Finding the Forgotten: Motivating Military Veterans to Register with a Primary Healthcare Practice

Finding the Forgotten: Motivating Military Veterans to Register with a Primary Healthcare Practice Abstract Introduction In the UK, primary healthcare practices choose from a series of Read codes to detail certain characteristics onto a patient’s medical documentation. One of these codes is for military veterans indicating a history relating to military service. However, veterans are poor at seeking help, with research indicating that this code is only applied in 7.9% of cases. Clinical staff have a clear role in motivating veterans to declare their ex-Forces status or register with a primary healthcare center. The aim of this study was to motivate veterans to notify primary healthcare staff of their armed forces status or register with a general practitioner, and to improve primary healthcare staff’s understanding of veterans’ health and social care issues. Materials and Methods Data were provided by four primary healthcare centers’ containing 40,470 patients in Lancashire, England during 2017. Pre- and post-patient medical record Read Code searches were conducted either side of a 6-wk intervention period centered on an advertising campaign. The data identified those veterans with the military specific Read code attached to their medical record and their age, gender, marital status and mental health disorders. Further information was gathered from interviews with eight members of staff, some of whom had completed an e-learning veteran healthcare academic module. The study was approved by the University of Chester’s Research Ethics Committee. Results The pre-intervention search indicated that 8.7% (N = 180) of veterans were registered and had the correct military specific code applied to their medical record. Post-intervention, this figure increased by nearly 200% to N = 537. Mental health disorders were present in 28% (N = 152) of cases, including 15% (N = 78) with depression. Interviews revealed the primary healthcare staff’s interpretation of the factors that motivated patients to declare their ex-Forces status and the key areas for development. Conclusion The primary healthcare staff took ownership and responsibility for this initiative. They were creative in introducing new ways of engaging with the local armed forces community. Many veterans’ and staff were unaware of veterans’ entitlement to priority medical services, or the wider provisions available to them. It is probable that veterans declaring their military status within primary healthcare, or registering with a general practitioner for the first time is likely to increase. Another review will be undertaken after 12 mo, which will provide a better indication of success. There remains however an ongoing need to reach out to those veterans who never access a primary healthcare practice. This paper adds to the limited international empirical evidence undertaken to explore help-seeking behavior in an armed forces community. The positive outcomes of increased awareness and staff commitment provide a template for improvement across the UK, and will potentially stimulate similar initiatives with international colleagues. INTRODUCTION Before leaving the UK Armed Forces, service leavers receive a final medical examination. They then receive a written summary containing limited information regarding their medical and mental health (MH) history, and are directed to deliver this document to staff when they register with a civilian primary healthcare (PHC) general practice. The UK Ministry of Defence (MoD) does not monitor if service leavers actually register. Since 1985, the UK has utilized Read Codes that are applied to a patient’s PHC medical record to annotate characteristics such as diagnosis, ethnicity, and therapeutic interventions.1 The UK’s Department of Health directs that a Read Code should be applied to medical documentation indicating a “history relating to military service.”2 However, there are multiple military Read Codes available for distinctions such as service, i.e., Royal Navy, Army, Royal Air Force or Royal Marine. While Health Education England (HEE) advocate the use of a single Read Code, there is no national agreement on which to apply.3 In addition, the utilization of different databases systems, including those that are not synched, does not facilitate the compatible exporting of data.2 Even in the UK, where all patients have a unique NHS identification number, there are still differences in the veteran numbering systems used in Scotland and Northern Ireland from that used in England, Wales and the Isle of Man. These factors contribute to an estimation that only 7.9% of PHC practices applied the Read Code correctly.4 This low figure is despite a National Health Service (NHS) website5 informing veterans of the healthcare benefits and there are no perceived barriers that specifically prevent veterans from registering. This study was funded by the UK NHS and assesses a strategy aimed at motivating veterans to register or notify their veteran status with their PHC General Practice, while improving PHC staff’s awareness and knowledge of veteran related issues. BACKGROUND Armed Forces Community The inclusion criteria for classification as a UK military veteran are 1 d of service in either the Regular Armed Forces or Reserves.5 The veteran population is estimated at approximately 2.6 million,6 embedded within the UK armed forces community (AFC) of 10 M that includes veterans’ families, and personnel still serving.5 This AFC is a diverse heterogeneous group differing by factors such as age, gender, and length of service. Veterans experience the same social and environmental stressors faced by the UK population,6 but are perceived as being more susceptible to MH issues due to previous “contact” situations (engagement with the enemy), particularly when colleagues were injured. As such, there is a public perception that Veterans are inevitably scarred by their military experiences,7 although a significant majority are physically and mentally well,8 and there is a need to redress this balance.9 Demographics The veteran population is 89.5% (N = 2,348,000) male and 10.5% (N = 276,000) female.6 A Royal British Legion study10 indicated that of those aged 16–44 yr olds, 1 in 10 reports problems assimilating into society, and that they are more likely than the general population of the same age to report certain long-term illness such as depression. Veterans have entered the criminal judicial system in large numbers for violent crimes,11 while Australian research indicates that there is an increase in alcohol intake after leaving the Armed Forces.12 52% of the veteran population is estimated at being 75 yr old or older,6,10 and 70% are 60 yr and over.6 They contribute to an estimated 190,000–290,000 of the “hidden” ex-Service community e.g., those dwelling in communal institutions such as residential nursing homes.10 This study was completed in North West (NW) England, where Veterans form 5.1% (N = 291,000) of the regional population. Many face social deprivation challenges,13 although the local civilian population are generally keen to help, which makes this a particularly apt setting for this study.14 NHS and Help-Seeking Behavior Military veterans are entitled to priority NHS treatment for operationally related physical and MH conditions.15 For enduring psychological problems, there are bespoke Military Veteran Improved Access to Psychological Therapies Services. This model has benefits over statutory NHS services,16 including a better understanding of service culture, and is most effective for early services leavers.17,18 A transition, intervention, and liaison service offers another treatment option with multiple points of access including self-referral.19 Veterans often “bottle up” their feelings; fearing the impact of sharing personal burdens with their family or appearing weak.20,21 Veterans may believe that civilian health professionals will not understand their past military experiences and not register with a PHC practice,16 or not disclose their Veteran status.22 Poor help seeking leads to excessive delays in addressing operationally attributable MH issues; often left until they are in crisis and social isolation.23 Innovations including social prescribing have emerged to positively and successfully promote help seeking. EUROFIT24 is exploring the use of iconic football clubs to reach out to men,25,26 while utilizing creative motivators promoted by mobile applications.27 PHC have a clear role in improving and promoting the physical and mental wellbeing of the AFC and PHC doctors can positively change behavior patterns.28 NHS staff require an understanding and awareness of the health and social issues associated with the AFC and the treatment/referral pathways. To achieve this, HEE have provided a free online veterans education module29 and are supporting undergraduate AFC training sessions that will provide a common foundation for all clinical staff.30 AIM To motivate veterans to notify PHC staff of the armed forces status or register with a GP. The objectives were to: Identify whether an advertising campaign would motivate veterans to notify PHC staff of their armed forces status or register with a GP. Identify trends regarding age, gender, and marital status. Evaluate PHC staff assessment of the intervention, including the effectiveness, benefits, problems, and means for improvement. Determine PHC clinical personnel’s views regarding an online HEE educational module. Distinguish the potential for transferability to a larger national initiative. THEORY AND METHODOLOGY This initiative intended to indicate how many veterans were registered with a PHC practice and the influence of an advertising campaign in improving this number. This information would help highlight if the health and social care services being provided for military veterans were being utilized. Data were drawn from a cluster of four PHC practices containing 40,470 patients in Lancashire, England. A mixed methods approach was adopted. Quantitative data were collected from patient medical records. PHC personnel completed pre- and post-Read Code searches either side of a 6-wk intervention based around an advertising campaign that commenced in May 2017. This aim being to assess pre- and post-intervention the number of ex-military personnel with the correct veteran specific code annotated onto their medical records. Data collection captured demographic detail including age, gender, marital status, and any MH clinical diagnoses. A single Veterans Read Code was used (13Ji), thereby facilitating a robust, consistent, valid and reliable measurement. This strategy ensured conformity from different data collectors across the four practices. This search format was familiar to staff who routinely completed this task as a mandated quality return to their Clinical Commissioning Group. The data were anonymous and confidential, with the completed databases encrypted and sent directly to the first author before exporting to a SPSS database for analysis. When a suspected error was identified in the data, then the governance mechanism was to return to the PHC with the observation. This helped validate and confirm anomalies, although no other audit mechanism was in place to ensure compliance. Qualitative data was obtained from interviews conducted in each Practice with the intent of capturing a balanced view. This provided an opportunity to gauge their observations of the intervention and to determine their views of what was appropriate and what could be made better. Finally, questions regarding benefits, shortfalls, and recommendations for improvements and their views on the HEE online module. These responses were subjected to content analysis31 incorporating modified grounded theory methodology32 that included: constructing analytical codes and categories from the data and not from preconceived assumptions; using the constant comparative method to construct comparisons during each stage of the analysis, and memo-writing to elaborate between categories, specify their properties, define correlations, and identify gaps. The evaluation was designed as a manageable pilot study that could be developed into a larger study if the results indicated the potential for wider transferability. Therefore, it did not matter if this initiative worked; the intent was to assert if it could offer a cost effective method to meet the aim and objectives of the study. METHOD The first author visited each of the four PHC practices on three occasions. The first visit was utilised to meet staff and discuss their views on the initiative. This provided an opportunity to critically appraise the study and augment additional means for improving data capture. The lead author designed a Zap/display stand, and information for the PHC Practice’s website and TV screens. External avenues of advertising included local professional sports clubs match day programs, stadium announcements, social media including Facebook and local health networks. Author 2 circulated a press release (See Table I). The common message conveyed was that veterans may be entitled to priority treatment including psychological therapies and to make their veteran status known. Alternatively, to stimulate family members to encourage their veteran relative to inform the PHC practice. Table I. Press Release: Finding the Forgotten People who have served in the Armed Forces are being urged to inform their local doctor as part of a new study  The University of Chester is carrying out the study to determine the number of military veterans registered at four GP practices in Fylde and Wyre  Veterans at The Village Practice in Thornton, Ash Tree House in Kirkham, The Mount View Practice in Fleetwood and Queensway Medical Center in Poulton-le-Fylde have been asked to let their practice know between 8 May and 19 June  Dr Robin Jackson, Chairman of the NHS Armed Forces Network North West, said: “A military Veteran is anyone who has served at least one day in our Armed Forces. Estimates of the numbers of veterans in the North West vary from 250,000 to 560,000  Veterans can have a greater likelihood of some illnesses than their civilian counterparts, such as hearing loss and limb and joint problems. Service personnel can also experience specific mental health problems as a result of their military service. These include Post Traumatic Stress Disorder, Depression and alcohol misuse.  In order to provide the correct health resources to meet the needs of these people it is important to have accurate data on the number of veterans.”  Organizers of the study have assured veterans that the study will identify numbers only. Personal data will remain confidential.  Contact:  Dr Robin Jackson, Chairman NHS Armed Forces Network (North West)  People who have served in the Armed Forces are being urged to inform their local doctor as part of a new study  The University of Chester is carrying out the study to determine the number of military veterans registered at four GP practices in Fylde and Wyre  Veterans at The Village Practice in Thornton, Ash Tree House in Kirkham, The Mount View Practice in Fleetwood and Queensway Medical Center in Poulton-le-Fylde have been asked to let their practice know between 8 May and 19 June  Dr Robin Jackson, Chairman of the NHS Armed Forces Network North West, said: “A military Veteran is anyone who has served at least one day in our Armed Forces. Estimates of the numbers of veterans in the North West vary from 250,000 to 560,000  Veterans can have a greater likelihood of some illnesses than their civilian counterparts, such as hearing loss and limb and joint problems. Service personnel can also experience specific mental health problems as a result of their military service. These include Post Traumatic Stress Disorder, Depression and alcohol misuse.  In order to provide the correct health resources to meet the needs of these people it is important to have accurate data on the number of veterans.”  Organizers of the study have assured veterans that the study will identify numbers only. Personal data will remain confidential.  Contact:  Dr Robin Jackson, Chairman NHS Armed Forces Network (North West)  Table I. Press Release: Finding the Forgotten People who have served in the Armed Forces are being urged to inform their local doctor as part of a new study  The University of Chester is carrying out the study to determine the number of military veterans registered at four GP practices in Fylde and Wyre  Veterans at The Village Practice in Thornton, Ash Tree House in Kirkham, The Mount View Practice in Fleetwood and Queensway Medical Center in Poulton-le-Fylde have been asked to let their practice know between 8 May and 19 June  Dr Robin Jackson, Chairman of the NHS Armed Forces Network North West, said: “A military Veteran is anyone who has served at least one day in our Armed Forces. Estimates of the numbers of veterans in the North West vary from 250,000 to 560,000  Veterans can have a greater likelihood of some illnesses than their civilian counterparts, such as hearing loss and limb and joint problems. Service personnel can also experience specific mental health problems as a result of their military service. These include Post Traumatic Stress Disorder, Depression and alcohol misuse.  In order to provide the correct health resources to meet the needs of these people it is important to have accurate data on the number of veterans.”  Organizers of the study have assured veterans that the study will identify numbers only. Personal data will remain confidential.  Contact:  Dr Robin Jackson, Chairman NHS Armed Forces Network (North West)  People who have served in the Armed Forces are being urged to inform their local doctor as part of a new study  The University of Chester is carrying out the study to determine the number of military veterans registered at four GP practices in Fylde and Wyre  Veterans at The Village Practice in Thornton, Ash Tree House in Kirkham, The Mount View Practice in Fleetwood and Queensway Medical Center in Poulton-le-Fylde have been asked to let their practice know between 8 May and 19 June  Dr Robin Jackson, Chairman of the NHS Armed Forces Network North West, said: “A military Veteran is anyone who has served at least one day in our Armed Forces. Estimates of the numbers of veterans in the North West vary from 250,000 to 560,000  Veterans can have a greater likelihood of some illnesses than their civilian counterparts, such as hearing loss and limb and joint problems. Service personnel can also experience specific mental health problems as a result of their military service. These include Post Traumatic Stress Disorder, Depression and alcohol misuse.  In order to provide the correct health resources to meet the needs of these people it is important to have accurate data on the number of veterans.”  Organizers of the study have assured veterans that the study will identify numbers only. Personal data will remain confidential.  Contact:  Dr Robin Jackson, Chairman NHS Armed Forces Network (North West)  A pilot study was completed by veterans, lay people and academics. This determined that the advertising information conveyed the key messages, and in a format where the content was easily and consistently understood. For additional governance, the University of Chester’s Westminster Veteran’s Center steering committee33 provided constructive comment. The second occasion the author visited the practices was to deliver advertising materials, and information for uploading onto the practice TV screens. This also provided an opportunity to address any outstanding concerns. The PHC’s practice manager was the nominated lead with responsibility for ensuring that the Read Code searches were completed in a timely fashion and for coordinating feedback. Each practice also nominated a lead general practitioner, and each received a small financial remuneration. Certain PHC staff also completed an HEE e-learning package29 and received educational advice. The third occasion the author visited the practices was following the advertising period to complete eight post-intervention interviews with the nominated lead and PHC staff. All interviews were recorded onto a digital audio recorder. SPSS Version 24 was used for the management and analysis of quantitative information with the data exposed to descriptive statistical examination, predominately with frequency distributions and percentages. A one-sample test of binomial proportions was used to test whether rates of veteran registration differed per practice before and after the intervention was conducted. The authors acknowledge that each practice developed and introduced their own initiatives, and it is clear that there was no standardized start point, as certain practices were already more actively engaged with the veteran community due to factors such as a staff member having a relative who was a veteran. The study was approved by the University of Chester’s Research Ethics Committee and is in line with NHS Health Research Authority Guidelines.34 RESULTS Pre- and Post-Testing The NW England veteran population is estimated at 291,000 veterans, this being 5.1% of the Great Britain Population.6 The sample group was 40,470; equating to an estimated 2,064 veterans registered within all four GP practices. The study’s initial Read Code search indicated that 8.7% (N = 180) of veterans had registered and had the correct Read Code applied to their medical record. Following the advertising intervention this increased by nearly 200% to N = 537. This number equated to 26% of the estimated number of veterans. In comparing rates of veteran registration before and after the intervention (See Table II), all practices experienced significantly higher rates post-intervention (z range from 6.46 to 43.69, p < 0.0001 for all practices). Table II. Number of Veterans Registered Pre- and Post-Intervention Serial  Name  Number of Patients  ONS Predicted Number of Veterans (5.1%)  Number of Veterans Registered (Pre-Search)  Number of Veterans Registered (Post-Search)  z  p-Value  1  A  11,750  599  74 (12.3%)  126 (21.0%)  6.46  <0.0001  2  B  8,920  455  48 (10.5%)  115 (25.3%)  10.22  <0.0001  3  C  9,100  464  14 (3.0%)  175 (37.7%)  43.69  <0.0001  4  D  10,700  546  44 (8.1%)  121 (22.2%)  12.11  <0.0001  Total    40,470  2,064  180 (8.7%)  537 (26.0%)  27.85  <0.0001  Serial  Name  Number of Patients  ONS Predicted Number of Veterans (5.1%)  Number of Veterans Registered (Pre-Search)  Number of Veterans Registered (Post-Search)  z  p-Value  1  A  11,750  599  74 (12.3%)  126 (21.0%)  6.46  <0.0001  2  B  8,920  455  48 (10.5%)  115 (25.3%)  10.22  <0.0001  3  C  9,100  464  14 (3.0%)  175 (37.7%)  43.69  <0.0001  4  D  10,700  546  44 (8.1%)  121 (22.2%)  12.11  <0.0001  Total    40,470  2,064  180 (8.7%)  537 (26.0%)  27.85  <0.0001  Table II. Number of Veterans Registered Pre- and Post-Intervention Serial  Name  Number of Patients  ONS Predicted Number of Veterans (5.1%)  Number of Veterans Registered (Pre-Search)  Number of Veterans Registered (Post-Search)  z  p-Value  1  A  11,750  599  74 (12.3%)  126 (21.0%)  6.46  <0.0001  2  B  8,920  455  48 (10.5%)  115 (25.3%)  10.22  <0.0001  3  C  9,100  464  14 (3.0%)  175 (37.7%)  43.69  <0.0001  4  D  10,700  546  44 (8.1%)  121 (22.2%)  12.11  <0.0001  Total    40,470  2,064  180 (8.7%)  537 (26.0%)  27.85  <0.0001  Serial  Name  Number of Patients  ONS Predicted Number of Veterans (5.1%)  Number of Veterans Registered (Pre-Search)  Number of Veterans Registered (Post-Search)  z  p-Value  1  A  11,750  599  74 (12.3%)  126 (21.0%)  6.46  <0.0001  2  B  8,920  455  48 (10.5%)  115 (25.3%)  10.22  <0.0001  3  C  9,100  464  14 (3.0%)  175 (37.7%)  43.69  <0.0001  4  D  10,700  546  44 (8.1%)  121 (22.2%)  12.11  <0.0001  Total    40,470  2,064  180 (8.7%)  537 (26.0%)  27.85  <0.0001  Demographics In this study, 87% (N = 465) were men and 13% (N = 72) women. The mean age was 63 yr old although there were notable differences between each practice (see Fig. 1). FIGURE 1. View largeDownload slide Mean age. FIGURE 1. View largeDownload slide Mean age. The median age was 64 yr old with a mode of 79 yr old. The standard deviation was 8 and the range 81 (16–97 yr). Forty four percentage (N = 234) were aged 68 yr old or over; 60% (N = 324) were 58 yr or over and 80% (N = 429) 48 yr or older. Ten percentage (N = 53) were 37 yr or younger and 1.5% (N = 8) were 27 yr or younger (see Fig. 2). Eighty one percentage (N = 439) of the relationship status detail was not available. From the remaining 19% (N = 98); those potentially living with a partner was estimated at 68% (N = 67) and 32% (N = 31) living alone (see Table III). MH disorders were present in 28% (N = 152) of veterans, including 15% (N = 78) with depression. FIGURE 2. View largeDownload slide Post-intervention – participants age. FIGURE 2. View largeDownload slide Post-intervention – participants age. Table III. Sample Demographics Serial          1  Gender  Male  87%  N = 465  2    Female  13%  N = 72  3  Age  Range  81  16–97  4    Average  63    5  Status  Married or partner  68% (valid %)  N = 67  6    Single or living alone  32%  N = 31  Serial          1  Gender  Male  87%  N = 465  2    Female  13%  N = 72  3  Age  Range  81  16–97  4    Average  63    5  Status  Married or partner  68% (valid %)  N = 67  6    Single or living alone  32%  N = 31  View Large Table III. Sample Demographics Serial          1  Gender  Male  87%  N = 465  2    Female  13%  N = 72  3  Age  Range  81  16–97  4    Average  63    5  Status  Married or partner  68% (valid %)  N = 67  6    Single or living alone  32%  N = 31  Serial          1  Gender  Male  87%  N = 465  2    Female  13%  N = 72  3  Age  Range  81  16–97  4    Average  63    5  Status  Married or partner  68% (valid %)  N = 67  6    Single or living alone  32%  N = 31  View Large Staff Interviews Interviews were conducted with eight members of staff (individually or groups) from all four practices; lasting for a total of 109 min; with a mean of 27 min and they ranged from 12 to 45 min. Interviews revealed the PHC staff’s opinions of how they can improve veterans’ registration: characteristics of the veterans’ population that influence their engagement; the impact of the advertising campaign and the role of education and further research. These are presented diagrammatically in Figure 3. The interviews also provided feedback regarding the value of the HEE education module. Table IV. Study Recommendations Include a routine question on admission proforma regarding veteran status  Awareness campaign to inform staff and veterans of the 1-d inclusion criteria  Respect the views of those patients’ who do not want their veteran status recorded  Further research including engaging with the wider armed forces community and help-seeking behavior  Introduce health and social care needs of the Armed Forces Community into the undergraduate educational programs to ensure a common knowledge foundation  Include a routine question on admission proforma regarding veteran status  Awareness campaign to inform staff and veterans of the 1-d inclusion criteria  Respect the views of those patients’ who do not want their veteran status recorded  Further research including engaging with the wider armed forces community and help-seeking behavior  Introduce health and social care needs of the Armed Forces Community into the undergraduate educational programs to ensure a common knowledge foundation  Table IV. Study Recommendations Include a routine question on admission proforma regarding veteran status  Awareness campaign to inform staff and veterans of the 1-d inclusion criteria  Respect the views of those patients’ who do not want their veteran status recorded  Further research including engaging with the wider armed forces community and help-seeking behavior  Introduce health and social care needs of the Armed Forces Community into the undergraduate educational programs to ensure a common knowledge foundation  Include a routine question on admission proforma regarding veteran status  Awareness campaign to inform staff and veterans of the 1-d inclusion criteria  Respect the views of those patients’ who do not want their veteran status recorded  Further research including engaging with the wider armed forces community and help-seeking behavior  Introduce health and social care needs of the Armed Forces Community into the undergraduate educational programs to ensure a common knowledge foundation  FIGURE 3. View largeDownload slide Factors that influence veterans’ willingness to register with a PHC practice. FIGURE 3. View largeDownload slide Factors that influence veterans’ willingness to register with a PHC practice. Presentation of the findings is intended to protect the anonymity of the respondents, and no published material will contain references or specific attributable reference to the study participants or patient group. To help maintain the flow of the narrative, examples of the participant’s commentary is embedded in the following discussion section. DISCUSSION In 2015, Simpson and Leach reported that only 8% of UK veterans were registered at a PHC practice with the appropriate Read Code attached to their medical record. Two years later, and despite significant investment in veterans’ health and social care, the pre-intervention Read Code search in this study identified only 8.7% with the correct code. In this study’s 6-wk intervention period, there was an increase to 26%; with a one practice rising from 3% to 38%. An important factor in this improvement was motivating all PHC staff to be involved. They accepted ownership and responsibility for making this initiative work. The PHC staff were creative in introducing original ways of enhancing recruitment, with some practices developed additional display materials. The study raised awareness, including reception staff who viewed the campaign as a worthy cause and enjoyed contributing to the campaign. “It has raised awareness with the staff; whereas before nobody saw the relevance of it so it has been good to inform our staff what was going on because they didn’t know.” This commitment was confirmed in that each PHC wanted to continue the recruitment drive. Indeed, three PHC practices kept their advertising Zap Stands on display after the closing date of the advertising campaign and one had the TV screen display still reaching out with information for the veteran community. They were actively recording veteran’s status, and all the PHCs added the Read Coding criteria for a military veteran to new patient registration forms. “If we leave it up longer (Display Stand) then we’ll get more. Many won’t go online unless they need an appointment. I think it would be interesting to see what happens when we do the flu clinics in October. Because we get a lot of the older age people coming in.” In one practice, all the staff approved and engaged in a new patient booking triage system. Thereby, booking a patient consultation activated a message prompting the question “Has the patient been in military service?” This added the veterans Read Code when the answer was yes. The same structure was applied to telephone requests for an appointment, and staff asked this question of every patient during the 6-wk intervention period. One practice placed an alert on family members. The rationale being that while the Read Code is for veterans, referrals for MH services or bereavement counseling impacts on the whole family. “We have also labelled their families as well. At the minute, there is only a military veterans code. So we now put an alert on so that their families can access support as well. Alert comes up on the first screen – Military Veteran Family.” Staff were pleased to see an increase in the number of veterans correctly registered and to receive positive feedback for their efforts. They were interested in empirical evidence regarding veterans’ health and social needs, and how these correlated with the veterans past military service. They wanted to know what services were available including the role of charities, and they wanted an information/resource pack that could give to their patients to take home with them. “They might be telling you they are going to get kicked out of the house. If they take the pack home, they would read and then ask for help. They don’t tell you the social things that cause the stressors. It’s paying bills, relationship problems. At Christmas these (the nurses) are like financial advisors directing people to someone who can help.” Respondents perceived veterans as a proud patient group, and reported men and women veterans of all ages welcomed this initiative. Some veterans visited PHC surgeries with the sole intent of highlighting their status, while others informed their GP. This formed part of multiple access points including informing nursing and reception staff. Some wanted to share their stories, in particular older patients wanted to discuss their military service with reception staff. Veterans reported visiting GP practices regularly over many years without knowledge that they may be entitled to priority care, and therefore had never mentioned their service history. Others simply did not class themselves as veterans, for example post-World War 2 conscripts who completed UK National Service. A significant factor for non-declaration of veteran status was the inclusion criteria of serving one day in the Armed Forces. This was a surprise to staff, veterans and other patients. Many of whom disagreed with this position, expressing difficulty in correlating 1 day’s service into a lifetime military status and entitlement to benefits. “Everyone surprised about one day. Priority for mental health services and being in the Forces; if you have only been there one day then you are highly unlikely to be affected.” Others veterans were interested in what priority treatment was available, the referral pathways, and their GP’s specialist scope of practice. One patient wanted his priority treatment immediately, and there was a raising of expectations. However, choice and communication is important as some did not want their veteran status recorded. They did not offer a reason, and staff felt it best not to press them. “even when told that we weren’t after any further questions or it was purely to collate numbers; they didn’t like it at all. They said “I’m a veteran, but I don’t want anything recorded or anything. I don’t want my name put down for that”. But provided no reason. You don’t want to push them, they close the door and don’t look back, it’s not their life anymore.” The advertising campaign at multiple levels was successful, and a three-fold increase of veterans registered with the correct coding clearly indicates that they responded positively to this campaign. However, even in the short intervention period there were nevertheless challenges with the advertising campaign affected by unpredictable events. These included a NHS cyber-attack35 and a flash general election leading to a period of purdah.36 It is difficult to create a hierarchy of what was most successful. Inside the GP practice, the Zap Stand was a focal point, and staff, patients and veterans were impressed with the message and impact. “The girls said: a lot of the patients you didn’t have to ask them. They were sat in the waiting area and then saw it on the screen or come to pick their prescription up and saw the stand.” The intervention was designed to reach out to younger veterans and those that rarely visit a GP practice and the support of the local professional sports clubs is likely to have influenced their registration. For all patients, the campaign included utilizing information technology and social media such as Facebook and Twitter. One Facebook message received 920 likes (a best positive response) and a number of shares, and did not generate any negative comments. Not least, in close communities, word of mouth communication was viewed as particularly relevant, and there appeared to be an especially good uptake over the 2 wk period either side of an Armed Forces weekend in June 2017. “In TOWN, good news goes fast; bad news very quickly. People talk to each other, and if positive it helps.” While healthcare systems differ between the UK and the USA, there are similarities and overlap between this initiative and the American Academy of Nursing “Have You Ever Served in the Military?” advertising campaign37 that suggest that elements are transferable. These include reaching out to relatives and the positive engagement and education of all frontline healthcare staff across all available treatment systems. This may lead to more veterans accessing the Veterans Association. The HEE online module aimed at helping clinical staff understand the unique needs of the veteran community was viewed as being informative, although there were reports of it being repetitive, and time consuming. CONCLUSION The positive outcomes of this study in a very short time period are extremely encouraging, and it is highly likely that the number of veterans declaring their veteran status or registering with a GP for the first time is likely to increase. However, only a small number of younger veterans had registered, and there remains a need to catch those who never access a PHC practice. Research should explore the role of strong cultural links such as professional sports clubs (present in every UK city) and their role in promoting help seeking and mental/public health awareness. This should include if these mediums are: an attractive option for women; impacting on the family; influencing minority groups living in regions of health inequality including socially deprived areas. These important differences will add to an emerging coherent body of knowledge. This will present a better means for diversity and equability and produce a clear pathway to better PH and wellbeing models. In addition, there remains a requirement to reach family members who may act as a conduit to reach the elderly isolated veteran community living in care homes. There is an ongoing requirement to inform ex-service personnel of the 1 d inclusion criteria for veteran status, and the service provision available. The introduction of a one stop “Veteran’s Gateway”38 may achieve this, although how veterans will become aware of this service is untested. A better understanding of the Read Coding is required, reinforced by a re-invigoration of the campaign to routinely ask patients; “Have you or your family served?” The HEE29 online module advocates the use of a single veteran specific Read Code and there is a compelling case to confirm this position in policy. This would be assisted by developing health record systems that were synched to each other. Educational packages should prepare staff for the typical case presentations; reinforce person-centered and individualized care packages while encouraging staff to remain cognizant of the complexity behind those indicators. The developments in online educational program should be underpinned by common undergraduate syllabi. There is clear area for further development and evaluation, and to forge a relationship with a funder to support the initiative and research. All staff stated that they would agree to future studies if the human resource implications were addressed. There remains a need to encourage and help veterans to either self-support or seek help as early as possible. The reason for the improved numbers is multi factorial, and it is clear that the advertising campaign was a motivator. What is less clear is the impact that the researcher’s personal advocacy and intervention with staff had on motivating them to reach out to veterans within their PHC practice. The paper adds to the limited empirical research undertaken to explore help-seeking behavior in the armed forces community. It provides pointers to help isolated veterans to engage. The positive increase may result in those patients accessing care from specialist MH services. The striking aspect of this study is the simplicity of the intervention that can be replicated virtually anywhere. Therefore, the positive outcomes of increased awareness and staff commitment provide a template for sustainability that could be replicated nationally. STUDY LIMITATIONS The number of the veteran population is estimated on sampling, with the potential that the appraisal is artificially high. No data was collected regarding the Veteran’s military background such as length of service, service background, number and frequency of operational tours. The sample size for female veterans was small. The data did not define the impact that the author’s personal intervention and advocacy had on motivating staff to engage with veterans, and this has implications for wider transferability. It was recognized that the advertising strategy was unlikely to access every veteran, but the intent was to determine if this cost effective strategy could be successful. Read coding was from patient declaration, and no checks were in place to determine that they served in the Armed Forces. The study recommendations are in Table IV. Previous Presentations This paper has been presented at the VA hospital in Pennsylvania, USA on 6 September 2017 and at the University of Chester, England Veterans Symposium on 5 October 2017. Funding UK National Health Service. Acknowledgments Colonel Nick Medway. References 1 National Health Services Digital. Read codes. 2017. Available at: https://digital.nhs.uk/article/1104/Read-Codes; accessed 19 October 2017. 2 Royal College of General Practitioners, The Royal British Legion, Combat Stress. Meeting the healthcare needs of veterans. A guide for general practitioners. 2011. Available at: https://www.chester.ac.uk/sites/files/chester/MeetingTheHealthcareNeedsOfVeteransLeaflet.pdf; accessed 19 October 2017. 3 National Health Service England. Veterans and GP practices. 2017a. Available at: https://hee.nhs.uk/sites/default/files/documents/Leaflet%20for%20GP%20staff.pdf; accessed 19 October 2017. 4 Simpson RG, Leach J.: The general practitioner and the military veteran. J R Army Med Corps  2015; 161( 2): 106– 8. Google Scholar CrossRef Search ADS PubMed  5 National Health Services. Choices: Healthcare for the armed forces community. 2017. Available at: http://www.nhs.uk/NHSEngland/Militaryhealthcare/Pages/Militaryhealthcare.aspx; accessed 19 October 2017. 6 Ministry of Defence. Annual Population Survey: UK Armed Forces Veterans residing in Great Britain, 2015 Published 13 October 2016. Available at: At: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/559369/20161013_APS_Official_Statistic_final.pdf; accessed 19 October 2017 7 Wessely S: Risk, psychiatry and the military. Br J Psychiatry  2005; 186( 6): 459– 66. Google Scholar CrossRef Search ADS PubMed  8 Hynes C, Thomas M: What does the literature say about the needs of veterans in the areas of health? Nurse Educ Today  2016; 47: 81– 8. Google Scholar CrossRef Search ADS PubMed  9 Farmer B: Public viewing soldiers as victims risks damaging Army. The Telegraph 8 July. 2017. Available at http://www.telegraph.co.uk/news/2017/07/08/public-viewing-soldiers-victims-risks-damaging-army-says-chief/; accessed: 11 September 2017. 10 Royal British Legion. A UK Household Survey of the Ex-Service Community. 2014. Available at: http://www.britishlegion.org.uk/get-involved/campaign/public-policy-and-research/the-uk-ex-service-community-a-household-survey/ ; accessed 19 October 2017. 11 MacManus D, Rona R, Dickson H, Somaini G, Fear N, Wessely S: Aggressive and violent behavior among military personnel deployed to Iraq and Afghanistan: prevalence and link with deployment and combat exposure. Epidemiol Rev  2015; 37: 196– 212. Google Scholar CrossRef Search ADS PubMed  12 McKenzie D, McFarlane AC, Creamer M, et al.  : Hazardous or harmful alcohol use in Royal Australian Navy veterans of the 1991 Gulf War: identification of high risk subgroups. Addict Behav  2006; 31( 9): 1683– 94. Google Scholar CrossRef Search ADS PubMed  13 Department for Communities and Local Government. The English Indices of Deprivation Research report from the Department for Communities and Local Government 2015; Available at: https://www.gov.uk/government/statistics/english-indices-of-deprivation-2015; accessed 19 October 2017. 14 Finnegan AP, Steen S, Templeton J, Brownsell M: Westminster Centre for Veterans Westminster Centre for Research and Innovation in Veterans Wellbeing. Events page. University of Chester. 2017. Available at: http://www.chester.ac.uk/health/crivw; accessed on 19 October 2017. 15 National Health Services. Choices: Priority health for veterans. 2017. Available at: http://www.nhs.uk/NHSEngland/Militaryhealthcare/veterans-families-reservists/Pages/veterans.aspx; accessed 19 October 2017 16 National Health Service. IAPT: Improving access to psychological therapies. Veterans: Positive Practice Guide. 2013. Available at: https://www.uea.ac.uk/documents/246046/11991919/veterans-positive-practice-guide-2013.pdf/a6460796-2715-4724-8547-d5cf959f0b86; accessed 19 October 2017. 17 Clarkson P, Giebal CM, Challis D, True M: Cost-effectiveness of a pilot social care service for UK military veterans. J Care Serv Manage  2014; 7( 3): 95– 106. DOI:10.1179/1750168714Y.0000000030. Google Scholar CrossRef Search ADS   18 Clarkson P, Giebel CM, Challis D, Duthie P, Barrett A, Lambert H: Outcomes from a pilot psychological therapies service for UK military veterans. Nurs Open  2016; 3( 4): 227– 35. Google Scholar CrossRef Search ADS PubMed  19 National Health Service England. Next steps on the NHS Five Year Forward View: 17,500 forces veterans and service personnel to benefit from £9m investment in new and improved NHS mental health services. 2017b. Available at: https://www.england.nhs.uk/2017/04/next-steps-on-the-nhs-five-year-forward-view-veterans/; accessed 19 October 2017. 20 Finnegan AP, Finnegan S, Thomas M, Deahl M, Simpson R, Ashford R.: The presentation of depression in the British Army. Nurse Educ Today  2014; 34( 1): 83– 91. Google Scholar CrossRef Search ADS PubMed  21 Ahern J, Worthen M, Masters J, Lippman SA, Ozer EJ, Moos R: The challenges of Afghanistan and Iraq veterans’ transition from military to civilian life and approaches to reconnection. PLoS One  2015; 10( 7): e0128599. https://doi.org/10.1371/journal.pone.0128599. Google Scholar CrossRef Search ADS PubMed  22 Burdett H, Woodhead C, Iversen AC, Wessely S, Dandeker C, Fear NT: “Are you a veteran?” Understanding of the term “veteran” among UK ex-Service personnel. A research note. Armed Forces Soc  2012; 39( 4): 751– 9. Google Scholar CrossRef Search ADS   23 Combat Stress. Annual Report and Accounts. 2016. Available at: https://www.combatstress.org.uk/news/2016/09/annual-report-2016/; accessed 19 October 2017. 24 EUROFIT. Social innovation to improve physical activity and sedentary behaviour through elite European football European Commission. 2016. Available at: http://eurofitfp7.eu/; accessed 29 Nov 2016. 25 Hunt K, Wyke S, Gray CM, et al.  : A gender-sensitised weight loss and healthy living programme for overweight and obese men delivered by Scottish Premier League football clubs (FFIT): a pragmatic randomised controlled trial. Lancet  2014; 383( 9924): 1211– 21. Google Scholar CrossRef Search ADS PubMed  26 Bunn C, Wyke S, Gray C, MacLean A, Hunt K: ‘Coz football is what we all have’: masculinities, practice, performance and effervescence in a gender-sensitised weight-loss and healthy living programme for men. Sociol Health Illn  2016; 38( 5): 812– 28. Google Scholar CrossRef Search ADS PubMed  27 Van Nassau F, Hiddle P, Abrahamsen F, et al.  : Study protocol of European Fans in Training (EuroFIT): a four-country randomised controlled trial of a lifestyle program for men delivered in elite football clubs. BMC Public Health  2016; 16: 598. doi:10.1186/s12889-016-3255-y. Google Scholar CrossRef Search ADS PubMed  28 Aveyard P, Lewis A, Tearne S, et al.  : Screening and brief intervention for obesity in primary care: a parallel, two-arm, randomised trial. Lancet 2016  2016; 388( 10059): 2492– 500. 29 Health Education England; Royal College of General Practitioners. Veterans’ Health in General Practice. Online Module. 2017. Available at: http://www.rcgp.org.uk/courses-and-events/online-learning/ole/veterans-health-in-general-practice.aspx; accessed 19 October 2017. 30 Finnegan AP, McGhee S, Leach J: Educating nurses to provide better care for the military veteran and their families. Nurse Educ Today  2017; 54: 62– 3. Google Scholar CrossRef Search ADS PubMed  31 Burnard P: A method of analysing interview transcripts in qualitative research. Nurse Educ Today  1991; 11: 461– 6. Google Scholar CrossRef Search ADS PubMed  32 Charmaz K: Constructing Grounded Theory: A Practical Guide Through Qualitative Analysis , 2nd edn, London, Sage, 2014. 33 Westminster Centre for Veterans; Westminster Centre for Research and Innovation in Veterans Wellbeing. Who We Are: External Committee Members. University of Chester. 2017; Available at https://www.chester.ac.uk/health/crivw/staff/externally-employed; accessed 19 October 2017 34 National Health Service Health Research Authority. 2014. Available at www.hra.nhs.uk ; accessed 19 October 2017. 35 Graham C: NHS cyber attack: everything you need to know about ‘biggest ransomware’ offensive in history. Daily Telegraph, 20 May. 2017. Available at: http://www.telegraph.co.uk/news/2017/05/13/nhs-cyber-attack-everything-need-know-biggest-ransomware-offensive/; accessed 19 October 2017. 36 Dudman J: No politics, please – we’re UK public servants. A guide to election purdah. The Guardian, 20 April. 2017. Available at https://www.theguardian.com/public-leaders-network/2017/apr/20/purdah-general-election-civil-service ; accessed 19 October 2017. 37 Collins E, Wilmoth M, Schwartz L: “Have you ever served in the military?” campaign in partnership with the Joining Forces Initiative. Nursing Outlook  2013; 61: 375– 6. Google Scholar CrossRef Search ADS PubMed  38 Royal British Legion. The first point of contact for veterans seeking support 2017. Available at: https://www.veteransgateway.org.uk; accessed 19 October 2017. Author notes The views expressed are solely those of the authors and do not reflect the official policy position of the UK Royal Navy, British Army, Royal Air Force, Ministry of Defence, or UK Government. © Association of Military Surgeons of the United States 2018. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Military Medicine Oxford University Press

Finding the Forgotten: Motivating Military Veterans to Register with a Primary Healthcare Practice

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© Association of Military Surgeons of the United States 2018. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.
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Abstract

Abstract Introduction In the UK, primary healthcare practices choose from a series of Read codes to detail certain characteristics onto a patient’s medical documentation. One of these codes is for military veterans indicating a history relating to military service. However, veterans are poor at seeking help, with research indicating that this code is only applied in 7.9% of cases. Clinical staff have a clear role in motivating veterans to declare their ex-Forces status or register with a primary healthcare center. The aim of this study was to motivate veterans to notify primary healthcare staff of their armed forces status or register with a general practitioner, and to improve primary healthcare staff’s understanding of veterans’ health and social care issues. Materials and Methods Data were provided by four primary healthcare centers’ containing 40,470 patients in Lancashire, England during 2017. Pre- and post-patient medical record Read Code searches were conducted either side of a 6-wk intervention period centered on an advertising campaign. The data identified those veterans with the military specific Read code attached to their medical record and their age, gender, marital status and mental health disorders. Further information was gathered from interviews with eight members of staff, some of whom had completed an e-learning veteran healthcare academic module. The study was approved by the University of Chester’s Research Ethics Committee. Results The pre-intervention search indicated that 8.7% (N = 180) of veterans were registered and had the correct military specific code applied to their medical record. Post-intervention, this figure increased by nearly 200% to N = 537. Mental health disorders were present in 28% (N = 152) of cases, including 15% (N = 78) with depression. Interviews revealed the primary healthcare staff’s interpretation of the factors that motivated patients to declare their ex-Forces status and the key areas for development. Conclusion The primary healthcare staff took ownership and responsibility for this initiative. They were creative in introducing new ways of engaging with the local armed forces community. Many veterans’ and staff were unaware of veterans’ entitlement to priority medical services, or the wider provisions available to them. It is probable that veterans declaring their military status within primary healthcare, or registering with a general practitioner for the first time is likely to increase. Another review will be undertaken after 12 mo, which will provide a better indication of success. There remains however an ongoing need to reach out to those veterans who never access a primary healthcare practice. This paper adds to the limited international empirical evidence undertaken to explore help-seeking behavior in an armed forces community. The positive outcomes of increased awareness and staff commitment provide a template for improvement across the UK, and will potentially stimulate similar initiatives with international colleagues. INTRODUCTION Before leaving the UK Armed Forces, service leavers receive a final medical examination. They then receive a written summary containing limited information regarding their medical and mental health (MH) history, and are directed to deliver this document to staff when they register with a civilian primary healthcare (PHC) general practice. The UK Ministry of Defence (MoD) does not monitor if service leavers actually register. Since 1985, the UK has utilized Read Codes that are applied to a patient’s PHC medical record to annotate characteristics such as diagnosis, ethnicity, and therapeutic interventions.1 The UK’s Department of Health directs that a Read Code should be applied to medical documentation indicating a “history relating to military service.”2 However, there are multiple military Read Codes available for distinctions such as service, i.e., Royal Navy, Army, Royal Air Force or Royal Marine. While Health Education England (HEE) advocate the use of a single Read Code, there is no national agreement on which to apply.3 In addition, the utilization of different databases systems, including those that are not synched, does not facilitate the compatible exporting of data.2 Even in the UK, where all patients have a unique NHS identification number, there are still differences in the veteran numbering systems used in Scotland and Northern Ireland from that used in England, Wales and the Isle of Man. These factors contribute to an estimation that only 7.9% of PHC practices applied the Read Code correctly.4 This low figure is despite a National Health Service (NHS) website5 informing veterans of the healthcare benefits and there are no perceived barriers that specifically prevent veterans from registering. This study was funded by the UK NHS and assesses a strategy aimed at motivating veterans to register or notify their veteran status with their PHC General Practice, while improving PHC staff’s awareness and knowledge of veteran related issues. BACKGROUND Armed Forces Community The inclusion criteria for classification as a UK military veteran are 1 d of service in either the Regular Armed Forces or Reserves.5 The veteran population is estimated at approximately 2.6 million,6 embedded within the UK armed forces community (AFC) of 10 M that includes veterans’ families, and personnel still serving.5 This AFC is a diverse heterogeneous group differing by factors such as age, gender, and length of service. Veterans experience the same social and environmental stressors faced by the UK population,6 but are perceived as being more susceptible to MH issues due to previous “contact” situations (engagement with the enemy), particularly when colleagues were injured. As such, there is a public perception that Veterans are inevitably scarred by their military experiences,7 although a significant majority are physically and mentally well,8 and there is a need to redress this balance.9 Demographics The veteran population is 89.5% (N = 2,348,000) male and 10.5% (N = 276,000) female.6 A Royal British Legion study10 indicated that of those aged 16–44 yr olds, 1 in 10 reports problems assimilating into society, and that they are more likely than the general population of the same age to report certain long-term illness such as depression. Veterans have entered the criminal judicial system in large numbers for violent crimes,11 while Australian research indicates that there is an increase in alcohol intake after leaving the Armed Forces.12 52% of the veteran population is estimated at being 75 yr old or older,6,10 and 70% are 60 yr and over.6 They contribute to an estimated 190,000–290,000 of the “hidden” ex-Service community e.g., those dwelling in communal institutions such as residential nursing homes.10 This study was completed in North West (NW) England, where Veterans form 5.1% (N = 291,000) of the regional population. Many face social deprivation challenges,13 although the local civilian population are generally keen to help, which makes this a particularly apt setting for this study.14 NHS and Help-Seeking Behavior Military veterans are entitled to priority NHS treatment for operationally related physical and MH conditions.15 For enduring psychological problems, there are bespoke Military Veteran Improved Access to Psychological Therapies Services. This model has benefits over statutory NHS services,16 including a better understanding of service culture, and is most effective for early services leavers.17,18 A transition, intervention, and liaison service offers another treatment option with multiple points of access including self-referral.19 Veterans often “bottle up” their feelings; fearing the impact of sharing personal burdens with their family or appearing weak.20,21 Veterans may believe that civilian health professionals will not understand their past military experiences and not register with a PHC practice,16 or not disclose their Veteran status.22 Poor help seeking leads to excessive delays in addressing operationally attributable MH issues; often left until they are in crisis and social isolation.23 Innovations including social prescribing have emerged to positively and successfully promote help seeking. EUROFIT24 is exploring the use of iconic football clubs to reach out to men,25,26 while utilizing creative motivators promoted by mobile applications.27 PHC have a clear role in improving and promoting the physical and mental wellbeing of the AFC and PHC doctors can positively change behavior patterns.28 NHS staff require an understanding and awareness of the health and social issues associated with the AFC and the treatment/referral pathways. To achieve this, HEE have provided a free online veterans education module29 and are supporting undergraduate AFC training sessions that will provide a common foundation for all clinical staff.30 AIM To motivate veterans to notify PHC staff of the armed forces status or register with a GP. The objectives were to: Identify whether an advertising campaign would motivate veterans to notify PHC staff of their armed forces status or register with a GP. Identify trends regarding age, gender, and marital status. Evaluate PHC staff assessment of the intervention, including the effectiveness, benefits, problems, and means for improvement. Determine PHC clinical personnel’s views regarding an online HEE educational module. Distinguish the potential for transferability to a larger national initiative. THEORY AND METHODOLOGY This initiative intended to indicate how many veterans were registered with a PHC practice and the influence of an advertising campaign in improving this number. This information would help highlight if the health and social care services being provided for military veterans were being utilized. Data were drawn from a cluster of four PHC practices containing 40,470 patients in Lancashire, England. A mixed methods approach was adopted. Quantitative data were collected from patient medical records. PHC personnel completed pre- and post-Read Code searches either side of a 6-wk intervention based around an advertising campaign that commenced in May 2017. This aim being to assess pre- and post-intervention the number of ex-military personnel with the correct veteran specific code annotated onto their medical records. Data collection captured demographic detail including age, gender, marital status, and any MH clinical diagnoses. A single Veterans Read Code was used (13Ji), thereby facilitating a robust, consistent, valid and reliable measurement. This strategy ensured conformity from different data collectors across the four practices. This search format was familiar to staff who routinely completed this task as a mandated quality return to their Clinical Commissioning Group. The data were anonymous and confidential, with the completed databases encrypted and sent directly to the first author before exporting to a SPSS database for analysis. When a suspected error was identified in the data, then the governance mechanism was to return to the PHC with the observation. This helped validate and confirm anomalies, although no other audit mechanism was in place to ensure compliance. Qualitative data was obtained from interviews conducted in each Practice with the intent of capturing a balanced view. This provided an opportunity to gauge their observations of the intervention and to determine their views of what was appropriate and what could be made better. Finally, questions regarding benefits, shortfalls, and recommendations for improvements and their views on the HEE online module. These responses were subjected to content analysis31 incorporating modified grounded theory methodology32 that included: constructing analytical codes and categories from the data and not from preconceived assumptions; using the constant comparative method to construct comparisons during each stage of the analysis, and memo-writing to elaborate between categories, specify their properties, define correlations, and identify gaps. The evaluation was designed as a manageable pilot study that could be developed into a larger study if the results indicated the potential for wider transferability. Therefore, it did not matter if this initiative worked; the intent was to assert if it could offer a cost effective method to meet the aim and objectives of the study. METHOD The first author visited each of the four PHC practices on three occasions. The first visit was utilised to meet staff and discuss their views on the initiative. This provided an opportunity to critically appraise the study and augment additional means for improving data capture. The lead author designed a Zap/display stand, and information for the PHC Practice’s website and TV screens. External avenues of advertising included local professional sports clubs match day programs, stadium announcements, social media including Facebook and local health networks. Author 2 circulated a press release (See Table I). The common message conveyed was that veterans may be entitled to priority treatment including psychological therapies and to make their veteran status known. Alternatively, to stimulate family members to encourage their veteran relative to inform the PHC practice. Table I. Press Release: Finding the Forgotten People who have served in the Armed Forces are being urged to inform their local doctor as part of a new study  The University of Chester is carrying out the study to determine the number of military veterans registered at four GP practices in Fylde and Wyre  Veterans at The Village Practice in Thornton, Ash Tree House in Kirkham, The Mount View Practice in Fleetwood and Queensway Medical Center in Poulton-le-Fylde have been asked to let their practice know between 8 May and 19 June  Dr Robin Jackson, Chairman of the NHS Armed Forces Network North West, said: “A military Veteran is anyone who has served at least one day in our Armed Forces. Estimates of the numbers of veterans in the North West vary from 250,000 to 560,000  Veterans can have a greater likelihood of some illnesses than their civilian counterparts, such as hearing loss and limb and joint problems. Service personnel can also experience specific mental health problems as a result of their military service. These include Post Traumatic Stress Disorder, Depression and alcohol misuse.  In order to provide the correct health resources to meet the needs of these people it is important to have accurate data on the number of veterans.”  Organizers of the study have assured veterans that the study will identify numbers only. Personal data will remain confidential.  Contact:  Dr Robin Jackson, Chairman NHS Armed Forces Network (North West)  People who have served in the Armed Forces are being urged to inform their local doctor as part of a new study  The University of Chester is carrying out the study to determine the number of military veterans registered at four GP practices in Fylde and Wyre  Veterans at The Village Practice in Thornton, Ash Tree House in Kirkham, The Mount View Practice in Fleetwood and Queensway Medical Center in Poulton-le-Fylde have been asked to let their practice know between 8 May and 19 June  Dr Robin Jackson, Chairman of the NHS Armed Forces Network North West, said: “A military Veteran is anyone who has served at least one day in our Armed Forces. Estimates of the numbers of veterans in the North West vary from 250,000 to 560,000  Veterans can have a greater likelihood of some illnesses than their civilian counterparts, such as hearing loss and limb and joint problems. Service personnel can also experience specific mental health problems as a result of their military service. These include Post Traumatic Stress Disorder, Depression and alcohol misuse.  In order to provide the correct health resources to meet the needs of these people it is important to have accurate data on the number of veterans.”  Organizers of the study have assured veterans that the study will identify numbers only. Personal data will remain confidential.  Contact:  Dr Robin Jackson, Chairman NHS Armed Forces Network (North West)  Table I. Press Release: Finding the Forgotten People who have served in the Armed Forces are being urged to inform their local doctor as part of a new study  The University of Chester is carrying out the study to determine the number of military veterans registered at four GP practices in Fylde and Wyre  Veterans at The Village Practice in Thornton, Ash Tree House in Kirkham, The Mount View Practice in Fleetwood and Queensway Medical Center in Poulton-le-Fylde have been asked to let their practice know between 8 May and 19 June  Dr Robin Jackson, Chairman of the NHS Armed Forces Network North West, said: “A military Veteran is anyone who has served at least one day in our Armed Forces. Estimates of the numbers of veterans in the North West vary from 250,000 to 560,000  Veterans can have a greater likelihood of some illnesses than their civilian counterparts, such as hearing loss and limb and joint problems. Service personnel can also experience specific mental health problems as a result of their military service. These include Post Traumatic Stress Disorder, Depression and alcohol misuse.  In order to provide the correct health resources to meet the needs of these people it is important to have accurate data on the number of veterans.”  Organizers of the study have assured veterans that the study will identify numbers only. Personal data will remain confidential.  Contact:  Dr Robin Jackson, Chairman NHS Armed Forces Network (North West)  People who have served in the Armed Forces are being urged to inform their local doctor as part of a new study  The University of Chester is carrying out the study to determine the number of military veterans registered at four GP practices in Fylde and Wyre  Veterans at The Village Practice in Thornton, Ash Tree House in Kirkham, The Mount View Practice in Fleetwood and Queensway Medical Center in Poulton-le-Fylde have been asked to let their practice know between 8 May and 19 June  Dr Robin Jackson, Chairman of the NHS Armed Forces Network North West, said: “A military Veteran is anyone who has served at least one day in our Armed Forces. Estimates of the numbers of veterans in the North West vary from 250,000 to 560,000  Veterans can have a greater likelihood of some illnesses than their civilian counterparts, such as hearing loss and limb and joint problems. Service personnel can also experience specific mental health problems as a result of their military service. These include Post Traumatic Stress Disorder, Depression and alcohol misuse.  In order to provide the correct health resources to meet the needs of these people it is important to have accurate data on the number of veterans.”  Organizers of the study have assured veterans that the study will identify numbers only. Personal data will remain confidential.  Contact:  Dr Robin Jackson, Chairman NHS Armed Forces Network (North West)  A pilot study was completed by veterans, lay people and academics. This determined that the advertising information conveyed the key messages, and in a format where the content was easily and consistently understood. For additional governance, the University of Chester’s Westminster Veteran’s Center steering committee33 provided constructive comment. The second occasion the author visited the practices was to deliver advertising materials, and information for uploading onto the practice TV screens. This also provided an opportunity to address any outstanding concerns. The PHC’s practice manager was the nominated lead with responsibility for ensuring that the Read Code searches were completed in a timely fashion and for coordinating feedback. Each practice also nominated a lead general practitioner, and each received a small financial remuneration. Certain PHC staff also completed an HEE e-learning package29 and received educational advice. The third occasion the author visited the practices was following the advertising period to complete eight post-intervention interviews with the nominated lead and PHC staff. All interviews were recorded onto a digital audio recorder. SPSS Version 24 was used for the management and analysis of quantitative information with the data exposed to descriptive statistical examination, predominately with frequency distributions and percentages. A one-sample test of binomial proportions was used to test whether rates of veteran registration differed per practice before and after the intervention was conducted. The authors acknowledge that each practice developed and introduced their own initiatives, and it is clear that there was no standardized start point, as certain practices were already more actively engaged with the veteran community due to factors such as a staff member having a relative who was a veteran. The study was approved by the University of Chester’s Research Ethics Committee and is in line with NHS Health Research Authority Guidelines.34 RESULTS Pre- and Post-Testing The NW England veteran population is estimated at 291,000 veterans, this being 5.1% of the Great Britain Population.6 The sample group was 40,470; equating to an estimated 2,064 veterans registered within all four GP practices. The study’s initial Read Code search indicated that 8.7% (N = 180) of veterans had registered and had the correct Read Code applied to their medical record. Following the advertising intervention this increased by nearly 200% to N = 537. This number equated to 26% of the estimated number of veterans. In comparing rates of veteran registration before and after the intervention (See Table II), all practices experienced significantly higher rates post-intervention (z range from 6.46 to 43.69, p < 0.0001 for all practices). Table II. Number of Veterans Registered Pre- and Post-Intervention Serial  Name  Number of Patients  ONS Predicted Number of Veterans (5.1%)  Number of Veterans Registered (Pre-Search)  Number of Veterans Registered (Post-Search)  z  p-Value  1  A  11,750  599  74 (12.3%)  126 (21.0%)  6.46  <0.0001  2  B  8,920  455  48 (10.5%)  115 (25.3%)  10.22  <0.0001  3  C  9,100  464  14 (3.0%)  175 (37.7%)  43.69  <0.0001  4  D  10,700  546  44 (8.1%)  121 (22.2%)  12.11  <0.0001  Total    40,470  2,064  180 (8.7%)  537 (26.0%)  27.85  <0.0001  Serial  Name  Number of Patients  ONS Predicted Number of Veterans (5.1%)  Number of Veterans Registered (Pre-Search)  Number of Veterans Registered (Post-Search)  z  p-Value  1  A  11,750  599  74 (12.3%)  126 (21.0%)  6.46  <0.0001  2  B  8,920  455  48 (10.5%)  115 (25.3%)  10.22  <0.0001  3  C  9,100  464  14 (3.0%)  175 (37.7%)  43.69  <0.0001  4  D  10,700  546  44 (8.1%)  121 (22.2%)  12.11  <0.0001  Total    40,470  2,064  180 (8.7%)  537 (26.0%)  27.85  <0.0001  Table II. Number of Veterans Registered Pre- and Post-Intervention Serial  Name  Number of Patients  ONS Predicted Number of Veterans (5.1%)  Number of Veterans Registered (Pre-Search)  Number of Veterans Registered (Post-Search)  z  p-Value  1  A  11,750  599  74 (12.3%)  126 (21.0%)  6.46  <0.0001  2  B  8,920  455  48 (10.5%)  115 (25.3%)  10.22  <0.0001  3  C  9,100  464  14 (3.0%)  175 (37.7%)  43.69  <0.0001  4  D  10,700  546  44 (8.1%)  121 (22.2%)  12.11  <0.0001  Total    40,470  2,064  180 (8.7%)  537 (26.0%)  27.85  <0.0001  Serial  Name  Number of Patients  ONS Predicted Number of Veterans (5.1%)  Number of Veterans Registered (Pre-Search)  Number of Veterans Registered (Post-Search)  z  p-Value  1  A  11,750  599  74 (12.3%)  126 (21.0%)  6.46  <0.0001  2  B  8,920  455  48 (10.5%)  115 (25.3%)  10.22  <0.0001  3  C  9,100  464  14 (3.0%)  175 (37.7%)  43.69  <0.0001  4  D  10,700  546  44 (8.1%)  121 (22.2%)  12.11  <0.0001  Total    40,470  2,064  180 (8.7%)  537 (26.0%)  27.85  <0.0001  Demographics In this study, 87% (N = 465) were men and 13% (N = 72) women. The mean age was 63 yr old although there were notable differences between each practice (see Fig. 1). FIGURE 1. View largeDownload slide Mean age. FIGURE 1. View largeDownload slide Mean age. The median age was 64 yr old with a mode of 79 yr old. The standard deviation was 8 and the range 81 (16–97 yr). Forty four percentage (N = 234) were aged 68 yr old or over; 60% (N = 324) were 58 yr or over and 80% (N = 429) 48 yr or older. Ten percentage (N = 53) were 37 yr or younger and 1.5% (N = 8) were 27 yr or younger (see Fig. 2). Eighty one percentage (N = 439) of the relationship status detail was not available. From the remaining 19% (N = 98); those potentially living with a partner was estimated at 68% (N = 67) and 32% (N = 31) living alone (see Table III). MH disorders were present in 28% (N = 152) of veterans, including 15% (N = 78) with depression. FIGURE 2. View largeDownload slide Post-intervention – participants age. FIGURE 2. View largeDownload slide Post-intervention – participants age. Table III. Sample Demographics Serial          1  Gender  Male  87%  N = 465  2    Female  13%  N = 72  3  Age  Range  81  16–97  4    Average  63    5  Status  Married or partner  68% (valid %)  N = 67  6    Single or living alone  32%  N = 31  Serial          1  Gender  Male  87%  N = 465  2    Female  13%  N = 72  3  Age  Range  81  16–97  4    Average  63    5  Status  Married or partner  68% (valid %)  N = 67  6    Single or living alone  32%  N = 31  View Large Table III. Sample Demographics Serial          1  Gender  Male  87%  N = 465  2    Female  13%  N = 72  3  Age  Range  81  16–97  4    Average  63    5  Status  Married or partner  68% (valid %)  N = 67  6    Single or living alone  32%  N = 31  Serial          1  Gender  Male  87%  N = 465  2    Female  13%  N = 72  3  Age  Range  81  16–97  4    Average  63    5  Status  Married or partner  68% (valid %)  N = 67  6    Single or living alone  32%  N = 31  View Large Staff Interviews Interviews were conducted with eight members of staff (individually or groups) from all four practices; lasting for a total of 109 min; with a mean of 27 min and they ranged from 12 to 45 min. Interviews revealed the PHC staff’s opinions of how they can improve veterans’ registration: characteristics of the veterans’ population that influence their engagement; the impact of the advertising campaign and the role of education and further research. These are presented diagrammatically in Figure 3. The interviews also provided feedback regarding the value of the HEE education module. Table IV. Study Recommendations Include a routine question on admission proforma regarding veteran status  Awareness campaign to inform staff and veterans of the 1-d inclusion criteria  Respect the views of those patients’ who do not want their veteran status recorded  Further research including engaging with the wider armed forces community and help-seeking behavior  Introduce health and social care needs of the Armed Forces Community into the undergraduate educational programs to ensure a common knowledge foundation  Include a routine question on admission proforma regarding veteran status  Awareness campaign to inform staff and veterans of the 1-d inclusion criteria  Respect the views of those patients’ who do not want their veteran status recorded  Further research including engaging with the wider armed forces community and help-seeking behavior  Introduce health and social care needs of the Armed Forces Community into the undergraduate educational programs to ensure a common knowledge foundation  Table IV. Study Recommendations Include a routine question on admission proforma regarding veteran status  Awareness campaign to inform staff and veterans of the 1-d inclusion criteria  Respect the views of those patients’ who do not want their veteran status recorded  Further research including engaging with the wider armed forces community and help-seeking behavior  Introduce health and social care needs of the Armed Forces Community into the undergraduate educational programs to ensure a common knowledge foundation  Include a routine question on admission proforma regarding veteran status  Awareness campaign to inform staff and veterans of the 1-d inclusion criteria  Respect the views of those patients’ who do not want their veteran status recorded  Further research including engaging with the wider armed forces community and help-seeking behavior  Introduce health and social care needs of the Armed Forces Community into the undergraduate educational programs to ensure a common knowledge foundation  FIGURE 3. View largeDownload slide Factors that influence veterans’ willingness to register with a PHC practice. FIGURE 3. View largeDownload slide Factors that influence veterans’ willingness to register with a PHC practice. Presentation of the findings is intended to protect the anonymity of the respondents, and no published material will contain references or specific attributable reference to the study participants or patient group. To help maintain the flow of the narrative, examples of the participant’s commentary is embedded in the following discussion section. DISCUSSION In 2015, Simpson and Leach reported that only 8% of UK veterans were registered at a PHC practice with the appropriate Read Code attached to their medical record. Two years later, and despite significant investment in veterans’ health and social care, the pre-intervention Read Code search in this study identified only 8.7% with the correct code. In this study’s 6-wk intervention period, there was an increase to 26%; with a one practice rising from 3% to 38%. An important factor in this improvement was motivating all PHC staff to be involved. They accepted ownership and responsibility for making this initiative work. The PHC staff were creative in introducing original ways of enhancing recruitment, with some practices developed additional display materials. The study raised awareness, including reception staff who viewed the campaign as a worthy cause and enjoyed contributing to the campaign. “It has raised awareness with the staff; whereas before nobody saw the relevance of it so it has been good to inform our staff what was going on because they didn’t know.” This commitment was confirmed in that each PHC wanted to continue the recruitment drive. Indeed, three PHC practices kept their advertising Zap Stands on display after the closing date of the advertising campaign and one had the TV screen display still reaching out with information for the veteran community. They were actively recording veteran’s status, and all the PHCs added the Read Coding criteria for a military veteran to new patient registration forms. “If we leave it up longer (Display Stand) then we’ll get more. Many won’t go online unless they need an appointment. I think it would be interesting to see what happens when we do the flu clinics in October. Because we get a lot of the older age people coming in.” In one practice, all the staff approved and engaged in a new patient booking triage system. Thereby, booking a patient consultation activated a message prompting the question “Has the patient been in military service?” This added the veterans Read Code when the answer was yes. The same structure was applied to telephone requests for an appointment, and staff asked this question of every patient during the 6-wk intervention period. One practice placed an alert on family members. The rationale being that while the Read Code is for veterans, referrals for MH services or bereavement counseling impacts on the whole family. “We have also labelled their families as well. At the minute, there is only a military veterans code. So we now put an alert on so that their families can access support as well. Alert comes up on the first screen – Military Veteran Family.” Staff were pleased to see an increase in the number of veterans correctly registered and to receive positive feedback for their efforts. They were interested in empirical evidence regarding veterans’ health and social needs, and how these correlated with the veterans past military service. They wanted to know what services were available including the role of charities, and they wanted an information/resource pack that could give to their patients to take home with them. “They might be telling you they are going to get kicked out of the house. If they take the pack home, they would read and then ask for help. They don’t tell you the social things that cause the stressors. It’s paying bills, relationship problems. At Christmas these (the nurses) are like financial advisors directing people to someone who can help.” Respondents perceived veterans as a proud patient group, and reported men and women veterans of all ages welcomed this initiative. Some veterans visited PHC surgeries with the sole intent of highlighting their status, while others informed their GP. This formed part of multiple access points including informing nursing and reception staff. Some wanted to share their stories, in particular older patients wanted to discuss their military service with reception staff. Veterans reported visiting GP practices regularly over many years without knowledge that they may be entitled to priority care, and therefore had never mentioned their service history. Others simply did not class themselves as veterans, for example post-World War 2 conscripts who completed UK National Service. A significant factor for non-declaration of veteran status was the inclusion criteria of serving one day in the Armed Forces. This was a surprise to staff, veterans and other patients. Many of whom disagreed with this position, expressing difficulty in correlating 1 day’s service into a lifetime military status and entitlement to benefits. “Everyone surprised about one day. Priority for mental health services and being in the Forces; if you have only been there one day then you are highly unlikely to be affected.” Others veterans were interested in what priority treatment was available, the referral pathways, and their GP’s specialist scope of practice. One patient wanted his priority treatment immediately, and there was a raising of expectations. However, choice and communication is important as some did not want their veteran status recorded. They did not offer a reason, and staff felt it best not to press them. “even when told that we weren’t after any further questions or it was purely to collate numbers; they didn’t like it at all. They said “I’m a veteran, but I don’t want anything recorded or anything. I don’t want my name put down for that”. But provided no reason. You don’t want to push them, they close the door and don’t look back, it’s not their life anymore.” The advertising campaign at multiple levels was successful, and a three-fold increase of veterans registered with the correct coding clearly indicates that they responded positively to this campaign. However, even in the short intervention period there were nevertheless challenges with the advertising campaign affected by unpredictable events. These included a NHS cyber-attack35 and a flash general election leading to a period of purdah.36 It is difficult to create a hierarchy of what was most successful. Inside the GP practice, the Zap Stand was a focal point, and staff, patients and veterans were impressed with the message and impact. “The girls said: a lot of the patients you didn’t have to ask them. They were sat in the waiting area and then saw it on the screen or come to pick their prescription up and saw the stand.” The intervention was designed to reach out to younger veterans and those that rarely visit a GP practice and the support of the local professional sports clubs is likely to have influenced their registration. For all patients, the campaign included utilizing information technology and social media such as Facebook and Twitter. One Facebook message received 920 likes (a best positive response) and a number of shares, and did not generate any negative comments. Not least, in close communities, word of mouth communication was viewed as particularly relevant, and there appeared to be an especially good uptake over the 2 wk period either side of an Armed Forces weekend in June 2017. “In TOWN, good news goes fast; bad news very quickly. People talk to each other, and if positive it helps.” While healthcare systems differ between the UK and the USA, there are similarities and overlap between this initiative and the American Academy of Nursing “Have You Ever Served in the Military?” advertising campaign37 that suggest that elements are transferable. These include reaching out to relatives and the positive engagement and education of all frontline healthcare staff across all available treatment systems. This may lead to more veterans accessing the Veterans Association. The HEE online module aimed at helping clinical staff understand the unique needs of the veteran community was viewed as being informative, although there were reports of it being repetitive, and time consuming. CONCLUSION The positive outcomes of this study in a very short time period are extremely encouraging, and it is highly likely that the number of veterans declaring their veteran status or registering with a GP for the first time is likely to increase. However, only a small number of younger veterans had registered, and there remains a need to catch those who never access a PHC practice. Research should explore the role of strong cultural links such as professional sports clubs (present in every UK city) and their role in promoting help seeking and mental/public health awareness. This should include if these mediums are: an attractive option for women; impacting on the family; influencing minority groups living in regions of health inequality including socially deprived areas. These important differences will add to an emerging coherent body of knowledge. This will present a better means for diversity and equability and produce a clear pathway to better PH and wellbeing models. In addition, there remains a requirement to reach family members who may act as a conduit to reach the elderly isolated veteran community living in care homes. There is an ongoing requirement to inform ex-service personnel of the 1 d inclusion criteria for veteran status, and the service provision available. The introduction of a one stop “Veteran’s Gateway”38 may achieve this, although how veterans will become aware of this service is untested. A better understanding of the Read Coding is required, reinforced by a re-invigoration of the campaign to routinely ask patients; “Have you or your family served?” The HEE29 online module advocates the use of a single veteran specific Read Code and there is a compelling case to confirm this position in policy. This would be assisted by developing health record systems that were synched to each other. Educational packages should prepare staff for the typical case presentations; reinforce person-centered and individualized care packages while encouraging staff to remain cognizant of the complexity behind those indicators. The developments in online educational program should be underpinned by common undergraduate syllabi. There is clear area for further development and evaluation, and to forge a relationship with a funder to support the initiative and research. All staff stated that they would agree to future studies if the human resource implications were addressed. There remains a need to encourage and help veterans to either self-support or seek help as early as possible. The reason for the improved numbers is multi factorial, and it is clear that the advertising campaign was a motivator. What is less clear is the impact that the researcher’s personal advocacy and intervention with staff had on motivating them to reach out to veterans within their PHC practice. The paper adds to the limited empirical research undertaken to explore help-seeking behavior in the armed forces community. It provides pointers to help isolated veterans to engage. The positive increase may result in those patients accessing care from specialist MH services. The striking aspect of this study is the simplicity of the intervention that can be replicated virtually anywhere. Therefore, the positive outcomes of increased awareness and staff commitment provide a template for sustainability that could be replicated nationally. STUDY LIMITATIONS The number of the veteran population is estimated on sampling, with the potential that the appraisal is artificially high. No data was collected regarding the Veteran’s military background such as length of service, service background, number and frequency of operational tours. The sample size for female veterans was small. The data did not define the impact that the author’s personal intervention and advocacy had on motivating staff to engage with veterans, and this has implications for wider transferability. It was recognized that the advertising strategy was unlikely to access every veteran, but the intent was to determine if this cost effective strategy could be successful. Read coding was from patient declaration, and no checks were in place to determine that they served in the Armed Forces. The study recommendations are in Table IV. Previous Presentations This paper has been presented at the VA hospital in Pennsylvania, USA on 6 September 2017 and at the University of Chester, England Veterans Symposium on 5 October 2017. Funding UK National Health Service. Acknowledgments Colonel Nick Medway. References 1 National Health Services Digital. Read codes. 2017. 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Author notes The views expressed are solely those of the authors and do not reflect the official policy position of the UK Royal Navy, British Army, Royal Air Force, Ministry of Defence, or UK Government. © Association of Military Surgeons of the United States 2018. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

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Military MedicineOxford University Press

Published: May 9, 2018

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