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 pre-
deployment 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.
Keywords: Gulf War (1991); Voluntary Services Health Professional Veterans; Military Advice; Pre-Deployment
Introduction
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). Part-
time 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 (1950-53). Several United States (US) authors [2,3] report
that for US Reservists, pre-deployment to the GW proved to be
an unusually short time in which to make domestic preparations;
wind-up civilian work-life; mobilise into new military groups and
receive training specific to the requirements of deployment to a
war in the Middle East. Some US Reservists were reported as being
dissatisfied and distressed because they had not anticipated either
their call-up or their stressful transition from ‘civilian to soldier’
[3]. These reactions could well have been similar for the British
health professional veterans (HPVs) who like their US Reservist
counterparts, lived and worked in civilian communities and not in
military establishments [4,5]. Those in the part-time TA received
support from their community-based parent TA Units but the ex-
Regular Reservists both called up and volunteers, often had not
retained military connections. In effect and despite being on the
Reserve List, they were no longer part of the ‘military family’ [6].
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 [7-10]. 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
paucity of literature, this part of the study incorporated 4 questions:
a) What advice was received by the HPVs from the military?
b) In what form was it received?
c) How effective was it according to the perceptions of the
HPVs?
d) What recommendations do the HPVs suggest that could
improve advice during pre-deployment.
Methodology
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. The first of three stages of the recruitment of
the non-regular Service troops as study’s participants was initially
opportunistic. One HPV Reserve called-up nurse (a colleague known
to the lead author) held a personal contact list of 74 HPVs who had
returned home together by air in late March 1991 following the end
of the GW. As it would have been unethical for the researcher to
have had direct access to the contact list, the colleague acted as an
intermediary by forwarding a letter from the author to those named
with details of the study and a pre-paid postal return envelope for the
return of completed contact details and consent form. In the event,
57 (47 ex regular Reservists and 10 Territorial Army personnel)
of the 74 HPVs agreed to participate in the study: a return rate of
77%. In the second recruitment stage, a purposeful increase of the
VS TA group to match the size of the Stage 1 recruited Reservists
(n=47) and in similar health professional roles was sought. This
was achieved by asking the 10 consenting VS TA participants from
Stage 1, to act as ‘intermediaries’ in making a ‘snowball’ access
to similar others within their own or other TA units. To facilitate
this, each of them was supplied with 5 introductory letters (n=50)
with pre-paid return contact slips for direct return to the author.
As a result, a further 33 TA HPVs agreed to participate in the study
raising the total for the VS TA to 43. Although there was no way of
knowing if the total number of letters (n=50) had been issued by
the initial TA HPV participants, the estimated percentage (assuming
all letters had been issued) for recruitment in this stage was 66%.
Finally, in a third recruitment stage, a GW veteran Welfare Officer in
the Order of St John of Jerusalem (a voluntary service that provides
welfare support to the army) having heard of the study, made
direct contact with the author to seek inclusion for the 10 Welfare
Officers (WOs) who had been volunteers in the GW. Using the same
return system as in previous stages, 5 (50%) of these veterans
agreed to become participants. Personal, professional and military
demographic characteristic variables (as independent variables) of
the participant sample of 95 HPVs are given in Table 1.
Table 1: Composition of the HPV participant sample.
Procedure
First a pilot study with 5 participant HPVs
assisted the
researcher through focus groups and interviews in the preparation
of the first questionnaire that included the receipt and acceptability
of advice from the military during pre-deployment. Each of the
three questionnaires, issued at 6 monthly intervals, comprised
closed questions followed by related free text justification.
This dual approach provided opportunity for a greater depth
of understanding more so than either could have achieved if
employed alone [15]. The pilot study’s HPVs identified two forms of
pre-deployment advice that they claimed to have received from
the military:
a) advice for domestic preparations, e.g. wills, life insurance,
work and domestic financial affairs, and
b) advice for managing social relationships at home and in
the military.
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.
Table 2: Coding of IV and DV variables of interest for logistic regression.
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.
Results
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
[TA] and all were volunteers, whereas of the 47 in the Reserve, 26
(27%) were mandatorily called-up and the remaining 21 (21%)
were volunteers. There were 18% more officers than those in other
ranks. Sixty-eight (72%) of the HPVs were in nursing roles during
the GW as compared with 27 (28%) in other health professions. Of
the 95 HPVs, 27 (28%) had past warfare experience and of these,
17 (18%) were ex Regular Reservists and 10 (10%) were in the
TA. The remaining 68 (72%) had no experience of warfare. Sixtyseven
of the 68 nurses provided their civilian nursing qualifications
(1 missing) and during the GW, 49 (73%) worked as Registered General Nurses; 4 (6%) as Registered Mental Nurses, and the
remaining 14 (21%) were State Enrolled Nurses. All other health
professionals (doctors, physiotherapists, etc.) were allocated to
the same professional roles in the military as they held in civilian
life. Only combat medical technicians (akin to civilian ambulance
paramedics) worked in non-health civilian roles prior to the GW.
The time spent in the Gulf for most HPVs was between 2 and 3
months. When the HPVs’ length of time in the Gulf was compared
with their deployment military status using a Mann-Whitney U
test, Reservists spent less time in deployment (mean rank=37.16)
than those in the VS (mean rank = 58.61): a significant difference
(U=618.500, Z= -2.414, p<0.01).
Table 3: The HPVs’ personal and military characteristics.
Types of Advice
Table 4: Types of advice suggested in the Pilot Study as issued
by the British military during pre-deployment (N=95).
The Pilot Study participants identified two forms of advice given
by the military and/ or by related charities during pre-deployment
to the GW with their respective frequencies of receipt by the 95 HPV
participants, as shown in 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.
Frequency of Receipt of Advice for Pre-Deployment
Domestic Preparations
Table 5: HPVs’ thematic comments for the receipt or not of
advice for their domestic preparations.
Fifty-three of the 95 HPVs (56%) received advice from the
military regarding their domestic preparations. Eight HPVs provided
related descriptive comments and of these, five were in the TA. As
shown in Table 5, Theme 1, those in the TA confidently recounted
that their domestic affairs had already been adequately prepared
as a routine annual requirement for all members of the part-time
VS military and as such did not seem to need the advice. Of the
remaining 42 (44%) participants who did not receive this form of
advice, 33 provided written comments hypothesising on the effect
such advice might have had if it had been received. Comments from
the 33 non-recipients of advice for domestic preparations are given
as Themes 2 and 3 in 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.
Predicting the likelihood of Non-Receipt of Military Advice for Domestic Preparations
Table 6: Logistic regression to predict the likelihood of non-receipt of military advice for domestic preparations with sample
characteristics (N=95).
Using logistic regression as shown in Table 6, ‘time in military
service’ (shorter time) and gender (females) were the best
predictors of the ‘non-receipt of advice’. When both variables were
re-entered into the Logistic regression model as the interaction
term ‘gender/time in the military’, the output was not significant.
Thus, those who were female and those with a shorter length of
military service each had a significant and independent likelihood
of being the non-recipients of advice (shorter military service
R=0.260, β=0-910, p=0.033; female R=0.260, β=0.0986, p=0.045).
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%)
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).
Table 7: Logistic regression to predict the likelihood or not of effects from domestic preparations in sample characteristics (N=91).
*4 values excluded
Receipt of Pre-deployment Military Advice Regarding
the Management of Social Relationships
Four TA respondents commented that they had received
good advice from their TA Unit in the form of a ‘briefing’ for the
management of their social relationships prior to departure to the
Gulf. A further 4 Reservists stated that they had been recipients of
handouts from military charities such as Soldiers, Sailors, Air Force
Association (SSAFA) but had received nothing directly from the
military. The remaining 87 (92%) stated that this type off advice had
not been received. Thirty-two HPVs provided related comments. Of
these, 8 had received advice and 24 were from non-recipients, who
speculated upon the potential usefulness of such advice had they
received it. Examples drawn from both sets of comments are given
below in Table 8 under thematic headings. Thematic analysis of the
24 non-recipient HPVs’ comments given in Table 8 revealed that
all participants believed hypothetically that if they had received
advice on how to manage their social relationships, it could have
been beneficial. Those with close partners (Theme 3) suggested
that such advice could have lessened their tendency towards
selfcentredness
and withdrawal which caused spousal resentment
and upset with other family members prior to departure. Other
HPVs hypothesised that the receipt of this advice could have been
beneficial in their coping with the relationship difficulties that arose
when joining new military groups both during pre-deployment
training and following arrival in the Gulf (Theme 4).
Table 8: Thematic comments for advice for the management of social relationships.
HPVs’ Recommendations to Improve Advice During Pre-deployment
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].
The non-receipt of pre-deployment advice for domestic
preparations was associated independently with the HPVs who
were female and those with a shorter military service. One tentative
explanation for this gender effect could lie in the observed unequal
distribution in civilian life in the undertaking of housework
workload where the greater share is more likely to be undertaken
by females rather than males [23]. Conversely males tend to attend
to matters of family finances. These factors, coupled with the
additional family pressures associated with the festive season at
the end of 1990, may have led a significant number of females to
become overwhelmed by the enormity of juggling personal, family
and military tasks in the short pre-deployment time. Females were
the most likely non-recipients of advice for their domestic affairs,
but female Reservists were those most likely to have reported
adverse stress effects from undertaking them. The latter took
the form of anticipatory morbid thoughts of death and injury
when making wills or taking out new or additional insurance.
It seems plausible that the lack of adverse effects from domestic
preparations in VS TA females could have been influenced by their
close alignment with males through shared military training and
roles; mutual commitment to the TA’s organisational requirements,
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 [7-10], there is little
evidence of any prioritisation for the issue of British military advice
for managing social relationships before departure to the GW. Less
than ten per cent of the HPVs received advice for the management of
their social relationships prior to departure (even though the pilot
study respondents raised it as an available form of military advice).
However, had it been received, the non-recipient HPVs believed
that the pre-departure strain on family relationships, arising all
be it understandably from the HPVs’ self-confessed war-focused
attitudes since call-up, could have been eased. Others hypothesised
that had it been received, it could have reduced the inter-personal
tensions reported in other parts of this study concerned with the
HPVs’ entry into new military groups during pre-deployment and
later during deployment. The paucity of such advice could be of
relevance to other published data from this study whereby it has
been suggested that the HPVs’ lack of stress management training
from the military during pre-deployment [22] showed a tendency
towards avoidance by the military of issues that were perceived to
be of ‘psychosocial’ origins.
It is not possible from these data to quantify whether the
receipt or not of either form of advice is related to: its availability
from the military; the ability and desire of the individual to
access it; the receptiveness of the individual’s open or closed
mind towards its content; avoidance or denial of its context, or
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.
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