Effect of September 11th Terrorist Attacks on the Self-Reported Health Status of Department of Defense Health Care Beneficiaries

Military Medicine, Nov 2004 by Linton, Andrea, Hartzell, Michael C, Peterson, Michael R

This study examined the changes in the self-reported health status of Department of Defense health care beneficiaries associated with the September 11th terrorist attacks. Responses to a single-item, general health measure from pre- and post-September 11 quarterly survey events for the calendar year 2001 were analyzed to compare the unfavorable health response rates before and after the attacks. Increases in rates of unfavorable health status following the terrorist attacks were reported by the total population and 39 of 44 subgroups examined. Statistically significant increases in unfavorable health were reported by active duty personnel and dependents of active duty personnel; beneficiaries under the age of 44 years; beneficiaries affiliated with the Army and Marines; and beneficiaries in the Mid-Atlantic, Mid-West/Central, and Pacific Rim regions. These findings suggest that stress associated with the likelihood of being deployed or having a family member deployed following the terrorist attacks significantly contributed to the increase in unfavorable health response reported on the post-September 11 survey.

Introduction

On September 11,2001, the United States suffered one of the most brutal attacks ever witnessed on its soil. Although most U.S. citizens were far removed from the direct terrorist activity in the eastern United States, many repeatedly witnessed the attacks via graphic television coverage. Breaking news stories brought images of destruction and chaos, while eye witness accounts shared traumatic emotional stories 24 hours a day. On September 11, 2001, America's sense of well-being changed.

This change in people's sense of well-being was the subject of intense discussion in the mass media and later analyzed and reported in the literature. Although many studies focused on the New York City residential population,'~3 other surveys were conducted to assess the prevalence of symptoms of posttraumatic stress disorder (PTSD) and clinical distress following the September 11 attacks for the nation at large.4"7 Although individuals closest in proximity to the attack sites reported the highest rate of stress reactions, many others throughout the country also suffered significant stress reactions immediately following September 11.5·6 One study found that nearly one-half of the respondents surveyed the week following the attacks reported one or more physical symptoms including tension, nervousness, difficulty sleeping, disorientation, fatigue, nausea, and loss of appetite. A higher prevalence of symptoms was reported by women, individuals with previous psychiatric conditions, and younger age groups.47 Another study found positive associations between the prevalence of clinical distress and PTSD symptoms, and the amount of time the respondent spent each day watching graphic, September 1 !-related television coverage.4 These findings suggest that the reactions were attributable to U.S. citizens everywhere identifying with the victims and perceiving themselves as potential victims. There are few data, however, regarding U.S. citizens' sense of well-being directly before the attacks with which to compare the post-September 11 findings.

The beneficiary survey programs conducted within the Department of Defense's (DoD) military health care system allow a unique opportunity to monitor the health status of active duty and retired military members and their families over time. DoD has used the Health Care Survey of DoD Beneficiaries (HCSDB) since 1995 to assess beneficiaries' satisfaction with their health care and their overall health status. Although the survey does not regularly collect information regarding specific symptoms, the literature supports the associations between self-reported health status and the severity of self-reported health symptoms; symptoms of PTSD and depression; objectively assessed mental and physical health conditions; and mortality.8"16 This survey allows the unique opportunity to compare post-September 11 self-reported health status assessments with pre-September 11 data.

Materials and Methods

Sample

The HCSDB is a self-administered mailed survey consisting of approximately 100 questions. It is administered in four quarterly (by calendar year) sampling events, each of which is designed to assess the sampled beneficiaries' satisfaction with health care over the preceding year. Approximately 45,000 adults from the nearly 6.4 million adult beneficiaries eligible to receive DoD health care benefits are sampled each quarter. The HCSDB uses a stratified sample design based on enrollment status in TRICAfIE (the military's managed health care plan), beneficiary group (active duty, active duty family members, military retirees and their family members under 65 years, and retirees and their family members 65 years and older), and geographic region. Within each strata, beneficiaries are randomly selected to be surveyed only once per year. The returned surveys were compiled in a dataset and subjected to a series of edit checks for appropriate response values and consistent responses throughout the questionnaire. Blank or incomplete returned questionnaires were not included in the dataset. In the first quarter, 13,843 complete questionnaires were received, yielding a response rate of 31%. In quarters IHV, 14,629, 14,902, and 14,888 complete questionnaires were received, respectively, yielding response rates of 33% for each quarter. Following the fourth quarter survey, a dataset combining results from the four consecutive quarters was constructed that included additional completed surveys that were received after the fielding period for each quarter. The final response rates for the annual dataset were 33.7%, 36.1%, 33.3%, and 34.5% for quarters 1, 2, 3, and 4, respectively.17 A total of 60,160 survey responses were analyzed in this study.