Racial, Ethnic, and Sex Disparities in Mental Health Among US Service Members and Veterans: Findings From the Millennium Cohort Study.

Although disparities in mental health occur within racially, ethnically, and sex-diverse civilian populations, it is unclear whether these disparities persist within US military populations. Using cross-sectional data from the Millennium Cohort Study (2014-2016; n = 103,184; 70.3% male; 75.7% non-Hispanic White), a series of logistic regression analyses were conducted to examine whether racial, ethnic, and/or sex disparities were found in mental health outcomes (posttraumatic stress disorder (PTSD), depression, anxiety, and problematic anger), hierarchically adjusting for sociodemographic, military, health-related, and social support factors. Compared with non-Hispanic White individuals, those who identified as American Indian/Alaska Native, non-Hispanic Black, Hispanic/Latino, or multiracial showed greater risk of PTSD, depression, anxiety, and problematic anger in unadjusted models. Racial and ethnic disparities in mental health were partially explained by health-related and social support factors. Women showed greater risk of depression and anxiety and lower risk of PTSD than men. Evidence of intersectionality emerged for problematic anger among Hispanic/Latino and Asian or Pacific Islander women. Overall, racial, ethnic, and sex disparities in mental health persisted among service members and veterans. Future research and interventions are recommended to reduce these disparities and improve the health and well-being of diverse service members and veterans.

Comparing self-reported quality of life in youth with bipolar versus other disorders.

OBJECTIVES: This study benchmarks quality of life (QoL) of youth with bipolar disorder (BD) against healthy youth, youth with chronic medical conditions, and youth with other psychiatric disorders. The relative impacts of depressive, (hypo)manic, mixed, and externalizing symptoms on QoL are tested for youth with BD. METHOD: In total, 657 youth completed the Schedule for Affective Disorders and Schizophrenia for Children (KSADS), the KSADS depression and mania scales, the Parent General Behavior Inventory (PGBI), and the Child Behavior Checklist (CBCL). Youth-reported QoL was determined by the Revised Children Quality of Life Questionnaire (KINDL) and was compared to healthy youth, youth with chronic medical conditions, and youth with other psychiatric disorders. RESULTS: Youth with BD reported poorer QoL overall and on most subscales compared to healthy youth, youth with chronic medical conditions, youth with behavior disorders, and youth with other non-behavior/non-mood disorders. QoL in youth with BD did not differ significantly from QoL in youth with unipolar depression. Parent-report and interview-rated depressive symptoms were associated with decreases in Total QoL and all QoL subscales except Family. Externalizing symptoms were associated with decreases in Family QoL and increases in Friend QoL, and (hypo)manic symptoms were associated with increases in Emotional Well-Being QoL. CONCLUSIONS: Depressive symptoms may drive the decline in QoL causing youth with BD to rate their QoL worse than healthy youth, youth with chronic medical conditions, and youth with behavior disorders, but not worse than youth with unipolar depression.

Web-based LGBT cultural competency training intervention for oncologists: Pilot study results.

BACKGROUND: Lesbian, gay, bisexual, and transgender (LGBT) cancer patients experience substantial health disparities, including poorer overall health and lower satisfaction with their cancer care than their heterosexual and cisgender counterparts, which may be due in part to a lack of culturally competent providers. To address these disparities, a web-based LGBT cultural competency training tailored to oncologists was developed by an interdisciplinary team of scientists, LGBT cancer survivors, cultural competency experts, oncologists, a web designer, and an instructional designer. METHODS: Oncologists (n = 44) were recruited from 3 academic cancer centers in Florida. Participants were administered the LGBT cultural competency training Curriculum for Oncologists on LGBT populations to Optimize Relevance and Skills (COLORS) and completed pre- and posttraining measures regarding LGBT-related knowledge, attitudes (including general negative attitudes and health care-related attitudes), and clinical practices. After the training, participants completed training acceptability measures. RESULTS: Of the 44 participants, 33 (75%) completed the COLORS training. Participants were 55% non-Hispanic white, 63% male, and had a mean age of 47 years. Participants demonstrated significant improvements in LGBT-related knowledge (t = -4.9, P < .001), attitudes (Z = -3.0, P = .002; t = -2.5, P = .019), and clinical practices (Z = -3.5, P < .001) after completing the COLORS training (Wilcoxon signed rank tests were used for nonnormally distributed variables). Moreover, training acceptability was high, with 82% of participants rating the training as high quality, and 97% being willing to recommend the training to a colleague. CONCLUSION: The COLORS training is both feasible to administer and acceptable for use with oncologists, and may improve oncologists' LGBT-related knowledge, attitudes, and clinical practices. Larger trials are needed to examine the training's effectiveness in reducing LGBT cancer disparities, as well as its applicability to other types of care providers.

Associations Among Trajectories of Sleep Disturbance, Depressive Symptomology and 24-Hour Urinary Cortisol in HIV+ Women Following a Stress Management Intervention.

Objective: The burden of sleep disturbance and depressive symptomology is high for persons living with HIV and particularly so for women. While cognitive behavioral stress management (CBSM) is shown to reduce symptoms of depression and 24-hr urinary free cortisol output (CORT) in HIV+ men, less is known about the effects of CBSM on mood and concomitant sleep disturbance in HIV+ women. The study aim is to model longitudinal change in sleep disturbance, depressive symptomology, and CORT for HIV+ women exposed to a 12-week CBSM intervention or control condition. Methods: Self-reported sleep quality and depressive symptomology, along with CORT, was collected from surveys at baseline and approximately every three months thereafter for nine months from 130 HIV+ women (Mage = 38.44, SD = 7.73). The data was used to specify a parallel process latent growth model with CORT as a time-varying covariate. Results: The model showed acceptable fit. There was a linear decline in sleep disturbance (ß = -0.32, p < .05) and logarithmic decline in depressive symptomology (ß = -0.33, p < .05) for those receiving the intervention. Decline in sleep disturbance predicted lower CORT at nine months. Furthermore, having less depressive symptoms at baseline was associated with lower initial levels of sleep disturbance and greater improvement in sleep quality over time. There was no discernible association between sleep and mood disturbance in the control group. Across groups, there was a consistent association between older age and greater sleep disturbance (r = 0.34, p < .01). Conclusion: Sleep disturbance appears to be a behavioral target for CBSM in HIV+ women although older age, preintervention levels of depressive mood, and time-varying levels of CORT output may limit improvement in sleep quality over time.

A randomized trial of mailed HPV self-sampling for cervical cancer screening among ethnic minority women in South Florida.

PURPOSE: HPV self-sampling has previously been shown to increase cervical cancer screening among ethnic minority and immigrant women. We conducted a randomized pragmatic trial to examine the effectiveness of HPV self-sampling delivered via in-person versus by US mail for medically underserved Hispanic, Haitian, and non-Hispanic Black women living in South Florida. METHODS: We randomized women aged 30-65 who had not completed Pap smear screening in the past 3 years into two groups: (1) HPV self-sampling delivered in-person (IP) by a community health worker (CHW; IP + SS) or (2) HPV self-sampling delivered via US mail (SS + Mail). Our primary outcome was HPV self-sampling completion by 6-month post-study enrollment. RESULTS: We enrolled 600 women. Approximately 65% were Hispanic and 35% were Haitian or non-Hispanic Black. Nearly half (43%) had an income of less than $20,000/year and 67% were uninsured. In intent-to-treat analyses, 71.6% of participants in the SS + Mail group and 81.0% of participants in the IP + SS group completed HPV self-sampling. CONCLUSION: Mailed HPV self-sampling is an effective strategy to increase cervical cancer screening among underserved immigrant and ethnic minority women.

HPV Self-Sampling for Cervical Cancer Screening Among Ethnic Minority Women in South Florida: a Randomized Trial.

BACKGROUND: Ethnic minority women are at increased risk of cervical cancer. Self-sampling for high-risk human papillomavirus (HPV) is a promising approach to increase cervical screening among hard-to-reach populations. OBJECTIVE: To compare a community health worker (CHW)-led HPV self-sampling intervention with standard cervical cancer screening approaches. DESIGN: A 26-week single-blind randomized pragmatic clinical trial. PARTICIPANTS: From October 6, 2011 to July 7, 2014, a total of 601 Black, Haitian, and Hispanic women aged 30-65 years in need of cervical cancer screening were recruited, 479 of whom completed study follow-up. INTERVENTIONS: Participants were randomized into three groups: (1) outreach by CHWs and provision of culturally tailored cervical cancer screening information (outreach), (2) individualized CHW-led education and navigation to local health care facilities for Pap smear (navigation), or (3) individualized CHW-led education with a choice of HPV self-sampling or CHW-facilitated navigation to Pap smear (self-swab option). MAIN MEASURES: The proportion of women in each group whom self-reported completion of cervical cancer screening. Women lost to follow-up were considered as not having been screened. KEY RESULTS: Of the 601 women enrolled, 355 (59%) were Hispanic, 210 (35%) were Haitian, and 36 (6%) were non-Haitian Black. In intent-to-treat analyses, 160 of 207 (77%) of women in the self-swab option group completed cervical cancer screening versus 57 of 182 (31%) in the outreach group (aOR 95% CI, p < 0.01) and 90 of 212 (43%) in the navigation group (aOR CI, p = 0.02). CONCLUSIONS: As compared to more traditional approaches, CHW-facilitated HPV self-sampling led to increased cervical cancer screening among ethnic minority women in South Florida. TRIAL REGISTRATION: Clinical Trials.gov Identifier: NCT02121548.

Survivorship care needs among LGBT cancer survivors.

OBJECTIVE: To better understand survivorship care needs among LGBT cancer survivors. DESIGN: We administered an anonymous online survey. SAMPLE: LGBT cancer survivors living in the United States. METHODS: Participants were recruited via the National LGBT Cancer Project. The survey measured sociodemographic characteristics, social support, posttraumatic stress, and survivorship care needs. RESULTS: Approximately 72% of our 114 participants were cisgender male and 87% were white. Almost all participants reported at least some unmet survivorship care needs (73%), with over half of participants reporting unmet psychological and sexuality care needs. Participants who reported their oncologist was not LGBT-competent had greater unmet needs (t(82) = 2.5, p = 0.01) and greater posttraumatic stress (t(91) = 2.1, p = 0.035). CONCLUSIONS: LGBT cancer survivors have significant unmet survivorship care needs, and lack of oncologist LGBT-competence is associated with unmet needs. Implications for Psychosocial Providers: Our results suggest the need for LGBT competency training for providers.

Intravaginal practices are associated with greater odds of high-risk HPV infection in Haitian women.

OBJECTIVE: Haitian women have the highest incidence of cervical cancer within the Western hemisphere. Intravaginal hygiene practices have been linked with human papilloma virus (HPV) infection and cervical dysplasia. These practices, known as 'twalet deba' in Haitian Creole, are common among Haitian women and are performed with various natural and synthetic agents. As part of a community-based participatory research initiative aimed at reducing cervical cancer disparities in rural Haiti, we explored the use of intravaginal agents and their associations with high-risk HPV infection. DESIGN: Community Health Workers recruited 416 women for cervical self-sampling from two neighborhoods within Thomonde, Haiti. Participants were interviewed regarding intravaginal hygiene practices and completed a cervical self-sampling procedure. Cervical samples were analyzed for the presence of high-risk HPV infection. Associations between each intravaginal agent and high-risk HPV infection were examined via univariate logistic regression analyses, as well as via multivariate analyses controlling for sociodemographic factors and concurrent agent use. RESULTS: Nearly all women (97.1%) performed twalet deba, using a variety of herbal and commercially produced intravaginal agents. Approximately 11% of the participants tested positive for high-risk HPV. Pigeon pea and lime juice were the only agents found to be associated with high-risk HPV in the univariate analyses, with women who used these agents being approximately twice as likely to have high-risk HPV as those who did not. Only pigeon pea remained significantly associated with high-risk HPV after controlling for sociodemographic factors and concurrent agent use. CONCLUSION: Two agents, pigeon pea and lime juice, may contribute to risk for HPV infection in this population. Results suggest that in addition to cervical cancer screening interventions, future preventive initiatives should focus on minimizing risk by advocating for the use of less-toxic twalet deba alternatives.

Get Vaccinated! and Get Tested! Developing Primary and Secondary Cervical Cancer Prevention Videos for a Haitian Kreyòl-Speaking Audience.

Although routine screening reduces cervical cancer rates between 60% and 90%, thousands of women worldwide are diagnosed with the disease on an annual basis because of inadequate screening. Haitian women in South Florida experience a disproportionate burden of cervical cancer, with disease rates 4 times higher than the average for women in Miami. An ongoing community-based participatory research initiative to assess and reduce this burden has revealed that a complex interplay of factors contributes to a lack of access to screening in this community, including socioeconomics, language barriers, and traditional understandings of health and disease. In an effort to address some of these barriers and encourage uptake of primary and secondary cervical cancer prevention strategies, 2 videos on cervical cancer prevention were created using a community-based participatory research framework. The video screenplays were created by a Haitian screenwriter using evidence-based medical information provided by academic researchers. The films feature Haitian actors speaking a Haitian Kreyòl dialogue with a storyline portraying friends and family discussing human papillomavirus disease and vaccination, Papanicolaou testing, and cervical cancer. Focus groups held with Haitian women in South Florida suggested that the films are engaging; feature relatable characters; and impact knowledge about human papillomavirus, cervical cancer development, and current prevention recommendations.

The ABCs of Trait Anger, Psychological Distress, and Disease Severity in HIV.

BACKGROUND: Trait anger consists of affective, behavioral, and cognitive (ABC) dimensions and may increase vulnerability for interpersonal conflict, diminished social support, and greater psychological distress. The concurrent influence of anger and psychosocial dysfunction on Human Immunodeficiency Virus (HIV) disease severity is unknown. PURPOSE: The purpose of this study was to examine plausible psychosocial avenues (e.g., coping, social support, psychological distress), whereby trait anger may indirectly influence HIV disease status. METHODS: Three hundred seventy-seven HIV seropositive adults, aged 18-55 years (58% AIDS-defined), completed a battery of psychosocial surveys and provided a fasting blood sample for HIV-1 viral load and T lymphocyte count assay. RESULTS: A second-order factor model confirmed higher levels of the multidimensional anger trait, which was directly associated with elevated psychological distress and avoidant coping (p<.001) and indirectly associated with greater HIV disease severity (p<.01) (comparative fit index (CFI)=0.90, root-mean-square error of approximation (RMSEA)=0.06, standardized root-mean-square residual (SRMR)=0.06). CONCLUSION: The model supports a role for the ABC components of anger, which may negatively influence immune function through various psychosocial mechanisms; however, longitudinal study is needed to elucidate these effects.

Ethnicity moderates the relationship between perceived stress and benefit finding in HIV+ men who have sex with men (MSM).

BACKGROUND: Numerous studies conducted within the USA demonstrate higher levels of benefit finding in ethnic minority individuals compared to nonminority individuals living with chronic disease. PURPOSE: As benefit finding may be a salient buffer for the effects of stress, the current study examined the association between perceived stress and benefit finding in human immunodeficiency virus (HIV)+ men who have sex with men (MSM) living in the southeast USA and investigated whether ethnicity was a moderator of this relationship. We hypothesized that benefit finding would be greater in ethnic minority MSM than in white MSM and that ethnic minority MSM with high levels of stress would experience greater benefit finding than their white MSM counterparts. METHOD: The current study utilized baseline (T1) and 3-month follow-up (T2) data drawn from a previous trial of a psychosocial intervention in HIV+ MSM. Participants were 130 HIV+ MSM; 52 % were white and 48 % belonged to minority ethnic groups (African-American, Caribbean-American, Hispanic). RESULTS: Analyses revealed that benefit finding was greater in ethnic minority MSM at baseline; however, this difference became nonsignificant when age, education level, highly active antiretroviral therapy adherence, and CD4 count were added to the model. Moderated regression analyses revealed a significant interaction between T1 perceived stress and ethnicity in predicting T2 benefit finding, such that higher levels of T1 perceived stress predicted lower levels of T2 benefit finding in ethnic minority MSM only. This association was independent of intervention group assignment. CONCLUSION: The current study's results highlight potential differences in the relationship between stress and benefit finding processes in white and ethnic minority HIV+ MSM.

Oxytocin, social support, and sleep quality in low-income minority women living with HIV.

Sleep disturbances are highly prevalent in women with HIV, and few studies examine potential protective factors that may reduce risk for sleep disturbances in this high-risk population. This study predicted that HIV-specific social support from various sources (i.e., friends, family members, and spouses), as well as oxytocin (OT), would explain sleep quality in 71 low-income minority women living with HIV. Social support from family members was associated with better sleep quality in women. For women with high OT, support from friends was associated with better sleep quality, whereas for women with low OT, support from friends was associated with poorer sleep quality. Women with low OT may not effectively interpret and utilize available support resources, which may be associated with sleep disturbances.

Stress Management, Depression and Immune Status in Lower Income Racial/Ethnic Minority Women Co-infected with HIV and HPV.

The stress of co-infection with HIV and Human Papillomavirus (HPV), in race/ethnic minority women, may increase depression and immune decrements. Compromised immunity in HIV+ HPV+ women may increase the odds of cervical dysplasia. Thus we tested the efficacy of a 10-wk cognitive behavioral stress management (CBSM) group intervention and hypothesized that CBSM would decrease depression and improve immune status (CD4+ T-cells, natural killer [NK] cells). HIV+HPV+ women (n=71) completed the Beck Depression Inventory (BDI) and provided blood samples, were randomized to CBSM or a control condition, and were re-assessed post-intervention. Women in CBSM revealed less depression, greater NK cells, and marginally greater CD4+ T-cells post-intervention vs. controls. Stress management may improve mood and immunity in HIV+HPV+ lower income minority women.

Risk and Protective Factors for Cancer Mortality among United States Service Members and Veterans (2001-2018).

BACKGROUND: Prior research linking military factors with cancer-specific mortality has shown inconsistent findings, with few studies examining these associations among U.S. service members and veterans who served in Operation Iraqi Freedom/Operation Enduring Freedom conflicts. METHODS: Cancer mortality between 2001 and 2018 was ascertained from the Department of Defense Medical Mortality Registry and National Death Index for 194,689 Millennium Cohort Study participants. Cause-specific Cox proportional hazard models were used to examine links between military characteristics and cancer mortality [overall, early (<45 years), and lung]. RESULTS: Compared with individuals who deployed with no combat experiences, non-deployers had a greater risk of overall [HR = 1.34; 95% confidence interval (CI) = 1.01-1.77] and early cancer mortality (HR = 1.80; 95% CI = 1.06-3.04). Enlisted individuals had a greater risk of lung cancer mortality compared with officers (HR = 2.65; 95% CI = 1.27-5.53). No associations by service component, branch, or military occupation and cancer mortality were observed. Higher education was associated with reduced overall, early and lung cancer mortality risk and smoking and life stressors were associated with elevated overall and lung cancer mortality risk. CONCLUSIONS: These findings are consistent with the healthy deployer effect in which military personnel who were deployed tend to be healthier than those who did not deploy. Further, these findings highlight the importance of considering socioeconomic factors, such as military rank, that may have long-term implications for health. IMPACT: These findings highlight military occupational factors that may predict long-term health outcomes. Additional work is necessary to investigate more nuanced environmental and occupational military exposures and cancer mortality.

HPV-Related Cancers: A Growing Threat to U.S. Military Health and Readiness.

The incidence of human papillomavirus (HPV) related cancers is growing in the United States. Active duty service members (ADSM) have higher rates of HPV infection than civilians and are therefore at greater risk of developing HPV-related cancers. The purpose of this commentary is to examine the burden of HPV-related cancers in ADSM. The current HPV vaccination and cervical cancer screening uptake rates of U.S. ADSM are presented, including a literature review of military-focused studies on HPV vaccination and cervical cancer screenings. We provide directions for future research, interventions, and policy recommendations to improve HPV-related cancer prevention among ADSM.

Perceptions of Practitioner Support for Patient Autonomy are Associated with Delayed Health Care Seeking among Haitian Immigrant Women in South Florida.

Few empirical studies have evaluated how perceptions of the patient-provider relationship affect health care seeking among Haitian immigrants. In this cross-sectional study, we examined whether perceptions of practitioner support for patient autonomy facilitate or hinder health care seeking among Haitian women enrolled in a cervical self-sampling trial. Perceived autonomy support was measured using an adapted health care climate questionnaire. Associations between perceived autonomy support and health care seeking were modeled using logistic regression and classification and regression trees. Covariates included socioeconomic and structural access indicators. Dependent variables included receipt of any medical care in the past year and delayed health care seeking. Having a usual source of care was strongly associated with both dependent variables. Lower perceived autonomy support was associated with delayed health care seeking in regression models and classification and regression trees. Addressing the capacity of health workers to deliver autonomy-supportive care is essential for improving health services utilization in vulnerable populations.

Cervical cancer screening compliance among active duty service members in the US military.

Previous research suggests active duty service members (ADSM) experience higher rates of human papilloma virus infection and cervical dysplasia, which puts them at greater risk for cervical cancer. The current study examined crude rates and correlates of cervical cancer screening compliance in 2003-2015 among screening-eligible ADSM in the Millennium Cohort Study (MCS). Data were drawn from the MCS, Defense Manpower Data Center, and Military Health System Data Repository. Screening eligibility and compliance were calculated each year and initial analyses examined crude rates of compliance. Generalized estimating equations were calculated to determine whether sociodemographic, military, and mental/behavioral health covariates were associated with cervical cancer screening compliance. A majority of participants were 21-29 years old (79.4%), non-Hispanic White (60.6%), and enlisted (82.2%). Crude rates of cervical cancer screening compliance increased from 2003 (61.2%) to 2010 (83.1%), and then declined from 2010 to 2015 (59.8%). Older ADSM and those who had a history of deployment had lower odds of screening compliance. ADSM in the Air Force and those in healthcare occupations had higher odds of screening compliance. Study findings suggest that cervical cancer screening compliance is declining among ADSM. Interventions to improve screening should target groups with lower screening compliance.

Assessing the effectiveness of a LGBT cultural competency training for oncologists: study protocol for a randomized pragmatic trial.

BACKGROUND: LGBT patients may have unique psychosocial cancer care needs, and healthcare providers should have knowledge and understanding of these unique needs to effectively address disparities through the delivery of personalized healthcare. As such, our group developed and piloted a web-based LGBT cultural competency training designed specifically for oncologists called the Curriculum for Oncologists on LGBT populations to Optimize Relevance and Skills (COLORS). We designed a randomized pragmatic trial for oncologists to compare the effectiveness of the COLORS training versus a general online LGBT cultural competency training in improving LGBT-related knowledge, attitudes, and clinical practices. METHODS/DESIGN: Study procedures include an 8-step approach for recruitment, randomization, retention, and completion of the interventions. Oncologists of any subspecialty who are currently practicing physicians will be identified from the American Medical Association Masterfile. Approximately 5000 oncologists will be sent a FedEx envelope with an invitation letter and study timeline. Electronic consent is obtained using a secure REDCap (Research Electronic Data Capture) portal hosted at the Moffitt Cancer Center (Tampa, FL) where the oncologists will complete the eligibility questionnaire, pre-training assessments, and then will be randomized to complete the COLORS training or an online general healthcare training offered by the National LGBT Health Education Center. Effectiveness of both trainings will be assessed utilizing self-reported measures of LGBT-related knowledge, attitudes, and affirming clinical practices. The measures will be collected before and directly after training completion, as well as 3-month post-training completion. The primary outcomes are changes in knowledge, attitudes, and practice behaviors regarding LGBT cancer patients from pre-test to post-test training in the COLORS training vs. the comparison training. DISCUSSION: The overarching premise of this trial is to assess the effectiveness of the COLORS cultural competency training program. If successful, among oncologists who completed the COLORS training should yield statistically significantly improvements in knowledge, attitudes, and affirming practice.

Factors Associated with Human Papillomavirus Vaccine Initiation and Compliance Among U.S. Military Service Members.

INTRODUCTION: The primary objective of the current study was to assess factors associated with Human Papillomavirus (HPV) vaccine initiation and compliance in a cohort of active duty US military service members (SM). MATERIALS AND METHODS: We included active-duty participants aged 18-26 years from the Millennium Cohort Study, a longitudinal cohort study of over 200,000 military SMs. The eligible study population included 22,387 female SMs and 31,705 male SMs. Vaccination was assessed over the period 2006-2017. Logistic regression was used to estimate the odds of vaccine initiation and compliance (3 doses within a 1-year period) in relation to demographic, military, health, and behavioral characteristics. RESULTS: Among female SMs, 37.8% initiated the vaccine and 40.2% of initiators completed the series within a year. Among male SMs, 3.9% initiated the vaccine and 22.1% of initiators completed the series within a year. Differences by sociodemographic factors, deployment status, branch of service, occupation, and smoking status-but not by selected mental health conditions-were observed. CONCLUSION: HPV vaccination uptake is subpar across all military service branches. Certain subgroups of SMs could be targeted to increase overall HPV vaccine coverage in the US military population.