Proposed explanations for excess injury among veterans of the Persian Gulf War and a call for greater attention from policymakers and researchers.

INTRODUCTION: Death rates among US veterans of the Persian Gulf War were lower than rates among non-deployed veterans and the US population at large, with the exception of injury deaths; returning veterans were at significantly greater risk of injury mortality. Similar patterns of excess injury mortality were documented among US and Australian veterans returning from Vietnam. In spite of these consistent findings little has been done to explain these associations and in particular to determine whether or not, and how, war related exposures influence injury risk among veterans returning home after deployments. HYPOTHESIZED PATHWAYS: Several potential pathways are proposed through which injury might be related to deployment. First, increases in injury mortality may be a consequence of depression, post-traumatic stress disorder, and symptoms of other psychiatric conditions developed after the war. Second, physical and psychological traumas experienced during the war may result in the postwar adoption of "coping" behaviors that also increase injury risk (for example, heavy drinking). Third, greater injury risk may be the indirect consequence of increased experiences of ill defined diseases and symptoms reported by many returning veterans. Fourth, veterans may experience poorer survivability for a given injury event resulting in greater mortality but not morbidity. Finally, the process that selects certain individuals for deployment may lead to a spurious association between deployment status and injury mortality by preferentially selecting individuals who are risk takers and/or exposed to greater hazards. CONCLUSIONS: More research and attention from policymakers is needed to clarify the link between deployment and postwar increased risk of injury.

Alcohol and other risk factors for drowning among male active duty U.S. army soldiers.

BACKGROUND: Risk factors for drowning are largely undocumented among military populations. HYPOTHESIS: Accident report narratives will provide important information about the role of alcohol use and other behaviors in drownings among active duty male U.S. Army soldiers. METHODS: Using a case series design, we describe drowning deaths reported to the U.S. Army Safety Center (1980-1997), documenting associated demographic factors, alcohol use, and other risk-taking behaviors. RESULTS: Drowning victims (n = 352) were disproportionately young, black, and single, with less time-in-service, and no college experience. Most drownings occurred off-duty (89%). Alcohol use was involved in at least 31% of the cases overall. Alcohol use was also associated with a 10-fold increase in reckless behavior (OR 9.6, 95% Cl 4.5-20.7) and was most common among drownings in Europe (OR = 4.3, 95% Cl 1.5-13.4). Most drownings occurred where no lifeguard was present (68%), but almost two-thirds occurred in the presence of others, with CPR initiated in less than one-third of these cases. Drownings involving minority victims were less likely to involve alcohol, but more likely to occur in unauthorized swimming areas. While most drownings did not involve violations of safety rules, over one-third of the cases involved some form of reckless behavior, particularly for those under age 21. CONCLUSIONS: Intervention programs should be tailored to meet the needs of the demographic subgroups at highest risk since behavioral risk factors vary by race and age. CPR training and skills maintenance can improve survival rates. Narrative data are important for developing hypotheses and understanding risk factors for injuries.

Demographic, physical, and mental health factors associated with deployment of U.S. Army soldiers to the Persian Gulf.

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.

Progress toward attainment of the Healthy People 2000 objectives in the U.S. Army: measured by health risk appraisal results.

BACKGROUND: Healthy People 2000 (HP2000) is a national agenda of health promotion and disease prevention objectives, with specific health behavior goals in 22 priority areas. The U.S. Army Health Risk Appraisal (HRA) is a self-administered health-habits survey, inquiring about tobacco and alcohol use, physical activity, nutrition, and safety-related practices, given to more than 400,000 active-duty U.S. Army soldiers in the 1990s. This article compares the health behaviors of U.S. Army soldiers, as measured by the HRA, with the HP2000 objectives. METHODS: We compared cross-sectional analyses of self-reported health behaviors of active-duty Army personnel responding to HRA questionnaires in 1991 (n=78,256) and in 1997-1998 (n=59,771) with corresponding HP2000 objectives. We also calculated longitudinal changes for personnel who took more than one HRA (n=86,393). RESULTS: By 1997-1998, the Army exceeded HP2000 physical fitness goals by at least 50% and also exceeded goals for eating high-fiber foods and using bicycle helmets. The Army did not meet goals for nutrition, tobacco use, and seat-belt use. CONCLUSIONS: The Army has made good progress toward the HP2000 goals. However, improvement is needed to meet the tobacco, nutrition, and safety goals.

Viewpoint: a comparison of cause-of-injury coding in U.S. military and civilian hospitals.

INTRODUCTION: Complete and accurate coding of injury causes is essential to the understanding of injury etiology and to the development and evaluation of injury-prevention strategies. While civilian hospitals use ICD-9-CM external cause-of-injury codes, military hospitals use codes derived from the NATO Standardization Agreement (STANAG) 2050. DISCUSSION: The STANAG uses two separate variables to code injury cause. The Trauma code uses a single digit with 10 possible values to identify the general class of injury as battle injury, intentionally inflicted nonbattle injury, or unintentional injury. The Injury code is used to identify cause or activity at the time of the injury. For a subset of the Injury codes, the last digit is modified to indicate place of occurrence. This simple system contains fewer than 300 basic codes, including many that are specific to battle- and sports-related injuries not coded well by either the ICD-9-CM or the draft ICD-10-CM. However, while falls, poisonings, and injuries due to machinery and tools are common causes of injury hospitalizations in the military, few STANAG codes correspond to these events. Intentional injuries in general and sexual assaults in particular are also not well represented in the STANAG. Because the STANAG does not map directly to the ICD-9-CM system, quantitative comparisons between military and civilian data are difficult. CONCLUSIONS: The ICD-10-CM, which will be implemented in the United States sometime after 2001, expands considerably on its predecessor, ICD-9-CM, and provides more specificity and detail than the STANAG. With slight modification, it might become a suitable replacement for the STANAG.

Boater training, drinking and boating, and other unsafe boating practices.

OBJECTIVES: Identify associations between lack of formal boater training, drinking and boating, and other unsafe boating practices. METHODS: A telephone survey queried respondents (age 16 or older in continental United States) about boating experience, type of boat used, and training. RESULTS: Of the 3,042 boaters surveyed (70% response), most had no formal training (73%). Boaters with formal training failed to use PFDs about as often as those without formal training and were equally or more likely to use alcohol while boating. CONCLUSIONS: The unexpected association between formal training and unsafe boating practices is probably due to reduced risk perception and inadequacies of boater training programs. Such programs seldom mention the risks of alcohol use while boating. Decisions to mandate formal training should be informed by these results; if mandated, training should address the risks of alcohol use while boating, and should be renewed frequently enough to offset reductions in risk perception.