1
Introduction

The U.S. Department of Defense (DoD) faces short-term and long-term challenges in selecting and recruiting an enlisted force to meet personnel requirements associated with diverse and changing missions. The DoD has established standards for aptitudes/abilities, medical conditions, and physical fitness to be used in selecting recruits who are most likely to succeed in their jobs and complete the first term of service (generally 36 months). In 1999, the Committee on the Youth Population and Military Recruitment was established by the National Research Council (NRC) in response to a request from the DoD. One focus of the committee’s work was to examine trends in the youth population relative to the needs of the military and the standards used to screen applicants to meet these needs.

Mission requirements drive the size and shape of the force, which in turn drive recruiting goals. The ability of the Services to meet recruiting goals is influenced by a number of contextual factors, including the state of the economy and the threats to those who are serving. Although the Services generally meet their goals, there are times when shortfalls occur. When recruiting is difficult, the questions of the current characteristics of youth and the scientific basis for enlistment standards become central. What are the implications for changing the standards in terms of performance, attrition, and cost? If there is a shortfall in recruiting with current standards, can one or more standards be lowered and by how much without compromising readiness?

When the committee began its work in 1999, the Army, the Navy, and the Air Force had recently experienced recruiting shortfalls. By the



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Assessing Fitness for Military Enlistment: Physical, Medical, and Mental Health Standards 1 Introduction The U.S. Department of Defense (DoD) faces short-term and long-term challenges in selecting and recruiting an enlisted force to meet personnel requirements associated with diverse and changing missions. The DoD has established standards for aptitudes/abilities, medical conditions, and physical fitness to be used in selecting recruits who are most likely to succeed in their jobs and complete the first term of service (generally 36 months). In 1999, the Committee on the Youth Population and Military Recruitment was established by the National Research Council (NRC) in response to a request from the DoD. One focus of the committee’s work was to examine trends in the youth population relative to the needs of the military and the standards used to screen applicants to meet these needs. Mission requirements drive the size and shape of the force, which in turn drive recruiting goals. The ability of the Services to meet recruiting goals is influenced by a number of contextual factors, including the state of the economy and the threats to those who are serving. Although the Services generally meet their goals, there are times when shortfalls occur. When recruiting is difficult, the questions of the current characteristics of youth and the scientific basis for enlistment standards become central. What are the implications for changing the standards in terms of performance, attrition, and cost? If there is a shortfall in recruiting with current standards, can one or more standards be lowered and by how much without compromising readiness? When the committee began its work in 1999, the Army, the Navy, and the Air Force had recently experienced recruiting shortfalls. By the

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Assessing Fitness for Military Enlistment: Physical, Medical, and Mental Health Standards early 2000s, all the Services were meeting their goals; however, in the first half of calendar year 2005, both the Army and the Marine Corps experienced recruiting difficulties and, in some months, shortfalls. This was due to a combination of factors, including a decline in unemployment rates, increasing accession demand, and the effect of the ground troop deployments in Afghanistan and Iraq. When recruiting goals are not being met, scientific guidance is needed to inform policy decisions regarding the advisability of lowering standards and the impact of any change on training time and cost, job performance, attrition, and the health of the force. The first focus of the committee was (1) to examine trends in the attitudes, aptitudes, and aspirations of American youth relative to education and ability standards set by the Services and (2) to explore the competition from other options available to youth after high school, such as jobs in the private sector and higher education. In 2003, the committee produced a report on this topic (National Research Council, 2003). The current focus of the committee is on (1) the health and physical fitness of American youth as they relate to current screening standards and (2) the validity of these standards for predicting attrition, injury, and performance in training and on the job. Some important questions follow. Is there a scientific basis for existing standards, and should they be modified on the basis of characteristics of today’s youth or the new medical treatments available to them? Are there changes to training or health-related support services that should be considered to supplement screening standards? What are the cost implications of modifying physical, medical, and mental health screening standards for recruits? CHARGE TO THE COMMITTEE The objective of the current project is to critically examine the current physical, medical, and mental health standards for military enlistment in light of (1) trends in the physical condition of the youth population; (2) medical advances for treating certain conditions, as well as knowledge of the typical course of chronic conditions as young people reach adulthood; (3) the role of basic training in physical conditioning; (4) the physical demands and working conditions of various jobs in today’s military services; and (5) the measures that are used by the Services to characterize an individual’s physical condition. The focus is on the enlistment of 18- to 24-year-olds and their first term of service. There are five related subtasks geared to DoD’s need for guidance on physical, mental, and medical standards for enlistment that form the charge to the committee:

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Assessing Fitness for Military Enlistment: Physical, Medical, and Mental Health Standards Develop a profile of the physical and medical condition of American youth today and in the future. Characterize youth, using scientific literature that offers insight into their anthropometric characteristics, fitness, nutrition, medical, and mental health status. Evaluate demographic trends in light of existing and potential physical and medical standards for military service. Examine the changing nature of work generally and the new demands placed on the military in the post–cold war era, using the work of the NRC’s Committee on Techniques for the Enhancement of Human Performance: Occupational Analysis as a point of departure. Review the literature on the physical requirements of military jobs. Consider the implications of current and projected trends in work as they impact approaches to selecting youth with appropriate health status and physical abilities. Review the literature on the predictive validity of medical and physical selection standards for training and job performance in the military and in the civilian population. Gather evidence on the utility of such standards from experimental and observational studies. Develop policy options. Consider a full range of personnel options for ensuring that recruits are healthy and fit for military service, including greater coordination of standards and measurement procedures among the military services, changes in the physical and medical standards applied to recruits, changes to the measures used to implement the standards, methods of validating standards, and changes in training to accommodate recruits selected under new standards. Conduct a workshop on the physical requirements of military service. The workshop should provide a forum for discussions on methodological and substantive issues among committee members, DoD officials, and other experts. The committee assembled to accomplish the charge is composed of experts in the areas of psychology, military personnel policy, military occupational analysis, military and occupational medicine, military sociology, obesity, physical fitness, chronic diseases, and mental health. Biographical sketches of committee members and staff are provided in Appendix D. In responding to the charge, the committee made a series of assumptions about the scope of the project and the key variables of interest. The Committee’s View of the Project Scope With regard to scope, three decisions guided the committee’s work. First, we decided to focus on American youth ages 18-24 as they relate to

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Assessing Fitness for Military Enlistment: Physical, Medical, and Mental Health Standards active-duty enlisted personnel through the first tour of duty. Whenever possible, trends in the youth population were examined by race and gender. This decision was guided by the sponsor’s interest in recruiting and retention of the first-term enlisted force. The DoD Office of Accession Policy deals primarily with developing recruiting guidelines for selecting these individuals. Individuals attending the military academies or participating in the Reserve Officers’ Training Corps (ROTC), Reserve, and National Guard units are outside the sponsor’s purview. The military academies and ROTC attract high school students who are interested in obtaining a college education and joining the officer corps. The second decision regarding scope was to confine the committee’s examination of standards to the military’s current policy that all enlistees should be deployable—that is, ready for combat. Even though there is a wide variety of jobs in the military that require different skills, different levels of physical conditioning, and different types of medical and mental health, we did not think that it was within our scope or expertise to render an opinion as to whether or not the military should shift from a policy that all enlistees should be deployable to a policy that enlistees should be matched to particular jobs, some not requiring exposure to combat. The third decision was to include a consideration of modifying basic training in ways that might reduce injury without reducing resulting fitness. The high level of injury in women during basic training was a particular concern. Developing physical fitness programs is clearly within the committee’s expertise, and we decided that physical fitness screening and training should be considered in combination. Key Variables The committee’s charge calls for a critical examination of physical, medical, and mental health issues. In addition, we decided to include drug, alcohol, and tobacco use and related behavioral issues. With regard to selecting medical standards for consideration, the committee was guided by several factors: (1) the frequency of occurrence of various disqualifying conditions in the youth population and in the population of applicants; (2) the extent to which disqualification for a condition could be waived by one of the Services; (3) the existence of military research regarding the effect of the condition on the first-term enlisted force by the Accessions Medical Standards Analysis and Research Activity (AMSARA), the U.S. Army Research Institute of Environmental Medicine (USARIEM), the U.S. Army Center for Health Promotion and Preventive Medicine (USACHPPM), and the U.S. Military Enlistment Processing Command (USMEPCOM); (4) the existence of research and medical advances in the civilian sector that should be evaluated; and (5) standard

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Assessing Fitness for Military Enlistment: Physical, Medical, and Mental Health Standards TABLE 1-1 Medical Failures and Waivers, May 1, 2003 to April 30, 2005, Active Forces (most frequent medical failures, ranked by frequency; excludes cases with 2+ failures) Medical Status Total Applicants Name No Failure Failure % Waived % Occurrence No failure 359,082       All othera   20,804 36 29.7 Weight   16,312 46 23.3 Marijuanab   8,796 20 12.6 Psychiatric   4,303 34 6.1 Lower extremities   4,058 46 5.8 Lungs/chest   3,700 38 5.3 Hearing   3,637 28 5.2 Vision   2,868 41 4.1 Upper extremities   2,840 53 4.1 Skin   2,716 41 3.9         100.0 Totals 359,082 70,034 38   Total accessions   239,940     Total not accessed   189,176     Total applicants   429,116     aAll other medical fail codes with N < 2,000, e.g., blood pressure, abdomen, feet. bPositive test at physical. SOURCE: Committee analysis based on data provided by USMEPCOM (2005). changes that could make a difference in the eligibility of significant numbers of potential recruits. Table 1-1 presents the distribution of failure codes assigned in the medical examination and the waivers assigned in those failure codes by the various Services for applicants between May 2003 and April 2005. The top five disqualifiers are all part of the committee’s examination: body mass index (BMI)/weight (23.3 percent), marijuana (12.6 percent), psychiatric/mental health (6.1 percent), lower extremity/musculoskeletal (5.8 percent), and chest and lungs (5.3 percent). Together the top five disqualifiers account for 53 percent of the medical failures. The committee’s evaluation of existing standards includes their effects on attrition and injury. Specifically, attrition was examined in basic training and through the first term of service. Measures relating to injury or illness include days lost, the need for hospitalization, cost, and attrition

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Assessing Fitness for Military Enlistment: Physical, Medical, and Mental Health Standards resulting from injury and illness. Although of considerable interest, measuring posttraining job performance is problematic because it is difficult to obtain valid and reliable measures of individual performance. APPROACH AND INFORMATION GATHERING Framework Military and civilian research efforts have identified several risk factors associated with injury and attrition. These factors have been divided into three categories. The first includes characteristics of the individual and involves cognitive capabilities, attitudes, motivation, physical fitness, medical status, mental health, age, gender, and race. Each of the characteristics can have some impact on an enlistee’s success. The second factor is the physical environment and the job that the individual will be asked to perform. It includes task variables, such as fully loaded marching, lifting, jumping, shooting, and so forth. The third factor is the psychosocial character of the work environment and the attending mental and emotional stressors. Each factor makes an important contribution; however, the interactions among them must also be considered when developing selection standards and fitness training programs for the enlisted force. The committee used these factors and their interactions as a framework for its analysis. Information Gathering The committee gathered information on the enlistment process and existing standards from a series of briefings provided by representatives form the U.S. Military Enlistment Processing Command, the U.S. Army Accession Command, and the U.S. Navy Service Training Command. Briefings on research related to the development of screening standards and the relationship among various physical fitness, medical, and mental health conditions and injury and attrition were provided by representatives from the Air Force Research Laboratory (AFRL), USACHPPM, USARIEM, and AMSARA. Some of this material was provided at committee meetings and some at the committee-designed workshop held in January 2005. Other topics presented at the workshop include (1) research on standard setting and testing in the civilian sector, (2) a cost-benefit framework for examining the implications of changes in enlistment standards, and (3) reasons for attrition through various stages in the first term of service based on data from the Army Longitudinal Study using the 1999 cohort. All individuals providing information to the committee are listed in Appendix C.

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Assessing Fitness for Military Enlistment: Physical, Medical, and Mental Health Standards The committee also used data provided by military organizations in its analysis. Data provided by the Defense Manpower Data Center (DMDC) were used to examine attrition rates for enlistees waived for a variety of medical conditions. Data provided by USACHPPM were used to examine the relationship between BMI levels and injury and attrition and the relationship between physical fitness levels and injury and attrition. These data were based on large research studies conducted at Ft. Jackson. Data provided by USMEPCOM were used to examine medical failure codes and the breakdown (according to the International Classification of Diseases, ICD-9) of those used most frequently. These failure codes are assigned on the basis of medical examinations at the military entrance processing stations (MEPS). The data provided also include the number of individuals in each failure code who received a waiver and was allowed to enter a Service. Other sources of military data were obtained from articles and technical reports identified by MEDLINE, the Defense Technical Information Center, and AMSARA. Most of these reports contain data that were provided to the committee through the briefings noted above. On the civilian side, data from the National Health and Nutrition Examination Survey were analyzed to describe the distribution of BMI and aerobic fitness or maximal oxygen consumption (as measured by VO2max, described in Chapter 4) in the youth population ages 17 to 24. Each of these analyses is discussed in detail in the following chapters. Data on trends in the youth population were obtained through a review of the professional literature. Major topics in this review include body composition and body fat, asthma, physical fitness, the biomechanics of musculoskeletal injury, various categories of mental health, and drug, alcohol, and cigarette use. Whenever possible, these reviews include breakdowns by gender and race. Finally, methodological topics dealing with the development and use of the recruiting cost model and the application of validity tests in research on selection were reviewed. DIVERSITY IN THE ENLISTED FORCE Men and women from all racial and ethnic groups have equal opportunity to seek a military career, provided they meet basic entry requirements. Throughout this report, various terms are used to describe racial and ethnic populations, including African American/black; Caucasian/ white; Hispanic/Mexican; Native American/Alaskan Native; Asian American/Pacific Islander, and multiracial. These terms reflect the history of racial discourse in American society. Comparisons between the civilian population and the military population ages 18 to 44 indicate that blacks are overrepresented in the Services (21.8 versus 12.6 percent) and Hispanics are underrepresented (10

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Assessing Fitness for Military Enlistment: Physical, Medical, and Mental Health Standards versus 13.9 percent). Although women represent a substantial proportion of the force (17.3 percent), the proportion is significantly less than their representation in society of slightly over 50 percent. In fiscal year (FY) 2002, approximately 381,000 individuals applied to the Services in the active enlisted military force. Not all applicants are eligible to enlist, and thus not all applicants join the Services. In all, 78 percent of the applicants were male, of whom 66 percent were white, 16 percent black, 12 percent Hispanic, and 7 percent other. For female applicants, approximately 54 percent were white, 26 percent black, 13 percent Hispanic, and 8 percent other (U.S. Department of Defense, Under Secretary of Defense Personnel and Readiness, 2004). The growth of racial and ethnic minority populations in the civilian population and their significant engagement in the armed forces requires special attention to health and fitness factors that may influence their eligibility for military service. Throughout this report, data are presented to illuminate the differential impact of medical, physical, and mental health status on the military service eligibility of racial and ethnic minority populations. As data in the following chapters demonstrate, the medical, physical, and mental health status of the youth population may diminish the pool of applicants eligible for military service. In addition, the documented disproportionate burden of risk factors for chronic disease affecting racial and ethnic minority populations may slow or reverse historic positive trends in military service for these groups. Any change in eligibility standards must take into consideration the impact on recruitment of racial and ethnic minority populations. THE STATE OF MILITARY REQUIREMENTS All the Services have policies that require every member, regardless of his or her job classification, to be fit for deployment. Soldiers in the Army are expected, among other things, to be able to react to combat situations, to move through the battlefield, to employ hand-to-hand techniques, and to control and evacuate crowds. All these tasks are physically demanding, and many will be performed under extreme environmental conditions of heat or cold, dampness or dryness, at high altitudes, and so forth. Both officers and enlisted personnel must be prepared to use force as required and must be ready to put themselves in harm’s way. The military assumes that its personnel will sacrifice their lives as part of their jobs. In order to meet the physical requirements, the Services have made some assumptions about what fitness level is needed and how this level of fitness should be maintained. In addition, the U.S. Department of De-

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Assessing Fitness for Military Enlistment: Physical, Medical, and Mental Health Standards fense and the Services have developed guidelines specifying the desired medical and mental health condition of members of the enlisted force. These guidelines are used as screening standards—some are based on strong clinical and scientific evidence about the links between a health condition and the ability to perform in combat (e.g., blindness, deafness), and others are based on assumptions about this relationship (e.g., body composition, certain mental health conditions). Currently there is little or no screening for physical fitness at the MEPS. For some Services, there are conditioning programs for the recruits while they are waiting in the delayed entry program (DEP) to be shipped to basic training. Recruits may remain in the DEP for up to one year. For the most part, however, physical fitness tests administered at the beginning and throughout basic training are the selection screens. Basic training is intense and physically demanding. Those who do not pass the fitness tests at the end of training will not be able to remain in the Services. This test generally consists of sit-ups or crunches, push-ups or pullups, and a run of 1.5 to 3 miles. Maintaining fitness is also a concern. Each Service has its own set of tests and testing schedules to measure physical fitness at various points in the first term. Medical and mental health standards for screening are contained in the recently revised DoD Instruction 6130.4 (Appendix A—<http://www.dtic.mil/whs/directives/corres/html/61304.htm>). This instruction specifies all medical conditions for which an applicant can be disqualified. As noted earlier, some of these have a clear basis, while others may be interpreted more broadly, depending on the individual case and the need of a particular Service. Thus, some conditions cannot be allowed under any circumstances while disqualification for others can be waived by a Service. Conditions that are frequently waived are of particular interest to the committee. REPORT ORGANIZATION This report is organized into eight chapters. Chapter 2 provides an overview of enlistment processing procedures and standards and includes a description of the medical processing at MEPS. Chapter 3 discusses the methodology for linking standards to outcomes, provides an example of how the accession quality cost trade-off model can be applied, and examines the characteristics of current databases and the needs for the future. The next four chapters focus on analyses of particular standards. Each includes (1) a discussion of trends in the youth population as well as in the military enlisted force, (2) an examination of the available data on the relationship between a selected condition and injury or attrition, and (3) an analysis of various interventions found effective in the civilian sector.

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Assessing Fitness for Military Enlistment: Physical, Medical, and Mental Health Standards Chapter 4 covers physical fitness considerations in selection, preconditioning, and training. Chapter 5 covers body composition and asthma, two medical factors that lead to a substantial number of disqualifications and subsequent waivers. Chapter 6 includes mental health concerns. Chapter 7 discusses substance abuse and smoking. Chapter 8 presents a summary of findings and the committee’s conclusions and recommendations.