Sexual and reproductive health in military settings: A qualitative study

Mission readiness is critical to the operational success of the United States (US) military and includes having a healthy and fit fighting force. Service members and their dependents have access to a wide range of sexual and reproductive health services with no out-of-pocket costs. Despite this access, negative outcomes such as sexually transmitted infections (STIs) and unintended pregnancy persist. Semi-structured, in-depth interviews were conducted with service members and stakeholders (e.g. medical providers). Interviews explored the individual, interpersonal, organizational, and institutional factors that inform sexual norms, behaviors, and healthcare experiences in the US military. Interview transcripts were coded manually; data were summarized for themes related to unique aspects of military culture and healthcare affecting sexual and reproductive health. Twenty-five (25) service members and 15 stakeholders completed interviews. Four themes emerged: 1) despite free access, both general and military-specific barriers to sexual and reproductive healthcare persist; 2) general and military-specific cultural norms apply to sexual behavior and care seeking; 3) sexual and reproductive health-related norms can be perceived as confusing and contradictory within the military; and 4) resources addressing sexual assault are ubiquitous in military settings, but resources addressing prevention of STIs and unintended pregnancy are limited. Both general and military-specific norms, behavior, and healthcare experiences need to be considered in clinical care, public health campaigns, and other efforts to promote sexual and reproductive health in military settings.

Profiles of Military Medical Students' Well-being, Burnout, and Retention

BACKGROUND

Well-being concerns among medical students are more prevalent than their age-matched peers in the United States. It remains unknown, however, if individual differences in well-being exist among U.S. medical students serving in the military. In this study, we sought to identify profiles (i.e., subgroups) of well-being in military medical students and examine the associations between these well-being profiles and burnout, depression, and intended retention in military and medical fields.

METHODS

Using a cross-sectional research design, we surveyed military medical students and then conducted latent class analysis to explore profiles of well-being, and applied the three-step latent class analysis method to assess predictors and outcomes of well-being profiles.

RESULTS

Heterogeneity in well-being was identified among the 336 military medical students surveyed, portraying medical students' falling into three distinct subgroups: High well-being (36%), low well-being (20%), and moderate well-being (44%). Different subgroups were associated with different risks of outcomes. Students in the subgroup of low well-being were at the highest risk of burnout, depression, and leaving medicine. In contrast, students in the moderate well-being group were at the highest risk of leaving military service.

CONCLUSIONS

These subgroups may be clinically important as burnout, depression, and intention to leave medical field and/or military service occurred with varying likelihoods among medical students across the different well-being subgroups. Military medical institutions may consider improving recruitment tools to identify the best alignment between students' career goals and the military setting. Besides, it is crucial for the institution to address diversity, equity, and inclusion issues that may lead to alienation, anxiety, and a sense of wanting to leave the military community.

Breaking Down Grit: Persistency and Flexibility in the Career Plans of Military Medical Students

INTRODUCTION

The field of medicine is experiencing a crisis as high levels of physician and trainee burnout threaten the pipeline of future physicians. Grit, or passion and perseverance for long-term goals, has been studied in high-performing and elite military units and found to be predictive of successful completion of training in adverse conditions. The Uniformed Services University of the Health Sciences (USU) graduates military medical leaders who make up a significant portion of the Military Health System physician workforce. Taken together, an improved understanding of the relationships between burnout, well-being, grit, and retention among USU graduates is critical to the success of the Military Health System.

MATERIALS AND METHODS

The current study was approved by the Institutional Review Board at USU and explored these relations among 519 medical students across three graduating classes. These students participated in two surveys approximately one year apart from October 2018 until November 2019. Participants completed measures on grit, burnout, and likelihood of leaving the military. These data were then merged with demographic and academic data (e.g., Medical College Admission Test scores) from the USU Long Term Career Outcome Study. These variables were then analyzed simultaneously using structural equation modeling to examine the relationships among variables in a single model.

RESULTS

Results reaffirmed the 2-factor model of grit as both passion and perseverance (or interest consistency). No significant relationships emerged between burnout and other study variables. Sustained and focused interest was predictive of less likelihood of staying in the military.

CONCLUSION

This study offers important insights into the relationship among well-being factors, grit, and long-term career planning in the military. The limitations of using a single-item measure of burnout and measuring behavioral intentions in a short time frame during undergraduate medical education highlight the importance of future longitudinal studies that can examine actual behaviors across a career lifespan. However, this study offers some key insights into potential impacts on the retention of military physicians. The findings suggest that military physicians who are most likely to stay in the military tend to embrace a more fluid and flexible medical specialty path. This is critical in expectation setting for the military to train and retain military physicians across a wide range of critical wartime specialties.

Well-being at a Military Medical School and Implications for Military Retention

INTRODUCTION

Physical and psychological well-being play a critical role in the academic and professional development of medical students and can alter the trajectory of a student's quality of personal and professional life. Military medical students, given their dual role as officer and student, experience unique stressors and issues that may play a role in their future intentions to continue military service, as well as practice medicine. As such, this study explores well-being across the 4 years of medical school at Uniformed Services University (USU) and how well-being relates to a student's likelihood to continue serving in the military and practicing medicine.

METHODS

In September 2019, 678 USU medical students were invited to complete a survey consisting of three sections-the Medical Student Well-being Index (MSWBI), a single-item burnout measure, and six questions regarding their likelihood of staying in the military and medical practice. Survey responses were analyzed using descriptive statistics, analysis of variance (ANOVA), and contingency table analysis. Additionally, thematic analysis was conducted on open-ended responses included as part of the likelihood questions.

RESULTS

Our MSWBI and burnout scores suggest that the overall state of well-being among medical students at USU is comparable to other studies of the medical student population. ANOVA revealed class differences among the four cohorts, highlighted by improved well-being scores as students transitioned from clerkships to their fourth-year curriculum. Fewer clinical students (MS3s and MS4s), compared to pre-clerkship students, indicated a desire to stay in the military. In contrast, a higher percentage of clinical students seemed to "reconsider" their medical career choice compared to their pre-clerkship student counterparts. "Medicine-oriented" likelihood questions were associated with four unique MSWBI items, whereas "military-oriented" likelihood questions were associated with one unique MSWBI item.

CONCLUSION

The present study found that the overall state of well-being in USU medical students is satisfactory, but opportunities for improvement exist. Medical student well-being seemed to have a stronger association with medicine-oriented likelihood items than with military-oriented likelihood items. To obtain and refine best practices for strengthening engagement and commitment, future research should examine if and how military and medical contexts converge and diverge throughout training. This may enhance the medical school and training experience and, ultimately, reinforce, or strengthen, the desire and commitment to practice and serve in military medicine.

Extending growth curves: a trajectory monitoring approach to identification and interventions in struggling medical student learners

Given gaps in both identifying and providing targeted interventions to struggling learners, the purpose of this study is to both improve rapid identification and to improve individualized academic advising for learners using this visual representation of performance. Across three graduating classes, individual growth curves were calculated for each student on National Board of Medical Examiners customized assessments during the pre-clerkship period using their deviation from the class average at each assessment point. These deviation scores were cumulatively summed over time and were regressed onto the sequence of exams. We analyzed the difference between the regression slopes of those students placed on Academic Probation (AP) versus not, as well as differences in slopes based on the timing of when a struggling learner was placed on AP to explore learner trajectory after identification. Students on AP had an average growth slope of - 6.06 compared to + 0.89 for those not on AP. Findings also suggested that students who were placed on AP early during pre-clerkship showed significant improvement (positive changes in trajectory) compared to students identified later in the curriculum. Our findings suggest that earlier academic probation and intervention with struggling learners may have a positive effect on academic trajectory. Future research can better explore how academic trajectory monitoring and performance review can be regularly used in advising sessions with students.

The preparation phase in the multiphase optimization strategy (MOST): a systematic review and introduction of a reporting checklist

Multicomponent behavioral interventions developed using the multiphase optimization strategy (MOST) framework offer important advantages over alternative intervention development models by focusing on outcomes within constraints relevant for effective dissemination. MOST consists of three phases: preparation, optimization, and evaluation. The preparation phase is critical to establishing the foundation for the optimization and evaluation phases; thus, detailed reporting is critical to enhancing rigor and reproducibility. A systematic review of published research using the MOST framework was conducted. A structured framework was used to describe and summarize the use of MOST terminology (i.e., preparation phase and optimization objective) and the presentation of preparation work, the conceptual model, and the optimization. Fifty-eight articles were reviewed and the majority focused on either describing the methodology or presenting results of an optimization trial (n = 38, 66%). Although almost all articles identified intervention components (96%), there was considerable variability in the degree to which authors fully described other elements of MOST. In particular, there was less consistency in use of MOST terminology. Reporting on the MOST preparation phase is varied, and there is a need for increased focus on explicit articulation of key design elements and rationale of the preparation phase. The proposed checklist for reporting MOST studies would significantly advance the use of this emerging methodology and improve implementation and dissemination of MOST. Accurate reporting is essential to reproducibility and rigor of scientific trials as it ensures future research fully understands not only the methodology, but the rationale for intervention and optimization decisions.

Primary Care Behavioral Health Training in Family Medicine Residencies: A Qualitative Study From a Large Health Care System

BACKGROUND AND OBJECTIVES

Primary care behavioral health (PCBH) is a service delivery model of integrated care linked to a wide variety of positive patient and system outcomes. However, considerable challenges with provider training and attrition exist. While training for nonphysician behavioral scientists is well established, little is known about how to train physicians to work efficiently within integrated teams.

METHODS

We conducted a case study analysis of family medicine residencies in the military health system using a series of 30 to 45-minute semistructured interviews. We conducted qualitative template analysis of these cases to chart programs' current educational processes related to PCBH. Thirteen individuals consisting of program directors, behavioral and nonbehavioral faculty, and residents across five programs participated in the study.

RESULTS

Current educational processes included a variety of content on PCBH (eg, treatment for depression, clinical referral pathways, patient-centered communication), primarily using a mix of didactic and practice-based placements. Resource allocation was seen as a critical contributor to quality. There was variability in the degree to which integrated behavioral health providers were incorporated as residency faculty, such that programs where these specialists were more incorporated reported more intentional curriculum development and health care systems-level content.

CONCLUSIONS

While behavioral health content was well represented in family medicine residency curriculum, the depth and integration of content was inconsistent. More intentional and integrated curriculum accompanied faculty development and integration of behavioral health faculty. Future research should evaluate if faculty development programs and faculty status of behavioral scientists results in different educational or health care outcomes.

Understanding Excellence: a Qualitative Analysis of High-Performing Learner Study Strategies

INTRODUCTION

Remediation in medical education tends to focus on the struggling learner. However, understanding successful learners may provide valuable insights to problematic academic behavior. This study explored core study strategies reported by high-performing medical school students.

METHOD

In the Fall of 2018 and 2019, high-performing first- and second-year medical students, defined as those who had performed over 90% on a national standardized assessment, were requested via e-mail to describe the study strategies that they believe contributed to their success. Student responses were analyzed using a template-driven approach, which drew upon common frameworks from cognitive learning theory.

RESULTS

Thirty-seven high-performing students provided brief unstructured descriptions of their study strategies. Retrieval practice-the cognitive learning strategy of attempting to draw out information to active recall, typically through means of self-quizzing, practice questions, or flashcards-was the most commonly endorsed strategy, followed by spaced repetition. Use of outside commercial resources was commonly referenced, and approximately one-third endorsed a perception that some form of regularly practiced self-care contributed to their academic success.

DISCUSSION

Retrieval practice, particularly combined with some form of spaced repetition, is often attributed as contributing to the success of high-performing learners. The use of commercial resources bears further exploration and consideration. Finally, the finding that self-care was identified as a contribution to academic performance goes beyond a focus on self-care solely for medical student well-being. This is an important distinction for both medical education and future research in this area.

Curricular Change and Resiliency in the Era of Coronavirus (COVID-19): The Uniformed Services University of the Health Sciences (USU) Experience

INTRODUCTION

The Coronavirus (COVID-19) pandemic has presented a myriad of organizational and institutional challenges. The Uniformed Services University of the Health Sciences, like many other front line hospitals and clinics, encountered a myriad of challenges in fostering and sustaining the education of students enrolled at the nation's only military medical school. Critical to the function of any academic medical institution, but particularly one devoted to the training of future physicians for the Military Health System, was the ability to rapidly adapt, modify, and create new means of keeping medical students engaged in their core curricula and progressing toward full and timely attainment of established educational goals and objectives.

METHODS

This article highlights some of the particular challenges faced by faculty and students during the first 6 months of the COVID-19 pandemic and describes how they were managed and/or mitigated.

RESULTS

Six key "lessons learned" were identified and summarized in this manuscript. These lessons may be applicable to other academic institutions both within and outside of the Military Health System.

CONCLUSIONS

Recognizing and embracing these key tenets of academic change management can accelerate the generation of a cohesive, organizational response to the next pandemic or public health crisis.

Interventions to Improve Sexual and Reproductive Health in US Active Duty Military Service Members: A Systematic Review

OBJECTIVE

To identify and describe behavioral interventions to promote sexual and reproductive health among US active duty military service members.

DATA SOURCES

Systematic searches of PubMed, CINAHL, and PsychINFO (N = 1609 records).

INCLUSION CRITERIA

English-language articles published between 1991 and 2018 and retrieved using search terms related to military service, interventions, and sexual and reproductive health.

EXCLUSION CRITERIA

Articles excluded if not empirically based, not published in peer-reviewed journals, did not sample active duty US military personnel, and did not examine the effectiveness of specified preventive sexual or reproductive health intervention(s).

DATA EXTRACTION

Teams of paired authors extracted study rationale; aims; design; setting; description of the intervention; measures; sample demographics; clinical, behavioral, and psychosocial outcomes; and conclusions.

DATA SYNTHESIS

Given the heterogeneity of studies, narrative synthesis was performed.

RESULTS

Fifteen articles met inclusion criteria: 10 focused on sexually transmitted infection (STI) acquisition and/or unintended pregnancy and 5 on sexual assault. Studies that assessed clinical outcomes found that interventions were associated with lower rates of STIs and/or unintended pregnancy. Significant effects were found on knowledge-related outcomes, while mixed effects were found on attitudes, intentions, and behaviors.

CONCLUSIONS

Current evidence on the effectiveness of sexual and reproductive health interventions in the US military is limited in quality and scope. Promoting sexual and reproductive health in this population is critical to maintaining well-being among servicemembers, their families, and the communities surrounding military installations.

To go or not go: Patient preference in seeking specialty mental health versus behavioral consultation within the primary care behavioral health consultation model

INTRODUCTION

Much of behavioral health care takes place within primary care settings rather than in specialty mental health settings. Access to specialty mental health care can be difficult due to limited access to mental health providers and wait times to receive mental health care. The purpose of this study is to determine patient satisfaction with behavioral health consultation visits that take place within the context of the primary care behavioral health consultation model. Patient likelihood to seek out specialty mental health care services if behavioral health consultation services were not provided was also examined.

METHOD

Two primary care clinic systems were examined in this study. The first was a primary care clinic predominately serving low-income patients: 100 individuals participated. The second was primary care in the context of military treatment centers: 539 individuals participated.

RESULTS

Results show that 61% of the patients in the low-income primary care clinic would not attend a specialty mental health appointment versus 30% in the military population.

DISCUSSION

This study suggests that primary care behavioral health is a patient-centered approach to care and reaches populations that otherwise may not receive behavioral health services. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Training the Doctors: A Scoping Review of Interprofessional Education in Primary Care Behavioral Health (PCBH)

Primary care behavioral health (PCBH) is a model of integrated healthcare service delivery that has been well established in the field of psychology and continues to grow. PCBH has been associated with positive patient satisfaction and health outcomes, reduced healthcare expenditures, and improved population health. However, much of the education and training on PCBH has focused on developing behavioral health providers to practice in this medical setting. Less attention has been paid to physician team members to support and practice within an integrated environment. This is problematic as underdeveloped physician team members may contribute to low utilization and attrition of behavioral health consultants. A scoping review was conducted to examine the training of physicians in this domain since 2006. Twenty-one studies were identified, predominantly in Family Medicine training programs. Although PCBH training was generally well received, more program evaluation, formalized curriculum, and faculty development are needed to establish best practices.

Understanding Primary Care Behavioral Health Across Military Settings: A Preliminary Comparison Between Deployed and In-Garrison Care

BACKGROUND

Integrated primary care behavioral health (PCBH) is a growing trend in health care delivery, particularly in the Department of Defense and the Department of Veterans Affairs. This consultative model has been applied within the U.S. Air Force for over 15 years and has demonstrated positive health impacts and patient satisfaction. With extended conflicts and engagements, including Operation Enduring Freedom and Operation Iraqi Freedom, deployment behavioral health care has expanded and positively received, but there is less empirical support of particular models of care in a deployed environment. Brief, solution-focused strategies commonly utilized in PCBH are likely to be particularly good candidates for the deployed environment. One key feature the Air Force's PCBH program is the collaborative team-based approach to care centered around a patient and driven by a primary care manager. This study expands the evaluation of the Air Force's PCBH program to include its novel application in a combat setting.

METHOD

A retrospective review of 516 archival patient satisfaction surveys across Air Force military treatment facilities utilizing a PCBH program compared patient satisfaction surveys collected in a deployed environment at a large combat support hospital to noncombat facilities.

FINDINGS

Results indicated that patient satisfaction in theater was comparable to satisfaction at Air Force military treatment facilities in noncombat environments, with one exception; patients seen in garrison rated higher satisfaction with the treatment plan than those seen in a deployed setting, F(509) = 5.36, p < 0.01, consistent with limited resources available in theater.

DISCUSSION

Given patient satisfaction across settings was found to be relatively equivalent, results suggests that the PCBH consultation model may be an appropriate model of care to meet a majority of the population's needs for a deployed environment. This pilot study has implications not only for military combat environments, but other austere settings, including civilian rural mental health settings. These findings inform provision of care in a deployed environment by demonstrating the benefits of the primary care behavioral model. Additionally, the Department of Veterans Affairs and other federal health care agencies will benefit from reviewing the structured and standardized PCBH model employed by the U.S. Air Force for nearly two decades as they expand care in rural mental health settings across the country.

US Air Force Behavioral Health Optimization Program: team members' satisfaction and barriers to care

BACKGROUND

Research has shown significant contribution of integrated behavioural health care; however, less is known about the perceptions of primary care providers towards behavioural health professionals.

OBJECTIVE

The current study examined barriers to care and satisfaction with integrated behavioural health care from the perspective of primary care team members.

DESIGN

This study utilized archival data from 42 treatment facilities as part of ongoing program evaluation of the Air Force Medical Service's Behavioral Health Optimization Program.

SETTING

This study was conducted in a large managed health care organization for active duty military and their families, with specific clinic settings that varied considerably in regards to geographic location, population diversity and size of patient empanelment.

STUDY PARTICIPANTS

De-identified archival data on 534 primary care team members were examined.

RESULTS

Team members at larger facilities rated access and acuity concerns as greater barriers than those from smaller facilities (t(533) = 2.57, P < 0.05). Primary Care Managers (PCMs) not only identified more barriers to integrated care (β = -0.07, P < 0.01) but also found services more helpful to the primary care team (t(362.52) = 1.97, P = 0.05). Barriers to care negatively impacted perceived helpfulness of integrated care services for patients (β = -0.12, P < 0.01) and team members, particularly among non-PCMs (β = -0.11, P < 0.01).

CONCLUSIONS

Findings highlight the potential benefits of targeted training that differs in facilities of larger empanelment and is mindful of team members' individual roles in a Patient Centered Medical Home. In particular, although generally few barriers were perceived, given the impact these barriers have on perception of care, efforts should be made to decrease perceived barriers to integrated behavioural health care among non-PCM team members.

Cyber victimization by peers: Prospective associations with adolescent social anxiety and depressive symptoms

Peer victimization that occurs via electronic media, also termed cybervictimization, is a growing area of concern for adolescents. The current study evaluated the short-term prospective relationship between cybervictimization and adolescents' symptoms of social anxiety and depression over a six-week period. Participants were 839 high-school aged adolescents (14-18 years; 58% female; 73% Hispanic White), who completed measures of traditional peer victimization, cybervictimization, depression, and social anxiety at two time points. Findings supported the distinctiveness of cybervictimization as a unique form of peer victimization. Furthermore, only cybervictimization was associated with increased levels of depressive symptoms over time, and only relational victimization was associated with increased social anxiety over time, after controlling for the comorbidity of social anxiety and depression among youth. Cybervictimization appears to be a unique form of victimization that contributes to adolescents' depressive symptoms and may be important to target in clinical and preventive interventions for adolescent depression.

Aversive Peer Experiences on Social Networking Sites: Development of the Social Networking-Peer Experiences Questionnaire (SN-PEQ)

Cyber victimization is an important research area; yet, little is known about aversive peer experiences on social networking sites (SNSs), which are used extensively by youth and host complex social exchanges. Across samples of adolescents (n=216) and young adults (n=214), we developed the Social Networking-Peer Experiences Questionnaire (SN-PEQ), and examined its psychometric properties, distinctiveness from traditional peer victimization, and associations with internalized distress. The SN-PEQ demonstrated strong factorial invariance and a single factor structure that was distinct from other forms of peer victimization. Negative SNS experiences were associated with youths' symptoms of social anxiety and depression, even when controlling for traditional peer victimization. Findings highlight the importance of examining the effects of aversive peer experiences that occur via social media.