Chapter 3: Description of UK Help-Seeking Veterans . ..... Historical and current adversities relating to social and economic background have been associated ...
Multiple deprivation in help-seeking UK veterans Multiple deprivation in help-seeking report compiled by Combat Stress UKA veterans Dr Dominic Murphy, Emily Palmer & Rachel Ashwick
Multiple Deprivations in Help-Seeking UK Veterans
Contents
Executive Summary and Recommendations........................................................................................... 2 Acknowledgements ................................................................................................................................. 7 Chapter 1: Background Information ....................................................................................................... 8 Chapter 2: Report Methods ................................................................................................................... 13 Chapter 3: Description of UK Help-Seeking Veterans ......................................................................... 18 Chapter 4: Exploring Multiple Deprivation of Veterans in England .................................................... 27 Chapter 5: Exploring Multiple Deprivation of Veterans in Northern Ireland ....................................... 38 Chapter 6: Exploring Multiple Deprivation of Veterans in Scotland ................................................... 49 Chapter 7: Exploring Multiple Deprivation of Veterans in Wales ....................................................... 60 Chapter 8: Comparisons across the UK ................................................................................................ 71 Chapter 9: Strengths and Limitations of this Report ............................................................................. 80 Appendices............................................................................................................................................ 82 Reference List ....................................................................................................................................... 86
Page | 1
Executive Summary and Recommendations
Aims:
The aim of this report is to provide an overview on the experiences of deprivation in a national sample of veterans with mental health difficulties. As such, we hope that this will aid service development and planning by informing on how to best target specialised military support to veterans. It is also hoped that the overview will serve as a guide to other service providers and charitable organisations working with veterans.
The UK Government routinely collects data on a range of deprivation indices which are combined to be called the Index of Multiple Deprivation (IMD). The IMD is a relative measure of the different social and economic types of deprivation; including financial, health, education and crime rates. Being a relative measure allows for an individual’s score to be compared nationally.
In this study we linked the IMD to a sample of veterans who were engaged with Combat Stress. Combat Stress is the largest provider of community and residential multidisciplinary evidencebased mental health interventions in the United Kingdom, after the NHS. It is the leading specialist clinical service provider for veterans with some services commissioned by the NHS.
Method
This report explored demographics, multiple deprivation (using the IMD), military history and help-seeking from a national sample of UK veterans who were at all stages of treatment at Combat Stress. The sample comprised of 3,120 veterans who were all active clients of Combat Stress as of 1 February 2016 and had had an appointment with the charity in the preceding year.
Page | 2
Main Findings: 1. The majority of the UK sample was male, with a fairly even age distribution (mean age 48.3 years) and relationship status (48% in a relationship vs 52% single) 2. The majority had served in the Army (87%) compared to the Royal Navy (7%) and Royal Air Force (6%). 3. Nearly one in five (18%) veterans seeking support from mental health difficulties from Combat Stress were Early Service Leavers. 4. On average, individuals took approximately 11 years after leaving the military to seek help. 5. Only 4% of help-seeking veterans were in receipt of a war pension. 6. 63% of the sample resided in England, 17% in Northern Ireland, 11% in Scotland and 9% in Wales. Compared to the relative size of the general population, a greater proportion of the sample than expected was based in Northern Ireland, (17% of the sample compared to 3% of the UK population), Scotland (11% vs 8%) and Wales (9% vs 5%). 7. Veterans with mental health difficulties are more likely to reside within areas of the UK with higher risks of deprivation. (It should be noted that the IMD gives an overall deprivation score and also an indication of the deciles the score is found in nationally. As such, this allows the deciles score to be an indicator as to how the individual’s deprivation score compares to the national population. When looking at the distribution of deprivation scores within this sample, evidence was observed suggesting veterans with mental health difficulties are more likely to reside within areas of the UK at higher risks of deprivation. For example, 40% of the sample resided in areas classified as being the most deprived areas in the UK compare to 20% living in the three least deprived areas.) 8. Veterans living in Scotland appeared to be at the greatest risk of deprivation, followed by English and Welsh veterans. In contrast, veterans living in Northern Ireland were on average at less risk of deprivation. 9. The exploration of associations between demographic and military characteristics revealed that in all four countries, there was an association between higher levels of deprivation and not being
Page | 3
in a relationship. Other variables associated with higher levels of deprivation were being an Early Service Leaver and taking longer to seek help. 10. When exploring associations with deprivation specific to UK countries, it appeared that in England there was a trend towards higher levels of deprivation for those who were in the Army rather than the Royal Navy and RAF. In Scotland and Wales, there seemed to be a greater risk of deprivation in those in the younger age brackets compared to the older ones. 11. The locations veterans resided in were geographically spread across the UK. 12. There were a greater number of veterans residing in urban areas compared to rural locations, and those living in urban areas appeared to be at greater risk of experiencing deprivation.
Limitations: 1. The main limitation of the report is that it is restricted to veterans who had sought help from Combat Stress; further research is needed to identify ex-servicemen and women who are unable to access support in order to understand their deprivation risks. 2. Other limitations are considered in more detail within Chapter Nine of this report.
Page | 4
Recommendations and Further Investigation and Research Required:
1. Veterans with mental health difficulties appear to be at an increased risk of residing within more deprived parts of the UK. The findings from this report point to the possible application of using geographic information to help target support to those most at risk. 2. In general there is an increased risk of experiencing multiple deprivations in veterans seeking help for mental health issues compared to the general public. This highlights the importance of not only treating the symptoms of mental illness but also considering the context within which an individual lives. For example, the impact of residing in an area with poor access to local services, or where there are high levels of unemployment. 3. Veterans were spread across the UK. This suggests that there is an ongoing need for a nationally provided service with community-based support to provide easier access to services for veterans. In the context of funding restrictions, the finding that more veterans live in urban areas supports the notion that targeted service delivery in these areas using a clinic based Hub and Spoke model, and other interventions such as setting up a Peer Support framework will reach the majority. However, other means of service delivery such as telemedicine and planned residential admission or targeted home visits in the context of assertive outreach; if clinically indicated, may be appropriate for those whose access may not be comparable because of their geographical rural location.
4. The relative size of the help-seeking veteran populations in England, Northern Ireland, Scotland and Wales differed from what might be expected compared to the general public. Following on from this, funding allocation for the provision of veteran services should not be based on the relative size of each nations population, or even based on geographical boundaries set out by Combat Stress area boundaries, but rather, reflect the regional proportion of help-seeking veterans. 5. Experiences of deprivation for help-seeking veterans differed between the nations. As the risk of deprivation was greatest in Scotland and somewhat greater in England and Wales compared Page | 5
to Northern Ireland. Specific support for issues related to deprivation should be targeted to these countries. 6. Factors related to individuals’ service history were found to increase the risk of deprivation. Of particular note was that Early Service Leavers were at increased risk of deprivation. This reinforces the need to highlight those who might be at increased risk during their military service and then provide early intervention support for veterans during transition from service. 7. The finding that almost one fifth of veterans accessing care at Combat Stress are Early Service Leavers is a major finding. Prior to this study the number of ESLs engaged in the clinical services at Combat Stress was unknown and their demographics and location were also unknown. Other researchers in the field had commented that this was a group that probably engaged with few clinical services. This has now been proven to be untrue and valuable data and information has been gathered about this group as a result of this study. The literature has demonstrated that ESLs are most at risk of mental illness and that they display a suicide rate three times higher than their non-veteran counterparts. A separate study is warranted to examine in more depth the demographics, clinical characteristics and need and service design modifications that may be required for this particular group. Other points of investigation should include method of referral, access into clinical services, treatment engagement completion rates and clinical outcomes. 8. Other demographics associated with an increased risk of deprivation included having served in the Army, being of a younger age and being single. These demographics require further evaluation and will probably form part of the further study now planned into the ESLs, as these findings are likely to be linked. 9. Taking longer to seek help was associated with a higher risk of experiencing multiple deprivations. Whilst the cause of this is not known, the association reinforces the need to improve access and engagement in services for those in more deprived areas.
Page | 6
Acknowledgements We would like to thank the Office of National Statistics, Department for Communities and Local Government, Northern Ireland Statistics and Research Agency, the Scottish Government and the Knowledge and Analytical Services, Welsh Government for making the deprivation and postcode data freely available.
Appreciation also goes to Ben Weijers, Senior Data Analyst at Combat Stress for his assistance in extracting the client data and producing the maps that appear in chapter eight of this report. In addition, thanks to Rachel Ashwick, Research Assistant at Combat Stress for proof reading and editing the report.
Page | 7
Chapter 1: Background Information
Chapter 1 Background Information Chapter highlights:
Multiple deprivation is a relative measure of social and economic deficit, encompassing a broad range of domains, including financial, health, education and crime.
It is provided by Government departments for each of the countries in the UK by neighbourhood
Understanding deprivation in the context of mental health difficulties can be valuable in drawing implications about accessing services, impact on severity of mental health presentations and engagement and effectiveness of treatments.
Veterans seeking help for mental health difficulties have a particularly high burden of mental illness, welfare and social care needs.
Studies indicate that veterans experience practical and stigma-related barriers to accessing help for mental health difficulties.
Studies indicate that deprivation may be associated with poorer outcomes of mental health treatment.
This report explored patterns of demographic characteristics and deprivation in UK veterans seeking help for mental health difficulties.
Page | 8
Chapter 1: Background Information Defining Multiple Deprivation Multiple deprivation is a measure of social and economic deficit. It encompasses a broad range of domains such as financial, health, education, services and crime. As such, it describes a multidimensional problem that is broader than affluence or a deficit in a single domain 1. It represents overall quality of life and availability of resources across a range of domains that influence our social and economic experience. In the UK this data has been compiled by relevant government bodies and is based upon a geographic area. Multiple deprivation incorporates a number of quantitative indices that represent different indicators of deprivation. For instance, in England, multiple deprivation is measured based on 37 separate statistical indicators 2. Such measures are used to understand the distribution of social inequalities and can, with caution, be used to allocate resources.
In the UK these measures of multiple deprivation are available by geographical areas or neighbourhoods, and are known as Indices of Multiple Deprivation (IMD). These indices give an overall measure of multiple deprivation of the people living in that area. However, experiences of deprivation can vary from person to person within similar areas or even between generations within families. The IMD measures give an overall score which can then be ranked to make comparisons between the most deprived and least deprived areas across the country possible.
Multiple Deprivation and Mental Health Understanding multiple deprivation is important to those providing mental health services. First, several aspects of deprivation may lead to barriers in accessing services. These may be low income and related barriers such as the ability to attend appointments or residential care due to travel or childcare costs. Another aspect of multiple deprivation involves physical distances to key services; it may be that areas with greater deprivation experience greater challenges in attending a GP surgery for referral. Lower educational attainment may also influence awareness of mental health, meaning people will be less likely to seek help due to not recognising when there is a need.
Page | 9
Chapter 1: Background Information Secondly, the experience of deprivation may directly or indirectly influence mental health. Historical and current adversities relating to social and economic background have been associated with psychological distress 3. The influence of deprivation on mental health has been found to be significant when considering deprivation at a community level, even after controlling for individual risk factors 4; 5
. The reasons for this association are not known. One reason could be that those who are experiencing
mental health difficulties may be more dependent on collective resources for support, and when these are lacking due to neighbourhood multiple deprivation, problems are exacerbated. Furthermore, deprivation has been associated with a greater likelihood of experiencing a mental health problem as part of a complex ‘co-morbidity’, which refers to an individual experiencing several physical and mental health problems concurrently 6.
Thirdly, systemic thinking and evidence suggests that the context an individual lives in is highly influential in their treatment success. On a household level, evidence has shown that distress in the home environment has a negative impact on treatment outcomes 7. It is reasonable to suggest that increased deprivation could increase distress in the home environment, as concerns about money, employment or education may be a source of daily stressors. The time, effort and emotional demands therapeutic treatments place on individuals may be difficult to manage when also dealing with the wider demands of deprivation. For example, guidelines for the treatment of PTSD in the UK 8 involve a period of stabilisation and then, following trauma-focused treatment, a period of re-integration. Understanding the social context, particularly regarding multiple deprivation, will help tailor these stages of intervention to the challenges potentially faced by the population, thereby making treatments more accessible and improving adherence rates.
Multiple Deprivation and Veteran Mental Health It has been estimated that over 16,000 service personnel leave the UK Armed Forces each year 9. Evidence suggests there has been an increase in referrals of veterans seeking mental health support in the UK over recent years 10. Whilst the reasons for this are not known, it has been suggested that veterans from more recent conflicts in Iraq and Afghanistan are seeking help sooner. However, there is still a Page | 10
Chapter 1: Background Information significant overall delay between leaving the Armed Forces and seeking help. Furthermore, evidence suggests there may be large numbers of Armed Forces personnel meeting the criteria for PTSD who are not accessing help; one study found that only 23% of those with identified mental health issues were seeking help
11
. Studies into barriers for accessing mental health services in military and veteran
populations have suggested stigma and logistical barriers to be influential
12, 13
. Understanding any
patterns in multiple deprivation in the population who have sought help may begin to elucidate areas requiring attention to improve more effective access to services for others in need.
UK veterans seeking help present with complex mental health needs, with 80% reporting difficulties for common mental health problems and 73% for PTSD 14. Evidence suggests that not all mental health issues in serving and veteran populations are directly attributable to military experience; when considering PTSD specifically only 50% of cases in current serving personnel are directly attributable to deployments 15. Deprivation may play a role in exacerbating or triggering mental health difficulties in veterans. High education attainment and higher socio-economic background are associated with better mental health 16. For example in the Armed Forces, it has been reported that Officers have lower rates of mental health difficulties compared to other Ranks 17.
Whilst research has suggested that veterans in general are not at risk of social exclusion, those who reported symptoms of mental illness were more likely to be unemployed and experience continued mental health difficulties at a 3-year follow-up
18
. Directionality of this association is not known,
however it does suggest there is a relationship between some aspect of deprivation and lack of mental health recovery in this group of the veteran population. Given the influence that context has on mental health and success of treatments, it is important to understand the prevalence and type of deprivation experienced by help-seeking veterans. This could have implications for the treatment pathway regarding additional support veterans needs prior to, during, or after treatment.
Page | 11
Chapter 1: Background Information What is the Value in Exploring Multiple Deprivation of Help-Seeking Veterans? As discussed earlier in the report, understanding patterns of deprivation in a population of help-seeking veterans could have multiple benefits and implications. In general, exploring the relative deprivation across sub-domains may help identify specific problematic areas of deprivation that are potentially heightened in this group (e.g. health, access to services or income). This may elucidate ways in which to remove barriers to accessing treatment, understand where poor mental health may be exacerbated by deprivation and improve treatment outcomes by further considering context. With on-going pressure on funding for the provision of veteran mental health services, exploring these areas will be valuable in ensuring the efficiency and effectiveness of future investments in services. For example, identifying sub-groups of help-seeking veterans who are at an increased risk of deprivation may provide insight into how to best target cost-effective support to remove help-seeking barriers.
Aim of this Report The aim of this report was to explore whether UK veterans seeking help for mental health difficulties are at an increased risk of deprivation. This report summarised the linkage of data from UK multiple deprivation indices and neighbourhoods lived in by population of veterans who have contacted Combat Stress. It will explore the overall picture of relative deprivation experienced by the Combat Stress helpseeking population. It will also explore associations between demographics, such as age, and military history, such as length of service, with deprivation. This analysis will be conducted separately for England, Northern Ireland, Scotland and Wales. A UK-wide comparative summary will also be included.
Page | 12
Chapter 2: Report Methods
Chapter 2 Report Methods Chapter highlights:
The report linked data for deprivation provided by UK Government departments (known as the Index of Multiple Deprivation) to demographic, military and help-seeking data for a sample of veterans seeking help from Combat Stress.
Indices of Multiple Deprivation are statistical measures of deprivation comprised of a range of domains and underlying statistical indicators. For example, the measure in England consists of seven differently weighted domains: income, employment, health, education, crime, access to services, and environment.
The sample of veterans comprised all active clients of Combat Stress as of 1 February 2016 who had had an appointment with the service in the preceding year.
After linking the data sets, the sample consisted of 3,120 veterans.
Patterns of deprivation and demographics were explored using descriptive statistics and graphical presentations.
Page | 13
Chapter 2: Report Methods Study Design The aim of this study was to link a UK population of veterans who have sought help for mental health difficulties to data reflecting multiple deprivation in the geographical area they reside in. The veteran data was provided by Combat Stress, as it is the leading mental health charity that provides clinical services for military veterans throughout the UK. Deprivation data was provided by UK Governmental departments, independently for each of the four countries of the UK. It is referred to as an Index of Multiple Deprivation. Using a sample of clients of Combat Stress ensured the report explored a homogenous group in line with this criterion.
Sample The sample comprised of all active clients who had attended at least one appointment with Combat Stress between January 2015 and January 2016. Data was cleaned to ensure any duplicate clients were removed. An appointment was defined as attendance at a treatment programme, an outpatient psychiatric appointment, or a community-based appointment. This broad definition ensured that our sample was representative of all veterans who sought help from Combat Stress, encompassing all stages of the treatment pathway. Of the 3,185 clients retrieved from the veterans’ database, demographic and military data was extracted for the following variables: postcode, gender, age, marital status, employment status, military service type, military service length, and time since leaving the military.
Index of Multiple Deprivation Index of Multiple Deprivation (IMD) is a relative measure of deprivation reported by geographical areas, or neighbourhoods, across the four countries of the UK. It is calculated based on seven subdomains of deprivation (eight in Wales) which are broadly represented by the categories of: Income, Employment, Health, Education, Crime, Barriers to Services, and Living Environment. The weightings assigned to each sub-domain vary between countries.
IMD is represented by a score based on the underlying statistical indicators for each of the sub-domains. For example, a statistic representing numbers of adults and children in income support families Page | 14
Chapter 2: Report Methods combines with other statistics to give a numerator for the Income sub-domain; this combines with the other domains to give an IMD score for that area. These IMD scores are used to give a rank and decile for each neighbourhood, which gives a level of deprivation relative to other neighbourhoods.
Whilst there is substantial overlap in sub-domains, the specific definitions and indicators underlying each vary between countries. Details of the indicators used for each country can be found in the appendices. The weightings given to each sub-domain across the four countries are presented in Table 2.1.
Table 2.1: Sub-domains and weightings that comprise the indices by country. Income
Employment
Education
Health
Crime
Barriers
Environment
England
22.5%
22.5%
13.5%
13.5%
9.3%
9.3%
9.3%
NI
25%
25%
15%
15%
5%
10%**
5%
Scotland
28%
28%
14%
14%
5%
9%†
2%#
Wales
23.5%
23.5%
15%
14%
5%*
10%††
5%#
5%##
* Referred to as Community Safety; ** Referred to as Proximity; † Referred to as Geographic Access; †† Referred to as Access to Services; # Referred to as Housing; ## Referred to as Physical Environment.
IMD is organised by small geographical areas, with averages of 800 to 2000 residents per area. In England, the Index of Multiple Deprivation is organised by ‘Lower-layer Super Output Area’ (LSOA). A LSOA has an average of 1,500 residents, there are 32,844 LSOA’s in England. In Northern Ireland, the Multiple Deprivation Measure is organised by ‘Super Output Area Geography’ (SOA). A SOA has an average of 2,000 residents, there are 890 SOA’s in Northern Ireland. In Scotland, the Index of Multiple Deprivation is organised by ‘Datazones’. Datazones have an average of 800 residents, there are 6505 datazones in Scotland. In Wales, the Index of Multiple Deprivation is organised by ‘Lowerlayer Super Output Area’ (LSOA). A LSOA has an average of 1,600, there are 1,909 LSOA’s in Wales. IMD is an overall measure of deprivation experienced by people living in these specified geographical areas, or neighbourhoods.
Page | 15
Chapter 2: Report Methods Data Linkage Methods Veterans in our population were linked to the Index of Multiple Deprivation (IMD) for the neighbourhood they lived in, based on their postcode. This was done by matching veteran postcode to the code for their neighbourhood by which the deprivation data was organised by. This in turn was matched to the IMD for that area. Two per cent of the original sample were not found as part of these matching processes, yielding a final sample size of 3,120. This process is shown in Figure 2.1.
Figure 2.1: Linking veteran data to the Index of Multiple Deprivation
Database 1 Veteran Database (Demographics and veteran postcode) N=3,185
Database 2 Postcode Directory (Matched veteran postcode to neighbourhood)
Database 3 Index of Multiple Deprivation Reports (Matched veteran neighbourhood to IMD data)
46 veteran postcodes were not found (1.4%)
19 veteran small neighbourhood areas were not found (0.6%)
Report Database Veteran sample, each client matched to IMD data N=3,120
Further, when linking the veteran postcode to neighbourhood in the postcode directory, data referring to the urban versus rural classification of that area were also extracted. In line with the Office of National Statistics definition of rural and urban for England and Wales, urban is classed as living within a settlement of 10,000 or more. This criteria was also applied to the data for Scotland. There was no rural versus urban data available for Northern Ireland.
Data sources The data for Combat Stress clients were extracted from the electronic patient database (CareNotes, provided by Advanced Health and Care). This system holds a single electronic patient record for each client and is a UK-wide database. Data was anonymised during extraction. The Postcode Directory was sourced from the Office of National Statistics (ONS). It was the ONS Postcode Directory, February Page | 16
Chapter 2: Report Methods 2016 edition. It provides postcode data coverage for the whole of the UK. There were 2,573,419 postcodes in this directory.
The English Index of Multiple Deprivation was released by the Department for Communities and Local Government in September 2015. The Northern Ireland Multiple Deprivation Measure was released by the Northern Ireland Statistics and Research Agency in May 2010. The Scottish Index of Multiple Deprivation was released by The Scottish Government in December 2012. The Welsh Index of Multiple Deprivation was released by Knowledge and Analytical Services, Welsh Government in November 2014.
Analysis methodology We explore characteristics of the sample in chapter three. The separate analyses regarding deprivation for each country were are explored in chapters four to seven. Finally, we compare the data from the four countries in chapter eight. Frequency statistics for all demographic, military and help-seeking characteristics were calculated and reported as percentages, for the UK and each of the four countries individually. To explore whether there were any differences in frequencies in these variables across the countries, a Pearson’s chi-squared analysis test was used. To explore distributions of deprivation, bar graphs by decile were plotted for each country. Then for each country, this distribution was plotted by the demographics and other variables, in order to explore any potential associations with these. How to interpret these graphs is depicted in chapter three.
Analysis was conducted using IBM SPSS Statistics version 22 and Microsoft Excel 2013. To explore any potential geographical patterns, geographical spread of veterans by deprivation, relationship status, length of service and time to contact CS were plotted on maps of the UK using software provided by Bing, the online search engine by Microsoft.
Page | 17
Chapter 3: Description of Help-Seeking Veteran Sample
Chapter 3 Description of UK Help-Seeking Veterans Chapter highlights:
The sample consisted of 3,120 UK veterans, with an over-representation for Northern Ireland and an under-representation of England (although to a lesser extent). Scotland and Wales were also over-represented compared to the general populations of the UK.
The sample was majority male (97%), and had a fairly even spread across age groups and roughly even split between those in a relationship and those who were not (51% to 47% respectively).
The sample comprised of a majority of Army veterans (87%) and the majority did not have a war pension granted (96%).
Nearly one in five veterans had left service after fewer than four years (18%) and nearly half the sample took 11 years or more to contact Combat Stress for support (46%).
Veterans residing in Northern Ireland appeared to differ in terms of demographics and military characteristics compared to the other nations. There were fewer males, more veterans aged over 65 years old and more in a relationship as opposed to single. There were more veterans who served in the Army and more who served for over 15 years. There were no significant differences between countries for time to contact Combat Stress for help after leaving the military.
There were more veterans in the sample living in the most deprived deciles than the least deprived deciles (40% in the most three deprived deciles, compared to 20% in the three least deprived deciles). This suggests a higher level of deprivation in this sample compared to the general UK population.
Page | 18
Chapter 3: Description of Help-Seeking Veteran Sample Distribution of Sample across the UK The sample of help-seeking veterans used in the production of this report had a sample size of 3,120. Table 3.1 shows the distribution of the sample of help-seeking veterans across the four countries of the UK.
Table 3.1: Distribution of veteran sample by country Country
Number of veterans 1967
Distribution of sample 63%
Distribution of general population 84%
England Northern Ireland
550
17%
3%
Scotland
332
11%
8%
Wales
271
9%
5%
General population data extracted from the 2011Census, published by the Office of National Statistics 2011
In comparison with UK population, England is under-represented in our sample. Northern Ireland, Scotland and Wales are over-represented 19.
Page | 19
Chapter 3: Description of Help-Seeking Veteran Sample Demographic Characteristics of the Sample Table 3.2 shows the demographic characteristics of the overall sample.
Table 3.2: Demographic characteristics of the veteran sample
Demographic
Percentage
Sex Female
3%
Male
97%
Age
