Structural and Functional Social Support in UK Military Veterans During the COVID-19 Pandemic and Associations with Mental Health and Wellbeing: A Cross-sectional Study

doi:10.21203/rs.3.rs-4288695/v1

Background

The coronavirus disease (COVID-19) pandemic led to the implementation of social distancing laws in the UK. This had several negative consequences on health, wellbeing and social functioning within the general population. Military veterans may have had unique experiences of social isolation during this time. This study examined the level of, and relationship between, structural and functional social support, and its association with mental health and wellbeing in a sample of UK veterans during the COVID-19 pandemic.

Methods

Throughout the first summer of the pandemic (June-September 2020), an additional wave of cross-sectional data was collected from UK Armed Forces personnel who had left regular military service and were participating in a longitudinal cohort study. In total, 1562 participants (44.04% response rate) completed a series of online questionnaires measuring sociodemographic characteristics, COVID-19 experiences and psychosocial health and wellbeing. Multivariable logistic and ordinal regression analyses were conducted.

Results

For structural social support, 86.8% were in a relationship and 89.0% lived with others. For functional social support, one-quarter reported feelings of loneliness (27.4%) and low levels of perceived social support (28.1%). Structural support was associated with functional support. Being single, living alone and experiencing loneliness were associated with worse mental health and wellbeing, while living with other adults and reporting high levels of perceived social support were associated with better mental health and wellbeing.

Conclusions

UK veterans showed greater social support than the UK general population during the first summer of the COVID-19 pandemic. This study has enhanced our understanding of social support among veterans and its implications for health and wellbeing. This knowledge is essential for advising the development of psychosocial interventions and policies to improve the psychological wellbeing of veterans in future pandemics and more broadly in their daily lives.

Military

Veterans

Social Support

Mental Health

Wellbeing

Coronavirus

During the first summer of the COVID-19 pandemic in 2021, social relationships may have been negatively affected by social distancing laws in the UK. This may have been problematic for some military veterans¹, who present with unique experiences of loneliness due to reintegration challenges following the transition from military to civilian life (1). In a sample of UK veterans, 27.4% reported feelings of loneliness during the pandemic (2). Loneliness and a lack of social support are associated with poor health and wellbeing (3). Therefore, understanding potential mechanisms to reduce these negative consequences is important for the health and wellbeing of current and future military veterans.

One potential mechanism to reduce negative health and wellbeing consequences following the COVID-19 pandemic is to increase social support. Social support is defined within the psychological and epidemiological literature as the availability and adequacy of social connections (4). Definitions of social support are generally divided into two domains with conceptual distinctions: structural and functional (5). Structural support refers to the presence of social relationships, for example, the size of a social network, while functional support incorporates quality of support and examines how successfully a relationship fulfils one’s needs (4,6). Perceived social support refers to an individual’s beliefs about the support they receive from social relationships (7).

Social support is a protective factor against mental health problems across a variety of populations (3,8) and military populations may especially benefit from increased levels of social support. Military culture is centred around comradery, and many veterans rely on strong connections with social contacts to ease the burden of transition from military to civilian life (9). Conversely, leaving a cohesive military environment and adapting to civilian life may reduce sociability and trigger disengagement from military contacts. Research has shown that veterans reported less social participation and were more likely to experience symptoms of anxiety, depression and post-traumatic stress disorder than those still serving in the military (10).

According to the social identity model of identity change, adapting to changes in one’s environment can trigger stressful reactions. The ability to adopt new identities that align with the environment is important for wellbeing during any life transition or change (11). For example, entering parenthood, leaving the military or during the COVID-19 pandemic. The implementation of social distancing laws in the UK during the pandemic, as well as fears of contracting COVID-19, led to a reduction in group activities and prevented many veterans from attending social, sporting or community groups. Levels of formal volunteering, which often opens up opportunities to expand social networks, had decreased in veterans during this time (12). This prolonged separation from others may therefore have had a profound impact on veterans’ mental health and wellbeing.

During the COVID-19 pandemic, studies have shown that lower levels of functional social support are associated with poorer mental health in treatment-seeking veterans experiencing mental health problems (13,14). However, little is known about the level of structural and functional social support and its association with mental health and wellbeing in a non-clinical sample of veterans during the pandemic. Studies conducted in the general population have shown that functional social support is a stronger predictor of wellbeing outcomes than structural (15); however, it is unknown whether this translates to outcomes for military veterans.

The literature suggests that social support, as well as mental health and wellbeing, can vary depending on an individual’s age, sex, education level and military rank (16–19); therefore these variables will be adjusted for in the analyses.

Objectives:

To investigate the level of structural and functional social support and the relationship between these two variables, in a sample of UK veterans during the COVID-19 pandemic.
To explore whether structural or functional social support is associated with mental health and wellbeing in this population.

Study design and participants

This study reports on cross-sectional data from the Veterans-CHECK study. The data were collected from an additional wave of the King’s Centre for Military Health Research (KCMHR) health and wellbeing study. This is a prospective cohort study investigating the health and wellbeing of regulars and reservists of the UK Armed Forces who served during the Iraq and Afghanistan era across all three services (British Army, Royal Air Force and Royal Navy). To date, four phases of data collection have been undertaken over 20 years (20). Participants received an email invitation to participate in Veterans-CHECK if they had completed phase 3 of the main cohort study, were ex-serving regular members of the Armed Forces and were living in the UK.

Procedure

The data were collected during the first summer of the COVID-19 pandemic (June-September 2020). Data collection occurred online whereby participants completed a questionnaire using their personal device. Informed consent was obtained before the questionnaire was completed by the participant. The questionnaire covered (a) sociodemographic characteristics, (b) COVID-19 experiences and stressors and (c) current mental health and wellbeing. The full details of the Veterans-CHECK study are available elsewhere (2).

Study data were collected and managed using Research Electronic Data Capture (REDCap) hosted at King’s College London (21,22). REDCap is a secure, web-based software platform designed to support data capture for research studies. Ethical approval was obtained from the King’s College London Research Ethics Committee (Ref: HR-19/20-18626).

Measures

Outcomes: mental health and wellbeing

Mental wellbeing was measured using the Warwick Edinburgh Mental Wellbeing Scale (WEMWBS) (23), a 14-item measure with scores ranging from 14 to 70, covering experiences across the past two weeks. Scores were categorised as low (14–39), moderate (40–59) or high (60–70) using cut-off points of plus or minus one standard deviation of the sample mean. Higher scores indicate better mental wellbeing.

Symptoms of common mental disorders (CMD), including anxiety and depression, were measured using the General Health Questionnaire-12 (GHQ-12) (24). This consisted of 12 items, and caseness was defined as a score ≥ 4 with scores ranging from 0 to 12.

Hazardous drinking was measured using the Alcohol Use Disorder Identification Test (AUDIT) (25). This included 10 items with scores ranging from 0 to 40; scores ≥ 8 indicated hazardous drinking.

Exposure: structural and functional social support

Structural social support was measured using relationship status and living arrangements. Specifically, participants were asked “Are you currently: (1) married/cohabiting, (2) partnered/in a relationship, (3) separated, (4) divorced, (5) widowed, (6) single/never married, (7) prefer not to say”. Categories 1 and 2 were combined to form a new variable of “in a relationship”, and the remaining categories were combined to form a “single” category. Participants were also asked, “Do you live alone? (1) yes, (2) no”. Those who answered yes were asked, “Who do you usually live with? Tick all that apply: (1) spouse/partner, (2) children, (3) parents/in-laws, (4) other family, (5) friends, (6) lodger/tenant/house share, (7) other”. These were categorised into: “with others (including children)” (reference category, to indicate a typical family structure), “with others (not children)”, “with children only” and “alone”.

Functional social support was measured using two scales. First, the University of California (UCLA) Loneliness Scale, a 3-item measure with scores ranging from 3 to 9 (26). Loneliness score thresholds of ≥ 6 indicate lower levels of functional social support. Second, a brief form of the Perceived Social Support Questionnaire (F-SozU) (27). This is a 6-item measure with scores ranging from 6 to 30. Scores were categorised as low (6–19), medium (20–26) or high (27–30) using the median and interquartile range to define thresholds. High scores indicate better functional social support.

Analysis

Descriptive statistics were produced to summarise participant sociodemographic characteristics, military factors, the level of structural and functional social support, and mental health and wellbeing. Response weights were generated to account for non-response and defined as the inverse probability of responding once sampled, driven by covariates shown empirically to predict response. Regression diagnostics were performed. The following logistic and ordinal logistic regression analyses were conducted to assess associations between the following variables:

Structural support (relationship status or living arrangements) and functional support (perceived social support or loneliness)
Structural or functional social support and mental health and wellbeing outcomes

Multivariable logistic and ordinal logistic regression analyses were adjusted for potential a-priori confounders, including age, sex, education level and military rank. Military rank was also used as a proxy for socioeconomic status (28). Missing data were minimal; therefore, a complete case analysis was conducted. Analyses were performed using Stata 18 (49) with survey commands used to account for weighting. Weighted percentages, unweighted odds ratios (OR) and adjusted odds ratios (AOR) are presented in tables along with unweighted cell counts.

Characteristics of the study sample

Out of the 3547 potential participants who were emailed, 1562 veterans participated in the survey (44.04% response rate). The majority were male (89.26%, n=1383), had served in the Army (58.26%, n=873), were Non-Commissioned Officers (NCOs) (61.45%, n=954) and left the Army more than 10 years ago (52.24%, n=870). The full demographic and military characteristics of the participants are presented elsewhere (2).

Levels of social support and mental health and wellbeing

Most of the participants were in a relationship (Table 1) (86.76%, n=1361), and almost half were living with others, excluding children (45.98%, n=768), or others, including children (41.39%, n=593). Just over a quarter of the sample (27.42%, n=395) reported feelings of loneliness and reported low levels of social support (28.14%, n=399). See Appendix 1 for a tabulation of structural social support measures (relationship status by living arrangements) and Appendix 2 for functional social support measures (loneliness by perceived social support). For mental health and wellbeing, 19.40% (n=263) reported low mental wellbeing and approximately a quarter of the sample met the criteria for CMD (24.42%, n=354) and hazardous drinking (27.86%, n=368).

Table 1 Structural and functional social support and mental wellbeing
Structural social support	Relationship status	Response	n (%)*
		In a relationship	1361 (86.76)
		Single (separated, divorced, widowed, never married)	199 (13.24)
	Living arrangements	Response
		With others (including children)	593 (41.39)
		With others (not children)	768 (45.98)
		With children only	26 (1.59)
		Alone	170 (11.04)
Functional social support	Perceived social support	Score
		Low	399 (28.14)
		Medium	653 (42.75)
		High	453 (29.12)
	Loneliness	UCLA case ≥ 6
		Not lonely	1125 (72.58)
		Lonely	395 (27.42)
Mental health and wellbeing	Mental wellbeing	Score
		Low	263 (19.40)
		Medium	949 (65.53)
		High	243 (15.06)
	Common mental disorders	GHQ-12 case ≥ 4
		No	1190 (75.58)
		Yes	354 (24.42)
	Hazardous drinking	AUDIT case ≥ 8
		No	1035 (72.14)
		Yes	368 (27.86)
*Percentages are weighted with unweighted cell counts. UCLA, University of California Los Angeles Loneliness Scale; GHQ-12, General Health Questionnaire-12; AUDIT, Alcohol Use Disorders Identification Test

Associations between structural and functional social support

We found evidence that being single (compared to being in a relationship) was associated with decreased odds of reporting higher levels of perceived social support (Table 2). Those who were single also had increased odds of reporting feelings of loneliness.

Those who live alone or with children only (compared to those who live with others including children) have decreased odds of reporting higher levels of perceived social support and increased odds of loneliness. The associations remained unchanged following adjustment for potential confounders.

Table 2 Association between structural social support and functional social support
			Functional social support
			Perceived social support†			Loneliness (UCLA ≥ 6, n=395, 27.42%)
Structural social support		n (%)	OR (95% CI)	AOR (95% CI)*	p-value	OR (95% CI)	AOR (95% CI)*	p-value
Relationship status	In a relationship	1361 (86.76)	Reference
Relationship status	Single	199 (13.24)	0.24 (0.17 to 0.34)	0.22 (0.15 to 0.31)	< 0.001	5.47 (3.90 to 7.66)	5.42 (3.84 to 7.65)	< 0.001
Living arrangements	With others (including children)	593 (41.39)	Reference
	With others (not children)	768 (45.98)	1.17 (0.94 to 1.47)	0.99 (0.78 to 1.26)	0.940	0.60 (0.45 to 0.80)	0.76 (0.55 to 1.03)	0.079
	With children only	26 (1.59)	0.28 (0.13 to 0.61)	0.22 (0.10 to 0.47)	< 0.001	3.64 (1.60 to 8.31)	3.36 (1.43 to 7.88)	0.005
	Alone	170 (11.04)	0.30 (0.21 to 0.43)	0.26 (0.17 to 0.38)	< 0.001	3.73 (2.55 to 5.45)	4.35 (2.94 to 6.43)	< 0.001
Weighted percentages are presented in tables to account for response weights *Adjusted for: age, sex, education level and military rank †Used as a count variable OR/AORs presented in bold are significant at p<0.05 OR, Odds Ratio; AOR, Adjusted Odds Ratio; CI, Confidence Interval; UCLA, University of California Los Angeles Loneliness Scale

Associations between social support and mental health and wellbeing

Structural social support and mental health and wellbeing

Being single (compared to being in a relationship) was associated with decreased odds of reporting higher levels of mental wellbeing (Table 3). Being single was not associated with CMD or hazardous drinking.

Living alone (compared to living with others including children) was associated with decreased odds of reporting higher levels of mental wellbeing, while living with others and no children (compared to living with others including children) was associated with increased odds of reporting higher levels of mental wellbeing. Living arrangements were not associated with CMD or hazardous drinking.

Functional social support and mental health and wellbeing

Reporting feelings of loneliness was associated with decreased odds of reporting higher levels of mental wellbeing. Loneliness was also associated with increased odds for CMD and hazardous drinking.

Reporting low levels of perceived social support was associated with decreased odds for greater mental wellbeing and increased odds for CMD and hazardous drinking, while high social support was associated with increased odds for greater mental wellbeing and decreased odds for CMD and hazardous drinking. The associations remained unchanged following adjustment for potential confounders.

Table 3 Association between structural or functional support (exposure) and mental health and wellbeing (outcome)

n (%)

Mental wellbeing†

Common Mental Disorder

(GHQ-12 ≥ 4, n=354, 24.42%)

Hazardous drinking

(AUDIT ≥ 8, n=368, 27.86%)

OR

(95% CI)

AOR

(95% CI)*

p-value

OR

(95% CI)

AOR

(95% CI)*

p-value

OR

(95% CI)

AOR

(95% CI)*

p-value

Structural support

Relationship status

In a relationship

1361 (86.76)

Reference

Single

199 (13.24)

0.46 (0.33 to 0.65)

0.49 (0.34 to 0.70)

< 0.001

1.27 (0.87 to 1.85)

1.19 (0.81 to 1.74)

0.385

0.95 (0.63 to 1.45)

1.00 (0.66 to 1.53)

0.992

Living arrangements

With others (including children)

593 (41.39)

Reference

With others

(not children)

768 (45.98)

1.76 (1.38 to 2.24)

1.28 (0.98 to 1.68)

0.049

0.85 (0.65 to 1.12)

1.08 (0.80 to 1.47)

0.608

0.87 (0.67 to 1.15)

1.12 (0.83 to 1.51)

0.474

With children only

26 (1.59)

0.54 (0.26 to 1.14)

0.53 (0.23 to 1.23)

0.139

0.95 (0.37 to 2.43)

0.99 (0.38 to 2.58)

0.976

0.78 (0.25 to 2.46)

1.03 (0.32 to 3.32)

0.964

Alone

170 (11.04)

0.73 (0.49 to 1.08)

0.62 (0.41 to 0.94)

0.023

1.32 (0.86 to 2.02)

1.47 (0.95 to 2.26)

0.081

1.15 (0.75 to 1.76)

1.43 (0.92 to 2.23)

0.110

Functional support

Loneliness

Not lonely

1125 (72.58)

Reference

Lonely

(UCLA ≥ 6)

395 (27.42)

0.11 (0.08 to 0.15)

< 0.001

3.44 (2.61 to 4.53)

3.28 (2.46 to 4.37)

< 0.001

2.08 (1.57 to 2.76)

2.02 (1.51 to 2.69)

< 0.001

Perceived social support

Medium

653 (42.75)

Reference

Low

399 (28.14)

0.25 (0.18 to 0.33)

0.27 (0.20 to 0.37)

< 0.001

1.52 (1.14 to 2.05)

1.44 (1.06 to 1.94)

0.019

1.46 (1.07 to 1.98)

1.38 (1.01 to 1.89)

0.042

High

453 (29.12)

4.93 (3.69 to 6.60)

4.95 (3.69 to 6.63)

< 0.001

0.39 (0.27 to 0.57)

0.38 (0.26 to 0.54)

< 0.001

0.71 (0.51 to 0.98)

0.78 (0.49 to 0.98)

0.040

Weighted percentages are presented in tables to account for response weights

*Adjusted for: age, sex, education level and military rank

†Count variable

OR/AORs presented in bold are significant at p<0.05

OR, Odds Ratio; AOR, Adjusted Odds Ratio; CI, Confidence Interval; GHQ-12, General Health Questionnaire-12; AUDIT, Alcohol Use Disorders Identification Test; UCLA, University of California Los Angeles Loneliness Scale

This study aimed to examine the level of, and relationship between, structural and functional social support, and its association with mental health and wellbeing in a sample of UK veterans during the COVID-19 pandemic. We used two measures of structural social support (relationship status and living arrangements) and two measures of functional social support (loneliness and perceived social support). For structural support, most were in a relationship or living with others. For functional support, approximately one-quarter of the respondents reported feelings of loneliness or low perceived social support. Structural support was associated with functional support. Being single, living alone and experiencing loneliness were associated with worse mental health and wellbeing, while living with others (but not children) and reporting high levels of perceived social support were associated with better mental health and wellbeing.

Levels of structural and functional social support

The findings suggest that veterans experienced relatively high levels of structural social support during the COVID-19 pandemic, as most were in a relationship (89%) or lived with others (89%). In comparison, the UK COVID-19 Social Study, a civilian study that commenced during a similar period as the Veterans-CHECK Study, reported that 70% of the sample were in a relationship and 82% were living with others (29). Structural support appears to be greater in our UK veteran sample than in a civilian sample during a similar period. However, participants in these studies are not age/sex-matched but provide a useful comparison. Structural support was also greater in the current study than in a sample of UK mental health treatment-seeking veterans during this time (61% in a relationship, 69% living with others) (14).

Approximately one-quarter of the respondents reported low levels of functional social support, specifically low perceived social support or feelings of loneliness. Findings from the COVID-19 Social Study showed greater levels of loneliness in the general population (30) than in veterans (39.3% v 27.4%). This may be explained by the presence of additional protective factors among veterans; for example, a high percentage were in a relationship and living with others and therefore had more direct access to support. The availability of social support is influenced by the size and density of one’s social network (31). Furthermore, this may be explained by resilience within the veteran community, defined as being adaptable in the face of adversity (32). Participants in Veterans-CHECK served during the Iraq/Afghanistan era where a majority of the sample had deployed to Iraq and/or Afghanistan and a third reported a combat role on their last deployment. Although combat-exposed military personnel have an increased risk of experiencing mental health problems (33), studies have also shown positive outcomes such as increased resilience, coping skills (34) and post-traumatic growth (35), potentially leading to greater levels of functional support.

Associations between structural and functional support

Overall, structural measures of social support were associated with functional measures. We found that being single was associated with decreased odds of reporting higher levels of perceived social support and increased odds of loneliness. Furthermore, living alone or with children only was associated with increased levels of loneliness. This was likewise found in the COVID-19 Social Study (30). Living with children only is indicative of single parenting, which is accompanied by other stressors during COVID-19 such as financial concerns, competing time demands (36) and an increase in home-schooling, resulting in less time to make contact with others and less functional support. However, in this study the number of participants within the living arrangements categories were relatively small and the confidence intervals were wide, which may have resulted from reduced power; therefore, these findings should be interpreted with this in mind.

Associations between social support and mental wellbeing

Being single and living alone was associated with worse mental health and wellbeing, while living with others but not children was associated with better mental health and wellbeing. This finding appears to align with evidence collected across a variety of countries and cultures during the pandemic (37,38). For some, contact with cohabitants was the only source of social companionship during multiple phases of the pandemic, particularly if one was enrolled in the furlough scheme (a temporary cessation of employment) and did not have other sources of social contact. Therefore, being single and living alone would have reduced social and physical contact, potentially leading to feelings of isolation and boredom, and thus reinforcing a negative emotional state (39). Structural social support was not associated with CMD or hazardous drinking. This may be because much variation exists surrounding the quality of relationships and living arrangements, hence it is important to measure functional support.

For functional measures, loneliness was associated with worse mental health while high levels of perceived social support were associated with better mental health. General population studies have found associations between loneliness, depression, anxiety and suicidal ideation (40). Likewise, existing evidence in veterans found associations between loneliness and increased alcohol misuse (41), as well as a bi-directional relationship between loneliness and depression (42). In a study of treatment-seeking veterans during the COVID-19 pandemic (November 2020), no association was found between functional measures of social support and mental health outcomes, but participants who reported lower levels of perceived social support were more likely to express increases in anger (13). Anger is a central clinical feature and is listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR) as an associated symptom alongside a range of mental health conditions (43). The pandemic led to widespread changes that may have been difficult to cope with. Difficulty tolerating uncertainty plays a key role in the maintenance of CMD (44). Social networks shape our standards of behaviour and provide avenues through which we can obtain sources of information, share norms and beliefs and offer support (10). Feeling dissatisfied with one’s network, i.e., reporting low levels of functional social support may negatively impact our behaviours and beliefs, resulting in an increased risk of experiencing mental health problems.

Overall, functional social support had stronger associations with mental health and wellbeing outcomes than structural social support. This aligns with existing evidence in the general population which found that functional social support is a stronger predictor of health and wellbeing than structural measures (15).

Strengths and limitations

This study examined various dimensions of social support, including structural and functional support. Measuring structural support alone is not sufficient to fully understand the implications of social support for health and wellbeing. For example, an individual may have a partner and report contact with a large social network yet feel dissatisfied and unsupported. Furthermore, we used validated measures of functional social support to allow for cross-study comparison, including the UCLA Loneliness Scale and the F-SozU.

The study has several limitations. First, the perceived social support and mental health and wellbeing data are cross-sectional which limits our ability to determine the direction of causality. This analysis only provides evidence from a snapshot in time across a three-month period (June-September 2020). Other longitudinal studies have shown a decrease in social support over the course of the pandemic in a veteran sample (14); therefore our study may not capture the extent of the pandemic impact on social support in our sample. Despite this, our findings can pave the way for additional longitudinal research within this population given the potential ongoing consequences of the pandemic. Second, the dataset relies on self-report questionnaires, which may give rise to several biases, including recall bias and social desirability bias. Traditionally, military culture is consistent with stoicism, defined as the endurance of pain or hardship without expression, which has been described as a necessity for operational readiness, particularly in combat settings (45). It is possible that this stoic culture may impact their responses. However, more recent evidence suggests that this theory of military stoicism is potentially outdated (46). Increases in help-seeking behaviour among serving and ex-serving military personnel also suggest that this is the case (47). Finally, as this cohort included veterans who served during the Iraq/Afghanistan era of conflicts, the findings may not be generalisable to veteran communities across other eras of military service.

Implications

Most veterans in our sample reported sufficient levels of structural and functional social support. However, given that there is still a minority who reported feelings of loneliness and low social support, and that this may have a considerable impact on their mental health and wellbeing, it is important to consider recommendations for policy and practice to improve these outcomes and any longer-term impacts from their pandemic experiences. Functional support is more modifiable than structural support, such that decisions to be in a relationship, or who one lives with, are personal choices and often situation dependent. Despite this, we suggest interventions could be aimed at providing more support for veterans who are living alone and for veterans who are single parents and living alone with children. Furthermore, interventions that aim to increase levels of functional support may be beneficial for improving outcomes. These include projects to address loneliness within the UK Armed Forces (48) and charities that focus on social participation and engagement.

To conclude, we broadly found greater levels of structural and functional social support in this veteran sample than in the general UK population during the COVID-19 pandemic. While most veterans show sufficient levels of social support, approximately one-quarter of them reported low functional support and may benefit from intervention to improve these levels of support. Being single, living alone and experiencing loneliness were associated with worse mental health and wellbeing, while living with other adults and having greater perceived social support were associated with better mental health and wellbeing.

This study has added to our understanding of social support among veterans during the first summer of the COVID-19 pandemic and its implications for health and wellbeing. This knowledge is important for informing the development of targeted and focused psychosocial interventions, projects to address loneliness and policies to improve the overall health and wellbeing of veterans in future pandemics and more broadly in their daily lives.

*CMD*	Common Mental Disorder
*COVID-19*	Coronavirus Disease
*DSM-5-TR*	Diagnostic and Statistical Manual of Mental Disorders
*GHQ-12*	General Health Questionnaire-12
*KCMHR*	King’s Centre for Military Health Research
*NCO*	Non-Commissioned Officer
*UCLA*	University of California
UK	United Kingdom
*WEMWBS*	Warwick-Edinburgh Mental Wellbeing Scale

Ethics approval and consent to participate

Ethical approval was obtained from the King’s College London Research Ethics Committee (Ref: HR-19/20-18626). All participants provided fully informed consent before participation.

Consent for publication

Not applicable.

Availability of data and materials

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.

Competing interests

L.E.G. is funded by the Armed Services Trauma Rehabilitation Outcome (ADVANCE) Charity. Key contributors to this charity are the Headley Court Charity (principal funder), HM Treasury (LIBOR Grant), Help for Heroes, Nuffield Trust for the Forces of the Crown, Forces in Mind Trust, National Lottery Community Fund, Blesma - The Limbless Veterans and the UK Ministry of Defence.

M.L.S and M.J. are funded by a grant by the Office for Veterans’ Affairs (OVA).

H.B. is part-funded by a grant from the UK Ministry of Defence (MoD).

N.T.F. is part-funded by a grant from the UK MoD and is a trustee (non-paid) of a charity supporting the health and wellbeing of military personnel, veterans and their families.

Funding

This work was funded by the Office of Veterans’ Affairs, Cabinet Office, UK Government (Contract Ref: CCZZ20A51)

Authors’ contributions

L.E.G. Conception, analysis, interpretation, drafting.

M.L.S. Conception, interpretation, review.

M.J. Conception, interpretation, review.

H.B. Interpretation, review.

N.T.F. Acquisition of funding, conception, interpretation, review.

Acknowledgements

We acknowledge the contributions of David Pernet, Dr Danai Serfioti, Lisa Hull, Professor Dominic Murphy, and Professor Sir Simon Wessely in the original set-up, creation and data collection of the Veterans-CHECK study from which this analysis was performed.

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In the UK, the term military veteran is used to describe an ex-serving member of the Armed Forces.

Competing interest reported. L.E.G. is funded by the Armed Services Trauma Rehabilitation Outcome (ADVANCE) Charity. Key contributors to this charity are the Headley Court Charity (principal funder), HM Treasury (LIBOR Grant), Help for Heroes, Nuffield Trust for the Forces of the Crown, Forces in Mind Trust, National Lottery Community Fund, Blesma - The Limbless Veterans and the UK Ministry of Defence. M.L.S and M.J. are funded by a grant by the Office for Veterans’ Affairs (OVA). H.B. is part-funded by a grant from the UK Ministry of Defence (MoD). N.T.F. is part-funded by a grant from the UK MoD and is a trustee (non-paid) of a charity supporting the health and wellbeing of military personnel, veterans and their families.

Appendices.docx

Structural and Functional Social Support in UK Military Veterans During the COVID-19 Pandemic and Associations with Mental Health and Wellbeing: A Cross-sectional Study

Status:

Version 1

Abstract

Background

Objectives:

Methods

Study design and participants

Procedure

Measures

Outcomes: mental health and wellbeing

Exposure: structural and functional social support

Analysis

Results

Characteristics of the study sample

Levels of social support and mental health and wellbeing

Associations between structural and functional social support

Associations between social support and mental health and wellbeing

Structural social support and mental health and wellbeing

Functional social support and mental health and wellbeing

Discussion

Levels of structural and functional social support

Associations between structural and functional support

Associations between social support and mental wellbeing

Strengths and limitations

Implications

Conclusions

Abbreviations

Declarations

Ethics approval and consent to participate

Consent for publication

Availability of data and materials

Competing interests

Funding

Authors’ contributions

Acknowledgements

References

Footnotes

Additional Declarations

Supplementary Files

Status:

Version 1