A Study of the Health of Australia's Vietnam Veteran
Community
Volume II Female Vietnam Veterans Survey and Community
Comparison Outcomes
[Drawn directly from a final draft
of the Report, prepared by DVA. Any errors are those introduced
by my transcription - Clive Mitchell-Taylor A direct
cross-reference to the final document will be provided in place
of this extract, when and if the information is posted to the
Internet by DVA. DVA copyright applies to this extract as it does
to the Report itself.]
This study of the health and
morbidity of Vietnam veterans was established by the Commonwealth
Government following Ex-Service Organisation (ESO) representation
and the study by the Department of Veterans' Affairs, Mortality
of Vietnam Veterans: The Veteran Cohort Study, released in May
1997. Two prior morbidity studies of male Vietnam veterans exist,
one undertaken in 1983 titled Australian Veterans Health Studies
and the other The Australian Vietnam Veterans Health Study, by
O'Toole et al, published in 1996.
Volume I of the study, the male
survey results, was released in April 1998. This report is Volume
II of the findings and presents the results of the health survey
of female Vietnam veterans. A final report covering the results
of validation arising from the recommendations contained in
Volume I, will be published as Volume III.
It should be noted that, of the
female veterans, only those who served in Vietnam in the Army,
Air Force, Navy and certain philanthropic organisations are
eligible for benefits under the Veterans' Entitlements Act 1986
(VEA). As this study was undertaken by the Repatriation
Commission, its findings relate principally to that Act.
Non-military female veterans may be covered for conditions
incurred whilst in employment in Vietnam under other
arrangements.
The Vietnam veterans morbidity
study covers both male and female veterans. The aims are to:
A Study Advisory Committee was
established in April 1996 to oversee the conduct of all aspects
of the study.
The Advisory Committee was chaired
by the Repatriation Commissioner. In addition to medical
officers, senior officers and supporting staff from DVA, its
membership comprised representatives from each of. the Returned
and Services League of Australia (RSL), Vietnam Veterans'
Association of Australia (VVAA), and the Australian Veterans And
Defence Services Council (AVADSC).
ACNielsen Research Pty Ltd was
engaged to conduct the survey of veterans and representatives of
ACNielsen reported to the Advisory Committee. Professionals in
statistical methodology and epidemiology were engaged to provide
data and professional advice to the Committee.
For the purpose of the study, the
Advisory Committee accepted the definition of Vietnam veterans
contained in the Nominal Roll of Vietnam Veterans:
All members of the
Australian Defence Force (ADF) and the Citizen Military Forces
(CMF) who landed in Vietnam or entered Vietnamese waters
including those who were seconded to the Army of the Republic of
Vietnam (ARVN), the United States Air Force (USAF), the United
States Navy (USN) and any other allied service, all members of
Australian Army Training Teams Vietnam, all members, male and
female, of civilian medical and surgical teams, all members of
philanthropic organisations, all members of the Australian Forces
Overseas Fund and all official entertainers and war
correspondents who saw service in Vietnam during the period
between 23 May 1962 and 1 July 1973
When considering design options
for the male and female study, the Advisory Committee decided to
survey all Vietnam veterans who could be located. The committee
believed that it was important for all veterans to have the
opportunity to participate in the study and ESO advice was that
this was the expectation of the veteran community. Further, it
was believed that a survey of the entire population of veterans
had the benefit of allowing for the identification of rare
conditions.
The decision to survey all
locatable veterans dictated that the study instrument would be a
mailed-out, self-reporting questionnaire. Three distinct
questionnaires were developed: male veteran, female veteran, and
widow(er)s/divorced and separated partner(s).
The Advisory Committee agreed that
the study should be conducted in three phases, with the need for
Phases 2 and 3 dependent upon the outcome of Phase 1. The agreed
Phases were:
Phase 1 - A mailed survey of
all surviving Vietnam veterans.
Phase 2 - Analysis of Phase
1, production of a report on the outcome of Phase 1, and decision
on potential Phase 3 studies.
Phase 3 - Follow-on
investigations if required, including the possibility of
interview of a representative sample of Vietnam veterans.
The major limitation of the survey
of the health of female Vietnam veterans was that only half of
the potential survey population could be located. This resulted
in an apparent under-representation of married women due to the
difficulty in locating those whose names had changed since
service in Vietnam.
The small cohort size of female
Vietnam veterans (484 versus 59,520 male veterans) combined with
the incomplete sample (278 female veterans located) makes it
difficult to reach definitive conclusions in regards to this
study.
Of the women who were contacted
and defined themselves as Vietnam veterans (that is, were in
scope of the study), 8 1 % returned completed questionnaires.
The return rates of completed
questionnaires were high for ex-service personnel: Army 46/47 Air
Force 72/106. This makes the data subset from these groups a
potentially valuable tool for further examination of the health
of these veterans, as it is less subject to the sampling problems
that applied to the remainder of the female Vietnam veteran
cohort. There were no Navy female veterans.
Address lists compiled by the
Department of Veterans' Affairs and Ex-Service Organisations were
used as a means of locating female Vietnam veterans for the
purposes of this study.
Of the 484 female Vietnam veterans
on the Nominal Roll 278 were located. A copy of the relevant
questionnaire was posted to each female Vietnam veteran whose
address was obtained.
From the 278 questionnaires that
were posted, 223 completed questionnaires were returned. There
were three respondents who wrote in to say that they were not
Vietnam veterans. These responses were classified as being out of
scope of the survey. Thus the response rate for the female
Vietnam veterans survey was 8 1 % (calculated from 223 responses
out of a possible 275).
Where practical, community data
were obtained on the prevalence of the conditions surveyed in the
questionnaire. This enabled comparisons to be made between the
number of veterans reporting each condition and the expected
prevalence in a representative community sample.
A number of difficulties were
encountered when comparing data from other community surveys with
the data from the female veterans survey.
The first was that of relevance of
community data. The most relevant comparisons would be those from
surveys where the definition of a condition was compatible with
that used in the veterans survey, and where a match in the age of
participants, their socio-economic status (including occupation)
and the time period under consideration could be made. These
criteria were generally not able to be fully satisfied.
Another difficulty was that
Australian data were not always available. When Australian data
were not found, international comparisons have been offered where
possible, or it is noted that comparative community data are
simply not available.
The questions asked in other
community health surveys were often not directly comparable with
questions from the female veterans questionnaire. The veteran
survey results show the overall prevalence of conditions
post-Vietnam, including an unknown proportion which would have
been cured since the time of diagnosis. Community surveys
typically do not seek such a long-term prevalence, and instead
record a present time 'snapshot' of prevalence, or the prevalence
over a specific interval, often 12 months. Where possible,
allowances have been made for this by selecting comparable data,
by calculations (for example by age adjustment or adjusting
incidence to prevalence), or in the interpretation offered.
Another point of contention is
that some of the medical conditions in the survey can be defined
or measured in a number of different ways. The varying
definitions used in the reference surveys and the veterans health
study make direct comparisons of some of the results problematic.
Care has been taken to ensure that the comparisons presented are
based on compatible definitions: however in cases where the most
appropriate definition is uncertain, a number of alternative
comparisons have been listed. Inconsistency of definition may
lead to biases that are unable to. be quantified, but allowance
for this has been made where appropriate.
It should be noted that the US
Department of Veterans Affairs has commissioned a study into the
health of US female Vietnam Veterans. The US study is to be
released in 1999. Once released, the results of the US study will
be considered by DVA. This may lead to additional research into
the health of Australian female Vietnam Veterans.
The findings from the female
survey, summarised below are the result of initial analysis.
Locations were found for only 57%
of the total female Vietnam veteran cohort. There is also an
apparent sample bias towards single rather than married/defacto
female Vietnam veterans. As health status is linked to marital
status, this has had an unknown but probably major impact on the
study results. The relatively small size of the total female
veteran cohort further amplifies the uncertainties of
interpretation introduced by this possible bias.
The results of this study are
drawn from the 223 completed questionnaires that were received
from participants. This number represents only 46% of the female
Vietnam veterans recorded on the Nominal Roll.
Developing a register of female
Vietnam veterans would enable the profile for the cohort to be
expanded and enhance any further study of this group.
When asked to assess their health
as excellent, very good, good, fair or poor (Question E I of the
survey) 12% of veterans who responded reported their health as
excellent, 27% as very good, 37% as good, 19% as fair, and 5% as
poor.
The majority of female veteran
respondents thus reported that their health was good or very
good. However, community comparison indicates that the female
veterans are less likely than other Australian women of the same
age to classify their overall health as excellent or very good,
and more likely to report their health as being good or fair. The
female respondents and the community comparison group were
equally likely to classify their health as poor (5% in both
cases).
Although the female respondents'
rating of their health falls below that of their community
counterparts, their view of their health is more positive than
that of male veterans. Female veterans were twice as likely as
male veterans to report their health as excellent or very good,
and three times less likely to report their health as poor.
The response to Question E1
reflects the trend of a number of specific conditions reported in
excess by female veterans in Part A of the questionnaire.
Recognising the sampling
limitations of the survey, the conditions for which there is
apparent statistically significant excess in female veterans in
comparison to the general community are:
An excess level is defined as
statistically in excess of what may be expected in a community
sample.
These conditions are presented in
alphabetical order. Where appropriate, provisional judgements are
made about the public health importance of the differences
between the veteran and comparison populations in the commentary
of Section 7 of the Female Vietnam Veterans Morbidity Study
report.
It is a reasonable hypothesis that
some aspect of the association between the veterans and their
service in Vietnam may have contributed to these conditions.
However, because of the small sample size and potential sample
bias in the survey group, none of these conditions (with the
probable exception of malaria) should be considered to have a
properly established association with war service. It is also
generally not possible to distinguish between factors that would
have led women to be recruited for service, and environmental or
other possible causes of disease that these women may have
experienced while in, or since leaving, Vietnam.
Notwithstanding, the overall
outcome lends some weight to the hypothesis that the general
health of female Vietnam veterans is worse than that of other
Australian women of comparable age. It should be noted that the
degree of severity of this finding does not seem as marked as in
male veterans.
It is noted that the prevalence of
Post Traumatic Stress Disorder (PTSD) does not appear to be
excessive in female veterans. However, other psychiatric
conditions (panic attacks, depression) appear to be significantly
in excess. This result supports the recommendation flowing from
the male survey results that there should be a broader diagnostic
and treatment focus on mental health conditions in veterans,
notwithstanding the incidence of PTSD
Additionally, in regard to the
hypothesis that the prevalence of cancer is greater in Vietnam
veterans than in other Australians of comparable age, the
findings of this study appear consistent with this hypothesis for
a cumulative total of all the cancers investigated. It should be
noted that the findings are not as pronounced as those for the
male survey.
A particular hypothesis that this
study set out to investigate is that the cumulative prevalence of
hysterectomy amongst female veterans is greater than in a
comparable age cohort within the general female population of
Australia. The survey results indicate that the cumulative
prevalence of hysterectomy appears to be comparable to that for
Australian women in a similar age group.
Although there are acknowledged
limitations associated with the reliability of self reported
surveys, it is not recommended that validation of the responses
made by female veterans be undertaken. Treatment, compensation
and counselling, if required, for the conditions surveyed are
already available under the VEA to eligible veterans following
diagnosis and acceptance of a claim.
The survey results can thus be
accepted as indicative without the need for further research. It
is recommended that veterans reporting suffering the conditions
should be urged to seek acceptance of the condition for treatment
and compensation purposes, if they have not already done so.
It is also recommended that the
Department of Veterans' Affairs uses the responses to Parts A and
E as a guide in planning the coverage of treatment and
counselling services, and of preventative programs for female
Vietnam veterans.
The male study reports that the
prevalences of Multiple Sclerosis and cancers are significantly
higher than in a comparable community sample. Those results are
being validated. Results for these conditions in the female study
do not show an excess. Nevertheless, it is recommended that the
cases reported in the female study be considered alongside the
male validation study results.
For veterans entitled under the
VEA, compensation is governed by Statements of Principles (SOPS)
prepared for individual medical conditions by the Repatriation
Medical Authority (RMA). It is recommended that the findings of
the survey be referred to the RMA for their consideration.
It is further recommended that the
outcomes of this survey be forwarded to the Australian Defence
Force for use in refinement of preventative measures. Similarly,
it is recommended that the findings be referred to Comcare for
consideration.
Part B of the survey sought to
ascertain the marital status of veterans. Responses to this part
show that the numbers of married, separated, divorced and widowed
female veterans are lower than would be expected in a similar
group of Australian women, while the number of female veterans
who never married greatly exceeds community expectations.
This finding could be the result
of the inability to locate about half of the female Vietnam
veterans.
As it stands, the finding tends to
support a hypothesis that the marital-status profile of female
veterans is different to that of the general population. The
primary difference lies in the number who never married.
In this part, 13% of respondents
reported that service in Vietnam, or health problems arising as a
consequence of their service in Vietnam, have had a serious
adverse effect on current or past partners. Fourteen per cent
(14%) reported physical or psychological health problems in their
partners which may be related to the veteran's Vietnam service.
Stress (14%) anxiety (12%) and insomnia/sleep disturbance (9%)
were the most commonly cited conditions. Thirteen per cent (13 %)
of respondents reporting these conditions indicated that
treatment for their partner had been required.
Part C of the questionnaire sought
to ascertain the effect of the health of veterans on the health
of their partners.
Community comparisons are not
available for these data. The responses themselves, lend some
support to the hypothesis that the health status of the veteran
has an effect on the health status of the immediate family.
Again, these findings may have been affected by sample bias.
These findings support the
recommendation made in the male veterans report that the level of
resources available for counselling on mental health conditions
experienced by veterans and their families be reviewed for
adequacy.
Seventeen per cent (17%) of female
veterans reported trying for more than twelve months without
success to conceive a child. Twenty-six per cent (26%) reported a
miscarriage, 9% a termination, 3% a child that was stillborn, 1 %
an ectopic pregnancy, and 4 1 % a birth with labour
complications.
Reliable estimates of infertility,
miscarriage and stillbirth rates are difficult to obtain from
community data. Notwithstanding, all conditions surveyed appeared
to be within or under the expected community rates with the
potential exception of stillbirth.
In relation to the number of
children, female veterans reported a total of 215 births since
the first day of service in Vietnam. This is approximately half
the number that might have been expected based on the Australian
average. This result, and others concerning fertility and adverse
pregnancy outcomes, may have been affected by the number
reporting never having married, and by sample bias.
One per cent (1 %) of veterans
reported that at least one of their children had suffered an eye
condition not correctable by spectacles, and 6% reported children
with long-term hearing or ear problems. Twenty-eight per cent
(28%) indicated that a child had suffered a major illness. In
regard to mental health issues, 7% of veterans reported that they
had one or more children diagnosed with a psychiatric problem and
23% reported having one or more children with an anxiety
disorder.
Definitional problems precluded
precise comparison with community data for these conditions, but
it was concluded that it was unlikely that any of these
conditions were occurring excessively in the children of female
Vietnam veterans.
Responses were sought from
veterans in relation to diagnoses of spina bifida, anencephaly,
Down's syndrome, tracheo-oesophageal fistula, cleft lip or
palate, absent or extra body parts, and other abnormalities in
their children.
Responses indicated one instance
each of Down's syndrome, tracheo-oesophageal fistula and absent
body parts, and two instances of extra body parts. Fifteen
instances of other abnormalities were reported.
These responses neither confirm
nor refute an increased level of genetic abnormality in the
children of Vietnam veterans. The sample size of the survey was
too small to give the statistical power needed to enable valid
comparison of the rates of these relatively rare conditions.
Responses to the male survey
indicated an increased incidence of such defects, and the male
report recommended that the reported rates be validated as c.
matter of urgency. The validation* results will be contained in
Volume Ill of the results of the Vietnam Veterans Morbidity
Study. For reasons stated below, the results of the female study
will not be validated. However, it is recommended that the
findings of the female veterans study be considered in
conjunction with the Volume Ill results when developing potential
policy action.
Responses were sought to the
incidence of three specific forms of cancer in female veterans'
children: leukaemia, Wilms' tumour and cancer of the nervous
system. An opportunity was also provided to report any other
forms of cancer the children had.
Two cancers were reported: one
case of Wilm's tumour, and one of melanoma.
The statistical power of the
survey was insufficient to either confirm or refute the
hypothesis of an increased prevalence of cancer in the children
of female Vietnam veterans.
Responses to the male survey
indicated an increased incidence of cancers in children, and the
male report recommended that the reported rates be validated as a
matter of urgency. The validation results will be contained in
Volume 111 of the results of the Vietnam Veterans Morbidity
Study. The results of the female study will not be validated.
However, it is recommended that the findings of the female
veterans study be considered in conjunction with the Volume Ill
results when developing potential policy action.
Veterans were asked whether any of
their children had died from illness, suicide, accident or any
other reason. Four deaths from illness, and one from
accident/other reason were reported. No deaths from suicide were
reported.
Community comparison of these
responses is not possible. The exact number of children and their
age distribution for the purpose of making a comparison is
unknown. The reason is that the question sought responses in
relation to all of the veterans' children, but the survey only
requested that veterans enumerate the number of children born
after service in Vietnam. The total number of children born to
the veterans, and the number born prior to Vietnam service, is
unknown. The survey also did not seek the age of the children.
However, at face value, reported instances of deaths do not seem
excessive.
Responses to the male survey
indicated an increased incidence of suicide and accidental death
in the children of male Vietnam veterans. The male report
recommended that the reported rates be validated as a matter of
urgency. The validation results will be contained in Volume Ill
of the results of the Vietnam Veterans Morbidity Study. The
results of the female study will not be validated. However, it is
recommended that the findings of the female veterans study be
considered in conjunction with the Volume Ill results when
developing potential policy action.
Consideration was given as to
whether validation should occur as a result of the female
veterans survey. On balance, a decision was made that validation
would not be recommended.
The decision was taken in the
light of the following points:
As a result of the outcomes of the female veterans survey the
following recommendations are made:
For Female Vietnam Veterans with Entitlement Under the
VEA
- It is recommended that the results in this report be
accepted by DVA as indicative of the health status of
female Vietnam veterans.
- It is recommended that DVA uses the responses to Parts A
and E of the survey as a guide in planning the coverage
of treatment and counselling services, and of
preventive programs.'
- It is recommended that the level of resources available
for counselling veterans and their families
experiencing mental health conditions be reviewed for
adequacy.
- It is recommended that veterans reporting the conditions
surveyed in Part A of the questionnaire be urged to
submit a claim under the VEA for these conditions if
they have not already done so.
- It is recommended that while recognising the importance
of PTS1), there be a broader diagnostic and treatment
focus on other mental health conditions common in
veterans.
- No validation of survey findings is recommended.
However, it is recommended that the results obtained
for the following conditions be considered in
conjunction with the male validation study as
additional data:
- Multiple Sclerosis;
- All Cancers (with the exception of non-melanotic skin
cancers);
- Children's Conditions:
- Down's Syndrome;
- Tracheo-oesophageal Fistula;
- Absent Body Parts;
- Extra Body Parts;
- Wilm's Tumour; and
- Accidental Death.
- It is recommended that the findings of the survey be
referred to the RMA for their consideration,
particularly in respect to:
- Hydatidiform Mole;
- Asthma;
- Eczema and Dermatitis; and
- Hepatitis.
General Recommendations
- It is recommended that DVA develop a register of
information, including mailing addresses for living
female Vietnam veterans and causes of death for
deceased female Vietnam veterans. This register would
provide a sound basis for any further studies into the
health of Australian female Vietnam veterans.
- It is recommended that DVA consider the feasibility of
undertaking further research in this area in light of
the soon to be released US study into the health of
female Vietnam veterans.
- It is recommended that the findings of the survey be
drawn to the attention of the Australian Defence Force
for use in the refinement of preventative measures.
- It is recommended that the findings of the survey be
drawn to the attention of the organisations responsible
for the compensation support of non-military veterans.
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