Australian Defence Force (ADF) personnel are part of a highly organised, large and disciplined force. As such you would expect that asking its members to participate in research should be a very smooth and straight forward process. Yet, the recruitment and data collection process for the Military Health Outcomes Program (MilHOP) studies illustrated that a completely voluntary process, with strict ethical guidelines as set by four separate university and Defence ethic committees, introduces unique challenges that need to be considered when undertaking research studies involving ADF personnel. Recruitment and data collection was made all the more difficult as some participants were members of the Special Services whose personal information required even higher levels of confidentiality. My role as the Defence Liaison Officer (DLO) was primarily to facilitate and coordinate all aspects of the data collection process, when face to face involvement with Defence personnel was required by the research staff.
The MilHOP studies included all current serving regular ADF members (except those undertaking initial training), reservists and ex-serving personnel comprising of approximately 70,000 personnel.
ADF personnel of specific interest fell into one or more of the following MilHOP studies:
The Middle East Area of Operations (MEAO) Prospective Health Study which aimed to collect data from ADF personnel pre- and post deployment to the MEAO from 2010 to end of 2011 and aimed to better understand the effects of deployment to the MEAO on a range of physical and psychological parameters.
- The MEAO Census Study which aimed to collect survey data from all serving and ex-serving ADF personnel who deployed to the MEAO between 01 October 2001 – 31 December 2009 and aimed to ascertain the physical, emotional and environmental effects of deployment in order to better manage the health care needs of current and former veterans.
- The Health and Wellbeing Survey which aimed to collect data from currently serving ADF members who have not deployed to the MEAO and will complement the Census Study and cover the entire ADF. The study had three goals; to establish the baseline prevalence of mental disorder, to refine current mental health detection methods and to investigate the specific occupational stressors that influence mental health.
- The MEAO Mortality and Cancer Incidence Study which will collect relevant data on mortality and cancer rates from the Australian Institute of Health and Welfare.
The most important lessons I learnt from the MilHOP recruitment process was that to achieve the greatest success it is essential to have;
- the support, commitment and buy in from Command,
- Command staff produce ‘Task Orders’ or ‘Weekly Orders’ detailing the data collection times and venues and provide primary points of contact (POC’s) for the DLO,
- support, commitment and understanding from middle management about the relevance and importance of gathering as much data as possible. Also to explain the importance of the study and its potential to help with future health issues possibly not apparent now but may manifest in the future. (These are the guys that get the personnel to show up),
- face to face contact and phone contact between the DLO, Command and primary POC’s and to also have a secondary POC for each unit,
- the involvement of research staff and the volunteer ADF personnel, and
- the means to undertake individual phone follow up when appropriate.
Many onsite unit visits were required to promote the study and give personnel the opportunity to participate. To facilitate this the DLOs were responsible for arranging access for up to 20 research and health personnel onto bases, units and ships, as well as booking the venues for the completion of questionnaires for hundreds of personnel and coordinating suitable facilities for the collection of physical and neurocognitive data. Often these activities were running concurrently with ADF members completing questionnaires and another group undergoing the physical and neurocognitive testing. One occasion included setting up the physical and neurocognitive testing equipment within the live firing range facilities an hour outside of Townsville. It was quite an impressive sight to see two Light Armoured Vehicles (LAV’s) parked outside the testing facility with the unit personnel who had been contacted for testing. It also provided an opportunity for the research staff to have a look in the back of the LAV and get a sense of the environment these soldiers operate in when deployed. Despite the extraordinary efforts in planning and coordination there were occasions when particular units and establishments just simply failed to attend.
Various incentives were also used by the researchers, which included the distribution of MilHOP pens, made available at time of completing the questionnaires, the inclusion of bags of jellybeans in the questionnaire envelopes and the distribution of chocolate bars and health drinks at the physical and neurocognitive testing sites. The drinks and chocolate bars were provided as a precaution, as particularly Army personnel had often been in very hot conditions and were having physical testing and blood samples taken.
The equipment required to conduct the testing included centrifuges for spinning down blood, fridges and a supply of ice for transporting the samples, also neurocognitive caps, sensors and computers used to measure the participants brain wave activity when presented with a series of stimuli via a computer.
There were a number ways that to ADF members were able to participate including completing an online questionnaire or a hard copy version. Phone follow up was conducted in an attempt to reach those who had not responded to the online or hard copy methods. Other opportunities were taken to promote participation in the study including taking advantage of the ADF wide Safety Days. Hard copies of the study questionnaires were delivered to ADF establishments, units and ships and made available for completion by individuals and included reply paid envelopes for the questionnaire to be posted back to CMVH. The most effective means for the recruitment of participants proved to be via email. For instance, in the MEAO Census Study 92 per cent of respondents completed their surveys online.
It was also the responsibility of the DLOs to try and overcome the barriers that were encountered to enable data collection from ADF personnel. These barriers included ADF personnel being: recently discharged from ADF, away on course, already posted to another unit since return from deployment, not available, in hospital or on sick leave, conflicting unit and personal priorities, unit training requirements, difficulty locating personnel, a lack of access to the Defence Restricted Network (DRN) and personnel not aware of the study or timings. Underlying all of these obstacles was that participation was completely voluntary!
The validity of these studies relies heavily on the percentage of the ADF who participated. The MilHOP study reports have been submitted to Defence and are part of the largest health research program ever undertaken by the ADF.
The final result was that close to 50 per cent of the total current ADF population participated in the MilHOP studies representing about 25,000 individuals. As a result of these studies Defence now have a snap shot of the current health and wellbeing of the ADF. Defence will be able to examine the possible effects of deployment in a physical and neurocognitive sense and how this may affect personnel in regard to conditions such as Post Traumatic Stress Disorder (PTSD), depression and suicide. The health data collected will also provide the baseline information for future longitudinal studies, looking at emerging or currently unknown medical conditions that may be caused as a result of deployment or service related activities.
I believe that every reasonable means possible was used to communicate, inform, and enable as many ADF personnel as possible to participate in this very large study. Awareness of successful recruitment strategies was key to ensuring the validity of the study. Our efforts saw the study introduced into vastly different regions across Australia and work environments as well as at times our team having to adapt to single service cultures. Despite low participation rates in some areas (possibly from study fatigue), to achieve a study response rate of nearly 50 per cent of the ADF is a remarkable achievement. The major undertakings to recruit even one person to the study was quite simply “this is just what it takes” and as a team we did whatever we could!