LAY SUMMARY The Canadian Forces Cancer and Mortality Study (CFCAMS) is an example of a study that uses the life-course approach to research. This article provides an overview of CFCAMS challenges and solutions. Institutional challenges arise from the different mandates of the Department of National Defence and Veterans Affairs Canada. These challenges were addressed by collaboration with Statistics Canada. Data-driven challenges were addressed by data linkage in a secure environment at Statistics Canada. Budget-based challenges could be addressed only for topics that aligned with funded priorities. Human-resource-related challenges include recruitment and retention of experienced personnel, and addressing these challenges is an ongoing issue. These interconnected challenges can leave gaps that result in unrealized stakeholder expectations. Policy-relevant research must incorporate these expectations. Understanding the roles and structures required to generate life-course research can lead to increased influence on policy and practice.
Background Military personnel may be exposed to hazardous substances or environments, making health surveillance critical. However, surveillance is frequently handicapped by long lag times between exposure(s) and outcomes, which often manifest post-military release and are often not recorded.
Aims To describe the burden of mortality in still serving and released Canadian Armed Forces (CAF) personnel.
MethodsThe Canadian Forces Cancer and Mortality Study II (CF CAMS II) is an interdepartmental record linkage study using CAF pay data and Statistics Canada cancer and mortality data. The cohort included all Regular Force and class C Reservist men and women who first enrolled in the CAF between 1976 and 2012, inclusive. The anonymized linked data included death data, including cause and location of death. All-cause mortality (ACM) and International Classification of Disease (ICD)-10 chapter-level mortality (CLM) were quantified using standardized mortality ratios (SMRs), with the Canadian general population (CGP) as the reference population.
ResultsApproximately 6870 deaths occurred during over 5 million person-years of observations. For ACM, the CAF risk of death was significantly lower than the CGP for both sexes (females: n = 540, SMR = 0.76 [95% CI 0.69–0.82]; males: n = 6330, SMR = 0.79 [95% CI 0.77–0.81]). In the CLM analysis, SMRs were significantly lower than, or not statistically different from, 1.0 for all ICD chapters.
ConclusionsMilitary service may have a protective effect that may be partly explained by the healthy soldier effect and the stringent selection process at enrolment.
LAY SUMMARY The Veteran Suicide Mortality Study describes the risk of death by suicide for Canadian Veterans using data linkage at Statistics Canada. The study includes Veterans released with Regular Force or Reserve Force Class C service over the period 1976-2012. Both male and female Veterans had higher risk of suicide if they released at non-officer ranks. For men, the risk of suicide death peaked around four years after release from the military. For women, the risk of suicide death peaked around 20 years after release. This study provides information for the timing of prevention efforts.
BACKGROUND: Self-rated health is an useful indicator of the general health in specific populations and used to propose interventions after service in the military context. However, there is scarce literature about self- rated health (SRH) in the Canadian Veterans of the Reserve Force and its relationship with demographic, health and occupational characteristics of this specific group. The aims of this research were to determine the SRH in Canadian Reserve Force Veterans and to explore the relationship between demographic, military service and health factors by reserve class. METHODS: Data from the individuals was collected from the Life After Service (LASS) 2013 survey, including Veterans with Reserve Class C (n = 922) and Class A/B (n = 476). Bivariate and multivariate analysis using logistic regression models, were used to assess the association between the demographic characteristics, physical health, mental health, and military service characteristics and the self-rate health by both reserve classes. RESULTS: The overall prevalence of poor SRH in Reserve Class C Veterans was 13.1% (CI:11.08–15.4) and for Reserve Class A/B was 6.9% (CI:5.0–9.1). Different degrees of associations were observed during the bivariate analysis and two different models were produced for each reserve class. Veterans of Reserve Class C showed that being single was (OR = 2.76, CI: 1.47–5.16), being 50–59 years old (OR = 4.6, CI: 1.28–17.11), reporting arthritis (OR = 2.49, CI: 1.33–4.67), back problems (OR = 3.02, CI:1.76–5.16), being obese (OR = 1.96, CI: 1.13–3.38), depression (OR = 2.34, CI: 1.28–4.20), anxiety (OR = 4.11, CI: 2.00–8.42), PTSD (OR = 2.1 CI: 0.98–4.47), PTSD (OR = 20.9, CI:0.98–4.47) and being medically released (OR = 4.48, CI: 2.43–8.24) were all associated with higher odds of poor SRH. The Reserve Class A/B model showed that completing high school (OR = 4.30, CI: 1.37–13.81), reporting arthritis (6.60, CI: 2.15–20.23), diabetes (OR = 11.19, CI: 2.72–46.0), being obese (OR = 3.37, CI: 1.37–8.27), daily smoking (OR ...
LAY SUMMARY This work investigated factors associated with medicinal cannabis authorization dosage among 9,104 Canadian Armed Forces Regular Force Veterans in Canada with a valid Cannabis for Medicinal Purposes reimbursement on Dec. 31, 2020, and identified various socio-demographic, Veterans Affairs Canada (VAC) pensionable conditions, and military service characteristics associated with higher-dose medicinal cannabis authorizations. Among those with higher dose reimbursements were Veterans under the age of 30 years, males, those receiving benefits for health conditions (e.g., hearing loss, musculoskeletal, or mental health conditions), those participating in VAC rehabilitation services, those with an earlier year of reimbursement, those who were released involuntarily from service, and those indicating land military environment service at date of release. In statistical models investigating the impact of multiple factors, some of the strongest associations with higher dosages were observed for Veterans with mental health conditions, those with earlier reimbursements, and province of residence. Introduction: Since 2008, Veterans Affairs Canada (VAC) has provided Canadian Armed Forces Regular Force Veterans with reimbursement of Cannabis for Medical Purposes (CMP) authorizations. The authorized dosage and authorization criteria have changed with time. This study investigated factors associated with CMP authorizations and dosage among CMP-authorized Veterans. Methods: CMP authorizations among 9,104 Veterans residing in Canada on Dec. 31, 2020, were linked with VAC reimbursement, VAC client, and military personnel records. Multivariable logistic regression models were used to examine relationships between CMP dosage and socio-demographic, health, and military characteristics. Results: Among Veterans with CMP authorizations, the strongest associations with a larger authorization dosage (4–10 grams vs. 1–3 grams) were observed for Veterans receiving benefits for mental health conditions in combination with other health conditions (OR = 3.47 compared with those with no mental health conditions). A larger authorization dosage was associated with province of residence (OR = 3.36 for New Brunswick compared with Ontario), earlier year of authorization (OR = 2.19 for 2014) compared with 2016, being male (OR = 1.68), active participation in a rehabilitation program (OR = 1.45), land environment at the time of release from military service (OR = 1.24) compared with air environments, and involuntary release from service (OR = 1.65) and medical release (OR = 1.11) compared with voluntary release. Discussion: Factors associated with larger CMP authorization dosage among military Veterans in Canada appeared multifactorial, spanning socio-demographic, health, and military characteristics. This complexity should be considered by treatment providers and clinicians working with military Veterans.
Introduction: Suicide prevention for Veterans is a public health priority. However, it has been challenging to study suicide in Canadian Veterans post-release from the military. The Veteran Suicide Mortality Study (VSMS) has assembled data on the risk of death by suicide for Canadian Veterans compared to other Canadians. Methods: This was a record linkage study of Canadian cause of death data from Statistics Canada linked with a cohort of Canadian Veterans from pay data of the Canadian Armed Forces (CAF). The population-based cohort included Veterans released with Regular Force or Reserve Force Class C service for the period 1976–2012. Death by suicide was identified by International Classification of Diseases (ICD) codes. Estimates of relative risk for suicide were calculated using standardized mortality ratios (SMRs) with the Canadian general population (CGP) as the reference. Results: Male Veterans had a higher risk of suicide compared to the CGP (SMR = 1.36 [95% CI, 1.30–1.44]). Female Veterans also had a higher risk (SMR = 1.81 [95% CI, 1.40–2.31]). Suicide risk for Veterans was consistently higher than for the CGP over the 37 years of follow-up. Risk for male Veterans was highest for those under 25 years old and decreased with age, but risk for females was higher than the CGP regardless of age. Discussion: The finding of higher risk of death by suicide for both male and female Veterans compared to the CGP informs the action plans of the recently released suicide prevention strategy. Future studies will identify other characteristics of subgroups of Veterans at higher risk of suicide.
Introduction: Work satisfaction contributes to the health and well-being of Veterans transitioning to civilian life after service. Therefore, the purpose of this study is to examine the factors contributing to work satisfaction among Canadian Veterans. Methods: We examine multiple factors thought to be associated with work satisfaction using the cross-sectional 2010 survey of the Life After Service Studies (LASS) program of research, which includes a national sample of 3,154 Canadian Veterans released from the regular forces between 1998 and 2007. We performed both unadjusted and adjusted logistic regression models for three rank groupings: privates and cadets, Non-Commissioned Members (NCMs), junior and senior, and officers (junior and senior). Results: In the year after release, 73% of Veterans were satisfied with their work. Officers (89%) were the most satisfied, followed by NCMs (77%), and privates and cadets (52%). Using unadjusted models, factors associated with higher satisfaction rates were: release due to reaching retirement age; being older than 50; reporting no work stress; reporting knowledge, skills, and ability transferability; and similar job tasks between military and civilian occupations; reporting easy adjustment to civilian life; and being satisfied with finances. Using adjusted models, only satisfaction with finances was associated with work satisfaction for NCMs, privates, and cadets. Only involuntary release and years of service were associated with work satisfaction for officers. Discussion: Work satisfaction rates varied considerably according to military rank, and were highest among officers and lowest among privates and cadets. This suggests a need to account for rank when developing strategies to improve work satisfaction rates and reintegration into civilian life among Veterans.
LAY SUMMARY The objective of this research was to explore the association between demographic and service characteristics and mental health in Canadian Veterans of the Reserve Force. The Reserve Force Class C model showed that marital status, age, chronic pain, depression, anxiety, posttraumatic stress disorder (PTSD), and type of release were associated with mental health. The Reserve Force Class A/B model showed that age, depression, anxiety, PTSD, and type of release were associated with mental health. These results showed that similar factors were associated with the mental health score, with different degrees of association by reserve class. These results will help to better describe Reserve Force Veterans that may require mental health assistance.
Introduction: In Canada, there are an estimated 700,000 Veterans of the Canadian military. Veterans are disproportionately prevalent in sub-populations of males, persons with chronic physical conditions, chronic pain, mental health conditions, and those with disabling activity limitations. Veterans are a population of interest to Canadian researchers, but there is no publicly available comprehensive list of Veterans in Canada. This creates a need for a standard set of screening questions suitable for self-report surveys. This article proposes a series of screening questions to identify Canadian Veterans. Methods: The content of the questions were developed considering self-identity, past Canadian surveys, legislation, and relevant characteristics of Canadian military service. Results: The recommended Canadian Veteran identifier questions are: "Have you ever had any Canadian military service? Was this service with the Regular Force? Reserve Force? Navy? Army? Air Force? Are you currently in the Canadian Armed Forces? What year were you released from the Canadian Armed Forces? What year did you join the Canadian Armed Forces?" Discussion: The consistent use of these screening questions allows for comparisons with other studies and will contribute to a better understanding of Veterans in Canada and of the transition from military to civilian life.
Introduction: The Survey on Transition to Civilian Life (STCL) was created to measure the adjustment outcomes of recently released Canadian Armed Forces (CAF) members. The survey was administered to a sample of CAF regular force members released from 1998 to 2007. The aim of the current study was to examine resources that promote the successful adjustment to civilian life. Specifically, the goal was to conduct a secondary analysis of the STCL that examined the roles of mastery and social environment (that is, community belonging and satisfaction with support) in the transition to civilian life, as well as how these variables correlate with health and life stress. Methods: The sample data were used to conduct Kendall's tau correlations. Prevalence estimates, 95 per cent confidence intervals, and ordinal logistic regressions were conducted using weighted data that accounted for the complex survey design to ensure findings were representative of the sampled veteran population. Results: Ordinal logistic regression results revealed that mastery, satisfaction with types of social support (friends and family), and a sense of community belonging acted as potential protective factors that were associated with easier adjustment to civilian life for Veterans with physical health conditions, mental health conditions, and higher levels of life stress. The first model showed that the odds of an easier adjustment were lower for those who were more stressed (adjusted odds ratio [AOR]=0.13), self-reported a physical health condition (AOR=0.53), and self-reported a mental health condition (AOR=0.23). The second model revealed that the odds of an easier adjustment were lower for those Veterans dissatisfied with their family relationships (AOR=0.42) and their relationships with friends (AOR=0.47) and those with a very weak sense of community belonging (AOR=0.39), and they were higher among those with high levels of mastery (AOR=3.93). Discussion: The results of this study point to the importance of personal characteristics and aspects of the social environment in the adjustment to civilian life among military veterans. As well, ensuring a successful adjustment to civilian life may lead to better outcomes, such as enhanced mastery, following transition.
Exposure assessment is an important factor in all epidemiological research seeking to identify, evaluate, and control health risks. In the military and veteran context, population health research to explore exposure-response links is complicated by the wide variety of environments and hazards encountered during active service, long latency periods, and a lack of information on exposures in potentially vulnerable subgroups. This paper summarizes some key considerations for exposure assessment in long-term health studies of military populations, including the identification of hazards related to military service, characterization of potentially exposed groups, exposure data collection, and assignment of exposures to estimate health risks. Opportunities and future directions for exposure assessment in this field are also discussed.
LAY SUMMARY Little is known about the mental health of Veterans as they get older. How does the mental health and aging process of Veterans compare to people who have not served in the military? The Canadian Longitudinal Study on Aging (CLSA) is a long-term national study of the aging adult population in Canada. A total of 51,338 participants across Canada aged 45 to 85 years were recruited at the study baseline between 2011 and 2015. Of the CLSA participants, about 4,500 self-identified as Veterans, with military service dating back as early as 1941. The goal of this study was to describe the mental health, in particular posttraumatic stress disorder, of Veterans in the CLSA at the study baseline and examine differences across Veteran sub-groups and compared to non-Veterans.
Introduction: The risks of suicidality (suicidal ideation or behaviour) are higher in Canadian Armed Forces (CAF) Veterans (former members) than in the Canadian general population (CGP). Suicide prevention is everyone's responsibility, but it can be difficult for many to see how they can help. This article proposes an evidence-based theoretical framework for discussing suicide prevention. The framework informed the 2017 joint CAF – Veterans Affairs Canada (VAC) suicide prevention strategy. Methods: Evidence for the framework was derived from participation in expert panels conducted by the CAF in 2009 and 2016, a review of findings from epidemiological studies of suicidality in CAF Veterans released since 1976, suicide prevention literature reviews conducted at VAC since 2009, and published theories of suicide. Results: Common to all suicide theories is the understanding that suicide causation is multifactorial, complex, and varies individually such that factors interact rather than lie along linear causal chains. Discussion: The proposed framework has three core concepts: a composite well-being framework, the life course view, and opportunities for prevention along the suicide pathway from ideation to behaviour. Evidence indicates that Veterans are influenced onto, along, and off the pathway by variable combinations of mental illness, stressful well-being problems and life events, individual factors including suicidal diathesis vulnerability, barriers to well-being supports, acquired lethal capability, imitation, impulsivity, and access to lethal means. The proposed framework can inform discussions about both whole-community participation in prevention, intervention and postvention activities at the individual and population levels, and the development of hypotheses for the increased risk of suicidality in CAF Veterans.
IntroductionTo compare 1990-91 Gulf War Veterans (GWV) survival outcomes with a comparable cohort, UK's Ministry of Defence and Canada's Department of National Defence combined data from their respective cohorts. The survival estimates/comparisons emanating from this collaboration will be novel as they will control for healthy worker/soldier effect (HW/SE).
Objectives and ApproachGWV cohort building and record linkage methods used by Canada and the UK are described in more detail elsewhere. To ensure comparability in mortality outcomes between cohorts, the following steps will be conducted prior to analysis:
ICD-9 causes of death (COD) will be recoded to ICD-10; recoding by each country will be cross-validated by the other, to ensure high inter-coder reliability;
CODs will be analysed at the ICD-chapter level;
Calculated age- and sex-specific rates will be directly standardized using the WHO 2012-2022 Standard Population. Cox proportional hazards will be used to compare survival between cohorts.
ResultsWe are currently in the process of completing this exciting cross-sectoral linkage study and expect to have preliminary results to present. To our knowledge, this will be the first time that mortality outcomes for two discrete Gulf War veteran cohorts (ascertained by record linkage) will be analytically compared, rather than comparing to the general population. These findings will not only provide a more recent evaluation of the health status of GWV in Canada, but will also be a rare opportunity to control for the HW/SE, using comparisons with non-equivalent cohorts (e.g., general population, other deployment) cannot achieve.
Conclusion/ImplicationsBeyond evidence of a strong inter-sectoral research relationship between military nations, these findings also represent a feasible solution to controlling for the HW/SE. The ability to control for this will mean more accurate UK and Canada GWV mortality/survival estimates than either country can generate on their own.
Introduction: Veteran homelessness is an issue gaining in visibility. Both Veterans and the homeless seem to be more susceptible to an array of physical health issues than the general population. However, very little is known about the health status of homeless Veterans in Canada. A more thorough knowledge of the physical health status of homeless Veterans could help better target services. This study has two objectives: (1) to estimate the prevalence of physical health conditions in a Canadian sample of homeless Veterans with mental illness and (2) to compare the prevalence observed in Veterans with a matched sample of homeless non-Veterans. Methods: The data come from a Canadian multi-site randomized trial, At Home/Chez Soi, that studies the effectiveness and efficiency of a Housing First program combined with a recovery-oriented approach to care. The present article is a cross-sectional analysis of baseline data. The participants are a volunteer sample of 99 homeless or precariously housed Veterans suffering from severe and persistent mental health problems and a matched sample of 99 non-Veterans. The data come from self-reported measures administered at baseline that describe chronic health conditions. Results: Veterans presented with five physical health conditions on average, the more common being dental problems, head injuries, musculoskeletal injuries, and foot problems. Both the number of conditions and the prevalence of each condition were similar to that of a matched comparison group of non-Veterans. Discussion: The number and severity of physical health conditions observed in our sample of homeless Veterans and non-Veterans suggest similar needs for physical health services in addition to housing services. Interventions targeting this population should therefore include a wide array of expertise and interdisciplinary collaboration to fit the various profiles of Veterans and non-Veterans in terms of housing, mental health, and physical health needs.
