Hypertension at the nexus of veteran status, psychiatric disorders, and traumatic brain injury: Insights from the 2011 Behavioral Risk Factor Surveillance System

Variable military service-related experiences, such as combat exposure, psychiatric disorders (PD), and traumatic brain injuries (TBI), may differentially affect the likelihood of having health care professional-identified high blood pressure (i.e., hypertension).

PURPOSE

Compare the odds of self-reported hypertension among non-combat and combat veterans with and without PD/TBI to non-veterans and each other.

METHODS

We used data from men from the 2011 Behavioral Risk Factor Surveillance System and distinguished: non-veterans (n = 21,076); non-combat veterans with no PD/TBI (n = 3,150); combat veterans with no PD/TBI (n = 1,979); and veterans (combat and non-combat) with PD and/or TBI (n = 805). Multivariable, hierarchical logistic regression models included exogenous demographic, socioeconomic attainment and family structure, health behavior and conditions, and methodological control variables.

RESULTS

One-third of men reported having been told at least once by a medical professional that they had high blood pressure. Bivariate analyses indicated that each veteran group had a higher prevalence of self-reported hypertension than non-veterans (design-based F = 45.2, p<0.001). In the fully adjusted model, no statistically significant differences in the odds of self-reported hypertension were observed between non-veterans and: non-combat veterans without PD/TBI (odds ratio [OR] = 0.92); combat veterans without PD/TBI (OR = 0.87); veterans with PD and/or TBI (OR = 1.35). However, veterans with PD and/or TBI had greater odds of reporting hypertension than both combat and non-combat veterans without PD/TBI (p<0.05).

DISCUSSION

Military service-related experiences were differentially associated with a survey-based measure of hypertension. Specifically, veterans self-reporting PD and/or TBI had significantly higher odds of self-reporting hypertension (i.e., medical provider-identified high blood pressure).

Risk Factors Explaining Military Deaths From Suicide, 2008-2017:A Latent Class Analysis

Military suicide prevention efforts would benefit from population-based research documenting patterns in risk factors among service members who die from suicide. We use latent class analysis to analyze patterns in identified risk factors among the population of 2660 active-duty military service members that the Department of Defense Suicide Event Report (DoDSER) system indicates died by suicide between 2008 and 2017. The largest of five empirically derived latent classes was primarily characterized by the dissolution of an intimate relationship in the past year. Relationship dissolution was common in the other four latent classes, but those classes were also characterized by job, administrative, or legal problems, or mental health factors. Distinct demographic and military-status differences were apparent across the latent classes. Results point to the need to increase awareness among mental health service providers and others that suicide among military service members often involves a constellation of potentially interrelated risk factors.

Estimated pulse wave velocity as a measure of vascular aging

BACKGROUND

Carotid-femoral pulse wave velocity (cfPWV), the referent measure of aortic stiffness, is an established measure of vascular aging. In studies where cfPWV cannot be measured, alternative methods are needed to help promote research on vascular aging. This study examines the construct validity of a measure of PWV estimated from age and blood pressure (ePWV). The specific aims of the study are to: 1) explore the strength of association between ePWV, cfPWV, and other established measures of vascular aging; 2) examine the sensitivity and specificity of elevated ePWV (≥10m/s) in relation to elevated cfPWV (≥10m/s).

METHODS

We measured cfPWV in two-hundred and fifty-two adults (mean age 57±12 years, 48% female) and calculated each participant's ePWV from their age and brachial blood pressure. Additional measures of vascular aging included: carotid intima-media thickness (cIMT); carotid stiffness measured as elastic modulus (cEp); and carotid augmentation index (cAIx).

RESULTS

The correlations between cfPWV and measures of vascular aging were: cEp (r = 0.36), cIMT (r = 0.49), and cAIx (r = 0.04). The correlations between ePWV and measures of vascular aging were: cEp (r = 0.45), cIMT (r = 0.60), and cAIx (r = 0.24). The correlation between ePWV and cfPWV was (r = 0.67). The sensitivity and specificity of elevated ePWV (≥ 10 m/s) for concomitantly identifying high cfPWV (≥ 10 m/s) were 85.4% and 73.0% respectively.

CONCLUSION

ePWV is associated with established measures of vascular aging, such as carotid thickness, carotid stiffness and carotid augmentation index. ePWV may be a useful tool to help promote research on vascular aging.

Estimated Pulse Wave Velocity and All-Cause Mortality: Findings from the Health and Retirement Study

Background and Objectives

The gold standard method for the assessment of vascular aging is carotid–femoral pulse wave velocity (cfPWV). cfPWV can be estimated from 2 commonly assessed clinical variables—age and blood pressure. This analysis uses data from the Health and Retirement Study to examine the relationship between estimated pulse wave velocity (ePWV) and mortality among 9,293 middle age and older adults.

Research Design and Methods

Cox proportional hazard models were used to predict mortality occurring over a 10- to 12-year period. Controls were included for sociodemographic characteristics (age, gender, race, ethnicity, wealth, income, and education), health status (history of cardiovascular disease [CVD], diabetes, and stroke and related medication use), health behaviors (smoking, physical activity, and body mass index), and CVD-related biomarkers (systolic and diastolic blood pressure, C-reactive protein, cystatin c, hemoglobin A1c, total cholesterol, and high-density lipoprotein cholesterol).

Results

By 2018, 26.19% of the weighted analytic sample were reported as deceased. In the fully specified models that control for age, age-squared, systolic and diastolic blood pressure, sociodemographic variables, health status and behaviors, and biomarkers, ePWV was associated with a greater likelihood of mortality.

Discussion and Implications

An estimate of PWV derived from age and blood pressure is independently associated with an increased likelihood of death in a representative sample of middle age and older adults in the United States.

Perceived access to PrEP as a critical step in engagement: A qualitative analysis and discrete choice experiment among young men who have sex with men

Young Men who have Sex with Men (MSM) continue to face disproportionate HIV risk. Despite its well accepted role in HIV prevention, pre-exposure prophylaxis (PrEP) uptake remains below desired goals. Systemic barriers to PrEP access, including insurance complexity, cost, and wait times to start PrEP may contribute to low PrEP engagement. We conducted in-depth interviews and designed a discrete choice experiment (DCE) to assess preferences for and barriers to PrEP access in the United States. Methods: We conducted in-depth interviews with 18 MSM aged 18–30 years old who were not on PrEP and created a DCE based on the results. For the DCE, a convenience sample of young MSM in the United States who reported recent condomless anal sex was recruited through social media applications. Consenting participants provided sociodemographic information and responded to a series of 10 choice tasks about PrEP access. Preferences were analyzed utilizing marginal willingness-to-pay (mWTP) methods. Results: In-depth interviews revealed preferences for highly effective PrEP and concerns about barriers to access due to insurance coverage and privacy. The online DCE was completed by 236 eligible MSM aged 18–30. The most-preferred PrEP package—with all elements significantly preferred over other options—was insurance covered, could be maintained confidential from parents and employers, was available immediately, and had an online option. Need to take out new insurance or add a supplemental insurance in order to cover PrEP significantly detracted from willingness to pay for a PrEP program. Attributes most associated with willingness to pay for PrEP were PrEP being covered by an insurance the client already has and insurance coverage that was private. Conclusions: Young MSM at high risk for HIV in the United States who are not currently on PrEP showed strong preferences for PrEP options that were covered by insurance and could be kept confidential from parents and employers. Lack of these options may present major barriers to PrEP access among young MSM who are at particularly high risk. Rapid access to PrEP, as well as the option of receiving some care online, may also enhance PrEP uptake.

Attention deficit hyperactivity disorder and the age pattern of adult mortality

We draw upon the life-course perspective and examine whether Attention Deficit Hyperactivity Disorder (ADHD) moderates the age pattern of adult mortality using data from the 2007 and 2012 National Health Interview Survey Sample Adult File linked to National Death Index data through 2015. Overall, 7.0% of respondents died by 2015. Discrete-time hazard analysis indicates that the log odds of mortality were significantly lower among 18 and 19 year old adults ever diagnosed with ADHD and significantly higher among 46 to 64 year old adults ever diagnosed with ADHD, with a crossover occurring at age 33. Results were similar among men and women. It is not known specifically which risks drive changes in the risk of mortality documented among persons with ADHD during the transition to adulthood, the increased risk of mortality in midlife, or whether some risks operate more or less at particular ages. Additional research can lead to targeted, age- and life-course stage-focused interventions for specific risks and contribute to the reduction of ADHD-related mortality.

'It's history in the making all around us': examining COVID-19 through the lenses of HIV and epidemic history

Research increasingly considers how collective narratives/experiences of HIV influence understandings of and responses to COVID-19 among men who have sex with men and how these discussions articulate with the larger literature on the social significance of epidemics. Drawing on interviews with 30 men who have sex with men, as well as discussion of epidemics as dramaturgical events, this study aimed to determine how men living in the USA make sense of COVID-19 in the light of their collective knowledge and/or memories of the HIV pandemic. Participants experienced progressive revelations regarding COVID-19's seriousness and constructed frameworks with which to manage the unpredictability of infection. Participants also believed that the initial public response to COVID-19 on the part of the US federal government, health officials and the scientific community, although inadequate, was stronger and more extensive than the response had been to HIV. As communities and the USA negotiated their pandemic responses, participants negotiated their own personal responses with incomplete, uncertain, dynamic and conflicting information. This study provides evidence regarding the social organisation of a contemporary pandemic and how individuals perceive and guard against risk, assign responsibility for virus transmission and acquisition, and navigate the threat of a potentially deadly infection.

Depression and mental health service use among 12-17 year old U.S. adolescents: Associations with current parental and sibling military service

Objective

To examine whether having a parent and/or a sibling currently serving in the military is associated with major depression and use of mental health services among 12-17 year old adolescents in the United States.

Method

Descriptive and multivariate logistic regression analyses are conducted using pooled data from the 2016-2019 National Survey of Drug Use and Health (NSDUH). Analyses are weighted and standard errors are adjusted for the complex sampling design.

Results

Adolescents are more likely to have a sibling than a parent currently serving in the military. Having a sibling currently in the military increases the likelihood of having a lifetime and a past-year major depressive episode (MDE), but not a past-year MDE with severe role impairment or use of mental health services. Having a parent in the military is not associated with any measure of MDE, but increases use of specialty outpatient, specialty inpatient/residential, and non-specialty mental health services net of MDE and sociodemographic controls.

Conclusion

Considerable attention has focused on risk and resilience among the dependent children of current service members. A better understanding of how the current military service experiences of siblings, as well as parents, influences related adolescents' mental health, mental health care service use, substance use, and health behaviors has the potential to contribute to programs and interventions that can enhance the well-being of youth with intra-generational, as well as inter-generational, connections to the military. Adolescents who have a sibling currently serving in the military are an at-risk population for MDE and potentially other mental and behavioral health problems.

Cohort Change in the Prevalence of ADHD Among U.S. Adults: Evidence of a Gender-Specific Historical Period Effect

Objective: To document inter- and intra-cohort changes in adult ADHD and examine whether changes vary by gender. Method: We analyze data from the 2007 and 2012 U.S. National Health Interview Survey. Results: The prevalence of ADHD among adults aged 18 to 64 years increased from 3.41% in 2007 to 4.25% in 2012. As expected, patterns of inter- and intra-cohort change varied by gender. At younger ages, inter-cohort gender differences are more distinct due to a spike in prevalence among boys/men born in or after 1980. Consistent with a gender-specific historical period effect, recent intra-cohort increases among women have narrowed the gender gap. Conclusion: The gender gap in the prevalence of ADHD among adults decreased by 31.1% from 2007 to 2012 due to increased prevalence among adult women of all ages. We discuss these results in relation to diagnostic practice, adult health and well-being, data limitations and needs, and directions for future research.

Same-Sex Sexuality and the Risk of Divorce: Findings from Two National Studies

Despite symbolic linkages between heterosexuality and marriage, and a pervasive heteronormative ideology of romantic love, little population-representative research examines whether same-sex sexuality - desire/attraction, behavior, and gay, lesbian, or bisexual identity - increases the likelihood of divorce from an different-sex spouse. We examine this association using data from the 1992 National Health and Social Life Survey and the 2011-2013 National Survey of Family Growth. In both sub-studies, multivariate logistic regression analyses indicate that same-sex sexuality reduces the odds of ever marrying. However, among the once-married, same-sex desire/attraction, sexual behavior, and gay, lesbian, or bisexual identity respectively increase the odds of different-sex divorce net of demographic and early-life factors. Same-sex sexuality puts a brake on divorce by preventing some different-sex marriages that would ultimately end in divorce, but is associated with an increase risk of different-sex divorce among once-married individuals.

Self-Reported ADHD and Adult Health in the United States

Objective: Informed by a social determinants of health framework, we investigate the relationship between self-reported ADHD diagnosis status and adult health, and whether observed associations are attenuated by biomedical and socioeconomic factors. Method: Using 2007 National Health Interview Survey data (N = 19,104), we present multivariate logistic regression analyses of associations between self-reported ADHD diagnosis status and five adult health outcomes. Results: ADHD diagnosis was significantly associated with higher odds of injury, physical health conditions, functional limitations, fair/poor health, and psychological distress in fully specified models (adjusted odds ratios [AORs] = 1.62-2.36). Inclusion of controls for exogenous demographic characteristics, psychiatric comorbidities and health behaviors, and adult social and economic statuses attenuated but did not eliminate observed associations between ADHD and poorer adult health. Conclusion: Research on adult health outcomes for those with ADHD should include consideration of the mechanisms by which a diagnosis of ADHD leads to cumulative social disadvantages that independently contribute to poorer health outcomes.

The Influence of Military Service Experiences on Current and Daily Drinking

Background: An extensive public health literature associates military service with increased alcohol consumption and problematic drinking. However, few well-controlled population-based studies compare alcohol use among nonveterans and veterans with diverse military service experiences, and no such study examines everyday drinking. Methods: We use population-representative data from the 2010 and 2011 Behavioral Risk Factor Surveillance System and distinguish four groups of men: nonveterans; non-combat veterans without a psychiatric disorder (PD) or traumatic brain injury (TBI); combat veterans without a PD or TBI; and veterans (non-combat and combat combined) with a PD and/or TBI. We estimate hierarchical multivariate logistic regression models of current drinking (N = 21,947) and daily drinking (among current drinkers; N = 11,491). Results from supplemental analyses are discussed. Results: Relative to nonveterans, non-combat veterans with no PD or TBI and veterans with a PD and/or TBI, respectively, but not combat veterans with no PD or TBI, are more likely to be current drinkers. Among current drinkers, non-combat and combat veterans with no PD or TBI, respectively, are less likely than nonveterans to be daily drinkers. Conversely, among current drinkers, veterans with a PD and/or TBI are more likely to be daily drinkers than nonveterans, non-combat veterans with no PD or TBI, and combat veterans with no PD or TBI. Conclusion: We document heterogeneous and countervailing influences of military service experiences on current and daily drinking. Results indicate that harmful military service experience may be associated with an increased risk of current, moderate daily drinking, which may represent a form of self-medication.

VETERAN MORTALITY DISADVANTAGE AMONG RURAL, SUBURBAN, AND URBAN RESIDENTS

Although veterans tend to have higher mortality rates than non-veterans, recent research suggests there is substantial heterogeneity in veteran mortality on the basis of various characteristics such as race, period of service, type of health insurance coverage, and service-connected disability status. This analysis extends the extant literature by using the 1978-2014 General Social Survey linked to the National Death Index (GSS-NDI) to examine veteran status differences in mortality by geographic location. We estimate a series of Cox regression models predicting death for male veterans and nonveterans, controlling for age, race/ethnicity, education, income, and work status. Separate models are presented for rural, suburban, and urban residents. All models are weighted and include robust standard errors. The results indicate that rural veterans have higher mortality risk than rural non-veterans, particularly among older adults. There are no significant differences in mortality risk between veteran and non-veterans living in suburban and urban areas.

THE HEALTH OF MALE VETERANS IN LATER LIFE

Veterans have the opportunity to accrue health-promoting “military capital,” but they are also at risk of experiencing a “military hazard” effect that undermines later-life health and mortality outcomes. Given these possibly competing effects, there is substantial heterogeneity in physical and mental health among older male veterans. The health and mortality outcomes of older veterans who were not substantially harmed during military service appear to be just as good as, if not better than, those of nonveterans. However, older veterans who served in-theater, were exposed to combat or hazardous chemicals, and/or were physically or psychologically harmed during service tend to have worse health and higher mortality than non¬veterans. Some older veterans with these experiences struggle with life-long or late-onset PTSD, while others exhibit resilience and posttraumatic growth. Additional population-level, life-course research is needed on specific war-era cohorts to identify the mechanisms that shape veteran status differences in late-life health and mortality.

Race, Remarital Status, and Infertility in 1910: More Evidence of Multiple Causes

The dominant approach to studying historical race-related fertility differences has been to limit samples to first-married and younger women. We argue that studying historical race-related fertility differences in the context of remarriage is also important: remarriage and fertility patterns are both rooted in the biosocial conditions that produce racial disparities in health. We employ a multiple causes framework that attributes variation in fertility patterns to voluntary limitation and involuntary factors (infecundity/subfecundity). We use data from the 1910 Integrated Public Use Microdata Series and estimate zero-inflated negative binomial models that simultaneously distinguish those who are infecund (vs. fecund) and estimate the number of remarital births among the fecund. Our approach allows us to evaluate historical remarital (in)fertility differences, accounting for marital, socioeconomic, and geographic influences on fecundity and fertility, while empirically accounting for the influence of children "missing" from the household due to mortality and fostering/aging out. Consistent with past studies that emphasized poorer African American health as a major influence on involuntary infertility, we find that African American women were more likely than white women to be in the always-zero (infecund) group and to have fewer remarital births. Supplemental analyses nuance these findings but indicate that these results are robust. Overall, we find support for a multiple-causes perspective: while the findings are consistent with the adoption of deliberate fertility control among urban and higher-status women at higher parities, remarital fertility differences in 1910 also reflected greater infecundity/subfecundity among subgroups of women, especially African American women.

The Influence of Men's Military Service on Smoking Across the Life Course

The military is described as a social context that contributes to the (re-)initiation or intensification of cigarette smoking. We draw on data from the 1985-2014 National Survey of Drug Use and Health (NSDUH) and the Wisconsin Longitudinal Study (WLS) to conduct complementary sub-studies of the influence of military service on men's smoking outcomes across the life course. Descriptive findings from an age-period-cohort analysis of NSDUH data document higher probabilities of current smoking and heavy smoking among veteran men across a broad range of cohorts and at all observed ages. Findings from sibling fixed-effects Poisson models estimated on the WLS data document longer durations of smoking among men who served in the military and no evidence that selection explains the observed relationship. Together, these results provide novel and potentially generalizable evidence that participation in the military in early adulthood exerts a causal influence on smoking across the life course.

Attention Deficit Hyperactivity Disorder and adult mortality

This study examines the relationship between self-reported ADHD and adult mortality over a four-year period, and whether ADHD is associated with underlying cause of death (accidents versus all others). If ADHD increases mortality risk through accidents, then interventions may be designed and implemented to reduce risk and prevent premature death. We estimate descriptive statistics and multivariate logistic regression models using data from the 2007 U.S. National Health Interview Survey (NHIS) Sample Adult File linked to National Death Index (NDI) data through 2011 (N=23,352). Analyses are weighted and standard errors are adjusted for the complex sampling design. We find that the odds of dying are significantly higher among those with ADHD than among those without ADHD net of exogenous sociodemographic controls (adjusted odds ratio=1.78, 95% confidence interval=1.01, 3.12). Although marginally non-significant, accidental death is more common among those with ADHD than among those without ADHD (13.2% versus 4.3%, p=0.052). Few population-representative studies examine the relationship between ADHD and adult mortality due to data limitations. Using NHIS data linked to the NDI, we are only able to observe a few deaths among adults with ADHD. However, ADHD is associated with significantly higher odds of dying for adults and results suggest that accidents may be an underlying cause of death more often for decedents with ADHD. Future research should further examine the mechanisms linking ADHD to adult mortality and the extent to which mortality among persons with ADHD is preventable. Regular measurement of ADHD among adults in the NHIS is warranted.

Military Service and (Dis)Continuity in the Life Course

This study uses a life-course framework and data from the Health and Retirement Study and the Study of Assets and Health Dynamics Among the Oldest-Old to examine three hypotheses related to (dis)continuity in the effects of early-life disadvantage (African American race and low paternal education) and military service on later-life mortality. Specifically, the authors consider whether military service (and age at enlistment) mediates or moderates the effects of early-life disadvantage on later-life mortality and whether mid- to late-life marital status, socioeconomic status, health status, and health behaviors mediate the effects of military service on mortality. The authors find very little evidence to support the notion that any mortality benefits accrue to men as a consequence of military service overall or enlistment at any particular age. Most of the evidence is consistent with life-course disruption and continuity of disadvantage interpretations.

Race, Incarceration, and Health

Significant racial disparities in health outcomes have been consistently documented in the United States. Life-course and population-health models are often used to explain these disparities, but they generally do not take incarceration effects into account. Incarceration may have direct effects on health, but it is more likely to indirectly affect health by shaping employment, income, and marital trajectories. The authors contend that the failure of health researchers to take incarceration effects into account is problematic given the large increase in the incarceration of Black men over the past few decades. Moreover, because large numbers of incarcerated Black men are not present in research samples, racial disparities in health outcomes may be underestimated. Incarceration effects should be included in life-course and population-health models, study designs, and policy development processes.

Veteran status and paid sex among American men: results from three national surveys

Surprisingly little population-based, social scientific research directly examines the association between veteran status and ever paying for sex although there are theoretical reasons to expect that such an association might emerge across the life course. In this article, we examined the relationship between veteran status and ever paying for sex among American men who turned 18 years old between 1922 and 2010 using data from three independent national samples: Wave 1 of the 2005-2006 National Social Life, Health, and Aging Project (NSHAP); the 1992 National Health and Social Life Survey (NHSLS); and pooled data from the 1991, 1993, 1994, and 2010 General Social Survey (GSS). In all three datasets, we found that veterans were significantly more likely than non-veterans to report ever having paid for sex: rates across the three sub-studies ranged from 10.86 to 14.57 % among non-veterans and from 25.27 to 33.92 % among veterans. In multivariate models that controlled for demographic and early-life factors to the extent possible with available data, the odds of ever paying for sex were estimated to be 2.25-3.10 times higher among veterans than among non-veterans. In a supplemental analysis using data from the GSS, we found that longer duration of service was associated with an increased odds of ever paying for sex. While these results do not demonstrate a causal relationship between serving in the military and ever paying for sex, the strength and consistency of the findings provide compelling evidence of an association that is worthy of further theorizing and empirical investigation. There is considerable room for advancing knowledge related to the influence of military service on the initiation, maintenance, frequency, and timing of paid sexual relationships in relation to other life events.

The use of VA Disability Compensation and Social Security Disability Insurance among working-aged veterans

BACKGROUND

Although there is substantial disability among veterans, relatively little is known about working-aged veterans' uptake of Department of Veterans Affairs (VA) Disability Compensation and Social Security Disability Insurance (DI).

OBJECTIVES

This study identifies levels of veteran participation in VA disability and/or DI benefit programs, examines transitions into and out of VA and DI programs among veterans, and estimates the size and composition of the veteran population receiving VA and/or DI benefits over time.

METHODS

Data from the 1992, 1993, 1996, 2001, 2004, and 2008 Survey of Income and Program Participation (SIPP) are used to describe VA and DI program participation among veterans under the age of 65.

RESULTS

The majority of working-aged veterans do not receive VA or DI benefits and joint participation is low, but use of these programs has increased over time. A higher percentage of veterans receive VA compensation, which ranges from 4.9% in 1992 to 13.2% in 2008, than DI compensation, which ranges from 2.9% in 1992 to 6.7% in 2008. The rate of joint participation ranges from less than 1% in 1992 to 3.6% in 2008. Veterans experience few transitions between VA and DI programs during the 36-48 months they are observed. The number of veterans receiving benefits from VA and/or DI nearly doubled between 1992 and 2008. There have been substantial shifts in the composition of veterans using these programs, as cohorts who served prior to 1964 are replaced by those who served after 1964.

CONCLUSIONS

The findings suggest potential gaps in veterans' access to disability programs that might be addressed through improved coordination of VA and DI benefits.

Economic well-being among older-adult households: variation by veteran and disability status

This analysis uses data from the Survey of Income and Program Participation (SIPP) to examine whether veteran and disability statuses are jointly associated with poverty and material hardship among households that include an older adult. Compared to households that do not include a person with a disability or veteran, disabled nonveteran households are more likely to be in poverty and to experience home hardship, medical hardship, and bill-paying hardship. Disabled veteran households are not significantly different in terms of poverty, but exhibit the highest odds of home hardship, medical hardship, bill-paying hardship, and food insufficiency. The implications for social work practice are discussed.

Unlocking insights about military children and families

As this issue of the Future of Children makes clear, we have much yet to learn about military children and their families. A big part of the reason, write Anita Chandra and Andrew London, is that we lack sufficiently robust sources of data. Until we collect more and better data about military families, Chandra and London say, we will not be able to study the breadth of their experiences and sources of resilience, distinguish among subgroups within the diverse military community, or compare military children with their civilian counterparts. After surveying the available sources of data and explaining what they are lacking and why, Chandra and London make several recommendations. First, they say, major longitudinal national surveys, as well as administrative data systems (for example, in health care and in schools), should routinely ask about children's connections to the military, so that military families can be flagged in statistical analyses. Second, questions on national surveys and psychological assessments should be formulated and calibrated for military children to be certain that they resonate with military culture. Third, researchers who study military children should consider adopting a life-course perspective, examining children from birth to adulthood as they and their families move through the transitions of military life and into or out of the civilian world.

Veteran Status and Men’s Later-Life Cognitive Trajectories

Objective: The aim of this study is to determine the extent to which men’s later-life cognitive trajectories vary by veteran status. Method: We use Health and Retirement Study (HRS) data to estimate growth curve models examining men’s later-life cognitive trajectories by veteran status, war service status, and period of service. Analyses control for early-life characteristics that influence selection into military service and later-life cognition, and mid- to late-life characteristics that potentially mediate the relationship between military service and later-life cognition. Results: Veterans have higher cognition scores relative to nonveterans around retirement age, but their cognition scores decline more rapidly with increasing age, such that cognition scores are similar in both groups among the oldest old. Veterans who served during the Korean War have lower cognition scores around retirement age, but less steep age-related declines, than veterans who served during World War II. Discussion: Findings are discussed in relation to the extant literature, future research, potential service needs, and study limitations.

Service utilization among older adults with HIV: the joint association of sexual identity and gender

This study examines the association of sexual identity and gender among older clients with HIV at an AIDS service organization using the Andersen Model. Data confirm those aging with HIV exhibit high rates of age-associated illnesses 10 to 20 years before expected. They have fragile social networks that cannot supply the informal supports needed. This aging population will need to increasingly access community-based services. Sexual identity and gender were weak covariates of service utilization. Although heterosexual men used more services, utilization was largely predicted by service needs and the use of case management. Implications for service delivery and policy are discussed.

The effects of the military's antidrug policies over the life course: the case of past-year hallucinogen use

We analyze long-term trends in past-year hallucinogen use among veterans as compared to nonveterans. This topic is theoretically strategic because the military adopted stringent and successful antidrug policies in the mid-1980s, which serves as a natural experiment to examine the potential long-term impact of comprehensive drug policies on illegal drug use. Drawing on self-reported data from the National Survey of Drug Use and Health in years 1985, 1988, and 1990-2010, the analysis uses age-period-cohort analysis to update trends in past-year hallucinogen use and to examine the impact of veteran status. Results are consistent with the hypothesis that a stringent antidrug policy can lead to a life-long reduction in hallucinogen use. Among birth cohorts who were young adults immediately before the implementation of the antidrug policies (those in the 1960-1964 birth cohort) odds of past-year hallucinogen use were twice as high for veterans as compared to nonveterans over the life course. This difference disappeared among birth cohorts that were young adults after the antidrug policies were implemented, when the prevalence of past-year hallucinogen use would be expected to be higher for veterans because of their significantly higher rates of illegal drug use in adolescence. After the drug-testing policies were implemented veterans actually had significantly lower prevalence of past-year hallucinogen use in comparison to nonveterans among the subgroup of respondents who reported a history of illegal drug use before age 18 (OR = .77, p < .01). These trends across veterans and nonveterans were not explained by trends in recruits' tendencies for illegal drug use. These findings point to service in today's armed forces as a turning point that, overall, leads to a lasting, lifelong reduction in substance use.

Military service and men's health trajectories in later life

OBJECTIVES

This study examines differences in the relationship between veteran status and men's trajectories of health conditions, activities of daily living limitations, and self-rated health.

METHODS

We use data on 12,631 men drawn from the 1992-2006 waves of the Health and Retirement Study to estimate growth curve models that examine differences in health trajectories between nonveterans and veterans, veterans with and without wartime service, and war service veterans who served during World War II, Korea, Vietnam, and multiple wars.

RESULTS

The results indicate that veterans have better health at the mean age of 66.2 years, but experience greater age-related changes in health than nonveterans. Similarly, men who served during wartime have better health at the mean age, but more age-related changes in health than men who did not serve during wartime. Among war veterans, Vietnam veterans are in poorer health at the mean age, but they experience less substantial age-related health changes than men who served during previous wars.

DISCUSSION

Although veterans experience better health relative to nonveterans around retirement age, they have poorer health than nonveterans among the oldest old. These findings inform our understanding of the veteran-nonveteran health-mortality paradox found in previous research and suggest a health crossover among veterans and nonveterans in later life.

Maternal employment and the health of low-income young children

This study examines whether maternal employment affects the health status of low-income, elementary-school-aged children using instrumental variables estimation and experimental data from a welfare-to-work program implemented in the early 1990s. Maternal report of child health status is predicted as a function of exogenous variation in maternal employment associated with random assignment to the experimental group. IV estimates show a modest adverse effect of maternal employment on children's health. Making use of data from another welfare-to-work program we propose that any adverse effect on child health may be tempered by increased family income and access to public health insurance coverage, findings with direct relevance to a number of current policy discussions. In a secondary analysis using fixed effects techniques on longitudinal survey data collected in 1998 and 2001, we find a comparable adverse effect of maternal employment on child health that supports the external validity of our primary result.

Maternal work hours and adolescents' school outcomes among low-income families in four urban counties

We examine how changes in maternal work hours affect adolescent children's school participation and performance outcomes using data from interviews in 1998 and 2001 with approximately 1700 women who, in May 1995, were welfare-reliant, single mothers of adolescents living in neighborhoods of concentrated poverty in Cuyahoga (Cleveland), Los Angeles, Miami-Dade, and Philadelphia counties. Analyses control for a broad array of mothers' characteristics, including their psychological and physical health, experiences with domestic violence and substance abuse, as well as unobserved time-invariant characteristics. In fixed-effects models, we find unfavorable effects of increased maternal work hours on three of six outcomes: skipping school, performing above average, and parental contact about behavior problems. Adolescent-aged sons seem to be particularly sensitive to changes in mothers' hours of work.

Correlates of HIV/AIDS knowledge among U.S.-born and foreign-born Hispanics in the United States

No national study of Hispanics has examined variation in HIV/AIDS-related knowledge by ethnicity, place of birth, and duration in the United States (for the foreign born) at least in part because of data constraints. Data from the 1991 and 1992 National Health Interview AIDS Supplements were used to examine the influence of these factors, and other sociodemographic and HIV/AIDS-related variables, on a 25-item HIV/AIDS knowledge scale. Descriptive and multivariate analyses indicate that foreign-born Hispanics with shorter durations in the United States have significantly lower levels of HIV/AIDS knowledge, as do those of Mexican and Cuban ethnicity. Numerous other factors, most of which are known to be associated with HIV/AIDS knowledge in the general population, were found to be significantly associated with HIV/AIDS knowledge among Hispanics in multivariate analyses; these include age, education, gender, rural residence, residence in the West, knowing a person with HIV/AIDS, personal risk for HIV/AIDS, and having been tested for HIV outside of the blood donation system. Results suggest that HIV/AIDS information campaigns targeted to Hispanics may not be equally effective in reaching foreign-born and U.S.-born subgroups or persons of differing ethnicities. Future studies should examine sources of HIV/AIDS information and the mechanisms of knowledge acquisition and transmission within specific subgroups of the Hispanic population.

Moving for care: findings from the US HIV Cost and Services Utilization Study

This paper examines sociodemographic and HIV-related factors associated with moving post-HIV diagnosis for non-care- and care-related reasons (versus never moving post-HIV diagnosis). Distinctions are made between those who move for informal care only, formal care only, or informal and formal care. Data come from the nationally representative US HIV Cost and Services Utilization Study (N=2,864). Overall, 31.8% moved at least once post-HIV diagnosis and 16.3% moved most recently for care. Among those who moved for care, 32.6% moved for informal care only, 26.8% for formal care only, and 40.6% moved for both. Post-HIV diagnosis moves for reasons unrelated to care were less likely among African Americans and older persons, and more likely among those with longer durations positive. Moves for care were less likely among African Americans, older persons, and persons with higher educational attainments, while they were more likely among those with an AIDS diagnosis and longer durations HIV-positive. Among those who moved for care, women and persons with higher incomes were less likely to move for formal or mixed care than informal care only. Given that moving for care may reflect disparities in access to care and unmet needs, additional analyses with more detailed data are warranted.

Use of alternative therapists among people in care for HIV in the United States

OBJECTIVES

This study examined the influence of sociodemographic, clinical, and attitudinal variables on the use of alternative therapists by people in care for HIV.

METHODS

Bivariate and multivariate analyses of baseline data from the nationally representative HIV Cost and Services Utilization Study were conducted.

RESULTS

Overall, 15.4% had used an alternative therapist, and among users, 53.9% had fewer than 5 visits in the past 6 months. Use was higher for people who were gay/lesbian, had incomes above 40,000 dollars, lived in the Northeast and West, were depressed, and wanted more information about and more decisionmaking involvement in their care. Among users, number of visits was associated with age, education, sexual orientation, insurance status, and CD4 count.

CONCLUSIONS

Among people receiving medical care for HIV, use of complementary care provided by alternative therapists is associated with several sociodemographic, clinical, and attitudinal variables. Evaluation of the coordination of provider-based alternative and standard medical care is needed.

The prevalence of alcohol consumption and heavy drinking among people with HIV in the United States: results from the HIV Cost and Services Utilization Study

OBJECTIVE

To establish population-based estimates of the prevalence of any alcohol consumption and heavy drinking among individuals who tested positive for human immunodeficiency virus (HIV) and to identify the factors associated with alcohol consumption and heavy drinking in this population.

METHOD

Data from the HIV Cost and Services Utilization Study (HCSUS), a national probability survey of HIV-infected adults receiving medical care in the U.S. in early 1996 (N = 2,864: 2,017 men, 847 women), were used to estimate the prevalence of any alcohol consumption and heavy drinking. Logistic regression was used to identify independent influences of sociodemographic, health status, and substance use variables on alcohol consumption and heavy drinking.

RESULTS

Approximately 53% of persons in care for HIV reported drinking alcohol in the preceding month and 8% were classified as heavy drinkers. Of those who drank, 15% were heavy drinkers. The odds of heavy drinking were significantly higher among users of cocaine or heroin and significantly lower among the better educated and those with an AIDS-defining illness.

CONCLUSIONS

Alcohol consumption is common among people in care for HIV, with rates of heavy drinking almost twice those found in the general population. Heavy drinking is especially higher among individuals with lower educational levels and users of cocaine or heroin.

Re-estimating the prevalence of psychiatric disorders in a nationally representative sample of persons receiving care for HIV: results from the HIV Cost and Services Utilization Study

The objective of this study was to obtain accurate estimates of the prevalence of psychiatric disorder in the population represented by the HIV Costs and Services Utilization Study cohort. We constructed logistic regression models to predict DSM-IV diagnoses of depression, generalized anxiety disorder, panic, and dysthymia among a subsample of the HCSUS cohort who in separate interviews completed the CIDI-SF and the full CIDI diagnostic interview. Diagnoses were predicted using responses to the CIDI-SF as well as other variables contained in the baseline and first follow-up interviews. Resulting regression equations were applied to the entire baseline and first follow-up samples to obtain new estimates of the prevalence of disorder. Compared to estimates based on the CIDI-SF alone, estimates obtained from this procedure provide a more accurate representation of the prevalence of the presence of any one of these four psychiatric disorders in this population, yielding more correct classifications and a lower false-positive rate. Prevalence rates reported in this study are as much as 16% lower than rates estimated using the CIDI-SF alone, but are still considerably higher than estimates for the general community population.

Effects of drug abuse and mental disorders on use and type of antiretroviral therapy in HIV-infected persons

OBJECTIVE

To distinguish the effects of drug abuse, mental disorders, and problem drinking on antiretroviral therapy (ART) and highly active ART (HAART) use.

DESIGN

Prospective population-based probability sample of 2,267 (representing 213,308) HIV-infected persons in care in the United States in early 1996.

MEASUREMENTS

Self-reported ART from first (January 1997-July 1997) to second (August 1997-January 1998) follow-up interviews. Drug abuse/dependence, severity of abuse, alcohol use, and probable mental disorders assessed in the first follow-up interview. Adjusted odds ratios (AORs) and 95% confidence intervals (CIs) estimated from weighted models for 1) receipt of any ART, and 2) receipt of HAART among those on ART.

RESULTS

Of our study population, ART was reported by 90% and HAART by 61%. Over one third had a probable mental disorder and nearly half had abused any drugs, but drug dependence (9%) or severe abuse (10%) was infrequent. Any ART was less likely for persons with dysthymia (AOR, 0.74; CI, 0.58 to 0.95) but only before adjustment for drug abuse. After full adjustment with mental health and drug abuse variables, any ART was less likely for drug dependence (AOR, 0.58; CI, 0.34 to 0.97), severe drug abuse (AOR, 0.52; CI, 0.32 to 0.87), and HIV risk from injection drug use (AOR, 0.55; CI, 0.39 to 0.79). Among drug users on ART, only mental health treatment was associated with HAART (AOR, 1.57; CI, 1.11 to 2.08).

CONCLUSIONS

Drug abuse-related factors were greater barriers to ART use in this national sample than mental disorders but once on ART, these factors were unrelated to type of therapy.

Psychiatric disorders and drug use among human immunodeficiency virus-infected adults in the United States

BACKGROUND

There have been no previous nationally representative estimates of the prevalence of mental disorders and drug use among adults receiving care for human immunodeficiency virus (HIV) disease in the United States. It is also not known which clinical and sociodemographic factors are associated with these disorders.

SUBJECTS AND METHODS

We enrolled a nationally representative probability sample of 2864 adults receiving care for HIV in the United States in 1996. Participants were administered a brief structured psychiatric instrument that screened for psychiatric disorders (major depression, dysthymia, generalized anxiety disorders, and panic attacks) and drug use during the previous 12 months. Sociodemographic and clinical factors associated with screening positive for any psychiatric disorder and drug dependence were examined in multivariate logistic regression analyses.

RESULTS

Nearly half of the sample screened positive for a psychiatric disorder, nearly 40% reported using an illicit drug other than marijuana, and more than 12% screened positive for drug dependence during the previous 12 months. Factors independently associated with screening positive for a psychiatric disorder included number of HIV-related symptoms, illicit drug use, drug dependence, heavy alcohol use, and being unemployed or disabled. Factors independently associated with screening positive for drug dependence included having many HIV-related symptoms, being younger, being heterosexual, having frequent heavy alcohol use, and screening positive for a psychiatric disorder.

CONCLUSIONS

Many people infected with HIV may also have psychiatric and/or drug dependence disorders. Clinicians may need to actively identify those at risk and work with policymakers to ensure the availability of appropriate care for these treatable disorders.

Use of mental health and substance abuse treatment services among adults with HIV in the United States

BACKGROUND

The need for mental health and substance abuse services is great among those with human immunodeficiency virus (HIV), but little information is available on services used by this population or on individual factors associated with access to care.

METHODS

Data are from the HIV Cost and Services Utilization Study, a national probability survey of 2864 HIV-infected adults receiving medical care in the United States in 1996. We estimated 6-month use of services for mental health and substance abuse problems and examined socioeconomic, HIV illness, and regional factors associated with use.

RESULTS

We estimated that 61.4% of 231 400 adults under care for HIV used mental health or substance abuse services: 1.8% had hospitalizations, 3.4% received residential substance abuse treatment, 26.0% made individual mental health specialty visits, 15.2% had group mental health treatment, 40.3% discussed emotional problems with medical providers, 29.6% took psychotherapeutic medications, 5.6% received outpatient substance abuse treatment, and 12.4% participated in substance abuse self-help groups. Socioeconomic factors commonly associated with poorer access to health services predicted lower likelihood of using mental health outpatient care, but greater likelihood of receiving substance abuse treatment services. Those with less severe HIV illness were less likely to access services. Persons living in the Northeast were more likely to receive services.

CONCLUSIONS

The magnitude of mental health and substance abuse care provided to those with known HIV infection is substantial, and challenges to providers should be recognized. Inequalities in access to care are evident, but differ among general medical, specialty mental health, and substance abuse treatment sectors.

The influence of remarriage on the racial difference in mother-only families in 1910

Historical demography documents that mother-only families were more common among African Americans than among Euro-Americans early in the twentieth century. We find direct evidence that African American males in both first and higher-order marriages were more likely to have (re)married previously married women and were more likely to have (re)married women with children. This racial difference in (re)marital partner choice reduced the racial difference in the prevalence of mother-only families such that, in the absence of such remarriage choices, the prevalence of mother-only families in the turn-of-the-century African American population would have been even higher than has been reported. Remarriage in this period countered the various demographic, economic, cultural, and social-institutional forces that disproportionately destabilized African American marriages; it must be taken into account more fully by analysts concerned with racial differences in family structure.

Use of unpaid and paid home care services among people with HIV infection in the USA

This paper examines utilization of paid and unpaid home health care using data from a nationally representative sample of HIV-positive persons receiving medical care in early 1996 (N = 2,864). Overall, 21.0% used any home care, 12.2% used paid care and 13.6% used unpaid care. Most (70.0%) users of home care received care from only one type of provider. Substantially more hours of unpaid than paid care were used. We also found evidence of a strong association between type of service used and type of care provider: 62.4% of persons who used nursing services only received paid care only; conversely, 55.5% of persons who used personal care services only received care only from unpaid caregivers. Use of home care overall was concentrated among persons with AIDS: 39.5% of persons with AIDS received any home health care, compared to 9.5% of those at earlier disease stages. In addition to having an AIDS diagnosis, logistic regression analyses indicated that other need variables significantly increased utilization; a higher number of HIV-related symptoms, lower physical functioning, less energy, a diagnosis of CMV and a recent hospitalization each independently increased the odds of overall home care utilization. Sociodemographic variables had generally weak relationships with overall home care utilization. Among users of home care, non-need variables had more influence on use of paid than unpaid care. Both paid and unpaid home health care is a key component of community-based systems of care for people with HIV infection. The results presented in this paper are the first nationally representative estimates of home care utilization by persons with HIV/AIDS and are discussed with reference to policy and future research.

The co-occurrence of correct and incorrect HIV transmission knowledge and perceived risk for HIV among women of childbearing age in El Salvador

This article examines the co-occurrence of correct and incorrect knowledge about documented and undocumented modes of HIV transmission among women of childbearing age in El Salvador, and the relationship between HIV transmission knowledge and perceived risk. Incorrect beliefs about HIV transmission co-occur at high levels with, and are largely independent of, accurate knowledge about documented modes of transmission. The co-occurrence of correct and incorrect HIV transmission knowledge was shown to have important implications for perceived risk. Both correct and incorrect HIV transmission knowledge increased the odds of risk perception; uncertainty about risk was decreased among those with higher levels of correct knowledge and increased among those with higher levels of incorrect knowledge. Among those who considered themselves to be at some risk for HIV, higher levels of correct knowledge reduced uncertainty about the degree of risk, while higher levels of incorrect knowledge increased the degree of risk perceived. High levels of endorsement of the documented modes of HIV transmission do not necessarily indicate accurate or adequate knowledge about HIV transmission in the population. Co-occurring inaccurate beliefs about undocumented modes of transmission reflect cultural understandings of contagion and disease, and influence how individuals make sense of medical-scientific information about transmission. Our results suggest that the co-occurrence of correct and incorrect HIV transmission knowledge shapes individual-level risk perceptions. Given the independence of accurate knowledge and inaccurate beliefs. HIV/AIDS education and prevention programs must seek to directly undermine inaccurate beliefs about HIV transmission as part of their efforts to promote behavior change.

The integration of informal care, case management and community-based services for persons with HIV/AIDS

This research examines the integration of informal and formal care for persons with HIV/AIDS. Data come from a panel survey of informal HIV/AIDS caregivers (N = 642) and are analyzed using a modified version of the Behavioral Model that allows for inclusion of predisposing, enabling and need characteristics of persons with HIV/AIDS and their caregivers. The outcome component of our model emphasizes the role of case management as an intermediary service designed to facilitate linkage to other services. Results indicate: substantial use of case management and other services among persons receiving informal care; characteristics of care recipients, caregivers and dyads directly influence case management and service use; case management positively influences service use at baseline and change in service use over time; and the association between case management and service use generates indirect influences on service use related to characteristics of care recipients, caregivers and dyads. These results highlight the importance of case management as a mechanism for integrating informal and formal care and demonstrate that service utilization is influenced by the social context of illness.

The physical costs of AIDS caregiving

Informal care has become an increasingly important element in the delivery of health and social services to people living with HIV disease or AIDS (PWAs), yet the provision of such care does not come without costs to the caregiver. Instead, caregiving imposes burdens that may compromise caregiver health. Common ailments among AIDS caregivers were examined with two waves of data from a diverse sample of informal care providers in Los Angeles and San Francisco (N = 642). Symptoms of poor physical health are markedly present among AIDS caregivers and are significantly associated with care-related demands and stressors. This stress and health relationship varies significantly between caregivers who are HIV seropositive and those who are seronegative. Care-related effects are more direct among seronegative caregivers who are perhaps less overwhelmed with the maintenance of their own health. For all caregivers studied, level of depression and prior physical health are strong correlates of these physical ailments. Implications of these results are discussed.

Socio-demographic correlates, HIV/AIDS-related cofactors, and measures of same-sex sexual behaviour among northern Thai male soldiers

We use data from an anonymous self-administered 1991 survey of military personnel in northern Thailand to estimate overall levels of and socio-demographic differentials in same-sex sexual behaviour in this population. Additionally, we examine the relationship between sexual experience with another male and a variety of outcomes relevant to HIV prevention and policy. Overall, 16.3 per cent of the sexually active soldiers report ever having had anal or oral sex with other males. Same-sex sexual behaviour in this sample is positively associated with several indicators of higher socio-economic status. All of the men who report having had sex with other men report having had vaginal intercourse with females as well. Comparison of our estimate of same-sex sexual behaviour with those obtained from two similar samples drawn in 1991 suggests that the lower estimates observed in the other two studies are largely due to differences in data collection methods. Regarding the HIV/AIDS-related outcomes we examined, men who have had sex with other men are significantly more likely than those who have not to have ever injected drugs, to personally know someone with HIV/AIDS, to have had sex with a female prostitute in the last six months, and to have had a sexually transmitted disease in the last six months. In this sample, men who have had sex with other men are also less knowledgeable about HIV/AIDS than are men who have not. These results are discussed in terms of their implications for HIV-prevention policy in Thailand.

Testing for human immunodeficiency virus infection among tuberculosis patients in Los Angeles

To investigate patterns of testing for human immunodeficiency virus (HIV) infection in tuberculosis patients, we obtained data from the tuberculosis registry and from medical records of 500 tuberculosis patients in Los Angeles County. Sixty-three percent of tuberculosis patients were tested for HIV infection, and multivariate logistic regression analysis revealed that the likelihood of testing was significantly higher among males, persons between 20 and 49 yr old, individuals with HIV risk factors, and patients treated by public health care providers. A minimum of 12% of the total sample, 2% of females, 2% of those outside the ages of 20 to 49, 7% of patients without recorded HIV risk factors, and 17% of patients treated by private practitioners were infected with HIV. These results suggest that health care providers, particularly private practitioners, do not follow national recommendations for universal HIV testing of tuberculosis patients. Instead, HIV testing is preferentially performed on patients perceived to be at high risk for HIV infection. Because HIV seroprevalence is at least 2 to 7% in "low-risk" groups, failure to test these patients may result in significant missed opportunities for diagnosis and treatment of HIV coinfection.

The impact of advances in medicine on the biometric analysis of infant mortality

Bourgeois-Pichat's biometric model was developed as a method to decompose infant mortality into endogenous and exogenous components. The model assumes that no endogenous deaths occur after the first month of life. This paper uses data for the United States to examine the hypothesis that recent advances in medicine extend endogenous mortality past the first month of life. The biometric model is found consistently to underestimate the endogenous infant mortality rate and to overestimate the exogenous infant mortality rate relative to cause of death analysis. Direct examination of the age distribution of infant mortality shows that the proportion of all infant mortality that occurs in the first month of life declined from 75.37 per cent in 1970 to 65.40 per cent in 1985, and that a significant and increasing proportion of the mortality occurring after the first month of life is due to endogenous causes. The development of new empirical models is suggested.