Introduction to Women in Combat.

This is an introduction to the second Women in Combat Supplement and provides an editorial on the topic.

The Military Women's Health Delphi Study: A Research Agenda for the Next Decade.

INTRODUCTION: As the burgeoning roles of women afford them the opportunities to perform in all combat and combat support assignments, the impact of all environmental, occupational, physical, and psychosocial factors inherent in military training and operations on their health must be considered. A robust foundation of knowledge is necessary to ascertain, prevent, and treat the potential impacts on women's health. However, a systematic review of the literature from 2000-2015 revealed widespread gaps in scientific knowledge of the musculoskeletal, psychological, occupational, and reproductive health of military women. The purpose of this study is to determine priorities for military women's health (MWH) research that will serve to fill these gaps in knowledge. METHODS: An advisory group of 11 senior military and women's health experts conducted a structured gap analysis of the results of a scoping review of literature from 2000 to 2015 and Military Health System utilization data to identify 15 topics for prioritization in MWH research. A modified e-Delphi study was conducted and consensus was achieved after two rounds. Participants (N = 32) included subject matter experts (SME) representing various professions enrolled, 23 completed both rounds. In round 1, topics were rated on forced Likert scales for relevance and feasibility to medical readiness and comments were elicited from the SMEs. Relevance and feasibility scores and themes from the comments guided the development of the round 2 survey, in which SMEs categorized the topics in terms of urgency and forced-choice ranked the priority of each topic. The quantitative data were analyzed using multilevel regression methods. Linear mixed models were fit separately on the numeric outcomes for feasibility, relevance, and urgency with research topic as the primary predictor. To analyze the rankings of research topic priority, crude and adjusted linear regression models were fit on the numeric outcome rank. RESULTS: The adjusted top five topics for research priorities as indicated by ranking were: genitourinary health, sleep, physical assault, behavioral health, and menstrual cycle research. The advisory group reviewed the findings in the context of Department of Defense strategic priorities and provided guidance on the design and dissemination of the MWH research agenda. CONCLUSIONS: The MWH research agenda is a validated research agenda of high-priority research topics that will promote enduring efforts to ensure evidence-based practices and health policies for military women through research.

Continuing the legacy of a military women's health research interest group.

The Military Women's Health Research Interest Group (MWHRIG) was established in 2010. The purpose of the MWHRIG is to support military clinicians and leaders in determining research priorities, and making evidence-based practice and policy decisions relevant to sex- and gender-appropriate healthcare. This article highlights the history of the MWHRIG, and current activities inclusive of research, mentorship, and collaboration. Future activities for the MWHRIG will focus on continued use of a theoretical framework for military women's health research, inclusivity of gender sexual diversity (GSD), and metrics for future success.

A Social Ecological Model for Military Women's Health.

BACKGROUND: U.S. military women's health (MWH) is influenced by unique life experiences while serving in combat and combat support roles in the armed forces. Daily accomplishment of the military mission exposes women to occupational, physical, and psychosocial factors that affect their health status. Here, we present the theoretical framework for a social ecological model (SEM) for MWH. METHODS: By synthesizing the common elements of various SEMs for health, we describe the layers in the military social ecological system that are typical of the milieu of servicewomen. With the individual's knowledge, beliefs, behaviors, and physiology at the center of the model, relevant components of the microsystem, mesosystem, exosystem, and macrosystem are identified. RESULTS: Support for the SEM-MWH can be found in all layers of the social ecological system. Distinguishing factors of the SEM-MWH include characteristics of the military environment, community, health care system, regulations and policies, and the military culture in which women live and work. Servicewomen's life experiences in the microsystem, mesosystem, exosystem, and macrosystem occur in a nested, interactive system that affects their health behaviors and their health status. CONCLUSIONS: The social ecological system of servicewomen is unique and must be fully explored and appreciated to ensure the health of women who serve. Investigation of the effects of policies throughout all layers of the SEM-MWH on the individual servicewoman is warranted.

Sleep Health in U.S. Military Women: A Scoping Review of the Literature, 2000-2019.

BACKGROUND: Sleep, critical to military operational effectiveness, is among the top five outpatient conditions for which military women seek care, yet sleep research in active duty servicewomen is sparse. We conducted a scoping review to 1) describe literature focused on sleep disorders and promotion of sleep health among U.S. active duty servicewomen and 2) identify opportunities for future health policies and research that may improve sleep health and decrease incidence of disordered sleep in servicewomen. METHODS: The PRISMA-ScR guidelines for scoping reviews informed this project. We searched Ovid; MEDLINE and Epub Ahead of Print, In-Process and Other Non-Indexed Citations, Daily and Versions; Embase; CINAHL; Cochrane Central; the Cochrane Database of Systematic Reviews; PsycInfo; and the Web of Science, and several sources of grey literature, from January 2000 through March 2019. We used a three-step screening and data extraction process: 1) title and abstract screening, 2) full-text article screening, and 3) data extraction from included articles. RESULTS: Seventeen of 1464 articles met the inclusion criteria. Most articles were retrospective, descriptive, or observational research. No intervention studies were identified. Sleep diagnoses and dimensions included insomnia, obstructive sleep apnea, disordered sleep quality and duration, and narcolepsy. Sex/gender differences were documented in screening, diagnosis, risk factors, and conditions associated with disordered sleep, for example, pregnancy and postpartum status. Actionable leverage points involve military culture, training, education, treatment, and self-care behaviors related to sleep health. CONCLUSIONS: Although we identified leverage points where policy changes have the potential to improve sleep health in active duty servicewomen, there is an urgent need for intervention research to address the gaps in knowledge about sleep health in this population.

A Scoping Review of Pregnancy, Childbirth, and the Postpartum Period in Active Duty U.S. Military Women.

PURPOSE: Women in the U.S. military encounter unique challenges during the perinatal period that are driven by military requirements for mission readiness. The purpose of this scoping review was to systematically examine the extent, range, and nature of the literature on pregnancy, childbirth, and the postpartum period of active duty military women. A secondary aim was to identify leverage points for changes to improve perinatal health of servicewomen. METHODS: We used a PRISMA-ScR protocol to guide this scoping review of research and non-research articles germane to the perinatal health of servicewomen. In the protocol, we identified the rationale, objectives, eligibility criteria, search strategy, sources of evidence, and data charting processes for the review. We used the social ecological model for military women's health framework to guide the synthesis of results. FINDINGS: Eighty-four articles on the topics of pregnancy, childbirth, and the postpartum period of servicewomen published from 2000 to 2018 were identified. The articles were mainly research studies (n = 76), of which 49 had observational designs. Leverage points to promote workplace safety and support of pregnant women, perinatal screening, recognition of pregnancy and postpartum depression, and maintaining physical fitness during pregnancy and the postpartum period were identified in multiple levels of the social ecological model for military women's health. CONCLUSIONS: Literature published from 2000 to 2018 is broad in scope, yet generally lacks a robust body of evidence on any one topic. Implementing strategies and military policies that are directed at the identified leverage points could enhance the health of childbearing servicewomen.

A Scoping Review of Breastfeeding in Active Duty U.S. Military Women.

PURPOSE: Active duty (AD) women in the U.S. military experience challenges during childbearing owing to unique occupational demands. The purpose of this article is to report the findings from a scoping review on pregnancy, childbirth, and the postpartum period that are specific to breastfeeding among servicewomen. A secondary aim is to identify leverage points that would promote breastfeeding in this population. METHODS: We developed a PRISMA-ScR protocol to identify publications from 2000 to 2018 regarding pregnancy, childbirth, and the postpartum period in AD women. Among articles pertaining to the postpartum period, we recognized those specific to breastfeeding for separate analysis. Using the social ecological model for military women's health (SEM-MWH) to synthesize our results, we identified actionable leverage points in the military setting for positive change. RESULTS: Research articles specific to breastfeeding (n = 8) included descriptive, cross-sectional, and qualitative studies. Non-research articles (n = 7) were either an integrative review, nonsystematic review, or commentary. Thirty-four leverage points were identified throughout the social ecological system of military women, including support for lactation in the workplace, employment of lactation consultants, occupational hazards assessment, personnel policies that delay the separation of women and their infants, and research to fill gaps in knowledge about breastfeeding while on AD. The greatest number of leverage points are in the SEM-MWH mesosystem and exosystem. CONCLUSIONS: There are multiple potential leverage points throughout the SEM-MWH to generate positive changes in the social ecological system of military women. These changes could serve to enhance the breastfeeding experiences of AD women.

Developing an instrument to assess empowering nurse leader communication behaviours.

AIM: The overall purpose of the study was to develop an instrument to assess empowering nurse leader communication behaviours. BACKGROUND: Effective communication by nurse leaders promotes empowerment, yet communication assessments are often broad in nature without specifying precise behaviours. METHODS: An instrument development process was used to identify empowering nurse leader communication behaviours. Nurses working in United States military health care facilities (n = 240) provided responses to 47 pilot items, along with a 12-item psychological empowerment instrument to test for concurrent criterion validity. RESULTS: After review of item performance, 12 items were deleted. An exploratory factor analysis supported either a 2- or 3-factor model, with confirmatory factor analyses conducted to validate the underlying latent variables of empowering and limiting behaviours. The final nurse leader communication assessment consists of 2 factors consisting of 20 positive items (empowering subscale) and 15 negative items (limiting subscale). CONCLUSION: The final 2-factor assessment supports the theoretical premise of the empowering and limiting behaviours. Further testing may provide further dimensional clarity. IMPLICATIONS FOR NURSING MANAGEMENT: Use of the assessment can provide a basis for the development of training for individual nurse leaders or for facility nurse leaders as a collective.

Why Nurses Are Essential to Research on Birth Outcomes in the United States.

In a consensus study on birth settings in the United States, the National Academy of Sciences, Engineering, and Medicine concluded that childbirth outcomes are influenced by quality of care, access to services, and choices of women within the maternity health care system. The United States has one of the highest rates of maternal mortality among the most developed nations in the world, and outcomes are marked by disparities among racial and ethnic groups of women. However, recommendations for improving birth outcomes are limited by the lack of an evidence base related to the physical and psychological safety of women during childbirth. Nurses who care for pregnant women and their infants are dedicated to ensuring that safe, high-quality care is provided during every encounter. Therefore, they are uniquely positioned to conduct the research on the fundamental elements of safety, quality, and inequities in health care that is needed to improve the maternity care system and outcomes for women and infants.

Identifying the constructs of empowering nurse leader communication through an instrument development process.

AIM: The purpose of this article was to describe the constructs of empowering front-line nurse leader communication behaviours. BACKGROUND: Leaders' communication behaviours are instrumental in establishing a positive work environment. Nurse empowerment, a characteristic of a positive work environment, is influenced by communication behaviours. However, characteristics of empowering nurse leader communication behaviours have not been well-defined. METHODS: The constructs of empowering nurse leader communication behaviours were identified and refined during the instrument development process. A priori constructs were identified through a literature search, presented to focus groups of military nurses (N = 16), and refined during the procedures of item development. RESULTS: Eight final constructs emerged as a result of the iterative methods of item development: comprehensibility, listening, openness, feedback, empathy, nonverbal, paralanguage and manner. CONCLUSION: The constructs that describe empowering nurse leader communication behaviours are based on theoretical tenets of empowering communication and leadership, as well as the perspectives of military nurses. IMPLICATIONS FOR NURSING MANAGEMENT: Nurse managers can use the findings to implement innovative leadership assessments and training that focuses on Nurse Leader communication to enhance the nursing workplace environment.

Auricular Acupuncture for Chronic Pain and Insomnia: A Randomized Clinical Trial.

Objective: In the United States, ∼1.6 million adults use complementary and alternative or integrative medicine for treating pain and insomnia. However, very few studies have tested the use of auricular acupuncture using a standard protocol for chronic pain and insomnia. The aims of this research were to assess the feasibility and credibility of auricular acupuncture, and to evaluate the effects of auricular acupuncture on pain severity and interference scores, and on insomnia severity over an 8-day study period. Materials and Methods: Forty-five participants were randomized to either an auricular acupuncture group (AAG) or a usual care group (CG) on study day 4. A standard auricular acupuncture protocol was administered, with penetrating semipermanent acupuncture needles in place for up to 4 days. The main outcome measures were feasibility of conducting the study, credibility of auricular acupuncture as a treatment modality, Brief Pain Inventory pain severity and interference scores, and Insomnia Severity Index (ISI) scores. Results: There was high interest in the study and the retention was 96%. Credibility of auricular acupuncture as a treatment was high in both groups. The use of the standard auricular acupuncture protocol in the AAG led to significant within- and between-group reduced pain severity and interference scores, compared to the CG. Both groups showed within-group decreased ISI scores. However, the AAG showed significant between-group reduced ISI severity scores compared to the CG. Conclusions: With the heightened focus on the opioid crisis in the United States, this easy-to-administer protocol may be an option for treating military beneficiaries who have chronic pain and insomnia.

Using the RE-AIM Model of Health Promotion to Implement a Military Women's Health Promotion Program for Austere Settings.

The health concerns for military women who serve in austere environments include feminine hygiene, risk of infection, and limited knowledge of gynecologic conditions, symptoms, and prevention. The purpose of this study is to evaluate the effectiveness of the Women's Health Promotion Program (WHPP) for Austere Environments that was implemented in the military community setting of a large operational military unit on a southeastern U.S. military base. The WHPP is a pilot-tested program designed to educate women to recognize and prepare for environments that require alteration of feminine hygiene behaviors, with the goal of maintaining genitourinary health. Evaluation of the WHPP was designed according to the RE-AIM framework, which measures the Reach, Efficacy/effectiveness, Adoption, Implementation, and Maintenance of a health promotion program. The WHPP was offered to 49 military units (none of which declined) and presented to 443 military women in those units. One year after the implementation of the WHPP, the rates of urinary tract infections, vaginal candidiasis infections, and menstrual disorders decreased among the units that participated in the WHPP. These findings lay the foundation for an Army-wide adoption of this WHPP that could enhance readiness in military women.

Synthesis strategy: building a culturally sensitive mid-range theory of risk perception using literary, quantitative, and qualitative methods.

AIM: This article presents a discussion of development of a mid-range theory of risk perception. BACKGROUND: Unhealthy behaviours contribute to the development of health inequalities worldwide. The link between perceived risk and successful health behaviour change is inconclusive, particularly in vulnerable populations. This may be attributed to inattention to culture. DATA SOURCES: The synthesis strategy of theory building guided the process using three methods: (1) a systematic review of literature published between 2000-2011 targeting perceived risk in vulnerable populations; (2) qualitative and (3) quantitative data from a study of Samoan Pacific Islanders at high risk of cardiovascular disease and diabetes. DISCUSSION: Main concepts of this theory include risk attention, appraisal processes, cognition, and affect. Overarching these concepts is health-world view: cultural ways of knowing, beliefs, values, images, and ideas. This theory proposes the following: (1) risk attention varies based on knowledge of the health risk in the context of health-world views; (2) risk appraisals are influenced by affect, health-world views, cultural customs, and protocols that intersect with the health risk; (3) strength of cultural beliefs, values, and images (cultural identity) mediate risk attention and risk appraisal influencing the likelihood that persons will engage in health-promoting behaviours that may contradict cultural customs/protocols. IMPLICATIONS: Interventions guided by a culturally sensitive mid-range theory may improve behaviour-related health inequalities in vulnerable populations. CONCLUSIONS: The synthesis strategy is an intensive process for developing a culturally sensitive mid-range theory. Testing of the theory will ascertain its usefulness for reducing health inequalities in vulnerable groups.

Prevention is the key to maintaining gynecologic health during deployment.

Researchers have indicated that since Operation Desert Storm, the majority of gynecologic problems exhibited during deployment are from vaginal and urinary tract infections and menstrual disorders. The purpose of this article is to provide an overview of military women's health issues during military operations and summarize current knowledge and recommendations to promote their gynecologic health needs while deployed. Military women would benefit from predeployment health-promotion programs that focus on preventive measures to enhance gynecologic health while deployed.

Women at war: implications for mental health.

Few studies have investigated the impact of deployment stressors on the mental health outcomes of women deployed to Iraq in support of Operation Iraqi Freedom. This pilot study examined exposure to combat experiences and military sexual harassment in a sample of 54 active duty women and assessed the impact of these stressors on post-deployment posttraumatic stress disorder (PTSD) symptoms and depressive symptoms. Within 3 months of returning from deployment to Iraq, participants completed (a) the Combat Experiences Scale and the Sexual Harassment Scale of the Deployment Risk and Resilience Inventory, (b) the Primary Care PTSD Screen, and (c) an abbreviated version of the Center for Epidemiological Studies-Depression scale. Approximately three quarters of the sample endorsed exposure to combat experiences, and more than half of the sample reported experiencing deployment-related sexual harassment, with nearly half of the sample endorsing both stressors. Approximately one third of the sample endorsed clinical or subclinical levels of PTSD symptoms, with 11% screening positive for PTSD and 9% to 14% of the sample endorsing depressive symptoms. Regression analyses revealed that combat experiences and sexual harassment jointly accounted for significant variance in post-deployment PTSD symptoms, whereas military sexual harassment was identified as the only unique significant predictor of these symptoms. Findings from the present study lend support to research demonstrating that military sexual trauma may be more highly associated with post-deployment PTSD symptoms than combat exposure among female service members and veterans.

Military women's attitudes toward menstruation and menstrual suppression in relation to the deployed environment: development and testing of the MWATMS-9 (short form).

PURPOSE: To determine military women's attitudes toward menstruation and menstrual suppression with oral contraceptives in the deployed environment. METHODS: A cross-sectional descriptive design with the administration of the Menstrual Attitude Questionnaire (MAQ) and the 55-item Military Women's Attitudes Towards Menstrual Suppression Scale (MWATMS) to a convenience sample (n = 278) of women in the U.S. Army with deployment experience. FINDINGS: The MAQ's five subscales' mean scores ranged from 3.4 (+/-1.11) to 5.1 (+/-1.06), indicating neutral to moderate attitudes toward menstruation. Measurement development on the MWATMS produced a nine-item scale with three components: stress effects, benefits to self, and environmental barriers. CONCLUSION: Menstrual attitudes were generally neutral in this sample; however, military women favor menstrual suppression during deployment owing to the effects of stress during deployment, benefits that suppression would provide, and the barriers to menstrual hygiene in the deployed environment. Women who perceived menstruation as bothersome and debilitating had positive attitudes toward menstrual suppression. These findings can contribute to appropriate predeployment women's health care and improve the readiness for deployment in female soldiers. Providers should educate women on the risks and benefits of menstrual suppression methods and provide guidance on impact that the deployed environment can have on their menstrual experiences.

Development of the Military Women's Attitudes Toward Menstrual Suppression Scale: from construct definition to pilot testing.

The Military Women's Attitudes Toward Menstrual Suppression scale (MWATMS) was created to measure attitudes toward menstrual suppression during deployment. The human health and social ecology theories were integrated to conceptualize an instrument that accounts for military-unique aspects of the environment on attitudes toward suppression. A three-step instrument development process was followed to develop the MWATMS. The instrument was pilot tested on a convenience sample of 206 military women with deployment experience. Reliability was tested with measures of internal consistency (alpha = .97); validity was tested with principal components analysis with varimax rotation. Four components accounted for 65% of variance: Benefits/Interest, Hygiene, Convenience, and Soldier/Stress. The pilot test of the MWATMS supported its reliability and validity. Further testing is warranted for validation of this instrument.

Theoretical substruction: establishing links between theory and measurement of military women's attitudes towards menstrual suppression during military operations.

AIM: The aim of this paper is to establish a theoretical model for the exploration of the phenomenon of menstruation and women's attitudes towards menstrual suppression during military operations. BACKGROUND: In the emerging field of literature that explores menstruation among military women, there are indications that menstrual symptoms and hygiene are problematic under the circumstances of deployment to military operations. While menstrual suppression may be a solution to problems that women encounter with menstruation during deployment, there is little research exploring the phenomenon. DATA SOURCES: CINAHL and Medline were used to locate peer reviewed journal papers published from 1977 to 2007. International military reports were obtained through an internet search engine (Google). DISCUSSION: Issues that military women encounter surrounding menstruation during deployment are framed according to components of human ecology and social ecology theories, creating a theoretical model for the study of military women's menstrual health. Theoretical substruction is then used to evaluate the proposed theoretical and operational systems for measuring military women's attitudes during deployment. The process of theoretical substruction validates the model and the theoretical integrity of the proposed research on women's attitudes towards suppression. CONCLUSION: A theory-based model for women's health under challenging environmental conditions will enhance the holistic consideration of women's health issues by care providers. The theoretical model clearly explicates the phenomenon of menstruation during deployment and the theoretical and operational systems are soundly linked in the proposed measurement model of military women's attitudes towards menstrual suppression.

Military women's menstrual experiences and interest in menstrual suppression during deployment.

OBJECTIVE: To develop a preliminary description of military women's menstrual experiences and their awareness of menstrual suppression during deployment. DESIGN: Qualitative descriptive with content analysis. SETTING: Recruitment and sampling occurred at a large U.S. military base from December 2005 to January 2006. PARTICIPANTS: Nine women who had been deployed to U.S. military operations. RESULTS: Seven themes were generated from the data: (a) Menses is intensified during deployment, (b) It's hard to take care of yourself during your period, (c) Menstrual challenges: heat, dirt, and port-a-potties, (d) Menstruation is an inconvenience when you are deployed, (e) Dealing with menstruation in the military world, (f) Negative aspects of menstruation outweigh the positive during deployment, and (g) Menstrual suppression. CONCLUSION: Menstruation is problematic during deployment and participants expressed interest in menstrual suppression. However, concerns about the side effects and safety of continuous oral contraceptives limited participants' use of this therapy. Education on menstrual hygiene and methods of menstrual cycle control should be provided prior to deployment to prepare women for the experience.