A Health Assessment Survey of Veteran Students: Utilizing a Community College-Veterans Affairs Medical Center Partnership

Abstract

Objective

To assess health status among student veterans at a community college utilizing a partnership between a Veterans Affairs Medical Center and a community college.

Participants

Student veterans at Cuyahoga Community College in Cleveland, Ohio, in January to April 2013.

Methods

A health assessment survey was sent to 978 veteran students. Descriptive analyses to assess prevalence of clinical diagnoses and health behaviors were performed. Logistic regression analyses were performed to assess for independent predictors of functional limitations.

Results

204 students participated in the survey (21% response rate). Self-reported depression and unhealthy behaviors were high. Physical and emotional limitations (45% and 35%, respectively), and pain interfering with work (42%) were reported. Logistic regression analyses confirmed the independent association of self-reported depression with functional limitation (odds ratio [OR] = 3.3, 95% confidence interval [CI] 1.4–7.8, p < 0.05, and C statistic 0.72) and of post-traumatic stress disorder with pain interfering with work (OR 3.9, CI 1.1–13.6, p < 0.05, and C statistic 0.75).

Conclusion

A health assessment survey identified priority areas to inform targeted health promotion for student veterans at a community college. A partnership between a Veterans Affairs Medical Center and a community college can be utilized to help understand the health needs of veteran students.

INTRODUCTION

Recently returned veterans may be at high risk for poor chronic disease management given the potential prevalence of mental health issues in this population^1–5 and its possible effects on both health-seeking behavior and the coping mechanisms necessary to optimally manage chronic disease. Mental health issues can affect both risks for development⁶ and for poor control⁷ of chronic disease. Increased utilization of nonmental health Veterans Affairs (VA) medical services of recent veterans who have mental health diagnoses has been reported, with 91% greater utilization of outpatient services of veterans with post-traumatic stress disorder (PTSD) than of veterans with no mental health disease,⁸ which may suggest a link between mental health and nonmental health medical problems of veterans. Female veterans who had been deployed to recent conflicts may face unique issues such as increased risk of PTSD and effects of combat experiences⁹ which may confer greater risk for poor chronic disease control in this group. Depression and PTSD symptoms have been associated with family reintegration problems in veterans,¹⁰ which can affect the management of chronic disease as optimal control of diseases such as diabetes often requires family support.

Health risk behaviors and psychological symptoms affecting adjustment of student veterans have been identified.^11,12 Widome et al¹³ have called for the promotion of healthful behaviors in young veterans to prevent chronic illness and suggested a need “to establish partnerships that cut across traditional institutional domains. . . .”

Primary prevention programs will require strong partnerships between health care providers and organizations serving these veterans in the community. This study focuses on the health of veterans with a primary prevention approach involving outreach to students in the community through a partnership between a local Veterans Affairs Medical Center (VAMC) and a community college where veterans are enrolled. The goal of this exploratory work was to assess the health of veterans enrolled in a local community college in order to identify future areas of focus for health promotion efforts.

METHODS

Study Design

The specific objective of the study was to assess health risks in a group of community college veterans utilizing a cross-sectional health assessment survey. No personal identifiers were collected during this study. The protocol was granted an exemption by the Institutional Review Board and approved by the Research and Development Committee at the Louis Stokes Cleveland VAMC and was approved by the Institutional Review Board at Cuyahoga Community College (Tri-C) in Cleveland, Ohio.

Study Setting

This study was conducted at the campuses of Tri-C in collaboration with the Tri-C Department of Veterans Services and Programs. Tri-C is the largest public community college in Ohio with four main campuses, serving over 60,000 students annually.¹⁴

Study Participants

The study population included all identified student veterans enrolled at Tri-C in Spring Semester 2013 (978 students). Of note, an estimated 83% of veterans enrolled at Tri-C in the spring semester 2012 utilized the post-9/11 GI Bill benefits available to those who served after September 2001( personal communication, Tri-C Office of Institutional Research). Population sampling for all enrolled veteran students was used.

Data Collection

Survey questions (available from authors upon request) included those used with permission from the National Health Study for a New Generation of U.S. Veterans Questionnaire, a national survey tool currently in use for recent veterans,¹⁵ and additional questions added by the research team.

Specific measures in the survey included 

1. Demographic information including self-reported biometric data and descriptive information about branch of service and deployment (questions 1–6, 8–9, and 26–33)

2. Utilization of health care services (questions 7 and 13–14)

3. Medical history (questions 10–12 and 15)

4. Health behaviors (questions 22–25 and 34–38)

5. Health status (questions 16–21)

The six questions exploring health status on the survey were from the original version of the Medical Outcomes Survey Short-form 12(SF-12)¹⁶ reformatted as in The Veterans RAND 12-Item Health Survey(VR-12)¹⁷ or from the Medical Outcomes Survey Short-form12-version 2 (SF-12v2).¹⁸ One of these questions asked the participant to rate their health on a 5-point scale and the five additional questions requested participants to report level of limitation in daily activities as a result of physical or emotional issues or related to pain, also on a 5-point scale.

Survey study data was collected and managed using Research Electronic Data Capture hosted at Case Western Reserve University. Research Electronic Data Capture “is a secure, web-based application designed to support data capture for research studies, providing: 1) an intuitive interface for validated data entry; 2) audit trails for tracking data manipulation and export procedures; 3) automated export procedures for seamless data downloads to common statistical packages; and 4) procedures for importing data from external sources.”¹⁹ The electronic survey was initially piloted for usability by sending the survey to a group of 17 veteran students enrolled at Tri-C in Fall Semester 2012. These results are not included in the analysis. No significant problems were identified with students’ ability to complete the electronic survey during the pilot testing; thus, the survey was not altered after the pilot phase.

The survey was sent to 978 veterans in Spring Semester 2013. An introductory e-mail letter with a link to the electronic survey was sent to students requesting voluntary participation. Over the next 2 weeks, a reminder was included in an electronic newsletter and an e-mail reminder was also sent. An invitation was then sent by mail with a paper survey and postage paid return envelope as well as a link to the electronic survey, with a $5 grocery store gift card to all veterans requesting their participation in the survey. This incentive amount was chosen based on previous studies.^20–22 As the survey was anonymous, the gift card was sent to all students. After 2 weeks, an e-mail reminder was sent (without survey link), with a final e-mail reminder after 10 days. Results include responses received up to 1 month after the final reminder (April, 2013).

Data Analysis

Data were analyzed using IBM SPSS Statistics software, Version 20. Descriptive analyses to assess self-reported prevalence of clinical diagnoses and health behaviors were performed. Chi-square and t-tests were performed to allow for comparison of male vs. female veterans and veterans deployed to Iraq, or Operation Iraqi Freedom (OIF), or Afghanistan, or Operation Enduring Freedom (OEF) vs. other veterans. Logistic regression analyses were performed to assess the possibility of independent predictors of functional limitations. For the logistic regression analysis regarding the outcome of accomplishing less related to emotional problems, the survey question responses were dichotomized from the five choices of “all (1),” “most (2),” “some (3),” “a little (4),” or “none of the time (5)” to some or more (3, 2, and 1) as a positive response. For the pain interfering with normal work outcome, the options of “not at all (1),” “a little bit (2),” “moderately (3),” “quite a bit (4),” or “extremely (5)” were analyzed as responses of moderately or more (3, 4, and 5) as a positive response. The predictor variables included self-reported diagnoses of diabetes, hypertension, PTSD, or depression, and history of deployment to OIF/OEF conflicts.

RESULTS

Of the 978 surveys sent by both e-mail and U.S. Postal Service, 30 surveys were returned to sender because of an incorrect address, of which one was resent to an alternate address. One survey was returned with the statement “I am not a veteran” thus was excluded from analysis. A total of 204 responses were obtained (50 electronic and 154 by mail) for a response rate of 21%.

The self-reported demographic description of survey respondents showed that they were 78% male (n = 158), 42% Black (n = 86), 49% White (n = 99), and mean age was 44 (n = 157). Twenty percent of respondents (n = 40) had been deployed to OIF/OEF conflicts. Compared to the reported demographic distribution of veteran students enrolled at Tri-C (personal communication, Tri-C Office of Institutional Research), the survey respondents had slight over-representation of Black or African–American veterans (42% vs. 38%), under-representation of female veterans (22% vs. 29%), and were older than most Tri-C veterans (mean age 44 vs. 36 years). The OIF/OEF student veteran respondents had a mean age of 34 and student veterans never deployed to OIF/OEF had mean age of 47 (2-sided t test; p < 0.05). The mean age difference among males and female respondents did not reach statistical significance (males 45 years, females 41 years, 2-sided t test; p = 0.07). 64% of all respondents had an income less than $35,000. 65% of the respondents reported that they had accessed VA services since separation from active duty (85% of those deployed to OIF/OEF and 60% of other veterans; 2-sided Fisher’s exact test, p < 0.05).

Prevalence of specific health behaviors, indicators of health status, and self-reported medical diagnoses/conditions are shown in Table I. Of note, the difference between tobacco use in male and female respondents did not reach statistical significance in this sample (39% male vs. 23% female, 2-sided Fisher’s exact test, p = 0.05).

TABLE I.

Survey Results

Variable	Self-Reported Prevalence % (N)
Tobacco Use: Past 12 Months	35 (71)
Alcohol ≥4 Times per Week	6 (13)
Alcohol Use: Never	34 (69)
Recreational Drugs: Past Month	9 (19)
Energy Drinks: Any per Week	15 (30)
Fast Foods: 3–4 Days or More per Week	16 (33)
Sugary Drinks: 3–4 Days or More per Week	27 (55)
Exercise: Any per Week	75 (152)
Prescription Medications: Past 12 Months	82 (164)
Accomplished Less: Physical Health (Some or More of the Time)	45 (91)
Limited Activities: Physical Health (Some or More of the Time)	36 (73)
Accomplished Less: Emotional (Some or More of the Time)	35 (70)
Activities Less Carefully: Emotional (Some or More of the Time)	27 (54)
Pain Interfere with Normal Work (Moderately or More)	42 (86)
Health Rating Fair/Poor	15 (31)
Health Rating Excellent/Very Good	36 (73)
Diabetes	6 (12)
Hypertension	22 (44)
PTSD	14 (29)
Depression	30 (61)
TBI	4 (9)

Prescription drug use in the past 12 months was 82%. Additional analyses revealed that over 90% of the survey respondents with a diagnosis of depression reported prescription medication use and accounted for over one-third of the prescription medication users in this population.

A significant percentage of students reported functional limitation related to physical (45%) and emotional (35%) issues some or more of the time in the past 4 weeks, and 42% reported that pain interfered with normal work at least moderately (24% of female student veteran respondents and 47% of male respondents, 2-sided Fisher’s exact test, p < 0.05). Only 36% of respondents rated their health as excellent or very good.

Regarding self-reported medical diagnoses/conditions, the prevalence of depression was 30% in this population, of PTSD 14%, of traumatic brain injury (TBI) 4%, and hypertension 22%. Male veterans and those never deployed to OIF/OEF reported a hypertension diagnosis more frequently (26% in males vs. 7% in females; 2-sided Fisher’s exact test, p < 0.05, and 8% OIF/OEF vs. 26% other veterans, p < 0.05). 33% of veterans deployed to OIF/OEF reported a PTSD diagnosis vs. 9% of veterans not deployed to OIF/OEF (2-sided Fisher’s exact test and p < 0.05). Recent veteran students also more frequently reported a diagnosis of TBI as compared to veterans of previous conflicts (18% vs. 1%; 2-sided Fisher’s exact test, p < 0.05).

Logistic regression analysis (Table II) confirmed the independent association of a self-reported diagnosis of depression (OR = 3.3, 95% CI 1.4–7.8, p < 0.05, and C statistic 0.72) with a report of “accomplished less than you would like with your work or other regular daily activities” over the past 4 weeks as a result of any emotional problems some or more of the time (dichotomized outcome variable). There was no association of diagnoses of hypertension, diabetes, PTSD, or OIF/OEF status with this outcome. An additional logistic regression analysis (Table III) confirmed an independent association of a PTSD diagnosis (OR 3.9, CI 1.1–13.6, p < 0.05, and C statistic 0.75) with pain interfering with normal work moderately or more (dichotomized outcome variable). A hypertension diagnosis (OR 2.7, CI 1.1–6.6, p < 0.05) was also associated with the pain outcome; there was no association of a diabetes diagnosis, depression, or OIF/OEF veteran status with this outcome. Analyses were adjusted for age, sex, and black/white race.

TABLE II.

Logistic Regression Model for “Accomplish Less as Result of Emotional Problems”

Variable	OR (95% CI)	p Value
Diabetes Diagnosis	1.1 (0.2–5.4)	0.92
Hypertension Diagnosis	1.1 (0.4–3.2)	0.75
PTSD Diagnosis	2.6 (0.8–8.3)	0.11
Depression Diagnosis	3.3 (1.4–7.8)	0.01
OIF/OEF Veteran Status	1.0 (0.3–3.1)	0.97

Adjusted for age, black/white race, gender. C statistic 0.72.

TABLE III.

Logistic Regression Model for Pain Interfering With Normal Work Moderately or More

Variable	OR (95% CI)	p Value
Diabetes Diagnosis	1.9 (0.4–8.7)	0.42
Hypertension Diagnosis	2.7 (1.1–6.6)	0.04
PTSD Diagnosis	3.9 (1.1–13.6)	0.03
Depression Diagnosis	1.3 (0.5–2.9)	0.60
OIF/OEF Veteran Status	2.0 (0.6–6.8)	0.25

Adjusted for age, black/white race, gender. C statistic 0.75.

COMMENT

This initial assessment of current health risks and health status of a group of veteran students is a first step in addressing the needs of this population utilizing a partnership between a local community college and a VAMC. This exploratory work identified health risks as well as self-reported limitations related to physical and emotional issues which can inform targeted health promotion initiatives.

The majority of respondents had low income and many reported unhealthy behaviors.

The self-reported depression diagnosis prevalence of 30% in the survey respondents was higher than reported in recent veterans seeking VA care (17%)²³ and in the general population (9%).²⁴ The analyses suggest that the high level (82%) of prescription drug use over the past 12 months in the study population may be associated with depression diagnoses. By comparison, much lower prescription drug use among adults in the United States has been reported at 48.5% for at least one prescribed drug in the past month 2007–2010.²⁵

The prevalence of PTSD of 14% is consistent with a previous report²⁶ and may be slightly lower as compared to a report which found 22% prevalence of PTSD in recent veterans seeking care at VA Hospitals.²³ Traumatic brain injury prevalence, however, is lower than previous estimates of up to 20% in veterans of recent wars,⁴ as may be expected in this study population where the majority of respondents had not been deployed to recent conflicts. Regarding recreational drug use, prevalence has been reported as 6.3% in adults age 26 or older and 21.4% in ages 18–25.²⁷ Given the average age of the survey respondents, the result of 9% obtained may be higher than expected.

As the impact of depression as well as PTSD and substance abuse on overall health in this group of veteran students may be significant, and can affect the motivation to improve health long term, the self-reported prevalence of this conditions in this study is concerning. Efforts to link veteran students to necessary health services through appropriate screening at the time of enrollment in college may be beneficial in this group.

Regarding identified cardiovascular risk factors, while combat deployment has been reported as a risk factor for hypertension,²⁸ the overall prevalence of hypertension in this study was lower than the general population.²⁹ The prevalence of cigarette smoking in this study of 35% is likely in an expected range for a group of adult veterans, most of whom are not currently employed, as national data suggests that current cigarette smoking is more common in unemployed adults (41%) as compared to those who are employed (23%).²⁷ Smoking prevalence is similar to that reported for active duty military personnel in 2008.¹³ Offering smoking cessation programs to students either on campus or through a local VAMC may help to decrease the future burden of chronic disease in these veteran students. Regarding fast food and sugary drink consumption, a significant percentage of respondents reported consuming these unhealthy foods on 3 or more days per week. By comparison, a study in California reported mean fast food intake of 1.5 times per week and mean sugar-sweetened soft drink intake of 2.2 times per week³⁰ while data from the National Health and Nutrition Examination Survey from 2007–2010 reported that adults in the United States get 11.5% of their caloric intake from fast foods.³¹ Energy drink consumption in this sample was significant although lower than the 44.8% prevalence reported in recent active duty service members.³² Energy drinks contain varying amounts of caffeine and recently presented data suggest adverse effects such as increased systolic blood pressure and changes on electrocardiogram after energy drink use,³³ thus possibly contributing to cardiovascular risk. Health promotion related to smoking cessation, and education about healthy food intake and availability of healthy food options on campus can be areas for targeted interventions for veterans to decrease cardiovascular risk.

Overall, the survey demonstrated unhealthy behaviors, high depression prevalence, and functional limitations in this group of veterans at a community college. Although more physically unhealthy days have been previously reported in veterans when compared to civilians,³⁴ these results should be viewed as especially alarming as this population consists of students who are faced with significant academic demands and for whom health limitations may impede academic success and future opportunities to ease the reintegration of these student veterans into communities.

Interestingly, male and female veterans, and OIF/OEF and other veterans were similar in more ways than they differed in this study. The lower prevalence of hypertension in recent veteran students is expected because of the lower mean age, and higher prevalence of PTSD and TBI is expected in this group given the timing of these conflicts and TBI being a “signature injury” of the recent conflicts.¹ For colleges, interventions focused on easing access to mental health services would be especially beneficial for OIF/OEF veterans. Regarding sex differences, there was a lower prevalence of hypertension and of pain significantly interfering with normal work in the female respondents. However, continued efforts by colleges and the VA system to ensure access to preventive services to maintain health in female veterans are needed.

LIMITATIONS

This study is limited by the fact that the survey is cross-sectional, and that the data are based on self-report of symptoms and diagnoses, which may change over time. It is possible that mood disorders may have seasonal variation, thus the timing of the survey in the winter and early spring months may also have affected responses. In addition, for the survey questions regarding health status and report of limitations from physical or emotional issues or pain, while the scales from which these six items are derived are of established reliability and validity, as we have used only a portion of the questions from the SF12 or VR-12 and SF12v2, we are not able to comment on the reliability and validity of the individual questions used, and not as part of the complete scales.

However, despite this limitation, the results obtained from this exploratory work, intentionally an investigation of a wide variety of issues in this first study, are valuable as an initial assessment, as this led to identification of key issues for those who are interested in conducting further research involving this group.

Another limitation is that our survey response rate was low and OIF/OEF veteran students were not well represented in the survey. Given the number of veterans utilizing post-9/11 GI Bill benefits at Tri-C is over 80%, a large percentage of students at the community college are likely recent veterans. However, only 20% of survey respondents reported deployment to OIF/OEF, raising a concern for response bias.

Approximately two-thirds of the survey respondents had accessed VA services since separation from active duty. It is thus possible that the rates of mental health diagnoses and functional limitations in this study are overestimated, reflecting another possible bias in the respondents in that those with medical conditions who were already seeking VA care may have been more likely to respond. As the study respondents may not fully represent the student veteran population at the community college, this limits generalizability of these findings to larger populations of veterans and calls for the need for larger studies of veteran students.

Finally, although this is a single-site study, with no comparison group of veteran students in other settings, this study describes how to utilize a health center–community college partnership to explore and identify the health needs of veteran students in the local community surrounding the health center, with the goal of creating future health promotion initiatives for these veterans. The model of collaboration described in the study may be generalizable while specific characteristics of each health center and community college may require tailored approaches to connecting with veteran students in different settings. Future work should address how to optimally develop these collaborations in other settings to provide needed services to veteran students.

CONCLUSION

A health assessment survey identified priority areas to inform targeted chronic disease prevention efforts for student veterans at a community college. The results suggest the need for further exploration of health needs of veterans in the community and consideration of unique venues for health centers to connect with veterans. It is important for the VA health care system to reach both recent veteran students as well as veterans of previous conflicts as the groups may not differ as much as expected. Utilizing a partnership between a VAMC and a community college encourages future collaborative interventions to improve knowledge of health risks, targeting unhealthy behaviors, and efforts to help decrease functional limitations from both physical and emotional issues in student veterans.