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BackgroundAlcohol misuse is higher in the UK Armed Forces than in the general population. Previous research has shown that interventions delivered via smartphones are efficacious in promoting self-monitoring of alcohol use, have utility in reducing alcohol consumption, and have a broad reach. ObjectiveThis single-blinded randomized controlled trial (RCT) aims to assess the efficacy of a 28-day brief alcohol intervention delivered via a smartphone app (Drinks:Ration) in reducing weekly self-reported alcohol consumption between baseline and 3-month follow-up among veterans who drink at a hazardous or harmful level and receive or have received support for mental health symptoms in a clinical setting. MethodsIn this two-arm, single-blinded RCT, a smartphone app that includes interactive features designed to enhance participants’ motivation and personalized messaging is compared with a smartphone app that provides only government guidance on alcohol consumption. The trial will be conducted in a veteran population that has sought help through Combat Stress, a UK veteran’s mental health charity. Recruitment, consent, and data collection will be carried out automatically through the Drinks:Ration platform. The primary outcome is the change in self-reported weekly alcohol consumption between baseline (day 0) and 3-month follow-up (day 84) as measured using the Time-Line Follow back for Alcohol Consumption. Secondary outcome measures include (1) change in the baseline to 3-month follow-up (day 84) Alcohol Use Disorder Identification Test score and (2) change in the baseline to 3-month follow-up (day 84) World Health Organization Quality of Life-BREF score to assess the quality of adjusted life years. Process evaluation measures include (1) app use and (2) usability ratings as measured by the mHealth App Usability Questionnaire. The primary and secondary outcomes will also be reassessed at the 6-month follow-up (day 168) to assess the longer-term benefits of the intervention, which will be reported as a secondary outcome. ResultsThe study will begin recruitment in October 2020 and is expected to require 12 months to complete. The study results will be published in 2022. ConclusionsThis study assesses whether a smartphone app is efficacious in reducing self-reported alcohol consumption in a veteran population that has sought help through Combat Stress using personalized messaging and interactive features. This innovative approach, if successful, may provide a means to deliver a low-cost health promotion program that has the potential to reach large groups, in particular those who are geographically dispersed, such as military personnel. Trial RegistrationClinicalTrials.gov NCT04494594; https://clinicaltrials.gov/ct2/show/NCT04494594 International Registered Report Identifier (IRRID)PRR1-10.2196/19720

BackgroundElectronic health care records (EHRs) are a rich source of health-related information, with potential for secondary research use. In the United Kingdom, there is no national marker for identifying those who have previously served in the Armed Forces, making analysis of the health and well-being of veterans using EHRs difficult. ObjectiveThis study aimed to develop a tool to identify veterans from free-text clinical documents recorded in a psychiatric EHR database. MethodsVeterans were manually identified using the South London and Maudsley (SLaM) Biomedical Research Centre Clinical Record Interactive Search—a database holding secondary mental health care electronic records for the SLaM National Health Service Foundation Trust. An iterative approach was taken; first, a structured query language (SQL) method was developed, which was then refined using natural language processing and machine learning to create the Military Service Identification Tool (MSIT) to identify if a patient was a civilian or veteran. Performance, defined as correct classification of veterans compared with incorrect classification, was measured using positive predictive value, negative predictive value, sensitivity, F1 score, and accuracy (otherwise termed Youden Index). ResultsA gold standard dataset of 6672 free-text clinical documents was manually annotated by human coders. Of these documents, 66.00% (4470/6672) were then used to train the SQL and MSIT approaches and 34.00% (2202/6672) were used for testing the approaches. To develop the MSIT, an iterative 2-stage approach was undertaken. In the first stage, an SQL method was developed to identify veterans using a keyword rule–based approach. This approach obtained an accuracy of 0.93 in correctly predicting civilians and veterans, a positive predictive value of 0.81, a sensitivity of 0.75, and a negative predictive value of 0.95. This method informed the second stage, which was the development of the MSIT using machine learning, which, when tested, obtained an accuracy of 0.97, a positive predictive value of 0.90, a sensitivity of 0.91, and a negative predictive value of 0.98. ConclusionsThe MSIT has the potential to be used in identifying veterans in the United Kingdom from free-text clinical documents, providing new and unique insights into the health and well-being of this population and their use of mental health care services.

BackgroundAlcohol consumption in the UK Armed Forces is higher than in the general population, and this pattern continues after leaving the service. Smartphone apps may be useful to increase ex-serving personnel’s awareness of their alcohol consumption, support self-monitoring, and prompt a change in behavior. ObjectiveThe study aimed to explore the acceptability of Information about Drinking in Ex-serving personnel (InDEx), a tailored smartphone app, combined with personalized short message service (SMS) text messaging designed to target ex-serving personnel who meet the criteria for hazardous alcohol use. MethodsThe InDEx intervention included 4 key modules: (1) assessment and normative feedback, (2) self-monitoring and feedback, (3) goal setting and review, and (4) personalized SMS text messaging. A semistructured telephone interview study was conducted with ex-serving personnel after using the app for a 28-day period. Interviews were used to explore the acceptability of app modules and its functionality and the perceived changes in participant’s drinking. Interview transcripts were analyzed using inductive thematic analysis. ResultsOverall, 94% (29/31) participants who used InDEx agreed to take part in a telephone interview. Overall, 4 themes were identified: Credibility, Meeting their needs, Simplicity, and Helpful for ex-serving personnel. The importance of credibility, functionality, and meeting the individual needs of ex-serving personnel was emphasized. Acceptability and engagement with specific modules of the app and text messages were influenced by the following: (1) if they felt it provided credible information, (2) whether the content was appropriately personalized to them, (3) the ease of use, and (4) beliefs about their own drinking behaviors. Participants recommended that the app would be most suitable for personnel about to leave the Armed Forces. ConclusionsInDEx was an acceptable smartphone app for ex-serving personnel for monitoring alcohol consumption and in providing meaningful feedback to the individual. Pages that met the participant’s interests and provided real time personalized, credible feedback on their drinking and text messages tailored to participant’s interactions with the app were particularly favored.

BackgroundSelf-reported alcohol misuse remains high in armed forces personnel even after they have left service. More than 50% of ex-serving personnel meet the criteria for hazardous alcohol use; however, many fail to acknowledge that they have a problem. Previous research indicates that interventions delivered via smartphone apps are suitable in promoting self-monitoring of alcohol use, have a broad reach, and may be more cost-effective than other types of brief interventions. There is currently no such intervention specifically designed for the armed forces. ObjectiveThis study sought to describe the development of a tailored smartphone app and personalized text messaging (short message service, SMS) framework and to test the usability and feasibility (measured and reported as user engagement) of this app in a hard-to-engage ex-serving population. MethodsApp development used Agile methodology (an incremental, iterative approach used in software development) and was informed by behavior change theory, participant feedback, and focus groups. Participants were recruited between May 2017 and June 2017 from an existing United Kingdom longitudinal military health and well-being cohort study, prescreened for eligibility, and directed to download either Android or iOS versions of the ”Information about Drinking for Ex-serving personnel” (InDEx) app. Through the app, participants were asked to record alcohol consumption, complete a range of self-report measures, and set goals using implementation intentions (if-then plans). Alongside the app, participants received daily automated personalized text messages (SMS) corresponding to specific behavior change techniques with content informed by the health action process approach with the intended purpose of promoting the use of the drinks diary, suggesting alternative behaviors, and providing feedback on goals setting. ResultsInvitations to take part in the study were sent to ex-serving personnel, 22.6% (31/137) of whom accepted and downloaded the app. Participants opened the InDEx app a median of 15.0 (interquartile range [IQR] 8.5-19.0) times during the 4 week period (28 days), received an average of 36.1 (SD 3.2) text messages (SMS), consumed alcohol on a median of 13.0 (IQR 11.0-15.0) days, and consumed a median of 5.6 (IQR 3.3-11.8) units per drinking day in the first week, which decreased to 4.7 (IQR 2.0-6.9) units by the last week and remained active for 4.0 (IQR 3.0-4.0) weeks. ConclusionsPersonnel engaged and used the app regularly as demonstrated by the number of initializations, interactions, and time spent using InDEx. Future research is needed to evaluate the engagement with and efficacy of InDEx for the reduction of alcohol consumption and binge drinking in an armed forces population.

Author(s): Rebecca Lane [sup.1] , Rachael Gribble [sup.2] , Filipa Alves-Costa [sup.1] [sup.3] , Anna Taylor [sup.4] , Louise M Howard [sup.5] , Nicola T Fear [sup.2] , Deirdre MacManus [...], Purpose The prevalence of Intimate Partner Violence and Abuse (IPVA) perpetration and victimisation has been found to be higher in serving and ex-serving military samples compared to civilians. Despite this, there is a lack of qualitative research exploring the IPVA experiences of couples in which one or both partners are serving or have served in the military. This qualitative study aimed to explore IPVA experiences within the UK military community from the perspective of serving and ex-serving military personnel and civilian partners of UK military personnel. Method One-to-one telephone interviews were conducted with 40 serving and ex-serving military personnel (29 male, 11 female) and 25 female civilian partners. Data was analysed using thematic analysis. Results Four superordinate themes were derived: (1) patterns and directions of IPVA, (2) types of IPVA, (3) perceived drivers of IPVA and (4) perceived impact of IPVA. The findings point to frequent bidirectional abuse in part driven by poor communication and emotion regulation, whilst also highlighting the experiences of severe IPVA victimisation of civilian partners by military personnel motivated by power and control. Perceived drivers of both IPVA perpetration and victimisation include military factors borne of military culture or training, alcohol and mental health difficulties. Conclusion These results highlight the role of cultural norms, as well as the role of emotion dysregulation, poor communication skills and mental health difficulties in explaining and perpetuating abuse within ecological theoretical frameworks of violence among couples within which one or both partners are serving or ex-serving military personnel.

Author(s): Filipa Alves-Costa [sup.1], Rebecca Lane [sup.1], Rachael Gribble [sup.2], Anna Taylor [sup.3], Nicola T Fear [sup.2], Deirdre MacManus [sup.1] Author Affiliations: (1) grid.13097.3c, 0000 0001 2322 6764, Department of [...], There is evidence that Intimate Partner Violence and Abuse (IPVA) is more prevalent among military populations compared with civilian populations. However, there has been limited research into the help-seeking experiences of civilian victim-survivors who have experienced IPVA within relationships with military personnel. This qualitative study aimed to explore the experiences of, and barriers to, help-seeking for IPVA victimisation among civilian partners of military personnel in order to identify strategies to improve the management of IPVA both within the military and civilian sectors. The study adopted a descriptive cross-sectional study design and used qualitative research methods. One-to-one telephone interviews were conducted with civilian victim-survivors (n = 25) between January and August 2018. Interview transcripts were analysed using thematic analysis. Three superordinate themes were derived: (1) Drivers to help-seeking; (2) Barriers to help-seeking; and (3) Experiences of services. The findings indicate difficulties in help-seeking for IPVA among civilian partners of military personnel due to stigma, fear, dependency, poor understanding of IPVA, lack of appropriate and timely support, and a perceived lack of victim support. Difficulties in help-seeking were perceived by participants to be amplified by military culture, public perceptions of the military, military protection of personnel and the lack of coordination between civilian and military judicial services. This study reinforces the need for a military specific Domestic Abuse strategy, identifies vulnerable groups and highlights a need for both increased awareness and understanding of IPVA within civilian and military services in order to provide adequate victim protection.

Little is known about the functioning of children in veteran-connected families, who may experience a unique constellation of stressors including exposure to parental mental health symptoms and unemployment. Further, research has not previously considered the role of school climate in counteracting these stressors for veteran-connected students. This preliminary study examines the relationship between veteran parent's mental health and employment with adverse outcomes for their school-age children, as well as the potential moderating effect of safe school climate. Participants were 218 veteran parents of children in K-12 schools, who completed the Chicago Veterans Survey, including measures of PTSD and depression, unemployment, a school safety scale drawn from the California School Parent Survey, and an adverse child functioning screening tool. Regression models suggest that depression symptomatology and perceptions of less safe school climate were significantly associated with adverse outcomes among veteran-connected students. Safe school climate buffered against the negative effects of parents' depression symptoms, particularly at lower levels of depression severity. Findings suggest the need for future research to explore the potentially crucial role for schools, including teachers, administrators, and particularly school-based mental health providers, in supporting the healthy functioning of veteran-connected students and their families.

Background: The coronavirus disease (COVID-19) pandemic led to the implementation of social distancing laws in the UK. This had several negative consequences on health, wellbeing and social functioning within the general population. Military veterans may have had unique experiences of social isolation during this time. This study examined the level of, and relationship between, structural and functional social support, and its association with mental health and wellbeing in a sample of UK veterans during the COVID-19 pandemic. Methods: Throughout the first summer of the pandemic (June-September 2020), an additional wave of cross-sectional data was collected from UK Armed Forces personnel who had left regular military service and were participating in a longitudinal cohort study. In total, 1562 participants (44.04% response rate) completed a series of online questionnaires measuring sociodemographic characteristics, COVID-19 experiences and psychosocial health and wellbeing. Multivariable logistic and ordinal regression analyses were conducted. Results: For structural social support, 86.76% were in a relationship and 88.96% lived with others. For functional social support, one-quarter reported feelings of loneliness (27.42%) and low levels of perceived social support (28.14%). Structural support was associated with functional support. Being single, living alone and experiencing loneliness were associated with worse mental health and wellbeing, while living with other adults and reporting high levels of perceived social support were associated with better mental health and wellbeing. Conclusions: This study has enhanced our understanding of social support among veterans and its implications for health and wellbeing. This knowledge is essential for advising the development of psychosocial interventions and policies to improve the psychological wellbeing of veterans in future pandemics and more broadly in their daily lives. [ABSTRACT FROM AUTHOR]

The ArmeD SerVices TrAuma RehabilitatioN OutComE (ADVANCE) study is investigating long-term combat-injury outcomes; this sub-study aims to understand the association of osteoarthritis (OA) biomarkers with knee radiographic OA (rOA), pain and function in this high-risk population for post-traumatic OA. ADVANCE compares combat-injured participants with age, rank, deployment and job-role frequency-matched uninjured participants. Post-injury immunoassay-measured serum biomarkers, knee radiographs, Knee Injury and Osteoarthritis Outcome Scale, and six-minute walk tests are reported. The primary analysis, adjusted for age, body mass, socioeconomic status, and ethnicity, was to determine any differences in biomarkers between those with/without combat injury, rOA and pain. Secondary analyses were performed to compare post-traumatic/idiopathic OA, painful/painfree rOA and injury patterns. A total of 1145 male participants were recruited, aged 34.1 ± 5.4, 8.9 ± 2.2 years post-injury (n = 579 trauma-exposed, of which, traumatic-amputation n = 161) or deployment (n = 566 matched). Cartilage oligomeric matrix protein (COMP) was significantly higher in the combat-injured group compared to uninjured (p = 0.01). Notably, COMP was significantly lower in the traumatic-amputation group compared to non-amputees (p < 0.001), decreasing relative to number of amputations (p < 0.001). Leptin was higher (p = 0.005) and adiponectin lower (p = 0.017) in those with v without knee pain, associated with an increased risk of 22% and 17% for pain, and 46% and 34% for painful rOA, respectively. There were no significant differences between trauma-exposed and unexposed participants with rOA. The most notable findings of this large, unique study are the similarities between those with rOA regardless of trauma-exposure, the injury-pattern and traumatic-amputation-associated differences in COMP, and the relationship between adipokines and pain. [ABSTRACT FROM AUTHOR]

Background/aims: Suicidal Ideation (SI) is a risk factor for suicide, a leading cause of death amongst young men globally. In this study we assess whether sustaining a serious physical combat injury is associated with SI and whether leaving service mediates this association. Methods: We analysed data from male UK Armed Forces personnel who sustained a combat injury in Afghanistan and a frequency-matched comparison group who did not sustain such an injury (the ADVANCE cohort). SI was measured from the Patient Health Questionnaire-9 item 'thoughts that you would be better off dead or of hurting yourself in some way'. Results: Approximately, 11.9% (n = 61) of the uninjured group, 15.3% (n = 83) of the overall injured group, 8.5% (n = 13) of an Amputation injury (AI) subgroup and 17.6% (n = 70) of a Non-Amputation Injury (NAI) subgroup reported SI in the past 2 weeks. The NAI subgroup reported greater likelihood of SI (Relative Risk Ratio (RR) = 1.44, 95% confidence interval (CI) [1.04, 2.00]) compared to the comparison group, whereas the overall injured group (RR = 1.23, 95% CI [0.90, 1.68]) and AI subgroup (RR = 0.65, 95% CI [0.36, 1.18]) did not. Leaving service fully mediated the association between sustaining a NAI and SI (natural direct effect RR = 1.08, 95% CI [0.69, 1.69]). Conclusions: UK military personnel with NAI reported significantly higher rates of SI compared to demographically similar uninjured personnel, while those who sustained AIs reported no significant difference. Leaving service was associated with greater rates of SI for both injured and uninjured personnel and fully mediated the association between sustaining a NAI and SI. [ABSTRACT FROM AUTHOR]

Background: Respiration is a crucial determinant of autonomic balance and heart rate variability (HRV). The comparative effect of spontaneous versus paced breathing on HRV has been almost exclusively explored in healthy adults and never been investigated in an injured military cohort. Objective: To examine the effect of spontaneous versus paced breathing on HRV in veterans with combat‐related traumatic injury (CRTI). Design: Observational cohort study. Setting: ArmeD serVices trAuma rehabilitatioN outComE (ADVANCE) study, Stanford Hall, UK. Participants: The sample consisted of 100 randomly selected participants who sustained CRTI (eg, amputation) during their deployment (Afghanistan 2003–2014) and were recruited into the ongoing ADVANCE prospective cohort study. Intervention: Not applicable. Main Outcome Measure: HRV was recorded using a single‐lead ECG. HRV data were acquired during a sequential protocol of 5‐minute spontaneous breathing followed immediately by 5 minutes of paced breathing (six cycles/minute) among fully rested and supine participants. HRV was reported using time domain (root mean square of successive differences), frequency domain (low frequency and high frequency) and nonlinear (sample entropy) measures. The agreement between HRV during spontaneous versus paced breathing was examined using the Bland–Altman analysis. Results: The mean age of participants was 36.5 ± 4.6 years. Resting respiratory rate was significantly higher with spontaneous versus paced breathing (13.4 ± 3.4 vs. 7.6 ± 2.0 breaths/minute; p <.001), respectively. Resting mean heart rate and root mean square of successive differences were significantly higher with paced breathing than spontaneous breathing (p <.001). Paced breathing significantly increased median low frequency power than spontaneous breathing (p <.001). No significant difference was found in the absolute power of high frequency between the two breathing protocols. The Bland–Altman analysis revealed poor agreement between HRV values during spontaneous and paced breathing conditions with wide limits of agreement. Conclusion: Slow‐paced breathing leads to higher HRV than spontaneous breathing and could overestimate resting "natural‐state" HRV. [ABSTRACT FROM AUTHOR]