Disparities in COVID-19 Vaccination Coverage Between Urban and Rural Counties - United States, December 14, 2020-April 10, 2021.

Approximately 60 million persons in the United States live in rural counties, representing almost one fifth (19.3%) of the population.* In September 2020, COVID-19 incidence (cases per 100,000 population) in rural counties surpassed that in urban counties (1). Rural communities often have a higher proportion of residents who lack health insurance, live with comorbidities or disabilities, are aged ≥65 years, and have limited access to health care facilities with intensive care capabilities, which places these residents at increased risk for COVID-19-associated morbidity and mortality (2,3). To better understand COVID-19 vaccination disparities across the urban-rural continuum, CDC analyzed county-level vaccine administration data among adults aged ≥18 years who received their first dose of either the Pfizer-BioNTech or Moderna COVID-19 vaccine, or a single dose of the Janssen COVID-19 vaccine (Johnson & Johnson) during December 14, 2020-April 10, 2021 in 50 U.S. jurisdictions (49 states and the District of Columbia [DC]). Adult COVID-19 vaccination coverage was lower in rural counties (38.9%) than in urban counties (45.7%) overall and among adults aged 18-64 years (29.1% rural, 37.7% urban), those aged ≥65 years (67.6% rural, 76.1% urban), women (41.7% rural, 48.4% urban), and men (35.3% rural, 41.9% urban). Vaccination coverage varied among jurisdictions: 36 jurisdictions had higher coverage in urban counties, five had higher coverage in rural counties, and five had similar coverage (i.e., within 1%) in urban and rural counties; in four jurisdictions with no rural counties, the urban-rural comparison could not be assessed. A larger proportion of persons in the most rural counties (14.6%) traveled for vaccination to nonadjacent counties (i.e., farther from their county of residence) compared with persons in the most urban counties (10.3%). As availability of COVID-19 vaccines expands, public health practitioners should continue collaborating with health care providers, pharmacies, employers, faith leaders, and other community partners to identify and address barriers to COVID-19 vaccination in rural areas (2).

SARS-CoV-2 Infection Among Correctional Staff in the Federal Bureau of Prisons.

Objectives. To examine SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) epidemiology and risk factors among Federal Bureau of Prisons (BOP) staff in the United States.Methods. We calculated the SARS-CoV-2 case rate among 37 640 BOP staff from March 12 to June 17, 2020, using payroll and COVID-19-specific data. We compared occupational factors among staff with and without known SARS-CoV-2 using multiple logistic regression, controlling for demographic characteristics. We calculated relative risk among staff in stand-alone institutions versus complexes (> 1 institution).Results. SARS-CoV-2 was reported by 665 staff across 59.8% of institutions, a case rate of 1766.6 per 100 000. Working in dorm-style housing and in detention centers were strong risk factors, whereas cell-based housing was protective; these effects were erased in complexes. Occupational category was not associated with SARS-CoV-2.Conclusions. SARS-CoV-2 infection was more likely among staff working in institutions where physical distancing and limiting exposure to a consistent set of staff and inmates are challenging.Public Health Implications. Mitigation strategies-including augmented staff testing, entry and exit testing among inmates, limiting staff interactions across complexes, and increasing physical distancing by reducing occupancy in dorm-style housing-may prevent SARS-CoV-2 infections among correctional staff.

County-Level COVID-19 Vaccination Coverage and Social Vulnerability - United States, December 14, 2020-March 1, 2021.

The U.S. COVID-19 vaccination program began in December 2020, and ensuring equitable COVID-19 vaccine access remains a national priority.* COVID-19 has disproportionately affected racial/ethnic minority groups and those who are economically and socially disadvantaged (1,2). Thus, achieving not just vaccine equality (i.e., similar allocation of vaccine supply proportional to its population across jurisdictions) but equity (i.e., preferential access and administra-tion to those who have been most affected by COVID-19 disease) is an important goal. The CDC social vulnerability index (SVI) uses 15 indicators grouped into four themes that comprise an overall SVI measure, resulting in 20 metrics, each of which has national and state-specific county rankings. The 20 metric-specific rankings were each divided into lowest to highest tertiles to categorize counties as low, moderate, or high social vulnerability counties. These tertiles were combined with vaccine administration data for 49,264,338 U.S. residents in 49 states and the District of Columbia (DC) who received at least one COVID-19 vaccine dose during December 14, 2020-March 1, 2021. Nationally, for the overall SVI measure, vaccination coverage was higher (15.8%) in low social vulnerability counties than in high social vulnerability counties (13.9%), with the largest coverage disparity in the socioeconomic status theme (2.5 percentage points higher coverage in low than in high vulnerability counties). Wide state variations in equity across SVI metrics were found. Whereas in the majority of states, vaccination coverage was higher in low vulnerability counties, some states had equitable coverage at the county level. CDC, state, and local jurisdictions should continue to monitor vaccination coverage by SVI metrics to focus public health interventions to achieve equitable coverage with COVID-19 vaccine.

COVID-19 Vaccine Second-Dose Completion and Interval Between First and Second Doses Among Vaccinated Persons - United States, December 14, 2020-February 14, 2021.

In December 2020, two COVID-19 vaccines (Pfizer-BioNTech and Moderna) received Emergency Use Authorization from the Food and Drug Administration.*,† Both vaccines require 2 doses for a completed series. The recommended interval between doses is 21 days for Pfizer-BioNTech and 28 days for Moderna; however, up to 42 days between doses is permissible when a delay is unavoidable.§ Two analyses of COVID-19 vaccine administration data were conducted among persons who initiated the vaccination series during December 14, 2020-February 14, 2021, and whose doses were reported to CDC through February 20, 2021. The first analysis was conducted to determine whether persons who received a first dose and had sufficient time to receive the second dose (i.e., as of February 14, 2021, >25 days from receipt of Pfizer-BioNTech vaccine or >32 days from receipt of Moderna vaccine had elapsed) had received the second dose. A second analysis was conducted among persons who received a second COVID-19 dose by February 14, 2021, to determine whether the dose was received during the recommended dosing interval, which in this study was defined as 17-25 days (Pfizer-BioNTech) and 24-32 days (Moderna) after the first dose. Analyses were stratified by jurisdiction and by demographic characteristics. In the first analysis, among 12,496,258 persons who received the first vaccine dose and for whom sufficient time had elapsed to receive the second dose, 88.0% had completed the series, 8.6% had not received the second dose but remained within the allowable interval (≤42 days since the first dose), and 3.4% had missed the second dose (outside the allowable interval, >42 days since the first dose). The percentage of persons who missed the second dose varied by jurisdiction (range = 0.0%-9.1%) and among demographic groups was highest among non-Hispanic American Indian/Alaska Native (AI/AN) persons (5.1%) and persons aged 16-44 years (4.0%). In the second analysis, among 14,205,768 persons who received a second dose, 95.6% received the dose within the recommended interval, although percentages varied by jurisdiction (range = 79.0%-99.9%). Public health officials should identify and address possible barriers to completing the COVID-19 vaccination series to ensure equitable coverage across communities and maximum health benefits for recipients. Strategies to ensure series completion could include scheduling second-dose appointments at the first-dose administration and sending reminders for second-dose visits.

COVID-19 Case and Mortality Rates in the Federal Bureau of Prisons.

INTRODUCTION: People living in correctional facilities are at high risk for contracting COVID-19. To characterize the burden of COVID-19 in the Federal Bureau of Prisons, inmate testing, case, and mortality rates are calculated and compared with those of the U.S. METHODS: Federal Bureau of Prisons data were derived from its inmate management system and a Federal Bureau of Prisons COVID-19-specific database. U.S. data were derived from the Centers for Disease Control and Prevention and the U.S. Census. Data were aggregated from February to September 2020 and accessed in September and November 2020. Testing rates were calculated for both the Federal Bureau of Prisons and the U.S. Case and infection fatality rates were calculated overall and by institution and compared with those of the U.S. An age- and sex-standardized mortality ratio was calculated. RESULTS: The Federal Bureau of Prisons tested more than half of its inmates (50.3%); its crude case and mortality rates were 11,710.1 and 77.4 per 100,000, respectively. Compared with the U.S., the case ratio was 4.7, and the standardized mortality ratio was 2.6. The infection fatality rate for both the Federal Bureau of Prisons and the U.S. was 0.7%. Among institutions that tested ≥85% of inmates, the combined infection fatality rate was 0.8% and ranged from 0.0% to 3.0%. CONCLUSIONS: The Federal Bureau of Prisons COVID-19 case rates and standard mortality ratio were approximately 5 and 2.5 times those in U.S. adults, respectively, consistent with those of prisons nationwide. High testing rates and standardized death reporting could result in a more accurate infection fatality rate in the Federal Bureau of Prisons than in the U.S. Testing and other mitigation strategies, including reducing the population, have likely prevented further transmission and mortality in the Federal Bureau of Prisons.

Demographic Characteristics of Persons Vaccinated During the First Month of the COVID-19 Vaccination Program - United States, December 14, 2020-January 14, 2021.

In December 2020, two COVID-19 vaccines (Pfizer-BioNTech and Moderna) were authorized for emergency use in the United States for the prevention of coronavirus disease 2019 (COVID-19).* Because of limited initial vaccine supply, the Advisory Committee on Immunization Practices (ACIP) prioritized vaccination of health care personnel† and residents and staff members of long-term care facilities (LTCF) during the first phase of the U.S. COVID-19 vaccination program (1). Both vaccines require 2 doses to complete the series. Data on vaccines administered during December 14, 2020-January 14, 2021, and reported to CDC by January 26, 2021, were analyzed to describe demographic characteristics, including sex, age, and race/ethnicity, of persons who received ≥1 dose of COVID-19 vaccine (i.e., initiated vaccination). During this period, 12,928,749 persons in the United States in 64 jurisdictions and five federal entities§ initiated COVID-19 vaccination. Data on sex were reported for 97.0%, age for 99.9%, and race/ethnicity for 51.9% of vaccine recipients. Among persons who received the first vaccine dose and had reported demographic data, 63.0% were women, 55.0% were aged ≥50 years, and 60.4% were non-Hispanic White (White). More complete reporting of race and ethnicity data at the provider and jurisdictional levels is critical to ensure rapid detection of and response to potential disparities in COVID-19 vaccination. As the U.S. COVID-19 vaccination program expands, public health officials should ensure that vaccine is administered efficiently and equitably within each successive vaccination priority category, especially among those at highest risk for infection and severe adverse health outcomes, many of whom are non-Hispanic Black (Black), non-Hispanic American Indian/Alaska Native (AI/AN), and Hispanic persons (2,3).

School Use and Normative Perceptions of Electronic Nicotine Product Use Among Middle and High School Students-November 2018.

PURPOSE: This study examined U.S. middle and high school student observations of electronic nicotine product (ENP) use in and around the school building and students' normative perceptions of use among peers. METHODS: Adolescents and young adult participants enrolled in middle (n = 672) or high school (n = 962) were recruited from an online nationally representative panel and surveyed from November 2 to 15, 2018. They answered questions on observed ENP use in and around the school building as well as perceptions of use among peers. RESULTS: Nearly one in five U.S. middle and high school students believed that at least half of their peers used ENPs. Confirming anecdotal reports, nearly six in 10 reported ever seeing someone use ENPs in or around their school, most often outside the school building and in bathrooms or locker rooms. CONCLUSIONS: The findings of this study underscore the importance of targeted prevention strategies and education efforts to prevent and combat adolescent ENP use in and around schools.

Mass Testing for SARS-CoV-2 in 16 Prisons and Jails - Six Jurisdictions, United States, April-May 2020.

Preventing coronavirus disease 2019 (COVID-19) in correctional and detention facilities* can be challenging because of population-dense housing, varied access to hygiene facilities and supplies, and limited space for isolation and quarantine (1). Incarcerated and detained populations have a high prevalence of chronic diseases, increasing their risk for severe COVID-19-associated illness and making early detection critical (2,3). Correctional and detention facilities are not closed systems; SARS-CoV-2, the virus that causes COVID-19, can be transmitted to and from the surrounding community through staff member and visitor movements as well as entry, transfer, and release of incarcerated and detained persons (1). To better understand SARS-CoV-2 prevalence in these settings, CDC requested data from 15 jurisdictions describing results of mass testing events among incarcerated and detained persons and cases identified through earlier symptom-based testing. Six jurisdictions reported SARS-CoV-2 prevalence of 0%-86.8% (median = 29.3%) from mass testing events in 16 adult facilities. Before mass testing, 15 of the 16 facilities had identified at least one COVID-19 case among incarcerated or detained persons using symptom-based testing, and mass testing increased the total number of known cases from 642 to 8,239. Case surveillance from symptom-based testing has likely underestimated SARS-CoV-2 prevalence in correctional and detention facilities. Broad-based testing can provide a more accurate assessment of prevalence and generate data to help control transmission (4).

LINKS Training and Unit Support for Mental Health: a Group-randomized Effectiveness Trial.

The LINKS curriculum, adapted from Britt et al. (2018a), was designed to improve unit climate, knowledge, and attitudes about mental health treatment seeking in military personnel. The present study extends this research by examining implementation options, comparing the effectiveness of LINKS to an active control condition with training delivered by non-experts and comparing modules that varied in training length. Eight Army platoons were randomly assigned to one of four conditions: (1) 1-h Active Control, (2) 2-h Active Control, (3) 1-h LINKS, or (4) 2-h LINKS. Two platoons were assigned to each condition. Surveys were administered at pre-training (T1), post-training (T2), and 3 months later (T3). Eighty-four participants completed all study phases. Regardless of training content, participants receiving the 2-h modules reported greater training acceptability than those receiving the 1-h modules. At T3, participants in the LINKS conditions reported more mental health knowledge than participants in the Active Control conditions. Sustained effects were also observed on a number of treatment barriers and facilitators, with the LINKS conditions generally leading to better outcomes. At T3, 2-h LINKS condition participants reported receiving more mental health treatment relative to the other conditions. Findings suggest that LINKS can be effectively delivered by non-expert trainers, is a viable intervention for targeting mental health treatment-seeking, and is optimally packaged in a 2-h module. The training might benefit from additional leadership training efforts.

Fidelity to Best Practices of Psychiatric Assessments in Army Behavioral Health Settings.

While civilian and military psychiatric clinical practice guidelines (CPGs) exist for psychiatric assessments, data are lacking on providers' adherence to these criteria. This study evaluated the use of psychiatric CPGs' assessment criteria by Army behavioral health providers (BHPs). In a weighted cross-sectional survey, 348 BHPs were evaluated on their assessment of a systematically selected patient on 15 total domains recommended by the Departments of Veterans Affairs and Defense CPGs for substance use disorders, posttraumatic stress disorder, and major depressive disorder. The proportion of BHPs providing high-quality assessment and the association between high-quality assessment and BHP and patient characteristics were examined. Using the weighted sample, 80% of BHPs provided a high-quality assessment. BHPs who saw ≥20 patients per week were significantly more likely to provide high-quality assessments compared with BHPs who saw <20 patients per week [odds ratio (OR)=1.72, 95% confidence interval (CI)=1.01-2.92]. Patients diagnosed with generalized anxiety disorder [adjusted OR (AOR)=0.42, 95% CI=0.18-0.96] or whose BHPs did not assess patients' current overall physical health (AOR=0.26, 95% CI=0.07-0.97) or lifetime duration of treatment for mental health (AOR=0.03, 95% CI=0.01-0.20) were less likely to receive high-quality assessments. A majority of Army BHPs are conducting high-quality assessments for the 3 most common mental disorders in military populations. If recommendations to increase fidelity to assessment could be implemented, more patients could receive optimized care.

Self-reported mindfulness and soldier health following a combat deployment.

OBJECTIVE: Combat exposure has been linked to health-related challenges associated with postcombat adjustment, including mental health symptoms, behavior-related problems, physical pain, and functional impairment. Mindfulness, or acceptance of the present moment without reactivity or judgment, may be associated with better mental health following a combat deployment. This study examined whether self-reported mindfulness predicted soldier health outcomes over the course of the postdeployment period. METHOD: U.S. soldiers (n = 627) were surveyed 4 months after a deployment to Afghanistan (T1) and again 3 months later (T2). Mindfulness was assessed using the nonreactivity to inner experience subscale of the Five-Facet Mindfulness Questionnaire. Hierarchical linear regressions examined how mindfulness (T1) moderated the impact of combat exposure (T1) on outcomes at T2. RESULTS: Controlling for rank, the interaction between combat exposure and mindfulness significantly predicted posttraumatic stress disorder (PTSD) symptoms, depression symptoms, risk-taking behaviors, pain symptoms, and functional impairment. The interaction term explained 1% to 2% of the variance in these health outcomes. Simple slopes analyses revealed that combat exposure was associated with more PTSD symptoms, depression symptoms, risk-taking behaviors, pain symptoms, and functional impairment when soldiers reported low levels of mindfulness. There was no effect for alcohol misuse, sleep difficulties, or aggressive behaviors. CONCLUSIONS: Nonreactivity to inner experience may mitigate the detrimental effects of high-levels of combat exposure on both mental and physical health outcomes. These findings indicate that mindfulness strategies such as nonreactivity may be particularly useful for employees facing potentially traumatic stressors in a high-risk occupational context. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Energy Drink Use in U.S. Service Members After Deployment: Associations With Mental Health Problems, Aggression, and Fatigue.

Introduction: Energy drink use has become widespread, particularly by service members, but its association with mental health problems and other behavioral and health problems such as aggression and fatigue is unclear. The present study examines the association between energy drink use and mental health problems, aggressive behaviors, and fatigue in a military population. Materials and Methods: At 7 months following a combat deployment, 627 male infantry soldiers were surveyed. Prevalence rates were examined for the frequency (defined as the number of energy drinks consumed per day) and volume of energy drink use (defined as the number of ounces of energy drink consumed per day). Regression models examined the associations between energy drink use and mental health problems (i.e., sleep problems, depression, anxiety, post-traumatic stress disorder, alcohol misuse), aggressive behaviors, and fatigue. This study was approved by the Walter Reed Army Institute of Research Institutional Review Board. Results: Past month energy drink use was reported by 75.7% of soldiers with 16.1% consuming high levels (2+ energy drinks/day). High energy drink use, when examined by frequency, was associated with mental health problems (adjusted odds ratios from 2.0 to 2.7), aggressive behaviors (adjusted odds ratios from 2.3 to 3.5), and fatigue (ß = 0.143, p = <0.001) relative to those drinking none or less than one per week. These patterns were consistent when examining volume of energy drink consumption (high levels = 24 ounces or more/day). Conclusion: High energy drink use was reported by one in six soldiers and was significantly related to mental health problems, aggressive behaviors, and fatigue in a military population following a combat deployment. Messaging regarding energy drinks should encourage moderation and highlight the association with negative health outcomes and paradoxical association with fatigue. Future studies should examine these relationships in a longitudinal design to understand how high energy drink use may impact or be impacted by these health-related variables.

Correlates of current and heavy smoking among U.S. soldiers returning from combat.

Smoking rates are higher in U.S. soldiers than civilians, with combat-experienced soldiers particularly at risk for heavy smoking (≥20 cigarettes/day). While heavy smoking is correlated with mental health symptoms in civilian samples, the extent to which these symptoms, background variables, and unit climate (self-reported assessments of cohesion, organizational support, and leadership) are linked to smoking in at-risk soldiers remains unclear. The present study examines a range of correlates of smoking-related behavior. Cross-sectional, anonymous surveys were collected from 3,380 soldiers following a deployment in 2008-2009. Measures included demographics, combat exposures, unit climate (e.g., unit cohesion, perceived organizational support, leadership), short sleep duration, and behavioral health variables (e.g., posttraumatic stress disorder, depression, anxiety, alcohol misuse, aggression, adverse childhood experiences [ACEs]). Logistic regression modeled the effects of these variables on two outcome variables: daily smoking and heavy smoking. In the current sample, nearly half (47%) of soldiers reported smoking daily, with 35% of all smokers reporting heavy smoking (17% of the entire sample). Daily smoking was associated with demographic (age, gender, education, rank), behavioral health (ACE, alcohol misuse, sleep duration, aggression), and unit characteristics (unit cohesion); only increased combat exposures and aggression were specifically associated with heavy smoking. Interventions focused on the postdeployment period could incorporate messages about alternatives to smoking as a coping strategy while unit interventions or individual counseling addressing aggression could also address smoking as a negative coping strategy. (PsycINFO Database Record

Prevalence of Bystander Intervention Opportunities and Behaviors Among U.S. Army Soldiers.

The bystander intervention model is one approach utilized to reduce risky behaviors within the U.S. Army; however, it is unclear how frequently soldiers experience opportunities to intervene and whether they already intervene in such situations. The present analysis aims to ascertain frequencies for opportunities to intervene and the rates at which soldiers intervene when presented with such opportunities. Soldiers ( N = 286) were asked whether they had witnessed particular risky behavior scenarios of interest to the Army (i.e., suicide-related behaviors, alcohol misuse, or sexual harassment/assault) during the previous 2 months and whether they had intervened in those scenarios. Prevalence rates within this sample were calculated to determine the frequency of such situations and subsequent interventions. Logistic regression was used to ascertain any differences in witnessing scenarios by demographic groups. Nearly half (46.8%) of the soldiers reported witnessing at least one scenario involving risky behaviors. Most soldiers who witnessed an event relating to suicide or alcohol misuse also reported consistently intervening (87.9% and 74.4%, respectively), whereas just half consistently intervened in response to scenarios relating to sexual harassment/assault (49.2%). Lower ranking soldiers were twice as likely as higher ranks to witness scenarios involving alcohol misuse (odds ratio = 2.18, 95% confidence interval [1.11, 4.26]) and sexual harassment/assault (odds ratio = 2.21, 95% confidence interval [1.05, 4.62]). These data indicate that soldiers regularly encounter opportunities to intervene in risky behaviors, and while a majority intervened in such scenarios, more training is warranted, particularly around sexual assault and harassment. This supports the notion that bystander intervention training is a worthwhile investment for the Army.

Can Anger Be Helpful?: Soldier Perceptions of the Utility of Anger.

Studies have found that soldiers returning from combat deployment report elevated levels of anger and aggression. The present study examined the perception that anger was helpful in performing occupationally related duties and whether this perception was associated with mental health problems, somatic symptoms, and functioning. Soldiers (N = 627) completed a survey 4 months after their deployment to Afghanistan and again 3 months later. When examining anger over time, findings revealed four groups of different latent classes: low stable (resilient), high stable (chronic), decreasing over time (improved), and increasing over time (delayed problems). For two of the groups (chronic and delayed problems), perceiving anger as helpful was closely related to anger reactions. Perceiving anger as helpful was also associated with worse mental health symptoms. Further work in understanding how to mitigate this positive perception of anger in prevention initiatives may be useful in addressing anger reactions.

The Impact of Unit Membership on Smoking Among Soldiers.

Cultural, organizational, and dyadic influences have been found to be associated with smoking in the military while group-level influences have been identified in the general population. However, there are few studies examining group-level influences in the military and none using group-level analyses. Such studies are essential for understanding how to optimally forestall or cease smoking. This study, using mixed effects modelling, examined whether unit membership influenced smoking behavior in soldiers from brigade combat teams. Unit membership was assessed in 2008 to 2009 at the company level (n = 2204) and in 2012 at the platoon level (n = 452). Smoking was assessed by the number of daily cigarettes smoked (range: 0-99) with smoking status (nonsmoker vs. smoker) and smoking level (none, smoker, and heavy [20 + cigarettes/day]) as the outcomes. For both samples, unit membership was not significantly associated with a soldier's propensity to smoke when comparing either all smokers to nonsmokers or heavy smokers to smokers. These results suggest typical military unit-level training programs are unlikely to be the most effective mode of intervention for smoking prevention or cessation. Smoking rates in the military may be influenced instead by small group or individual relationships or by overall military culture.

Provider and Nonprovider Sources of Mental Health Help in the Military and the Effects of Stigma, Negative Attitudes, and Organizational Barriers to Care.

OBJECTIVE: This study examined sources of help (providers or nonproviders) used by soldiers for mental health problems. Differences in perceived barriers to care by type of help used were also assessed. METHODS: Active-duty soldiers from four brigade combat teams (N=3,380) were surveyed in 2008-2009. Items assessed posttraumatic stress disorder; depression; anxiety; help needed because of a stress, emotional, alcohol, or family problem; stigma; negative attitudes toward care; and organizational barriers. Participants reported receipt of help in the past three months from providers (mental health or medical professionals or an Army resource hotline) or nonproviders (fellow soldier, medic, chaplain, or chain of command). RESULTS: Nearly a third (31%) were identified as being in need of mental health care. Of those, 5% reported using nonprovider help exclusively, 14% used provider help exclusively, and 7% used both types. Stigma was rated significantly lower as a barrier among those who used help exclusively from providers than among those who did not use help from any source; however, no significant differences in stigma scores were found between those who used help from nonproviders and those who did not use help from any source. Soldiers who used help from nonproviders were more likely than those who used help from providers to perceive organizational barriers. CONCLUSIONS: Results show that soldiers may view nonproviders as alternative sources of mental health help, suggesting that the Army should ensure that such resources are adequately trained and integrated into the mental health community so that soldiers can receive the help they need.

Grief and physical health outcomes in U.S. soldiers returning from combat.

BACKGROUND: Few studies have measured the burden of physical health problems after Iraq/Afghanistan deployment, except in association with post-traumatic stress disorder (PTSD) or mild traumatic brain injury (mTBI). Grief, a correlate of health problems in the general population, has not been systematically examined. We aimed to identify the prevalence of post-deployment physical health problems and their association with difficulty coping with grief. METHODS: Infantry soldiers (n=1522) completed anonymous surveys using validated instruments six months following deployment in November-December 2008. Multiple logistic regression was used to assess the association of difficulty coping with grief and physical health. RESULTS: The most frequent physical health symptoms reported were: sleep problems (32.8%), musculoskeletal pain (32.7%), fatigue (32.3%), and back pain (28.1%). Difficulty coping with grief over the death of someone close affected 21.3%. There was a dose-response relationship between level of difficulty coping with grief and principal physical health outcomes (ps<.002). Controlling for demographics, combat experiences, injuries, PTSD, depression, and other factors, grief significantly and uniquely contributed to a high somatic symptom score (adjusted odds ratio (AOR)=3.6), poor general health (AOR=2.0), missed work (AOR=1.7), medical utilization (AOR=1.5), difficulty carrying a heavy load (AOR=1.7), and difficulty performing physical training (AOR=1.6; all 95% confidence intervals>1). LIMITATIONS: Data are cross-sectional and grief was measured with one item. CONCLUSIONS: Over 20% of soldiers reported difficulty coping with grief. This difficulty was significantly associated with physical health outcomes and occupational impairment. Clinicians should be aware of the unique role grief plays in post-deployment physical health when treating patients.

Preventing young children's injuries: analysis of data from a population-based surveillance.

The objective of this study is to determine prevention strategies for potentially serious injury events among children younger than 3 years of age based upon circumstances surrounding injury events. Surveillance was conducted on all injuries to District of Columbia (DC) residents less than 3 years old that resulted in an Emergency Department (ED) visit, hospitalization, or death for 1 year. Data were collected through abstraction of medical records and interviews with a subset of parents of injured children. Investigators coded injury-related events for the potential for death or disability. Potential prevention strategies were then determined for all injury events that had at least a moderate potential for death or disability and sufficient detail for coding (n = 425). Injury-related events included 10 deaths, 163 hospitalizations, and 2,868 ED visits (3,041 events in total). Of the hospitalizations, 88% were coded as moderate or high potential for disability or death, versus only 21% of the coded ED visits. For potentially serious events, environmental change strategies were identified for 47%, behavior change strategies for 77%, and policy change strategies for 24%. For 46% of the events more than one type of prevention strategy was identified. Only 8% had no identifiable prevention strategy. Prevention strategies varied by specific cause of injury. Potential prevention strategies were identifiable for nearly all potentially serious injury events, with multiple potential prevention strategies identified for a large fraction of the events. These findings support developing multifaceted prevention approaches informed by community-based injury surveillance.