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.

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.

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.

An Adapted Cognitive Behavioral Stress and Self-management Intervention for Sexual Minority Men Living With HIV and Cancer Using the SmartManage eHealth Platform: Protocol and Study Design.

BACKGROUND: Sexual minority men are disproportionately affected by HIV. Medical advances in HIV treatment have extended life expectancy, and as this group ages, medical and psychological challenges become more prominent. Older people with HIV experience a higher incidence of cancer and other comorbidities; these burdens along with sexual minority stress can strain coping resources and diminish health-related quality of life. Interventions such as cognitive behavioral stress and self-management (CBSM) can mitigate some of this burden; however, no manualized, eHealth-based interventions have focused on the unique needs of sexual minority men living with HIV and cancer. OBJECTIVE: This study aims to refine and finalize a web-based, CBSM-based intervention to meet the unique needs of this population, including sexual health, comanagement of 2 chronic conditions, and coping with sexual minority stress. METHODS: This mixed methods study used a previously completed qualitative phase (n=6) to inform the development of a web-based platform and intervention called SmartManage. The pilot phase study (n=50) involved randomization (1:1) into either 10 sessions of adapted CBSM or an attention control health promotion. Both conditions used the SmartManage platform, a web-based eHealth program designed to deliver CBSM and health promotion content and host live groups. Feasibility and acceptability (eg, rates of participant engagement and retention) were the primary outcomes. RESULTS: Participant-related activities are expected to be completed by November 2022, and results are expected to be submitted for publication by February 2023. CONCLUSIONS: We hypothesize that participants would find the intervention acceptable (compared with engagement and retention rates observed in similar CBSM studies). We also hypothesize that participants receiving the SmartManage intervention would have reduced symptom burden and improved health-related quality of life before and after treatment compared with those who do not. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/37822.

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.

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.

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.

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.

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.

Increasing uptake of evidence-based screening services though a community health worker-delivered multimodality program: study protocol for a randomized pragmatic trial.

BACKGROUND: Underserved ethnic minority populations experience significant disparities in HIV, hepatitis C virus (HCV), colorectal cancer (CRC), and cervical cancer incidence and mortality. Much of the excess burden of these diseases among underserved communities is due to lack of preventive care, including screening. Barriers to disease screening include low awareness, lack of access to care and health insurance, and cultural beliefs regarding disease prevention. Our current trial aims to examine community health worker (CHW)-delivered, home-based multi-modality screening for HIV, HCV, CRC, and cervical cancer simultaneously. DESIGN: We are conducting a randomized pragmatic trial among 900 Haitian, Hispanic, and African-American participants from diverse underserved communities in South Florida. People between the ages of 50 and 65 who have not had appropriate HIV, HCV, CRC, and cervical cancer screening per United States Preventive Services Task Force (USPSTF) recommendations are eligible for the study. Participants are recruited by CHWs and complete a structured interview to assess multilevel determinants of disease risk. Participants are then randomized to receive HIV, HCV, CRC, and cervical cancer screening via navigation to care by a CHW (Group 1) or via CHW-delivered home-based screening (Group 2). The primary outcome is completion of screening for each of these diseases within 6 months post-enrollment. DISCUSSION: Our trial is among the first to examine the effectiveness of a CHW-delivered, multimodality, home-based disease-screening approach. If found to be effective, this approach may represent a cost-effective strategy for disease screening within underserved and underscreened minority groups. TRIAL REGISTRATION: Clinical Trials.gov # NCT02970136, registered November 21, 2016.

Implementing Two Randomized Pragmatic Trials of HPV Self-sampling among Underserved Women: Challenges and Lessons Learned.

BACKGROUND: Haitian and Hispanic immigrant women experience substantial disparities in cervical cancer screening. Recently, our team completed two randomized trials of human papillomavirus (HPV) self-sampling as a cervical cancer screening strategy among Haitian and Hispanic women, using a community-based participatory research (CBPR) approach. OBJECTIVE: To reflect on lessons learned in the process of completing two large randomized cancer screening trials within underserved communities. METHODS: Haitian and Hispanic women were randomized to HPV self-sampling versus navigation to Pap smear versus standard cervical cancer screening education in the first trial, and HPV self-sampling delivered in-person versus via mail in the second trial. LESSONS LEARNED: During the two trials, our team encountered several challenges. The lessons learned from these challenges allowed for the strengthening of our community partnerships, study procedures, and our ability to conduct CBPR within an academic setting. CONCLUSIONS: Lessons learned from our trials may be useful to other researchers engaging in CBPR within underserved communities.

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.

Developing a web-based LGBT cultural competency training for oncologists: The COLORS training.

OBJECTIVE: Despite substantial LGBT cancer health disparities, there are no LGBT cultural competency trainings tailored for oncologists. Here we describe the systematic development of a web-based, oncology-focused LGBT cultural competency training. METHODS: A literature review regarding LGBT cancer outcomes and competency training was conducted to identify potential training content. An expert panel meeting, including LGBT cancer survivors, cultural competency experts, oncologists, a web designer, and an instructional designer, was held to solidify the training content focus. Following the panel, the training was developed in collaboration with an instructional designer, a web designer, and LGBT community members. RESULTS: The training modules include: 1) LGBT Basics; 2) Inclusive Environments; 3) Initiating Oncology Care with LGBT Patients; and 4) Issues in Cancer Survivorship among LGBT Patients. Module content is interactive, and models effective communication. CONCLUSION: The process of collaboration with a diverse group of stakeholders and three cancer centers in Florida has resulted in a practical and efficient web-based resource for LGBT cultural competency training for oncologists. PRACTICE IMPLICATIONS: Feedback from stakeholders indicates that training in this area is needed and will be well-received by oncologists. We are currently conducting an evaluation of this training among oncologists and LGBT community members.

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.

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.

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.