Adjusting Suicide Rates in a Military Population: Methods to Determine the Appropriate Standard Population.

The choice of the standard population is important when calculating adjusted rates for a military population: results can influence policies and funding allocations for programs and initiatives for suicide prevention. We describe the methodological considerations and decision-making process used in choosing a standard population for adjusting rates to compare suicide among US Army soldiers and the general US population. We examined 5 different standard populations, using the direct method to adjust annual suicide rates for the Army and the US population, 2004 to 2015, for age and for age and sex. The pattern of the Army and US population age- and sex-adjusted rates remained consistent with crude rates when adjusted to any of the Army standard population distributions. Using an Army distribution as the standard population produces suicide rates consistent with routine messaging about suicide trends among Army soldiers.

Performance excellence: using Lean Six Sigma tools to improve the US Army behavioral health surveillance process, boost team morale, and maximize value to customers and stakeholders.

Lean Six Sigma (LSS) is a process improvement, problem-solving methodology used in business and manufacturing to improve the speed, quality, and cost of products. LSS can also be used to improve knowledge-based products integral to public health surveillance. An LSS project by the Behavioral Social Health Outcomes Program of the Army Institute of Public Health reduced the number of labor hours spent producing the routine surveillance of suicidal behavior publication. At baseline, the total number of labor hours was 448; after project completion, total labor hours were 199. Based on customer feedback, publication production was reduced from quarterly to annually. Process improvements enhanced group morale and established best practices in the form of standard operating procedures and business rules to ensure solutions are sustained. LSS project participation also fostered a change in the conceptualization of tasks and projects. These results demonstrate that LSS can be used to inform the public health process and should be considered a viable method of improving knowledge-based products and processes.

Prevalence of childhood trauma among U.S. Army soldiers with suicidal behavior.

In 2009, suicide was reported to be the third leading cause of death among U.S. Army personnel. The increase of suicides in the Army indicates the need for additional research to better understand the problem. Research in civilian populations found that experiencing childhood trauma increases the risk for various negative health outcomes, including suicide and suicide attempts, during adulthood. To date, there has been very little focus on pre-existing mental health before joining the service because of a lack of existing data. Participants were active duty Army Soldiers who attempted or completed suicide as identified by the Department of Defense Suicide Event Report. Among Soldiers exhibiting suicidal behavior, analyses were completed to identify significant associations with specific types of childhood trauma experienced before joining the Army. The prevalence of childhood trauma in this population was 43.3% among the suicide cases and 64.7% among the attempt cases. The most common types of childhood trauma among Soldiers were family problems and abuse. The need for further research among military populations is clear given the high prevalence of childhood trauma found among these Soldiers with suicidal behavior and the lack of complete data for this population.

Injury rates and injury risk factors among Federal Bureau of Investigation new agent trainees.

BACKGROUND: A one-year prospective examination of injury rates and injury risk factors was conducted in Federal Bureau of Investigation (FBI) new agent training. METHODS: Injury incidents were obtained from medical records and injury compensation forms. Potential injury risk factors were acquired from a lifestyle questionnaire and existing data at the FBI Academy. RESULTS: A total of 426 men and 105 women participated in the project. Thirty-five percent of men and 42% of women experienced one or more injuries during training. The injury incidence rate was 2.5 and 3.2 injuries/1,000 person-days for men and women, respectively (risk ratio (women/men) = 1.3, 95% confidence interval = 0.9-1.7). The activities most commonly associated with injuries (% of total) were defensive tactics training (58%), physical fitness training (20%), physical fitness testing (5%), and firearms training (3%). Among the men, higher injury risk was associated with older age, slower 300-meter sprint time, slower 1.5-mile run time, lower total points on the physical fitness test (PFT), lower self-rated physical activity, lower frequency of aerobic exercise, a prior upper or lower limb injury, and prior foot or knee pain that limited activity. Among the women higher injury risk was associated with slower 300-meter sprint time, slower 1.5-mile run time, lower total points on the PFT, and prior back pain that limited activity. CONCLUSION: The results of this investigation supported those of a previous retrospective investigation emphasizing that lower fitness and self-reported pain limiting activity were associated with higher injury risk among FBI new agents.

Retrospective examination of injuries and physical fitness during Federal Bureau of Investigation new agent training.

BACKGROUND: A retrospective examination was conducted of injuries, physical fitness, and their association among Federal Bureau of Investigation (FBI) new agent trainees. METHODS: Injuries and activities associated with injuries were obtained from a review of medical records in the medical clinic that served the new agents. A physical fitness test (PFT) was administered at Weeks 1, 7 and 14 of the 17-week new agent training course. The PFT consisted of push-ups, sit-ups, pull-ups, a 300-meter sprint, and a 1.5-mile run. Injury data were available from 2000 to 2008 and fitness data were available from 2004 to early 2009. RESULTS: During the survey period, 37% of men and 44% of women experienced one or more injuries during the new agent training course (risk ratio (women/men) = 1.18, 95% confidence interval = 1.07-1.31). The most common injury diagnoses were musculoskeletal pain (not otherwise specified) (27%), strains (11%), sprains (10%), contusions (9%), and abrasions/lacerations (9%). Activities associated with injury included defensive tactics training (48%), physical fitness training (26%), physical fitness testing (6%), and firearms training (6%). Over a 6-year period, there was little difference in performance of push-ups, sit-ups, pull-ups, or the 300-meter sprint; 1.5-mile run performance was higher in recent years. Among both men and women, higher injury incidence was associated with lower performance on any of the physical fitness measures. CONCLUSION: This investigation documented injury diagnoses, activities associated with injury, and changes in physical fitness, and demonstrated that higher levels of physical fitness were associated with lower injury risk.

Injuries and injury risk factors among British army infantry soldiers during predeployment training.

PURPOSE: This prospective cohort study examined injuries and injury risk factors in 660 British Army infantry soldiers during a predeployment training cycle. METHODS: Soldiers completed a questionnaire concerning physical characteristics, occupational factors, lifestyle characteristics (including physical training time) and previous injury. Direct measurements included height, body mass, sit-ups, push-ups and run time. Electronic medical records were screened for injuries over a 1-year period before operational deployment. Backward-stepping Cox regression calculated HR and 95% CI to quantify independent injury risk factors. RESULTS: One or more injuries were experienced by 58.5% of soldiers. The new injury diagnosis rate was 88 injuries/100 person-years. Most injuries involved the lower body (71%), especially the lower back (14%), knee (19%) and ankle (15%). Activities associated with injury included sports (22%), physical training (30%) and military training/work (26%). Traumatic injuries accounted for 83% of all injury diagnoses. Independent risk factors for any injury were younger age (17-19 years (HR 1.0), 20-24 years (HR 0.71, 95% CI 0.55 to 0.93), 25-29 years (HR 0.89, 95% CI 0.66 to 1.19) and 30-43 years (HR 0.41, 95% CI 0.27 to 0.63), previous lower limb injury (yes/no HR 1.49, 95% CI 1.19 to 1.87) and previous lower back injury (yes/no HR 1.30, 95% CI 1.03 to 1.63). CONCLUSION: British infantry injury rates were lower than those reported for US infantry (range 101-223 injuries/100 soldier-years), and younger age and previous injury were identified as independent risk factors. Future efforts should target reducing the incidence of traumatic injuries, especially those related to physical training and/or sports.

Systematic review of the parachute ankle brace: injury risk reduction and cost effectiveness.

INTRODUCTION: Military parachuting has been shown to result in injuries. This investigation systematically reviewed studies examining the influence of the parachute ankle brace (PAB) on injuries during military parachuting and performed a cost-effectiveness analysis. EVIDENCE ACQUISITION: Parachute ankle brace studies were obtained from seven databases, personal contacts, and other sources. Investigations were reviewed if they contained original, quantitative information on PAB use and injuries during parachuting. Meta-analysis was performed using a general variance-based meta-analysis method that calculated summary risk ratios (SRR) and 95% CIs. EVIDENCE SYNTHESIS: Five studies met the review criteria. Compared with PAB users, PAB non-users had a higher risk of ankle injuries (SRR=2.1, 95% CI=1.8-2.5); ankle sprains (SRR=2.1, 95% CI=1.4-3.1); ankle fractures (SRR=1.8, 95% CI=1.1-2.9); and all parachuting injuries combined (SRR=1.2, 95% CI=1.1-1.4). The PAB had little effect on lower body injuries exclusive of the ankle (SRR [no PAB/PAB]=0.9, 95% CI=0.7-1.2). Cost-effectiveness analysis estimated that, for every dollar expended on the PAB, a savings of about $7 to $9 could be achieved in medical and personnel costs. CONCLUSIONS: The PAB reduces ankle injuries by about half and is a cost effective device that should be worn during military airborne operations to reduce injury risk.

Injury risk factors in parachuting and acceptability of the parachute ankle brace.

INTRODUCTION: This investigation examined risk factors for injuries during military parachute training and solicited attitudes and opinions regarding a parachute ankle brace (PAB) that has been shown to protect against ankle injuries. METHODS: Male Army airborne students (N = 1677) completed a questionnaire after they had successfully executed 4 of the 5 jumps necessary for qualification as a military paratrooper. The questionnaire asked about injuries during parachute descents, demographics, lifestyle characteristics, physical characteristics, physical fitness, airborne recycling (i.e., repeating airborne training because of failure to qualify on a previous attempt), PAB wear, problems with aircraft exits, and injuries in the year before airborne school. A final section of the questionnaire solicited open-ended comments about the PAB. RESULTS: Increased risk of a parachute-related injury occurred among students who had longer time in service, were older, taller, heavier, performed fewer push-ups, ran slower, were airborne recycles, did not wear the PAB, had an aircraft exit problem, and/or reported an injury in the year prior to jump school. Among students who wore the brace, most negative comments about the PAB had to do with design, comfort, and difficulties during parachute landing falls. CONCLUSIONS: This study supported some previously identified injury risk factors (older age, greater body weight, and not using a PAB) and identified a number of new risk factors. To address PAB design and comfort issues, a strap is being added over the dorsum of the foot to better hold the PAB in place.