Sheila F. Castaneda

Introduction: Military service members face unique occupational stressors (e.g., combat deployment) that are compounded by additional life stressors (e.g., adverse childhood experiences [ACEs], financial problems). As stress has been shown to be associated with the increased risk of cardiovascular disease (CVD) in civilian populations, the present study examined the associations between stress exposure and cardiovascular health (CVH) among a contemporary military population. Materials and Methods: Using a cross-sectional design, survey data from 40,525 service members (71% men, 58% non-Hispanic White, 94% <35 years old) enrolled in the Millennium Cohort Study from 2020 to 2021 were analyzed to estimate associations between stress exposure and CVH. Individual stressors, including self-reported combat severity, bullying, hazing, discrimination, sexual harassment, ACEs, and stressful life events (SLEs) (e.g., divorce, financial problems), were z-score transformed and combined to form a cumulative stress measure. An index CVH score was adapted from the American Heart Association’s Life’s Essential 8 measure (i.e., self-reported sedentary time <8 hours/day, sleeping 7-9 hours/day, no daily fast-food intake, not currently smoking, healthy body mass index [18.5-24.9 kg/m2], no diabetes, no high cholesterol, and no hypertension). Linear regression models examining the relationship between individual stressors and cumulative stress with CVH were adjusted for sociodemographic, military, and behavioral factors. Results: Higher cumulative stress scores were associated with lower CVH scores among service members in our sample. When examining individual stressors, SLEs were most strongly related with poorer CVH, followed by ACEs, bullying, and combat severity. Conclusion: Cumulative stress may have a significant impact on the CVH of service members. Moreover, SLEs (e.g., divorce, financial problems, moving) that occur outside of their military duties may have a substantial impact on force readiness and retention. A consideration of specific stressors and screening for multiple stressors during routine health care visits can provide an opportunity for early CVD prevention among military populations.

Background: This study aimed to assess whether self-reported physical and mental health-related quality of life (HRQOL) scores could be useful indicators of military health readiness. Methods: Survey data and Department of Defense administrative and medical records from 51,589 active duty Millennium Cohort Study participants across four enrollment panels (2001, 2004, 2007, 2011) were examined at baseline and 3- to 5- year follow-up endpoints. Baseline measures included HRQOL measured by the Veterans RAND 12-Item Health Survey (VR-12) mental and physical component summary scores, health behaviors (e.g., smoking, insomnia symptoms), and demographic and military covariates. Readiness outcomes measured at follow-up included health care utilization, separation status, military satisfaction, lost workdays, and non-obese body mass index (BMI). Poisson regression models with a robust error variance were used to examine the prospective relationship between HRQOL and military readiness outcomes. Results: HRQOL remained a significant predictor of all five readiness outcomes after adjustment for covariates and other health behaviors. Participants with baseline physical HRQOL scores in the highest 15th percentile were more likely to meet readiness metrics (e.g., increased odds of non-obese BMI, fewer annual lost workdays, less annual health care utilization, and a higher likelihood of remaining in service or completing their service term) compared with those in the middle 70th percentile. Scoring in the lowest 15th percentile for baseline physical or mental HRQOL was associated with being less likely to meet readiness metrics 3–5 years later. Conclusion: Higher physical HRQOL may be a positive indicator of military readiness, while lower physical and mental HRQOL may signal impaired readiness. Assessment of HRQOL using the VR-12 is an easy, patient-centered tool that may help military leaders identify service members needing early interventions and improve readiness and retention.

Background: Implementing evidence-based interventions for population-level benefit can be challenging in resource-limited primary care settings. Research is needed to identify, specify, and systematically study implementation strategies that address the multilevel, contextual influences on implementation in these settings. This study reviewed and compared the implementation strategies proposed by Research Projects (RPs) funded through the Accelerating Colorectal Cancer Screening through Implementation Science (ACCSIS) initiative. ACCSIS research projects implemented multilevel interventions to increase colorectal cancer screening and follow-up among their local populations. Methods: Participating AC`CSIS RPs provided structured information about activities proposed to facilitate the implementation of evidence-based interventions to increase colorectal cancer screening, follow-up, and referral across project phases (i.e., exploration, preparation, implementation, sustainment). Three implementation science experts reviewed and matched program data to implementation strategies and domains using the Expert Recommendations for Implementing Change (ERIC) classification. ACCSIS RP teams then reviewed and validated matched strategies. Analyses examined similarities and differences among implementation strategies used by each RP and tracked across the screening continuum. Results: Seven ACCSIS RPs participated in this analysis. Collectively, they reported 89 unique activities that matched 68 ERIC implementation strategies (range: 3 to 17 per site). Several similarities were noted across RPs, such as: four RPs developed and distributed educational materials and three used external facilitation as an implementation strategy. Of the nine domains under which the ERIC strategies are classified, most strategies used by the ACCSIS RPs fell under the domain of using evaluative and iterative strategies (e.g., conducting a local need assessment), followed by training and education (e.g., provider education). All RPs used strategies focused on screening and six used strategies to ensure screening follow-up; only one RP used strategies to improve access to treatment. Most strategies were reported in the preparation and implementation phases. Conclusions: Systematically documenting and collating implementation strategies across ACCSIS RPs contributes to the evidence base of how multilevel interventions can be implemented to reduce the burden of colorectal cancer through screening and follow-up. Study findings can be used to guide real-world implementation efforts, including future scale-up and sustainment.

Supplementary Materials and Methods

Supplemental Table 1. Health-related Factors and Self-Reported Diagnoses at Study Entry across Combat/Deployment Experience

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.

Introduction: Service members and veterans remain a challenging population for survey research. As the Millennium Cohort Study is the largest and longest running prospective cohort study in United States military history and has follow-up data collection planned through 2068, it is critical to determine factors that may help bolster participant retention. Materials and Methods: A satisfaction survey was administered in 2023 to obtain feedback for quality improvement efforts. Of the eligible Millennium Cohort Study participants, 27,224 (45%) completed the satisfaction survey. Chi-square tests were used to examine responses stratified by service status (active duty, Reserve/National Guard, and veterans). Natural language processing was utilized to uncover latent topics from open-text data. Results: A majority of respondents (96%) were satisfied with their experience in the study. The main motivations for continued participation included helping fellow service members and veterans (96%) and learning about military health issues (82%). Major topics that emerged in open-ended feedback provided by 25% of the sample included the importance of tracking health outcomes related to military exposures, a desire to help service members and veterans, and a desire to see study results and impacts. Conclusions: Altruism toward the military community was a key motivation for continued participation and efforts to highlight these values may help to increase study recruitment and retention.

Neighborhood conditions are dynamic; the association of changing neighborhood socioeconomic factors with cancer preventive behaviors remains unclear. We examined associations of neighborhood socioeconomic deprivation, gentrification, and change in income inequality with adherence to the American Cancer Society Guidelines on Nutrition and Physical Activity for Cancer Prevention in The Hispanic Community Health Study/Study of Latinos (HCHS/SOL). The HCHS/SOL enrolled 16,415 adults, ages 18–74 years, at baseline (2008–2011), from communities in the Bronx, NY, Chicago, IL, Miami, FL, and San Diego, CA. Geocoded baseline addresses were linked to the 2000 decennial Census and 5-year American Community Survey (2005–2009 and 2012–2016) tracts to operationalize neighborhood deprivation index (NDI), gentrification, and income inequality. Complex survey multinominal logistic regression models estimated the relative risk ratio (RRR) with overall guideline adherence level (low, moderate, high) and by components—diet, physical activity, body mass index (BMI), and alcohol intake. Overall, 14%, 60%, and 26% of the population had low, moderate, and high ACS guideline adherence, respectively. NDI was negatively associated with risk of high (vs. low) guideline adherence [RRR = 0.87, 95% confidence interval (CI) = 0.78–0.98], although attenuated after controlling for individual socioeconomic status (SES; RRR = 0.89, 95% CI = 0.80–1.00), and associated with lower adherence to BMI recommendations (low vs. moderate RRR = 0.90, 95% CI = 0.84–0.97; high RRR = 0.86, 95% CI = 0.77–0.97). Gentrification was associated with higher likelihood of meeting the dietary recommendations (low vs. moderate RRR = 1.04, 95% CI = 1.01–1.07), but not with overall adherence or individual components. Change in income inequality was not associated with outcomes. Neighborhood deprivation may be negatively associated with ACS guideline adherence among Hispanic/Latino adults.Significance:This study provides new evidence on the link between neighborhood gentrification, changing income inequality and adoption and maintenance of cancer preventive behaviors in an understudied population in cancer research. We observed that while neighborhood deprivation may deter from healthy lifestyle behaviors, positive changes in neighborhood SES via the process of gentrification, may not influence lifestyle guideline adherence among Hispanic/Latino adults.