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. Author manuscript; available in PMC: 2023 Dec 1.
Published in final edited form as: Health Psychol. 2021 Nov 15;40(11):737–746. doi: 10.1037/hea0001110

Post-9/11 Veterans’ Heart Disease Knowledge, Self-Perceived Risk, and Prevention Beliefs and Behaviors

Allison E Gaffey a,b, Sally G Haskell a,c, Cynthia A Brandt a,d, Lori A Bastian a,c, Judith L Meadows a,b, Matthew M Burg a,b,e
PMCID: PMC10691753  NIHMSID: NIHMS1853969  PMID: 34780203

Abstract

Objective:

Veterans, including the growing number of women veterans, have a greater risk of heart disease than non-veterans, and the incidence of heart disease is increasing among the most recent veterans who participated in post-9/11 military conflicts. Investigating heart disease-related knowledge, self-perceived risk, and prevention beliefs and behavior among these veterans and identifying potential differences in knowledge, risk, beliefs and behavior between men and women, may guide prevention strategies.

Methods:

Cross-sectional data from a nationwide survey of 1,141 (53% women) post-9/11 veterans were used to examine heart disease awareness and information-seeking, perceived risk and importance of heart disease risk factors, beliefs about traditional (e.g., weight, blood pressure) and nontraditional (e.g., stress, sleep) factors, and engagement in prevention behaviors. Differences between men and women were also tested, using t-tests, chi-square and Fisher’s exact tests.

Results:

Only one third reported they felt very informed or sought information about heart disease, or that their providers had discussed heart disease with them. Although veterans generally believe that addressing traditional and nontraditional factors can reduce their risk of heart disease, far fewer endorsed the value of mental health treatment in prevention. Overall, women were slightly more knowledgeable about heart disease risk, and of behaviors that can lower this risk, but for both men and women, this knowledge did not translate to engaging in equivalent prevention behaviors.

Conclusions:

Post-9/11 veterans, and potentially their providers, may each benefit from improved education regarding their risk of heart disease. Veterans may also require better, more personalized approaches to prevention.

Keywords: cardiovascular disease, health knowledge, attitudes, practice, prevention, sex differences, veterans

Introduction

Compared to the general population, military service veterans show a higher prevalence of behavioral and psychological factors that are associated with an increased risk for heart disease (e.g., smoking, obesity, hypertension, posttraumatic stress disorder [PTSD] (Haskell et al., 2017; Rose, Farmer, Yano, & Washington, 2013; Vimalananda et al., 2013)), and heart disease is more prevalent among veterans than their non-veteran counterparts (Assari, 2014; Han, Yano, Watson, & Ebrahimi, 2019; Hoerster et al., 2012; Lehavot, Hoerster, Nelson, Jakupcak, & Simpson, 2012). As the onset of heart disease typically occurs during middle and older adulthood, it is concerning that rates of heart disease are increasing among the most recent cohort of veterans, those who served during conflicts in Iraq and Afghanistan (i.e., post-9/11 veterans), even though ~75% of the cohort are aged 45 years or younger (National Center for Veterans Analysis and Statistics, 2017). Thus, post-9/11 veterans may require better education concerning heart disease prevention and risk factor mitigation (Haskell et al., 2017; Whitehead et al., 2013), and may yield the greatest long-term health benefit from these efforts.

The proportion of veterans who are women has doubled in the last decade (Frayne et al., 2014) and women are expected to represent 20% of veterans by 2045 (Veteran Population Projections: FY2015 to FY2045, 2018). Women veterans are considerably younger, and more racially and ethnically heterogenous compared to their male counterparts, particularly members of the post-9/11 cohort (Haskell et al., 2011). Among veterans, sex differences have been observed in risk factors for heart disease, screening and management, and in the provision of evidence-based treatment (Han et al., 2019; Haskell et al., 2014; Haskell et al., 2017; Vimalananda et al., 2013; Virani et al., 2015; Whitehead et al., 2019), possibly because women’s risk profile includes more nontraditional factors associated with heart disease (e.g., mental health disorders) compared to that of men (Farmer et al., 2019; Han et al., 2019). As women who enroll in care at Veterans Affairs (VA) medical centers utilize more services than men (Frayne et al., 2018), the Veterans Health Administration (VHA) and private healthcare systems alike face a growing need to address heart health for a more diverse, yet medically-complex veteran population, and to ensure that preventive care meets the distinct needs of women as well as those of men (Frayne et al., 2018; Frayne et al., 2014).

Although men and women veterans show a higher risk for heart disease than non-veterans (Hoerster et al., 2012; Lehavot et al., 2012), only a few small studies have examined their heart disease awareness and self-perceived risk, or if women veterans differ from their male counterparts. One sample of 104 veterans aged 35 years and older (14% women), scored an average of 85% on the Heart Disease Fact Questionnaire, indicating “adequate” knowledge of heart disease, but with no difference by sex (Angosta, Reyes, Cross, Pollom, & Sood, 2021). Another study of 162 women veterans aged 45–85 who had a moderate or high risk of heart disease found low levels of knowledge and awareness of heart disease, and of risk factors for, and health consequences of heart disease (Canter, Atkins, McNeal, & Bush, 2009). In a survey of 328 women veterans aged 35 years and older, only 42% reported concern about coronary artery disease (Biswas, Calhoun, Bosworth, & Bastian, 2002), less than half of those with hypertension, sedentary lifestyles, or regular tobacco use endorsed worrying about their risk, and 76% indicated that they were less likely to be diagnosed with coronary artery disease than other same-aged women. It is important to note that these small studies included veterans from multiple military service eras, including Korea and Vietnam, along with service eras in between conflicts. Furthermore, the collected data do not provide for a test of whether differences in knowledge, perceived risk, or related behaviors differ between men and women veterans.

With the emerging evidence of their early elevated risk for heart disease, it remains important to determine how knowledgeable post-9/11 veterans are about heart disease and the factors that contribute to heart disease risk, the degree of their self-perceived risk, and of their engagement in lifestyle behaviors that contribute to or reduce the risk of heart disease. Assessment of these factors can help to identify potential knowledge gaps and help translate these gaps into better targeted disease prevention efforts that can be tailored according to any identified differences between men and women veterans. The objectives of these analyses were therefore to determine the degree of heart disease-related knowledge, beliefs about heart disease risk and prevention, and engagement in heart disease prevention behavior among a cohort of men and women post-9/11 veterans. As men and women may demonstrate differences in these heart disease-related metrics, a second objective was to test if there were differences by sex. Addressing both objectives may help to identify opportunities to improve heart disease awareness and for earlier prevention among this higher risk group of men and women veterans.

Method

Participants and Procedures

The Women Veterans Cohort Study (WVCS) is a longitudinal investigation of physical and mental health, risk factors for health conditions, and healthcare utilization among both men and women veterans who were discharged from military service as of October 1, 2001 (i.e., post-9/11 military conflicts - Operations Enduring Freedom, Iraqi Freedom, or New Dawn) and who elected to utilize VA care (Gaffey et al., 2021). WVCS includes an electronic health record (EHR) cohort, and a survey cohort that is comprised of a geographically-representative subsample of the EHR cohort. Among veterans who were discharged from military service after the index date and receiving healthcare at VAs located in Durham, North Carolina; Indianapolis, Indiana; Los Angeles, California; and throughout the New England VA system, all women, and a random sample of men were invited to participate in the survey cohort. Enrollment occurred from February 11, 2016-October 28, 2019, during which eligible veterans received enrollment letters, the consent form, and a paper version of the survey. Of the 4,729 veterans who were eligible to participate, 1,145 completed the survey (32.2%), with 1,141 providing information about their sex. Survey respondents received $20 in compensation. Study procedures were approved by the VA Connecticut Healthcare System Institutional Review Board.

Demographics and Health Information

Participants reported sociodemographic information including age, sex, race, ethnicity, marital status, education, employment, personal income, living with children <18 years old, military service branch (i.e., Army, Air Force, Navy/Coast Guard, Marines), and health insurance status. Included in the survey were questions pertained to heart disease risk (e.g., smoking, height and weight to calculate body mass index [BMI]). Recent health status was also assessed by querying participants about medical treatment that they had received in the past 12 months for among other things, high blood pressure, diabetes, stroke, depression, anxiety, or an emotional disorder, PTSD, and drug or alcohol abuse.

Heart Disease Knowledge, Risk Awareness, and Preventive Behavior

The evaluation of heart disease knowledge, perceived risk, and preventive behavior was derived from questions in the Women’s Health Study that was sponsored by the American Heart Association (Mosca, Ferris, Fabunmi, & Robertson, 2004; Mosca, Mochari-Greenberger, Dolor, Newby, & Robb, 2010). The first section concerned how participants had learned about heart disease and how informed they viewed themselves. Specific questions included, “How informed are you about heart disease?” with 5 response options: Very well-informed, Well-informed, Somewhat informed, Not at all informed, and Don’t know. Participants were also asked “Have you used any of the following internet sources to learn more about heart disease in the last 12 months?” Participants could respond Yes, No, or, “I have not used any internet sources to learn more about heart disease” to a list of sources (e.g., news websites such as CNN, medical information websites such as WebMD, and search engines such as Google). A third question was, “Have any of your doctors ever discussed heart disease with you when discussing your health?” Potential responses were Yes, No, or Don’t know or remember.

The second section concerned knowledge of specific heart disease risk factors and perceived level of heart disease risk. Questions included, “How important do you think each of the following is as a risk factor for having a heart attack or stroke (e.g., heredity, high blood pressure, depression, PTSD)?” Responses were recorded on a 7-point scale ranging from Very little importance = −3 to Very much importance = +3, with 0 as a midpoint. Descriptive data are presented for those who endorsed a risk factor as “very much importance” (i.e., 3 on the scale). This section also included the question: “If you compare yourself with other veterans of your age and gender, what is your likelihood of experiencing the following health problems?” followed by a list of health problems (e.g., high blood pressure, diabetes, stroke). Responses were recorded on a 7-point scale ranging from Much below Average = −3 to Much above average = +3, with 0 as a midpoint. Descriptive data are presented for those who endorsed an “above average” likelihood of a health problem (i.e., 1–3 on the scale).

The third section concerned heart disease prevention. Questions were, “Which of the following activities do you believe can prevent or reduce the risk of getting heart disease?” and “Which of the following activities do you do to prevent or reduce the risk of getting heart disease?” These two questions were accompanied by a duplicate checklist of activities (e.g., quitting smoking, losing weight, reducing stress). Finally, participants responded to the question, “Have you done any of these activities to monitor or improve your health in the last year?” Participants were asked to endorse all behaviors that applied to them based on a detailed list (e.g., visited a health care professional, lost weight, tried to better manage stress).

Statistical Analysis

Analyses were performed using SAS Version 9.4 (SAS Institute, Cary, NC) with p<0.05 (two-sided) indicating statistical significance. Regression-based multiple imputation (5 iterations) was used to account for missing data. Data are first presented for the entire cohort and by sex using means, standard deviations, proportions, and percentages. Potential sex differences in demographics, health risk factors, medical conditions, health insurance, and heart disease knowledge, awareness, and behavior were next examined using t-tests for continuous variables, Fisher’s exact test for binary variables, and Pearson’s chi-square test for nominal variables with more than two categories. The phi (ϕ; for binary comparisons) and Cramer’s V coefficients (φc; for comparisons with more than two categories) were calculated to measure the effect size. The statistics range from 0 to 1.00, with 0–0.10 signifying a very weak association, 0.10–0.20 as a weak association, 0.20–0.30 as a moderate association, and ≥.30 as a strong association. There was no adjustment for multiple comparisons.

Results

Sociodemographic Characteristics (Table 1)

Table 1.

Sociodemographic Characteristics of Women Veterans Cohort Study (WVCS) Respondents.

Overall (n = 1141) Sex
Men (n = 555) Women (n = 586) P
Age 43.85±10.89 46.22 ±11.02 41.61±10.29 <0.001
 20–29 60 (5.26) 20 (3.60) 40 (6.83) <0.001
 30–39 443 (38.83) 170 (30.63) 273 (46.59)
 40–49 258 (22.61) 143 (25.77) 115 (19.62)
 50–59 276 (24.19) 150 (27.03) 126 (21.50)
 ≥60 104 (9.11) 72 (12.97) 32 (5.46)
Race/Ethnicity 0.035
 White 881 (77.21) 448 (80.72) 433 (73.89)
 Black 108 (9.47) 41 (7.39) 67 (11.43)
 Hispanic 79 (6.92) 36 (6.49) 43 (7.34)
 Other/Unknown 73 (6.40) 30 (5.41) 43 (7.34)
Marital status <0.001
 Married 637 (55.83) 364 (65.59) 272 (46.59)
 Divorced/Separated 226 (19.81) 86 (15.49) 140 (23.89)
 Single 274 (24.01) 104 (18.74) 170 (29.01)
Education <0.001
 High school 238 (20.86) 152 (27.39) 86 (14.68)
 Some college 274 (24.01) 127 (22.88) 147 (25.09)
 ≥ College graduate 629 (55.12) 276 (49.73) 353 (60.23)
Employment <0.001
 Employed 692 (60.76) 362 (65.46) 330 (56.31)
 Unemployed 73 (6.41) 36 (6.51) 37 (6.31)
 Student 100 (8.78) 31 (5.61) 69 (11.77)
 Homemaker 38 (3.34) 1 (0.18) 37 (6.31)
 Unable to Work 65 (5.71) 24 (4.34) 41 (7.00)
 Retired 171 (15.01) 99 (17.90) 72 (12.29)
Personal Income <0.001
 <$25,000 348 (30.50) 130 (23.42) 218 (37.20)
 $25,001-$50,000 291 (25.50) 145 (26.13) 146 (24.91)
 $50,001-$100,000 368 (32.25) 196 (35.32) 172 (29.35)
 ≥$100,001 104 (9.12) 71 (12.79) 333 (5.63)
Living with Children <18 Years Old 466 (40.84) 213 (38.38) 253 (43.17) 0.100
Branch <0.001
 Army 695 (60.91) 333 (60.00) 362 (61.77)
 Air Force 188 (16.48) 78 (14.05) 110 (18.77)
 Navy/Coast Guard 165 (14.46) 83 (14.95) 82 (13.99)
 Marines 84 (7.36) 56 (10.09) 28 (4.78)
Medical History
 Current Smoker 160 (14.02) 75 (13.51) 85 (14.51) 0.45
 Obese 723 (63.37) 341 (61.44) 382 (65.19) 0.20
 High blood pressure 228 (19.98) 143 (25.77) 85 (14.51) <0.001
 Diabetes 81 (7.10) 54 (9.73) 27 (4.61) <0.001
 Stroke 8 (0.70) 2 (0.36) 6 (1.02) 0.18
 Depression, anxiety, or an emotional disorder 496 (43.47) 206 (37.12) 290 (49.49) <0.001
 Drug or alcohol abuse 54 (4.73) 31 (5.59) 23 (3.92) 0.19
 PTSD 420 (36.81) 200 (36.04) 220 (37.54) 0.60
Health Insurance 0.17
 Medicaid/Medicare/VA 339 (29.71) 162 (29.19) 177 (30.20)
 Private insurance/self-pay 672 (58.90) 339 (61.08) 333 (56.83)
 Uninsured 130 (11.39) 54 (9.73) 76 (12.97)
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Notes. Data are presented as mean ± standard deviation or n (%). Comparisons by sex are based on t-tests, chi-square tests, or Fisher’s exact test. PTSD, posttraumatic stress disorder; VA, Veterans Affairs medical centers.

The mean age of the WVCS survey sample was 43.9 ± 10.9 years, and the largest age group was 30–39 years (38.8%). Women were significantly younger than men (41.6 vs. 46.2 years, p < 0.001), more racially diverse (e.g., 11.4% vs. 7.4% Black, p = 0.035), more likely to be single (29.0% vs. 18.7%, p < 0.001), and more educated (60.2% vs. 49.7%, graduated college, p < 0.001). Yet, women were also less likely to be employed (56% vs. 65%, p < 0.001), and reported a lower income (e.g., 5.6% vs. 12.8% endorsed a salary of ≥$100,001/year). More women than men served in the Air Force (18.8% vs. 14.1%) but fewer had served in the Marines (4.8% vs. 10.1%, p < 0.001). Obesity (63.4%), depression/anxiety (43.5%), and PTSD (36.8%) were the most prevalent health risk factors for the full cohort. Fewer women than men reported recent treatment for high blood pressure (14.5% vs. 25.8%, p < 0.001) or diabetes (4.6% vs. 9.7%, p < 0.001), but treatment for depression/anxiety/an emotional disorder was more commonly endorsed by women (49.5% vs. 37.1%, p < 0.001).

Heart Disease Knowledge and Information-seeking (Table 2)

Table 2.

Heart Disease Knowledge and Information-seeking Among Men and Women Veterans.

Question Overall (n = 1141) Men (n = 555) Women (n = 586) p φc/ϕ
How informed are you about heart disease? 0.80 0.03
Very well-informed 140 (12.31) 65 (11.75) 75 (12.84)
Well-informed 246 (21.64) 117 (21.16) 129 (22.09)
Somewhat informed 531 (46.70) 266 (48.10) 265 (45.38)
Not at all informed 164 (14.42) 77 (13.92) 87 (14.90)
Don’t know 60 (5.26) 30 (5.41) 30 (5.12)
Have you used any of the following internet sources to learn more about heart disease in the last 12 months?a
News websites 84 (7.36) 51 (9.19) 33 (5.63) 0.007 0.07
Medical information websites 233 (20.42) 93 (16.76) 140 (23.89) 0.003 0.09
Search engines 232 (20.33) 110 (19.82) 122 (20.82) 0.71 0.01
Government websites 86 (7.54) 38 (6.85) 48 (8.19) 0.43 0.03
Magazine websites 22 (1.93) 14 (2.52) 8 (1.37) 0.20 0.04
General information 90 (7.89) 51 (9.19) 39 (6.66) 0.12 0.05
Social networking 53 (4.65) 29 (5.23) 24 (4.10) 0.40 0.03
Nonprofit health organization sites 116 (10.17) 39 (7.03) 77 (13.14) <0.001 0.10
Other websites 70 (6.13) 42 (7.57) 28 (4.78) 0.06 0.06
None 710 (62.23) 336 (60.54) 374 (63.82) 0.27 0.03
Has a doctor ever discussed heart disease with you? 0.001 0.11
Yes 396 (34.83) 214 (38.77) 182 (31.11)
No 583 (51.28) 252 (45.65) 331 (56.58)
Don’t know or remember 162 (14.20) 89 (16.04) 73 (12.46)
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Notes. Data are presented as n (%). Comparisons by sex are based on chi-square and Fisher’s exact tests. φc/ϕ refers to the Cramer’s V and phi effect sizes.

a

Statistics are based on those who responded affirmatively to each item.

Overall, only a third of the sample (34.0%) reported being “well-informed” or “very well-informed” or about heart disease, with no difference between women and men (X2 (4, N = 1141) = 1.07, p = 0.80). A little more than one third (37.8%) reported using the internet to learn about heart disease, and of these, more women reported that they searched medical information (23.9% vs. 16.8%, p = 0.003) and nonprofit health organization websites (13.1% vs. 7.0%, p < 0.001), while more men reported that they searched news websites (9.2% vs. 5.6%, p = 0.007). Similarly, only approximately one-third (34.8%) reported that a doctor had discussed heart disease with them, with a significantly lower percentage of women reporting this than men (31.1% vs. 38.8%, (X2 (2, N = 1141) = 13.59, p = 0.001).

Importance of Heart Disease Risk Factors and Personal Risk Assessment (Table 3)

Table 3.

Importance of Heart Disease Risk Factors and Personal Risk Assessment Among Men and Women Veterans.

Overall N=1141 Men n=555 Women n=586 p φc
 How important do you think each of the following is as a risk factor for having a heart attack or stroke?a
Heredity 433 (37.95) 168 (30.27) 265 (45.22) <0.001 0.16
Smoking 648 (56.79) 303 (54.59) 345 (58.87) 0.18 0.07
High blood pressure or hypertension 691 (60.56) 306 (55.1) 385 (65.70) 0.003 0.12
Diabetes 406 (35.58) 187 (33.69) 219 (37.37) 0.66 0.05
Lack of regular exercise 425 (37.24) 195 (35.14) 230 (39.25) 0.49 0.06
Being overweight 597 (52.32) 273 (49.19) 324 (55.29) 0.17 0.08
Diet 457 (40.05) 196 (35.32) 261 (44.54) 0.021 0.10
High cholesterol 523 (45.83) 225 (40.54) 298 (50.85) 0.008 0.11
Combat exposure 192 (16.83) 88 (15.86) 104 (17.75) 0.005 0.11
Depression 207 (18.14) 98 (17.66) 109 (18.60) 0.32 0.06
PTSD 229 (20.07) 116 (20.90) 113 (19.28) 0.31 0.07
TBI 179 (15.69) 91 (16.40) 88 (15.02) 0.46 0.06
  What is your likelihood of experiencing the following health
problems?b
High blood pressure or hypertension 524 (45.92) 285 (51.35) 239 (40.78) 0.005 0.11
High cholesterol 497 (43.56) 280 (50.45) 217 (37.03) <0.001 0.15
Diabetes 346 (30.32) 181 (32.61) 165 (28.16) 0.11 0.08
A heart attack 440 (38.56) 229 (41.26) 211 (36.01) 0.30 0.07
A stroke 384 (33.65) 198 (35.68) 186 (31.74) 0.22 0.07
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Notes. Data are presented as n (%). Comparisons by sex are based on chi-square tests. φc refers to Cramer’s V effect sizes.

a

Each item was rated on a scale from −3 (“Very little importance”) to 3 (“Very much important”). Percentages are listed for those who endorsed a factor as very much important.

b

Each item was rated on a scale from −3 (“Much below average”) to 3 (‘Much above average”) compared with other veterans of same age and sex. Percentages are listed for those who endorsed above average risk.

Smoking, high blood pressure, and weight were endorsed as the most important risk factors for heart disease by over half of veterans, while less than 20% endorsed depression, combat exposure, and traumatic brain injury as very important. Heredity (X2 (4, N = 1141) = 28.10, p < 0.001), high blood pressure (X2 (4, N = 1141) = 16.06, p = 0.003), diet (X2 (4, N = 1141) = 11.53, p = 0.021), high cholesterol (X2 (4, N = 1141) = 13.93, p = 0.008), and combat exposure (X2 (4, N = 1141) = 14.80, p = 0.005) were rated as very important risk factors by more women than men. Comparing themselves to veterans of the same age and sex, over 40% of the sample rated their personal risk of high blood pressure and high cholesterol as above average, with more men rating their risk of each condition as above average than women (high blood pressure: X2 (4, N = 1141) = 14.78, p = 0.005; high cholesterol: X2 (4, N = 1141) = 24.14, p < 0.001).

Heart Disease Prevention Beliefs and Behaviors (Table 4)

Table 4.

Heart Disease Prevention Beliefs and Behaviors Among Men and Women Veterans.

Overall N=1141 Men n=555 Women n=586 p ϕ
Which of the following do you believe can prevent or reduce the risk of getting heart disease?
Quitting smoking 1024 (89.75) 492 (88.65) 532 (90.78) 0.24 0.04
Getting physical exercise 1095 (95.97) 522 (94.05) 573 (97.78) 0.001 0.09
Losing weight 1050 (92.02) 504 (90.81) 546 (93.17) 0.16 0.04
Reducing stress 1046 (91.67) 498 (89.73) 548 (93.52) 0.024 0.07
Reducing sodium or salt in your diet 858 (75.20) 420 (75.68) 438 (74.74) 0.73 0.01
Reducing animal products in your diet 544 (47.68) 249 (44.86) 295 (50.34) 0.066 0.05
Maintaining a healthy blood pressure 1007 (88.26) 482 (86.85) 525 (89.59) 0.17 0.04
Maintaining a healthy cholesterol level 975 (85.45) 462 (83.24) 513 (87.54) 0.044 0.06
Praying or meditating 453 (39.70) 207 (37.30) 246 (41.98) 0.12 0.05
Getting adequate sleep 915 (80.19) 428 (77.12) 487 (83.11) 0.012 0.08
Mental health treatment 633 (55.48) 294 (52.97) 339 (57.85) 0.11 0.05
Which of the following activities do you do to prevent or reduce the risk of getting heart disease?
Quitting smoking 363 (31.81) 186 (33.51) 177 (30.20) 0.25 0.04
Getting physical exercise 809 (70.90) 385 (69.37) 424 (72.35) 0.27 0.03
Losing weight 609 (53.37) 294 (52.97) 315 (53.75) 0.81 0.01
Reducing stress 616 (53.99) 307 (55.32) 309 (52.73) 0.41 0.03
Reducing sodium or salt in your diet 472 (41.37) 225 (40.54) 247 (42.15) 0.59 0.02
Reducing animal products in your diet 254 (22.26) 102 (18.38) 152 (25.94) 0.002 0.09
Maintaining a healthy blood pressure 660 (57.84) 307 (55.32) 353 (60.24) 0.09 0.05
Maintaining a healthy cholesterol level 582 (51.01) 270 (48.65) 312 (53.24) 0.12 0.05
Praying or meditating 321 (28.13) 143 (25.77) 178 (30.38) 0.09 0.05
Getting adequate sleep 506 (44.35) 238 (42.88) 268 (45.73) 0.34 0.03
Mental health treatment 363 (31.81) 155 (27.93) 208 (35.49) 0.006 0.08
What have you done to monitor or improve your health in the last year?
Visited a doctor/other health care professional 936 (82.03) 459 (82.70) 477 (81.40) 0.59 0.02
Increased physical activity 634 (55.57) 295 (53.15) 339 (57.85) 0.12 0.05
Decreased consumption of unhealthy foods 642 (56.27) 298 (53.69) 344 (58.70) 0.09 0.05
Quit smoking/using tobacco products 142 (12.45) 86 (15.50) 56 (9.56) 0.003 0.09
Lost weight 462 (40.49) 229 (41.26) 233 (39.76) 0.63 0.02
Tried to better manage stress 704 (61.70) 315 (56.76) 389 (66.38) 0.001 0.10
Diagnostic test for heart disease 119 (10.43) 66 (11.89) 53 (9.04) 0.12 0.05
Cholesterol checked 686 (60.12) 360 (64.86) 326 (55.63) 0.002 0.09
Blood pressure checked 784 (68.71) 400 (72.07) 384 (66.53) 0.018 0.07
Started vitamins or dietary supplements 347 (30.41) 148 (26.67) 199 (33.96) 0.008 0.08
Used MyHealthEVet, a smartphone ‘app’ or activity monitor (e.g., FitBit) 264 (23.14) 110 (19.82) 154 (26.28) 0.011 0.08
None 33 (2.89) 20 (3.60) 13 (2.22) 0.21 0.04
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Notes. Data are presented as n (%). Comparisons by sex are based on Fisher’s exact tests. ϕ refers to the phi effect size.

Over 90% of survey respondents endorsed the belief that getting physical exercise (96.0%), losing weight (92.0%), and reducing stress (91.7%) can help prevent heart disease, with more women than men endorsing these beliefs about exercise (97.8% vs. 94.5%, p = 0.001), reducing stress (93.5% vs. 89.7%, p = 0.024), and maintaining healthy cholesterol levels (87.5% vs. 83.2%, p = 0.044). More women also endorsed getting adequate sleep as a behavior that can prevent heart disease (83.1% vs. 77.1%, p = 0.012). Regarding risk reduction behaviors, significantly more women reported reducing dietary animal products (25.9% vs. 18.4%, p = 0.002), and engaging in mental health treatment (35.5% vs. 27.9%, p = 0.006), although, the reporting of behaviors engaged in was markedly lower than reporting of beliefs endorsed.

Among specific activities to improve health in the last year, most veterans endorsed visiting a health care professional (82.0%), having their blood pressure checked (68.7%), and trying to better manage stress (61.7%). Relative to women, more men reported quitting tobacco products (9.6% vs, 15.5%, p = 0.003), as well as having their cholesterol (55.6% vs. 64.9%, p = 0.002) and blood pressure checked (66.5% vs. 72.1%, p = 0.018). Significantly more women than men reported that they tried to better manage stress (66.4% vs. 56.8%, p = 0.001), started dietary supplements (34.0% vs. 26.7%, p = 0.008), and used a health monitoring application or device (25.3% vs. 19.8%, p = 0.011).

Discussion

WVCS offers the first comprehensive survey concerning knowledge about, and self-perceived risk of heart disease, and engagement in activities to prevent heart disease among the largely young and middle-aged veterans of post-9/11 military conflicts. The study also represents the largest inquiry to-date concerning these factors among a cohort that is specifically structured to have equal representation of men and women veterans. Only one third of veterans felt that they were informed about heart disease, sought related information via the internet, or had been informed about heart disease risk by their provider. Despite these information deficits, over half of the sample (approximately 50–60%) categorized high blood pressure, smoking, and weight as the most important risk factors for having a heart attack or stroke, and women categorized more factors as very important compared to men. Although a majority of respondents endorsed the beliefs that addressing traditional (e.g., weight loss, blood pressure management) and nontraditional (e.g., stress, sleep) factors can reduce their risk of heart disease, far fewer endorsed the value of mental health treatment for heart disease prevention. Finally, while women veterans may be slightly more knowledgeable about heart disease risk and of the behaviors that can lower this risk, for both men and women, this knowledge was not matched with engagement in prevention behaviors.

It is the responsibility of health care providers to assess heart disease risk and provide information for those who are identified as at risk, and to do so equally for younger men and women. Just over a third of veterans reported that a doctor had spoken with them about heart disease, with only slightly higher rates reported by men than women. Yet, a previous investigation of post-9/11 veterans showed that in the initial five years after discharge from the military, 68% of men and 50% of women develop one risk factor for cardiovascular disease, and that 86% of men and 70% of women developed at least one risk factor within the first decade after service (Haskell et al., 2017). Together these findings indicate that for this young veteran cohort, there is a gap in the circulation of information about heart disease, suggesting that information is either not well-disseminated or received, or that other conditions are given priority (Jensen & Moser, 2008). These results are especially concerning given the early heart disease risk emerging for this cohort and the more general finding that for these veterans, risk of heart disease increases dramatically with age (Frayne et al., 2018). Given the overall utilization of healthcare through the VHA, the findings suggest that there may be many missed opportunities to discuss and implement primary prevention following military discharge, or secondary prevention in the early years after care is established and when risk factors for heart disease begin to manifest. In lieu of receiving information about heart disease from a provider, it is increasingly common to consult internet websites for health information (Tan & Goonawardene, 2017), but only 38% of respondents used this resource. Gaining a better understanding of health information-seeking among veterans (e.g., social networking sites, television, the newspaper, interpersonal relationships) and how such behavior is associated with heart disease risk evaluation or reduction activities is a key future direction.

Most veterans who completed the survey endorsed the belief that addressing traditional factors - e.g., quitting smoking, getting physical exercise, and losing weight - can help to prevent heart disease. This overall endorsement was largely mirrored with regard to some nontraditional factors - e.g., poor sleep and psychological stress, but not others - e.g., mental health conditions. It is important to note that these mental health conditions - depression, anxiety, PTSD – can each increase heart disease risk (Cohen, Edmondson, & Kronish, 2015; Ebrahimi et al., 2020) and disproportionately affect women and veterans (Agarwala, Michos, Samad, Ballantyne, & Virani, 2020; Cohen et al., 2015). The failure to appreciate the potential value of mental health treatment may be especially problematic for heart disease prevention among women veterans, a group with higher rates of trauma, depression, and anxiety than men or civilians overall (Frayne et al., 2018; Han et al., 2019; Lehavot et al., 2012).

Contrasting the reported belief in what efforts can prevent heart disease with the prevention activities that these post-9/11 veterans reported engaging in suggests a significant disconnect between their beliefs and actions, and furthermore, important gaps in risk mitigation. Specifically, for each prevention activity, the percentage of veterans who endorsed the belief - e.g., maintaining a healthy cholesterol level reduces risk of heart disease (85%) was substantially higher than the percentage that endorsed engaging in the associated activity - e.g., maintaining healthy dietary cholesterol (51%). Overall, veterans view these factors as essential for heart disease prevention, but they may have difficulty implementing the prevention strategy. These difficulties may be a function of various barriers – individual, provider, clinical, or systems level factors – that could explain the observed disconnect (Cavanagh et al., 2020). Although there were only small differences between men and women in both beliefs and prevention activities, barriers to prevention may differ by sex. For example, the role of women in the family may pose an interpersonal barrier to self-care. Similar percentages of men and women in this sample reported living with children in their household, and while data were unavailable concerning caregiving for parents, women traditionally assume more caregiving responsibilities and family obligations, and may benefit from accommodations and support to navigate this barrier (Cavanagh et al., 2020).

Importantly, differences between knowledge and belief on the one hand, and prevention activities on the other were observed for both patient-directed prevention activities (e.g., stress management, use of health tracking devices) and provider-directed activities (e.g., lipid and blood pressure management). As shown previously, 40% of veterans in this cohort reported lacking confidence in their ability to make lifestyle changes (Cavanagh et al., 2020). VA clinicians may bolster veterans’ sense of agency in managing their health by using empirically-supported tools to mutually raise heart disease awareness and encourage risk reduction. For example, offering a composite heart-age risk score can help to calibrate an individual’s personal risk awareness and is associated with greater patient engagement (Navar et al., 2018; Soureti, Hurling, Murray, van Mechelen, & Cobain, 2010). It is also incumbent upon clinicians to understand and leverage existing knowledge of the nontraditional factors that contribute to heart disease among the veterans under their care. Given growing evidence supporting the roles of stress and sleep in heart disease risk among veterans (Alexander et al., 2016; Gaffey et al., 2020; Ulmer et al., 2015), the present findings suggest high potential for patient buy-in to address these factors, and evidence-based behavioral health interventions are widely available in the VA (Oishi et al., 2011). In contrast, more education is likely needed about the value of mental health treatment, in part because of the potential that this treatment could have as part of an overall approach to reducing heart disease risk.

Clinical Considerations for Improving Heart Disease Prevention

Greater and more tailored efforts to reduce heart disease risk among post-9/11 veterans may be warranted. Women in this veteran cohort in particular, are high-utilizers of VA and non-VA healthcare, offering ample opportunities to assess, intervene, and decrease heart disease risk (Frayne et al., 2018), but suggesting that more targeted patient education strategies may be desirable. Fortunately, the VA electronic health record includes clinical reminders and other tools, which could aid providers with identifying and initiating related discussions about risk reduction (Frayne et al., 2018). Given that for post-9/11 veterans, primary care and mental health clinics have the highest levels of contact, they may be the best clinical settings for testing heart disease education and interventions (Goldstein et al., 2017). Tailored VA Patient Aligned Care Teams may offer more streamlined multidisciplinary communication and referrals and thus, could be one effective approach (Grijalva, 2016; Haskell et al., 2014). Various heart disease prevention platforms have also shown promise among veterans, including web-based health risk assessment or telehealth initiatives, structured programs, and peer-support interventions (Goldstein et al., 2018; Moin et al., 2015; Oddone et al., 2018).

With the rising proportion of veterans who are women, ensuring that providers are properly trained to address heart disease prevention for women as well as for men is a necessary, complementary focus (Mattocks et al., 2020). According to one national survey, most physicians knew that men and women present with different risks for heart disease but only 22% of primary care providers and 42% of cardiologists reported feeling “extremely well prepared” to assess heart disease risk in women specifically (Merz et al., 2017). No study to-date has focused on VA clinicians’ perceived preparation to evaluate heart disease in men or women veterans.

Limitations

The WVCS survey provides important information concerning heart disease knowledge, perceived risk, and prevention activities, but it is not without limitations. Data were cross-sectional rather than longitudinal, preventing causal inferences, and the effect sizes for comparisons by sex were small. Survey respondents were a subset of the larger veteran population who were discharged from military service after October 1, 2001, who received care at a select set of VA medical centers, and elected to participate, factors that may limit the sample’s representativeness and the generalizability of findings. Relatedly, 53% of post-9/11 veterans do not enroll in VA care, and those individuals could have different knowledge, beliefs and behaviors related to heart disease (Profile of Post-9/11 Veterans: 2016). Also, there are known racial and ethnic differences in risk of heart disease and other cardiovascular conditions among veterans (Haskell et al., 2017; Kovesdy et al., 2015) and low heart disease risk awareness has been reported among minorities (Mozaffarian et al., 2015; Villablanca, Slee, Lianov, & Tancredi, 2016), but the demographic subgroups in this survey were not large enough to make comparisons based on race or ethnicity. Often associated with minority status, adverse social determinants of health - lower income, less education, living in an unsafe neighborhood - may also influence a person’s ability to engage in preventive health behavior (e.g., less access to healthy foods or opportunities to be physically active). The 32% survey response rate is somewhat low, but it is within the rate of responses from veterans who completed other paper surveys (Gaeddert et al., 2020). Non-responders were more likely to be significantly younger, male, and members of racial or ethnic minority groups (all p < 0.001 (Gaffey et al., 2021)). These demographic differences could have resulted in under- or overestimated statistics compared to the population of post-9/11 veterans. Additionally, survey data were not linked with health record data to ascertain actual risk factor status or receipt of associated care, and thus specific risk reduction strategies may not have been endorsed because the associated risk factor was not present (e.g., smoking cessation, weight loss). Concordance between self-report and health record data ranges from fair-to-high, with worse agreement among younger individuals (Pakhomov, Jacobsen, Chute, & Roger, 2008; Thorpe et al., 2016), and also depends on the condition - e.g., low agreement for chest pain (Pakhomov et al., 2008) and higher agreement for diabetes (Barber, Muller, Whitehurst, & Hay, 2010).

Conclusions

This is the first study to present data concerning heart disease knowledge, perceived risk, and prevention beliefs and behaviors among men and women post-9/11 veterans. Although heart disease is more prevalent among veterans than in the general population (Haskell et al., 2017; Rose et al., 2013; Vimalananda et al., 2013), heart disease appears to be less often discussed with patients from this service era, those who are the youngest veteran group served by the VA. Health care providers must be motivated to assess for and educate veterans, beginning early in their care, and equitably among men and women. Providers may also consider how to augment general information about heart disease depending on the traditional and non-traditional heart disease-related factors that a veteran presents with. Post-9/11 veterans largely demonstrate a high level of awareness of traditional and nontraditional risk related factors, yet considerable gaps are found between this knowledge and prevention behavior, with only subtle differences between men and women in the receipt and use of health information. Members of the post-9/11 veteran cohort and the providers who care for them may benefit from greater VA investment in heart disease education. VA providers might also consider how to translate this knowledge into better integrated practice. Finally, Veterans themselves could benefit from additional, long-term support to bolster their awareness and implement meaningful health behavior change.

Support/Funding:

This study was supported by grants from the Department of Veterans Affairs (CIN 13-407, HIR 09-007, DHI 07-065-1, IIR 12-118) to Drs. Haskell, Brandt, and Bastian. Dr. Gaffey was supported by an Advanced Fellowship in Women’s Health and a National Institute of Heart, Lung, and Blood grant (R01HL126770) to Dr. Burg; Potential conflicts of interest: NONE; Previous presentations: NONE

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