The health and wellbeing needs of veterans: a rapid review

Background For the majority of serving members, life in the military has a positive effect on wellbeing. However, the type, intensity and duration of service, along with the transition from fulltime military to civilian life, may have a negative effect on veterans’ wellbeing. Such negative consequences, alongside the growing veteran population, indicate the need for greater exploration of veterans’ physical, mental and social wellbeing. Methods The current paper reports on the findings of a rapid review of the literature on the health and wellbeing needs of veterans, commissioned by the Australian Department of Veterans’ Affairs to inform future programs and services. The databases Embase, Medline, Cinahl, PubMed, Web of Science and Cochrane Database were searched for systematic reviews reporting on veterans’ physical, mental and social wellbeing published in English in peer-reviewed journals. Results A total of 21 systematic reviews were included. The reviews reported on a range of mental, physical and social health problems affecting veterans. While there was limited information on prevalence rates of physical, mental and social health problems in veterans compared to civilian populations, the reviews demonstrated the interconnection between these domains and the effect of demographic and military service factors. Conclusions A key finding of the review is the interconnection of the mental, physical, and social health of veterans, highlighting the importance that an integrated approach to veterans’ wellbeing is adopted. It is suggested that understanding key factors, such as demographic factors and factors relating to military service, can support improved service provision for veterans. Electronic supplementary material The online version of this article (10.1186/s12888-017-1547-0) contains supplementary material, which is available to authorized users.


Background
Veterans (defined here as ex-members of the armed forces) are a growing population in Australia, the United Kingdom (UK) and other countries, particularly since the return of veterans from the Iraq and Afghanistan conflicts [1][2][3]. In the United States (US), for example, the Department of Defence estimates that there will be over 200,000 new veterans each year [4]. Serving in the armed forces potentially affects many aspects of a person's life. For the majority of serving members, life in the armed forces has a positive effect on wellbeing [5]. However, some members will leave the armed forces facing health and wellbeing needs related to their military service [6][7][8].
Veterans have been observed to have a lower mortality risk relative to the general population. This has been referred to as the 'healthy soldier effect' , resulting from the high physical health standards of entry into the armed forces [5]. However, more recent research suggests an erosion of the healthy soldier effect in veterans of contemporary conflicts [9]. Bollinger et al. [9] found US veterans of Iraq and Afghanistan had equivalent or higher expected mortality when compared to the general US population. The authors were unable to determine the reasons for this change in mortality, but postulated that it may result from prolonged and repeated deployments, survival from injuries that would have resulted in death in previous conflicts and/or a strong reliance on Guard and Reserve forces.
The healthcare needs of veterans are complex [10,11], related to both their experiences as serving members and also the unique psychosocial issues associated with transitioning to civilian life [12,13]. A number of factors associated with military service may contribute to the development of mental, physical and social health problems in veterans. These include the intensive physical activity associated with military life, lifestyle factors such as cigarette smoking and alcohol consumption, physical trauma, psychological trauma, viruses and exposure to toxic substances [14]. The transition to civilian life itself has also been identified as potentially problematic [12]. In the US, the Washington Post/Kaiser Family Foundation study [13] found that in a sample of 800 veterans, 70% felt that the general community misunderstood their experience. Many felt disconnected from civilian life due to profound differences between civilian and military life.
Within the structured environment of the Australian Defence Force, as in most countries, fulltime members enjoy unrestricted access to health care services that cater to the general wellbeing needs of individuals. Following transition from the defence force, veterans may need to adjust to a new, and less structured, environment, which may not provide them with the same support provided while serving. In 2015 the Australian Department of Veterans' Affairs (DVA) commissioned a rapid review of the literature on the health and wellbeing needs of veterans in order to inform future programs and services. The World Health Organization [15] defines health across three attributes, namely physical, mental and social wellbeing. While a number of studies and reviews of the literature exploring veterans' health have been conducted, no reviews were identified that focus on veterans' wellbeing across all three attributes. Given the complexity of the issues facing the growing number of veterans, we sought to capture the scope of the issues across the attributes of mental, physical and social health by undertaking a rapid review of the literature.

Method
The decision to undertake a rapid review of the literature was based on the needs of the knowledge user (in this case, the DVA) for rapid access to current knowledge on the topic. While rapid reviews are undertaken more quickly than systematic reviews, and limit aspects of the review process (e.g., use of grey literature), they are reported to produce similar conclusions to systematic reviews of the literature [16]. We followed the rapid review process outlined by Khangura et al. [16] in order to develop an 'evidence summary' -an overview of the available evidence about the health and wellbeing needs of veterans. The stages were as follows: (1) Needs assessment; (2) Question development and refinement; (3) Proposal development and approval; (4) Systematic literature search; (5) Screening and selection of studies; (6) Narrative synthesis of included studies; (7) Report production; (8) Ongoing follow-up and dialogue with knowledge users.
The needs assessment began with a proposal by the DVA for an evidence synthesis on the health and wellbeing needs of veterans. Consultations with the DVA were undertaken to further refine the scope of the project and gather information on their needs and interests. The needs assessment then informed the next stage of the process, where the questions were developed and refined. The final questions for the review were: 1. What are the mental, physical and social wellbeing needs of veterans? 2. What are the factors associated with the mental, physical and social wellbeing needs of veterans?
With these questions in mind, a literature search was conducted using an a priori review protocol. Following Khangura et al. [16], the decision was made to draw the information exclusively from evidence reported in systematic reviews. Systematic reviews are considered to be the highest form of evidence available [16], and focussing on systematic reviews allowed the review to be undertaken in a timely manner, reflecting the nature and purpose of a rapid review and the needs of the DVA. The search was further limited to peer-reviewed journal articles published in English.
The following databases and search terms were used: The term 'veteran' was used as the primary population search term because it is the Medical Subject Headings (MeSH) term relating to former members of the armed services. No synonyms (such as 'ex-forces') were used because in a test search these were found to yield high numbers of unrelated results, which is prohibitive in a rapid review. Given that the review was focussed on all aspects of veterans' wellbeing, the decision was made to initially search for all systematic reviews relating to veterans. Had this yielded a prohibitively large number of results then the search would have been further delimited using date limits and, if necessary, adding search terms relating to physical, mental and social wellbeing. The initial search was conducted in July 2015 and updated in September-October 2016.
Inclusion criteria for the review were: systematic review of the literature; includes military veterans who are no longer in active service; explores the physical, mental and/or social health of veterans; published in English; peer reviewed. Exclusion criteria were: non-systematic review; systematic review protocol; does not include veterans; focussed on a health care intervention; published in a language other than English.

Results
The search yielded 386 abstracts, reduced to 320 after removal of duplicates. An abstract screening form was developed for screening against the inclusion and exclusion criteria [17]. The form was piloted with 20 abstracts reviewed by two authors (CO and AV) to ensure that both authors understood the criteria. Each author then reviewed half of the remaining abstracts (150 each) against the screening form. Articles where the reviewers were unsure if they should be included were discussed and consensus reached.
A total of 39 articles were identified for full-text collection and assessed again for eligibility against the selection criteria. Eleven articles were excluded at this stage because they were: a systematic review protocol (n = 2), not a systematic review (n = 1), could not access full text within the timeframe (n = 1), did not include veterans in the study population (n = 2), were focussed on interventions (n = 4) or were focussed on diagnosis and treatment (n = 1). An additional file includes the list of studies excluded at this stage of the review (see Additional File 1). A further three systematic reviews identified from reference lists were collected, leaving a final number of 31 included in the quality review.
Two authors (CO and AV) then reviewed the included articles against the 11-item AMSTAR (A Measurement Tool to Assess Systematic Reviews) tool for measuring the quality of systematic reviews [18]. The AMSTAR tool was developed following a review of available tools and then further developing and updating them. It was chosen for use in this study because it has been tested and found to be a valid and reliable tool for assessing the quality of systematic reviews [19]. While originally developed and validated for systematic reviews of randomised controlled trials, the tool has recently been validated for systematic reviews of non-randomised studies [20].
Following Seo and Kim [21] a score of 0-4 was classified as low quality, 5-8 as moderate quality and 9-11 as high quality. The reviews were of predominantly moderate quality (n = 21; 71%), with no high and ten low quality reviews. The ten low quality reviews (scoring ≤4) were removed (these are listed in Additional File 1), leaving a final number of 21 systematic reviews, published between 2003 and 2016, included in the analysis. Figure 1 summarises the literature search process and outcome and Table 1 summarises the literature included in the rapid review.

Description of the included literature
Five reviews focussed on veterans in general. Other reviews focussed on veterans of particular wars, including the Gulf War (n = 5) and the recent Iraq and Afghanistan conflicts (Operation Enduring Freedom (OEF)/Operation Iraqi Freedom (OIF); n = 6), and veterans from particular countries (US: n = 8). Three reviews focussed on female veterans.
As per Khangura et al.'s [16] rapid review process, a narrative synthesis of the reviews was developed. This involved categorising the reviews into themes. The themes reflect the rapid review questions devised in consultation with the DVA ('What are the mental, physical and social wellbeing needs of veterans?'; 'What are the factors associated with the mental, physical and social wellbeing needs of veterans?'), in addition to the theme 'Interconnection between wellbeing areas'. The themes are described in Table 2.     All of the included systematic reviews were independently reviewed by two authors (CO and SL) and assigned to the identified themes, with disagreements discussed and resolved. The number of reviews categorised into each of the identified themes is summarised in Table 3.
The literature is described below within each identified theme.

Veterans' mental wellbeing
The majority of the articles discussed the mental wellbeing of veterans (n = 17; 81%). Mental health research  Articles reporting an interconnection or association between physical, mental, and/or social wellbeing (i.e., between any two or all three) Factors affecting wellbeing Articles reporting on factors affecting the physical, mental and/or social wellbeing of veterans relating to veterans has a strong focus on PTSD. Wall [22] found rates of PTSD in veteran populations varied between 11% and 79%. Focussing on combat-related PTSD, Xue et al. [23] found the prevalence ranged from 1.09% to 34.84%. Variations in rates are likely due to differences across studies in their design, sampling and measurement [22].
The systematic reviews provided limited information about the prevalence of mental health problems in veterans outside of the experience of PTSD. None of the systematic reviews reported on the prevalence estimates of depression, anxiety, psychotic or other mental health disorders in the general population of veterans, nor compared rates of mental health problems in veterans to rates in civilian populations. They did, however, report on mental wellbeing in relation to deployment status [24] and in association with, and as a risk factor for, physical and social wellbeing, discussed later.

Veterans' physical wellbeing
Fourteen articles discussed the physical wellbeing of veterans (n = 14; 67%). According to one review veterans do display a healthy soldier effect, with veterans' mortality rates being 10% to 25% lower than the general population [25]. The review evaluated the effect of military service on mortality by comparing the mortality of veterans to that of the general (civilian) population using the Standard Mortality Ratio (SMR; used to compare the mortality of the group in question with that of the general population).
Despite the healthy soldier effect, veterans are still at risk of serious injury and illness relating to their military life. However, as with the reviews relating to veterans' mental wellbeing, reviews discussing physical wellbeing provided limited information on prevalence rates in the general population of veterans or comparisons to civilian populations. Rates of particular physical health problems explored in the reviews included TBI, hearing impairment/tinnitus and Hepatitis C Virus.
Three systematic reviews explored TBI, only one of which reported prevalence rates between 4.9% and 41% of US OEF/OIF veterans [22]. The other two reviews did not examine TBI prevalence but did indicate that TBI is associated with a wide range of health problems such as headaches, pain, vestibular outcomes, vision-related outcomes, hearing related outcomes, neurological outcomes and outcomes related to appetite and nausea [26,27].
A review of hearing impairment and tinnitus in veterans of the OEF/OIF conflicts [28] found 16.4%-26.6% of men and 7.3%-13.4% of women were diagnosed with hearing problems. Rates of auditory complaints in some injured OEF/OIF veteran populations were greater than 50%. No information on rates in veterans of other wars was presented.
Finally, one review reported on the prevalence of chronic Hepatitis C Virus in US Department of Veterans Affairs' (VA) health-care users [29]. Based on a descriptive review of the literature, the authors reported approximately 175,000 (3%) VA patients with diagnosed HCV infection and an estimated 45,000 (0.8%) undiagnosed patients. The review did not include a comparison with civilian populations or veterans from other countries. Further information on veterans' physical wellbeing will be discussed in relation to associations with, and risk factors for, mental and social wellbeing.

Veterans' social wellbeing
Ten articles discussed the social wellbeing of veterans (n = 10; 48%). Overall, the literature describes veterans as being at greater risk of substance use/misuse and homelessness than civilians. For example, Lan et al. [30] reported relatively high rates of alcohol use disorders (32% using diagnostic criteria; 10% using administrative criteria) and drug use disorders (20% using diagnostic criteria; 5% using administrative criteria) in US veterans. The observed prevalence was higher than civilians but showed a gradual decline over time. Hoggatt et al. [31] reported rates ranging from 4% to 37% for alcohol misuse and from 7% to 25% for binge drinking in female veterans. There were no clear differences identified in rates between female veterans and civilians.
Three reviews reported on the issue of homelessness in veteran populations [32][33][34]. No information on rates of homelessness in veterans in general were reported, but two studies reported prevalence rates for homelessness in female veterans, with rates ranging from 1% to 2% of all female veterans [32,33]. In addition, female veterans were 2.1-2.5 times as likely as women in the general population to be homeless [32]. Tsai and Rosenheck [34] reported that veterans in general were at greater risk for homelessness than civilian populations, but did not provide prevalence rates for this statement.
In addition to substance abuse/misuse and homelessness, one study reviewed aggressive and violent behaviour in veterans. Pooled estimates of 10% for physical assault and 29% for physical aggression in the last month were reported [35]. No information on rates in civilian populations was included. Further information on veterans' social wellbeing will be discussed in relation to associations with, and risk factors for, mental and physical wellbeing.

Interconnection between wellbeing areas
A key issue identified in the systematic reviews is the interconnection between the three wellbeing areas discussed above. The interconnection between veterans' physical wellbeing, mental wellbeing and social wellbeing was discussed in 14 (67%) reviews. Five reviews reported an interconnection between physical and mental wellbeing, four between mental and social wellbeing, and five between all three areas. The most commonly reported interconnection was related to PTSD. A diagnosis of PTSD was reported to increase veterans' risk of physical health problems [33,36]; substance use/ misuse [30,31]; suicide [36]; homelessness [32,34]; and aggression/ violence [35]. Associations were also reported between PTSD and TBI [26,27], and between PTSD and hearing impairment and tinnitus [28]. Lack of social support, including support from peers, family and spouse/ partner, was also discussed as a risk factor for PTSD [37].
The interconnection between other mental health problems, such as anxiety and depression, and physical wellbeing was also reported [26,27]. For example, veterans with physical impairment were reported to have high rates of PTSD (2-59%), anxiety (16.1-35.5%), depression (9.7-46.4%) and psychological distress (13.4-36%) [38]. Mental health problems were also associated with homelessness [32,34] and substance use/ abuse [33]. In addition, homelessness was associated with physical disability and poor health status [32] and substance use/ misuse [34]. Hoggatt et al. [31] found substance misuse to be associated with higher rates of trauma, psychiatric and medical conditions, and increased mortality and suicide rates. Low social support was also reported as a risk factor for homelessness [34].
More complex interconnections between the various domains were also discussed. For example, Lan et al. [30] found PTSD comorbidity with substance use disorders to be particularly high among veterans with other mental health problems. Wall [22, p.278] reported that there is "some evidence that comorbid PTSD and TBI result in greater reports of postconcussive symptomology than either condition alone". Finally, Godzweig et al. [33] reported an association between trauma (in the form of sexual harassment, abuse and assault) and poorer health status and higher rates of medical and psychiatric conditions in female veterans.

Factors affecting the physical, mental, and/or social wellbeing of veterans
In addition to the reported interconnection between the various attributes of veterans' wellbeing, eleven reviews (57%) reported on the factors affecting the physical, mental and/ or social health of veterans. As the previous section suggests, problems in one or more of these areas are themselves risk factors for problems in other areas.
Other key factors affecting the health and wellbeing of veterans are factors related to veterans' military service and demographic factors.

Factors related to veterans' military service
The most commonly identified factor related to military service was the effect of deployment on veterans' wellbeing. Aspects of deployment included whether or not the veteran was deployed, the number of deployments and the location of deployment. Deployment, in particular multiple deployments, was associated with an increased risk for PTSD and other mental health problems [23,24,33,39,40], hearing impairment/ tinnitus [28], pain [41], multi-symptom conditions [42], and aggressive and violent behaviours [35]. However, McLaughlin et al. [25] found no differences in the healthy soldier effect in deployed compared with non-deployed veterans.
The location of deployment was another factor reported to affect veterans' wellbeing. Deployment to the Gulf War was explored in the three systematic reviews, all three reporting Gulf War veterans to be at greater risk of physical and mental health problems than veterans of other wars. Blore et al. [24] found Gulf War veterans to be more than twice as likely as non-Gulf War veterans to experience depression, dysthymia and chronic dysphoria. In a review comparing pain in Gulf War compared to non-Gulf War veterans [41], a higher proportion of Gulf veterans reported pain at each of the five main sites of pain identified in the review (muscle, joint, chest/ heart, back and abdominal pain), with abdominal pain being most strongly associated with Gulf War deployment. Gulf War deployment was also associated with greater reporting of multi-symptom conditions (chronic fatigue syndrome, multiple chemical sensitivity, CDC-defined chronic multi-symptom illness, fibromyalgia, or symptoms of either fatigue or numbness and tingling) compared to non-Gulf War deployment [42].
The experience of trauma during deployment also affected veterans' health. Exposure to combat reportedly increased veterans' risk of PTSD [23,36], and post deployment physical aggression and violence [35]. Military sexual trauma (sexual assault or harassment) also increased female veterans' risk of PTSD and other psychiatric conditions [33], homelessness [32] and increased numbers of medical conditions [33].
Another important service-based factor discussed in the literature relates to support. Service-based support in the form of unit cohesion and post-deployment support were discussed in two reviews [23,37]. Low unit cohesion and lack of post deployment support were reported as risk factors for PTSD in these reviews.
Finally, military rank and branch were also discussed. Xue et al. [23] found an association between PTSD and non-officer ranks. Theodoroff et al. [28] reported an association between hearing impairment/ tinnitus and military branch (e.g., army, navy, air force) and the unit within the branch.

Demographic factors
In addition to service-based factors, demographic factors were also reported to affect the health and wellbeing of veterans. Gender was the most commonly discussed factor, reported in five reviews. For example, the reviews identified that female veterans experienced more mental health problems than men, including panic disorder, depression and other anxiety disorders [33], and PTSD [23,33].
In addition, Byrne et al. [32] reported that there is some evidence that female veterans have a higher risk of homelessness than male veterans. Female veterans who were homeless were also characteristically different from males (younger, with higher levels of unemployment, lower rates of drug or alcohol dependence or abuse, and higher rates of mental health problems). By contrast, female veterans were reported to be at lower risk than male veterans for substance use/ misuse [31] and hearing problems [28].
The impact of age on veterans' health was reported in four reviews. Older age was associated with homelessness in female veterans [32], with Tsai and Rosenheck [34] also reporting that veterans who were homeless were generally older than other adults who were homeless. Younger age was associated with an increased risk of being diagnosed with a psychiatric disorder in female veterans [33]. In addition age was associated with hearing loss and tinnitus ( [28]; although the review did not report on the direction of the association).
Factors reported less frequently included unemployment/ low income, education and ethnicity. Ethnicity was discussed in two reviews; Arriola & Rozelle [26] found high rates of physical, cognitive, behavioral and emotional symptoms in Hispanic veterans with TBI, and Xue et al. [23] reported ethnic minority status to be associated with PTSD. Being unemployed or on a low income increased the risk of homelessness [32,34]. Finally, Xue et al. [23] found low education to be associated with PTSD.

Discussion
In this rapid review of the literature we have explored the wellbeing needs of veterans within the context of their broader mental, physical and social determinants of health. We examined the findings of 21 moderate quality systematic reviews exploring a wide range of issues. High levels of effective general functioning are reported in studies of veteran populations [63,64]. However, as this rapid review demonstrates, a large number of veterans still experience mental, physical and social health problems related to life after the military, with the associated health care costs that come with this. The current review sought to better understand these needs to provide policy makers, service providers and healthcare professionals with an understanding of veterans' wellbeing encompassing all three attributes of wellbeing [15]. Understanding and recognising the interconnectedness across these attributes may facilitate the early identification and improved management of veterans' health.
The mental health literature demonstrates high rates of PTSD in veteran populations. The literature furthermore highlights the worrying interconnection between PTSD and the increased risks for veterans of physical health problems, substance use/ misuse, suicide, homelessness and aggression/ violence. However, the literature fails to adequately report on prevalence rates of mental health problems other than PTSD, and in particular to compare these rates to the general (civilian) population. Veterans clearly experience a range of mental health problems in addition to PTSD, particularly anxiety and depression, and comorbidy of mental health problems. However, as Blore et al. [61, p.1577] noted in their review of depression in Gulf War veterans, "[t]he reality is that depression is often ignored in studies of veterans' mental health, which tend to focus on PTSD". The same can be said for anxiety and other mental health problems, and more systematic reviews focussing on these issues in the general population of veterans are needed, along with comparisons of rates between veteran and civilian populations.
When considering the physical wellbeing of veterans, McLaughlin et al.'s [25] review supports the notion of a healthy soldier effect (although a review of more recent research is needed, given reports of a reduced healthy soldier effect in veterans of recent conflicts [9]). However, the literature also demonstrates a range of physical health problems directly related to veterans' previous military role, particularly traumatic brain injury, hearing impairment, tinnitus, pain and multi-symptom conditions. Veterans' physical health also interconnects with their mental and social wellbeing, such as the increased prevalence of mental health disorders in veterans with a physical impairment [38] and the association of homelessness with physical disability and poor health status [32] and substance use [34]. While other studies have reported that veterans experience low levels of general health and health related quality of life [43][44][45] and increased risk of physical disability and chronic illness [46][47][48][49], no systematic reviews focussing on these issues in veterans were identified.
The literature describing veterans' social health furthermore articulates the potential difficulties of transitioning to civilian life post-military service [13,50]. Problems reported in the literature included substance use/ misuse, homelessness, inadequate social support, issues relating to financial wellbeing and aggressive behaviours. These problems point to difficulties in adjusting to the less stable social variables that veterans might encounter when leaving the structured military environment. Of particular importance is the interconnection of veterans' social health, principally homelessness and substance use/ misuse, with veterans' mental and physical wellbeing. The literature on homelessness in veteran populations demonstrates the compounding of risk when several issues (in particular substance misuse disorders, mental illness and low income) are present [34].
When considering the literature describing the various factors associated with veterans' mental, physical and social wellbeing, demographic factors in particular could help identify those veterans who might be at greater risk (though the question of why is still open for more research). There has been an increase in studies focussing on the issues facing female veterans, reflecting increasing numbers of women in the military and engaged in conflicts [51]. Issues of particular concern for female veterans include reported higher rates of PTSD and military sexual trauma than male veterans, and greater effects of these issues on women's mental, physical and social wellbeing. The studies of service type add a further layer of understanding to the scale and complexity of risk by examining the influence of the actual soldier role and experience.
When serving in the military, individuals are provided with structured, comprehensive health care; care that is often no longer available after transitioning to civilian life, unless the veteran has been assessed as having ongoing healthcare needs related to their military service. Research with Vietnam veterans, for example, has shown that many do not have their healthcare needs recognised until several years after their return to civilian life, for a range of reasons including delays in help-seeking and delayed onset (for example, PTSD) [52]. The results of this rapid review, and in particular the identification of the interconnection between veterans' physical, mental, and social wellbeing, suggests a need for the provision of veterans' health care that is streamlined and integrated across these areas. This is likely important for prevention and early identification of veterans at risk of developing problems in any or all of these three areas.
Veterans' reported reluctance to seek help, particularly for mental health problems [53,54], furthermore highlights the importance of policy makers, service providers and health care professionals having a structured process by which they can comprehensively assess and support the health care needs of this unique population. For example, in a recent paper by Reed et al. [55], the authors introduced the Australian Defence Force Post-discharge GP Health Assessment. This structured assessment aims to promote early detection and intervention across the mental, physical and social health domains in veteran populations, with the aim of helping former members of the defence force to access primary health care after transitioning to civilian life. Further research on the impact of this type of assessment is needed [55].

Limitations
Being a rapid review of the literature, this paper is by definition limited by its short timeframe [16]. However, it has included a large number of systematic reviews covering a broad range of veterans' physical, mental and social care needs. The systematic reviews were of a moderate quality according to the AMSTAR ratings, with no high quality systematic reviews identified. This could relate to the quality of the studies themselves, or to the application of the AMSTAR assessment tool, designed for systematic reviews of randomised controlled trails, to reviews of both randomised and non-randomised studies. While the tool has been validated for application to these studies, showing good psychometric properties [20], the items on the tool most responsible for lower scores (no a priori design provided, failure to include potential sources of support for both the systematic review and for each of the included studies, and failure to include a list of excluded studies) are perhaps less commonly included in reviews of non-randomised studies.

Conclusions
In this rapid review we have described the broad range of veterans' mental, physical and social health care needs, in addition to the factors that affect the health and wellbeing of veterans. A key finding of the review is the interconnection between veterans' physical, mental and social wellbeing. The findings therefore support the value of integrating veterans' health care across the domains of physical, mental and social health in order to ensure that members of the military are taken care of both inside and outside of the uniform.