In recent decades, women have entered traditionally male-dominant and physically demanding sectors, including the military, construction, and protective services. Their employment in these sectors, has been accompanied by greater health and safety concerns due to persistent deficiencies in workplace design, physical standards for entry, employment practices, and access to appropriate apparel, training, support, and health and medical care.1–3 Women employees must adapt to their workplace's organizational culture and meet demanding fitness and performance standards, and often are held to societal expectations for home and child-rearing responsibilities. Employers wanting to sustain a motivated and capable workforce should directly address women employees’ health, occupational risk, and life-cycle challenges.
The Department of Defense's (DoD) Defense Health Board (DHB) reviewed the health and occupational risks that active duty women in the US armed services face—risks both similar to and different from their civilian counterparts. Unhealthy lifestyles and environments have led to earlier onset of chronic diseases and early mortality in the US population.4,5 The declining health status of American adolescents and young adults from physical inactivity, obesity, unmet mental health needs, and poor nutrition pose a particular threat to military recruitment, performance, and retention.3,6–8 In 2010,47% of men and 59% of women failed the Army's entry-level physical fitness standards.7 Military recruits with a history of low physical activity but who meet physical fitness entry standards have a higher incidence of training-related injuries.7
Active duty women in the US armed services have greater health and safety risks than men. Biological differences between men and women, if not properly understood and proactively addressed, place women at an elevated risk for musculoskeletal injury, cardiovascular disease, reproductive abnormalities, and mental health conditions.3 Despite decades of attention and resources devoted to improving the health of military women, they continue to experience higher health risks and adverse outcomes.3
The Department of Defense (DoD) asked the Defense Health Board (DHB), a federal advisory committee composed of health care experts that reports to the Secretary of Defense, to review previous reports, scientific evidence in the military and civilian sectors, and best practices of US armed services and security allies, and make specific, data-driven recommendations to reduce disparities in the health and safety outcomes between active duty women and men. The DHB, after a year of study, which included visits to selected military bases, produced a thorough report advocating a comprehensive approach to education, health care access and treatment, professional workforce development, customization of workplace standards and equipment, and accountable outcomes metrics to guide improvement. In this editorial, we summarize the findings and recommendations from the DHB report. While the report focused on women in military service, many of the findings are applicable to other employers, especially those that require physically demanding work, to increase the recruitment, performance, and retention of their female workforce.
GAPS IN IMPLEMENTATION AND ACCOUNTABILITY
The DHB found many worthwhile recommendations in prior studies aimed at eliminating health and safety disparities between active duty women and men, but best practices in these reports had been implemented only in isolated locations and commands. Disparities persist because of limited dissemination of findings, inattention to the principles of implementation science, and unassigned accountability. Long-standing cultural norms and attitudes, insensitive to gender-based differences in performing training and operational tasks, reinforced those implementation gaps.
To address the implementation gaps, the DHB recommended that DoD establish an authoritative and accountable women's health-focused office with a clear charter for implementing recommendations to improve active-duty women's health, fitness, safety, and performance. The office would be the focal entity to eliminate gender-associated differences in health care delivery, and guide health care personnel, research, and the dissemination and implementation of best health care practices. The office would modify DoD purchasing and supply chains to support the acquisition and distribution of gender-customized clothing, equipment, and medical products and services. The office would also help modify personnel policies, such as “one size fits all” fitness, performance, and promotion standards, and standardize family planning policies and services. Most importantly, a high-level DoD women's health-focused office would lead the change in military culture to overcome some persistent and counterproductive male-centric values.
The DHB adopted a life-cycle perspective based on data showing that women voluntarily separated from active duty earlier than men and experienced lower promotion rates to leadership positions.4,9 The life-cycle, as illustrated in Fig. 1, begins at recruitment and extends out to retirement or separation from military service. Figure 1 shows the most significant underlying work-related factors and challenges that contribute to military women's premature attrition from service. The DoD's process to improve and promote women's occupational health can serve as a model for how employers—and other nations’ militaries—might address these challenges.
Disability (including injuries), pregnancy, and failure to meet weight or body fat standards were among the 10 leading causes of attrition during the first term of military enlistment.10 The attrition disparity between men and women accelerates at mid-career (4 to 10 years of service), when many military women consider motherhood.9 Military women must manage both gender and military-specific stressors. Gender-specific stressors include health needs related to common gynecologic concerns such as contraception and pregnancy as well as caregiving responsibilities. Moreover, many military women have added stressors such as musculoskeletal injury concerns as well as interpersonal violence, adapting to a maledominant culture, and harassment.11 Military-specific stressors include a gender-neutral “up-or-out” promotion policy that fails to reflect the added time that women spend in family planning, child-raising, and other family responsibilities. These stressors increase during deployments and with frequent relocations.4
The military, with its more stressful training and work environment, can serve to highlight, for the civilian sector, the benefits from optimizing women's health, safety, and readiness through an integrated program that enables them to receive care from the right personnel, at the right time, and at the right place. An integrated life-cycle perspective, addressing a healthy balance of personal, family and work issues, will also enable women in civilian employment to productively address their work-life challenges.
Optimizing Life-Cycle Costs
The life-cycle approach also encourages longer-term, more expansive thinking about investments in women's health. Decisions about whether to fund programs that improve productivity and readiness among active duty women should factor in the cost savings achieved by avoiding attrition and resignation due to injury and poor health, and the loss of the readiness, experience, and training that departs with these women. Additionally, the high costs of recruitment and training to replace them—preparing a new recruit for active duty service costs about $75,000—further justifies the financial investment in women's health.12
STRESS FRACTURES AND OTHER MUSCULOSKELETAL INJURIES
The physical demands of a military career led to workplace injuries that disproportionately affect women. Women enter the military with lower fitness levels than men and are more susceptible to overuse and lower limb injuries.13–15 The DHB report recommended that military recruiters improve preparation of female recruits before they start basic military training. The recruiting offices can educate new female recruits—and male recruits too—in healthy behaviors (stop smoking, reduce excess alcohol consumption, and adopt healthy eating habits) and encourage them to begin gender-specific aerobic and strength conditioning. Such preparation should reduce the risks of injury and increase the likelihood of success in basic military training and military service.
During basic military training, women trainees experience twice the rates (50% vs 25%) of musculoskeletal injuries than their male counterparts.3 Reasons for this disparity include anatomic and physiologic gender differences, underlying health status prior to entry, cultural attitudes, and gender-neutral training regimens and conditioning practices. In particular, active duty women lack access to gender-customized equipment (eg, properly fitting sports bras, backpacks, protective armor, footwear, and insoles) necessary for them to meet training standards while reducing musculoskeletal injuries. Long-standing attitudes and traditions such as “working through pain” and deferring care may motivate women to avoid the stigma of being sidelined during training, which eventually leads to more severe injuries and complications.
The DHB observed embedded licensed sports medicine professional within basic military training units as a best practice. These professionals can promote and implement evidence-based training practices that enhance performance and promote rapid injury recovery, particularly for women recruits. The additional cost for trainers and physical therapists is likely far lower than the life-cycle costs from injury, poor health, loss of readiness, and recruit replacement.
The military's “one size fits all” approach for health fitness also contributes to increased training injuries among women, especially as they attempt to make the transition from sub-optimal baseline fitness levels. The military has already identified fitness standards based on two components: health fitness standards that are gender-specific, and occupationally-focused fitness standards that should be gender-neutral. The DHB report encouraged universal deployment of gender-specific fitness standards and gender-neutral occupational-specific and operationally-relevant standards. Adoption of this evidence-based dual approach would reduce unnecessary training injuries among women, preserve their general fitness levels, and allow those that can meet mission-specific capabilities to serve in more demanding roles.
Studies report an association between increased risk of stress fractures and injuries in women with iron and vitamin D deficiencies, and with higher rates of smoking, and amenorrhea.16–18 While scientific evidence was not yet definitive, the DHB recommended that the DoD study interventions or policies that could remediate nutritional deficiencies with calcium, vitamin D, and iron supplements. The DoD, with its size and controlled training environments, is uniquely positioned to conduct definitive studies on these topics.
GYNECOLOGICAL AND FAMILY PLANNING ISSUES
Active duty women encounter unique challenges to urogenital health at their first and subsequent duty assignments. These include potentially hazardous exposures, unpredictable and demanding work schedules, and frequent moves and deployments. Deployment and austere field settings worsen gynecologic and urogenital health due to limited access to preventive and therapeutic care and lack of privacy for urination. Pre-deployment education—for women as well as for their male and female leadership—about prevention, diagnosis, and treatment of urogenital infection in the field setting can mitigate this risk. The DoD can empower deployed women to self-medicate by providing them with urogenital infection self-testing and self-treatment kits and hygiene devices, such as female urinary diversion devices, as standard equipment.
Deployment reduces women's access to contraceptive services and devices. Unintended pregnancy is 50% higher for active duty women than for civilian women.3 Since pregnancy makes women non-deployable for at least 18 months, the high rate of unintended pregnancy reduces mission readiness and occasionally contributes to adverse health incidents. DoD can reduce the incidence and consequences from unintended pregnancies by proactively providing contraceptive counseling and access to long-acting reversible contraception, walk-in contraceptive clinics, and improved access to women's health services and contraceptive devices in deployed settings.
Active duty women, like many other working women, struggle between work-related obligations and plans to start or expand their families. Some active duty women choose to defer pregnancy in favor of career advancement opportunities, and the stress from these decisions and other career health concerns can lead to voluntary separation from the military. More flexible work schedules, including liberal parental leave policies, can mitigate the tension between work and life priorities.19
Post-partum psychological and physical fitness practices are highly variable across the military services. The DoD can follow the Air Force's innovative post-pregnancy return-to-duty program that offers new mothers a customized program of postpartum recovery, contingent on types of pregnancy outcomes, such as miscarriage, stillbirth, pre-, and full-term delivery.20
Breastfeeding produces positive effects on the physical, emotional, and psychological health of military mothers and their infants. Since military mothers typically experience work environments not conducive for breastfeeding, breastfeeding rates among them lag behind civilian rates, and fall far short of the Healthy People 2020 goal.3 The DoD can follow best practices in the civilian sector by providing better and expanded access to private and secure breastfeeding accommodations.
Some military women's assignments and transitions disrupt fertility and access to reproductive health care services. Active duty women at the mid to late stage of their career may experience fertility-related stress due to occupational hazards and inconsistent access to fertility treatments across duty stations. Best practices in fertility planning and success already exist in isolated locations of the military.3 The DoD, at a minimum, should document such best practices, and standardize fertility benefits and services across all military locations.
SEXUAL HARASSMENT AND ASSAULT
Despite extensive efforts by the DoD, active duty women continue to experience high rates of workplace sexual harassment, assault, and intimate partner violence, similar to the rates for women in the civilian workforce. Active duty women have a higher incidence of post-traumatic stress disorder (PTSD) from sexual violence than from exposure to combat.21,22 Many women fear stigma and reprisal from reporting incidents. In order to change the paradigm, women should be provided access to a private and secure process for reporting incidents of sexual assault, such as through mobile apps. The DoD should promptly investigate allegations, conduct timely medical forensic examinations, and adjudicate and deliver judgment/punishment when indicated. The DoD should raise awareness of the magnitude of the ongoing problem and hold commander and noncommissioned officers accountable for instituting a zero-tolerance culture towards sexual harassment and violent incidents. Recently proposed congressional legislation, introduced after publication of the DHB report, aims to help by requiring commanding officers to refer all sexual assault allegations to civilian authorities for investigation.23
“You can’t manage what you don’t measure.” This management principle applies to any attempt to improve women's health and safety. The DoD has a Military Health System (MHS) Dashboard and a Women's and Infant Clinical Community Dashboard with many different types of women's health measures. However, similar to much measurement in civilian healthcare, the DoD dashboard metrics focus on inputs, processes, compliance, and complications.24 Few of the dashboards contain measures of outcomes, such as active duty women's medical readiness, musculoskeletal injuries, unintended pregnancies, and rates of sexual assault. Patient-reported outcome measures are especially rare. The Dashboard metrics do not display health and safety indicators at the different points of an active duty's woman's life-cycle of military service, are not widely accessible or disseminated, and not up to date, with the timeliest metrics having at least a 3 to 6 months lag.
The DHB report recommended that DoD create an interactive and customizable MHS Dashboard to provide frontline and health personnel with access to current data on the key drivers and outcome measures of active duty women's readiness and health. The Dashboard should track both nationally-accepted and military-relevant women's health metrics, and feature customizable options to reflect the differential needs of the end-users (eg, commanders able to track musculoskeletal injury rates and readiness by gender; senior civilian leadership and legal personnel tracking incidences and resolution of sexual harassment and assault). The Dashboard should feature patient-reported-outcome-metrics specific to the needs and concerns of military women over their life cycle in the military (such as those outlined in Fig. 1).
Female employee health, fitness, and performance are enduring challenges and important concerns for employers in the public and private sectors. Large organizations, such as the DoD, can and should establish the leadership and practices that optimize women's health, safety, and performance at work. The DHB's recommendations, grounded in a woman's life-cycle career perspective, represent a proactive, quantifiable, and holistic response to women's health, performance, and career challenges. The recommendations could, in many cases, be profitably applied to private sector female employees with attendant reduction in short and long-term morbidity leading to a happier and more productive workforce.
The authors would like to thank the women of the US Armed Services and subject matter experts on women's health who provided invaluable input into the Defense Health Board report.
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