defence health research framework

Abstract Presentations

November 11th, 2022 --> In Conference Abstracts   Issue Volume 30 No. 4

A case for employing DEXA for health monitoring and injury prevention in the ADF

Capt angela uphill 1,2 .

• Australian Defence Force, Swanbourne, Australia
• Edith Cowan University, Joondalup, Australia

No consent to publish abstract

CAPT Angela Uphill has been an Army Physiotherapist in the Regular and Reserve Army for over 17 years.

She is currently working in SOCOMD Human Performance and is completing her PhD investigating the health and performance consequences of Australian Special Forces selection and training courses.

A Journey to Trauma Verification with the Royal Australasian College of Surgeons

Dr julian williams 1 , lieutenant colonel anna reinhardt 1.

1 Army, Australia

LIEUTENANT COLONEL ANNA REINHARDT,

Commanding Officer 2nd Health Battalion

Lieutenant Colonel Reinhardt is a broadly skilled General Service Officer who has benefited from diversity of regimental, command, operations, training and staff opportunities. Her career appointments have spanned a variety of environments within 6th Brigade, 17th Sustainment Brigade, the Australian Defence Force Academy, Headquarters 1st Division, Army Headquarters, Headquarters Joint Logistics Command and Headquarters Joint Health Command. These experiences have provided broad opportunities to lead and work within highly skilled and integrated teams across dynamic settings.

Lieutenant Colonel Reinhardt has overseas and domestic operational experience.

Lieutenant Colonel Reinhardt holds a Bachelor of Arts (Information Systems), a Masters of Military and Defence Studies and a Masters of Health Management. She is a member of the Australasian College of Health Service Managers.

Lieutenant Colonel Reinhardt assumed command of the 2nd General Health Battalion in January 2020 and is now the inaugural Commanding Officer of the 2nd Health Battalion.

ADF Health Research Framework 2021-25

Dr michael drew 1.

1 Department Of Defence – Joint Health Command, Campbell, Australia

Members of the ADF perform a unique role, often in dangerous circumstances, and represent the foundation of Defence’s capability. The ADF takes its duty of care to Defence members seriously and their health and wellbeing is a key Defence priority.

As Defence moves to shape, deter and respond to the rapid global changes affecting Australia’s interests, the Defence Health System must also display agility and adapt to the future strategic environment and respond to government priorities.

This presentation will provide an overview of the ADF Health Research Framework 2021-25. This Framework marks a new chapter in setting a strategic approach to shaping Defence health research to have the greatest potential to contribute to ADF capability and improved health outcomes for ADF members.

The Framework aims to optimise Australia’s relative advantages in health research expertise and infrastructure and outlines a more streamlined and systematic engagement process between  Defence and research partners. Implementation of each of the four strategies which underpin the Framework will ensure high quality, relevant and timely research is delivered to optimise ADF capability.

This presentation will also showcase in more detail the first key strategy of the Framework which is the identification of strategic health research priorities. These priority areas will be integral to the future of Defence health research, and research within these priority themes will support the health and wellbeing of ADF members.

Dr Michael Drew is the Director of Health Research within Joint Health Command at Defence. In this role he oversees the strategy, governance and partnerships relating to health research as well undertaking and commissioning research that preserves and optimises the health of the Australian Defence Force. Prior to this role, he worked at the  Australian  Institute  of Sport for over a decade in various roles to improve Australian Olympians’ health and performance. Prior to his AIS role, he worked in Private Practice and as a Physiotherapist for the Newcastle Knights. Dr Drew has a Bachelor of Physiotherapy (Honours), Master of Clinical Epidemiology, PhD in Physiotherapy. Dr Drew holds an Adjunct Associate Professor appointment at University of Canberra, is a Fellow of the Australian College of Physiotherapy (by Original Contribution), Fellow of the Australasian Institute of Digital Health, and a Fellow of the Australian Sports Medicine Federation. Dr Drew has been involved in 16 PhD Supervisory Panels across physiotherapy, infectious disease, nutrition, biomechanics, sport science, epidemiology and sports performance. Michael has peer-reviewed over 75 publications and presented over 60 conference presentations including invited/ keynote presentations. In 2018,  his  team  received an Australia Day Award for their work in improving athlete health.

Corresponding author name: Michael Drew

Corresponding author email: [email protected]

ADF students learning Global Health and Global Health Engagement at the US Uniformed Services University of the Health Sciences

Brigadier michael reade 1,2,3,4 colonel paul byleveld 3,4 dr lynn lieberman lawry 4 ,colonel brad boetig 4.

• University Of Queensland, Herston, Australia
• Joint Health Command, Canberra, Australia
• Australian Army, Sydney, Australia
• Uniformed Services University of the Health Sciences, Bethesda, United States of America

The two-year USUHS Graduate Certificate in Global Health and Global Health Engagement via distance learning enrols over 200 students per year from the

U.S. military and international partner countries. Following the trial participation of two candidates in 2019, Australia has now enrolled cohorts of 20 students in 2020 and 13 in 2021, with a further 20 nominated to commence in 2022.

General global health topics covered include International Health Regulations, development economics, maternal and reproductive health, child health, nutrition, global health diplomacy, and an introduction to the role of the military in global health (and how different nations approach this). Complex topics such as female genital mutilation, abortion, and other serious ethical challenges are discussed. Advanced courses deal with:

• Contemporary and historical examples of Military Global Health Engagement, such as the US Medical Civil Aid Programs during the Vietnam War, engagements in Iraq and Afghanistan, and the evolution of Exercise Pacific Partnership in response to an increasingly sophisticated understanding of what benefits partner
• Public Health Issues of Disasters in Developing Countries, including the role of different responders to disasters and some of the most important public health issues among disaster
• Monitoring and Evaluation methods used by government and non-government organisations involved in aid, development and security co-operation, culminating in writing an M&E plan using “real life” USAID solicitations for international development projects.
• Health Context Analysis, which prepares military health professionals to consider the cumulative influence of socio-cultural background, health culture, determinants of health, and the health system to develop a standardized tool to collect, organise, and interpret information about a specific country or region and to inform global health

Through participation in discussion groups, ADF students build an international network of military health professional peers that will assist them in postings requiring interactions with partner nations.

The courses are designed so that students complete approximately one module per week. Students read the materials and watch the lectures in their own time, and then convene as a class once  per week online (via live video  teleconference) for seminars with course faculty and their fellow students. Individual courses may also require discussion board participation, a term paper, and  possibly a final exam. Most courses run for 11 weeks. Most live sessions are held on weekday evenings, U.S. Eastern Standard Time, which is mid-morning in eastern Australia.

Ideal ADF candidates will have a strong academic record in previous tertiary studies, some previous experience working in an international environment, and a military posting or career plan that demonstrates likely personal and service benefit from this qualification and professional network. Applications are sought in November – December each year from SERCAT 3-7 members of all ranks and in all health professions including General Service Officers.

Brigadier Reade is an  intensivist,  anaesthetist,  and the Professor of Military Medicine and Surgery at the University of Queensland. He has worked throughout PNG, including the current DFAT-supported project to enhance intensive care in Lae. He is a faculty member in the USUHS Global Health course.

ADDITIONAL SPEAKERS:

Colonel Byleveld is posted to the Directorate of Army Health as Clinical Advisor. He has experience as an Environmental Health Officer in PNG, East Timor, and Banda Aceh. He is a faculty member in the USUHS Global Health course. Dr Byleveld is a specialist in water, sanitation, hygiene, and public health with experience with the ICRC and the UNHCR in Africa, the Middle East, Asia, and the Pacific.

Dr Lieberman Lawry is a physician and epidemiologist at USUHS. She has 28 years experience in disaster response and development. She has worked in more than 24 countries conducting population-based studies and impact evaluations.

Colonel Boetig is Director of the Global Health Program at USUHS, having established this initiative in 2016. A USUHS medical graduate, he continues to work in paediatric medicine in the USAF. He holds an MPH from USUHS and an MA in Strategic Policy from the US Naval War College.

Corresponding author name: Michael Reade

Corresponding author email: [email protected]

An integrated care approach to support ADF members with complex needs across transition from the military

Ms kirsty chapman 1 , dr charles betts 1,2 , ms rebecca mcfarlane 1 , dr cameron korb-wells 1,2.

• National Centre for Veterans’ Healthcare, Concord Repatriation General Hospital, Sydney, Australia,
• University of Sydney, Sydney, Australia

The National Centre for Veterans Healthcare (NCVH) at Concord Repatriation General Hospital was established in 2019 and offers a unique integrated case managed model of care for veterans and ADF members with complex care needs. The service incorporates Psychiatry, Drug Health, Pain & Rehabilitation Medicine, along with Clinical Psychology and a comprehensive  allied  health team. It is a patient-centred model of care driven by veterans’ and members’ goals, with embedded telehealth capability and residential accommodation available for those needing to travel for care.

The transition from  ADF  to  civilian  health  care can be destabilising for separating personnel, with challenges navigating complex care needs across multiple providers. The availability of clinical services to support  ADF  members  across  this  transition has been identified as an opportunity to better coordinate continuing healthcare supports. Through its multidisciplinary focus and case managed model, the NCVH is well placed to facilitate a less disruptive transition to civilian life for those with some of the highest medical and psychological needs.

The NCVH has, to-date, received referrals for 25 ADF members approaching transition from the military. These referrals have spanned all service branches (11 Army, 11 Navy, 3 Air Force), with the majority of members (76%, n=19) having deployed, with all but one medically separating. Most members were married or in de facto relationships (72%, n=18), which were identified as potential supports over the transition period. The majority of members required care across disciplines for physical, mental and psychosocial health needs. A high burden of chronic pain with multiple musculoskeletal injuries was noted, along with high burdens of mental health diagnoses in these transitioning members. The availability of the NCVH clinical service to support members both in advance and subsequent to transition has supported effective coordination of care and mitigated risks of loss to follow-up through this period.

Dr Charles Betts is a consultant psychiatrist with public appointments within Sydney Local Health District in addition to working at St John of God Richmond Hospital. He is a fellow of the Royal Australian and New Zealand College of Psychiatrists.

Dr Betts graduated medical school in 2013 (MBBS, Sydney University) and previously studied at the University of Massachusetts Amherst. He also served five years in the United States Air Force prior to relocating to Australia.

Corresponding author name: Dr Cameron Korb- Wells

Corresponding author email: [email protected]

Army Psychology: preparing for Accelerated Warfare and supporting an Army in Motion

Lieutenant colonel maureen montalban 1.

1 Australian Army, Australia

The evolution of the Australian Army Psychology (AAPSYCH) capability for Army has been heavily influence by the last two decades of high operational tempo, the creation of Joint Health Command (JHC) where Army psychologists have been key clinicians within the Mental Health & Psychology Teams, and external drivers with respect to reforms, reports and recommendations that have squarely put a focus on clinical mental health care; and for very good reason, AAPSYCH has been at the forefront of the provision of mental health care to ADF personnel in the last two decades.

However, AAPSYCH as a capability is at a pivot point. As a capability, we  are  repositioning ourselves to focus on command decision  support and organisational psychology tasks. This is as a result of the 2020 Health Capability Establishment Review (CER) outcomes, the formal sign off of the AAPSYCH capability statement by Director General Future Land Warfare in 2021 and the decision by the  Surgeon   General   Australian   Defence   Force in 2022 to delineate the services provided by JHC (mental health services) and the single Services (organisational psychology activities).

The role of AAPSYCH has always been to support the warfighter, and we have done so in our long history of service: whether it be ensuring we have selected, recruited and retained the  right  people  for  the right jobs, to looking after their mental health and wellbeing to ensure they are ‘fit to fight’, to ensuring that we help enable Commanders to make the tough decisions. AAPSYCH is posturing itself to be Future Ready, within the context of Accelerated Warfare and Army in Motion by reviewing, re-envisaging and realigning many aspects so that we can  provide Army the full suite of tasks outlined in our capability statement. We don’t have everything right, right now. But as history has shown, we have continually provided Army and its people what it needs, at that particular point in time and we will continue to do so, now and into the future.

Lieutenant Colonel Montalban is an Army psychologist who  has  worked   at   the   tactical,   operational and strategic environment within the Australian Defence Force, providing psychological advice and interventions to individuals, units and Commanders. She has done so within Australia and on operational deployments to Timor-Leste, the Solomon Islands and the Middle East.

Lieutenant Colonel Montalban has completed her Bachelor of Economics (Social Sciences), Graduate Diploma in Science (Psychology), Graduate Diploma in Public Health, Master of Psychology (Health) and is currently working towards completion of her Doctor of Philosophy at the Research School of Population Health at the Australian National University.

Corresponding author name: Lieutenant Colonel Maureen Montalban

Corresponding author email: [email protected]

Attention control training to improve PTSD symptoms for transitioning veterans

Mr dan botros 1 , dr olivia metcalf 2 , dr tracey varker 2 , mr doug scott 1.

• Open Arms – Veterans & Families Counselling, Department of Veterans’ Affairs, Australia
• The University of Melbourne, Australia

Altered threat monitoring in military and veteran populations may contribute to  the  development of mental health issues. A simple computer-based program, known as attention control training, developed in the Israeli Defence Force, has the potential to re-calibrate threat monitoring in veterans before they leave the military and transition to civilian life, in order to improve mental health.

In this pilot randomised controlled trial Australian Defence Force personnel and veterans (N = 59) received four weekly sessions of either attention control training, or a placebo attention training. Participants who received attention control training reported significantly lower levels of PTSD symptoms, anxiety symptoms, and significantly improved work and social functioning. No participants who received attention control training worsened  with  regard to PTSD symptoms, whereas 23.8% of those who received the placebo attention training experienced an increase. The potential for attention control training, a simple, seven minute computer task, to prevent the development of PTSD is significant, and these preliminary findings are world-first.

The aim of this presentation is to discuss these findings, as well as provide a clinician’s experience of recruiting and engaging participants to take part in attention control training,  learnings  from the study, and future directions. The majority of participants were veterans who had transitioned within the last 12 months. The main barrier to participation in this trial for ADF personnel was the nature of transition as a busy time, in that members discharging from Defence have multiple other commitments to complete to assist with their ADF transitional requirements. Participation was also hindered by excess travel requirements to complete the trial for members on remote bases, and a lack of understanding around data collection and privacy barriers. The learnings from this preliminary study include the need to consider a ‘virtual implementation’ of attention training, which would involve delivery to an individual’s own computer, as well as deeper integration within the transition space. To validate these preliminary findings, a randomised controlled trial with transitioning personnel is needed.

Dan Botros has been employed  with  Open  Arms for 4 years and held multiples positions across the organisation including acting Director of Transitioning Members  (DVA),  Acting  Regional  Director  Vic/ TAS, Group Programs Coordinator and currently is employed as the Assistant Director of Clinical Outreach and Group programs across Victoria and Tasmania. Dan has 18 years’ experience in a variety of private and corporate organisational psychology positions including youth mental health services, Security industries, Correctional Centres, Petroleum Off-shore Company,  and  the  Australian  Defence  Force.  Dan is currently a Royal Australian Air Force Specialist Reservist Organisational Psychologist and board approved psychology supervisor.  Dan  was  engaged as a research assistant to implement the Open Arms and Phoenix Australia SOAR research trial.

Dr Olivia Metcalf is a behavioural scientist who specialises in digital mental health and trauma- affected populations. Olivia is interested in leveraging technology, including wearables and smartphones, in assessing and treating mental health problems that can result after trauma, including PTSD, addiction, and problem anger. She has been researching novel ways to treat common mental health issues in veteran and military populations for the past nine years. Olivia has expertise in experimental research and as a clinical trial methodologist.

Corresponding author name: Dr Olivia Metcalf

Corresponding author email: [email protected]

Aural Barotrauma in ADF Diver Trainees

Associate professor dale edwards 1 , mr peter gough 1,2 , lcdr jason watterson 1,2.

• University of Tasmania, Australia
• Royal Australian Navy,

POMED Peter Gough is a graduate of the Bachelor of Paramedic Practice (ADF Conversion) which comprises part of the Navy Clinical Manager Course and is also an Underwater Medic. Since graduating PO Gough has enrolled in the Bachelor of Paramedic Practice (Honours) research degree and has been investigating the incidence of Aural Barotrauma in ADF divers.

Corresponding author name: Dale Edwards

Corresponding author email: [email protected]

Australian Defence Force – Defence Health System Assurance

Lieutenant colonel fred parker 1.

1 Joint Health Command, Australia

The Defence Health System (DHS) is a complex array of consumers, providers, services, stakeholders, locations, contexts and governance responsibilities. Articulating the health of this complex system and its ability to generate and sustain directed health capability effects is a significant task. This is made all the more challenging as not all elements of this array are under the direct control of the Surgeon General Australian Defence Force (SGADF).

The approach to DHS assurance requires a broad view and understanding of  that  complexity  and of the levers available to influence and govern it. Application of a comprehensive assurance framework requires collaboration, cooperation and buy-in from all stakeholders.

Generating and sustaining  required  health capability and capacity is dependent on integrating, coordinating and managing a range of fundamental capability inputs, ensuring they are delivered in required state, quantities, characteristics, timescales and tempo needed for the required effects.

The ADF Health Strategy (the Strategy) identified that a health system assurance function would be an appropriate mechanism by which the SGADF would apply guidance and technical authority through Defence health across key operating contexts of garrison, deployed and civilian influences.

The DHS assurance framework articulates how Health Strategy Office (HSO) will, in combination and coordination with existing audit and governance programs of the services and groups, provide positive systems wide assurance that Defence health capability is fit for purpose, ready to deliver, responsive to change and resilient in facing challenges.

Lieutenant Colonel Fred Parker is a General Service Officer within the Royal Australian Army Medical Corps. On completion of university in Sydney he graduated as a Registered Nurse. Following a few years employed in acute care environments,  he joined the Army ‘just to have a look’. Over the last 28 years, he has undertaken variety of appointments across all military environments. He is currently the Deputy Director, Health Strategy Office at Joint Health Command

Corresponding author name: Dr Anna Samson

Corresponding author email: [email protected]

Bruxism in military members – misconceptions and occupationally centred considerations in management

Jessica kuk.

Recognising the controversies and contention about bruxism, this presentation aims to identify and dispel misconceptions about its diagnosis, clinical consequences and associated disorders by drawing from current literature. It discusses important considerations of patient factors within the military population in order to provide appropriate patient centred care.

Patients presenting to the dentist frequently report grinding of teeth at night. This is often accompanied or preceded by reports of jaw  joint  and  muscle pain, headaches and  tooth  wear.  Historically, within the Defence population, there is an almost reflexive treatment to provide an occlusal splint or a ‘nightguard’ without further investigation or review. Unsurprisingly, patient compliance and success are either poor or unknown. Indeed, this is not always appropriate treatment and may even leave other associated conditions undiagnosed and untreated.

In some cases, the provision of a nightguard can cause further detriment.

In order to appropriately manage presentations of reported bruxism and its accompanying complaints, the dental practitioner must conduct  accurate history taking and investigation.  This  should involve discussions and questions about any pain, parafunctional habits, psychosocial stressors and general health and wellness. In some cases, it may warrant collaboration with other health practitioners. Understanding the individual’s military context, the lifestyle of the Defence member and its influence on these factors is crucial to comprehensively  colour the presenting picture. Greater  appreciation  of these patient factors, facilitates provision of patient centred, holistic and where necessary, mulit- disciplinary care.

There may be challenges in providing this care within the military context such as practitioner education, resource availability, environmental factors, availability to attend appointments and requirement to remain dentally and medically fit to deploy in accordance with conditions stipulated by Defence Health Policy. The practitioner’s understanding of these challenges facilitates  successful  navigation and ultimately leads  to  better  patient  outcomes and ideally reduced risk of dental casualties and maintenance of capability.

In the current climate where retention of capability is a priority, the dental practitioner has a responsibility to empathetically deliver care to increase patient satisfaction and  prevent  deterioration  of  oral health that may hamper dental readiness– that is, healthcare to ensure members are Fit to Bite, Fit to Fight.

LCDR Jessica Kuk joined the RAN as an undergraduate dentist studying at University of Adelaide. She began her Naval dental career in WA, prior to serving as a Fleet Mobile Dental Officer on multiple platforms. LCDR Kuk is currently enjoying her posting to HMAS Cairns, providing dental support to crews of hydrographic survey and patrol vessels, whilst studying a Master of Science in Medicine (Pain Management) Orofacial Pain. Through her further study, LCDR Kuk continues to develop interest in delivering evidence based, patient centred care within the military context.

Corresponding author name: Jessica Kuk

Corresponding author email: [email protected]

Co-Designed and Peer Led Programs

Mr matt newlands 1 , dr jonathan lane.

1 Military & Emergency Services Health Australia, Adelaide, Australia

The lack of cultural competence of frontline and military health service providers is considered a barrier to accessing and remaining in care, especially mental health services. This is particularly relevant to individuals with a strong service identity which is inherently shaped by the training they receive, their experiences on deployment and the norms, traditions and values of their service culture.

The presentation will provide an overview of three unique programs co-designed and delivered by Lived Experience Service Peers which are successfully breaking down these help-seeking barriers. These three programs: “Group Emotional And Relationship Skills” (GEARS), “MindRight” & “StoryRight” provide a transdiagnostic, skills-based approach to mental health aimed at providing service  personnel  with the skills and knowledge to monitor, address and manage what is within their own control. All of these programs are delivered by supervised lived experience peers with the cultural expertise and the credibility to role model functional recovery, thus improving content and skills uptake. Facilitators are trained using a ‘train the trainer’ model of participation, observation, and gradual increase of responsibility for delivery, whilst receiving formal clinical training and are provided with high level clinical oversight.

All three programs provided by Military and Emergency Services Health Australian are providing a renewed sense of purpose and meaning for Frontline and Military personnel nationally through the application of relevant service-related skills and experience to assist peers in their journey of recovery and/or growth.

Matt is a husband and father with 10 years-service with South Australia Police (2006 – 2016). Having been diagnosed with PTSD and depression in 2015, Matt fought a personal battle with suicidal thoughts and refusal of his diagnosis resulting in the destruction of his personal life and the end of his Policing career in very dramatic circumstances.

Matt spent the following years learning strategies and tools to optimise and maintain his wellbeing before turning his attention to supporting other military and first responders.

Matt is now the Lived Experience Stakeholder Engagement Manager and Program Manager for Military and Emergency Services Health Australia; and is also a qualified counsellor, peer work consultant, program facilitator and volunteers as a national Community Ambassador for RUOK?

Corresponding author name: Jonathan Lane

Corresponding author email: [email protected]

Damage Control Resuscitation – are we missing the POInT?

Dr andrew cahill 1.

Effective Damage Control Resuscitation (DCR) involves the principles of permissive hypotension, damage control surgery and haemostatic resuscitation. The availability of appropriate blood products in austere, resource-limited and complex prehospital environments is a critical vulnerability to adequate resuscitation. In the military context, operational constraints such as logistic resupply limitations, cold chain compliance, tactical signature, and equipment manoeuvrability may additionally restrict availability. The paucity of blood product redundancy requires an operational solution.

The Point Of Injury Transfusion (POInT) program is a proposal to enable fresh whole blood to be available and utilised in extreme circumstances where commercial blood product components are deplete or logistically untenable. The proposal closely aligns with established programs in coalition militaries by paralleling the use of pre-screened pre-identified ADF donors to avail Low Titre Group O Whole Blood (LTOWB) to causalities in haemorrhagic shock.

The Committee on Tactical Combat Casualty Care (CoTCCC), in its 2020 amendment to the TCCC guidelines, removed crystalloid therapy as a resuscitation fluid of choice option for casualties in haemorrhagic shock. As a result, ADF Medical Technicians, often the most proximate clinician to the point of injury, do not routinely carry any of the resuscitation fluids recommended to treat trauma causalities in haemorrhagic shock. To address this deficit, the POInT proposal offers a formalised means of sourcing and transfusing LTOWB at the point of injury.

The key elements of the POInT proposal can be discussed as three phases: approval, pre-deployment and deployment considerations. Firstly, as LTOWB is currently not commercially available in Australia, an appropriate proof of concept, with national and Defence legislative compliance and relevant health policy review is required for approval. Secondly, the pre-deployment processes involve identifying low titre Group O donors within the deploying force, scheduled screening for transfusion transmissible diseases, ensuring equipment familiarisation, training donors and clinicians on the procedure as a battle drill, and outlining the strict clinical governance requirements regarding blood product handling and use. Thirdly, deployment considerations include personnel planning, the utility of pre-mission collections, coalition interoperability and the tactical donation and administration procedure.

Examples of LTOWB transfusions in  austere, remote, and operational conflict settings have been increasingly documented. Whilst domestically screened blood components remain sourced as first line products, redundancy options when operational constraints prevent such availability should be considered; mission success and casualty survivability may depend on this. Articulated  in this introductory proposal, the POInT program may deliver, in extremis, whole blood critical for damage control resuscitation far forward to support ADF operations.

Major Cahill is an Army Medical Officer, currently completing a clinical year in Acute Medicine at John Hunter Hospital. Commissioning in 2011, he has had sequential postings to operational units in the Australian Army and has international and domestic operational experience as a Regimental Medical Officer.

Major Cahill is a Fellow of the Royal Australian College of General Practitioners, a Defence Aviation Medical Officer and enrolled in Master of Medicine (Critical Care Medicine).

Corresponding author name: Andrew Cahill

Corresponding author email: andr [email protected]

Environmental exposures on deployment and reproductive health: What’s the deal, baby?

Dr rachelle warner 1,2 , dr jodie avery 1,2 , associate professor susan neuhaus 1 , professor michael davies 1,2.

• University of Adelaide, Australia
• Robinson Research Institute, Adelaide, Australia

Military personnel deployed on operations may encounter a  variety  of  hazards  with  the  capacity to adversely affect reproductive health. This paper investigates the association between self-reported exposure to reproductive toxicants and adverse pregnancy outcomes in Australian Defence Force veterans who deployed to Iraq and Afghanistan during the period 2001–2009. Utilising the Middle East Area of Operations (MEAO) Census Study data set, descriptive analyses of participants’ self-reported exposure were compared with the occupational environmental monitoring data taken at their reported deployment location. Univariate analyses assessed the significance of unadjusted associations between self-reported exposures and reproductive outcomes. Overall, self-reported adverse reproductive outcomes were significantly increased in veterans who deployed to both Afghanistan and Iraq (p = 0.04) compared to those who only deployed to only one of those locations; particularly in women (p = 0.009). Miscarriage was the most likely of these (p = 0.008). These figures would benefit from being confirmed against medical records but are worthy of further study. In this historical cohort study, causal inference cannot be made due to absence of control groups to exclude  sources  of  potential  bias.  Imprecision in the assessment of environmental hazards  in the MEAO and other methodological constraints make it impossible to calculate precise estimates of risk. The results warrant continued investigation, especially when combined with previous findings related to pregnancy outcomes in this population, the importance of reproductive outcomes, and the potential emergence of new hazards.

Rachelle Bonner joined the public service as a multitasking ninja, and that pretty much describes her career to date. She has deployed into the Middle East, Iraq and the Philippines, and has some experience in international and operations law, including undertaking health threat risk assessments of new weaponry. Fuelled mostly by caffeine and dogs, she is also a certified geek with a PhD in Reproductive

Medicine, designs and makes wedding accessories for pets and cosplay props, and is an expert procrasti- baker.

Corresponding author name: Rachelle Warner

Corresponding author email: [email protected]

Every doctor a trauma practitioner: clinical immersion as a pathway to operational clinical readiness for general duties medical officers

Major adam mahoney 1 , major kyle bender.

1 Australian Army, Hobart, Australia

The ADF expects a great deal from its generalist medical practitioners on operations. Preservation of the deployed force requires that medical officers are experts in primary care and occupational medicine. Accordingly, when not deployed, most full-time ADF medical officers augment the  experience  gained in garrison health support by engaging in clinical placements in general practice or civilian emergency departments. This model of learning produces broadly skilled medical officers well equipped to meet the needs of disease non-battle casualties.

But what about trauma? Australian service members deploy on operations confident in the expectation that, if they are wounded, they will receive best- practice trauma care. In recent years, work has begun on an Operational Clinical Skill Set (OCSS) for deployed general surgeons, recognising the growing gap between military and civilian practice. Likewise, it has been recognised by many authors that routine civilian clinical activity offers variable exposure to the situations surgeons may encounter in the field; there is a need for a purposeful approach to learning – an Operational Clinical Readiness Pathway (OCRP). This is equally the case for generalist medical officers. Civilian primary care and emergency department placements do not offer the concentrated experience of  in-hospital  trauma  management  necessary  to allow non-specialists to care  for  injured  soldiers  in the wards, or while awaiting evacuation and onward movement.

In this presentation, we propose a pilot program in which general duties medical officers are offered the opportunity to be embedded within an admitting trauma unit for a period of four weeks. This period of clinical immersion will enable attainment of pre- defined learning objectives centring on the knowledge and skills required to provide comprehensive medical care to trauma casualties in the period following initial resuscitation and damage  control  surgery. Key competences would include tertiary survey completion, prevention and recognition of common complications of trauma, and  understanding  the role of nursing and allied health specialists  in trauma care. If successful, we hope to expand the program to include other military health disciplines, acknowledging that it is the entire healthcare team, not isolated experts, who support optimal function of the deployed trauma system. Ultimately, we believe that trauma clinical immersion can emerge as one of many learning experiences within an OCRP that will allow every serving doctor to be a confident and competent trauma clinician.

Major  Mahoney  is  an  anaesthetist  and  intensive care registrar in the ADF Medical Specialist Program seconded to the Royal Hobart Hospital where he is also the Director of Trauma. He has research interests in military medical education and trauma epidemiology.

Corresponding author name: Adam Mahoney

Corresponding author email: [email protected]

Experiences from a Medical Technicians perspective during Middle East region draw down – preparation, training and future planning.

Cpl allana smith 1.

1  Australian Defence Force, Enoggera, Australia

Al Minhad Air Base, Camp Baird, is a Coalition Military facility accommodating multi-national personnel who together support military personnel operating within the Middle East region (MER). Headquarters Middle East exercises command and control of deployed ADF units in the MER through Op Accordion. Op Accordion enables contingency planning and enhancement of regional relationships in the MER by providing communications, force support, airbase operations and health care. Camp Baird has been the home to thousands of soldiers, sailors and airmen and women over the past two decades however in the last six months has undergone a substantial decrease of personnel. This draw down process has led to large teams being reduced considerably.

The AMAB Health facility is currently responsible for the health care of ADF personnel both in location and within the greater MER. The purpose of this presentation is to outline the different roles and responsibilities of an Australian medical technician in a coalition medical facility prior to, during and post the draw down process. Additionally this presentation will outline future planning for a medical facility when expansion is required to support a larger number of personnel.

Lastly, this presentation will detail the improvements to training required by medical technicians prior to deploying to a non-warlike environment. This includes the upskilling of medical technicians to perform more advanced medical procedures, AME responsibilities and administrative roles.

This presentation will expand on the following points:

• Preparation and pre-deployment training for medical technicians
• The roles and responsibilities expected of a medical technician
• Overview of injury patterns, patient presentation and management
• General staffing, layout and services available in the AMAB Medical facility
• Different standards in training and treatment between different coalition forces
• Improvements in training inclusive of specific training deemed pertinent for a medical technician prior to deployment in non-warlike

The presenter will cover topics mentioned above during the presentation. They will outline the importance for improvement in pre-deployment training for a Medical Technician and how best we prepare ADF medical personnel for changes in circumstances on operations. This  information is especially relevant as their role both  nationally and internationally is constantly transforming. The threats to coalition personnel are rarely consistent; therefore, in order to be ready for the next mission, Medical Technicians need to be adaptable and prepared.

CPL Allana Smith enlisted into the Australian Regular Army in the Royal Australian Medical Corp as a Medical Technician on 24 February 2014.

On the completion of the Australian Defence Force Medical Course CPL Smith was posted to the 1st Close Health Battalion based in Darwin, Northern Territory.

She deployed with 1st Battalion Royal Australian Regiment on Operation AUGURY to the Philippines in 2018. During this posting she completed Subject

1 Corporal Course and subsequently promoted to Corporal in 2019.

CPL Smith then posted to the 2nd General Health Battalion Brisbane, Queensland, now 2nd Health Battalion in January 2020, where she deployed to Operation ACCORDION in the United Arab Emirates in 2021.

CPL Smith has been awarded the Australian Operational Service Medal, Australian Operational Service badge, Australian Defence medal, Philippines Military Merit Medal and Australia Day Medallion.

CPL Smith grew up in Glenelg, South Australia where her parents and younger brother reside. She has a keen interest in sport and plays Netball, Tennis and Australian Rules Football.

Corresponding author name: Allana Smith

Corresponding author email: [email protected]

Forward Medicine Competition for Defence Health Personnel

Stewart robertson 1.

1 Army, Sandringham, Australia

In the past, the Royal Australian Army Medical Corp has conducted clinically focussed and driven inter-unit competitions, the Cerliter and First Aid in particular to build spirit-de-corp and a competitive culture within and across health units/sub units. The competitions at the time provided  sub-units with the opportunity to strive for excellence in the provision of forward medical care in a simulated field environment. Due to operational tempo requirements and incremental training liabilities, Army wide inter- unit competitions in health units have ceased  to exist and have not been conducted over an extended period of time.

The Forward Medicine competition will be a premier event to test the skills and prowess of teams of Health personnel from across the country. The event/activity is designed to test the Tactical Combat Casualty skill set over a wide variety of tactical medicine components. Teams will be faced with a Full Mission Profile scenario that will play over a series of phases, with each phase, the scenario will unfold a little further. The overall scenario will be physically demanding and teams should be prepared for exertion over an extended period. Teams will have the opportunity to challenge themselves, push themselves hard, and excel beyond any obstacles they face.

The Forward Medicine Competition (FMC) should be considered a high yield solution to cement Tactical Medicine as the centre of health training excellence and reinforce the Medical Technician brand and to set the standard for clinical training and commensurate with our coalition partners

The Global War On Terror seen a period of intensive kinetic operations, health training must not lose the momentum gained and should continue to focus the training of health personnel, in particular Medical Technicians, in the forward space to maintain “core combat and operational behaviours”. The centrepiece for these behaviours is Tactical Combat Casualty Care principles that encompass Point of Injury Care, stabilisation, prolonged field care  and  the  rapid and effective evacuation to the appropriate Medical Treatment facility.

With the new Army Health reformation structure with four integrated elements that have distinct identities, the activity could serve as a great opportunity to build unit cohesion, dare say it rivalry and a pride in unit capability. Furthermore, the advent of JMED course, there is no reason why this competition could not eventually incorporate Medical Technicians from across the three services.

The development of the event/competition could also lead to the establishment of an Australian version of the American Expert Field Medical Badge. Recognition of the skills of a tactical medical capability is something we should continue to invest in, support and reward.

Major Robertson has served in Army Health Services for more than 30 years firstly as a Medic and then commissioned for the last 10 years. He has been deployed overseas and domestically,   and   has had a variety of postings in Close Health and Trg environments.

Corresponding author name: Stewart Robertson

Corresponding author email: stewart-r [email protected]

From Defence to DVA Care – Safe passage for improved health and wellbeing

Professor jenny firman 1 , dr fletcher davies 1.

• Department of Veterans’ Affairs, Canberra, Australia
• Department of Defence, Canberra, Australia

Defence and DVA continue to forge closer connections to improve healthcare and support for Defence members as they make the journey from military service to civilian life.

We know that transition can be a stressful period and that transitioning members will often seek the advice of the healthcare team to help them navigate this process successfully

This presentation will consider the journey of a transitioning Defence member including the potential impacts of any early injuries while still in service, through to transition and beyond into civilian life as a veteran receiving support from DVA.

Why do we encourage planning for transition well before the date? What is the role of the health professional in this claims process and what can you recommend to your transitioning patients to assist them?

The panel of Defence and DVA representatives will provide answers to these questions and others, and use case studies to explore the issues. We will discuss the medical separation process, GP referrals, Defence and DVA support services, and the process for compensation claims, which are required to activate some of these supports.

We will help to demystify the claims process and provide insights about how healthcare professionals can best support a swift and efficient passage of claims, while minimising unnecessary paperwork. And we will dispel the myth that healthcare professionals need a detailed understanding of the complex Acts that define compensation and rather focus on the importance that clinical knowledge and expertise brings to the claims process.

DVA will highlight the health-based initiatives in place to ensure transitioned members and veterans can receive the health treatments and services they need, even if their claims have not yet been finalised.

Defence will outline the support available to transitioning members both from within health and more broadly across Defence.

Attendees will gain important insights about the transition process and their role in helping members have a positive transition experience and enter civilian life better prepared for lifelong health and wellbeing.

Professor Jenny Firman AM completed her medical degree at University of Melbourne and while a student joined the Royal Australian Navy. Over the next 22 years of full time service, she was posted to a range of positions in Navy and ADF. She transitioned to the Navy Reserves in 2002 and in February 2015 was promoted to Rear Admiral and appointed as Surgeon General Australian Defence Force Reserve.

After a decade in the Australian Government Department of Health working on communicable diseases and health emergencies, she was appointed as the Chief Health Officer in DVA in 2019.

In July 2020 she was appointed as an Honorary Professor at the Australian National University in the College of Health and Medicine and in 2021 was honoured to be appointed as a Member of the Order of Australia in the Military Division for her exceptional performance of duty in the field of military medicine.

Dr Fletcher Davies completed his medical degree at the University of Adelaide and spent the next 15 years working in acute hospital medicine throughout South Australia and Victoria. After completing Masters Degrees in Public Health and Healthcare Management, he joined DVA in 2013.

While at DVA, he has contributed to the design of the current claims processing IT system, rationalisation of provider-facing paperwork, the development of a governance framework for clinical advisers, and the implementation of an assertive case management program for vulnerable veterans. He has been in the role of Principal Medical Adviser – Compensation since 2019.

Corresponding author name: Jenny Firman

Corresponding author email: jenny.fir [email protected]

Future Maritime Warfare Medical Considerations – Trauma Systems, Workforce and Interoperability

Dr luke edwards 1.

1 Royal Australian Navy, Sydney, Australia

Recently delivered to the RIMPAC22 Medical Symposium the presentation aims to discuss, analyse and provide perspectives on future military medical considerations by reviewing the historical context & injury patterns present in the maritime environment; modern trauma curves, interventions and treatment liabilities. This baseline is then developed for application to the current and likely near-future battlespace.  In  discussing  interoperability  as   a key foundation to warlike joint trauma systems capability an overview of mobilisation, training & workforce dilemmas of maritime medical enablers will then be made. An expanded discussion on the interoperability spectrum and aims for its future use will conclude the presentation.

CMDR Luke Edwards is the current Royal Australian Navy (RAN) Fleet Medical Officer; Australia’s delegated technical authority for the provision of military maritime healthcare. He is a primary care specialist with post graduate qualifications and training in aerospace medicine, underwater medicine, medical administration and is a 2019 graduate of Australian Command and Staff Course. He has served across the majority platform types and operational contexts across the navy and wider Australian Defence Force enterprise.

Group Emotional And Relationship Skills (GEARS): A culturally informed, peer led, transdiagnostic psychoeducation and skills-based group intervention with military, veterans and emergency services personnel

Dr jonathan lane, 1,2.

• Military and Emergency Services Health Australia (MESHA), Parkville, Australia
• University of Tasmania, Hobart, Australia

Introduction: The Group Emotional And Relationship Skills (GEARS) program is being delivered in Adelaide and Hobart by lived experience facilitators for military, veteran and first responder (MVFR) personnel with stress and trauma conditions. The manualised 12-week program is adjunctive to normal mental health (MH) care in that it is community based and aimed at psychoeducation and skills for stabilisation and recovery from a transdiagnostic perspective. It also unique in the way in which it is culturally specific and delivered by peers. This presentation will describe the preliminary clinical outcomes of the program evaluation (DDVA271-20) to date.

Methods: The MVFR participants’ individual pre- and post-program primary clinical outcomes of psychological distress (K-10); Depression (PHQ-9); Anxiety (GAD-7); Anger (DAR-5); post-traumatic stress disorder (PTSD) (PCL) scores; Insomnia Severity Index (ISI); Resilience (BRS) and Disability (SDS) will be discussed. Emotional Regulation (ER), as measured by the Dimensions of Emotional Regulation Scale (DERS-SF), is hypothesised to be strongly associated with all outcomes.

Results: The individual results from participants (N=58 as at the time of this abstract) who have completed the program demonstrate statistically significant pre-post changes on all measures except resilience and disruption to work. There is a strong association between ER and all measures, suggesting that ER skills moderate symptoms of psychological distress and therefore ER is a key skill for stabilisation and functioning.

Conclusion: Emotional dysregulation underlies many of the symptoms of  psychological distress in the MVFR population. Per led transdiagnostic psychoeducation and skills-based stabilisation programs for stress and trauma disorders are both novel and potentially effective programs to support clinical treatment. This is particularly relevant for MVFR populations due to the high occupational risk for these conditions.

Dr Lane, FRANZCP, MBBS (Hons), has been in the Army for over 30 years and an Afghanistan veteran. He is completing a PhD developing and evaluating the effectiveness of skills-based interventions for mental health problems for military, veterans, police and emergency services personnel. He is the Psychiatry Lead for the University of Tasmania School of Medicine; the lived experience clinician for Military and Emergency Services Health Australia (MESHA); and consults for the Department of Veteran’s Affairs (DVA), Tasmania Police, the Australian Defence Force (ADF); a member of advisory boards for Veterans for Tasmania and DVA; was the Coach of the Australian Invictus team for archery in 2018 and 2022; and a Churchill Fellow. He has been an invited speaker and presented at a wide range of clinical and educational conferences both internationally and in Australia due to his expertise in the field of military, veteran, and emergency services mental health. His passion is advocating for, and implementing, culturally informed and peer-led interventions that have functional outcomes. He was awarded the inaugural 2019 Society for Mental Health Research lived experience research medal for his work.

Corresponding author name: Dr Jonathan Lane

Haemostatic resuscitation in practice – an analysis of blood products administered during Op HERRICK, Afghanistan

Lieutenant colonel rhys davies 1 , major james thompson 1 , ms ruth mcguire 2 , major stacey webster 1 , surgeon captain jason smith 1 , colonel tom woolley 1.

• Defence Medical Services, United Kingdom
• Defence Science and Technology Laboratory, United Kingdom

Lieutenant Colonel Rhys Davies is a consultant anaesthetist working at the University Hospital Southampton, UK. Alongside major trauma and transfusion, he has a special interest in neuro and vascular anaesthesia.

Corresponding author name: Rhys Davies

Corresponding author email: r [email protected]

Healing Minds and Bodies. A Holistic Service for Veterans and Serving Members

Dr gavin angus-leppan 1 , dr the chow chow 1.

1 Ncvh, Concord Hospital, Concord, Sydney, Australia

The unique and complex nature of the veteran’s health create major obstacles to establishing  wellbeing. This presentation will explore our experiences  at The National Centre for Veterans Health Care with veterans and serving members suffering physical, psychological and substance use issues. This multidisciplinary service offers integrated care from a range of specialties. We discuss two cases which exemplify the challenges arising from interactions between multiple diagnoses, multiple professional stakeholders and multiple therapeutic  regimes. Some of the problems we have encountered include overlapping polypharmacy, the stigma of mental health care, the early use of irreversible surgical treatments, psychological blocks to good response to medical treatment and issues around perceived legitimacy of medical complaints in the context of a psychological disorder. We see these issues as particularly pertinent to the areas of pain and trauma.

Arising from experiences, we reflect on the benefits of a multidisciplinary team with regular and efficient communication between its members and of the identification of interactions, both pharmacological and psychosocial. Multiple perspectives on and interactions with patients have yielded a richer understanding and deeper engagement with patients. For instance, a patients increased awareness of the specific and personal meaning and associations of their pain helps disentangle the experience of pain from other issues. The acknowledgement of multiplicity of needs has also fostered a sense of containment and help alleviate the distress of patients troubled by competing issues.

Dr Gavin Angus-Leppan is a Psychiatrist with an interest in Psychosomatic Medicine, Trauma and Psychotherapy including EMDR. In addition to working with Veterans, he works at the Aboriginal Medical Service at Redfern.

Dr Angus-Leppan has a background in Psychiatry of Old Age, General Acute Psychiatry and Consultation Liaison Psychiatry in Australia an the UK.

Dr Tze Chow Chow is a Specialist in Pain Medicine and Anaesthesia. He is also a staff specialist and supervisor of trainees at the National Centre for Veterans Healthcare (NCVH).

Dr Chow Chowprovidesanintegratedmultidisciplinary pain management approach with clinical precision, early intervention, tailored management plans to provide a refreshing bespoke experience. Majority of his clients include Australia Defence Force (ADF) members with multiple injuries, Veterans with complex trauma and degenerative diseases, patients with widespread pain and psychosocial implications that required pain management consolidation.

His expertise covers most pain conditions like nerve pain, joint pain, spinal back pain, headache and complex regional pain syndrome. He is also specialised in advance pain interventional techniques such as nerve blocks, joint blocks, radiofrequency treatments and spinal cord stimulators.

Corresponding author name: Gavin Angus-Leppan

Corresponding author email: [email protected]

Health leadership & Mission Command: is it really rocket surgery?

Dr steve adamson 1 , lieutenant colonel kelly dunne 1.

1 Australian Army, Canberra, Australia

The Australian military medical system is complex, comprising garrison operations (the day-to-day health care  of  ADF  personnel),  the  responsibility to prepare the ADF medically for Operations, and the need to field a broad array of combat-ready medical capabilities. At the same time, the military medical system must maintain functioning  links with equally complex external agencies such as the wider Australian  health  system,  the  Departments of Health and Veterans Affairs, a large contracted health workforce and, of course, the ADF’s war- fighting elements that rely on our support to achieve their mission.

So how do our health leaders navigate this complex web of organisational challenges in an ever changing global and domestic environment? Do we devolve decision making down to the lowest level practical and empower junior leaders and clinicians? Or do we embrace the opposite approach – pushing all decision making and health policy to the very top, to those isolated from the patient and the mission and risk paralysing the health system in the process? I think we intuitively know the answer lies somewhere in between those extremes, but this illustrates a dilemma faced by those in the ADF health system today.

The  judicious  application  of   Mission   Command in health organisations, has the  potential  to  shift the focus from centralised decision making, to empowered leaders and clinicians at the  tactical level who are focused on achieving the mission in line with the Commander’s Intent. At its foundation, the idea of mission command recognises that once we move from planning to execution things can and do change. It recognises that the speed of decision making and agility can sometimes be the difference between mission success and mission failure. An equally important concept that underpins Mission Command is that  usually,  the  person  best  placed to make timely decisions is the one doing the job. A brief analysis of history will show that mission command has and does win wars, but only if the principles are practiced in peacetime too. It is not easy, and will require investment in our junior leaders and increased agility from our senior leaders moving forward.

There is no prescription and no endorsed leadership style – our health leaders will need to  adapt, frequently, and sometimes outside of their comfort zone. It is a skill that requires investment and often years of practice. Leadership is hard to get right – it is difficult to be all things to all people when the lens through which we view leadership  is  subjective  and we each have our own opinion of  ‘what  right  looks like’ when it comes to health leadership. But we can and should do more to improve – so as not to  fail our junior leaders of the future if/when the flag goes up. Encountering this reality for the first time in “the face of battle” will likely have dire consequences. Preparation for the inevitable demands of this environment should, therefore, start now and, arguably, be built into the “DNA” of our peacetime health systems.

Kelly Dunne, CSC, BA, MHM, MMDS, is a Lieutenant Colonel working in the Directorate of Army Health as part of Army Headquarters. She is passionate about mentoring junior leaders, the delivery of combat healthcare to Army, and ab-initio training.

Corresponding author name: Kelly Dunne and Steve Adamson

Corresponding author email: [email protected]

Hearing loss in the Australian Defence Forces

Dr david sly 1 , professor gary rance, professor stephen o’leary.

1 Ear Science Institute Australia, Swinburne University of Technology, The University of Melbourne, Perth, Australia

Hearing loss is the most prevalent health problem of returned soldiers, with over 30% of soldiers suffering permanent hearing damage.

When there is a potential hearing loss on the battlefield, there is currently no way to quickly confirm this, placing soldiers and crew at risk due to lost situational awareness. There is also no current drug treatment for hearing loss.

Recently there has been a paradigm shift in the laboratory and clinical understanding of the onset and progression of hearing loss due to noise exposure. Our new understanding of the ‘hidden hearing loss’ due to damage to the nerves in the inner ear suggests that hearing loss may be well advanced before the standard hearing test (i.e. the audiogram) used for decades in military and other populations detects any deficits. It also suggests new drug treatments targeting this nerve loss may be more achievable than previously thought.

Here we outline recent studies by our group and others indicating that new devices, new tests and new drug therapeutics are needed and on the foreseeable horizon for detection and mitigation of hearing loss in military and civilian populations. We describe the results of our studies of mobile hearing test devices in and hidden hearing loss in soldiers from Victoria and Simpson barracks. We also outline our translational studies into nerve growth factors as a possible drug treatment for noise-induced hearing loss and recent clinical trials of these drugs for treating hearing loss.

Dr Sly is Chief Operating Officer – Research at the Ear Science Institute Australia. He is also Senior Lecturer in Clinical Technologies, Swinburne University of Technology and holds an   honorary   appointment at the Department of Otolaryngology, University of Melbourne and Royal Victorian Eye and Ear Hospital. Dr Sly’s research interests are in hearing loss, hearing diagnostics, inner ear protection and cochlear implants.

Corresponding author name: David Sly

Corresponding author email: [email protected]

Heat stress management in the Australian Army: Enhancing capability through improved policy and a Heat Stress Management Tool (HSMT)

Ms alison fogarty 2 , ltcol sandy hedger 1 , dr sean notley 2.

• Australian Army, Canberra, Australia
• Defence Science and Technology Group, Melbourne, Australia

Lieutenant Colonel Sandy Hedger is a General Service Officer in the Royal Australian Army Medical Corps. She is currently posted to the Directorate of Army Health. Ms Alison Fogarty and Dr Sean Notley are Defence Human Performance Scientists. Their area of expertise is optimising safe work in extreme environments.

High Tech Wars: Emerging Threats to the Reproductive Health of Military Members and Veterans

Dr rachelle warner 1,2 , associate professor susan neuhaus 1 , dr jodie avery 1,2 , professor michael davies 1,2.

War and conflict constantly evolve. However, war is about much more than combat or the technologies we fight with, and focusing on weaponry may blind us to the broader social, political and cultural context and effects of these technologies on the humans who constitute our militaries. The potential of exposing military members to fertility compromise is both a physical and a moral issue. Exposure to reproductive toxicants, side effects of protective equipment and medical prophylaxis, and the potential to weaponize biological or chemical substances that could cause infertility are issues that should be considered rigorously. This paper considers emerging threats, both current and futuristic, to the reproductive health of military veterans and the implications for preventative medicine policy.

Rachelle Bonner joined the public service as a multitasking ninja, and that pretty much describes her career to date. She has deployed into the Middle East, Iraq and the Philippines, and has some experience in international and operations law, including undertaking health threat risk assessments of new weaponry. Fuelled mostly by caffeine and dogs, she is also a certified geek with a PhD in Reproductive Medicine, designs and makes wedding accessories for pets and cosplay props, and is an expert procrasti- baker.

Corresponding author email: rachelle.war [email protected]

How biofeedback technologies are being used within XR systems for training and/or educational applications

Associate professor karen blackmore 1 , mr benjamin krynski 2 , dr shamus smith 3.

• University of Newcastle , Newcastle, Australia
• Real Response, St Kilda, Australia, 3Griffith University, Brisbane, Australia

Introduction

Augmented Reality (AR), Virtual Reality (VR) and Mixed Reality (MR), or inclusive as Extended Reality (XR), describe immersive technologies that can merge the physical and virtual worlds. Physiological measures provide a quantitative evaluation of user response to certain stimuli in these computer- generated synthetic environments, or “virtual environments”,  and  can  provide  a  feedback  loop to significantly improve user experience and performance in such environments.

This presentation will explore how biofeedback technologies  and  approaches  are  being  used within AI enabled XR systems for training and/or educational applications. The biosignals explored provide insights into physiological and/or emotional processes in users/participants. The presentation will discuss how biometric feedback is used in XR technologies, with a focus on specific biofeedback sensor use in the context of simulation training and education, concluding with recommendations about how biometrics can appropriately be used in XR synthetic training systems.

A systematic review was conducted following the PRISMA guidelines looking at ‘What biofeedback technologies and approaches are being used within AI enabled XR systems for training and/or educational applications?’. An initial scoping search of existing research revealed many theoretical and untested-on- human concepts and approaches. From this scoping search, the key inclusion criteria for this literature review were defined. Of importance is that the included biofeedback enabled systems are validated on real human participants and therefore provide actual experiment results. A total of 803 studies were identified for screening and post evaluation, 48 met the search criteria and were included for analysis.

A total of 11 different biosignals were captured across the different studies. When considering the use of biosignals by primary measure, stress made use of the most individual biosignal types. Electrodermal activity, also referred to as galvanic skin response (GSR), was the most widely used biosignal, with most application in the measurement of stress, cognitive load, and emotions. Eye tracking was also frequently used in the measurement of stress, cognitive load, and attention.

A total of 42 different biosensor devices were identified in the resultant studies. These sensors covered a range of different implementation approaches, from purpose-built integrations, experimental lab setups, and implementations using commercial off-the-shelf equipment.

Each of the biosignals in the studies enables biofeedback mechanisms and can form the basis of AI/machine learning approaches to remove artifacts, process signals into usable data, and/or identify patterns. The biosignals themselves provide insights into physiological and/or emotional processes in users/participants.

Conclusion & recommendations

This paper summarises current research implementing XR technologies in combination with biofeedback and AI approaches, with a focus on the specific biofeedback sensor use in the context of simulation training or education contexts. Several important recommendations emerge from the research, including:

A minimum of two biosignals should be captured where possible, and thus devices that capture multiple biosignals are preferred.

The use of simpler sensor technologies and associated measures is preferred to limit the impact of movement artifacts and maximise reliability of data. Wristband devices present as particularly useful devices for biofeedback implementations in XR simulation training applications.

Given the dynamic innovation occurring in biosensing technology, implementations of biofeedback enabled XR synthetic training systems should focus on identifying appropriate biosignals and actuation of biofeedback in virtual environments and tasks. A “plug and play” approach to sensing technology is recommended, allowing sensing technologies to be updated/upgraded overtime while the fundamental benefits of the biofeedback implementation are retained. As such, details regarding integration of biosensing technologies with synthetic environment development tools (ie. game engines) should be a focus of development approaches.

Ben is the Co-Founder & Director of Future Projects at Real Response, he is also a Registered Paramedic with 15+ years of domestic and international pre- hospital experience. He has a strong passion  for human factors and searching for the most impactful solutions for critical skill training. He now leads the Serious Games team at Real Response working on cutting-edge technologies utilising Extended Reality (XR) systems, biometrics and Artificial intelligence (AI). Ben lives in Sydney and maintains his clinical hours with NSW Ambulance when not focused on researching, developing and testing new training technologies.

Corresponding author name: Benjamin Krynski

Corresponding author email: [email protected]

I’m old, not dead! Caring for our nation’s older veterans

Mr nathan klinge 1.

1 RSL Care SA, Australia

993,000 Australians served in the military forces during WW2 representing around 14% of the total population at the time, whereas only just under 60,000 Australians served in the Vietnam War, representing well under 1%.

Veterans from the Vietnam era are now moving through their later years into aged care, where veterans as a whole represent an ever-diminishing population in aged care as the WWII numbers dwindle. The impact of this will see a much-reduced capacity within the residential aged care sector to respond to the cultural and social care needs of veterans, given it is likely in the years ahead a provider operating a 100+ bed facility may only have one lone war veteran in their care.

Previous generations of veterans from WW1 and WWII have held a much more prominent and visible place within our aged sector, which in those times created more opportunities for aged care providers to facilitate appropriate care outcomes for veterans and their peers. So, what will happen to those from the Vietnam War era and beyond?

While there has been much focus in recent years on the transitional requirements of younger veterans leaving the ADF, little attention has been placed on the ‘transition’ of Vietnam Veterans as they move through into the later years of their life.

At RSL Care SA we believe that ageing is simply another of life’s transitions, and like all transitions, if its managed appropriately it can be done well and to the veteran’s advantage.

So what do we know?

When a veteran has a complex mental health background, their interaction with caregivers and services within the aged care industry may be adversely affected. Furthermore, older veterans with complex physical and mental health conditions have additional care requirements, and these cannot always be met within the existing skillsets and experiences of the aged care industry. In particular:

Post Traumatic Stress Disorder (PTSD) and impact on early ageing – People with PTSD can find that the ageing process exacerbates pre-existing PTSD symptoms. Medical illness and reduced physical ability may mean the individual is unable to manage symptoms using previous coping strategies, and concurrently their retirement from work and fewer family responsibilities can mean fewer distractions from their PTSD symptoms.

Social isolation – Experiences of social isolation throughout a veteran’s life can pose ongoing health and wellbeing risks for them as they age, particularly for those who live alone, have smaller social networks, and who have fewer opportunities to engage in meaningful social activities.

Dementia – Veterans with PTSD or who have been wounded in combat have significantly higher risk of developing dementia, when compared with groups without PTSD or who were not wounded in combat.

Veteran culture. In the past the aged care sector was quite well-informed with respect to the idiosyncrasies of veteran culture, partly due to the sheer weight of numbers that veterans held in the aged care community, but also because many of the caregivers themselves had direct family links to the WW1 or WWII veteran communities (or both). Increasingly however the veteran population represents a much smaller percentage of the aged care community and many of the care providers themselves come from overseas, meaning that the industry has largely lost its intrinsic capacity to meet the culture needs of our older veterans.

This presentation discusses the aged care sector’s capacity to provide culturally safe and person- centred care for veterans.

Suggestions will be provided to enable ESOs and other members of the veteran community to strengthen the aged care sector’s ability to better cope with the changing needs of our emerging and ageing veteran populations.

With over 23 years of full-time military experience, and now being employed as a CEO in aged care, Nathan has served in a variety of leadership, management and training positions. Nathan has served as a Director on a variety of not-for-profit boards, and he represents veteran health issues on South Australia’s Veterans Advisory Council and on SA Health’s Veterans Health Advisory Council. Nathan is also involved in a number of committees and working groups at the national level focused on improving outcomes for consumers in residential care.

Nathan is a passionate advocate of veteran health and wellbeing issues, particularly concerning older veterans and veterans who are homeless.

Nathan has three university-aged daughters, and for some reason he still seems to be mowing his ex-wife’s lawn.

Implementation of endorsed TCCC Medical Practitioner proficiency: Empowering Army clinical interventions from point of injury through evacuation to treatment facilities

Warrant officer class one nathan grumley 1.

1  Australian Defence Force, Australia

The primary intent of TCCC is to reduce preventable combat death through a means that enables mission success while providing the best possible care at the correct time to promote a battlefield casualties best chance of survival. The implementation of TCCC concepts has application in prehospital casualties beyond combat trauma, particularly with respect to treatment priorities, procedures and management of evacuation care goals.

Contemporary military forces have implemented widespread TCCC at the basic level, which the ADF has included as a tenet of combat behaviours within foundation warfighting.  The  Army  School of Health (ASH) has developed and implemented a training continuum for all health care providers to adopt the TCCC Medical Provider proficiency, which incorporates further procedural and clinical interactions to support tactical field care and evacuation to a destination treatment facility.

The implementation of the TCCC (MP) as endorsed by Director of Army Health, enables enhanced provision of care in austere and remote environments to include haemorrhage control, airway management, fluid resuscitation, analgesia, antibiotics and high impact clinical techniques as important adjuncts toward providing the best possible care in an environment characterised by limited resources and prolonged evacuation timelines. A session presented by the Senior Medical Technicians of the Health Battalions will outline the developmental background, endorsed deliverables and the implementation of the TCCC (MP) into training establishment and deployable training programs.

Integrated Aeromedical Support to the US Marine Corps in the Northern Territory

Mr mick frewen , dr paul hanley.

CareFlight will present on six years of fully integrated aeromedical support to the United States Marine Corps (USMC) in the Northern Territory.

CareFlight has been providing contracted aeromedical support to the USMC exercises and training  activities  in  the  Northern  Territory  for the last six years, across some of the most remote military training areas in the country. The support consists of a fully integrated aviation and medical service which has been delivered over both fixed wing and rotary wing platforms during that time to meet the USMC changing needs.

CareFlight will share its insights into aspects of contract management of aeromedical services and the advantages of being a true partner in the contract development and service design.

We will share lessons learnt from the contract that demonstrate innovation in the service delivery model and supply chain.

We will discuss the clinical governance framework in the Northern Territory and how CareFlight provided seamless integration of the USMC service into the Territory health system.

ADM extract March 15th 2022 US Marines Arrive in Darwin:

“Commanding Officer Headquarters Northern Command,  Colonel  Marcus  Constable  said  that the rotation would build on the  success  of  last year’s deployment which coincided with the 70th anniversary of the Australia, New Zealand, and United States (ANZUS) treaty.

“Australia’s alliance with the United States is our most important defence relationship and is central to Australia’s strategic and security arrangements,” he said.

“The MRF-D is a key way we increase regional cooperation with partners in the Indo Pacific and deepen interoperability between the ADF and the US Marine Corps.”

“Together we conduct a comprehensive range of training activities including humanitarian assistance, security operations and high-end live fire exercises. These better position our forces to respond to crises in the region,” Colonel Constable said.

CareFlight Background

As a veteran led for-purpose organisation CareFlight has long history of delivering critical Aeromedical services to the ADF and its allies such as the United States Marine Corps (USMC) and various State and Federal Police forces CareFlight is Australia’s only fully integrated provider of aeromedical and healthcare solutions across clinical services, helicopters, jets, turboprop aircraft and ground transport solutions. Our experience and depth are built on our national Clinical Governance and a depth of experience delivering services and training in every state and territory in Australia. We can tailor solutions to meet the most complex clinical and aeromedical requirements, evidenced by over 36 years’ experience supporting Government and Corporate clients ensuring they get the right support first time, every time.

Mick has 13+ years’ experience managing aeromedical retrieval services and large-scale evacuation capabilities utilising commercial aviation capabilities across the Asia Pacific Region. Mick commenced his career in the military, serving for 20 years in the army in Commando and SAS roles, utilising military aviation assets on operational deployments; retiring with the rank Lieutenant Colonel. Mick’s demonstrated experience in leading organisations in challenging commercial and military roles, combined with his experience in and knowledge of the emergency medical retrieval sector, make him eminently well qualified to lead CareFlight.

Dr Paul Hanley MB.Bs, B.Sc, FACEM, FRACGP.

Dr Paul Hanley is an Emergency Physician at Nepean Hospital and a General Practitioner Specialist Doctor.

Dr Hanley is a Retrieval Specialist whom  has worked for RFDS, Sydney HEMs and currently one of the Retrieval and Pre-Hospital Specialists with the Careflight Rapid Response Helicopter Service at Westmead. He has deployed on Humanitarian Mission to Bangladesh and Dr Hanley is the currently the Medical Director for Careflight- Special Projects. He is a Major. in the Royal Australian Army Medical Corps (RAAMC) and he has deployed to Bushfire Assist, Covid 19 Assist to North West Regional Hospital in Burnie, TAS and to Afghanistan.

Corresponding author name: Mick Frewen

Corresponding author email: [email protected]

Introducing Defence’s new $765m Health Knowledge Management (HKM) System

Mr richard wallace 1.

1   Department Of Defence, Canberra, Australia

No consent to publish abstract The panel will consist of:

• Brigadier Isaac Seidel, Director General, Operational Health, Joint Health Command
• Darrell Duncan, Director Strategic Clinical Assurance, Joint Health Command
• Nelson Bates, Assistant Secretary, Joint Integrated Capabilities Branch

Managing Japanese encephalitis risk in New South Wales and implications for the ADF

Dr paul byleveld 1.

1 NSW Health, St Leonards, Australia

Colonel Byleveld has served as an Army Reserve member of the Royal Australian Army Medical Corps for 30 years. He is currently posted to the Directorate of Army Health, Army Headquarters as Clinical Advisor NSW Region. He has operational experience as an Environmental Health Officer in Papua New Guinea, East Timor, and Indonesia (in post-tsunami Banda Aceh). Colonel Byleveld is an ADF faculty member for the Uniformed Services University of the Health Sciences distance learning program in Global Health and Global Health Engagement.

Dr Byleveld is currently Acting Director of the Central Coast Public Health Unit. During 2020-2021, Dr Byleveld was a team leader in the NSW Public Health Emergency Operations Centre and the COVID-19 Public Health Response Branch. His substantive role is Manager Water Unit, Environmental Health Branch, New South Wales Ministry of Health.

Dr Byleveld is a specialist in water, sanitation, hygiene, and public health. He has experience with the International Committee of the Red Cross, the Australian Government, and the United Nations High Commissioner for Refugees in humanitarian emergencies resulting from conflict, violence, natural disasters, and disease outbreaks. He has completed deployments in Africa, the Middle East, South Asia, Southeast Asia, and the Pacific.

Medical Aspects of the Non- combatant Evacuation Operation of Kabul, Afghanistan in August 2021

Dr steve adamson 1.

1 Department of Defence, Canberra, Australia

The recent evacuation of Australians (and Afghan citizens with Australian ties) during the fall of Kabul was one of the most complex Operations supported by the Australian Defence Force in recent memory. Integral to the success of the Operation was a range of operational health effects delivered by small teams of personnel from a variety of military and civilian backgrounds. Despite the significant risk, relentless tempo and multiple agencies involved, the Operation was deemed a resounding success, with 4100 people evacuated by Australian government agencies in a two week period.

This oral presentation will describe circumstances on the ground in Kabul and at Al Minhad Air Base in August 2021, and share observations that may be of interest to military medicine leaders and practitioners in other high tempo and complex settings. Lessons from the evacuation may assist in shaping a “pathway to the future” with a more apposite appreciation of military medical risk, an understanding of the unique strengths of medical practitioners, and an example of how technical control of health capabilities might be exercised in volatile and uncertain environments.

Lessons from the evacuation Operation include the importance of building resilience in teams, foundational skills and knowledge, trust, and a goal- focussed culture. The presentation will also highlight how the principles of “mission command”, well-used in combat operations, are indispensable to military medical practice in complex environments.

Lieutenant Colonel Adamson is the Senior Medical Officer at the Directorate of Army Health in Canberra. He is has served in a variety of roles as a doctor in the Australian Army including a three-year exchange posting in the United States. He has deployed to the Middle East on several occasions, most recently as the Senior Medical Advisor during the evacuation of Kabul in August 2021. He studied Medicine at the University of Queensland and is a Fellow of the Royal Australian College of General Practitioners.

Corresponding author name: Steven Adamson

Corresponding author email: [email protected]

Medical aspects of the war in Ukraine: An analysis of information from open sources

Colonel anthony chambers 1.

1 Headquarters 17 Sustainment Brigade, Sydney, Australia

On 24 February 2022, Russian military forces invaded the Ukraine. This was a major escalation of the armed conflict between these two states that began with the annexation of Crimea by Russia in 2014.

As at 29 June it has been estimated that the Ukraine military have sustained more than 10,000 killed and 30,000 wounded personnel. In this same period it is estimated that the Russian military have sustained 16,000 killed with an unknown number of wounded.

The civilian population of the Ukraine has also been heavily affected by the invasion with the United Nations estimating that 4,731 have been killed and 5,900 wounded in the conflict as at 26 June, with 7.1 million people internally displaced and 7.3 million refugees leaving the country.

The Ukrainian civilian health system has been placed under overwhelming pressure due to the number of civilian and military casualties, and numerous attacks affecting civilian health assets where 76 people have died and 59 have been injured in 295 separate incidents up to 15 June.

Information available from publicly accessible sources including the United Nations, World Health Organization, United States and United Kingdom government and non-government  agencies, Medline, Google Scholar, medical journals, media organisations and investigative journalism groups was collected and analysed. Information relevant to the medical aspects of the conflict including casualty numbers and rates, types and patterns of injury, battle versus non-battle injuries, medical support to military forces and the civilian population, disease threats, and effects on  the  existing  Ukrainian health infrastructure was identified and  collated. The  collected  information  was  analysed  to  create a picture of the medical aspects of the war, and to identify learning points for ADF health services.

Colonel Chambers is currently the Director of Clinical Services at Headquarters 17 Sustainment Brigade. He has served in multiple command appointments including Commanding Officer 3rd Health Support Battalion from 2018 to 2020. He has seen operational service in Timor Leste, Bougainville, disaster response to the tsunami in Indonesia, Iraq, Afghanistan and Ukraine. In his civilian role he is Head of General Surgery at St Vincent’s Hospital Sydney and Senior Lecturer at UNSW Sydney.

Corresponding author name: Anthony J. Chambers

Corresponding author email: [email protected]

Medical lessons from the Falklands campaign: A case study of minimum, better, best

Dr steve adamson 2 , major nick alexander 1.

• 1st Health Battalion, Holtze, Australia
• Directorate of Army Health – AHQ, Canberra, Australia

‘In these days of technical elaboration and conspicuous consumption it is chastening, and necessary, to be reminded of what can be achieved by knowledgeable cutting of corners, which can perhaps be more acceptably described as concentrating on essentials when dealing with fit young men.’

• S. London, FRCS – 1983

The geostrategic picture in the Indo-Pacific is changing, and the risk of near-peer conflict in our region increasing. As military health practitioners, we face these strategic circumstances with a major capability acquisition based on  decisions made well over a decade ago when small wars and counter-insurgency were the principal war fighting paradigm. We are grappling with a pivot away from delivering health support in secure, low intensity conflict to volatile liminal zones that require a truly joint approach; and a pervading mindset that strives for gold standard care in non-gold standard environments.

At times of great change, it is easy to think the problems we are facing are unprecedented. Rarely however is this the case. As GEN (retd.) James Mattis said;

‘Ultimately a real understanding of history means we face nothing new under the sun.’

This presentation will use the case study of the British Armed Forces campaign in the Falkland Islands in 1982 to describe previous solutions to current problems in the delivery of littoral and sea- based health care against a sophisticated enemy. It will explore the constraints we may be generating with developing littoral force doctrine and clinical policy framework—constraints that may limit our ability to support large scale manoeuvre forces in a near-peer warfighting environment. It will make recommendations regarding the need for a different approach to risk in clinical governance, capability acquisition and training, to better position us for success in the likely austerity of future combat.

Major Alexander B. Physio, Spec. Cert. Clin. Leadership, Grad. Dip. Pain Mgt

Major Alexander is currently the Officer Commanding Operational Support Company, 1 HB. He was appointed to the RAAMC in 2008 as a Physiotherapy Officer and division transferred to GSO RAAMC in 2018. He has completed postings within 1 HSB, 2 GHB, 1 CHB, JHC HQ and 1 HB across clinical, staff and command appointments.

Lieutenant Colonel Adamson, CSM B. Sc, MBBS, FRACGP

Corresponding author name: Nick Alexander

Corresponding author email: [email protected]

Military neurosurgery and the proposed deployable ADF joint Role 3 capability – a gap analysis.

Associate professor andrew davidson 1,2 , sqnldr rondhir jithoo 3 , major paul smith 4 , major david walker 5.

• Royal Australian Navy, Melbourne, Australia
• Royal Melbourne Hospital, Melbourne, Australia
• Royal Australian Air Force, Melbourne, Australia
• Royal Australian Army Medical Corps, Melbourne, Australia
• Royal Australian Army Medical Corps, Brisbane, Australia

Over the past 2 decades the Australian  Defence Force (ADF) has successfully deployed Role 2E medical capability on operations overseas, and has contributed specialist surgical teams to coalition Role 3 medical facilities, but has never been called upon to provide a stand-alone deployable joint Role 3 capability. In 2019, Joint Health Command (JHC) published a Feasibility Study, identifying that there was a “military and clinical need for a joint Role 3 capability”. A deployable ADF Role 3 capability will require Neurosurgery as a core specialist area.

More recently, between November 2020  and November 2021, four Australian Neurosurgeons deployed with an AUS Surgical Team  to  the  US Army’s Role 3 Hospital at BDSC, Iraq as part of the Combined Joint Task Force – Operating Inherent Resolve (CJTF-OIR).

A ‘gap analysis’ was performed, exploring the potential for the ADF to provide neurosurgical capability in support of a proposed ADF joint Role 3 capability.

As part of the analysis, the authors: 1)  identify the current state of ADF Neurosurgery, 2) analyse the JHC report on the feasibility of developing an ADF joint Role 3 capability, 3) discuss the gap between the current state of Neurosurgery  within the ADF and the required deployable Neurosurgery capability, and 4) propose strategies for closing the gap between current ADF Neurosurgical capability and the requirement to meet the proposed joint Role 3 capability.

Although the current cohort of ADF Neurosurgeons are able to meet the capability requirements for a short-term operational Role 3 deployment, there are several areas that need to be addressed if the ADF is to provide a sustainable Neurosurgical capability to the proposed ADF joint Role 3 capability. The authors identify several important capability  requirements as part of the “Raise, Train, Sustain” model for providing military capability. These strategies align with the Australian government’s  objectives to enhance Defence’s posture and partnerships in the region, and to provide health capabilities that ensure that joint health elements are able to meet Government direction and advance Australian’s strategic interests by shaping Australia’s strategic environment, deterring actions against Australia’s interests, and responding to credible military force when required.

The JHC Feasibility Study clearly determined that there is a military and clinical need for an ADF joint Role  3  capability.  A  “gap  analysis”  has  identified a  performance  gap  in  the  areas  of  specialist health workforce recruitment, skills acquisition & maintenance, and deployment opportunities & career progression for Role 3 specialists that will need to be addressed in order to meet the ADF’s need for a deployable joint Role 3 neurosurgical capability.

Associate Professor Andrew S Davidson (MB BS, MS, PhD, FRACS) is an academic neurosurgeon at the Peter MacCallum Cancer Centre, Royal Melbourne Hospital, and Melbourne Private Hospital. He is the neurosurgical lead for the Victorian Gamma Knife Centre at Peter Mac. His clinical interests include the multidisciplinary management of brain tumours, pituitary and skull base surgery (including minimally invasive and endoscopic surgery), neurotrauma, cerebrovascular surgery, and spine surgery.

Associate Professor Davidson holds the rank of Surgeon Lieutenant Commander in the Royal Australian Navy. LCDR Davidson has undertaken operation service in Bougainville and East Timor, and recently completed a deployment to the Combined Joint Task Force – OIR Role 3 Hospital in the Middle East, where he was awarded the ADF Operational Service Medal. He continues to serve as Assistant Professional Liaison Officer (Surgeons) and as a simulation instructor for the Australian Defence Force.

Corresponding author name: Andrew S Davidson

Corresponding author email: Andr [email protected]

Moral Injury and Pastoral Narrative Disclosure: An Intervention Strategy for Chaplains to Assist the Rehabilitation of Australian Veterans

Chaplain timothy hodgson 3,4 , associate professor lindsay b. carey 1,2,3.

1 School of Psychology and Public Health, La Trobe University, Melbourne, Australia

2 Institute of Ethics and Society, The University of Notre Dame, Australia

3 Joint Health Command, Australian Defence Force, Campbell Park, Canberra, Australia

4 School of Historical & Philosophical Inquirey, University of Queensland, Lucia, Australia

Internationally Moral Injury (MI) is an increasingly recognised  and  widespread  syndrome  (Koenig  & Al Zaben 2021). The Australian Defence  Force (ADF) defines MI as ‘a trauma related syndrome caused by the physical, psychological, social and spiritual impact of grievous moral transgressions, or violations, of an individual’s deeply held moral beliefs and/or ethical standards’ (ADF, 2021). Core symptoms  commonly identifiable are: (a) shame, (b) guilt, (c) a loss of trust in self, others, and/or transcendental/ultimate beings, and (d) spiritual/ existential conflict including an ontological loss of meaning in life. Secondary symptomatic features include (a) depression, (b) anxiety, (c) anger, (d) re- experiencing the moral conflict, (e) social problems, (f) relationship issues, and ultimately (g) self-harm.

Qualitative and quantitative research previously presented at AMMA (which was bestowed the Weary Dunlop Award 2019), confirmed  the  presence of MI among the majority of interviewed and surveyed Australian veterans (Hodgson & Carey, 2019; Hodgson et al  2021; 2022). The  research also highlighted the potential rehabilitation role of chaplains for addressing veteran MI (Carey, Hodgson, et al. 2016; Hodgson & Carey, 2017; Carey & Hodgson, 2018).

This paper will present further developments since AMMA 2019, with regard to the initiation of a novel and proactive systematic chaplaincy rehabilitation program for ADF veterans experiencing moral injury.

Based on Australian and international MI research, a unique eight-stage pastoral care rehabilitation program, called ‘Pastoral Narrative Disclosure’ for Moral Injury (PND-MI), is being developed and trialled for Australian chaplains to assist the care of veterans. An overview of both Australian MI research and the eight-stage PND-MI chaplaincy program will be presented.

The PND-MI strategy is designed to be an empirically based program to proactively assist chaplains to be competent in understanding MI and to enable chaplains to address MI among veterans, with the ultimate aim to improve their well-being and avert veteran suicide.

Chaplain (WGCDR) Dr. Lindsay Carey, MAppSc, Ph.D., RAAFSR, is an Associate Professor (Adjunct) with the School of Psychology and Public Health, La Trobe University, Melbourne, and Associate-Professor (Adjunct) with the Institute of Ethics and Society, University of Notre Dame, Australia. A part-time RAAF Chaplain for over 20 years, he is currently the Senior Research  Chaplain with Joint Health Command, researching veteran well-being, and is author of multiple publications regarding moral injury. Associate Professor. Carey was a co-recipient of the ‘Edward Weary Dunlop Award’ for 2019 by AMMA [along with Chaplain (SQNLDR) Dr. Timothy Hodgson], for their exploratory research into Moral Injury and its effects upon the well-being of military veterans. Biographical Details: https://scholars.latrobe.edu. au/lbcarey

Chaplain (SQNDLR) Dr. Timothy Hodgson, M.Int.Sec, MTh, PhD., is a RAAF Chaplain and Honorary Scholar with the University of Queensland. He provides advice and research support on issues relating to spiritual health and well-being for ADF Joint Health Command – particularly with regard to moral injury. Dr. Hodgson has served in the military for over 15 years and was co-awarded the ‘Edward Weary Dunlop Award’ for 2019 by AMMA for his exploratory research into moral injury and its effects upon the well-being of military veterans.

Corresponding author name: Lindsay B. Carey

Corresponding author email: [email protected]

Musculoskeletal complaint epidemiology in Australian elite military trainees

Lieutenant joanne stannard , capt lisa wolski, dr liam toohey, alison fogarty, dr michael drew.

1 Australian Army, Adelaide, Australia

Lieutenant Stannard is an ARES physiotherapist and PhD candidate at Edith Cowan University. She is a Sports and Exercise physiotherapist and has worked in several health centres across Australia over the last ten years. Lieutenant Stannard is interested in human performance optimisation and injury prevention in the military, with her thesis investigating musculoskeletal injury epidemiology and injury reporting behaviours in combat populations.

Corresponding author name: Joanne Stannard

Corresponding author email: [email protected]

Navigating military and civilian systems of care: Complex needs and care coordination

Dr angela maguire 1,2 , ms julieann keyser 1 ,ms kelly brown 1,2 , professor daniel kivlahan 1,3 , dr madeline romaniuk 1,2 , dr ian gardner 1 ms miriam dwyer 1,2.

• Gallipoli Medical Research Foundation, Greenslopes, Australia
• The University of Queensland, St Lucia, Australia,
• University of Washington, Seattle, USA

Dr Angela Maguire leads the Military Families research stream at Gallipoli Medical Research Foundation (GMRF). She is a member of the Australian Psychological Society (MAPS) and a Fellow of the College of Clinical Psychologists (FCCLP). She holds an adjunct Senior Fellow position with the University of Queensland, Faculty of Medicine. Dr Maguire has held research, teaching, clinical, and administrative roles across the university and public health sectors, and has provided consultancy services to the private and not-for-profit sectors. Her academic work has focused on human learning and memory; and more recently, military families. Her clinical work has focused on evidence-based intervention for people with complex needs and risky behaviours, particularly in the area of complex trauma. Dr Maguire has served on several advisory committees dedicated to aligning clinical practice, education, and research with health service priorities and population needs. She has considerable experience developing business case applications to support health service policy and planning, service (re)design, implementation, and evaluation.

Corresponding author name: Angela Maguire

Corresponding author email: [email protected]

No longer fixed in thought and location: mission focussed profiles for Army Role 1

Mr trent kirk 1 , mr richard niessl, dr peter zimmermann, mr nicholas alexander, mr ruan blignaut.

Army Health Services (AHS) has long grappled philosophically with the enduring friction of providing high value care that enables manoeuvre mission success. This challenge has become ever more pressing in the rapidly changing operational and strategic environment. Along with the rest of the Army, AHS are engaged in significant force design and modernisation initiatives to meet the challenges of Ready Now, Future Ready. This article explores the resurgence of Role 1 concepts and the current trials being undertaken within AHS to ensure we are positioned to provide the right care, at the right place, at the right time on the battlefield.

What does Role 1 need to look like in order to survive and thrive in a mid-high intensity warfighting environment? How does it mitigate against the threats posed by a sophisticated enemy on one day, while still being able to pivot to other operational mission sets AHS may be called upon to fulfil? The principles of health support have long guided our thinking to meaningful capability effects, in particular: conformity; flexibility; and protection and mobility.

We argue that the Role 1 solution cannot be the standardised one-size fits all capability it has become; instead, it needs to be a scalable mission specific entity that gives options to commanders. We propose four Role 1 mission profiles; Light, Manoeuvre, Heavy and Static. With options, a commander is able to manage the risk to people against the risk to mission. In this regard, AHS are enabling, rather than constraining, manoeuvre.

Throughout its history AHS has developed Role 1 solutions that met these mission requirements. Cycles of organisational amnesia  have  led  to these capabilities withering and disappearing. Acknowledging this capability gap for over a decade, 1 HB and its antecedent units have dabbled in concepts for Role 1 mobility without broad acceptance.

Recently there has been a resurgence of interest in Role 1 mobility by manoeuvre commanders. This has yielded dividends in redeveloping long forgotten capabilities. 1 CHB was able to revisit the concept and trial the tactical employment of R1 Manoeuvre (R1M) in support of the mechanised BG BOAR as part of EX KOOLENDONG 21; and during EX SOUTHERN JACKAROO, 11 Close Health Company, 2 HB delivered a mechanised R1M in support of the mechanised BG HEELER.

The mobility of the R1M at the A1 echelon enables it to  maintain  proximity  and  deliver  rapid  MO- led triage and optimisation for evacuation. Battle Groups are able to maintain combat tempo through shortened lines of evacuation and faster clinical decision making. This has been thoroughly tested in both simulated and NO DUFF situations.

Following this success, 1 and 2 HB, in collaboration with the 1st Brigade and 6 RAR have further developed the  tactical  and  clinical  employment of the R1M. This has been paired with conceptual development and testing of the R1 Light concept by 1 HB on OP RESOLUTE, and in support of other 1st Brigade littoral activities. The success has piqued the interest of Combat Brigades, FORCOMD and AHQ resulting in the development of an Army Land User Evaluation to be delivered in 2022.

To meet the challenges of the current and future operating environment Army’s Role 1 capability needs a shake up. Through projects like the R1M LUE and continued collaboration with manoeuvre commanders AHS can achieve our required enabling effects close to the fight, keeping patients in motion and getting them to the right place, for the right care at the right time.

Lieutenant Colonel Kirk is the CO of 1 HB. He has served within 1HB, 1 CSSB, DMO, JHC, 1 CHB, HQ

7 BDE, US Army Medical Department Center and School, CMA and HQ 1 BDE

Lieutenant Colonel Niessl is the CO of 6 RAR. He has served within 3 RAR, 4 RAR, 2 RAR, 9 RQR, ADFA and HQ 1 DIV. He has deployed on OP VISTA, TANAGER, CATALYST, ASTUTE and HIGHROAD.

Organisational Change Management Impacts on Emergency Services and Defence Interoperability – Towards Future High Risk Weather Seasons

Col toni bushby , dr david heslop , brig georgeina whelan 1.

1 Army, Campbell, Australia

The ACT Emergency Services Agency in collaboration with the Directorate of army Health and the UNSW is conducting a three year study to identify the various factors affecting the change management success across two areas (a) a multidisciplinary Emergency Services Agency and (b) a combined Emergency Services / Defence response to and recovery from natural disasters. This presentation will out line the work completed in the first year of the study. It is intended to follow up at subsequent AMMAs 2023 and 2004 with progress reports and study finding.

Brigadier Georgeina Whelan is a Reserve Project Officer for the Directorate of Army Health. She is also the Commissioner of the ACT Emergency Services Agency.

Colonel Toni Bushby is the Director of Army Health

Lieutenant Colonel David Heslop is a Reserve Medical Officer and an Associate Professor UNSW School of Population Medicine

Corresponding author name: Toni Bushby

Corresponding author email: T [email protected]

Pelvic health in female military personnel symposium: collaboratively mapping out an evidence-based pathway to the future

Dr simone o’shea 1.

1 Charles Sturt University, Albury, Australia

Background: As the proportion  of  women  within the Australian Defence Force continues to grow, unique gender specific health requirements across the broad spectrum of military contexts requires consideration. Pelvic health is a key area where the care and support needs  vary between sexes given differences in pelvic anatomy and function.  Despite a growing body of female military health research, a scoping review and gap analysis from 2019 identified that there were more gaps in evidence and a greater proportion of lower quality studies in the areas of female military pelvic and reproductive health. In addition, the vast majority of research has been undertaken in international contexts, predominantly the U.S. Armed Forces. In determining the policies, practices and services required to support and strengthen the pelvic health of female military personnel in the Australian Defence Force into the future, it is essential to bring together the best available evidence, knowledge of current practices and policies, understanding of service requirements and contexts, as well as and the overarching structural or organisation factors.

Aim: Therefore, the aim of this female pelvic health symposium is to comprehensively bring together Australian and international research, identify challenges and emerging issues, and collaboratively develop approaches to inform policies and practices that strengthen pelvic health, operational readiness, and occupational performance in female military personnel in the ADF

Simone has been a Physiotherapist for 22 years and is a lecturer in the Physiotherapy program at Charles Sturt University. She has clinical and research interests in women’s health and chronic health condition management. Since 2018 Simone has been leading a Defence Health Foundation funded project focused on female pelvic health in the Australian Defence Force.

Corresponding author name: Simone O’Shea

Corresponding author email: [email protected]

Plans are useless, planning is indispensable – resuscitating the art of health planning

Mr trent kirk 1 , major peter zimmermann 1 , major nick alexander 1.

1 1st Health Battalion, Holtze, Australia

‘Fools learn by their experience – I prefer to learn by the experience of others’

Otto von Bismarck

Health planning is so much more than conducting a casualty calculator, putting a start state of health assets on a map and then panicking once casualties start mounting because the plan hasn’t   survived first contact. As with all complex endeavours health planning takes practice, but it also requires the pragmatic application of the principles of health support and frankly – junior Army officers don’t do it enough.

We have lapsed into a false paradigm where our belief in the primary value proposition for junior health officers is the day to day Command, Lead and Manage functions of the Garrison environment. We have forgotten that arguably their most critical deployable function will be one of planning. This lack of exposure to and emphasis on realistic health planning for operations at the Lieutenant and Captain level is setting our people up to fail when they transition into deliberate planning roles at the Combat Brigade and Divisional level. This generates risk for the development of inadequate plans, and health planners who are not agile enough to adapt to the fog of war.

This presentation will explore a recent complex multinational exercise, undertaken amidst the COVID pandemic in the most remote and challenging training area in Australia. This forced health planners to develop novel solutions to enable the Commander to balance risk to people with risk to mission. The deliberate health planning process  ensured  both real time and scenario health support requirements were met and junior health planners were enabled and engaged in the process. This facilitated a true understanding of the principles  of  health  support as guiding markers to the art of health planning. Finally it will make recommendations on how  we can enhance the focus on deliberate health planning skills within our school houses and at Unit level.

Major Alexander is the Officer Commanding Operational Support Company, 1 HB. He was appointed to the RAAMC in 2008 as a Physiotherapy Officer and division transferred to GSO RAAMC in 2018. He has completed postings within 1 HSB, 2 GHB, 1 CHB, JHC HQ and 1 HB across clinical, staff and command appointments.

Lieutenant Colonel Kirk is the Commanding Officer of the 1st Health Battalion. He has completed postings at the 1HB, 1 CSSB, DMO, JHC, 1 CHB, HQ 7 BDE, US Army Medical Department Center and School, CMA and HQ 1 BDE. Lieutenant Colonel Kirk completed Australian Command and Staff College in 2019 as a distinguished graduate and is a graduate of the United States Army Medical Strategic Leadership Program.

Major Zimmermann is the Senior Medical Officer of 1 HB. He was appointed to the RAANC in 2001 as a Nursing Officer. He subsequently completed his medical degree and transferred to the RAAMC as a Medical Officer. He has served with 8 CSSB, 1 HSB, 1 CSSB, 7 RAR, ASH, 1 CHB and 1 HB. He has performed numerous clinical, instructional, administrative and command roles.

PNG Defence Force’s Medical Response to Tari Hospital

Major bradley maniha 1.

1 PNG Defence FORCE, Papua New Guinea

A team of PNGDF medical personnels were deployed to assist Tari Hospital located in the Hela Province of PNG, on the 26th February 2018.This call for assistance was in response to 2 types of disasters (Man-made and Natural) that occurred one after the other.

Initially there was an earthquake measuring 7.5 magnitide on the Richter  scale  which  caused  alot of damages. There were a significant number of casualties due to trauma as a result of this natural event. Fierce ethnic clash erupted (man-made disaster) during this time which saw an exponential increase in nasty traumatic injuries  presenting  to the Tari Hospital.

PNGDF presence was a great relieve for the then under resourced Tari Hospital.

Dr Bradley Maniha:

I am a surgical Registrar with the PNGDF. I graduated from the university of PNG’s school of medicine & health sciences in 2010 before enlisting with the PNGDF in 2013 following my residency program.

I was the OC clinical Wing of the PNGDF military hospital for 5 years before embedding to the PNGDF special forces unit in preparation to delivering a safe environment for the hosting of the 2018 APEC SUMMIT in PNG. It was during this time (2018) when I was called up to lead a medical contingent to assist with disaster (earthquake + ethnic war).

Corresponding author name: Bradley Maniha

Corresponding author email: [email protected]

Pregnancy, birth and motherhood in the Australian Army: The experience of healthcare as a form of regulation of bodies and babies

Lieutenant colonel maureen montalban 1,2.

1 Australian Army, Canberra, Australia 2 The Australian National University, Canberra, Australia

The military is a predominantly male dominated organisation that has entrenched hierarchical and patriarchal norms. Since 1975, women have been allowed to continue active service in the Australian Defence Force during pregnancy and after the birth of a child; prior to this time, pregnancy was grounds for an automatic termination. My research explores what it means to serve in the Australian Army as a woman through a gender lens, overlaid during a specific time period of their service; that is, during pregnancy, birth and being a mother.

The basic entitlement to the range of medical services provided to members  of  the  Permanent  Forces is that which is equitable to Medicare under the provisions of the Health Insurance Act 1973. Due to the requirement to meet and maintain operational readiness standards, the range of and access to health care provided to ADF members will usually exceed that available through the public health care system. Additionally, in order to be fit to deploy and defend Australia and its national interest, there is an expectation upon entry into military service that an individual relinquishes some autonomy over their body. To what extent does this relinquishment extend to servicewomen during their pregnancy, labour and the post-natal period? Furthermore, what is the operational imperative to refer ADF servicewomen to private obstetric care (the standard model of care offered to ADF servicewoman at the time of my data collection)?

My research provides a platform for the stories of women who have given birth during their military service with the Australian Army and the doctors that have provided care to servicewomen during pregnancy and post-partum. It articulates the type of care received, why it was provided and received, and how the experience of healthcare within military service in the Australian Army is a form of regulation over women’s bodies.

Maureen is a military psychologist who has worked at the tactical, operational and strategic environment within the Australian Army, providing psychological advice and interventions to individuals, units and Commanders. She has done so within Australia and on operational deployments to Timor-Leste, the Solomon Islands and the Middle East.

Maureen is undertaking a part-time PhD at the National Centre for Epidemiology and Population Health, the Australian National University. She is examining gender culture in the Australian Army through an investigation of the experience of servicewomen during pregnancy, birth and motherhood. Her research investigates the  external  demands  faced by servicewoman who are mothers and how they internally make sense of this with respect to identity and role expectation. It also seeks to uncover how Australian Army servicewomen who are mothers attempt to manage the dilemma of serving two greedy institutions, whether this is in fact, an impossible dilemma.

Corresponding author name: Maureen Montalban Corresponding author email: [email protected]

Preventing the development or persistence of mental health problems in high risk occupations: An evidence-based approach

Professor jennifer wild 1.

1 Phoenix Australia – Centre for Posttraumatic Mental Health, Australia

Research shows that individuals regularly exposed to trauma are at elevated risk for developing psychiatric disorders, such as major depression, post-traumatic stress (PTSD), and substance use disorders. Episodes of mental ill health are costly to individuals, their families and society and can trigger physical health comorbidities. Notably traumatic stress increases risk for later cardiovascular problems and in some cases,  early   death.   Physical   health   problems can, of course, pre-date mental health problems increasing risk for their emergence. A challenge for the field is determining how to prevent or reduce psychopathology from developing for individuals who will knowingly face significant stressors in their line of work. In this talk, I will give an overview of the systematic research I’ve conducted with my team in the UK which has culminated in interventions demonstrated to reduce the incidence of PTSD and depression in at-risk occupations by over 70% and clinically significant sleep problems by almost 30%. The interventions target cognitive processes that predict and maintain common psychiatric disorders. I will also present findings of our latest evaluation of a brief intervention we developed for frontline healthcare workers. This was delivered by low intensity wellbeing coaches during the pandemic and was associated with a reliable recovery rate of 94% for PTSD and 65% for depression. I will then focus on lessons learned from this approach that could be applied to improving the mental health trajectories of military members throughout their service and as they transition to civilian roles.

Professor Jennifer Wild is the Professor of Military Mental Health at Phoenix Australia, University of Melbourne. She is a clinical psychologist and holds an appointment at the University of Oxford. She is an international expert on how to build resilience to stress and trauma, and on how to overcome post-traumatic stress disorder (PTSD). She has successfully helped hundreds of people to reclaim and transform their lives.

Corresponding author name: Jennifer Wild

Procoagulopathy of Trauma- A Gift or a Curse

Capt anthony holley 1.

1 Royal Australian Navy, Canberra, Australia

Trauma results in a variety of alterations to the haemostatic system that can lead to an increased risk of bleeding soon after injury and an increased risk of thrombosis later. Haemorrhage remains a leading cause of preventable death following trauma, with as many as 25% of these patients presenting with an established coagulopathy. Paradoxically survivors of trauma with massive haemorrhage may subsequently experience a potentially hypercoaguable state. The incidence of DVT associated with major trauma is variably reported as 1.8 to 58% and is subsequently complicated by pulmonary embolism in at least 2% of these individuals, with a fatality rate approaching 50% in some series. Importantly, pulmonary embolism is the third leading cause of death among patients who survive the first 24 hours after trauma. The acute coagulopathy of trauma appears to be independent of the classical “lethal” triad which is characterised by acidosis, hypothermia and dilution. Significantly patients presenting with coagulopathy have a mortality approaching 50%, but also have greater transfusion requirements, organ injury, septic complications and length of intensive care stay. The same is true of trauma patients developing venous thromboembolism in the post injury period. The pathophysiological mechanism accounting for the early onset coagulopathy appears to be hypoperfusion and  tissue  injury  resulting in the subsequent activation  of  hyperfibrinolysis and the protein C cascade. Several studies have demonstrated that severe trauma increases the levels of circulating procoagulant phospholipids, tissue factor–bearing microparticles, activated platelets and monocytes, potentially  resulting  in  the  activation of the coagulation and fibrinolytic systems. This hyperacute coagulation defect has only relatively recently been identified and therefore has been the focus of a myriad of management strategies to control massive haemorrhage. Systemic exposure or release into the vascular system of substances that activate the coagulation system (procoagulants) may have a role in consumptive coagulopathies and indeed subsequent thrombus formation. In light of the high incidence of thromboembolic disease in survivors of traumatic haemorrhage, it is important to consider the novel strategies to control haemorrhage and indeed the subsequent risk of thrombo-embolism..

Anthony is an intensivist at the Royal Brisbane and Women’s Hospital. He is an Associate Professor with the University of Queensland Medical School. Anthony is currently the ANZICS Immediate Past President and has served on the ANZICS Board and Executive since 2012. He is a senior examiner for the Fellowship of the College of Intensive Care Medicine of Australia and New Zealand. Anthony has authored eight book chapters and 53 peer reviewed publications. He is an EMST course director and senior instructor for BASIC. He is also a director of the Current Concepts in Critical Care Course and the Trauma Traps course. Anthony serves as a representative for the National Blood Authority Critical Care Group in developing the Australian Patient Blood Management Guidelines. He is a member of the National COVID-19 Clinical Evidence Taskforce  Steering Committee. Anthony is a current serving officer in the Royal Australian Navy, as the Director Navy Health Reserves. He has deployed on active service on multiple occasions, including several tours to Afghanistan, the Persian Gulf, border protection, four tours to Iraq, the 2020 Bushfires and is as the Senior Medical Officer for the Operation COVID Assist Joint Task Group 629.3.

Corresponding author name: Anthony Holley

Corresponding author email: [email protected]

Review of Humanitarian Guidelines to Ensure the Health and Well- being of Afghan Refugees on U.S. Military Bases

Dr lynn lieberman lawry 1.

1 Uniformed Services University, Bethesda, United States

Dr Lieberman Lawry is a physician, epidemiologist and biostatistician who has twenty-eight years of experience in humanitarian aid, disaster response, development and global health implementation and research. She spent 20 years as faculty at Brigham and Women’s Hospital, Harvard Medical School, and concurrently held  faculty  appointments  with the Department of International Health, Bloomberg School of Public Health, Johns Hopkins and Uniformed Services University of the Health Sciences where she is currently an Associate Professor in Preventive Medicine and Biostatistics. She has extensive experience in dozens countries coordinating the provision of aid, facilitating development, and conducting population-based studies in conflict and post-conflict settings. Her studies elucidate the needs of populations regarding human rights, healthcare access, disease prevalence, mental health and gender based violence – utilizing these data to improve policy to address global health needs in conflict and to better  understand  community  dynamics  that  lead to insecurity. She developed courses and teaches extensively at USUHS for in-resident and global health distance learning certificate students. In  addition, she developed courses through the Defense Institute of Medical Operations for teaching international militaries who will serve as Peacekeepers about the prevention of sexual exploitation and abuse.

Corresponding author name: Lynn Lieberman Lawry

Corresponding  author  email:   [email protected]

ROLE 2 FORWARD: A Critical Component of the Land-Based Trauma System

Nursing officer princess rull 1.

1 Adf, Enoggera, Australia

On 23 January 2019, Australia’s Chief of Army declared his intentions for the military to be ready now and future ready, consistent with its aim to operate on land, from the land and across all domains, including cyber, space, maritime and air. Being ready now insinuates conducting training, allowing preparation, providing education and being equipped and organised for the range of military tasks required for the Australian Government. Being future ready alludes to the modernising, adapting and transforming against emerging threats, geopolitical challenges and advances in technology. These intentions have particularly placed Army Health capabilities under scrutiny concerning ability to provide outcomes that align with Chief of Army’s intentions.

The purpose of this presentation is to highlight Army Health’s specific capability in the Role 2 Forward (R2F). This evolving Forward Resuscitation and Damage Control Surgery asset is designed to bring specialist-led  damage  control  intervention  closer to the point of wounding, and is currently under Command of 1 Surgical Company, 2 Health Battalion in Brisbane. This presentation will highlight R2F current capability and future direction and its potential contribution to the improvement of trauma care for battle casualties.

Through multiple internal and supporting Exercises, the 2HB R2F capability will test its responsiveness to tasks, identify integrated work-force requirements, logistical considerations, capability limitations, deployment options and verify administrative and clinical processes. This presentation will expand on the following points:

• Concept – Role within the battlefield, multiple brick layout, adapt Standard Operating Procedures (SOP) of coalition partners US Army R2F equivalent
• Personnel – Roles and responsibilities and roles beyond clinical profession
• Equipment – Real time diagnostics, Surgical instruments
• Transport – Self deployable, Bushmasters
• SOP – Standard drills, patient documentation and casualty tracking
• Clinical Logistics/Governance – Blood management and administration, re-supply capability

The presentation will outline the importance of training and how to bridge the gaps within the capability. This will ensure that R2F is constantly adapting to the ever-changing military tasks and achieve Commander’s intent to operate on land, from the land and across all domains.

Princess Rull was born in Manila, Philippines. At the age of eight, Princess Rull and her family moved to Brisbane, Queensland where she completed her Primary, Secondary and Tertiary schooling and later employed as a Registered Nurse at Queensland Children’s Hospital and Royal Children’s Hospital in Melbourne.

In 2018, Princess Rull enlisted in the Australian Regular Army as a General Entry Nursing Officer. She pursued a career in Defence in order to provide Australia, the country that offered her family abundant of opportunities, her life and nursing skills.

Princess Rull was posted to 11 Close Health Company as a Treatment Team Nurse, 2nd General Health as Operating Theatre OIC and now 2nd Health Battalion as Role 2 Forward OIC. Tasks included Clinical Training Officer, Equipment management, Clinical Governance, Operation Augury, Operation Covid Assist NSW immunisation, Covid Assist Melbourne.

CAPT Rull is studying Master of Nursing, in Education, and Art  of  Coaching  Diploma.  Princess  Rull  has a serving brother in the Infantry Reserves Corps. Princess Rull enjoys an active lifestyle and spending time with her family and friends. Princess Rull enjoys volunteering for charitable organisations such as Cancer Council, Australian Red Cross, Leukaemia Foundation, Braveheart, Act for Kids and many more.

Corresponding author name: Princess Rull

Corresponding author email: [email protected]

SafeSide in Defence: Enhancing Suicide Prevention Culture, Practice, and Education

Ms jennifer harvey , associate professor anthony pisani 1,3 , ms kirsti claymore 2 , colonel laura sinclair 2 , ms emily jallat 2 , ms. nikki jamieson 2.

1 University Of Rochester, Rochester, United States,

2 Department of Defence, Canberra, Australia

3 SafeSide Australia, Brisbane, Australia

Defence has embarked on a major initiative to strengthen suicide prevention that will touch all personnel. In this session, leaders  from  Joint Health Command, ADF Centre for Mental Health, and SafeSide Prevention  will  present  alongside lived experience advocates about plans toward: strengthening organisational culture of safety and prevention; implementing effective policies and practices; and continuously engaging the workforce with role-specific education.

The SafeSide project builds upon the strong foundation of the existing ADF Suicide Prevention Programme (SPP), which includes: learning initiatives; policy and governance; Defence employee benefits; and environmental products and resource. Each will be optimised consistent with innovative best practice, and with other government entities (DVA/ Open Arms, NSW Health, Queensland Health) that have adopted all or part of the SafeSide Framework.

Organisational culture of safety and prevention. Perspectives on suicide prevention have widened beyond individuals’ skills and practices toward suicide-safer systems. Engaged leadership within Health and Command  and  strong  involvement from ‘experts by experience’ is key. Participation from individuals who have experienced suicide or mental health concerns is critical for  addressing gaps in messaging and member experience. This involvement is consistent with objectives of the recently established Defence Lived Experience Program.

A culture that supports suicide prevention must also promote healing, learning, and improvement after suicide-related incidents and deaths. Pursuing the bold goal of reducing suicide requires  safety and support for members, friends, and family if loss does occur. Informed by recent advances in postvention, the project will update post-incident policy, procedures, and resources.

Best practices and policies. The SafeSide Framework for Recovery Oriented Suicide Prevention provides a map of best practices and a common language organisationwide. We reviewed administrative, principle-based, and procedural-focused policies of the Defence Health Manual as well as those pertaining to welfare boards and member support. A subgroup with broad Defence representation will consider 11 key practice areas identified by this review. Revisions will be informed by the interim report of the Royal Commission into Defence and Veteran Suicide anticipated in August.

Customised workforce education and development. SafeSide’s approach to education (Pisani  et  al., 2012; Cross et al. 2019; Pisani et al. 2021; Conner et al. 2013) is founded on evidence that practice and culture change requires shared understanding and educational experiences across roles and disciplines. SafeSide programs utilise video-guided modules that groups complete together, along with ongoing opportunities for learning interactions in and outside the organisation. Bull (DVA unpublished report, 2021) found that Open Arms clinicians and peers felt a greater sense of belonging to the organisations as a result of cross-disciplinary group interaction around the SafeSide Framework.

Our project will tailor the SafeSide program to the unique settings and dilemmas faced within Defence. To begin customisation, we held six feedback sessions with 26 mental health and 21 primary health staff using the standard program. Participants showed marked improvements on research-based self-efficacy measures, especially: “ability to develop person-specific safety plans” and “extend support to those at risk beyond when I am in contact with them.” More than 85% positively endorsed the ability to transfer learning into practice. The major exception was that 40% positively endorsed: “situations used in this workshop are very similar to those I encounter at my job.” This expected finding validated the need for Defence customisation. Similar data will be gathered for non-health programming. The project includes updated mandatory awareness training to enhance suicide protective norms, connection, and resources (Wyman et al 2020) via engaging testimonials and conversations.

Colonel Laura Sinclair, Acting Director of General Health Policy, Programs & Assurance, is a psychologist with vast operational experience including multiple tours in the Middle East. Colonel Sinclair was a recipient of the Conspicuous Service Cross (CSC) for command and leadership of the Joint Health Unit North Queensland.

Ms. Kirsti Claymore has been Defence Lived Experience Program Manager role since January 2022 after serving 30+ years in the Australian Army.

Jennifer Harvey, Acting Deputy Director and Assistant Director Health Workforce Development, ADF Centre for Mental Health, is an experienced psychologist and educator with 25 years’ experience.

Ms. Nikki Jamieson, Assistant Director of the Defence Suicide Prevention Programme, is a suicidologist and social worker specialising in moral injury and suicide.

Dr. Tony Pisani, Associate Professor at the Center for the Study and Prevention of Suicide at the University of Rochester and the Founder of SafeSide Prevention. He is an international leader in suicide prevention education and consultation.

Corresponding author name: Anthony R. Pisani

Corresponding author email: [email protected]

Seeking a preferred model for navy mental health nurses

Capt(ran) david west 1,2.

1 Royal Australian Navy, Australia

2 Flinders & Upper North Local Health Network, Port Augusta, Australia

The Australian Defence Force (ADF) is committed to having an integrated qualified and credentialed mental health workforce. The Defence Health Manual is ‘agnostic’ about what discipline provides mental health care for our members, but for historical reasons it is mostly Army psychologists who lead mental health care in the ADF. This is in stark contrast with  the  multi-disciplinary  manner in which the Australian community and our allied navies receive mental health care.

To determine a suitable model that is consistent with clinical best practice and the maritime environment to sustain uniformed mental health nurses (MHNs) in the Royal Australian Navy (RAN).

The authors will compare two international navies’ models of engaging uniformed MHNs to provide specialist mental health clinical services. This will then be contrasted with the current limited practice model for the Maritime Operational Health Unit.

The United Kingdom and Canadian navies have integrated multidisciplinary mental health clinicians within their health service structures. MHNs make up the majority of clinicians in their mental health services in contrast with the ADF experience. Both navies have a paradigm of uniformed MHNs providing the majority of clinical services which is consistent with established best practice, contributing to a multidisciplinary team of clinicians.

Conclusions

The RAN has the opportunity of incorporating uniformed MHNs, providing specialist care to support serving members which may mitigate against mental disability after their service. Navy MHNs can work alongside psychiatrists and psychologists to integrate a model of care that is aligned with current standards of best practice.

Captain David West RAN is a Naval Mental Health Nurse. He trained as a General Nurse, graduating in 1982 and later qualified in Perioperative Nursing and Psychiatric Nursing. He holds a Graduate Certificate in Community Mental Health from Flinders University and a Certificate of Traumatic Stress Syndromes from University of Melbourne. He also has a vocational qualification  in  Government   Investigation.   He has extensive clinical and operational experience managing a range of inpatient and community mental health services in country South Australia.

He has been an Australian Defence Force (ADF) Reservist since 1978 joining 3RNSWR as an infantry soldier. He has come through the ranks and changed over to Navy in 1988. He has a Defence qualification in military leadership from the Australian Defence Command and Staff College.

He has served as part of the mental health screening (RtAPS) teams on HMAShips returning from operations in the Middle East Area of Operations, and Team Leader for RtAPS on return from Operation Sumatra Assist II and Operation Resolute.

Captain West’s civilian role is the Director of Mental Health for Flinders & Upper North Local Health Network, covering the northeast third of country South Australia.

Corresponding author name: David West

Corresponding author email: [email protected]

Servicewomen’s experiences of managing their pelvic health

Dr kate freire 1 , dr simone o’shea 1 , professor rod pope 1,2 , professor rob orr 2.

1 Charles Sturt University, Australia 2 Bond University, Australia

The growing female representation in the Australian Defence Force (ADF) necessitates a focus upon health areas where men and women differ to ensure appropriate prevention strategies and healthcare are provided. Genitourinary health is one of these areas.

The aim of this investigation was to explore the impacts of genitourinary health issues on ADF women, and their experiences of managing their pelvic health in occupational settings.

The study was part of a mixed methods study which explored the genitourinary health issues experienced by biological servicewomen in the ADF. Semi- structured  telephone  interviews   were   conducted in 2020. Six servicewomen and two veterans took part. This presentation focuses  on  the  findings from the interviews with the six currently serving servicewomen. A systematic thematic analysis of the interviews was conducted by identifying and coding responses in each interview transcript that addressed the study aim. Codes were then refined into themes by identifying commonalities and differences in responses across the data set.

Servicewomen reported moderating their fluid consumption and manipulating their  menstrual cycle because they worked in contexts where toilet access and privacy were limited. They described occupational contexts where, due to operational requirements, service personnel were expected to work without access to toilets or time for breaks for four or more hours. Some servicewomen discussed how they had little knowledge about maintaining pelvic  health  when  they  joined  the   ADF,   and how the predominantly male environment stifled opportunities to identify norms of female pelvic health. A workplace culture where women felt they could not ‘be seen as a girl’, low levels of insight into norms, and limited prevention education and strategies to support management of female pelvic health issues in the ADF contributed to some servicewomen self- managing significant pelvic health conditions prior to seeking treatment. They utilised strategies to self- manage their symptoms in the workplace, including some that may have negatively impacted their health and wellbeing, such as restricting fluid intake and limiting their physical activity levels. Servicewomen reported that the doctors they saw in the ADF were keen to provide access to specialist care. This was beneficial, as it was not until they consulted with medical specialists and physiotherapists that they appreciated the possible impacts of their occupational requirements on their pelvic health, e.g. bladder desensitisation  from  long   hours   without   access to toilet facilities. The servicewomen were keen to provide practical suggestions to improve experiences of their fellow service personnel in maintaining pelvic health in the ADF, such as introducing questions about pelvic health into health questionnaires and education programs.

Discussion/conclusion

This study suggests workplace culture, low levels of insight into pelvic health norms, and limited prevention and health care strategies within the ADF have contributed to servicewomen self-managing pelvic health issues using  approaches  that  may have had significant impacts upon their health and wellbeing. Servicewomen identified several practical suggestions to highlight and improve managing pelvic health within the evolving culture in the ADF, including increased monitoring and education. Specific education suggestions included developing greater awareness of the impacts of bladder desensitisation which can result from operational demands restricting toilet access for four or more hours. Educating the entire workforce to ensure they take prompt toilet breaks when their bladder is full, when not restricted by operational requirements, may lead to procedural changes that benefit the health and wellbeing of all service personnel.

Dr Freire is a experienced physiotherapist with over twenty years of clinical experience in the UK, US and Australia. Her clinical experience has included both occupational, musculo-skeletal and women’s health physiotherapy; and work as a civilian physiotherapist in Australia. She works as a Research Fellow at Three Rivers Department of Rural Health, Charles Sturt University with a particular focus on participatory and qualitative research.

Corresponding author name: Kate Freire

Corresponding author email: [email protected]

Smoking Prevalence and its Determinants in the Australian Defence Force

Dr jessica marshall 1 , richard beaton, nisha changela, clare whittingham, dr shahd al-janabi, dr christina wilkinson.

Dr Jessica Marshall completed her Doctorate investigating the genetic and pharmacological targeting of Heat Shock Protein 72 on  a  novel mouse model of Alzheimer’s disease. Her research was funded by the Australian Dementia Research Foundation, in  affiliation  with  the  Baker  Heart and Diabetes Institute and the Florey Institute of Neuroscience and Mental Health. Since joining the Department of Defence, Jessica has worked in the National Security space and as a Capability analyst, before moving into Joint Health Command as a Health Insights Officer. Here, she analyses health data and health records to provide Joint Health Command with health and health business intelligence and actionable insights to inform healthcare, capability, and business operations.

Corresponding author name: J Marshall

Corresponding author email: [email protected]

Strategic health impacts of climate change on ADF personnel and operations – Modelling the demand to inform the response

Capt nathan george 1,2.

1 3rd Health Battalion, Australian Army, Adelaide, Australia

2 University of New South Wales, Kensington, Sydney, Australia

Climate change has been declared the most significant health threat of the 21st century and the most significant threat multiplier of the modern era. A national security agenda seeks to anticipate and mitigate risks to stability and prosperity through proportional and timely response. This  response is achieved through strategic assessment of geopolitical, environmental, and socio-demographic risk. Systematic literature review and thematic analysis of climate related health risk demonstrated Australian preparations for the domestic and regional risks associated do not align with peer reviewed or intergovernmental organisational assessments.

To address the deficits in available planning data determined in initial phases of the research, system dynamic modelling is being employed to construct predicative models of demand on the ADF, resulting from climate related extreme weather events. Conceptually this approach requires the combination of three sub-models: ADF population, ADF available capacity in person days, and operational demand on organisational capacity associated with combat and non-combat operations. Non-combat operational demand metrics extrapolated from historical data demonstrate a clear escalation of ADF  response, with variable patterns of demand, and resulting chronological complex of health impacts, based on the scale and type of climate event.

By establishing climate event profiles based on frequency and magnitude of the three key climate events which engender an ADF response (fire, flood and storms), and extrapolating on historicalpersonnel deployment data, a predictive model of future demand on the ADF can be produced. Iterations of this model will then be bound by parameters related to climate event type occurring in a specified geographic location within a known climate zone to shape model output which can inform the scenario- based planning required by strategic leadership and government.

The current work seeks to produce a  viable predictive model through which the growing risk of climate related health impacts can be  anticipated and mitigated in support of Australia’s strategic agenda. Through increasing refinement, and in combination with a growing body of parallel research on the pattern of health impacts that climate events generate, modelling associated with this research seeks to inform strategic planning to produce a sustainable and effective domestic and regional response.

CAPT Nathan George commenced his academic career through a Bachelor of Psychology with Honours in Clinical Psychology, and later transitioned to a Master of International Studies. Thesis work across these fields spanned from “the psychological and physiological tension release mechanisms of self  – harm behaviours”, to “the use of conventional socio- cultural intelligence collection to expedite post-conflict security and stability operations”.

Seeking experience in post-conflict environments, CAPT George lived and worked with grassroots development agencies in provincial Cambodia for over two years. This  experience  clarified  the  necessity of formal training in health, security, logistics and leadership, of the type inherent to military service. Commissioned in 2014 as a General Service Officer for the Royal Australian Army Medical Corps, CAPT George served in the 1st Close Health Battalion, the Army School of Health, the Australian Army Research Centre, the 3rd Health Support Battalion, and now 3rd Health Battalion.

CAPT George was selected for the University of New South Wales Future Health Leaders Program as a candidate for a Doctorate of Public Health in 2018, and the Chief of Army Scholarship in 2020 for ongoing work on :strategic health implications of climate change on ADF personnel and operations throughout Australia and the Pacific”.

Corresponding author name: Nathan George

Corresponding author email: [email protected]

Strongyloides stercoralis infection in United Kingdom military populations

Squadron leader william nevin 1,2,3,4 , captain jake melhuish 4 , captain rebecca wakefield 4 , mr romeo toriro 2,4 , major matthew routledge 4 , flight  lieutenant  luke  swithenbank 1,2,4 , major tom troth 4 , mrs jayne jones 2 , surgeon lieutenant commander stephen woolley 2,4 , group captain ed nicol 1.4 , group captain mark dermont 1,4,5 , professor nicholas beeching 2 , lieutenant colonel lucy lamb 3,4 , lieutenant colonel simon guest 4 , surgeon commander matt o’shea 4 , lieutenant colonel tom fletcher 2,4.

1 Royal Air Force, United Kingdom 2 Liverpool School of Tropical Medicine, Liverpool, United Kingdom 3  Imperial College London, London, United Kingdom 4 Defence Medical Services, United Kingdom 5 Defence Public Health Unit, United Kingdom

Squadron Leader William Nevin is Medical Officer in the Royal Air Force, undertaking higher specialist training in Infectious Diseases and General Internal Medicine. He is currently a PhD candidate at Liverpool School of Tropical Medicine, and an Honorary Clinical Fellow at Imperial College London. As the Principal Investigator on the Join Well, Train Well, Leave Well Study, he is investigating screening for infectious diseases in at-risk UK military populations. He has an interest in parasitic disease, particularly Strongyloides stercoralis in military personnel, returning travellers and migrant populations.

Corresponding author name: W D Nevin

Corresponding author email: [email protected]

Surveillance and Characterisation of Infectious Pathogens affecting Defence Personnel (SCIP Study)

Dr rebecca suhr 1.

1 ADFMIDI, Gallipoli Barracks, Australia

The Department of Clinical Studies and Surveillance (CSS) of the Australian Defence Force Malaria and Infectious Disease Institute (ADFMIDI), is currently conducting a research project designed to  help better understand and characterise infectious diseases of importance to ADF personnel. Combined research methodologies include; (i) analysis of existing, summary, disease–specific health data, (ii) retrospective assessment of patient disease exposure and case histories, (iii) real time investigation of disease outbreaks, (iv) laboratory molecular testing relevant to the pathogen of interest. Disease focus includes arboviruses, ‘environmentally acquired’ pathogens such as leptospirosis and Q fever and other notifiable infectious diseases of interest. Research methodologies and some recent results will be presented.

Major Rebecca Suhr is an Army Medical Officer. She enlisted through the Undergraduate Medical Scheme in 2011. After completing her junior years at the Royal Melbourne Hospital, she posted to 1CHB, obtaining her FRACGP, and then 2GHB where she obtained FASLM. She is currently thoroughly enjoying a posting to ADFMIDI which is being complemented by a MPH. She has deployed on OP COVID ASSIST in 2020 and OP ACCORDION in 2021.

Corresponding author name: Samantha Nind

Surveillance approach to investigate and mitigate risk of skin and soft tissue infections in ADF training areas.

Capt jessica chellappah 1,2 , major rebecca suhr 1.

1 Clinical Studies and Surveillance, ADF Malaria And Infectious Disease Institute, Brisbane, Australia 2 School of Public Health, University of Queensland, Brisbane, Australia

Staphylococcus aureus (SA), also called “staph”, is a bacterium that commonly colonises the human skin. Colonisation occurs in the nose of about 25 to 30 per cent of adults. SA can exist in this form without harming its host or causing symptoms. However, if there is a break in the skin from a wound, surgery or intravenous access device, or if there is a suppression of a person’s immune system, SA  can  cause  skin and soft tissue infections (SSTIs). Infections of particular concern are those caused by antibiotic Methicillin resistant SA (MRSA). Community- acquired infections of SA including  MRSA  have been reported among sporting teams, U.S. military cadets and adolescent camping groups. There are no such studies conducted in the ADF. Both land- based military settings and shipboard deployments represent a high-risk environment for the spread of virulent SA strains due to crowded conditions, shared equipment, and limited opportunities for personal hygiene that facilitate colonization. Although rates of antibiotic resistance incidence in Australia is low compared to other countries, it has been on the rise due to travel and people movement, giving credence for the benefit of monitoring incidence over time.

no such studies conducted in the ADF. Both land- based military settings and shipboard deployments represent a high-risk environment for the spread of virulent SA strains due to crowded conditions, shared equipment, and limited opportunities for personal hygiene that facilitate colonization. Although rates of antibiotic resistance incidence in Australia is low compared to other countries, it has been on the rise due to travel and people movement, giving credence for the benefit of monitoring incidence over time.

Dr Jessica Chellappah is an experienced Epidemiologist and Clinical Microbiologist. She has worked in Melbourne, VIC with Baker Heart Research Institute and Burnet Institute for over

10 years in  Non-Communicable  Disease research, and subsequently another 8 years as a Medical Diagnostic Scientist in Infectious Diseases with Sullivan & Nicolaides Pathology. She now serves as a Scientific Research Officer with the ADF Malaria and Infectious Disease Institute and adjunct fellow at University of Queensland, focussing on infectious disease surveillance and   characterisation. Jessica is passionate about public health interventions and policy and actively works with different communities locally and internationally to improve health awareness and outcomes.

Corresponding author name: Jessica Chellappah

Corresponding author email: [email protected]

The Australian Defence Force Centre for Mental Health Second Opinion Clinic- First 200 patients

Dr duncan wallace 1,2 , dr carla meurk 3,5 , associate professor ed heffernan 3,4,5.

1 ADF Centre For Mental Health, Mosman, Australia 2 School of Psychiatry, University of NSW, Sydney, Australia 3  Queensland Centre for Mental Health Research Forensic Mental Health Group, Brisbane, Australia 4 Queensland Forensic Mental Health Service, Brisbane, Australia 5 School of Public Health, University of Queensland, Brisbane, Australia

Established in 2011 as part of the Australian Government’s response to the Dunt Review of Mental Health Services in the Australian Defence Force (ADF), the Second Opinion Clinic (SOC) is a tertiary-referral service at the ADF Centre for Mental Health. Uniformed and civilian psychiatrists and psychologists perform comprehensive, one-off mental health assessments of ADF personnel with complex, chronic or difficult to treat conditions and provide expert clinical advice on diagnosis and treatment.

We report the first ten years of operation of the Second Opinion Clinic after assessing over 200 patients, including the demographic, service related, telehealth and mental health characteristics of patients.

Dr Duncan Wallace has been a consultant psychiatrist since 1990, practising mainly in public hospitals with special interests in emergency departments, rural psychiatry, telepsychiatry and military psychiatry.

Dr Wallace has been a psychiatrist at the Australian Defence Force Centre for Mental Health since 2010. He has operational experience as a medical officer in the Navy Reserve and was promoted to Commodore in 2012.

Corresponding author name: Duncan Wallace

Corresponding author email: [email protected]

The introduction of a Nurse Practitioner led walk-in model of care designed to improve access to Defence provided health care: A quality improvement project

Mr john mikhail 1 , major joanne briggs 1.

1 ACT Health Centre, Australia

Access to health care services is a global guiding principle for health care systems. The introduction of Nurse Practitioners (advanced trained clinicians that bridge the nursing medical divide)  globally has seen barriers to health care access fall. The Australian Defence Force has not been immune to access issues with demand for same day services often outpacing availability. In addition, traditional sick parade timings appear to  have  created  a barrier to accessing health care for many Defence members. The incorporation of Nurse Practitioners into the ACT Health Centre is viewed as an enabler to address access to health care services by extending the traditional sick parade hours to a full day walk- in service.

To explore the impact of a Nurse Practitioner led service for unscheduled primary health care at the ACT Health Centre.

We began our quality improvement journey by developing a model of care for a Nurse Practitioner led unscheduled care service – akin to  a  civilian walk-in clinic – that incorporated contractor and military providers. The second step was to develop an education program that standardised the triage process for all staff at the ACT Health Centre to align with current Joint Health Command policy. The third step involved the development of data collection tools that captured quantitative (case presentations) and qualitative (patient satisfaction survey) data points. Both data collection tools were piloted and revised prior to the official opening of the ACT Health Centre in May 2021. Formal  data  collection  occurred  from 1st June 2021 – 30th June 2022.

Of the 15,380 Defence members who presented to the ACT Health Centre without appointments, 12,264 were reviewed in the Unscheduled Care Clinic. Unfortunately, acute illnesses and injuries only accounted for approximately 50% of the presentations to Unscheduled Care. This was due to a lack of availability of booked appointments in Scheduled Care which impacted on the original aim of the quality improvement project. The overwhelming majority of respondents reported positive experiences with the Nurse Practitioner led service. Almost 90% of members surveyed were satisfied or strongly satisfied with the level of knowledge and competence of the Nurse Practitioners and of the care received. Over 91% of respondents reported that they would consider accessing Nurse Practitioner services in the future.

The introduction of the Nurse Practitioner model of care at the ACT Health Centre has seen a significant improvement in access to health care services by Defence members in the ACT. The Nurse Practitioner-led Unscheduled Care service has created an opportunity to extend the sick parade hours in support of a full day walk-in service and has ensured that the needs of Defence members with acute illnesses and injuries are triaged and treated in a timely and appropriate manner.

John Mikhail is a contracter Nurse Practitioner for Defence with over 20 years of nursing experience. John was one of the first contracted Nurse Practitioners to work in the ACT region and has used his research skills and clinical knowledge to develop the Nurse practitioner Model of Care for contracted employees.

His interest in research led to him being the lead investigator for the quality improvement project conducted at the ACT Health Centre.

Corresponding author name: John Mikhail

Corresponding author email: [email protected]

The Pathway from Compliance to Capability. A new framework for safety and quality in Healthcare– Resilient Health Care… Drawing from the passion of our people to deliver on our purpose.

Group captain andrew johnson 1 , wing commander alan turner 1 , squadron leader sally faulks 1.

1 Royal Australian Air Force, Brisbane, Australia

“As Defence moves to shape, deter, and respond to the rapid global changes affecting Australia’s interests, the Defence health system must also display agility and adapt to the future strategic environment and respond to Government priorities. The ADF Health Strategy is our response to the challenge of delivering world-class health care to our people wherever they serve. It will ensure we deliver a Defence Health System that is ready, responsive, and resilient.” ADF Health Strategy 2020-2030

Healthcare is amongst the most complex of human endeavours. Every day, healthcare  is  delivered  in an array of settings from remote clinics to tertiary centres to  Defence  in  operational  deployments. The capability of systems continues to  grow,  yet they  remain  under  pressures  of  demand,   cost, and productivity. Our health professionals deliver outstanding care to our communities. Yet, even with the best of intentions and the commitment of the talented people who work within the systems, things go wrong.

Current reported rates of adverse events in healthcare remain high, with approximately 1 in 10 hospital admissions  encountering  adverse  events,  despite huge investment in systems safety. We have limited data in Defence, and no reason to believe that  we would be doing better. Defence health professionals operate in environments that directly contribute to errors – environments where  resources  are  often poor, time is critical and the evolving situation unpredictable.

To  improve  our  systems,  we  must  understand how they work, and how our people work within them. We must make them better in the real-life, confusing reality of competing demands, conflicting priorities and incomplete information, volatility, and ambiguity.

Compliance with defined standards simply isn’t enough. It doesn’t allow the agility to enable capability.

Resilient Health Care (RHC) offers an alternative understanding of how we may approach the wicked problem of improvement in health care. RHC brings together the understanding of resilience engineering with health care. At its core, it challenges us to develop a much clearer understanding of the real world of health care and the work required within it. That is “Work as Done” rather than “Work as Imagined”.

Health Care systems have characteristically been organised along hierarchical lines. RHC questions this orthodoxy and promotes an understanding of Health Care as a Complex Adaptive System (CAS). CAS are characterized by self-organisation and emergent behaviours. Perhaps this could be described as the workers getting on and delivering health care, with a focus on intent rather than process.

The new way of thinking about patient safety allows us to “engineer-in” resilience within a complex and adaptive system, that is the capacity to “get it right” despite things going wrong along the way, rather than the traditional approach to “engineer-out” risk. “Safety Two” vs “Safety One”.

RHC challenges our understanding of hierarchical management structures and operational  models, and introduces some paradigm shifts into the way we view risk and safety. It allows us to identify and recognise the importance of context, flexibility, and complexity that we have considered and responded to over the years, without the framework to fully understand why some things work and others don’t.

This presentation explores the tenets of Resilient Health Care, and outlines practical approaches to how we may address the issues of safety and quality in our unique Defence Health environment. We discuss how to select the right safety and quality tool for the job… and how to avoid wasting our time on measures that do not matter.

Compliance only where it is meaningful, managed within a framework of partnership for performance… a clear-eyed focus on developing our people to establish a level of capability that no measure of compliance can deliver.

GPCAPT (Professor) Andrew Johnson MBBS, MHA, MConfMgtResol, FRACMA(Distinguished).

Andrew is the Senior Clinical Advisor of the newly- formed Clinical Governance-Air Force Cell, a Professor with the College of Medicine and Dentistry at James Cook University and an Honorary Professor with the Australian Institute of Health Innovation at Macquarie University. He is a Censor of the Royal Australasian College of Medical Administrators and a long-term member of the Education and Training Committee. Andrew was recognised as a “Distinguished Fellow” of the College for his work in medical workforce and patient safety and has twice received international awards for safety and quality innovations. Andrew is the lead author of five book chapters, several peer-reviewed publications and conference abstracts and is regularly invited to present at national and international meetings. Recent studies in Conflict Management and Resolution have led to accreditation as a mediator and coach. His current major areas of interest are conflict competence, mentoring and coaching. After leaving the Permanent Air Force in 1995, Andrew has spent over 25years as a hospital executive, some of that time in RAAFSR. He has re- joined Air Force as a part-timer in 2021, bringing his civilian experience in safety, quality and leadership coaching back to Defence.

Corresponding author name: Andrew Johnson

Corresponding author email: [email protected]

The role of Aeromedical Evacuation in the 2021 Afghanistan Non- combatant Evacuation Operation

Lacw dayna martin 1 , lacw georgia smith 1.

1 Royal Australian Air Force, Australia

LACW Dayna Martin enlisted in the Royal Australian Air Force in 2017 as a Medical Technician. Since then she has had postings to Army School of Health and No. 3 Aeromedical Evacuation Squadron  (3AMES). She deployed with 3AMES on the Afghanistan Non- combatant Evacuation Operation (NEO).

Dayna holds a Diploma of Paramedicine and a Diploma of Nursing. She is currently working towards her Bachelor of Nursing through Charles Sturt University.

Dayna lives in Sydney and in her spare time she likes to catch up with friend and go camping and fishing.

LACW Georgia Smith enlisted in the Royal Australian Navy (RAN) in 2014 as a Medic. She subsequently was posted to The Navy Ward- St Luke’s Hospital, HMAS Adelaide and HMAS Waterhen. She deployed on RAN operations as part of Indo-Pacific Endeavour in 2017.

In 2019 she transferred to the Royal Australian Air Force as a Medical Technician and posted to No. 1 Expeditionary Health Squadron where in 2021 she was a part of the Afghanistan NEO mission. She then posted to 3AMES in January 2022.

Georgia holds Diploma of Paramedicine and a Diploma of Nursing.

Georgia enjoys spending quality time with her family and friends and travelling.

The Unsung Heroes – The importance of the Walking Blood Bank program and use of Low Titre Whole Blood during conflict

Ms jullie vidler 1.

1 2nd Health Battalion, Enoggera, Australia

In the deployed setting, being able to maintain the ideal ratio of components remains a challenge due to logistical and storage constraints. Walking blood banks (WBB) are an invaluable resource to provide fresh whole blood (FWB) in situations where the availability of component therapy is not sufficient or effective for the resuscitation of a patient. Although the use of the WBB (also known as the emergency donor panel) is written into ADF policy for the use of type-specific blood for emergencies, its limitations can present its own challenges. The use of Low-titre O Whole Blood is widely used by many militaries like the United States who heavily rely on its use within their Ranger O Low-titre (ROLO) program. Under the guidance of the US Armed Services Blood Program and utilising the Joint Trauma Systems Clinical Practice Guidelines, Australian Scientific Officers managed the WBB Program for the multinational Role 2 Hospital based at Hamid Karzai International Airport (HKIA) in Kabul Afghanistan between the years of 2016-2021.

This presentation will explore the importance of the Walking Blood Bank Program and use of O Low-titre blood during two MASCAS events in Afghanistan in 2019. This will include the ongoing  management of the donor list, activation, outcomes, problems identified and lessons learnt. It will detail current Australian policy regarding the use of FWB and identify where this policy may  require  updating to better support operations, increase warfighter survivability and align with our coalition partners and their policies.

This presentation will expand on the following topics:

• What is the WBB and O Low-titre blood?
• Limitations of type specific blood donations versus O Low-titre
• Current ADF policy on WBB from Defence Health Manual – Military Transfusion
• Distribution of Blood Groups and expected statistics of O Low-titre blood groups within the Australian population and Australian Military
• Managing the WBB at the HKIA
• Activation of the WBB in 2019 during MASCAS events in
• Problems identified and lessons learnt from the
• The potential way forward for the

The presenter was the Scientific Officer present at the two WBB activations during the MASCAS events that occurred at HKIA during 2019. She has had operational experience managing both the ADF and US Armed Services walking blood banks and will share her experiences, perspectives and the potential way forward for ADF.

CAPT Jullie Vidler graduated from Queensland University of Technology as a Medical Scientist in 2013. She worked for 5 years in Histopathology for Sullivan Nicolaides Pathology during her University years and as a graduate. In 2015 she joined the Australian Army as a Scientific Officer. During her time in the Military she has deployed to Taji, Iraq in 2017 working in the Role 2 as a sole Scientist and to Kabul, Afghanistan in 2019 working at the American- led multi-national Role 2 at Hamid Kazir International Airport. During her deployment to Afghanistan she was involved in a large number of Mass Casualty (MASCAS) events with two requiring activation of the Walking Blood Bank and use of Low Titre O Whole Blood donations. Jullie is currently posted to 2nd Health Battalion in Brisbane.

Corresponding author name: Jullie Vidler

Corresponding author email: [email protected]

The weight of an all-seeing, all- knowing eye: implementation of the Wellbeing & Resilience Framework project enhancing safety and wellbeing within RAAF. A trial Peer Support Program supporting Information Warfare Intelligence

Chaplain timothy hodgson 1 , dr (fltlt) khristin highet 1.

1  Royal Australian Air Force, Edinburgh , Australia

Closer attention has been paid towards the direction and character of military capability and warfighting adopting the use of remote warfare. This has been particularly the case when capabilities involving processing intelligence within the distributed ground system, as well as platforms employing Remotely Piloted Aircraft (RPA) and the introduction of new technologies present specific occupational hazards. Such challenges relate to abhorrent imagery exposure, as well as a deployed in garrison context where transition between the combat mindset and domestic life occurs within the same 24-hour cycle. To add, the very nature of increased target knowledge through high-resolution sensors and dwell time presents its own unique potential risks related to moral injury.

In early 2019, Information Warfare Directorate (IWD) developed the Wellbeing and Resilience Framework (WARF) project aimed to more effectively support the wellbeing of IWD Intelligence analysts, as well as optimise their occupational safety and performance. The WARF is compliant with Air Warfare Centre Safety Management Plan and Assurance Policy and is aligned with the Joint Health Command Directorate of Spiritual Health and Wellbeing and the Air Force Mental Health  and  Wellbeing  Plan  2020-2023. The framework utilises evidence-informed, best practice from safety, medical, psychological, high performance and chaplaincy fields and is comprised of five elements: social, physical, technical and operational, spiritual, and psychological. It provides an integrated and multi-faceted approach to supporting welfare and wellbeing where all programs, concepts and mitigation efforts are aimed to target each of these elements. The desired end state is to provide a deliberate and pre-emptive effort to ensure the IWD workforce has the skills, mechanisms and resources to maintain and enhance their individual and collective wellbeing and resilience to achieve their ongoing missions.

Peer support programs have increasingly been implemented in high risk agencies to provide workforce wellness support to employees (Levenson & Dwyer, 2003;  Marks et al., 2017;  Millard, 2020; Nash, 2006). Peer-based support has been specifically identified in the Air Force Mental Health and Wellbeing Plan 2020-2023 as being fundamental to building and maintaining mental health and wellbeing. In 2021, a trial of an important element of the WARF, the IWD Peer Support Program, was commenced. The embedding of a formalised peer- to-peer support wellbeing initiative within IWD Intelligence has been the first in RAAF history. Twelve Peer Support Members from 83SQN were recruited and undertook specialised and tailored training to provide an additional layer of support by individuals who are not only familiar to unit members, but have intimate knowledge of their unique occupational demands. The program was  implemented  to address key goals of increased overall awareness and utilisation of wellbeing supports, increased confidence in proactively utilising  relationships for additional support within the workplace, and targeted wellbeing support provision during operations. In early 2022, the Peer Support Program was subsequently implemented into 460SQN. The recruitment, selection and training of additional Peer Support Members in both 83SQN and 460SQN will occur in the remainder of the year.

This presentation will cover the targeted initiatives of the WARF, including the IWD Peer Support Program. It will also seek to consider future directions of remote warfare for RAAF, the associated potential impacts on wellbeing and safety management, and possible proactive support frameworks aiming to provide a continuum of care and enable preservation of the military force.

Dr (FLTLT) Khristin Highet, D.Psych (Clin), is a RAAF Specialist Reserve Clinical Psychologist, posted to No. 2 Expeditionary Health Squadron working within HQ IWD. She is the Lead Program Developer and Trainer for the IWD Peer Support Program (PSP). Throughout her civilian career, she has worked in clinical assessment/intervention, organisational consulting and in strategic wellbeing program development. Khristin holds a Doctor of Psychology (Clinical) degree and has been a regular guest lecturer for Flinders University in the areas of mental fitness, wellbeing, trauma awareness and managing exposure, and for the University of South Australia in relationship management.

Rev Dr (SQNLDR) Tim Hodgson, PhD, has served as a Military Chaplain for 15 years, with deployments to the Middle East, Iraq, Afghanistan, and Timor Leste. Prior to rejoining the PAF recently, Tim was the Executive Officer for UnitingCare South Australia.

He is posted to IWD and serves as their Human Performance Team/WARF Coordinator, which includes oversight of the IWD PSP. Tim is a Honorary Research Fellow with the University of Queensland, has a PhD in Moral Injury and has published in a number of peer-reviewed journals. Tim alongside Rev Dr (WGCDR) Lindsay Carey won the AMMA Sir Weary Dunlop award in 2019.

Corresponding author name: Khristin Highet

Corresponding author email: [email protected]

The well-being of ex-serving ADF members: a MADIP analysis

Mrs caitlin szigetvari 1.

1 Australian Institute of Health and Welfare, Bruce, Australia

Ex-serving members of the Australian Defence Force (ADF) are an important group of people for wellbeing monitoring, as the nature of military service means their needs and outcomes can differ from those of the general population.

The unique nature of military service can enhance a person’s health and wellbeing; a phenomenon known as the ‘healthy soldier  effect’.  Military  personnel are generally physically and mentally fit, receive regular medical assessments, and have access to comprehensive medical  and  dental  treatment  as a condition of service. Selection  processes  also mean they may be fitter than people in the broader Australian population when they enlist. However, ADF service  increases  the  likelihood  of  exposure to trauma (either directly or indirectly) and affects support networks, for example, separation from family during deployment.

To help understand the well-being of ex-serving members of the ADF, AIHW, in conjunction with DVA developed a Veteran-centred model of wellbeing in 2018.

This project uses linked data to inform outcomes against five of the social determinant  domains  of the Veteran-centred model of well-being for the first time: education and training; social support; income and finance; employment; and housing.

To conduct the analyses, information on ex-serving ADF members obtained from the Department of Defence staff and payroll management system that contains information on all people with ADF service on or after 1 January 2001 and who separated from the ADF prior to September 2020 was used. This data was linked to the 2016 Census of Population and Housing within the MADIP data asset, hosted by the ABS. The data was then analysed to examine key wellbeing outcomes for ex-serving ADF members.

Results of this analysis show that most ex-serving ADF members were doing well in 2016,  with the majority having attained higher education qualifications, were employed, earned higher incomes, owned their own homes (including those paying mortgages), and were socially connected by living in a family type household. However, some ex- serving ADF members are not faring as well. These people are typically those who separated from the ADF involuntarily for medical reasons, have served fewer years in the ADF, and who separated from the Navy.

This is the first of an expected series of analyses based on this data linkage project which aim to investigate the social determinants of the wellbeing of veterans using the Veteran-centred model as the conceptual basis for the work.

Caitlin is a professional data analyst with nearly 20 years’ experience in the Australian Public Service and has a Bachelor of Science in Mathematics and Statistics. She has led numerous teams responsible for data acquisition, management, governance, integration and analysis to provide quality information to inform decision making. Caitlin has experience leading the ABS’ health analytical work program, as well as previously leading the ABS’ education and labour work programs. She is currently responsible for the Veterans’ Insights and Project Unit at the AIHW, leading research projects to build a profile of the health and wealth of Australia’s veteran population.

Corresponding author name: Caitlin Szigetvari

Corresponding author email: [email protected]

Treating military related trauma co-occurring with substance use disorder – a quest for collaboration

Ms lee brient 1.

1 Open Arms – veterans and families counselling, Devonport, Australia

Client presentations to Open Arms – veterans and families counselling frequently include both military related trauma and  a  substance  use  disorder  –  this is  often  referred  to  as  having  a   dual-diagnosis. Such clients have commonly had considerable involvement with specialist state-based  alcohol and drug services, whose core business is treating substance use. AOD services are restricted in their practice through both policy  and  resources,  and this often means that client trauma goes untreated. Attempting to reduce and control substance use without treating the trauma that likely underlies the clients’ ill-founded attempts to manage their trauma symptoms will inevitably meet with limited success. Often a cycle of escalating trauma symptoms is combined with escalating substance use. Treatment of the trauma condition that is perpetuating the substance use disorder is often either overlooked or relegated as next in a sequential treatment modality. EMDR is a gold standard trauma treatment that has the potential to treat both disorders, however some management of the substance  use  is  necessary. This is difficult for clients receiving treatment in the community, which is the case with the majority of Open Arms clients. Pursuit of the establishment of a collaborative care approach across services is an overarching goal, thereby ensuring provision of the support required to enable the most unwell client to engage in trauma treatment.

I achieved General registration as a Psychologist in January 2015, after commencing as a Provisional Psychologist with the Tasmanian Alcohol and Drug Services in Launceston in Jan 2012. In June 2016 I began working with Veterans and Veterans’ families Counselling Service (VVCS),  in  September  2019  I was selected as part of the Mental Health team for the Invictus Games, Sydney. I gained a Masters of Addictive Behaviours (Monash University) in Jan 2021. Currently my role is the Tasmanian Clinical Program Manager for Open Arms – veterans and families counselling (formerly VVCS), providing  support  for the Tasmanian counselling team and organisational processes, and maintaining a counselling load focussing on trauma therapy (EMDR) and substance use.

Other achievements include InPsych journal article (addiction feature edition): ‘Ice and Methamphetamine use: Clinical considerations and complications’, September 2017; joint Symposium presenter at APS Conference 2015 – ‘AOD issues: everyone’s business’; prepared and delivered webinar  presentation  on ICE on behalf of APS PSU interest group;  paid panel member for MHPN webinar July 17th, 2019 ‘collaborating to recognise and address depression in cannabis users’.

My personal life revolves around my 3 adult children, my 4 grand-children, my pets (including a now 12-month-old rescue lamb), nature and music.

Corresponding author name: Lee Brient

Corresponding author email: [email protected]

United States Veterans Benefits Administration – a global service to US Veterans and Active Duty Service Members

Doctor (phd) judy swann.

1 International SOS, Kingston, Australia

It was announced in April 2022 that International SOS will support the Veterans Benefits Administration (VBA), an agency of the U.S. Department of Veterans Affairs (VA) to deliver services to US veterans and Active Duty Service Members (ADSMs) around the world.

The VBA is responsible for administering the department’s programs that provide financial and other forms of assistance to veterans, their dependents, and survivors.

Utilising our global footprint and network, International SOS will identify, recruit, train, and support carefully selected medical providers in over 37 countries around the world to conduct several specific Medical Disability Examinations in support of the Veterans Benefits Administration.

International SOS’ dedicated Program Team will be fully integrated with prime contractor Leidos and their subsidiary QTC. QTC  is  the  largest  provider of disability occupational health examination services in the US. Over its 40- year history, QTC has carefully developed as  the  leading  provider of these examinations for US based veterans and Active Duty Service Members (ADSMs). Leveraging this experience, QTC will utilise its longstanding experience, business processes, and program- specific information technology infrastructure.

The results  of  the overseas MDEs conducted by International SOS’ Network Providers will facilitate entitlement determinations for disability compensation and pension claims, as MDEs help determine the extent of permanent impairment incurred during military service.

International SOS’ Network Services Providers will perform MDEs for more than 100,000 veterans, ADSMs, their dependents, and their survivors located outside of the United States in more than 37 countries around the globe, including the Philippines, Germany, Japan, Italy, Puerto Rico and South Korea.

An extension of our support to the US military

Our support of the VBA is an extension of our substantial and long-term support of the United States military. International SOS has supported TRICARE in ensuring that Actie Duty Service

Since 1998, International SOS has supported TRICARE in ensuring that over 9.5 million Active Duty Service Members and their families receive the highest quality care, no matter where their work or travels take them. their work or travels take them.

International SOS administers the TRICARE Overseas Program (TOP) benefit, delivering  health care services for Active Duty Service Members (ADSMs), their family members, retirees, and other TRICARE-eligible beneficiaries in 200+ countries and territories outside the 50 United States and District of Columbia.

This new program highlights the critical value of International SOS’ medical fitness examination line of business services and also our global network. The global footprint of International SOS and our ability to work with providers on the ground in the 37 locations  will  deliver easy to access services and support to this program across the world. International SOS Government Services is a key partner of the Veteran Affairs in their work outside of the United States.

Dr Mark Parrish is the Regional Medical Director Pacific and ANZ for International SOS, responsible for all health support, consulting and advisory services across the region. He is based in Sydney.

Prior to this Mark was in London with International SOS, where he led the Northern Europe team and grew the consulting  business; before this he was in Australia with International Health and Medical Services, a subsidiary of International SOS, heading up a team of 500 health professionals providing healthcare across Australia’s Immigration Detention network.

Mark previously worked for Microsoft’s Health Solutions Group covering the Asia and Middle East regions. He was also a Healthcare Consultant with IBM Global Business Services; CEO of North Shore Private Hospital (a large private hospital within a tertiary public teaching hospital in Sydney); General Manager of Hornsby Hospital (a major metropolitan hospital in Northern Sydney); and had a number of roles in the Royal Australian Navy and Royal Navy around the world including the Antarctic, Arabian Gulf, Caribbean, Mediterranean and Pacific.

Mark is a keen cyclist, photographer and adventurer having travelled, explored and climbed in the Hindu Kush in Afghanistan and Pakistan, the Himalaya and the Chinese Pamirs.

Dr Judy Swann is the Head of  Military  Health Services at International SOS. Judy is responsible for the Defence, Paramilitary, Naval Maritime and peace- keeping sectors within the Pacific region.

Judy has a decorated career with the Australian Department of Defence. Specifically, Judy has been involved with Australia’s COVID-19 response, Pacific Islands police and military forces and the Pacific Islands Maritime Security Program. Judy holds an Order of Australia Medal, several official Defence commendations and has completed doctoral studies in the police and military forces of the South Pacific.

Corresponding author name: Judy Swann

Corresponding author email: [email protected]

Veteran homelessness – Why is that a thing?

Andrew Russell Veteran Living (ARVL) is a homeless veteran program which aims to ensure that ex-service personnel in South Australia can access appropriate and affordable housing solutions. Since 2016 ARVL have provided well over 20,000 nights of emergency accommodation to veterans who are homeless or on the homeless spectrum.

Through ARVL much has been learnt about the pathways and “upstream” factors that contribute to a veteran’s experience of homelessness, as well as for those factors that can enable a veteran to find stable and permanent housing solutions longer term.

This presentation will present data exploring:

-Upstream factors – Pathways to veteran homelessness -Actively homes veterans – What does this population look like (service history etc)? -Downstream effects – how do we prevent veterans from cycling back through an experiences of homelessness.

ARVL provides housing options for vulnerable veterans in three ways:

-Through an emergency accommodation program designed for those that are homeless or at risk of homelessness (10 living units) -An affordable housing portfolio designed to provide long term housing affordable solutions (38 units/homes). -Through meaningful and purposeful relationships with selected providers from the community housing

ARVL’s emergency accommodation consists of 10 units, in the suburb of Sturt, Adelaide. These units are designed to provide temporary emergency accommodation for veterans who  are homeless, at risk of homelessness or in need of emergency transit accommodation. The program operates with a ‘housing first’ approach, and is designed to provide a stable housing environment that enables pathways to be formed that can assist veterans to secure the support they need, and permanent housing solutions.

Through ARVL’s emergency accommodation the veterans receive a fully furnished unit, and the length of stay will be determined on a case by case basis and will be in alignment with personal circumstances and housing needs.

With over 50% of ARVL’s resident’s reporting experiences of suicidal ideation, the issue of veteran homelessness is particularly relevant as the Royal Commission into Defence and Veteran Suicide progresses through its investigations.

The issue of housing instability is a growing problem for the ex-service community, but it is a problem that can be addressed.

Come along to this presentation and learn how.

White Island Volcano Aeromedical Evacuation by the Royal Australian Air Force

Mr david-john howarth 1.

On the 9th of December 2019, the White Island volcano located in the Bay of Plenty, north east of Whakatane, New Zealand erupted unexpectedly. At the time of the eruption, there were 47 people on the island who were visiting as tourists with local tourist companies. As a result of the eruption, there were 25 people severely injured and sadly 22 people that were killed on the island.

Rescue attempts by local emergency responses were hindered due to the volatility of the volcano. A local non-medical helicopter crew decided to fly to White Island and do their best to help others in need. Some victims were able to be flown back to Whakatane while others had to be transported via boat, a 90-minute trip to the mainland, with excruciating thermal and chemical burns. New Zealand health activated its mass casualty trauma centres and dispersed the survivors to multiple facilities across the country. Majority of the survivors were admitted to ICUs due to the extent of their injuries.

As a number of the survivors were Australian, the New Zealand Government sought to repatriate these patients back to Australia to alleviate the pressure on the New Zealand health system and to bring those people home. This resulted in the Royal Australian Air Force being tasked to activate 3 Aeromedical Evacuation Squadron to provide three Aeromedical Evacuation (AE) teams and six Military Critical care AE Teams (MCAT) to retrieve the patients utilising two C-17’s and one C-130.

Four of the five patients were intubated due to inhalation and thermal burns to a significant portion of their bodies. Aircrafts departed New Zealand bound for Sydney International for the patients to then be taken to various burns units in Australia for further care and rehabilitation. The focus of inflight care included ensuring sedation continued, pain was kept to a minimum, burns dressings were attended to and ensuring the parkland formula fluid administration was adhered to.

Once the aircraft landed in Sydney, the 3AMES clinicians provided a comprehensive handover to the local ICU staff. Handover marked the conclusion of the AE and the AE teams could stand down after almost 24 hours. The mission was able to successfully repatriate five patients to Australia within 48 hours of the event occurring.

Corporal DJ Howarth  joined  the  Royal  Australian Air Force (RAAF) in January 2012 as an Avionics Technician. He remustered to Medical Technician (MEDTECH) in late 2013 and completed his MEDTECH training in 2015 and was posted to No. 1 Expeditionary Health Squadron (1EHS) Detachment Townsville. During this posting DJ deployed on exercises Talisman Sabre, Pitch Black and Regiment White. He was also deployed internationally on Exercise Cope North and to Operation Accordion.

On return from Operation Accordion in 2019, DJ was posted to No. 3 Aeromedical Evacuation Squadron (3AMES) Detachment Amberley and was able to combine passions for aircraft with his skills as a clinician. DJ was promoted to Corporal in 2020 and was posted to 1EHS Amberley where he was able to guide and mentor younger MEDTECH’s. In 2021 CPL Howarth was selected to deploy to Red Flag Alaska, which was the first major exercise that the RAAF had participated in since the start of the COVID-19 pandemic. DJ worked closely with the Medical Officer and successfully looked after the deployed force during a highly contagious Delta wave. In 2022, DJ was posted back to 3AMES where he has taken an interest in instructing his colleagues in driver training

Wingman-Connect: Upstream Suicide Prevention for US Air Force Personnel

Associate professor anthony pisani 1 , professor peter wyman 1 , mr. bryan yates 1 , dr. chris goode 2.

1 University Of Rochester, Rochester, USA 2 United States Air Force, Pentagon, USA

Wingman-Connect (WC) is an upstream universal suicide prevention program developed with the US Air Force (USAF) that targets relationship networks of military personnel to strengthen suicide-protective functions of social networks. We will present the rationale for upstream military suicide prevention, describe and show video of WC, share results from a rigorous randomised trial and current piloting to extend the program into operational bases, as well as preliminary work adapting the program for other settings and cultures.

US military suicide rates increased 61% from 2008– 2019 and suicide is the second leading manner of death. In the US Air Force (USAF), suicide rates increased an average of 7% yearly from 2011–2019. Beyond lost lives, suicides impact decedents’ families and broader networks. Up to 2/3rds of military personnel and recent veterans know a suicide decedent; those with closer bonds to decedents are at increased risk for PTSD, depression and suicidal behaviour. Current military suicide prevention focuses primarily on identifying and treating those already suicidal or high risk. Although  necessary, this approach is insufficient. Among US military suicide decedents, fewer than 30% received any mental health services in the past 90 days. Efforts to increase treatment-seeking have not yielded impact on suicide rates.

We conducted a cluster RCT with 215 technical training classes randomly assigned to either WC or an active control (Wyman et al 2020). Of 1,897 Airmen, 85.7% enrolled, 1,485 completed assessments at 1- and 6-mo (93% and 84% retention). Primary outcomes: suicide risk and depression subscales of computerised adaptive test (CAT-MH 31); and military occupational impairment. Wingman-Connect trained Airmen reported lower suicide risk (ES = −0.23; p=.001) and depression (ES = −0.24; p =.002) at end of tech school. W-C trained Airmen were also 50% less likely to report corrective training (OR, 0.51). WC benefits on reduced depression were maintained after transfer to first base assignment, whereas suicide risk scores, while directionally lower, were outside significance (ES = −0.13; P = .06). WC participants were 20% less likely to report elevated depression with high probability of diagnosis at either follow-up point (OR, 0.80; P = .01), and the NNT to produce 1 fewer Airmen with elevated depression was 21. A formal test of mediation validated the network health model: cohesion, morale, positive group bonds, and healthy class norms (latent factor) was a mechanism that reduced suicide risk and depression symptoms.

We tested a social network mechanism for WC impact using Airmen’s nominations of valued classmates to create social networks and network integration metrics (Wyman et al 2022). WC increased social network integration overall, with largest impact for Airmen at elevated suicide risk). For elevated risk Airmen, W-C improved all network integration metrics including 53% average gain in valued connection nominations received from others (RR=1.53) and eliminated group isolates vs. 10% isolates among at-risk controls (P > .035). WC counteracted drift towards disconnection for at-risk Airmen found in the active control condition, despite no explicit intervention content targeting connections to at-risk members.

Wingman-Connect is the first universal prevention program to reduce suicidal ideation and depression symptoms in a general USAF population. Group training that builds cohesive, healthy military units is promising for upstream suicide prevention. Extension of the program to the operational Air Force is ongoing and will be tested for prevention impact on suicidal behaviour.

Peter Wyman is Co-Director of the Center for the Study and Prevention of Suicide at the University of Rochester. He leads the Network Health Prevention Science Program, where his work is at the intersection of behavioural science, developmental epidemiology, and social network methods.

Tony Pisani is an Associate Professor of Psychiatry and Pediatrics at the Center for the Study and Prevention of Suicide at the University of Rochester. His career is devoted to preventing suicide and promoting strength, recovery, and wellbeing. Dr. Pisani’s federally-funded research program and public health practice spans the prevention continuum–from upstream to crisis intervention. His models have been widely adopted in Australia.

Bryan Yates has served as project coordinator since 2015, leading logistics and liaising with Air Force Headquarters. Mr. Yates served 6 years as an active- duty US Army combat medic (deployed to Iraq and Afghanistan) and 9 years in the Army Reserves.

Chris Goode is a social psychologist and Branch Chief of the Research & Development Division for Headquarters of the USAF Integrated Resilience Directorate. He has authored numerous peer- reviewed articles and government reports. His team oversees primary prevention programs with the aim of decreasing self harm across the USAF.

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The presentation took place at the  Human Performance Optimisation Symposium  hosted by 1 Brigade at the Darwin Convention Centre on 16 September '22.

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This Cove Clips explores his work within the ADF Health Strategy, focusing on Pillar 4: Force Optimisation. The priority themes are musculoskeletal injuries, mental health and well-being, health system performance and efficiency, and health of the future warfighter. How is Defence enabling performance through health research and innovation?

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• http://orcid.org/0000-0002-9035-0607 Sue Foley 1 ,
• http://orcid.org/0000-0003-1114-8249 T Falconer Hall 2 ,
• http://orcid.org/0000-0001-5440-6039 D Bates 3 and
• K Attridge 4
• 1 Medical Operational Support Unit (MOSU) , British Army , York , UK
• 2 AMS Support Unit , Army Medical Services , Camberley , UK
• 3 Institute of Health , University of Cumbria , Carlisle , UK
• 4 Public Health , Royal Air Force Medical Service , Naphill , UK
• Correspondence to LtCol Sue Foley, Medical Operational Support Unit (MOSU), British Army, York, YO32 5SW, UK; 148odams{at}armymail.mod.uk

Global health practice is becoming a key enabler within UK Defence and foreign policy. The definition of global health remains debated, though some important themes have been identified including: the multidisciplinary nature of global health, its ethical foundation and the political nature of global health. This paper contributes to the ongoing rational discourse that this important discipline deserves and recommends a framework and principles to apply to military health and care system strengthening in the Defence Engagement (Health) (DE(H)) practitioner role. DE(H) involves complex multiorganisational relationships and processes, and while practitioners should be mindful of the political nature of their role, the broad aims of preventing conflict and building stability mean DE(H) should contribute positively to global health.

This paper forms part of a special issue of BMJ Military Health dedicated to Defence Engagement.

• International health services
• PUBLIC HEALTH
• Organisational development
• EDUCATION & TRAINING (see Medical Education & Training)

https://doi.org/10.1136/military-2023-002374

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WHAT IS ALREADY KNOWN ON THIS TOPIC

Despite the growing amount of literature on the subject, the definition of global health remains debated. Some important themes have been identified including: the multidisciplinary nature of global health, its ethical foundation and the political nature of global health.

WHAT THIS STUDY ADDS

This paper contributes to the ongoing rational discourse that this important subdiscipline deserves and recommends principles to apply to military health and care system strengthening.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

This study highlights the impact that health and care have on improving human security to inform effective Defence Engagement in health.

Introduction

This article examines the concepts of global health, global health security, the different types of international health systems (including military) and recommends a framework and principles to apply to military health and care system strengthening in the Defence Engagement (Health) (DE(H)) practitioner role. It forms part of a special issue of BMJ Military Health dedicated to Defence Engagement.

What is global health?

Global health has developed as a prominent discipline in parallel with the advance of globalisation, highlighting not only common regional vulnerabilities but also reinforcing the collective sense of responsibility for inequalities globally. Global health practice is becoming a key enabler within UK Defence and foreign policy, with an increased emphasis given in the 2021 Integrated Review 1 and the 2023 publication of the UK Global Health Framework. 2 In 2019, Michaud et al outlined the ‘growing willingness to use militaries to support global health’, 3 while in 2018, Bricknell and Sullivan argued that the establishment of the Centre of Defence Healthcare Engagement was directly related to ‘UK national goals in global health ’ . 4

The term global health is contested in the academic literature, with no consensus on a common definition. A 2021 systematic review identified four themes relating to key aspects of global health displayed in table 1 . 5

• View inline

Recurring themes in global health 2009–2019

Despite much exploration in the literature, the term remains debated. However, important themes exist: the multidisciplinary nature of global health, its ethical foundation and the political nature of global health. Critiques of the equitable delivery of global health have gained more attention through the COVID-19 pandemic and there are growing calls for more meaningful diversity and inclusivity. 6 This is particularly pertinent to DE(H) in which wealthy ‘Global North’ countries (such as the UK) seek to influence other, often poorer countries. 6 DE(H) practitioners should note the themes identified by the 2021 systematic review and other literature to assist them in their approach to a complex area. They should be aware of tensions surrounding the themes when considering global health in their work.

Since DE(H) aims to prevent conflict, build stability and gain influence, 4 7 a more practical framework for the DE(H) practitioner is the scope and nature of global health outlined by Koplan et al . 8 The elements of their approaches will form the basis of discussion for this paper and act as a framework for DE(H) practitioners 8 :

Transnational health issues including communicable disease and pandemics.

Public health (population-based prevention) including the wider determinants of health, health security and human security.

Global health systems (individual-level clinical care) including military health systems.

This framework also reflects the main themes of the literature in stating that the nature of global health is characterised by a number of elements that reach beyond the health sciences (including economics and the social sciences), promotes interdisciplinary collaboration, and is heavily influenced by wider aspects such as governance, politics, the natural world, crime, conflict, migration, etc. This is encompassed in the concept of human security in the Global health systems section below. Overall, Koplan et al concluded that ‘global health is an area for study, research, and practice that places a priority on improving health and achieving equity in health for all people worldwide ’ . 8

There is an argument however that DE(H) cannot fit into the definition of global health as it seeks to influence and advance UK foreign policy rather than purely focusing on health needs and equity. It is acknowledged that militaries’ efforts may not be perceived as humanitarian as they lack neutrality, impartiality and independence 3 though they are expected to strive for this. However, the improvement in global health and health security is a shared objective for the UK government. 2 Therefore, although not in a position to comply completely with the humanitarian principles, 9 DE(H) practitioners must aim to make the health benefits the main focus of their work as these are likely to achieve the most influence and advancement. 7

This article will now outline how DE(H) practitioners can help achieve those shared UK government objectives using the Koplan et al framework:

Transnational health issues: communicable disease and pandemics

The first International Sanitary Regulations were developed in 1851 in an attempt to control communicable disease. 10 These were adopted by the WHO in 1948, revised in 1951 and then renamed the International Health Regulations (IHRs) in 1969. 10

The IHRs (last updated in 2005) place a legal obligation on all WHO member states to report all Public Health Emergencies of International Concern (PHEIC), defined as ‘an extraordinary event which is determined to constitute a public health risk to other States through the international spread of disease and to potentially require a coordinated international response ’ . 10 The first PHEIC was declared by the WHO in 2009 in response to the H1N1 (swine influenza) pandemic, followed by the Ebola outbreak in 2014, COVID-19 in 2020 and mpox in 2022. 10 An example of DE(H) here is Operation GRITROCK, the UK military operation in Sierra Leone. It focused on three key areas: (1) training of local healthcare workers; (2) the provision of UK quality healthcare to entitled infected healthcare workers and (3) strategic support to the Sierra Leonean leaders coordinating the response. Key to DE(H) success was the ability to work effectively with other government agencies—a skill developed during previous stabilisation operations, added to the deep relationships that existed between the two countries resulting from previous DE activities. 11

The IHRs form the basis of international law to control transnational health hazards, but enforcement mechanisms are relatively weak. This has led to calls for further revision to increase their effectiveness, 12 while other states have developed their own additional voluntary coalitions to mitigate the threats from health hazards such as the US-led Global Health Security Agenda. 12

However, understanding communicable disease is not sufficient for advancing global health. Focus also needs to be placed on wider causes of ill health, which can also cross international borders. This brings us to the second topic in the framework.

Public health (population-based prevention)

Population-based prevention or public health is concerned with the health of populations and communities. Public health focuses on societal conditions that influence health, also known as the determinants of health. In 1986, the WHO outlined eight conditions for health in the Ottawa Charter: peace; shelter; education; food; income; a stable ecosystem; sustainable resources; social justice and equity. 13 A population’s health will only improve if these conditions are met.

Several models have been developed to demonstrate the relationship between health and its determinants which can be of use in DE(H). Perhaps the best known is the Dahlgren and Whitehead model of health determinants ( figure 1 ). 14 The model outlines four levels of determinants ranging from the structural to the individual.

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Dahlgren and Whitehead diagram. 14

On the outer level of the diagram highlights a society’s macroeconomic outlook, stability, quality of institutions and availability of employment opportunities for its citizens. The next level displays the various aspects of living and working conditions, such as access to good quality housing, education and nutrition. Healthcare services are included at this level and explored in greater detail in the next section of this paper. At a more local level, social and community networks such as family and other forms of social support will influence an individual’s health. The final level of modifiable health determinants occurs at the individual level. Individual lifestyle factors such as smoking and maintaining a healthy diet will have a profound impact on their health. The inner core of the model represents those determinants that are (arguably) non-modifiable such as genetics, sex, age and ethnicity.

The relationship between these determinants is complex and symbiotic, even with the non-modifiable constitutional factors. For example, a society that places greater emphasis on gender equity, including sustained investment in maternal health, is likely to see superior health outcomes for its women than an otherwise similar society that does not. 15

Public health interventions can be developed based on each level of the model to improve a population’s health. It is worth considering that other units in the military can assist with tackling wider determinants of health such as engineers in constructing schools and rebuilding bridges.

As a DE(H) practitioner, it is important to understand that health can be addressed at several levels outlined by Dahlgren and Whitehead, but that they can all also have a positive and negative effect on each other. Often, DE(H) practitioners are working to address imminent or actual threats to health. This is where an understanding of health and human security is essential.

Health security

Linking a public health approach and the determinants of health to combating health threats is the concept of health security. Health security is defined by the WHO as: ‘the activities required, both proactive and reactive, to minimize the danger and impact of acute public health events that endanger people’s health across geographical regions and international boundaries ’ . 16

Much of the literature refers to communicable disease as a threat to ‘health security’. For example, the Global Health Security Agenda is primarily concerned with infectious diseases. 12 Others have made the alternative case (after the Ebola outbreak) that the scope of health security should be widened to include all threats to health. 17 Examples of aspects identified include human security, global governance, surveillance and public health capacity and conflict and natural disasters. 18 Others have included antimicrobial resistance and climate change as priorities and highlighted the link to the Sustainable Development Goals. 2 The One Health concept highlights the natural and animal environment as well. 2 19 All these present further strategic direction and a framework for monitoring, evaluation, accountability and learning that military planners should build into their DE(H) strategies.

The DE(H) practitioner will need to have a broad understanding of the concepts of public health, wider determinants and health security in order to maximise their effectiveness in preventing conflict, building stability and gaining influence. They often are called to work in places where threats to health are far more numerous and impactful than at home.

Human security: links to health security

Human security is defined as: ‘an approach to national and international security that gives primacy to human beings and their complex social and economic interactions ’ . 20 It may be thought of as the security of individuals, groups and communities (culturally and society determined) as opposed to state security (which is geographically and politically determined). Global health and health security are inextricably linked to human security. Full guidance on the UK Military approach to human security can be found in Joint Service Publication 985, where it is recognised as essential to operational success. 20

The United Nations identifies health security as an integral component of human security as shown in the model at table 2 . 21 We can see how each component may impact on another. Accurate information and a gender-sensitive approach are viewed as cross-cutting themes. This appreciates that many individual and community needs may be met through information activities, and the gender-sensitive approach to international security acknowledges the roles of civilians (women and children as well as men of fighting age) where DE(H) may take place.

Types of human insecurities and possible root causes

Communication, media information and intelligence shape the thinking and behaviour of people and communities. Public health policy contributes to this by binding the components of human security together. Reliable information and actionable intelligence are essential to address health insecurity and undertake effective DE(H).

UK Defence personnel, including health and care professionals, directly contribute to human security objectives of freedom from fear, want and to live in dignity. Health is integral to all of these as defined in the Ottawa Charter. 13 Health planners and medical intelligence are intrinsic to helping those already working in, or planning to undertake, DE(H) to understand the needs of the target population together with the potential frictions and politics involved.

UK Defence understands that individual and community security is the foundation for long-term stability. DE(H) is not the sole responsibility of the UK’s Defence Medical Services (DMS) but can include all arms, services and peers across missions encompassing outreach and building partner capacity. Operation GRITROCK illustrates the value of a public health approach. This effort was led by the Department for International Development but was delivered by cross-departmental, international organisation and non-government organisations further integrated with the local Sierra Leone capability and capacity. The DMS provided tactical expertise and effective planning based on sound doctrine that enabled other government departments and agencies to operate in a very challenging environment. Another example is from South Sudan where Horne et al described how the DMS were requested to help write the major incident plan for their protection of civilian camps. 22 The deployed commanding officer saw an opportunity for building capacity in partner organisations. Horne et al concluded that ‘this is a fundamental function of Defence Engagement, which seeks to enhance UK national influence and security through overseas capacity building and conflict prevention.’ 22

The DE(H) practitioner should also think long term. DE(H) as a subset of persistent engagement or building partner capacity might learn from the global development community’s lessons. For example, national, regional and international policies, whether ‘obligatory’, ‘aspirational’ or ‘an intent’, need to be articulated at all levels as defined in the UK government’s ‘The Good Operation’, 23 and DE(H) also must take the opportunity to prevent conflict or work ‘upstream’. 24 This may present difficulties in terms of resource and political will.

Global health systems (including military health systems)

Individual clinical care takes place within a healthcare system. According to the WHO, ‘a health system consists of all organisations, people and actions whose primary intent is to promote, restore or maintain health.’ 25 This includes organisations involved in the determinants of health already discussed as well as those actors delivering healthcare services. Healthcare systems differ from country to country, which can make understanding the essential components for a health system difficult. The WHO has developed a framework for this consisting of six building blocks (service delivery, health workforce, health information systems, access to essential medicines, financing leadership/governance), four goals or outcomes (improved health, responsiveness, social and financial risk protection, improved efficiency) and four attributes (access, coverage, quality, safety). 25

Individual countries’ health systems have developed based on characteristics on individual societies, their political, economic and social conditions as well as their healthcare needs. Comparative health research has developed a heterogeneous classification of health systems, 26 with a 2009 article identifying a taxonomy of 27 systems. 27 These are outlined in further detail in table 3 . 28

International models of healthcare systems

Some countries’ health systems may encompass multiple models. For example, healthcare in the USA arguably encompasses the market model (private insurance and out-of-pocket payments), the national health insurance model (Medicare) and the Beveridge model (Veterans Health Administration). 29 The market model is often more common in low/middle-income countries, where methods of social protection are still limited (if in place at all). These systems are characterised by a high ratio of out-of-pocket payments, which can lead to family catastrophic health spending due to lack of insurance or other methods of collative protection, leading to debts and destitution.

An alternative method of understanding a nation’s health system is to focus on its providers. This is the basis of the 2021 framework above developed specifically for the purposes of DE(H) ( figure 2 ). 30

Framework for defence healthcare engagement. 30

It is important that the DE(H) practitioner understands global health systems, including how they function and are funded. This should help to ensure suggested interventions are sustainable with adequate funding, to be aware that catastrophic health expenditure can impact health security and that there are political and cultural aspects regarding health systems that need to be appreciated. However, there have been successful DE(H) operations in countries where the military deliver a substantial amount of healthcare, such as Pakistan. 11

All three aspects of the Koplan et al 8 framework on global health as it relates to DE(H) have been discussed throughout this article. Table 4 summarises the global health principles relating to DE(H) that have been highlighted.

Global health principles relating to DE(H)

Although there is no settled definition of global health, it is of growing importance to policymakers including defence. It is therefore important that DE(H) practitioners understand its scope (transnational health issues, public health including health and human security, and global health systems) and differences between countries. The limitations of DE(H) as a global health intervention also need to be acknowledged such as issues regarding equity, political influence and resources. Table 4 summarises relevant global health principles relating to DE(H).

DE(H) will involve complex multiorganisational relationships and processes, and while practitioners should be mindful of the political nature of their role, the broad aims of preventing conflict and building stability mean DE(H) should contribute positively to global health.

Ethics statements

Patient consent for publication.

Not required.

Ethics approval

Not applicable.

• HM Government
• Michaud J ,
• Licina D , et al
• Bricknell M ,
• Minihane M , et al
• Koplan JP ,
• Centers for Disease Control and Prevention
• Tallowin S ,
• Naumann DN ,
• Dahlgren G ,
• Whitehead M
• Heymann DL ,
• Takemi K , et al
• Beckfield J ,
• Olafsdottir S ,
• Frisina L ,
• Columbia Mailman School of Public Health
• Hinrichs-Krapels S ,
• Ismail S , et al

Contributors SF contributed to the authorship of the sections on health and human security and the overall paper, its editing, primary submission and resubmission. TFH authored the main sections on transnational health issues including communicable disease and pandemics and public health (population-based prevention). DB contributed to the authorship of the health and human security section of the paper. KA authored the global health systems (including military health systems) of the paper.

Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests None declared.

Provenance and peer review Commissioned; externally peer reviewed.

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• Defence and armed forces

Defence People Health and Wellbeing Strategy - 2022 to 2027

The strategy sets out the vision for all Defence People to be in a state of positive physical, mental and social health and wellbeing

PDF , 1.02 MB , 25 pages

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The strategy recognises the importance of positive health and wellbeing for Defence People and directs a coordinated operating approach to promote, prevent, detect and treat poor health and wellbeing early, to enable optimal recovery.

It aims to promote the importance of health and wellbeing across Defence, adopting a holistic approach to mental health, physical health and social health, recognising the requirement to educate.

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Understanding the structure of a country’s health service providers for defence health engagement

Martin bricknell.

1 Conflict and Health Research Group, King's College London⁠—Strand Campus, London, UK

S Hinrichs-Krapels

2 Policy Institute, King's College London, London, UK

3 Department of Primary Care and Public Health, Imperial College London Faculty of Medicine, London, UK

4 Conflict and Health Research Group, King's College London, London, UK

There are a variety of structural and systems frameworks for describing the building blocks of country’s public health and health systems. In this paper, we propose a conceptual framework for a holistic view of a country’s health service providers in order to inform the plan for Defence Health Engagement activities with partner countries. This includes all potential government ministries involved in healthcare provision, the independent, private sector and the non-government organisation/charity sector. The framework provides a visualisation to support the analysis of a country’s health services providers. We propose that recognising and analysing the different contributions of all these national health providers is essential for understanding the wider political economy of a nation’s health systems. This can inform a plan of Defence Health Engagement for capacity building in crisis response, development and health systems strengthening.

Introduction

The role of the Defence Medical Services in Defence Engagement was formalised by the creation of the Centre for Defence Healthcare Engagement in 2015. 1 Defence Healthcare Engagement (DHE) requires a full understanding of the context of the partner country, including the role of the military health system within the wider health economy. 2 This paper provides a conceptual framework to support the development of tools to support practitioners to undertake such analyses.

The terms ‘ health system ’, ‘ health sector ’ or ‘ health economy ’ are used interchangeably to describe the range of stakeholders and actors within a state that provide health services for a country’s population. 3 WHO defines a health system as consisting of all organisations, people and actions whose primary intent is to promote, restore or maintain health . 4 The definition is supported by a conceptual framework for health systems based on the following thematic building blocks: service delivery; health workforce; information; medical products, vaccines and technologies; financing; leadership and governance (stewardship). There is a need to deconstruct the service delivery building block in order to understand the range of providers that meet the health needs of the country’s population and to ensure deconfliction with DHE activities.

While a government’s Ministry of Health (or, Ministry of Public Health) will have primary responsibility for the technical aspects of stewardship for a nation’s health sector, it will not be the only actor or the only provider of health services. The WHO defines health services as ‘ service delivery systems that are responsible for providing health services for patients, persons, families, communities and populations in general, and not only care for patients’. 5 In general terms, health services providers may be divided into horizontal services that are designed to provide comprehensive coverage of a populations’ health needs (such as those financed by public health systems, eg, primary care) or vertical services that are designed to provide coordinated interventions for a specific condition (such as HIV/AIDS). 6

This paper substantially refines the framework based on experiences from Op HERRICK, partially described in a paper published in 2011 7 and issued as policy in Joint Doctrine Note 3/14 The Military Medical Contribution to Security and Stabilisation (8, withdrawn). 8 The changes result from testing the framework and explanation in military and civilian educational settings since the idea was first conceived. This paper also provides a full explanation of the framework and introduces new ideas such as ‘ security ministries ’ and ‘ independent health services ’. It expands the frame of reference to capture all the actors that may be involved in providing health services for a country. Beyond Ministries of Health, this framework explicitly includes the potential roles of wider actors such as other government ministries (Ministries of Higher Education, Defence, Interior), the independent sector and International Agencies (IAs)/non-Government Organisations (NGOs)/charities. The framework is offered as an analytical tool to identify all providers within a country’s health system to support comparisons of providers within and between countries.

The components of ‘ a country’s health service providers ’

‘ A country’s health service providers ’ framework that describes all potential providers of health services within a country is shown in figure 1 . Broadly, these are divided into state and non-state services. In principle, state services are funded by the Ministry of Finance through budget allocations to government ministries based on political choices using government income from taxation. In some countries, compulsory contributions to social security funds may be managed separately from taxation income and so the Ministry of Social Security is also shown as a source of government funding. External donors may also provide direct grant support to government ministries, and non-government third-party funders (including non-public insurers) may also provide finance to government-provided hospitals. The model shows five government ministries that potentially provide health services: Ministry of Health, Ministry of Higher Education, Ministry of Defence, Ministry of Interior and Ministry of Justice. There could be even more in individual countries.

A country’s health service providers framework.

Non-state providers lie outside formal control of the government, although should be subject to national laws and regulations. These are independent providers (commercial providers, not-for-profit providers and the informal sector including pharmacists and traditional healers) and the IA/NGO/charity sector. The Ministry of Health is often the focus for stewardship of the health system including the frameworks for regulation of healthcare workers, pharmaceuticals and medical devices. The relative size of each sector is stylised in figure 1 . The size will vary from country to country and on the unit of measure (eg, dependent population, proportion of nation’s health expenditure, per capita expenditure). Each of the sectors will be considered in turn.

The model also shows four types of health services: curative care, public health and prevention, emergency preparedness and response and health education and training. These types overlap between providers, although the principle focus for policy and regulation is likely to lie with a specific government department.

The Ministry of Health

The essential functions/operations of the public health system managed by Ministries of Health include: surveillance of population health and well-being; monitoring and response to health hazards and emergencies; health protection; health promotion; disease prevention; assuring governance for health and well-being; assuring a competent and proficient public health workforce; assuring sustainable organisational structures and financing; advocacy communication and social mobilisation for health; advancing public health research to inform policy and practice. 9 10 This list reflects an assumption that governance for population health lies at the central state level (referred to as ‘ public health and prevention ’ in figure 1 ).

Many states devolve the management of government funds for the delivery of healthcare for patients to regional or local bodies (‘ curative care ’ in figure 1 ). Devolved governance may have local democratic accountability or may be a delegated responsibility of the central government Ministry of Health depending on the legal, political and sociocultural construct. It may even lie outside state control in areas of contested governance. This will also be influenced by the funding model that will be a balance between central taxation, local taxation, insurance and out-of-pocket expenditure. The division of responsibilities between central and local governance will also depend on the structure of individual clinical services.

The Ministry of Higher Education

The capability and capacity of the healthcare workforce is one of the biggest strategic challenges facing all health systems. 11 Responsibility for training the workforce may lie with the Ministry of Higher Education rather than the Ministry of Health, if responsibility for healthcare education aligns with other undergraduate/postgraduate education programmes within universities. The setting for the education of healthcare professionals is often shared between university teaching environments and clinical settings such as teaching hospitals. These teaching hospitals may be run by the Ministry of Higher Education and therefore operate within the state health sector but not subordinate to the Ministry of Health.

The ‘ Security Ministries ’—Ministries of Defence, Interior and Justice

The security institutions provide external security and internal security for the country, often including the emergency preparedness and response command and control system. The Ministry of Health may provide the health contribution to this system and may be the primary source of ambulances, emergency medical teams, hospital emergency departments and hospital beds. The security ministries control the armed forces, the police, the intelligence services and the penal system. Personnel will either be formally uniformed with specific duties beyond general employment (eg, subject to military law rather than civilian law) or civilian employees. At least three ministries may provide health services for defined security populations.

The Ministry of Defence, through the Armed Forces, is usually responsible for protecting the integrity of the country from external threats. Most armed forces have an integral medical service that both maintains the health of armed forces personnel and can deploy in support of the armed forces. 12 The beneficiaries of the military medical system will include military personnel, and may also include their families, veterans and civilian employees. 13 Some military systems also treat civilians either on a private basis or as state-based funding. Military medical systems are often an integral part of the country’s emergency preparedness and response system as it is the only health system that is organised for field deployment and relatively uncommitted to the local civilian community. 14

The Ministry of Interior is usually responsible for internal security through the management of police services. Police services may be split by different functions including border security, local policing, national response and paramilitary population control. In some countries, the police services have their own medical system like the Armed Forces. This may be necessary if the security environment is such that security personnel are not safe under medical care in the public health system. 15

The Ministry of Justice usually controls the judicial and penal system. This will include responsibility for the health and welfare of prisoners. This is often a neglected component of a health system, although prisoners may have health needs (especially in mental health) that exceed the general population. These unique health needs and settings should be considered as part of a country’s public health system. 16

There may be other state providers of health services. Delegated governance might place responsibility for health-related social services on regional governments or local authorities. This might include residential care for physically and mentally disabled citizens, and rehabilitation services. Large state employers might also provide occupational and curative health services for their workforce; examples include the railway sector 17 or extractive industries. 18

The independent sector

The model separates the independent sector into those providers that raise charges for services for financial gain (commercial and not-for-profit providers) and those that provide subsidised services free or at nominal cost (the NGO and charity sector, including social enterprises). The commercial group covers those healthcare providers that operate to make a profit for shareholders. This includes private hospitals, diagnostic centres and other clinical services. This segment of the market represents an expanding component of health systems in many low-income and middle-income countries. 19 The not-for-profit group covers healthcare providers that operate independently of government but are not profit generating for shareholders. Examples include occupational health services provided for employees of private companies, non-government insurance or mutually funded services, personally owned practices (including pharmacies) and traditional healers. The final category is the IA, NGO and charity sector. This can be divided into indigenous organisations and international organisations. The international group can also be divided into large multinational charitable IAs and NGOs that operate alongside the international development assistance funders and smaller charities that rely on private donations. Some multinational movements, such as the International Federation of Red Cross and Red Crescent Societies, have national societies that operate in most nations.

Conclusions

This paper builds on previously published work and, through further analysis, testing and debate, the original framework has been refined to be valid as a generic tool for DHE. It provides a comprehensive description of the concepts and thinking behind this holistic framework that captures the full breadth of national government and non-government health service providers. In addition to the state-provided services for public/population health and curative care, other state actors include government ministries such as Higher Education, Defence, and Interior. The actors in the non-government sector includes commercial and private providers alongside NGOs and charities.

We offer this model as a conceptual framework that can inform the development of DHE tools including collaboration between DHE and wider civilian global health systems strengthening activities. The model allows an analysis of the interdependencies across health services providers in order to identify opportunities for collaboration or deconfliction in DHE beyond solely the Ministry of Defence. We intend to test the validity of this model through cross-disciplinary case studies of specific country health systems and to develop a method to illustrate the relative contribution of each provider to the whole system. The model may also help in understanding how patients navigate health systems to meet their health needs, including consideration of seeking health services from outside their country. 20

Twitter: @MartinBricknell

Contributors: The paper was conceived and drafted by MB. All contributing authors made substantial contributions during the refinement of the paper.

Funding: MB, SI are partially funded through the UK Research and Innovation GCRF Research for Health in Conflict developing capability, partnerships and research in the Middle and Near East programme (R4HC-MENA) ES/P010962/1. RS is the Principal Investigator for the programme.

Competing interests: MB and RS salaries are partially funded by the UK Research and Innovation GCRF Research for Health in Conflict programme (R4HC-MENA) ES/P010962/1.

Provenance and peer review: Not commissioned; externally peer reviewed.

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• Volume 14, Issue 3
• What impact has the Centre of Research Excellence in Digestive Health made in the field of gastrointestinal health in Australia and internationally? Study protocol for impact evaluation using the FAIT framework
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• http://orcid.org/0000-0002-8647-5933 Natasha Koloski 1 , 2 , 3 ,
• Kerith Duncanson 1 , 4 ,
• http://orcid.org/0000-0003-1374-5565 Shanthi Ann Ramanathan 1 , 4 ,
• Melanie Rao 4 ,
• Gerald Holtmann 3 , 5 ,
• Nicholas J Talley 1 , 4
• 1 School of Medicine and Public Health , University of Newcastle , Callaghan , New South Wales , Australia
• 2 School of Health & Behavioural Sciences , University of Queensland , St Lucia , Queensland , Australia
• 3 Department of Gastroenterology & Hepatology , Princess Alexandra Hospital , Woolloongabba , Queensland , Australia
• 4 Hunter Medical Research Institute , Newcastle , New South Wales , Australia
• 5 School of Medicine , University of Queensland , St Lucia , Queensland , Australia
• Correspondence to Nicholas J Talley; nicholas.talley{at}newcastle.edu.au

Introduction The need for public research funding to be more accountable and demonstrate impact beyond typical academic outputs is increasing. This is particularly challenging and the science behind this form of research is in its infancy when applied to collaborative research funding such as that provided by the Australian National Health and Medical Research Council to the Centre for Research Excellence in Digestive Health (CRE-DH).

Methods and analysis In this paper, we describe the protocol for applying the Framework to Assess the Impact from Translational health research to the CRE-DH. The study design involves a five-stage sequential mixed-method approach. In phase I, we developed an impact programme logic model to map the pathway to impact and establish key domains of benefit such as knowledge advancement, capacity building, clinical implementation, policy and legislation, community and economic impacts. In phase 2, we have identified and selected appropriate, measurable and timely impact indicators for each of these domains and established a data plan to capture the necessary data. Phase 3 will develop a model for cost–consequence analysis and identification of relevant data for microcosting and valuation of consequences. In phase 4, we will determine selected case studies to include in the narrative whereas phase 5 involves collation, data analysis and completion of the reporting of impact.

We expect this impact evaluation to comprehensively describe the contribution of the CRE-DH for intentional activity over the CRE-DH lifespan and beyond to improve outcomes for people suffering with chronic and debilitating digestive disorders.

Ethics and dissemination This impact evaluation study has been registered with the Hunter New England Human Research Ethics Committee as project 2024/PID00336 and ethics application 2024/ETH00290. Results of this study will be disseminated via medical conferences, peer-reviewed publications, policy submissions, direct communication with relevant stakeholders, media and social media channels such as X (formely Twitter).

• Protocols & guidelines
• Irritable Bowel Syndrome
• Inflammatory bowel disease

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:  http://creativecommons.org/licenses/by-nc/4.0/ .

https://doi.org/10.1136/bmjopen-2023-076839

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STRENGTHS AND LIMITATIONS OF THIS STUDY

This protocol provides a prospective view of the application of the Framework to Assess the Impact of Translational health research to the Centre for Research Excellence in Digestive Health (CRE-DH with the explicit aim of optimising research impact and providing direction for future digestive health planning and prioritisation.

This protocol describes three validated methods of impact assessment including the Payback Framework that describes impact using quantified metrics in different domains, economic analyses to quantify the return on research investment and narratives to describe the pathway to impact and provide qualitative evidence of impact.

There is always a lag in the health research translation process resulting in delays in reporting the full extent of research impact. This lag will limit the reporting of the longer-term benefits of the CRE-DH, for which evidence will not be available.

Introduction

Chronic gastrointestinal (GI) diseases are a major health burden in Australia and worldwide. 1 2 More than one-third of Australians experience chronic or relapsing unexplained GI symptoms. 3 4 In half of these cases, symptoms are serious enough to require a medical consultation usually at a general practitioner clinic or an emergency department. These cases also currently make up half of all referrals to GI specialists. 5 For the majority of cases, however, no structural or biochemical abnormality is found after comprehensive and costly diagnostic workup resulting in a diagnosis of a disorder of gut-brain interaction (DGBI) most notably irritable bowel syndrome (IBS) or functional dyspepsia. 6 7 Currently, there is no cure and for DGBIs treatment approaches are suboptimal, leading to frequent healthcare consultations by these patients. 8 IBS alone has been estimated to cost more than US$41 billion annually in the USA. 2 For other chronic GI conditions, including gastro-oesophageal reflux disease and inflammatory bowel disease (IBD), the prevalence is increasing, placing pressure on the healthcare system. 9 10 Chronic GI diseases are also associated with significantly impaired quality of life, reduced work productivity, work absenteeism, relationship problems, higher levels of psychological distress and extraintestinal symptoms. 11–16

While there have been impressive advancements into the underlying pathology of chronic GI diseases in recent years, 17 18 there have been delays in the development of novel, pathology-based, subtyping of DGBI to facilitate improved integrated care and rationalised therapeutic strategies in clinical practice. This critical need was recognised by the Australian National Health and Medical Research Council (NHMRC) which funded the Centre for Research Excellence in Digestive Health (CRE-DH) from 2019 to 2024. The CRE’s vision is to advance the understanding, identification and treatment of chronic digestive diseases by implementing a risk-based and pathophysiology-based categorisation of patients and targeted treatments that are suitable for all sectors of the healthcare system (including primary care).

The specific objectives of the CRE scheme are to improve health-related outcomes and enhance translation of research outcomes into policy and/or practice while also building capacity in the health and medical research workforce. 19 This is aligned with the NHMRC definition of the impact of research as ‘the verifiable outcomes that research makes to knowledge, health, the economy and/or society, and not the prospective or anticipated effects of the research’. 20 However, the NHMRC also recognises that ‘the relationship between research and impact is often indirect, non-linear and not well understood and depends on complex interactions and collaboration across the health innovation system. 20 ’ This emphasis on research impact arises from the growing pressure on grant funding bodies to be accountable for taxpayer-funded research and provide evidence of the wider benefits of research above and beyond traditional academic outputs (eg, publications). Examples include evidence of translation to new drugs and devices, changes to policy and practice and ultimately the social and economic impacts on society including the return on research investment, in order to support continued research funding.

In light of the complexities involved in assessing the impact from research, a myriad of Research Impact Assessment Frameworks (RIAFs) have been developed that provide a conceptual framework and methods against which the translation and impact of research can be assessed. 21 22 However, most RIAFs tend to focus on specific research studies rather than research programmes such as CREs and are typically used retrospectively to justify past research investments. In contrast, the Framework to Assess the Impact from Translational health research (FAIT), developed by a team of health economists and health and medical researchers from the Hunter Medical Research Institute, is prospective in design and incorporates monitoring and feedback with the specific aim of increasing translation and impact. 23 Ramanathan et al applied FAIT to the CRE in Stroke Rehabilitation and Brain Recovery and assessed its validity and feasibility. 24 Overall, they found FAIT allowed a wide range of impacts to be reliably reported beyond the standard academic achievements. Thus, to take advantage of FAIT’s comprehensive design and prospective application, and allow for better benchmarking with other CREs, we have selected FAIT to assess the impact of the CRE-DH. This paper describes the protocol of a mixed methods study to:

Demonstrate the research impact and monetise the return on investment in the CRE-DH.

Provide a prospective view of optimising research impact.

Assess the suitability of FAIT.

The anticipated outcomes will be greater transparency and translation of research within CRE-DH, and the data will set the direction for future digestive health planning and prioritisation. In addition, this paper will contribute to this growing area of research impact assessment.

We prospectively applied FAIT to measure the impact of the CRE-DH. FAIT incorporates three validated methods of impact assessment. The Payback Framework describes impact within domains of benefit. Within FAIT, it has been modified to capture impact using quantitative indicators rather than qualitative data. Economic analyses are applied to quantify the return on research investment and narratives are used to describe the pathway to impact and provide qualitative evidence of impact. The assessment of the suitability of FAIT will take the form of a facilitated discussion among authors, at the conclusion of the impact evaluation, to identify the strengths and limitations of FAIT in the context of its application to the CRE and to make suggestions, if appropriate, for its future application

Details of FAIT have been previously published. 23

The setting is the CRE-DH, which is composed of senior, mid-career, early career and student researchers, clinicians, consumers and other key stakeholders in the fields of gastroenterology, immunology, microbiology, epidemiology, dietetics, psychology and biostatistics primarily from four major research centres across Australia. These include the University of Newcastle and Macquarie University in New South Wales, Princess Alexandra Hospital and University of Queensland in Queensland, and Monash University in Victoria, along with substantial international contributions from the University of Leuven in Belgium, McMaster University in Canada, Mayo Clinic in USA and Kings College in the UK. The CRE-DH researchers pool their highly complementary expertise and capabilities for projects within the CRE-DH, which facilitates recruitment of large representative patient cohorts, the availability of cutting-edge methodologies and translation of findings into practice and policy. The CRE-DH was funded ($A2.5 million) from 2019 to 2024.

Participants

These include a mix of experienced, early career and student researchers associated with the CRE-DH and end users of the findings and outputs of the CRE-DH including other DGBI researchers, patients, consumers more broadly, clinicians, health services, policy-makers and industry partners.

Patient and public involvement

Development of the FAIT model involved extensive and broad end user engagement including interviews with the following key stakeholder groups—researchers from across the research spectrum, multiple Australian medical research institutes, health and medical research funders including the NHMRC, Australian Research Council, The Medical Research Futures Fund, NSW Office for Health and Medical Research, Brunel University, UK and Karolinska Institute, Sweden who were leaders in the field at the time and policy-makers. All interviews were conducted by staff from the Health Economics and Impact team at HMRI and covered attitudes to impact measurements, barriers and enablers, what was being done at the time and opinions about what should be done. There was a diversity of views and differences which were reconciled by designing a comprehensive framework (FAIT) that addressed all their needs. There is an absolute bias to selecting and reporting metrics for which there are data and this is addressed by impact planning that ensures as much data as possible is collected from the start. Other ways this bias is mitigated is by expressing the limitations and bias inherent in an impact assessment framework like FAIT.

This was supplemented by broad consumer representation on the CRE-DH advisory board that provided feedback at all stages of CRE-DH impact framework development. The use of the existing Payback domains and input from consumers with a range of conditions and experiences will ensure that the metrics selected reflect a broad range of potential impacts beyond academic impacts.

The study involves a five-stage sequential mixed method design, summarised as follows:

Phase 1: Development of a programme logic model (PLM) to map the pathway to impact and establish domains of benefit and aspirational impacts.

Phase 2: Identifying and selecting appropriate, measurable and timely impact indicators for each of these domains and establishing a data plan to capture the necessary data.

Phase 3: Developing a model for the cost–consequence analysis and identification of relevant data for micro costing and valuation of consequences (where appropriate).

Phase 4: Determining selected case studies to include in the narrative including the data collection for these.

Phase 5: Collation, data analysis and completion of the reporting of impact using the three methods.

Phase 1: development of a logic model to map the pathway to impact and establish domains of benefit

A PLM is a critical component of any FAIT impact assessment. The PLM used in FAIT is a map that follows the pathway from the need for the CRE through its aims, activities, outputs and aspirational impacts. The CRE-DH logic model ( figure 1 ) shows how the needs and aims drive CRE activities. These activities should produce outputs that, when used by an end user, creates an opportunity for the generation of impact. These impacts are articulated as both short-term and medium-long-term impacts under broad domains of benefit such as impacts on knowledge advancement, capacity building, clinical implementation, policy legislation, community and economic impacts. While the PLM appears linear, its application over the lifetime of the CRE-DH will most likely be non-linear and subject to change.

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Logic model for the CRE-DH. CRE-DH, Centre for Research Excellence in Digestive Health; DGBI, disorder of gut brain interaction; GI, gastrointestinal; QOL, quality of life; TGA, Therapeutic Goods Administratio; EMCR, Early/Mid career researchers

Phase 2: identifying and selecting appropriate, measurable and timely impact indicators for each of these domains and establishing a data plan to capture the necessary data

The PLM ( figure 1 ) identifies the Payback domains of benefits under which the CRE’s impact will be assessed. Impact metrics have been developed and customised for the CRE-DH taking into account their appropriateness for the CRE-DH and its aims and their ability to be measured in a timely manner. Table 1 shows the list of Payback metrics under each domain for which evidence is captured.

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Payback metrics table for the CRE-DH

Routine monitoring of implementation embedded into each project stream

The purpose of this data collection method is to collect quantitative data to monitor and measure the impact of specific studies within the CRE-DH and its capacity building and translational activities. Initial data collection involves annual distribution of a CRE-DH impact data survey via REDCap to chief investigators and associate investigators to be populated for all their CRE-DH affiliated researchers. Results of the survey are being collated into an Excel file that includes individual spreadsheets that are aligned with impact indicators. Additional data are being retrieved from available sources including publicly available online data from researchers’ university profiles, data collected for triannual CRE-DH advisory board meetings, through ethics systems, publication tracking and evaluation of CRE-DH organised capacity building and translational activities. The Excel spreadsheets for each project stream are being emailed annually to each CI to add any data that has not been captured using the above methods.

Reports during the regular team meetings

This data collection method aims to collect quantitative and qualitative data to monitor and measure the translation, implementation and impact of CRE-DH that are not obtained from routine monitoring. The data are collected online by accessing the recorded monthly CRE-DH meeting minutes and added to project stream spreadsheets or flagged for further discussion in semistructured interviews for vignettes or case study examples of CRE-DH impact, described as part of phase 4.

Phase 3: developing a model for the cost–consequence analysis and identification of relevant data for microcosting and valuation of consequences (where appropriate)

To determine whether the cost associated with the delivery and participation in activities associated with the CRE-DH and the consequences achieved represent a good return on investment, a cost–consequence analysis will be undertaken. 25

First, we will detail out the activities funded by the NHMRC investment. Second, we will microcost any activity and other costs not covered by the US$2.5 million NHMRC research investment and add these to the NHMRC investment as implementation costs. This will include costing all in-kind investigator time and capacity building participation time not directly funded by the CRE monies.

Microcosting data will involve a log of all intervention activities including the individual’s involved, their roles and wages and the time taken for implementation. Other resources such as travel and consumables will also be costed. The proportion of cost attributable to CRE-DH activity will be estimated where feasible.

In collaboration with the lead investigators of the CRE-DH, the consequences of the CRE-DH will be established including the consequences that cannot be monetised and appear in their natural units in the Payback metrics table. For those consequences that can be monetised, economic methods will be employed to adequately monetise their value and determine the appropriate level of attribution to the CRE-DH. This will include a search of the literature for established values for these consequences (where they occur), clearly defined assumptions about these values and sensitivity analyses to account for any variance in these values. Given that CRE-DH activity will be occurring concurrently with other research activities supported by the research institutions from which CRE-DH researchers are affiliated, attribution of consequences (eg, leveraged funding) will take this into account. Where practical, researchers will be asked for their own assessment of CRE-DH attribution to a particular consequence or a conservative attribution percentage will be applied to avoid overclaiming the consequences and impacts of CRE-DH. All values will be converted into Australian dollars and valued in the year that the final analysis is conducted.

Phase 4: determining selected case studies to include in the narrative including the data collection for these

During the course of the CRE-DH, the pathways to adoption of the outputs will be documented by the team and team meetings will be used to highlight potential case studies that can be developed to demonstrate outstanding impacts of the CRE-DH or case studies that describe key learnings. Semistructured interviews will be conducted to collect relevant data that will inform these case studies. It is anticipated that these interviews will be with CRE-DH researchers and key end users, where appropriate.

Semistructured interviews involving CRE-DH staff, collaborative investigators, advisory group members and other key stakeholders

Qualitative data will be collected, to provide context and a richer, more comprehensive overall understanding of the impact of the CRE-DH. Topics of interest will be flagged through the quantitative data collection and in meeting discussions, based on the underlying question of ‘How did this publication, conference presentation, collaboration, capacity building activity or project lead to an impactful outcome that would not have been achieved without the CRE-DH?’ Interviews will be facilitated by the HMRI FAIT team, who have expertise in qualitative data collection for impact evaluation. These data will be narratively synthesised and triangulated with quantitative data and incorporated into impact evaluation reporting within the narrative method and include specific quotes from the researchers and end-users.

Impact assessment data will be collected for the 5-year period from November 2019 to October 2024.

Phase 5: collation, data analysis and completion of the reporting of impact using the three FAIT methods

The data collected over the course of the CRE-DH using the various methods described above will be reported using the FAIT scorecard format. 23

Results for the metrics table will be collated and where bibliometric results are required, a cut-off date will be established after which time, the results will not be updated. The cost–consequence will be reported by way of a cost–consequence table that will only include the consequences that can be monetised. Other consequences will be reported in their natural units in the Payback metrics tables. The narratives will be reported as vignettes highlighting some of the outstanding achievements of the CRE-DH including the pathway to translation and impact.

Ethics and dissemination

This impact evaluation study has been registered with Hunter New England Human Research Ethics Committee as project 2024/PID00336 and ethics application 2024/ETH00290. Results of this study will be disseminated via medical conferences, peer-reviewed publications, policy submissions, direct communication with relevant stakeholders, media and social media channels such as X (formerly Twitter).

This protocol aims to define and describe processes to collect, collate and synthesise data for the CRE-DH to evaluate the impact of the CRE-DH from inception in November 2019 to final data collection in mid-2024 for reporting of outcomes in October 2024. We plan to operationalise this protocol as a mixed-methods study by applying a PLM to the original aims and needs identified in our CRE-DH application, to use that modelling to review CRE-DH progress towards our aims, and to inform prospective direction for the CRE-DH based on ongoing progress and at specified annual data collection review time points. Therefore, our impact evaluation will be an organic, prospective, informative and responsive process, as well as providing an overall final and retrospective account of CRE-DH impact by the end of 2024. Impact will be reported and used to inform future funding applications and direction for digestive health research in Australia, and position the CI, AI and affiliate team as leaders in the field internationally. This impact evaluation will also inform future directions for DGBI and other digestive diseases research, which we expect to overlap and integrate more with related fields such as immune and microbiome research in coming years. The prospective design of our impact evaluation will facilitate expansion into new fields throughout the life of the CRE-DH, which will enhance translation potential, impact and transformative research and clinical practice change.

Although, there are other frameworks from various medical fields 26 to assess evaluation of research outcomes, this evaluation applied the FAIT to the CRE-DH with the explicit aim of optimising research impact and providing direction for future digestive health planning and prioritisation.

Despite the benefits of comprehensively assessing the impact of the CRE-DH using three distinct methods namely quantified impact metrics, a cost–consequence analysis and a narrative of the impact there are some potential risks and limitations. These include (1) Lag in translation could impact on the ability to capture and demonstrate longer-term impacts. (2) Data collection for impact reporting while feasible, does require additional commitment by CRE partners to ensure it is comprehensive and complete. Therefore, this could be seen as an added administrative burden and may not be completed as required. However, the desire to continue the collaboration and the fact that CRE affiliates have been engaged with the impact assessment from the start should provide a counterbalance to the burden. The inclusion of the HMRI Research Impact Team as expert advisors will also ensure that multiple strategies previously used in other CRE impact assessments are employed to enhance data collection. (3) Attribution of impacts is challenging and will have to rely on researchers to attribute the contribution of CRE-DH to a particular consequence. (4) Selection of case studies means other potential impact stories may be foregone.

The novelty of this work is that the application of FAIT is still very much in its infancy with only two protocol papers (both using very different framings for the application) 24 27 and only one results paper published. 28 There is still much to learn and reflect on in the application of such a comprehensive framework, and this protocol paper will provide a useful roadmap for other GI research collaborations planning formal impact evaluations. A deepened understanding about what enhances the impact of a CRE will only be possible when we have benchmarked protocols and outcomes. We will then have the ability to undertake meta-analyses to ascertain what works under what circumstances in order to further enhance the impact in a large and complex research collaborative such as a CRE. Contribution to a larger bank of metrics will give visibility to the potential capacity and capability impacts from CREs.

This study will capture outputs and impacts that have been initiated or enhanced as a result of the CRE-DH’s collaborative efforts of basic scientists, allied health and medical clinician researchers, translational scientists, consumers and advisors across the spectrum from animal, preclinical laboratory research to health service delivery from acute to integrated and primary care settings. All costs for CRE-DH activity will be valued and where possible, the economic analysis will monetise reportable CRE-DH outcomes and impacts. If this is not possible, these impacts will be reported in their natural units. We expect this impact evaluation to comprehensively describe the contribution of the CRE-DH to a range of impacts including any improved outcomes for people suffering with chronic and debilitating digestive disorders. The impact evaluation will inform future directions for digestive health research and assessment of its impact.

Ethics statements

Patient consent for publication.

Not applicable.

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Twitter @Ramanathan

Contributors NK was involved in conceptualisation, methodology, project administration, writing of the original draft, revisions and editing. KD contributed to conceptualisation, writing of the original draft,revisions and editing. SAR was involved in the conceptualisation, methodology and writing of the original draft. MR, GH and NT were involved in the writing of the original draft, revisions and editing. In addition, GH and NT were involved in funding acquisition and resources.

Funding This work was supported by National Health and Medical Research Council of Australia, APP1170893.

Competing interests NK, KD, SAR and MR disclose no conflicts. NT is Emeritus Editor-in-Chief of Medical Journal of Australia, Section Editor of Up to Date and has research collaborations with Intrinsic Medicine (human milk oligosaccharide), Alimentry (gastric mapping) and is a consultant for Agency for Health Care Research and Quality (fiber and laxation), outside the submitted work. In addition, he has licenced Nepean Dyspepsia Index (NDI) to MAPI, and Talley Bowel Disease Questionnaire licensed to Mayo/Talley, 'Diagnostic marker for functional gastrointestinal disorders' Australian Provisional Patent Application 2021901692, 'Methods and compositions for treating age-related neurodegenerative disease associated with dysbiosis' US Patent Application No. 63/537,725. GH received unrestricted educational support from the Falk Foundation. Research support was provided via the Princess Alexandra Hospital, Brisbane by GI Therapies, Takeda Development Center Asia, Eli Lilly Australia, F. Hoffmann-La Roche, MedImmune, Celgene, Celgene International II Sarl, Gilead Sciences, Quintiles, Vital Food Processors, Datapharm Australia Commonwealth Laboratories, Prometheus Laboratories, FALK GmbH & Co KG, Nestle, Mylan and Allergan (prior to acquisition by AbbVie). GH is also a patent holder for a biopsy device to take aseptic biopsies (US 20150320407 A1).

Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details.

Provenance and peer review Not commissioned; externally peer reviewed.

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