11.4% (CI: 10.6-12.2) reported using energy drinks at least three times per week, 1.2% (CI: 0.9-1.5) reported using OTC drugs at least three times per week, and 2.0% (CI: 1.6-2.3) reported using prescription drugs at least three times per week.

Drug and Substance Use

The HRBS did also a survey to find out the use of alcohol, tobacco and nicotine products, marijuana and synthetic cannabis, other drugs, and prescription drugs.

• Of the reservists, 29.0% (CI: 27.9-30.1) were binge drinkers, defined as men who had had five or more drinks on one occasion in the past 30 days or women who had had four or more drinks in the past 30 days, and 7.4% (CI: 6.8-8.1) were heavy drinkers, defined as binge drinkers who had binge drank at least one day a week in the past 30 days. In the 2018 National Survey on Drug Use and Health (NSDUH), 26.5% of US adults were binge drinkers and 8.9% were heavy drinkers.
• 4.8% (CI: 4.2-5.3) stated that binge drinking in the past 12 months led to serious consequences (such as a fight), 6.1% (CI: 5.5-6.7) stated that binge drinking led to risky situations (as a drunk driver or passenger in a vehicle), and 5.3% (CI: 4.8-5.9) stated that binge drinking led to decreased productivity at work
• 20.2% (CI: 19.2-21.2) thought that the military culture encouraged alcohol consumption (e.g., if you don't drink, it's hard to fit in with your command).
• 30.5% (CI: 29.3-31.6) reported current use of tobacco or nicotine products. According to the National Health Interview Survey, 19.3% of the population currently uses tobacco, although this estimate is not directly comparable to the HRBS.
• 9.9% (CI: 9.1-10.7) reported using e-cigarettes. Data from the 2017 Behavioral Risk Factor Surveillance System indicate that 4.6% of US adults currently smoke e-cigarettes.
• 2.7% (CI: 2.2 to 3.2) reported using drugs (e.g., over-the-counter medications to get high). 2.7% (CI: 2.2 to 3.2) reported using drugs (e.g., over-the-counter medications to get high, anabolic steroids, marijuana or synthetic cannabis, or drugs such as cocaine or methamphetamine to get high) in the past 12 months; 1.4% (CI: 1.1-1.8) reported using drugs (e.g., using over-the-counter medications to get high) in the past 30 days; 1.4% (CI: 1.1-1.8) reported using drugs in the past 30 days.
• HRBS reservists reported using fewer stimulants, tranquilizers, and painkillers in the past 12 months than civilians, as well as lower rates of abuse.

Mental Health and emotional Well-Being

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

• 6.5% (CI: 5.8-7.1) of reservists reported experiencing severe psychological distress in the past 30 days, and 9.3% (CI: 8.6-9.9) reported symptoms suggestive of probable post-traumatic stress disorder (PTSD) in the past 30 days. Between 2.9% and 5.2% of the general population reported severe psychological distress in the past 30 days, and 3.5% met criteria for PTSD in the past 12 months.
• 46.9% (CI: 45.7-48.1) reported having experienced angry or aggressive behavior in the past 30 days.
• 7.8% (CI: 7.3-8.3) reported unwanted sex since joining the military, and 1.6% (CI: 1.2-1.9) reported unwanted sex in the past 12 months. It is important to remember that the Survey of Reserve Members' Workplace and Gender Relationships (WGRR) and the HRBS measure different constructs. The WGRR measures sexual violence. The HRBS measures unwanted sexual contact, which is a broader construct. The HRBS defines unwanted sexual contact as “someone who touches you sexually, has sex with you, or attempts to have sex with you without your consent or when you are unable to give it.” By sexual contact we mean any sexual contact and any oral, anal, or vaginal penetration.” Therefore, the results between the two studies are not comparable.
• 3.8% (CI: 3.4-4.2) reported being physically abused since joining the military and 0.7% (CI: 0.5-0.9) reported being physically abused in the past 12 months. Among those aged 12 years and older, 1.7% reported physical violence in the past 12 months.
• Among reservists, 6.0% (CI: 5.4-6.6) reported having had suicidal thoughts in the past 12 months, 2.0% (CI: 1.6-2.4) reported having planned suicide, and 0.9% (CI: 0.6-1.3) reported having attempted suicide. In the general population of adults aged 18 years or older, 4.3% reported suicidal thoughts in the past 12 months, 1.3% reported suicide plans, and 0.6% reported suicide attempts.
• Among reservists, 21.0% (CI: 20.1-21.9) reported having used mental health services in the past 12 months; this rate is about 5 percentage points higher than rates in the NSDUH population for the same age group.
• Reservists were almost as likely to see a specialist (13.5%, CI: 12.7-14.2) for mental health services as they were to see a general practitioner (12.7%, CI: 12.6-14.3). In contrast, the general population is more likely to consult a family physician for mental health services. Reservists who sought mental health services consulted a family physician an average of 9.7 times in the past 12 months (CI: 9.0-10.5).
• 8.2% (CI: 7.6-8.8) of reservists reported using medication for mental health problems in the past 12 months; 12.2% of US adults aged 18 years or older did so.
• 4.6% (CI: 4.1-5.0) of reservists reported needing mental health services but not receiving them in the past 12 months. The most common reason for not receiving services was that they did not know they needed them, which is consistent with civilian results.
• 29.9% (CI: 28.8-30.9%) of reservists who responded felt that seeking mental health services would be detrimental to their military career.

Disabilities and General Physical Health

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

• 36.6% (CI 35.5-37.7) of reservists stated that a health care provider had told them in the past 12 months that they had at least one chronic condition. The most common were bone, joint, or muscle injuries and back pain.
• The most common physical symptoms that reservists reported experiencing in the past 30 days were body aches, including headaches (21.1 percent, CI: 20.2-22.0), sleep disturbances (13.7 percent, CI: 12.9-14.5), and fatigue or lack of energy (11.9 percent, CI: 11.2-12.7).
• 4.3 percent (CI: 3.8-4.8) of reservists tested positive for mTBI.
• 57.4 percent (CI: 56.2-58.5) reported very good or excellent health.
• On average, reservists reported missing 0.53 days (CI: 0.47-0.59) of work due to mental or physical symptoms and 1.50 days (CI: 1.39-1.61) of reduced productivity due to mental or physical symptoms in the previous 30 days.

Sexual Health and Sexual Behavior

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

• 15.9% (CI: 14.9-16.8) of reservists reported having had more than one sexual partner in the past 12 months, 33.2% (CI: 32.0-34.3) did not use condoms with new sexual partners, and 17.7% (CI: 16.7-18.7) were at high risk of HIV infection.
• 1.9% (CI: 1.6-2.1) reported having had a sexually transmitted disease in the past 12 months.
• 3.2% (CI: 2.5-3.9%) of female reservists reported having had an unintended pregnancy in the past year, and 2.3% (CI: 1.8-2.7%) of male reservists reported having induced a pregnancy. Less than 1% (0.02, CI: 0.00-0.05) of all reservists had an unintended pregnancy while deployed in the past year.
• 19.1% (CI: 18.2-20.0) of reservists reported not using contraception the last time they had vaginal intercourse in the past 12 months. Of those at risk of unintended pregnancy, 73.8% (CI: 71.4-76.1) used contraception at last vaginal intercourse in the last 12 months, which is below the HP2020 target (91.6%).
• 25.5% (CI: 24.5-26.4) of reservists reported using highly effective contraception at last vaginal intercourse in the past 12 months.
• Most reservists deployed in the past 12 months did not receive contraceptive counseling prior to deployment. Men (15.2%, CI: 13.1-17.3) were less likely to receive such counseling than women (33.4%, CI: 29.3-37.5).
• Seventy-one point four percent (CI: 70.2-72.5) of reservists reported having been tested for HIV in the past 12 months, including 84.2% (CI: 77.8-90.6) of male reservists who had sex with men. Of those at risk for HIV (male reservists who had sex with one or more men in the past 12 months, reservists who had vaginal or anal sex with more than one partner in the past 12 months, and reservists with a history of STIs in the past 12 months), 79.1% (CI: 76.3-81.9) reported having been tested for HIV in the past 12 months.

Health and Sexual Orientation

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

• 2.8% (CI: 2.3-3.3) of male reservists and 9.8% (CI: 8.6-11.0) of female reservists reported having had one or more same-sex partners in the past 12 months.
• 6.1% (CI: 5.6-6.7%) of reservists reported being homosexual, of whom 3.8% (CI: 3.2-4.4%) were male and 15.4% (CI: 13.9-16.9%) were female. For both men and women, approximately half of LGB reservists were bisexual.
• LGB reservists were less likely than other reservists to be overweight or obese, but also less likely to have had a routine medical checkup in the past 12 months and less likely to have had good or enough sleep in the past 30 days.
• LGB reservists were more likely than non-LGB reservists to use alcohol, regular or electronic cigarettes, and illegal drugs. LGB reservists used less smokeless tobacco than non-LGB reservists.
• LGB reservists were more likely to have had sex with a new partner without a condom in the past 12 months, to have had more than one sexual partner, and to have had a sexually transmitted disease. They were also more likely than others to have been tested for HIV in the past six months.
• LGB reservists were more likely to report severe psychological distress or suicidal thoughts in the past 12 months, as well as to report post-traumatic stress disorder and angry or aggressive behavior in the past 30 days than their non-LGB counterparts. They were also more likely to use mental health services and medication for mental health problems. They were more likely to report that they believed their need for mental health services was not being met and that they thought mental health treatment would be detrimental to their military career.
• LGB reservists were also more likely to report unwanted sexual contact and physical abuse since joining the military and in the past 12 months.

Deployment experiences and health

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

• 52.9% (CI: 51.7-54.1) of reservists reported being deployed at least once.
• 19.7% (CI: 18.5-20.8) of reservists who reported ever being deployed reported no combat experience.
• 66.7% (CI: 65.4-68.0) of reservists who reported ever being deployed had not been deployed in the past 12 months.
• 41.2% (CI: 39.9-42.5) of reservists who reported being deployed also reported having one or more traumatic combat experiences. The most common traumatic experiences were witnessing someone killed in action (25.2%; CI: 24.1-26.3), witnessing a unit member or ally seriously wounded or killed (23.1%; CI: 22.0-24.2), and witnessing civilians seriously wounded or killed (23.1%; CI: 22.0-24.2).

Implications and Suggestions for preparedness, health and General Well-Being

Health promotion and disease prevention

The Ministry of Defense, Services, and Coast Guard should address the lack of compliance with health checks. Annual medical checkups are mandatory. In addition, many reservists do not have health insurance.

The DoD, Services and Coast Guard should work to educate reservists and commanders about sleep health, using models that have been successful with similar populations. Most reservists did not get the recommended amount of sleep, and many described their sleep as poor or said the lack of sleep was disruptive, which could affect their readiness.

Substance and Drug use

Defense forces, the services, and the Coast Guard may want to promote alcohol reduction and prevention programs that change cultural beliefs about alcohol use and encourage self-management. Many reservists report excessive alcohol consumption, and some report adverse consequences or loss of productivity.

Reducing tobacco use in all its forms should be a priority for Defense Forces, units, and Coast Guardsmen, given the long-term health effects of smoking. The use of tobacco and nicotine products was also higher than in the civilian population.

Health and mental well-being

The MoD, Services, and Coast Guard must continue to monitor, understand, and support reservists' mental health and mitigate problems associated with seeking mental health treatment. Among reservists, symptoms of mental health problems were common. If left untreated, stress can persist and lead to decreased functional capacity and readiness.

The Defense Forces, Services, and Coast Guard should consider the role of peers and commanders in mental health skills training and efforts to increase awareness of mental health resources.

Physical health and disability

Pain was common among reservists. The MOD, Services, and Coast Guard should increase their efforts to prevent and treat pain.

Sexual behavior and Sexual Health

The MoD, Services and Coast Guard should consider how to increase the proportion of personnel receiving contraceptive counseling prior to deployment. It should be made clear to both reservists and military health care providers that guidance on contraceptive counseling applies to all personnel.

To prevent STDs and unintended pregnancies, the defense forces, services, and Coast Guard should ensure that reservists have ready access to free or low-cost condoms.

Sexual Orientation and Sexual Health

Large-scale health promotion measures within the defense forces, services, and coast guard should include LGB-specific considerations when necessary. Given the widespread use of tobacco and nicotine products among LGB personnel, the defense forces, services, and coast guard may wish to use targeted clinical screening and intervention to support tobacco cessation.

The defense forces, services, and coast guard could reduce sexual health disparities among LGB personnel by training medical officers. Incorrect assumptions about bisexual service personnel based on the gender of their current partner may lead to inappropriate or incorrect counseling.

Recommendations for future versions of the HRBS

Consider the use of survey incentive scheme

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

Shorten the survey and focus on its content

Although the 2018 HRBS took less time to complete than the 2015 version, it was still a long survey that may be boring for respondents, especially if they have recently answered similar questions in other surveys. The MoD could examine the degree of overlap between the HRBS and other data already collected.

For example, some of the content of the Periodic Health Assessment (PHA) overlaps with HRBS topics. The Ministry should consider whether overlap is necessary, perhaps by first examining whether there are differences between the PHA and the confidential HRBS.

Another approach would be the use of modules. Modules could cover topics such as smoking or musculoskeletal injuries. With this approach, not all staff members would receive all items on the questionnaire, but rather certain modules would be selected.

Investigate the use of a panel of officials to monitor risk behavior over time

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

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

Summary

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

Methodology

RAND conducted the 2018 HRBS survey among active and reserve military personnel in the United States from October 2018 through March 2019. Five reserve forces – Air Force, Army, Army, Navy, Marine Corps, and Coast Guard – and two National Guard forces – Air National Guard and Army National Guard – participated in the Reserve Forces Survey.

The 2018 HRBS was a confidential online survey that allowed researchers to address reminders to non-respondents and reduce survey burden by linking responses to administrative data. A random sampling strategy was used to select the sample, which was stratified by grade, class, and gender.

The overall weighted response rate was 9.4%, resulting in a final sample of 16,475 responses. To deal with missing data, RAND researchers used imputation, a statistical procedure that uses available data to estimate missing values. To represent reservists, responses were weighted to account for oversampling of service members in some sections. Point estimates and 95% CIs are presented in this study note.

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

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

Limitations & Restrictions

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