Self-Reported Health Care Avoidance Behavior in U.S. Military Pilots Related to Fear for Loss of Flying Status

ABSTRACT

Introduction

U.S. military pilots are required to meet certain medical standards in order to maintain an active flying status. Military pilots face potential temporary or permanent loss of flying privileges in the setting of a new condition or symptom that does not meet required standards, which could result in negative social and occupational repercussions for the pilot. For this reason, it has been proposed that U.S. military pilots participate in health care avoidance behavior, but little evidence exists to characterize such a trend in this population.

Materials and Methods

We conducted a non-probabilistic Internet survey of the general population of U.S. pilots from November 1, 2019 through August 1, 2021. The current study is a sub-analysis of military pilots.

Results

A total of 4,320 pilots answered the informed consent question, and 264 selected one military pilot type and were included in this sub-analysis. There were 72% of military pilots who reported a history of health care avoidance behavior (n = 190), and no statistical difference was found between age groups, gender, and military pilot types. There were 55.5% of pilots who reported a history of seeking informal medical care (n = 147), 33.7% of pilots who have flown despite a new symptom they felt required medical evaluation, 42.5% of pilots who reported withholding information on aeromedical screening (n = 111), and 11.4% of pilots who reported a history of undisclosed prescription medication use (n = 30).

Conclusions

U.S. military pilots may participate in health care avoidance behavior because of fear for loss of flying status.

INTRODUCTION

U.S. military pilots are required to meet certain medical standards to maintain an active flying status.^1–4 These medical standards are instituted to ensure pilots are medically fit to fly. U.S. military pilots undergo periodic flight surgeon examinations, at intervals directed by their military service, to ensure medical standards are met.^1–4 If a military pilot does not meet medical standards because of a new symptom or medical condition, the pilot may face temporary or permanent loss of flying privileges. Select medical conditions can be granted a waiver by the appropriate authority after assessment and/or treatment, although certain medical conditions can result in permanent disqualification from flying. Loss of flying status in a military pilot could have social and occupational repercussions, including an adverse impact on career progression, a need for retraining after a prolonged period off of flying status, and psychosocial/financial stress, ultimately resulting in a disincentive to seeking medical care or disclosing new health information. For this reason, it has been proposed that military pilots experience anxiety related to seeking medical care and/or disclosing health information because of the potential social and occupational repercussions of a change in health status on their ability to fly.

Several recent studies have demonstrated health care–seeking anxiety in several pilot populations. A 2019 cross-sectional study of 613 U.S. airline, recreational, and military pilots showed that 78.6% reported feeling worried about seeking medical care because of how it could impact their ability to fly.^5,6 These findings may have consequences on health care behavior in pilots. In total, 38.8% of pilots in the study reported withholding information from a physician because of fear of losing their medical certificate, whereas 60.2% of pilots reported delaying or forgoing medical care because of concerns related to their ability to fly.^5,6 Other work has demonstrated aversion to health information disclosure in the military pilot population. A study of 173 active duty and reserve U.S. Air Force (USAF) pilots showed that only 44.1% of pilots felt comfortable discussing a major medical concern with a flight surgeon, whereas 57.6% of pilots felt comfortable discussing a minor medical issue with a flight surgeon.⁷ Interestingly, 74% of pilots reported a belief that pilots could withhold major, potentially disqualifying medical information from flight surgeons. Beyond pilots, other work has demonstrated that the degree of health information disclosure may be related to how the receiving party might be able to occupationally or financially impact the discloser. A 2019 study of 843 adults showed that participants were less likely to disclose health information if they felt the receiving party could negatively impact them (i.e., their employer or medical insurance company).^8,9 This point was further made in another article, showing that the number one cited factor that influenced mental health care utilization in a cohort of U.S. military soldiers was professional concerns.¹⁰

An unanswered question is whether U.S. military pilots report health care avoidance behavior because of fear for loss of flying status. Furthermore, it is uncertain what type of health care avoidance behaviors military pilots might exhibit and could include (1) informal medical care seeking (an unauthorized behavior for military pilots^1–4,11), (2) flying despite experiencing a new and concerning psychological or physical symptom, (3) use of an undisclosed medication, and (4) or misrepresentation or withholding of health information on aeromedical screening. It is also unknown if demographic factors, such as (1) age, (2) gender, and (3) pilot type, impact health care avoidance behavior in the military cohort. To the best of our knowledge, little data are available regarding health care avoidance behavior in U.S. military pilots. The current study is a sub-analysis of self-reported health care avoidance behavior from a cohort of U.S. pilots.¹²

METHODS

Study Design

The current study is a sub-analysis of a larger sample of U.S. pilots with methods that mirror that of previously published work by select authors of the current study.¹² The study was conducted in accordance with the Declaration of Helsinki per the Brooke Army Medical Center Institutional Review Board–approved study protocol (protocol no. C.2019.158e). The study used a non-probabilistic Internet survey of the general population of U.S. pilots. The survey was hosted using Qualtrics software (Qualtrics XM, Seattle, WA, USA) and was accessible by respondents via a publically available URL between November 1, 2019 and August 1, 2021. The inclusion criteria for consideration as a respondent included any individual who reported to be an active pilot in the USA. This sub-analysis used an additional inclusion criterion of a responder who selected one of the military subgroups when asked to self-identify the setting of their primary flying duties. Pilots of unmanned aerial vehicles and other flight crew members such as navigators were not specifically included in the study.

The study was advertised on social media platforms, including Facebook.com and Instagram.com, by searching for aviation-focused interest groups using the following keywords: aviation, flying, student pilots, pilots, and airline. Additionally, “Aviation LO Down,” a large aviation interest podcast, advertised the study on several episodes as well as on the associated social media sites. Study recruitment materials noted that the research topic was pilot health behavior. The researchers supplemented the primary social media advertisement campaign by distributing the study advertisement through the following communication channels: the e-mail lists of a large U.S.-based university with an aviation program and the Civil Air Patrol (civilian auxiliary of the USAF). Additionally, the USAF’s chief of aerospace medicine distributed the study advertisement via e-mail to subordinate aerospace medicine specialists to consider distribution.

Questionnaire

The survey contained eight items in English only and did not solicit personally identifiable information. Given the limited research on health care–seeking behavior in this population, the authors were able to find no previously published manuscripts that have directly studied these specific topics to use in survey development. The below survey questions were developed by the following group: one military flight surgeon, one internal medicine attending physician, one military aeromedical researcher/epidemiologist, one civilian aeromedical/occupational health physician, and two resident physicians/aeromedical researchers. The questions were not externally pre-validated before survey distribution. Two items addressed respondent demographic factors: age (<25, 25-40, 41-60, or >60) and gender (male, female, or other). Two items addressed respondent occupational factors: predominant type of flying during the past 5 years (military, jet [fighter, bomber, attack, and high altitude reconnaissance]; military, transport [cargo, tanker, and airborne intelligence/surveillance/reconnaissance]; military, other [rotary and undergraduate pilot training]; civilian, mainline airline transport; civilian, regional airline transport; civilian, non-airline commercial; and civilian, general aviation). One binary (yes or no) item inquired if the respondent ever sought informal medical care from anyone other than his or her health care provider for fear of jeopardizing aeromedical certification. Two binary (yes or no) items inquired if the respondent ever (1) piloted an aircraft with symptoms or (2) taken a prescription medication that he or she believed a physician should have evaluated before flight. Lastly, a single item inquired if the respondent ever misrepresented or withheld information on a written health care questionnaire for fear of jeopardizing aeromedical certification (yes, no, or prefer not to answer). The full survey can be seen in the Supplementary data.

Data Analysis

Surveys were excluded from the analysis if the responder left more than one demographic question unanswered. Pilots who identified as one of the provided military pilot types were included in the sub-analysis. Military pilot types included (1) military, jet [fighter, bomber, attack, and high altitude reconnaissance]; (2) military, transport [cargo, tanker, and airborne intelligence/surveillance/reconnaissance]; and (3) military, other [rotary and undergraduate pilot training]. Additional pilot-type questions were added midway through the study in hopes of clarifying military pilot subtypes. The decision was made to use the original pilot-type categories listed above because of small enrollment numbers after this change. The primary outcome of this study was answering yes to any of the four health care avoidance behavior questions. Categorical data were summarized using percentages and analyzed using the chi-squared test. Significance for results was established when P-values were less than .05. Factors associated with subjects’ responses to the four-question pooled response were then added to a multivariable logistic regression model. Odds ratios and their corresponding 95% CI and P-values were then reported for all factors in the model. All statistical analysis was performed using JMP v 13.2 SAS Corp (Cary, NC, USA).

RESULTS

There were 4,320 pilots who answered the informed consent question, 3,270 who answered every question, and 495 who either did not answer or selected “prefer not to answer” for at least one question. There were 264 pilots who selected one military pilot type and were included in this sub-analysis. The data for the remaining 4,056 pilots were excluded from this manuscript. Table I shows the rate of answering yes to at least one type of health care avoidance behavior by demographic factors. Table II shows the total responses for each of the four primary health care avoidance behavior questions.

In order to assess whether there were relationships between demographic factors within the data, a logistic regression model was built. This model did not yield any differences in statistically significant variables, nor were any interactions detected. Based on this, the model was not utilized further, and the analysis proceeded with descriptive statistics.

DISCUSSION

To our knowledge, the current effort appears among the largest studying U.S. military pilot health care avoidance behavior because of fear for loss of flying status. In this cohort, a significant majority of military pilots (72%) reported at least one type of health care avoidance behavior because of this concern, suggesting that this behavior may exist in the population of U.S. military pilots. Interestingly, the rate of self-reported health care avoidance behavior was higher in the military population than in non-military group of the same cohort published in other work.¹² Specifically, 66% of paid civilian pilots (airline pilots, commercial pilots, etc.) reported at least one type of health care avoidance behavior, whereas only 44% of non-paid civilian pilots (general aviation/recreational pilots) reported health care avoidance behavior,¹² suggesting that the military population may be at particular risk for this behavior. There are several possible explanations for this finding that could include (but not limited to) (1) factors unique to the military aeromedical system, (2) factors unique to operational military aviation, and (3) a higher representation of younger pilots in the military population that are early in their career and have concerns related to the impact of their health status on their career. In the military population, we found no differences in rates of self-reported health care avoidance behavior based on age, gender, or military pilot type, suggesting that this observation may be independent of the specific demographic factors that were studied. Alternatively, it is possible that the sample size was too small to detect a difference between these demographic factors. Future work could focus on understanding factors that might influence health care avoidance in the military population that were not identified in this study.

Interestingly, nearly a third of military pilots in our sample reported a history of flying despite experiencing a symptom (physical or psychological) that the pilot felt warranted evaluation by a physician. This is a behavior that is overtly against regulations for U.S. military pilots^1–4,11 because of aviation safety concerns but could also result in increased health risks to the pilot. These data speak to the risk (both aviation safety and individual health-related) certain military pilots may willingly tolerate to avoid health care because of fear of losing their flying status. The rate of this behavior in the military pilot population was nearly double that of the non-military pilot sample, which was reported by only 15.5% of U.S. civilian pilots. Interestingly, there were 42.5% of military pilots who reported misrepresenting or withholding health information during flight surgeon examinations because of fear for loss of active flying status. This finding is in line with previous studies that showed that a proportion of military pilots are hesitant to fully disclose health information because of fear for loss of their flying status.⁷ Incomplete disclosure during aeromedical screening could result in operational and readiness challenges to flying units, and future research should focus on identifying modifiable factors that could encourage disclosure and care seeking. Further work should also study factors unique to military aeromedical systems that might elucidate explanations for care-seeking differences suggested in this study and in other work.^5–7

Any conclusions should be drawn within the limitation of this study. Non-probability sampling may lead to response bias, and retrospective studies are at risk for recall bias. Furthermore, we were unable to calculate a response rate because it is unknown how many pilots were invited to participate. Importantly, we were unable to verify any single answer, and there were a minority of pilots who answered “prefer not to answer” for several questions, which could have influenced the results. It should also be noted that we did not specifically ask whether informal medical care was sought outside of the military health care system. Data were not collected on the military branch of each pilot, which precludes conclusions on specific military subgroups. There are also limitations in the individual military pilot-type groupings, recognizing that there are likely to be cultural differences between groups (e.g., jet fighter and bomber pilots). Although the study did not specifically recruit pilots of unmanned aerial vehicles or other flight crew members such as navigators, we were not able to determine whether one may have inadvertently been included. A study of health care avoidance in these populations may be an opportunity for future work. Finally, all health conditions/symptoms were fully self-reported and not corroborated with health care professionals.

CONCLUSIONS

U.S. military pilots may participate in health care avoidance behavior because of fear for loss of flying status. Future research should focus on studying factors unique to the U.S. military aeromedical system that might influence pilot health care–seeking behavior.

ACKNOWLEDGMENTS

The authors thank Lieutenant General (Dr.) Thomas W. Travis, USAF (Ret.); Major General (Dr.) John D. DeGoes, USAF; Colonel (Dr.) Mark S. True, USAF (Ret.); Mr. John W. Desmarais, CAP; Mr. Ron D. Olienyk, CAP; William Sullivan, United Airlines; Dana McIlwain; Milo Smith, University of North Dakota Alumni Association; Shane Hersch, University of North Dakota Alumni Association; Reyné O’Shaughnessy; and David Lombardo.

SUPPLEMENTARY MATERIAL

Supplementary Material is available at Military Medicine online.

FUNDING

Funding for the current study was provided by the USAF.

CONFLICT OF INTEREST STATEMENT

None declared.

REFERENCES

Author notes