The Association Between Food Insecurity and Intimate Partner Violence Among U.S. Army Soldiers.

Food insecurity in the military ranges between 25% and 33%, significantly higher than the 10.5% for civilians reported by the U.S. Department of Agriculture. The primary objective of this study is to analyze the association between food insecurity and intimate partner violence (IPV) victimization among U.S. Army Soldiers. The secondary objective is to determine if there are any moderating effects in the relationship between food insecurity and IPV victimization by demographic, financial, and mental health covariates. A cross-sectional, online survey was administered by the U.S. Army Public Health Center at an Army installation in 2019; 56% of respondents reported that they were married or in a relationship (n = 2,740). The main predictor was the two-item food insecurity screener (Hunger Vital Signs), which measures marginal food insecurity (encompassing marginal, low, and very low food security). The main outcome was IPV victimization as measured by the Hurt, Insult, Threaten, Scream scale. Multiple logistic regression was used to assess the association between marginal food insecurity and IPV victimization, controlling for demographic, financial, and mental health covariates. In a multivariable model, marginally food insecure respondents had 2.05-fold greater adjusted odds of reporting any IPV victimization when compared to highly food secure respondents (95% confidence interval [1.40, 3.00]). The only interaction that was statistically significant was between anxiety and food insecurity on IPV victimization (p = .0034). Interactions by soldier's military rank, birth sex, and race and ethnicity were not statistically significant. IPV has implications for the emotional and physical health of survivors. In addition, service members who are food insecure may experience similar decrements in emotional and physical health due to suboptimal nutrient intake. By addressing both food insecurity and IPV, the military has the potential to increase the overall well-being of its service members and their dependents.

COVID-19 Concerns, Information Needs, and Adverse Mental Health Outcomes among U.S. Soldiers.

INTRODUCTION: The coronavirus disease 2019 (COVID-19) pandemic disrupted U.S. Military operations and potentially compounded the risk for adverse mental health outcomes by layering unique occupational stress on top of general restrictions, fears, and concerns. The objective of the current study was to characterize the prevalence of COVID-19 concerns and information needs, demographic disparities in these outcomes, and the degree to which COVID-19 concerns and information needs were associated with heightened risk for adverse mental health outcomes among U.S. Army soldiers. MATERIALS AND METHODS: Command-directed anonymous surveys were administered electronically to U.S. soldiers assigned to one of three regional commands in the Northwest United States, Europe, and Asia-Pacific Region. Surveys were administered in May to June 2020 to complete (time 1: n = 21,294) and again in December 2020 to January 2021 (time 2: n = 10,861). Only active duty or active reservists/national guard were eligible to participate. Members from other branches of service were also not eligible. RESULTS: Highly prevalent COVID-19 concerns included the inability to spend time with friends/family, social activities, and changing rules, regulations, and guidance related to COVID-19. Some information needs were endorsed by one quarter or more soldiers at both time points, including stress management/coping, travel, how to protect oneself, and maintaining mission readiness. COVID-19 concerns and information needs were most prevalent among non-White soldiers. Concerns and information needs did not decline overall between the assessments. Finally, COVID-19 concerns were associated with greater risk of multiple adverse mental health outcomes at both time points. CONCLUSIONS: COVID-19 concerns and information needs were prevalent and showed little evidence of decrement over the course of the first 6 months of the pandemic. COVID-19 concerns were consistently associated with adverse mental health outcomes. These data highlight two targets and potential demographic subgroups such that local leadership and Army medicine and public health enterprises can be better prepared to monitor and address to maintain force health and readiness in the face of possible future biomedical threats.

Training, Deployment Preparation, and Behavioral Health of New York National Guard Personnel Deployed to Assist with COVID-19 Decedent Work.

INTRODUCTION: A small body of research conducted mostly among civilians has shown that adequate training and preparation can prevent or reduce the development of behavioral health problems in first responders. Several civilian studies have shown that social support is protective against behavioral health problems. However, very few studies have examined the impact of these factors on the behavioral health of military first responders. Military first responders, who serve in the aftermath of natural disasters and disease outbreaks such as the coronavirus disease 2019 (COVID-19) pandemic, are often members of the National Guard (NG). The purpose of this study was to examine the impact of mortuary affairs training/handling human remains, role preparation, equipment preparation, and unit social support provided to families on the behavioral health of New York (NY) NG personnel deployed to assist the NY Office of Chief Medical Examiner with handling the remains of COVID-19 decedents. MATERIALS AND METHODS: We invited 410 NYNG personnel who deployed for the Office of Chief Medical Examiner mission to complete an anonymous online questionnaire 3 to 6 months post-mission. Of the 158 participants, we used the data of the 141 participants who provided consent. Standard behavioral health measures (depression, anxiety, post-traumatic stress disorder, alcohol misuse, and insomnia) as well as study-specific items designed to understand the unique dynamics of this deployment were included. Hierarchical logistic regression analysis was used to examine the relationships between mortuary training, role preparation, equipment preparation, and unit support with behavioral health. RESULTS: Close to two-thirds of the sample reported that they had not been trained in mortuary affairs/handling human remains before the mission. We also found that that lower levels of role preparation and unit support provided to the service members' families increased the odds of meeting criteria for one or more behavioral health problems, but that training in mortuary affairs and equipment preparation was unrelated to behavioral health. CONCLUSIONS: Our research points to the importance of emotionally and cognitively preparing service members for the specific dynamics of a deployment and the roles that that they are expected to play. Furthermore, it suggests that supporting the families of NG personnel during domestic missions can benefit the behavioral health of the NG personnel. Additional research is needed to corroborate these findings, particularly the impact of unit support provided to family members on service members' behavioral health.

Cross-Sectional Examination of Physical Abuse Victimization Differences Between Lesbian, Gay, Bisexual, and Heterosexual Service Members in the U.S. Military, 2018.

Purpose: The primary objective was to analyze the association between sexual orientation and physical abuse victimization using a representative sample from the U.S. active-duty military population. The secondary objective was to determine if differences exist by sexual orientation in perceived barriers (e.g., stigma) to mental health care utilization among physical abuse victimization survivors. Methods: The 2018 Department of Defense Health Related Behaviors Survey (HRBS) (n = 17,166 active-duty respondents) was used for analysis. Weighted logistic regressions and Poisson regressions were used for multivariable analyses, controlling for demographic and military variables. Results: Approximately 93.7% of respondents identified as heterosexual or straight, 2.3% identified as gay or lesbian, and 4% as bisexual. Bisexual active-duty service members had 1.5-fold greater odds of reporting any form of physical abuse victimization (adjusted odds ratio: 1.50 and 95% confidence interval: 1.07-2.10). However, there was no difference observed between gay/lesbian and heterosexual service members for physical abuse victimization. Among survivors of physical abuse victimization, bisexual (p = 0.0038) and gay (p < 0.0001) service members were more likely to report more than one mental health care barrier compared to their heterosexual counterparts. Conclusions: Bisexual service members were more likely to experience physical abuse victimization when compared to their heterosexual counterparts. In addition, gay and bisexual survivors of physical abuse were more likely to experience barriers to mental health care. Tailored interventions should explore strategies to prevent victimization and disparities in mental health care utilization by sexual orientation.

National Guard service members decedent recovery and processing operations during the COVID-19 pandemic in New York City.

In Spring 2020, the New York Army and Air National Guard (NYNG) rapidly deployed to New York City (NYC) to assist in the recovery, processing, and transport of COVID-19 decedents. This study reports on a survey conducted by NYNG service members three to six months post-mission (n = 177). Data showed that there was a dose-response relationship between mission stress exposure and decremented mental health, but certain activities were associated with better mental health outcomes. The paper also reviews resources provided by behavioral health personnel to support service members during the mission and lessons learned to inform future decedent recovery missions.

Impact of the COVID-19 pandemic on army families: Household finances, familial experiences, and soldiers' behavioral health.

The Coronavirus Disease 2019 (COVID-19) pandemic has significantly impacted employment and finances, childcare, and behavioral health across the United States. The Behavioral Health Advisory Team assessed the pandemic's impact on the behavioral health of U.S. Army soldiers and their families. Over 20,000 soldiers at three large installation groups headquartered in the northwestern continental U.S., Republic of Korea, and Germany participated in the cross-sectional survey. Multivariable logistic regression models indicated that key demographics (gender, rank), severity of household financial impact, changes in work situation due to childcare issues, and family members' difficulty coping (both self and spouse/partner and/or child) were independently and consistently associated with greater odds of screening positive for probable clinical depression and generalized anxiety, respectively. These findings highlight how Army families were impacted similarly by the pandemic as their civilian counterparts. Army leadership may action these findings with targeted support for soldiers and their families to ensure they are utilizing supportive services available to them, and that military services continually evolve to meet soldier and family needs during times of crisis and beyond.

Mental Health Outcomes Among American Indian and Alaska Native U.S. Army Soldiers: A Serial Cross-Sectional Analysis.

INTRODUCTION: American Indian and Alaska Native (AI/AN) individuals in the USA experience higher rates of mental illness and preventable death than the general population. Published research demonstrates that AI/AN veterans experience similar disparities to other minorities compared to non-minority veterans; few studies, however, have assessed mental health outcomes in AI/AN active duty military members. The objective of this study was to determine differences in depression, anxiety, hazardous alcohol consumption, and suicidal ideation among AI/AN soldiers compared to soldiers of other races during the Coronavirus Disease 2019 (COVID-19) pandemic. MATERIALS AND METHODS: We conducted repeated cross-sectional electronic surveys to assess the mental health of active duty and activated reserve U.S. Army soldiers within three commands in the Northwestern Continental United States , Republic of Korea, and Germany during May-June 2020 (T1) and December 2020-January 2021 (T2). The primary exposure of interest in the present analysis was race and ethnicity, and the primary outcomes were probable depression with functional impairment (subsequently "depression"), probable anxiety with functional impairment (subsequently "anxiety"), hazardous alcohol use, and suicidal ideation. Multivariable logistic regression models were used to determine the association between demographics and COVID-19 concerns on mental health outcomes for each time point. RESULTS: A total of 21,293 participants responded to the survey at T1 (participation rate = 28.0%), and 10,861 participants responded to the survey at T2 (participation rate = 14.7%). In the multivariable model, AI/AN participants had 1.36 higher adjusted odds of suicidal ideation (95% CI: 1.02-1.82) at T1 and 1.50 greater adjusted odds of suicidal ideation at T2 (95% CI: 1.00-2.24), when compared to non-Hispanic White participants. During T1, there was no significant difference detected between AI/AN and non-Hispanic White participants for anxiety (adjusted odds ratio: 1.21; 95% CI: 0.91-1.60) (Table IV). However, AI/AN participants had 1.82 greater adjusted odds of anxiety when compared to non-Hispanic White participants at T2 (adjusted odds ratio: 1.82; 95% CI: 1.29-2.57). There were no significant differences detected between AI/AN participants and non-Hispanic White participants in multivariable models for either depression or hazardous alcohol use at both time points. CONCLUSIONS: Although we hypothesized that all adverse mental health outcomes would be higher for AI/AN service members at both time points, there were no significant differences at each of the time points analyzed for most of the outcomes analyzed. However, differences in suicidal ideation were found at both time points. Analyses and proposed interventions should account for diversity and heterogeneity of AI/AN populations.

Translating Public Health Recommendations Using the Army Design Methodology.

The U.S. Army employs over 470,000 active duty soldiers throughout the world. Although the Army also employs hundreds of public health professionals, public health recommendations are often not framed in ways that are readily actionable to senior Army leaders. This case study shows how public health findings were translated into actionable recommendations using the Army Design Methodology (ADM) and subsequently implemented by installation leadership. Following a perceived increase in suicides at Fort Wainwright, Alaska, in 2019, installation leadership requested that the U.S. Army Public Health Center conduct an epidemiological consultation. A mixed-methods approach was used to gather qualitative and quantitative data. The ADM was used to translate the findings and provide actionable recommendations for senior Army leaders. Many recommendations were implemented within a year of the report's release and included modifications to gym facilities, dining halls, and sleeping areas. Key improvements included the installation of $900,000 worth of new gym equipment in existing physical fitness facilities, increasing the basic daily food allowance by 44% to facilitate the purchase of healthy options, and the installation of blackout blinds in all barracks to ensure more restful sleep during times of peak sunlight. The ADM is well understood by senior Army leaders. Use of the ADM in future military-specific public health studies could ensure a more effective uptake and implementation of public health recommendations.

COVID-19 Vaccination Attitudes and Intentions Among U.S. Soldiers: Results from the U.S. Army Behavioral Health Advisory Team (BHAT).

INTRODUCTION: The objective of this study is to characterize the associations between demographic, attitudinal, and leadership factors with COVID-19 vaccination rates, vaccination intentions among those not vaccinated, and attitudes about vaccination safety, effectiveness, and importance. METHODS: A serial cross-sectional anonymous online survey was administered to soldiers at two large U.S. Army Divisions located in the Southwestern region of the U.S. at two different time points (April-May 2021 [Time 1; T1] N = 24,629; July-August 2021 [Time 2; T2] N = 21,116). Binary logistic regressions were used to assess demographic and attitudinal predictors of vaccination receipt and vaccination intent. Multinomial logistic regressions were used to assess demographic and leadership predictors of endorsement of three vaccination attitudes concerning effectiveness, safety, and importance. RESULTS: Approximately 43% of soldiers reported that they received a COVID-19 vaccine at T1, increasing to 67% at T2. Soldiers who agreed with three separate statements on vaccination effectiveness, safety, or importance were more likely to indicate that they intended to get the vaccination at both time points. Soldiers who reported that their immediate supervisor encouraged soldiers to get a COVID-19 vaccine were more likely to indicate that the vaccination was effective, safe, or important at both time points. DISCUSSION: Negative attitudes about COVID-19 vaccines were prevalent and correlated with less intention to get a vaccination. However, prioritizing leadership engagement around the importance of vaccinations may be a simple but widely effective intervention point to increase future vaccine uptake following the development of novel vaccines to future COVID-19 variants.

Suicide behavior among heterosexual, lesbian/gay, and bisexual active component service members in the U.S. Armed Forces.

Lesbian, gay, and bisexual (LGB) individuals are at a particularly high risk for suicidal behavior in the general population of the United States. This study aims to determine if there are differences in the frequency of lifetime suicide ideation and suicide attempts between heterosexual, lesbian/gay, and bisexual service members in the active component of the U.S. Armed Forces. Self-reported data from the 2015 Department of Defense Health-Related Behaviors Survey were used in the analysis. Multivariable logistic regression demonstrated that lesbian/gay and bisexual service members were more likely to report past suicide ideation when compared to heterosexual service members (adjusted odds ratio [AOR] for lesbian/gay: 1.79; 95% CI:1.14-2.82; AOR for bisexual: 2.33; 95% CI: 1.56-3.49). Similar results were observed for past suicide attempt for lesbian/gay (AOR: 2.29; 95% CI: 1.15-4.57) and bisexual SMs (AOR: 2.04; 95% CI: 1.24-3.38). Despite disparities in suicide ideation and attempt by sexual orientation, a majority of service members' behavioral health questionnaires do not assess sexual orientation. Clinical screenings of suicide risk in military settings should factor in sexual orientation to more comprehensively assess association between sexual orientation and suicidal behavior in this population.

The association between two bogus items, demographics, and military characteristics in a 2019 cross-sectional survey of U.S. Army soldiers.

Careless responding to surveys has not been sufficiently characterized in military populations. The objective of the current study was to determine the proportion and characteristics of careless responding in a 2019 survey given to a large sample of U.S. Army soldiers at 1 installation (n = 4,892). Two bogus survey items were asked to assess careless responding. Nearly 96% of soldier respondents correctly answered both bogus items and 4.5% incorrectly answered at least 1 bogus question. In the adjusted multiple logistic regression model, race and marital status were associated with incorrect answers to bogus item questions after controlling for all other covariates. Specifically, the odds of Black respondents incorrectly answering the bogus items (adjusted odds ratio [AOR]: 2.53; 95% CI: 1.74-3.68) were more than 2.5 times those of White respondents. The recommendations that stem from the results of surveys can influence policy decisions. A large proportion of careless responses could inadvertently lead to results that are not representative of the population surveyed. Careless responding could be detected through the inclusion of bogus items in military surveys which would allow researchers to analyze how careless responses may impact outcomes of interest.

Stigma and healthcare access among men who have sex with men and transgender women who have sex with men in Senegal.

Objectives: Cisgender gay, bisexual, and other men who have sex with men and transgender women experience HIV incidence disparities in Senegal. These analyses determined how depression and different stigma mechanisms related to sexual behavior are associated with healthcare access, sexually transmitted infection testing, and HIV testing among cisgender gay, bisexual, and other men who have sex with men and transgender women across three cities in western Senegal. Methods: Logistic regression assessed the relationship of three stigma scales (stigma from family and friends, anticipated healthcare stigma, and general social stigma) and depression with these outcomes. Results: Depression and stigma were not associated with healthcare access, sexually transmitted infection testing, or HIV testing. However, individuals who had disclosed their sexual identity to a medical provider were more likely to test for HIV. Conclusions: Sexual behavior stigma experienced by cisgender gay, bisexual, and other men who have sex with men and trans women in Senegal may not limit access to routine healthcare, but may limit disclosure of sexual orientation and practices, limiting access to appropriate HIV prevention services.

US soldiers and the role of leadership: COVID-19, mental health, and adherence to public health guidelines.

BACKGROUND: Previous studies have documented the impact of domain-specific leadership behaviors on targeted health outcomes in employees. The goal of the present study was to determine the association between specific leadership behaviors addressing COVID-19 and US soldiers' mental health and adherence to COVID-19 public health guidelines. METHODS: An electronic, anonymous survey was administered to US Army soldiers across three major commands (N = 7,829) from December 2020 to January 2021. The primary predictor of interest was soldiers' ratings of their immediate supervisors' behaviors related to COVID-19. The outcomes were soldiers' mental health (i.e., depression and generalized anxiety) and adherence to COVID-19 public health guidelines. Covariates were rank, gender, ratings of immediate supervisors' general leadership, level of COVID-19 concerns, and COVID-19 status (e.g., tested positive, became seriously ill). Logistic regressions were used to model the unique association of COVID-19 leadership behaviors with outcomes after adjusting for covariates. RESULTS: High levels of COVID-19 leadership behaviors were associated with lesser likelihood of soldiers' screening positive for depression (AOR = 0.46; 95% CI [0.39, 0.54]) and anxiety (AOR = 0.54; 95% CI [0.45, 0.64]), and greater likelihood of frequent adherence to preventive health guidelines (AORs = 1.58; 95% CI [1.39, 1.80] to 2.50; 95% CI [2.01, 3.11]). CONCLUSION: Higher levels of COVID-19 leadership behaviors may support soldiers' mental health and encourage their adherence to COVID-19 public health guidelines. Given the link between these leader behaviors and soldier adaptation to the pandemic over and above general leadership, training for supervisors should focus on targeting specific health-promoting behaviors. Results can inform leader training for the military and other high-risk occupations.

Food insecurity among active duty soldiers and their families during the coronavirus disease 2019 pandemic.

OBJECTIVE: We examined the determinants of food insecurity among active duty Army households that transitioned into food insecurity during the coronavirus disease 2019 (COVID-19) pandemic. DESIGN: We compared Army households that recently transitioned into marginal food insecurity with those households that remained highly food secure (n 2832) to better understand how these households differ in their resilience to food insecurity during economic downturns using data from a military installation in the USA in 2020. SETTING: A US military installation in the USA. PARTICIPANTS: Active duty US Army soldiers. RESULTS: Prior to the pandemic, the prevalence of marginal food insecurity among Army households was similar to that reported for households in the general population. Marginal food insecurity among Army households increased over 1·5-fold - from 19 % to 33 % - with the onset of the pandemic. Relative to Army households with consistently high food security, the Army households that transitioned into marginal food insecurity after the onset of the pandemic were more likely to report concerns about financial insecurity and the job security of their family members. CONCLUSIONS: Army households, like their civilian counterparts, are vulnerable to food insecurity because of instability in their income during periods of economic uncertainty. Periods of economic uncertainty are more common for Army households because of the frequent relocations associated with military service which could lead to predictable periodic spikes in their food insecurity.

Cross-sectional analysis of the association between perceived barriers to behavioral health care and intentions to leave the U.S. Army.

The attrition of service members is a costly concern for the U.S. military and can lead to reduced readiness. While there have been studies identifying reasons for attrition, little is known about the relationship between perceived barriers to behavioral health care and attrition. A cross-sectional survey was conducted as part of a behavioral health epidemiological consultation at a U.S. Army division (n=5,842) during the COVID-19 pandemic in 2020. Odds of intending to leave the Army increased by 6% for each additional perceived barrier to behavioral health care. Soldiers' concerns about the potential negative impacts on their careers or work environments were the most frequently cited barriers to behavioral health care.

Association between first oral examination characteristics and dental treatment needs in privately insured children: A claims data analysis.

BACKGROUND: Early childhood caries (ECC) remains the most common, preventable infectious disease among children in the United States. Screening is recommended after the eruption of the first tooth, but it is unclear how the age at first dental examination is associated with eventual restorative treatment needs. The authors of this study sought to determine how provider type and age at first dental examination are associated longitudinally with caries experience among children in the United States. METHODS: Deidentified claims data were included for 706,636 privately insured children aged 0 through 6 years as part of the nationwide IBM Watson Health Market Scan (2012-2017). The authors used Kaplan-Meier survival analysis to describe the association between the age of first visit and restorative treatment needs. RESULTS: A total of 21% of this population required restorative treatment, and the average age at first dental examination was 3.6 years. A multivariable Cox proportional hazards model showed increased hazard for restorative treatment with age at first dental visit at 3 years (hazard ratio, 2.05; 95% CI, 1.97 to 2.13) and 4 years (hazard ratio, 3.99; 95% CI, 3.84 to 4.16). CONCLUSION: The high proportion of children requiring restorative treatment and late age at first dental screening show needed investments in educating general dentists, medical students, and pediatricians about oral health guidelines for pediatric patients. PRACTICAL IMPLICATIONS: Communicating the importance of children establishing a dental home by age 1 year to parents and health care professionals may help reduce disease burden in children younger than 6 years.