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1.  The Reliability and Validity of the Self-Reported Drinking Measures in the Army’s Health Risk Appraisal Survey 
The reliability and validity of self-reported drinking behaviors from the Army Health Risk Appraisal (HRA) survey are unknown.
We compared demographics and health experiences of those who completed the HRA with those who did not (1991–1998). We also evaluated the reliability and validity of eight HRA alcohol-related items, including the CAGE, weekly drinking quantity, and drinking and driving measures. We used Cohen’s κ and Pearson’s r to assess reliability and convergent validity. To assess criterion (predictive) validity, we used proportional hazards and logistical regression models predicting alcohol-related hospitalizations and alcohol-related separations from the Army, respectively.
A total of 404,966 soldiers completed an HRA. No particular demographic group seems to be over- or underrepresented. Although few respondents skipped alcohol items, those who did tended to be older and of minority race. The alcohol items demonstrate a reasonable degree of reliability, with Cronbach’s α = 0.69 and test-retest reliability associations in the 0.75–0.80 range for most items over 2- to 30-day interims between surveys. The alcohol measures showed good criterion-related validity: those consuming more than 21 drinks per week were at 6 times the risk for subsequent alcohol-related hospitalization versus those who abstained from drinking (hazard ratio, 6.36; 95% confidence interval=5.79, 6.99). Those who said their friends worried about their drinking were almost 5 times more likely to be discharged due to alcoholism (risk ratio, 4.9; 95% confidence interval=4.00, 6.04) and 6 times more likely to experience an alcohol-related hospitalization (hazard ratio, 6.24; 95% confidence interval=5.74, 6.77).
The Army’s HRA alcohol items seem to elicit reliable and valid responses. Because HRAs contain identifiers, alcohol use can be linked with subsequent health and occupational outcomes, making the HRA a useful epidemiological research tool. Associations between perceived peer opinions of drinking and subsequent problems deserve further exploration.
PMCID: PMC2141695  PMID: 12766628
Alcohol; Military; Reliability; Validity; Survey
2.  The Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) 
Psychiatry  2014;77(2):107-119.
Although the suicide rate in the U.S. Army has traditionally been below age-gender matched civilian rates, it has climbed steadily since the beginning of the Iraq and Afghanistan conflicts and since 2008 has exceeded the demographically matched civilian rate. The Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) is a multicomponent epidemiological and neurobiological study designed to generate actionable evidence-based recommendations to reduce Army suicides and increase knowledge about risk and resilience factors for suicidality and its psychopathological correlates. This paper presents an overview of the Army STARRS component study designs and of recent findings.
Army STARRS includes six main component studies: (1) the Historical Administrative Data Study (HADS) of Army and Department of Defense (DoD) administrative data systems (including records of suicidal behaviors) for all soldiers on active duty 2004–2009 aimed at finding administrative record predictors of suicides; (2) retrospective case-control studies of fatal and nonfatal suicidal behaviors (each planned to have n = 150 cases and n = 300 controls); (3) a study of new soldiers (n = 50,765 completed surveys) assessed just before beginning basic combat training (BCT) with self-administered questionnaires (SAQ), neurocognitive tests, and blood samples; (4) a cross-sectional study of approximately 35,000 (completed SAQs) soldiers representative of all other (i.e., exclusive of BCT) active duty soldiers; (5) a pre-post deployment study (with blood samples) of soldiers in brigade combat teams about to deploy to Afghanistan (n = 9,421 completed baseline surveys), with sub-samples assessed again one, three, and nine months after returning from deployment; and (6) a pilot study to follow-up SAQ respondents transitioning to civilian life. Army/DoD administrative data are being linked prospectively to the large-scale survey samples to examine predictors of subsequent suicidality and related mental health outcomes.
Main outcome measures
Measures (self-report and administratively recorded) of suicidal behaviors and their psychopathological correlates.
Component study cooperation rates are comparatively high. Sample biases are relatively small. Inefficiencies introduced into parameter estimates by using nonresponse adjustment weights and time-space clustering are small. Initial findings show that the suicide death rate, which rose over 2004–2009, increased for those deployed, those never deployed, and those previously deployed. Analyses of administrative records show that those deployed or previously deployed were at greater suicide risk. Receiving a waiver to enter the Army was not associated with increased risk. However, being demoted in the past two years was associated with increased risk. Time in current deployment, length of time since return from most recent deployment, total number of deployments, and time interval between most recent deployments (known as dwell time) were not associated with suicide risk. Initial analyses of survey data show that 13.9% of currently active non-deployed regular Army soldiers considered suicide at some point in their lifetime, while 5.3% had made a suicide plan, and 2.4% had attempted suicide. Importantly, 47–60% of these outcomes first occurred prior to enlistment. Prior mental disorders, in particular major depression and intermittent explosive disorder, were the strongest predictors of these self-reported suicidal behaviors. Most onsets of plans-attempts among ideators (58.3–63.3%) occurred within the year of onset of ideation. About 25.1% of non-deployed U.S. Army personnel met 30-day criteria for a DSM-IV anxiety, mood, disruptive behavior, or substance disorder (15.0% an internalizing disorder; 18.4% an externalizing disorder) and 11.1% for multiple disorders. Importantly, three-fourths of these disorders had pre-enlistment onsets.
Integration across component studies creates strengths going well beyond those in conventional applications of the same individual study designs. These design features create a strong methodological foundation from which Army STARRS can pursue its substantive research goals. The early findings reported here illustrate the importance of the study and its approach as a model of studying rare events particularly of national security concern. Continuing analyses of the data will inform suicide prevention for the U.S. Army.
PMCID: PMC4075436  PMID: 24865195
3.  Demographic, Physical, and Mental Health Factors Associated with Deployment of U.S. Army Soldiers to the Persian Gulf 
Military medicine  2000;165(10):762-772.
A total of 675,626 active duty Army soldiers who were known to be at risk for deployment to the Persian Gulf were followed from 1980 through the Persian Gulf War. Hospitalization histories for the entire cohort and Health Risk Appraisal surveys for a subset of 374 soldiers were used to evaluate prewar distress, health, and behaviors. Deployers were less likely to have had any prewar hospitalizations or hospitalization for a condition commonly reported among Gulf War veterans or to report experiences of depression/suicidal ideation. Deployers reported greater satisfaction with life and relationships but displayed greater tendencies toward risk-taking, such as drunk driving, speeding, and failure to wear safety belts. Deployed veterans were more likely to receive hazardous duty pay and to be hospitalized for an injury than nondeployed Gulf War-era veterans. If distress is a predictor of postwar morbidity, it is likely attributable to experiences occurring during or after the war and not related to prewar exposures or health status. Postwar excess injury risk may be explained in part by a propensity for greater risk-taking, which was evident before and persisted throughout the war.
PMCID: PMC2141685  PMID: 11050874
4.  Rationale and Methods of the Substance Use and Psychological Injury Combat Study (SUPIC): A Longitudinal Study of Army Service Members Returning from Deployment in FY2008–2011 
Substance use & misuse  2013;48(10):863-879.
SUPIC will examine whether early detection and intervention for post-deployment problems among Army Active Duty and National Guard/Reservists returning from Iraq or Afghanistan are associated with improved long-term substance use and psychological outcomes. This paper describes the rationale and significance of SUPIC, and presents demographic and deployment characteristics of the study sample (N=643,205), and self-reported alcohol use and health problems from the subsample with matched post-deployment health assessments (N=487,600). This longitudinal study aims to provide new insight into the long-term post-deployment outcomes of Army members by combining service member data from the Military Health System and Veterans Health Administration.
PMCID: PMC3793632  PMID: 23869459
Military Health System; deployment; observational study design; outcomes; urinanalysis; active duty; National Guard/Reservists; veterans; alcohol use disorder; posttraumatic stress disorder; depression
5.  Drinking and Spouse Abuse Among U.S. Army Soldiers 
This study examines the relationship between typical weekly drinking and perpetration of spouse abuse as well as the relationship between the perpetrator’s typical weekly drinking and alcohol use during the abuse event among U.S. Army male soldiers.
Cases include all active duty, male, enlisted Army spouse abusers identified in the Army’s Central Registry who had also completed an Army Health Risk Appraisal Survey (HRA) between 1991 and 1998 (N = 9534). Cases were matched on sex, rank, and marital status with 21,786 control subjects who had also completed an HRA.
In multivariate logistic regression models, heavy drinkers (22 or more drinks per week) were 66% more likely to be spouse abusers than were abstainers (odds ratio 1.66; 95% confidence interval 1.40–1.96). In addition, self-reported moderate and heavy drinkers were three times as likely and light drinkers (1–7 drinks per week) were twice as likely as nondrinkers to be drinking during the time of the abuse event.
Self-reported heavy drinking is an independent risk factor for perpetration of spouse abuse among male, enlisted Army soldiers. Even 5 years or more after ascertainment of typical drinking habits, there is a significant association between self-reported heavy drinking and alcohol involvement at the time of the spouse abuse event. Personnel who work with perpetrators and victims of spouse abuse should be trained carefully to query about current and typical drinking patterns.
PMCID: PMC1351131  PMID: 15608606
Spouse Abuse; Violence; Alcohol; Injury; Military
6.  Cross-sectional assessment of prevalence and correlates of blood-borne and sexually-transmitted infections among Afghan National Army recruits 
BMC Infectious Diseases  2012;12:196.
Few data are available in Afghanistan to shape national military force health practices, particularly with regard to sexually-transmitted infections (STIs). We measured prevalence and correlates of HIV, syphilis, herpes simplex 2 virus (HSV-2), and hepatitis C virus (HCV) among Afghan National Army (ANA) recruits.
A cross-sectional sample of male ANA recruits aged 18–35 years were randomly selected at the Kabul Military Training Center between February 2010 and January 2011. Participants completed an interviewer-administered questionnaire and serum-based rapid testing for syphilis and hepatitis C virus antibody on-site; HIV and HSV-2 screening, and confirmatory testing were performed off-site. Prevalence of each infection was calculated and logistic regression analysis performed to identify correlates.
Of 5313 recruits approached, 4750 consented to participation. Participants had a mean age of 21.8 years (SD±3.8), 65.5% had lived outside Afghanistan, and 44.3% had no formal education. Few reported prior marijuana (16.3%), alcohol (5.3%), or opiate (3.4%) use. Of sexually active recruits (58.7%, N = 2786), 21.3% reported paying women for sex and 21.3% reported sex with males. Prevalence of HIV (0.063%, 95% CI: 0.013- 0.19), syphilis (0.65%, 95% CI: 0.44 – 0.93), and HCV (0.82%, 95% CI: 0.58 – 1.12) were quite low. Prevalence of HSV-2 was 3.03% (95% CI: 2.56 - 3.57), which was independently associated with age (Adjusted Odds Ratio (AOR) = 1.04, 95% CI: 1.00 - 1.09) and having a television (socioeconomic marker) (AOR = 1.46, 95% CI: 1.03 – 2.05).
Though prevalence of HIV, HCV, syphilis, and HSV-2 was low, sexual risk behaviors and intoxicant use were present among a substantial minority, indicating need for prevention programming. Formative work is needed to determine a culturally appropriate approach for prevention programming to reduce STI risk among Afghan National Army troops.
PMCID: PMC3482585  PMID: 22909128
Afghanistan; Military populations; HIV; Sexual risk behavior; Drug use
7.  Returning home: forced conscription, reintegration, and mental health status of former abductees of the Lord's Resistance Army in northern Uganda 
BMC Psychiatry  2009;9:23.
Since the late 1980s, the Lord's Resistance Army (LRA), a spiritualist rebel group in northern Uganda, has killed and mutilated thousands of civilians and abducted an estimated 52,000 to 75,000 people to serve as soldiers, porters, and sex slaves for its commanders. This study examines the types of violence to which former abductees have been exposed and the extent to which these acts have affected their psychological well-being.
This is a cross-sectional study of 2,875 individuals selected through a multi-stage stratified cluster sampling design conducted in 8 districts of northern Uganda. Multivariate logistic regressions were performed with symptoms for Post-traumatic Stress Disorder (PTSD) and depression as the main outcome measures.
One-third of the respondents (33%) self-reported having experienced abduction (49% among the Acholi, the largest tribal group in northern Uganda). Over half (56%) of all the respondents and over two-thirds of those who experienced abduction met the criteria for symptoms of post-traumatic stress disorder (PTSD). Multivariate analysis shows that several factors increased the risk of former LRA abductees developing symptoms of PTSD. These factors included gender (females were more susceptible than males), being a member of the Acholi ethnic group, participating in or witnessing a cumulative number of traumatic events, and encountering difficulties re-integrating into communities after abduction. Factors associated with increased risk of meeting criteria for symptoms of depression included older age of males at the time of abduction, lower score on social relationship scale, high incidence of general traumatic event exposure, high incidence of forced acts of violence, and problems reintegrating into communities after abduction.
Abduction and forced conscription of civilians has affected the psychological well-being of a significant number of northern Ugandans. The sources of psychological trauma are multiple, ranging from witnessing to being forced to commit violent acts, and compounded by prolonged exposure to violence, often for months or years. Community-based mental health care services and reintegration programs are needed to facilitate the reintegration of former abductees back into their communities.
PMCID: PMC2693494  PMID: 19445689
8.  Spouse Abuse and Alcohol Problems Among White, African American, and Hispanic U.S. Army Soldiers 
Prior studies suggest racial/ethnic differences in the associations between alcohol misuse and spouse abuse. Some studies indicate that drinking patterns are a stronger predictor of spouse abuse for African Americans but not whites or Hispanics, while others report that drinking patterns are a stronger predictor for whites than African Americans or Hispanics. This study extends prior work by exploring associations between heavy drinking, alcohol-related problems, and risk for spouse abuse within racial/ethnic groups as well as variations associated with whether the perpetrator is drinking during the spouse abuse incident.
Cases (N = 7,996) were all active-duty male, enlisted Army spouse abusers identified in the Army’s Central Registry (ACR) who had also completed an Army Health Risk Appraisal (HRA) Survey between 1991 and 1998. Controls (N = 17,821) were matched on gender, rank, and marital and HRA status.
We found 3 different patterns of association between alcohol use and domestic violence depending upon both the race/ethnicity of the perpetrator and whether or not alcohol was involved in the spouse abuse event. First, after adjusting for demographic and psychosocial factors, weekly heavy drinking (>14 drinks per week) and alcohol-related problems (yes to 2 or more of 6 alcohol-related problem questions, including the CAGE) were significant predictors of domestic violence among whites and Hispanics only. Also for the white soldiers, the presence of family problems mediated the effect of alcohol-related problems on spouse abuse. Second, alcohol-related problems predicted drinking during a spouse abuse incident for all 3 race groups, but this relation was moderated by typical alcohol consumption patterns in Hispanics and whites only. Finally, alcohol-related problems predicted drinking during a spouse abuse incident, but this was a complex association moderated by different psychosocial or behavioral variables within each race/ethnic group.
These findings suggest important cultural/social influences that interact with drinking patterns.
PMCID: PMC2141684  PMID: 17010139
Alcohol; Violence; Intimate Partner Violence; Ethnicity; Race; Army
9.  Mosquito Species Composition and Plasmodium vivax infection Rates for Korean Army Bases near the Demilitarized Zone in the Republic of Korea, 2011 
Vivax malaria is a significant military and civilian health threat in northern Republic of Korea (ROK). Mosquito collections were performed at two ROK army installations, Paju near the demilitarized zone (DMZ) using black light traps in 2011. The DMZ, a 4 km wide border, is the northernmost point of the ROK and separates the ROK from the Democratic People's Republic of Korea (DPRK). Anopheles spp. were identified by polymerase chain reaction and screened for Plasmodium vivax sporozoites. Of 4,354 female Anopheles mosquitoes identified, Anopheles kleini (61.8%) was the most frequently collected, followed by Anopheles pullus (16.0%), Anopheles belenrae (9.0%), Anopheles sinensis (7.4%), Anopheles sineroides (4.2%), and Anopheles lesteri (1.6%). Anopheles kleini, An. pullus, and An. sineroides showed the highest population densities in June, whereas population densities were highest for An. belenrae, An. lesteri, and An. sinensis in August. The maximum likelihood estimation (estimated number of positive mosquitoes/1,000) for P. vivax was highest for An. lesteri (28.9), followed by An. sineroides (23.3), An. belenrae (15.8), An. sinensis (9.6), An. pullus (5.8) and An. kleini (4.2). The seasonal maximum likelihood estimation (MLE) values were variable among Anopheles species. Anopheles belenrae, An. Pullus, and An. sineroides showed the highest seasonal MLE's in July, whereas An. lesteri and An. sinensis exhibited the highest seasonal MLEs in September and An. kleini during August. This is the first report implicating An. sineroides as a vector of P. vivax in the ROK, and extends our knowledge of the distribution and potential role in malaria transmission.
PMCID: PMC3541740  PMID: 23243112
10.  A revision of the Chinese Trigonalyidae (Hymenoptera, Trigonalyoidea) 
ZooKeys  2014;1-207.
The Chinese fauna of the family Trigonalyidae Cresson, 1887, is revised, keyed and fully illustrated for the first time. Eight genera of this family (Bakeronymus Rohwer, 1922, Bareogonalos Schulz, 1907, Jezonogonalos Tsuneki, 1991, re-instated, Lycogaster Shuckard, 1841, Orthogonalys Schulz, 1905, Pseudogonalos Schulz, 1906, Taeniogonalos Schulz, 1906 and Teranishia Tsuneki, 1991) are recorded from China. The genus Ischnogonalos Schulz, 1907, is synonymized with Taeniogonalos Schulz, 1906. In total 40 valid species are recognized. Twenty species are new for science: Jezonogonalos elliptifera sp. n., J. jiangliae sp. n., J. luteata sp. n., J. nigrata sp. n., Lycogaster angustula sp. n., L. flavonigrata sp. n., L. nigralva sp. n., Orthogonalys cheni sp. n., O. clypeata sp. n., O. robusta sp. n., Pseudogonalos angusta sp. n., Taeniogonalos bucarinata sp. n., T. cordata sp. n., T. geminata sp. n., T. sculpturata sp. n., T. triangulata sp. n., T. tricolorisoma sp. n., T. uncifera sp. n., Teranishia crenulata sp. n. and T. glabrata sp. n. Two species are reported new for China: Orthogonalys elongata Teranishi, 1929 and Nanogonalos flavocincta Teranishi, 1929 (renamed to Taeniogonalos subtruncata nom. n.). Seven new synonyms are proposed: Poecilogonalos yuasai Teranishi, 1938, and P. maga taiwana Tsuneki, 1991, of Taeniogonalos taihorina (Bischoff, 1914); Taiwanogonalos minima Tsuneki, 1991, and T. similis Tsuneki, 1991, of Taeniogonalos alticola (Tsuneki, 1991); P. intermedia Chen, 1949, and P. unifasciata Chen, 1949, of Taeniogonalos formosana (Bischoff, 1913). Six taxa are recognised as valid species: Bakeronymus seidakka Yamane & Terayama, 1983, Jezonogonalos laeviceps (Tsuneki, 1991), J. satoi (Tsuneki, 1991), Taeniogonalos alticola (Tsuneki, 1991), T. flavoscutellata (Chen, 1949) and T. gestroi (Schulz, 1908). Five new combinations are made: Jezonogonalos laeviceps (Tsuneki, 1991), comb. n., J. satoi (Tsuneki, 1991), comb. n., Taeniogonalos flavoscutellata (Chen, 1949), comb. n., T. gestroi (Schulz, 1908), comb. n. and T. lachrymosa (Westwood, 1874), comb. n. Lectotypes are designated for Lycogaster violaceipennis Chen, 1949, Poecilogonalos flavoscutellata Chen, 1949, P. rufofasciata Chen, 1949, and P. tricolor Chen, 1949.
PMCID: PMC3950486  PMID: 24624023
Revision; Trigonalyidae; Bakeronymus; Bareogonalos; Jezonogonalos; Lycogaster; Orthogonalys; Pseudogonalos; Taeniogonalos; Teranishia; keys; new species; new synonyms; new combinations; China
11.  An Occupational Health Nursing Computer Application in Medical Care: An Army Approach 
Occupational health nursing has become an increasingly important specialty in the field of nursing during this century. In the broadest concept, occupational health is concerned with all factors which influence the health of people at work. Nurses, as well as other health care professionals, are attempting to apply the evolving technology of the computer to direct client care applications in the workplace. One such relevant use of the computer has been that of targeted disease surveillance in an occupational health setting. This paper will address the process utilized by community health nurses to assess, plan, implement and evaluate a computerized disease surveillance program in an occupational health setting. The program was a joint effort between the United States Army Medical Department Activity, Fort Irwin, California and the Epidemiology Consultant Service of the Division of Preventive Medicine, the Walter Reed Army Institute of Research, Washington, DC. (WRAIR).
PMCID: PMC2578424
12.  Efficacy of a Pilot Internet-Based Weight Management Program (H.E.A.L.T.H.) and Longitudinal Physical Fitness Data in Army Reserve Soldiers 
The primary aims of this article are to describe the utilization of an Internet-based weight management Web site [Healthy Eating, Activity, and Lifestyle Training Headquarters (H.E.A.L.T.H.)] over a 12–27 month period and to describe concurrent weight and fitness changes in Army Reserve soldiers.
The H.E.A.L.T.H. Web site was marketed to Army Reserve soldiers via a Web site promotion program for 27 months (phase I) and its continued usage was observed over a subsequent 12-month period (phase II). Web site usage was obtained from the H.E.A.L.T.H. Web site. Weight and fitness data were extracted from the Regional Level Application Software (RLAS).
A total of 1499 Army Reserve soldiers registered on the H.E.A.L.T.H. Web site. There were 118 soldiers who returned to the H.E.A.L.T.H. Web site more than once. Registration rate reduced significantly following the removal of the Web site promotion program. During phase I, 778 Army Reserve soldiers had longitudinal weight and fitness data in RLAS. Men exceeding the screening table weight gained less weight compared with men below it (p < .007). Percentage change in body weight was inversely associated with change in fitness scores.
The Web site promotion program resulted in 52% of available Army Reserve soldiers registering onto the H.E.A.L.T.H. Web site, and 7.9% used the Web site more than once. The H.E.A.L.T.H. Web site may be a viable population-based weight and fitness management tool for soldier use.
PMCID: PMC3208890  PMID: 22027327
Army Reserve; Internet; military; obesity prevention; weight management
13.  Development of an Internet/Population-Based Weight Management Program for the U.S. Army 
A significant number of Army soldiers are sufficiently overweight to exceed the maximum weight allowances defined by the Army weight control program (AR600-9). Also, the body weights of a substantial number of soldiers approach the maximum weight allowances. These soldiers should not gain additional weight if they are to meet Army weight allowances. The conventional approach to this overweight problem is assigning soldiers to remedial physical training and mandatory referral for nutrition counseling by a health care provider. An alternative to this conventional approach is to target the entire population of soldiers (population-based intervention) to promote weight loss in overweight soldiers and weight gain prevention in soldiers who are approaching overweight status. To accomplish this objective, the Healthy Eating, Activity, and Lifestyle Training Headquarters (H.E.A.L.T.H.) program was developed. This article describes the rationale for developing the program, the components of the program, and the utilization promotion strategies of the program. The H.E.A.L.T.H. program includes two primary components: (1) a Web site tailored to the standards established in Field Manual 21-20, Physical Fitness Training, Army physical fitness test, and AR600-9, the army weight control program, and (2) a health promotion program designed to promote awareness of the H.E.A.L.T.H. Web site and to facilitate use of the Web site by soldiers and their family members. The Web site is equipped with personalized planning tools and progress tracking over time related to fitness, caloric intake, and lifestyle behavior change goals. The health promotion program includes media advertisements and “ground roots” efforts to facilitate use by soldiers.
PMCID: PMC2769719  PMID: 19885186
AR600-9; Army; Army weight control program; Department of Defense; Internet intervention; obesity prevention; population-based approach; soldiers; weight management
14.  What are the effects of having an illness or injury whilst deployed on post deployment mental health? A population based record linkage study of UK Army personnel who have served in Iraq or Afghanistan 
BMC Psychiatry  2012;12:178.
The negative impact of sustaining an injury on a military deployment on subsequent mental health is well-documented, however, the relationship between having an illness on a military operation and subsequent mental health is unknown.
Population based study, linking routinely collected data of attendances at emergency departments in military hospitals in Iraq and Afghanistan [Operational Emergency Department Attendance Register (OpEDAR)], with data on 3896 UK Army personnel who participated in a military health study between 2007 and 2009 and deployed to Iraq or Afghanistan between 2003 to 2009.
In total, 13.8% (531/3896) of participants had an event recorded on OpEDAR during deployment; 2.3% (89/3884) were medically evacuated. As expected, those medically evacuated for an injury were at increased risk of post deployment probable PTSD (odds ratio 4.27, 95% confidence interval 1.80-10.12). Less expected was that being medically evacuated for an illness was also associated with a similarly increased risk of probable PTSD (4.39, 1.60-12.07) and common mental disorders (2.79, 1.41-5.51). There was no association between having an OpEDAR event and alcohol misuse. Having an injury caused by hostile action was associated with increased risk of probable PTSD compared to those with a non-hostile injury (3.88, 1.15 to 13.06).
Personnel sustaining illnesses on deployment are just as, if not more, at risk of having subsequent mental health problems as personnel who have sustained an injury. Monitoring of mental health problems should consider those with illnesses as well as physical injuries.
PMCID: PMC3507752  PMID: 23095133
Mental Health; Military; PTSD; Alcohol use; Depression; Deployment
15.  The Health of the American Slave Examined by Means of Union Army Medical Statistics 
The health status of the American slave in the 19th century remains unclear despite extensive historical research. Better knowledge of slave health would provide a clearer picture of the life of the slave, a better understanding of the 19th-century medicine, and possibly even clues to the health problems of modern blacks. This article hopes to contribute to the literature by examining another source of data. Slaves entering the Union Army joined an organization with standardized medical care that generated extensive statistical information. Review of these statistics answers questions about the health of young male blacks at the time American slavery ended.
PMCID: PMC2561819  PMID: 3881595
16.  Wealth Accumulation and the Health of Union Army Veterans, 1860–1870 
The journal of economic history  2005;65(2):352-385.
How did the wartime health of Union Army recruits affect their wealth accumulation through 1870? Wounds and exposure to combat had strong negative effects on subsequent savings, as did illnesses while in the service. The impact of poor health was particularly strong for unskilled workers. Health was a powerful determinant of nineteenth-century economic mobility. Infectious diseases’ influences on wealth accumulation suggest that the economic gains from the improvement of the disease environment should be enormous. The direct economic costs of the Civil War were probably much greater than previously thought, given the persistent adverse health effects of wartime experiences.
PMCID: PMC2840618  PMID: 20300440
17.  Rationale and design of a multicenter randomized controlled trial on a 'minimal intervention' in Dutch army personnel with nonspecific low back pain [ISRCTN19334317] 
Researchers from the Royal Netherlands Army are studying the potential of isolated lumbar extensor training in low back pain in their working population. Currently, a randomized controlled trial is carried out in five military health centers in The Netherlands and Germany, in which a 10-week program of not more than 2 training sessions (10–15 minutes) per week is studied in soldiers with nonspecific low back pain for more than 4 weeks. The purpose of the study is to investigate the efficacy of this 'minimal intervention program', compared to usual care. Moreover, attempts are made to identify subgroups of different responders to the intervention.
Besides a baseline measurement, follow-up data are gathered at two short-term intervals (5 and 10 weeks after randomization) and two long-term intervals (6 months and one year after the end of the intervention), respectively. At every test moment, participants fill out a compound questionnaire on a stand-alone PC, and they undergo an isometric back strength measurement on a lower back machine.
Primary outcome measures in this study are: self-assessed degree of complaints and degree of handicap in daily activities due to back pain. In addition, our secondary measurements focus on: fear of movement/(re-) injury, mental and social health perception, individual back extension strength, and satisfaction of the patient with the treatment perceived. Finally, we assess a number of potential prognostic factors: demographic and job characteristics, overall health, the degree of physical activity, and the attitudes and beliefs of the physiotherapist towards chronic low back pain.
Although a substantial number of trials have been conducted that included lumbar extension training in low back pain patients, hardly any study has emphasized a minimal intervention approach comparable to ours. For reasons of time efficiency and patient preferences, this minimal sports medicine approach of low back pain management is interesting for the population under study, and possibly for comparable working populations with physical demanding job activities.
PMCID: PMC533884  PMID: 15535881
18.  Socioeconomic Differences in the Health of Black Union Army Soldiers 
Social science history  2009;33(4):427-457.
This paper investigates patterns of socioeconomic difference in the wartime morbidity and mortality of black Union Army soldiers. Among the factors that contributed to a lower probability of contracting and dying from diseases were (1) lighter skin color, (2) a non-field occupation, (3) residence on a large plantation, and (4) residence in a rural area prior to enlistment. Patterns of disease-specific mortality and timing of death suggest that the differences in the development of immunity against diseases and in nutritional status prior to enlistment were responsible for the observed socioeconomic differences in wartime health. For example, the advantages of light-skinned soldiers over dark-skinned and of enlisted men formerly engaged in non-field occupations over field hands resulted from differences in nutritional status. The lower wartime mortality of ex-slaves from large plantations can be explained by their better-developed immunity as well as superior nutritional status. The results of this paper suggest that there were substantial disparities in the health of the slave population on the eve of the Civil War.
PMCID: PMC3427919  PMID: 22933827
19.  Prevalence of Human Immunodeficiency Virus Drug Resistance Mutations and Subtypes in Drug-Naive, Infected Individuals in the Army Health Service of Rio de Janeiro, Brazil 
Journal of Clinical Microbiology  2004;42(1):426-430.
The prevalence of mutations that confer resistance to antiretroviral drugs was examined in 56 drug-naive, human immunodeficiency virus type 1 (HIV-1)-infected individuals from the Army Health Service in Rio de Janeiro, Brazil. No primary protease inhibitor mutations were found, but secondary mutations were observed in 51.2% of the samples. Fourteen percent of the viruses had reverse transcriptase inhibitor-associated mutations. Comparative analysis of protease secondary mutations from four different time periods in drug-naive patients in the city of Rio de Janeiro has indicated constant rates for particular mutations. Changes in CD4 cell counts and HIV viral load over time in subtype B- and non-B-infected drug-naive patients were not significantly different.
PMCID: PMC321664  PMID: 14715797
20.  Out of hours attendance in an army practice. 
There is some evidence that rates of out of hours calls in army general practices are higher than the average for the NHS. In an attempt to reduce out of hours demand a programme of preventive and educational initiatives for patients was introduced at an army practice in Hohne, West Germany early in 1985. This included regular child development clinics, well woman clinics, a practice booklet and leaflets about the management of simple illnesses, a library of books and videos for patients and health education videos in the waiting room. The project was complemented by an audit of doctors' prescribing habits followed by drawing up agreed protocols for the treatment of common disorders such as sore throat. Annual attendance rates per registered patient were recorded for 1984-86 to compare use of out of hours services by patients before and after the introduction of the project. Out of hours attendance rates fell by 35% (from 0.17 per annum to 0.11 per annum) overall and by 61% in young children. The total annual attendance rate dropped by 14% (from 5.13 to 4.43) during the same period, but fell by only 1% over the same period at a similar practice in Osnabruck. The decrease was particularly marked for out of hours attendances which the doctor classified as lower urgency: attendances classed as very low urgency decreased by 78% between 1984 and 1986 but those classed as medium urgency decreased by only 2%.(ABSTRACT TRUNCATED AT 250 WORDS)
PMCID: PMC1371659  PMID: 1878273
21.  The natural history and risk factors of musculoskeletal conditions resulting in disability among US Army personnel 
Work (Reading, Mass.)  2002;18(2):99-113.
We describe the natural history of 13 musculoskeletal conditions requiring hospitalization and identify demographic, behavioral, psychosocial, occupational, and clinical characteristics most strongly associated with disability discharge from the Army. Subjects included 15,268 active-duty personnel hospitalized for a common musculoskeletal condition between the years 1989–1996 who were retrospectively followed through 1997. Back conditions had the greatest 5-year cumulative risk of disability (21%, 19%, and 17% for intervertebral disc displacement, intervertebral disc degeneration, and nonspecific low back pain, respectively). Cox proportional hazards models identified the following risk factors for disability among males: lower pay grade, musculoskeletal diagnosis, shorter length of service, older age, occupational category, lower job satisfaction, recurrent musculoskeletal hospitalizations, more cigarette smoking, greater work stress, and heavier physical demands. Among females, fewer covariates reached statistical significance, although lower education level was significant in more than one model. Modifiable risk factors related to work (job satisfaction, work stress, physical demands, occupation) and health behaviors (smoking) suggest possible targets for intervention.
PMCID: PMC2151132  PMID: 12441574
Musculoskeletal conditions; natural history; disability; epidemiology; occupation; military personnel; injury
22.  Hospitalizations for fall-related injuries among active-duty Army soldiers, 1980–1998 
Work (Reading, Mass.)  2002;18(2):161-170.
Data from the Total Army Injury and Health Outcomes Database (TAIHOD) were used to describe 28,352 fall-related hospitalizations among active-duty Army soldiers between 1980 and 1998. Soldiers who were younger than age 26, single, and had a high school education or less were at greatest risk. Falls from a height were more likely to be fatal than other types of falls, accounting for 88% of all fatalities. In cases where duty status was known, 64% of the falls took place while the soldier was on duty and half of these occurred during training. The most common type of fall during training was fall from a height (37%). Falls on stairs and ladders accounted for 49% of all off-duty falls. Future research should include identification of specific behavioral and occupational risk factors for falls, particularly those occurring during training activities, and falls occurring off duty.
PMCID: PMC2141687  PMID: 12441580
Accidental falls; Army; injuries and wounds; hospitalizations; database; military; free text
23.  Causes, types and severity of injury among army soldiers hospitalized with alcohol comorbidity* 
Addiction (Abingdon, England)  2007;102(9):1411-1420.
To examine the relationship between alcohol use and the cause, type and severity of hospitalized injuries.
We used the Total Army Injury and Health Outcomes Database (TAIHOD) to conduct cross-sectional analyses of the association between alcohol comorbidity and the cause, type and severity of soldiers’ non-combat injuries requiring hospitalization.
Subjects were active-duty US army soldiers (n = 211 790) hospitalized with a primary diagnosis of injury between 1980 and 2002.
Alcohol comorbidity was positively associated with hospitalized injuries resulting from fights and falls and negatively associated with sports injuries; positively associated with hospitalized cases of head injury, open wounds and poisonings and negatively associated with musculoskeletal injury; and, overall, associated with shorter length of stay. Controlling for demographic factors did not moderate the association between alcohol and cause, type or severity of injury.
Alcohol comorbidity is specifically associated with injuries related to impairment and antisocial behavior.
PMCID: PMC2141693  PMID: 17697276
Alcohol; head injuries; injury cause; injury severity; injury type; military; soldiers; sports injuries
24.  Drinking and other risk taking behaviors of enlisted male soldiers in the US Army 
Work (Reading, Mass.)  2002;18(2):141-150.
High-risk drinking is among the top three prevention priorities of the Department of Defense. Research suggests that enlisted male soldiers are particularly at risk for unhealthy drinking behaviors. 292,023 enlisted male soldiers who responded to a Health Risk Appraisal (HRA) survey between 1990 and 1998 were dichotomized into high and low-risk drinking groups. Logistic regression analysis showed that high-risk drinkers wore seatbelts less frequently, were more likely to drive > 15 mph over the speed limit, and to smoke more than 20 cigarettes/day. This high-risk group was predominately young (< 25), Caucasian, high school educated or less, and most likely employed as infantrymen or craftsworkers. The two highest risk occupational groups (infantrymen and craftsworkers) differ from each other, and from other Army occupations. Intervention programs should include safe driving habits and smoking cessation, as well as high-risk drinking, and should be tailored to the specific needs of the group at highest risk.
PMCID: PMC2141688  PMID: 12441578
25.  Occupational Career and Risk of Mortality among Union Army Veterans 
Social science & medicine (1982)  2009;69(3):460-468.
Previous studies have extended the traditional framework on occupational disparities in health by examining mortality differentials from a career perspective. Few studies, however, have examined the relation between career and mortality in a historical U.S. population. This study explores the relation between occupational career and risk of mortality in old age among 7,096 Union Army veterans who fought the American Civil War in the 1860s. Occupational mobility was commonplace among the veterans in the postbellum period, with 54 percent of them changing occupations from the time of enlistment to 1900. Among veterans who were farmers at enlistment, 46 percent of them changed to a non-farming occupation by the time of 1900. Results from the Cox Proportional Hazard analysis suggest that relative to the average mortality risk of the sample, being a farmer at enlistment or circa 1900 are both associated with a lower risk of mortality in old age, although the effect is more salient for veterans who were farmers at enlistment. Occupational immobility for manual labors poses a serious threat to chance of survival in old age. These findings still hold after adjusting for the effects of selected variables characterizing risk exposures during early life, wartime, and old age. The robustness of the survival advantage associated with being a farmer at enlistment highlights the importance of socioeconomic conditions early in life in chance of survival at older ages.
PMCID: PMC2852134  PMID: 19552993
Career; Occupational Mobility; Mortality; Union Army Veterans; USA

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