Apr 28, 2021
The Health Related Behaviors Survey (HRBS) is the U.S. Department of Defense's (DoD's) flagship survey for understanding the health, health-related behaviors, and well-being of service members. Fielded periodically for more than 30 years, the HRBS includes content areas that might affect military readiness or the ability to meet the demands of military life. The Defense Health Agency asked the RAND Corporation to revise and field the 2018 HRBS among members of both the active component and the reserve component. This brief discusses findings for the reserve component.
This brief presents high-level summary results for broad topics of the HRBS, as well as policy implications of key findings. The results for the reserve component are compared with Healthy People 2020 (HP2020) objectives established by the U.S. Department of Health and Human Services for the general U.S. population and with findings for the active component. Because the military differs notably from the general population (for example, military populations are more likely to be young and male than is the general population), the HP2020 comparisons are offered only as a benchmark of interest. Ways of improving future iterations of the HRBS are also suggested.
The HRBS examined weight status, physical activity, annual physical assessments, and sleep.
The HRBS examined use of alcohol, tobacco and nicotine products, marijuana and synthetic cannabis, other drugs, and prescription drugs.
The HRBS examined mental health, social and emotional factors associated with mental health, perceived unmet treatment needs, barriers to mental health service use, and concerns that mental health treatment would damage one's military career.
The HRBS examined chronic health conditions, physical symptoms, pain, mild traumatic brain injury (mTBI) and postconcussive symptoms, and self-reported health.
The HRBS examined sexual risk behaviors, sexually transmitted infections (STIs) and unintended pregnancies, use of and access to contraception, and human immunodeficiency virus (HIV) testing in the past 12 months.
The HRBS estimated the percentage of servicemen and servicewomen who are lesbian, gay, or bisexual (LGB) and identified key information about the health-related behavior and health status of LGB service members.
The HRBS examined the frequency and duration of deployments (both combat and noncombat), combat trauma experience, and deployment experiences and health.
DoD policy seeks to "[s]upport the achievement of the Department of Health and Human Services' vision for improving the health of all Americans as outlined in Healthy People 2020." As such, it is important to be able to compare results from the HRBS with HP2020 goals. Again, readers should consider such comparisons cautiously because they ignore differences in demographic indicators (e.g., gender, age) related to health outcomes and health behaviors. At the same time, members of the reserve component might look more like civilian peers than members of the active component do.
Table 1 shows comparisons between HP2020 goals and findings from the 2018 HRBS. Teal cells indicate where the reserve component is doing as well or better than the relevant HP2020 goal; tan cells indicate where it is doing worse.
The reserve component is doing well with respect to several HP2020 goals: obesity, physical activity, strength training, high blood pressure, high cholesterol, and HIV testing among men who have sex with men. It falls short of HP2020 goals for alcohol use, tobacco use, sleep health, and contraceptive use.
|Topic||HP2020 Goal||2018 HRBS|
|Health promotion and disease prevention|
|Obesity (ages 20+)||30.5% (or less)||teal 19.0%|
|Normal weight (ages 20+)||(at least) 33.9%||tan 31.4%|
|Moderate physical activity at least 150 minutes/week or vigorous physical activity 75 minutes/week||(at least) 47.9%||teal 67.2%|
|Moderate physical activity for more than 300 minutes/week or vigorous physical activity for at least 150 minutes/week||(at least) 31.3%||teal 41.6%|
|Muscle-strengthening activities on 3+ days/weeka||(at least) 24.1%||teal 43.1%|
|Sleep: 8 hours/24-hour period for those 18–21 years of age, 7 hours/24-hour period for those older than 21||(at least) 72.8%||tan 45.4%|
|Binge drinking||24.2% (or less)||tan 29.0%|
|Current cigarette smoking||12.0% (or less)||tan 13.3%|
|Current cigar smoking||0.3% (or less)||tan 8.0%|
|Current smokeless tobacco use||0.2% (or less)||tan 11.0%|
|Physical health and functional limitations|
|High blood pressure||26.9% (or less)||teal 9.3%|
|High cholesterol||13.5% (or less)||teal 6.8%|
|Sexual behavior and health|
|Use of contraceptive at most-recent sex (ages 15–44)||91.6% (or higher)||tan 73.8%b|
|Use of moderately or most-effective contraceptive (ages 20–44)||69.3% (or higher)||tan 60.3%|
|Annual HIV testing among men who have sex with men||68.4% (or higher)||teal 84.2%|
a The HP2020 goal is for two or more days per week, but the HRBS measure cannot be disaggregated in this way. Instead, the HRBS value represents strength training of three or more days per week, which thus underestimates the percentage of service members meeting the HP2020 goal.
b The HRBS estimate is for women ages 17 to 44 because women under age 17 are not eligible to join the military.
Demographic differences between the active and reserve components make direct comparisons inadvisable. To consider differences between the two components in assessing HRBS results, RAND researchers used a regression model approach that accounted for demographic and other differences. Table 2 summarizes the results of comparisons using this regression approach. Darker teal cells indicate where the reserve component did better than the active component, darker tan where the reserve component did worse, and lighter tan where there was no difference. "Better" could mean significantly higher or lower prevalence, depending on the outcome. Lighter teal cells indicate where prevalence in the reserve component was significantly smaller than in the active component, but it is unclear whether this is "better." (For example, lower numbers of mental health care visits are not better if more mental health needs are going unmet.)
These results show that reservists were more likely to be obese and less likely to meet activity goals than active component members were. This could impact readiness should these reservists be called for active-duty service. At the same time, reservists appear to have better sleep health and to be less likely to binge drink and to use tobacco and nicotine products. Reservists were less likely to report mental health problems and less likely to indicate experiencing physical assault or unwanted sexual contact. Reservists also reported fewer chronic physical health conditions and were less likely to engage in risky sexual practices.
|Health Promotion and Disease Prevention||Substance Use||Mental and Emotional Health||Physical Health and Functioning||Sexual Behavior and Health|
|dark tan Obesity (HP2020 goal)||dark teal Binge drinking||dark teal Past-month and past-year serious psychological distress||dark teal Physician-diagnosed chronic conditions: high blood pressure; back pain; bone, joint, or muscle injury (including arthritis)||dark teal 2+ sex partners in past year|
|light tan Normal weight (HP2020 goal)||dark teal Heavy drinking||dark teal Probable PTSD||light tan Physician-diagnosed chronic conditions: diabetes, high cholesterol, asthma, angina or coronary heart disease, heart attack||dark teal New partner sex without condom use past year|
|dark tan Medium activity level (HP2020 goal)||dark teal Any alcohol consequences||dark teal Any angry or aggressive behavior in past 30 days||dark teal No medical condition diagnosed in past year||dark teal Condom use during most-recent vaginal sex|
|dark tan High activity level (HP2020 goal)||light tan Risky drinking and driving behavior||dark teal Unwanted sexual contact in past 12 months and since joining the military||dark teal Physical conditions: stomach or bowel problems, back pain, arm/leg/joint pain, headaches, chest pain or shortness of breath, tired or low energy||dark teal STI in past year|
|dark teal Strength training 3+ days per week||light tan Any productivity loss due to drinking||dark teal Physically assaulted in past 12 months and since joining the military||light tan Physical conditions: dizziness||light tan No contraceptive use at most-recent sex|
|dark teal Less than one hour of screen time per day||dark teal Military culture supportive of drinking||light tan Past-year gambling problem||dark teal Any bodily pain (including headache)||dark tan Used highly effective contraceptive at most-recent sex|
|light tan Routine annual physical exam||dark teal Current cigarette smoker||dark teal Past-year suicidal thoughts, suicide plans, and suicide attempts||dark teal Any bodily pain (excluding headache)||dark tan Used moderately or most effective birth control method at last sex (women 20–44 years old)|
|dark teal Hours of sleep (HP2020 goal)||dark teal Current e-cigarette use||dark teal Perceived unmet need for mental health services||dark teal High physical symptom severity||dark tan HIV test in past year|
|dark teal Very good and fairly good self-rated sleep quality||dark teal Current smokeless tobacco user||light teal Past-year mental health care service utilization||dark teal Excellent and very good self-rated health||dark teal High risk for HIV|
|dark teal Moderate to severe lack of energy due to poor sleep||dark tan Any past-12-month and past-30-day drug use (including marijuana)||light teal Total mental health visits in past year||dark teal Absenteeism||dark tan High risk for HIV tested in past year|
|dark teal Frequent use of medication to sleep (3+ times per week)||light tan Any past-12-month and past-30-day drug use (excluding marijuana)||light teal Use of medication for mental health problem in past year||dark teal Presenteeism||light tan Unintended pregnancy in past year|
|light tan Frequent use of other caffeinated beverages (e.g., tea, coffee), over-the-counter medications, and prescription medications to stay awake (3+ times per week)||dark teal Any prescription drug use (including stimulants, sedatives, and pain relievers)||light teal Perceived career-related stigma associated with mental health care service utilization||light tan Contraceptive counseling prior to deployment|
|light tan Any prescription drug misuse (including stimulants, sedatives, and pain relievers)||light tan Able to get preferred birth control before and while deployed|
NOTES: Darker teal cells indicate that the reserve component did better than the active component on the outcome in question. Darker tan indicates that the reserve component did worse on the outcome in question. Lighter tan indicates no difference between the two components. Lighter teal indicates an outcome where the reserve component prevalence rate was significantly smaller, but it is unclear whether this was a "better" outcome; these outcomes are primarily related to use of mental health care services.
DoD, the services, and the Coast Guard should address the low compliance rate for physical examinations. Annual exams are required. Many reservists also lack health insurance.
DoD, the services, and the Coast Guard should seek to educate reserve component service members and leaders on sleep health, using models that have been successful in similar populations. Most reservists did not get recommended amounts of sleep, and many rated their sleep as bad or reported being bothered by a lack of sleep, potentially impacting readiness.
DoD, the services, and the Coast Guard might wish to promote alcohol reduction and prevention programs that change cultural beliefs about alcohol use and promote self-care. Many reservists reported binge drinking, with some also reporting adverse consequences or lost productivity.
Reducing tobacco use in all forms should be a high priority for DoD, the services, and the Coast Guard, given the long-term health consequences of tobacco use. Use of tobacco and nicotine products was also higher than for the civilian population.
DoD, the services, and the Coast Guard should continue to monitor, understand, and support mental health for reservists and to mitigate challenges associated with seeking mental health treatment. Symptoms of psychological distress were common among reservists. If untreated, distress could persist and cause functional impairment and reduce readiness.
DoD, the services, and the Coast Guard should explore the role of peers and commanders in mental health literacy training and efforts to increase awareness of mental health resources.
Pain was common among reservists. DoD, the services, and the Coast Guard should increase pain prevention and treatment efforts.
DoD, the services, and the Coast Guard should consider ways to increase the proportion of personnel who receive predeployment contraceptive counseling. Educational efforts should make clear to both reservists and military health care providers that directives to provide contraceptive counseling are relevant for all personnel.
To prevent STIs and unintended pregnancies, DoD, the services, and the Coast Guard should ensure that condoms are easily available to reservists at no or reduced cost.
Broadly targeted health promotion efforts by DoD, the services, and the Coast Guard should include LGB-specific considerations as appropriate.
Given high LGB personnel use of tobacco and nicotine products, DoD, the services, and the Coast Guard might wish to use targeted clinical screening and intervention to assist with smoking cessation.
DoD, the services, and the Coast Guard could reduce sexual health disparities for LGB personnel through education of military health providers. Incorrect assumptions about bisexual service members based on the sex of their current partners might lead to incomplete or incorrect counseling.
Even though the survey is now administered completely by internet, HRBS response rates remain a continuing concern. Research has shown that incentives can increase response rates. DoD policy permits federal contractors to compensate service members, who are considered federal employees, for survey participation. The next iteration of the HRBS should explore the use of targeted incentives to increase participation among groups with low response rates.
Though the 2018 HRBS took less time to complete than the 2015 version, it was still a lengthy survey that can become tedious for respondents, especially if they have recently answered similar items in other surveys. DoD might consider what overlap there is between the HRBS and other data it already collects. For example, some of the content in the Periodic Health Assessment (PHA) overlaps with HRBS topics. DoD should consider whether this duplication is necessary, perhaps by first exploring whether the PHA and the confidential HRBS differ.
An alternative approach would involve the use of modules. Modules might, for example, focus on tobacco use or musculoskeletal injuries. In this approach, not every service member would receive every set of items on the survey but would instead be selected to receive certain modules.
As a supplement to the HRBS, DoD could consider a service member panel to gather information about certain health outcomes and health-related behaviors on a real-time basis. Panels are groups of individuals who agree to participate in a series of surveys for a period of time and are replaced at regular intervals. Panels do require constant maintenance to ensure that they remain representative of the population of interest, and they are not efficient for assessing prevalence of rare outcomes. They could, however, reduce the overall scope of the HRBS and thereby improve its response rates.
HRBS data provide an overview of health outcomes and health-related behaviors across multiple domains affecting force well-being and readiness. The HRBS faces some challenges in the future—decreasing response rates, overlapping content, and competition for resources—but it remains an important source of data for tracking trends, informing policy, and making programmatic decisions.