FORUM: The U.S. Air Force HEART program model

The goal of the Health Evaluation and Risk Tabulation (HEART) Program is to reduce the incidence of cardiovascular disease in the U.S. Air Force. The program is midway through a demonstration phase operating at four Air Force bases in the United States. At each base, active-duty personnel are given a selective clinical screen to assess their risk of a cardiovascular incident in the next 8 years. At two of the four bases, intervention in the form of behavior modification, small-group treatment for smoking cessation and/or blood lipid/weight reduction is offered to volunteers who have been found at above-average risk. In addition, two bases (one with the intervention present and one with the intervention absent) have a basewide education component consisting of events and activities which teach specific techniques of CVD prevention.     

Risk reduction in the U.S. Air Force primary prevention HEART program

The United States Air Force (USAF) is developing a preventive cardiology program, the Health Evaluation and Risk Tabulation (HEART) program. This article describes the goals and methods of the HEART program's Risk Reduction Component (RRC), which is to assist high-risk active-duty USAF personnel to modify specific health behaviors associated with arteriosclerotic disease: cigarette smoking, and food patterns high in calories from fat and exogenous cholesterol. Also, education is offered to confirmed hyptertensives, whose pharmacological treatment is provided by the base medical facility. The RRC strategy is being tested at two air bases, Pease, New Hampshire, and Charleston, South Carolina. Designated airmen are invited to participate in RRC on these bases after notification of their risk status. Voluntary participation is encouraged at two levels: orientation sessions: and at subsequent focal groups in smoking cessation and/or food pattern modification. Focal groups emphasize techniques of self-management in smoking cessation and eating behavior, including post-treatment maintenance behavior for long-term risk reduction.     

Evaluation of the U.S. Air Force HEART program demonstration

The HEART program is being demonstrated on four Air Force bases to provide experience that will aid in making plans to extend the program Air Force-wide. Much of the experience will be preserved in the form of two major types of data. One type is the medical and biographical data from the participants, some of which is used in conducting the HEART program activities. The other type of data, relating to the performance of these activities, includes office records and results of some studies designed to furnish detailed information about some of the program activities. We outline plans for summarizing the data and presenting it in a form that will be useful to those who will plan the Air Force-wide program.     

The Air Force health study: an epidemiologic retrospective

In 1979, the U.S. Air Force announced that an epidemiologic study would be undertaken to determine whether the Air Force personnel involved in Operation Ranch Hand-the program responsible for herbicide spraying in Vietnam-had experienced adverse health effects as a result of that service. In January 1982 the Air Force Health Study (AFHS) protocol was approved and the 20 year matched cohort study consisting of independent mortality, morbidity and reproductive health components was initiated. This controversial study has been criticized regarding the study's potential scientific limitations as well as some of the administrative aspects of its conduct. Now, almost 30 years since the implementation of the AFHS and nearly a decade since the final follow up examinations, an appraisal of the study indicates that the results of the AFHS do not provide evidence of disease in the Ranch Hand veterans caused by their elevated levels of exposure to Agent Orange.     

Predictors of low physical fitness in a cohort of active-duty U.S. Air Force members

BACKGROUND: Each branch of the U.S. armed forces has standards for physical fitness as well as programs for ensuring compliance with these standards. In the U.S. Air Force (USAF), physical fitness is assessed using submaximal cycle ergometry to estimate maximal oxygen uptake (VO2(max)). The purpose of this study was to identify the independent effects of demographic and behavioral factors on risk of failure to meet USAF fitness standards (hereafter called low fitness). METHODS: A retrospective cohort study (N=38,837) was conducted using self-reported health risk assessment data and cycle ergometry data from active-duty Air Force (ADAF) members. Poisson regression techniques were used to estimate the associations between the factors studied and low fitness. RESULTS: The factors studied had different effects depending on whether members passed or failed fitness testing in the previous year. All predictors had weaker effects among those with previous failure. Among those with a previous pass, demographic groups at increased risk were toward the upper end of the ADAF age distribution, senior enlisted men, and blacks. Overweight/obesity was the behavioral factor with the largest effect among men, with aerobic exercise frequency ranked second; among women, the order of these two factors was reversed. Cigarette smoking only had an adverse effect among men. For a hypothetical ADAF man who was sedentary, obese, and smoked, the results suggested that aggressive behavioral risk factor modification would produce a 77% relative decrease in risk of low fitness. CONCLUSIONS: Among ADAF members, both demographic and behavioral factors play important roles in physical fitness. Behavioral risk factors are prevalent and potentially modifiable. These data suggest that, depending on a member's risk factor profile, behavioral risk factor modification may produce impressive reductions in risk of low fitness among ADAF personnel.     

Family practice in the US Air Force

The United States Air Force Medical Service is well suited for family practice because of its early identification with the small community hospital. A plan was originally developed in 1968 to bring family practice to every Air Force member. This paper traces the progress of the program, identifies problem areas, specifies the planning factors and implementation plan, and gives the final goal for full family practice in the USAF.     

Suicide prevention among active duty Air Force personnel--United States, 1990-1999

During 1990-1994, suicide accounted for 23% of all deaths among active duty U.S. Air Force (USAF) personnel and was the second leading cause of death (after unintentional injuries) (Table 1). During those years, the annual suicide rate among active duty USAF personnel increased significantly (p<0.01) from 10.0 to 16.4 suicides per 100,000 members (Figure 1). In 1995, senior USAF leaders initiated prevention programs in several commands because of the increasing suicide rate. In May 1996, an in-depth study by a team of medical and nonmedical civilian and military experts was initiated to produce a comprehensive, communitywide prevention strategy that viewed suicide not only as a medical but a USAF problem, thus addressing overall social, behavior, and health issues (1). The plan was implemented across the entire USAF during 1996-1997. This report describes protective and prevention strategies and summarizes the study findings, which indicate that a substantial decline in the suicide rate was associated with the communitywide program.     

Costs of smoking among active duty U.S. Air Force personnel--United States, 1997

Smoking is the leading cause of preventable disease and death in the United States (1). The health consequences of smoking impose a substantial economic toll on persons, employers, and society. Smoking accounts for $50-$73 billion in annual medical-care expenditures, or 6%-12% of all U.S. medical costs (2-5). The costs associated with lost productivity also are extensive (2). In 1997, approximately 25% of male and 27% of female active duty Air Force (ADAF) personnel aged 17-64 years were smokers (6). A 1997 retrospective cohort study was conducted among ADAF personnel to estimate the short-term medical and lost productivity costs of current smoking to the U.S. Air Force (USAF). This report summarizes the results of the study, which indicate that current smoking costs the USAF approximately $107.2 million per year: $20 million from medical-care expenditures and $87 million from lost workdays.     

The US Air Force Suicide Prevention Program: Implications for Public Health Policy

Objectives. We evaluated the effectiveness of the US Air Force Suicide Prevention Program (AFSPP) in reducing suicide, and we measured the extent to which air force installations implemented the program.Methods. We determined the AFSPP''s impact on suicide rates in the air force by applying an intervention regression model to data from 1981 through 2008, providing 16 years of data before the program''s 1997 launch and 11 years of data after launch. Also, we measured implementation of program components at 2 points in time: during a 2004 increase in suicide rates, and 2 years afterward.Results. Suicide rates in the air force were significantly lower after the AFSPP was launched than before, except during 2004. We also determined that the program was being implemented less rigorously in 2004.Conclusions. The AFSPP effectively prevented suicides in the US Air Force. The long-term effectiveness of this program depends upon extensive implementation and effective monitoring of implementation. Suicides can be reduced through a multilayered, overlapping approach that encompasses key prevention domains and tracks implementation of program activities.Although much is known about risk factors for suicide, there are few examples of multifaceted, sustainable programs for reducing morbidity and mortality attributable to suicide and suicidal behaviors. The Air Force Suicide Prevention Program (AFSPP) has been found to have achieved significant relative risk reductions of rates of suicide and other violence-related outcomes, including accidental death and domestic violence.¹ The AFSPP, now in its 13th year, is an example of a sustained community-based effort that directly addresses suicide as a public health problem.The AFSPP, launched in 1996 and fully implemented by 1997,¹ emphasizes leadership involvement and a community approach to reducing deaths from suicide. The program is an integrated network of policy and education that focuses on reducing suicide through the early identification and treatment of those at risk. It uses leaders as role models and agents of change, establishes expectations for airman behavior regarding awareness of suicide risk (i.e., policymaking), develops population skills and knowledge (i.e., education and training), and investigates every suicide (i.e., outcomes measurement). The program represents the air force''s fundamental shift from viewing suicide and mental illness solely as medical problems and instead seeing them as larger service-wide community problems (Gen T. S. Moorman Jr, US Air Force, personal communication, June 2001).The program''s approach is predicated on current knowledge that individuals at risk exhibit warning signs and that intervention at an early stage lowers risk and results in improved outcomes. Thus, the program aims to reduce stigma and encourage early help-seeking behavior by changing social norms through education and policy. This is achieved at the community level by changing the community''s knowledge, values, beliefs, attitudes, and behaviors concerning distress, help-seeking, and suicide. The AFSPP affirms and encourages help-seeking behavior, normalizes the experience of distress, promotes the development of coping skills, fights the stigma associated with receiving mental health care, and educates the community about the absence of negative career consequences for seeking and receiving treatment. The program also seeks to improve outcomes in putative distal risk factors for suicide, including family violence, alcohol and substance use, diminishing work performance, and depression. The result over the years has been the creation of an atmosphere of responsibility and accountability for reducing deaths from suicide that includes new expectations for behavior at the community and individual levels.With little theoretical guidance available in 1996 to shape the program, the air force developed an overlapping programmatic design, resulting in far-reaching enhanced capacity of organizational responsiveness in critical areas at multiple levels. These overlapping components became known formally as the 11 Initiatives of the Air Force Suicide Prevention Program, which are described briefly in the box on the next page and in detail online (AFPAM 44–160; available at http://afspp.afms.mil/idc/groups/public/documents/afms/ctb_056459.pdf).We studied the effect of the AFSPP on air force suicide rates from 1997, when the program was fully implemented, through 2008. We examined rates in the context of a 27-year period, from 1981 through 2008, during which time there have been 3 military conflicts and a major downsizing of the air force during the early 1990s. This 27-year period provides an important historical perspective on suicide rates in an organization that underwent rapid, widespread change in force structure and that dealt with the onset and continuation of Operation Enduring Freedom in Afghanistan in 2001 and Operation Iraqi Freedom in 2003. We also conducted a naturalistic experiment from 2004 through 2006, when we measured the implementation of program components during and after a transient increase in suicide rates.     

Establishing a physical criterion for assigning personnel to U.S. Air Force jobs

The Air Force has had problems with personnel being physically unable to perform the tasks within their assigned Air Force Specialty Code (AFSC). An assignment criterion was developed based on a single isoinertial strength score (X1): the incremental 1.83 m lift. The job assignment criterion was developed through three phases of work: Phase I analyzed AFSC tasks; Phase II developed strength/stamina tests; and Phase III established the assignment criteria.     

Temporal changes in TCDD levels in 1419 Air Force Vietnam-era veterans not occupationally exposed to herbicides

We summarize temporal changes in the distribution of 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) measurements made in serum drawn in 1987, 1992, and 1997 from 1419 Air Force Vietnam-era veterans who served as comparisons in a 20-year prospective study of health and exposure to herbicides and their TCDD contaminant in Air Force veterans of Operation Ranch Hand, the unit responsible for aerial spraying of Agent Orange and other herbicides in Vietnam. Among comparison veterans, TCDD levels decreased significantly with time at a rate of -- 0.25 parts per trillion per year. We also describe paired serum TCDD measurements in a subgroup of 33 veterans who had detectable levels in both 1987 and 1992. The paired measurements suggested that serum TCDD levels decreased with time, including those near the limit of detection.     

Rubella screening and vaccination program for US Air Force trainees: an analysis of findings.

A preventive medicine program of rubella control for trainees at the Air Force Military Training Center, Lackland AFB, Texas, was begun in October 1977. Incoming trainees were screened for rubella susceptibility, and female trainees were additionally screened for pregnancy. During the period October 1977 to December 1978, an overall rubella susceptibility rate of 17.3 per cent was determined for 71,387 trainees entering basic training. Flights (50 persons each) to which these trainees are assigned varied widely in susceptibility from 0.0-47.7 per cent. Comparisons of susceptibility rates for trainees for for geographic areas and states indicated the highest overall percentage of susceptibles were from the Pacific geographic area with California showing the highest susceptibility (24.5 per cent). Race specific susceptibility rates were found to differ significantly between Whites and Blacks, 17.6 vs 14.8 per cent, respectively. The immunization program was effective as judged by a dampening of the incidence of clinical rubella at the basic training center and at other secondary training centers.     

Weight gain as a barrier to smoking cessation among military personnel.

PURPOSE: To assess the relationships between active-duty military status, military weight standards, concern about weight gain, and anticipated relapse after smoking cessation. DESIGN: Cross-sectional study. SETTING: Hospital-based tobacco cessation program. SUBJECTS: Two hundred fifty-two enrollees, of 253 eligible, to a tobacco cessation program in 1999 (135 men, 117 women; 43% on active duty in the military). MEASURES: Independent variables included gender, body mass index (weight/height2), and military status. Dependent variables included about weight gain with smoking cessation and anticipated relapse. RESULTS: In multivariate regression analyses that controlled for gender and body mass index, active-duty military status was associated with an elevated level of concern about weight gain (1.9-point increase on a 10-point scale; 95% confidence interval [CI], 1.0- to 2.8-point increase), as well as higher anticipated relapse (odds ratio [OR] = 3.6; 95% CI, 1.3 to 9.8). Among subjects who were close to or over the U.S. Air Force maximum allowable weight for height, the analogous OR for active-duty military status was 6.9 (p = .02). CONCLUSIONS: Occupational weight standards or expectations may pose additional barriers for individuals contemplating or attempting smoking cessation, as they do among active-duty military personnel. These barriers are likely to hinder efforts to decrease smoking prevalence in certain groups.     

A Comparison of the Rates of Sickness Absence between the Male Population of Royal Air Force Waddington and the Lincolnshire Police Force During November 1980

A survey of male sickness absence notifications during the monthof November 1980 was performed at Royal Air Force Waddingtonand at the Lincolnshire Police Force Headquarters. The results,when analysed, showed a statistically significant (P<0.05)lower absence rate amongst RAF personnel, independent of theparameters used for comparison. The study points to the existence of an occupational healthservice as a major contribution to lower sickness absence ratesamongst RAF personnel. Accepted        1 January 1982 Flight Lieutenant R. Guest, Medical Centre, United Kingdom Support Unit, Ramstein Air Base, BFPO 109     

US military service members vaccinated against smallpox in 2003 and 2004 experience a slightly higher risk of hospitalization postvaccination

This study explores adverse events severe enough to warrant hospitalization that may have been associated with receiving the smallpox vaccine in conjunction with military service. Cox proportional hazards modeling was used to identify the risk of hospitalization among US active-duty military personnel during a 1-year period following receipt of the smallpox vaccine. The reference group consisted of active-duty military personnel who also received the smallpox vaccine after the conclusion of their health care observation period, allowing for comparison to a temporally and demographically similar population. The risk of hospitalization was slightly elevated among the postvaccine group for any-cause hospitalization and for hospitalization in several broad diagnostic categories. Hospitalizations for asthma, autoimmune diseases, and myopericarditis, were more likely in the postvaccine group. The increased risk of hospitalization for varied outcomes does not necessarily imply a cause-effect relationship, but it does offer areas for more focused study, using longitudinal data to explore the long-term impact of smallpox vaccination on the health of young adults.     

Distributional records from the U.S. Air Force ovitrapping program--1990.

During 1990, ovitrapping was conducted at 38 U.S. Air Force installations. Twelve installations were positive for Aedes albopictus. The August 24 collection of Ae. albopictus at Tinker Air Force Base, OK, is a first record for Oklahoma County. Four installations recorded the presence of Ae. aegypti; 14 installations were positive for Ae. triseriatus. During the previous 3 years, an increase in the distribution and abundance of Ae. albopictus coincided with a decline in Ae. aegypti.     

Serum dioxin, testosterone, and subsequent risk of benign prostatic hyperplasia: a prospective cohort study of Air Force veterans

BACKGROUND: Operation Ranch Hand veterans were involved in spraying herbicides, including Agent Orange, during the Vietnam War in 1962-1971; Agent Orange was contaminated with 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD). It has been hypothesized that dioxins may be partially responsible for an increase of male reproductive tract disorders such as testicular cancer, cryptorchidism, and hypospadias. OBJECTIVES: In this study, our objective was to assess the effect of serum TCDD concentration on the risk of development of benign prostatic hyperplasia (BPH) and on serum testosterone levels. METHODS: This study was a longitudinal, prospective cohort study made up of U.S. Air Force veterans involved in Operation Ranch Hand. Other Air Force veterans who did not spray herbicides were included as comparisons. BPH was determined by medical record review and by medical examinations conducted during the study. Data were available for 971 Ranch Hand and 1,266 comparison veterans. We investigated the relationship between BPH and serum TCDD level using the Cox proportional hazards models adjusted for testosterone levels, body mass index (BMI), and the percentage change in BMI per year. RESULTS: In univariate and multivariate analyses, the risk of BPH decreased with increasing serum TCDD in the comparison group. The multivariate risk ratio for BPH in the comparison group was 0.84 (95% confidence interval, 0.73-0.98). Excluding men with prostate cancer, inflammatory or other prostatic diseases did not substantially alter the association. Serum testosterone levels were inversely associated with serum TCDD levels in both Ranch Hand and comparison groups. CONCLUSIONS: TCDD exposure at general population levels is associated with a decreasing risk of BPH with higher exposure levels. TCDD exposure is also negatively associated with serum testosterone levels.     

Air Force court affirms assault conviction of major

The Air Force Court of Criminal Appeals upheld the conviction and sentencing of Major James T. Goldsmith, who had vaginal intercourse with two women without warning them that he was HIV-positive. Goldsmith was ordered not to engage in sexual intercourse unless he first informed his partner that he was infected. He was also ordered to use condoms. According to the court martial, both of these orders were disobeyed. Both women have tested negative for HIV antibodies. On appeal, Goldsmith argued that evidence was insufficient to establish that he posed a risk of transmitting the virus. The three-judge appeals panel found in favor of the Air Force.     

Distributional records from the U.S. Air Force ovitrapping program--1991.

During 1991, ovitrapping was conducted by 37 U.S. Air Force installations. Sixteen installations were positive for Aedes albopictus. The number (449) and percent (21.5%) of Ae. albopictus-positive ovipaddles was almost 4 times that of the previous year. The collections of Ae. albopictus at Columbus Air Force Base (AFB), MS, and Shaw AFB, SC, are new records for Lowndes and Sumter counties, respectively. Nine installations were positive for Ae. aegypti; 21 were positive for Ae. triseriatus.