Bonds and Barriers

Chapter 7 follows nonblack minorities through their training and service in the United States. America’s World War II military, from its top leaders to its enlisted personnel, simultaneously built and blurred a white-nonwhite divide alongside its black-white one. On the one hand, the blurring stemmed from a host of factors, including the day-to-day intermingling of troops, the activism of nonblack minorities, and, paradoxically, the unifying power of the black-white divide among nonblacks. On the other hand, this blurring had its limits. White-nonwhite lines cropped up in some of the same places black-white ones did and in some different ones, too, especially those related to national security and Japanese Americans. In the end, these lines remained in place throughout the war years, despite continuous blurring. They did so in part because of these racialized national security concerns and because of the power of civilian racist practices and investments.

Brain–Immune Interactions as the Basis of Gulf War Illness: Clinical Assessment and Deployment Profile of 1990–1991 Gulf War Veterans in the Gulf War Illness Consortium (GWIC) Multisite Case-Control Study

The Boston University-based Gulf War Illness Consortium (GWIC) is a multidisciplinary initiative developed to provide detailed understanding of brain and immune alterations that underlie Gulf War illness (GWI), the persistent multisymptom disorder associated with military service in the 1990–1991 Gulf War. The core GWIC case-control clinical study conducted in-depth brain and immune evaluation of 269 Gulf War veterans (223 GWI cases, 46 controls) at three U.S. sites that included clinical assessments, brain imaging, neuropsychological testing, and analyses of a broad range of immune and immunogenetic parameters. GWI cases were similar to controls on most demographic, military, and deployment characteristics although on average were two years younger, with a higher proportion of enlisted personnel vs. officers. Results of physical evaluation and routine clinical lab tests were largely normal, with few differences between GWI cases and healthy controls. However, veterans with GWI scored significantly worse than controls on standardized assessments of general health, pain, fatigue, and sleep quality and had higher rates of diagnosed conditions that included hypertension, respiratory and sinus conditions, gastrointestinal conditions, and current or lifetime depression and post-traumatic stress disorder. Among multiple deployment experiences/exposures reported by veterans, multivariable logistic regression identified just two significant GWI risk factors: extended use of skin pesticides in theater (adjusted OR = 3.25, p = 0.005) and experiencing mild traumatic brain injury during deployment (OR = 7.39, p = 0.009). Gulf War experiences associated with intense stress or trauma (e.g., participation in ground combat) were not associated with GWI. Data and samples from the GWIC project are now stored in a repository for use by GWI researchers. Future reports will present detailed findings on brain structure and function, immune function, and association of neuroimmune measures with characteristics of GWI and Gulf War service.

Sex Differences in the Incidence and Risk of Ankle-Foot Complex Stress Fractures Among U.S. Military Personnel

Background: The objective of this study was to evaluate sex differences in the incidence and risk of ankle–foot complex (AFC) stress fractures among U.S. military personnel, which could assist in developing management strategies as females assume a greater role in U.S. military operations. Methods: The Defense Medical Epidemiological Database was used to identify all diagnosed AFC stress fractures in military personnel from 2006 to 2015. Cumulative incidence of AFC stress fractures was calculated and compared by year, service branch, and military rank. Sex differences in the risk of AFC stress fractures by occupation were examined, and integrated (i.e., male and female) occupations were compared with non-integrated (i.e., male–only) occupations. Results: A total of 43,990 AFC stress fractures were identified. The overall incidence rate was 2.76 per 1,000 person-years for males and 5.78 per 1,000 person-years for females. Females consistently had higher incidence of AFC stress fractures across all subgroups, particularly among enlisted personnel. Female enlisted service members had the highest risk of AFC stress fractures in aviation [relative risk (RR) = 5.74; 95% confidence interval [CI] 4.80–6.87] and artillery/gunnery (RR = 5.15; 95% CI 4.62–5.75) occupations. Females in integrated occupations had significantly higher rates of AFC stress fractures than males in both integrated and non-integrated occupations (i.e., special forces, infantry, and mechanized/armor). Conclusions: Females in the U.S. military have a higher risk of AFC stress fractures than males. As integration of females into previously sex-restricted occupations continues, focused prevention efforts may be needed to reduce injury burden and maximize medical readiness.

289 Rack curtains improve sailors’ sleeping conditions in berthing compartments of the United States Navy (USN) ships

Introduction Ambient light is one of the primary factors affecting sailor sleep in berthing compartments on USN ships. Each “rack” (i.e., bunk) has a curtain, however, intended only for privacy. Current rack curtain specifications do not address light-blocking properties. We assessed the effects of replacing existing, standard rack curtains with enhanced rack curtains that provide superior light-blocking in the sleeping environment. Methods Longitudinal (~2 weeks), naturalistic observation of sailors (N=52; 41 enlisted personnel) on a USN destroyer during deployment. The standard curtain was used for one week followed by one week with the enhanced light-blocking curtain. Sleep-related attributes (Epworth Sleepiness Scale–ESS, Insomnia Severity Index–ISI, Pittsburgh Sleep Quality Index–PSQI) were assessed at the end of each week. Actigraphy and rack temperature data (both inside and outside the rack) were collected throughout the study. Results are presented as median±median absolute deviation. Results Participants slept on average 6.8±1.0 hours/day. ESS scores improved with decreases from 9.0±3.0 with standard curtains to 7.0±3.0 with the enhanced curtains (p=0.020). Sailors with normal daytime sleepiness improved from 33 (63.5%) with standard curtains to 40 (76.9%) with the enhanced curtains. ISI scores decreased from 11.0±3.0 to 8.0±2.0 in the two conditions (p<0.001). The number of Sailors with ISI scores ≥15 decreased from 11 (21.2%) with standard curtains to 8 (13.5%) with the enhanced curtains (p=0.103). PSQI scores (8.0±2.0), however, did not change between the control and the intervention periods (p=0.527). Preliminary analysis showed that, compared to outside the rack, temperature inside the rack was slightly warmer on average with new curtains (~1 °F; p=0.096). Conclusion Our results suggest that the enhanced curtains reduced average daytime sleepiness and severity of insomnia symptoms. A greater difference in rack temperature with the enhanced curtains was observed; however, this may be attributed to the ship sailing in southern latitudes during the intervention period. Ongoing analysis will provide more insight on the utility of the enhanced curtains and their efficacy in improving sleeping conditions. Support (if any) Supported by the Naval Medical Research Center’s Advanced Medical Development Program, the US Navy 21st Century Sailor Office, and the US Navy OPNAV N1.

Does the U.S. Navy’s reliance on objective standards prevent discrimination in promotions and retentions?

To prevent discrimination, the U.S. Navy enlisted-personnel promotion process relies primarily on objective measures. However, it also uses the subjective opinion of a sailor’s superior. The Navy’s promotion and retention process involves two successive decisions: The Navy decides whether to promote an individual, and conditional on that decision, the sailor decides whether to stay. Using estimates of these correlated decision-making processes, we find that during 1997–2008, Blacks and Hispanics were less likely to be promoted than Whites, especially during wartime. The Navy’s decision-making affects Blacks’ differential promotion rates by twice as much as differences in the groups’ characteristics. However, Nonwhite retention probabilities, even when not promoted, are higher than for Whites, in part because they have fewer opportunities in the civilian market. Females have lower promotion rates than males and slightly lower retention rates during wartime.

Sleep quality, occupational factors, and psychomotor vigilance performance in the U.S. Navy sailors

Study Objectives This field study (a) assessed sleep quality of sailors on the U.S. Navy (USN) ships while underway, (b) investigated whether the Pittsburgh Sleep Quality Index (PSQI) scores were affected by occupational factors and sleep attributes, and (c) assessed whether the PSQI could predict impaired psychomotor vigilance performance. Methods Longitudinal field assessment of fit-for-duty USN sailors performing their underway duties (N = 944, 79.0% males, median age 26 years). Participants completed questionnaires, wore actigraphs, completed logs, and performed the wrist-worn 3-min Psychomotor Vigilance Task (PVT). Results Sailors slept on average 6.60 ± 1.01 h/day with 86.9% splitting their sleep into more than one episode/day. The median PSQI Global score was 8 (interquartile range [IQR] = 5); 80.4% of the population were classified as “poor sleepers” with PSQI scores >5. PSQI scores were affected by sailor occupational group, rank, daily sleep duration, and number of sleep episodes/day. Sleep quality showed a U-shape association with daily sleep duration due to the confounding effect of split sleep. Sailors with PSQI scores >9 had 21.1% slower reaction times (p < 0.001) and 32.8%–61.5% more lapses combined with false starts (all p < 0.001) than sailors with PSQI scores ≤9. Compared to males and officers, females and enlisted personnel had 86% and 23% higher risk, respectively, of having PSQI scores >9. Sailors in the PSQI > 9 group had more pronounced split sleep. Conclusions Working on Navy ships is associated with elevated PSQI scores, a high incidence of poor sleep, and degraded psychomotor vigilance performance. The widely used PSQI score>5 criterion should be further validated in active-duty service member populations.

Army wives’ consumer vulnerability and communities of coping

Purpose The spouses or partners of serving members of the UK Armed Forces are often subject to similar constraints to those of enlisted personnel. This paper aims to examine the experiences and wellbeing of a group of army wives. In particular, it focuses on their shared experiences of consumer vulnerability and related challenges, exploring the extent to which membership of military wives’ communities can help them to cope. Design/methodology/approach Using an interpretivist approach, data were collected through four focus group discussions involving 30 army wives, and seven individual in-depth interviews. Findings The paper highlights shared experiences of consumer vulnerability and demonstrates how army wives’ approaches to coping incorporate both individual and community-based approaches. It proposes that communities of coping develop within the army wives community, providing women with both practical and emotional support. Research limitations/implications The paper acknowledges that there is a range of factors that will impact military spouses’ experiences of consumer vulnerability and strategies for coping. This heterogeneity was difficult to capture within a small exploratory study. Practical implications The UK Government should consider their duties towards military spouses and children. This would entail a significant cultural shift and recognition of military personnel’s caring responsibilities. Originality/value This research contributes to understandings regarding the potentially shared nature of both consumer vulnerability and coping strategies. The study introduces the relevance of communities of coping to consumer contexts, highlighting how members can benefit from both practical and emotional support.

Determinants of mental and physical health treatment-seeking among military personnel

BackgroundAlthough research has documented factors influencing whether military personnel seek treatment for mental health problems, less research has focused on determinants of treatment-seeking for physical health problems.AimsTo explicitly compare the barriers and facilitators of treatment-seeking for mental and physical health problems.MethodUS soldiers (n = 2048) completed a survey with measures of barriers and facilitators of treatment-seeking for mental and physical health problems as well as measures of somatic symptoms and mental health.ResultsThe top barrier for both mental and physical health treatment-seeking was a preference for handling problems oneself. The top facilitators for both symptom types were related to treatment improving quality of life. Differential endorsement of barriers occurred for treatment of mental versus physical health symptoms. In contrast, facilitators were endorsed more for physical than for mental health treatment. While there were few gender differences, officers reported more barriers and facilitators than did enlisted personnel. Screening positive for mental or physical health problems was associated with greater endorsement of both barriers and facilitators for physical and mental health treatment, respectively.ConclusionsThe leading barriers and facilitators for seeking treatment for mental health and physical problems are relatively similar, suggesting that health education should consider decision-making in seeking both mental and physical healthcare. Interventions should be tailored to reduce barriers for officers and improve facilitators for junior enlisted personnel, and address barriers and facilitators for service members screening positive for a mental or physical health problem.

Exploring the Role of Depressive Symptoms, Service Members, and Spousal Demographic Characteristics on Military Spousal Employment

Military spouses, most of whom are women, often contend with a number of factors that can influence their employment status. Previous studies have examined the role of service-member and spousal demographic characteristics on wives’ employment. However, little is known about the role spousal mental health has on employment while controlling for demographic characteristics. Using repeated-measures logistic regressions, this longitudinal study explored associations between spousal mental health and employment while controlling for service-member and spousal characteristics in a sample of 1,164 women. Fewer depressive symptoms were significantly associated with employment ( p < .05). Spouses of enlisted personnel, women who were older, racial/ethnic minorities, homeowners, or had city stability, had higher odds of employment ( p < .05). Military spouses of active duty service members and those less educated had lower odds of employment ( p < .05). Depressive symptoms and demographic characteristics should guide employment opportunity programs for military spouses.

Clinician Interface and Experience

Clinical applications are evolving from purely transactional systems to systems more capable of providing cognitive support; particularly in the area of decision support, user-centered design and iterative development approaches are leading to improvements. But, at the same time, growing administrative and quality reporting requirements are providing new burdens on clinician time and threaten the clinician-patient experience. Efficiency, usability, and effective workflow integration remain primary concerns. The focus in this chapter is on the user experience, how the electronic health record vendors are working with users and experts to improve this experience. Among the enlisted personnel are not only software and hardware engineers, but also psychologists, physiologists, cognitive neuroscientists, data scientists, stakeholders, and users.