This Research Review examines two Studies one qualitative and

This Research Review examines two Studies one qualitative and another one quantitative regarding stigma and barriers on health and mental health issues that make military personnel seek help outside military services. Wars and multiple conflicts in the world have lead to massive deployment of military personnel for fights, protection of civilians and peace keeping; beside a number of military who lose their lives, those who survive are vulnerable to different mental health problems but find difficult to disclose their mental health status or seek treatment in their services due to fear of stigma; they choose to solicit help outside their services ( Colman et al 2017; Waitzkin et al 2018).

These two studies aims at exploring the different problems and causes of these issues in order to change the situation tackle stigma and promote help seeking for mental health problems in military personnel.

The first is quantitative study about "Military Personnel Who Seek Health and Mental Health Services outside the Military performed at the civilian resources centre network at University of New Mexico in America"(Waitzkin et al; 2018) .

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The second study is a qualitative one that looks at "Stigma-related barriers and facilitators to help seeking for mental health issues in the armed forces: a systematic review and thematic synthesis of qualitative literature conducted at a military treatment centre at King's Centre for Military Health Research, King's College London, and Weston Education Centre" (Colman et al, 2017) .

This first quantitative study performed at the civilian resources centre Network, at university of Mexico in America; conducted a research on 233 military, who sought help in their services; the research at the Civilian Medical Resource network (CMRN) basis aimed at discovering the common patterns of all the military personnel who requested assistance from their services( Waitzkin et al 2018). The military personnel got referred to them via a hotline managed by faith based and peace organisation located in different states: different materials, methods and methodology were used such as recruitment through the charities, data collection and instruments, devices and tools that they used to carry out the study:the research started in 2005at the Civilian Medical Resource Network. As the personnel was serving in different countries such America, Europe and Asia, accessibility became an issue, the verbal consent by devices such telephone was a useful option was used before the study starts and used technology devices like telephone. Then Data both quantitative and qualitative from the 233-military personnel based in different from countries 2013 to 2016 was taken ( Waitzkin et al 2018).

Different strategies like descriptive statistics were used to characterize participants into the study; determine mental problems for the absences without leave' and then compare the general rate of problems to the ones in recent studies in military population. Serious measures were used to examine regression in mental health problems patient such as suicidal ideation ( Waitzkin at al 2018). As there were doubt that the sample could not represent properly the inferences of parametric logistic regression; randomized re-sampling techniques that do not require normal distribution of data was used and also completed boostrap logistic regression; then regression resulting from the booststrap and non bootstrap analyses were compared but did not reveal significant differences ( Waitznkin et al 2018).

As methodology;Psychologists, Psychiatrists and Social Workers working at the civilian resources centre network Conducted standard interviews every two weeks and every two months to find out their clients' issues and aims in order to supply them diagnosis information through screening. The interviews were compared, interpreted and arranged into coded themes. Data was read several times' to explain general themes and 'focused coding to find out the repetitively of themes. Open coding was relate to 'what are the client's most serious worries?' and 'why is the client soliciting health services from a no-military provider''. Responses were like 'medical care needs', 'neglect 'fear of experiencing trauma' and racial discrimination mistrust of the command, insufficient and unresponsive services and deception during recruitment where the information was misleading or incorrect. In the focussed coding popular themes such as 'unmet health needs'' unable to see military doctor'; 'prohibited from seeking second opinion'' and cost especially in 'Absence without Leave' personnel where some military decided to be absent to stay with their families due to health, social and financial concerns. Some participants claimed suffering of sexual trauma like sexual assaults; gender identity disorder, enlistment remorse about killing and filling guilt for example before deployment for going kill other people and pre-existing disorder tha have not been assessed when the joined the army (Waitzkin; et al 2018). From the results the researchers constructed a table of distribution of themes frequencies. However in respect of the methodology, it was advised to associate qualitative themes and quantitative demographic findings with regards to validity and generalisability matters. (Waitzkin et al; 2018.

Regarding the frequency : the most frequent theme that recorded a high percentage was "insufficient and unresponsive services' (93%), fear of reprisal for seeking services (56%), mistrust of command (48%), pre-existing mental health (22%), military sexual trauma (22%) and cost as a barrier to receiving health care (19%).It was stressed that, 80% of the military personnel referred to the civilian resources centre network; has mental problems, 20% had physical issues and a 10% involved in both mental and physical health problems. A great number of clients were associated with pre-military (46%) and military (73%) physical trauma. Seventy-two percent showed an increased level of depression, (62%) by post trauma depression, 48% were concerned with suicidal ideation and (20%) with absence without leave" (Waitzkin et al 2018). .

.Regarding limitation and weaknesses, this quantitative research has limitation and weakenesses: It was conducted on only military that were referred to the civilian centre by faith and peace-based organisations, thus results could not be generalized on all military personnel who experience mental health issues in other places. Also the centre started to care for them from the time they were referred to it thus has little knowledge about for example factors such as the work environment where they were bases, the relationship with their colleagues and command; beside this, the research environment was completely different to the military one as it is a civilian centre staffed with Volunteers except one part time Centre activities Coordinator( Waitzkin et al 2018). There were, the limitation in terms of research methods, such as not adopting randomized controlled trial, or control group to avoid ethical issues emerging from requested support. The cost was another issue; the civilian centre used only funding from 'Robert Wood Johnson foundation centre for health policy at University of Mexico and donations through the Allende Program in Social Medicine', but did not want to apply for more funding anywhere else to avoid conflict of interest or reporting necessity that could limit the civilian resources centre network abilities to respond to army forces goals (waitnzkin et al 2018).

The second study that is qualitative took place at King College military treatment centre in London; It came to shed light on concerns that researchers have about why a number of military personnel suffering metal health were not requesting help in their available treatment centres and preferred to solicit help from outside their services? A brief answer was that the participants did not like to discuss some sensible themes such as 'no trust to the command; neglect or mistakes made in the recruitment processes with people working in a military centre; such ethic issue was one of the reasons of seeking help outside the military( Colman et al 2017). It came to compensate the quantitative study in order to find consistent solution to the problems.

Mental health is a social constructed phenomenon despite being a very common health condition known in health services, professionals and in the society; the researcher at King college in London noted that in the military service environment, some soldiers did not want to open up about mental health, kept it secret and were suffering in silence; some of the Patients expressed concerns about being treated differently once their command and colleagues new their mental health status and prefer to seek help and support outside the military service ( Coleman et al 2017). The other ones have a feeling that the stigma attached to mental health would make them being labelled 'weak' and less mentally capable to a demanding military work; what could lead to rejection and discrimination from their colleagues and command; Those who were brave to seek help from their military services were some time told they were healthy or their request could not be taken seriously (Colman et al 2017). Also a group of MPS from the house of common who looked into these issues agreed that despite improvement, it is still obvious that military personnel, veteran and their families who need mental health care are still being completely failed by the system (BBC News, 2019)

The researchers used already available data: they looked at "multi data base text including psychological information; MDLINE,EMBASE, ERIC AND EBM social policy and social work practices work (1980 - April 2015); analysed databases between (1980 - 2015); then chose a proportion of studies against the selected scale that was cleared of irregularities. Inclusion/ exclusion assisted in selecting only reliable studies" (Colman et al 2017). "Empirically based studies analysed help seeking and stigma in military or veteran populations, using mixed methods with a qualitative constituent, on adults from the age of 18 to 59.The critical Skills Programme (CASP) tool helped to assess the quality of the methods used. Three low quality studies were excluded while appraisal skills programme tool helped to test the literature. Five coded themes produced 8 studies; with 1012 participants fulfil the inclusion basis. The five themes were: non-disclosure, individual beliefs in mental health; anticipated and personal experience of stigma, carrier concerns, and factors influencing stigma .they performed a data synthesis by using thematic synthesis. The researchers highlighted all the findings discussed but did not analyse Relationship between research and participant due to inability to include any evidence of good reflective practice; these studies aimed at: the barriers and help seeking, the facilitator issue for help seeking; 'distress and expressed stigma', beliefs in mental health medical support; signs and assistance request attitude" (Coleman et al 2017).

The House of Common inquiry into Armed Forces mental health issues, among both serving personnel and veterans, found out that most of the veterans leave the services with no life-effect of mental health but the public still view them as 'mad', 'bad' or 'sad'; and it is those public stereotypes that hurt veterans morally (House of Common 2019). But more than '90% of soldiers and Marines returning from Iraq reported encountering stressors relate to roadside bombs, length of deployment, handling human remains, killing, an enemy, seeing dead or injured Americans, and being unable to stop a violent situation'(Greene-Shortridge et al 2007).

As method of analysis; "four studies employed thematic analysis, three used content analysis and one used interpretative phenomenological analysis and one was eliminated for being unclear. Two studies relied on mixed-method designs that added a quantitative component like questionnaires and samples. Two studies retained both focus groups and interviews; seven studies employed a reliable hiring approach whereas the remaining study had a responsible individual to command the members to join the focus groups" (Colman et al2017).

Findings in both studies "highlighted that stigma and help seeking for mental health difficulties in the military services were very interrelated; the public and institutional stigma was evident: people seemed to discriminate individuals with mental health; Own internalized stigma that leaded to low self- esteem appeared to be significant as well. Some military personnel felt ashamed and demoralized such as, I m a seen as a 'dangerous, I am crazy, weak'," (Colman et al 2017; Waitzkin). "Military traumatic experiences can create ethical dilemmas that result in moral injury; Issues such as isolation, social anxiety, depression and suicide ' thus shame attached to the trauma experience acts as a barrier to care seeking"(Gaudet et al 2015).

The two "studies had the same research objective and implication that was to understand the clients' characteristics and concerns of no seeking care in their military services in order to advise on solutions and necessary measures to reduce stigma and promote help seeking. The research at the military treatment centre in London used a big sample: 1072 participants whereas the civilian centre at University of Mexico used only 233 clients ( Colman et al 2017; Waitnkin et al 2018). Bryman advises that sampling should be representative, carefully carried out for reliable results and expresses that random sampling is the best way to achieve inclusion (Bryman , 2016); but in these studies especially at the Civilian centre the staff choice or decision on the sample were not possible they only work with volunteers and deal with those who seek help at their Centre; also the could not use random sampling to avoid ethical issue (

The two "studies departed from different research methods and methodology: the Civilian Centre Network at University of Mexico used interviews whereas, at King College in London they choose to search already available data; but arrived at the same conclusion that; stigma towards mental health in military personnel is evident and the command attitude towards those who disclosed their status was not encouraging , also the military treatment Centres being double agencies for the command and the personnel was not trustable" (Colman et al 2017; Waitfkin et al 2018).

Concerning implication of practice, "deduction from both studies recommended professionals to help reduce the stigma and support seek for help. Also screening of military personnel was suggested to facilitate an early diagnosis including those with own stigma. The recruitment process should be carefully conducted: recruitment staff needs to provide clear and correct information because some military stated that they had a history of mental health but were ignored and some of them were even told to not mention it on their application form" (Waitnzkin et al 2018; Colman et al 2017).

To conclude, "both studies claim that stigma towards mental health problems is obvious in military services. The very demanding military job expects the personnel to be physical and mentally strong, thus the command and colleagues tend to lose trust into personnel with mental health. Military treatment services may neglect or minimise the symptoms and provide inappropriate treatment. The two studies recommend professionals to help reduce stigma. An ethics issue appeared at the military treatment centre at king college, presented as being a '' double agency': serving the personnel and the command; the personnel could not trust them and were reluctant to discuss issues such as fear of killing other people, or seeing colleagues being killed, also worried about confidentiality( Waitzkin et al 2018) . This was the main cause of seeking help outside military health services" (Colman et al 2017; Waitzkin et al 2018). The civilian resource centre Network is convenient to accommodate military personnel needs, as they operate in different policies and procedures (Waitzkin,et al 2018). Both studies had some limitations, the study conducted at king college in London had to leave out study results that were qualified 'poor' (Colman et al 2017). The civilian centre had limited funding, only received support from the 'Robert Wood Johnson foundation centre for health policy at University of New Mexico and donation through the Program in social Medicine Allende to avoid conflict of interest (Waitzkin et al 2018) ,and could not use randomised controlled trial as well to eliminate conflict of interest from assistance providers.