The relationships between body image, self-esteem and quality of life in adults with trauma-related limb loss sustained in the Syrian war.

BACKGROUND: Numerous military soldiers have lost limbs as a result of the Syrian War. While there are variations between trauma-related amputations in military and civilian populations, both scenarios result in life-changing injuries. OBJECTIVE: To explore the relationship between body image, self-esteem, and quality of life (QOL) domains following trauma-related major amputation. It will be the first study in Syria on the correlation between self-esteem and body image. It will help improve our quality of care to meet patient needs and increase well-being, which in turn will help to address body image, self-esteem, and QOL. METHOD: A cross-sectional study that recruited 235 soldiers with amputations in two centers and two military hospitals in Latakia and Tartous. Patients were given an 81-item questionnaire that included the Amputee Body-Image Scale (ABIS), the Rosenberg Self-esteem (RSE) scale, the WHOQOL-BREF questionnaire, and unidimensional pain measures. The ANOVA test, a student's t-test, multiple linear regression, internal consistency, and test-retest reliability were utilized for statistical analysis. RESULTS: There was a strong relationship between body image, self-esteem, and QOL, with the presence of body image concerns significantly associated with lower self-esteem scores and lower QOL scores (p=0.001). Patients with phantom pain sensation had significantly reduced self-esteem (p =0.001), greater body image concerns (p =0.001), and lower scores in all domains of QOL. We found that body image and self-esteem impacted the psychological, social, and environmental domains. After controlling for pain level and number of co-morbid conditions, body image and self-esteem did not predict WHOQOL-BREF scores, with the exception of the environmental domain, where no pain and low self-esteem predicted better environmental domain scores. CONCLUSION: Patients' body image and self-esteem were greatly impacted by lower-limb amputations. Additionally, phantom pain further impacted self-esteem, body image, and QOL. The image of the body had a profound effect on psychological, social, and environmental domains, and self-esteem was influenced by almost all aspects of QOL.

Factors associated with burnout in military police officers in a city in Paraná.

OBJECTIVE: to analyze the association between burnout and sociodemographic, work factors, lifestyle habits and health conditions of military police officers in a municipality in the state of Paraná, Brazil. METHOD: cross-sectional research with 131 military police officers. Data were analyzed using the Statistical Package for the Social Sciences software and the R program. Chi-square, Fisher's exact and Poisson Generalized Linear Model tests were used. RESULTS: most participants (65.6%) had a high level of burnout. In relation to protective factors, those who carried out leisure activities had a 33.6% chance of not developing burnout. Conjugality was also a protective factor. Not practicing physical activity and leisure activities are factors that can contribute to the occurrence of burnout. CONCLUSIONS: important factors and high rates of burnout were observed in the police officers investigated. It is necessary to implement public health policies to reduce burnout with attention focused on this professional category.

Key Improvements to the Army's Suicide Prevention and Intervention Training: An Interagency Collaboration to Develop the New "ACE Base +1" Curriculum.

INTRODUCTION: Suicide is a prevalent problem impacting the military community. The U.S. Army recognized the need to address this complex issue; one line of effort has been to provide suicide prevention and intervention education and training that is informed by current research, doctrine, and implementation best practices. The purpose of this article is to outline and present the genesis of the Army's new suicide prevention and intervention training-"Ask, Care, Escort (ACE) Base +1"-that aligns with the DoD newly published regulation-driven initiatives. MATERIALS AND METHODS: The development of the "ACE Base +1" curriculum was a collaborative effort between two organizations within the Defense Health Agency: The Defense Centers for Public Health-Aberdeen and the WRAIR. A multidisciplinary team was formed by selecting specific operational and subject-matter experts from each organization based on educational qualifications and practical experiences expected to aid the development of curriculum content (e.g., subject-matter experts) and/or the training design. Revisions to the curriculum were informed by the Army's existing suicide prevention training module, current research in suicide prevention and public health, updated and relevant Army regulations, and current public health policy guidance from the CDC and the Department of Suicide Prevention Office. A detailed account of the systematic and iterative curriculum development process is provided. RESULTS AND CONCLUSIONS: The interagency collaborative efforts resulted in a suite of training products, "ACE Base +1" version 1.3 that is modernized in training content, delivery methods, and design. Four primary elements shaped the final products: (1) A modular framework allowing a tailored approach to mandatory training, (2) a public-health approach that focuses on earlier intervention opportunities while building trust and cohesion, (3) a training design centered on peer discussions and behavioral rehearsal, and (4) an expansion of the curriculum to be inclusive of the entire Army community. Practical implications for each element are discussed.As the program of record, "ACE Base +1" training satisfies the annual requirement for all Active Army, Army National Guard, U.S. Army Reserve, and Department of the Army (DA) civilians. Both the training content (e.g., public-health concepts) and design of "ACE Base +1" reflect a comprehensive approach, focused on developing concrete, applicable skills that support the shared responsibility to suicide prevention and intervention. Limitations, such as delayed interagency collaboration and time constraints, are discussed. Future directions include recommendations for future curriculum projects, specifically within military populations, such as interprofessional, interagency collaboration, and selecting a multidisciplinary team of subject-matter experts. Additionally, WRAIR plans to continue their support to Directorate of Prevention, Resilience and Readiness with the expansion of the +1 menu of trainings, ongoing program evaluation, and longitudinal analysis to inform future revisions and ensure the content and delivery methods remain modernized, relevant, and effective.

Behavioral KSA Intervention Class to Boost Positive Airway Pressure Adherence Among Active Duty Military Personnel With Obstructive Sleep Apnea.

INTRODUCTION: Obstructive sleep apnea (OSA) is a treatable cause of daytime sleepiness and associated medical problems that can negatively impact soldier readiness and performance. This study examined adherence to positive airway pressure (PAP) by soldiers who were newly diagnosed with OSA and prescribed PAP therapy and participated in a Knowledge, Skills, and Attitudes (KSA) behavioral intervention class. MATERIALS AND METHODS: The KSA was a one-time, interactive 90-minute class attended by up to 10 patients per class. PAP adherence was examined using Medicare standard at 30-, 60-, 90-, and 180 days post class. The analytic sample comprised 379 active duty patients (93% men; mean age 40.21 ± 8.06) categorized into 3 groups: KSA (n = 235), did not show (DNS; n = 61), and mandatory education class (MEC; n = 83). The MEC group comprised patients from an education class in a previous year. RESULTS: Baseline scores on the apnea hypopnea index, body mass index, sleepiness, insomnia severity, and age were non-significant among the 3 groups. At 30 days, significantly more patients in KSA (48%) and MEC (51%) were adherent than the DNS group (16%). At 60 days, the adherence rates for the KSA, DNS, and MEC were significantly different at 39%, 22%, and 27%, respectively. At 90- and 180 days, the adherence rates among the KSA, DNS, and MEC groups did not differ significantly at 34%, 17%, and 26% (90 days) and 34%, 27%, and 25% (180 days), respectively. Consistently, more patients in KSA were adherent than those in DNS and MEC, except at 30 days. Additionally, adherence rates for KSA intervention declined more gradually over the 6 month period. The mean PAP usage on nights used was 4.6 hours that computed to a 34% non-use rate based on an optimal 7-hour/night sleep time. CONCLUSION: KSA could be a behavioral intervention that enhances PAP adherence with a booster session implemented at the 90 days mark.

Psychological Risk Factors for Delayed Recovery Among Active Duty Service Members Seeking Treatment for Musculoskeletal Complaints at a Navy Shore-Based Military Medical Treatment Facility.

INTRODUCTION: Musculoskeletal injuries (MSIs) are a leading cause of separation from the U.S. Navy. Data have shown that several psychological responses to MSI are associated with treatment outcomes. Yellow flags are maladaptive psychological responses to injury and predict delayed recovery, whereas pink flags indicate resilience after MSI and are associated with good treatment outcomes. Identifying these factors in patients with MSI would permit early targeted care to address factors that may delay their readiness for deployment and enhance factors that support recovery. MATERIALS AND METHODS: Active duty service members with MSI who reported to physical therapy outpatient services at a naval hospital were recruited for the study. Yellow flags were assessed at baseline as part of a larger study. Participants completed the Fear Avoidance Beliefs Questionnaire (with two subscales, physical activity and work), the Pain Catastrophizing Scale, and the Hospital Anxiety and Depression Scale. Clinically relevant cut-off scores were used to indicate risk factors of delayed recovery. Pink flags were assessed with the Pain Self-Efficacy Questionnaire and a measure of positive outcome expectations for recovery. RESULTS: Two hundred and ninety participants responded to some or all of the questionnaires. Of these, 82% exceeded the cut-off scores on the physical activity subscale of the Fear Avoidance Beliefs Questionnaire, and 39% did so on the work subscale. Pain catastrophizing exceeded the cut-off in only 4.9% of the sample. Forty-three percent of these exceeded the cut-off for the anxiety subscale of the Hospital Anxiety and Depression Scale; 27% exceeded the cut-off on the depression subscale of the Hospital Anxiety and Depression Scale. Additionally, 54% endorsed scores greater than 40 on the Pain Self-Efficacy Questionnaire, and 53% endorsed a high score on the positive outcome expectations. CONCLUSIONS: A substantial portion of the sample endorsed elevated scores on one or more indicators of delayed recovery from MSI. Most participants showed a fear of physical activity, and approximately half reported pain-related distress (anxiety and depression). In addition, feelings of self-efficacy and positive outcome expectations of treatment were endorsed by only about half of the participants, indicating that the remaining half did not report adaptive responses to MSI. Early identification of these risk factors will allow for targeted treatment approaches that incorporate these yellow flags into treatment and support a psychologically informed approach to physical therapy. This approach is likely to reduce delayed recovery and improve deployment readiness.

Platform Design for Optical Screening and Conditioning for Injury Resilience.

INTRODUCTION: Musculoskeletal injuries (MSKIs) among active duty soldiers result in more than 10 million limited duty days each year and account for more than 70% of the medically nondeployable population. Overuse injuries in lower limbs from running, foot marching long distances with heavy loads, and lifting heavy objects are the most common types of injuries in the military. Physical training and rehabilitation exercises for greater resiliency through aerobic, muscle strength, endurance, and agility conditioning programs can prevent or reduce the effects of MSKIs if Soldiers adhere to proper biomechanics and training techniques. We are introducing a three-dimensional (3D) camera-based platform for Optical Screening and Conditioning for Injury Resilience (OSCIR) that is designed to identify and correct high-risk movement patterns based on quantifiable biomechanical measurements in clinical or field settings. Our goal is to improve resilience to MSKI by offering greater access to quality of movement skills in warfighters through an autonomous device that can be used in Sports Medicine and Reconditioning Team (SMART) clinics and High-Intensity Tactical Training (HITT) sites. MATERIALS AND METHODS: OSCIR fuses four pairs of Kinect Azure cameras into a concise footprint to achieve suitable sampling rates and an unobstructed field of view for accurate dynamic movement tracking using a custom point cloud solution. We designed a unique multistage 3D joint tracking algorithm architecture to methodically isolate the human body point cloud from the background, identify individual limb segments, and perform iterative joint optimization at the global and local joint levels. We evaluated the feasibility of our prototype system among N = 12 control participants (6 M/6 F; 21-37 years) in compliance with the Western Institutional Review Board (Tracking #20225920, approved on November 4, 2022). Five task-specific MSKI outcome metrics identified by end-user physical therapists and athletic trainers as indicators for movement quality were assessed across 7 lower-extremity exercises derived from standardized MSK assessment/conditioning batteries used in the military. Data were recorded concurrently by OSCIR and a reference standard Vicon motion capture system for validating system accuracy. RESULTS: Task-specific MSKI indicators for knee flexion and hip flexion range of motion achieved an average error of 4.05 ± 2.34°, while 3D position-based postural outcomes of left-right foot distance, left-right hand distance, and step length obtained mean absolute errors of 2.58 ± 2.30 cm. Results support the feasibility of our system in achieving outcomes that are comparable to currently accepted laboratory standards. CONCLUSIONS: Our study describes the integration process for a 3D camera-based clinical system for MSKI conditioning and rehabilitation. The impact of our system will enable key stakeholders in the military to manage MSKIs in warfighters by automating key assessment and rehabilitation test batteries; making tests more readily accessible, and interpretations more accurate by providing objective biomechanical measures. OSCIR is undergoing turn-key design features to serve as a screening tool for warfighters to readily assess susceptibility to MSKI or as a training platform to help guide exercise techniques to achieve resiliency against future injuries.

Specialized Vaccine Care for Adverse Events Following Immunization and Impact on Vaccine Hesitancy in the Military Health System.

INTRODUCTION: The World Health Organization identified vaccine hesitancy as one of the top 10 threats to global health. Vaccine hesitancy is defined as a delay in acceptance or refusal of vaccination despite the availability of vaccination services. Because vaccine safety concerns are important contributors to hesitancy, people who have experienced adverse events following immunization (AEFI) may be at especially high risk for subsequent vaccine hesitancy. The Defense Health Agency Immunization Healthcare Division (DHA IHD) provides specialized vaccine care to persons who have experienced AEFI. The impact of this specialized vaccine care on subsequent vaccine hesitancy has not been fully explored. MATERIALS AND METHODS: A cohort of patients (n= 146) was identified among those who received consultative care from DHA IHD clinicians for AEFI concerns between April 2017 and September 2022. Analyses were restricted to non-uniformed beneficiaries of the Military Health System (MHS). Uniformed beneficiaries of the MHS were excluded from this analysis since vaccination mandates preclude the use of vaccine uptake as a measure of vaccine hesitancy. Outcomes were evaluated by reviewing MHS vaccination records after initial AEFI consultation through January 2023. Vaccine acceptance was considered the inverse of hesitancy, and was defined by: (a) receipt of any subsequent vaccination, (b) receipt of seasonal influenza vaccine, (c) receipt of subsequent doses of the AEFI-associated vaccine, if clinically recommended, and (d) receipt of COVID-19 vaccine. RESULTS: A diverse group of patients with a wide range of AEFI concerns received specialized vaccine care from DHA IHD clinicians during this period. Among the cohort, 78% of patients received any subsequent vaccination, 55.2% received seasonal influenza vaccine, 57.8% received a subsequent dose of their AEFI-associated vaccine when the vaccine was clinically recommended, and 48.9% received COVID-19 vaccine. The proportion of patients who received influenza vaccine exceeded the reported rate of influenza vaccine uptake by the general population during this time period. CONCLUSION: Specialized vaccine care after AEFI concerns was associated with relatively high acceptance of subsequent vaccinations. The experiences of DHA IHD clinicians, in providing specialized vaccine care to AEFI patients, may serve as a model for other organizations that are working to reduce vaccine hesitancy, even beyond the MHS.

Unlocking What Makes Military Behavioral Health Interventions Work, Stumble, or Fade Away.

INTRODUCTION: The Office of the Secretary of Defense and each of the services have made an unprecedented commitment to the prevention of sexual assault and related behavioral health phenomena. Indeed, the Department of Air Force has selected, in some cases tailored, and disseminated a wide array of evidence-based preventative programs, policies, and practices (EBPs) over the last few decades. However, many of these efforts seem to follow a predictable life course. EBPs are initially implemented with great enthusiasm, supported for a few years, then fall out of favor, and are replaced by a different effort. This research effort aims to build on the existing civilian implementation science research to (1) offer a military-specific model of sustained, high-quality implementation and (2) test this model in a series of interconnected studies. MATERIALS AND METHODS: New York University's Institutional Review Board approved the study protocols, and the Army's Human Research Protection Office provided permission to collect data. We conducted interviews first with prevention leaders in the services and at the Office of the Secretary of Defense level regarding factors that they thought helped or hurt the sustainment of EBPs. We used these interviews to identify EBPs currently implemented in Department of Air Force and selected four EBPs out of the 25 identified for intensive study. We then interviewed implementers of those four EBPs regarding what they thought helped or hurt the sustainment of that EBP. We also gathered information about the 25 currently implemented EBPs themselves and gathered policy and guidance, as well as leadership communication about those EBPs and the target problems they focus on. We coded this information to allow us to test EBP parameters and policy and leader communication that predict sustained high-quality implementation. We conducted over 100 observations of the 4 EBPs we are studying intensively and have collected quantitative data from implementers and participants to help us test factors related to sustained high-quality implementation within each of those 4 EBPs and across the EBPs. RESULTS: Several military-specific factors were nominated for inclusion in the military-specific model of implementation sustainment. The implementation of even highly standardized EBPs varies greatly. Implementers and participants are generally highly engaged, but implementers vary in the extent to which they understand the mechanisms of action for the EBP they are implementing. CONCLUSIONS: We recommend training implementers in the mechanisms of action in the EBPs they are expected to implement and including quality assurance as a component of prevention efforts in a manner more similar to how the military addresses aspects of the operational mission. By moving beyond counting classes and attendance, and specifying how to engage participants in the EBPs in the manner that produces the key outcomes, it is likely that EBPs will have more robust implementations that can be better sustained over time.

Service Members' Attitudes Toward Reporting Hazing Incidents.

INTRODUCTION: Addressing hazing within the U.S. Military has become a critical concern to safeguard the well-being of service members; recent attempts to assess hazing prevalence in the military have been unsuccessful due to under representative data. METHODS: To delve into the hazing climate and reporting culture at Fort Bragg, now Fort Liberty, 227 individuals took part in an anonymous online survey. The survey collected demographics and insights on hazing attitudes and behaviors, perceptions of group experiences including hazing/non-hazing activities, views on leadership, familiarity and experiences with reporting procedures, and bystander intervention. RESULTS: The findings echoed existing literature: while only 17.2% admitted to experiencing hazing, a striking 70.3% acknowledged involvement in specific hazing behaviors. Only 40% of participants who acknowledged experiencing hazing (n = 35) disclosed that they reported or confided in someone about the incident. Responses highlight reporting hurdles including concerns about anonymity, confidence in the reporting process, leadership reactions to reports, and the normalization of these events as tradition. DISCUSSION: Distinct elements of military culture, such as the hierarchical chain of command, loyalty to the brotherhood/sisterhood, and the emphasis on resilience, likely amplify these responses. This study adds to the mounting evidence showcasing gaps in assessing hazing within the U.S. Military. It emphasizes the necessity for a comprehensive hazing prevention program. Presently, prevention relies on mandatory training, often integrated into safety briefings or harassment workshops. However, service members require further assistance in recognizing, rejecting, and reporting instances of hazing despite these trainings.

Efficacy of Computerized vs. Traditional Cognitive Interventions for the Treatment of Chronic mTBI Symptoms Among Service Members.

INTRODUCTION: Military service members (SMs) with mild traumatic brain injury (mTBI or concussion) frequently report cognitive and behavioral difficulties. Currently, military clinical guidelines recommend clinician-run, manualized cognitive rehabilitation (CR) to treat these symptoms; however, it is unclear whether this approach adequately addresses the unique needs of warfighters. Computerized cognitive training (CCT) programs represent an innovative, promising approach to treating cognitive difficulties; however, whether these programs can effectively remediate cognitive impairment in individuals with mTBI remains unclear. MATERIALS AND METHODS: A total of 65 SMs with a history of at least 1 diagnosed mTBI were recruited from a military hospital. Participants received 1 of 2 interventions: Clinician-run, manualized CR (Study of Cognitive Rehabilitation Effectiveness [SCORE]; n = 37), consisting of 60 total intervention hours over 6 weeks, or CCT (n = 28), in which participants trained with either a commercial CCT (n = 14) or noncommercial CCT (n = 14), for a total of 12 hours over 4 weeks. Participants were assessed pre- and postintervention, using a combination of self-report and objective outcome measures: Key Behaviors Change Inventory (KBCI), a self-report measure of functional difficulties; Paced Auditory Serial Addition Test (PASAT), an objective cognitive assessment that measures both information processing speed and sustained and divided attention; and Symbol Digit Modalities Test (SDMT), an objective cognitive assessment that measures information processing speed. RESULTS: Mixed ANOVA revealed no interaction effect between intervention type and time (pre- and postassessment) on the PASAT (P = .643, ηp2 = 0.003), SDMT (P = .423, ηp2 = 0.010), or KBCI (P = .434, ηp2 = 0.010); however, there was a significant within-group main effect (time) on all 3 outcome measures (PASAT P < .001, ηp2 = 0.54; SDMT P < .001, ηp2 = 0.25; and KBCI P = .001, ηp2 = 0.15). On average, participants showed improvement over baseline on the PASAT (SCORE delta = 6.98, SD = 7.25, P < .001; CCT delta = 7.79, SD = 6.45, P < .001), SDMT (SCORE delta = 4.62, SD = 8.82, P = .003; CCT delta = 6.58, SD = 10.81, P = .003), and KBCI (SCORE delta = -3.22, SD = 7.09, P = .009; CCT delta = -2.00, SD = 4.72, P = .033). Additional analysis comparing the relative effectiveness of the 2 different CCTs revealed that while training with either program resulted in improved performance on the PASAT (P < .001, ηp2 = 0.627), SDMT (P = .003, ηp2 = 0.286), and KBCI (P = .036, ηp2 = 0.158), there was no interaction effect of CCT program type and change over time for any measure (PASAT P = .102, ηp2 = 1.00; SDMT P = .317, ηp2 = 0.038; and KBCI P = .719, ηp2 = 0.005). CONCLUSIONS: We showed that CCT programs do not differ in efficacy compared to clinician-run, manualized CR for treating symptoms associated with mTBI; however, exploratory analyses suggest that each approach may have distinct advantages for treating specific symptoms. Additionally, we showed that the improvement in the CCT intervention did not differ between those who trained using the commercial program vs. those who trained with the noncommercial program.

Outpatient Prescriptions for Insomnia Medications During the First Year Following Combat-Related Amputations.

INTRODUCTION: Sleep-related disorders are associated with pain, fatigue, and deficits in cognitive performance, which may interfere with successful rehabilitation. The study objectives were to (1) quantify outpatient prescriptions for insomnia medications during the first year following combat-related amputations, (2) examine longitudinal changes in prescriptions for insomnia medications, and (3) analyze patient characteristics associated with prescriptions for insomnia medications. MATERIAL AND METHODS: This was a retrospective study of DoD casualty records from the Expeditionary Medical Encounter Dataset and prescriptions for outpatient medications from the Pharmacy Data Transaction Service. Patients were a total of 1,651 U.S. service members who sustained major limb amputations in Operations Iraqi and Enduring Freedom from 2001 through 2017 and had outpatient prescriptions for any medication during the first year postinjury. Prescriptions for medications recommended for insomnia were low-dose antidepressants, anxiolytic sedatives, benzodiazepines, melatonin receptor agonist, and low-dose quetiapine. These prescription medications were analyzed by medication type, postinjury time, and patient characteristics during the first year postinjury. RESULTS: During the first year postinjury, 78% of patients (1,291 of 1,651) had outpatient prescriptions for insomnia medications, primarily anxiolytic sedative drugs (e.g., zolpidem), averaging a total of 86 prescription days (median = 66). The prevalence of these prescriptions declined substantially during the first year, from 57% of patients during the first quarter to 28% during the fourth quarter postinjury. In univariate analyses, multiple patient characteristics, including high Injury Severity Score, continued opioid and non-opioid analgesic prescriptions, and diagnoses of chronic pain, mood disorder, and posttraumatic stress disorder, were significantly associated with higher prevalence and duration of outpatient prescriptions for insomnia medications. CONCLUSIONS: The present results indicate a high prevalence of outpatient prescriptions for insomnia medications following combat-related amputations, a prevalence that is substantially higher than previously reported among active duty personnel. These findings can inform DVA/DoD guidelines for amputation care and insomnia among military subpopulations. The results highlight the need for more research on the treatment of insomnia during early postinjury rehabilitation among patients who sustained serious combat injuries.

The Effects of Burnout, Team Support, and Perceived Leader Effectiveness on Career Intentions Among JAG Corps Personnel.

INTRODUCTION: Destructive interpersonal relationships at work may result in negative feelings among employees that hinder personal and organizational productivity, which may also result in high levels of job disengagement and subsequent career turnover intentions. Leaders play a key role in creating work environments conducive to optimizing employee performance, organizational culture, and workplace well-being. Social support, which may include support from one's supervisor, colleagues, and loved ones, has been shown to reduce strains and perceived stressors at work. In the Army, the Judge Advocate General's Corps (JAGC) personnel have a unique position as lawyers and legal staff and have been shown to have high rates of burnout. To promote soldier health, well-being, and career longevity, it is important to understand the impact interpersonal relationships have on career intentions. The current study assesses the relationship between perceived leadership effectiveness and career intentions as moderated by burnout measured by job disengagement and team care activities in JAGC personnel. MATERIALS AND METHODS: The Walter Reed Army Institute of Research conducted a survey to understand factors affecting the well-being of the JAGC's soldier and civilian personnel as requested by the JAGC. JAGC personnel were administered several questionnaires covering a range of work and mental health topics. Job disengagement, career intentions, team care activities, and general leadership were assessed. A total of 831 JAGC personnel completed the survey, the majority (92%) of which were soldiers. Among soldiers, first lieutenants and captains (∼49%) were the majority. The sample largely consisted of men (∼63%), White individuals (∼76%), married individuals, (70%), and individuals with graduate degrees (∼81%). RESULTS: One in four participants (∼29%) experienced high levels of disengagement, with their work. Over two-thirds of participants agreed that their immediate supervisor is an effective leader. When asked about career intentions, the majority of JAGC participants (54%) indicated that they would probably or definitely stay in the JAGC until retirement. Ordinal logistic regressions were conducted to assess the relationship between perceived leader effectiveness and career intentions, assessing the main effects of job disengagement and team care activities, and the interactions between those variables. No interaction effects were found to be significant, but main effects for perceived leader effectiveness were significant. CONCLUSIONS: JAGC personnel reported higher levels of job disengagement for those with career intentions that were undecided or definitely leaving the JAGC after their current obligation. Those who were engaged in more team care activities had lower levels of disengagement. While the majority of the JAGC participants indicated career intentions to stay in the JAGC until retirement, increasing perceived effectiveness of leaders could help increase attrition and career intentions to stay in the JAGC beyond one's current obligation.

Predictors of Positive Airway Pressure Therapy Adherence Among U.S. Active Duty Military Personnel With Obstructive Sleep Apnea.

INTRODUCTION: Obstructive sleep apnea (OSA) is prevalent among U.S. military personnel, but adherence to positive airway pressure (PAP) treatment is suboptimal. This study sought to identify factors that predict the adherence to PAP therapy of active duty military patients newly diagnosed with OSA. MATERIALS AND METHODS: The study was a retrospective cross-sectional analysis of 239 active duty military patients (94% men, mean age 40.0 ± 7.8 years), who were admitted into PAP therapy and participated in a single 90-minute behavioral intervention session. The session included a self-assessment of sleep trouble, sleep distress, impact of sleep on functioning, emotional difficulty from sleep, stress appraisal, and beliefs about OSA and PAP. PAP usage data of the patients were analyzed at 30-, 60-, and 180 days post-intervention using descriptive statistics and multivariable linear regression analysis. RESULTS: Positive airway pressure adherence of at least 4 hours nightly usage decreased slightly over the course of the study; mean number of days used over a 30-day timeframe at the 30-, 60-, and 180-day mark were 15.6, 14.9, and 14.1 days, respectively. On nights used, PAP usage remained consistent at 4.8 to 5.0 hours over the 30-, 60-, and 180-day mark. Age, apnea-hypopnea index, readiness, self-efficacy or confidence in treatment implementation, and worries about sleep were statistically significant predictors of adherence. Furthermore, worries about sleep negatively affected PAP usage hours on nights used, regardless of meeting adherence criterion, in the early phase of treatment and in the long run at the 180-day mark. CONCLUSIONS: Readiness for therapy, self-efficacy, confidence in putting into action the treatment plan, and worries about sleep are modifiable variables that may be targeted in programs to boost PAP adherence and usage among the military population. Future studies should explore the predictive aspects of each of these variables and identify interventions to improve them.

Identifying Predictors of Positive and Negative Affect at Mid-Deployment Among Military Medical Personnel.

INTRODUCTION: Positive and negative affect influence an individual's ability to utilize available physical, psychological, and social resources to maximize responses to life events. Little research has examined the factors that influence the development of positive affect or reduction of negative affective responses among deployed military personnel. The present study aimed to investigate the relationship between deployment-related stressors and symptoms of behavioral health concerns with affectivity among deployed U.S. service members. MATERIALS AND METHODS: Participants were 1148 U.S. Air Force medical personnel deployed to Balad, Iraq, between 2004 and 2011. All participants completed self-report measures of PTSD symptoms, general military and combat exposure, stress, and affectivity. The Institutional Review Board at Wilford Hall Medical Center, the Air Force Personnel Survey Program, and the U.S. Army's Joint Combat Casualty Research Team reviewed and approved the study. RESULTS: Most respondents (89%, 1,018/1,139) reported a positive military experience, but many respondents reported exposure to a potentially traumatic event during deployment. For example, seeing dead or seriously injured Americans (47%, 523/1,123) was the most common exposure reported by participants. A large portion of personnel (21%, 232/1,089) reported clinical levels of PTSD symptoms (score of 33 or higher on the Posttraumatic Stress Disorder Checklist-Military version). Risk factors, including PTSD symptoms, combat exposure, and stress, explained 39% of the variance in negative affect, R2 = 0.39, F(1046) = 224.96, P < .001. Conversely, these risk and resilience factors, including PTSD symptoms, combat exposure, stress, and general military experiences, explained 28% of the variance in positive affect, R2 = 0.28, F(1050) = 103.79, P < .001. No significant gender differences were found between models predicting positive and negative affect. CONCLUSIONS: Negative mood states may be partly an epiphenomenon of PTSD, which has been shown to be safely and effectively treated in the deployed environment. Social support during deployments is uniquely associated with a positive mood. These findings extend beyond the military and into any high-stress occupation wherein leaders could interpret these findings as a need to build or reinforce efforts to provide opportunities to sustain healthy relationships in personnel. These critical indigenous resources support mission readiness and enable the maintenance of positive psychological health.

Examining Retention Sentiments and Attrition Among Active Duty Army Medical Officers.

INTRODUCTION: Providing quality care and maintaining exceptional medical providers are important priorities for military medicine. The present study examines the association between retention sentiments and voluntary separation from army service among Army Medical Corps and Nurse Corps Officers. Retention sentiments are derived from the Department of the Army Career Engagement Survey, a voluntary survey that Active Duty Soldiers complete annually. MATERIALS AND METHODS: The sample included active Army officers in the Medical Corps (n = 1198) and Nurse Corps (n = 1016) who completed the Department of the Army Career Engagement Survey between May 06, 2020 and November 02, 2023, passed the embedded attention check, and said their responses could be used for research purposes. The most frequently cited "Extremely Important" reasons to leave the army were identified within each sample. Binomial logistic regression was used to examine the likelihood of separating from army service based on the top five reasons to leave the Army as identified on the Department of the Army Career Engagement Survey. This study was determined by Exempt Human Subjects Research. RESULTS: An examination of the factors most frequently endorsed as an "Extremely Important" reason to leave the Army revealed that "Effects of deployments on Family or personal relationships" and "Impact of military service on my Family's well-being" were among the five most cited "Extremely Important" reasons to leave the army within both the Medical Corps and the Nurse Corps samples. When examined together (i.e., summed), the Composite Leave Score was associated with a significantly greater odds of separating from army service in each sample. Specifically, each additional top five "Extremely Important" leave reason identified was associated with a 38% greater odds of separating from army service within the Medical Corps and 50% greater odds of separating from army service within the Nurse Corps. CONCLUSIONS: The current study highlights unique retention concerns among army medical providers in the Medical Corps and Nurse Corps. Additionally, this study ties medical provider sentiments to subsequent voluntary separation from the army. These findings can help army senior leaders evaluate, draft, and revise policy aimed at increasing retention among army medical providers, and increasing access to quality healthcare for service members and their families.

Project Safe Guard: Evaluating a Lethal Means Safety Intervention to Reduce Firearm Suicide in the National Guard.

INTRODUCTION: The purpose of this paper is to examine a scalable secure firearm storage intervention in the U.S. National Guard (NG) in preventing firearm injury and suicide. A study among firearm-owning members of the Mississippi NG testing Project Safe Guard (PSG), a 10 to 15 min lethal means counseling intervention, found that PSG increased self-reported secure firearm storage practices. Here, we sought to examine a "real world" rollout of a modified PSG program in the NG in which NG members were trained to understand the importance of lethal means safety and to deliver PSG to Guardsmen peers within their units. MATERIALS AND METHODS: The PSG team collaborated with the NG to identify 4 states for the rollout; for each state, the NG was responsible for identifying key personnel ("facilitators") who would receive the training. Team members provided in-person training at 5 locations across 4 states (AZ, GA, IA, and NV) from January to April 2023. Attendees were provided with combination trigger locks or cable locks and evaluation instructions. Questionnaires were administered to training attendees via REDCap at pre-training and post-training. We conducted descriptive and comparison statistics of questionnaire data. RESULTS: A total of 186 facilitators were trained at 5 in-person training locations across 4 states (AZ, GA, IA, and NV) from January to April 2023; data collection concluded in August 2023. There were 137 pre-training responses (74% pre-survey response rate) and 88 post-training responses (64% response rate from those who took the pre-training survey). Findings demonstrate increases in self-reported knowledge, attitudes, and beliefs regarding firearm injury and suicide and a reported desire to store personal firearms more securely. CONCLUSION: The adapted version of PSG shows promise as a relevant and acceptable intervention among Guardsmen to enhance knowledge and attitudes regarding firearm suicide, increase secure firearm storage practices, and normalize conversations about firearm suicide prevention among peers. This intervention seeks to frame firearm suicide prevention within a culture of safety, complementary to the existing prevention methods and training within the NG.

A Functional Restoration Program for Active Duty Service Members With Chronic Pain: Examining the Impact of Co-occurring PTSD on Treatment Response.

INTRODUCTION: Standard medical intervention for chronic pain may be less effective in the presence of co-occurring PTSD. Functional restoration programs (FRPs), which combine psychological interventions and progressive exercise rehabilitation, represent an alternative to standard medical intervention for chronic pain. The objective of the current study is to evaluate a FRP serving Active Duty Service Members with chronic pain and to examine whether co-occurring PTSD symptoms are associated with differential treatment response. METHODS: This is a retrospective observational study of data previously collected at Naval Medical Center San Diego approved by the Naval Medical Center San Diego Institutional Review Board. The study included 81 Active Duty Service Members, primarily Sailors and Marines, who completed a FRP, and examined pre- to post-treatment changes in Pain Impact Score-a composite measure of pain intensity, pain interference, and physical functioning-as well as measures of mental health and pain cognitions. Co-occurring PTSD symptoms were examined as a potential moderator of treatment response. RESULTS: Twenty-three patients (28.4%) screened positive for PTSD during baseline assessments. Repeated measures analysis of variance showed statistically significant improvement in Pain Impact Score for the full sample (P <.001). Although no significant interactions with probable PTSD were demonstrated for measures of pain intensity and physical functioning (both Ps >.05), patients screening positive for PTSD demonstrated a lesser decrease in pain interference compared to patients screening negative for PTSD (P <.01). Improvements in measures of mental health and pain cognitions were also statistically significant for the full sample (all P values <.05) and did not differ as a function of PTSD symptoms (all P values >.05). CONCLUSION: This FRP primarily serving Sailors and Marines contributed to broad overall improvements in the domains of pain and functioning as well as mental health and pain cognitions. Co-occurring PTSD symptoms were not associated with poorer treatment response on most measured outcomes.

Identifying Suicide-Related Predictors Using Overseas Airborne Infantry Brigade Serious Incident Reports.

INTRODUCTION: Suicidal ideation and attempts are considered to be graduated risks for suicide, yet they remain under studied. Suicide is among the leading causes of death in the U.S. for all individuals between the ages of 10 and 64 years. Suicide is a critical problem in the U.S. Military. The U.S. Army suicide rates surpassed civilian rates in 2008 and continue to climb steadily; with U.S. Army soldiers at more than twice the risk than U.S. civilians, and enlisted personnel at more than twice the risk of officers. Suicidal ideation and attempts are routinely reported within U.S. Army brigades using suicide-related serious incident reports (SR-SIRs). These reports could form a useful source of information for prevention planning, but to date there have been no efforts to summary these reports. This paper analyzes SR-SIRs among enlisted personnel for a 4-year period for 1 Army brigade, to test the usefulness of this information and to explore whether risk factors for attempts compared to ideation can be identified. MATERIALS AND METHODS: This report analyzes 130 de-identified reports of suicidal ideation (n = 102) and suicide attempts (n = 28) reported as SR-SIRs from August 2018 to June 2022 among enlisted personnel in an airborne infantry brigade combat team (BCT) outside the continental U.S. Analysis of de-identified data was not considered research by brigade and university human subject/IRB authorities. Fourteen soldier characteristics and context factors were examined to determine if they differentiate the two types of incidents, suicidal ideations and suicide attempts. RESULTS: Unit location and alcohol use at the time of the incident were strongly associated with suicide attempts compared to ideation. Attempts occurred disproportionately during off duty hours, and attempters were more likely to have had prior contact with behavioral health services than ideators; however, these differences did not attain conventional statistical significance. CONCLUSIONS: The study can help inform unit-specific suicide prevention and intervention strategies. Off duty hours and alcohol use are risk factors for attempts, particularly among soldiers who have sought behavioral health care. Plans to engage and support soldiers who have sought behavioral health care during off duty hours, and information regarding the risks of alcohol use, could meaningfully reduce their risk. This is the first known attempt to examine active duty U.S. Army brigade combat team SR-SIRs, and they are a potentially valuable source of health and mental health-related information.

Adaptive Leadership and Burnout in Military Healthcare Workers During a Global Health Pandemic.

INTRODUCTION: Occupational burnout among healthcare workers has continued to climb, impacting workforce well-being, patient safety, and retention of qualified personnel. Burnout in military healthcare workers, who have had the added stress of increased deployments, remains unknown. Although certain leadership styles have been associated with lower rates of burnout, the association between adaptive leadership and burnout in military healthcare has not previously been described. The aim of this study is to examine the role of adaptive leadership in burnout among military healthcare workers following the Coronavirus Disease 2019 (COVID-19) pandemic. MATERIALS AND METHODS: A convenience sampling of military healthcare workers employed at a military medical treatment facility between March 2020 and March 2023 was anonymously surveyed using an online link, which included demographics, the Maslach-Burnout Inventory Health Services Survey (MBI-HSS), the Adaptive Leadership with Authority Scale, and the Pandemic Experiences and Perceptions Survey. Data were analyzed for associations. Structural equation modeling (SEM) was performed using MPlus 8.0, which included demographics, all three subscales that contribute to burnout (emotional exhaustion, depersonalization, and personal accomplishment [PA]), adaptive leadership (indicated by a subscale mean), and COVID impact and COVID risk perception. RESULTS: Of the 365 participants analyzed, 88.5% had high emotional exhaustion, and 80.4% had high depersonalization. Burnout was significantly associated with adaptive leadership (r = -0.302, P < .001), COVID impact (r = 0.208, P < .001), and COVID risk perception (r = 0.174, P < .001). A total of 93.0% scored high in at least one subscale of the MBI-HSS (i.e., emotional exhaustion ≥27, depersonalization ≥10, or PA ≤33), although 78 (21.8%) met the complete definition of burnout, because of the overwhelmingly high levels of PA (77.8% reported high PA). In the SEM model, burnout was significantly and negatively predicted by adaptive leadership (b = -0.28, SE = 0.05, Standardized b = -0.31, P < .001). Burnout was also significantly and positively predicted by COVID impact (b = 0.25, SE = 0.09, Standardized b = 0.17, P = .028) and health professions' perception of risk (b = 0.15, SE = 0.07, Standardized b = 0.14, P = .008). Together, this model explained 17% of the total variance in health professions' reported burnout. CONCLUSIONS: The findings of burnout in this military healthcare worker population were higher than have previously been described in healthcare workers or other military personnel, and the significant associations between adaptive leadership and burnout suggest the protective role of adaptive leadership in healthcare systems to address burnout. Implementing adaptive leadership training or selecting leaders with more adaptive leadership skills may be beneficial in a health care system where employee burnout is prevalent, especially during periods stressed by adaptive problems. This may be especially important in military healthcare when active duty service obligations preclude attrition in the presence of additional stressors such as deployments and Federal Emergency Management Agency responses. Further research is needed to determine whether this intervention is successful at reducing healthcare burnout.

A Baseline Model of PTSD From the ACES Cohort.

INTRODUCTION: Post-traumatic stress disorder (PTSD) is a primary military psychiatric condition with complex etiology including strong genetic and/or environmental influences. Environmental influences and demographics can play a role in supporting underlying genetic traits for clinical utility evaluation as risk modifying factors. We are undertaking an IRB approved study to evaluate polygenic scores of PTSD risk in the adverse childhood experience and serotonin (ACES) transporter cohort. MATERIALS AND METHODS: Baseline demographic characteristics and statistical modeling of 291 active duty service members from ACES cohort were used and excluded individuals with traumatic brain injury-induced loss of consciousness, pre-deployment PTSD or anxiety disorder, and pre-deployment prescription of antidepressants or psychoactive medications. Summary of categorical and numerical variables were evaluated using chi-square and t-test, respectively. We model PTSD risk and associated scores using linear and logistic regressions. RESULTS: The ACES subset was 79.1% males, multi-ancestry, and mean age of 38.3 years. Most PTSD individuals received behavioral therapy (89.6%) and/or prescribed antidepressants (67%) had higher scores in ACES, combat exposure scales, PTSD checklist military version, neurobehavioral symptom inventory, Pittsburg sleep quality index, insomnia severity index, and composite autonomic symptom score surveys and were less likely to expect future deployment. A positive correlation between age, total months deployed, ACES, CES, PCL-M, and positive-PTSD diagnosis were consistent but not in older individuals, who were more likely and frequently deployed although increasing risk for combat exposure. CONCLUSION: Demographic characteristics of the ACES cohort fit a coherent model of risk for PTSD to evaluate polygenic scores. Additional research is merited to understand PTSD effects on these confounding factors.