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.

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.

Sleep, Activity, and Nutrition Among an Army Sample: Strengths, Deficits, and Demographic Differences.

Sleep, activity, and nutrition (SAN) are key components in overall health, and an individual's knowledge about and self-confidence to engage in healthy SAN behaviors can have an impact on their actions. This evaluation examined SAN knowledge, self-confidence, and behaviors among U.S. Army Soldiers prior to participating in a health promotion program. Baseline surveys from participating Soldiers provide evidence in this evaluation. U.S. Army Soldiers (N = 11,485) participating in a health promotion program completed surveys. Participants completed an online survey assessing SAN knowledge, self-confidence, and behaviors (among other constructs). We examined the common patterns of SAN behaviors, the associations between them, and the differences based on gender and rank. Knowledge, self-confidence, and behaviors were correlated within each of the three SAN domains. Men reported more aerobic exercise (d = .48) and more resistance training (d = .34) per week than women. Officers reported greater self-confidence in their ability to consume a post-exercise snack (i.e., refuel; d = .38), greater refueling behaviors (d = .43), greater activity knowledge (d = .33), and greater self-confidence in their ability to achieve activity goals (d ranging from .33 to .39), compared to enlisted Soldiers. Finally, greater confidence in one's ability to achieve healthy sleep correlated with getting more sleep, both during workweek (r = .56, p < .001) and weekend (r = .25, p < .001). These baseline data support the need for health promotion of SAN behaviors among these Soldiers.

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.

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.

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.

The Role of Program Evaluation in Keeping Army Health "Army Strong": Translating Lessons Learned Into Best Practices.

Service Members and military beneficiaries face complex and ill-structured challenges, including suicide, sexual violence, increasing health care costs, and the evolving coronavirus pandemic. Military and other government practitioners must identify effective programs, policies, and initiatives to preserve the health and ensure the readiness of our Force. Both research and program evaluation are critical to identify interventions best positioned to prevent disease, protect the public's health, and promote health and well-being within our ranks to retain a medically ready force and reduce the global burden of disease. While military and medical leaders are typically well versed in research and understand the role of research in evidence-informed decisions, they may be less aware of program evaluation. Program evaluation is the systematic application of scientific methods to assess the design, implementation, improvement, or outcomes of a program, policy, or initiative. Although program evaluators commonly utilize scientific or research methods to answer evaluation questions, evaluation ultimately differs from research in its intent. Several recently published federal and Department of Defense policies specifically reference program evaluation, emphasizing its importance to the military and government as a whole. The Army is uniquely positioned to conduct medical and public health evaluation activities and there are several Army organizations and entities that routinely perform this work. For example, the United States Army Public Health Center (APHC) is among recognized military experts in public health assessment and program evaluation. Given the breadth of our work, the APHC understands the challenges to conducting evaluation studies in the Army and we have thoughtfully examined the conditions common to successful evaluation studies. In this commentary, we share our lessons learned to assist military colleagues, potential partners, and others in successfully evaluating the programs, policies, and initiatives necessary to keep our Service Members and beneficiaries healthy and ready. There are several challenges to executing evaluation studies in the Army that may be relevant across all Services. These include but are not limited to frequent Army leadership transitions, urgency to report study results, lack of program documentation and adequate planning for evaluation, expectation management to ensure stakeholders are well-informed about the evaluation process, and a disorganized data landscape. These challenges may hinder the successful execution of evaluation studies, or prevent them from being attempted in the first place, depriving Army leaders of quality, actionable information to make evidence-informed decisions. Despite the aforementioned challenges, we have identified a number of best practices to overcome these challenges and conduct successful evaluation studies. These facilitators of successful evaluations can be summarized as: collaboration with engaged stakeholders who understand the value of evaluation, evaluation studies aligned with larger strategic priorities, agile methodology, thoughtful evaluation planning, and effective communication with stakeholders. We wholeheartedly recommend and encourage program evaluation at every opportunity, and we anticipate the call for evaluation and evidence-informed decisions to continually increase. Our hope is that others - to include partners and stakeholders within and external to the military - will be able to leverage and apply this information, especially the identified best practices, in their evaluation efforts to ensure success.

'Nutrition is out of our control': soldiers' perceptions of their local food environment.

OBJECTIVE: To explore the perceptions of soldiers participating in a US Army Office of The Surgeon General's worksite health promotion programme (WHPP) on the local food environment within their campus-style workplace. DESIGN: Focus groups were conducted to evaluate the perceived effectiveness of the WHPP implementation. Further exploration of focus group data through thematic analysis focused on perceived contributions of the military campus-style food environment to soldiers' nutrition behaviours. SETTING: Three US Army installations located in the continental USA. PARTICIPANTS: Active duty soldiers (n 366) participating in one of the fifty-eight focus groups. RESULTS: Soldiers shared a common belief of self-discipline and personal responsibility as the foothold to nutrition behaviour change. Soldiers described aspects of the military campus-style food environment as factors impeding achievement of optimal nutrition. Collectively, soldiers perceived the proximity and density of fast-food restaurants, lack of healthy alternatives on the installation and the cost of healthy food as inhibitors to choosing healthy foods. Overwhelmingly, soldiers also perceived time constraints as a factor contributing to unhealthy food choices. CONCLUSIONS: Although nutrition behaviour is individually driven, soldiers perceived the military campus-style food environment inhibits healthy decision making. Nutrition programming in military WHPP must integrate food environment changes to improve soldiers' nutrition behaviour outcomes. Applicable to the military, food choice behaviour studies suggest environmental changes must be appealing to young adults. Considerations for environmental changes should include an increased portion size for healthy options, broadened use of soldiers' daily food allowances on local produce and increased availability of grab-and-go options.

Restricting Retail Hours of Alcohol Sales within an Army Community.

INTRODUCTION: Excessive alcohol consumption continues to be a significant concern to overall military readiness; each year, it results in non-deployable active duty service members and service members separated from service. In 2009, The Community Preventive Services Task Force recommended limiting the hours of alcohol sales as an evidence-based and effective intervention to reduce alcohol-related harms. In June 2014, partnerships at an Army Installation in the Midwestern United States implemented a policy to reduce excessive alcohol consumption and associated alcohol-related harms. Although community-based interventions have been shown to successfully reduce alcohol-related negative consequences, little research has explored the effects of these interventions in military communities. MATERIALS AND METHODS: The intervention reduced the retail sale of alcoholic beverages by eight hours daily (11:01 pm to 6:59 am) within the installation community. The U.S. Army Public Health Review Board approved this study as public health practice. The quantitative assessment from a mixed-methods evaluation implemented an interrupted time series design to assess changes in the community resulting from the intervention. Revenue and crime data were collected 11 months and 12 months prior to and after the onset of the intervention, respectively, to quantify the adherence to and effectiveness of the policy. The outcome variables measured in the evaluation were Serious Incident Reports (SIRs) and Driving Under the Influence/Driving While Intoxicated (DUI/DWI) citations. A Wilcoxon Signed-Rank Test of significance was used to measure changes in crime outcomes post-policy. RESULTS: The results indicated that pre-policy rates of overall DUI/DWI citations, and DUI/DWI citations on-post were significantly higher than post-policy DUI/DWI citations (p < 0.05). The results also indicated that pre-policy rates of overall SIRS, alcohol-related SIRs, and SIRs occurring at night were not statistically higher than post-policy rates (p ≥ 0.05). The pre-policy DUI/DWI citations occurring off-post and DUI/DWI citations occurring at night did not reach statistical significance (p > 0.05). Policy adherence was good and total alcohol sales revenue remained stable before and after policy implementation. CONCLUSIONS: This was the first known evaluation within a military community to report improvements in crime statistics following an eight hour reduction in daily retail sale hours of alcohol. The reduction in alcohol-related harms presented in this evaluation are typical for small communities implementing alcohol-related policies; however, the effect sizes reported here are larger than those reported in the current literature, suggesting that the policy positively impacted the installation community in decreasing alcohol-related harms. Evaluation data did not show statistically significant reductions in DUI/DWI citations and SIRs occurring during night hours. Further, the evaluation design disallows the ability to draw a causal relationship between the intervention and measured outcomes. Additional installations should consider implementing similar policies to determine if observed effects are replicable. Future studies should include a longitudinal design that would allow for long-lasting changes to be observed within the population, measurement of additional proximal outcomes (e.g., reported alcohol consumption), and investigating social and health outcomes both inside and outside the confines of the installation community.

Marching on the Road to Quality: Army Public Health Experience Adopting NACCHO's Roadmap to a Culture of Quality Framework.

The US Army Public Health Center (APHC) adopted the National Association of County and City Health Officials' (NACCHO) Roadmap to a Culture of Quality (CoQ) Improvement framework to define its current culture and adapted the NACCHO's Organizational CoQ Self-Assessment Tool for applicability to a federal agency and workforce. More than 500 Civilian and Military personnel completed the self-assessment in October 2017. The results indicated that the APHC was categorized in the third of six total phases of the NACCHO's Roadmap to a CoQ (Phase 3: Informal or Ad Hoc QI Activities), which generated 13 transitional strategies to advance the APHC toward a CoQ. The APHC demonstrated that a federal public health organization can use and apply results from currently available self-assessment tools and frameworks related to a CoQ. By doing so, the APHC is optimizing its ability to ensure America's Soldiers and the Army Family receive essential and effective public health services.

A Tobacco-Free Medical Campus Policy is Associated With Decreased Secondhand Smoke Exposure and Increased Satisfaction Among Military Medical Employees: Results of a Mixed-Methods Evaluation.

INTRODUCTION: Tobacco control is an ongoing concern for the U.S. Army. Although tobacco use is currently prohibited within all military hospitals and clinics, known as military treatment facilities (MTFs), no such facility had implemented a tobacco-free medical campus (TFMC) policy before 2012. This evaluation examined the effects of one Army installation's TFMC policy implementation at its medical facilities. MATERIALS AND METHODS: Online questionnaires were distributed to medical campus employees, including Active Duty Soldiers, civilians, and contractors, before policy implementation (N = 1,210) and 12 months following policy implementation (N = 1,147). Chi-square analyses, independent t tests, and logistic regression models were utilized to examine pretest/post-test changes in employees' secondhand smoke (SHS) exposure; tobacco use, motivation to quit, and cessation; and health outcomes. Twenty-three focus groups, interviews, and informal discussions with 65 employees and patients were conducted 13 months after initial policy implementation to capture both the intended and unintended policy effects. RESULTS: After controlling for demographic characteristics, the study found that employees had more than twice the odds of exposure to SHS in the workplace at baseline than at 12-month follow-up (odds ratio: 2.06, 95% confidence interval: 1.73-2.46, p < 0.001). Employees also reported a lower prevalence of diagnosis with chronic bronchitis (p < 0.05) at follow up compared to baseline. Although the mean number of sick days taken for respiratory illness decreased over time, results were not significant after controlling for demographic factors. No significant differences existed in tobacco-use prevalence or quit rates among tobacco users over time. Employees reported significantly higher levels of satisfaction with a TFMC policy than the original policy (p < 0.001) though this finding was moderated by smoker status such that smokers reported lower levels of satisfaction with the policy over time. Qualitative findings revealed that the most common policy effect was that the policy caused smokers to change the location of where they used tobacco to off campus. Findings further revealed several unintended policy effects, including safety concerns and greater visibility of smokers in front of the MTF. CONCLUSION: The first Army MTF TFMC policy was associated with reported reductions in SHS exposure and improvements in some short-term health outcomes. The policy had no observed association with tobacco-use prevalence, motivation to quit, or cessation at 12-month follow-up. Focus group participants discussed several positive and negative policy effects. These policies should be expanded and studied in more depth across military installations, and policy makers should plan mitigation strategies to reduce unintended effects. This is an important step in military tobacco control, but additional efforts will be necessary to curb tobacco use within this population.