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Published in final edited form as: Psychol Health Med. 2024 Jan 9;29(7):1195–1207. doi: 10.1080/13548506.2024.2303409

United States Army Reserve/National Guard soldiers’ healthcare experiences, attitudes, and preferences: Differences based on deployment status

Rachel A Hoopsick 1, Bonnie M Vest 2, D Lynn Homish 3, Gregory G Homish 4
PMCID: PMC11223970  NIHMSID: NIHMS1957786  PMID: 38193498

Abstract

Some United States Army Reserve/National Guard (USAR/NG) soldiers have substantial health needs, which may be service-related, but not necessarily resulting from deployment. However, most USAR/NG members need to have been deployed to qualify for Veterans Administration (VA) benefits. Therefore, many USAR/NG soldiers seek care from civilian healthcare providers (HCPs). Using a subset (N = 430 current/former soldiers) of Operation: SAFETY study data, we used regression models to examine differences in healthcare experiences, attitudes, and preferences by deployment status (never-deployed vs. previously-deployed). Final models controlled for age, sex, rank (enlisted vs. officer), military status (current vs. former military), and RAND SF-36 General Health Score. Over 40% of soldiers agreed that civilian HCPs should ask patients about their military service, but never-deployed soldiers were less likely to report being asked about their service (p < 0.05) or how their service affects their health (p < 0.10). Never-deployed soldiers were also less likely to attribute their health concerns to military service (p < 0.001). Although never-deployed soldiers were more likely to prefer receiving physical (p < 0.05) and mental (p < 0.05) healthcare outside of the VA than previously-deployed soldiers, never-deployed soldiers had low confidence in their HCP’s understanding of their needs (49% thought that their civilian HCP did not understand them; 71% did not think that their civilian HCP could address military-related health concerns; 76% thought that their civilian HCP did not understand military culture). Findings demonstrate that although civilian HCPs may be the preferred (and only) choice for never-deployed USAR/NG soldiers, they may need additional support to provide care to this population.

Keywords: military, deployment, healthcare experiences, healthcare attitudes, healthcare preferences

INTRODUCTION

The United States (US) military relies on the health of its service members to conduct large, complex operations. Although military service members tend to have better health than the general population (Smith et al., 2007), this does not extend to all health conditions, reflecting the unique demands and hazards of military service. For example, service members have a significantly higher prevalence of prehypertension and hypertension (Shrestha et al., 2019), and higher rates of certain cardiovascular conditions (Hinojosa, 2020) compared to civilians. Further, service members experience higher rates of sexual assault (Suris & Lind, 2008), traumatic brain injuries (Summers et al., 2009), and some mental health symptomatology (e.g., anxiety, posttraumatic stress) than civilian populations (Trautmann et al., 2016). These unique risks have implications for military readiness, community health, and the long-term health of military-connected populations. However, the healthcare preferences, experiences, and attitudes of certain military subgroups are largely unknown, particularly in the context of community-based care.

US Military Reservists

Reservists comprise approximately one-third of the US military (Department of Defense, 2021). Despite similarities in duties and deployment experiences, service members in the US reserve forces may be particularly vulnerable to adverse health behaviors and outcomes. For example, reservists are less likely to meet military requirements for body composition and physical fitness tests than active duty service members (Kazman et al., 2015; Russell et al., 2019). These differences are accompanied by notable differences in mental health (Beckman et al., 2021; Cohen et al., 2015; Ursano et al., 2018). For example, reservists are more likely to report suicidal ideation, suicide attempts, posttraumatic stress symptomatology, and current drug use (Beckman et al., 2021; Lane et al., 2012), and have a higher prevalence of alcohol use disorder than active duty service members (14.5% vs. 11.7%, respectively; Cohen et al., 2015).

Role of Deployment

Although research primarily focuses on combat deployment experiences, growing literature demonstrates that service-related health problems are prevalent among both previously-deployed and never-deployed service members. For example, non-combat-related musculoskeletal injuries (e.g., injuries occurring during training exercises) are far more prevalent than those occurring during combat (Grimm et al., 2019), often resulting from repeated stress during physical training (Andersen et al., 2016). Additionally, rates of mental health symptomatology, substance use, and substance use disorders do not appear to differ between service members who have and have not experienced deployment (Hoopsick et al., 2019; Trautmann et al., 2014). However, there remains limited research regarding never-deployed service members, which is critical given that many reservists are never deployed.

Despite similar health and behaviors, emerging research suggests never-deployed service members may be less likely to seek or receive some healthcare services than previously-deployed service members (Chapman et al., 2014; Hoopsick et al., 2021). Additionally, current federal policy imposes service-related eligibility restrictions (i.e., deployment) on access to care for those who only served in the Reserves or National Guard (TRICARE, 2022; US Department of Veterans Affairs, 2022). This restriction results in reservists remaining ineligible for military healthcare benefits while serving in the military and not qualifying for VA healthcare benefits upon separation from the military if they were never federally deployed. Many current and former reservists receive their care in community-based settings from civilian healthcare providers (HCPs) (Finley et al., 2010; Hinojosa et al., 2010; Straits-Troster et al., 2011; Vest et al., 2022) who have limited military cultural competency (Fredricks & Nakazawa, 2015; Vest et al., 2018; Vest et al., 2019).

The current study addresses these gaps by examining a subset of soldier data from Operation: SAFETY (Soldiers and Families Excelling Through the Years), an ongoing survey-based study of the health and well-being of US Army Reserve/National Guard (USAR/NG) soldiers and their partners. Using a cross-sectional design, we aimed to characterize the healthcare experiences, attitudes, and preferences of USAR/NG soldiers and examine associations between deployment status (never-deployed vs. previously-deployed) and healthcare-related outcomes.

MATERIALS AND METHODS

Participants and Procedure

We recruited participants for Operation: SAFETY from 47 USAR/NG units across New York state from 2014–2015. At enrollment, participants met the following criteria: (1) the couple had to be married/cohabitating; (2) one member of the couple had to be a current USAR/NG soldier; (3) the soldier had to be between the ages of 18 and 45; (4) able to speak and understand English; (5) willing and able to participate; and (6) had at least one alcoholic beverage in the past year, as people who abstain from alcohol tend to differ in health behaviors from non-abstainers (Green & Polen, 2001). After giving informed consent, couples completed yearly electronic surveys. Each participant received $60 at baseline and $70 at each follow-up. The study was approved by the Institutional Review Board of the University at Buffalo, the Army Human Research Protections Office, the Office of the Chief, Army Reserve, as well as the Adjutant General of the National Guard.

The current study examined a subset of data from USAR/NG soldiers (N = 430). Soldiers were predominantly male (79.1%), non-Hispanic White (80.5%), with a mean (± standard deviation) age of 33.6 (±6.5) years (Table 1). Notably, approximately 2 in 5 soldiers reported never having been deployed. Civilian partners were excluded from the current analyses.

Table 1.

Characteristics of US Army Reserve/National Guard Soldiers (N = 430)

Characteristics % (n) or mean (± standard deviation)
Age, years 33.6 (± 6.5)
Sex
 Male 79.1% (340)
 Female 20.9% (90)
Race-ethnicity
 Non-Hispanic White 80.5% (346)
 Non-Hispanic Black 5.6% (24)
 Hispanic 7.2% (31)
 Other 4.9% (21)
Education
 High School 12.1% (52)
 Some College 54.4% (234)
 College Degree 33.5% (144)
Family Income
 Less than $19,999 6.7% (29)
 $20,000 - $39,999 18.8% (81)
 $40,000 - $59,999 22.1% (95)
 $60,000 - $79,999 19.1% (82)
 $80,000 - $99,999 12.3% (53)
 $100,00 - $119, 999 8.4% (36)
 $120,000 or More 9.5% (41)
Years of Military Service 9.4 (± 6.1)
Rank
 Enlisted 82.3% (354)
 Officer 14.7% (63)
Military Status
 Current soldier 83.7% (360)
 Former soldier 16.3% (70)
RAND-36 General Health Score 72.7 (± 18.9)
Deployment Status
 Never deployed 41.2% (177)
 Previously deployed 58.8% (253)
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Measures

Healthcare Experiences, Attitudes, and Preferences.

The following questions were coded “yes” vs. “no” among soldiers who indicated they had a civilian HCP: 1) Has your civilian healthcare provider or their office staff asked if you are a veteran or if you have served in the military? (Please note: “civilian” refers to non-military/non-VA health care providers/facilities.); and 2) Has your healthcare provider ever asked about how your military experience affects your current health? The following questions were measured on a Likert scale ranging from “strongly disagree” to “strongly agree” and were dichotomized into “agree/strongly agree” vs. “neither disagree nor agree/disagree/strongly disagree”: 1) It is important for my civilian healthcare provider to ask about my military service; 2) My civilian healthcare provider is able to adequately address my military service-related health concerns; 3) I believe that my current health concerns are related to my military service; 4) My healthcare provider understands me; and 5) My healthcare provider understands military culture. Lastly, participants were asked, in an ideal world, whether they would prefer to receive physical and mental health care at a “VA or other military facility” or “civilian facility.”

Deployment Status.

Soldiers who reported never having been deployed overseas were coded as “never-deployed,” and participants who reported being deployed at least once were coded as “previously-deployed.” Participants who were only ever activated to respond to stateside emergencies (e.g., natural disasters) were coded as “never-deployed.”

Covariates.

Adjusted models included several covariates, including age and sex, given that older or male soldiers were more likely to have been deployed than their younger or female counterparts, and age and sex also likely influence healthcare experiences, attitudes, and preferences. Final models also included rank (enlisted vs. officer) and military status (current vs. former military), given that some soldiers had separated from the military during this longitudinal study. Military rank is a proxy for socioeconomic status and is associated with healthcare experiences and health-related outcomes (Blattner et al., 2018; Burdett et al., 2021). Additionally, benefits available to currently serving US military personnel are different from those available to former service members, which may influence the outcomes of interest. Lastly, adjusted models also included soldiers’ General Health Score (α = 0.77), a subscale developed at RAND as a part of the Medical Outcomes Study (Ware, 1993; Ware & Sherbourne, 1992), and one of the most widely used health-related quality of life instruments (Hays & Morales, 2001). Being deployed impacts service members’ health in a variety of ways (Teplova et al., 2021), and health status likely affects healthcare outcomes.

Analytic Approach

We used descriptive statistics to characterize the sample and compare their healthcare experiences, attitudes, and preferences by deployment status. Next, we used logistic regression models to examine associations between deployment status (never-deployed vs. previously-deployed) and each healthcare-related outcome. We then added age, sex, rank (enlisted vs. officer), military status (current vs. former military), and RAND-36 General Health Score as covariates to each model. All models were bootstrapped with 500 replications to enhance the sample-to-population inferences made with these data using Stata version 17.0 (Stata Corporation, College Station, TX).

RESULTS

Descriptive Results

When soldiers were asked if it was important for civilian HCPs to ask about their military service, over 40% agreed or strongly agreed (Figure 1). Yet nearly two-thirds of soldiers never had a civilian HCP ask about their military service. Remarkably, 83.0% of the soldiers in this sample reported that they were never asked by a civilian HCP how their military service affects their health, despite 2 in 5 soldiers agreeing that their current health concerns were related to their military service. Further, the majority of soldiers (67.1%) reported feeling that their civilian HCP was unable to adequately address their service-related health concerns. Approximately half of the sample (49.5%) felt that their civilian HCP did not understand them, and nearly three-quarters (73.3%) perceived that their civilian HCP did not understand military culture. Despite the perceived deficits that soldiers identified in their civilian care, most soldiers indicated that they would prefer to seek their physical (71.6%) and mental healthcare (66.1%) at non-military/non-VA facilities.

Figure 1.

Figure 1

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US Army Reserve/National Guard Soldiers’ Healthcare Experiences, Attitudes, and Preferences for the Overall Sample and by Deployment Status

Effects of Deployment Status on Healthcare Experiences, Attitudes, and Preferences

Never-deployed soldiers had significantly lower odds of being asked about military status by their civilian HCP than previously-deployed soldiers (OR = 0.57; 95% CI: 0.36, 0.89; Table 2). After controlling for the effects of age, sex, rank, military status, and RAND-36 General Health Score, this relationship persisted (aOR = 0.51; 95% CI: 0.30, 0.88). Never-deployed soldiers also had lower odds of being asked how military service affects their health (OR = 0.49; 95% CI: 0.27, 0.90), but this association was only significant at a trend level after covariate adjustment (aOR = 0.53; 95% CI: 0.26, 1.09). There were no significant differences in soldiers’ odds of agreeing/strongly agreeing (hereafter: agreeing) that civilian HCPs should ask about their military service on the basis of deployment in either unadjusted (OR = 0.91; 95% CI: 0.59, 1.40) or adjusted (aOR = 1.00; 95% CI: 0.57, 1.76) models.

Table 2.

Effects of Deployment Status on US Army Reserve/National Guard Soldiers’ Healthcare Experiences, Attitudes, and Preferences

Unadjusted Adjusteda
Model: Deployment Status OR (95% CI) aOR (95%CI)
1 Previously-deployed Never-deployed Referent 0.57 * (0.36, 0.89) Referent 0.51 * (0.30, 0.88)
2 Previously-deployed Never-deployed Referent 0.91 (0.59, 1.40) Referent 1.00 (0.57, 1.76)
3 Previously-deployed Never-deployed Referent 0.49 * (0.27, 0.90) Referent 0.53† (0.26, 1.09)
4 Previously-deployed Never-deployed Referent 0.70 (0.45, 1.11) Referent 0.76 (0.43, 1.34)
5 Previously-deployed Never-deployed Referent 0.37 *** (0.25, 0.56) Referent 0.40 *** (0.24, 0.65)
6 Previously-deployed Never-deployed Referent 1.03 (0.69, 1.52) Referent 1.05 (0.66, 1.65)
7 Previously-deployed Never-deployed Referent 0.77 (0.49, 1.21) Referent 0.91 (0.53, 1.56)
8 Previously-deployed Never-deployed Referent 2.13 ** (1.32, 3.43) Referent 1.82 * (1.09, 3.03)
9 Previously-deployed Never-deployed Referent 2.35 *** (1.52, 3.63) Referent 1.83 * (1.12, 2.99)
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Models:

1 = Odds of being asked about military status by civilian HCP

2 = Odds of agreeing/strongly agreeing that civilian HCP should ask about military status

3 = Odds of being asked about how military service affects health by civilian HCP

4 = Odds of agreeing/strongly agreeing that civilian HCP can address military-related health concerns

5 = Odds of agreeing/strongly agreeing that current health concerns are related to military service

6 = Odds of agreeing/strongly agreeing that civilian HCP understands me

7 = Odds of agreeing/strongly agreeing that civilian HCP understands military culture

8 = Odds of preferring to seek physical healthcare from civilian healthcare facility

9 = Odds of preferring to seek mental healthcare from civilian healthcare facility

Note.

†

p < 0.10

*

p < 0.05

**

p < 0.01

***

p < 0.001

OR = odds ratio; aOR = adjusted odds ratio; CI = confidence interval; HCP = healthcare provider

a

Adjusted models control for age (years), sex (male vs. female), rank (enlisted vs. officer), military status (current vs. former military), and RAND-36 General Health Score

Similarly, deployment status was not associated with agreeing that soldiers’ civilian HCPs can address their military-related health concerns before (OR = 0.70; 95% CI: 0.45, 1.11) or after adjustment (aOR = 0.76; 95% CI: 0.43, 1.34). However, never-deployed soldiers had significantly lower odds of agreeing that their current health concerns are related to their military service (OR = 0.37, 95% CI: 0.25, 0.56), and this effect remained after adjustment (aOR = 0.40; 95% CI: 0.24, 0.65). In both unadjusted and adjusted models, there were no associations between deployment status and soldiers agreeing that their civilian HCPs understand them (ps > 0.10) or military culture (ps > 0.10). Never-deployed soldiers had two-fold greater odds of preferring care in community settings than previously-deployed soldiers (physical healthcare OR = 2.13; 95% CI: 1.32, 3.43; mental healthcare OR = 2.35; 95% CI: 1.52, 3.63). These associations were attenuated after adjustment but remained significant (physical healthcare aOR = 1.82; 95% CI: 1.09, 3.03; mental healthcare aOR = 1.83; 95% CI: 1.12, 2.99).

DISCUSSION

Our findings reveal differences in USAR/NG soldiers’ healthcare-related experiences, preferences, and attitudes based on their deployment history. Our results also suggest that reservists, generally, perceive that civilian HCPs may need additional training and support to provide culturally competent care. Notably, our results demonstrate that many USAR/NG soldiers think that civilian HCPs should ask about military service, but never-deployed soldiers had 49% lower odds of actually being asked about their military service than previously-deployed soldiers. These findings are consistent with national data, which show that never-deployed reserve veterans are less likely to be asked about their alcohol consumption by HCPs (Hoopsick et al., 2021). Research suggests that civilian HCPs do not regularly ask patients about their military history and may not recognize that there are military-connected patients on their caseload (Vest et al., 2018). It is possible that never-deployed service members are less likely to initiate conversations about military service with their HCP, perhaps believing that their military service is not relevant to their plan of care. This may result from military training and culture which, regardless of deployment history, engrains deindividuation, obedience, chain-of-command, and dissociation – each at odds with civilian expectations – which can result in downplaying or not disclosing health concerns, and also have a profound effect on service members’ mental health, likelihood of engaging in problematic substance use, and propensity for interpersonal violence (Coll et al., 2012; Smith & True, 2014).

Only 1 in 6 soldiers had ever been asked how their military service affects their health, with never-deployed soldiers being the least likely. Given that military populations are at increased risk for numerous health problems (Hinojosa, 2020; Shrestha et al., 2019; Summers et al., 2009; Suris & Lind, 2008; Trautmann et al., 2016) and that the number of veterans with a service-connected disability has increased significantly (US Department of Veterans Affairs, 2019), our results suggest that civilian HCPs may miss potential connections between military experiences and health, especially among those who have never been deployed. Further, harmful occupational and environmental exposures are prevalent in both training and non-training settings, which may result in adverse health effects, including chronic conditions with long latency periods (Geretto et al., 2021). The deleterious effects of these service-related exposures may be missed if HCPs are unaware of patients’ military history, resulting in missed opportunities for screening and intervention.

Service members frequently experience service-related health problems not related to deployment (Grimm et al., 2019), but never-deployed soldiers may be reluctant to attribute their health problems to their military service. In our sample, never-deployed soldiers had 60% lower odds of attributing their current health problems to their military service than previously-deployed soldiers, even though they experience many of the same health problems (Grimm et al., 2019; Hoopsick et al., 2019; Kang et al., 2015; Trautmann et al., 2014). Prior research demonstrated that some never-deployed USAR/NG soldiers experience negative emotions related to never having been deployed, which have been associated with a number of adverse mental health outcomes and health behaviors (Hoopsick, Homish, Bartone, et al., 2018; Hoopsick et al., 2022; Hoopsick, Homish, Vest, et al., 2018). It is possible that never-deployed soldiers may fail to connect their health problems to their military experiences because of their non-deployment, highlighting a need for recognition of patients’ military histories and the provision of military culture competent care.

Not attributing their health problems to their military service may explain why we found that never-deployed soldiers were nearly twice as likely as previously-deployed soldiers to prefer receiving healthcare from civilian HCPs. However, under current federal policies, this is also often the only choice for never-deployed USAR/NG soldiers and veterans (TRICARE, 2022; US Department of Veterans Affairs, 2022). While we observed differences in these preferences by deployment status, the majority of the sample reported that, in an ideal world, they would prefer to seek physical and mental healthcare services from civilian providers. This is important and in line with prior research showing many military-connected populations receive their care in community settings (Finley et al., 2010; Hinojosa et al., 2010; Straits-Troster et al., 2011; Vest et al., 2022). This suggests that while many USAR/NG soldiers and veterans are already receiving healthcare in their preferred setting, some are unable to access the military/VA healthcare facilities that they prefer.

Although our participants generally preferred receiving healthcare from HCPs in community settings, findings also suggest that patients perceive substantial gaps in the knowledge and skills of civilian HCPs to provide care to military-connected populations. Half of the sample reported feeling that their civilian HCP did not understand them, and most reported a perception that their civilian HCP did not understand military culture. Moreover, regardless of deployment status, most soldiers reported feeling that their civilian HCP could not address their military-related health concerns. These findings are consistent with research showing that non-VA HCPs do not regularly ask their patients about military history (Kilpatrick et al., 2011; Vest et al., 2018). Further, findings from a recent qualitative study of civilian HCPs suggest that they may have limited insight into the possible health impacts of patients’ military history (Vest et al., 2019). Our results underscore the need for additional training and support for civilian HCPs to provide more effective care for military populations, particularly for reservists and never-deployed service members who may be less likely to be recognized as military-connected and to seek and receive the healthcare services that they need (Chapman et al., 2014; Hoopsick et al., 2021).

Limitations

The current study has limitations. First, data are observational and cross-sectional, which limits our ability to draw causal inferences. Second, all data are self-reported and may be affected by response bias. However, Operation: SAFETY uses computer-assisted self-interviewing, a valid way to collect sensitive health information that is preferred over interviewer-based methods (Willis et al., 2001). Third, participants were recruited from a single state and were married/cohabitating at baseline, which may limit external validity. However, units sampled included a diverse range of occupational specialties (e.g., combat, engineer, medical, logistics, and support roles), sample demographic characteristics are consistent with reservists nationally (Office of the Deputy Assistant Secretary of Defense, 2019), and more than half of US service members are married (Office of the Deputy Assistant Secretary of Defense, 2019), lending confidence to generalizability.

Conclusions

Our findings demonstrate that although civilian HCPs may be the preferred (and often only) choice for never-deployed USAR/NG soldiers, these providers may need additional support to deliver effective care. We recommend that HCPs in community settings screen all patients for military history and consider the ways in which military service, beyond deployment, can affect health, including environmental or toxic chemical exposures, injury, psychological trauma, military sexual trauma, hearing loss, and readjustment difficulties, among others (Bigelow & Fausone, 2021; Burgo-Black et al., 2016; Lee et al., 2014). Future work should examine civilian HCPs’ behaviors in the context of delivering care to military-connected populations regardless of deployment history to better understand why the healthcare experiences of these groups differ.

Funding:

This research was supported by the National Institute on Drug Abuse award number R01DA034072 to Gregory G. Homish and by the National Center for Advancing Translational Sciences of the National Institutes of Health under award number UL1TR001412 to the University at Buffalo.

Footnotes

Disclosures: The authors have no conflicts of interest or competing interests to disclose.

Data Availability:

The data that support the findings of this study will be available on request after the conclusion of the parent study. The data are not publicly available due to the ongoing and longitudinal nature of the Operation: SAFETY study.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The data that support the findings of this study will be available on request after the conclusion of the parent study. The data are not publicly available due to the ongoing and longitudinal nature of the Operation: SAFETY study.

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