Barriers and Facilitators of Mental Health Treatment‐Seeking in U.S. Active Duty Soldiers With Sexual Assault Histories

Despite significant mental health needs among sexual assault (SA) victims in the military, little is known about treatment‐seeking patterns or factors associated with service use. This study examined service use behavior, barriers, and facilitators of mental health treatment‐seeking in an active duty sample of 927 U.S. Army soldiers with mental health problems. SA victims (n = 113) did not differ from non‐victims on barriers or facilitators after adjusting for demographic and mental health variables, with stigma rated as the largest barrier. Most SA victims (87.6%) had sought informal support and 59.3% had sought formal treatment. One third of treatment‐seekers had dropped out of treatment. Multivariate logistic regression analyses identified several correlates of treatment‐seeking among SA victims: Black race (OR = 7.57), SA during the military (OR = 4.34), positive treatment beliefs (OR = 2.22), social support for treatment (OR = 2.14), self‐reliance (OR = 0.47), and stigma towards treatment seekers (OR = 0.43). Mental health symptoms were not associated with treatment seeking. Findings suggested that treatment‐facilitating interventions should focus on improving recognition of mental health symptoms, altering perceptions related to self‐reliance, and reducing stigma. Interventions should also enlist support for treatment‐seeking from unit members, leaders, and significant others.     

Surveying Treatment Preferences in U.S. Iraq–Afghanistan Veterans With PTSD Symptoms: A Step Toward Veteran‐Centered Care

This study examined health care barriers and preferences among a self‐selected sample of returning U.S. veterans drawn from a representative, randomly selected frame surveyed about posttraumatic stress disorder (PTSD) symptomatology and mental health utilization in the prior year. Comparisons between treated (n = 160) and untreated (n = 119) veterans reporting PTSD symptoms were conducted for measures of barriers and preferences, along with logistic models regressing mental health utilization on clusters derived from these measures. Reported barriers corroborated prior research findings as negative beliefs about treatment and stigma were strongly endorsed, but only privacy concerns were associated with lower service utilization (B = ?0.408, SE = 0.142; p = .004). The most endorsed preference (91.0%) was for assistance with benefits, trailed by help for physical problems, and particular PTSD symptoms. Help‐seeking veterans reported stronger preferences for multiple interventions, and desire for services for families (B = 0.468, SE = 0.219; p = .033) and specific PTSD symptoms (B = 0.659, SE = 0.302; p = .029) were associated with increased utilization. Outcomes of the study suggested PTSD severity drove help‐seeking in this cohort. Results also support the integration of medical and mental health services, as well as coordination of health and benefits services. Finally, the study suggested that outreach about privacy protections and treatment options could well improve engagement in treatment.     

An Examination of Successful Soldier Postdeployment Transition From Combat to Garrison Life

Previous studies have shown that combat exposures and deployment‐related stressors have negative implications on soldiers’ postdeployment health and well‐being. The current study aimed to examine the individual and combined effects of organizational and social support on the success of soldiers’ postdeployment reintegration. In this study, 2,922 U.S. soldiers were surveyed from a brigade combat team at 90–120 days postdeployment, measuring soldiers’ perceptions of postdeployment transition home, occupational and social support, stigma and barriers associated with accessing behavioral health care, and previous behavioral health care. Logistic regression analysis indicated that soldiers reporting a positive postdeployment transition home (n = 1,776; 61%) was significantly associated with leadership perceptions, adjusted odds ratio (AOR) = 1.19, 95% confidence interval (CI) [1.02, 1.39], unit cohesion, AOR = 1.29, 95% CI [1.09, 1.53], personal support, AOR = 1.37, 95% CI [1.23, 1.52], perceived levels of stigma, AOR = 0.73, 95% CI [0.65, 0.82] barriers to accessing care, AOR = 0.86, 95% CI [0.76, 0.97], and previously accessing behavioral health care, AOR = 0.34, 95% CI [0.28, 0.43]. These findings suggest redeploying soldiers may benefit from programs aimed at improving self‐efficacy and coping through fostering occupational and social support, with special concern taken to reduce stigma and barriers to care across the Army.     

Mental Health Beliefs and Their Relationship With Treatment Seeking Among U.S. OEF/OIF Veterans

Many veterans who would benefit from mental health care do not seek treatment. The current study provided an in‐depth examination of mental health‐related beliefs and their relationship with mental health and substance abuse service use in a national sample of 640 U.S. Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) veterans. Both concerns about mental health stigma from others and personal beliefs about mental illness and mental health treatment were examined. Data were weighted to adjust for oversampling of women and nonresponse bias. Results revealed substantial variation in the nature of OEF/OIF veterans’ mental health beliefs, with greater anticipated stigma in the workplace (M = 23.74) than from loved ones (M = 19.30), and stronger endorsement of negative beliefs related to mental health treatment‐seeking (M = 21.78) than either mental illness (M = 18.56) or mental health treatment (M = 20.34). As expected, individuals with probable mental health problems reported more negative mental health‐related beliefs than those without these conditions. Scales addressing negative personal beliefs were related to lower likelihood of seeking care (ORs = 0.80–0.93), whereas scales addressing anticipated stigma were not associated with service use. Findings can be applied to address factors that impede treatment seeking.     

Impediments to Mental Health Treatment as Predictors of Mental Health Symptoms Following Combat

This longitudinal study examined whether impediments to mental health treatment would predict changes in mental health symptoms (posttraumatic stress disorder [PTSD] and depression) in the months following soldiers returning from combat. Three‐hundred ten combat veterans completed measures of impediments to treatment and measures of PTSD and depression symptoms at 2, 3, and 4 months following a 15‐month combat deployment. Structural equation modeling revealed that greater impediments (a latent variable indexed by stigma, practical barriers, and negative treatment attitudes) at 2 months predicted increased PTSD and depression symptoms from 2–3 months (β = .14) and greater impediments at 3 months predicted increased symptoms from 3–4 months (β = .26). In contrast, evidence was not obtained for the opposite causal direction of symptoms predicting higher levels of impediments at the different periods. Possible mechanisms for the predictive effects of impediments are discussed.     

Posttraumatic Stress and Stigma in Active‐Duty Service Members Relate to Lower Likelihood of Seeking Support

Posttraumatic stress disorder (PTSD) is a common mental health concern for returning service members. Social support is a robust predictor of resiliency and recovery from PTSD; however, barriers to seeking support are understudied. PTSD and anticipated enacted stigma from family and friends were explored as correlates of the likelihood of seeking support among 153 Iraq/Afghanistan U.S. service members. Results showed that PTSD (r = ?.31, p < .001) and anticipated enacted stigma (r = ?.22, p ≤ .01) were negatively associated with likelihood of seeking support. Post hoc analyses showed that only dysphoria (r = ?.32, p < .001) was significantly related to the likelihood of seeking support after accounting for anticipated enacted stigma and other PTSD clusters. Implications of these findings and ways to increase likelihood of seeking support are discussed.     

Hardiness,avoidance coping,and alcohol consumption in war veterans: A moderated‐mediation study

Military personnel often engage in excessive alcohol use after returning from deployments. Thus far, research has paid scant attention to personality factors that may increase or diminish the risk for increased alcohol consumption in this population. The present study explores how psychological hardiness, avoidance coping, and stress exposure may interact to influence alcohol consumption patterns in soldiers following deployment. U.S. Army National Guard soldiers (N = 357) were surveyed shortly after returning from combat operations in Afghanistan. Conditional process analysis was used to test for mediation and moderation effects. Mediation effects were further tested in a replication sample of Norwegian Army soldiers (N = 230) deployed to Kosovo. Findings show that hardiness is a significant (negative) predictor of increased alcohol use and that this relation is mediated by avoidance coping. Further, this effect was moderated by combat stress exposure in the U.S. sample, such that the mediation is stronger for those with greater exposure (moderated‐mediation). Avoidance coping also mediated the effects of hardiness on alcohol consumption in the Norwegian sample. These findings suggest that avoidance coping and hardiness may be fruitful areas for interventions aimed at reducing risky drinking in high‐stress groups like the military.     

Resilience and Posttraumatic Stress Disorder Symptoms in National Guard Soldiers Deployed to Iraq: A Prospective Study of Latent Class Trajectories and Their Predictors

This study examined the prospective course of posttraumatic stress disorder (PTSD) symptoms in a cohort of National Guard soldiers (N = 522) deployed to combat operations in Iraq. Participants were assessed 4 times: 1 month before deployment, 2–3 months after returning from deployment, 1 year later, and 2 years postdeployment. Growth mixture modeling revealed 3 distinct trajectories: low‐stable symptoms, resilient, 76.4%; new‐onset symptoms, 14.2%; and chronic distress, 9.4%. Relative to the resilient class, membership in both the new‐onset symptoms and chronic distress trajectory classes was predicted by negative emotionality/neuroticism, odds ratios (OR s) = 1.09, 95% CI [1.02, 1.17], and OR = 1.22, 95% CI [1.09,1.35], respectively; and combat exposure, OR = 1.07, 95% CI [1.02, 1.12], and OR = 1.12, 95% CI [1.02, 1.24], respectively. Membership in the new‐onset trajectory class was predicted by predeployment military preparedness, OR = 0.95, 95% CI [0.91, 0.98], perceived threat during deployment, OR = 1.07, 95% CI [1.03, 1.10], and stressful life events following deployment, OR = 1.44, 95% CI [1.05, 1.96]. Prior deployment to Iraq or Afghanistan, OR = 3.85, 95% CI [1.72, 8.69], predeployment depression, OR = 1.27, 95% CI [1.20, 1.36], and predeployment concerns about a deployment's impact on civilian/family life, OR = 1.09, 95% CI [1.02, 1.16], distinguished the chronic distress group relative to the resilient group. Identifying predeployment vulnerability and postdeployment contextual factors provides insight for future efforts to bolster resilience, prevent, and treat posttraumatic symptoms.     

Reproductive Efficiency of Three Estrus Synchronization Schemes Comprising Fixed‐Time Insemination in Dairy Cows

The objective of this field trial was to compare the odds of pregnancy at 25 days (P25) and at 60 days (P60), of embryonic death (ED) between 25 and 60 days, and of non‐pregnant cows returning to heat 20–25 days after artificial insemination (AI). Three fixed‐time insemination protocols involving combined administration of either double gonadotrophin‐releasing hormone (GnRH) and prostaglandins (A) or GnRH, human chorionic gonadotrophin (hCG) and prostaglandins (B), or double treatment with prostaglandins (C) were used. Cows included in the trial were selected from five herds, comprising a total of 735 (herd size range 85–250, median 120) Holstein dairy cows. Animals used for the study were multiparous, 4–7 years of age, had expressed at least one overt postpartum heat, were between 60 and 120 days of lactation and had at least one palpable corpus luteum and no gross morphological anomalies of their reproductive tracts. They were randomly allocated to receive treatment A (n = 89), B (n = 93), or C (n = 65). Pregnancy of cows not observed in heat 18–24 days post AI was diagnosed by transrectal ultrasonography at 25–30 days and confirmed by rectal palpation at 60–75 days post AI. Those that were detected in heat in the normal period post AI were re‐inseminated. No differences were detected among the three treatment groups concerning the odds of P25 (P = 0.5), P60 (P = 0.2) and ED (P = 0.13). In contrast, non‐pregnant cows that were administered treatment A were less likely to exhibit estrous signs in the normal period post AI than those administered treatments B (P = 0.02) or C (P = 0.005).     

Pretrauma Power and Control Beliefs and Posttraumatic Stress: A Longitudinal Study of Combat Soldiers

Belief in one's ability to exert power and control over outcomes following trauma has long been understood as protective against the development of posttraumatic stress disorder (PTSD). The role of pretrauma beliefs about power and control, however, remains unclear. Though a strong pretrauma belief in power and control may similarly be protective, we predicted such a belief may actually be a diathesis for PTSD. When exposed to trauma, individuals with a strong pretrauma belief in power and control may believe they should have prevented the trauma and/or their acute reactions. Such expectations may lead to negative self‐beliefs and a higher level of PTSD symptoms. Longitudinal structural equation modeling in a sample of combat soldiers (N = 305) supported our hypothesized model. Stronger predeployment power and control beliefs predicted more negative postdeployment self‐beliefs, β = .15, p = .035, 95% CI [.11, .18], and in turn, a higher level of PTSD symptoms, β = .08, 95% CI [.01, .15]. Prior combat exposure moderated these effects in that soldiers with no prior combat experience evidenced the hypothesized associations, whereas those with moderate or high prior combat exposure did not. Resilience interventions for soldiers who are first entering combat may thus benefit from promoting acceptance of uncontrollable events in addition to agentic change skills.     

Impact of Deployment‐Related Sexual Stressors on Psychiatric Symptoms After Accounting for Predeployment Stressors: Findings From a U.S. National Guard Cohort

This study used a longitudinal research design to examine the impact of predeployment stressors and deployment‐related sexual stressors on self‐reported psychiatric symptoms of U.S. National Guard soldiers returning from deployments to Iraq or Afghanistan. Prior to deployment, participants completed measures of depression and posttraumatic stress symptoms, along with an inventory of predeployment stressor experiences. At 3‐months postdeployment, participants (468 men, 60 women) again completed self‐report measures of psychiatric symptoms, along with an inventory of sexual stressors experienced during deployment. We compared a cross‐sectional model of sexual stressors’ impact on psychiatric symptoms, in which only postdeployment reports were considered, to a longitudinal model in which we adjusted for participants’ predeployment stressors and psychiatric symptoms. No participants reported sexual assault during deployment, though sexual harassment was common. The cross‐sectional model suggested that deployment‐related sexual stressors were significantly associated with postdeployment depression (R² = .11) and posttraumatic stress symptoms (R² = .10). Once predeployment factors were taken into consideration, however, sexual stressors were no longer significant. The results did not support the notion of lasting negative impact for low‐level sexual stressors (e.g., sexual harassment) during deployment after predeployment stressors are accounted for. Future studies of sexual stressors should consider longitudinal designs.     

Adjuvant treatment with ursodeoxycholic acid reduces acute rejection after liver transplantation

Acute rejection, occurring with a reported frequency of 50–70%, is still a dominating problem after liver transplantation. Medication with ursodeoxycholic acid (UDCA) has beneficial effects in different cholestatic conditions and has also been shown to reduce HLA class I antigen expression on hepatocytes in patients with PBC. Since August 1989 we have consecutively treated all patients with primary graft function with UDCA (n = 41). Patients transplanted in the first half of 1989 served as a control group (n = 8). All patients in this study were given sequential quadruple drug immunosuppression. The treatment group were given oral UDCA 10 mg/kg per day. During the first postoperative month, 17% of the UDCA-treated patients had an episode of acute rejection compared with 75% of the control patients (P < 0.01). Liver biochemistry tests 1 month postoperatively were significantly better in patients treated with UDCA. The results suggest that adjuvant treatment with UDCA reduces acute liver graft rejection.     

Barriers and facilitators to HIV testing among young men who have sex with men and transgender women in Kingston,Jamaica: a qualitative study

Introduction : Young men who have sex with men (MSM) in Jamaica have the highest HIV prevalence in the Caribbean. There is little information about HIV among transgender women in Jamaica, who are also overrepresented in the Caribbean epidemic. HIV‐related stigma is a barrier to HIV testing among Jamaica's general population, yet little is known of MSM and transgender women's HIV testing experiences in Jamaica. We explored perceived barriers and facilitators to HIV testing among young MSM and transgender women in Kingston, Jamaica. Methods : We implemented a community‐based research project in collaboration with HIV and lesbian, gay, bisexual and transgender (LGBT) agencies in Kingston. We held two focus groups, one with young (aged 18–30 years) transgender women (n = 8) and one with young MSM (n = 10). We conducted 53 in‐depth individual semi‐structured interviews focused on HIV testing experiences with young MSM (n = 20), transgender women (n = 20), and community‐based key informants (n = 13). We conducted thematic analysis to identify, analyze, and report themes. Results : Participant narratives revealed social‐ecological barriers and facilitators to HIV testing. Barriers included healthcare provider mistreatment, confidentiality breaches, and HIV‐related stigma: these spanned interpersonal, community and structural levels. Healthcare provider discrimination and judgment in HIV testing provision presented barriers to accessing HIV services (e.g. treatment), and resulted in participants hiding their sexual orientation and/or gender identity. Confidentiality concerns included: clinic physical arrangements that segregated HIV testing from other health services, fear that healthcare providers would publicly disclose their status, and concerns at LGBT‐friendly clinics that peers would discover they were getting tested. HIV‐related stigma contributed to fear of testing HIV‐positive; this intersected with the stigma of HIV as a “gay” disease. Participants also anticipated healthcare provider mistreatment if they tested HIV positive. Participants identified individual (belief in benefits of knowing one's HIV status), social (social support) and structural (accessible testing) factors that can increase HIV testing uptake. Conclusions : Findings suggest the need for policy and practice changes to enhance confidentiality and reduce discrimination in Jamaica. Interventions to challenge HIV‐related and LGBT stigma in community and healthcare settings can enhance access to the HIV prevention cascade among MSM and transgender youth in Jamaica.     

Skin Autofluorescence,a Measure of Cumulative Metabolic Stress and Advanced Glycation End Products,Decreases During the Summer in Dialysis Patients

Tissue advanced glycation end products (AGEs) are a measure of cumulative metabolic and oxidative stress and cytokine‐driven inflammatory reactions. AGEs are thought to contribute to the cardiovascular complications of hemodialysis (HD) patients. Skin autofluorescence (SAF) is related to the tissue accumulation of AGEs and rises with age. SAF is one of the strongest prognostic markers of mortality in these patients. The content of AGEs is high in barbecue food. Due to the location in northern Sweden, there is a short intense barbecue season between June and August. The aim of this study was to investigate if seasonal variations in SAF exist in HD patients, especially during the barbecue season. SAF was measured noninvasively with an AGE Reader in 34 HD‐patients (15 of those with diabetes mellitus, DM). Each time the median of three measures were used. Skin‐AF was measured before and after each one HD at the end of February and May in 31 patients (22 men/9 women); the end of May and August in 28 (20 m/8 w); the end of August and March in 25 (19 m/6 w). Paired statistical analyses were performed during all four periods (n = 23, 17 m/6 w); as was HbA1c of those with DM. There was at a median 5.6% increase in skin‐AF during the winter period (February–May, P = 0.004) and a 10.6% decrease in the skin‐AF during the summer (May–August, P < 0.001). HbA1c in the DM rose during the summer (P = 0.013). In conclusion, skin‐AF decreased significantly during the summer. Future studies should look for favorable factors that prevent skin‐AF and subsequently cardiovascular diseases.     

Findings from the Tushirikiane mobile health (mHealth) HIV self-testing pragmatic trial with refugee adolescents and youth living in informal settlements in Kampala,Uganda

Introduction

Urban refugee youth remain underserved by current HIV prevention strategies, including HIV self-testing (HIVST). Examining HIVST feasibility with refugees can inform tailored HIV testing strategies. We examined if HIVST and mobile health (mHealth) delivery approaches could increase HIV testing uptake and HIV status knowledge among refugee youth in Kampala, Uganda.

Methods

We conducted a three-arm pragmatic controlled trial across five informal settlements grouped into three sites in Kampala from 2020 to 2021 with peer-recruited refugee youth aged 16–24 years. The intervention was HIVST and HIVST + mHealth (HIVST with bidirectional SMS), compared with standard of care (SOC). Primary outcomes were self-reported HIV testing uptake and correct status knowledge verified by point-of-care testing. Some secondary outcomes included: depression, HIV-related stigma, and adolescent sexual and reproductive health (SRH) stigma at three time points (baseline [T0], 8 months [T1] and 12 months [T2]). We used generalized estimating equation regression models to estimate crude and adjusted odds ratios comparing arms over time, adjusting for age, gender and baseline imbalances. We assessed study pragmatism across PRECIS-2 dimensions.

Results

We enrolled 450 participants (50.7% cisgender men, 48.7% cisgender women, 0.7% transgender women; mean age: 20.0, standard deviation: 2.4) across three sites. Self-reported HIV testing uptake increased significantly from T0 to T1 in intervention arms: HIVST arm: (27.6% [n = 43] at T0 vs. 91.2% [n = 135] at T1; HIVST + mHealth: 30.9% [n = 47] at T0 vs. 94.2% [n = 113] at T1]) compared with SOC (35.5% [n = 50] at T0 vs. 24.8% [ = 27] at T1) and remained significantly higher than SOC at T2 (p<0.001). HIV status knowledge in intervention arms (HIVST arm: 100% [n = 121], HIVST + mHealth arm: 97.9% [n = 95]) was significantly higher than SOC (61.5% [n = 59]) at T2. There were modest changes in secondary outcomes in intervention arms, including decreased depression alongside increased HIV-related stigma and adolescent SRH stigma. The trial employed both pragmatic (eligibility criteria, setting, organization, outcome, analysis) and explanatory approaches (recruitment path, flexibility of delivery flexibility, adherence flexibility, follow-up).

Conclusions

Offering HIVST is a promising approach to increase HIV testing uptake among urban refugee youth in Kampala. We share lessons learned to inform future youth-focused HIVST trials in urban humanitarian settings.     

Missed opportunities for HIV testing among those who accessed sexually transmitted infection (STI) services,tested for STIs and diagnosed with STIs: a systematic review and meta-analysis

Introduction

Of 37.7 million people living with HIV in 2020, 6.1 million still do not know their HIV status. We synthesize evidence on concurrent HIV testing among people who tested for other sexually transmitted infections (STIs).

Methods

We conducted a systematic review using five databases, HIV conferences and clinical trial registries. We included publications between 2010 and May 2021 that reported primary data on concurrent HIV/STI testing. We conducted a random-effects meta-analysis and meta-regression of the pooled proportion for concurrent HIV/STI testing.

Results

We identified 96 eligible studies. Among those, 49 studies had relevant data for a meta-analysis. The remaining studies provided data on the acceptability, feasibility, barriers, facilitators, economic evaluation and social harms of concurrent HIV/STI testing. The pooled proportion of people tested for HIV among those attending an STI service (n = 18 studies) was 71.0% (95% confidence intervals: 61.0–80.1, I² = 99.9%), people tested for HIV among those who were tested for STIs (n = 15) was 61.3% (53.9–68.4, I² = 99.9%), people tested for HIV among those who were diagnosed with an STI (n = 13) was 35.3% (27.1–43.9, I² = 99.9%) and people tested for HIV among those presenting with STI symptoms (n = 3) was 27.1% (20.5–34.3, I² = 92.0%). The meta-regression analysis found that heterogeneity was driven mainly by identity as a sexual and gender minority, the latest year of study, country-income level and region of the world.

Discussion

This review found poor concurrent HIV/STI testing among those already diagnosed with an STI (35.3%) or who had symptoms with STIs (27.1%). Additionally, concurrent HIV/STI testing among those tested for STIs varied significantly according to the testing location, country income level and region of the world. A few potential reasons for these observations include differences in national STI-related policies, lack of standard operation procedures, clinician-level factors, poor awareness and adherence to HIV indicator condition-guided HIV testing and stigma associated with HIV compared to other curable STIs.

Conclusions

Not testing for HIV among people using STI services presents a significant missed opportunity, particularly among those diagnosed with an STI. Stronger integration of HIV and STI services is urgently needed to improve prevention, early diagnosis and linkage to care services.     

Intimate relationships among returning soldiers: The mediating and moderating roles of negative emotionality,PTSD symptoms,and alcohol problems

Research examining relationship quality among combat veterans largely focuses on the role of posttraumatic stress disorder (PTSD), with less attention devoted to other correlates of PTSD and relationship quality, such as personality and problematic drinking. In a sample of combat‐exposed National Guard soldiers recently returned from Iraq (N = 308), we examined (a) a meditational pathway from negative emotionality, to elevated postdeployment PTSD symptoms, to poorer relationship quality; and (b) the moderating role of problematic drinking. Moderated mediation regression strategies supported the mediating role of postdeployment PTSD symptoms, but not the moderating role of problematic drinking on soldiers' relationship quality. Findings suggest negative emotionality creates a vulnerability to more severe early postdeployment PTSD symptoms and poorer early postdeployment relationship quality.     

Psychosocial education improves low back pain beliefs: results from a cluster randomized clinical trial (NCT00373009) in a primary prevention setting

The general population has a pessimistic view of low back pain (LBP), and evidence-based information has been used to positively influence LBP beliefs in previously reported mass media studies. However, there is a lack of randomized trials investigating whether LBP beliefs can be modified in primary prevention settings. This cluster randomized clinical trial investigated the effect of an evidence-based psychosocial educational program (PSEP) on LBP beliefs for soldiers completing military training. A military setting was selected for this clinical trial, because LBP is a common cause of soldier disability. Companies of soldiers (n = 3,792) were recruited, and cluster randomized to receive a PSEP or no education (control group, CG). The PSEP consisted of an interactive seminar, and soldiers were issued the Back Book for reference material. The primary outcome measure was the back beliefs questionnaire (BBQ), which assesses inevitable consequences of and ability to cope with LBP. The BBQ was administered before randomization and 12 weeks later. A linear mixed model was fitted for the BBQ at the 12-week follow-up, and a generalized linear mixed model was fitted for the dichotomous outcomes on BBQ change of greater than two points. Sensitivity analyses were performed to account for drop out. BBQ scores (potential range: 9–45) improved significantly from baseline of 25.6 ± 5.7 (mean ± SD) to 26.9 ± 6.2 for those receiving the PSEP, while there was a significant decline from 26.1 ± 5.7 to 25.6 ± 6.0 for those in the CG. The adjusted mean BBQ score at follow-up for those receiving the PSEP was 1.49 points higher than those in the CG (P < 0.0001). The adjusted odds ratio of BBQ improvement of greater than two points for those receiving the PSEP was 1.51 (95% CI = 1.22–1.86) times that of those in the CG. BBQ improvement was also mildly associated with race and college education. Sensitivity analyses suggested minimal influence of drop out. In conclusion, soldiers that received the PSEP had an improvement in their beliefs related to the inevitable consequences of and ability to cope with LBP. This is the first randomized trial to show positive influence on LBP beliefs in a primary prevention setting, and these findings have potentially important public health implications for prevention of LBP.     

Posttraumatic Stress Disorder and Barriers to Care in Eastern Cape Province,South Africa

A range of barriers to seeking mental health care in low‐ and middle‐income countries has been investigated. Little, however, is known of the barriers to care and help‐seeking behavior among people with posttraumatic stress disorder (PTSD) in low‐ and middle‐income countries. This was a population‐based study including 977 people aged 18–40 years from the Eastern Cape Province in South Africa. Current PTSD was assessed by using a diagnostic questionnaire (Mini International Psychiatric Interview). An additional questionnaire captured socioeconomic and health‐related data. The prevalence of current PTSD was 10.8%. Only 48.1% of people with current PTSD accessed health care services. Younger people aged 18 to 29 years were less likely to seek health care, OR = 0.36, 95% CI [0.15, 0.85]. People earning a salary or wage, OR = 2.91, 95% CI [1.26, 6.71]; and those with tuberculosis, OR = 11.63, 95% CI [1.42, 95.56], were more likely to seek health care. A range of barriers to seeking care were identified, the most striking being stigma and a lack of knowledge regarding the nature and treatment of mental illness. People with current PTSD may seek help for other health concerns and brief screening means those affected may be readily identified.