Review Reports - Causes and Consequences of Freezing Cold Injuries in the Norwegian Armed Forces from the Soldier’s Perspective—A Qualitative Study

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

The primary objective of this manuscript was to share the perspectives of soldiers' enlisted in the Norwegian Armed Forces on the causes and the aftereffects of freezing cold injuries (FCI) via qualitative interviews.

The topic is relevant to the field as it's focus is on qualitative feedback from soldiers' perspectives on the causes and outcomes of FCI. The paper is relevant to the field as it further outlines the potential precipitants to FCI which may allow for better prevention measures for FCI as well as the examination of military culture in the role of FCI.

There have been quantitative studies on the physiological and epidemiological aspects of FCI. However, this topic is original and relevant to the field because it is the first qualitative study to examine the soldiers' perspectives of FCI which adds a unique perspective to the phenomenon.

The authors should further utilize the COREQ Guidelines, Domain 2: Study Design to add further details to the methodology. This includes discussing the methodological orientation and theory, participant selection (type of sampling, method of approach, non-participation, setting, presence of non-participants, and duration). In the recruitment section, I am wondering if the authors could share how many soldiers had received or reported a second degree FCI vs. how many consented to participate in this study.

The results section was very well organized and the conclusions are consistent with the evidence presented. The authors are able to address the main objective of the study by providing direct quotes from the participants and sharing their lived experiences with FCI.

The references are appropriate for this article. No additional comments regarding the tables and figures. Both are appropriate for this publication.

Overall, this article is very interesting and well-written. The results are nicely organized.

Comments on the Quality of English Language

I believe that line 84 should say "field" rather than "filed".

The quality of the English Language was good. The authors should complete a read through paying attention to proper tense and use of commas where appropriate.

Author Response

Answer: Thank you.

Answer: We have followed COREQ checklist and all items has now been addressed in the manuscript. The checklist is submitted as supplementary material. However, we have added additional information and revised the following text (L152-158, p.4): Potential participants were identified from individuals registered with FCI in the Norwegian Armed Forces Health Registry (NAFHR) between 2004 and 2021 who also took part in a national survey (n=1141) conducted in 2021 where 220 soldiers sustained a grade 2 FCI (1, 2). Among these, 88 soldiers answered that they were asked to participate in an interview study and if interested they contacted the first author by email. Despite two reminder invitations, 16 participants gave their informed consent. Thus, purposive sampling was used in this study (3). (L145-147, p.4): The interview guide was developed based on findings from a survey from 2023 (1), relevant scientific literature and the research team´s expertise. It was then piloted. (L648-651, p.15): However, this was accounted for and balanced by the rest of the research team, who are not affiliated with the NAF and consisted of one individual with an MD/ PhD, one anthropologist (PhD) and one who holds a PhD in medical science. This collaboration contributed ensure an objective and thorough analysis of the data.

In the recruitment section, I am wondering if the authors could share how many soldiers had received or reported a second degree FCI vs. how many consented to participate in this study.

Answer: Thank you for the comment. We have added the following, and the section reads now: (L 152-158, p 4):

Potential participants were identified from individuals registered with FCI in the Norwegian Armed Forces Health Registry (NAFHR) between 2004 and 2021 who also took part in a national survey (n=1141) conducted in 2021 where 220 soldiers sustained a grade 2 FCI (1, 2). Among these, 88 soldiers answered that they were asked to participate in an interview study and if interested they contacted the first author by email. Despite two reminder invitations, only 16 participants gave their informed consent. Thus, purposive sampling was used in this study (3).

Answer: Thank you.

The references are appropriate for this article. No additional comments regarding the tables and figures. Both are appropriate for this publication.

Overall, this article is very interesting and well-written. The results are nicely organized.

Answer: Thank you.

Reviewer 2 Report

Comments and Suggestions for Authors

I want to congratulate the authors on this very nice manuscript. The topic is very relevant, particularly for military personnel and other cold exposed professions. Since the qualitative approach is underrepresented in the existing literature, the findings give valuable insights into environmental, organizational, and cultural factors contributing to fci and its long-term consequences.

Find below my comments:

- The article explores the important topic of “military culture”. However, it would be nice if the discussion would include a clearer definition of this term and a clearer differentiation between structural factors (e.g. formal hierarchies) and normative or cultural expectations (e.g. toughness, stigma).

- The role of the interviewer as a army physician is acknowledged. However, since military culture is a prominent topic in the manuscript, its implications could be explored in greater detail, as it may have influenced data collection and participant disclosure.

- Recruitment of study participants was done from the army's health registry and was limited to 2° FCI. This may underrepresent soldiers who did not report FCI or who had milder or more severe FCI. This potential selection bias should be discussed, also because underreporting is discussed in the article.

- The absence of standardized diagnostic criteria for FCI in the army is stated. However, further clarification on 2° FCI was defined for the study would be useful. it might be nice to know whether the degree recorded by the treating physician was used as such, whether the degree was verified by the authors based on more detailed data from theregistry, and how possible diagnostic variability could have influenced the results.

- As far as I know, the role of hydration in FCI remains unclear. In line 447, dehydration is mentioned as a contributing factor. However, the cited reference is about cognitive performance, fatigue, and physiological stress and does not show that dehydration is an independent risk factor. It should be clarified whether hydration is being proposed as a direct physiological risk factor or as a proxy for overall exhaustion. Alternatively, the statement could be formulated differently to reflect the current evidence.

- Table 1 could include summary statistics (e.g. mean or median time since injury etc.).

Author Response

Thank you for your comments on our manuscript, “Causes and consequences of freezing cold injuries in the Norwegian Armed Forces from the soldier’s perspective - A Qualitative Study”, (Manuscript ID: ijerph-3997575). We believe that these suggestions will substantially improve the manuscript. Below we have given a point-by-point response.

Reviewer 2:

Answer: Thank you.

Find below my comments:

Answer: We have added a clearer discussion accordingly, and the section now reads (L567- 577, p 13-14): Military culture encompasses both structural factors, such as formal hierarchies and discipline, and normative expectations, such as toughness and endurance. Structural necessities like weapon-handling protocols, high operational tempo, and training schedules can increase cold exposure and reduce opportunities to rewarm. Normative expectations, stoicism, fear of reprimand, and a strong collective orientation can suppress self-protective actions and delay help-seeking. The interplay of these factors shapes soldiers’ responses to physical strain, potentially leading to health risks. While some structural necessities are indispensable for operational effectiveness, they may also create situations in which health concerns are subordinated to mission demands (4).

- The role of the interviewer as an army physician is acknowledged. However, since military culture is a prominent topic in the manuscript, its implications could be explored in greater detail, as it may have influenced data collection and participant disclosure.

Answer: Thank you for this comment. The section now reads (L641-651, p.15): A limitation of the study is that the interviewer and first author is a physician at the NAF, which may have influenced the participants' responses. Participants may have provided responses they perceived as favourable to the interviewer (please the researcher bias (5)). Alternatively, the interviewer’s role as a physician in the military may have fostered trust, encouraging participants to share accurate and detailed information. To minimize potential hierarchical challenges and reduce the influence of military rank or authority, she chose not to wear a military uniform during the interviews. However, this was accounted for and balanced by the rest of the research team, who are not affiliated with the NAF and consisted of one individual with an MD/ PhD, one anthropologist (PhD) and one who holds a PhD in medical science. This collaboration contributed ensure an objective and thorough analysis of the data.

Answer: Thank you for this comment. The section now reads (L652-663, p15): Another limitation was that recruiting participants from the NAFHR, focusing solely on grade 2 FCI, may introduce selection bias, potentially underrepresenting soldiers with milder or more severe FCI or those who did not report FCI. We focused on grade 2 FCI due to its clear diagnostic features (notably clear-fluid blisters), while grade 1 is more challenging to diagnose with certainty. While this approach may have limited generalizability, it ensured a more reliable identification of cases. Moreover, the sample comprised 8 men and 8 women. This differs from the gender distribution in the NAF, where approximately 32% of conscripts are women (61). Consequently, it is uncertain whether a higher proportion of women would have yielded different findings. Despite two reminder invitations, no additional participants were recruited. Moreover, saturation was achieved after 14 interviews, meaning that no additional information was received. (see section 2.8 Data analysis) (23).

- The absence of standardized diagnostic criteria for FCI in the army is stated. However, further clarification on 2° FCI was defined for the study would be useful. it might be nice to know whether the degree recorded by the treating physician was used as such, whether the degree was verified by the authors based on more detailed data from the registry, and how possible diagnostic variability could have influenced the results.

Answer: Thank you for this comment. We have added additional information in this section and the section now reads (L635-636, p.15): However, the study is based on data from a specific group of soldiers diagnosed with FCI grade 2 and diagnosis were verified during interviews.

Answer: Thank you for this comment. We have changed this section accordingly and it now reads (L453-460, p.11):

Our findings indicate that prolonged physical exertion, when coupled with limited hydration and reduced nutritional intake, may increase susceptibility to FCI. This aligns with the RTG HFM-310 final report (7). According to the report, optimal performance in Arctic conditions rests on a comprehensive foundation. It requires appropriate cold-weather clothing and equipment, as well as environmental knowledge built through education and training. It also depends on adequate nutrition and hydration and the body’s responses to cold. Psychological resilience and healthy sleep are additional pillars. Without this integrated preparation, performance declines and vulnerability to FCI increases (7).

- Table 1 could include summary statistics (e.g. mean or median time since injury etc.).

Answer: Thank you for this comment. Mean time has been added in table 1: Mean years since injury was 4.5 years.