title: Military Generation and Its Relationship to Mortality in Women Veterans in the Women's Health Initiative.
abstract: OBJECTIVE
  Women's military roles, exposures, and associated health outcomes have changed over time. However, mortality risk-within military generations or compared with non-Veteran women-has not been assessed. Using data from the Women's Health Initiative (WHI), we examined all-cause and cause-specific mortality by Veteran status and military generation among older women.
  
  
  METHODS
  WHI participants (3,719 Veterans; 141,802 non-Veterans), followed for a mean of 15.2 years, were categorized into pre-Vietnam or Vietnam/after generations based on their birth cohort. We used cox proportional hazards models to examine the association between Veteran status and mortality by generation.
  
  
  RESULTS
  After adjusting for sociodemographic characteristics and WHI study arm, all-cause mortality hazard rate ratios (HRs) for Veterans relative to non-Veterans were 1.16 (95% CI: 1.09-1.23) for pre-Vietnam and 1.16 (95% CI: 0.99-1.36) for Vietnam/after generations. With additional adjustment for health behaviors and risk factors, this excess mortality rate persisted for pre-Vietnam but attenuated for Vietnam/after generations. After further adjustment for medical morbidities, across both generations, Veterans and non-Veterans had similar all-cause mortality rates. Relative to non-Veterans, adjusting for sociodemographics and WHI study arm, pre-Vietnam generation Veterans had higher cancer, cardiovascular, and trauma-related morality rates; Vietnam/after generation Veterans had the highest trauma-related mortality rates (HR = 2.93, 1.64-5.23).
  
  
  CONCLUSIONS
  Veterans' higher all-cause mortality rates were limited to the pre-Vietnam generation, consistent with diminution of the healthy soldier effect over the life course. Mechanisms underlying Vietnam/after generation Veteran trauma-related mortality should be elucidated. Efforts to modify salient health risk behaviors specific to each military generation are needed.
authors.affiliation: VA Health Services Research and Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, California. University of California Los Angeles, Geffen School of Medicine. donna.washington@va.gov.
authors.forename: Donna L
authors.initials: DL
authors.lastname: Washington
authors.affiliation: RAND Corporation, Pardee Rand Graduate School, Santa Monica, California.
authors.forename: Chloe E
authors.initials: CE
authors.lastname: Bird
authors.affiliation: Department of Epidemiology and Environmental Health, School of Public Health and Health Professions, State University of New York at Buffalo.
authors.forename: Michael J
authors.initials: MJ
authors.lastname: LaMonte
authors.affiliation: Durham VA Health Care System, North Carolina.
authors.forename: Karen M
authors.initials: KM
authors.lastname: Goldstein
authors.affiliation: Fred Hutchinson Cancer Research Center, Seatle, Washington.
authors.forename: Eileen
authors.initials: E
authors.lastname: Rillamas-Sun
authors.affiliation: Stanford University School of Medicine, Stanford Center for Health Research on Women & Sex Differences in Medicine, California.
authors.forename: Marcia L
authors.initials: ML
authors.lastname: Stefanick
authors.affiliation: Division of Biobehavioral Nursing & Health Systems, University of Washington School of Nursing, Seattle.
authors.forename: Nancy F
authors.initials: NF
authors.lastname: Woods
authors.affiliation: VA Connecticut, and University of Connecticut Health Center, West Haven.
authors.forename: Lori A
authors.initials: LA
authors.lastname: Bastian
authors.affiliation: The North American Menopause Society, Mayfield Heights, Ohio.
authors.forename: Margery
authors.initials: M
authors.lastname: Gass
authors.affiliation: VA Palo Alto Health Care System, Sierra Pacific MIRECC and Center for Innovation to Implementation, California. Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, California.
authors.forename: Julie C
authors.initials: JC
authors.lastname: Weitlauf
mesh_terms: D000368:Aged; D002318:Cardiovascular Diseases / Q000401:mortality*; D015988:Cohort Effect; D005260:Female; D006801:Humans; D047869:Korean War; D008137:Longitudinal Studies; D008875:Middle Aged; D009369:Neoplasms / Q000401:mortality*; D016016:Proportional Hazards Models; D014481:United States; D014728:Veterans / Q000706:statistics & numerical data*; D047829:Vietnam Conflict; D047789:World War II; D014947:Wounds and Injuries / Q000401:mortality*
keywords: Cohort effect; Longitudinal study; Mortality; Women Veterans