ABSTRACT
Introduction
As the burgeoning roles of women afford them the opportunities to perform in all combat and combat support assignments, the impact of all environmental, occupational, physical, and psychosocial factors inherent in military training and operations on their health must be considered. A robust foundation of knowledge is necessary to ascertain, prevent, and treat the potential impacts on women’s health. However, a systematic review of the literature from 2000–2015 revealed widespread gaps in scientific knowledge of the musculoskeletal, psychological, occupational, and reproductive health of military women. The purpose of this study is to determine priorities for military women’s health (MWH) research that will serve to fill these gaps in knowledge.
Methods
An advisory group of 11 senior military and women’s health experts conducted a structured gap analysis of the results of a scoping review of literature from 2000 to 2015 and Military Health System utilization data to identify 15 topics for prioritization in MWH research. A modified e-Delphi study was conducted and consensus was achieved after two rounds. Participants (N = 32) included subject matter experts (SME) representing various professions enrolled, 23 completed both rounds. In round 1, topics were rated on forced Likert scales for relevance and feasibility to medical readiness and comments were elicited from the SMEs. Relevance and feasibility scores and themes from the comments guided the development of the round 2 survey, in which SMEs categorized the topics in terms of urgency and forced-choice ranked the priority of each topic. The quantitative data were analyzed using multilevel regression methods. Linear mixed models were fit separately on the numeric outcomes for feasibility, relevance, and urgency with research topic as the primary predictor. To analyze the rankings of research topic priority, crude and adjusted linear regression models were fit on the numeric outcome rank.
Results
The adjusted top five topics for research priorities as indicated by ranking were: genitourinary health, sleep, physical assault, behavioral health, and menstrual cycle research. The advisory group reviewed the findings in the context of Department of Defense strategic priorities and provided guidance on the design and dissemination of the MWH research agenda.
Conclusions
The MWH research agenda is a validated research agenda of high-priority research topics that will promote enduring efforts to ensure evidence-based practices and health policies for military women through research.
INTRODUCTION
Optimizing the health status and preserving the readiness of the nation’s military fighting forces is contingent upon the delivery of high quality, evidence-based health care to all service members. However, since the 1970s, a plethora of recommendations to improve the health care and readiness of active duty women (ADW) has largely been disregarded.1 Currently, women make up 17.5% of the active duty U.S. Armed Forces.2 Although women were officially integrated as permanent members of the U.S. Military in 1948, their occupational roles remained limited until 2016, when they became eligible to serve in all combat military occupational specialties. The impact of the full spectrum of environmental and occupational conditions on the health of military women needs consideration to strengthen the military readiness of these service members. Health care professionals and Department of Defense (DOD) military and civilian service leaders require evidence-based recommendations supported by rigorous scientific research to ensure and promote policies that lead to the delivery of quality care and improve the wellbeing of all service members. However, DOD research and policy efforts in promoting military women’s health (MWH) over the last several decades have demonstrated significant limitations and resulting gaps in the current state of knowledge. Research efforts are critical in advancing sex- and gender-specific health care that enhances military women’s readiness. For over 70 years, women have honorably served alongside their male counterparts, yet the foundational knowledge required to optimize their health falls short of apparent needs.
RESEARCH FOCUSED ON MILITARY WOMEN’S HEALTH 1994–2005
Over two decades ago, $40 million was congressionally directed for a DOD biomedical research program for military women’s issues. In 1994, the DOD launched the Defense Women’s Health Research Program (DWHRP), responding to a:
…growing awareness of gender-unique problems, such as high injury rates; renewed questions about women’s psychological fitness as fighters; assumptions about the fragility of the female reproductive system; and new concerns about occupational and environmental exposure hazards that might affect pregnant Servicewomen or harm their fetuses.3(p765)
In 1994, the DWHRP called for proposals to address 10 specific research priorities for military women based on recommendations from Congress and the Defense Advisory Committee on Women in the Military (DACOWITS), and considerations of other “identified service problems” in the female military population.3(p767) A decade after DWHRP research initiation, varying levels of success were noted among the 10 identified research priorities. Extramural programs appeared more successful than intramural projects, which was attributed to differences between the processes of scientific discovery (a hallmark of academia) and reacting to near-term problems, which is characteristic of military research laboratory intramural efforts.3 Shortly following the launch of the DWHRP, many of the pre-established research priorities required revision after they were found to have been established in accordance to the propensity for continued funding, gender-biased “longstanding myth,”3(p794) and presumptions about female physiology and military-related risks that were “astoundingly wrong.”3(p764) Regardless, the findings of 134 DWHRP-funded projects eventually led experts to refine the research gaps for military women: psychological support for military families, musculoskeletal injuries, psychological resilience in response to traumatic events, reproductive hazards in the workplace, and deficiencies in clinical care, specifically gynecological and contraceptive care.3
HEALT HCARE UTILIZATION TRENDS AMONG MILITARY WOMEN 2005–2015
In the decade following the DWHRP, both hospitalization and ambulatory care trends in ADW demonstrated a need for further inquiry into the health and care of women in obstetrics, genitourinary, and mental health. The gap between the research and the actual military women’s needs was more evident when placed in the context of the specific health care issues that ADW sought for care in the MHS.4 For example, in 2008 pregnancy-related conditions including labor and delivery accounted for 20.8% of “all active duty service member” hospitalizations.5 Furthermore, the hospitalization rate for women was 34% higher than men, with the largest rate differences in genitourinary and mental disorders. Women also sought ambulatory care for illness and injuries at higher rates than men for unspecified joint and back disorders, adjustment disorders, common vision disorders (accommodation and refraction), and acute upper respiratory infection.6 Six years later, in 2014, there were more cases of mental disorders, musculoskeletal disorders, and injury/poisoning among women than men in both the outpatient and inpatient settings; women received ambulatory care most often for musculoskeletal conditions, mental disorders, diseases of the nervous system/sense organs (including vision), the genitourinary system, injuries/poisoning, and other ill-defined conditions.7 These trends in health care utilization not only substantiate the gaps in research that were identified in 2005, but also reveal further need to assess the adequacy of the existing research to address the most common conditions in women, particularly when they occur at higher rates than among men.
GAPS IN THE LITERATURE 2000–2015
The ongoing gaps in research related to MWH have been characterized by the lack of quantity and quality in research publications. In an extensive scoping review of the literature from 2000 to 2015 that included 979 publications, Englert and Yablonsky8 found significant gaps in eight major topics: psychological health, readiness, injury, acute care and preventive medicine, deployment health, sexual and physical assault, obstetrics and gynecology (OB/GYN), and chronic illness. Based on a comparison with MHS health care utilization data from 2014, they concluded that there was an insufficient base of knowledge in the context of the high rates of health care utilization for specific conditions. OB/GYN and psychological health were identified as having the most gaps in knowledge, which was evident by the low quantity of research and the high proportion of low-quality publications in those areas. Furthermore, despite the wide scope of topics in comprehensive literature reviews, the analyses consistently revealed a lack of in-depth analysis and availability of high-quality studies in most areas.7,9 Most recently, in a directed review of ADW’s health care services, the Defense Health Board (DHB) validated the ongoing lack of knowledge, research, and policies in the same areas that have been consistently identified over the past 25 years.1 The overall goal of this study is to develop an evidence-based women’s health research agenda that combines science, expertise, and strategic considerations in order to direct future research, resources, and policy efforts to the topics that are most pertinent to conserving the strength of the force.
Research agendas enhance the efficiency of research investigators and facilitate progress towards filling knowledge gaps in a particular field/area. Setting clear, need-based priorities also helps leverage and promotes good stewardship of limited research resources and includes input from multidisciplinary stakeholders to include end users.10,11 A research agenda consisting of the high-priority areas that lack a substantive knowledge base will facilitate the allocation of resources for research that are required to optimize health outcomes for women. A military women’s health research agenda (MWHRA) that is developed through a rigorous process by key stakeholders could be a significant lever for advancing the science. The purpose of this study is to determine priorities for MWH research that will serve to fill the gaps in knowledge and promote evidence-based practices and health care policies for military women. The specific aims were to generate a list of MWH research priorities that are validated through subject matter expert (SME) consensus and to produce the MWHRA.
METHODS
This study was conducted in three phases from October 2017 to May 2019. In phase 1, an advisory group (AG) of 13 senior military and international women’s health leaders with a wide breadth of expertise, including active duty and reserve members of the U.S. Army, Navy, and Air Force and experts from diverse settings such as DOD Health Affairs, the U.S. Public Health Service, NIH Office of Research on Women’s Health, Veterans Affairs Health Services Research and Development, and academia, was convened. The AG conducted a structured gap analysis between the literature and MHS utilization data and generated a broad list of initial research topics for consideration by the SMEs. In phase 2, a modified e-Delphi process was conducted with a panel of SMEs until consensus on priorities was reached. In phase 3, the AG reviewed the findings in the context of current DOD strategic priorities and provided guidance on the production and dissemination of the MWHRA. The study protocol was approved by the appropriate human subjects regulatory authority. Investigators adhered to the policies for the protection of human subjects as prescribed in 45 Code of Federal Regulation 46.
Phase 1 Methods
In phase 1, the AG met to examine the findings from the literature reviews, conduct a gap analysis, and establish an initial list of MWH research topics for consideration by the SMEs. The AG members were sent a comprehensive read-ahead file that included bios of all group members, the systematic and scoping review study reports by Trego et al.9 and Yablonsky et al.,7 respectively, and a study team developed gap analysis guide. The gap analysis guide provided detailed descriptions of the three key questions for consideration by the AG, as well as the operational definitions for the gap analysis process. Following briefings on the 2015 and 2017 reports, the AG members met in breakout groups to consider the previously identified gaps within the context of their area of expertise. See Fig. 1 for an overview of the gap analysis process.
FIGURE 1.
An overview of the gap analysis process.
Phase 2 Methods
In phase 2, we conducted the Delphi process, a method to achieve the consensus of SMEs through an iterative process known as rounds.12,13 A SME was defined as a person with bona fide expert knowledge and proficiency stemming from education and experience in MWH, clinical practice, management of care services, planning/purchasing health care, research, research funding, health care education, or health care policy. SME participants were recruited through purposive sampling of military, academic, and professional agencies via social media, listservs, the Service Consultants to the Surgeons General of each Service, and at targeted conferences through recruitment flyers. An electronic Delphi (e-Delphi) survey was designed and administered in REDCap (Research Electronic Data Capture) electronic data capture tools hosted at the University of Colorado Denver.14 REDCap is a secure, web-based application designed to support data capture for research studies. As an incentive/token of appreciation, participants were offered a link to a $5 e-gift card after completing each survey round.
The first round of the Delphi survey was a confirmatory process of the a priori research topics that were identified in phase 1. SME’s completed a Likert-type scale of 1 (strongly disagree) to 4 (strongly agree) for each topic in terms of “relevance” and “feasibility.” “Relevance” was defined as the relation of a research topic to the Medical Readiness of female service members, with relevance referring to the provision of health care services that promote medically fit female service members. “Feasibility” was defined as the likelihood that research on the topic will result in recommendations for clinical practice, education, or policies that will improve the readiness of female service members.
Additionally, The SMEs were provided with optional free text boxes to state their rationale and provide comments for the score for each topic, as well as overall comments about topics in round 1. Following content analysis of the free text entries from round 1, these qualitative data were incorporated into the preparation of the e-Delphi Survey round 2.
In the Delphi method, knowledge of critical issues is gained during each round. Accordingly, the quantitative and qualitative results from round 1 were synthesized by the study team and considered during the preparation of the e-Delphi survey for round 2. The revised topics, definitions, feasibility comments, and specifically recommended research studies were provided for participants to consider in round 2. In accordance with Delphi methodology, the study team organized the results in a manner that addressed differences of opinion and retained anonymity.
In the round 2 e-Delphi survey, participants assessed the “urgency” of research on each topic. “Urgency” was defined as the immediacy of the need for research on a topic as it relates to the medical readiness of female service members. They were first asked to indicate the level of urgency as “not urgent, somewhat urgent” (research should be conducted within 3–6 years), or “most urgent” (research should be conducted within the next 3 years). Then, they were asked to prioritize the research topics in order of importance to the medical readiness of female service members by ranking them from 1 (highest priority) to 15 (lowest priority).
Following round 2, the SMEs were requested to complete a survey consisting of five questions to evaluate the e-Delphi process on their satisfaction with providing input, preserving anonymity, reflecting individual input, representing individual ideas, and advancing MWH.
Phase 3 Methods
In phase 3 of the study, the AG met virtually to review study findings in the context of current DOD strategic priorities. The key strategic documents provided for their consideration were the Defense Health Agency (DHA) Strategy Map FY17,15 Department of the Navy Strategic Guidance FY20–23,16 USAF Posture Statement 2020,17 Army Strategy 2018,18 Army Medicine 2020 Campaign Plan,19 and a summary of the 2018 National Defense Strategy.20 Then they were requested to provide guidance on the effective design and dissemination of the MWHRA to key decision makers involved in health care policy, research, and funding.
ANALYSIS
The qualitative data were analyzed using content analysis methods: members of the study team coded the SMEs’ comments on the topics and overall research priorities, developed themes for each topic, and conducted inter-rater reliability on each topic with two other coders. The quantitative data were analyzed using multilevel regression methods. Descriptive statistics were calculated for demographic characteristics and the e-Delphi process satisfaction data. Linear mixed models were fit separately on the numeric outcomes for “feasibility,” “relevance,” and “urgency” with research topic as the primary predictor. A random effect for participants (each SME) was included in each model to account for repeated measurements on participants. To analyze the rankings of research topic priority, crude and adjusted linear regression models were fit on the numeric outcome rank. Research topic was the primary predictor and the adjusted model also included feasibility, relevance, and urgency as covariates. A Pearson’s correlation was performed to determine the correlation between the crude and adjusted mean importance ranks. The data analysis for this study was generated using SAS software. Copyright © 2013 SAS Institute Inc.
RESULTS
Phase 1 Results
Fifteen topics emerged from the first AG meeting: Cancer, Chronic Illness, Sleep, Genitourinary Health, Sexually Transmitted Infections, Menstrual Cycle, Contraception, Behavioral Health, Fertility, Unplanned Pregnancy, Obstetrics, Breast Wellness, LGBTQ, Sexual Assault, and Physical Assault. The 15 topics were broadly defined by the study team members for inclusion in round 1 of the Delphi Survey. See Supplementary Appendix 1 for topic definitions.
Phase 2 Results
Thirty-two SMEs enrolled and participated in round 1 of the Delphi survey. Participants were affiliated (either civilian or military) with the Army (n = 9), Navy (n = 2), Air Force (n = 3), Veterans Affairs (n = 8), the Uniformed Services University of Health Sciences (n = 7), and/or other academic/research organization (n = 13). Four participants were active duty military, 3 retired military, 28 identified as females, and 32 identified as white.
Round 1 Results
Relevance
The relevance of the research topic is represented by the respondents’ mean scores. The higher the mean score, the stronger the SMEs agreed that a topic was relevant, demonstrating a degree of consensus on relevance. The range of mean scores was 2.94 to 3.78.
Feasibility
The feasibility of the research topic is represented by the respondents’ mean scores. The higher the mean score, the stronger the SMEs agreed that a topic was feasible, demonstrating a degree of consensus on feasibility. The range of mean scores was 3.04 to 3.73.
Following content analysis of the free text entries from round 1, the revised topics, definitions, feasibility comments, and specifically recommended research studies were provided for participants in round 2. See Supplementary Appendix 2 for the Revised Research Topic Definitions and Examples.
Round 2 Results
Urgency
The urgency of the research topics was categorically assessed (1 = Not urgent, 2 = Somewhat urgent, or 3 = Most urgent). “Urgency” was defined as the immediacy of the need for research on a topic as it relates to medical readiness of female service members. The higher the mean score, the stronger the respondents agreed on the immediacy of the need for research on that topic, demonstrating a degree of consensus on the urgency to conduct research on the topic. In summary, the mean relevance, feasibility, and urgency scores all significantly differed by topic (P < .0001, P = .0002, and P < .0001) (Table I).
TABLE I.
Relevance, Feasibility, and Urgency of Research Topics
| Round 1 (N = 32) |
Round 2 (n = 23) |
||
|---|---|---|---|
| Research topic | Relevance estimate (95% CI) | Feasibility estimate (95% CI) | Urgency estimate (95% CI) |
| Behavioral health | 3.53 (3.27, 3.79) | 3.63 (3.34, 3.92) | 2.57 (2.32, 2.81) |
| Breast wellness | 2.94 (2.68, 3.21) | 3.04 (2.74, 3.34) | 1.82 (1.57, 2.06) |
| Cancer | 3.20 (2.94, 3.46) | 3.09 (2.79, 3.38) | 1.91 (1.66, 2.16) |
| Chronic illness | 3.52 (3.27, 3.77) | 3.17 (2.89, 3.46) | 1.86 (1.62, 2.11) |
| Contraception | 3.78 (3.52, 4.04) | 3.73 (3.44, 4.02) | 2.49 (2.23, 2.74) |
| Fertility | 3.23 (2.98, 3.49) | 3.37 (3.08, 3.67) | 1.73 (1.48, 1.97) |
| Genitourinary health | 3.76 (3.49, 4.02) | 3.57 (3.28, 3.87) | 2.20 (1.95, 2.45) |
| LGBTQ | 3.17 (2.91, 3.43) | 3.07 (2.78, 3.37) | 1.87 (1.63, 2.11) |
| Menstrual cycle | 3.76 (3.49, 4.02) | 3.54 (3.25, 3.84) | 2.05 (1.79, 2.32) |
| Obstetrics | 3.42 (3.16, 3.67) | 3.38 (3.09, 3.68) | 2.11 (1.85, 2.36) |
| Physical assault | 3.26 (3.00, 3.52) | 3.36 (3.07, 3.65) | 2.57 (2.32, 2.81) |
| Sexual assault | 3.74 (3.49, 3.99) | 3.52 (3.24, 3.81) | 2.83 (2.58, 3.07) |
| Sleep | 3.30 (3.05, 3.56) | 3.35 (3.06, 3.63) | 2.22 (1.98, 2.46) |
| STI | 3.01 (2.75, 3.26) | 3.14 (2.85, 3.43) | 2.04 (1.80, 2.29) |
| Unplanned pregnancy | 3.23 (2.98, 3.49) | 3.41 (3.12, 3.70) | 2.22 (1.98, 2.46) |
| P-value | <.0001 | .0002 | <.0001 |
Type III test of fixed effects P-value. Possible scores range from 1 (strongly disagree) to 4 (strongly agree) for relevance and feasibility. Possible score for urgency range from 1 (not urgent) to 3 (most urgent). Nine participants did not complete the round 2 survey.
Abbreviations: LGBTQ = lesbian, gay, bisexual, transgender, and questioning; STI = sexually transmitted infections.
Priority ranking
SME’s then rank-ordered topics from 1 to 15 (1 = highest priority, 15 = lowest priority) to prioritize the order of importance of each topic to medical readiness for female service members. Crude simple linear regression models were fit on the numeric outcome for rank. Topic, feasibility, relevance, and urgency were all single primary predictors of rank of importance in four separate models. The crude model with topic as the predictor shows the observed (crude) mean rank of each topic (Table II).
TABLE II.
Crude and Adjusted Estimates of Rank Predicted by Subject Matter Experts’ Scores for Topic Importance, Feasibility, Relevance, and Urgency
| Predictor | Crude estimate (95% CI) | Crude P-value | Adjusted estimate (95% CI) | Adjusted P values |
|---|---|---|---|---|
| Topic | See Table III | <.0001 | See table 3 | .0144 |
| Feasibility | −0.958 (−1.60, −0.32) | .0033 | 0.308 (−0.44, 1.06) | .4208 |
| Relevance | −1.67 (−2.35, −0.99) | <.0001 | −0.746 (−1.61, 0.12) | .0905 |
| Urgency | −2.64 (−3.28, −2.00) | <.0001 | −2.00 (−2.76, −1.24) | <.0001 |
The crude estimates are from four different models using each of the predictors separately.
The predictors that had a crude significant relationship with the rank were used in an adjusted model. An adjusted multiple linear regression model was fit on rank. Topic, feasibility, relevance, and urgency were the primary predictors. This final model showed the predicted (adjusted) mean importance rank (Table III).
TABLE III.
Topic Estimates from the Crude and Adjusted Estimates for the Effect of Topic on Subject Matter Expert’s Importance Ranking
| Predictor | Research topic | Crude estimates (95% CI) | Crude P-value |
Adjusted estimatesa (95% CI) |
Adjusted P-value |
|---|---|---|---|---|---|
| Topic | <.0001 | .0144 | |||
| Behavioral health | 6.26 (4.65, 7.88) | 6.93 (5.28, 8.58) | |||
| Breast wellness | 10.26 (8.65, 11.88) | 9.21 (7.47, 10.95) | |||
| Cancer | 10.43 (8.82, 12.05) | 9.44 (7.68, 11.19) | |||
| Chronic illness | 8.65 (7.04, 10.27) | 7.89 (6.23, 9.54) | |||
| Contraception | 6.77 (5.12, 8.42) | 7.66 (5.93, 9.4) | |||
| Fertility | 10.17 (8.56, 11.79) | 8.8 (7.06, 10.53) | |||
| Genitourinary health | 5.65 (4.04, 7.27) | 5.27 (3.59, 6.95) | |||
| LGBTQ | 9.96 (8.34, 11.57) | 9.06 (7.38, 10.74) | |||
| Menstrual cycle | 6.78 (5.17, 8.4) | 7.14 (5.36, 8.92) | |||
| Obstetrics | 10.13 (8.51, 11.75) | 9.89 (8.22, 11.55) | |||
| Physical assault | 5.91 (4.3, 7.53) | 6.68 (5.01, 8.34) | |||
| Sexual assault | 5.74 (4.12, 7.35) | 7.23 (5.57, 8.89) | |||
| Sleep | 6.57 (4.95, 8.18) | 6.57 (4.98, 8.16) | |||
| STI | 8.61 (6.99, 10.22) | 7.95 (6.3, 9.6) | |||
| Unplanned pregnancy | 7.86 (6.21, 9.52) | 7.71 (6.04, 9.38) |
The adjusted estimates indicate the mean rank adjusted for how relevant, feasible, and urgent the topics are.
Abbreviations: LGBTQ = lesbian, gay, bisexual, transgender, and questioning; STI = sexually transmitted infections.
Topic, feasibility, relevance, and urgency were all significantly associated with rank in the crude models (P < .0001, P = .0033, P < .0001, and P < .0001). However, in the adjusted model, topic and urgency were the only significant predictors of rank (P = .0144, P < .0001).
Based on the observed (crude) ranks, genitourinary health, sexual assault, physical assault, behavioral health, and sleep were ranked as the top five most important topics. Once feasibility, relevance, and urgency were factored in, the predicted (adjusted) ranks showed that genitourinary health, sleep, physical assault, behavioral health, and menstrual cycle were ranked as the top five most important topics (Table IV).
TABLE IV.
Comparison of Research Topic Ranks from Crude and Adjusted Models
| Rank | Observed rank (crude) | Predicted rank (adjusted) |
|---|---|---|
| 1 | Genitourinary health | Genitourinary health |
| 2 | Sexual assault | Sleep |
| 3 | Physical assault | Physical assault |
| 4 | Behavioral health | Behavioral Health |
| 5 | Sleep | Menstrual cycle |
| 6 | Contraception | Sexual assault |
| 7 | Menstrual cycle | Contraception |
| 8 | Unplanned pregnancy | Unplanned pregnancy |
| 9 | STIs | Chronic illness |
| 10 | Chronic illness | STIs |
| 11 | LGBTQ | Fertility |
| 12 | Obstetrics | LGBTQ |
| 13 | Fertility | Breast wellness |
| 14 | Breast wellness | Cancer |
| 15 | Cancer | Obstetrics |
Observed rank = the mean rank of each topic. Predicted rank = the mean rank accounting for feasibility, relevance, and urgency scores.
Abbreviations: LGBTQ = lesbian, gay, bisexual, transgender, and questioning; STI = sexually transmitted infections.
A Pearson’s R correlation analysis between the observed (crude) and predicted (adjusted) ranks revealed a moderate positive correlation (r = 0.494, P = < .0001).
Delphi Process Evaluation
Thirteen SME’s completed the process evaluation survey, with 100% indicating that to a large or the fullest extent: the process preserved anonymity, subsequent rounds of surveys reflected their input, the priorities represented their ideas, and research based on the priorities would advance MWH. The Delphi Process Evaluation Survey revealed that the e-Delphi Process was valuable in determining MWH research priorities.
Phase 3 Results
Synthesis of data
AG members provided their perspectives on the top research priorities and their alignment with DOD strategic priorities. There was general agreement that topics of sexual assault, behavioral health, and genitourinary issues would provide the most valuable data to promote the health, performance, and provision of care for ADW. Members of the AG concurred that the MWHRA supports the DOD strategic objectives of readiness and performance, thereby contributing to the strategy of maximizing human capital in defense of the nation. But, there is a need to incorporate strategic terminology in the MWHRA to ensure the strength of alignment and conveyance that women’s health and medical readiness are synonymous with DOD readiness. As one AG member wrote:
Building readiness/investing in people are DOD priorities; given the increased % of women in uniform, women’s health issues, if not addressed, will negatively impact readiness. The key is to make the case that women’s health and medical readiness = DOD readiness.
The AG considered the following to be the target audiences for the MWHRA: MHS, Veterans Affairs, Centers for Disease Control, academia, major health organizations, key funding agencies, and key decision makers such as the Surgeons General, DHA Director, and the line leadership. Suggested dissemination strategies included peer-reviewed publications, national webinars, military and scientific research conferences, social media, DOD and Health and Human Services briefings, and Congressional briefings.
In order to ease dissemination of the MWHRA among non-scientific stakeholders, the study team synthesized the reviews by the AG with the results of the e-Delphi surveys to develop five categorical priorities for MWH research that will be promoted by the MWHRA: reproductive health, violence against women, behavioral health, general health promotion, and chronic conditions. Reproductive health research priorities included the topics genitourinary health, sexually transmitted infections, menstrual cycle health, contraception, unplanned pregnancy, obstetrics, and fertility. Violence against women priorities included sexual assault and physical assault. General health promotion priorities included sleep health, breast health, and LGBTQ health. Chronic conditions priorities included cancer and research on non-acute conditions that result from musculoskeletal injuries, environmental exposures, nutrition, metabolic, cardiovascular, and reproductive dysfunction (e.g., polycystic ovary syndrome). Behavioral health research priorities remained a stand-alone priority category.
DISCUSSION
Research Priorities
Our goal was to provide a roadmap for researchers, policymakers, leaders, and other stakeholders seeking to address DOD strategic health care goals. The topics of reproductive health, violence against women, behavioral health, general health promotion, and chronic conditions have subsequently been identified to impact medical readiness in various reports on the health of members of the Armed Forces.1,21,22 The DHB specifically identified seven topics that impact the military readiness and health of women that are also included in our 15 priority topics: musculoskeletal injuries, urogenital infections, unintended pregnancies, sexual and intimate partner violence, anxiety, depression, adjustment disorders, and eating disorders.1 The MWHRA will begin to fill the gaps in research and contribute to the development of practice and policy guidelines that the DBH recommends to enhance female readiness in garrison, in the field, and during deployment. See Supplemental Material for the suggested topics in the MWHRA that would address DHB recommendations. Similarly, the MWHRA will inform research efforts to fill gaps in scientific knowledge identified in the DOD Health of the Force (HOF) Report.22 The DOD HOF reports that mental health disorders and disordered sleep have the potential to impact the readiness of the total force, with women having greater rates of insomnia and mental health disorders than men. Despite a greater prevalence in women, gender-sensitive sleep and mental health interventional research are understudied.1,23 Furthermore, insufficient sleep is also associated with chronic diseases; 20% of ADW in the Army were treated for chronic conditions, including cardiovascular disease, hypertension, cancer, asthma, arthritis, chronic obstructive pulmonary disease (COPD), and diabetes in 2019,21 indicating a need for research on the impact of chronic conditions on readiness.
The Delphi process revealed that our knowledge about violence against women, including prevalence, treatment, and prevention, is thin. In spite of efforts to reduce sexual harassment, assault, and intimate partner violence, ADW continue to experience elevated and unacceptable rates of gender-related, intentional trauma.1 Sexual and physical assault have the potential to degrade the physical and mental readiness of warfighters and lead to attrition; 55% of service women reported sexual harassment and 25% reported sexual assault over her career as a factor that led to the decision to leave military service.1 To preserve and support the health and wellness of service women, DOD efforts require going beyond simply raising awareness around the magnitude of the ongoing problem. Research to identify factors leading to violence against women and to identify effective interventions to mitigate them is required. Focused research informed by scientific and clinical MWH leaders must be pursued.
Strategic Priorities
The results of the Delphi process were regarded by the AG as strategically relevant to the missions of the DHA and the MHS. The research priority categories align with the DHA strategic objectives of (1) a great outcome of a medically ready force, (2) a ready medical force of health care professionals who care for operational forces, and (3) satisfied patients who feel taken care of and achieve their goals, in that filling the gaps in knowledge will help the DHA to recognize, care for, and prepare ADW to maintain readiness in light of the health issues in each category. Knowledge gained by research in the five priority areas will contribute to the MHS priorities of supporting the readiness of ADW to deploy, increase the skills of health care professionals who care for ADW, and improve ADW’s access to high-quality care. Of note, the difference between the priorities in the MWHRA and the strategic priorities lies in the level of outcomes, which are mainly focused on individual and provider level outcomes in the former, and DOD-level systems outcomes in the latter. Regardless, when considering the results of this study in the context of current strategic priorities, each of the 15 topics can be conceptualized as integral to achieving one or more of the three DHA priorities.
Future Research
The findings of this study lend evidence-based guidance for future research efforts that will improve the health and readiness of female service members. The MWHRA should guide priorities for the design, funding, and execution of research for the next decade. The MWHRA should serve to direct future scientific efforts to provide evidence-based care for military women. Topics on the MWHRA, particularly in behavioral health and violence (sexual assault and domestic violence), warrant a multidisciplinary approach to assess the full impact on women’s lives and careers, as well as the negative health outcomes. Collaborating closely with behavioral health and forensic experts would increase our ability to address the gaps in knowledge. There are opportunities for collaborative research efforts under funding mechanisms associated with the Joint Program Committees (JPC) and the Congressionally Directed Medical Research Program (CDMRP). However, it would benefit the DOD for the JPC and CDMRP to develop future requests for proposals after consideration of the MWHRA. The impact of the MWHRA on future research could be evaluated by metrics related to funding, policy, and publications, and the AG recommended future development of outcomes metrics for topics that aligned with strategic outcomes. This study established the feasibility of strengthening the rigorous Delphi process with strategic guidance in order to develop priorities that are relevant to military readiness. Therefore, we conclude that this innovative method could be employed in establishing other research agendas for military health or for deep exploration of each topic. As an overarching premise, the experts recommended the consideration of sex-based differences in “all” future research that involves military personnel.
Limitations
Generalizability of the findings of this study is limited to women in the U.S. Armed Forces (Army, Navy, Marines, Air Force). Despite the rigorous process used to conduct the e-Delphi surveys, there are inherent limitations in the process that could produce biases in the findings: identification of a priori topics by the AG, self-identified SMEs, the length of time to administer the rounds of surveys, and potential ambiguity in the survey questions. Specifically, the findings are limited by the representativeness of the SMEs who volunteered to participate in the Delphi process. It is possible that not all expert opinions related to MWH are represented in the findings. The length of time between the rounds of surveys may have limited the stability of participants’ responses, as well as contributed to attrition—there was a 28% drop out rate of SME’s between rounds. Although we used questions with Likert-type responses, a common tool for consensus-building, we did not pilot-test the surveys before administration. Limitations in statistical analysis include the inability to account for random effects for participants in any model with rank as the outcome due the limitation in the statistical software package to account for competing risks in rank.
CONCLUSIONS
This study provides a validated research agenda of 15 high-priority research topics in MWH that, if investigated, will improve evidence-based practices and health policies for military women. By conducting research that fills relevant gaps in knowledge about each topic, scientists will be able to progress from discovery to implementation science, which has the potential to result in changes in health-related practice and policies in this population. Because the MWHRA is evidence-based, there is a high likelihood that findings from future research will contribute to improving the readiness of women in the military, the training and education of health care professionals who care for them, and the ability of the MHS to fulfill their health needs. Viewed in the context of DOD strategic priorities, the MWHRA will contribute to the readiness of military women, thereby supporting the National Defense Strategy.
Supplementary Material
ACKNOWLEDGMENTS
We sincerely thank the members of the advisory group for their time and dedication to the future of Military Women’s Health Research. We thank Dr. Patricia Jordan for her assistance with statistical design and preliminary data analyses.
Contributor Information
COL Lori L Trego, University of Colorado Anschutz Medical Campus College of Nursing, Aurora, CO 80045, USA.
Molly C A Middleton, University of Colorado Anschutz Medical Campus College of Nursing, Aurora, CO 80045, USA.
Sophia Centi, University of Colorado Anschutz Medical Campus College of Nursing, Aurora, CO 80045, USA.
Bryan McNair, Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA.
CAPT Lisa Braun, AdventHealth Tampa, Research Institute-Western Division, Tampa, FL 33613, USA.
LTC Leilani Siaki, Regional Health Command - Pacific, Tripler Army Medical Center, Honolulu, HI 96859, USA.
Lt Col Dawnkimberly Hopkins, Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD 20817, USA.
Col Candy Wilson, Daniel K. Inouye Graduate School of Nursing, Uniformed Services University, Bethesda, MD 20814, USA.
SUPPLEMENTARY MATERIAL
SUPPLEMENTARY MATERIAL is available at Military Medicine online.
FUNDING
Research reported in this document was funded by the TriService Nursing Research Program (TSNRP) HU0001-17-1-TS02. The use of REDCap for this study was supported by National Institutes of Health National Center for Advancing Translational Sciences (NIH/NCATS) Colorado Clinical and Translational Science Awards (CTSA), CTSA Grant Number UL1 TR002535.
This article appears as part of the supplement “Forging the Future: How Servicewomen Will Enhance the Fighting Force,” sponsored by The Henry M. Jackson Foundation.
CONFLICT OF INTEREST STATEMENT
None declared.
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