Career Enhancement Training Study (USAF)
Phase: NA
Conditions: Suicidal Ideation
Sponsor: University of Rochester

PHASE 2 PROTOCOL – RANDOMIZED CONTROLLED TRIAL (RCT)   
June 20, 2017 
 
1
20170829 – Expanded enrollment window, addition of AF prevention training participation 
20200415 – last IRB approval 
 
Study Title:  
Career Enhancement Training Study (US-AF) 
 
 
 
 
 
Principal Investigator:  
Peter A. Wyman, PhD 
Department of Psychiatry, University of Rochester 
 
 
Co-Investigators: 
 
Kerry L. Knox, PhD 
Anthony R. Pisani, PhD 
Eric D. Caine, MD 
Department of Psychiatry, University of Rochester 
 
C Hendricks Brown, PhD 
David Mohr, PhD 
Northwestern University 
Robert Gibbons, PhD 
University of Chicago 
 
Key Staff: 
 
 
Bryan Yates, Senior Project Coordinator 
 
 
 
 
Lacy Morgan-DeVelder, LMFT, Lead Trainer 
 
 
 
 
Karen Schmeelk-Cone, PhD, Data Manager 
 
 
1. Overview: Project Objectives and Phase 1 Accomplishments 
Relationship disruptions and social isolation are major precipitants for military suicides and 
a range of problems that impair functioning and reduce mission readiness (DoD, 2012). However, 
nearly all current military suicide prevention programming focuses on a narrow range of approaches 
for individuals already at high-risk (e.g., training to detect warning signs and refer for treatment 
services). This project addresses the need for universal prevention approaches to proactively 
strengthen protective factors across military populations, including strengthening social 
connectedness and skills to grow and sustain relationships across service.  
The aims of this project are to (a) adapt the Sources of Strength intervention (Wyman et al., 
2010) for young, enlisted United States Air Force personnel, and (b) test the adapted intervention 
(i.e., Wingman-Connect) using a rigorous randomized controlled trial (RCT) design. Sources of 
Strength has proven efficacy in strengthening social integration, social support interactions, and 
healthy orientation to managing stressors such as relationship break-ups that increase vulnerability 
to emotional problems including suicidal behavior (Wyman et al., 2010). Those gains spread across 
a population in education settings to untrained individuals (Wyman et al., 2010; Petrova, Wyman, 
Schmeelk-Cone, & Pisani, 2015).  
This project was planned as three phases: adaptation and development (Phase 1); field test to 
assess acceptability and feasibility of the adapted intervention (Phase 2); and randomized controlled 

PHASE 2 PROTOCOL – RANDOMIZED CONTROLLED TRIAL (RCT)   
June 20, 2017 
 
2
trial with 6-month follow-up (Phase 3). We have completed Phase 1 through a period of curriculum 
development with Airman-in-Training (AiT) at the 82nd Training Wing (82 TRW, Sheppard Air 
Force Base) from August 2015 – February 2017. Due to the extended Phase 1 (approximately 16 
months beyond the initially planned duration), the project leadership team (including Air Force 
partners) determined that the ‘field test’ phase is unnecessary. A revised Statement of Work (SOW) 
eliminating the field test was approved by the DoD funder (May 4, 2017). 
In Phase 1 we enrolled a total of 296 Airman-in-Training (from 29 technical training 
classes) in 10 cohorts over 18 months to pilot and evaluate new training modules aimed at 
strengthening social connectedness and coping resources. Participants completed assessments of 
targeted constructs (e.g., class cohesion, help-seeking acceptance) prior to training and again at 
1-month follow-up, as well as measures of knowledge retention and preparation to apply skills. 
Rates of training retention (completing all 5 hrs. of training) were also collected for each cohort. 
Data were used to revise and improve training modules and evaluate progress of the adaptation. 
Data collected during Phase 1 suggest that Wingman-Connect training is engaging AiTs, the 
concepts are retained, students view the training as beneficial, and those indicators have 
improved over time. Retention of core concepts (active recall) was 20% higher in the last several 
cohorts trained (reaching nearly 100% at the end). More recent versions of the training show 
increased gains in class cohesion over time. Class cohesion change scores (pre-training to 1-
month follow-up) doubled in size after cohort 4 (0.5 SD to 1.0 SD).  
Wingman-Connect (adapted Sources of Strength program) focuses Airman-in-Training 
on building protective factors in: Kinship (healthy bonds); Guidance (support from mentors and 
mental health); Purpose (goals, sense of being valued and valuable); and Balance (self-care and 
support). Half of the training is focused on the class as a group to build belonging and shared 
purpose. The Wingman-Connect training manual was completed in February 2017; findings from 
Phase 1 suggest the intervention is ready for efficacy testing (Phase 2).  
 
The following sections of this human subjects research protocol pertain only to the Phase 2 
Randomized Controlled Trial (RCT).  Phase 1 was previously approved.  
 
2.  Characteristics of the Research Population and Study Site  
2.1 Subject Characteristics. Approximately 1440 Airman-in-Training attending 
technical school at Sheppard Air Force Base (82 TRW) will participate as research subjects.  We 
project 15-20% attrition, resulting in approximately 1200 participants completing the follow-up 
(6-months post-training). 
Based on Air Force administrative databases regarding AF personnel, the demographics 
of the 1440 subjects are projected to approximate the overall AF active-duty population: 19% 
female (n=274) and 81% male (n=1166).   We project that approximately 78% of personnel can 
be expected to be White (n=1123), 20% Black (n=288), and 2% Asian (n=29). The proportion of 
other race groups (e.g., Native American; Alaskan Native) is not known.  Based on estimates 
from the Air Force Personnel Center 
(http://www.afpc.af.mil/library/airforcepersonneldemographics.asp) approximately 7% (n=101) 
are projected to self-identify as Hispanic ethnicity. All subjects will be 18 years or older, with 
expected range of 18 – 35. Based on Air Force recruiting standards, all participants are expected 
to have completed high school, partial college or college degree (2- or 4-year), and possess 
English language proficiency required for informed consent. 
 

PHASE 2 PROTOCOL – RANDOMIZED CONTROLLED TRIAL (RCT)   
June 20, 2017 
 
3
2.2 Research Site.  All subjects and training will be located in two squadrons of the 82nd 
Training Wing (Sheppard Air Force Base, Wichita Falls, Texas): the 365th TRS and the 363rd 
TRS. Letters of participation from the squadron commanders are attached to this Phase 2 
protocol.  
 
 
2.3 Inclusion/Exclusion Criteria. Airmen-in-Training (AiT) in Technical Training 
classes in the 365 or 363 Training Squadrons of the 82 Training Wing (82 TRW) will be eligible 
to participate. There are no restrictions based on age, sex, race/ethnicity or any other personal 
characteristic. All AiTs are expected to have sufficient English language proficiency for training 
and standardized assessments. By enrolling AiTs in two training squadrons, 365 and 363, study 
participants will reflect diversity of job classifications. The 365 trains Airman primarily in 
avionics (electronics systems), and the 363 trains in weapon systems. Overall, more than 40 
different job classifications (AFSCs) are trained across both squadrons. 
Both intervention conditions (Wingman-Connect and Stress Management Training) have 
a brief text messaging component. Owning a phone and using text messaging is not required for 
participation in the study.  
Classes will be selected to receive information about the study (time and place of 
informational meetings) that fit in a ‘window’ of instructional length. Specifically, classes will 
receive study information that have a training duration long enough for participants to complete 
the 1-month follow-up assessment while still enrolled in training program at Sheppard Air Force 
Base (pre-graduation) and short enough so that participation in the follow-up assessment will 
occur 2-4 months after transfer to first duty base. In the 363rd eligible classes will be those with 8 
– 12 week duration; in the 365th, 16 – 25 week duration, which includes a 7 week fundamentals 
class prior to entering their specific AFSC technical class and being eligible to enroll. Classes 
will be invited to enroll in the first 2 – 8 weeks of starting their AFSC technical training class.  
Baseline assessments will be completed after enrollment through an on-line system (see 
below).  Individual characteristics are not examined prior to enrollment, and there are no 
exclusion criteria due to any self-reported mental health symptom or other attribute.  
 
3. Study Personnel, Design, Recruitment, and Consent  
 
3.1. Study Personnel and Roles. University of Rochester Medical Center (URMC) 
personnel will conduct all subject recruitment, enrollment, in-person surveys, and training at the 
study site (Sheppard Air Force Base). No other study personnel (from Northwestern University 
or University of Chicago) will have direct contact with subjects or access to identifiable subject 
data.    
 
3.2. Randomized Trial Design. The study design will involve randomizing 
approximately 1440 Airman-in-Training within 160 Technical Training classes to one of two 
conditions: Wingman-Connect or a brief Stress Management training. Randomization will occur 
at the class level, since Wingman-Connect is designed to train AiTs within a class together as a 
group (those who voluntarily enroll).  We have designed this trial to stagger recruitment and 
training of the different groups over the course of 14-16 months in a “roll-out” randomized trial 
design (Brown et al., 2009). In this design, we will form clusters of class units within training 
squadron in order to balance the two conditions on key characteristics including age, job 
classification and time of year. We have documented that such designs that randomize across 
"place and time", i.e. workforce group and cohort, have both beneficial statistical properties and can 

PHASE 2 PROTOCOL – RANDOMIZED CONTROLLED TRIAL (RCT)   
June 20, 2017 
 
4
be conducted effectively in large systems (e.g. schools and county service organizations) (e.g., 
Wyman, Brown et al., 2008). 
 
In the randomly assigned control condition, AiTs will receive a 2-hr training on stress 
management (Stress Management Training). Participants in both Wingman-Connect and Stress 
Management conditions will be sent brief informational text messages. Comparing Wingman-
Connect with an alternative training is a stronger design than using a no-intervention condition, by 
increasing the extent to which the design ‘controls’ for potential impact that could come from 
individual’s knowledge that he/she is participating in a training designed to improve well-being and 
from receiving messages about how to enhance personal well-being, particularly for isolated 
personnel.  
 
3.3. Method of Subject Identification and Recruitment. We will use procedures 
developed for Phase 1 designed to optimize informed consent and eliminate any potential 
pressure that AiTs could perceive to participate in the study.  
UR research staff will identify 6-12 eligible technical training classes on a monthly or bi-
monthly basis made up of 60 – 70 AiTs (frequency depending on availability within squadron), 
from training registries obtained from the Sheppard AFB registrar (which will only list classes, 
no names or other identifiers). The Squadron staff will confirm eligibility of proposed classes 
and provide those AiTs with information on the time and place that the researchers will be 
available if they wish to learn about the study (see attached recruitment script), during a ‘non-
restricted’ portion of the training day. The researchers will be at a different location than 
leadership (Commander, Supervisors, Instructors), and the recruitment will occur at that location. 
No leadership (of the squadron or other group) will be present during the recruitment. The 
leadership will not encourage participation in the study, and the researchers will not provide any 
information to leadership about whether students enrolled. Each AiT will be introduced to the 
study and can decide whether to participate. Research staff presenting to AiT groups for 
recruitment will clearly state that participation in the study is voluntary. They will be informed 
that they can decline to participate in the research study and, if they do choose to participate in 
the research, to withdraw their participation at any time.  
  
3.4. Process of Consent.  Each prospective participant will receive a consent form 
outlining all required elements. A trained URMC research staff member will summarize the key 
elements of the consent document, including voluntary nature of the study; rights of subjects to 
withdraw at any time; the purpose and procedures of the study, including the types of 
information and data being collected, and random assignment into one of two trainings 
(Wingman-Connect, or Stress Management); potential risks and steps that will be taken to 
address those risks, and limits of confidentiality of data. During the consent form review, 
research staff will inform potential subjects that individual responses to questionnaires covering 
behavioral and emotional health (including the measures of mood and distress) will be de-
identified by the URMC Department of Bioinformatics before being received by the research 
team and not examined for the purpose of identifying individuals for referrals. All individuals 
will receive information about available mental health resources (including external help lines). 
URMC research staff will inform prospective participants that enrollment requires providing an 
email address and/or a mobile phone number, so that participants can be sent information about 
how to complete the 6-month follow-up assessment. Potential subjects will be informed that 

PHASE 2 PROTOCOL – RANDOMIZED CONTROLLED TRIAL (RCT)   
June 20, 2017 
 
5
assessments will be completed through a secure on-line platform, and ID codes linking each 
subject to his/her data will be de-identified before the data is analyzed.  
Time will be allotted for participants to read the consent documents and ask questions of 
qualified research staff.  Individuals who choose to enroll as subjects will provide signed a 
consent document to research staff (who will sign to document obtaining consent and having 
provided opportunity for the subject to ask questions).  Because participation in the study is 
minimal risk and involves training on knowledge and skills to (a) build and sustaining healthy 
relationships and social networks (Wingman-Connect), or (b) understand stress and how to 
manage/reduce stress (Stress Management), a formal ‘check’ of understanding of the study 
procedures/elements is not necessary. All subjects are expected to be English-proficient, which is 
a requirement of being active-duty AF personnel. Subjects will not receive payment for 
participation while they remain in training. Per recommendation of Sheppard Air Force Base 
Leadership, all training and assessments will be conducted during non-restricted portions of their 
duty day, during which airmen may not receive extra compensation. Potential subjects will be 
informed that they will be eligible for a $50 honorarium for completing the final 6-month follow-
up assessment during off-duty hours, after transfer to their first duty base. Participants will also 
be given the option to decline the honorarium, based on recommendations from the PI of a large 
military cohort study, which found that some service members prefer to forego payment 
(personal communication, Dennis Faix, MD, MPH, Director, Military Population Health, Naval 
Health Research Center). Participants will be asked to provide a primary and back-up electronic 
contact (phone or email) in order to be contacted for the final survey and payment. This 
information will be stored separately from participant’s research data and will be deleted at the 
completion of the study. 
At the time subjects provide written consent, each subject will be given a second copy of 
the consent form for his/her records, which includes information about how to contact the 
researchers and RSRB at University of Rochester.  Subjects will be asked to sign both copies. 
Photocopying machines may not be routinely available, so copies of signed consent forms may 
not be available to provide subjects, and it is viewed as more important that subjects receive a 
copy immediately for contact information.  
 
3.5. Process of Randomization.  Randomization will occur at the Technical Training 
Class level, since Wingman-Connect is designed to promote skills of individuals as well as 
cohesion at the unit (class) level. Following squadron leadership identifying eligible classes of 
60-80 AiTs, the classes will be paired and randomly assigned using a random number generator 
to either Wingman-Connect or Stress Management Training condition. Classes will be paired 
within squadron. By pairing Technical Training Classes within the same squadron that begin 
instruction at approximately the same period in time, our design reduces the potential for 
external events (e.g., leadership change, violent incident on base) biasing students’ behavior or 
self-reports within one of the conditions, which could reduce our ability to evaluate intervention 
impact (Brown et all., 2006). To conduct the randomization, class numbers will be sent to 
Northwestern University site PI (C Hendricks Brown, PhD) who will conduct the randomization. 
No names or identifying information about the class will be sent, just an ID code (for class).  
AiTs who enroll will complete a baseline assessment (see below for measures). After 
completing the assessment, participants will be informed of the time and location of the training 
to which they are assigned. Training will also occur during non-restricted portions of the day.  
 

PHASE 2 PROTOCOL – RANDOMIZED CONTROLLED TRIAL (RCT)   
June 20, 2017 
 
6
4. Training Procedures/Conditions 
 
4.1 Training.  Groups of 25-35 subjects will participate in either (a) Wingman-Connect, 
or (b) Stress Management Training based on random assignment.  
 
4.2 Wingman-Connect Training. Wingman-Connect was created by adapting the 
evidence-based Sources of Strength program (LoMurray, 1995; Wyman et al., 2010) for the US 
Air Force.  Sources of Strength has proven efficacy in strengthening social integration, social 
support interactions, and healthy orientation to managing stressors, and those gains spread to 
untrained individuals (Wyman et al., 2010; Petrova, Wyman, Schmeelk-Cone & Pisani, 2015). 
Wingman-Connect total training time is 5 hours, typically spread over three consecutive training 
‘blocks’(or days), plus 1-hour of booster training (one month later).  
Wingman-Connect training focuses on strengthening skills to grow and sustain four 
protective factors: Kinship (healthy bonds); Guidance (support from mentors; access to medical 
and mental health expertise); Purpose (goals, sense of being valued and valuable); Balance (self-
care and support) (Four Cores). Trained facilitators, who apply an evidence-based active training 
model developed through training thousands of young adults and adolescents in Sources of 
Strength, lead interactive modules to draw out “real world” narratives of healthy bonds and 
coping as the primary method of teaching about the Four Core protective factors. The training 
has a total of 22 modules comprised of specific learning objectives and activities. Key modules 
and associated skills include: eliciting reasons for enlisting as a motivational foundation for the 
training; introducing Four Cores as protective factors that promote fitness, well-being and 
preparedness to benefit from AF career opportunities; elicit self-reflection on participants’ own 
balance of Cores and ways to strengthen each Core; establishing the importance of personal and 
career success as depending on a strong network; extending learning into natural environment by 
inviting classes to work together to strengthen collective kinship, purpose, guidance or balance; 
establishing norm that AiTs are strengthening Cores and consolidating gains by drawing out 
narratives about how participants’ are keeping one or more Cores strong.  
 Between the first and second training Day (or “block”), approximately 8-10 of the 
enrolled AiTs in a cohort will be invited to attend an additional 1-hr voluntary ‘Key Wingman’ 
meeting (during unrestricted time). These “Key Wingman” are selected by nominations of 
classmates on the baseline social network measure (participants name classmates who they trust 
and would choose to spend time with). The 1-hr ‘Key Wingman’ session has modules designed 
to empower this group with knowledge that they are seen by their peers as influential; provide 
them experience of articulating their experiences in growing Four-Core protective factors so they 
can model healthy narratives to others and serve as positive role models during the training.  No 
additional data is collected from Key Wingman and no additional activities are required of those 
individuals outside of usual Wingman-Connect training that would require additional consent 
procedures (standard consent forms describe nomination, voluntary additional meeting).  
A core concept of Wingman-Connect is that individuals sharing real-world examples of 
strength helps create a healthy culture. Participants in the training will therefore be invited to 
contribute to two optional video-recorded public service campaigns. These strength-based 
campaigns provide opportunities for participants to share a brief “testimonial” about how they 
maintain and strengthen supportive relationships and other “Four-Cores” of strength. Participants 
will be informed at the time they are given the option to participate that these strength-based 
videos: are voluntary; will be sent out to participants in their training cohort (email, text); and 

PHASE 2 PROTOCOL – RANDOMIZED CONTROLLED TRIAL (RCT)   
June 20, 2017 
 
7
will be available to share with other Airmen and family outside the training group via a weblink 
on Wistia.com. These digital recordings will not contain any sensitive information (all video 
recordings are reviewed by the PI). These public service campaign videos do not identify anyone 
as a study participant, could not be used to link any individual to study data, and will be not be 
retained as data.  
After 1 month, Wingman-connect has a 1 hr. “Booster” session. The Booster has seven 
modules aimed at reviewing and consolidating accomplishments and strategies to overcome 
barriers to maintaining strong Cores; encouraging continuation of growing Cores and building 
bonds to benefit from strengths around them.  
 
 
4.3. Stress Management Training. The control training condition will consist of a 2 hr. 
informational training that provides an overview of the human stress response system and 
strategies to manage stress. The training will be delivered through lecture format using 
PowerPoint, supplemented by brief videos and interactive discussion. The first 1-hr. session 
covers: the basics of the HPA axis stress-response system; common experiences of stress 
(physiological, cognitive, emotional); the impact of chronic stress on the brain and other domains 
of health; how exercise reduces harmful effects of stress; and relaxation techniques that have 
been shown to reduce stress and adverse effects of stress on health. Two brief videos are 
embedded in the first hour: a summary of stress effects on health and an overview of guided 
relaxation techniques. A 1-hr booster session (delivered one month later) reviews the 
physiological stress response and effects of stress on health; introduces how cognition influences 
stress responses; common cognitive distortions/attributions are reviewed that affect stress 
including strategies to strengthen protective cognitive responses. A brief video summarizes a 
strategy for identifying and changing cognitive distortions that can magnify stress.  
 
4.4. Text Messages to Reinforce Training Concepts. Participants in both training 
conditions will be sent post-training informational and motivational text messages, 
approximately one message per week for the duration of the study. The messages aim to: 
increase retention of intervention content over time; reinforce group norms regarding 
intervention practices and content; and encourage personal reflection. Several messages will 
contain links to a video. In Wingman-Connect condition videos will include the “Class Legacy 
video” created during the third training session and links to clips from the ‘Four Cores Update’ 
videos that participants may contribute to during the follow-up period. In the Stress Management 
condition videos will include brief clips on stress response and stress management. A small 
portion of the messages will “poll” participants, e.g., in the Wingman-Connect condition: 
“Which of the Four-Cores are you finding most helpful in easing your transition to your new 
base? Text back 1 for Kinship, 2 for Purpose, 3 for Balance, and 4 for Guidance.” Group 
response will be tallied and sent back to the group to promote norms and group ownership of the 
concepts. Participation in the polls may be examined as an indicator of engagement with the text 
messages. 
No protected health information (PHI) will be sent via text message in either direction. In 
the consent form (see attached), participants will be informed that both interventions have text 
message components.  
 
5. Assessment Measures and Strategy.  
5.1. Assessment Approach. The assessment package and procedures were selected to:  

PHASE 2 PROTOCOL – RANDOMIZED CONTROLLED TRIAL (RCT)   
June 20, 2017 
 
8
a. Assess key outcomes and hypothesized mediators multiple times (baseline, 1-month and 6-
month follow-up). 
b. Create assessment procedures that are sustainable and will retain participants by minimizing 
participant burden: computerized adaptive testing that maximizes efficiency and brief, 
validated measures. Total time to complete assessment is projected at 20-25 minutes on a 
tablet. 
c. Protect Airmen’s confidentiality regarding their self-report of mental health, by de-
identifying sensitive data before it is received by the study team. 
d. Collect high-quality data by using measures of outcomes that have considerable reliability 
and validity and have been used with active military populations. 
Unless noted otherwise, all measures will be administered on three occasions: (1) at baseline 
immediately following enrollment (before training), (2) at 1-month follow-up (while AiTs are still 
in technical training), and (3) 6-month follow-up.  
 
5.2. Measures 
Demographic Information 
At baseline, participants will be asked to provide: age (range 18-32+), sex, race/ethnicity, 
educational background, and prior military service (e.g., ROTC). At 6-month follow-up questions 
will assess base type (i.e., CONUS, OCONUS) and whether base is rural, metropolitan or outside 
the U.S. (base name or location will not be assessed). 
 
Training Satisfaction.  Participants will be administered Foran’s (2013) three-item scale 
to assess satisfaction with training. Questions (e.g., perceived value, ability to use training) are 
rated on a four-point scale: not at all, a little, somewhat, very much. This measure will be 
administered only at the 1-month follow-up.  
 
Measures of Class/Unit Protective Processes 
Cohesion. We will use a 3-item scale used in prior research with active military units (Williams, 
et al., 2016). The questions ask each participant if members of their class are cooperative with 
each other, know they can depend on each other and stand up for each other; each question is 
rated on a four-point scale (Strongly agree to Strongly disagree). Pilot testing during intervention 
developed showed high reliability of this 3-item scale (Cronbach’s alpha of 0.83). The items will 
be administered at baseline and 1-month follow-up only during technical training phase.  
 
Class Relationship Networks: We will use standard social network tools to assess characteristics 
of relationship networks among class members (Valente, 2009). Each participant will be asked to 
name the individuals in in their tech class who “you respect and would choose to spend time 
with” (up to 5). It is necessary to collect names in order to create ‘social networks’ that include 
information about which individuals name each other. Names will not be retained (names deleted 
and replaced with code numbers). Measures of total network ties, including in-nominations (friend 
nominations received) and out-nominations (friend nominations made) and reciprocity of 
nominations, will be calculated for individuals and for the total class. Variables indicative of class 
cohesion will include density of ties and reciprocity of ties. Nominations will be used at baseline 
to identify Key Wingman (select participants with greatest number of nominations received and 
reach to others).  

PHASE 2 PROTOCOL – RANDOMIZED CONTROLLED TRIAL (RCT)   
June 20, 2017 
 
9
At 1-month assessment, participants will be asked as a follow-up question to write in 
names of instructors or MTLs (enlisted officers) who they view as having qualities that would 
make them strong mentors (up to 5). Specific names of instructors/MTLs are also required to 
identify subjects in the same class are more likely to name the same ‘mentors’ which is an index 
of cohesion (i.e., shared views on strong mentors and learning from each other about mentors). 
Names of the instructors/MTLs will not be saved (replaced by code numbers).   
 
Morale. Participants will be asked to rate their unit (class) morale with a single item on a 5-point 
scale (1 very low to 5 very high). This measure has also been validated in other studies (Britt & 
Dickinson, 2006). Class morale will be assessed at baseline and 1-month follow-up. Personal 
morale will be rated on a 5-point scale (1 very low to 5 very high). This single-item measure has 
good validity in military samples (Britt & Dickinson, 2006; Britt, Dickinson, Moore, Castro, & 
Adler, 2007). A class measure of aggregate morale will be created by combining class ratings at 
baseline and 1-month follow-up. 
Help-Seeking Acceptability (Schmeelk-Cone, Pisani, Petrova, & Wyman, 2012; Wyman et al., 
2010). This scale assesses perceptions of friends’ and family members’ support for getting help 
(perceived norms), intentions to seek help for distress, and expectations of receiving help. 
Respondents rate each item using a four-point Likert scale (Cronbach’s α=0.86–.90). HSA has been 
linked with greater likelihood that distressed adolescents sought help (Pisani et al., 2012). 
 
Healthy Class Norms and Practices: To assess perceptions that classmates support behaviors that 
strengthen protective factors taught through Wingman-Connect training, we developed and 
piloted a 6-item scale. Each items begins with a stem “Students in my tech class…”: ‘take steps 
to learn about each other’s strengths’, ‘work towards a healthy balance between studying and 
healthy activities’, ‘pay attention to growing career goals and direction’, pay attention to growing 
career goals and direction’, learn from each other how to be a better airman’, would encourage 
me to seek help for an issue before it becomes a problem’. These will be rated on a four-point 
scale from Strongly Agree to Strongly Disagree. These items will be used at baseline and 1-
month follow-up. During piloting these yielded a scale with Cronbach’s alpha of .87.  
 
Individual Protective Processes  
Loneliness-Social Disconnection. A three-item version of the UCLA Loneliness Scale (Hughes, 
Waite, Hawkley, & Cacioppo, 2004) will be administered to assess extent to which participants’ 
feel they lack companionship, feel left out and feel isolated from others (Hardly Ever, Some of 
the Time, Often). These items will be administered at all three assessment points.  
 
Thwarted Belongingness and Perceived Burdensomeness.  We will use the Interpersonal Needs 
Questionnaire (Van Orden, K. A., Cukrowicz, K. C., Witte, T. K., & Joiner, T. E., 2012) to measure 
thwarted belongingness and perceived burdensomeness on a seven-point scale, Not at all true for me (0) 
to Very true for me (6), and will be administered  at all three assessment points. 
 
Unit Integration. We will use a three-item scale (Adler et al., 2017) to assess integration into 
new operational base. Items assess feeling alone and finding it hard to make friends since their 
arrival time at new unit, rated on a four-point scale: Never, Rarely, Sometimes, Often. This scale 

PHASE 2 PROTOCOL – RANDOMIZED CONTROLLED TRIAL (RCT)   
June 20, 2017 
 
10
will be used only at the 6-month follow-up to assess perceived integration into new unit/setting 
since leaving technical training.  
 
Difficulties with Emotion Regulation (DERS) (Gratz & Roemer, 2004). The 8-item subscale, 
Limited Access to Strategies for Emotion Regulation, will be administered to assess the degree to 
which an individual feels powerless to manage emotional reactions and recover from feelings of 
upset. This scale has high reliability and evidence of validity based on self-report of behavioral and 
emotional difficulties.  
 
Maladaptive Coping Attitudes (Gould et al., 2004). This four-item scale (Cronbach’s α > .90 in 
previous studies) evaluates coping attitudes and practices. The four-item scale includes questions 
about the acceptability of getting help for problems (“People should be able to handle their own 
problems without outside help.”), endorsement of drugs and alcohol as ways to solve problems, and 
endorsement of suicide (“Suicide is a possible solution to problems”). The scale has been used in 
numerous studies and higher endorsement of overall maladaptive norms on this scale differentiated 
adolescents who had made suicide attempts from those who had not (e.g., (Gould et al., 2004; 
Schmeelk-Cone et al., 2012; Wyman et al., 2010).  
 
Behaviors for Career Protective Factors. To assess behaviors to strengthen protective factors, 
we developed six items inquiring about the frequency in the past month. Each item begins with a 
stem “In the past month how often have you: sought out instructors or MTLs to get mentoring?” 
Taken steps to strengthen a healthy relationship? Drawn strength or support from a relationship 
to overcome a challenge? Dedicated time to a healthy activity to stay balanced? Taken steps to 
further my purpose and career goals?  Items are rated on a four-point scale: never, a few times, 
several times, almost every day. 
 
Perceived Competence for Career Protective Factors. We will use the PC scale framework 
(Williams et al., 1998) to assess feelings or perceptions of competence in regard to building 
healthy relationships, purpose, mentoring and balance during career. The PC scale is a measure 
framework derived from self-determination theory intended to be used to assess perceptions 
regarding competence in specific domains or activities. This measure will have a total of 9 items 
(e.g., “I am confident in my ability to work on my goals and beliefs when they are shaken up”; 
know when I need to do more to balance career and personal life”).  
 
Measures of Mental Health, Behavioral, and Tech Training Outcomes 
Depression, Anxiety and Suicidal Ideation Risk: Computerized Adaptive Testing-Mental Health 
(CAT-MH) (Gibbons et al., in press; Gibbons et al., 2012). To reduce participant burden and 
promote valid responses to questions about mental health, we will use two sub-domains of the 
CAT-MH to measure symptoms of depression (CAT-DI), anxiety (CAT-AX) and risk for suicidal 
ideation (CAT-SS). The CAT-MH developer (Robert Gibbons, PhD) is a co-investigator and 
has worked with the study team to optimize the measure and administration for this RCT of a 
universal prevention program with a military population.  
The CAT-Depression Inventory (CAT-DI), CAT-Anxiety (CAT-AX) and the CAT-Suicide 
Scale (CAT-SS) are dimensional measures that produce continuous severity scores based on 
symptomatology experienced in the past two weeks. In contrast to traditional assessment tools in 
which all items are administered to all subjects, the CAT-MH uses a computerized adaptive 

PHASE 2 PROTOCOL – RANDOMIZED CONTROLLED TRIAL (RCT)   
June 20, 2017 
 
11
approach that begins with a large “bank” of items (1008 items) and adaptively administers (based 
on a respondent’s ongoing answers) a small and statistically optimal subset of the items (on average 
12 items for each domain), while maintaining a correlation of close to r=0.95 with the entire bank of 
items for each test (389 depression items) and sensitivity of 0.95 and specificity of 0.87. Thus, with 
only 12 items in 2 minutes, the CAT-MH can extract the information contained in hundreds of items 
in the item bank (Gibbons et.al. 2012). In addition to efficiency, a major advantage of using CAT in 
this study is that repeat testing need not involve the same items, which reduces test fatigue.  
The CAT-SS item bank draws on 111 statistically related items from depression and anxiety 
domains that are syndromally associated with suicidality. The CAT-SS also includes 11 items from 
well-validated scales specific to assessing risk for suicidal ideation or behavior. To encourage valid 
responses in this military population, the questions that participants will be administered are 
‘indirect’ to suicide (e.g., I felt that life was empty or wondered it was worth living.”). We will not 
administer the single question currently in the CAT-SS item bank that directly queries about 
self-harm thoughts or behaviors - “Did you think about taking your own life”- in light of 
evidence that military personnel are reluctant to endorse any level of personal suicide 
concerns (e.g., Vannoy et al., 2016). Removal of this single item from the 111-item bank will not 
impact the validity of the adaptive suicide scale scores because there are several other items 
regarding suicidal ideation with similar or even higher discrimination (Gibbons et al., in press) and 
similar item threshold. 
The CAT-SS yields a continuous score indicating the probability of current suicidal 
ideation, rather than a discrete score indicating that an individual is suicidal. In this study of a 
general AF population, the focus will be on testing the impact of the universal intervention on 
reducing risk across the population (reflected by this continuous score), rather than on high 
risk individuals.  
As an added protection to participants’ confidentiality, responses regarding mental 
health (CAT-DI, CAT-AX, and CAT-SS) will be completed on a secure server separate from 
other responses and stored by CAT-MH administrator that has no ability to link those data to 
specific individuals; identifiers will be removed CAT-MH data before that data is sent to the 
research team (see below for details). 
 
Alcohol Use Disorders Identification Test-C (AUDIT-c) (Bush et al., 1998). The AUDIT-C is a 3-
item scale designed to identify persons who are hazardous drinkers or have active alcohol use 
disorders (including alcohol abuse or dependence), based on a modification of the 10-item AUDIT. 
The AUDIT-C can be used as a continuous indicator of potential problem drinking. Research shows 
acceptability sensitivity and specificity including for use with veteran populations (Bradley et al., 
2003).  
 
Sleep Problems-Insomnia Severity Index (Bastien et al., 2002).  Sleep problems will be assessed 
with the four-item version of the Insomnia Severity Index (ISI; Bastien et al, 2001; Adler et al., 
2009). Two items will rate the current severity of difficulty falling asleep and staying asleep 
(scale: None, Mild, Moderate, Severe, Very Severe). One asks how satisfied/dissatisfied the 
respondent is with their current sleep pattern (scale: Very satisfied, Satisfied, Neutral, 
Dissatisfied, Very dissatisfied). And the last asks about how much sleep problems interfere with 
daily functioning (scale: Not at all/No sleep problem, A little, Somewhat, Much, Very much 
interfering). 
 

PHASE 2 PROTOCOL – RANDOMIZED CONTROLLED TRIAL (RCT)   
June 20, 2017 
 
12
Dimensions of Anger Reactions-5 (Forbes et al., 2014). Anger will be assessed by the DAR-5 
(Forbes, et al., 2014), a five-item scale. Specific items inquire about getting angry, staying angry, 
intensity of anger and anger affecting getting along with others (response scale: None or almost 
none of the time, A little of the time, Some of the time, Most of the time, All or almost all of the 
time). The DAR-5 yields a continuous sum scores that has strong internal reliability and 
concurrent validity with longer measures of trait anger.  
 
Absenteeism (Hoge, Terhakopian, Castro, Messer, & Engel, 2007). Following Hoge et al, we will 
measure absenteeism using participants’ report of the number of sick call (primary care) visits and 
the number of missed workdays in the past month. Reports will be dichotomized at two or more.  
 
Functional Impairment. Participant functioning will be assessed with three subscales from the 
Walter Reed Functional Impairment Scale (Herrell et al., 2014): Social, Personal, and 
Occupational. Social functioning is a 4-item scale on difficulty getting along with coworkers, 
interacting with social groups, getting along with family or friends or ability to have a close 
relationship. Personal functioning has two items on difficulty handling personal responsibilities 
and getting bills paid on time. Both are rated on a five-point scale: No difficulty at all, a little 
difficulty, moderate difficulty, quite a bit of difficulty, extreme difficulty. Occupational 
functioning is a set of 5 yes/no questions about job performance, including if superior has 
expressed concerns about work performance, if Airman has received corrective training for 
substandard performance, received a negative counseling statement, received a Letter of 
Reprimand. Validity of the measure is supported by correlation with independent measures of 
psychosocial functioning and wellbeing with a military population (Herrell et al., 2014).  
 
Technical School Training Completion. Each participant’s AFSC qualification information at the 
end of technical training (i.e., graduated, ‘washed back’ for retraining, or separated from the AF) 
will be collected from the squadron administrator directly into REDCap on the University of 
Rochester secure platform.  We will also collect information pertaining to subject participation in 
other prevention training programs offered to technical training classes.  This information will be 
merged with self-report data (and de-identified before being sent to the research team, at the same 
time other data are de-identified. See below). This information will be used to determine if 
Wingman-Connect increases successful and timely completion of technical training and 
qualification to perform duty (AFSC being trained for).  
 
 
6. Data Collection, Storage and Confidentiality.   
 
6.1. On-Line Assessment Process, Storage, De-Identification.  
Assessments will be conducted using an approach that we developed through our prior 
NIMH-funded randomized trials of Sources of Strength with 40 secondary schools involving 
more than 15,000 participants. This on-line process has several advantages for protecting safety 
and confidentiality of subjects in a population-level prevention trial such as this one.  
Enrolled subjects will be given an access code to enter a secure server on the web-based 
University of Rochester REDCap System using a hand-held tablet. REDCap servers are housed 
in a secure, local data center at the University of Rochester administered by the Department of 
Bioinformatics, and all web-based information transmission is encrypted. REDCap was 
developed in a manner consistent with HIPAA security requirements and is recommended to 

PHASE 2 PROTOCOL – RANDOMIZED CONTROLLED TRIAL (RCT)   
June 20, 2017 
 
13
University of Rochester researchers by the URMC Research Privacy Officer and Office for 
Human Subject Protection. Security for the database is managed in accordance with industry 
standards for Role Based Access Control (RBAC) to create custom roles and permission for the 
project and assign roles to each user (e.g., administrator). Passwords are one-time use and will be 
managed in accordance with URMCs institutional policies. At baseline and at the 1-month 
follow-up assessments, University of Rochester research personnel will be present for the 
assessments, which will be held in the same private location as enrollment (with no leadership 
present); research personnel will ensure that participants have adequate space, privacy and 
opportunity to ask questions. At the 1 month follow-up, we will ask participants to confirm their 
primary and backup contact information so that we may contact them for the 6-month survey and 
participant payment.  
For the 6-month follow-up assessment, participants will be sent a URL to the email 
address or cell phone number provided at enrollment (on the Consent form). The URL will 
provide a single-time use access to the REDCap system. If participants do not complete the 
survey, we will send two reminders through email (or phone call). Emails will be sent from a 
dedicated, password protected email account behind University of Rochester firewalls, so that 
email addresses provided by participants are protected and can be deleted once surveys are 
complete. 
During the on-line assessment, participants in the REDCap platform will be directed to 
the CAT-MH™ through an embedded URL to answer questions about behavioral and emotional 
health. CAT-MH is a separate, secure web application that administers a series of questions (i.e., 
“interview”) using computer adaptive testing algorithms to maximize efficiency. The component 
runs on a Java application server and reside on a U.S.-located, hardened server and store results 
in a SQL Server database.  The client interface is based on HTML5 and all communication 
between it and the server use an encrypted transport layer (256-bit SSL encryption) for privacy 
and message integrity.  Besides the standard server practice of logging Internet Protocol (IP) 
addresses for auditing purposes, the only information collected as part of the interview process is 
the start time of the interview, the questions adaptively administered, the subject's response to 
each question and the length of time to select that response.  The questions asked and the 
responses selected during the interview are encoded based on table indexes in a separately 
encrypted and secured database.  The databases are only accessed by the web applications and 
are not 'exposed' to the Internet at all.  No data are stored on the participant.  The only 
information related to an individual in the database is an encoded identifier to uniquely identify 
her within the context of the database.  At the end of the project the CAT-MH administrator will 
send data through a secure, encrypted VPN to the URMC RED-Cap administrator for the study.    
  
De-Identification of Data. Individual data on REDCap are encrypted and identified only by 
an ID. The Department of Bioinformatics will not have access to any participant names or 
other identifiers, which provides an additional source of protection for confidentiality of the data. 
The ID numbers used to log onto the website (and the ID assigned on the CAT-MH records) will 
be changed by the URMC Department of Bioinformatics to a new assigned ID before any survey 
data is sent to Dr. Wyman’s research team or to Northwestern University for data analyses. Thus, 
the data are de-identified, although each individual’s data is linked over time through the new 
assigned ID. Phone numbers for text messaging and email addresses for reminders and the final 
survey will be kept separate from the survey data.  

PHASE 2 PROTOCOL – RANDOMIZED CONTROLLED TRIAL (RCT)   
June 20, 2017 
 
14
 
The only other potential identifiers are audio recordings and public service announcements. 
Neither will be retained as data, and in no way can subjects’ data be linked to those 
recordings/images. 
 
6.2. Data from Nominations of Key Wingmen.  
Participants will be asked to nominate classmates whom they respect and would choose 
to spend time with (described in Social Network measures above). These nominations will be 
made on a REDCap survey separate from questions about fitness and health, so the study team 
can access nominations to identify well-connected Key Wingman without accessing responses 
on fitness and health (which are de-identified before being sent to the research team). Likewise, 
subjects will name instructors and MTLs using social network measures (names are required). 
Names of classmates and instructors/MTLs will be changed to ID numbers within the database at 
the earliest convenience and names deleted. Any names of other people will either be given 
numbers (such as instructors) or given designations (such as ‘friend’, ‘teacher’, etc.).  
 
6.3. Audio Recording of Training.  
Trainings will be audio recorded for quality control purposes only and not retained as 
study data. Recordings will be made directly onto a secure, encrypted hard drive, and uploaded 
to University of Rochester secure servers. Participants will be informed that trainings will be 
audio taped. A URMC research staff member will review to ‘check off’ that all training 
components were delivered, and then the audio recordings will be deleted at the earliest 
opportunity. 
 
6.4. Text Message System, Email, and Video Storage. 
To distribute text messages, we have selected a commercial SMS service that meets 
evolving healthcare industry standards, including compliance with HIPAA, HITECH, HITRUST 
and ISO. In order to personalize text messages (which was requested by pilot participants and is 
suggested as best practice in the literature, Fjeldsoe, Marshall, & Miller, 2009; Head et al., 
2013), participants’ last names will be entered into the texting system along with their phone 
number. No sensitive information will be sent or received and stored. As noted in Text message 
description above, a few “polls” will be conducted that invite optional ‘numerical” responses 
(e.g., choose 1, 2, or 3 indicating which ‘Core’ you are prioritizing to strengthen). Participation 
in polls and clicks onto the videos may be examined as indicators of involvement with the text 
messaging. Participants will be informed that texts are computer-generated and are not for 
texting interaction with study personnel. Participants will be informed how they can stop 
receiving texts at any time.  
Emails for the follow-up survey at 6-months will be sent from a dedicated, password 
protected email account behind University of Rochester firewalls, so that email addresses 
provided by participants are protected and can be deleted once surveys are complete. 
 Public service campaign videos in Wingman-Connect will be recorded during training on 
phones or cameras and stored in encrypted hard-drives. The second campaign, the Four Core 
Updates, participants are contacted by texting (they provide cell phone number when they sign 
up to participate in those videos) and asked to provide a 20-min time-slot during off-duty hours, 
and choose a preferred video call platform (skype, google hangout, Face Time).  After reminding 
the participant that the chat will be recorded for “Four core Update video”, the chat is recorded 
using ScreenFlow and stored directly on an encrypted hard-drive. Edited videos will be stored on 

PHASE 2 PROTOCOL – RANDOMIZED CONTROLLED TRIAL (RCT)   
June 20, 2017 
 
15
Wistia.com and can be accessed via a private URL that is accessible within login but not indexed 
on the web (i.e., cannot be found via search engine). Participants will be informed about how 
videos are stored, and their participation is voluntary. No videos will contain sensitive 
information and will not be retained as study data.  
 
7. Risk/Benefits and Measures to Minimize Risks and Safety Monitoring 
 
7.1 Risks to Subjects. (1) During training in both Wingman-Connect and Stress 
management conditions, some of the topics discussed include common stressors and challenges, 
which could elicit stress and/or distress; (2) Subjects could disclose personal information - such 
as what was challenging in adjusting to AF life and impact on family relationships - and another 
participating subject could repeat that information out of the training context, resulting in a loss 
of confidentiality. (3) The text messages and emails that are sent to participants as part of the 
intervention (optional) or for follow-up assessment (required) contain no personal information, 
but these messages could be accidently seen by another person who has physical access to their 
phones or computers, revealing the subject’s participation in this training study. (4) In 
completing questionnaires about emotional distress (e.g., depression, hopelessness), participants 
may become aware that they, or someone else, requires help (discovery).  
 
7.2 Measures to Minimize Risks.   
(1) Each training will be facilitated by one or more senior trainers (Ms. DeVelder, Mr. Yates, Dr. 
Pisani, Dr. Wyman). All have extensive experience in leading trainings and have attended 
Sources of Strength training for trainers. Drs. Wyman and Pisani are experienced clinical 
psychologists, and Ms. DeVelder is a Licensed Marriage and Family Therapist (NY). The 
facilitators will pay close attention to group process, including indications that any subject is 
distressed or indicating need for further follow-up. At the beginning and end of each group, the 
facilitators will invite members of the group to contact them to discuss any concerns about their 
experiences in the group.  The facilitators will have information on each site about behavioral 
health resources and can provide information about resources for help to any subject who 
requests this information.   
(2) To protect privacy and confidentiality, subjects will be reminded at the beginning and end of 
each session that content shared by individuals should not leave the group.  During the consent 
process (and in the consent document), subjects will be notified that their privacy and 
confidentiality cannot be guaranteed and they should be mindful when sharing personal 
experiences.  
(3) Participants will be reminded that other people who have physical access to their phones or 
computers could see the texts and emails that they receive as part of this study; the consent form 
will advise subjects to use secret passcodes if they wish to keep their participation in this training 
study private.  
(4) All Participants Informed About Mental Health Resources. All participants completing the 
assessment will receive information about mental health resources should they require help for 
themselves or for another individual (information will appear a screen during the assessment). As in 
our prior RCTs with Sources of Strength with secondary school populations, the project team has 
determined that greatest population benefit comes from providing resource information to all 
participants in this type of RCT testing a universal prevention program (not a clinical population). In 
order to address reluctance that many participants may experience in seeking help from mental 
health services on base, the information will include the number for the National Suicide Prevention 
Lifeline and two large “therapeutic chat rooms” that are popular with young adults: TalkLife 

PHASE 2 PROTOCOL – RANDOMIZED CONTROLLED TRIAL (RCT)   
June 20, 2017 
 
16
(http://talklife.co/category/mental-health/[talklife.co]), and Koko 
(https://itskoko.com/[itskoko.com]). Emerging data suggests that young adults such as this 
technical training population are more likely to access on-line services or chat rooms versus 
telephone call-in numbers.  
 
7.3 Benefits to Subjects. Subjects could benefit by learning strategies for strong 
relationships and managing stress and challenges of Air Force life.  This information could help 
them to apply those strategies in their own lives to improve resilience and relationships.   
 
7.4. Data Safety Monitoring.  A Data Safety Monitoring Committee (DSMC) will be 
comprised of: (a) Col Steven Pflanz, MD; S-AF Director of Psychological Health; (b) Robert 
Klesges, PhD., Professor, University of Tennessee Health Sciences Center. Dr. Klesges currently 
has four federally funded projects testing alcohol, smoking and other prevention programs with 
the US-AF. (c) Wilfred Pigeon, PhD, Director of the Veterans Affairs Center for Excellence in 
Suicide Prevention and Associate Professor of Psychiatry, University of Rochester Medical 
Center. The PI (Dr. Wyman), co-investigators (Drs. Knox and Pisani) and Senior Project 
Coordinator (Mr. Yates), while not members of the DSMC, will be available for each to meeting 
to provide a progress report of the study, answer questions and receive additional guidance from 
the DSMC, including requests for additional information.  
The DSMC will meet every six months during the course of the RCT to review interim 
data, and may schedule additional meetings as needed. In advance of those meetings the members 
will receive data summarizing intervention (Wingman-Connect) and control (Stress Management 
Training) groups. Data selected for interim reports will include comparison of the intervention and 
control groups on: continuous measures of depression and suicide risk scales (CAT-DD and CAT-
SI), 
technical 
school 
graduation/completion; 
functional 
impairment; 
loneliness/social 
disconnection. Obtaining data for DSMC review will follow the study protocol of de-identification 
prior to being sent to the study team. A major aim of this study is to determine if Wingman-Connect 
compared to Stress Management training reduces risk for suicidal ideation using the continuous 
measure of risk (CAT-SS). Along with interim data summary, the chief statistician (Dr. C. 
Hendricks Brown) will oversee analyses computing whether suicide ideation risk varies by training 
condition (at each DSM report). 
The DSMC will be informed of any unanticipated problems that may occur during 
recruitment or participation in training or assessments. The DSMC will also be informed of any 
adverse advents that may occur (e.g., deaths) and come to the attention of the project team, 
including those unrelated to study participation. The study team is likely to be aware of adverse 
events during the 2-4 months that participants are at Sheppard Air Force Base for Technical 
training, but is unlikely to be aware of deaths or other serious adverse events that occur after 
participants have transferred to operational air force bases.  
 
8. Data Analysis and Data Monitoring 
8.1 Specific Analyses for Phase II Randomized Trial 
After receiving de-identified data, analyses will be completed by Dr. C. Hendricks Brown, an 
internationally-recognized biostatistician and methodologist and Director of the Center for 
Prevention Implementation Methods (Northwestern University), working closely with the URMC 
Project Director and Team.  
    To test the hypothesis that Wingman-Connect will increase healthier social connectedness, unit 

PHASE 2 PROTOCOL – RANDOMIZED CONTROLLED TRIAL (RCT)   
June 20, 2017 
 
17
integration, and norms for coping relationships and transitions, we will use multilevel growth 
models in Mplus (Brown, Costigan, & Kendziora, 2008; Muthén & Asparouhov, 2003; B. 
Muthén, 2004; Muthén & Muthén, 2012). This modeling will allow us to examine the change in 
these relationship quality and norms over time. In particular, at the individual level, we will model 
subject i's response on pertinent measures at time t (baseline, 3 months, 6 months) in the gth 
workforce group, Yigt, as having a linear growth model that is specified by a random intercept aig 
and random slope big, Yigt,= aig+ big t + εigt where the last term is an independent error representing 
variation of each observation about one's linear trajectory. In this model, the slopes big carry the 
information about intervention effect, and because randomization is at the level of the group, the 
overall change in perceived norms and practices due to Wingman-Connect (Hg = 1) compared to 
control (Hg = 0), is modeled as big = μ + β Hg + γg + εig. Here β is the mean difference in slopes for 
Wingman-Connect versus control, and the two error terms, γg and εig, represent variation across and 
within groups respectively. The test of change will be based on a Wald-type test of the magnitude of 
the estimate of β relative to its standard error. Both standard fit indices for latent variable models 
and diagnostics (C. Wang, Hendricks Brown, & Bandeen-Roche, 2005) will be used to examine 
the fit and if necessary improve the model.  
For hypotheses that Wingman-Connect will reduce individual symptoms of depression, 
symptoms that predict risk for suicide ideation, as well as reported substance use and the mediation 
effect of social connectedness and norms, we will conduct growth model analyses similar to those 
we have reported before for antidepressant effects on depressive symptoms (Gibbons, Hur, Brown, 
Davis, & Mann, 2012) and suicide related outcomes (Gibbons, Brown, Hur, Davis, & Mann, 
2012). In particular, we will examine the mediational influence of social connectedness and 
emotion regulation on depression and suicide risk symptoms by testing whether the product of the 
two relationships, the first from intervention condition to connectedness/emotion regulation, and the 
second from mediators to symptoms, is significantly different from zero (MacKinnon & Luecken, 
2008). These analyses will also examine the interactive effect of intervention by proposed mediator 
(Gibbons et al., 2012). 
We also plan to conduct additional mediation analyses that clarify how the putative 
intervention effect is being achieved. Specifically, we hypothesize that Wingman-Connect would 
work when more healthy relationship ties are created and strengthened among those in the same 
workforce group. These analytic models will allow us to assess how the level of implementation of 
Wingman-Connect, including its reach to those airmen who are originally on the periphery of the 
social networks, receive messages and find them useful. 
In all of these analyses, we will handle missing data using full information likelihood methods 
(FIML), which is known to reduce bias and outperform other procedures such as throwing away 
incomplete cases or using last observation carried forward (Siddique et al., 2008) To reduce the 
chances of finding spurious results due to the large numbers of statistical tests, we are relying 
mostly on growth models rather than repeated analyses at single time points. Also, we plan to 
incorporate similar measures (e.g., suicide risk and depression) in the same growth model. As a 
third approach to reducing the chance of spurious findings, we will conduct any tests for model 
development, e.g., those that would check for nonlinearity, for example, by blinding the decision-
making for arriving at a best-fitting model to any potential effects due to intervention. That is, all 
tests of intervention will be done after identifying best fitting models (Kellam et al., 2008). 
Statistical Power. Using Optimal Design (OD) software, we computed the effect size that 
we expect to obtain in this group-based randomized trial on detecting a change in the continuous 
measure of suicide risk (CAT-SS).  We assumed there would 160 groups with a total of 1440 

PHASE 2 PROTOCOL – RANDOMIZED CONTROLLED TRIAL (RCT)   
June 20, 2017 
 
18
airmen, and over a 6-month period the attrition rate would be 25%.  We set a Type I error rate of 
5%, power at 80% and assumed a small intra-class correlation ranging from 0.02 to 0.05 on the 
primary outcome of interest, the suicide scale predictor.   Conservatively, we can achieve 80% 
power in this design with an effect size of 0.18 when the ICC is 0.02 and an effect size of 0.20 
when the ICC is 0.05.  
 
References 
 
Adler, A. (2016, personal communication). Personal Integration scale. 
Adler AB, Bliese PD, McGurk D, Hoge CW, Castro CA. (2009). Battlemind debriefing and 
battlemind training as early interventions with soldiers returning from Iraq: 
randomization by platoon. J Consult Clin Psych, 77: 928–40. 
Bastien, C. H., Vallieres, A., & Morin, C. M. (2001). Validation of the Insomnia Severity Index 
as an outcome measure for insomnia research. Sleep Medicine, 2, 297-307.  
Britt, T.W. & Dickinson, J.M. (2006). Morale during military operations: A positive psychology 
approach. In Britt, Castrol, Adler (Eds). Military life: The psychology of serving in peace 
and combat: Military performance., Vol. 1 (pp. 157-184). xi, 255 pp. Westport, CT: 
Praeger Security International. 
Britt, T.W., Dickinson, J.M., Moore, D., Castro,C.A. & Adler, A. (2007). Correlates and 
consequences of morale versus depression under stressful conditions. Journal of 
Occupational Health Psychology, 12(1), 34-47. 
Brown, C.H., Costigan, T.E. & Kendziora, K.T. (2008). Data analytic frameworks: Analysis of 
variance, latent growth, and hierarchial models. In Nezu,A.M. & Nezu, C.M. (Eds). 
Evidence-based outcome research: A practical guide to conducting randomized controlled 
trials for psychosocial interventions (pp. 285-313). New York, NY: Oxford University 
Press. 
Brown, C.H., Ten Have, T.R., Jo, B., Dagne, G., Wyman, P.A., Muthén, B., Gibbons, R.D. 
(2009). Adaptive designs for randomized trials in public health. Annual Review of Public 
Health, 30: 1-25. 
Brown, C.H., Wyman, P.A., Guo, J. & Pena, J. (2006). Dynamic wait-listed designs for 
randomized trials: New designs for prevention of youth suicide. Clinical Trials, 3(3): 259-
71. 
Bush, K., Kivlahan, D. R., McDonell, M. S., Fihn, S. D. and Bradley, K. A. (1998) The AUDIT 
Alcohol Consumption Questions (AUDIT-C): an effective brief screening test for problem 
drinking. Archives of Internal Medicine, 158, 1789–1795. 
Department of Defense. (2012). Department of defense suicide event report (DoDSER) 
Foran, H.M., Garber, B.G., Zamorski, M.A., Wray, M., Mulligan, K., Greenberg, N., Castro, 
C.A. & Adler, A. (2013). Postdeployment military mental health training: Cross-national 
evaluations. Psychological Services, 10(2): 152-160. 
Forbes, D., Alkemade, N., Mitchell, D., Elhai, J.D., McHugh, T., Bates, G., Novaco, R.W., 
Bryant, R. & Lewis, V. (2014). Utility of the dimension of anger reactions-5 (DAR-5) 
scale as a brief anger measure. Depression and Anxiety, 31, 166-173. 
Gibbons, R.D., Hur, K., Brown,C.H., Davis, J.M. & Mann, J.J. (2012). Benefits from 
antidepressants: synthesis of 6-week patient-level outcomes from double-blind placebo-
controlled randomized trials of fluoxetine and venlafaxine. Archives of General Psychiatry, 
69(6), 572-9. 

PHASE 2 PROTOCOL – RANDOMIZED CONTROLLED TRIAL (RCT)   
June 20, 2017 
 
19
Gibbons, R.D., Brown, C.H., Hur, K., Davis, J.M. & Mann, J.J. (2012). Suicidal thoughts and 
behavior with antidepressant treatment: reanalysis of the randomized placebo-controlled 
studies of fluoxetine and venlafaxine. Archives of General Psychiatry, 69(6), 580-7. 
Gibbons, R.D., Kupfer, D., Frank, E., Moore, T., Beiser, D.G., & Boudreaux, E. (2017). 
Development of a computerized adaptive suicide scale: CAT-SS. Journal of Clinical 
Psychiatry, in press. 
Gibbons, R.D., Weiss, D. J., Pildonis P., et al. (2012). Development of a computerized adaptive 
test for depression. Archives of General Psychiatry, 69(11): 1104 – 1112. 
Gould, M. S., Velting, D., Kleinman, M., Lucas, C., Thomas, J.., & Chung, M. (2004). 
Teenagers' attitudes about coping strategies and help-seeking behavior for suicidality. 
Journal of the American Academy of Child & Adolescent Psychiatry, 43(9), 1124-1133. 
Gratz, K.L., & Roemer, L. (2004). Multidimensional assessment of emotion regulation and 
dysregulation: Development, factor structure, and initial validation of the difficulties in 
emotion regulation scale. Journal of Psychopathology and Behavioral Assessment, 26(1), 
41-54. 
Herrell, R.K., Edens, E. N., Riviere, L.A., Thomas, J.L., Bliese, P.D. & Hoge, C.W. (2014). 
Assessing functional impairment in a working military population: The Walter Reed 
functional impairment scale. Psychological Services, 11(3): 254-264. 
Hoge, C.W., Terhakopian, A., Castro, C.A., Messer, S.C. & Engel, C.C. (2007). Association of 
posttraumatic stress disorder with somatic symptoms, health care visits, and absenteeism 
among Iraq war veterans. American Journal of Psychiatry, 164, 150-153. 
Hughes, M.E., Waite, L.J., Hawkley, L.C.  & Cacioppo, J.T. (2004) A short scale for measuring 
loneliness in large surveys: Results from two population-based studies. Research on Aging, 
26(6), 655-672. 
Institute of Medicine Committee on the Assessment of Readjustment Needs of Military 
Personnel, Veterans, and their Families. (2013). Returning home from Iraq and Afghanistan: 
Assessment of readjustment needs of veterans, service members, and their families. 
Washington, DC: The National Academies Press Washington, DC. 
Kellam S.G., Brown, C.H., Poduska, J.M., Ialongo, N.S., Wang, W., Toyinbo, P., Petras, H., 
Ford, C., Windham, A. & Wilcox, H.C. (2008). Effects of a universal classroom behavior 
management program in first and second grades on young adult behavioral, psychiatric, and 
social outcomes. Drug and Alcohol Dependence, 95 (Suppl 1), S5-S28. 
LoMurray, M. (2005). Sources of strength facilitators guide: Suicide prevention peer gatekeeper 
training. Bismarck, ND: The North Dakota Suicide Prevention Project. 
MacKinnon, D.P. & Luecken, L.J. (2008). How and for whom? Mediation and moderation in 
health psychology. Health Psychology, 27(2, Suppl), S99-S100. 
Muthén, B. O., & Asparouhov, T. (2003). Advances in latent variable modeling, Part I: 
Integrating multilevel and structural equation modeling using Mplus. Unpublished 
manuscript. 
Muthén, B. (2004). Latent variable analysis: Growth mixture modeling and related techniques 
for longitudinal data. In D. Kaplan (ed.), Handbook of quantitative methodology for the 
social sciences (pp. 345-368). Newbury Park, CA: Sage Publications.  
Muthén, L.K., & Muthén, B.O. (2012) Mplus: Statistical analysis with latent variables: User’s 
Guide (5th ed.). Los Angeles:Authors. 
Petrova, M., Wyman, P.A., Schmeelk-Cone, K. & Pisani, A. R. (2015). Positive-themed suicide 
prevention messages delivered by adolescent peer leaders: Proximal impact on classmates’ 

PHASE 2 PROTOCOL – RANDOMIZED CONTROLLED TRIAL (RCT)   
June 20, 2017 
 
20
coping attitudes and perceptions of adult support. Suicide and Life Threatening Behavior, 
45(6): 651-663 
Pisani, A. R., Schmeelk-Cone, K., Gunzler, D., Petrova, M., Goldston, D. B., Tu, X., & Wyman, 
P. A. (2012). Associations between suicidal high school students’ help-seeking and their 
attitudes and perceptions of social environment. Journal of Youth and Adolescence, 41(10), 
1312–1324 
Pisani, A. R., Wyman P.A., Mohr, D.C., Perrino,T., Gallo,C., Villamar, J., Kendziora, K., Howe, 
G.W., Sloboda, Z. & Brown, C.H. (2016). Human subjects protection and technology in 
prevention science: Selected opportunities and challenges. Prevention Science, 17(6), 765-
778. 
Ritchie, E. C., Keppler, W. C., & Rothberg, J. M. (2003). Suicidal admissions in the United 
States military. Military Medicine, 168(3), 177-181.  
Russell, D. W. (1996). UCLA Loneliness Scale (Version 3): Reliability, Validity, and Factor 
Structure. Journal Of Personality Assessment, 66(1), 20. 
Schmeelk-Cone, K., Pisani, A., Petrova, M. & Wyman, P.A. (2012).  Three scales assessing high 
school students’ attitudes and perceived norms about seeking adult help for distress and 
suicide concerns.  Suicide and Life Threatening Behavior, 42(2):157-72.  
Siddique J, Brown, C.H., Hedeker, D, Duan, N., Gibbons, R.D., Miranda, J. & Lavori, P.W. 
(2008). Missing data in longitudinal trials – Part B, Analytic issues. Psychiatry Annals, 
38(12), 793-801. 
Valente, T.W., Fujimoto, K., Chou, C.P. & Sprijt-Metz, D. (2009). Adolescent affiliations and 
adiposity: A social network analysis of friendships and obesity. Journal of Adolescent 
Health, 45(2), 202-4. 
Vannoy, S.D., Andrews, B.K., Atkins, D.C., Dondanville, K.A., Young-McCaughan, S. & 
Peterson, A.L. (2016). Under reporting of suicide ideation in US Army population 
screening: An ongoing challenge. Suicide and Life-Threatening Behavior. 
Wang C. P., Brown, C. H., and Bandeen-Roche K (2005).  Residual diagnostics for growth 
mixture models: Examining the impact of a preventive intervention on multiple trajectories 
of aggressive behavior.  Journal of the American Statistical Association, 100, 1054-1076. 
Williams, G. C., Freedman, Z.R., & Deci, E. L. (1998). Supporting autonomy to motivate 
glucose control in patients with diabetes. Diabetes Care, 21, 1644-1651.  
Williams, J., Brown, J. M., Bray, R. M., Anderson Goodell, E. M., Rae Olmsted, K., & Adler, A. 
B. (2016, March 17). Unit Cohesion, Resilience, and Mental Health of Soldiers in Basic 
Combat Training. Military Psychology. Advance online publication. 
http://dx.doi.org/10.1037/mil0000120 
Wyman, P. A., Brown, C. H., LoMurray, M., Schmeelk-Cone, K., Petrova, M., Yu, Q., Tu, X., 
Walsh, E., & Wang, W. (2010). An outcome evaluation of the Sources of Strength Suicide 
Prevention Program delivered by adolescent peer leaders in high schools. American Journal 
of Public Health, 100(9), 1653-1661.