Physical activity in postdeployment Operation Iraqi Freedom/Operation Enduring Freedom veterans using Department of Veterans Affairs services.
Veterans (Beliefs, opinions and attitudes)
Buis, Lorraine R.
Kotagal, Lindsey V.
Porcari, Carole E.
Rauch, Sheila A.M.
Krein, Sarah L.
Richardson, Caroline R.
|Publication:||Name: Journal of Rehabilitation Research & Development Publisher: Department of Veterans Affairs Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2011 Department of Veterans Affairs ISSN: 0748-7711|
|Issue:||Date: August, 2011 Source Volume: 48 Source Issue: 8|
|Topic:||Event Code: 310 Science & research; 680 Labor Distribution by Employer|
|Product:||Product Code: E198380 Veterans|
|Geographic:||Geographic Scope: United States Geographic Code: 1USA United States|
Despite the high degree of physical fitness required for Active Duty servicemembers of the U.S. Armed Forces and when compared with nonveterans of all ages, the veteran population has a greater prevalence of being overweight  and obese [1-2]. Furthermore, veterans receiving healthcare services from the Department of Veterans Affairs (VA) have a greater prevalence of obesity than the general public [3-4] as well as veterans not using VA services [2,4]. In comparison with the general public and veterans not using the VA, veterans using VA services have also been shown to self-report poorer health [4-6]; are more likely to be physically inactive ; and are more likely to carry one or more chronic diagnoses such as hypertension, hypercholesteremia, and diabetes [2,4,6-7]. Moreover, U.S. veterans who have spent time in theater often experience mental illnesses, pain syndromes, and musculoskeletal complaints [8-12]. These represent independent risk factors for sedentary behavior and obesity and are associated with increased morbidity and mortality [13-20].
Recently returned Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) veterans represent a unique population served by the VA. Having recently been engaged in a physically demanding environment, these veterans, many with physical and/or mental sequelae from their tour of duty, face an abrupt transition to civilian life [11,21-28]. In light of the growing body of evidence demonstrating the benefits of physical activity, including decreasing both obesity-associated morbidity and mortality [29-30] and disability from chronic musculoskeletal pain , OIF/OEF veterans using the VA are an ideal population for interventions centered around increasing physical activity.
Of the postdeployment OIF/OEF veterans using the VA, this study identified their perception of physical activity and the types of physical activity engaged in during Active Duty and postdeployment. By further understanding postdeployment veterans' perceptions of physical activity as well as physical activities they engage in postdeployment, the VA may be able to develop targeted interventions to manage optimal weight and prevent overweight and obesity, along with its sequelae, in this population.
We conducted a cross-sectional survey of postdeployment OIF/OEF veterans who were registered with the VA Ann Arbor Healthcare System, Ann Arbor, Michigan, from October 2001 through July 2007. The survey was open for a period of 3 months (June-August 2008). The Computerized Patient Record System, the electronic medical record system used by the VA, was used for recruitment to create a database of 3,352 OIF/OEF veterans and servicemembers. The vast majority of these identified veterans were separated from the military. Those veterans who were deceased, had an unclear period of military service or unclear registration date with the VA, or had an incomplete address were excluded from the database (n = 1,089). Invitations to participate in the online survey were sent to the remaining 2,263 OIF/OEF veterans through the U.S. mail. Of those mailed, 214 were returned as undeliverable, resulting in 2,049 delivered invitations. These invitations included a link to the online survey as well as a unique 6-digit personal identification number (PIN) that was required to access the survey. The online survey was conducted through SurveyMonkey (http://www.surveymonkey.com/; Palo Alto, California), a for-profit Web site that allows users to design and manage online surveys as well as compile survey responses. After following the survey link, participants were presented with information regarding the survey and an informed consent statement. Participants were required to agree to the informed consent statement to proceed. After consenting, participants were asked to provide their PIN. This PIN was used to screen for uninvited survey respondents and identify any possible duplicate respondents. To increase the response rate, 1,959 reminder letters were sent approximately 3 weeks after the initial mailing to those who had not already responded. A $10 Target gift card, to be sent by U.S. mail at survey completion, was offered as an incentive to all participants in both the initial recruitment and reminder letters.
The survey questions used for this study were included as part of and analyzed separately from a larger survey examining help-seeking behavior in OIF/OEF veterans using VA services. The survey collected demographic and anthropometric data from participants, including sex, age, race, height, weight, branch of service, employment status, time back from most recent OIF/OEF deployment, total time in theater, number of deployments, Active Duty status, and service-connected disability. In addition, participants responded to 10 questions with a Likert scale response set (ranging from 1-5, where 1 = strongly disagree and 5 = strongly agree) assessing perceptions of physical activity. To understand physical activities engaged in during Active Duty and postdeployment, participants were asked to "List the kinds of physical activity or exercise you did in a typical day while you were on Active Duty," and "List the kinds of physical activity or exercise you did in a typical day now postdeployment." For each of those questions, participants were given four free-text response fields in which to respond. Furthermore, participants were provided one free-text response field to answer the question, "What is the kind of physical activity that you most enjoy doing?" Finally, the survey assessed email use, cellular telephone ownership, smoking status, and self-reported ability to comfortably walk one block without assistance for all participants.
Descriptive statistics included means [+ or -] standard deviations (SDs) for continuous and normally distributed variables. Frequencies and percentages were calculated for categorical data. Likert scale responses regarding perceptions of physical activity were grouped into "agree," "neutral," or "disagree" categories and analyzed as frequencies.
A research assistant analyzed the free-text responses of types of physical activities engaged in during Active Duty and postdeployment and coded them according to themes (Table 1). Free-text responses not considered to represent a physical activity or with an unclear meaning were omitted. Furthermore, responses indicating an inability to be physically active were analyzed separately. Once all responses had been coded, a second coder reviewed categorical assignments for accuracy. The number of categories of physical activities each participant reported for Active Duty and postdeployment was calculated and compared using a Wilcoxon signed rank test, a nonparametric test for repeated measures used when normal distributions cannot be assumed.
Finally, to compare Active Duty and postdeployment participation in each physical activity category, we used a logistic regression model with a first dichotomous-dependent variable indicating participation in or no participation in the physical activity category and a second dichotomous-independent variable indicating Active Duty versus postdeployment as a predictor of physical activity. Robust standard errors were calculated to account for clustering by individual participants. All statistics were calculated with use of STATA 10.0 (StataCorp; College Station, Texas).
In total, 319 individuals (15.6% of delivered invitations) responded to the physical activity portion of the survey. The age of participants was 35.5 [+ or -] 9.7 years (mean [+ or -] SD), and the majority were male (86%), Caucasian (87%), >2 years since most recent OIF/OEF deployment (76%) (Table 2), and separated from the military (98.5%). According to body mass index (BMI) calculations, approximately 75 percent of participants were overweight or obese, with 44 percent classified as overweight (BMI: 25.0-29.9), and 32 percent as obese (BMI: [greater than or equal to] 30). Nearly one-third of participants (27%) smoked cigarettes. Finally, OIF/OEF veterans using the VA were frequent technology users: 74 percent of participants reported checking email almost every day or more and 93 percent reported carrying a cellular telephone.
Attitudes Toward Physical Activity
The majority of participants reported a positive attitude toward physical activity, recognizing it as a way to reduce stress (70% agree or strongly agree) and citing it as "important" (77% agree or strongly agree). Participants also endorsed exercise for maintaining health (90% agree or strongly agree) and worried about gaining weight (72% agree or strongly agree). Regarding physical activity settings, a similar proportion of participants enjoyed exercising by him or herself (46% agree or strongly agree) or with one or two friends (49% agree or strongly agree). Only a minority of participants enjoyed exercising in a group (22% agree or strongly agree). In terms of exercise limitations, 39 percent of participants reported health problems that made exercising difficult, and 52 percent of participants reported chronic pain that interfered with exercise (Table 3).
Patterns of Physical Activity
Table 1 shows the 12 categories of physical activity that coders identified.
Participants reported 2.08 [+ or -] 1.08 types of physical activity (median = 2) performed during a typical Active Duty day. Running, Exercise with Gym Equipment, Occupational Activities, and Walking represented the most frequently mentioned physical activity categories with 30.0, 21.5, 14.9, and 13.0 percent of responses, respectively (Table 4). Thirty-two participants did not list any codable activities during Active Duty, and three participants indicated an inability to perform physical activities during Active Duty.
Participants reported 1.59 [+ or -] 1.20 types of physical activity (median = 2) during a typical day postdeployment. Walking, Running, Exercise with Gym Equipment, and Occupational Activities represented 21.1, 18.5, 17.9, and 9.5 percent of the total responses, respectively (Table 4). Participants engaged in fewer types of physical activity during postdeployment than during Active Duty (Wilcoxon signed rank test: p < 0.001). The odds of a participant reporting Walking, Cycling, Outdoor Activities, and Other during postdeployment were significantly greater than during Active Duty (1.37, 1.70, 5.73, and 6.20 times, respectively) (Table 4). The odds of a participant reporting Running, Exercise with Gym Equipment, Occupational Activities, and Calisthenics/Aerobics were significantly lower postdeployment compared with Active Duty (0.25, 0.49, 0.39, and 0.53 times, respectively). Finally, 76 participants did not list any codable activities during postdeployment, and 23 participants reported being unable to perform physical activities postdeployment. This difference was significant (logistic regression: odds ratio = 8.18, p < 0.001), with the odds of reporting an inability to perform physical activities postdeployment being eight times greater than an inability to perform physical activities during Active Duty.
Favorite Physical Activity
Running was the most common response to the question about favorite physical activity (18.1%), followed by Exercise with Gym Equipment (16.6%), Sports (16.6%), Walking (13.7%) and Outdoor Activities (12.3%). Cycling and Other represented an additional 9.0 and 5.4 percent, respectively, and Calisthenics/Aerobics, Occupational Activities, Martial Arts, and Pool-Based Activities each represented <3 percent of responses. Although participants were not asked whether they were able to engage in their favorite physical activities postdeployment or not, 24 participants indicated pain, depression, or inability to engage in previously enjoyed physical activities.
Despite the demand for physical fitness during Active Duty OIF/OEF deployment and the positive perceptions of physical activity among OIF/OEF veterans using the VA, this postdeployment population struggles to maintain a physically active lifestyle and avoid weight gain. In our sample of 319 OIF/OEF veterans using the VA, 75 percent were overweight or obese, which is greater than the estimated nationwide prevalence of overweight and obesity (68%) . Additionally, 72 percent worried about gaining weight.
When comparing lists of physical activities supplied by participants, we found fewer reported physical activities engaged in during postdeployment than during Active Duty. Although Running, Exercise with Gym Equipment, Occupational Activities, and Walking represented the most prevalent physical activities of veterans during both Active Duty and postdeployment, the prevalence of Running, Exercise with Gym Equipment, and Occupational Activities that accompanied the return to civilian life clearly decreased while Walking nearly doubled. It appears that participants shifted from higher-intensity physical activity during Active Duty to lower-intensity physical activity such as Walking postdeployment.
The reason for the significant decreases in the number of physical activities engaged in postdeployment is likely multifactorial. Civilian life is typically not structured around physical activity, because exercise is frequently viewed as an individual, supplemental, or leisure activity. This contrasts to Active Duty service in the U.S. Armed Forces, which involves jobs that are physical in nature and often includes regimented daily exercise. Additionally, the burden of medical morbidity and pain in the veteran population may limit physical activity in OIF/OEF veterans using VA, because these veterans have been shown to represent a lower socioeconomic group, have greater comorbidity, and have a greater prevalence of overweight and obesity than veterans not using VA [1-7,33-34]. The frequency of free-text responses indicating pain, depression, or disability in place of a favorite physical activity (n = 24) likely underrepresents the true prevalence, but taken together with the large percentage of participants endorsing pain or health as a limitation for physical activity (52% and 39%, respectively), it would be consistent with this national trend among VA users (Table 3). Littman et al. reported a similar percentage (45.7%) of veterans using VA reporting physical activities limited by disability compared with 24.1 percent of veterans not using VA and 19.1 percent of nonveterans . Additionally, Littman et al.'s study showed that, particularly among older age groups, veterans were more likely to meet physical activity recommendations and less likely to be inactive than their non-veteran peers. However, after analyzing populations of veterans using and not using VA, they found that veterans using VA were more likely to be inactive and less likely to meet physical activity recommendations than veterans not using VA.
Regardless of the reasons why participants listed fewer types of physical activities during postdeployment, the need to create targeted interventions within the VA to increase the physical activity of this population is evident. Intercepting veterans postdeployment through targeted prevention-oriented interventions for maintaining optimal weight and physical activity should be a priority for preventing the onset of weight-related chronic disease in this population. The Veterans Health Administration has created innovative national programs such as MOVE! , which targets overweight and obese veterans receiving services from the VA. However, this program serves all overweight and obese veterans and is not specifically tailored to OIF/OEF veterans, who are generally younger, more recently active, and more technologically savvy than previous veteran cohorts. Qualification for participation in MOVE! requires preexisting morbidity, specifically a diagnosis of overweight or obesity as well as a weight-related disease, leaving veterans without targeted intervention at risk for becoming overweight or obese.
Although few studies have investigated physical activity as an intervention in the veteran population, available data are promising. Peterson et al. demonstrated that in a sample of 44 older veterans (72.9 [+ or -] 6.9 years), those participating in an outpatient exercise program (n = 23) performed comparably with the national average in measures of physical function (30 s chair stand, 6 min walk test), whereas sedentary older veterans (n = 21) performed worse than both the exercising older veterans (p < 0.05) and the national average (p < 0.05) . This study did not measure health outcomes, but we can infer that a more active population can potentially benefit from the health gains demonstrated in other studies.
Given the numbers of veterans returning from OIF/OEF deployment with injuries (as of January 25, 2011, 42,164 OIF/OEF veterans were reported wounded in action) , the lack of lifestyle and behavior-focused preventive programs for this population, many of whom are experiencing health problems and chronic pain, is a major gap in the VA's suite of healthcare programs for veterans. Results from this study suggest that walking as a form of physical activity nearly doubles in prevalence in postdeployment; thus, structured VA interventions focused on walking may be particularly well suited for this population. Furthermore, since 74 percent of participants report checking email almost every day or more and 93 percent report having access to a cellular telephone, Internet-based and/or text message-based interventions may prove effective for maintaining and/or increasing physical activity in our target population. Such technology-mediated approaches to lifestyle and behavior-change interventions have previously proven to be efficacious in increasing physical activity and promoting healthy diets in other at-risk groups [38-44].
Although the current study is one of the first to examine VA-using OIF/OEF veterans' perceptions of physical activity postdeployment, this research is not without limitations. The first limitation is that, despite sending reminders to eligible individuals to participate in this survey, we still had a relatively low response rate (15.6%). Although post hoc analysis on demographic variables did not reveal any significant differences between survey participants and nonparticipants, the two groups may possibly have differed in other ways that were not measured, which may skew the results and limit the generalizability of our findings.
The second limitation is our reliance on self-reported recall data for Active Duty and postdeployment physical activities. Because the majority of our participants were >2 years from their last OIF/OEF deployment, the potential for recall bias in the form of under- or overreporting physical activities, particularly for Active Duty measures, is increased. Moreover, participants may not have provided exhaustive accounts of physical activities engaged in during Active Duty and postdeployment.
The third limitation was that we did not use a validated physical activity instrument that gathers useful physical activity duration and frequency data. Self-reported measures of physical activity are inherently problematic and particularly poor at capturing less-intensive and less-structured physical activity. We focused on collecting data on types of physical activity rather than on quantitatively assessing amounts of physical activity. While we did attempt to obtain self-reported data on duration and frequency of exercise bouts from participants for Active Duty and postdeployment physical activities, the quality of these data was poor because of incomplete and ambiguous responses. The poor quality of self-reported duration and frequency data, coupled with the fact that this was not the focus of the current study, meant that we chose not to use these data in a quantitative analysis. Future investigations that seek to build on our work and focus on quantitative physical activity levels, rather than on the types of physical activities engaged in during Active Duty and postdeployment, should consider using objective measures of physical activity to better assess the frequency, duration, and intensity of physical activity in this target population.
The fourth limitation is that, because this investigation focuses solely on OIF/OEF veterans receiving care at the VA, results from this investigation have limited generalizability to OIF/OEF veterans outside of the VA system.
Despite these limitations, this investigation has many strengths. First, although our response rate was low, a large sample of participants completed this survey, which adds to the validity of our findings. Second, because we specifically asked participants about their preferences for physical activity and use of technology, we now have valuable information that may be useful for developing future interventions aimed at increasing physical activity in postdeployment OIF/OEF veterans using the VA. Third, using free-text response questions gave us a more accurate view of physical activity in our target population, because participants were able to add qualifying statements such as an inability to engage in physical activity postdeployment.
Given these findings, future studies to identify specific barriers and motivations among veterans using the VA would help in developing appropriate physical activity programs. Additionally, future longitudinal research investigating deconditioning and health-related changes postdeployment would help us understand the effect of civilian life on the health of postdeployment veterans and could provide additional evidence to bolster the importance of early prevention.
Results from this investigation indicate that postdeployment OIF/OEF veterans using the VA recognize the benefits of regular physical activity, yet many report barriers to physical activity caused by health problems and/or chronic pain.
JRRD at a Glance
While during Active Duty, veterans typically engaged in high levels of physical activity. These levels may decrease dramatically postdeployment, increasing veterans' risks of developing chronic diseases. This research demonstrates that postdeployment Operation Iraqi Freedom/ Operation Enduring Freedom veterans using the VA recognize the benefits of regular physical activity, yet many report barriers caused by health problems and/or chronic pain. Furthermore, participants reported engaging in fewer types of physical activity postdeployment than during Active Duty. This research may be of interest to individuals who can help develop strategies, particularly ones that address overcoming barriers, to facilitate physical activity among postdeployment veterans.
Abbreviations: BMI = body mass index, OEF = Operation Enduring Freedom, OIF = Operation Iraqi Freedom, PIN = personal identification number, SD = standard deviation, VA = Department of Veterans Affairs.
Study concept and design: L. R. Buis, S. L. Krein, C. E. Porcari, S. A. M. Rauch, C. R. Richardson.
Acquisition of data: C. E. Porcari.
Analysis and interpretation of data: L. R. Buis, L. V. Kotagal, C. E. Porcari, S. A. M. Rauch, C. R. Richardson.
Drafting of manuscript: L. R. Buis, L. V. Kotagal.
Critical revision of manuscript for important intellectual content: C. E. Porcari, S. A. M. Rauch, S. L. Krein, C. R. Richardson.
Statistical analysis: L. R. Buis, L. V. Kotagal, C. E. Porcari, C. R. Richardson.
Obtained funding: C. E. Porcari, S. A. M. Rauch.
Administrative, technical, or material support: L. R. Buis, C. E. Porcari, S. A. M. Rauch.
Study supervision: S. L. Krein, S. A. M. Rauch, C. R. Richardson.
Financial Disclosures: The authors have declared that no competing interests exist.
Funding/Support: This material was based on work supported by the Eastern Michigan University Psychology Department; a Blue Cross and Blue Shield of Michigan student award program grant (Dr. Porcari); a career development award from the Veterans Health Administration, Office of Research and Development, Clinical Sciences Research and Development (grant 2006-00052, Dr. Rauch); VA Health Services Research and Development Services (grant DIB 98001, Dr. Krein); a career development award from the National Heart, Lung, and Blood Institute (grant K23 HL075098, Dr. Richardson); and a Physician Faculty Scholars Program award from the Robert Wood Johnson Foundation (grant 57408, Dr. Richardson).
Institutional Review: All methods were reviewed and approved by the institutional review board at the VA Ann Arbor Healthcare System.
Participant Follow-Up: The authors do not plan to inform participants of the publication of this study because of a lack of contact information.
Submitted for publication August 6, 2010. Accepted in revised form February 23, 2011.
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Lorraine R. Buis, PhD; (1) Lindsey V. Kotagal, BA; (2) Carole E. Porcari, PhD; (3) Sheila A. M. Rauch, PhD; (3-5) Sarah L. Krein, PhD, RN; (6-7) Caroline R. Richardson, MD (2,7) *
(1) College of Nursing, Wayne State University, Detroit, MI; (2) Department of Family Medicine, University of Michigan Medical School, Ann Arbor, MI; (3) Posttraumatic Stress Disorder and Mental Health Clinic, Department of Veterans Affairs (VA) Ann Arbor Healthcare System, Ann Arbor, MI; (4) Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI; (5) Research Service, VA Ann Arbor Healthcare System, Ann Arbor, MI; (6) Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI; (7) VA Center for Clinical Management Research, VA Health Services Research and Development Center of Excellence, VA Ann Arbor Healthcare System, Ann Arbor, MI
* Address all correspondence to Caroline R. Richardson, MD; Department of Family Medicine, University of Michigan Medical School, 1018 Fuller St, Ann Arbor, MI 481041213; 734-998-7120; fax: 734-998-7335.
Table 1. Free-text response categories, definitions, and examples of physical activity. Category Definition Calisthenics/Aerobics Gymnastics or aerobic activities performed without apparatus. Cycling Cycling, excluding stationary exercise bike at home or gym. Domestic Chores Indoor activities related to maintaining living space. Exercise with Gym Equipment Exercise involving stationary equipment or weights, excluding treadmill running or walking. Martial Arts Any form of martial arts. Occupational Activities Activity involved in military Active Duty or post-deployment occupational responsibilities. Outdoor Activities Physical activities that can only be performed outdoors, excluding running and walking. Pool-Based Activities Activities that can only be performed in body of Running W aid. Running or jogging, including using treadmill. Sports Competitive activity involving at least two people. Walking Walking, excluding that associated with occupational activities. Other Activities that do not fit into any other category. Category Example Calisthenics/Aerobics Push-ups, sit-ups, calisthenics, cardio, aerobics, pull-ups. Cycling Cycling, biking, mountain biking. Domestic Chores Doing laundry, cleaning house, helping parent around house, vacuuming. Exercise with Gym Equipment Gymnasium, working out, weight training, weight lifting, rowing machine, elliptical machine, stationary bike, muscle-failure lifting. Martial Arts Martial arts, mixed martial arts, Muay Thai Kickboxing. Occupational Activities Loading truck, lifting heavy objects or boxes, walking at work, road marching, hiking, ruck marches, working on vehicles, cutting concrete, working as factory laborer, carrying machines, climbing ladders, working as union plumber. Outdoor Activities Gardening, fishing, hunting, camping, mowing lawn, cutting wood, snowboarding. Pool-Based Activities Swimming, water sports, water aerobics. Running Running, jogging (indoor, outdoor, or treadmill). Sports Basketball, volleyball, boxing, competitive sports, touch football, golf. Walking Walking, walking specific speed or distance. Other Salsa dancing, rock climbing, playing with kids, yoga. Table 2. Participant demographics (N = 319). Demographic n (%) * Male 274 (86) Age, yr (mean [+ or -] SD) 35.5 [+ or -] 9.7 BMI (score) <18.5 2 (<1) 18.5-24.9 74 (23) 25.0-29.9 140 (44) [greater than or equal to] 30 100 (32) Cigarette Smoker 86 (27) Able to Walk 1 Block Comfortably 302 (96) Without Assistance Race Caucasian 279 (87) African American 18 (6) Hispanic 12 (4) Asian 2 (<1) American Indian/Alaska Native 4 (1) Don't Wish to Respond 4 (1) Employment Full-Time (35-40 h/wk) 215 (67) Part-Time (<35 h/wk) 32 (10) Unemployed 46 (14) Disability 26 (8) Military Branch Army 151 (47) Navy 23 (7) Air Force 23 (7) Marine Corps 37 (12) National Guard 85 (27) Time Since Last OIF/OEF Deployment <6 mo 6 (2) 6 mo-1 yr 12 (4) 1.0-1.5 yr 29 (9) 1.5-2.0 yr 30 (9) >2 yr 242 (76) Carry Cellular Telephone 291 (93) Frequency of Email Use Never 4 (1)
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