Purpose: Because up to 40% of veterans may have multiple health issues, the purpose of this study was to assess the relations between number of health conditions and use of special equipment with the general, physical, and mental health status of veterans ages 35-64 in the general population.
Methods: This cross-sectional analysis utilized data from the 2016 Behavioral Risk Factor Surveillance System (BRFFS) for veterans ages 35-64 in Florida (N=1844), Maryland (N=971), New York (N=1320), Texas (N=518), and Washington (N=735). Ordered logistic regression analysis was conducted separately by state and health outcome to assess relations between health status and number of health conditions and use of special equipment after controlling for healthcare access, demographic factors, socioeconomic status, and substance use.
Results: Across states, about one-fifth of veterans reported poor or fair general health (13-22%) and about one-third reported low to moderate physical health (32-41%) and mental health (27-30%). In addition, up to one-third of veterans reported having 2 or more health conditions (25-34%) and use of special equipment (9-33%). In adjusted analyses, general health, physical health, and mental health were moderately- to highly-related to the number of health conditions and use of special equipment across states.
Conclusions: The results of this study indicate general health, physical health, and mental health are all consistently impacted by the number of health conditions and use of special equipment in veterans ages 35-64 in the general population. In primary care, up to one-third of veterans may report low to moderate health outcomes, multiple health conditions, or use of special equipment. Since all are related, if veterans present with any of these, they should be screened for all. Healthcare for any of these issues should be coordinated and concurrent.

Keywords: General health, Use of equipment, Health conditions, Activity limitations, Veterans

Two million Americans have served in Iraq and Afghanistan, and up to 40% may return to the Veterans Affairs (VA) from Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) with health issues [1]. Having poor health can have detrimental effects on many aspects of an individual's life, including decreased physical and mental health as well as increased issues with work, social, and family relationships [2]. Poor health also contributes to the potential for drug addiction and overdoses; suicidal ideation, tendencies, and attempts; homelessness; and death [3].
The Center for Disease Control and Prevention [4] reports that 19% of male veterans ages 45-54, and 31% of veterans ages 55-64, may have two or more medical conditions. In addition, the Veterans Administration (VA) indicates that up to 41% of veterans receiving VA care may have two or more health conditions [5]. Health conditions and disabilities are factors that could impact an individual's health; however, veteranrelated research shows conflicting findings. Cully, et al. [6] found no relation between general health and number of medical comorbidities, while other studies indicate that total number of comorbidities and needing assistance with activities of daily living were both significantly related to quality of life [7-9]. Additional studies also found a significant relationship between chronic disease and general health [3] and between mortality and total number of health conditions [5].

In addition to medical conditions, disabilities affect a significant portion of the veteran population. It has been estimated that roughly 23% of veterans within the population are classified as having service-connected disabilities [10], which may result from combat exposure and war-related incidents, but also from training or disease processes obtained during time in service. Disabilities can require the use of special equipment which includes wheelchairs, prostheses, and other auxiliary devices. Additionally, the uses of special equipment due to amputations have been found to show moderate to strong negative effects on OEF/OIF veterans' quality of life [11].
General, physical, and mental health's are intrinsic components to the overall well-being of an individual. Assessing the relations between these aspects of health with number of medical conditions and use of special equipment in veterans will allow practitioners to better provide care to veteran patients that may not utilize services through the VA. The purpose of this study was to assess the relationship between number of health conditions and use of special equipment with general, physical, and mental health of veterans ages 35-64 in the general population.

We used data from veterans ages 35-64 in Florida (N=1844), Maryland (N=971), New York (N=1320), Texas (N=518), and Washington (N=735). These states were selected based on their higher prevalence of veterans throughout the U.S. [13].

There were three outcomes: general health status, physical health status, and mental health status. General health was categorized in BRFSS as "poor," "fair," "good," "very good," and "excellent." These categories were collapsed into "poor/fair," "good," and "very good/excellent" as a result of low frequencies within some categories. Physical health status was originally measured in BRFSS as "low" (defined as 0 days), "moderate" (defined as 1-13 days), and "high" (defined as 14 or more days) days of "not good" physical health in the past 30 days, which includes "physical illness and injury," The categories were reversed to reflect days of good physical health as "low" (defined as 16 or less days), "moderate" (defined as 17-29 days), and "high" (defined as 30 days). Mental health status was also originally measured in BRFSS as "low," "moderate," or "high" number of "not good" mental health days in the past 30 days, which includes "stress, depression, and problems with emotions," These categories were also reversed to reflect days of good mental health as "low," (defined as 16 or less days), "moderate," (defined as 17-29 days), and "high" (defined as 30 days).
There were two factors of interest: number of health conditions and use of special equipment. Number of health conditions was measured by the number of "yes" responses to being diagnosed with any of the following conditions: coronary heart disease, stroke, skin cancer, cancer, chronic obstructive pulmonary disease, arthritis, depression, kidney disease, diabetes, and asthma. This number was then categorized as "none", "one", "two", "three or more" health conditions. Use of special equipment was measured as "yes" or "no" to having a "health problem that requires special equipment." Control variables included healthcare access, gender, age, ethnicity/race, number of children at home, education level, income level, employment status, tobacco use, and alcohol use. Healthcare access was categorized as "cost precluded seeing a doctor in the past 12 months" vs. "cost did not preclude seeing a doctor in the past 12 months." Age was categorized as "35- 44 years," "45-54 years," and "55-64 years." Ethnicity/race was categorized as "white" vs "other" because the majority of the sample reported white race. The number of children at home was categorized as "none," "one," "two," and "three or more." Education level was categorized as "graduated college/technical school" vs. "did not graduate college/technical school." Income level was categorized as "$50,000 or more" vs. "less than $50,000." Employment was categorized as "employed" vs. "not employed." Tobacco was categorized as "current smoker" vs. "non-smoker." Alcohol use was categorized as "no use (0)," "light use (more than 1)," "moderate use (1-4 for males; 1-3 for females)," or "excessive use (5 or more for males; 4 or more for females)" in the past 30 days [14]. All variables, categories, and frequencies are listed in Table 1.

Frequency distributions were used to determine the sample characteristics and identify any issues in the distributions of variables. Data was analyzed by state and health status to determine patterns in variable relations across similar samples. Similar results in the majority of samples (three or more of the five states) were considered evidence of reliable relationships between variables. Ordered logistic regression analysis was conducted separately by state and outcome to determine the relationship between general, physical, and mental health status and number of health conditions and activity limitations after controlling for factors that have been shown to be related to veteran health, including healthcare access, gender, age, ethnicity/race, number of children at home, education level, income level, employment status, tobacco use, and alcohol use [2- 4,9-10]. An ordered logistic regression model is used to estimate a relationship between an ordinal dependent variable and a set of independent variables. The proportional odds produced for each IV relates "proportionally" or equally applies to comparisons of DV groups greater than k versus those who are in groups less than or equal to k, where k is any level of the response variable. Therefore, the interpretation of an associated OR is that for a one unit change in the predictor variable, the odds for a group that is greater than k versus less than or equal to k are the proportional odds times larger. Any observations with missing data for any variables were excluded from the adjusted analysis. Adjusted results are shown by state and health status in Table 2. All analyses were conducted in STATA 15 (version 15.1 Copyright 1985-2017 StataCorp LLC).

Table 1 shows participant characteristics for veterans ages 35-64 in Florida, Maryland, New York, Texas, and Washington. Across states, about one-fifth of veterans reported poor/fair general health (13-22%) and about one-third reported low to moderate physical health (32-41%) and mental health (27-30%). In addition, up to onethird of veterans reported having 2 or more health conditions (25- 34%) and use of special equipment (9-33%). For healthcare access, most reported that cost did not prevent them from seeing a doctor in the past 12 months (87-93%). Regarding demographic factors, most of the respondents were male (78-85%) and between the ages of 45-64 (81-84%). In addition, the majority reported having no children at home (66-73%) and were white race (61-86%). For socioeconomic factors, the majority did not graduate from college or technical school (53-72%), had an income of $50,000 or more (52- 78%), and were employed (59-72%). For substance use, most were not current smokers (72-84%) and the majority reported no or light use of alcohol (52-58%).

Adjusted results for general health status, physical health status, and mental health status as related to health conditions and use of special equipment are shown in Table 2.
For general health status, the results of ordered logistic regression analysis for veterans ages 35-64 in Florida, Maryland, New York, Texas, and Washington indicated that after controlling for all other variables in the model, general health was significantly related to number of health conditions and use of special equipment. Across five states, compared to those that had zero health conditions, participants with one health condition were about 2 to 3 times less likely, those with two health conditions were about 4 to 5 times less likely, and those with three or more health conditions were about 5 to 12.5 times less likely, to report each successive level of general health. In addition, participants in all five states who used special equipment were about 3 to 5.5 times less likely to report each successive level of general health compared to those who did not use special equipment.

For physical health status, the results of ordered logistic regression analysis for veterans ages 35-64 in Florida, Maryland, New York, Texas, and Washington indicated that after controlling for all other variables in the model, physical health was significantly related to number of health conditions and use of special equipment. Across five states, compared to those that had zero health conditions, participants with one health condition were about 2 to 3 times less likely, those with two health conditions were about 2 to 4 times less likely, and those with three or more health conditions were about 2 to 7 times less likely to report each successive level of physical health. In addition, participants in all five states who used special equipment were about 4.5 to 10 times less likely to report each successive level of physical health compared those who did not use special equipment. For mental health, the results of ordered logistic regression analysis for veterans ages 35-64 in Florida, Maryland, New York, Texas, and Washington indicated that after controlling for all other variables in the model, mental health was significantly related to number of health conditions and use of special equipment. In four out of five states, compared to those that had zero health conditions, participants with one health conditions were about 2 times less likely, those with two health conditions were about 2.5 to 3.5 times less likely, and those with three or more health conditions were about 2.5 to 10 times less likely to report each successive level of mental health. In addition, participants in three out of five states who used special equipment were about 1.5 to 3 times less likely to report each successive level of mental health compared to those who did not use special equipment.

Using BRFSS data allowed large samples of community based veterans from which to assess the relationship between number of health conditions, activity limitations, general health status, physical health status, and mental health status. However, information was lacking regarding the cause, severity, and management of physical and mental health issues, health conditions, and use of special equipment. Future studies should include these. Moreover, future studies may need to consider differences in the functional capabilities of special equipment as related to health outcomes and track improvements in the development of prosthetics and other special equipment that have the potential to impact health outcomes for those with activity limitations.

The results of this population-based study may generalize to veterans ages 35-64 in primary care settings. Up to onethird of veterans may report low to moderate levels of general, physical, or mental health, as well as multiple health conditions and use of special equipment. Based on the results of this study, all three health outcomes were consistently and moderately- to highly-related to number of health conditions and use of special equipment. Providers should screen for general, physical, and mental health along with health conditions and use of special equipment in patients with veteran status presenting for care with any of these. Resulting healthcare for physical health and mental health should be coordinated and concurrent. Treatment options for any health conditions should be assessed and optimized as needed, and additional attention should be given to those requiring the use of special equipment. The need for initial or follow up consultation with medical personnel specializing in relevant durable medical equipment requirements, such as physical or occupational therapy and prosthetics departments, should be addressed as part of each primary care visit.

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