Measurement of Military Combat Exposure Among Women: Analysis and Implications

Early-Life War Exposure and Later-Life Frailty Among Older Adults in Vietnam: Does War Hasten Aging?

OBJECTIVES

To assess the nature and degree of association between exposure to potentially-traumatic wartime experiences in early life, such as living in a heavily bombed region or witnessing death first-hand, and later-life frailty.

METHODS

The Vietnam Health and Aging Study included war survivors in Vietnam, 60+, who completed a survey and health exam between May and August 2018. Latent Class Analysis is used to construct classes exposed to similar numbers and types of wartime experiences. Frailty is measured using a deficit accumulation approach that proxies biological aging. Fractional logit regression associates latent classes with frailty scores. Coefficients are used to calculate predicted frailty scores and expected age at which specific levels of frailty are reached across wartime exposure classes.

RESULTS

LCA yields nine unique wartime exposure classes, ranging from extreme exposure to non-exposed. Higher frailty is found among those with more heavy/severe exposures with a combination of certain types of experiences, including intense bombing, witnessing death first-hand, having experienced sleep disruptions during wartime, and having feared for one's life during war. The difference in frailty-associated aging between the most and least affected individuals is more than 18 years.

DISCUSSION

War trauma hastens aging and warrants greater attention toward long-term implications of war on health among vast post-conflict populations across the globe.

Association of Lifetime TBI and Military Employment with Late-Life ADL Functioning: A Population-Based Prospective Cohort Study

OBJECTIVE

To determine associations of traumatic brain injury (TBI) and military employment with activities of daily living (ADL) in late life.

SETTING

Community-based integrated healthcare delivery system.

PARTICIPANTS

Male (n=2066) and female (n=2887), aged 65+ and dementia-free.

DESIGN

Population-based prospective cohort study with biennial follow-up and censoring at time of dementia diagnosis.

MAIN OUTCOME MEASURES

ADL difficulties at baseline and accumulation during follow-up.

RESULTS

TBI with loss of consciousness (LOC) before age 40 was associated with slightly higher ADL difficulty at baseline for females (RR=1.44, 95% CI: 1.08-1.93, p=0.01). For males, TBI with LOC at any age was associated with greater ADL difficulty at baseline (age <40: RR=1.58, 95% CI: 1.20 - 2.08, p = 0.001; age 40+: RR=2.14, 95% CI: 1.24 - 3.68, p = 0.006). TBI with LOC was not associated with the rate of accumulation of ADL difficulties over time in males or females. There was no evidence of an association between military employment and either outcome, nor of an interaction between military employment and TBI with LOC. Findings were consistent across a variety of sensitivity analyses.

CONCLUSION

Further investigation into factors underlying greater late-life functional impairment among TBI survivors is warranted.

Psychosocial functioning in veterans with combat-related PTSD: An evolutionary concept analysis

BACKGROUND

Veterans returning from combat have a greater risk for developing posttraumatic stress disorder (PTSD) and greater severity of psychosocial functioning impairment. Previous research has demonstrated the strong association between PTSD and psychosocial functioning impairment. Psychosocial functioning is an ambiguous term often used in literature to discuss PTSD-associated consequences, intervention response, and symptom progression. An evolutionary concept analysis was conducted to clarify understanding of psychological functioning in veterans with combat-related PTSD. Rodgers' method for an evolutionary concept analysis was used to examine the concept of psychosocial functioning. A literature search using the Cumulative Index to Nursing and Allied Health Literature and SCOPUS databases and subsequent screening yielded twenty articles meeting established criteria for analysis. The analysis highlights significant attributes, antecedents, consequences, and implications for future concept development. Psychosocial functioning environment/domain, social support, and engagement in treatment were distinguishing attributes identified. Combat exposure and various PTSD symptoms are related antecedents. Consequences such as decreased intimacy, decreased work function, low parenting satisfaction, and inadequate productivity in educational settings are all components of this concept. The concept of psychosocial functioning is meaningful in the everyday lives of US combat veterans with PTSD and requires special consideration in treatment planning by healthcare providers.

Military Deployments and Suicide: A Critical Examination

Deployment to a combat zone is a fundamental mission for most military forces, but prior research suggests that there is a complex and nuanced association between deployment and related risk factors for suicide. Deployment and combat experiences vary greatly among military personnel and can affect a variety of protective and risk factors for suicide. This article offers a critical examination of the association among modern U.S. military deployments, suicide attempts, and death while considering the context of a prominent theory of suicide. Although previous work has demonstrated that deployment is not associated with suicide overall in this population, there is growing evidence that risk may be elevated shortly after deployment, and for some subgroups. Specific aspects of combat exposure, including the experience of killing or witnessing death in combat, may be important contributing factors. An analysis of the literature illustrates that deployment-related risk factors for suicide are complex. The limitations of the literature are discussed, and future directions are suggested.

Depression in Female Veterans Returning from Deployment: The Role of Social Factors

Objective

Women are serving in the armed forces and deployed to areas of conflict in increasing numbers. Problems such as depressive symptoms and risks related to combat exposure can have negative effects on adjustment following service; understanding the relationship between these problems may contribute to strategies providers can use to facilitate healthy adjustment after deployment. The purpose of this study is to examine social factors as they relate to mental health adjustment, namely depressive symptoms among female veterans who served in Iraq and Afghanistan as part of Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn (OND). We hypothesized that combat exposure would predict higher levels of depressive symptoms and that social support would moderate the relationship between combat exposure and depression.

Methods

In a cross-sectional design, 128 female Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn veterans completed an online survey about combat experience, social support, depression, demographic characteristics, and behavioral health symptom history. We conducted multiple regression analyses to examine linear and moderating relationships.

Results

There was no significant relationship between combat exposure and depression; social support did not significantly moderate the relationship between combat exposure and depression. However, higher levels of social support and financial comfort were significantly related to lower levels of depression.

Conclusion

This study highlights the role of social factors, specifically social support and perceived financial status, as potential barriers to healthy emotional readjustment following deployment. These findings suggest that it may be beneficial for mental health providers to screen female veterans and refer them to appropriate services to reduce financial stressors and strengthen their use of social support. More research should continue to examine more fully the impact of combat exposure on female service members' mental health and work to isolate the factors most strongly related to depression.

Development of Veteran-Centric Competency Domains for Psychiatric-Mental Health Nurse Practitioner Residents

The mental health needs of military service members, Veterans, and their families are a designated national priority; however, there has been little emphasis on the inclusion of Veteran-centric domains in competency-based nursing education for psychiatric-mental health nurse practitioners (PMHNPs). The current article describes the identification and application of Veteran-centric domains in an innovative pilot residency program for PMHNPs, funded by the Veterans Health Administration Office of Academic Affiliations. Fourteen Veteran-centric competency domains were developed from literature review, including knowledge, attitudes, and skill behaviors. Adoption and application of these domains in curricular components included the resident competency evaluation, baseline assessment of military experience, and evidence-based practice seminars and training. Methods of competency domain evaluation are presented, along with gaps related to the evaluation of competency skills. The delivery of mental health services reflecting these domains is consistent with the VA core values and goal of developing a positive service culture. [Journal of Psychosocial Nursing and Mental Health Services, 54(11), 31-36.].

Deployed Women Veterans: Important Culturally Sensitive Care

PROBLEM

Today, with almost 23 million veterans in the nation, and currently only about 10 million, or less, of them seeking active services associated with the Veterans Administration (VA) health facilities, these men and women veterans will be seeking some, more, or even all of their health care over their life time in civilian-based facilities.

METHODS

Pertinent literary sources were reviewed to gather applicable data about the problem.

FINDINGS

Every patient that enters your health facility should be asked an essential assessment question: "Have you served in the military?" Importantly, to gain effective rapport when they present, civilian nurses will need to anticipate their health needs and provide culturally sensitive care. Specific issues of deployed women veterans are provided in a series of two articles.

CONCLUSION

This article provides a snapshot of the uniquely entrenched military culture, as well as women service member experiences in wartime, including the Global War on Terror (Iraq and Afghanistan). The next article discusses the various healthcare differences (e.g., post-traumatic stress disorder and military sexual trauma), difficulties (e.g., reproductive, gynecologic, urinary, employment, homelessness issues), and gender disparities (varied treatment patterns) so the civilian nurse can better advocate for women veterans.

Assessment of a Revised Wartime Experiences Scale for Vietnam-Era Women: The Health of Vietnam-Era Women's Study (HealthViEWS)

PURPOSE

Few wartime experiences scales capture unique issues related to women's service, address their military roles, or have been validated with women. The Women's Wartime Stressor Scale was developed for use with women who served during the Vietnam era, primarily as nurses in Vietnam. We revised this measure by modifying existing items, adding new items, and revising response formats to create a scale less nursing specific and nondeployment specific, and conducted a preliminary assessment of the revised scale.

METHODS

The Women's Wartime Exposure Scale-Revised (WWES-R) was included in a mail survey as part of the U.S. Department of Veterans Affairs Health of Vietnam-Era Women's Study (HealthViEWS) study. Construct and criterion validity, and internal consistency, were assessed with a sample of 4,839 women veterans using exploratory factor analysis, analysis of variance, and multiple linear regression.

RESULTS

Six wartime experience factors consistent with previous research were identified and scales were created based on salient item loadings. Compared with women serving in the United States, women serving in Vietnam had higher mean scores on all scales, and nurses had significantly higher scores on three scales than non-nurses.

CONCLUSIONS

Evaluation of the WWES-R suggests service and/or deployment location and service in a military health care versus a non-health care role may predict women veterans' reports of certain wartime experiences. Further psychometric evaluation of the WWES-R is recommended with later era veterans and through comparisons to other wartime exposure measures.

Suicide Risk Among Wounded U.S. Service Members

The association between suicide and combat injuries sustained during the wars in Iraq and Afghanistan was examined. A retrospective population-based cohort design was conducted using official military records to identify combat injuries (October 7, 2001, to December 31, 2007). Those who were injured during combat had higher crude suicide rates than those who deployed and were not injured (incidence rate ratio [IRR] = 1.50; confidence interval [CI] = 1.06, 2.12), or never deployed (IRR = 1.46; CI = 1.04, 2.06). After adjusting for demographics, these findings were no longer statistically significant. Although our data did not support an elevated suicide risk among wounded service members, additional research is needed to examine the impact of injury severity.

Advocating for Deployed Women Veterans' Health Differences, Difficulties, and Disparities

PROBLEM

The preceding article presented a glimpse of deployed women veterans, their military culture, and their experiences in the Global War on Terror (Iraq and Afghanistan) to assist civilian nurses to gain significant rapport and provide important culturally sensitive care.

METHODS

Pertinent literary sources were reviewed to gather applicable data about the problem.

FINDINGS

A confirmatory answer from the assessment question of "Have you served in the military?" and the use of the Military Health History Pocket Card for Clinicians (available at http://www.va.gov.oaa/pocketcard) will assist with revealing possible health risks from the increased amounts of military men and women veterans seeking (and/or returning to) a variety of community-based health services. This article about deployed women veterans examines their specific health differences (e.g., research literature, post-traumatic stress disorder, and military sexual trauma), difficulties (e.g., reproductive, gynecologic, urinary, suicide), and gender disparities (varied treatment patterns).

CONCLUSION

Understanding these gender situations, civilian nurses can better advocate with increasing evidence-based decisions that their physical and behavioral responses were different from their male counterparts. Continual assessment, knowledgeable care, ongoing literature review, interdisciplinary health team development, and the presence of resourceful community agencies should be a significant part of their holistic care. Conard Armstrong.

Gender differences in the impact of warfare exposure on self-rated health

BACKGROUND

This study examined gender differences in the impact of warfare exposure on self-reported physical health.

METHODS

Data are from the 2010 National Survey of Veterans, a nationally representative survey of veterans from multiple eras of service. Regression analyses assessed gender differences in the association between warfare exposure (deployment to a war zone, exposure to casualties) and health status and functional impairment, adjusting for sociodemographics.

FINDINGS

Women reported better health status but greater functional impairment than men. Among men, those who experienced casualties only or both casualties and deployment to a war zone had worse health compared with those who experienced neither stressor or deployment to a war zone only. Among women, those who experienced casualties only or both stressors reported worse health than those who experienced war zone only, who did not differ from the unexposed. No association was found between warfare exposure and functional impairment in women; in men, however, those who experienced exposure to casualties or both stressors had greater odds of functional impairment compared with those who experienced war zone only or neither stressor.

CONCLUSIONS

Exposure to casualties may be more predictive of health than deployment to a war zone, especially for men. We did not find a stronger association between warfare exposure and health for women than men. Given that the expansion of women's military roles has allowed them to serve in direct combat, their degree and scope of warfare exposure is likely to increase in the future.

Impact of exposure to combat during deployment to Iraq and Afghanistan on mental health by gender

BACKGROUND

Interest in the mental health of women deployed to modern military campaigns is increasing, although research examining gender differences is limited. Little is known about experiences women have had on these deployments, or whether men and women respond differently to combat exposure.

METHOD

The current study used data from a representative sample of UK Armed Forces personnel to examine gender differences among those deployed to Iraq and Afghanistan (n=432 women, n=4554 men) in three measures of experience: 'risk to self', 'trauma to others' and 'appraisal of deployment'. We examined the impact of such experiences on post-deployment symptoms of post-traumatic stress disorder (PTSD), symptoms of common mental disorder (CMD) and hazardous alcohol use.

RESULTS

After adjustment, men reported more exposure to 'risk to self' and 'trauma to others' events and more negative appraisals of their deployment. Among both genders, all measures of combat experience were associated with symptoms of PTSD and CMD (except 'risk to self' events on symptoms of CMD among women) but not with alcohol misuse. Women reported higher scores on the PTSD Checklist--Civilian Version (PCL-C) among those exposed to lower levels of each experience type but this did not hold in the higher levels. Women reported greater symptoms of CMD and men reported greater hazardous alcohol use across both levels of each experience type. Examining men and women separately suggested similar responses to exposure to adverse combat experiences.

CONCLUSIONS

The current findings suggest that, although gender differences in mental health exist, the impact of deployment on mental health is similar among men and women.