Mental Wellbeing Differential Survey of America's Veterans

Mental Wellbeing Differential Survey of Americas Veterans
Mental Wellbeing Differential Survey

of Americas Veterans
Matthew John Brennan

HSC4202
Hodges University
ii
Abstract
The population of U.S. military veterans has ballooned in the last 15 years due to the
ever expanding and ever complicated Global War on Terrorism (GWOT). Most sources
identify ~2.4 million Americans have deployed since 2001. Of this population roughly 25% are
suffering from mental health conditions including Post Traumatic Stress (PTS) according to the
US Department of Veterans Affairs. There is a stark lack of published scientific literature
related to the mental wellbeing of veterans. This study applies a relatively new tool for
measuring mental wellbeing called the Warwick-Edinburgh Mental Wellbeing Scale
(WEMWBS) to a US veteran population. Significantly different WEMWBS scores were found
for the veteran population as well as with more specific descriptors e.g. self-reported health
and self-reported socialization frequency. Additionally, trends were identified that might lead to
WEMWBS predictions based on the extent of past combat exposure.
Keywords: veteran, wemwbs, mental wellbeing
iii
Table of Contents
Abstract
ii
Table of Contents
iii
List of Tables
iv
List of Figures
Introduction
Materials and Methods
Results
Discussion
12
References
17
Appendices
A. Survey
22
iv
List of Tables
Table 1. WEMWBS baseline statistics with UK population survey 2011
Table 1: Pairwise Comparisons - Veteran Status
Table 3: Pairwise Comparisons Veteran Self-Reported Health
Table 4: Crosswise Comparisons Veteran Self-Reported Socialization
11
List of Figures
Figure 2: Kruskal-Wallis Test - Veteran Status
Figure 2: Sorted WEMWBS Scores versus Branch of Service
Figure 3: Kruskal-Wallis Veteran Self-Reported Health
Figure 4: Kruskal-Wallis Veteran Self-Reported Socialization
10
Introduction
The mental wellbeing of this latest generations new combat veteran population is
a hot topic issue, both politically as well as socially. Most of the published evidence
related to veteran wellbeing is anecdotal and found mostly in the media as supplied by
the myriad of advocacy groups that have arisen to serve this group, each conducting
private research to further their own ends.
During WWII approximately 12% of the population was deployed to fight. During
Vietnam this percentage fell to 9.7% of Americans serving. Since 1973, at the end of
the Selective Service Draft, the military has been employed a total of 114 times.
Preceding 1973, for 27 years, while the draft was in effect, the military was used only 19
times (Eikenberry & Kennedy, 2013).
The study of the latest generation of GWOT veterans is important because never
before in the history of the country have so few served overseas in a combat capacity.
Only a miniscule 0.5% of the population have served the military and political aims of
this country in the last 15 years (Kos, n.d.). This divide and detachment between this
new military caste and the civilian leadership is alarming.
In 2007, a report on the validity of a new technique to quantify mental well-being
was published. This new technique was called the Warwick-Edinburgh Mental
Wellbeing Scale (WEMWBS). This scale measures mental wellbeing which can be
defined as two separate components, one which includes state of happiness or life
satisfaction and the other which includes positive psychological functioning. It is
important to understand that Mental Wellbeing and Mental Health are different. Mental
Wellbeing describes positive states of thinking and feeling while mental health
encompasses the entire gamut of mental conditions from positive to negative (Tennant
R et al., 2007). There have been a handful of studies conducted with WEMWBS on
more specific samples and in other languages, and it holds up well, but there have not
been any studies done in the U.S. specifically on combat veterans (Waqas et al., 2015).
In order to explore and better understand Americas veteran population, this
study was conducted in two parts. First, a broadly representative group was surveyed
using the Warwick-Edinburgh Mental Wellbeing Scale (WEMWBS) to determine if the
mental well-being scores of a veteran population are significantly different from their
civilian counterparts. Secondly, four possible informers of mental well-being were
analyzed for significance. This data taken in whole will serve to better describe the
overall mental well-being of the US veteran population as well as some of the possible
key factors.
The implications of application of the WEMWBS to a veteran population is mostly
theoretical except for one instance of it being applied in the UK to a group of veterans
participating in a combat stress clinic (Busuttil & Bellwood, 2009) . In the Busuttil study,
a simple before and after treatment measurement was taken and compared. The
results showed that WEMWBS scores generally improved after treatment. It is hoped
that this study will provide further validation of the WEMWBS protocol as well as serve
to highlight some possible influences on mental wellbeing.
Materials and Methods

The aim of this study was to examine a veteran population and the best method
for doing this, capturing the most participants of the target group, was to create an
online survey utilizing the fourteen question WEMWBS protocol with an additional seven
demographic questions and two quality of life related questions. In order to facilitate
accurate data collection with a large response rate, survey software from the website
www.constantcontact.com was used. Links to the survey were distributed via several
online means, primarily through a Facebook contact list as well as three other online
forums which promised to have a relatively high veteran population. No incentives were
given to complete the survey. The survey was made available for a week and cutoff
after the number of new cases started to drop precipitously. In rough estimation, the
survey link was distributed to more than 2000 potential participants with 337 cases
ultimately being validated and accepted in the study.
Age, gender, veteran/civilian status are all represented well. As predicted, the
percentage of veterans participating is skewed extremely high at 43% compared to the
general population at 6.8% (US. Census).
All participants read a brief introduction to the survey explaining its origins as well
as the goals of the study. Author contact information was provided. In a number of
cases, the author responded on public forums to questions submitted questioning the
use of the survey and its methodology. Additionally, all participants were advised that
all submissions were anonymous and that no identifying information would be recorded.
The dataset compiled reflects this policy. Measures were instituted at the survey
software level to ensure that surveys were filled out completely. The study had an
excellent level of internal consistency as measured by a Cronbachs alpha of 0.917

(Cronbach, 1951).
The primary survey tool was acquired from the Warwick Medical School,
University of Warwick, U.K.. Permission was asked and granted to use the WEMWBS
survey. The study survey also asked participants to self-report their overall health as
well as levels of social interaction on a five and seven point Likert-type scale
respectively. If participants identified as a veteran or as a spouse/dependent of a
veteran, they were asked to choose which military branch they were affiliated with.
Data was exported from the www.constantcontact.com website into Microsoft
Excel 2016 where WEMWBS scores were calculated in accordance to instrument
guidelines. The data was then imported into IBM SPSS Statistics 23 and analyzed.
The primary data analysis was conducted using a Kruskal-Wallis test and when
significance was found between groups, pairwise comparisons were made using post
hoc Dunns (1964) procedure with a Bonferroni correction to account for the multiple
comparisons. Please note that while this study treated its Likert results as nonparametric ordinal data, most existing studies of WEMWBS use ANOVA analysis due to
its data strongly fitting a normal distribution despite not being technically continuous.
Results
Participant baseline WEMWBS statistics are presented in Table 1. Each of the
three veteran categories, (veteran, spouse/dependent and civilian) can best be
described as having left skewed, platykurtic distributions. For clarification, the veteran
category is defined as a current or former member of the military. The
spouse/dependent category is the spouse or immediate family dependent of a military
veteran. The civilian category is everyone else with no immediate connections to the
military. At the bottom of Table 1., data showing the WEMWBS scores for the most
recent UK population survey are shown. The UK data distribution more closely
resembles the normal distribution with a left skewness.
The ages of the participants ranged from 14 to 82 with a mean of 40.79 years.
Gender is perfectly represented with 168 males and 169 females. Fully 87% percent of
respondents are married or otherwise in a committed relationship. The survey was
targeted to a veteran population and the numbers support this with veterans
representing 43.3%.
WEMWBS baseline statistics with UK population survey 2011

Veteran Status
Mean
Median
Std.
Error
Std.
Dev
Kurtosis
Skewness
25%
Quartile
50%
Quartile
75%
Quartile
Veteran
145
42.159
41.000
0.841
10.125
-.408
-.110
35.50
41.00
50.00
Spouse/Dependent
122
45.680
45.000
0.702
7.755
-.440
-.184
40.00
45.00
51.25
Civilian
68
48.132
48.000
0.998
8.232
-.462
-.243
42.25
48.00
54.00
Total
335
44.582
45.000
0.504
9.248
-.261
-.276
38.00
45.00
52.00
7020 51.607
53.000
0.104
8.706
1.221
-0.664
47.00
53.00
57.00
UK Population
2011
Table 1. WEMWBS baseline statistics with UK population survey 2011
The first test conducted was to establish whether or not US veterans WEMWBS
scores are significantly different from the civilian population. A Kruskal-Wallis test was
run to determine if there were differences in WEMWBS scores between the three
veteran status groups, described as Veteran (n=145), Spouse/Dependent (n=122)
and Civilian (n=68). See Figure 1.
Figure 3: Kruskal-Wallis Test - Veteran Status
Distributions of WEMWBS scores were similar for all three groups based on a
visual inspection of a boxplot. The Median WEMWBS scores were statistically
significantly different between groups, 2(2) = 20.307, p < .001. Because significance
was found, pairwise comparisons were performed using Dunns (1964) procedure with a
Bonferroni correction for multiple comparisons. See Table 2. Adjusted p-values are
presented. This post hoc analysis revealed statistically significant differences in
WEMWBS scores between the Veteran (Mdn = 41) and Spouse/Dependent (Mdn = 45)
(p = 0.11) and Veteran and Civilian (Mdn = 48) (p < .001) groups, but not between any
other group combinations. The veterans scores were significantly lower than both the
civilian population and the immediate family spouse/dependent population.
Table 4: Pairwise Comparisons - Veteran Status
Because this study is primarily interested in describing the veteran population,

three further significance tests were conducted on the veteran population (n = 145)
data. The second test amounted to a comparison of veteran WEMWBS scores versus
the military branch served in. No significant difference was observed, 2(4) = 4.721, p =
.317. However, when ranked by WEMWBS score and graphed (exclusive of the Coast
Guard, n=1, for clarity) there appears to be a visible trend which will be explored later.
See Figure 2.
Figure 2: Sorted WEMWBS Scores versus Branch of Service

The third comparison was between WEMWBS scores and veteran self-reported
health data as measured on a five point Likert scale in the following groups, Excellent
(n=9), Very Good (n=27), Good (n=49), Fair (n=47), and Poor (n=13). See Figure
3.
Figure 3: Kruskal-Wallis Veteran Self-Reported Health
Based on a Kruskal-Wallis test, significance was found, 2(4) = 46.556, p < .001.
In order to identify the precise location of the significance, pairwise comparisons were
performed using Dunns (1964) procedure with a Bonferroni correction for multiple
comparisons. Adjusted p-values are presented. This post hoc analysis revealed
statistical significance in WEMWBS scores between all groups except Poor and Fair,
Fair and Good, Good and Excellent, Excellent and Very Good. In every case,
regardless of significance, there is a corresponding fall in WEMWBS scores as the selfreported health scores decline. Note that significant relationships are highlighted in gold
in Table 3.
Table 3: Pairwise Comparisons Veteran Self-Reported Health
10
The last comparison made for the veteran population was between WEMWBS
scores and self-reported socialization frequency as measured on a seven point Likert
scale. The groups were, Never (n=8), Less than once a month (n=39), Once a
month (n=33), Several times a month (n=26), Once a week (n=16), Several times a
week (n=13), and Everyday (n=10). See Figure 4.
Figure 4: Kruskal-Wallis Veteran Self-Reported Socialization

The Median WEMWBS scores were statistically significantly different between
groups, 2(6) = 32.192, p < .001. Because significance was found, pairwise
comparisons were performed using Dunns (1964) procedure with a Bonferroni
correction for multiple comparisons. Adjusted p-values are presented. This post hoc
analysis revealed statistically significant differences in WEMWBS scores between
Never and Several times a month, Never and Several times a week, Less than once a
month and Several times a month, Less than once a month and Several times a week,
Once a month and Several times a week. Again, there appears to be a correlation
between socialization frequency and WEMWBS scores. No other significant
11
comparisons for this category were observed. Significant relationships are highlighted
in gold, see Table 4.
Table 4: Crosswise Comparisons Veteran Self-Reported Socialization
12
Discussion
The original hypothesis was confirmed (p < .001). There is a significant
difference between the WEMWBS scores of US veterans and the greater civilian
population. Veterans had a median score of 42, spouses and dependents had a
median score of 45 and the greater civilian population was highest at 48. The
differentiation between spouses/dependents and civilians is noteworthy because it
seems to show that while they did not serve directly in the military, their direct
association with a veteran seems to impact their WEMWBS scores to some degree. It
is common knowledge in the veteran community that the families of veterans, especially
those that have deployed multiple times, suffer additional hardships that the general
population does not. Also, the spouses/dependents of veterans seem to mirror, to
some degree, the lower mental wellbeing scores of their veteran sponsors. If the
validity of the WEMWBS protocol is accepted, the daily mental stresses that veterans
suffer are shared by their families. Conversely, the general population that is insulated
from the military caste and its associated stressors has a higher mental wellbeing score.
The UK Study (Busuttil 2009) referenced earlier, was conducted on UK veterans
utilizing the services of a combat stress center. The study indicated relatively low
scores for the veterans compared to the UK General Census (2011) scores, but making
direct comparisons to this current study is not possible because the tests were
administered under different circumstances (before/after treatment vs one-time survey).
Additionally, the UK General Census survey data does not make a distinction between
veterans, spouses/dependents, or civilians as this current study does.
13
Once it was established that the veteran population has a distinct mental
wellbeing range, three other variables were looked at to see if they mirrored WEMWBS
scores. The first of these was whether or not the specific military branch the veteran
served in had any impact on WEMWBS scores. The Kruskal-Wallis analysis showed
that there was no significant difference between scores (p = .317). However, as shown
in Figure 2. when the WEMWBS scores for each branch are ordered from lowest to
highest, there is a trend visible. Both the Army and the Marine Corps. had lower scores
than the Navy and Air Force. While the differences are not statistically significant with
the current testing, it is telling that the two services most responsible for ground close
combat also score the lowest.
The second variable examined was that of veteran self-reported health. These
comparisons were highly significant as the numbers showed a strong correlation
between WEMWBS scores and health. As the health scores decreased, so did the
mental wellbeing scores. As seen in Figure 3. there is an almost twenty-five point
difference between the health scores of poor and excellent. Veteran health appears to
be a very good predictor of mental wellbeing.
The last variable examined was the frequency of socialization. Again, this
variable was found to be significant when related to mental wellbeing. According to the
analysis, the greatest benefits to wellbeing scores were found when the veteran
socialized more than once a month while the benefit slowly declined as the frequencies
became greater. For those that are effectively shut in and reclusive, they scored the
lowest.
14
Both health and socialization frequency appear to share a similar Spearmans

monotonic covariance with WEMWBS score (rs = .556 and .423, p < .001). The greater
implications of this shared predictor of mental wellbeing is alarming. Veterans in poor
health and those who socialize less than once a month, have predictably low mental
wellbeing scores. Addressing these two variables in a veterans life, improving health
and increasing socialization, would lead us to predict an increase in mental wellbeing
scores.
There are a number of study limitations recognized by the author. The
WEMWBS survey purports to be useful for monitoring mental wellbeing changes in a
population over time, so limiting this survey to a one-time application is one obvious
limitation of its overall usefulness. If this same population was able to be tested again
after a period of time or after some other change, these scores collected would be used
as a baseline. Without follow up data however, the best we can accomplish is to
describe some simple trends in the veteran population. Other limitations include the
self-reporting subjective nature of the survey. For obvious reasons, self-reported health
is a less than scientific description of an individuals health. It would be completely
reasonable to claim that someone who reports good or excellent health could simply
have a positive outlook on life, regardless of actual health. This same problem applies
to the entire survey as written. Scores recorded for an American civilian population
were measurably lower across the board when compared to the 2011 UK population
data. At this time, this discrepancy between these two groups using the WEMWBS
protocol, which has shown to have validity in other studies (Taggart et al., 2013), cannot
be reconciled.
15
In a paper done by the United States Army, it found that across all units found in
garrison (not deployed), the rate of reported metal health rates for PTSD is between
5%-8% (Castro, 2009). Note that this 8% is a baseline for all Army units prior to combat
duty. In theatre units that have actively engaged in combat, report screened numbers
as high as 30% increasing upwards to 50% during sustained combat operations. This
paper argues that as the number of deployments and combat intensity increases,
positive screening for PTSD and other mental health disorders becomes the norm
rather than the exception.
Another study conducted by the German armed forces looked at the correlation
between an increased risk of developing PTSD and (Schwartz, 1992) inspired Basic
Human Values. This study found a strong negative correlation between PTS suffering
and those who held stimulation, hedonism and achievement values. Conversely, those
who fell on the benevolence, tradition and conformity side of the scale generally
suffered more from symptoms (Zimmermann et al., 2014).
Every study looked at indicates that those who serve in combat are at a greater
risk of suffering from PTSD and other mental health problems than the general public.
This study helps fill in the gaps of this sparsely populated field of veteran mental
wellbeing knowledge and increases the visibility of this issue. Furthermore, it
contributes to the validity of the WEMWBS protocol and helps identify powerful
predictors for mental wellbeing.
The factors that affect a veterans mental wellbeing should be studied. Better
understanding these factors not only benefit the veteran, but also the greater civilian
population. While beyond the scope of this study, similar trends in WEMWBS scores
16
within the civilian population were also observed. In fact, none of the broad conclusions
reached in this study are contradicted when run against the entire dataset. The health
of the nation could be judged based on the health of its veterans. Never, in the history
of the Republic, have so few been responsible for guarding the freedoms of so many. It
would behoove the greater population to better understand those that are asked to bear
the burden of national defense.
17
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22
Introduction
The purpose of this survey is to measure mental well-being. Mental well-being is not to
be confused with mental health. Mental health is measured on a positive and negative
scale, while mental well-being is only concerned with the positive side of the scale. I am
interested in comparing a veteran centric population with the general public. This study
is the first time the Warwick-Edinburgh Mental Well-being Scale (WEMWBS) has been
applied to a U.S. military veteran population.
This original research project is part of 4000 level research methods course that
counts towards my degree program. The survey comes in two parts and is comprised
of approximately 24 multiple choice questions. It should take you less than 5 minutes to
complete. The first part is the WEMWBS survey and the second part consists of basic
demographic questions.
Your participation is greatly appreciated and It would be extremely helpful if you
would forward this survey to as many of your contacts as possible. I would encourage
you to share this survey with your family as I am also interested in input from
spouses/significant others and older children.
All data is anonymized and no personal identifying information is kept. Thank you
for your time and for your service.
Semper Fidelis.
Warwick-Edinburgh Mental Well-being Scale (WEMWBS) NHS Health Scotland,

University of Warwick and University of Edinburgh, 2006, all rights reserved.
23
Survey
Demographics
In general, how would you rate your overall health? Circle.
Excellent
Very Good Good
Fair
Poor
What is your gender? Circle.
Male
Female
What is your age?
Are you married or in a committed relationship?

Yes
No
What best describes your professional status? Circle or describe.
Full Time
Part Time
Not
Retired
Student
Work
Work
Employed
Volunteer
Caregiver
Other: ____________________________________________
What best describes your association with the military?

Veteran
Spouse/Dependent
What branch of the Military are you associated with?
Army
Navy
Air Force
Not affiliated
Marine Corps
Coast Guard
Generally speaking, would you say that most people can be trusted, or that you can't be too
careful in dealing with people? Please give a score of 0 to 10, where 0 means you can't be too
careful and 10 means that most people can be trusted. Circle.
0
1
Least Trust
How often do you meet socially with friends, relatives or colleagues? Circle.
Never
Less than
Once a
Several
Once a
Several
once a
month
times a
week
times a
month
month
week
10
Most Trust
Every day
24
Below are some statements about feelings and thoughts. Please circle the number that best
describes your experience of each over the last 2 weeks.
Conclusion
This concludes the survey. Thank you for your time. I will be publishing my
results in late December so let me know if you are interested in follow up or have any
questions. I can be reached directly at mbrennan@mail.hodges.edu.
Have a great day.
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Mental Wellbeing Differential Survey of America&#39;s Veterans

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Mental Wellbeing Differential Survey of Americas Veterans