Improving health in the military and beyond using salutogenic design

Purpose Service members of the US Department of Defense (DoD) have alarmingly high rates of depression, anxiety, probable stress disorders and suicidality, all of which are negative health conditions exacerbated by various external stressors. High-stress work conditions – to include shift work, hazardous territories, high-stakes mission sets and generally disconnected sites – require a work environment that facilitates, rather than inhibits, stress reduction and mental well-being. This paper aims to present “salutogenic design” as an innovative approach: Salutogenic design offers demonstrated architectural solutions that improve health and well-being. Design/methodology/approach This paper describes salutogenic design strategies beginning with the need for such an approach, the call to action to implement strategic and tactical solutions and the challenges and financial impacts of such a broad and innovative strategy to improve workplace health, well-being and performance in the DoD and beyond. Examples of these strategies, via biophilic design solutions, are presented in the central Table 1 as an easy-to-reference tool and supported by the voluminous literature as referenced, in part, through this research paper. Findings Salutogenic design strategies offer innovative, financially viable solutions to help mitigate stress and improve workforce well-being while maintaining the highest level of building security requirements in access-controlled spaces and disconnected sites, such as military installations and government compounds. Research limitations/implications Issues of mental and physical health are complex and multi-faceted, and they require complex and multi-faceted solutions. Salutogenic design is presented as one facet of that solution: a tangible solution to an often-intangible issue. Further, as a novel approach to address a critical DoD issue, Table 1 bridges the common gap between high-concept design theory and practical construction-application solutions, with positive value to the health, performance, quality-of-life and well-being of service members. Originality/value To the best of the author’s knowledge, this paper is the first to approach the DoD’s imperative to reduce service members’ mental stress with “salutogenic design.”

Military service experiences and reasons for service separation among lesbian, gay, and bisexual individuals in a large military cohort

Background The well-being of lesbian, gay, and bisexual (LGB) individuals is a topic of increasing concern within the military where significant institutional barriers, targeted aggression, and differential organizational policies such as “Don’t Ask Don’t Tell” have historically contributed to experiences of exclusion and discrimination. However, limited research has examined specific military and post-separation experiences among LGB service members and veterans. The goal of this study was to examine differences in military and service separation experiences by sexual orientation among a large representative sample of United States service members and veterans. Methods Survey data from the 2016 Millennium Cohort Study follow-up questionnaire were used to assess sexual orientation and multiple outcomes of interest: military experiences (morale, feelings about the military, missed workdays) and service separation experiences (reasons for separation, post-separation employment). The associations between sexual orientation (LGB versus heterosexual) and each of these outcomes were evaluated in a series of adjusted logistic regression models, stratified by sex when interactions were observed. Results Of the 99,599 participants, 3.4% identified as LGB. In adjusted models, LGB service members had significantly higher odds than heterosexual service members of feeling: unimpressed by the quality of unit leadership, unsupported by the military, and negative about the military overall. Bisexual women were more likely than heterosexual women to feel less unit camaraderie; both gay and bisexual men felt less camaraderie than heterosexual men. LGB veterans were more likely than heterosexual peers of the same sex to separate from service due to unplanned administrative reasons. Compared to heterosexual women, lesbian and bisexual women were more likely to separate from service due to dissatisfaction with promotions/pay and disability/medical reasons, while bisexual women specifically separated due to dissatisfaction with leadership and incompatibility with the military. Gay and bisexual men also reported separating due to incompatibility with the military, but only bisexual men were more likely to report separating due to disability/medical reasons compared to heterosexual men. Conclusions Less positive military- and separation-specific experiences disproportionately affected LGB service members in this study. Promoting inclusion and increasing support for LGB service members may improve satisfaction with military service and retention.

Evacuation Strategies for U.S. Casualties with Traumatic Brain Injury (TBI) with and without Polytrauma

ABSTRACT Introduction According to the Military Health System Traumatic Brain Injury (TBI) Center of Excellence, 51,261 service members suffered moderate to severe TBI in the last 21 years. Moderate to severe TBI in service members is usually related to blast injury in combat operations, which necessitates medical evacuation to higher levels of care. Prevention of secondary insult, and mitigation of the unique challenges associated with the transport of TBI patients in a combat setting are important in reducing the morbidity and mortality associated with this injury. The primary goal of this study was a secondary analysis comparing the impact of time to transport on clinical outcomes for TBI patients without polytrauma versus TBI patients with polytrauma transported out of the combat theater via Critical Care Air Transport Teams (CCATT). Our secondary objective was to describe the occurrence of in-flight events and interventions for TBI patients without polytrauma versus TBI with polytrauma to assist with mission planning for future transports. Materials and Methods We performed a secondary analysis of a retrospective cohort of 438 patients with TBI who were evacuated out of theater by CCATT from January 2007 to May 2014. Polytrauma was defined as abbreviated injury scale (AIS) of at least three to another region in addition to head/neck. Time to transport was defined as the time (in days) from injury to CCATT evacuation out of combat theater. We calculated descriptive statistics and examined the associations between time to transport and preflight characteristics, in-flight interventions and events, and clinical outcomes for TBI patients with and without polytrauma. Results We categorized patients into two groups, those who had a TBI without polytrauma (n = 179) and those with polytrauma (n = 259). Within each group, we further divided those that were transported within 1 day of injury, in 2 days, and 3 or more days. Patients with TBI without polytrauma transported in 1 or 2 days were more likely to have a penetrating injury, an open head injury, a preflight Glascow Coma Score (GCS) of 8 or lower, and be mechanically ventilated compared to those transported later. Patients without polytrauma who were evacuated in 1 or 2 days required more in-flight interventions compared to patients without polytrauma evacuated later. Patients with polytrauma who were transported in 2 days were more likely to receive blood products, and patients with polytrauma who were evacuated within 1 day were more likely to have had at least one episode of hypotension en route. Polytrauma patients who were evacuated in 2–3 days had higher hospital days compared to polytrauma with earlier evacuations. There was no significant difference in mortality between any of the groups. Conclusions In patients with moderate to severe TBI transported via CCATT, early evacuation was associated with a higher rate of in-flight hypotension in polytrauma patients. Furthermore, those who had TBI without polytrauma that were evacuated in 1–2 days received more in-flight supplementary oxygen, blood products, sedatives, and paralytics. Given the importance of minimizing secondary insults in patients with TBI, recognizing this in this subset of the population may help systematize ways to minimize such events. Traumatic Brain Injury patients with polytrauma may benefit from further treatment and stabilization in theater prior to CCATT evacuation.

Examination of military personnel’s changed psychological states during long-term deployment in a war zone

Examining military personnel’s psychological states is an effective way to prevent negative mental health consequences during their deployment in a war zone. The present study identifies changes in the psychological states of military personnel (n = 192) during a 6-month deployment in a war zone in eastern Ukraine. The results confirmed both of our proposed hypotheses. First, with regard to time limits on military personnel’s deployment on the front lines in eastern Ukraine on the basis of examined psychological states, the estimated recommended deployment duration was three months. Second, we found significant differences in the dynamics of the psychological states of service members with versus without previous deployment experience. The results also substantiate that military personnel’s psychological states should be monitored during deployment in order to prevent negative mental health consequences and to ensure that military units successfully accomplish their tasks. Una de las formas más eficaces para prevenir las consecuencias negativas del despliegue en la zona militar para la salud mental de los militares es diagnosticar su estado psicológico. En el presente estudio se determinan las particularidades de los cambios en el estado psicológico de los militares (n = 192) durante el despliegue de seis meses en la zona militar en el este de Ucrania. Los resultados obtenidos confirmaron ambas hipótesis formuladas: en cuanto a la posibilidad de determinar, sobre la base del diagnóstico del estado psicológico, el plazo recomendado para el despliegue de los militares en la línea de demarcación en el este de Ucrania, que es de tres meses. Así como también sobre las posibles diferencias significativas en la dinámica del estado psicológico de los militares que tienen y no tienen experiencia en el despliegue. Asimismo, se argumenta la necesidad de monitorear el estado psicológico de los militares durante el despliegue con el propósito de prevenir oportunamente las consecuencias negativas para su salud mental y para la ejecución exitosa de las tareas de la subunidad militar.

The Role of Program Evaluation in Keeping Army Health “Army Strong”: Translating Lessons Learned Into Best Practices

ABSTRACT Service Members and military beneficiaries face complex and ill-structured challenges, including suicide, sexual violence, increasing health care costs, and the evolving coronavirus pandemic. Military and other government practitioners must identify effective programs, policies, and initiatives to preserve the health and ensure the readiness of our Force. Both research and program evaluation are critical to identify interventions best positioned to prevent disease, protect the public’s health, and promote health and well-being within our ranks to retain a medically ready force and reduce the global burden of disease. While military and medical leaders are typically well versed in research and understand the role of research in evidence-informed decisions, they may be less aware of program evaluation. Program evaluation is the systematic application of scientific methods to assess the design, implementation, improvement, or outcomes of a program, policy, or initiative. Although program evaluators commonly utilize scientific or research methods to answer evaluation questions, evaluation ultimately differs from research in its intent. Several recently published federal and Department of Defense policies specifically reference program evaluation, emphasizing its importance to the military and government as a whole. The Army is uniquely positioned to conduct medical and public health evaluation activities and there are several Army organizations and entities that routinely perform this work. For example, the United States Army Public Health Center (APHC) is among recognized military experts in public health assessment and program evaluation. Given the breadth of our work, the APHC understands the challenges to conducting evaluation studies in the Army and we have thoughtfully examined the conditions common to successful evaluation studies. In this commentary, we share our lessons learned to assist military colleagues, potential partners, and others in successfully evaluating the programs, policies, and initiatives necessary to keep our Service Members and beneficiaries healthy and ready. There are several challenges to executing evaluation studies in the Army that may be relevant across all Services. These include but are not limited to frequent Army leadership transitions, urgency to report study results, lack of program documentation and adequate planning for evaluation, expectation management to ensure stakeholders are well-informed about the evaluation process, and a disorganized data landscape. These challenges may hinder the successful execution of evaluation studies, or prevent them from being attempted in the first place, depriving Army leaders of quality, actionable information to make evidence-informed decisions. Despite the aforementioned challenges, we have identified a number of best practices to overcome these challenges and conduct successful evaluation studies. These facilitators of successful evaluations can be summarized as: collaboration with engaged stakeholders who understand the value of evaluation, evaluation studies aligned with larger strategic priorities, agile methodology, thoughtful evaluation planning, and effective communication with stakeholders. We wholeheartedly recommend and encourage program evaluation at every opportunity, and we anticipate the call for evaluation and evidence-informed decisions to continually increase. Our hope is that others – to include partners and stakeholders within and external to the military – will be able to leverage and apply this information, especially the identified best practices, in their evaluation efforts to ensure success.