British Non-Regular Services Health Professional Veterans’ Perceptions of Pre-Deployment Military Advice for The Gulf WarBritish Non-Regular Services Health Professional Veterans’ Perceptions of Pre-Deployment Military Advice for The Gulf WarBritish Non-Regular Services Health Professional Veterans’

Little has been written about the receipt of advice and its perceived usefulness, or even if it was routinely provided by the British military to Voluntary and Reserve (non-Regular) Services troops in preparation for deployment to the Gulf War. The study in its entirety comprised data from three postal questionnaires (each six months apart) completed by 95 veterans commencing six months after their return home. Their perceptions of the usefulness of two forms of advice were explored] for domestic preparations (e.g. wills and insurance) and ii] for managing social relationships (close relationships and other military personnel) during predeployment to the Gulf War 1991. They also provided recommendations as to how such advice could be improved. Advice for domestic preparations (completion of wills and insurance, etc.) was received by 56% of the participants, but advice for managing social relationships with family and other military personnel once mobilised was sparse (8:8%) and in the main, was provided by charities. This last form of advice was perceived by most of the non-recipient veterans as being of a low priority for the military even though most of the veterans indicated qualitatively that it would have been useful. The veterans’ recommendations are discussed.


The Mobilisation of British Voluntary Services and Reserve Health Personnel
In November 1990, the `British Government recognised that there was an insufficient number of Regular Services medical personnel to meet the projected casualties from the impending war with Iraq, commonly known as the Gulf War (GW). Parttime Territorial Army (TA) and equivalent Voluntary Services' (VS) personnel working in health professional roles (doctors, nurses, and other professions allied to medicine) were invited to volunteer [1]. As the initial response proved to be inadequate, retired ex Regular Services health professional personnel whose names had been retained by the military on the Reserve List were compulsorily called up: an action not undertaken since the Korean War . Several United States (US) authors [2,3] report that for US Reservists, pre-deployment to the GW proved to be The importance of giving support to military families prior to and during British and other nations' military separations in peace and war has been emphasised by many authors prior to the GW, as a means of avoiding disruption to the psychological wellbeing of service personnel during deployment [7][8][9][10]. Early evidence of such support for British families during the GW was found only in one small British study by Quinault (1992) in which 12 wives of RAF deployed personnel described their military support as adequate but found that as with US military families [11], a lack of accurate information-giving increased their levels of stress [12].
There appears to be a paucity of early research concerned with the reactions of British non-regular Services health professional troops towards the GW's unique conventional and expected unconventional (chemical/biological) warfare context and circumstances. In its place, it seems that there has been a reliance upon the outcomes of the more extensive early US GW research [13,14] to fill the British experiential gaps with the assumption that socially, organisationally and culturally, US troops were 'like with like' in relation to their British counterparts. Therefore, despite the time lapse since data collection and this article, it is believed that this study and its findings remain relevant. In response to the

Design
The study utilised a longitudinal design comprising an initial postal questionnaire survey and two follow up postal questionnaires, each issued six months apart. The first questionnaire sought retrospective experiential data comprising reactions to warrelated (pre-deployment and deployment) circumstances; advice; health; social support, and social and professional relationships in the six months before and in the first six months following the return home. The second and third questionnaires requested the provision of prospective repeated data at 12 months and at 18 months post war in the above key areas of interest where change could be anticipated.

Recruitment of the Participant Sample
Recruitment was conducted between July and August 1991 some 4-5 months after the non-regular Services' troops return home from the GW.  These form the focus of this article and coupled with demographic data given in Table 1, enabled the analysis of advice to be seen from personal, civilian and military perspectives.

Variables of Interest and Data Analysis
In 1993, the data were first analysed and then re-analysed in 2012 when presented as part of a successful PhD thesis. Quantitative data were analysed using the Statistical Package for the Social Sciences (SPSS) Version 20. Logistic regression was employed to establish the relationship between a categorical dependent variable (DV) with one or more of the above characteristic independent variables (IV). It calculates the likelihood (ratio of the odds) of an event occurring or not. Table 2 provides the two types of variables and their values of interest (given as 1). Qualitative data were examined by two researchers independently identifying and categorising the key words or phrase labels using Thematic Analysis [16]. The labels were devised to capture as closely as possible the meaning of the HPVs' original words or phrases [16,17]. Where there were differences of interpretation between the researchers, a joint reanalysis of the data was made to facilitate consensus.

Ethical Considerations
Although the study preceded the introduction of formal National ethical standards and procedures for British research, the general principles of: doing no harm; seeking participant informed consent; the acceptance of participant autonomy over compliance, and of respect for rights to privacy, anonymity and confidentiality [18] were upheld throughout the research process. Authoritative military and academic advice were taken before and throughout the study to avoid sensitive issues. All information forwarded to the HPVs cautioned them against breaching the Official Secrets Act.
The data have been held securely and in accordance with the Data Protection Act, 1987 and its update in 1998. All data has been stored anonymously in digital format on a password-protected computer.

Return Rate
A total of 134 contact letters were issued across the three recruitment stages resulting in 95 consenting HPVs and provided an estimated minimum overall response rate of 71%. It is of note that at the time of recruitment to the study, the total numbers of volunteer TA and Reserve personnel deployed to the GW had not been reported in the public domain but figures given some years after the GW suggest that the 95 HPVs in the participant sample represent a subset of some 9% of the total Reserve and TA (or similar VS organisations) health professional personnel sent to the GW [19].

Characteristics of the Participant Sample
The personal, military and health professional details of the participants were collected. As shown in Table 3, there were 6% more females than males and the HPVs' ages ranged from 23 to 53 years (mean=37; SD=8.59; median=35). Of the 48 in the Voluntary Services, all save the 5 Welfare Officers were in the Territorial Army    Table 4. ' Advice for domestic preparations was the most frequently received form of advice (56%), whereas the receipt of advice regarding social relationships was considerably lower (8%). Both forms of advice were given in a written format and in the case of those in the TA, also in verbal briefings.

Theme 2: Lack of time between mobilisation and departure
'There was very little time to get things ready between being accepted and reporting for duty -it was also over the Christmas/New Year period and this meant sorting out jobs, will, insurance and advice for same was nearly impossible to find and added to the stress.' (Female Reservist volunteer, junior officer, nurse) 'The army seemed to very quickly forget that Reservists were civilians and therefore had arrangements in their civilian life to make. No time or advice was given for this.' (Female Reservist called up, junior officer nurse.)

Theme 3: Advice as reality
'When asked if I wanted to be buried or cremated when making a will, the realisation that I might not come back hit me forcibly'.  Table 5. In theme 2, some HPVs associated their non-receipt of advice with not having enough time between mobilisation and departure to the Gulf in which to access or put advice into practical use. It is also suggested that the timing of such preparations (during the run-up to Christmas 1990) had a negative effect upon their stress levels even before departure to the Gulf as they tried to juggle home commitments with military requirements.
Furthermore, some Reservists called-up emphasised that they had civilian responsibilities that required additional attention (e.g. rearranging care for dependent relatives, arranging work cover if self-employed) but the military were perceived as making little or no allowances for these issues. As indicated in the last comments in Table 5, the making of wills raised the HPVs' consciousness of the gravity of their situation and its potential for life-threat (injury or death). This was likely to have been particularly difficult for Reservists call-up, who had no choice in having to place their lives at risk. Using logistic regression as shown in Table 6 When the 95 HPVs were asked to indicate if they had experienced any effects (practical or psychological) from undertaking domestic preparations, 34 (36%) HPVs described experiencing 'adverse' effects and 57 (60%) stated that they had 'no effects'. The remaining 4 (4%) HPVs perceived these effects as 'positive' indicating a sense of relief at having made adequate provision for themselves and their families (in some cases, will-making was a task that had been put off in the past). Of those with adverse effects, a majority (28:82%)

Predicting the likelihood of Non-Receipt of Military Advice for Domestic Preparations
provided written comments indicating that making their wills heightened a morbid anticipatory fear about going to war. As shown in Table 7, using logistic regression to predict those most likely to have adverse effects from domestic preparations, a significant interaction between gender and military status indicated that female reservists were those most likely to have adverse effects (R=0.185, β=7-280, p=0.001). Using chi-square, no significant relationship was found between those in receipt of advice for domestic preparations with those with adverse effects arising from undertaking such preparations (χ2 =0.33, df=1, p>0.05).

Receipt of Pre-deployment Military Advice Regarding the Management of Social Relationships
Four TA respondents commented that they had received   Table 8 under thematic headings. Thematic analysis of the 24 non-recipient HPVs' comments given in Table 8    ' Advice would have been useful to some TA personnel with no regular service experience as some have not lived in small cadres and although they attend camp once per year it is with people they know, hence many are not good at interpersonal relationships with different people. The ex-regular TA and Reservists were better 'mixers' from outset.' (Female TA ex-regular service volunteer, senior officer nurse) Table 9: HPVs' recommendations to improve advice for pre-deployment. Ninety-seven recommendations were given by 81 (85%) of the 95 HPVs, regarding improvements to all aspects of the experience of pre-deployment to war. Of these, the most frequently suggested recommendation by 48 (59%) of the 81 HPVs) was to improve advice for domestic preparations. Of these, three themes were formed as given in Table 9. In theme 1, some HPVs recommended that they should be pre-warned regarding the reality of the war that lay ahead as part of their preparations and most wanted this to be delivered by an experienced war veteran. Others (theme 2) wanted written information listing the practical domestic requirements to be met before departure as described above but they also included a direct military contact via letter to partners explaining why the non-regular health professionals had been requested to volunteer or had been called up. The final theme addressed the psychosocial issue of entry to new groups and recommended being forewarned of the likelihood of inter-group difficulties and how to manage these. The remaining 14 (15%) said that 'no improvements were necessary'.

Discussion
The study aimed to describe the frequency of receipt of the two forms of advice received during pre-deployment by the HPVs, how they were accessed and their perceived quality and usefulness. The small number of VS TA recipients of pre-deployment advice for domestic preparations accessed it through their units with delivery from personnel with experience of participation in previous wars. As such, there appears to have been dissemination of verbal and written advice concerning these TA preparations. From the comments, the TA HPVs appear to have had their domestic preparations well in hand as a requirement for their military routine preparations for annual exercises. As they appeared to regard their upkeep as a personal responsibility rather than a pressure from the military, this might suggest that they had adopted a problem-focussed coping strategy towards domestic preparations rather than the emotion-focussed coping strategy apparent in the comments from some Reservists. Meredith [20] contend that by adopting the first approach, it is likely that the sense of internal control and resilience to stress could increase [21]. The above findings are akin to other published findings from this study showing that the TA HPVs were more satisfied with their pre-deployment training for the GW than their Reservist counterparts [22]. and their self-confidence in having relatively unproblematic and in-place preparations. Additionally, Wood [24] suggest that females can learn male dominance behaviours through shared training, which in turn can lead to greater gender equality [24].
In this study, those with a shorter military service were more likely to have had less advice for domestic preparations than those with a longer service. This is not dissimilar to the findings of McCubbin [25] who found that younger service personnel (i.e., by default, those who are the most likely to have a shorter military service experience) were those who tended to avoid formal and informal advice. Case [26] in reviewing the knowledge-base for people's assessment of threat report that the uptake of information is determined by the nature of the stressor, the would-be recipient's appreciation of the effectiveness of responses to the threat (response efficacy), and their beliefs about their own ability to carry out effective responses (self-efficacy) [26]. Thus, it seems that HPVs with shorter service time could have had less anticipatory understanding about warfare; less recourse to war-related advice, and less belief that such advice could make a difference to their actions. For them, advice could have seemed irrelevant. In a study of US females deployed to the more recent Iraq and Afghanistan wars, Carter-Visscher [27] reported that females perceived themselves as having a lower level of preparedness for deployment and exhibited greater pre-deployment concerns about family than males [27].
These findings re-echo some of the present study's gender findings, despite differences in sampling, military structures and cultures.
Pincus [28] notes that as the military person becomes more involved with military preparations for deployment so too is there a gradual withdrawal from family up to the date of departure [28].
Although the importance of the provision of military support to families prior to and during the time of military separation has been emphasised by many authors before the GW [7][8][9][10] anticipation of its relevance to a given situation [29]. For these, further research with the close co-operation of the military would be necessary. Certainly, as the receipt or not by the HPVs of advice for domestic preparations was not significantly associated with its effects, this could suggest that even when there was receipt of this form of advice, it did not appear to act as a stress moderator, as previously reported in a study of the receipt of health care advice [30]. Furthermore, in comparative research by Sharpley [31], no evidence was found that military pre-deployment stress briefings reduced psychological stress [31]. It could be argued that advice for social relationships from any source was so low that it is impossible to determine its therapeutic value, but the HPVs' recommendations were clear that more effort should be made by the military to target audiences where there is likely to be the most need; and that the form of the advice (content, presentation), and logistics (its timing) are tailored to meet the reality of their needs.

Limitations
The study in its entirety is believed to be one of the earliest of the British GW studies and although some 28 years have passed since the War's end and the study's data collections began, interest in the GW and its unique circumstances (including the unresolved illness in some veteran troops) has not waned. Indeed, unlike this study, many British Gulf War studies have been based upon data collected not months but many years after the GW. Such lengthy delays have been recognised as raising the possibility of increasing error in participants' recall [32,33]. As with many studies that seek to explore, describe and explain unforeseen life events (and including aspects of warfare), the ideal of representative samples and controls before, during and after such events [34] was neither feasible nor realistic for the present study. It is acknowledged that the non-random sample selection could have caused bias but it is believed that the efforts to 'engineer' the same-subject sample with participant representation in the key military dimensions of military category (Reserve/ VS), deployment category (called up/ volunteer) and GW occupation (nurses/ CMTS/ other health professionals), go some way towards lessening this potential effect.
It can also be suggested that the study's reliability is strengthened by the high 'acceptance to participate' of the HPVs (71%) and the high HPV participation retention level (90.5%) across the 18 months of the duration of the study.

Conclusions
Although those in the TA were comparatively well organised for the GW due to their annual domestic preparations for military exercises, this was not the case for some of the female Reservists who qualitatively showed morbid stress responses to their preparations. Overall females and those with a shorter military service were the least likely to have received this form of advice.
Advice for the management of social relationships with families and with new military groups during the pre-deployment phase did not appear to have been recognised by the military as areas where advice could be useful. In contrast, veterans were clear in their recommendations as to how future need for advice for these social relationship's difficulties could be met. We suggest that listening to the voices of those who have experienced warfare can better support the development of advice with relevant content and an efficacious mode of delivery in the future. By doing so, some of the stress of pre-deployment could be reduced.