Stigma doesn’t discriminate: physical and mental health and stigma in Canadian military personnel and Canadian civilians

Illness-related stigma has been identified as an important public health concern [1, 2], with many documented negative effects including anxiety [3], stress [4], depression [5], reduced self-esteem/self-efficacy [6], reduced or delayed care-seeking [7, 8], and lowered adherence to treatment [9].

There are multiple ways to conceptualize stigma. Link and Phelan [10] argue that, due to the complexities of stigma as a construct, it is important to allow variation as long as a clear definition of stigma is provided by the researchers. In this research, we are drawing on the multi-layered definition of stigma outlined by Scambler and Hopkins [11] who suggest there are two facets of stigma: enacted stigma and felt stigma. Whereas enacted stigma refers to the perceived act of discrimination against individuals with a stigmatizing condition, felt stigma refers to the individual’s embarrassment and shame associated with the condition. This conceptualization allows for a multifaceted assessment of stigma by including both behaviours towards the individual, and feelings of the individual. Both mental and physical health problems can lead to enacted or felt stigma, though mental disorder-related stigma has been a particular focus recently, with major organizations such as the World Health Organization identifying stigma reduction as a key target for population mental health strategies [12].

The associations between felt and enacted stigma and mental health issues have been documented in many domains, including access to health care, housing, intimate relationships, and employment [13–15]. Findings have consistently shown that those who have mental health conditions are at increased risk of discrimination and negative feelings [16–18]. Findings have also similarly linked physical health problems (e.g., epilepsy, HIV, obesity) with stigma, where those with physical health conditions have a higher likelihood of experiencing discrimination and embarrassment [19–22]. Health-related stigma is strongly related to one’s social environment and, for employed individuals, the workplace is a crucial part of one’s social environment. In the workplace health-related stigma is associated with a lack of career advancement, poor quality of work, as well as diminished employability, and increased likelihood of being unemployed or under-employed [23, 24].

Military organizations are large employers, and their personnel fulfill crucial functions in the protection of national interests and promotion of international peace and security. The mental health of military personnel has attracted attention over the past 15 years, as a result of the deployment of millions of Western military personnel in support of the conflicts in Southwest Asia [25] as well as peacekeeping missions in Africa, Asia, and South America [26]. The impact of such deployments on mental health have been substantial. Not only are mental health issues more prevalent in the military than in the general public [27–31], but a recent study found the prevalence rates of mental health issues in the Canadian Armed Forces (CAF) have increased over the past 10 years, with significant increases in post-traumatic stress disorder (PTSD), general anxiety disorder, and panic disorder [32]. Being in the CAF also has a significant impact on a member’s physical health. Indeed, those in the military have a higher risk of experiencing training- or deployment-related injuries or illnesses, such as musculoskeletal injuries [33], traumatic brain injury [34, 35], or tinnitus/hearing loss [36].

A disproportionate burden of mental disorder-related stigma has been posited in military personnel [37]. The same factors that explain why a disproportionate risk of mental-health stigma may exist also relate to why there may be a disproportionate risk of physical-health stigma. First, the armed forces have strict fitness and health standards. Those with restrictions related to physical or mental health may be deemed unfit for promotion or continued service, or unable to go on course or deploy [38–41]. This impact to their professional development may be perceived as discriminatory by the person in question. Additionally, in the CAF, both physical and mental health care is provided by the employer, which means there is an increased risk of having one’s superiors find out about one’s health status (e.g., if an individual needs to be sent home for a medical reason while on training or deployed). Confidentiality issues appear to be a top concern for members as a recent qualitative study examining barriers to care among military health care providers found concerns about confidentiality was one of the top system-level barriers [42]. Also, there is a general focus on being strong and tough within the military [43], which may enhance negative opinions of those who have a physical or mental health issue and are no longer able to do the same tasks they were once able to do. Last, due to the high physical and mental demands of the job and the strict fitness and health standards, physical and mental health issues have a substantial impact on job performance [44]. This may be problematic, as a study by McLaughlin, Bell, and Stringer [45] found work impact was the only significant predictor among a set of variables (e.g., onset controllability, social impact of disability) to consistently predict stigma and acceptance. That is, the more one’s health issue impacted one’s work, the more stigma and less acceptance were reported by colleagues.

Empirical evidence of the excess burden of stigma in military personnel relative to civilians had been limited until the recent publication of findings showing CAF military personnel were 1.7 times more likely to have mental health-related stigma relative to a comparable civilian sample, even after careful adjustment for the important differences in sociodemographic and need-related factors between the populations [37]. Additionally, CAF personnel also reported perceived stigma had more negatively affected their workplace experience compared to civilians. However, the analyses by Weeks and colleagues [37] did not distinguish between felt and enacted stigma and only looked at stigma related to mental health problems (and not physical health problems).

Research has yet to examine whether these same group differences emerge when assessing physical health-related stigma. In fact, very little research has been conducted to examine the impact of physical health issues on stigma in military populations. One study of United States (U.S.) soldiers returning from Bosnia suggested that many soldiers believed admitting a physical health issue would result in stigma, with 43% of the soldiers agreeing that admitting a physical issue would harm their career and 22% believing that admitting a physical health issue would cause their friends to distance themselves [46]. To our knowledge, no studies have explicitly explored differences between military personnel and civilians on physical health-related stigma. This is important as destigmatization messages in military populations have sought to reframe mental health problems as analogous to physical injuries, for example using the term operational stress injury [47]. Given this, it is important to understand whether a relationship between physical health and stigma exists in the military and whether the association is stronger for those in the military compared to civilians.

Given that both mental and physical health issues are related to the experience of enacted and felt stigma, there may also be an additive effects, should an individual experience both poor mental health and poor physical health. However, very little research to date has looked at the potential interaction between physical and mental health in relation to the experience of stigma and no research has looked at this potential interaction by population. One study in the general population found that perceived stigma was higher for those who had both a physical illness and a psychiatric illness compared to those who only had a psychiatric illness, offering some support for the supposition that physical health may contribute incrementally (in additive or interactive ways) to the prediction of stigma [48].

Adjusted predicted probabilities were calculated to explore the interaction between military/civilian status and physical health. Among both groups, as physical health increased, the likelihood of stigma decreased, but the strength of this relationship significantly differed by military/civilian status, B = −.05, SE = .01, p < .001, 95% C.I. [−.07; −.03]. The negative link between physical health and enacted stigma was much stronger for military personnel, B = −.07, SE = .01, p < .001, 95% C.I. [−.09; −.05], than civilians, B = −.02, SE = .01, p = .01, 95% C.I. [−.03; −.004]. Absolute adjusted risk differences were calculated at each level of health, revealing differences between the two populations were largest at poor physical health, decreasing as physical health improved until no significant difference was observed at excellent health (see Fig. 1).

Next, we tested whether the same models predicted felt stigma. Only physical health was a significant predictor of felt stigma, where better physical health was related to a lower likelihood of felt stigma (OR = 0.65, 95% C.I. [.42; .98]). Again, the interaction between mental health and population, as well as the interaction between mental health and physical health,¹ were not significant. Additionally, the three-way interaction between population, mental health, and physical health was also not significant (see Table 3).

This study assessed whether there was an association between physical health and the experience of enacted and felt stigma and whether this association was stronger among military personnel than civilians. The study also attempted to examine the relative impact of mental health and physical health on enacted and felt stigma. Last, the study explored the potential interaction between population (military versus civilians), physical health, and mental health in predicting enacted and felt stigma.

First, when assessing the association between physical health and stigma, the results showed a link between physical health and both enacted and felt stigma, where worse health was linked to an increased probability of experiencing felt and enacted stigma. This finding replicates past research that linked stigma and specific physical disabilities [20, 21, 65], and points to the existence of general physical health stigma. Furthermore, the population (military versus civilians) by physical health interaction was a significant predictor of enacted stigma, but not felt stigma. The link between physical health and enacted stigma was stronger for military personnel than for civilians, even after adjusting for differences in socio-demographics, mental health, and severity of disability. Differences in predicted probability of experiencing enacted stigma between military personnel and civilians were most pronounced when physical health was poor, with differences between the two populations decreasing as physical health improved. In other words, as health worsens, both groups have an increased probability of experiencing perceived discrimination, but this increased risk is amplified for military personnel. This pattern of findings expands on past research showing differences in reported stigma among military personnel and civilians [37]. While it is clear there is a difference in risk of health-related stigma between military personnel and civilians, it is currently unclear what drives this difference. For one, there may be factors inherent to the military environment. As mentioned earlier, those with physical or mental health issues in the military commonly (or exclusively for regular force members) seek care through their employer (the CAF). Due to this, their chain of command may become aware of their health issues through either a ‘need to know’ or through a breach in confidentiality. In their qualitative review Born and colleagues [42] found that health care providers reported seeing confidentiality breaches among the health care staff (regarding both their own information as well as other patient’s information). In turn, this may result in not being promoted, sent on course, or deployed, which could be perceived as discriminatory by the individual [38–41]. Additionally, the ‘culture of toughness’ in the military may contribute to this difference, as those who are unable to do the physical tasks they once were able to do prior to an injury or illness may be perceived as weak or less valuable to the organization/team. Second, the physical demand of the employment is potentially a factor. As noted, the military has high physical standards for service. Physical health issues may result in the member no longer being eligible for service and being medically discharged, even if their particular trade does not require a high level of physical activity, which also may be seen as discriminatory by the member. Additionally, for some trades (e.g., infantry) their job is physically demanding. As such, for those individuals injury or a decline in physical health may be much more detrimental to employment than it would be in professions that are much less physically demanding (e.g., office jobs). Previous research has found that job performance is a strong and significant predictor of acceptance in the workplace [45]. In future research, it is important to determine what factors are driving these group differences. Although physical health significantly predicted felt stigma, this association did not appear to be modified by population (civilian versus military). It may be that the association, while present, is simply weaker.

We also aimed to examine the relative influence of physical health issues and mental health issues on enacted and felt stigma. Results of our multivariate model suggest that, in both military and civilian populations, physical health has a strong association with enacted and felt stigma, whereas mental health does not. However, rather than reflecting reality, these findings more likely reveal a limitation of our stigma items. To better understand the results, we reexamined the stigma questions to assess whether the items were equally reflecting discrimination and embarrassment relating to physical conditions and mental health conditions (as the item prompt refers to both). First, we examined the questions from the Restriction of Activities section that directly preceded the enacted and felt stigma items and found the phrasing of the questions appeared more applicable to physical health conditions than mental health conditions (e.g., do you have any difficulty hearing, seeing, communicating, walking, climbing stairs, bending, learning or doing any similar activities?; does a long-term physical condition or mental condition or health problem, reduce the amount or the kind of activity you can do?). It is possible, given the phrasing of the questions, respondents were primed to refer to experiences relating to physical and not mental health conditions. As outlined in the results, we also examined responses to a question that assessed the cause of respondents’ health problem and noted very few individuals (< 5%) identified emotional or mental health as the cause for their illness. With these findings, we determined it was reasonable to conclude that most respondents were likely reporting on experienced stigma associated with a physical health condition and not a mental health condition. This would explain why there was such a strong effect of physical health on stigma and no significant effect of mental health, despite a substantial amount of research showing a link between mental health and stigma in both civilian and military populations [16–18, 37, 46, 48]. Moving forward, it will be important to test this hypothesis using a more suitable dataset that captures stigma related to mental and physical health problems either separately, or at least more equally.

We also explored a potential three-way interaction between physical, mental health, and population. This interaction was not significant in either of the analyses. Again, given the substantial amount of research that has shown a link between mental health and stigma [16–18, 37, 46, 48], it is unlikely that our findings represent a true pattern in the data. Rather, findings are more likely due to the failure of our stigma items to tap into mental health related stigma, as discussed previously.

Stigma, it seems, does not discriminate with respect to the nature of the health problem (mental versus physical). The findings suggest that, as physical health worsens, the risk of experienced discrimination and embarrassment increases. Furthermore, the increase in probability of enacted stigma is particularly problematic in the military, where the association is significantly stronger than in the general population. The findings suggest future stigma reduction campaigns should consider including physical health stigma as well as mental health stigma. Future research should examine what factors contribute to physical health stigma, and identify whether certain aspects of poor physical health modify the link between physical health and stigma.