Variations among Career Fields in Virtual Reality Suicide Crisis Training Effects among U.S. Air Force Personnel

Abstract

Suicide, a leading cause of death in the United States (U.S.), represents a substantial public and economic burden. Notably, suicide rates have risen over most of the past fifteen years, including among U.S. military personnel. Peer support may represent one example of a proven avenue towards suicide prevention. This study investigates the association between career fields and virtual reality (VR) training in peer support as a potential avenue to mitigate suicide risk within a military context. Data were collected from the Fairchild Air Force Base (N= 249) and analyses compared training outcomes between career fields. Analyses also evaluated skills competency among participants with prior in-person training, assessing their ability to conduct effective interventions using the ACE (Ask, Care, Escort) model and to communicate lethal means safety effectively. Overall, Airmen were generally effective in protecting at-risk peers and retained knowledge from prior suicide prevention trainings. Effective communication of lethal means safety was lowest in career fields with the highest suicide risk. Findings suggest that VR may be a promising tool for suicide prevention training, and that some career fields may require particular focus.

Suicide is a leading cause of death in the United States (U.S.) claiming nearly 50,000 lives in 2023 alone (Centers for Disease Control and Prevention, 2025). Further, millions more experience suicidal ideation or have a suicide attempt each year (Substance Abuse and Mental Health Services Administration, 2024). Additionally, these trends carry over to active-duty service members in the U.S. Armed Forces, including the U.S. Air Force, which had the highest percentage of suicide attempts in 2022 (Department of Defense, 2023).

Successful prevention strategies may benefit from incorporating theoretical frameworks for suicide and related behaviors. The Interpersonal Theory of Suicide (IPTS; Joiner, 2005; Van Orden et al., 2010) is one such framework; it posits that, among other factors and processes, persistent thwarted belongingness (i.e., an unmet need for social connection; Joiner, 2005; Van Orden et al., 2010) helps explain the onset and persistence of suicidal ideation. The IPTS has been thoroughly researched across varying participant severity levels, follow-up lengths, and settings and has supported the relationship between thwarted belongingness and suicidal ideation (Chu et al., 2017; Hill et al., 2020; Roeder & Cole, 2019; Robison et al., 2024; Silva et al., 2017). Given that empathy and interpersonal connection can mitigate suicide risk (Ammerman & Jacobucci, 2023; Kim et al., 2020), peer-to-peer approaches have promise (Baker et al., 2021; Ramchand et al., 2017). Additionally, peer support is widely accessible and does not depend on the availability of mental health care. While peer support is not a replacement for mental health care, it can serve in tandem with mental health care to reduce suicide risk (Liu et al., 2025). However, peer support alone may be successful in reducing suicide risk (Bowersox et al., 2021), and in its absence, communities may fail those most in need of connection and support.

Peer-to-Peer Training and the ACE Model

Peer support can take many different forms; for example, the Department of Defense uses Ask, Care, Escort (ACE) for peer support training (Gervasoni, 2010). The main purpose of ACE is to “escort the service member to safety” and ensure that individuals at risk are not left alone. Previously, between 1997 and 2002 when the Air Force employed a multi-layered suicide program focused on data-driven prevention, decreased stigma, enhanced social networks, there was a 33% risk reduction in deaths by suicide in Air Force personnel (Knox et al., 2003). Taken together, suicide prevention in the Air Force is achievable through engaging, thorough, and empirically supported interventions.

However, traditional delivery methods may be insufficient. In 2018, the U.S. Army Directorate of Prevention, Resilience, and Readiness requested that the Defense Centers for Public Health-Arberdeen revise the ACE trainings to incorporate updated techniques and suicide prevention literature. Further, in 2022, the Suicide Prevention and Response Independent Review Committee stated that service members complained that suicide prevention trainings relied on poorly designed PowerPoint presentations in dark auditoriums or computer-based modules that provided little improvement due to limited internet access. Service members reported falling asleep or being on their phones during these mandatory training days, further noting that trainers often had limited experience or preparation (Suicide Prevention and Response Independent Review Committee, 2023). Taken together, these inadequate trainings paired with Air Force suicide rates nearly doubling between 2011 and 2023 (Department of Defense, 2024), make it evident that suicide prevention trainings within the Air Force need improvement to reduce deaths by suicide.

Broad reviews for peer-to-peer suicide prevention trainings prior to these updates found that such programs improve declarative and perceived knowledge about suicide, may increase self-efficacy, and improve beliefs/attitudes about suicide (Burnette et al., 2015; Holmes et al., 2021). However, there is limited research on the extent to which these trainings impact intervention behavior (Burnette et al., 2015; Holmes et al., 2021). Amongst career fields, both clinical and non-clinical staff fields have shown increased knowledge and self-efficacy regarding suicide, though the increase for non-clinical staff tends to be higher (Burnette et al., 2015). Overall, peer-to-peer support models tend to have the best outcomes when they are engaging (Burnette et al., 2015) and designed to influence behavior change rather than attitudes or beliefs (Ramchand et al., 2017).

A review of updated ACE trainings after calls for improvement reported that updated suicide trainings focus on improving suicide prevention skills within military cultural contexts and organizational norms. Similarly, these trainings aim to dispel misconceptions of increased risk caused by assessing for suicide and improve the “escort” component of ACE by educating military personal on the military chains and resources to which to escort at-risk personnel. Overall, these trainings led to increased knowledge of suicide risk and protective factors and knowledge and skills for directly assessing for suicide and where to bring at-risk personnel.

Recently, there have been attempts to make peer support trainings more engaging by using virtual reality (VR; Alexander et al., 2019). A previous study examined VR suicide-related peer support training compared to traditional training and found the VR training to be favorable amongst Air Force personnel and an effective training modality ([Redacted for blindness]). Participants were assigned to groups (i.e., VR, traditional training) based on gender, race, job code, rank, and role. Using a net promoter approach, researchers found that significantly more participants in the VR group recommended the training and reported an increased likelihood to intervene compared to the traditional in-person (non-VR) group. Although these results are promising, it remains unclear whether such trainings are equally effective across different career fields within the Air Force (e.g., Aircrew, Logistics Plans, Medical & Dental; see Table 1).

Table 1.

Study sample Information

Baseline Characteristic	N	Percentage	Career Field Description
Age
18–25	113	45.38
26–30	65	26.10
31–35	43	17.27
36–40	24	9.64
41–45	3	1.20
46–50	1	0.40
Race/Ethnicity
White	153	61.45
Hispanic/Latino	34	13.65
Black/African American	31	12.45
Asian/Pacific Islander	15	6.02
Other	15	6.02
Native American	1	0.40
Gender
Man	101	40.56
Woman	30	12.04
Declined to Respond	118	47.39
Career Field
Aerospace Maintenance	78	31.33	Technicians performing mechanical and structural repairs on aircrafts.
Pilot	28	11.24	Commissioned officers responsible for the command, navigation, and tactical employment of an aircraft.
Aircrew	21	8.43	Enlisted members who operate aircraft.
Force Support	17	6.83	Personnel responsible for handling administrative tasks similar to Human Resources. First Sergeants are leadership-focused senior roles responsible for morale, discipline, and training.
Transportation & Vehicle Management	16	6.43	Personnel managing ground fleet operations and cargo movements.
Medical & Dental	15	6.02	Healthcare providers and technicians.
Aircrew Flight Equipment	10	4.02	Technicians that maintain life-support and survival gear.
Other	9	3.61
Command & Control Systems Operations	8	3.21	Controllers managing real-time tactical assets and communication.
Material Management	8	3.21	Personnel responsible for inventory, storage, and issuance of Air Force assets
Fuels	7	2.81	Technicians that handle the distribution and quality control of hazardous propellants.
Acquisitions	6	2.41	Personnel overseeing fiscal procurement and lifecycle of weapons systems.
Cyberspace Support	5	2.01	Information Technology and network defense specialists.
Logistics Readiness Officer	5	2.01	Commissioned officers overseeing supply chain, transportation, and contingency operations.
Intelligence	4	1.61	Analysts that specialize in the collection and interpretation of multisource strategic data.
Logistics Plans	4	1.61	Personnel focused on organization the logistics of global deployments and movements.
Security Forces	4	1.61	Personnel providing law enforcement and base defense
Professional	4	1.61	Legal and spiritual advisors.

The Current Study

Service members’ occupational role may influence their perceptions of—and responsiveness to—peer support initiatives due to variability in factors such as unit culture, exposure to stressors, mental health literacy, attitudes toward help-seeking, and rank (Castro et al., 2012). Importantly, some Airmen may be expected to intervene in crisis situations more frequently due to their occupational role (e.g., Medical and Dental, Force Support). The current study took an exploratory approach to assess how training outcomes varied across Air Force career fields for a VR ACE training, specifically whether they brought the at-risk Airman to safety based on the parent manuscript ([Redacted for blindness)] and examine areas of success and needs for potential improvement.

Methods

Participants

Participants were a subset of the sample described in [Redacted for blindness]. Of the original sample (N = 415), 166 individuals were excluded due to either incomplete responses or employment in a career field with fewer than three participants. The present study involved 249 Airmen who were primarily active-duty members in the U.S. Air Force at [Redacted for blindness] Air Force Base (AFB) in the state of Washington. Participants were eligible for participation if they were aged 18 or older and affiliated with [Redacted for blindness] AFB. Individuals were excluded if they lacked the ability to provide informed consent and/or lacked fluency in English. The majority of participants were between 18 and 25 years old (n = 117, 46.99%, see Table 1 for more demographic details).

Procedures

This study received IRB approval from [Redacted for blindness] and Human Research Protections Office approval from the military. Participants filled out a web-based consent form, completed VR peer support training, and online questionnaires. After completing study procedures, participants were thanked and debriefed. No compensation was provided.

Materials

The VR training engaged participants in a voice-activated, scenario-based training where participants virtually entered the house of an at-risk Airman and engaged in a crisis conversation. The training is based on the Ask, Care, Escort model where the participants choose between: (A) asking questions or making statements, (C) showing care or expressing judgement, and (E) escorting the Airman to safety or leaving the Airman alone (Gervasoni, 2010; [Redacted for Blindness]). The VR training built upon prior year trainings of the ACE model and was aligned with Air Force statistics which state that relationship issues, financial stress, and risk of investigation are among the most prevalent risk factors in suicide (Langhinrichsen-Rohling et al., 2019). The training’s storyline was designed to assess whether the participant demonstrates competency of primary prevention skills for suicide prevention (i.e., effective intervention using the ACE model and to effectively communicate lethal means safety).

The overall project focused on two key areas of peer support using the virtual vignettes: effective intervention utilizing the ACE model and effectively inquiring about lethal means safety. To examine whether an individual performed an effective intervention using the ACE model, the scenario climax was designed as a negotiation between the participant and the at-risk Airman about escorting the Airman to get help from a base resource or leaving the at-risk Airman alone when he says he wants to go to sleep. This skill is essential for peer support, and despite annual training, there are several documented suicides and attempts resulting from leaving at-risk service members alone while on suicide watch (Reitman, 2024). See Fig. 1 for a flowchart of the virtual vignettes. To test competency on lethal means safety, participants were faced with a decision to ask if a gun is in the house, if there are pills in the house that could be used for a suicide attempt, or to avoid the lethal means topic altogether.

Fig. 1.

Progression of Virtual Vignettes. The virtual vignettes consisted of 28 different prompts. Prompts used for rapport-building and context-setting have been grouped into a single step for simplicity. Branching is shown only at critical decision points where the participant’s choice may alter the outcome

The training consisted of 28 different prompts that followed the ACE model. Participants were sent to an airman’s house who was determined to be at risk based on a concerning post on social media. Final outcomes included leaving the airman alone (fail) or bringing the at-risk airman to the First Seargent’s house (pass). The 12th prompt served as an opportunity to gather critical information about access to lethal means and covered the “Ask” component of ACE. Participants could either: prompt to take the airman to the First Seargent, which was the least optimal choice and avoided lethal means safety, inquire about concerning pill use, which was the suboptimal choice, and inquire about the presence of a gun, which was determined the optimal choice. There were three possible places in which participants could choose to leave the at-risk Airman alone, and if selected, the virtual vignette ended.

Data-Analytic Approach

Descriptive statistics were performed using Microsoft Excel 365 (Microsoft Corporation, 2024). The present study examined the overall training outcome as pass/fail depending on whether the participant brought the at-risk airman to safety (pass) or left the at-risk airman alone (fail). We conducted chi-square analyses to examine group differences between different career fields, such that each career field was examined separately and compared to all other career fields combined. Regarding means safety, a 3 × 2 chi-square was conducted for each career field separately comparing the response rate of the three options (optimal, suboptimal, and least optimal) to those of all other career fields combined. Analyses were performed using an online chi-square calculator (Standard Deviation Calculator n.d.; https://www.standarddeviationcalculator.io/chi-square-calculator). Bonferroni corrections were applied to control for Type I error.

Results

Virtual Vignette Outcome

Overall, 88.75% of participants got the Airman to safety in the VR training. Additionally, seven out of the 18 career fields (i.e., Aircrew, Cyberspace Support, Intelligence, Security Forces, Logistics Plans, Acquisitions, and Professional) had a 100% success rate in bringing the at-risk Airman to safety. Bonferroni corrections were applied to control for Type I error. See Table 2 for additional descriptive statistics about the ACE intervention outcomes by career fields. The chi-squares that compared specific career fields to the remaining sample revealed that there were no significant differences amongst career fields (see Table 2).

Table 2.

Descriptives and Chi-Square Comparisons on Effective ACE Intervention Split by Career Field

Career Field	Brought to Safety N(%)	Left Alone N(%)	Left Alone T1 (%)	Left Alone T2 (%)	Left Alone T3 (%)	χ²	p-value
Aerospace Maintenance	67(85.90)	11(14.10)	3.85	0	10.26	0.93	1
Pilot	24(85.71)	4(14.29)	0	0	14.29	0.29	1
Aircrew	21(100)	0(0)	0	0	0	2.91	1
Force Support	13(76.74)	4(23.53)	0	17.65	5.88	2.76	1
Transportation & Vehicle Management	15(93.75)	1(6.25)	0	6.25	0	0.43	1
Medical & Dental	13(86.67)	2(13.33)	0	0	13.33	0.07	1
Aircrew Flight Equipment	9(90.00)	1(10.00)	0	10.00	0	0.02	1
Other	8(88.89)	1(11.11)	0	0	11.11	< 0.01	1
Command & Control Systems Ops	7(87.50)	1(12.50)	0	0	12.50	0.01	1
Material Management	7(87.50)	1(12.50)	0	0	12.50	0.01	1
Fuels	6(85.71)	1(14.29)	0	0	14.29	0.07	1
Acquisitions	6(100)	0(0)	0	0	0	0.78	1
Cyberspace Support	5(100)	0(0)	0	0	0	0.65	1
Logistics Readiness Officer	4(80.00)	1(20.00)	0	0	20	0.39	1
Intelligence	4(100)	0(0)	0	0	0	0.52	1
Logistics Plans	4(100)	0(0)	0	0	0	0.52	1
Security Forces	4(100)	0(0)	0	0	0	0.52	1
Professional	4(100)	0(0)	0	0	0	0.52	1

One participant in the Command & Control Systems Operations group did not have a recorded response. The reported p-values are those after applying Bonferroni corrections

Lethal Means

Generally, participants avoided the lethal means topic entirely (n = 132, 53.01%) despite a training the year prior where the primary learning objective was lethal means safety. A suboptimal choice for participants during the means safety portion was to inquire about concerning pill use in the house of the at-risk Airman. Of participants, 50 (20.08%) asked about concerning pill use and 66 (26.50%) completed the optimal choice and asked about the presence of a gun. When the data were broken down by career field, a similar trend to the ACE competency results appeared. The Force Support career field avoided the lethal means topic 65% of the time and Aircrew 67% of the time, see Table 3 for descriptives on means safety across career fields. No career field asked about the presence of a gun 100% of the time. When viewed by career field, Force Support participants only asked about the gun 14% of the time. None of the chi-square analyses displayed significant differences between specific career fields and the remaining cohort, however (see Table 3).

Table 3.

Descriptives and Chi-Square Comparisons of Effective Means Safety Conversation Split by Career Field

Career Field	Avoided N (%)	Asked about substance use N (%)	Asked about Gun N (%)	χ²	p-value
Aerospace Maintenance	40 (51.28%)	13 (16.67%)	25 (32.05%)	2.03	1
Pilot	12 (42.86%)	9 (32.14%)	7 (25.00%)	2.92	1
Aircrew	14 (66.67%)	4 (19.05%)	3 (14.29%)	2.10	1
Force Support	11 (64.71%)	2 (11.76%)	4 (23.53%)	1.16	1
Transportation & Vehicle Management	9 (56.25%)	2 (12.50%)	5 (31.25%)	0.67	1
Medical & Dental	10 (66.67%)	1 (6.67%)	4 (26.67%)	1.98	1
Aircrew Flight Equipment	6 (60.00%)	3 (30.00%)	1 (10.00%)	1.67	1
Other	6 (60.00%)	3 (30.00%)	1 (10.00%)	1.66	1
Command & Control Systems Ops	4 (50.00%)	1 (12.50%)	2 (25.00%)	0.15	1
Material Management	2 (25.00%)	3 (37.50%)	3 (37.50%)	2.84	1
Fuels	5 (71.42%)	2 (28.57%)	0 (0.00%)	2.62	1
Acquisitions	1 (16.67%)	3 (50.00%)	2 (33.33%)	4.36	0.661
Cyberspace Support	2 (40.00%)	1 (20.00%)	2 (40.00%)	0.51	1
Logistics Readiness Officer	4 (80.00%)	0 (0.00%)	1 (20.00%)	1.80	1
Intelligence	3 (75.00%)	1 (25.00%)	0 (0.00%)	1.49	1
Logistics Plans	2 (50.00%)	1 (25.00%)	1 (25.00%)	0.06	1
Security Forces	3 (75.00%)	1 (25.00%)	0 (0.00%)	1.49	1
Professional	1 (25.00%)	0 (0.00%)	3 (75.00%)	5.01	0.455

One participant in the Command & Control Systems Operations did not have a recorded response for this portion. The reported p-values are those after applying Bonferroni corrections

Discussion

The present study aimed to examine outcome differences between career fields in an Airforce suicide prevention peer-support training. Overall, we found that Airmen were generally successful (88.75%) at bringing Airmen at risk for suicide to safety within the VR scenario and retaining information from past suicide prevention training. Further, in seven career fields (i.e., Aircrew, Cyberspace Support, Intelligence, Security Forces, Logistics Plans, Acquisitions, and Professional), Airmen performed exceptionally well and had 100% success at bringing at-risk Airmen to safety in the training. On the other hand, there are a few career fields in which individuals performed below average. Research has shown that a community-based approach, rather than just a medical one, creates an “atmosphere or responsibility and accountability” for reducing deaths by suicide (Knox et al., 2010) and these career fields may have instilled greater cultures of accountability, making these participants more attuned to signs of distress in others or more willing to take action when necessary. Another possible reason is that the career fields with this higher performance tended to have smaller sample sizes; this issue represents a limitation of the study. Additionally, career fields such as Cyberspace Support, Logistics Plans, and Acquisitions likely heavily rely on procedural fidelity, and the skills obtained through their jobs may translate well into strictly following suicide intervention protocols. Further, in small, more specialized teams (e.g., Intelligence, Aircrew), there may be increased peer trust and a sense of personal responsibility for teammates, more so than in other career fields and comradery has been shown to decrease suicide risk (Knox et al., 2003; Knox et al., 2010).

In contrast, our results indicated that every career field struggled with discussing lethal means safety with at-risk Airmen, despite a recent in-person training on this topic. More often than not, Airmen avoided the topic altogether with the at-risk Airman in the training. Interestingly, the Medical & Dental and Force Support career fields had two of the lowest rates of lethal means inquiry despite holding positions where it may be the most critical to ask about lethal means. It is worth noting that suicide rates in the Force Support career field are some of the highest in the Air Force (Department of Defense, 2024), suggesting that career field can be a potential risk factor for suicide and that peer support competency in that career field could contribute towards–or aid in mitigating–that risk. Military personnel often avoid topics of firearm ownership due to fear of stigma, impact on career, and removal of firearm (Hoyt et al., 2021). This observed trend is of concern because firearms represent one of the most common and one of the most lethal ways people die by suicide, and 68.4% of suicides within the Air Force were by firearms. Further, access to firearms is higher than in the general public, and it has been shown that increased accessibility to firearms may be associated with higher suicide rates (Anglemyer et al., 2014).

A recent report of Air Force suicide mortality (Ghahramanlou-Holloway et al., 2023) speculated that the main reasons suicide rates are high within Air Force personnel include mental health stigma; the report indicated a significant lack of help-seeking from medical and mental health and non-health related resources by suicide decedents. Further, they reported that some individuals avoid mental health altogether to avoid appearing “broken” or “damaged.” Additionally, stereotypes involving masculinity and military identity may also be implicated in the elevated suicide rates (Coleman et al., 2020). Specifically, a general unwillingness to disclose about life stressors, show weakness, or seek emotional support may be operative. It may be possible that Airmen were less likely to ask about means safety out of fear of tapping into these stigmatized beliefs. Additionally, a fear of responsibility, escalation of consequences, and uncertainty of next steps are likely other potential reasons for poor means safety outcomes, as past ACE trainings lacked training on these components. Finally, the difference between effective ACE intervention outcomes and means safety may be due to the general comradery of “no man left behind,” a core component to military culture, implying Airmen may be willing to remain with an at-risk Airman, but have concerns about being invasive with questions, leading to reduced means safety.

One of the main shortfalls of suicide prevention that has been reported within the Air Force is inadequate recognition and/or response to warning signs for suicide. It was reported that 68.4% of Airmen who died by suicide communicated their intent to die at some point during their life (Ghahramanlou-Holloway et al., 2023). Further, 26.5% of Airmen who died by suicide had a prior suicide attempt. Therefore, it is crucial for other Airmen to understand the warning signs (e.g., frequently showing up late to work, appearing distressed; Ghahramanlou-Holloway et al., 2023).

This study possesses several notable strengths, including the novelty and relevance of VR suicide crisis training, yet it is important to acknowledge its limitations to inform the interpretation of results and shape future investigations. One such limitation is this study was cross-sectional and was unable to ascertain skill retention across career fields. Future studies may benefit from longer term follow-up to assess skill retention, particularly in intervention behaviors, which would provide further insight on areas for training improvements. Additionally, it is important to examine how training and skill retention translate into the real world. Another limitation to be noted is the small sample size overall and within the individual career fields, with some career fields having single digit numbers. Therefore, future research would benefit from examining this training within a larger sample. It may also be beneficial to develop suicide intervention trainings for specific career fields to best match what individuals in each career would see daily. The developers of this VR training have developed multiple other VR trainings that span a wide variety of topics, including more career and seniority level trainings and trainings that address suicide prevention at different stages of suicide risk. Their program has witnessed a reduction in suicide risk and improved understanding of suicide intervention; it may be beneficial to conduct research studies on all of their current VR trainings. Finally, future research would benefit from creating trainings or interventions that familiarize Airmen more fully to means safety, to improve this critical component to suicide prevention.

The present study provides novel insight into how suicide prevention behaviors may vary across Air Force career fields. Overall, Airmen demonstrated understanding in bringing an Airman at-risk for suicide to safety, and all fields showed relative difficulty in addressing means safety – a critical component to suicide risk reduction. Further, there are innovative and effective treatments presently and others to be developed that can continue to improve peer-to-peer suicide risk intervention and means safety. These findings underscore the need for targeted training for means safety and to reduce mental health stigma amongst Air Force personnel; these targets have the potential to substantially improve the Air Force broader suicide prevention efforts.

Author contributions

Sara Prostko – Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Writing – original draft, Writing – review & editing Morgan Robison – Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Writing – original draft, Writing – review & editing Victor Jones – Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Supervision, Writing – original draft, Writing – review & editing Thomas E. Joiner – Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Supervision, Writing – original draft, Writing – review & editing.

Funding

Morgan Robison was supported by the National Institute of Mental Health (Grant No. 5T32MH093311-12). Opinions, interpretations, conclusions, and recommendations are those of the authors and are not necessarily endorsed by the National Institute of Mental Health.

Data Availability

Data is not publicly available.

Declarations

Ethical approval

This study received IRB approval from Florida State University and Human Research Protections Office approval from the military.

Informed consent

Informed consent was obtained from all individual participants included in the study via a web-based consent form.

Author areas of interests

Sara Prostko: suicide, substance use, self-harm. Morgan Robison: suicide, self-dehumanization. Victor Jones: suicide prevention, military personnel. Thomas Joiner: suicide prevention.

Clinical trial number

Not applicable.

Conflicts of interest

The authors have no conflicts of interest to declare.