Introduction: Canadian military spouses have reported issues accessing and maintaining high quality health care. There is no Canadian research quantifying the scope of the problem. Methods: This is a retrospective cohort study using administrative data. We included military spouses and dependents relocated to Ontario between January 8, 2008 and March 31, 2013, along with a matched civilian reference group. We measured hospitalizations, emergency department (ED) visits, and physician visits. Comparisons of first health care contact, medical health services use, and time to first health services use controlled for age, sex, and geography. Results: The cohort included 7,508 military family members and 30,032 matched civilians. Point of first health care system contact differed between military family members and the civilian reference group ( p < 0.001). Military family members had a longer time to their first health care contact than the civilian reference group (median 118 days vs. 84 days, p < 0.001). Similarities and differences between military family and civilian health services use existed. For example, military children and youth were less likely to see a paediatrician than the civilian reference group (17.7% vs. 26.0%, p < 0.001), and less likely to receive non-influenza vaccinations (23.2% vs. 32.3%, p < 0.001). Discussion: This study provides evidence supporting the hypothesis that military families have different access to, and use of, provincial health services than the general Ontario population and suggests support during relocations is needed. It is important to further understand how these patterns impact health outcomes and continuity of care and to contextualize these findings with potential differences in the underlying need for health services.
Contexte: Époux de militaires canadiens rapportent avoir des problèmes à recevoir et à maintenir un accès à des soins de santé de qualité pour elles-mêmes et leurs personnes à charge. Aucune recherche canadienne n’a encore quantifié l’ampleur de ce problème. Méthodologie : Cette recherche rétrospective est basée sur des données administratives. Nous avons inclus les épouses et leurs personnes à charge ayant déménagé en Ontario entre le 01/08/2008 et le 03/31/2013, ainsi qu’un groupe contrôle composé de civils résidant aussi en Ontario. Nous avons mesuré les hospitalisations, ainsi que les visites à l’urgence et chez le médecin. Des comparaisons en ce qui concerne le premier contact de soins, l’usage des services médicaux et le temps avant la première fréquentation des soins de santé ont été réalisées entre la famille militaire et le groupe de référence civile à partir des variables de l’âge, du genre et de la géographie. Résultats : L’échantillon incluait 7,508 familles militaires et 30,032 civils. Le premier point de contact en soins de santé variait entre les membres de la famille militaire et le groupe de référence (p<0.001). Le premier contact était avec un médecin de famille ou l’urgentologue dans 73% et 18% des cas respectivement chez les familles militaires, alors que les données indiquaient 64,7% et 14,7% des cas dans le groupe de contrôle (médiane 118 jours vs 84 jours, p<0.001). Des similitudes et des différences entre le recours aux soins dans les familles militaires et civiles existaient. Par exemple, les enfants de militaires et les jeunes étaient moins susceptibles de rencontrer un pédiatre que les civils du groupe de référence (17,7% vs 26%, p<0.001), et moins susceptibles de recevoir des vaccins non liés à l’influenza (23.2% vs 32.3%, p<0.001). Conclusion : Il existe des preuves soutenant l’hypothèse que les familles militaires ont un accès, et font un usage, différent des soins de santé provinciaux que la population ontarienne générale. Cela suggère qu’un soutien accru pendant les relocalisations est requis. Il est important de comprendre plus en profondeur comment ces tendances influencent la santé et la continuité des soins, ainsi que de contextualiser ces découvertes en ce qui concerne les différences inhérentes en ce qui concerne les besoins en matière de soins de santé.
In Canada, over 57,000 families of Canadian Armed Forces (CAF) members receive health care in the provincial and territorial health care systems from civilian health care providers.1 CAF families move three to four times more often than civilian families, which requires the family to start from scratch in their health care coordination efforts with each move.2,3 This differs from the experience of their serving CAF family member, who receives continuous health care within a highly specialized and coordinated federal, defence health care system.
CAF families have consistently identified access to high quality health care as a key concern related to the military career.4,5 CAF spouses have described difficulty in finding a new family doctor at each new posting location, lengthy, disrupted waits for specialist treatment, and difficulty in medical record transfer across jurisdictions.3,5–8 While there has been movement in the Canadian defence and health care communities to address the concerns of military families, very little is known about the health of Canadian military families, their health care access and quality compared to the civilian population. The body of international evidence suggesting that a military career may have negative health effects for military families9–13 is not representative of Canadian military families, Canadian military operations, or the Canadian health care system. The military community has put out a call to action for the creation of objective, quantitative evidence to support the health of Canadian military families.1,3,7,14 Therefore, our goals were to provide the first comparisons of provincial health care access and medical services use between military families and a matched civilian reference group.
This retrospective, matched cohort study comparing health services use for newly transferred military families to the general Canadian population was conducted in Ontario, Canada at the Institute for Clinical Evaluative Sciences (ICES). Ontario is home to eight of the 38 Canadian federal military bases, including Canadian Forces Base (CFB) Kingston, the largest military base in the country, the Royal Military College of Canada, and the Department of National Defence. As of 2007, Ontario was one of the first provinces to waive the 3-month waiting period for provincial health coverage to families of active Canadian Armed Forces personnel under the Fairness for Military Families Act.15 This legislation grants immediate access to provincial health services for the spouses and dependents of CAF regular forces members returning or new to the province following an out-of-province or out-of-country posting and to the families of reservists who were activated out of province.
Ethical clearance for this study was granted by the Queen’s University Health Sciences Research Ethics Board. The project was also approved by the Ontario Ministry of Health and Long-Term Care (MOHLTC), as well as the Privacy Office at the ICES, which holds prescribed entity status under Ontario’s privacy law and has the authority to collect and use provincial and national administrative health care data without individual consent.
The spouses and dependents of active CAF personnel and recently deployed reservists who applied for Ontario Health Insurance Plan (OHIP) coverage between April 1, 2008 and March 31, 2013 were identified using data provided by the MOHLTC. For OHIP purposes, a spouse was defined as a married partner, common law status, cohabitation for more than 1 year, or parents of a child. A dependent was considered a child under 22 years of age, or older than 22 years but with a mental or physical disability, as defined by restrictions to who may apply as a dependent for provincial health insurance coverage.
A comparator group was created by matching civilians on age, sex, and Local Health Integration Network (LHIN) of residence at a ratio of four civilians for one military family member. Our choice of referent group reflected our interest in studying the total effect of relocation, as well as membership in the military family (separation, risk) on health care access and use, with a more stable population. The OHIP registration date of the military family was used as the index date for entry into the cohort for both the military family and matched civilian reference group. Individuals were followed until death, out-of-province relocation, or for up to 3 years following the index date. Three years was chosen to reflect common timings between CAF postings. The last date of follow-up was March 31, 2014.
This study combined six administrative data sets held at ICES. These data sets were linked at the individual level using unique encoded identifiers and analyzed at ICES. The Registered Persons Database provided demographic data (age, sex, community-level socioeconomic status, rurality of residence, and LHIN). The OHIP database provided information on physician services, including consultations and immunizations, as well as diagnostic information. Physician specialty was measured using the ICES Physician Database. The National Ambulatory Care Reporting System (NACRS) provided diagnostic and service information on emergency department (ED) visits. The Canadian Institute for Health Information Discharge Abstract Database (CIHI-DAD) and the Ontario Mental Health Reporting System (OMHRS) database provided information on hospital admissions. Linkage of individual-level data on demographics, physician billings, and emergency department and inpatient admissions was possible across databases using encrypted, unique personal identifiers.
In this study, we also described and compared the use of various publicly funded medical health services use between military families and the civilian reference group. Physician visits were measured using OHIP data and sub-classified as being with a family physician, paediatrician, paediatric specialist, or non-paediatric specialist. Paediatric consultations were only measured in individuals who were aged 19 years and younger at the time of the study start date. ED visits were measured using the NACRS database. Hospitalizations were measured using the CIHI-DAD database. Medical and mental health services use may be influenced by different individual and system factors, and the discussion of both exceeds the scope of a single manuscript. Mental health-related physician visits, ED visits, and hospitalizations were excluded by removing all encounters associated with a primary International Classification of Disease Versions 9 and 10 (ICD-9 and ICD-10) mental disorder diagnosis, all psychiatrist visits, and all hospitalizations occurring in the OMHRS.
Influenza vaccinations were identified using OHIP records and the following billings codes G590, G591. Non-influenza vaccinations were measured using the following billing codes: G840, G841, G842, G843, G844, G845, G846, G847, G848, and G538. These other vaccinations included diphtheria, tetanus, hepatitis, human papilloma virus, measles, mumps, rubella, meningococcal, and others.
Medical health services use for each category was measured as dichotomous outcome (yes/no) and as a count (number of visits). First contact with the health care system was defined as the first visit to a physician, ED, or hospitalization. If more than one contact occurred on the same day, a hierarchy was used to assign the type of first contact. The type of first contact (categorical variable), as well as the time from index date to the date of first contact (number of days) was described and compared.
Descriptive analyses were presented using frequencies, means, and medians. Categorical data were compared between the military family and civilian reference groups using chi-square tests for independence. Relative risks and 95% confidence limits were calculated. Skewed continuous data were compared using non-parametric analysis of variance (ANOVA) and Kruskal-Wallis tests. Matching in the study design controlled for age, sex, and LHIN of residence. Baseline characteristics, such as age, were measured at the study start date. Age-stratified comparisons were performed to separately look at children, youth, and spouses in military families, as well as to explore potential age-specific patterns and differences in health services use. This stratification allows for the possibility to target more specific interventions, where needed. For the purpose of this study, age categories (in years) were chosen to match other general population reports, and individuals were categorized as being 0–6, 7–9, 10–14, 15–19, 20–24, 25–34, 35–40, and 41+. All analyses were performed using Base SAS 9.3, copyright 2011 (SAS Institute, Cary, NC, USA).
We identified 9,471 records of military spouses and dependents who registered for provincial health coverage following the Fairness for Military Families Act; 85% relocated to Ontario from another province, 14.7% relocated from out of country and less than 1% were the families of reservists returning from active duty. Of these, 7,897 spouses and dependents registered for OHIP during the study timeframe, and 7,508 were included in this study (Figure 1); 30,032 matched civilians constituted the reference group. Military spouses and dependents were followed for an average of 2.5 years. The civilian reference group was followed for an average of 2.6 years.
Table 1 compares characteristics of the military and civilian groups. The median age of the CAF spouses and dependents cohort was 13 years (IQR 5–32); 50% of individuals under 20 years of age were female, while almost 100% of military family members 20 years and older were female (see Figure 1). Ninety percent of the military family cohort lived in three geographic areas of Ontario, close to the active CAF bases in the province. Relative to the civilian reference group, a significantly smaller proportion of the military cohort lived in the communities with the lowest median income (p < 0.001). Military family members were more likely to live in urban or rural residences than the civilian reference group, and less likely to live in remote rural areas (p < 0.001).
Table 2 compares first contacts with the health care system between the military family and civilian groups. 10.7% of the civilian cohort did not have any contact with the health care system during the study time period, compared with 7.6% of the military family cohort (p < 0.001). A family physician was the first contact with the health care system for the majority of both groups; however, more than twice as many civilians than military family members had a first contact with a paediatrician, paediatric specialist, or non-paediatric specialist (p < 0.001). Military family members experienced a significantly longer interval to first contact; 118 days versus 83 days (p < 0.001). This difference was consistent across age categories, although the length of the interval varied by age (see Figure 2). Time to first visit with a family physician was shorter than for a specialist, for both the military family and civilian reference groups. For the military family group, time to first visit with a family physician or specialist ranged from a median of 136 days (IQR 70–289) to 327 days (IQR 164–582) respectively, compared with 121 days (IQR 45–286), and 249 days (IQR 85–533) for the civilian reference group (absolute differences of approximately 2 weeks and 11 weeks). These differences were statistically significant (p < 0.001).
|Military family (n=7,508)||Civilian reference (n=30,032)||p-value|
|Local Health |
|Erie St. Clair||<1.0||<1.0|
|Hamilton Niagara Haldimand Brant||<1.0||<1.0|
| North Simcoe |
|Lowest income quintile||9.0||19.3|
|Highest income quintile||23.0||20.5|
|Rurality of residence||<0.001|
|Rural remote or very remote||3.0||13.6|
* Matched characteristics = age, sex, Local Health Integration Network.
† Unmatched characteristics = rurality, income.
|Military family (n=6,938) |
|Civilian reference (n=26,819) |
|First contact with health care system*|
|Median time to first contact (any)||118 days||84 days||<0.001|
|Interquartile range (days)||63–241||29–207|
* In those who had contact with the health care system.
ED = emergency department.
Table 3 compares the proportion of military families and civilians who accessed medical health services at least once during the study timeframe, adjusted for age, sex, and residential geography and stratified by age. Overall, military family members were significantly more likely to have at least one visit with a family doctor, and significantly less likely to have at least one visit with a paediatrician, paediatric specialist, or non-paediatric specialist for non-mental health reasons than the civilian cohort members. There was some variation in the use of physician services documented by age; however, the trends of differences between the military and civilian cohorts were consistent across age groups. A similar proportion of the military family and civilian reference groups visited the ED for non-mental health reasons. This trend was consistent across age categories, although lower use was documented for military family members aged 15–19 years and for those 41 years and older (17% and 13% lower likelihood respectively). Overall, a similar proportion of the military family and civilian reference groups were hospitalized; however, this was different across age categories. Children and youth aged 0 to 6 in military families were 38% less likely to have a hospital admission during the study timeframe compared to children and youth in the civilian cohort (95% CI, 0.50–0.77). Older dependents and spouses aged 20 to 24 years were over twice as likely as civilian cohort members to be hospitalized (95% CI, 1.78–2.88).
A statistically significantly smaller proportion of military family members had a record for receiving the influenza vaccine, compared to the civilian reference group; however, the absolute difference was only 1% (15.5% vs. 16.5%) and not clinically meaningful. A smaller proportion of military children and youth received other vaccinations (p < 0.001), relative to the civilian reference group. Children and youth in military families were 28% less likely to have a non-influenza vacation documented during the study timeframe, compared to civilian cohort members (95% CI, 0.67–0.76). The probability of vaccination was different by age category.
|Medical health services use||Age category (years)||Military family (≥1visit)(%)||Civilian reference (≥1visit) (%)||Relative risk (95% CI)||p-value|
|Family physician||All ages||84.7||81.1||1.04 (1.02–1.07)||<0.001|
|Paediatrician||All ages||22.3||32.8||0.68 (0.63–0.73)||<0.001|
|Paediatric specialist||All ages||7.3||8.6||0.85 (0.76–0.95)||0.004|
|Non-paediatric specialist||All ages||55.4||59.5||0.93 (0.89–0.97)||<0.001|
|ED visits||All ages||46.0||46.5||0.99 (0.96–1.02)||0.45|
|Hospitalization||All ages||9.1||9.0||1.01 (0.93–1.10)||0.79|
|Flu vaccination||All ages||15.5||16.5||0.94 (0.88–1.00)||0.03|
|Other Vaccinations||All ages||22.9||32.0||0.72 (0.67–0.76)||<0.001|
† Age (reference category = civilian matched cohort, n=30,032).
‡ Matched characteristics = age, sex, Local Health Integration Network of residence.
RR = relative risk; LCL = lower 95% confidence limit; UCL = upper 95% confidence limit; ED = emergency department.
|Military family (n=7,508) ||Civilian reference (n=30,032) ||p-value|
|Average no. of visits* |
|Mean (SD)||Mean (SD)|
|Family physician||5.9 (6.1)||6.8 (6.1)||<0.001|
|Non-paediatric specialist||4.6 (5.5)||5.1 (7.0)||<0.001|
|Paediatrician||3.0 (3.1)||4.3 (5.2)||<0.001|
|Paediatric specialist||2.1 (2.3)||2.5 (3.6)||0.03|
|ED visit||2.6 (2.5)||2.6 (2.8)||0.40|
|Hospitalization||1.2 (0.9)||1.3 (1.0)||0.05|
* Health care use intensity was measured as the average number of visits or hospitalizations per person, in those who used the service at least once.
ED = emergency department.
Table 4 compares the average number of visits or hospitalizations between military families and civilians who accessed medical health services at least once during the study timeframe, and adjusting for age, sex, and residential geography. On average, for those who saw a physician, military family members had significantly fewer visits than their civilian counterparts; the absolute difference was approximately one visit. On average, for those who went to the ED or were hospitalized, military families and the civilian cohort members accessed these services a similar number of times.
This is the first Canadian study to quantify potential issues in the access to and use of health services for the spouses and dependents of active CAF members and fills a gap in knowledge about the health of Canadian military families. We documented differences in overall and age-specific health service use patterns between CAF family members and civilians who were matched for age, sex, and geographic location in Ontario. We documented higher rates of ED use as the first contact in the system, differences in the length of time to first use of health services, and slightly higher use of a family physician following a new posting to Ontario, compared to a matched civilian reference group. This study did not touch on continuity of care, and the family physicians’ visits may be associated with walk-in clinics, rather than a consistent primary care provider team. We also documented lower use of paediatricians and paediatric specialists, as well as lower rates of immunizations for children and youth. We also documented reduced use of non-paediatric by CAF family members 41 years and older and higher rates of hospitalization in CAF civilian family members aged 20–34 years. These differences suggest possible interruptions, compromised access to the provincial health care system, or different needs for Canadian military families.
No other study has described potential health care access issues for military families using routinely collected data or compared health services use with a civilian population. A limited number of studies in the United States have investigated the impact of military spouse/parent deployment on the use of health care services for the non-military family members.16 Larson et al. (2012) demonstrated that deployment changes the range of health care services used and shifts access points from military-specific providers, to private service provision. Eide et al. (2010) concluded that in single parent military families, dependent medical health care utilization decreases when the military spouse is deployed and utilization increases during the same time period in two parent families.17 However, these studies do not include a civilian comparison and are not generalizable to the Canadian context, as they are specific to American military operations and a combined private and military health care system.
Our findings support the Military Ombudsman’s call to action for more objective, quantitative research on the health of military families in Canada and underscore the concerns voiced previously by military families across the country concerning their health care needs, and the needs of their children.3,7 Our findings of longer time to first contact with health services and reduced access to medical specialists substantiate the conclusions of the Military Ombudsman that a concerted effort from the federal government, as well as our provincial and territorial health care systems, to support the health of CAF families is required.3 It is not clear if Canadian military families have different physical health needs, compared to civilian families, which may explain the differences in health services use. For example, higher rates of non-psychiatric hospitalizations in women aged 20–34 years may reflect a greater likelihood of pregnancy and child birth and therefore a greater need for support and resources in family planning during relocations. Data describing the health status of military families are needed to better provide supportive health services.
Several national health care associations in partnership with the Canadian Forces Morale and Welfare Services and the Vanier Institute of the Family are already actively engaged in initiatives to advance awareness, knowledge, and competency of their membership to effectively recognize and address access to care issues for military families. The College of Family Physicians of Canada recently published a guide for Canadian family physicians working with military families,6 and the Canadian Paediatric Society published a position statement describing special considerations in the care of military-connected children and youth.5 Health care providers should consider routinely asking clients about a family connection to military service, especially in practices where the region has a strong military presence. Providing additional support to new patients as they face the challenges of relocation, as well as to patients transitioning out of their practice to other geographic locations could alleviate some of these concerns.
These first data comparing the use of health care services between military family members and a civilian reference group are subject to several limitations. We could not account for clustering within families or identify a cohort of matched civilian families in our analysis, which may mean that we were more likely to find a difference between the groups, where one does not exist. We also did not adjust for all potential confounders, specifically socioeconomic status or rurality. However, given that a larger percentage of military family members lived in high income communities and a smaller percentage lived in the most rural communities, it is more likely that we underestimated the magnitude of access and health service use differences. We would have also liked to study the impact of CAF member military service on health care services use, such as rank, deployment13,18; however, these data are not available. In addition, the start point of data collection is not equal between groups (first accessing the system versus long-time residents), which does not allow us to separately comment on the ease of transition for military families into a new system compared to other Canadians moving across provinces. However, our reference group comparisons between military families and civilians capture the total effect of being in a military family and this includes accessing a new system and system navigation in a new area, which are of importance to the military family community and stakeholders. Comparing the transition of military families to other transitioning families and newly arrived OHIP registrants, who may be refugees or immigrants new to the Canadian health care system and experiencing a separate set of access issues was inappropriate. Finally, this study may have underestimated access issues for military families, if in fact they have a greater need for health care services. However, this study could not address the competing issues of need and access with the available data. Future work quantifying the types of health issues military families experience, especially related to mental health, are required.
This is the first study to quantify prolonged time periods from entry into the province to first use of health services for military families and to identify different patterns of medical health services use, compared to the civilian population, supporting the hypothesis that discontinuity of care across provinces or postings exists. These results are likely generalizable to military families relocated across the country, although the type and intensity of access issues may differ across provincial health care systems. Further studies addressing continuity of care, as well as targeting access to, and use of, mental health services are needed. Studies describing trajectories of care for military families with complex health care needs, as well as potential adverse outcomes such as missed or incomplete diagnoses are forthcoming. Inter-provincial and international comparisons of access issues within similar, public systems would allow a more complete understanding of the depth and scope of health care access issues faced by military families. These baseline data will allow follow-up studies evaluating the success of newly implemented programs and policies to remediate transitional issues will allow the maintenance of the family structure and unit across new postings and deployments.
|1.||Mahar AL, Aiken AB, Cramm H, A new resource to study the health of military families in Ontario. J Mil Vet Fam Health. 2015;1(2):3–4. https://doi.org/10.3138/jmvfh.1.2.002. Link, Google Scholar|
|2.||Vanier Institute of the Family. By the numbers: Military families in Canada. Ottawa, ON: Vanier Institute of the Family; 2012. Google Scholar|
|3.||Ombudsman Department of National Defence and Canadian Forces. On the homefront: assessing the well-being of Canada’s military families in the new millennium. Ottawa: Ombudsman National Defence and Canadian Forces; 2013. Google Scholar|
|4.||Darr W, Doan B. An examination of Canadian Forces spouses’ access to a family physician. Ottawa: Defence R&D Canada, Director General Military Personnel Research & Analysis, 2011. Contract No.: Technical Memorandum DGMPRA TM 2011–011. Google Scholar|
|5.||Rowan-Legg A. Caring for children and youth from Canadian military families: special considerations. Ottawa, ON: Canadian Paediatric Society; 2016. Google Scholar|
|6.||The College of Family Physicians of Canada; Canadian Military and Veteran Families Leadership Circle. Family physicians working with military families. Mississauga, ON: College of Family Physicians of Canada; 2016. Google Scholar|
|7.||Office of the Veterans Ombudsman. Support to military families in transition: A review. Ottawa, ON: Veterans Ombudsman; 2016. Contract No.: V104–11/2016E-PDF 978–0-660–04426–2. Google Scholar|
|8.||Vogel L. Military urges provinces to improve access to health care for soldiers’ families. CMAJ. 2014;186(1):E15–6. https://doi.org/10.1503/cmaj.109-4670. Medline:24295860 Google Scholar|
|9.||Burrell LM, Adams GA, Durand DB, The impact of military lifestyle demands on well-being, army, and family outcomes. Armed Forces Soc. 2006;33(1):43–58. https://doi.org/10.1177/0002764206288804. Google Scholar|
|10.||Chandra A, Lara-Cinisomo S, Jaycox LH, Children on the homefront: the experience of children from military families. Pediatrics. 2010;125(1):16–25. https://doi.org/10.1542/peds.2009-1180. Medline:19969612 Google Scholar|
|11.||Chandra A, London AS. Unlocking insights about military children and families. Future Child. 2013;23(2):187–98. https://doi.org/10.1353/foc.2013.0010. Medline:25518698 Google Scholar|
|12.||Dimiceli EE, Steinhardt MA, Smith SE. Stressful experiences, coping strategies, and predictors of health-related outcomes among wives of deployed military servicemen. Armed Forces Soc. 2010;36(2):351–73. https://doi.org/10.1177/0095327X08324765. Google Scholar|
|13.||Davis BE, Blaschke GS, Stafford EM. Military children, families, and communities: supporting those who serve. Pediatrics. 2012;129(Suppl 1):S3–10. https://doi.org/10.1542/peds.2010-3797c. Medline:22300827 Google Scholar|
|14.||Cramm H, Norris D, Tam-Seto L, Making military families in Canada a research priority. J Mil Veteran Fam Health. 2015;1(2):8–12. https://doi.org/10.3138/jmvfh.3287. Link, Google Scholar|
|15.||Government of Ontario. Fairness for Military Families Act (Employment Standards and Health Insurance), 2007, S.O. 2007, c. 16 – Bill 2. Queen’s Printer of Ontario; 2007. Google Scholar|
|16.||Larson MJ, Mohr BA, Adams RS, Association of military deployment of a parent or spouse and changes in dependent use of health care services. Med Care. 2012;50(9):821–8. https://doi.org/10.1097/MLR.0b013e31825516d8. Medline:22573256 Google Scholar|
|17.||Eide M, Gorman G, Hisle-Gorman E. Effects of parental military deployment on pediatric outpatient and well-child visit rates. Pediatrics. 2010;126(1):22–7. https://doi.org/10.1542/peds.2009-2704. Medline:20530074 Google Scholar|
|18.||Siegel BS, Davis BE; Committee on Psychosocial Aspects of Child and Family Health and Section on Uniformed Services. Health and mental health needs of children in US military families. Pediatrics. 2013;131(6):e2002–15. https://doi.org/10.1542/peds.2013-0940. Medline:23713100 Google Scholar|
All authors conceived, designed, researched, and drafted the manuscript and approved the final version submitted for publication.
Ethical clearance for this study was granted by the Queen’s University Health Sciences Research Ethics Board. The project was also approved by the Ontario Ministry of Health and Long-Term Care (MOHLTC), as well as the Privacy Offi ce at the ICES, which holds prescribed entity status under Ontario’s privacy law and has the authority to collect and use provincial and national administrative health care data without individual consent.