Moral injury among women military veterans and demand for cigarettes: A behavioral economic investigation using a hypothetical purchase task.

OBJECTIVES: Unlike the United States general population, veteran women - as opposed to veteran men - have greater smoking prevalence; yet, little is known regarding factors that influence smoking in veteran women. The purpose of this study was to begin examining the relationship between a psychological concept known as moral injury and demand for cigarettes among veteran women. METHODS: Veteran women who smoke (n = 44) were recruited for this cross-sectional study from Amazon MTurk, Reddit, and a veteran-serving non-profit organization in June-July 2023. Consenting participants received $2 for completing the cigarette purchase task (CPT), Fagerstrom Test for Nicotine Dependence (FTND), and the military version of the Moral Injury Symptom Scale (MISS-M-SF). We examined five CPT demand indices and calculated a modified exponential demand model stratified by moral injury severity status (i.e., probable vs. unlikely). RESULTS: Probable morally injured women exhibited significantly higher relative reinforcing value (RRV) for smoking than unlikely morally injured women (F1, 920 = 9.16, p = 0.003). Average cigarette consumption at $0 (i.e., Q0) was 48.56% higher (M = 22.24 vs. M = 13.55) in probable compared to unlikely morally injured women (p = 0.04, Hedge's g = 0.74). FTND scores were significantly correlated with Pmax (i.e., demand elasticity point) and Omax (i.e., maximum expenditure) values in both populations (rs = 0.42-0.68, ps < 0.05). CONCLUSIONS: We provide preliminary evidence of the relatively high RRV of smoking in morally injured veteran women. Continued research is needed to refine the characterization of this relationship.

A machine learning model for the prediction of unhealthy alcohol use among women of childbearing age in Alabama.

INTRODUCTION: This study utilizes a machine learning model to predict unhealthy alcohol use treatment levels among women of childbearing age. METHODS: In this cross-sectional study, women of childbearing age (n = 2397) were screened for alcohol use over a 2-year period as part of the AL-SBIRT (screening, brief intervention, and referral to treatment in Alabama) program in three healthcare settings across Alabama for unhealthy alcohol use severity and depression. A support vector machine learning model was estimated to predict unhealthy alcohol use scores based on depression score and age. RESULTS: The machine learning model was effective in predicting no intervention among patients with lower Patient Health Questionnaire (PHQ)-2 scores of any age, but a brief intervention among younger patients (aged 18-27 years) with PHQ-2 scores >3 and a referral to treatment for unhealthy alcohol use among older patients (between the ages of 25 and 50) with PHQ-2 scores >4. CONCLUSIONS: The machine learning model can be an effective tool in predicting unhealthy alcohol use treatment levels and approaches.

Chronic disease multimorbidity and substance use among African American men: veteran-non-veteran differences.

OBJECTIVES: The purpose of the study was to explore the extent to which prior military service may moderate the relationship between chronic disease multimorbidity and substance use among African American men in the United States. DESIGN: Data for this cross-sectional study was downloaded from the 2016 -2019 United States (US) National Survey on Drug Use and Health. We estimated three survey-weighted multivariable logistic regression models, where use of each of the following substances served as the dependent variables: illicit drugs, opioids, and tobacco. Differences in these outcomes were examined along two primary independent variables: veteran status and multimorbidity (and an interaction term for these variables). We also controlled for the following covariates: age, education, income, rurality, criminal behavior, and religiosity. RESULTS: From the 37,203,237 (weighted N) African American men in the sample, approximately 17% reported prior military service. Veterans with ≥ 2 chronic diseases had higher rates of illicit drug use (aOR = 1.37, 95% CI = 1.01, 1.87; 32% vs. 28%) than non-veterans with ≥ 2 chronic diseases. Non-veterans with one chronic disease had higher rates of tobacco use (aOR = 0.80, 95% CI = 0.69, 0.93; 29% vs. 26%) and opioid misuse (aOR = 0.49, 95% CI = 0.36, 0.67; 29% vs. 18%) than veterans with one chronic disease. DISCUSSION: Chronic disease multi-morbidity appears to be a context in which African American veterans may be at greater risk for certain undesirable health behaviors than African American non-veterans and at lower risk for others. This may be due to exposure to trauma, difficulty accessing care, socio-environmental factors, and co-occurring mental health conditions. These complex interactions may contribute to higher rates of SUDs among African American veterans compared to African American non-veterans.

Moral Injury is a Risk Factor for Substance Use and Suicidality Among US Military Veterans with and without Traumatic Brain Injury.

A national survey of United States veterans was conducted, yielding 252 veterans with Traumatic Brain Injury (TBI) and 1235 veterans without TBI. Participants were asked questions about moral injury, suicidality, substance use, and other sociodemographic variables. Multivariable linear regression analysis was used to examine the previously described relationships. Increasing severity of moral injury was associated with higher scores on the substance use tool (b = 0.02, p = 0.04), although the magnitude of effect was not different from those without TBI (Z = - 0.57, p = 0.72). Increasing severity of moral injury was positively associated with suicidal behavior scores (b = 0.10, p < 0.01). The strength of this relationship was stronger in veterans with TBI than those without TBI (Z = 1.78, p = 0.04). Rehabilitation programs that treat veterans for TBI may need to consider the evaluation of moral injury given its association with adverse events in this population.

Racial Residential Segregation and Colorectal Cancer Mortality in the Mississippi Delta Region.

INTRODUCTION: Few studies have examined the effects of racial segregation on colorectal cancer (CRC) outcomes, and none has determined whether rurality moderates the effect of racial segregation on CRC mortality. We examined whether the effect of segregation on CRC mortality varied by rurality in the Mississippi Delta Region, an economically distressed and historically segregated region of the United States. METHODS: We used data from the US Census Bureau and the 1999-2018 Surveillance, Epidemiology, and End Results (SEER) program to estimate mixed linear regression models in which CRC mortality rates among Black and White residents in Delta Region counties (N = 252) were stratified by rurality and regressed on White-Black residential segregation indices and 4 socioeconomic control variables. RESULTS: Among Black residents, CRC mortality rates in urban counties were a function of a squared segregation term (b = 162.78, P = .01), indicating that the relationship between segregation and CRC mortality was U-shaped. Among White residents, main effects of annual household income (b = 29.01, P = .04) and educational attainment (b = 34.58, P = .03) were associated with CRC mortality rates in urban counties, whereas only annual household income (b = 19.44, P = .04) was associated with CRC mortality rates in rural counties. Racial segregation was not associated with CRC mortality rates among White residents. CONCLUSION: Our county-level analysis suggests that health outcomes related to racial segregation vary by racial, contextual, and community factors. Segregated rural Black communities may feature stronger social bonds among residents than urban communities, thus increasing interpersonal support for cancer prevention and control. Future research should explore the effect of individual-level factors on colorectal cancer mortality.

Small Area Estimation of Mental Distress Among United States Military Veterans in Illinois.

The aim of the present study was to estimate the prevalence of mental distress at the county-level for the service member or veteran (SMV) population in Illinois. Multilevel small-area estimation methodology (SAE) was used to estimate and map the prevalence of SMV mental distress in Illinois counties using data from the 2016 Behavioral Risk Factor Surveillance System. Furthermore, local indicators of spatial association analysis (LISA) was conducted in order to identify hotspots of SMV mental distress in Illinois. For 2016, the average model-based mental distress rate for SMVs in Illinois counties was 8.6%. LISA analysis revealed a significant cluster (p < 0.01) of "high-high" SMV mental distress prevalence in St. Clair County and Clinton County. These findings highlight the importance of examining SMV health from a population perspective and reveal the need for further examination of geographic-based SMV health disparities.

Sexual Behaviors and Health Practices Among Student Service Members and Veterans.

The purpose of the study was to determine whether veteran students and non-veteran students differed in their sexual behaviors and health practices and, furthermore, whether or not those differences were gender specific. Demographic characteristics of the study sample were explored by calculating frequencies and percentages by military service status. Research questions were explored with maximum likelihood multiple logistic regression. Results showed that student veterans were more likely than non-veteran students to have sex with multiple partners, with males and transgender students more likely than females to report multiple sexual partners. Student veterans were more likely than non-veterans to perform a self-examination for either breast cancer or testicular cancer, with transgender students more likely than females to report having engaged in a self-examination. Student veterans were also more likely than non-veterans to have been vaccinated against HPV or Hepatitis B, with male students more likely than females to have been vaccinated. Furthermore, transgender student veterans were less likely than female veterans to have been vaccinated. Finally, male student veterans were more likely than female veterans to report an STI-related doctor visit, with transgender student veterans more likely than female veterans to report an STI-related doctor visit. College campuses are increasingly implementing student veteran-specific programs and services; however, little if any research specifically has explored ways in which safety and health can be promoted within university settings. We recommend that institutions of higher education make concerted efforts to promote safety and health among its student veteran population.

Correction to: Sexual Behaviors and Health Practices Among Student Service Members and Veterans.

Please note that the middle initial of coauthor Antoinette M. Landor was given incorrectly (as "A.") in this article as originally published.

Lack of community-oriented policing practices partially mediates the relationship between racial residential segregation and "black-on-black" homicide rates.

Although black-white racial residential segregation in the US has continued to decline, blacks still experience greater levels of segregation than other racial groups. The present study examined whether a lack of community policing practices in 2012 mediated the relationship between racial segregation in 2010 and intraracial (i.e., "black-onblack") homicides in 2013. We collected incorporated-place-level secondary data from several sources and performed mediation analysis to test relationships among variables. Consistent with previous research, higher levels of segregation were associated with higher intraracial homicide rates; however, the effect was mediated by lack of community policing efforts. Specifically, our findings suggest that lack of community policing practices might explain 13% of the relationship between black-white residential segregation and intraracial homicide. Given the history and complexity of racial residential segregation in the US, one immediate measure by which policymakers might improve health in segregated places is the implementation and expansion of community policing initiatives.

Spiritual Fitness for Military Veterans: A Curriculum Review and Impact Evaluation Using the Duke Religion Index (DUREL).

Suicide rates among military veterans exceed those found in the general population. While the exact reasons for these high rates are unknown, contributing factors may include the military's perceived rejection of patient identities, creating barriers to mental health care within the clinical sector and a mandate for prevention programs. Spiritual fitness has emerged over the last decade as an important concept in human performance optimization and is included among holistic approaches to developing and maintaining mentally fit fighting forces. In attempts to better understand the role that spiritual fitness and religion play in mitigating and/or reducing suicide risk among veterans, the aims of this study were twofold (1) to assess the utility of the Duke Religion Index as a psychometric instrument for use with veterans completing spiritual fitness training and (2) to offer a post-intervention process evaluation of the spiritual fitness module from one resilience program offered to military veterans of Iraq and Afghanistan in 2016. Twenty-eight attendees at the JRWI Wellness Resilient Leadership Retreat completed post-retreat surveys to assess their satisfaction with the coursework and specifically, to assess the spiritual fitness module of the resiliency retreat's curriculum. In total, the research team reviewed 25 completed post-intervention survey responses (89.3% response rate). Descriptive statistics indicated that respondents (n = 25) were subjectively religious, defined as belief in a higher power practiced in ritualized ways. Over half of program participants indicated they (a) attended religious meetings at least once a week and (b) engaged in private religious activity-such as meditation-at least once a day. Results showed that most program participants reported that the spiritual fitness skills learned during the resilient leadership program were useful (88%) (Z = 3.000, p < 0.001). Additionally, most program participants reported their interest in spiritual exploration was affirmed, renewed, or raised as a result of attending the peer-led resilient leadership program (76%) (Z = 6.000, p = 0.015). Culturally informed prevention programs that emphasize spiritual fitness are indicated for use in veteran outreach and well-being programs. More detailed research is needed to assess curriculum specifics.

Impact of social support on the dietary behaviors of international college students in the United States.

OBJECTIVE: International students in the US often adopt unhealthy dietary behaviors, perhaps due to lack of familiarity and social support. This study examined the impact of social support on international college students' dietary behaviors. PARTICIPANTS: This study surveyed international students (N = 318) from five public universities in one Midwest state. METHODS: Participants completed an electronic survey assessing self-reported eating habits and perceived social support using the Social Support for Eating Habits and the Starting the Conversation (STC) scales. Data analyses included multiple linear regression and multiple logistic regression to test the study's hypotheses. Comparisons were made to explore the impact of perceived social support on international students' dietary behaviors. RESULTS: Significant predictors of unhealthy dietary behaviors included region of origin (specifically, being from East Asia, Europe and North America) and having families that discouraged healthy eating habits. Additionally, living with immediate family members significantly decreased students' likelihood of having higher friend encouragement for healthy eating habits. Finally, the amount of time participants spent in the US significantly increased their likelihood of having more discouragement of healthy eating from their friends. CONCLUSIONS: International students' unhealthy eating habits increased when their families discouraged them from healthy eating. Interventions promoting healthy diet among international students should consider including family members to increase social support for healthy eating habits.

Perceptions of the double value coupon program in southern Illinois.

Introduction: Purchasing produce at farmers markets represents one method by which individuals can purchase and have access to healthful and seasonal fruits. Despite the extension of nutrition assistance programs to local farmers markets, fruit and vegetables consumption has remained below the recommended guidelines, specifically in rural geographical locations. Statement of purpose: The purpose of the study was to explore the aspects of the Link Up Illinois Double Value SNAP Nutrition Incentives Program (DVCP) and its effects on food selection at rural farmers markets for individuals enrolled in nutrition assistance programs. Methods/approach: The current study uses a qualitative methodology in order to uncover barriers local health departments and farmers markets face to implementing the DVCP in their communities and to discover the perspectives of low-income individuals who utilize the DVCP. This paper explores the organizational and community member perceptions of the DVCP and its administration. Semi-structured interviews and one focus group were conducted with health educators from county health departments, DVCP stakeholders, farmers market managers, local farmers, and residents who used the DVCP. A purposeful sampling method was used, intentionally selecting individuals with lived experiences of the research objective. Data were analyzed using a three-cycle coding process, then categorized into overarching themes until thematic saturation was reached. Results: There were a total of 19 individuals who participated in the study. Five themes and four subthemes emerged from data analysis, including organizational capacity, exposure to the DVCP, purchasing power, DVCP advancements, and values. Conclusion/implications: These findings contextualize the facilitators and barriers of multiple stakeholders when implementing nutrition assistance programs at farmers markets. Other similar "double value" programs can utilize these lessons when seeking to increase participation of underrepresented populations at local farmers markets.

Survey of barriers and opportunities for prescribing buprenorphine for opioid use disorder in Alabama.

Opioid-related overdose deaths have significantly increased in the USA and in Alabama. Despite this, medications for opioid use disorder (MOUD) remains significantly underutilized. Thus, this study aims to gain a better understanding of clinicians' viewpoints on potential barriers and opportunities that are likely to impact and improve the access to MOUD, especially buprenorphine prescribing. A cross-sectional survey study was conducted with Alabama's clinicians (n = 492). The survey containing a QR code was mailed to clinicians throughout the state and was asked about their viewpoints and thoughts on prescribing buprenorphine. Multivariable linear regression was used to examine associations between OUD self-efficacy, beliefs about the effectiveness of MOUD, attitudes regarding whether or not MOUD is addictive, and positive affect surrounding the treatment of OUD patients. A minority of respondents (39.8%) reported that they have an active X-waiver for MOUD. Results showed that beliefs that MOUD is addictive were significantly inversely correlated with beliefs about MOUD being effective. Furthermore, both self-efficacy and positive affect were significantly and positively associated with beliefs that MOUD is effective. Furthermore, nurse practitioners were more likely than physicians to have higher scores on the "MAT is Addictive" construct. Self-efficacy with OUD patients was positively associated with the "MOUD is Effective" construct. Finally, results showed that X-waivered providers expressed greater positive affect toward OUD patients than providers who were not X-waivered (b = 2.9, p < 0.001). Belief that MOUD is effective was also positively associated with higher scores on the positive affect construct (b = 0.5, p < 0.001). Several barriers and opportunities were identified in our survey data which could be used to explore MOUD expansion, especially buprenorphine prescribing. Strategic plans in expanding MOUD access may include educational trainings on MOUD, motivating clinicians to utilize their capacity by implementing incentive plans, increasing provider self-efficacy, reducing stigma around MOUD, and providing more financial support to uninsured patients.

Opioid Use Disorder Among the Economically Disadvantaged in the Rural South.

OBJECTIVE: This study aimed to identify county-level hotspots and associated risk factors for opioid use disorder (OUD) in the state of Alabama. METHODS: Using 2015 to 2019 Alabama Medicaid administrative claims data, Medicaid recipients with OUD were identified. We performed local indicators of spatial association analysis to identify hotspots of OUD rates. Using logistic regression, we examined county-level social determinants of health associated with county OUD hotspots. RESULTS: There was a +14.13% percentage change from 2015 to 2019. The county level local indicators of spatial association analysis found that 5 counties in the northwestern part of Alabama remained "hotspots" throughout the entire study period. Results of the logistic regression model showed that location within the Appalachian region was an independent predictor of high OUD rates ( b = 2.58; adjusted odds ratio, 13.27, P = 0.04). CONCLUSIONS: The high rates of OUD may reflect the economic distress and lack of access to resources germane to the Appalachian region in Alabama.

Examining the geographic distribution of six chronic disease risk factors for severe COVID-19: Veteran-nonveteran differences.

OBJECTIVES: We aimed to better understand where the prevalence of risk factors for severe COVID-19 occur, especially among veterans and nonveterans - populations that are given the opportunity to seek healthcare from separate entities. METHODS: In this cross-sectional study, we use data from the SMART Behavioral Risk Factor Surveillance System to estimate the prevalence (i.e., survey-weighted %) of six risk factors for severe COVID-19 (i.e., chronic obstructive pulmonary disorder [COPD], asthma, diabetes, obesity, cardiovascular disease, and kidney disease) for veterans and nonveterans at the national level, in 155 metropolitan/micropolitan statistical areas, and in Veteran Integrated Service Networks (veterans only). We examine differences in these outcomes among veterans and between geographic areas using chi-square analysis or multivariable logistic regression. RESULTS: In the national aggregate, veterans exhibited higher prevalence rates of COPD, diabetes, cardiovascular disease, and kidney disease than nonveterans, but not asthma and obesity. However, we show significant variation in the prevalence of risk factors for severe COVID-19 among veterans by geographic location. DISCUSSION: This study provides a dataset that can be used by healthcare providers in order to prioritize prevention programming for veterans who may be at higher risk for COVID-19 due to their increased risk for certain chronic diseases.

Alcohol screening and brief intervention among military service members and veterans: rural-urban disparities.

BACKGROUND: Access to screening, brief intervention and referral to treatment programmes for alcohol use have been shown to be effective; however, little is known about access to these services among service members and veterans. We examined the association of service member or veteran rural-dwelling area and the following outcomes: recent general health check-up, alcohol screening and alcohol brief intervention. METHODS: Data on 5080 military service members and veterans were obtained from the 2017 Behavioural Risk Factor Surveillance System of the USA. We estimated rural-urban disparities in the receipt of a recent voluntary general health check-up, as well as the receipt of alcohol screening and brief intervention, using a mixed logit model. RESULTS: Of the 5080 participants in the study, a total of 4666 (90.49%, 95% CI 89.39% to 91.48%) reported a general health check-up in the last 2 years. Results showed 7.48% of the sample (95% CI 6.64% to 8.41%) exhibited heavy alcohol consumption patterns. Of the 414 participants who did not undergo a general health check-up, 13.80% (95% CI 9.63% to 19.41%) exhibited a pattern of heavy alcohol consumption. Rural individuals were less likely to report a recent health check-up (adjusted OR=0.82, 95% CI 0.79 to 0.87). Rurality was also independently associated with decreased likelihood of receiving an alcohol screening and brief intervention. CONCLUSION: Greater access to telehealth or other geographically flexible screening and brief intervention programmes is needed in rural areas for service members and veterans.

Clinical encounter with three cancer patients affected by groundwater contamination at Camp Lejeune: a case series and review of the literature.

BACKGROUND: Advanced understanding of tumor biology has recently revealed the complexity of cancer genetics, intra/inter-tumor heterogeneity, and diverse mechanisms of resistance to cancer treatment. In turn, there has been a growing interest in cancer prevention and minimizing exposure to potential environmental carcinogens that surround us. In the 1980s, several chemical carcinogens, including perchloroethylene (PCE), trichloroethylene (TCE), and benzene, were detected in water systems supplying Camp Lejeune, a US Marine Corps Base Camp located in North Carolina. CASE PRESENTATION: This article presents three cases of cancer patients who have lived at Camp Lejeune, and, decades later, came to our clinic located 1000 miles from the original exposure site. The first patient is a young Caucasian man who was diagnosed with T cell acute lymphoblastic leukemia at the age of 37, and the second patient is a Caucasian man who had multiple types of cancer in the prostate, lung, and colon as well as chronic lymphocytic leukemia in his 60s and 70s. The third patient is another Caucasian man who had recurrent skin cancers of different histology, namely basal cell carcinomas, squamous cell carcinomas, and melanoma, from his 50s to 70s. CONCLUSIONS: The US Congress passed the Honoring America's Veterans and Caring for Camp Lejeune Families Act in 2012, which covers appropriate medical care for the people affected by the contamination. We hope that this article raises awareness about the history of Camp Lejeune's water contamination among cancer care providers, so the affected patients can receive appropriate medical coverage and cancer screening across the country.

Behavioural health outcomes in veterans compared to nonveterans by rural and urban areas in Alabama, 2015-2018.

In the United States, tobacco use, alcohol consumption and substance use disorders are more prevalent among veterans when compared to nonveterans. This is also seen in Alabama, which led the researchers to review county level data to examine possible links between substance use, mental health and suicide by veteran status. This study sought to evaluate behavioural health outcomes and impacting factors for military veterans and nonveterans living in rural and urban areas of Alabama. In phase one, we developed Alabama-specific behavioural health outcomes at the state and county level for military veterans and nonveterans. In phase two, we examined county-level correlates of behavioural health outcomes among veterans and nonveterans. The data were retrieved from the 2015-2018 National Surveys on Drug Use and Health (NSDUH) and the United States Census Bureau. Regarding tobacco use rates at the county level, nonveteran rates ranged from 23.93% to 34.56% while veteran rates ranged from 24.47% to 38.56%. Nonveteran illicit drug use rates ranged from 9.40% to 13.15% while veteran illicit drug use rates ranged from 5.50% to 10.67%. Nonveteran heavy alcohol use rates ranged from 4.54% to 7.92% while veteran heavy alcohol use rates ranged from 4.59% to 8.41%. Lastly, nonveteran suicidal ideation rates ranged from 3.64% to 4.60% while veteran suicidal ideation rates ranged from 3.16% to 4.51%. Veterans have a significantly higher potential of having suicidal ideations. We showed that illicit drug use and suicidal ideation have increased in Alabama among veterans and nonveterans. Behavioural health programmes and policies aimed at eliminating disparities between veterans and nonveterans are needed in Alabama.

Cigarette Use among Parents with Children in the Home: A Comparison of Civilian Parents and Parents with a Military Connection.

We tested the null hypothesis of equal likelihood of cigarette use among parents with a military connection and parents without a military connection, and independently compared risk factors for cigarette use. We obtained National Health Interview Survey (NHIS) data from 2015 to 2019 survey waves. We delimited analysis to 2-parent households who reported children aged <18 years living with them. After a 2:1 nonparametric age matching procedure, our sample included 1106 civilian parents and 553 parents with a military connection. Using the NHIS survey-design weights, we estimated a design-based F statistic for differences in cigarette use by military connection status. We also estimated population-stratified, survey-weighted multivariable logistic regression models to determine risk factors for parent cigarette use. Whereas 6.87% parents with a military connection used cigarettes, 16.64% of age-matched civilian parents reported cigarette use. This difference was significant even after adjustment for covariates (aOR = 0.49, 95% CI = 0.32, 0.74). Recommendations for programing and policy are provided.