Which term takes into account the mental and physical fitness of the soldier

Journal Article

Ulrich Wesemann, Ph.D,

Department of Psychiatry, Psychotherapy and Psychotraumatology, Bundeswehr Hospital, Scharnhorststr. 13, Berlin, Germany

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Revision received:

18 August 2017

Accepted:

05 February 2018

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  Ulrich Wesemann, Ph.D, Gerd D Willmund, MD, Jörn Ungerer, PhD, Günter Kreim, MSc, Peter L Zimmermann, MD, Antje Bühler, PhD, Michael Stein, PhD, Jakob Kaiser, MSc, Jens T Kowalski, PhD, Assessing Psychological Fitness in the Military – Development of an Effective and Economic Screening Instrument, Military Medicine, Volume 183, Issue 7-8, July-August 2018, Pages e261–e269, https://doi.org/10.1093/milmed/usy021

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Abstract

Introduction

In the German Armed Forces (Bundeswehr), the number of soldiers suffering from mission-caused mental disorders has increased during the past years.1 There are also relevant numbers of undiagnosed and untreated soldiers in the Bundeswehr with mental disorders. Besides stigma, the most reported reasons of this reserved behavior facing mental disorders were the soldiers feeling they could handle problems on their own, belief of treatment ineffectiveness, and work interference.2 Apart from mental disorders, researchers also found worsening of the mental health status in general after deployment.3–4 In order to identify risk factors as early as possible, the implementation of a screening tool is planned. In addition, health-promoting and training measures are considered. Therefore, this study aims at developing a screening instrument for assessing the psychological fitness of soldiers using questionnaires. Accordingly, screening programs already in existence were taken into account during conceptualization.

The UK armed forces implemented the threshold assessment grid triage5 as a brief written standard tool for mental health screening. The aim of this assessment tool is to identify the severity of mental illness.

The US Army started the Joint Medical Surveillance Program in 1996 for all its soldiers deployed in Bosnia for more than 30 d. This program included a form of psychological screening, which assessed mental health throughout the deployment cycle.6 The US Army then implemented the Global Assessment Tool (GAT)7 for screening the psychological fitness of soldiers, which is combined with physiological measures. Recruits are assessed when they join the military and re-evaluated at regular intervals throughout their career. The GAT includes 15 subscales that relate to (a) emotional, (b) social, (c) spiritual, and (d) family fitness. Most of the subscales have been adapted from pre-existing tests.8 Criticism of this tool focuses on the seemingly rushed development of this screening approach. It is criticized as not having been developed for the military and being only slightly change-sensitive. The results are given in percentiles, meaning that there are no stable scores to suggest the need for personalized training. Changes in the GAT are only interpreted in relation to others and not on an individual level.9

The Bundeswehr is the unified armed forces of Germany and comprised approximately 170,000 male (88%) and female (12%) soldiers. The Bundeswehr has been a volunteer army since the Federal Cabinet decided to suspend compulsory military service in 2011. Bundeswehr soldiers are deployed on UN-mandated missions in Europe, Asia, and Africa as well as in the Mediterranean and the Horn of Africa.10

The Bundeswehr developed a screening instrument based on previous research. Spiritual questionnaires were not included, since the German military after the reunification of East and West Germany is believed to be rather aspiritual. This is due to the long religious restrictions during the communist period. This psychological fitness approach focuses more heavily on resources (i.e., social support), easy-to-train skills (i.e., enjoyment), or quickly implementable conditions (i.e., current work relief), and less on deficits, such as mental health symptoms. This approach thus corresponds to primary prevention before the occurrence of mental health syndromes. This is intended to reduce the barriers and stigmatization and help to derive targeted health-promoting measures. To determine which measures are of interest for the German military population, an interview (TIPSYFIT) was developed. This interview queried a range of resources found to be protective in previous studies. The interview results in only one psychological fitness ranking. This ranking is stable over time so soldiers can be compared with all others and personal changes can be seen. Due to the large number of soldiers who potentially have to be assessed, the instrument must be both effective and economic. The objective of this study is therefore to identify psychological test scales that can be used as a screening instrument for assessing the psychological fitness of deployed Bundeswehr troops. As a limiting factor, it is not possible to generalize the results to the entire Bundeswehr. In this approach, psychological fitness describes a soldier’s ability to integrate and enhance his/her mental and emotional capabilities using resources and trainable skills. Psychological fitness in the Bundeswehr approach describes a soldier’s ability to integrate and enhance his/her mental and emotional capabilities. A concept of sustaining and enhancing psychological fitness has not yet been implemented. The interview is described in more detail in the method section.

The theoretical construct of psychological fitness combines a variety of resources that provide protection against the development of mental disorders. The focus is on mental health and military performance is not taken into consideration. Four components – resilience, sense of coherence, post-traumatic growth, and quality of life – were identified as relevant factors for this approach by an external team of experts.11 Health-promoting measures will be developed on the basis of this framework.

• Resilience describes a learnable ability to live through adverse, even threatening events and experience no more than slight disruptions in normal functioning, if any. In this context, burdens are viewed as a challenge rather than a threat or an insoluble crisis.12

  Special Forces soldiers who are deployed abroad are less likely to suffer from chronic stress than Special Forces soldiers stationed within Germany. Deployment is seen as a challenge and intensive deployment training could have a more preventive effect if put to use.13 In another study, high resilience was negatively correlated with the severity of symptomatology in soldiers after deployment.14

• Sense of coherence describes a feeling of confidence that “(a) the stimuli deriving from one’s internal and external environments in the course of living are structured, predictable and explicable; (b) the resources are available […] to meet the demands posed by these stimuli; and (c) these demands are challenges, worthy of investment and engagement.”15

  The decrease in sense of coherence was significantly related to the overall severity of trauma symptoms, depression symptoms, and general symptoms in soldiers.16 Apart from this study, sense of coherence has not yet been able to predict the development of psychological stress. However, due to the resource-oriented approach, it was included in the framework and will be evaluated.11

• Post-traumatic growth as described by Tedeschi and Calhoun17 refers to the transformation in people’s abilities following a traumatic event; they grow in relation to the pre-trauma state. Hence, they undergo a development that extends beyond the simple adaptation to the event as such. Growth includes (a) greater appreciation of life, (b) a changed sense of priorities, (c) warmer and more intimate relationships, (d) a greater sense of personal strength, and (e) recognition of new possibilities for one’s life or spiritual development.

  There is no research on post-traumatic growth and soldiers of the Bundeswehr. As this approach is resource-oriented and post-traumatic stress is very frequent after deployments, this concept has been tested.11

• The concept of quality of life describes people’s perceptions of their own life situations with respect to culture and values. It covers their goals, expectations, evaluation criteria, and interests. The main categories are (a) the physical, (b) mental, and (c) social well-being of an individual.18

Quality of life proved to be a protective factor for German soldiers against psychological impairments after deployments abroad.19–21

In order to obtain a complete picture of the interview, however, clinical questionnaires were also used, which are described in more detail in the method section.

The framework was established on behalf of the German Ministry of Defense. The project was carried out with approval from the Bundeswehr ethics regulatory board and in accordance with current German data protection rules. Confidentiality was maintained throughout the study.

Method

Procedure

Participants were asked to fill in either paper-and-pencil or computer-based forms of the test battery. Therefore, the comparability was tested based on all participants available at t1 (N = 496). The test battery included all the questionnaires below described for all the participants. All the participants were then interviewed. The interviewers were blinded for the test results. The questionnaire results of all the participants and the interview data of all the participants were therefore available for data analysis.

Interview data are used as a validation standard. The interview itself is validated on the soldiers who participated only at t1 and were lost to follow-up.

The second assessment was conducted between 3- and 6-month after deployment, till December 2014 (t2). It was embedded in obligatory post-deployment briefings, the procedure for data collection of the questionnaires, and the interview was the same as in t1. As there (t1) were no differences between paper-and-pencil and computer forms, the testing was already completely converted to the electronic version.

Measures

The questionnaires focus on resources. In order to avoid overlooking the influence of current clinical symptoms, the Patient Health Questionnaire as a clinical questionnaire was added. All questionnaires are available in a validated German version.

Resilience – RS-11

To quantify the resilience of the soldiers, the Resilience Scale23 was used in its German short version with 11 items (e.g., “I have a reason to get up in the morning.”).24 Cronbach’s alpha was 0.87 at t1 and 0.91 at t2.

Sense of Coherence – SOC-L9

The short version of the German Sense of Coherence Scale featuring nine items (SOC-L9; e.g., “Do you have a feeling that you are in an unfamiliar situation and don’t know what to do?” – from “very often” to “very seldom or never”)25,26 was used to measure the sense of coherence as defined by Antonovsky.11 Cronbach’s alpha of this questionnaire is 0.81 at t1 and 0.86 at t2.

Quality of Life – WHOQOL-BREF

The World Health Organization Quality of Life (WHOQOL) questionnaire is an instrument for measuring the subjective quality of life. The short form of this questionnaire (WHOQOL-BREF) consists of 26 items measuring five domains on a 5-point Likert scale: “Physical Health” (e.g., How much do you need any medical treatment to function in your daily life?”), “Psychological Health” (e.g., “How much do you enjoy your life?”), “Social Relationships” (e.g., “How satisfied are you with your personal relationships?”), “Environment” (e.g., “How satisfied are you with the conditions of your living place?”), and “Overall Quality of Life and General Health” (e.g., “How satisfied are you with your health?”).18 For all the scales, Cronbach’s alpha is acceptable or good, lying between 0.75 and 0.86 for t1 and t2. An exploratory factor analysis with five components and factor rotation was used to examine the structure of the WHOQOL-BREF. The structure could be supported, although for this sample, according to scree plot, a two-factor solution would have been more appropriate. The variance explained by the five factors was between 27% and 2%.

Mental Disorders – PHQ-D

PHQ-D (Patient Health Questionnaire) is a reliable instrument for screening mental disorders. It consists of 78 items, some of which allow two to five answers to be given. Three domains were considered in this study: PHQ-9 (depression – e.g., “Over the last 2 wk, how often have you been bothered by… Little interest or pleasure in doing things”), PHQ-15 (somatoform – e.g., “During the past 4 wk, how much have you been bothered by… Stomach pain”), and Stress (e.g., “In the last 4 wk, how much have you been bothered by… Worrying about your health”).27 Cronbach’s alpha was between 0.71 and 0.82 for the three domains at t1 and t2. The scree plot of an exploratory factor analysis supported the three components of this questionnaire. The sum of the explained variance is nevertheless weak and lies between 12.3% and 8.5%.

Post-traumatic Growth

The German version of the post-traumatic growth inventory (PPR; English: PTG)28 consists of 21 items assigned to five domains on a 6-point Likert scale: “New Opportunities” (e.g., “I developed new interests”), “Relationship to Others” (e.g., “A willingness to express my emotions.),” “Personal Strengths” (e.g., “Knowing I can handle difficulties.”), “Valuation of Own Life” (e.g., “Appreciating each day.”), and “Religion” (e.g., “I have a stronger religious faith.”). Cronbach’s alpha was between 0.71 and 0.92 for the domains at t1 and t2. An exploratory factor analysis with five components and factor rotation was used to examine the structure of the PPR. The structure could be supported, although for this sample, according to scree plot, only one factor would have been more appropriate. Nevertheless, the explained variance for the five factors was between 18.7% and 9.5%. This questionnaire was included, as the majority of the soldiers have already participated earlier in missions abroad.

Interview: TIPSYFIT Eighteen psychologists, all of whom had received a week of additional training in advance, participated in t1. Inter-rater reliability was 95% after training. After filling out the questionnaires, participants were randomly assigned to a troop psychologist for an interview. Eleven psychologists were selected as interviewers in t2. Two-way random intraclass correlation with absolute agreement for the psychological fitness ratings (t1 and t2) with 0.66 was small. This is attributed to the change sensitivity of this score after deployment. A t-test for independent samples showed no significant differences between the interviewers in the psychological fitness scores for t1 or t2.

The TIPSYFIT (Truppenpsychologisches Interview zur Erfassung der psychischen Fitness; English: Troop psychology interview for measuring psychological fitness) was used as a validation standard. It is a structured interview developed by the Bundeswehr Psychological Service on the basis of its own previous research. Nevertheless, it has not been evaluated in advance. This restricts the validation standard. No point values are given or scales calculated in the interviews. The screening results in only one psychological fitness ranking with a predetermined cutoff value in this first step. The scale is not calculated by point scores but summarizes all the interview results based on the qualitative expert rating of the interviewer.

TIPSYFIT assesses both current stress factors and resources available on the basis of the psychological fitness approach. The interview must be conducted, and the results documented, by trained troop psychologists. The first part covers socio-biographical information on subjects such as the participants’ military service (e.g., “How often were you deployed abroad?”). In the next part, participants provide information on personal resources and current stress factors. This covers aspects such as their relationships with their partners (e.g., “Did you have enough time for your partner in the last 6 mo?” or “Can you talk about problems with your partner?”), children, superiors, and buddies (e.g., “Please describe the relationship between you and your supervisor” or “Can you trust your buddies?”); their military training (e.g., “Do you feel well trained as a soldier?” or “Do you feel well prepared for the deployment abroad?“); and their subjective state of health, alcohol consumption, hobbies, and exercise.3,29–31 Afterward, previous military and non-military critical life events are assessed (e.g., “Have you ever had a very critical life event?… If so, how did you deal with it?”), as well as coping strategies (e.g.,”How do you solve problems in your partnership/with your superiors/with your comrades?”).32 Questions are then asked about symptoms related to perceived stressors (e.g., Are you currently more aggressive?), as well as about barriers to care and current treatments.2,33 The interviewees are also asked how they perceive their psychological fitness on a scale from 1 (psychologically fit) to 7 – (not fit at all). Finally, the interviewer assesses the psychological fitness of the soldiers interviewed, taking account of all the information obtained in the interview. This qualitative psychological fitness rating also ranges from 1 to 7 and is the main outcome of the interview in this study. According to the standard Bundeswehr ratings, a rating of 1–4 was considered an indication of a good psychological fitness level, whereas a rating of 5–7 is an indication of a poor psychological fitness level that requires further examinations to be conducted by a specialist.

Participants

The sample consists of the contingent that constituted the Northern Reaction Unit (NRU) for 6 mo in Afghanistan from January to June 2014. The first data were acquired in November 2013 (t1) during the training for the deployment.

Although 496 soldiers participated in t1, N = 361 soldiers also participated in t2, meaning that the dropout rate was 27%. Reasons given for this included changes in the resource planning of the NRU, personal reasons, and medical conditions. The soldiers were aged between 18 and 49 (mean: 26.54; SD: 4.92) yr. Two hundred and twelve participants (59%) were enlisted soldiers, 115 (32%) NCOs, and 30 (8%) officers (Table I). Four participants did not provide information about their rank, and only three were female (1%). This sample is not representative for the Bundeswehr, but it is for deployed combat troops.22

Table I.

Demographic Data of the Participants

Table I.

Demographic Data of the Participants

Statistical Procedures

The psychological fitness score of the interview was validated with N = 135 soldiers who participated only in t1 and were lost to follow-up. As an external validation criterion, Spearman’s correlations were performed for the continuous psychological fitness score and all the scales of the questionnaires described above.

To assess any influence, the participants who drop out (N = 135) have on the sample relevant sociodemographic parameters of participants and dropouts are compared using two-sample t-tests for metric and Pearson’s χ2-tests for categorical parameters. The same procedure was followed to test for differences between paper-and-pencil and electronic testing. All participants from t1 were included (N = 496). Due to the low number of female participants, no gender-related analyses are conducted.

Linear regression analyses are computed to predict psychological fitness levels from questionnaire scores. Normal P-P plot of regression standardized residual was performed and confirmed the assumption for the regression analysis. The normal distribution was tested and rejected by a Shapiro–Wilk test. However, due to the large sample size, the calculation was considered robust even of a violation of normal distribution.34 Missing data were excluded list-wise. The psychological fitness score is the regress and the scales of the questionnaires are the regressors. This is designed to be used for screening soldiers with respect to their psychological fitness. Regression analyses were conducted on 361 participants who provided data at both time points using all predictors separately for t1 and t2. A final model was then computed using only scales, which were significant at both time points 1 and 2. This allowed us to check whether the accuracy of the predictions remained constant or was only valid for one measurement. To select an appropriate cutoff and thus determine the accuracy of the predictions, receiver operating characteristic (ROC) curves are analyzed for the final model at t1 and t2. Psychological fitness ratings are therefore dichotomized. Participants with ratings of between 1 and 4 are considered to have a good psychological fitness level. Participants with ratings of between 5 and 7 are seen as having a lower psychological fitness level.

Results

For external validation, Spearman’s correlations of the continuous psychological fitness score and the scales of the questionnaires are given in Table II. Highest correlations (p < 0.001) were found for PHQ stress (r = 0.47) and PHQ depression (r = 0.51) as well as for psychological quality of life (r = −0.47). Although the correlations are not very high, they support the external validity of the psychological fitness score. This is a mixture of different approaches in order to get as broad a statement as possible.

Table II.

Spearman’s Correlation Matrix of the Psychological Fitness Score and Questionnaire Scales at t1 for External Validation of the Interview

**Bonferroni adjusted p < 0.001 (<0.00008); *Bonferroni adjusted p < 0.01 (<0.0008). Psych. Fit. Score, psychological fitness score; r, Spearman’s correlation; p-value, significance two-tailed; PTG, post-traumatic growth; PHQ depr., PHQ depression; PHQ somatic, PHQ somatic symptoms; PTG relationships, relationships to others; WHO social, WHO social relationships; WHO environ., WHO environment.

Table II.

Spearman’s Correlation Matrix of the Psychological Fitness Score and Questionnaire Scales at t1 for External Validation of the Interview

**Bonferroni adjusted p < 0.001 (<0.00008); *Bonferroni adjusted p < 0.01 (<0.0008). Psych. Fit. Score, psychological fitness score; r, Spearman’s correlation; p-value, significance two-tailed; PTG, post-traumatic growth; PHQ depr., PHQ depression; PHQ somatic, PHQ somatic symptoms; PTG relationships, relationships to others; WHO social, WHO social relationships; WHO environ., WHO environment.

There was no significant difference between paper-and-pencil and computer-based testing at t1. Dropout rates did not differ significantly from the actual test group from the point of view of psychological fitness or relationship status, but did so from the point of view of rank (χ2 [2, N = 490] = 7.76; p = 0.021) and age (t [484] = −4.67; p < 0.001), with the dropout rate for NCOs and officers being higher than for enlisted soldiers and older personnel. Spearman’s correlations revealed no significant relationship between psychological fitness and either rank, age, or relationship status. Descriptive statistics of the psychological fitness rating and a correlation matrix of the psychological fitness rating and questionnaires are presented in Tables III and IV.

Table III.

Descriptive Statistics for Psychological Fitness Scores at t1 and t2

Dichotomous: 0 = good psychological fitness; 1 = minor psychological fitness; SD: standard deviation.

Table III.

Descriptive Statistics for Psychological Fitness Scores at t1 and t2

Dichotomous: 0 = good psychological fitness; 1 = minor psychological fitness; SD: standard deviation.

Table IV.

Correlation Matrix of the Psychological Fitness Score and the Questionnaire Scales at t1 for the N = 361 Soldiers Included

**p < 0.01; *p < 0.05.

Psych. Fit. Score, psychological fitness score; r, Pearson correlation; p-Value, significance two-tailed; PTG, post-traumatic growth; PHQ depr., PHQ depression; PHQ somatic, PHQ somatic symptoms; PTG relationships, relationships to others; WHO social, WHO social relationships; WHO environ., WHO environment.

Table IV.

Correlation Matrix of the Psychological Fitness Score and the Questionnaire Scales at t1 for the N = 361 Soldiers Included

**p < 0.01; *p < 0.05.

Psych. Fit. Score, psychological fitness score; r, Pearson correlation; p-Value, significance two-tailed; PTG, post-traumatic growth; PHQ depr., PHQ depression; PHQ somatic, PHQ somatic symptoms; PTG relationships, relationships to others; WHO social, WHO social relationships; WHO environ., WHO environment.

The scales of all five questionnaires answered by the included participants at t1 are added to a linear regression model that predicts the psychological fitness score. Seven significant predictors are detected by this algorithm, which are the social relationship, the psychological and the environmental scale from WHOQOL-BREF, the somatoform and the stress scale from PHQ, the relationship and personal strength scales from post-traumatic growth, and the sense of coherence scale. The lower sample size is due to gaps in the questionnaire data. The same analysis was performed at t2. Regression coefficients and T-values for both time points are given in Table V. Four predictors remained significant by this algorithm, which are the social relationship and the psychological scale from WHOQOL-BREF and the somatoform and the stress scale from PHQ. The final model included this four-questionnaire scales and was performed for both time points. Regression coefficients show that high scores in the WHO scales are related to a high psychological fitness level, while high scores at PHQ are related to a low psychological fitness level. The explained variance R2 is 0.27 at t1 and R2 = 0.33 at t2 (Table VI).

Table V.

Regression Model at t1 and t2 Including All Questionnaire Scales as Predictors for the Psychological Fitness Rating

t1: F(15, 338) = 9.0; p < 0.001; R2 = 0.29. t2: F(15, 344) = 10.3; p < 0.001; R2 = 0.34.

Table V.

Regression Model at t1 and t2 Including All Questionnaire Scales as Predictors for the Psychological Fitness Rating

t1: F(15, 338) = 9.0; p < 0.001; R2 = 0.29. t2: F(15, 344) = 10.3; p < 0.001; R2 = 0.34.

Table VI.

Regression Model at t1 and t2 Including Only Significant Predictors of the Full Regression Analysis of Both Time Points (Table V) for the Psychological Fitness Rating

F(4, 352) = 29.1; p < 0.001; R2 = 0.27. F(4, 355) = 42.4; p < 0.001; R2 = 0.33.

Table VI.

Regression Model at t1 and t2 Including Only Significant Predictors of the Full Regression Analysis of Both Time Points (Table V) for the Psychological Fitness Rating

F(4, 352) = 29.1; p < 0.001; R2 = 0.27. F(4, 355) = 42.4; p < 0.001; R2 = 0.33.

When a cutoff of 0.05 is selected for the dichotomized data, 70.1% of those with a psychological fitness rating of between 5 and 7 are identified correctly as unfit, 15.0% of those with a good psychological fitness rating are falsely classified as unfit. When the same criterion is applied to the sample at t2, 79.0% of the participants with a psychological fitness rating of 5 or more are predicted correctly, whereas 29.6% of those with a good psychological fitness rating are predicted incorrectly.

Discussion

This study aimed at developing a screening instrument for assessing the psychological fitness of soldiers. Psychological fitness was assessed in a structured interview. The result served as an external criterion. The soldiers also had to answer five questionnaires that measured different components of psychological fitness. The screening model was developed on the basis of the scale scores obtained from these questionnaires at t1. The same model was then tested at t2. In the final model, only questionnaire scales that were significant at both time points were included.

When psychological fitness is predicted on the basis of questionnaire data, regression coefficients reveal that a low psychological and a low social relationship score on WHOQOL and high scores in the PHQ stress and PHQ soma scales correlate positively with a low psychological fitness level at t1 and t2. Nevertheless, due to the incorrect positive rate, 15.0–29.6% of all soldiers need an additional interview. This calls for a second step to be taken after the questionnaire. Soldiers can then be selected for individualized training programs.

Limitations

This study has some limitations that have to be considered. The structured TIPSYFIT interview used for assessing psychological fitness has not been tested for validity and reliability. Hence, its results might be biased. The age, gender, and rank of the soldiers who participated in the study are representative for combat soldiers deployed, but not for the Bundeswehr as a whole, so the generalizability of the results is limited.

The model was developed before the soldiers deployed and reviewed after they redeployed. As it is a related sample, another confirmatory study is in progress to verify the model. This sample will be representative for the Bundeswehr.

Conclusion

This study can be said to have successfully contributed to development of a screening instrument for assessing psychological fitness for deployed combat troops. Specificity requires further optimization before final deployment. By evaluating four scales of two questionnaires, it allows specialists to differentiate between soldiers who are psychologically fit and those who are unfit. As it takes approximately 20 min to fill out these questionnaires, the screening instrument is time-efficient. It allows soldiers to be screened regularly and those with a presumably low psychological fitness level to be selected for further examination and, if necessary, psychological training measures. However, as 15–29.6% were classified as false positives, further work is necessary to improve the prediction. Performing that many interviews, however, are beyond the scope of what is logistically feasible at the moment, the interview is analyzed in order to identify suitable training possibilities for the soldiers. Improving the assessment scheme, which takes into account several dimensions, could also improve the specificity.

Funding

This study was carried out on behalf of the German Ministry of Defense, Stauffenbergstraße 18, 10785 Berlin, Germany. There was no additional funding source.

Acknowledgment

Our special thanks go to Frank Eggen for IT support, Manuel Mahnke for the smooth organization, as well as Sandra Wetzel, Charlyn Löpke, and Jan Ukena, all from the Bundeswehrkrankenhaus Berlin.

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