Insufficient Sleep and Behavioral Health in the Military: A 5-Country Perspective.

PURPOSE OF REVIEW: The goal of this paper was to highlight the degree to which sleep, behavioral health, and leader involvement were interrelated using data from militaries in five English-speaking countries: Australia, Canada, New Zealand, the UK, and the United States. RECENT FINDINGS: Many service members reported sleeping fewer than the recommended 7 h/night: 34.9%, 67.2%, and 77.2% of respondents from New Zealand, Canada, and the United States, respectively. Countries reporting shorter sleep duration also reported fewer insomnia-related difficulties, likely reflecting higher sleep pressure from chronic sleep loss. Across all countries, sleep problems were positively correlated with behavioral health symptoms. Importantly, leader promotion of healthy sleep was positively correlated with more sleep and negatively correlated with sleep problems and behavioral health symptoms. Insufficient sleep in the military is ubiquitous, with serious implications for the behavioral health and functioning of service members. Leaders should attend to these risks and examine ways to promote healthy sleep in service members.

Recruiting Military Veterans into Alcohol Misuse Research: The Role of Social Media and Facebook Advertising.

Background: The use of digital technology within health care service delivery, monitoring, and research is becoming progressively popular, particularly given the ongoing COVID-19 pandemic. Mobile health (m-health) apps, one form of digital technology, are increasingly being used to promote positive health related behavior change. Therefore, it is important to conduct research to understand the efficacy of m-health apps. The process of participant recruitment is an essential component in producing strong research evidence, along with ensuring an adequately powered sample to conduct meaningful analyses and draw robust conclusions. Methods: In this work we outline and reflect on the strategies used to recruit help-seeking military veterans into an intervention study, which aimed to evaluate the efficacy of an app (Drinks:Ration) to modify behavior in alcohol misusers. Recruitment strategies included through (1) partner organizations and (2) social media and Facebook advertising (ads). Results: Facebook ads were live for a period of 88 days and were viewed by a total audience of 29,416 people. In total 168 military veterans were recruited across all recruitment strategies, meaning that Drinks:Ration exceeded its recruitment targets. Half of the sample (n = 84) were recruited through social media, including Facebook ads. Conclusions: The current article highlighted that targeted Facebook ads were an efficient strategy to recruit military veterans into a digital intervention trial aiming to reduce alcohol consumption because they reduced the amount of time and resources required to contact a large number of potentially eligible individuals for our study. This article acts as a starting point for other researchers to evaluate their recruitment pathways for recruiting military veterans into alcohol misuse research.

Smartphone-based alcohol interventions: A systematic review on the role of notifications in changing behaviors toward alcohol.

Background: Smartphone-based interventions are increasingly being used to facilitate positive behavior change, including reducing alcohol consumption. However, less is known about the effects of notifications to support this change, including intervention engagement and adherence. The aim of this review was to assess the role of notifications in smartphone-based interventions designed to support, manage, or reduce alcohol consumption. Methods: Five electronic databases were searched to identify studies meeting inclusion criteria: (1) studies using a smartphone-based alcohol intervention, (2) the intervention used notifications, and (3) published between 1st January 2007 and 30th April 2021 in English. PROSPERO was searched to identify any completed, ongoing, or planned systematic reviews and meta-analyses of relevance. The reference lists of all included studies were searched. Results: Overall, 14 papers were identified, reporting on 10 different interventions. The strength of the evidence regarding the role and utility of notifications in changing behavior toward alcohol of the reviewed interventions was inconclusive. Only one study drew distinct conclusions about the relationships between notifications and app engagement, and notifications and behavior change. Conclusions: Although there are many smartphone-based interventions to support alcohol reduction, this review highlights a lack of evidence to support the use of notifications (such as push notifications, alerts, prompts, and nudges) used within smartphone interventions for alcohol management aiming to promote positive behavior change. Included studies were limited due to small sample sizes and insufficient follow-up. Evidence for the benefits of smartphone-based alcohol interventions remains promising, but the efficacy of using notifications, especially personalized notifications, within these interventions remain unproven.

Holding and rupture: Describing post-traumatic stress among former UK Army and Royal Marine personnel deployed to Iraq and Afghanistan.

Former UK military personnel who were previously deployed to Iraq and Afghanistan in combat roles have exhibited elevated levels of Post-Traumatic Stress Disorder (PTSD) compared to other groups. The present qualitative analyses used semi-structured interviews and a framework analysis to compare the experiences of symptomatic (N=10) and asymptomatic (N=7) former Army and Royal Marine personnel who were exposed to combat. Participants were drawn from a large UK military health and wellbeing cohort study and were sampled based upon probable PTSD status using scores from the PTSD Checklist-Civilian Version (PCL-C). All symptomatic participants attributed the development of post-traumatic stress to deployment events, with one additionally ascribing symptoms to childhood events. Among the participants, post-traumatic stress was temporarily buffered, and held at bay, by the holding function of various military structures, including the military collective; cultural and ethical frameworks that helped to organise traumatic experiences; an operational necessity for psychological compartmentalisation and even the distraction of deployment itself. Leaving the military appeared to elicit a global rupture of these supports. As a result, the military-to-civilian transition led to an intensification of post-traumatic stress, including deployment-related memories, among the symptomatic participants. In contrast, asymptomatic participants tended to report continuity of their holding structures across the lifespan, especially across the military-to-civilian transition. The onset and maintenance of post-traumatic stress may thus be explained by an interplay between the capacity of holding structures and the magnitude of lifetime rupture. Overall, findings might provide an explanation for the widening discrepancies between those with enduring post-traumatic stress and those without and further research is required to determine the fit of our findings for other groups and contexts. This approach further illustrates the need to situate individual experiences of post-traumatic stress in wider structural, ecological, cultural and ethical contexts.

Risk and protective factors for self-harm and suicide behaviours among serving and ex-serving personnel of the UK Armed Forces, Canadian Armed Forces, Australian Defence Force and New Zealand Defence Force: A systematic review.

BACKGROUND: Self-harm and suicide behaviours are a major public health concern. Several factors are associated with these behaviours among military communities. Identifying these factors may have important implications for policy and clinical services. The aim of this review was to identify the risk and protective factors associated with self-harm and suicide behaviours among serving and ex-serving personnel of the United Kingdom Armed Forces, Canadian Armed Forces, Australian Defence Force and New Zealand Defence Force. METHODS: A systematic search of seven online databases (PubMed, Web of Science, Embase, Global Health, PsycINFO, PTSDpubs and CINAHL) was conducted alongside cross-referencing, in October 2022. Following an a priori PROSPERO approved protocol (CRD42022348867), papers were independently screened and assessed for quality. Data were synthesised using a narrative approach. RESULTS: Overall, 28 papers were included: 13 from Canada, 10 from the United Kingdom, five from Australia and none from New Zealand. Identified risk factors included being single/ex-relationship, early service leavers, shorter length of service (but not necessarily early service leavers), junior ranks, exposure to deployment-related traumatic events, physical and mental health diagnoses, and experience of childhood adversity. Protective factors included being married/in a relationship, higher educational attainment, employment, senior ranks, and higher levels of perceived social support. CONCLUSION: Adequate care and support are a necessity for the military community. Prevention and intervention strategies for self-harm and suicide behaviours may be introduced early and may promote social networks as a key source of support. This review found a paucity of peer-reviewed research within some populations. More peer-reviewed research is needed, particularly among these populations where current work is limited, and regarding modifiable risk and protective factors.

Shorter communications: Exploring the impact of a brief smartphone-based alcohol intervention app (DrinksRation) on the quality of life of UK military veterans.

Alcohol misuse - defined as consuming more than 14 units of alcohol per week - is a well-established problem among veterans. This study investigated the change in quality of life among help-seeking UK veterans who completed a 28-day brief alcohol intervention delivered via a digital smartphone application (called DrinksRation) and have previously sought clinical help for a mental health disorder. This study was a secondary outcome analysis of data collected during a randomised control trial. In total, 123 UK veterans participated in the study and were randomly allocated to either the intervention or control arm. Participants completed self-report questionnaires regarding their alcohol use and quality of life (WHOQOL-BREF) at baseline, day 28 (end of intervention), day 84, and day 168. At the primary endpoint (day 84), we found significantly greater improvements in the intervention arm compared to the control arm for psychological quality of life (Cohen's d = 0.47), and environmental quality of life (d = 0.34). However, we observed no statistically significant differences between the intervention and control arm for social relationships and physical quality of life. Further, for day 168 we found no significant differences. Findings suggest that DrinksRation can increase quality of life among help-seeking veterans who have previously sought help for a mental health disorder, but the increases were modest and restricted to certain domains. Additional treatment may be needed for long-term and sustained improvements in quality of life.

Caring for the carers: an evaluation of the recovery, readjustment and reintegration programme (R3P).

INTRODUCTION: The challenges faced by healthcare workers, not least during the response to the COVID-19 pandemic, have been extensively studied, and concerns continue to be highlighted in relation to their long-term mental health. Identifying the need to support their personnel, a leader-led structured programme of reflection: the recovery, readjustment and reintegration programme (R3P) was designed by the UK Defence Medical Services to mitigate the potential stressors associated with this outbreak and enhance the resilience of the workforce. METHODS: 128 military personnel completed an evaluation of R3P. A survey included measures of anxiety before and after the intervention, perceptions of the discussion themes and whether these brought a sense of closure to areas of distress, and attitudes to help-seeking. RESULTS: Most respondents (86%-92%) rated the five discussion themes either 'helpful' or 'very helpful', 51% of respondents reported a sense of closure about an issue that had been causing distress and 72% of respondents felt better able to seek help should it be necessary. Evaluating the effect R3P had on anxiety, a Wilcoxon signed rank test elicited a statistically significant difference in anxiety pre-R3P and post-R3P; Z=-3.54, p<0.001. The median anxiety rating was 3.5 (IQR 4.75, 95% CI 1.25 to 6.00) before undertaking R3P, which decreased to 3 (IQR 4.75, 95% CI 1.00 to 5.75) after undertaking R3P. 39.1% of participants reported decreased anxiety, 18.8% reported increased anxiety and 42.2% reported no change. CONCLUSION: This evaluation has identified several positive aspects to R3P with many personnel reporting a reduction in anxiety, a sense of closure and increased likelihood of help-seeking. Several participants did report an increase in anxiety and the long-term impact of R3P on mental health and well-being is unclear. Further mixed-methods evaluation incorporating a longer follow-up is required.

Digital Therapeutic Intervention for Women in the UK Armed Forces Who Consume Alcohol at a Hazardous or Harmful Level: Protocol for a Randomized Controlled Trial.

BACKGROUND: Alcohol misuse is common in the United Kingdom Armed Forces (UKAF), with prevalence significantly higher than in the general population. To date, digital health initiatives to support alcohol misuse have focused on male individuals, who represent approximately 89% of the UKAF. However, female veterans drink disproportionally more than female members of the public. OBJECTIVE: This 2-arm participant-blinded (single-blinded) confirmatory randomized controlled trial (RCT) aims to assess the efficacy of a brief alcohol intervention (DrinksRation) in reducing weekly self-reported alcohol consumption between baseline and a 3-month follow-up (day 84) among women who have served in the UKAF. METHODS: In this 2-arm single-blinded RCT, a smartphone app that includes interactive user-focused features tailored toward the needs of female veterans and designed to enhance participants' motivations to reduce the amount of alcohol they consume is compared with the UK Chief Medical Officer guidance on alcohol consumption. The trial will be conducted among women who have served at least 1 day of paid service in the UKAF. Recruitment, consent, and data collection will be carried out automatically through the DrinksRation app or the BeAlcoholSmart platform. The primary outcome is change in self-reported weekly alcohol consumption between baseline (day 0) and the 3-month follow-up (day 84) measured using the Timeline Follow Back for alcohol consumption. The secondary outcome is the change in the Alcohol Use Disorders Identification Test score measured at baseline and 3-month follow-up between the control and intervention groups. The process evaluation measures include (1) app use and (2) usability ratings as measured by the mHealth App Usability Questionnaire. RESULTS: RCT recruitment will begin in January 2024 and last for 5 months. We aim to complete all data collection, including interviews, by May 2024. CONCLUSIONS: This study will assess whether a smartphone app tailored to the needs of women who have served in the UKAF is efficacious in reducing self-reported alcohol consumption. If successful, the digital therapeutics platform could be used not only to support women who have served in the UKAF but also for other conditions and disorders. TRIAL REGISTRATION: ClinicalTrials.gov NCT05970484; https://www.clinicaltrials.gov/study/NCT05970484. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/51531.

Health and well-being of serving and ex-serving UK Armed Forces personnel: protocol for the fourth phase of a longitudinal cohort study.

INTRODUCTION: This is the fourth phase of a longitudinal cohort study (2022-2023) to investigate the health and well-being of UK serving (Regulars and Reservists) and ex-serving personnel (veterans) who served during the era of the Iraq and Afghanistan conflicts. The cohort was established in 2003 and has collected data over three previous phases including Phase 1 (2004-2006), Phase 2 (2007-2009) and Phase 3 (2014-2016). METHODS AND ANALYSIS: Participants are eligible to take part if they completed the King's Centre for Military Health Research Health and Wellbeing Cohort Study at Phase 3 (2014-2016) and consented to be recontacted (N=7608). Participants will be recruited through email, post and text message to complete an online or paper questionnaire. Data are being collected between January 2022 and September 2023. Health and well-being measures include measures used in previous phases that assess common mental disorders, post-traumatic stress disorder (PTSD) and alcohol misuse. Other areas of interest assess employment, help-seeking and family relationships. New topics include the impact of the British withdrawal from Afghanistan in 2021, complex PTSD (C-PTSD), illicit drug use, gambling and loneliness. Analyses will describe the effect size between groups deployed to Iraq and/or Afghanistan or not deployed, and those who are currently in service versus ex-service personnel, respectively, reporting prevalences with 95% CIs, and ORs with 95% CI. Multivariable logistic and multiple linear regression analyses will be conducted to assess various health and well-being outcomes and associations with risk and protective factors. ETHICS AND DISSEMINATION: Ethical approval has been granted by the Ministry of Defence Research Ethics Committee (Ref: 2061/MODREC/21). Participants are provided with information and agree to a series of consent statements before taking part. Findings will be disseminated to UK Armed Forces stakeholders and international research institutions through stakeholder meetings, project reports and scientific publications.

Evaluating the Efficacy of the Drinks:Ration Mobile App to Reduce Alcohol Consumption in a Help-Seeking Military Veteran Population: Randomized Controlled Trial.

BACKGROUND: Alcohol misuse is higher in the UK armed forces (AF) than in the general population. Research demonstrates that alcohol misuse persists after an individual leaves service, and this is notably the case for those who are seeking help for a mental health difficulty. Despite this, there is no work on testing a mobile alcohol reduction intervention that is personalized to support the UK AF. OBJECTIVE: To address this gap, we investigated the efficacy of a 28-day brief alcohol intervention delivered via a mobile app in reducing weekly self-reported alcohol consumption among UK veterans seeking help for mental health difficulties. METHODS: We performed a 2-arm participant-blinded randomized controlled trial (RCT). We compared a mobile app that included interactive features designed to enhance participants' motivation and personalized messaging (intervention arm) with a version that provided government guidance on alcohol consumption only (control arm). Adults were eligible if they had served in the UK AF, were currently receiving or had received clinical support for mental health symptoms, and consumed 14 units (approximately 112 g of ethanol) or more of alcohol per week. Participants received the intervention or the control mobile app (1:1 ratio). The primary outcome was a change in self-reported weekly alcohol consumption between baseline and day 84 assessed using the validated Timeline Follow Back for Alcohol Consumption (TLFB) (prior 7 days), with a secondary outcome exploring self-reported change in the Alcohol Use Disorder Identification Test (AUDIT) score. RESULTS: Between October 2020 and April 2021, 2708 individuals were invited to take part, of which 2531 (93.5%) did not respond, 54 (2%) were ineligible, and 123 (4.5%) responded and were randomly allocated (62, 50.4%, intervention; 61, 49.6%, control). At day 84, 41 (66.1%) participants in the intervention arm and 37 (60.7%) in the control arm completed the primary outcome assessment. Between baseline and day 84, weekly alcohol consumption reduced by -10.5 (95% CI -19.5 to -1.5) units in the control arm and -28.2 (95% CI -36.9 to -19.5) units in the intervention arm (P=.003, Cohen d=0.35). We also found a significant reduction in the AUDIT score of -3.9 (95% CI -6.2 to -1.6) in the intervention arm (Cohen d=0.48). Our primary and secondary effects did not persist over the longer term (day 168). Two adverse events were detected during the trial. CONCLUSIONS: This study examined the efficacy of a fully automated 28-day brief alcohol intervention delivered via a mobile app in a help-seeking sample of UK veterans with hazardous alcohol consumption. We found that participants receiving Drinks:Ration reduced their alcohol consumption more than participants receiving guidance only (at day 84). In the short term, we found Drinks:Ration is efficacious in reducing alcohol consumption in help-seeking veterans. TRIAL REGISTRATION: ClinicalTrials.gov NCT04494594; https://tinyurl.com/34em6n9f. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/19720.

Evaluating the Efficacy of a Mobile App (Drinks:Ration) and Personalized Text and Push Messaging to Reduce Alcohol Consumption in a Veteran Population: Protocol for a Randomized Controlled Trial.

BACKGROUND: Alcohol misuse is higher in the UK Armed Forces than in the general population. Previous research has shown that interventions delivered via smartphones are efficacious in promoting self-monitoring of alcohol use, have utility in reducing alcohol consumption, and have a broad reach. OBJECTIVE: This single-blinded randomized controlled trial (RCT) aims to assess the efficacy of a 28-day brief alcohol intervention delivered via a smartphone app (Drinks:Ration) in reducing weekly self-reported alcohol consumption between baseline and 3-month follow-up among veterans who drink at a hazardous or harmful level and receive or have received support for mental health symptoms in a clinical setting. METHODS: In this two-arm, single-blinded RCT, a smartphone app that includes interactive features designed to enhance participants' motivation and personalized messaging is compared with a smartphone app that provides only government guidance on alcohol consumption. The trial will be conducted in a veteran population that has sought help through Combat Stress, a UK veteran's mental health charity. Recruitment, consent, and data collection will be carried out automatically through the Drinks:Ration platform. The primary outcome is the change in self-reported weekly alcohol consumption between baseline (day 0) and 3-month follow-up (day 84) as measured using the Time-Line Follow back for Alcohol Consumption. Secondary outcome measures include (1) change in the baseline to 3-month follow-up (day 84) Alcohol Use Disorder Identification Test score and (2) change in the baseline to 3-month follow-up (day 84) World Health Organization Quality of Life-BREF score to assess the quality of adjusted life years. Process evaluation measures include (1) app use and (2) usability ratings as measured by the mHealth App Usability Questionnaire. The primary and secondary outcomes will also be reassessed at the 6-month follow-up (day 168) to assess the longer-term benefits of the intervention, which will be reported as a secondary outcome. RESULTS: The study will begin recruitment in October 2020 and is expected to require 12 months to complete. The study results will be published in 2022. CONCLUSIONS: This study assesses whether a smartphone app is efficacious in reducing self-reported alcohol consumption in a veteran population that has sought help through Combat Stress using personalized messaging and interactive features. This innovative approach, if successful, may provide a means to deliver a low-cost health promotion program that has the potential to reach large groups, in particular those who are geographically dispersed, such as military personnel. TRIAL REGISTRATION: ClinicalTrials.gov NCT04494594; https://clinicaltrials.gov/ct2/show/NCT04494594. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/19720.

Mental Health, Help-Seeking Behaviour and Social Support in the UK Armed Forces by Gender.

Background: Little is known about gender differences in mental health, related help-seeking behavior and social support in UK military personnel. Methods: 1714 UK military serving personnel and ex-service veterans were randomly selected if, in a cohort study, they endorsed experiencing a subjective stress, emotional, alcohol or mental health problem in the previous three years. Following exclusions, the final sample size was 1448 (participation rate 84.5%; women n = 219). Structured telephone interviews assessed anxiety, depression, PTSD symptoms, alcohol use, help-seeking and social support occurring both currently and in the past three years. Outcomes were assessed using weighted unadjusted and adjusted logistic regression analyses. Results: Mental health problems assessed at interview were broadly similar for men and women; for both genders, levels of social support were high. One-fifth of respondents screened positive for probable mental disorder or alcohol misuse; although rates of mental disorder symptoms did not differ by gender, women were significantly less likely than men to report alcohol misuse. Women were significantly more likely to have sought help from formal medical sources but significantly less likely to access informal support such as friends, family or unit welfare sources; reasons for seeking formal medical support were similar for men and women except for problem recognition and acting on advice from others, which were both significantly more common among women. Conclusion: For military personnel with a history of mental ill-health, women should make greater use of informal support networks while for men, engagement with formal medical help sources should be encouraged.