Army Service Members Research Articles

The Impact of Anterior Pelvic Tilt on Return to Duty/Return to Run in Active Duty Personnel After Hip Arthroscopy for Femoroacetabular Impingement.

Annually, 300,000 soldiers are rendered medically nondeployable because of musculoskeletal injuries (MSKIs). Of this population, nearly 10,000 (3.3%) involve injuries to the hip. Factors related to these injuries impose significant healthcare, financial, and readiness burdens on the Army system, degrading overall mission readiness. The purpose of this retrospective study was to assess for correlation between increased anterior pelvic tilt and a lower likelihood for return to duty/return to run (RTD/RTR) in active duty personnel who underwent hip arthroscopy for femoroacetabular impingement (FAI), thus identifying increased anterior pelvic tilt as a potential prognostic indicator for RTD/RTR. Ninety-two active duty U.S. Army service members aged 18 years or older who underwent hip arthroscopy for FAI at the William Beaumont Army Medical Center from September 1, 2014, to September 1, 2019, were included. Utilizing a retrospective review of existing data, the amount of anterior pelvic tilt, as estimated on a presurgical weight-bearing anterior-posterior pelvis radiograph using the distance from the pubic symphysis to the transischial line, was measured and compared to postoperative RTD/RTR statuses, assessing for correlation. The overall RTD rate was 39.1% with a 22.8% RTR rate. Only 6.5% (6/92) of subjects returned to full, unrestricted duty and running. Logistic regression analyses showed that individuals with increased anterior pelvic tilt (≥7°) were 2.6 times less likely to RTD and 2.9 times less likely to RTR compared to those with minimal or no anterior pelvic tilt (<7°) (respectively, odds ratio (OR) 2.619; 95% CI, 1.107-6.195; P = .029 and OR 2.897; 95% CI, 1.041-8.059; P = .042). Results support the study teams' hypothesis that increased anterior pelvic tilt is associated with a lower odds of RTD/RTR. Statistical analysis confirmed the correlation between an increased amount of anterior pelvic tilt and a lower odds of RTD and RTR after hip arthroscopy for FAI in active duty U.S. Army personnel. This information can be used in patient counseling to better inform shared decision-making, provide more thorough informed consent, and help determine the optimal timing for surgical intervention, thus contributing to better stewardship of medical resources and decreasing the ever-growing financial healthcare burden. These findings will spur future research to consider the causes and optimal treatment of anterior pelvic tilt, positively impacting the culture of Army medicine by focusing on preventive and targeted treatments in order to preserve and grow the force.

Gun Ownership for Safety/Protection and Unsecure Firearm Storage Practices: Suicide Risk and Prevention among U.S. Army Servicemembers

Introduction: 2021 had the highest number firearm suicide deaths in U.S. history, with veterans representing 62.4% of firearm suicide deaths. The study objective is to understand motivations for firearm ownership, storage practices, history of mental health disorders and suicide risk in servicemembers, as reported by family members. Methods. Data were obtained from a case-control psychological autopsy study of 135 suicide decedents in the U.S. Army compared to a probability sample of 255 living controls, who are also service members weighted to be representative of the Army. Next-of-kin and Army supervisor informants participated in structured interviews and assessed reasons for firearm ownership, and storage practices. The military medical record provided mental health history of suicide decedents. A subsample of 123 personal firearm owners (n = 31 cases and n = 92 living controls) addressed the study objectives. Multivariable logistic regression analyses were constructed to examine predictors of unsecured firearm storage practices. Results: Family members reported safety/protection as the main reason for suicide decedents’ firearm ownership, which was significantly associated with unsecure firearm storage practices (OR = 3.8, 95% CI, 1.65, 8.75, x2 = 9.88, p = 0.0017). Ownership for safety/protection and lifetime history of Generalized Anxiety Disorder (GAD) from the military medical record (OR = 3.65, 95% CI, 1.48 – 9.02, x2 = 7.89 p = 0.0050) predicted unsecure storage. Conclusions: Ownership for safety/protection and the presence of clinically significant anxiety predicted unsecure firearm storage practices. Future research examining motivations for gun ownership for safety/protection, anxiety, and unsecure storage practices may help target interventions to prevent suicide.

BMI changes among U.S. Navy and Marine Corps active-duty service members during the COVID-19 pandemic, 2019–2021

BackgroundThe COVID-19 pandemic disrupted the daily life and routines of Americans across the United States (U.S.), including those of our active-duty service members (ADSMs). Limited movement orders enacted during this time to promote social distancing prohibited access to fitness and dining facilities for ADSMs. This study aims to expand on previous work identifying changes in body mass index (BMI) among U.S. Army service members by identifying changes in body mass index (BMI) among active-duty service members from both the Navy and Marine Corps during the same time period.MethodsWe conducted a retrospective cohort study of active-duty service members from the Navy and Marine Corps using data from the Military Health System Data Repository. BMI was calculated and categorized according to CDC guidelines both before (February 2019 - January 2020) and during the pandemic (September 2020 - June 2021). Women who were pregnant or delivered during and one year prior to the study periods were excluded. Statistical analyses included paired t-tests evaluating mean BMI, percent change, and the Stuart-Maxwell test for marginal homogeneity.ResultsWe identified 98,330 active-duty Sailors and 55,298 active-duty Marines for inclusion in this study. During the pandemic period the percentage of Sailors with Underweight decreased by 11%, Healthy weight decreased by 11.1%, Overweight increased by 2.1%, and the percentage of Sailors with Obesity increased by 16.5%. During this same time period, Marines with Underweight decreased by 1%, Healthy weight decreased by 16%, Overweight increased by 3.0%, and Marines with Obesity increased by 51%. The largest increases in service members with overweight and obesity observed among both cohorts were among female service members, service members under age 20, and service members with a Junior Enlisted rank.ConclusionsSignificant increases in obesity were observed amongst active-duty United States Navy and Marine Corps service members during DoD pandemic mitigation efforts. Increased rates of obesity likely effected fitness and force readiness. Future interventions should be targeted at younger, Junior-Enlisted Marines and Sailors to promote healthy lifestyles and provide education on nutrition, appropriate exercise, sleep hygiene, and stress management.

A machine learning framework to classify musculoskeletal injury risk groups in military service members.

Musculoskeletal injuries (MSKIs) are endemic in military populations. Thus, it is essential to identify and mitigate MSKI risks. Time-to-event machine learning models utilizing self-reported questionnaires or existing data (e.g., electronic health records) may aid in creating efficient risk screening tools. A total of 4,222 U.S. Army Service members completed a self-report MSKI risk screen as part of their unit's standard in-processing. Additionally, participants' MSKI and demographic data were abstracted from electronic health record data. Survival machine learning models (Cox proportional hazard regression (COX), COX with splines, conditional inference trees, and random forest) were deployed to develop a predictive model on the training data (75%; n = 2,963) for MSKI risk over varying time horizons (30, 90, 180, and 365 days) and were evaluated on the testing data (25%; n = 987). Probability of predicted risk (0.00-1.00) from the final model stratified Service members into quartiles based on MSKI risk. The COX model demonstrated the best model performance over the time horizons. The time-dependent area under the curve ranged from 0.73 to 0.70 at 30 and 180 days. The index prediction accuracy (IPA) was 12% better at 180 days than the IPA of the null model (0 variables). Within the COX model, "other" race, more self-reported pain items during the movement screens, female gender, and prior MSKI demonstrated the largest hazard ratios. When predicted probability was binned into quartiles, at 180 days, the highest risk bin had an MSKI incidence rate of 2,130.82 ± 171.15 per 1,000 person-years and incidence rate ratio of 4.74 (95% confidence interval: 3.44, 6.54) compared to the lowest risk bin. Self-reported questionnaires and existing data can be used to create a machine learning algorithm to identify Service members' MSKI risk profiles. Further research should develop more granular Service member-specific MSKI screening tools and create MSKI risk mitigation strategies based on these screenings.

Mental Health Treatment Rates During Pregnancy and Post Partum in US Military Service Members

Although new parents' mental health is known to decline, less is known about changes in therapy attendance, especially among military service members. To investigate changes in therapy attendance among new parents and by parental leave length. This cohort study of US Army and Navy service members from January 1, 2013, to December 31, 2019, compared parents' monthly therapy attendance with matched nonparents' across childbirth and compared mothers' weekly therapy attendance before vs after returning to work. Eligible monthly sample members included service members with first births from January 1, 2014, to December 31, 2017, and 12 months of data before to 24 months after birth and nonparents with 36 months of data. Eligible weekly sample members included mothers with first births from January 1, 2013, to June 30, 2019, and data from 12 months before to 6 months after birth and nonparents with 18 months of data. Data analysis was performed from July 1, 2023, to January 15, 2024. Those exposed to parenthood had no prior children, acquired a dependent younger than 1 year, and, for mothers, had an inpatient birth. Unexposed matches did not add a dependent younger than 1 year. Monthly counts of mental health therapy sessions and any therapy sessions (weekly). The monthly sample included 15 554 193 person-month observations, representing 321 200 parents and matches, including 10 193 mothers (3.2%; mean [SD] age, 25.0 [4.9] years), 50 865 nonmother matches (15.8%; mean [SD] age, 25.0 [5.0] years), 43 365 fathers (13.5%; mean [SD] age, 26.4 [4.8] years), and 216 777 nonfather matches (67.5%; mean [SD] age, 26.4 [4.8] years). The weekly sample included 17 464 mothers. Mothers went to 0.0712 fewer sessions at 1 month post partum (95% CI, -0.0846 to -0.0579) compared with 10 months before birth. Fathers went to 0.0154 fewer sessions in the month of birth (95% CI, -0.0194 to -0.0114) compared with 10 months before. Parents with preexisting treatment needs had larger decreases in treatment. Weekly therapy attendance increased by 0.555 percentage points (95% CI, 0.257-0.852) when mothers returned to work from 6 weeks of leave and 0.953 percentage points (95% CI, 0.610-1.297) after 12 weeks of leave. In this cohort study of new parents, therapy attendance decreased around childbirth, especially among parents with prior mental health needs and mothers with longer maternity leaves. These findings suggest that more accessible treatment, including home visits or telehealth appointments, is needed.

Prevalence of Urogenital Mycoplasma genitalium Infection at 2 US Army Medical Facilities.

Sexually transmitted infections (STIs) have a high incidence in the US Armed Forces and can adversely impact service members' ability to perform their duties. Better knowledge of Mycoplasma genitalium (MG) epidemiology in the military is needed to understand the potential impact of this emerging pathogen on force readiness. We conducted cross-sectional analyses of data from US Army service members and other Military Health System beneficiaries participating in a trial of an STI/HIV behavioral intervention at Fort Liberty, NC, and Joint Base Lewis-McChord, WA. At enrollment, participants completed questionnaires and provided biological specimens for nucleic acid amplification testing for MG, Chlamydia trachomatis (CT), and Neisseria gonorrhoeae (NG). We used principal component analysis and robust Poisson regression to examine associations between participant characteristics and prevalent urogenital MG. Among 432 participants enrolled between November 2020 and February 2023, 43 had MG (prevalence, 10.0%), of whom 13 had coinfection with another bacterial STI (all 13 were positive for CT, with 1 also positive for NG). The prevalence of MG was significantly higher among female (13.5%) versus male (7.6%; P = 0.048) participants and non-Hispanic Black (14.9%) versus non-Hispanic White participants (6.6%; P = 0.045). Single relationship status and increased number of recent sexual partners were correlated, and their component was associated with higher MG prevalence (adjusted prevalence ratio, 2.11; 95% confidence interval, 1.29-3.48). The high prevalence of urogenital MG among Military Health System beneficiaries highlights the importance of understanding the potential clinical sequelae of MG and conducting additional epidemiologic research in military settings.

Estimates of Direct Medical and Indirect Costs Associated With COVID-19 Among U.S. Active Duty Army Soldiers.

This study estimated the direct medical and indirect costs associated with coronavirus disease 2019 (COVID-19) diagnoses among U.S. active duty (AD) Army service members (SMs). These cost estimates provide the U.S. Military with a better understanding of the financial burden of COVID-19 and provide a foundation for cost-effectiveness estimates. The study was approved as Public Health Practice (#17-605) by the U.S. Army Public Health Center, Public Health Review Board. U.S. AD Army SMs with COVID-19 were identified using an Army COVID-19 testing and surveillance database. Encounters for these SMs were captured from medical record where International Classification of Disease Tenth Revision, Clinical Modification code U07.1 was in the first or second diagnostic position. Analyses were conducted on SMs with COVID-19 who either had no healthcare encounters in the Military Health System (MHS); at least one MHS COVID-19 inpatient hospitalization; or at least one MHS outpatient COVID-19 encounter. Coronavirus disease 2019 (COVID-19) costs captured from the encounters were used to develop direct medical cost estimates. Literature on COVID-19 recovery post-hospitalization, along with the number of COVID-19 hospitalizations and outpatient visits from encounters were used to describe the intensity of COVID-19 care. Estimates of the indirect cost of lost duty were based on SMs salary information, along with recovery time, bed days, or outpatient visit time. The indirect cost of limited duty was estimated using the time associated with the Department of Defense (DoD) COVID-19 pandemic mitigation strategies in place when these SMs were identified as positive for COVID-19. Coronavirus disease 2019 (COVID-19) cost estimates were developed for the Army using data from 19,086 SMs identified as positive for COVID-19 between June 1, 2020, and December 31, 2020. Direct medical costs, or the amount paid by the DoD to facilities for COVID-19 care, averaged $606 per SM with an encounter. Indirect costs for lost duty or the cost for recovery and the time taken to seek care for COVID-19 averaged $319 per SM, while indirect costs for limited duty or isolation associated with COVID-19 averaged $4,111 per SM or $411 per day. Service members (SMs) with an inpatient hospitalization averaged 4.8 bed days (range 1-43) and 266 recovery hours while SMs who sought outpatient care for COVID-19 averaged two outpatient visits (range 1-60 visits). The direct medical costs of a COVID-19 encounter in the MHS ($606) are a small portion of the costs for a SM with COVID-19. Indirect costs of lost and limited duty associated with COVID-19 averaged seven times higher ($4,331) and accounted for the vast majority of costs. Recognition of these costs is important especially given that soldiers in the hospital or in quarters being quarantined are complete losses of manpower to the Army. While the COVID-19 pandemic is ongoing and prevention, treatment, and mitigation efforts continue to evolve, having reliable estimates of direct medical and indirect costs from this study allows the U.S. Army and MHS to better account for the cost of this pandemic for its population.

Do stigma and efficacy mediate the association between training and suicide prevention behavior among Army noncommissioned officers?

Rates of suicide in the Active Component of the military have significantly increased since 2010, with particularly high rates among Army service members. One element of the Army's approach to suicide prevention relies on noncommissioned officers (NCOs) as gatekeepers who have regular contact with soldiers. NCOs receive suicide prevention training, but there is limited evidence that such training leads to behavior change. We surveyed 2468 Army NCOs participating in leadership development courses to determine (a) if training on suicide prevention and soft skills (e.g., active listening) was associated with gatekeeper behavior and use of soft skills; and (b) whether that association was explained by two potential barriers, stigma and perceptions of efficacy. Both the number of suicide prevention training topics and soft skills trained were associated with increased gatekeeper behavior; these relationships were explained in part by lower stigma and higher efficacy for use of soft skills. The use of interactive training methods and receiving coaching after training were not associated with stigma or efficacy, though both methods were associated with more frequent use of soft skills. Results suggest that the content and format of training is important to preparing NCOs to fulfill a gatekeeper role.

Medical Evaluation Readiness Information Toolset (MERIT): Developing a Data-driven Decision Support Tool to Augment Complex Clinical Decisions.

Medical readiness continues to be a significant concern for the military. DoD policy directs medical authorities to refer service members to the Disability Evaluation System (DES) when the course of further recovery is relatively predictable or within 1 year of diagnosis, whichever is sooner. The Medical Evaluation Readiness Information Toolset (MERIT) is an application that leverages artificial intelligence within a clinical decision support tool to provide clinicians with predictions of a service member's likelihood of referral to the DES for the top 24 medical conditions that result in separation from the service, which represent more than 90% of all referral cases to the DES since 2000. Data spanned 19 years and contained records for over 3 million army service members. The MERIT team incorporated a novel approach using a Gamma window function to weight recent medical data more than older medical data in the creation of a "Disease Severity Index" (DSI) that summarized the progression of a health deterioration process per medical condition code. Time-dependent medical encounter data were aggregated into an individual-level DSI. The identified features including the DSI were used in logistic regression and random forest models to predict whether a service member is likely to be referred to the DES. Models were constructed for each of the top 24 unfitting medical conditions. MERIT produced a set of high-performing classification models with area under the receiver operating characteristics curves across all conditions exceeding 0.919 using logistic regression for all conditions. This project demonstrated with a high degree of accuracy that MERIT, using a combination of ICD codes and personnel records, can be used to develop an individual risk profile for each service member.

Opioid Prescription Clusters Associated With Early or Unplanned Military Separation.

Early/unplanned military separation in Active Component U.S. service members can result in reduced readiness during periods of high-tempo combat and increased demand for health care services within the Military Health System and Veterans Administration. Although current assessment tools leverage prescription data to determine deployment-limiting medication receipt and the need for interventions or waivers, there is a lack of understanding regarding opioid prescription patterns and subsequent early/unplanned military separation after return from deployment. As such, understanding these relationships could support future tool development and strategic resourcing. Therefore, the goal of the present study was to identify unique 12-month opioid prescription patterns and evaluate their relationship with early/unplanned military separation in Active Component service members who returned from deployment. This retrospective, IRB-approved cohort study included data from 137,654 Active Component Army service members who returned from deployment between 2007 and 2013, received a post-deployment (index) opioid prescription, and had at least 1 year of Active Component service post-opioid initiation. A k-means clustering analysis identified clusters using opioid prescription frequency, median dose, median days supply, and prescription breaks (≥30 days) over the 12-month post-initiation (monitoring) period. A generalized additive model examined whether cluster membership and additional covariates were associated with early/unplanned separation. In addition to the single opioid prescription (38%), the cluster analysis identified five clusters: brief/moderate dose (25%), recurrent breaks (16%), brief/high dose (11%), long/few prescriptions (8%), and high prescription frequency (2%). In the generalized additive model, the probability of early/unplanned military separation was higher for the high prescription frequency cluster (74%), followed by recurrent breaks (45%), long/few prescriptions (37%), brief/moderate dose (30%), and brief/high dose (29%) clusters, relative to the single prescription (21%) cluster. The probability of early/unplanned separation was significantly higher for service members with documented substance use disorders, mental health conditions, or traumatic brain injuries during the monitoring periods. Service members assigned male were more likely to have an early/unplanned separation relative to service members assigned female. Latinx service members and service members whose race was listed as Other were less likely to experience early/unplanned separation relative to white service members. Relative to Junior Officers, Junior Enlisted and Senior Enlisted service members were more likely to experience early/unplanned separation, but Senior Officers were less likely. Further evaluation to support the integration of longitudinal opioid prescription patterns into existing tools (e.g., a screening tool for deployment-limiting prescriptions) may enable more timely intervention and support service delivery to mitigate the probability and impact of early/unplanned separation.

Understanding a Time of High Risk for Suicide: Adversities Associated with Separation from Military Service among National Guard and Reserve Service Members

Objective The purpose was to examine five types of adversity and their associations with separating from military service among a nationally representative sample of U.S. National Guard and Reserve (NGR) service members. Methods Multivariate logistic regression analyses were conducted to examine the association between separating from the service and adversities, and demographic differences in adversities experienced among those who had separated from the service and those who stayed in the service. Results Those who left the military were more likely to report financial (OR = 1.65, 95% CI = 1.01–2.70) and healthcare access problems (OR = 2.21, 95% CI = 1.10–4.46). Among those who left the military, female service members were more likely to experience interpersonal adversity (OR = 4.28, 95% CI = 1.15–15.87), and Army and Marine service members were more likely to experience job-employment adversity (OR = 4.92, 95% CI = 1.50–16.12) and financial adversity (OR = 6.46, 95% CI = 1.22–34.33). Conclusion Separating service members experience financial adversity and challenges with healthcare access. Interpersonal difficulties are particularly experienced by female service members, and job/employment difficulties experienced by Army and Marine veterans. Continued efforts are needed to facilitate service delivery for NGR separating service members who need them.

Trends in suicide rates by race and ethnicity among members of the United States Army.

Efforts were focused on identifying differences in suicide rates and time-dependent hazard rate trends, overall and within age groups, by race and ethnicity among United States Army members who returned from an index deployment (October 2007 to September 2014). This retrospective cohort study was conducted using an existing longitudinal database, the Substance Use and Psychological Injury Combat Study (SUPIC). Demographic (e.g., race and ethnicity) and military data from the Department of Defense compiled within SUPIC, as well as Department of Veterans Affairs data were linked with National Death Index records (through 2018) to identify deaths by suicide including those that occurred after military service. The cohort included 860,930 Army Service members (Active Duty, National Guard, and Reserve). Age-adjusted (using the direct standardization method) and age-specific suicide rates per 100,000 person years were calculated and rate ratios (RR) were used for comparisons. Trends were evaluated using hazard rates over time since the end of individuals' index deployments. Among those aged 18-29 at the end of their index deployment, the suicide rate for American Indian/Alaskan Native (AI/AN) individuals was 1.51 times higher (95% confidence interval [CI]: 1.03, 2.14) compared to White non-Hispanic individuals (WNH), and lower for Hispanic and Black non-Hispanic (BNH) than for WNH individuals (RR = 0.65 [95% CI: 0.55, 0.77] and RR = 0.71 [95% CI: 0.61, 0.82], respectively). However, analyses revealed increasing trends in hazard rates post-deployment (≤ 6.5 years) within groups of Hispanic and BNH individuals (Average Annual Percent Change [APC]: 12.1% [95% CI: 1.3%, 24.1%] and 11.4% [95% CI: 6.9%, 16.0%], respectively) with a smaller, increase for WNH individuals (APC: 3.1%; 95% CI: 0.1%, 6.1%). Findings highlight key subgroups at risk for post-deployment suicide (i.e., WNH, AI/AN and younger individuals), as well as heterogeneous trends overtime, with rates and trends varying within race and ethnic groups by age groups. Post-deployment suicide prevention efforts that address culturally relevant factors and social determinants of health associated with health inequities are needed.

Inpatient residential treatment program for combat-related posttraumatic stress disorder (PTSD): Results from the 2020 Artsakh (Nagorno-Karabakh) War

ABSTRACT Inpatient residential treatment programs to evaluate active military service members for potential return to service or discharge are considered an integral component of rehabilitation for trauma related conditions. This retrospective study was conducted on combat-exposed military service members who were admitted to an inpatient residential treatment program for evaluation of fitness to serve and treatment of trauma related conditions. The PTSD Checklist for DSM-5 (PCL-5) was used to screen for PTSD, determine symptom severity, and monitor symptom change. At the time of admission, 54.3% of the service members met the provisional PTSD diagnosis, whereas at the time of discharge, 16.28% of the service members met the provisional diagnostic criteria. The most common symptoms rated moderately or higher were sleep troubles, followed by super alert, disturbing memories, feeling upset, disturbing dreams, physical reactions, avoiding memories, and negative feelings. Paired t-test results comparing the PCL-5 five Subscales and Total Score at the time of admission and discharge showed significant reductions. The five symptoms that improved the least were sleep troubles, feeling upset, avoiding memories, difficulty concentrating, and trouble remembering. The successful creation and implementation of an Armenian version of the PCL-5 was realized and, when put to the test, aided in screening, diagnosing, and monitoring PTSD symptoms among Armenian Army Service members. The results suggest that PTSD symptoms in an inpatient residential treatment program decreased over time. The symptoms that bothered the service members at most during the time of admission, however, improved the least at the time of discharge.

Improving HPV Immunization Practices (IHIP): A process improvement project assessing nursing education intervention towards improving HPV vaccination rates among Army Active-Duty Service Members at a large military base (109)

<b>Objectives:</b> Human papillomavirus (HPV) is the most common sexually transmitted infection in the United States and accounts for more healthcare visits than other sexually transmitted infections. Vaccination against HPV is safe and effective but is not required for military service. Rates of vaccination are extremely low among active-duty members in the Armed Forces, with only 26% of women and 6% of men initiating the multi-dose series. Thus, we conducted a quality improvement project to recommend and administer HPV vaccine to soldiers in- and out-processing at a large military base. <b>Methods:</b> In March 2021, we conducted a one-hour training on HPV vaccination for nursing staff (<i>n</i>=11) at the Medical One Stop, a facility for all in- and out-processing soldiers at a large military base. Training included information regarding the background of HPV vaccines and using presumptive recommendations to present HPV vaccine as the default choice in routine care. After the training, nursing staff integrated HPV vaccination into standard clinic procedures, and we tracked HPV vaccine uptake among soldiers for four weeks. We used multivariable logistic regression to assess demographic correlates of uptake. The nursing staff was surveyed to assess their confidence in recommending the HPV vaccine and their perception of how the intervention fit into clinic workflow on a 5-point response scale (1= "strongly disagree" to 5="strongly agree"). <b>Results:</b> A total of 611 soldiers presented for medical processing during the four-week intervention period. Of these, 85% were eligible to receive and were offered HPV vaccine. In comparison, 12% had already completed the HPV vaccine series, and 3% visited the clinic on a day when the HPV vaccine was unavailable (Table 1). Of the 521 soldiers who were offered the HPV vaccine, 203 (39%) accepted and received the vaccine, including 180 first doses, 11 second doses, and 12 third doses. Soldiers aged <21 years accepted the HPV vaccine more often compared with those ≥21 years (46% vs 33%, <i>p</i><0.01). Neither sex nor the number of other vaccines given was associated with uptake. Training increased nursing staff confidence about addressing soldiers' HPV vaccine concerns (mean: 3.4 pre-training vs 4.5 post-training, <i>p</i><0.05). Nursing staff strongly agreed that the presumptive recommendation approach fit with in-processing procedures (mean: 4.6), and all agreed to adopt the approach. <b>Conclusions:</b> Our findings suggest that training nursing staff to recommend and administer HPV vaccines to soldiers is feasible and may warrant wider-scale testing as a strategy to increase military readiness and protect soldie rs from HPV-attributable cancers. Until guideline and policy changes are implemented, the use of education strategies across all provider levels is one path to increase HPV vaccine coverage among soldiers to ensure protection from HPV-related diseases.

0434 The Relationship between Spirituality and Insomnia in Military Soldiers

Abstract Introduction Insomnia is prevalent among military soldiers and contributes to poor physical and mental health outcomes. Spirituality has been found to mitigate mental and physical health complaints; however, there is a dearth of research on its relationship with insomnia, particularly among military soldiers. Therefore, this study examined the associations between spirituality, religiosity, and insomnia in a sample of Army soldiers. Methods Data were acquired from the All Army Study of the Army Study to Assess Risk and Resilience in Servicemembers (STARRS; N=21,449; mean age= 28.6; 88.24% male). Participants completed the Brief Insomnia Questionnaire, and current insomnia status was determined by DSM-5 criteria. They also completed questions on religious affiliation, how often they attend religious services, and how religious or spiritual they consider themselves on a 4-point scale (1-Very to 4-Not at all). Chi-Square analyses were used to assess the magnitude of relationships. Results A total of 19.45% of this sample had insomnia. Self-reported religious affiliation was more common in those without insomnia (73.5%) than those with insomnia (69.9%; p&amp;lt;.0001). Self-reported spirituality and religiosity were associated with lower rates of insomnia (p&amp;lt;.0001; p&amp;lt;.0001). However, insomnia was associated with higher rates of regular attendance of religious services (29.8% vs. 26.0%; p&amp;lt;.0001). Conclusion In this sample of Army servicemembers, insomnia was less prevalent among those with a religious affiliation and those with regular attendance at religious services. In contrast, individuals with insomnia reported themselves to be less religious or spiritual compared to those without insomnia. These findings underline the importance of further research to understand whether spirituality provides any protective effects against insomnia. Support (If Any) This publication is based on public use data from Army STARRS (Inter-university Consortium for Political and Social Research, University of Michigan-http://doi.org/10.3886/ICPSR35197-v1), funded by U.S. NIMH-U01MH087981. KEM’s time was supported by the U.S Department of Veterans Affairs, Veterans Health Administration (Clinical Science Research and Development Service – IK2 CX001874). EAK’s time was supported by the U.S Department of Veterans Affairs, Rehabilitation Research and Development Service – 1IK2 RX001836.

Prevalence of Post-Traumatic Stress Disorder and its Associated Factors among Nepali Army Service Members and Veterans: 15 Years Post Insurgency

Globally, mental health problems constitute a serious public health problem, contributing 14 % to the global burden of disease. The aim of this epidemiological study was to identify prevalence rates of post-traumatic stress disorder (PTSD), factors associated and its relationship with combat exposure in a post-insurgency period in Nepali army personnel and Veterans. This cross-sectional study was conducted among 300 adults in 2021. In the study both quantitative and qualitative mixed approach with descriptive design was followed. The outcome measures used in the study were locally validated with PCL-M and combat exposure scale. Of the sample, 9 % met threshold for PTSD. The association of variable in reference to age, rank, education and service years with PTSD showed that Age group and Education in current study did not show significant association. However, PTSD with years of service and rank showed significant association. The study also showed a significant relationship between combat exposure and PTSD. There is a significant association between different level of education and combat exposure as well. Overall, the prevalence rates of PTSD in the sample are comparable to other studies conducted with populations affected by conflict and with refugees. However, the findings underscore the need to address the current mental health care awareness and resources in combatants who were exposed to traumatic events during combat in insurgency period. Traumatic exposure predicted increase in PTSD.

Association of deployment with maintenance of healthy weight among active duty service members in the Millennium Cohort Study.

ObjectiveUnderstanding body size in relation to deployment readiness can inform Department of Defense fitness policies. This study examined longitudinal associations between deployment and changes in body mass index (BMI) among active duty service members.MethodsService branch‐specific changes in BMI post‐deployment were examined using logistic regression models among active duty Millennium Cohort Study participants without obesity at baseline (n = 22,995). BMI was categorized using self‐reported height and weight as healthy weight (18.5–24.9 kg/m2), overweight (25.0–29.9 kg/m2), and obese (≥30 kg/m2). Number of deployments between baseline and follow‐up and initial deployment lengths (in months, using service branch‐specific deployment times) were examined.ResultsAmong the pooled population and specifically Army and Marine Corps service members without obesity, those with longer deployments were significantly less likely to maintain a non‐obese BMI than those deploying for shorter lengths. Each additional deployment increased the likelihood of maintaining a non‐obese BMI post‐deployment for personnel in the Army, Marine Corps, and within the pooled population.ConclusionsMultiple deployments may support healthy weight maintenance; longer deployments may adversely impact weight maintenance. Future research should determine modifiable behaviors related to weight gain post‐deployment to inform fitness policies designed to optimize service member readiness and deployability.

Alcohol use disorder in active duty service members: Incidence rates over a 19-year period

Background: Alcohol use is a concerning issue for the military given its potential negative impact on human performance. Limited data are available regarding the incidence of alcohol use disorder in the military, which is critical to understand to evaluate force readiness, as well as for preventative initiatives and treatment planning. The aim was to examine the alcohol use disorder incidence rates (overall and across demographics) among active duty service members from 2001 to 2018. Methods: Data on 208,870 active duty service members between 2001 and 2018 from the Defense Medical Epidemiology Database was examined. Incidence rates were analyzed to determine the diagnostic rates of AUD (including both alcohol abuse and dependence), which were then examined by sex, age, service branch, military pay grade, marital status, and race. Results: Incidence rates of AUD in active duty service members (per 1,000 service members) ranged from 6.45 to 10.50 for alcohol abuse and 5.21 to 7.11 for alcohol dependence. Initial diagnoses of new-onset AUD occurred most frequently within 20–24 year-old, white, male, and non-married U.S. Army service members in the enlisted pay grades of E-1 to E-4. Statistically significant differences (p <.001) were found between observed and expected counts across all examined demographic variables. Conclusions: To our knowledge, this is the first study to provide a comprehensive examination of AUD incidence rates in an active-duty military population over an extended 18-year period and during the last decade. Incidence rates were higher than expected for alcohol dependence and lower than expected for alcohol abuse. Given the untoward effects of AUD on overall health and force readiness, active-duty service members may benefit from more advanced preventative interventions to decrease incidence rates of AUD over time. Future research should use these data to develop targeted interventions for the demographics at greatest risk.

Do nonpharmacological services offset opioids in pain treatment for soldiers?

To examine the relationships between nonpharmacological treatment (NPT) utilization and opioid prescriptions and doses and whether these relationships vary according to the type of NPT service received. Secondary data from the US Military Health System, nationwide. Patterns of NPT utilization and opioid prescriptions were analyzed over the 23 months after initial pain treatment (index visit). Regression models were used to examine the relationship between opioid prescription use in a given month and NPT service utilization in the three preceding months, using person fixed effects to control for time-invariant patient characteristics, as well as time fixed effects. Analyses were stratified by whether the patient filled an opioid prescription in the first 30 days post index visit. Administrative data on health care utilization were extracted from the US Military Health System Data Repository for Army service members who returned from deployments in Afghanistan and Iraq that ended in fiscal years 2008 to 2014 and had at least one outpatient visit with a primary diagnosis of musculoskeletal pain in the subsequent year. Utilization of any NPT service in the past 3 months was positively associated with filling an opioid prescription in the given month, regardless of whether the patient was initially prescribed opioids (percentage point difference [PP] =2.87, P < 0.01) or not (PP=0.83, P < 0.01). However, for those not initially prescribed opioids, use of any NPT service in the past 3months was negatively associated with mean daily opioid dose in the given month (morphine milligram equivalent dose=-0.4017, P < 0.01). For those initially prescribed opioids, NPT was not associated with opioid dose. NPT only reduced the prescription opioid daily dose for some patients, whereas the probability of receiving an opioid prescription was positively associated with NPT. Future research should assess whether recent system-level policies and program changes influence referral and opioid prescribing patterns.

Male Service Members' and Civilian Wives' Perceptions of Partner Connection Regarding Deployment and PTSD Symptoms.

In general, a sense of understanding and connection is an important aspect of marital relationships. In the context of military couples in which a service member may have symptoms of PTSD, spouses' understanding of the nature and causes of service member PTSD symptoms may be protective for both partners' marital satisfaction. However, partners may vary in the degree to which they understand and connect around (1) historical experiences of combat and deployment, versus understanding and connecting around (2) any ongoing manifestation of PTSD symptoms post deployment. In a sample of 58 male Army service members and their civilian wives drawn from a larger study of military couple functioning, we found that a measure of "Combat/Deployment connection" and a measure of "PTSD connection" were strongly correlated with each other yet not isomorphic. Both Combat/Deployment connection and PTSD connection had unique predictive effects for marital satisfaction. Both husbands and wives reported higher levels of PTSD connection relative to Combat/Deployment connection. At low or average levels of Combat/Deployment connection, higher levels of PTSD symptoms were associated with lower levels of marital satisfaction, whereas at high levels of Combat/Deployment connection this association was no longer significant. No such moderation effects were found for PTSD connection. The utility of distinguishing these two domains of potential connection for military couples is discussed.