Out of the Shadows

Over the past decade, private contractors have been deployed extensively to conflict environments around the globe. In addition to supporting U.S. and allied forces in Iraq and Afghanistan, contractors have assisted foreign governments, nongovernmental organizations, and private businesses by providing a wide range of services, including base support and maintenance, logistical support, transportation, intelligence, communication, construction, and security. While exact numbers of contractors employed by various entities in conflict environments internationally are unknown, contractors employed by the U.S. Department of Defense (DoD) at the height of the conflicts in Iraq and Afghanistan outnumbered U.S. troops deployed to both theaters: For example, DoD employed 155,826 contractors alongside 152,275 U.S. troops in Iraq in 2008 and 94,413 contractors alongside 91,600 U.S. troops in Afghanistan in 2010 (Sié Chéou-Kang Center for International Security and Diplomacy, 2013). Such figures may not provide a true gauge of the industry's size, however, nor are they necessarily representative of future contractor deployments.

Although these contractors are not supposed to engage in offensive combat, they may nonetheless be exposed to such stressors as gunfire, improvised explosive devices (IEDs), and other modes of attack; serious injury; kidnapping; the deaths of fellow personnel; and the psychological aftermath of killing. These stressors are known to have physical and mental health implications for military personnel: It is estimated that 5–20 percent of U.S. service members returning from deployments suffer from posttraumatic stress disorder (PTSD) (Ramchand et al., 2010), with lower rates of PTSD among service members from other nations (for example, the rate is estimated to be 3–7 percent among UK personnel; see Engelhard et al., 2007; Iversen et al., 2009; Richardson, Frueh, and Acierno, 2010; and Fear et al., 2010). Yet, despite anecdotal evidence of similar problems among contractors, there has been very little study of this issue to date.

This article attempts to fill that void by presenting results from a RAND research study that explored the prevalence and nature of health problems among the deployed contractor population. Building on prior research on military mental health and wartime contracting, the study addressed two related questions:

1. What is the prevalence of mental and physical health problems among contractors who have deployed at least once to a theater of conflict in the 2011–2013 time frame?
2. To what extent do contractors who work in conflict environments use mental health care services, and what are the barriers and facilitators to receiving care?

Survey Approach

RAND conducted an online survey of 660 contractors who had deployed on contract to a theater of conflict at least once in the previous two years (early 2011 through early 2013). Two-thirds (61 percent) of respondents were U.S. citizens, 24 percent were UK citizens, and the rest were citizens of Australia, South Africa, New Zealand, or other nations. The majority (84 percent) had previously served in the armed forces. The largest proportion of respondents (38 percent) were engaged in land security services, including convoy security, static site security, and personal security details, during their contracts. The remaining proportion of respondents were engaged in transportation, training or advising, maritime security, base support, logistics, management, or other services during their contracts.

In addition to gathering demographic and employment information, the survey asked respondents about their deployment experience (including level of preparation for deployment, combat exposure, and living conditions), their mental health (including criteria for probable PTSD, depression, and high-risk alcohol use), their physical health, and their access to and use of health care. The purpose was to identify contractors' levels health and well-being and to explore differences by such factors as country of citizenship, job specialty, and length and frequency of deployment.

Major Findings

Contractor Deployment Experiences Vary with Their Circumstances

Deployment experiences likely play a role in shaping the health and well-being of contractors. We found that contractors' levels of deployment preparedness and combat exposure were roughly similar to those of military populations. Contractors' living conditions (e.g., access to clean clothing, ability to get sufficient sleep, access to means to communicate with friends and family) were better than those reported by a sample of Gulf War veterans (King et al., 2006), and contractor deployment preparation was slightly better than that of U.S. Army medics (Chapman et al., 2012). However, there were some notable differences among the contractors surveyed:

• UK citizens reported better preparation, lower levels of combat exposure, and better living conditions than U.S. citizens, on average. However, citizens of countries other than the United States and the United Kingdom reported even better experiences in these categories.
• Transportation contractors reported the lowest levels of preparation, the highest combat exposure, and the worst living conditions of all job specialties. Logistics/maintenance contractors fared best in all three categories, and maritime security contractors fared equally to logistics/maintenance contractors in terms of combat exposure and living conditions.
• Contractors with shorter, more-frequent deployments reported higher levels of preparedness than those with longer, less-frequent deployments. Shorter deployments were also correlated with lower combat exposure and better living conditions.
• Contractors who carried a weapon felt better prepared for deployment than those who did not.

Contractors Are Affected by Serious Mental Health Problems

The survey found that the proportion of respondents with mental health problems was at least as great as that in military populations:

• Twenty-five percent of contractors met criteria for probable PTSD. Moreover, 18 percent screened positive for depression, and 10 percent reported high-risk drinking. By comparison, the respective proportions of U.S. military troops deployed to Iraq or Afghanistan have been estimated at 4–20 percent for PTSD, 5–37 percent for depression, and 4.7–39 percent for alcohol abuse (Institute of Medicine, 2013). Rates of PTSD are lower among UK military personnel, with 4–7 percent reporting probable PTSD. However, the prevalence of other mental health problems among UK service members is similar to that among the contractors we surveyed, with 20 percent of UK military personnel reporting symptoms of common mental disorders, such as depression, and 13–67 percent reporting alcohol abuse (Fear et al., 2010, 2007).
• Transportation contractors showed the highest rate of probable PTSD (50 percent), most likely due to greater combat exposure than other job specialties (as noted earlier).*
• U.S. contractors reported more mental health problems than UK contractors: Thirty-two percent of U.S. contractors met criteria for probable PTSD (compared with 12 percent of UK contractors), and 23 percent of U.S. contractors met criteria for depression (compared with 9 percent of UK contractors). The difference may be due to cultural or societal differences in the experience of traumatic events or in the reporting of mental health symptoms. U.S. military personnel also experience higher rates of PTSD than do military personnel from other Western nations (Richardson, Frueh, and Acierno, 2010).
• Longer deployments and increased combat exposure were each associated with higher rates of PTSD and depression. Increased preparedness was associated with lower rates of mental health problems. Similarly, combat-exposed UK military personnel have reported higher rates of PTSD compared with those who were not exposed to combat (Fear et al., 2010).

Contractors Also Suffer from Physical Health Problems

In addition to mental health stressors, contractors may be exposed to physical health dangers, ranging from respiratory problems to serious, life-changing injuries. The survey asked respondents to assess their overall health, to report whether they had ever been diagnosed with a traumatic brain injury (TBI), and to describe any other health problems they believed they suffered as a result of their deployment on contract. Major findings are as follows:

• The majority of respondents said that they were in “excellent” or “very good” health. Ten percent had been diagnosed with a TBI at some point in their lives. Thirty-nine percent reported other health problems (most frequently, respiratory issues, back pain, and hearing problems) that they believed they had acquired from their contract deployment.
• Health problems varied considerably between contractors from different countries. Fifty-three percent of U.S. contractors reported suffering from a physical health condition due to their contracted deployment, compared with only 16 percent of UK contractors. The discrepancy holds true even after controlling for other factors, such as combat exposure, length of deployment, and mental health issues. The underlying reason deserves further examination.
• Health problems also varied by job specialty. Transportation contractors were most likely to report a physical health condition (55 percent), and maritime security contractors were least likely (15 percent).
• Respondents working on contracts funded by DoD or the U.S. Department of State (DoS) were more likely to report a physical health problem than were those working on other contracts. The rate of health problems was equal for DoD- and DoS-funded contractors.
• On average, those who reported physical health problems also had higher combat exposure, were more likely to meet criteria for probable PTSD, and had higher rates of depression.

Most Contractors Have Health Insurance, but Not All Health Care Needs Are Being Met

Having identified significant instances of physical and mental health problems among contractors, we next sought to determine whether contractors were seeking and receiving treatment. We asked respondents about their access to health insurance during and after deployment, whether they had filed claims under the Defense Base Act (DBA), and whether they had sought treatment for mental health issues during the previous year (and if not, why not). Our primary conclusions are as follows:

• Eighty-three percent of contractors surveyed had health insurance at the time of the survey, but there were differences from country to country. The proportion of U.S. contractors without health insurance was 21 percent, compared with 12 percent for UK contractors and 10 percent for those who were citizens of other countries. Eighty percent of respondents reported receiving health insurance from their contracting firm while they were deployed, but this was mostly limited to the deployment period or to a short time afterward.
• Only 16 percent of contractors sampled had ever made a DBA claim. Among those whose most recent contract had been funded by the U.S. government, 22 percent reported that they had made a DBA claim. The DBA mandates that all civilian employees working outside the United States on U.S. military bases or under a contract with the U.S. government for public works or national defense have access to workers' compensation for injuries or deaths sustained as a result of such employment. We found that, among respondents who applied for benefits, 57 percent of claims were approved and 37 percent were either denied or still being processed at the time of the survey. (Six percent of respondents reported that they did not know the outcome of their DBA claim.) Contractors from the United States were more likely to file DBA claims than those from other countries.
• There is a significant unmet need for health care, with only 28 percent of those with probable PTSD and 34 percent of those with probable depression receiving mental health treatment in the 12 months prior to the survey. This may be due to the perceived stigma of having a mental health problem or other barriers to receiving mental health care; contractors with probable PTSD or depression were twice as likely to report barriers to receiving mental health treatment, including cost, embarrassment, and concerns about being perceived as weak.

Recommendations

The survey results suggest that deployments to combat theaters place significant stresses on contractors, with implications for both physical and mental health. Mental health problems, especially probable PTSD and depression, are of particular concern, and many contractors are not getting the treatment they need. The following recommendations suggest how private companies, government entities, and the research community can help address these needs.

Increase Access to Stress Management and Mental Health Resources

Contractors receive infrequent training in stress management prior to a combat deployment, and there are few company-provided resources available during or after a combat deployment. We found that when such resources were available, instances of probable PTSD and depression were much lower. Private contracting firms employing these contractors—including but not limited to private military and security companies, risk consultancies, development companies, and construction and engineering companies, logistics firms, and transportation companies—should consider providing these resources more uniformly. In addition, funding agents that issue these contracts, such as DoD, might consider requiring that contractor personnel have access to stress and mental health resources as a condition of the contract.

Reduce the Stigma in Seeking Treatment for Mental Health Problems

The perceived stigma associated with mental health care is a significant barrier to contractors who need such care. Research on stigma reduction suggests that programs that provide education about mental health problems and contact with people who have been treated for mental health problems have been successful in reducing stigma (Collins et al., 2012; Penn and Couture, 2002; Thornicroft et al., 2008). To encourage greater usage of mental health care among those who need it, companies could implement programs to increase awareness about stress and mental health problems associated with contract deployments, train team leaders to identify and normalize stress reactions, and provide access to confidential counseling.

Conduct Additional Research to Better Understand the Needs of This Population

This research is intended as an exploratory study of the physical and mental health issues that affect contractors and the factors that facilitate or impede their treatment. Understanding the causes behind the results documented here will help policymakers and private companies take steps to improve the health and well-being of contractors. Additional research is therefore needed in the following areas:

• understanding how predeployment readiness training can protect contractors from deployment-related health conditions
• shaping deployment experiences to improve contractors' health and well-being
• developing a deeper understanding of the physical health problems that contractors face and any barriers to care (as a counterpart to this study's focus on mental health)
• investigating the reasons why contractors from different countries have different outcomes in many areas addressed in this study
• surveying a larger population of contractors in specific job specialties of interest, such as transportation and logistics/maintenance
• extending the scope of this analysis to contractors deployed over the past decade (and thus encompassing deployments as far back as the early years of both Iraq and Afghanistan).

References

Chapman, Paula L., David Cabrera, Christina Varela-Mayer, Monty Baker, Christine Elnitsky, Charles Figley, Ryan M. Thurman, Chii-Dean Lin, and Paul Mayer, “Training, Deployment Preparation, and Combat Experiences of Deployed Health Care Personnel: Key Findings from Deployed US Army Combat Medics Assigned to Line Units,” Military Medicine, Vol. 177, No. 3, March 2012, pp. 270–277.

Collins, Rebecca L., Eunice C. Wong, Jennifer L. Cerully, Dana Schultz, and Nicole K. Eberhart, Interventions to Reduce Mental Health Stigma and Discrimination: A Literature Review to Guide Evaluation of California's Mental Health Prevention and Early Intervention Initiative, Santa Monica, Calif.: RAND Corporation, TR-1318-CMHSA, 2012. As of August 27, 2013:
http://www.rand.org/pubs/technical_reports/TR1318.html

Engelhard, Iris M., Marcel A. Van Den Hout, Jos Weerts, Arnoud Arntz, Joop J. C. M. Hox, and Richard J. McNally, “Deployment-Related Stress and Trauma in Dutch Soldiers Returning from Iraq Prospective Study,” British Journal of Psychiatry, Vol. 191, No. 2, August 2007, pp. 140–145.

Fear, Nicola T., Amy Iversen, Howard Meltzer, Lorna Workman, Lisa Hull, Neil Greenberg, Christopher Barker, Tess Browne, Mark Earnshaw, Oded Horn, Margaret Jones, Dominic Murphy, Roberto J. Rona, Matthew Hotopf, and Simon Wessely, “Patterns of Drinking in the UK Armed Forces,” Addiction, Vol. 102, No. 11, 2007, pp. 1749–1759.

Fear, Nicola T., Margaret Jones, Dominic Murphy, Lisa Hull, Amy C. Iversen, Bolaji Coker, Louise Machell, Josefin Sundin, Charlotte Woodhead, Norman Jones, Neil Greenberg, Sabine Landau, Christopher Dandeker, Roberto J. Rona, Matthew Hotopf, and Simon Wessely, “What Are the Consequences of Deployment to Iraq and Afghanistan on the Mental Health of the UK Armed Forces? A Cohort Study,” The Lancet, Vol. 375, No. 9728, May 22, 2010, pp. 1783–1797.

Institute of Medicine, Returning Home from Iraq and Afghanistan: Assessment of Readjustment Needs of Veterans, Service Members, and Their Families, Washington, D.C.: National Academies Press, 2013.

Iversen, Amy C., Lauren van Staden, Jamie Hacker Hughes, Tess Browne, Lisa Hull, John Hall, Neil Greenberg, Roberto J. Rona, Matthew Hotopf, Simon Wessely, and Nicola T. Fear, “The Prevalence of Common Mental Disorders and PTSD in the UK Military: Using Data from a Clinical Interview-Based Study,” BMC Psychiatry, Vol. 9, No. 1, January 2009, pp. 68–79.

King, Lynda A., Daniel W. King, Dawne S. Vogt, Jeffrey Knight, and Rita E. Samper, “Deployment Risk and Resilience Inventory: A Collection of Measures for Studying Deployment-Related Experiences of Military Personnel and Veterans,” Military Psychology, Vol. 18, No. 2, 2006, pp. 89–120.

Penn, David L., and Shannon M. Couture, “Strategies for Reducing Stigma Toward Persons with Mental Illness,” World Psychiatry, Vol. 1, No. 1, February 2002, pp. 20–21.

Ramchand, Rajeev, Terry L. Schell, Benjamin R. Karney, Karen Chan Osilla, Rachel M. Burns, and Leah Barnes Caldarone, “Disparate Prevalence Estimates of PTSD Among Service Members Who Served in Iraq and Afghanistan: Possible Explanations,” Journal of Traumatic Stress, Vol. 23, No. 1, February 2010, pp. 59–68.

Richardson, Lisa K., B. Christopher Frueh, and Ronald Acierno, “Prevalence Estimates of Combat-Related Post-Traumatic Stress Disorder: Critical Review,” Australian and New Zealand Journal of Psychiatry, Vol. 44, No. 1, 2010, pp. 4–19.

Sié Chéou-Kang Center for International Security and Diplomacy, University of Denver, Private Security Monitor, online database. As of 2013:
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Thornicroft, Graham, Elaine Brohan, Aliya Kassam, and Elanor Lewis-Holmes, “Reducing Stigma and Discrimination: Candidate Interventions,” International Journal of Mental Health Systems, Vol. 2, No. 1, April 2008, pp. 3–9.

Notes

* It should be noted, however, that the size of our sample of transportation contractors was relatively small. This finding therefore speaks to the need for further research specifically on the health needs of the population of contractors engaged in transportation services.

This study is a product of the RAND Corporation's continuing program of self-initiated independent research. Support for such research is provided, in part, by donors and by the independent research and development provisions of RAND's contracts for the operation of its U.S. Department of Defense federally funded research and development centers. The research was conducted within the RAND National Security Research Division of the RAND Corporation.