Minor-attracted persons (MAPs; N = 293; 154 completed all questions) responded to 10 open-ended questions that were designed to capture in their own words their experiences of seeking treatment. We conducted a qualitative analysis of their responses using grounded theory, which is designed to allow themes to emerge from their responses without preconceived notions or expectations. Using this method, we coded answers and then calculated the total number of times that each theme was cited across the entirety of the survey. The most prominent theme that participants cited in their responses was the experience and/or fear of stigma (n = 87). Stigma plays a significant role in their willingness to engage in the treatment process. Some participants noted their concerns about how some attractions to minors should be viewed as “normal” and is unfairly stigmatized (“normalizing”; n = 63). Other prominent themes included shame (n = 50), which focused on internal views of themselves as a “bad person”; a perceived lack of understanding by professionals about MAPs (n = 50); and the importance of building a community with other nonoffending MAPs (either in person or online; n = 45). In addition, other identified themes included fear of being judged (n = 31), statements that they had never acted on their attractions (n = 31), and a fear of being reported (n = 31). Implications for practice and policy are discussed.

Background Military service inherently includes frequent periods of high-stress training, operational tempo, and sustained deployments to austere far-forward environments. These occupational requirements can contribute to acute and chronic sleep disruption, fatigue, and behavioral health challenges related to acute and chronic stress and disruption of team dynamics. To date, there is no centralized mobile health platform that supports self- and supervised detection, monitoring, and management of sleep and behavioral health issues in garrison and during and after deployments. Objective The objective of this study was to adapt a clinical decision support platform for use outside clinical settings, in garrison, and during field exercises by medics and soldiers to monitor and manage sleep and behavioral health in operational settings. Methods To adapt an existing clinical decision support digital health platform, we first gathered system, content, and context-related requirements for a sleep and behavioral health management system from experts. Sleep and behavioral health assessments were then adapted for prospective digital data capture. Evidence-based and operationally relevant educational and interventional modules were formatted for digital delivery. These modules addressed the management and mitigation of sleep, circadian challenges, fatigue, stress responses, and team communication. Connectivity protocols were adapted to accommodate the absence of cellular or Wi-Fi access in deployed settings. The resulting apps were then tested in garrison and during 2 separate field exercises. Results Based on identified requirements, 2 Android smartphone apps were adapted for self-monitoring and management for soldiers (Soldier app) and team supervision and intervention by medics (Medic app). A total of 246 soldiers, including 28 medics, received training on how to use the apps. Both apps function as expected under conditions of limited connectivity during field exercises. Areas for future technology enhancement were also identified. Conclusions We demonstrated the feasibility of adapting a clinical decision support platform into Android smartphone–based apps to collect, save, and synthesize sleep and behavioral health data, as well as share data using adaptive data transfer protocols when Wi-Fi or cellular data are unavailable. The AIRE (Autonomous Connectivity Independent System for Remote Environments) prototype offers a novel self-management and supervised tool to augment capabilities for prospective monitoring, detection, and intervention for emerging sleep, fatigue, and behavioral health issues that are common in military and nonmilitary high-tempo occupations (eg, submarines, long-haul flights, space stations, and oil rigs) where medical expertise is limited.

Introduction Multi-domain operational combat environments will likely restrict key components of current behavioral health (BH) service delivery models. Combat teams in far-forward outposts or extended missions may need to rely on their own internal assets to manage combat and operational stress reactions for extended periods of time. As such, combat medics are expected to take on additional responsibilities as providers of BH support for isolated teams. As they receive limited BH training, medics require additional training to sufficiently respond to combat and operational stress reactions in their assigned teams. This study provided combat medics with a BH training and a mobile application–based support tool that would assist them in identifying and responding to BH concerns in their soldiers. The current analysis examines pre- to post-training changes in attitudes related to utilizing BH skills. Materials and Methods We created a brief training aimed to increase medics’ ability and confidence regarding managing BH issues. Its development was part of a study on the feasibility of the Soldier and Medic Autonomous Connectivity Independent System for Remote Environments (AIRE) apps (NOCTEM, LLC), a digital system designed for far-forward BH and sleep monitoring and management. Participants were combat medics from two Army combat brigades preparing for a training rotation through a combat training center (CTC). A total of 16 medics consented to participation with nine medics available at the follow-up after the field exercise. Medics were surveyed before the training and after their return from the CTC. Results In pre-training surveys, most medics indicated it was within their scope to assess for stress/anxiety, suicidal risk, stress reaction, and sleep problems; assist soldiers with optimizing work performance; and provide interventions for BH concerns and sleep problems. Less than half believed it was within their scope to assess and address team communication issues or provide intervention for stress reactions. After the CTC rotation, more medics endorsed that it was in their scope to provide interventions for acute stress reactions to traumatic events. Before the CTC rotation, at most 60% of the group felt at least moderately confident in utilizing the BH skills of discussing problems, assessing for concerns, and providing interventions. After CTC, the confidence levels for each skill increased or remained the same for most medics. Intervention skills had the highest proportion of medics (66%) reporting increased confidence in using the skills. Conclusions A larger proportion of medics believed it was within their scope of work and felt confident in assessing BH problems, and a smaller proportion believed it is within their scope of work and felt confident in applying interventions. The training increased most medics’ confidence to administer interventions for BH and team communication issues. Similar training programs can help medics serve as support for a wide variety of circumstances when the brigade’s mental health teams are inaccessible. Additionally, the Medic AIRE app expanded the ability to evaluate and provide interventions without extensive training in treatment modalities or BH conditions. This concept shows promise for providing medics with actionable tools when training time is limited such as during preparation for extended deployments.

Introduction Sleep and fatigue management strategies can substantially impact the Armed Forces’ readiness and fitness. These strategies can be implemented with behavioral health personnel and Wi-Fi connectivity to support real-time assessment, monitoring, and intervention. However, these resources are not readily available in multi-domain operational (MDO) environments. An autonomous Wi-Fi-independent digital sleep and fatigue management tool (DSFMT) could offer a critical advantage in detecting, monitoring, and providing just-in-time sleep and fatigue recommendations for Soldiers and support unit performance. We describe how we adapted a validated sleep-focused clinical decision support platform into a DSFMT for use in MDO environments. Methods Semi-structured interviews were conducted with 6 Army Key Opinion Leaders (KOLs) to assess perceived utility of a DSFMT and identify key requirements. We also conducted a literature review to identify evidence-based sleep optimization and fatigue mitigation strategies in real or simulated military environments, or occupations with high sleep disruption. Directives for sleep and fatigue management from all branches of the U.S. Armed Forces were reviewed. Results KOLs were enthusiastic about the proposed DSFMT and emphasized three requirements: (1) brief and actionable content; (2) tap into Soldiers’ competitive nature; (3) provide unit level metrics to the medic. Five sleep education topics (e.g., consequences of insufficient sleep) and eight evidence-based sleep self-optimization strategies (e.g., sleep banking) were identified and included in the digital content. The resulting DSFMT consists of a smartphone-based Soldier App that captures self-reported sleep and fatigue data and offers individualized feedback and self-management strategies, and a Medic App that displays aggregate unit-level sleep and fatigue status. The apps operate when connected to Wi-Fi and have capabilities for offline data collection and transfer via Bluetooth. Conclusion We created an initial prototype of an autonomous Wi-Fi-independent DSFMT that can be used in MDO environments and meets KOL requirements. 246 Soldiers have field tested this prototype. Findings from ongoing acceptability and feasibility analyses will inform the next iteration. Support (If Any) This project is partially funded by MTEC-19-02-TeleSleep-001-2019-406. The opinions and assertions contained herein are those of the authors and do not necessarily reflect the views of the U.S. Army or the U.S. Department of Defense.

UNSTRUCTURED Introduction. Military service inherently includes frequent periods of high stress training, operational tempo and sustained deployments to austere far forward environments. These occupational requirements can contribute to acute and chronic sleep disruption, fatigue, as well as behavioral health (BH) challenges related to acute and chronic stress and disruption of team dynamics. To date, there is no centralized mobile health platform that supports self- and supervised detection, monitoring, and management of sleep and BH issues in garrison and during and after deployments. The objective of this study was to adapt a clinical decision support platform for use outside clinical settings, in garrison and during field exercises, by medics and soldiers to monitor and manage sleep and BH in operational settings. Methods. To adapt an existing clinical decision support digital health platform, we first gathered system, content, and context-related requirements for a sleep and BH management system from experts. Sleep and BH assessments were then adapted for prospective digital data capture. Evidence-based and operationally relevant educational and interventional modules were formatted for digital delivery. These modules addressed the management and mitigation of sleep, circadian challenges, fatigue, stress responses, and team communication. Connectivity protocols were adapted to accommodate the absence of cellular or Wi-Fi access in deployed settings. The resulting apps were then tested in garrison and during two separate field exercises. Results. Based on identified requirements, two Android smartphone apps were adapted for self-monitoring and management for Soldiers (Soldier app) and team supervision and intervention by medics (Medic app). Two-hundred and forty six soldiers, including 28 medics received training on how to use the apps. Both apps function as expected under conditions of limited connectivity during field exercises. Areas for future technology enhancement were also identified. Conclusion. We demonstrated the feasibility of adapting a clinical decision support platform into Android smartphone-based applications to collect, save, and synthesize sleep and BH data, as well as share data using adaptive data transfer protocols when Wi-Fi or cellular data are unavailable. The AIRE prototype offers a novel self-management and supervised tool to augment capabilities for prospective monitoring, detection, and intervention for emerging sleep, fatigue, and BH issues that are common in military and non-military high-tempo occupations (e.g., submarines; long-haul flights; space station; oil rigs) where medical expertise is limited.