Military veterans’ perception of quality of care following international operations

Abstract

A high number of military veterans seek professional help at primary healthcare centers for mental health problems. The main aim of this study was to map veterans’ perception of the quality of the care they received when seeking such help after their last tour of duty. A secondary aim was to explore personality and mission-related characteristics of veterans who seek professional help for mental health problems after missions. Questionnaire responses were obtained from 2512 Swedish veterans (43.4% response rate). Among the responders, 210 individuals had sought help for mental health problems at primary healthcare centers. Their perception of the quality of the healthcare was measured using the Quality from the Patient’s Perspective (QPP) questionnaire, which is derived from a theoretical model. Comparisons between the military help seekers and an age and gender matched group of civilian outpatients showed that the military group perceived the information they had received, and the commitment, empathy and respect shown by the physicians, considerably more negatively than the civilian patients. Comparisons between the help-seeking veterans and those who had not sought help, showed that the help seekers were younger and scored significantly lower on emotional stability and higher on conscientiousness. In addition, they perceived the leadership of their immediate commander during the last tour of duty more negatively and they reported fewer daily uplifts and more daily hassles during the tour. It was concluded that a more extensive collaboration between the armed forces and the healthcare system is strongly recommended and that it is necessary to provide education to healthcare providers.

Keywords:

• Veterans
• primary care
• quality of care
• theory-based assessment
• quality from the patient’s perspective (QPP) questionnaire
• age
• gender
• personality
• military
• leadership
• stress

REVIEWING EDITORS:

• Daryl O’Connor, Department of Leadership and Command & Control, Forsvarshogskolan, Karlstad, Sweden

Subjects:

• Social Sciences; Behavioral Sciences; Counseling Psychology; Mental Health; Medicine; Medicine, Dentistry, Nursing & Allied Health; Medicine; General Medicine

Introduction

The research regarding the reactions of soldiers and officers to their service during and after military operations is extensive. It has generally focused on severe reactions such as Post Traumatic Stress Disorder (PTSD), anxiety, depression, drug problems, suicidal behavior, etc. (Michel, 2014). However, most soldiers and officers return to their home countries with less severe symptoms of stress that do not meet the criteria for psychiatric diagnoses (Eng Berge et al., 2020). Nonetheless, a high number of veterans seek professional help for mental health problems after international tours of duty. This highlights the question of the perceived quality of the healthcare provided to veterans. In Sweden, like many other countries, the point of entry to professional healthcare system for mental health problems is the primary healthcare centers.

A large-scale study (Borowsky et al., 2002) compared veterans’ perceptions of healthcare in community-based outpatient clinics and Veteran Affairs Medical Center primary healthcare clinics. Only small differences were noted, with the community-based outpatient clinics receiving slightly more favorable patient ratings. Integrating behavioral health services into primary healthcare settings was found to increase patients’ and providers’ satisfaction (Cooper et al., 2016; Grant & Simpson, 2021; Simpson & Leach, 2013). Along the same lines, Budzi et al. (2010) found most veteran primary healthcare patients preferred nurses to physicians. It was argued that in addition to clinical care, nurses focus on health promotion, disease prevention, health education, attentiveness and counseling.

Studies on veterans’ perception of quality of care has also been conducted with a focus on female veterans. Kimerling et al. (2015) found that the availability of mental health services specialized for women was rated as extremely important by a high proportion of the participating female veterans. Primary healthcare colocation of such specialized care was also preferred. Similar results were reported by Bastian et al. (2014). They found that women veterans’ experiences of outpatient health care improved if the health care provided was specifically designated for women.

The extant research on veterans’ perception of quality of healthcare appears to be mainly empirically driven with limited or no attention paid to the theoretical base of such perceptions and to measurement issues. In Sweden, one of the most used models of quality of care from a patient perspective was originally presented by Wilde et al. (1993). The model stipulates that patients’ perceptions of what constitutes quality of care are formed by their encounters with an existing care structure and by their systems of norms, expectations, and experiences. Quality of care can be understood in the light of two cross-tabulated conditions, the resource structure of the care organisation and the patients’ preferences. The resource structure of the care organisation consists of person-related, as well as physical and administrative environmental qualities. Patients’ preferences have both rational and human aspects. Within this framework, patients’ perceptions of quality of care may be considered in four dimensions: the medical-technical competence of the caregivers, the physical-technical conditions of the care organisation, the degree of identity-orientation in the attitudes and actions of the caregivers, and the socio-cultural atmosphere of the care organisation. A questionnaire, Quality from the Patient’s Perspective (QPP), was developed and further refined using the theoretical model with the four dimensions (Larsson et al., 1998; Wilde Larsson & Larsson, 2002; Wilde et al., 1994).

Following this, the main aim of this study was to map military veterans’ perception of the quality of care they received when seeking professional help for mental health problems after their last performed tour of duty at primary healthcare centers. A secondary aim was to explore the personality and mission-related characteristics of veterans who seek professional help for mental health problems after missions. A pilot study based on a subgroup of the present study sample has already been presented (Larsson, 2019), and the entire study is documented in this paper.

Method

Participants and procedure

The study population included all men and women who had previously served in an international military operation, once or multiple times, in the Swedish Armed Forces, here labeled ‘veterans’, in the period 2011–2015. Individuals who had served as ‘single participants’ (e.g. military observers) were also included. The data collection took place in 2017. A list of 5792 people was obtained from the Swedish Tax Agency and a questionnaire was sent by physical mail to their home addresses. The questionnaire was complemented with an information letter from the Head of the Swedish Armed Forces’ Veteran Center and a letter from the research group and a prepaid reply envelope. An Internet link was also provided for digital responses. Three weeks later, a reminder was sent to all 5792 (the questionnaire was filled in anonymously, so we did not know who had responded). Responses were received from 2512 people. This yielded a response rate of 43.4%. General background data about those who responded include the following: age—M = 43.5 years, (SD = 13.3), gender—92% men and 8% women, education—34% high school and 66% college/university, living situation—78% being married/cohabitant and 22% living single and occupation—72% still employed by the Swedish Armed Forces and 28% had other occupations, were unemployed, students or retired.

Civilian comparison group

Responses on perceived quality of care were obtained in 2005 from 21475 patients visiting primary health care centers in Sweden for a variety of health problems (Wilde & Larsson, 2009). The following steps were taken to match this civilian patient group with the military subsample who had sought help for mental health problems at primary healthcare centers after their last tour of duty (n = 210). Regarding age, civilian patients 30–57 years old were selected. This represents plus/minus one standard deviation in the military group. Turning to gender, ten percent of the civilian women were randomly selected in the 30–57 years age bracket (SPSS procedure Sample). The result was an age and gender matched civilian group consisting of 9100 primary health care patients.

Measures

The questionnaire contained a combination of established scales and newly developed items. The latter were deduced from qualitative studies of Norwegian and Swedish veterans (Larsson et al., 2017; Tomteberget & Larsson, 2020).

Personality

Data were collected using the Single-Item Measures of Personality (SIMP) (Woods & Hampson, 2005) designed to measure the five dimensions/factors in the Big Five model of personality (Costa & McCrae, 1992): Extraversion, Agreeableness, Emotional Stability, Conscientiousness, and Openness. Each factor/item was measured on a nine-point graded line.

Perceived leadership during the mission

A selection of items from the Developmental Leadership Questionnaire (DLQ; Larsson, 2006) was used to assess leadership behaviors. Developmental leadership is a leadership style with six items designed to measure the three factors: Exemplary, authentic model, Individualized consideration, and Inspiration and motivation. Sample developmental leadership item: ‘NN acts in accordance with the opinions he or she expresses’. Cronbach alpha: .94. Conventional-positive leadership is a leadership style measured using three items covering the facets Demand and reward—seek agreements and Control—take necessary measures. Sample conventional-positive item: ‘NN aims to reach agreements on what must be done’. Cronbach alpha: .90. The factor Conventional-negative leadership was assessed using two items, measuring the two facets: Demand and reward—if, but only if, reward and Control—overcontrol. Sample conventional-negative item: ‘NN keeps a log of other people’s mistakes’. Cronbach alpha: .85. Finally, the Destructive leadership style consists of five items designed to measure the two factors Active destructive leadership and Passive destructive leadership (incorporated into the DLQ from the instrument Destrudo-L; Larsson et al., 2012). Sample destructive leadership item: ‘NN avoids making necessary decisions’. Cronbach alpha: .87. A detailed description of the leadership dimensions, factors and facets can be found in Larsson et al. (2018).

Respondents were asked to assess how frequently they experienced that their immediate commander engaged in the specific behavior described by each item during the last tour of duty. Each behavior was rated on a nine-point frequency scale ranging from never, or almost never (1) to always, or almost always (9). A ‘don’t know’ alternative was also provided for each item. Scale scores were computed by adding the raw scores of the items representing the scale and dividing the sum by the number of items (scale scores ranged from 1 to 9). Any missing values were replaced by the individual’s mean score for the other items of the index in question.

Daily uplifts during the mission

This was measured using 16 items (alpha = .87) and included a mix of one item from the Stress Profile (Setterlind & Larsson, 1995) and 15 newly constructed items based on interview responses obtained in the aforementioned two Scandinavian qualitative studies on veterans (Larsson et al., 2017; Tomteberget & Larsson, 2020). The new items were written by the principal author and then discussed with the co-authors. After this, they were tested on a research colleague who is also a military veteran. Thereafter, some final adjustments were made. Example: ‘Joy over trust in those who took part in the mission’. All items had 5-point response scales ranging from 1 (never) to 5 (very often). Scale scores were computed by adding the raw scores of the items representing the scale and dividing the sum by the number of items (scale scores ranged from 1 to 5).

Daily hassles during the mission

This was measured using 13 items (alpha = .80) with the same variety of sources reported above regarding daily uplifts (two items from the Stress Profile and eleven newly constructed items). Example: ‘Irritation over low-intensive periods’. All items had 5-point response scales ranging from 1 (never) to 5 (very often). Scale score computation, see Daily hassles during the last month above.

Perceived quality of care

Quality of care from a patient perspective was assessed using seven selected items from the questionnaire Quality from the Patient’s Perspective (QPP; Wilde Larsson & Larsson, 2002; Wilde et al., 1994). The items represented two factors within the quality dimension ‘degree of identity-orientation in the attitudes and actions of the caregivers’ (see above). The factor Information consisted of four items (alpha = .91 in the military sample and .86 in the civilian sample). Example: ‘I received useful information on self-care’. The factor Commitment, empathy and respect (doctors) consisted of three items (alpha = .93 in the military sample and .90 in the civilian sample). Example: ‘The doctors showed commitment; cared about me’.

Each item was related to the sentence ‘This is what I experienced…’. (for instance, the doctors showed commitment; cared about me). In this evaluation, a 4-point response scale ranging from 1 (do not agree at all) to 4 (completely agree), was used (each item also had a not applicable response alternative). Scoring on the QPP factor scales Information and Commitment, empathy and respect (doctors) was performed by adding the raw scores on items representing each factor and dividing that total by the number of items in the factor.

Statistics

SPSS Statistics version 25 was used in the statistical analyses. Summary indices were calculated for all the instruments mentioned, except the personality single item scales (see above). Descriptive statistics and bivariate correlations (Pearson) were calculated. Subgroup comparisons were performed using chi-square tests and t-tests. Statistical significance was assumed at p < .05.

Ethics

All participants were treated in accordance with human research principles formulated by the Swedish Research Council (2013) and in accordance with the Helsinki Declaration (World Medical Association, 2013). The study procedures, collection, storing and distribution of the data were performed in accordance with current general protection guidelines. The project was approved by the Swedish the Swedish Ethics Review Authority (n.d.) (Protokoll Dnr 2022-03754-01).

Results

Dropout analysis

The gender and age of the 2512 individuals who responded to the questionnaire were compared with the 3280 who did not. The responding group was comprised of 92% men and 8% women. The corresponding proportions among the dropouts were 91% men and 9% women. The difference is not statistically significant (chi-square (1) = 2.18, p >.05). The mean age among the responders was 43.5 years (SD = 13.5), while it was 40.9 years (SD = 11.5) in the non-responding group. This difference is statistically significant (t (5790) = 18.18, p < .001). No further comparisons could be made.

Comparisons within the military veterans sample

Participants reporting that they had sought professional help for mental health problems they felt were caused by the last international tour of duty, were compared to those who had not sought professional help.

Table 1 shows considerable differences between the two groups for all study variables except for the personality scales Extraversion, Agreeableness and Openness. Thus, those who had sought professional help showed lower Emotional stability, higher Conscientiousness, perceived all four leadership aspects during the last mission less favorably and experienced fewer daily uplifts and more daily hassles during the last mission. All significant differences except for the result on Conscientiousness remain significant after Bonferroni corrections.

Table 1. Comparison between participants who had sought professional help for mental health problems and all other participants.

	Participants who had sought professional help for mental health problems (n = 210)		All other participants (n = 2302)
Variable	M	SD	M	SD	t	p
Individual antecedents
Age	39.5	12.0	43.9	13.6	−4.38	.000
Extraversion^a	5.79	1.98	5.74	1.89	.34	.737
Agreeableness^a	5.48	1.99	5.47	1.68	.32	.915
Emotional stability^a	5.38	1.97	6.40	1.67	−8.06	.000
Conscientiousness^a	6.44	1.76	6.08	1.73	2.71	.007
Openness^a	4.89	1.86	4.85	1.76	.28	.777
Leadership during mission^a
Developmental	6.33	2.04	6.79	1.83	−3.36	.001
Conventional positive	6.38	2.27	6.86	1.92	−3.32	.001
Conventional negative	3.35	2.37	2.76	2.07	3.76	.000
Destructive	3.33	2.24	2.74	1.84	4.28	.000
Daily stress during mission^b
Uplifts	3.43	0.72	3.62	0.63	−4.05	.000
Hassles	2.63	0.60	2.30	0.55	8.93	.000

Note. ^aScores could range from 1 to 9. ^bScores could range from 1 to 5.

The two groups were also compared regarding background characteristics (chi-square tests). No statistically significant differences in proportions were found regarding gender, education, living situation and military branch.

Comparison with a civilian patient group

The military veterans who had sought help for mental health problems at a primary health care center were compared with an age and gender matched group of civilian patients who had sought help at a primary health care center for any kind of health problem (see Method section).

Table 2 shows that there are stark differences between the two groups. The military veterans score notably lower on both perceived quality scales as well as on the total quality of care scale. Chi-square tests showed that the civilian patient group had a higher level of education (chi-square = 184.11 (2), p < .001). No differences were noted regarding their living situation.

Table 2. Comparisons between Participants who had sought professional help for mental health problems at primary health care centers and age and gender matched civilians who had sought professional help for all kinds of health problem at primary health care centers.

	Participants who had sought professional help for mental health problems (n = 210)		Age and gender matched civilians who had sought help for all kinds of health problems (n = 9100)
	M	SD	M	SD	t	p
Perceived quality of care
Information	2.67	0.97	3.32	0.74	−12.20	.000
Commitment, empathy and respect (doctors)	2.69	1.02	3.52	0.70	−14.49	.000
Total quality of care score	2.68	0.94	3.42	0.67	−16.42	.000

Note. Scores could range from 1 (lowest perceived quality) to 4 (highest perceived quality).

Discussion

Military veterans’ perception of the quality of the care they received when seeking help for mental health problems after their last tour of duty at primary healthcare centers was studied using an established theoretical model and measurement tool (QPP). The main finding was that the present sample of Swedish veterans rated the quality of care considerably more negatively compared to an age and gender matched civilian outpatient group. In fact, the QPP instrument has been used in hundreds of internationally published papers and the present results are, to the best of our knowledge, the most unfavorable obtained so far. This also contrasts with the more favorable ratings provided by US veterans receiving help at community-based outpatient clinics (Borowsky et al., 2002).

The dissatisfaction of the present veteran group concerned both the information they received and the physicians’ commitment, empathy and respect. Free-form text responses to the questionnaire included statements like: ‘I wasn’t taken seriously’, ‘They didn’t understand me at all’, ‘They seem to think that all veterans have PTSD’, ‘They were negative towards the military’ and ‘Their level of knowledge was low’. These findings are negative in themselves and they may also be an indicator of additional problems. Perceived quality of care has been shown to be related to treatment adherence and future health care utilization (Johnson & Possemato, 2019; Wilde & Larsson, 2009), including proneness to use professionally recommended web and mobile health apps (Hogan et al., 2022). A possible contributing cause of the limited knowledge about military veterans among Swedish primary healthcare personnel, is Sweden’s extended time of peace, spanning more than 200 years. At the time of the data collection (2017), there was a relatively low interest in the military in the general population. Following the Russian invasion of Ukraine, the changed security situation in Europe and a major rebuilding of the Swedish total defense, we venture to guess that a changed societal climate spill over to the healthcare professions.

Another possible contributing factor is that the education provided for healthcare personnel in Sweden specified for primary health care, is based on the general health care concerns of the society at large. However, the education generally lacks a specific focus on subgroups, such as military personnel, refugees, etc., which may present specific needs outside of the societal norms.

The findings related to the secondary study aim concern the differences noted between the smaller group of veterans that had sought professional help for mental health problems and the vast majority that had not sought such help. The help seekers were younger, had a lower emotional stability and a higher level of conscientiousness. Otherwise, there were no personality differences or disparities regarding gender, education, living situation or military branch. The help seekers perceived the leadership of their immediate commander during the last mission more negatively than those who did not seek help. In addition to these individual and contextual characteristics, the help seekers also reported a higher level of everyday stress during their last mission in terms of fewer daily uplifts and more daily hassles. Regarding daily uplifts and hassles, it should be noted that the assessment reflects each participant’s subjective evaluation. A given event only constitutes an uplift or a hassle if it is appraised as such by the person in question (Lazarus, 1984).

Emotional stability and leadership quality have repeatedly been shown to be related to post-mission mental health (Bowles, Bartone, Ross, Berman, Rabinowitz, Hawley, Zona et al., 2017; Cornum & Lester, 2012; Laurence & Matthews, 2012; Rumsey & White, 2010) and now it was also found to be associated with help seeking and with perceptions of quality of care. Regarding daily uplifts and hassles, recent veteran studies have demonstrated significant associations with stress-related physical, emotional and cognitive symptoms (Larsson et al., 2021) and these findings also appear to have relevance for help-seeking and for quality-of- care perceptions.

The main practical suggestion is to improve the education of civilian physicians and nurses at primary healthcare centers regarding the specific needs of veterans. This has also been highlighted by Cooper et al. (2016). General practitioners in the United Kingdom have requested more information on how to assess veterans and a number of health care practices in the United Kingdom are already veteran-friendly accredited (Grant & Simpson, 2021). The Swedish health care system is falling behind in this respect, while, for example, education of primary healthcare personnel in Norway is carried out by the Norwegian Collection Agency of the Labour and Welfare Administration. In the Swedish case, we recommend a collaboration between the Swedish Armed Forces and the Swedish National Board of Health and Welfare to initiate such an educational program.

Practical implications also include increased attention to emotional stability at the selection stage, as well as efforts to improve leadership quality and to reduce unnecessary daily hassles during tours of duty.

The methodological strengths of the study include quality of care assessments founded on a theoretical model and measured using parts of an established tool. A drawback is that only parts of the model and instrument factors could be mapped. This was due to the decision to include other scales not reported here and wanting to avoid making the questionnaire too long. Our main suggestion for future research is to study help-seeking veterans’ perception of the whole panorama of care aspects included in the theoretical model (Wilde et al., 1993).

The response rate was fairly low (43.4%). The dropout analysis showed that the responders and non-responders did not differ regarding gender. However, the non-responders were slightly younger than the responders. Nonetheless, it is our view that the low response rate did not significantly affect the results. A second methodological weakness is the period between the military mission and the data collection. This period varied from two to seven years which may cause the memory to fade. However, it should be noted that it was only the questions about the perceived quality of the military leadership that were related to the service period. The other questions referred to the situation during the last month.

A third methodological weakness is the single-item measures of the Big-five personality dimensions. These dimensions are complex constructs and ideally a more comprehensive assessment should have been made. Therefore, the findings related to the personality scales should be interpreted with care. A final potential weakness is that the study participants were asked to report professional help seeking for mental health problems they felt were caused by their last international tour of duty. This means that other participants may have sought professional help for mental health problems but not reporting it, as they thought it was unrelated to their last military operation (but possibly to previous tours of duty). Thus, the help seeking proportion of the study ­population reported here may constitute an underestimation.

Conclusion

The main conclusion is that a deepened collaboration between the armed forces and health care providers is strongly recommended. The low quality ratings given by the veterans in the present study need to be taken seriously and educational measures are needed. Given the upgrading of military forces in several countries, including Sweden, these suggestions are important as the number of veterans seeking help for mental health problems is likely to increase.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

The data (SPSS file) can be obtained from the corresponding author.

Additional information

Funding

The study was supported by the Swedish Armed Forces and the Swedish Defence University.

Notes on contributors

Gerry Larsson

Gerry Larsson is a licensed psychologist and professor of leadership psychology at the Swedish Defence University. He also serves as an adjunct professor of stress psychology at the Inland University College of Applied Sciences, Norway. His research and teaching areas are leadership, stress and health.

Sofia Nilsson

Sofia Nilsson is associate professor in leadership during challenging conditions at the Swedish Defence University. Her research and teaching focuses on leadership, organisation, stress in general, and moral stress and moral injury in particular.

Alicia Ohlsson

Alicia Ohlsson is a licensed psychologist and has a PhD in psychology. She is an assistant professor at the Swedish Defence University. Her research and teaching focuses on health and well-being, leadership and organizational psychology.

Sofia Svensén

Sofia Svensén is a PhD candidate in traumapsychology at the Inland University College of Applied Sciences, Norway. She is also a research assistant at the Swedish Defence University. She is involved in research and teaching concerning leadership and the health and well-being of psychotrauma patients and military veterans.