Health and Wellbeing Cohort Study of Serving and Ex-Serving UK Armed Forces Personnel: Phase 4 Protocol

Introduction This is the fourth phase of a longitudinal cohort study (2022-2023) to investigate the health and wellbeing of UK serving (Regulars and Reservists) and ex-serving personnel (veterans) who served during the era of the Iraq and Afghanistan conflicts. The cohort study was established in 2003 and has collected data over three previous phases including Phase 1 (2004-2006), Phase 2 (2007-2009) and Phase 3 (2014-2016). Methods and analysis Participants are eligible to take part if they completed the King’s Centre for Military Health Research (KCMHR) Health and Wellbeing Cohort Study at Phase 3 (2014-2016) and consented to be recontacted. Participants meeting these criteria will be recruited through email, post, and text message to complete an online or paper questionnaire. The study provides a fourth phase of quantitative longitudinal data on this cohort. Data are being collected between January 2022 and September 2023. Health and wellbeing measures used in Phase 4 include measures used in previous phases that assess common mental disorders (CMD), post-traumatic stress disorder (PTSD) and alcohol misuse. Other areas of interest assess multiple symptom illness, employment, help-seeking, and family relationships. New topics include the impact of the British withdrawal from Afghanistan in 2021, Complex-PTSD (C-PTSD), illicit drug use, gambling, and loneliness. The main analyses will compare mental health status according to deployment experiences and serving status (serving or ex-service) reporting prevalences with 95% Confidence Intervals (CI), and Odds Ratios (ORs) with 95% CI. Analyses will describe the effect size between groups deployed to Iraq and/or Afghanistan or not deployed, and those who are currently in service versus ex-service personnel respectively. Multivariable logistic and multiple linear regression analyses will be conducted to assess various health and wellbeing outcomes and associations with risk and protective factors, adjusting for potential confounders. Ethics and dissemination Ethical approval has been granted by the Ministry of Defence Research Ethics Committee (Ref: 2061/MODREC/21). Participants are provided with information and agree to a series of consent statements before taking part. Data are kept on secure servers and in locked cabinets/offices, with access to personally identifiable information limited. Findings will be disseminated to UK Armed Forces stakeholders and international research institutions through stakeholder meetings, project reports and scientific publications. Strengths and limitations of this study ### Competing Interest Statement MLS, MJ, LH, SF and NM salaries are funded through a grant by the OVA. RL and HB salaries are part funded through a grant by the OVA. AS is a serving Regular member of the British Army, salaried and seconded by the MOD to King's College London. DL is a Reservist in the UK Armed Forces. This work has been undertaken as part of his civilian employment. NG is affiliated to the National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Emergency Preparedness and Response at King's College London in partnership with Public Health England, in collaboration with the University of East Anglia and Newcastle University and is also a trustee with the Faculty and Society of Occupational Medicine. DM is a trustee of the Forces in Mind Trust (unpaid) and is employed as the Head of Research for Combat Stress, a UK Veterans Mental Health Charity. DMacM is employed as joint head of service of the London NHS Veterans Mental Health and Wellbeing Service (Op Courage). SAM Stevelink is supported by the National Institute for Health and Care Research (NIHR) Maudsley Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and funded by the National Institute for Health and Care Research, NIHR Advanced Fellowship, Dr Sharon Stevelink, NIHR300592. The views expressed in this publication are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care. SW is Honorary Civilian Consultant Advisor in Psychiatry for the British Army (unpaid) and is a board member of NHS England. SW is affiliated to the National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Emergency Preparedness and Response at King's College London in partnership with Public Health England, in collaboration with the University of East Anglia and Newcastle University. NTF is a trustee of Help for Heroes - a charity supporting the wellbeing of veterans and their families, and their salary is part grant funded by the MOD. ### Funding Statement This project is being funded by the OVA, Cabinet Office, UK Government (Contract Ref: CCZZ20A88). ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The Ministry of Defence Research Ethics Committee gave ethical approval for this work (Ref: 2061/MODREC/21). I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes Data are available upon reasonable request. Data will be processed in accordance with the General Data Protection Regulation (GDPR) and the Data Protection Act 2018. We will not make any record-level data publicly accessible because we need to protect the confidentiality and security of the individual cohort members. You are welcome to contact us with proposals for collaborative research, which the investigators will consider on a case-by-case basis, and which will only occur as part of a legal collaborative agreement and after the collaborator has put in place the relevant research ethics, data protection and data access approvals.