Electronic Health Record Concordance with Survey-Reported Military Sexual Trauma Among Younger Veterans: Associations with Health Care Utilization and Mental Health Diagnoses.

Introduction: Military sexual trauma (MST) is more common among post-9/11 Veterans and women versus older Veterans and men. Despite mandatory screening, the concordance of electronic health record (EHR) documentation and survey-reported MST, and associations with health care utilization and mental health diagnoses, are unknown for this younger group. Materials and Methods: Veterans' Health Administration (VHA) EHR (2001-2021) were merged with data from the observational, nationwide WomenVeterans Cohort Study (collected 2016-2020, n = 1058; 51% women). Experiencing MST was defined as positive endorsement of sexual harassment and/or assault. From the EHR, we derived Veterans' number of primary care and mental health visits in the initial two years of VHA care and diagnoses of posttraumatic stress disorder (PTSD), depression, and anxiety. First, the concordance of EHR MST screening and survey-reported MST was compared. Next, multivariate analyses tested the cross-sectional associations of EHR screening and survey-reported MST with Veterans' health care utilization, and compared the likelihood of PTSD, depression, and anxiety diagnoses by MST group, while covarying demographics and service-related characteristics. With few MST cases among men, multivariate analyses were only pursued for women. Results: Overall, 29% of women and 2% of men screened positive for MST in the EHR, but 64% of women and 9% of men had survey-reported MST. Primary care utilization was similar between women with concordant, positive MST reports in the EHR and survey versus those with survey-reported MST only. Women with survey-reported MST only were less likely to have a PTSD or depression diagnosis than those with concordant, positive MST reports. There was no group difference in women's likelihood of anxiety. Conclusions: EHR MST documentation is discordant for many post-9/11 Veterans-both for men and women. Improving MST screening and better supporting MST disclosure are each critical to provide appropriate and timely care for younger Veterans, particularly women.

Blood Pressure Control and Maintenance in a Prospective Cohort of Younger Veterans: Roles of Sex, Race, Ethnicity, and Social Determinants of Health.

Background: Proactive blood pressure (BP) management is particularly beneficial for younger Veterans, who have a greater prevalence and earlier onset of cardiovascular disease than non-Veterans. It is unknown what proportion of younger Veterans achieve and maintain BP control after hypertension onset and if BP control differs by demographics and social deprivation. Methods: Electronic health records were merged from Veterans who enrolled in VA care 10/1/2001-9/30/2017 and met criteria for hypertension - first diagnosis or antihypertensive fill. BP control (140/90 mmHg), was estimated 1, 2, and 5 years post-hypertension documentation, and characterized by sex, race, and ethnicity. Adjusted logistic regressions assessed likelihood of BP control by these demographics and with the Social Deprivation Index (SDI). Results: Overall, 17% patients met criteria for hypertension (n=198,367; 11% of women, median age 41). One year later, 59% of men and 65% of women achieved BP control. After adjustment, women had a 72% greater odds of BP control than men, with minimal change over 5 years. Black adults had a 22% lower odds of BP control than White adults. SDI did not significantly change these results. Conclusions: In the largest study of hypertension in younger Veterans, 41% of men and 35% of women did not have BP control after 1 year, and BP control was consistently better for women through 5 years. Thus, the first year of hypertension management portends future, long-term BP control. As social deprivation did not affect BP control, the VA system may protect against disadvantages observed in the general U.S. population.

Female adolescents' early life stress and body mass index: Differential effects of anger and anxiety in response to rejection.

INTRODUCTION: Early life stress is linked to childhood obesity. As children enter adolescence, early life stress may be associated with increased rejection sensitivity, resulting in activation of behavioral and physiological changes that contribute to higher body mass index (BMI). Understanding the potential influence of rejection sensitivity on the association between early life stress and BMI is important to examine in female adolescents. For this secondary data analysis, we hypothesized that female adolescents with greater early life stress and greater rejection sensitivity would exhibit higher BMI-for-age 12 months later. METHODS: Seventy-eight adolescents (Mage = 13.1 years; 100% female sex; MBMI = 23.2 kg/m2) in the United States completed study procedures from 2012 to 2016. Among these procedures, the Psychosocial Schedule was used to assess cumulative early life stress and the Children's Rejection Sensitivity Questionnaire was used to assess anger and anxiety in response to rejection. Twelve months later, height and weight were measured to derive BMI-for-age. RESULTS: Higher early life stress was associated with higher BMI-for-age among female adolescents with low rejection-provoked anger (1 SD below the mean). However, this association was not observed among female adolescents with high rejection-provoked anger (1 SD above the mean). Finally, there was no significant interaction between early life stress and rejection-provoked anxiety in predicting BMI-for-age. CONCLUSIONS: Experiencing early life stress may interact with rejection-provoked anger, but not anxiety, to predict BMI-for-age. Findings inform a developmental perspective of how rejection sensitivity may influence the association between early life stress and early cardiometabolic risk.

Psychological Health and Ischemic Heart Disease in Women: A Review of Current Evidence and Clinical Considerations across the Healthspan.

PURPOSE OF REVIEW: Psychological health encompasses a constellation of negative and positive factors-i.e., psychosocial stress, depression, anxiety, trauma, loneliness and social isolation, anger and hostility, optimism, and a sense of purpose. This narrative review presents current evidence at the intersection of psychological health, risk of ischemic heart disease (IHD), and IHD-related outcomes, with an emphasis on associations in women. RECENT FINDINGS: For women, relations between psychological health and IHD reflect important sex and gender differences in biological and psychosocial factors. Although efforts devoted to understanding psychological health and IHD risk have varied by psychological factor-scientific evidence is strongest for psychosocial stress and depression, while anxiety, trauma, and positive psychological factors warrant more investigation-less optimal psychological health is consistently associated with an earlier and greater risk of IHD morbidity and mortality in women. Still, many past prospective studies of psychological factors and IHD risk had a limited representation of women, did not include analyses by sex, or failed to account for other influential, sex-specific factors. Thus, there are multiple pathways for further, rigorous investigation into psychological health-IHD associations, mechanisms, and empirically supported psychological interventions to mitigate IHD risk among women. Given the robust evidence linking psychological health with women's risk for IHD, implementing routine, brief, psychological screening is recommended. Significant life events, developmental milestones specific to women, and IHD diagnoses or events could cue further psychological assessment and referral, efforts which will mutually strengthen the evidence for integrated psychological and IHD care and delivery of such care to this vulnerable group.

Insomnia and Early Incident Atrial Fibrillation: A 16-Year Cohort Study of Younger Men and Women Veterans.

Background There is growing consideration of sleep disturbances and disorders in early cardiovascular risk, including atrial fibrillation (AF). Obstructive sleep apnea confers risk for AF but is highly comorbid with insomnia, another common sleep disorder. We sought to first determine the association of insomnia and early incident AF risk, and second, to determine if AF onset is earlier among those with insomnia. Methods and Results This retrospective analysis used electronic health records from a cohort study of US veterans who were discharged from military service since October 1, 2001 (ie, post-9/11) and received Veterans Health Administration care, 2001 to 2017. Time-varying, multivariate Cox proportional hazard models were used to examine the independent contribution of insomnia diagnosis to AF incidence while serially adjusting for demographics, lifestyle factors, clinical comorbidities including obstructive sleep apnea and psychiatric disorders, and health care utilization. Overall, 1 063 723 post-9/11 veterans (Mean age=28.2 years, 14% women) were followed for 10 years on average. There were 4168 cases of AF (0.42/1000 person-years). Insomnia was associated with a 32% greater adjusted risk of AF (95% CI, 1.21-1.43), and veterans with insomnia showed AF onset up to 2 years earlier. Insomnia-AF associations were similar after accounting for health care utilization (adjusted hazard ratio [aHR], 1.27 [95% CI, 1.17-1.39]), excluding veterans with obstructive sleep apnea (aHR, 1.38 [95% CI, 1.24-1.53]), and among those with a sleep study (aHR, 1.26 [95% CI, 1.07-1.50]). Conclusions In younger adults, insomnia was independently associated with incident AF. Additional studies should determine if this association differs by sex and if behavioral or pharmacological treatment for insomnia attenuates AF risk.

The Perceived Stress Scale as a Measure of Stress: Decomposing Score Variance in Longitudinal Behavioral Medicine Studies.

BACKGROUND: The Perceived Stress Scale (PSS) is a widely used measure designed to assess perceptions of recent stress. However, it is unclear to what extent the construct assessed by the PSS represents factors that are stable versus variable within individuals, and how these components might vary over time. PURPOSE: Determine the degree to which variability in repeated PSS assessments is attributable to between-person versus within-person variance in two different studies and populations. METHODS: Secondary analyses utilized data from two studies with up to 13 PSS assessments: An observational study of 127 patients with heart failure followed over 39 months (Study 1), and an experimental study of 73 younger, healthy adults followed over 12 months (Study 2). Multilevel linear mixed modeling was used to estimate sources of variance in the PSS total and subscale scores across assessments. RESULTS: Between-person variance accounted for a large proportion of the total variance in PSS total scores in Study 1 (42.3%) and Study 2 (51.1%); within-person variance comprised the remainder. Between-person variance was higher for shorter assessment periods (e.g., 1 week), and was comparable when examining only the first 12 months of assessments in each study (52.9% vs. 51.1%). CONCLUSIONS: Within two samples differing in age and health status, between-person variance accounted for approximately half of the total variation in PSS scores over time. While within-person variance was observed, the construct assessed by the PSS may substantially reflect a more stable characteristic of how an individual perceives stressful life circumstances than previously appreciated.

The Perceived Stress Scale (PSS) is a widely used questionnaire designed to assess how an individual perceives recent stress in their life. It is unclear, however, the degree to which the PSS is measuring factors that are consistent within individuals versus those that fluctuate, and how these components might change when the PSS is administered repeatedly over time. To address this knowledge gap, data from two studies were used­a study of 137 patients with heart failure followed for 39 months and a study of 73 younger, healthy adults followed for 12 months. In each, participants completed up to 13 PSS assessments, with 2,880 total PSS assessments completed across the studies. Multilevel linear mixed modeling was used to examine sources of score variance across assessments. Between-person variance (i.e., score variability that is relatively stable over time but differs between individuals) accounted for approximately half of the total variation in PSS scores over time, and was higher over shorter assessment periods. While within-person variance was observed (i.e., score variability that fluctuates within the same individual over time), these results suggest that the PSS may assess a substantially more stable characteristic of how an individual perceives stressful life circumstances than previously appreciated.

Depression, Insomnia, and Obesity Among Post-9/11 Veterans: Eating Pathology as a Distinct Health Risk Behavior.

INTRODUCTION: Understanding the interrelationships between co-occurring chronic health conditions and health behaviors is critical to developing interventions to successfully change multiple health behaviors and related comorbidities. The objective of the present study was to examine the effects of depression, insomnia, and their co-occurrence on risk of obesity and to examine the role of health risk behaviors as potential confounders of these relationships with an emphasis on eating pathologies. METHODS: Iraq and Afghanistan conflict era veterans (n = 1,094, 51.2% women) who participated in the Women Veterans Cohort Study between July 2014 and September 2019 were categorized as having depression, insomnia, both, or neither condition. Logistic regression models were used to examine group differences in the risk of obesity. Health risk behaviors (i.e., eating pathology, physical activity, smoking, and hazardous drinking) were then assessed as potential confounders of the effects of depression and insomnia on the likelihood of obesity. RESULTS: Obesity was most prevalent in individuals with co-occurring insomnia and depression (53.2%), followed by depression only (44.6%), insomnia only (38.5%), and neither condition (30.1%). Importantly, maladaptive eating behaviors confounded the depression-obesity association but not the insomnia-obesity association. There was no evidence that insufficient physical activity, smoking, or hazardous drinking confounded the effects of insomnia or depression on obesity. CONCLUSIONS: These findings exemplify the complex relationships between multiple health conditions and behaviors that contribute to obesity. Elucidating these associations can enhance the precision with which interventions are tailored to efficiently allocate resources and reduce the severe health impact of obesity among veterans.

Post-9/11 deployment history and the incidence of breast cancer among women veterans.

PURPOSE: To determine if women Veterans who deployed in support of Operations Enduring Freedom/Iraqi Freedom (OEF/OIF) would show a greater likelihood of breast cancer (BC) than other women Veterans. METHODS: This was a retrospective cohort study of women aged <60 years who received Veterans Affairs medical center primary care, 2001-2021. The exposure was OEF/OIF deployment and the outcome was a BC diagnosis after entering Veterans Affairs care. Poisson models evaluated the association between deployment and BC incidence, covarying demographics, lifestyle factors, and hormonal contraceptive and hormone replacement therapy use. Analyses were also stratified by age and race, and a sensitivity analysis adjusted for healthcare utilization over the initial 2 years. RESULTS: Of 576,601 women, 24.6% (n = 141,935) deployed during post-9/11 conflicts. Across follow-up [median: 8.2 years], 1.2% women were diagnosed with BC. Those who deployed in support of OEF/OIF were 23% less likely to be diagnosed with BC than women who did not deploy (95% CI: 0.73, 0.86). The association remained in stratified models and when including healthcare utilization. CONCLUSIONS: Despite the exposures of OEF/OIF deployment, there was a significantly lower incidence of BC among women who deployed versus not, possibly due to a healthy soldier effect or to differences in screening.

Adolescent girls' cardiovascular responses to peer rejection: exploring the impact of early life stress.

Detrimental effects of early life stress on cardiovascular health are evident in adolescence. Cardiovascular reactivity and recovery in response to interpersonal stress may be a mechanism. This study aimed to evaluate if adolescent girls with higher early life stress demonstrated greater cardiovascular reactivity and slower recovery to peer rejection. A sample of 92 adolescent girls (age: M = 13.24) self-reported early life stressors. Systolic blood pressure (SBP), diastolic blood pressure (DBP), and heart rate (HR) were continuously measured before, during, and after a laboratory peer rejection paradigm. Counter to hypotheses, adolescent girls with higher early life stress had lower, not higher, HR during the recovery period. Early life stress was not associated with SBP or DBP recovery. Additionally, early life stress was not associated with SBP, DBP, or HR reactivity. Future research is needed to assess if blunted cardiovascular reactivity to interpersonal rejection during adolescence is a mechanism linking early life stress and later cardiovascular disease risk in women.

Screening for Psychological Distress and Risk of Cardiovascular Disease and Related Mortality: A SYSTEMATIZED REVIEW, META-ANALYSIS, AND CASE FOR PREVENTION.

BACKGROUND: Psychological distress-elevated symptoms of depression, anxiety, post-traumatic stress disorder (PTSD), or psychosocial stress-has been associated with risk for cardiovascular disease (CVD). Despite increasing attention to the importance of these factors for CVD prevention, the state of this science requires updated synthesis to enable practice recommendations. Moreover, it is unknown whether psychological distress based on screeners, validated self-report instruments that efficiently identify those who may require mental health services or additional support, is associated with incident CVD. METHODS: MEDLINE, Embase, and PsycInfo were searched for studies published 2017-2022, including adults without a past psychiatric diagnosis, who were screened at baseline for depression, anxiety, PTSD, stress, or general mental health symptoms, and followed for >6 mo to determine their risk for incident CVD (ie, atrial fibrillation, acute coronary syndrome, coronary heart disease, peripheral vascular disease, heart failure, or a composite). A meta-analysis was used to aggregate results to determine whether clinically significant levels of psychological distress were associated with CVD onset. RESULTS: The search identified 28 investigations that represented 658 331 participants (58% women). Fifteen studies had adequate data for the primary meta-analysis, which indicated that those reporting high psychological distress showed a 28% greater risk of incident CVD compared with those with low or no distress. CONCLUSIONS: Rapid screening for psychological distress is a helpful and efficient approach to understanding the CVD risk profile of an individual. Additional investigations are needed to improve prospective evidence concerning psychosocial stress. Conducting analyses by sex may better elucidate the benefits of psychological distress screening for men and women, respectively, and encourage more widespread adoption in CVD prevention.

Military sexual trauma and incident hypertension: a 16-year cohort study of young and middle-aged men and women.

OBJECTIVES: Veterans, especially women, are three times more to experience sexual harassment and assault [military sexual trauma (MST)] than civilians. As trauma is associated with elevated cardiovascular risk, we investigated whether MST independently contributes to risk for incident hypertension and whether the effects are distinct among women. METHODS: We assessed 788 161 post-9/11 Veterans ( Mage  = 32.14 years, 13% women) who were free of hypertension at baseline, using nationwide Veterans Health Administration data collected 2001-2017. Time-varying, multivariate Cox proportional hazard models were used to examine the independent contribution of MST to new cases of hypertension while sequentially adjusting for demographics, lifestyle and cardiovascular risk factors, including baseline blood pressure, and psychiatric disorders including posttraumatic stress disorder. We then tested for effect modification by sex. RESULTS: Over 16 years [mean = 10.23 (SD: 3.69)], 35 284 Veterans screened positive for MST (67% were women). In the fully adjusted model, MST was associated with a 15% greater risk of hypertension [95% confidence interval (95% CI) 1.11-1.19]. In sex-specific analyses, men and women with a history of MST showed a 6% (95% CI, 1.00-1.12, P  = 0.042) and 20% greater risk of hypertension (95% CI, 1.15-1.26, P  < 0.001), respectively. CONCLUSION: In this large prospective cohort of young and middle-aged Veterans, MST was associated with incident hypertension after controlling for established risk factors, including trauma-related psychiatric disorders. Although MST is disproportionately experienced by women, and the negative cardiovascular impact of MST is demonstrated for both sexes, the association with hypertension may be greater for women. Subsequent research should determine if early MST assessment and treatment attenuates this risk.

Gender Differences in Guideline-Directed Medical Therapy for Cardiovascular Disease Among Young Veterans.

BACKGROUND: There is an increasing burden of cardiovascular disease, including coronary artery disease (CAD) and heart failure (HF), among women Veterans. Clinical practice guidelines recommend multiple pharmacotherapies that can reduce risk of mortality and adverse cardiovascular outcomes. OBJECTIVE: To determine if there are disparities in the use of guideline-directed medical therapy by gender among Veterans with incident CAD and HF. DESIGN: Retrospective. PARTICIPANTS: Veterans (934,504; 87.8% men and 129,469; 12.2% women) returning from Operations Enduring Freedom, Iraqi Freedom, and New Dawn. MAIN MEASURES: Differences by gender in the prescription of Class 1, Level of Evidence A guideline-directed medical therapy among patients who developed incident CAD and HF at 30 days, 90 days, and 12 months after diagnosis. For CAD, medications included statins and antiplatelet therapy. For HF, medications included beta-blockers and renin-angiotensin-aldosterone system inhibitors. KEY RESULTS: Overall, women developed CAD and HF at a younger average age than men (mean 45.8 vs. 47.7 years, p<0.001; and 43.7 vs. 45.4 years, p<0.02, respectively). In the 12 months following a diagnosis of incident CAD, the odds of a woman receiving a prescription for at least one CAD drug was 0.85 (95% confidence interval [CI], 0.68-1.08) compared to men. In the 12 months following a diagnosis of incident HF, the odds of a woman receiving at least one HF medication was 0.54 (95% CI, 0.37-0.79) compared to men. CONCLUSIONS: Despite guideline recommendations, young women Veterans have approximately half the odds of being prescribed guideline-directed medical therapy within 1-year after a diagnosis of HF. These results highlight the need to develop targeted strategies to minimize gender disparities in CVD care to prevent adverse outcomes in this young and growing population.

Exploring the Impact of Maternal and Paternal Acceptance on Adolescent Girls' Emotion Regulation.

Maternal acceptance is associated with youth emotion regulation (a correlate of depression among adolescent girls); however, less is known about the impact of fathers. In this prospective study, we examined effects of maternal and paternal acceptance on youth sadness inhibition (a facet of emotion dysregulation) among adolescent girls (n = 82; Mage = 13.28; 43% from minoritized racial/ethnic groups) over 1 year. Youth varied on depression risk, which was assessed via clinical diagnostic interviews. Bivariate results showed that maternal acceptance was associated with lower youth sadness inhibition at baseline and 1-year follow-up, while paternal acceptance was only associated with lower youth sadness inhibition at 1-year follow-up. Step-wise regressions showed that paternal acceptance was inversely associated with youth sadness inhibition over time, above and beyond effects of youth age, baseline sadness inhibition, depression risk, and maternal acceptance. Findings highlight the importance of examining both mothers' and fathers' impact on adolescent girls' development of emotion regulation.

Depressive Symptoms and Incident Heart Failure in the Jackson Heart Study: Differential Risk Among Black Men and Women.

Background Associations between depression, incident heart failure (HF), and mortality are well documented in predominately White samples. Yet, there are sparse data from racial minorities, including those who are women, and depression is underrecognized and undertreated in the Black population. Thus, we examined associations between baseline depressive symptoms, incident HF, and all-cause mortality across 10 years. Methods and Results We included Jackson Heart Study (JHS) participants with no history of HF at baseline (n=2651; 63.9% women; median age, 53 years). Cox proportional hazards models tested if the risk of incident HF or mortality differed by clinically significant depressive symptoms at baseline (Center for Epidemiological Studies-Depression scores ≥16 versus <16). Models were conducted in the full sample and by sex, with hierarchical adjustment for demographics, HF risk factors, and lifestyle factors. Overall, 538 adults (20.3%) reported high depressive symptoms (71.0% were women), and there were 181 cases of HF (cumulative incidence, 0.06%). In the unadjusted model, individuals with high depressive symptoms had a 43% greater risk of HF (P=0.035). The association remained with demographic and HF risk factors but was attenuated by lifestyle factors. All-cause mortality was similar regardless of depressive symptoms. By sex, the unadjusted association between depressive symptoms and HF remained for women only (P=0.039). The fully adjusted model showed a 53% greater risk of HF for women with high depressive symptoms (P=0.043). Conclusions Among Black adults, there were sex-specific associations between depressive symptoms and incident HF, with greater risk among women. Sex-specific management of depression may be needed to improve cardiovascular outcomes.

The Yale Roadmap for Health Psychology and Integrated Cardiovascular Care.

OBJECTIVE: Cardiovascular disease remains the leading cause of morbidity and mortality in industrialized nations. Many patients living with chronic cardiovascular disease suffer from complex multimorbidities requiring high-intensity care and behavioral risk factor management, and about a third copresent with a mental health disorder. These comanifestations are extremely taxing for patients and our health care system, complicate treatment, and increase the risk of adverse health outcomes. Health psychology emerged in response to a need for specialists who could design, deliver, and test evidence-based approaches to manage behavioral risk factors and the mental health burden of chronic diseases. We aimed to conduct a state-of-the-art review as to how health psychology emerged as a key specialty in delivering integrated care for cardiovascular populations, and to review challenges and opportunities that lie ahead of further integration of the specialty for integrated cardiovascular care. METHOD: As our health care system embraces more patient-centered care and big data science to detect at-risk patients and predict outcomes, health psychologists should be at the forefront to apply their expertise and demonstrate their value in designing and applying intervention models to improve outcomes. We first review challenges, then illustrate this framework using the Wagner chronic care model, present business case considerations, and conclude with an action agenda to promote the integration of health psychology as a cotreating specialty into cardiovascular care. RESULTS: To provide direction for this undertaking, we present a roadmap for the field of health psychology to sustainably extend existing holistic, integrated approaches in cardiovascular care. CONCLUSIONS: To lessen the burden and improve outcomes in cardiovascular disease, care must shift away from siloed delivery models that are focused on traditional atherosclerotic risk factors to holistic, integrated approaches that address biological, psychological, social, and behavioral factors relevant to cardiovascular disease. Using the presented roadmap, health psychology can play a major role to address these needs of integrated cardiovascular care. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Post-9/11 veterans' heart disease knowledge, self-perceived risk, and prevention beliefs and behaviors.

OBJECTIVE: Veterans, including the growing number of women veterans, have a greater risk of heart disease than nonveterans, and the incidence of heart disease is increasing among the most recent veterans who participated in post-9/11 military conflicts. Investigating heart disease-related knowledge, self-perceived risk, and prevention beliefs and behavior among these veterans, and identifying potential differences in knowledge, risk, beliefs and behavior between men and women, may guide prevention strategies. METHOD: Cross-sectional data from a nationwide survey of 1,141 (53% women) post-9/11 veterans were used to examine heart disease awareness and information-seeking, perceived risk and importance of heart disease risk factors, beliefs about traditional (e.g., weight, blood pressure) and nontraditional (e.g., stress, sleep) factors, and engagement in prevention behaviors. Differences between men and women were also tested, using t-tests, chi-square, and Fisher's exact tests. RESULTS: Only one-third reported they felt very informed or sought information about heart disease, or that their providers had discussed heart disease with them. Although veterans generally believe that addressing traditional and nontraditional factors can reduce their risk of heart disease, far fewer endorsed the value of mental health treatment in prevention. Overall, women were slightly more knowledgeable about heart disease risk, and of behaviors that can lower this risk, but for both men and women, this knowledge did not translate to engaging in equivalent prevention behaviors. CONCLUSIONS: Post-9/11 veterans, and potentially their providers, may each benefit from improved education regarding their risk of heart disease. Veterans may also require better, more personalized approaches to prevention. (PsycInfo Database Record (c) 2021 APA, all rights reserved).