Policy Review

Although the focus of the report is on the post-deployed context, for the policy review we included all sleep-related policies and programs, given that few were specifically related to the post-deployment period. We identified and analyzed DoD policies related to sleep by conducting custom searches for publications, issuances, and directives using online search engines and targeted DoD and Service-specific repositories. Appendix F includes a table outlining the DoD policies related to sleep in the Air Force, Army, Navy, and Marine Corps; in DoD generally; and in the U.S. Department of Veterans Affairs (VA).

We used search terms that would be applicable in the military context, such as instruction, policy, directive, sleep, clinical, prevention, operational, training, fatigue, crew rest, and shift work. In addition, when programs arose in our searches, we included them even though a program's existence or implementation may not necessarily be dictated or mandated by a policy. Sources below the Service or branch level, such as theater-specific policies, installation-specific policies, and unit-specific standard operating procedures, are likely to be unique to each individual command or unit; we excluded these sources because it can reasonably be inferred that such subordinate policies, at least in writing, would be consistent with higher-echelon guidance. We did not specifically target a review of policies for the National Guard or reserve components of any Service; however, many of these policies are likely applicable to all Service components.

Key Informant Discussions

To augment the literature reviews and to identify barriers to implementing codified (i.e., written) policies pertaining to sleep, we conducted interviews with a sample of 40 individuals, including medical professionals and sleep experts, health policymakers at multiple levels, military operators (e.g., pilots, brigade commanders, naval ship commanding officers), and personnel with military training responsibilities across the Service branches. Our strategy was designed to gather a range of expertise from both the military health system and the military departments. Appendix G provides details on our recruitment strategy, along with our interview guide and protocols. Briefly, the key informant interviews were conducted by phone (each lasting 30-60 minutes), recorded, transcribed, and subsequently coded for thematic content according to the methods of applied thematic analysis (Guest, MacQueen, and Namey, 2012). Related to the study's primary aims, the interview guide included questions about awareness of sleep-related policies and programs; the process and barriers to prevention, identification, and treatment of sleep problems; and perceived barriers to the implementation and enforcement of policies.

Expert Working Group

We organized and convened a one-day meeting on February 21, 2014, of experts with clinical, operational, and policy backgrounds related to sleep. The meeting included 31 researchers and clinicians, both civilian and military, and other uniformed personnel and RAND staff currently involved with various aspects of sleep and service-member health research. In consultation with DCoE, the research team developed four focus areas for the meeting and tasked each of the meeting's assigned subgroups to discuss current practices, barriers, and recommendations related to one of the following topic areas: (1) self-identification of sleep problems, (2) prevention of sleep disorders, (3) best sleep practices and programs in operational/training contexts, and (4) best sleep practices and programs in clinical/medical contexts. The research team took notes during the working group meeting and provided the participants with summaries of the discussions and recommendations. Further details about the meeting logistics and the summaries provided are included in Appendix H.

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