Strategic Analysis of the 2014 Wounded Warrior Project Annual Alumni Survey

Wounded Warrior Project (WWP) offers support for and raises public awareness of service members and veterans who incurred physical or mental health injuries associated with their service on or after September 11, 2001, as well as their family members and caregivers. Since 2003, the organization has striven to support and engage these service members, their families, and caregivers through programs focused on four main areas: (1) engagement, (2) mind, (3) body, and (4) economic empowerment.

Each year, WWP conducts an assessment—the WWP Annual Alumni Survey—of its members (known as Alumni), to understand how well its programs and services are helping achieve their vision of “fostering the most successful, well-adjusted generation of wounded service members in our nation's history” (WWP, undated). The survey administrator, Westat, made general survey results available to WWP in an initial report. After Westat presented the initial results to WWP, WWP asked RAND to offer an additional interpretation of survey results to supplement Westat's interpretation. This study documents our supplemental analysis of 2014 survey data.

How to Use This Analysis, and Changes in Our Assessment Goals for Wounded Warrior Project

The results presented in this study are intended to help WWP understand the needs of its current Alumni. Specifically, we present the physical, mental, and economic status and self-perceptions of WWP Alumni to provide WWP leaders with an opportunity to assess and meet the needs of the current Alumnus population.

This year's final study differs from our 2013 effort in three significant ways. First, we provide short assessments of WWP outcomes in relation to WWP programs targeting Alumnus health, education, and employment. The assessments are limited, however, because of the nature of the survey data; because the data are correlational, we cannot draw strong conclusions about whether program participation actually caused changes in program outcomes. Second, this study offers an expanded examination of Alumni's mental health service use. Third, this study offers recommendations based on the analysis of the 2014 Annual Alumni Survey.

Wounded Warrior Project 2014 Annual Alumni Survey, Survey Respondents, and Analytic Method

We based the analysis on data from the 2014 WWP Annual Alumni Survey. The survey included questions about Alumnus characteristics, such as age, gender, race and ethnicity, branch of service, military pay grade, and disability ratings as discerned by the U.S. Department of Veterans Affairs (VA). The survey also included questions regarding Alumnus mental health, physical health, educational, and economic status.

In 2014, 21,120 WWP Alumni completed the survey. Men made up 87 percent^[1] of 2014 survey respondents. Most respondents were white (71 percent), between the ages of 26 and 35 (48 percent), and married (67 percent). About 41 percent had completed associate's degrees or higher; 48 percent were employed full time, with an additional 7 percent employed part time. Most respondents (62 percent) reported having health insurance through VA, with an additional 46 percent reporting having some other form of government health care. Most respondents had served in the Army (67 percent) and had pay grades between E-5 and E-9 during their time in service (68 percent). However, most (76 percent) were out of the military at the time of the survey. Because WWP serves service members and veterans who experienced health conditions as a result of their service, it is not surprising that most respondents (69 percent) had VA disability ratings of 50 percent or higher. Alumni reported a variety of service-related health conditions with some of the most prevalent being posttraumatic stress disorder (PTSD) (77 percent); sleep problems (77 percent); back, neck, or shoulder problems (73 percent); depression (69 percent); anxiety (65 percent); tinnitus (56 percent); knee injuries or problems (52 percent); and migraines/other severe headaches (50 percent).

We assembled the data to assess underlying variables of interest and employed regression to estimate variables' quantitative effect on the physical and mental health and educational and economic outcomes of survey respondents. We weighted results of the survey sample to represent the entire population of WWP Alumni, not just survey respondents. We drew outcomes associated with WWP program participation from the same survey data. These data are limited in that they do not specify how respondents were involved with a program at the time in which they took the survey nor show whether program involvement caused changes in outcomes or are merely correlated with them.

Depression, Posttraumatic Stress Disorder, and Problem Drinking Challenge Wounded Warrior Project Alumni's Mental Health

Panel A of Figure 1 shows that more than half of all WWP Alumni screened positive for each of the following mental health or substance use disorders—any probable depression, PTSD, or problem drinking. In addition, many WWP Alumni screened positive for more than one probable mental health disorder (see panel B of Figure 1).

Accessing Mental Health Care Is a Challenge for Many

More than half of the Alumni screening positive for any probable depression, any probable PTSD, or any probable problem drinking said that they had visited a professional to assist with mental health challenges; 70 percent of those with any probable depression reported seeing a professional in the prior three months, as did 67 percent of those with any probable PTSD and 52 percent of those with any probable problem drinking. Alumni who screened positive for any probable problem drinking are less likely to have seen a professional for potential mental health problems than Alumni who screened positive for any probable depression or any probable PTSD.

That a large proportion of those needing care received it is a positive finding. However, the 2014 survey results suggest also that many of those in need of care had difficulty or delay getting it or simply did not get it; 47 percent of Alumni who screened positive for any probable depression reported difficulty or delays getting or simply not getting needed mental health care, as did 45 percent of those screening positive for any probable PTSD and 38 percent of those screening positive for any probable problem drinking. The most-common barriers to care reported by Alumni include wanting to avoid talking about painful or traumatic memories, discomfort with existing U.S. Department of Defense (DoD) or VA resources, logistic challenges related to scheduling or treatment consistency, and concern about the effects that obtaining care could have on career plans.

Obesity Is a Health Challenge for Wounded Warrior Project Alumni

Results of the 2014 WWP survey suggest that 80 percent of WWP Alumni have above what is considered a normal body mass index (BMI). Figure 2 presents the BMI of Alumni; a BMI below 18.5 is underweight, 18.5 to 24.9 is a normal weight, 25.0 to 29.9 is considered overweight, and 30 or greater is obese (Centers for Disease Control and Prevention, 2012).

The prevalence of obesity in the general U.S. population (41.3 percent) is similar to that among WWP Alumni (42.6 percent). However, the rate of overweight among WWP Alumni (39.5 percent) is higher than the rate in the general population (27.2 percent). Alumni with higher BMIs are more likely to report being in fair or poor health, being more limited because of their health, and exercising less than those with lower BMIs.

Analyses of exercise frequency and limitations in performing vigorous activity shed light on which Alumni are most challenged in performing physical activity. The following subgroups of Alumni exercised less: Alumni who screened positive for any probable depression (0.8 days fewer per week than Alumni who did not screen positive) or who were over the age of 45 (about 0.4 days fewer per week than Alumni between the ages of 26 and 30). Active-duty Alumni reported exercising 0.8 days more and activated National Guard and Reserve 0.5 days more than Alumni who are out of the military. Older Alumni (relative to Alumni ages 26 to 30), severely disabled Alumni (relative to Alumni with VA disability ratings of 10 to 20 percent), Alumni reporting service-related spinal-cord injuries (relative to those without), and Alumni who screened positive for any probable depression (relative to those who did not screen positive) reported the most limitations to vigorous activity. Many Alumni face significant challenges related to performing physical exercise. Physicians' restrictions, fear of reinjury, and discomfort with social situations pose significant limitations for many.

Mental Health and Physical Health of Wounded Warrior Project Alumni Are Related

The 2014 survey data demonstrate the interdependency of WWP Alumni's mental and physical health. Those who screened positive for any probable depression show greater reports of fair or poor health, greater limitations because of health, reduced exercise frequency, and being limited a lot in performing vigorous activity than those who did not screen positive for any probable depression. Similarly, Alumni who screened positive for any probable PTSD are more likely to report being in fair or poor health, greater limitations because of physical health, and being limited a lot in performing vigorous activity than Alumni who did not screen positive for any probable PTSD. Alumni who had screened positive for any probable depression or any probable PTSD are 3.3 and 1.4 times more likely, respectively, to report fair or poor health than Alumni who did not screen positive for any probable PTSD or any probable depression.

Many Wounded Warrior Project Alumni Are Unemployed and Do Not Access Veteran Employment and Education Benefits

In 2014, 51 percent of Alumni were employed full time and 7 percent were employed part time. Unemployed Alumni looking for work represented 8 percent of the sample, while 34 percent were not looking for work or were unable to work if a job were offered. WWP Alumni cited a variety of challenges in securing or changing work. Mental health challenges were the most commonly cited (30 percent), followed by a lack of education (21 percent), physical health challenges (20 percent), and difficulty finding jobs with sufficient pay (18 percent). Also among those unable to work were Alumni actively pursuing educational goals (19 percent).

As in the 2013 sample, few WWP Alumni take advantage of federal veteran employment and education programs. In brief, of Alumni enrolled in school, less than one-third reported that they were using the VA Vocational Rehabilitation and Employment (VR&E) program, and 57 percent reported using the Post-9/11 GI Bill (Post-9/11 Veterans Educational Assistance Act of 2008; Title V of Pub. L. 110-252) to further their education. A closer examination of Alumni using VR&E show that those with disability ratings of 30 percent or greater are more than 2.1 times more likely to use these benefits than Alumni with lower ratings of 10 to 20 percent (e.g., Alumni with ratings of 30 to 40 percent are 2.2 times more likely and Alumni with ratings of 50 to 60 percent are 2.9 times more likely). Alumni of several minority racial and ethnic groups, including black and Hispanic or Latino, are 1.2 to 1.5 times more likely than white Alumni to use VR&E benefits; Alumni who reported having traumatic brain injury are 1.2 to 1.5 times more likely than those without such injury to use the benefits. Alumni over the age of 40 are less likely than Alumni between the ages of 26 and 30 to use the benefits. Alumni who reported service-related health conditions of severe burns or migraine or other severe headache or who screened positive for probable problem drinking are all less likely to use VR&E benefits than Alumni without these health conditions.

Alumni of several racial or ethnic groups are more likely to use Post-9/11 GI Bill benefits than white Alumni: black (1.4 times), Hispanic or Latino (1.2 times), Asian (1.4 times), and Alumni who selected multiple races or ethnicities (1.3 times). Disability rating was not strongly related to benefit use, though the most—severely disabled Alumni, with ratings of 90 to 100 percent, are less likely to use the benefit than those with lower ratings of 10 to 20 percent.

Survey Data Suggest That Wounded Warrior Project Programs Attract Alumnus Participants with Greater Health Needs

WWP offers many programs that aim to promote the mental and physical well-being of its Alumni, including adaptive sporting events, helplines, and education and employment training. Caution should be used in interpreting this initial examination of WWP program participation and outcomes because the data are cross-sectional; changes in outcomes might not necessarily be due to program participation. Initial exploration suggests that some programs draw those Alumni who reported fair or poor overall health. Some programs draw Alumni with particular conditions. For example, participants in three programs (i.e., Restore Warriors, Project Odyssey® or Combat Stress Recovery Program, and WWP Talk) reported more PTSD symptoms than Alumni who did not participate in the programs. This information could indicate that at least some of the programs are enrolling Alumni with the greatest physical and mental health needs.

WWP offers a variety of programs that promote positive education and employment outcomes for Alumni. Limited data suggest that just over 12 percent cited their participation in these programs as enabling them to secure full-time employment.

Recommendations

Findings in this study suggest a range of recommendations for WWP leadership to consider as they continue to move forward with meeting WWP strategic goals and assisting military service members, veterans, and their families and caregivers:

1. Review existing capabilities and consider introducing new capabilities for identifying and referring or intervening with Alumni experiencing mental health symptoms. WWP already provides various programs, such as the Combat Stress Recovery Program, and individual support to Alumni and their families, as well as assistance on a range of behavioral health challenges, such as stress, anger, relationship problems, self-esteem issues, self-care challenges, loss, depression, alcohol abuse, and drug abuse. However, the 2014 Annual Alumni Survey data indicate that any probable depression, any probable PTSD, and any probable problem drinking are prevalent among WWP Alumni and warrant continued attention. Leadership might want to consider how to complement existing efforts or introduce new efforts to continue to assist Alumni experiencing mental health symptoms through appropriate referral and early intervention.
2. Explore ways to help WWP Alumni overcome common barriers to obtaining mental health care. The analysis suggests that a large percentage of Alumni who screened positive for probable mental health disorders are delaying, not getting, or having difficulty getting needed mental health care. WWP might consider taking inventory of its program and service offerings to determine how these barriers to care are being addressed, and bolster such offerings where possible. Where these barriers are not being addressed, WWP might wish to make efforts (evidence-based, where possible) to help Alumni overcome barriers. For example, Alumni with mental health disorders might benefit from illness management and recovery, an evidence-based practice that could allow them to engage more fully in their own treatment and possibly overcome the barriers of having inconsistent care or lapses in care and feeling uncomfortable with existing DoD and VA resources.
3. Pursue a greater understanding of health needs and service preferences of WWP Alumni who might have alcohol-use problems. The 2014 survey suggests that 53 percent of WWP Alumni screened positive for any probable problem drinking. However, these Alumni are less likely to receive care than those who screened positive for other mental health challenges, such as any probable depression or any probable PTSD. WWP might wish to consider focusing on Alumni with potential alcohol-use problems to better understand their characteristics, needs, and challenges.
4. Continue emphasizing weight maintenance and loss. Through the Physical Health and Wellness program, WWP addresses issues of fitness, nutrition, and wellness by enabling Alumni to participate in activities, such as adaptive sports, yoga, scuba diving, cycling, and culinary education. Because of the high rates of overweight and obesity among WWP Alumni and accompanying negative health outcomes (e.g., more reports of fair or poor health), we recommend that WWP continue emphasizing weight maintenance or loss and consider where efforts could be introduced to complement existing programs. For example, the VA system could provide examples of weight-maintenance or weight-loss interventions that have been successful among veteran populations that could be adapted for WWP Alumni or to whom WWP staff can refer Alumni.
5. Increase efforts to address education and employment needs of WWP Alumni who have VA disability ratings of 50 percent or greater. WWP aims to increase the economic well-being of all of its Alumni and provides opportunities to Alumni through various programs, such as Benefits Service, Education Services, Transition Training Academy, and Warriors to Work®. Data from the 2014 Annual Alumni Survey indicate that Alumni with VA disability ratings of 50 percent or greater might face extra challenges to employment that those with lower VA ratings do not experience. WWP might wish to augment existing programs or consider introduction of new efforts to enable this subpopulation of Alumni to overcome barriers to civilian employment.
6. Explore why WWP Alumni do not participate in the labor force. Many Alumni might be out of the labor force due to the nature or severity of their service-related health conditions, but others might not seek employment for other reasons. WWP might wish to explore why WWP Alumni do not participate in the labor force, focusing in particular on those who initially sought employment and later left the labor force, to determine whether specific barriers exist for those who wish they were employed.
7. Commission an objective, external evaluation of WWP programs to determine their effects on outcomes of interest. In addition to the Annual Alumni Survey, WWP regularly monitors progress toward annual goals and program objectives and tracks key performance indicators. However, WWP could benefit from commissioning an objective, external evaluation from a firm with evaluation expertise to complement internal measurement efforts. Such an evaluation could help provide a more-comprehensive understanding of how program participation results in desired changes in outcomes.

References

Centers for Disease Control and Prevention, “Defining Overweight and Obesity,” last updated April 27, 2012. As of November 7, 2014:
http://www.cdc.gov/obesity/adult/defining.html

Public Law 110-252, Supplemental Appropriations Act of 2008, Title V, Veterans Educational Assistance, June 30, 2008. As of June 29, 2015:
http://www.gpo.gov/fdsys/pkg/PLAW-110publ252/html/PLAW-110publ252.htm

Wounded Warrior Project, “Mission,” undated; referenced December 10, 2014. As of June 25, 2015:
http://www.woundedwarriorproject.org/mission.aspx

———, “Alumni Survey 2014,” 2014. As of June 25, 2015:
http://www.woundedwarriorproject.org/survey?utm_source=wwporg&utm_medium=nav&utm_campaign=survey-results

WWP—See Wounded Warrior Project.

Note

[1] We did not weight the percentages in this paragraph. We weighted all remaining percentages in this summary.

This research was conducted within the Forces and Resources Policy Center of the RAND National Security Research Division (NSRD).