United States Army Reserve/National Guard soldiers' healthcare experiences, attitudes, and preferences: Differences based on deployment status.

Some United States Army Reserve/National Guard (USAR/NG) soldiers have substantial health needs, which may be service-related, but not necessarily resulting from deployment. However, most USAR/NG members need to have been deployed to qualify for Veterans Administration (VA) benefits. Therefore, many USAR/NG soldiers seek care from civilian healthcare providers (HCPs). Using a subset (N = 430 current/former soldiers) of Operation: SAFETY study data, we used regression models to examine differences in healthcare experiences, attitudes, and preferences by deployment status (never-deployed vs. previously-deployed). Final models controlled for age, sex, rank (enlisted vs. officer), military status (current vs. former military), and RAND SF-36 General Health Score. Over 40% of soldiers agreed that civilian HCPs should ask patients about their military service, but never-deployed soldiers were less likely to report being asked about their service (p < 0.05) or how their service affects their health (p < 0.10). Never-deployed soldiers were also less likely to attribute their health concerns to military service (p < 0.001). Although never-deployed soldiers were more likely to prefer receiving physical (p < 0.05) and mental (p < 0.05) healthcare outside of the VA than previously-deployed soldiers, never-deployed soldiers had low confidence in their HCP's understanding of their needs (49% thought that their civilian HCP did not understand them; 71% did not think that their civilian HCP could address military-related health concerns; 76% thought that their civilian HCP did not understand military culture). Findings demonstrate that although civilian HCPs may be the preferred (and only) choice for never-deployed USAR/NG soldiers, they may need additional support to provide care to this population.

The Role of Military Identity in Substance Use and Mental Health Outcomes among U.S. Army Reserve and National Guard Soldiers.

We investigated how military identity (i.e., veteran identity centrality, the extent to which military service is central to an individual's sense of self) relates to substance use and mental health among U.S. Army Reserve and National Guard (USAR/NG) soldiers. Data were drawn from Operation: SAFETY, a longitudinal survey study of USAR/NG soldiers. Regression models (n=413 soldiers) examined relationships between military identity and substance use (i.e., alcohol problems, past 3-months non-medical use of prescription drugs (NMUPD), illicit drug use, tobacco use), and mental health (i.e., generalized anxiety, anger, depression, PTSD), controlling for sex, race, age, education, years of military service, military status (current/former), and deployment (ever/never). In adjusted models, stronger military identity was not related to alcohol, illicit drug, or tobacco use, but was associated with past 3-months NMUPD (OR: 1.40, 95% CI: 1.12, 1.75, p<.01) and greater symptoms of anger (IRR: 1.02, 95% CI: 1.01, 1.03, p<.01), generalized anxiety (IRR: 1.05, 95% CI: 1.01, 1.10, p<.01), depression (IRR: 1.06, 95% CI: 1.02, 1.10, p<.01), and PTSD (IRR: 1.07, 95% CI: 1.02, 1.12, p<.01). Findings demonstrate the importance of military identity for health-related outcomes. NMUPD suggests potential self-medication and an avoidance of help-seeking, as admitting difficulties may conflict with military identity.

Comparing Patient and Provider Experiences with Atrial Fibrillation to Highlight Gaps and Opportunities for Improving Care.

BACKGROUND: Atrial fibrillation (AF), the most common abnormal heart rhythm, places a considerable burden on patients, providers, and the US healthcare system. OBJECTIVE: The purpose of this qualitative study was to compare patients' and providers' interpretations and responses to AF symptoms and to identify where treatment can be improved to better address patient needs and well-being. DESIGN: Qualitative design using focus groups with patients (3 groups) and providers (3 groups). PARTICIPANTS: Patients with physician-confirmed AF (n=29) and cardiologists, primary care physicians, and cardiac nurses (n=24). APPROACH: Focus groups elicited patient and provider perspectives regarding the symptom experience of AF, treatment goals, and gaps in care. Patient and provider transcripts were analyzed separately, using a thematic content analysis approach, and then compared. KEY RESULTS: While patients and providers described similar AF symptoms, patients' illness experiences included a wider range of symptoms that elicited anxiety and impacted quality of life (QOL) across many biopsychosocial domains. Patients and providers prioritized different treatment goals. Providers tended to focus on controlling symptoms congruent with objective findings, minimizing stroke risk, and restoring sinus rhythm. Patients focused on improving QOL by reducing medication use or procedures. Both patients and providers struggled with patients' cardiac-related anxiety. Patients expressed an unmet need for education and support. CONCLUSION: Patients with AF experience a range of symptoms and QOL issues. While guidelines recommend shared-decision making, discordance between patient and provider perspectives on the importance, priority, and impact of patients' perceived AF symptoms and consequent cardiac anxiety may result in differing treatment priorities. Starting from a perspective that contextualizes AF in the broader context of patients' lives, prioritizes QOL, and addresses symptom-specific anxiety as a prime concern may better address patients' unmet needs.

Lifetime trauma exposure profiles and alcohol use over time among U.S. Reserve and National Guard soldiers.

Although trauma exposure is a recognized risk factor for alcohol use, research on military populations has emphasized combat exposure, with minimal consideration of exposure to other potentially traumatic events (PTEs). We aimed to (a) identify, characterize, and quantify subgroups of service members based on PTE patterns; (b) examine associations between trauma exposure subgroups and alcohol use; and (c) examine these associations longitudinally. Data were drawn from Operation: SAFETY, a longitudinal study of health and well-being among U.S. Army Reserve/National Guard soldiers (N = 478). Exposure to 15 PTEs, including childhood maltreatment, noninterpersonal events (e.g., natural disasters, accidents), interpersonal trauma, and military-related exposures, was assessed at baseline. Latent profile analysis was conducted to characterize mutually exclusive trauma profiles; profile membership was used to longitudinally predict alcohol use in generalized estimating equation models. Four exposure profiles were identified: intimate partner violence (IPV)/combat trauma (8.4%, n = 40), combat trauma (24.7%, n = 118), childhood trauma (8.4%, n = 40), and low trauma (58.6%, n = 280). In adjusted models, compared to the low trauma profile, IPV/combat profile membership was longitudinally associated with alcohol problems, OR = 2.44, p =.005. Membership in other trauma profiles was not associated with alcohol use. Within the IPV/combat profile, men had a higher risk of frequent heavy drinking than women. Results suggest a need to comprehensively screen for lifetime PTE exposure, particularly IPV, in military populations. Given the high prevalence of nonmilitary PTEs, an inclusive, trauma-informed approach to health care and service provision is warranted.

"Narcan encounters:" overdose and naloxone rescue experiences among people who use opioids.

BACKGROUND: Communities across the United States are confronting the precipitous rise in opioid overdose fatalities that has occurred over the past decade. Naloxone, an opioid antagonist, is a safe rescue medication that laypeople can administer to reverse an overdose. Community naloxone training programs have been well-documented. Less is known about overdose survivors' subjective experiences with naloxone reversal and its impacts on drug use behavior.Methods: Semi-structured interviews were conducted with 35 community-dwelling adults who had been reversed at least once with naloxone. Inductive thematic content analysis incorporating Atlas.ti software was used to identify themes.Results: Four broad thematic categories were identified. (1) Overdose experience and memory: Most participants remembered taking the drugs one minute and waking up the next-sometimes in different surroundings; (2) Naloxone rescue-waking up: Participants described acute withdrawal symptoms, disorientation, and volatile emotions; (3) Reasons for overdose: Polypharmacy; changes in opioid tolerance, or presence of fentanyl were the most common explanations. (4) Impacts of naloxone rescue: A variety of contextual factors influenced participants' responses to naloxone rescue, especially acute withdrawal symptoms. While some participants altered or tempered their opioid use, others resumed opioid use-especially to mitigate withdrawal. Participants overwhelmingly emphasized that naloxone saved their lives.Conclusion: Results suggest that a naloxone rescue may not be a wake-up call for many people who use opioids, but access to naloxone is an effective overdose harm reduction option, supporting its widespread implementation. The study findings underscore the importance of ongoing community overdose prevention and harm reduction initiatives, including take-home naloxone (THN) and medication assisted treatment in the Emergency Department.

Treatment Experiences Among People Who Use Opioids: A Social Ecological Approach.

The prevalence of opioid use disorder (OUD) and surge in overdose deaths remain key public health concerns. Despite evidence supporting the efficaciousness of medications for opioid use disorder, most people with OUD do not receive treatment. In this qualitative study, semi-structured interviews were conducted with 35 adults in a northeastern city to learn about their experiences with substance use treatment. Qualitative data were analyzed using an inductive thematic content analysis approach, and a social ecological model was applied to examine contextual factors affecting participants' experiences accessing and engaging in treatment. While we organized our findings following the individual, interpersonal, community, and society levels of the socio-ecological model, we also observed overlap and interconnectedness between and across these levels. Our findings suggest that retention in treatment often depends upon personal motivation, treatment availability, the match of the treatment modality to an individual's needs, and social support. A person-centered approach is needed to promote individualized care and tailor treatment components to the patient's needs.

Mental and physical health factors related to dual use of veterans affairs and non-veterans affairs healthcare among U.S. reserve soldiers.

This study examined the association between mental and physical health factors and dual use of Veterans' Affairs (VA) and non-VA healthcare among previously deployed male Reserve/National Guard (R/NG) soldiers (N = 214). Participants completed online annual surveys on a range of topics, including validated measures of mental and physical health, as well as questions about past-year healthcare utilization. Multinomial logistic regression models separately examined the association between mental health symptoms (PTSD, anxiety, depression, emotional role limitations), physical health symptoms (bodily pain, physical role limitations), and healthcare use (single use and dual use compared to no use), controlling for geography, trust in the VA, age, and race. Anxiety (aRR: 1.13; 95% Confidence Interval (CI): 1.02, 1.26; p<.05), depression (aRR: 1.23; 95% CI: 1.06, 1.43; p<.01), and PTSD (aRR: 1.05; 95% CI: 1.01, 1.10; p<.05) symptoms were all related to past year dual use of VA and non-VA healthcare, even after controlling for known demographic factors. Bodily pain and emotional and physical role limitations were not related to healthcare outcomes. This suggests that mental health symptoms themselves may be a primary factor driving healthcare use. Further study is needed to examine whether dual use of VA and non-VA healthcare is duplicative or complementary.

Effects of Social Network Characteristics on Mental Health Outcomes Among United States Army Reserve and National Guard Soldiers.

We sought to examine the relative salience of multiple social network structural characteristics (e.g., size, composition, quality, substance use) for understanding soldiers' mental health symptoms (anger, anxiety, depression, PTSD). Data are drawn from soldiers (N = 421) participating in the Operation: SAFETY study. Negative binomial regression models examined the relationship between ten social network characteristics and mental health outcomes, controlling for age, sex, years of military service, and deployment history. Greater number of close network ties was associated with fewer symptoms of anger, anxiety, and depression (ps < 0.05), but not PTSD. Having more illicit drug-using network ties was associated with greater severity of anxiety symptoms (p < 0.05). Finally, more days spent drinking with network members was related to higher levels of anger (p < 0.05). Interpersonal relationships that entail substance use are associated with greater anxiety and anger while a greater number of close ties is associated with fewer anger, anxiety, and depression symptoms.

Resilience to Hazardous Drinking Among Never-Deployed Male United States Army Reserve and National Guard Soldiers.

BACKGROUND: Negative emotions related to never having been deployed to active duty are associated with an increased risk of hazardous drinking among United States Army Reserve/National Guard (USAR/NG) soldiers. Resiliency factors are known to buffer the effects of combat on hazardous drinking among service members who have been deployed, but it is not known whether these factors are protective for never-deployed service members, or which domains of hazardous drinking might be affected. Therefore, we examined the effects of a range of resiliency factors (i.e., marital satisfaction, psychological hardiness, intrinsic religiosity) on the relation between nondeployment emotions (NDE) and domains of hazardous drinking. METHODS: We drew a subset of data from Operation: Soldiers and Families Excelling Through the Years (N = 112 never-deployed male soldiers), an ongoing study of USAR/NG soldiers. Regression models examined the main effects of NDE on each of the domains of hazardous drinking (i.e., total Alcohol Use Disorders Identification Test [AUDIT] score, consumption subscale, dependence subscale, alcohol-related problems subscale) and effect modification of each of the resiliency factors on the relations between NDE and the domains of hazardous drinking, separately. Final models controlled for years of military service, rank (enlisted vs. officer), number of military friends in the social network, and depression. RESULTS: Greater NDE were associated with a higher total AUDIT score, alcohol consumption, and alcohol dependence (ps < 0.05), but not alcohol-related problems (p > 0.05). Marital satisfaction and psychological hardiness buffered the effects of NDE on total AUDIT score and alcohol dependence (p < 0.05). Intrinsic religiosity only modified the effect of NDE on total AUDIT score. None of the resiliency factors modified the effects of NDE on alcohol consumption or alcohol-related problems. CONCLUSIONS: Soldiers with greater NDE had a greater risk of hazardous drinking in the presence of low resilience. Interventions to promote resiliency are an important consideration for protecting USAR/NG soldiers from hazardous drinking, regardless of their deployment history.

"I just need to be with my family": resettlement experiences of asylum seeker and refugee survivors of torture.

A global migration of individuals fleeing persecution, violence and armed conflict reached almost 60 million world-wide in 2015. This world-wide crisis of displacement reflects people seeking safety across borders and oceans; dangerous journeys that compound the trauma endured by these women, men and children. Refugees/asylum seekers face barriers upon entry to the U.S. The Western New York Center for Survivors (WNYCST) provides care coordination/trauma-informed care to mitigate these challenges. The objective of this study was to explore the resettlement experiences of survivors of torture living in Western New York, who had received services from the WNYCST; identifying challenges, unmet needs, and services that were helpful. Secondarily, we describe the experiences of asylum seekers and legally resettled refugees, who due to their differing legal status, might be expected to have different experiences. Data were collected using semi-structured qualitative interviews. RESULTS: Three themes emerged: mental health challenges, relating to their experiences in their home country and their separation from family; unmet needs, including lack of a sense of purpose and meaning, difficulty navigating services, and missing connections to community; and coping strategies, including WNYCST assistance with connecting with sources of social support in their new community. WNYCST services were helpful, particularly the assistance and connection with care coordinators and local support groups. This care and outreach helped to mitigate feelings of separation and apartness from their home countries and families. CONCLUSIONS: Some refugees/asylum seekers continue to struggle with unmet needs, issues of loss and isolation. If care providers recognize signs of stress early, appropriate interventions can be implemented. Care connections and trauma informed treatment with an emphasis on recreating ties with communities, may be one important factor in ensuring successful integration.

Variations in Risk and Motivations for Substance Use over the Course of Military Service.

BACKGROUND: Epidemiological data identify risk factors related to substance use among military service members to inform prevention and treatment. Less is known about how motivations and risks for substance use vary over a military service career. The study goal was to explore substance use patterns and motivations among a sample of United States undergraduate student veterans in order to identify periods of risk. Methods: Qualitative interviews were conducted (n = 31) between December 2018 and April 2019. Transcripts were coded in ATLAS.ti using thematic content analysis. Results: Interviews revealed complex motivations around substance use and identified key periods of risk. 1) Pre-service: Participants reported using alcohol and marijuana, primarily during social activities. 2) During service: Participants described a culture of heavy alcohol and tobacco use in social contexts, but little use of other substances. Post-deployment was a notable exception, when some reported heavier alcohol use and use of other drugs, including opiates, cocaine, and ecstasy. 3) Post-service: Transitioning out of the military was described as difficult; some participants reported heavier use of substances during this period. Some participants quit smoking after military service, or switched to vaping. Others reported use of alcohol and/or marijuana to calm themselves, relieve stress, and enable sleep. Conclusions: These data indicate that the periods immediately following deployment and transition out of the military may be especially high-risk for heavy substance use and use of a broader range of substances. This highlights the need for tailored interventions and messaging at different points of military service, particularly during periods of greatest risk.

Primary care and mental health providers' perceptions of implementation of pharmacogenetics testing for depression prescribing.

BACKGROUND: Pharmacogenetic testing (PGx) has the potential to improve the quality of psychiatric prescribing by considering patients' genetic profile. However, there is limited scientific evidence supporting its efficacy or guiding its implementation. The Precision Medicine in Mental Health (PRIME) Care study is a pragmatic randomized controlled trial evaluating the effectiveness of a specific commercially-available pharmacogenetic (PGx) test to inform antidepressant prescribing at 22 sites across the U.S. Simultaneous implementation science methods using the Consolidated Framework for Implementation Research (CFIR) are integrated throughout the trial to identify contextual factors likely to be important in future implementation of PGx. The goal of this study was to understand providers' perceptions of PGx for antidepressant prescribing and implications for future implementation. METHODS: Qualitative focus groups (n = 10) were conducted at the beginning of the trial with Primary Care and Mental Health providers (n = 31) from six PRIME Care sites. Focus groups were audio-recorded and transcribed and data were analyzed using rapid analytic procedures organized by CFIR domains. RESULTS: Analysis revealed themes in the CFIR Intervention Characteristics domain constructs of Evidence, Relative Advantage, Adaptability, Trialability, Complexity, and Design that are important for understanding providers' perceptions of PGx testing. Results indicate: 1) providers had limited experience and knowledge of PGx testing and its evidence base, particularly for psychiatric medications; 2) providers were hopeful that PGx could increase their precision in depression prescribing and improve patient engagement, but were uncertain about how results would influence treatment; 3) providers were concerned about potential misinterpretation of PGx results and how to incorporate testing into their workflow; 4) primary care providers were less familiar and comfortable with application of PGx testing to antidepressant prescribing than psychiatric providers. CONCLUSIONS: Provider perceptions may serve as facilitators or barriers to implementation of PGx for psychiatric prescribing. Incorporating implementation science into the conduct of the RCT adds value by uncovering factors to be addressed in preparing for future implementation, should the practice prove effective. TRIAL REGISTRATION: ClinicalTrials.gov ID: NCT03170362 ; Registered 31 May 2017.

Caring for veterans in US civilian primary care: qualitative interviews with primary care providers.

BACKGROUND: Non-VA health care providers in the USA have been called upon to screen patients for veteran status as a means to better identify military-related health sequelae. Despite this recognized need, many service members are still not being asked about veteran status. OBJECTIVE: The purpose of this research was to qualitatively assess, from non-VA primary care providers' point-of-view, barriers to providing care to veterans, the training providers perceive as most useful and the tools and translational processes they think would be most valuable in increasing military cultural competency. METHODS: Semi-structured qualitative interviews, with non-VA primary care providers (N = 10) as part of a larger quantitative study of primary care providers' attitudes around veteran care. Interviews asked about providers' approach to addressing veteran status in their practice and their thoughts on how to address the needs of this population. Qualitative data were analyzed using a thematic content analysis approach. RESULTS: Three major themes were identified: (i) barriers to caring for patients who are identified as veterans, (ii) thoughts on tools that might help better identify and screen veteran patients and (iii) thoughts on translating and implementing new care processes for veteran patients into everyday practice. CONCLUSIONS: Our study identified barriers related to non-VA providers' ability to care for veterans among their patients and possible mechanisms for improving recognition of veterans in civilian health care settings. There is a need for further research to understand how assessment, screening and follow up care for veteran patients is best implemented into civilian primary care settings.

Challenges to and Strategies for Formal Service Utilization among Caregivers in an Underserved Community.

Family caregivers face enormous challenges when attempting to oversee the medical, legal, financial, and daily affairs of loved ones with chronic or life-limiting illness. While formal services and agencies exist to assist caregivers with some of these tasks, caregivers in underserved communities do not utilize these services, or utilize them with unsatisfactory results. This study used focus groups (N = 5 groups) with underserved, minority caregivers (N = 22) to explore their experiences related to care provision, including barriers to support service use and challenges navigating systems related to the broad spectrum of caregiving demands. Thematic content analysis revealed three main themes: (1) prior difficulties with formal service use, (2) difficulties navigating financial, legal, and medical systems, and (3) caregivers' personal strategies to address challenges associated with formal service use and systems navigation. Findings from this study identify underserved caregivers' challenges in utilizing formal services, as well as caregiver-identified strategies for supporting their caregiving activities.

Alcohol Use Among Never-Deployed U.S. Army Reserve and National Guard Soldiers: The Effects of Nondeployment Emotions and Sex.

BACKGROUND: Limited research shows that mental health problems are prevalent among never-deployed soldiers and many experience negative emotions related to their nondeployment. U.S. Army Reserve/National Guard (USAR/NG) soldiers are also at high risk for alcohol misuse. However, it is not known if nondeployment emotions contribute to an increased risk of alcohol misuse among never-deployed USAR/NG soldiers. METHODS: Data are from Operation: SAFETY (Soldiers and Families Excelling Through the Years), an ongoing study of USAR/NG soldiers. We used regression models to examine the relations between nondeployment emotions, assessed by the Non-Deployment Emotions (NDE) Questionnaire, and a range of alcohol use outcomes, assessed by the Alcohol Use Disorders Identification Test and standard quantity and frequency questions, among a sample of never-deployed soldiers who were partnered at baseline (N = 174). Final models controlled for years of military service, current number of close military friends in the social network, marital satisfaction, and depression. We also tested for potential differences in these associations by sex. RESULTS: Nondeployment emotions were associated with frequency of getting drunk (adjusted risk ratio [aRR] = 1.02, 95% CI: 1.01, 1.04; p < 0.05) and typical number of drinks consumed during a drinking episode (aRR = 1.03, 95% CI: 1.01, 1.04; p < 0.01). Nondeployment emotions had a trend-level association with percent of days drinking (adjusted odds ratio = 1.05, 95% CI: 1.00, 1.11; p = 0.055). Nondeployment emotions had a significant interaction with sex (p < 0.05) on the likelihood of alcohol problems, such that only male soldiers experienced a greater likelihood of alcohol problems when they had highly negative nondeployment emotions. There was no relation between nondeployment emotions and alcohol problems among female soldiers. CONCLUSIONS: Findings demonstrate that greater nondeployment emotions are associated with increased alcohol use among never-deployed USAR/NG soldiers. The NDE Questionnaire may assist in identifying those at highest risk for alcohol problems.

What drives the relationship between combat and alcohol problems in soldiers? The roles of perception and marriage.

BACKGROUND: While the relationship between combat exposure and alcohol problems is well-established, the role of perceptions of trauma is less understood. The goal of this study was to explore associations between National Guard (NG) and reserve soldiers' perceptions of combat experiences as traumatic and alcohol problems, and to examine marital satisfaction as a possible protective factor. METHODS: The Operation: SAFETY study recruited US Army Reserve and NG soldiers and their partners to complete a questionnaire covering many physical and mental health, military service, and substance use topics. Negative binomial regression models examined the impact of perceived trauma of combat experiences on alcohol problems (N = 198). The potential role of marital satisfaction as a resiliency factor was also examined. RESULTS: The perception of combat experiences as traumatic was associated with increased risk of alcohol problems (risk ratio [RR] = 1.06, 95% confidence interval [CI] 1.01, 1.12; p = 0.024). Combat exposure itself showed no relationship. Marital satisfaction had a significant interaction with perceived combat trauma on alcohol problems (RR = 0.90, 95% CI 0.81, 0.99, p = 0.046), such that soldiers who perceived combat exposure as moderately-highly traumatic were less likely to have alcohol problems when they rated their marital satisfaction highly. CONCLUSIONS: Our results demonstrate that the perception of combat experiences as traumatic may be a greater contributor to adverse outcomes, such as alcohol problems, than mere combat exposure. They also demonstrate the importance of marital satisfaction as a resiliency factor, particularly at the highest levels of trauma.

Alcohol Misuse in Reserve Soldiers and their Partners: Cross-Spouse Effects of Deployment and Combat Exposure.

BACKGROUND: Military deployment and combat are associated with worse outcomes, including alcohol misuse. Less is known about how these experiences affect soldiers' spouses. OBJECTIVE: The study objective was to explore relationships between deployment, combat exposure, and alcohol misuse; especially cross-spouse effects (effect of one partner's experiences/behavior on the other partner), which has been under-examined in military samples. METHODS: U.S. Army Reserve/National Guard soldiers and their partners completed a questionnaire covering physical and mental health, military service and substance use. Negative binomial regression models examined number of deployments and combat exposure individually for alcohol misuse and frequent heavy drinking (FHD). In additional models, we examined combat exposure's role on alcohol outcomes, controlling for the soldiers' number of deployments, PTSD symptoms, age, and in cross-spouse models, alcohol use and FHD. We considered individuals' deployment experiences related to their alcohol outcomes and to their spouses' alcohol outcomes. RESULTS: The study sample included male soldiers with current/lifetime military service (n = 248) and their female partners. Combat exposure was related to FHD (RR: 1.01, p < .05, 95% CI: 1.01, 1.01) among male soldiers while controlling for PTSD symptoms, number of deployments, and age. Female partners of male soldiers were more likely to engage in FHD (RR: 1.01, p < .05, 95% CI: 1.01, 1.01) if their spouse experienced combat. CONCLUSIONS: Our results demonstrate that male soldiers and their spouses are at increased risk of FHD if the soldier experienced combat. This points to the need for better screening, particularly of spouses of soldiers, whose alcohol misuse may be overlooked.

Childhood trauma, combat trauma, and substance use in National Guard and reserve soldiers.

BACKGROUND: The goal of this work was to examine associations among childhood trauma, combat trauma, and substance use (alcohol problems, frequent heavy drinking [FHD], current cigarette smoking, and current/lifetime drug use) and the interaction effects of childhood trauma and combat exposure on those associations among National Guard/reserve soldiers. METHODS: Participants (N = 248) completed an electronic survey asking questions about their military experiences, physical and mental health, and substance use. Childhood trauma and combat exposure were examined jointly in regression models, controlling for age, marital satisfaction, and number of deployments. RESULTS: Childhood trauma was associated with current drug use (trend level, odds ratio [OR] = 1.44, 95% confidence interval [CI]: 0.97, 2.14; P = .072) in the main effect model; however, there was not a significant interaction with combat. Combat exposure had a significant interaction with childhood trauma on alcohol problems (b = -0.56, 95% CI: -1.12, -0.01; P = .048), FHD (b = -0.27, 95% CI: -0.47, -0.08; P = .007), and lifetime drug use (OR = 1.78, 95% CI: 1.04, 3.04; P = .035). There were no associations with either of the trauma measures and current cigarette smoking. CONCLUSIONS: These results demonstrate that childhood and combat trauma have differential effects on alcohol use, such that combat trauma may not add to the effect on alcohol use in those with greater child maltreatment but may contribute to greater alcohol use among those with low child maltreatment. As expected, childhood and combat trauma had synergistic effects on lifetime drug use. Screening for multiple types of trauma prior to enlistment and/or deployment may help to identify at-risk individuals and allow time for early intervention to prevent future adverse outcomes.

Using standardized patient encounters to teach longitudinal continuity of care in a family medicine clerkship.

BACKGROUND: Despite demonstrated benefits of continuity of care, longitudinal care experiences are difficult to provide to medical students. A series of standardized patient encounters was developed as an innovative curricular element to address this gap in training for medical students in a family medicine clerkship. The objective of this paper is to describe the development and implementation of the curriculum, evaluate the effectiveness of the curriculum for increasing student confidence around continuity of care and chronic disease management, and explore student opinions of the value of the experience. METHODS: The encounters simulate continuity of care in typical family medicine practice over four standardized patient visits, providing students with experience in longitudinal relationships, ongoing management of chronic and acute conditions, lifestyle counseling, and the use of an electronic medical record. Perceptions of the curriculum were obtained using a pre-post survey asking students to self-rate experience and confidence in continuity relationships, chronic disease management, and lifestyle counseling. Students were also asked about the overall effectiveness of the encounters for simulating family practice and continuity of care. Open-ended comments were gathered through weekly reflection papers submitted by the students. RESULTS: Of 138 third-year medical students, 137 completed the pre-survey, 126 completed the post-survey, and 125 (91%) completed both the pre- and the post-survey. Evaluation results demonstrated that students highly valued the experience. Complete confidence data for 116 students demonstrated increased confidence pre-post (t(115) = 14.92, p < .001) in managing chronic disease and establishing relationships. Open-ended comments reflected how the experience fostered appreciation for the significance of patient-doctor relationships and continuity of care. CONCLUSIONS: This curriculum offers a promising approach to providing students with continuity of care experience. The model addresses a general lack of training in continuity of care in medical schools and provides a standardized method for teaching chronic disease management and continuity relationships.

"Living well with diabetes": evaluation of a pilot program to promote diabetes prevention and self-management in a medically underserved community.

A substantial disparity exists in the prevalence and effective self-management of diabetes among African Americans in the United States. Community-level programs have the potential to affect self-efficacy and may be helpful in overcoming common barriers to self-management. The Neighborhood Health Talker Program used community members trained as cultural health brokers to engage their communities in conversations about "living diabetes well." Program evaluators used mixed methods to analyze post-conversation surveys and Health Talker field notes. These indicated an increase in diabetes-related knowledge and increased confidence among conversation participants. Conversations included discussion of barriers and facilitators to lifestyle changes and effective self-management that are frequently overlooked in a clinical setting.