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Patient Perception, Preference and Participation
Facilitating
culture-centered
communication
between
health
careproviders and veterans transitioning from military deployment tocivilian
life
Christopher J. Koenig a,b,d,*,
Shira Maguen a,c,
Jose D. Monroy a,e,
Lindsay Mayotta,d,Karen H. Seal a,c,d
a San Francisco Veterans Administration Medical Center, San Francisco, USAbPhilip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, USAcDepartment of Psychiatry, University of California, San Francisco, San Francisco, USAdDepartment of Medicine, University of California, San Francisco, San Francisco, USAeDepartment of Psychology, San Francisco State University, San Francisco, USA
1.
Introduction
Approximately 2.4 million United States military personnel
have been deployed to Iraq and Afghanistan since September 11,
2001. Military deployment and combat has historically shown to
result in medical [14], psychological [58], and social problems
[913], all of which affect veterans post-deployment health across
the life course [1316].
Prior research on reintegration among Iraq and Afghanistan
veterans has focused primarily on the physical and psychosocial
problems that arise in the process of re-adjustment, but only a
handful of previous studies focus on the cultural aspects of
reintegration, such as thedifferences betweenmilitary and civilian
social environments [1720]. Faulkner and McGaw [21] propose a
comprehensive model of reentry for Vietnam era veterans using a
three stage model: disengagement from military life; re-entry into
the world of the civilian after deployment; and, full reintegration
into civilian life. We build on this idealized temporal progression
Patient Education and Counseling 95 (2014) 414420
A
R
T
I
C
L
E
I
N
F
O
Article history:
Received 6 August 2013
Received in revised form 3 February 2014
Accepted 22 March 2014
Keywords:
Patient-centered care
Health communication
Culture
Post-deployment health
Readjustment experience
Military veterans
USA
A
B
S
T
R
A
C
T
Objective: To describe returning veterans transition experience from military to civilian life and to
educate health care providers about
culture-centered communication that promotes readjustment to
civilian life.
Methods: Qualitative, in-depth, semi-structured interviews with 17 male and 14 female Iraq and
Afghanistanveterans wereaudio recorded, transcribedverbatim,and analyzedusingGrounded Practical
Theory.
Results: Veterans described disorientation when returning to civilian life after deployment. Veterans
experiencesresulted from anunderlyingtensionbetweenmilitary andcivilian identities consistentwith
reverse culture shock. Participants described challenges and strategies formanaging readjustment stressacross three domains: intrapersonal, professional/educational, and interpersonal.
Conclusions: To provide patient-centered care to returning Iraq and Afghanistan veterans, health care
providers must be attuned to medical, psychological, and social challenges of the readjustment
experience, including reverse culture shock. Culture-centered communication may help veterans
integrate positive aspects of military and civilian identities, which may promote full reintegration into
civilian life.
Practice implications: Health care providers may promote culture-centered interactions by asking
veterans to reflect about their readjustment experiences. By actively eliciting challenges and helping
veterans to identify possible solutions, health care providersmay help veterans integrate military and
civilian identities through an increased therapeutic alliance and social support throughout the
readjustment process.
Published
by Elsevier Ireland Ltd.
* Corresponding author at: Department of Medicine, San Francisco Veterans
Administration Medical Center, 4150 Clement Street, 111-A1, San Francisco, CA
94121, USA. Tel.: +1 415 221 4810x6419; fax: +1 415 379 5573.
E-mail address: [email protected] (C.J. Koenig).
Contents lists available at ScienceDirect
Patient Education and Counseling
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e:
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ww.elsev ier .co
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atedu
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http://dx.doi.org/10.1016/j.pec.2014.03.016
0738-3991/Published
by
Elsevier
Ireland
Ltd.
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by focusing the experiences of Iraq and Afghanistan veterans as
they re-enter civilian life, but before they fully reintegrate into
civilian life. We investigate reintegration as a complex social and
temporal process [14,22].
Culture is commonly defined as the shared values,perspectives,
and routine, but taken-for-granted, practices within a community
[23,24].
Culture
shapes
heath
and
healthcare
in
diverse
popula-tions and communities as well as the course and outcomes of
various diseases and illness conditions [25,26]. Military veterans
have been widely studied as a community with a distinct and
recognizable culture resulting from participation in both civilian
and military contexts [20,2729], but whose health has been
shown to be particularly vulnerable due to deployment experi-
ences [3032]. Basic military training impacts individual develop-
ment through acculturation into military culture, which affects the
individuals sense of self or identity. However, upon returning
home veterans receive limited or no similar training to acculturate
back to civilian life [33,34]. As a result, many returning Iraq and
Afghanistan veterans face challenges reintegrating into civil
society, including identity conflict, alienation, depression, anxiety,
and interpersonal difficulties [20,3538]. Drawing from the
literature on educational and cross-cultural transition [3941],
Westwood et al. characterize reverse culture shock as a type of
stress associated with unanticipated adjustment difficulties and
unmet expectations by. . .following a re-entry experience [33].
While reverse culture shock has been documented in veterans
historically [10,21,42,43], few empirical studies use this construct
to contextualize post-deployment problems such as physical
chronic pain; psychological feelings of helplessness, irritability,
and moral contamination; and social problems of isolation
[20,22,33,44].
Recognizing these challenges, the Department of Veterans
Affairs (VA) launched the Office of Patient Centered Care and
Cultural Transformation (OPCCCT) to develop and evaluate new
health care models that provide effective and culture-centered
services for veterans. Because health disparities research that
shows ethnic, linguistic, and racialminorities canbeexcluded from
health care processes in large health care organizations [4547],
theOPCCCTmission shifts the significance of culture-centered care
to include all veterans [48], as veteran-provider encounters can be
intercultural due do systematic differences between civilian and
military cultures as well as lay patient and professional medical
cultures [49]. However, little prior research examines the
relationship
between
communication
and
patient-centered
care
using an expanded conception of culture [11,22,33,44].
To fill this knowledge gap, we conducted a qualitative study
with returning Iraq and Afghanistan veterans: (1) to describe the
challenges and opportunities veterans experience when transi-
tioning from military to civilian life; and (2) to develop a
theoretical model that identifies broad cultural domains ofsignificant for veterans readjustment. Our overall goal was to
develop a model of veteran readjustment that is of practical value
to foster culturally sensitive interactions between providers and
veterans after deployment.
2. Methods
We conducted in-depth semi-structured interviews with Iraq
and Afghanistan combat veterans who had returned from
deployment within the last two years. We purposively sampled
veterans who were seen in the Integrated Care, Primary Care, or
Womens clinics at the San Francisco VA Medical Center (SFVAMC)
at least twice within three months between October 31, 2008 and
October 31, 2010. We used administrative data to find veteranswith a positive screen for at least one mental health problem, i.e.,
posttraumatic stress disorder (PTSD), depression, or high-risk
drinking. We focused on Iraq and Afghanistan veterans because
they recently returned from a warzone, have a high prevalence of
mental health problems [50], and under-utilize mental health care,
all of which may hamper readjustment. We over-sampled female
veterans because they represent one of the fastest growing
segments of veterans seeking VA services, and little is known
about
the
unique
challenges
women
veterans
face
in
returninghome [35,51,52]. Eligible veteranswere sent an introduction letter,
a study information sheet, and an opt-out postcard. If the postcard
was not returned within 14 days, veterans were contacted by
telephone to describe the study and to invite participation. The
protocol was approved by the Committee on Human Research at
the University of California, San Francisco and the Research
Protection Programs at the SFVAMC and Department of Defense.
The study team developed an original semi-structured inter-
view guide drawing on the senior authors (KHS) experience as a
primary care physician caring for Iraq and Afghanistan veterans
and the first authors (CJK) expertise in health services research.
The interview began by describing the goal to investigate veterans
readjustment experiences. The interview guide included questions
about challenges associated with readjusting to civilian life
illustrated in Fig. 1. The interview guide was pilot tested over
the first five interviews, and questions were subsequently
prioritized to accommodate participant time constraints [53].
We used the interview as conversation model that emphasizes
interviewing as social interaction, a technique consistent with
investigating lifecourse transitions and culture [54]. During the
interview, if the opportunity arose,wedeviated from the interview
guide to explore novel topics not originally included. For example,
when recounting challenges to reintegration, participants fre-
quently offered advice of what they had found useful or what they
would have liked to have known before returning home. We
speculated that advice giving may be evidence for adaptation to
the challenges of homecoming as a possible indicator for
posttraumatic growth and resilience [55]. As a result, we added
questions to the interview guide that explicitly solicited partici-
pants advice to learn about the range of coping strategies they
employed during the readjustment period.
The first author, a medical sociologist and linguist, conducted
all individual semi-structured interviews over 6 months between
January and July, 2011. Interviews lasted a mean of 63 min
(SD 0.007 min), and were conducted either by telephone (54.8%) or
in person in a private interview room (45.2%) according to participant
preference
[56].
Participants
gave
informed
consent
prior
to
each
interview, and received $30 in compensation for the one-time
interview. Participants gave permission to audio-record interviews,
which
were
professionally
transcribed
verbatim
and
resulted
in
1156
double-spaced
pages
of
transcripts
(mean
length
=
37
pages;
SD
12
pages). We imported all transcripts into ATLAS.ti (v7.1) for qualitative
data management [57].We used Grounded Practical Theory (GPT) [58], to guide the
analysis. GPT employs interpretive analytic methods, such as
theme-oriented discourse analysis [59,60], to theoretically recon-
struct how members language use may construct communication
practices, recurrent social actions, and situated social identities.
The overall goal of GPT is to use empirical evidence to develop
normative theories that are practically useful. To construct our
analysis, we employed the editing approach [53], a multi-step
process that emphasizes a nave orientation to data by focusing on
what may be meaningful to participants rather than what may
have beenmeaningful fromprior research or clinicalperspectives a
priori. For example, when veterans described constantly scanning
the environment for a possible threat, rather than using a technical
term hypervigilence, we used a vernacular term, such as feeling onedge. We first identified explicit interviewer questions about
challenges and advice for returning home and located participants
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corresponding answers. Resulting question-answer segments
were the unit of analysis [61]. We then applied a provisional
code to each segment that broadly classified it as a challenge or
advice [62]. The authorship team reviewed segments across
interviews to create a preliminary inventory of all challenges
and advice. Next, we reviewed each segment for sub-classification
into non-mutually exclusive codes that captured participants
points of view, which was subsequently reviewed by the team.
Once all initially identified segmentswere sub-coded, we returned
to the original transcripts to search for additional instances of
challenges and advice elicited in the course of answering other
questions, iteratively adding codes as necessary to account
comprehensively for all segments. Throughout this process,
particularly information rich segments were assigned a unique
identifier, annotated, and iteratively reviewed for reporting. We
achieved theoretical saturation after identifying 278 segments,
which we defined as not adding new or additional dimensions to
the
emerging
analysis
[63].
Quotations
are
anonymized
and
edited
for clarity.
3.
Results
and
analysis
Of the 73 total eligible veterans contacted by mail, 31 (42.5%)
were interviewed. Forty-two veterans did not participate for thefollowing reasons: couldnotbe reached for follow-upby telephone
(n = 30); declined to be interviewed due to lack of time (n = 6) or
interest (n = 3), or failed to participate in a scheduled interview
(n = 3). Participants median age was 30 years old, 45.2% were
female, and 19 were members of diverse racial/ethnic groups
summarized in Table 1. All active military branches were
represented except Coast Guard. Except for the finding that
women were significantly more likely to participate, no statisti-
cally significant differences were discernible demographically,
including age, ethnicity, rank, military branch, number of
deployments.
Returning Iraq and Afghanistan veterans described various
challenges when readjusting to civilian life after deployment. All
veterans reported feeling once-familiar aspects of their civilianlives were altered no veteran returned home unchanged. In Fig. 2
we theorize that when describing the challenges of and offering
advice about their readjustment experience, veterans articulate an
implicit tension between military and civilian identities across
three interrelated cultural domains.Wespeculate this tensionmay
be due to perceived differences between military and civilian
cultures after returning home from military deployment.
3.1.
The
intrapersonal
domain
Participants identified several intrapersonal psychological
challenges they experienced in their transition from military to
civilian cultures. For example, service members are trained in
critical survival skills in a war zone, such as being on guard and
vigilant about their surrounding environment at all times. In
response to the interviewers (IVR) question, the veteran (VET)
describes adjusting back to civilian life after military deployment.
Extract 1. [29:4] Army, Female, Hispanic, 2630 years old.
IVR What was it like transitioning back to civilian life after being deployed?
VET Itwasweird.Justdriving, itwas just crazybecausewhen yougo to switch
lanes, you just see something on the street that I think is an IED
[improvised explosive device]. So its like, Iwas always alert even when I
came back. The neighbor down stairs slammed the door one night, and I
thought it was a bomb and I started looking for an IBA [Interceptor Body
Armor], my weapon.
In this case, unfamiliar objects in the street or unanticipated
loud sounds evoke the war zone. Other participants recounted
similar experiences of reaching for military equipment, such as a
firearm, helmet orbody armor, when surprised or caught off guard.
Because these skills are continuously practiced and reinforced
during deployment, on their return home, it is difficult to simply
stop being vigilant, despite the absence of obvious external
threat. Thus, survival skills that were highly valued in the warzone
can be maladaptive at home and contribute to mental health
problems.
3.2. The professional/educational domain
Participants also faced challenges associated with theirprofessional and educational lives. While serving, active duty
service members typically experience tight-knit social support
snoitseuQralpmexEniamodweivretnI
Eliciting re-adjustment
challenges How long have you been back home?
Can you tell me a little about your experience coming back
home?
What has been the best thing about coming home for you?
What has been the most challenging thing about coming
home for you?
What are some of the major problems facing Iraq and
Afghanistan veterans when they return home?
What resources have been the most helpful for you in
making the transition back home?
Have there been specific people in your life that have beenhelpful in making the transition to civilian life?
Educing posttaumatic
growth Imagine you are talking with a buddy who is still in the
military and about to come home, what advice would you
give her or him?
What advice would you liked to have heard before coming
home?
What advice would you give someone who has had
challenges similar to yours?
Suppose a buddy just came home, and you learned s/he was
having trouble coping with everyday life. What might you
say? Have you had trouble coping yourself? If so, how didyou handle it?
Fig. 1. Questions from the semi-structured interview guide about readjustment experiences from military deployment to civilian life.
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from fellow soldiers who share longworkdays, living quarters, and
a shared sense of meaningful work. In the following extract , the
participant contrasts her workplace camaraderie as a military
versus civilian nurse:
Extract 2. [26:3] Army, Female, Caucasian, 3135 years old.
IVR What were some of the major challenges that you faced when you came
back?VET Boredom. You know, [during deployment] you function at such a high
level of like, Whats gonna happen? Whats gonna happen? Even
though we were totally burned [out] and exhausted from the amount of
hours and time that we worked. . .But when I went back to my old job,
working on the maternity floor, I found it hard to even like stay awake at
work ((laughter)). I didnt feel like I had anyjob satisfaction. I didnt feel
like we had any camaraderie.
In the military, this veterans work was fast-paced and fostered
a sense of connectedness and shared purpose. By comparison, her
civilianjob in an inpatientmaternityunit wasboth slow-paced and
socially isolated. This shift from high- to low-intensity work, as
well as a lack of meaningful rapport with colleagues negatively
impacted her job satisfaction. Additionally, participants pursuing
college education emphasized the slow pace of traditional
academic environments compared to active duty deployment.
3.3.
The
interpersonal
domain
Returning veterans reported feeling socially isolated both
from military and civilian social networks. Serving one or more
deployments physically separates service members from their
close social networks and creates psychological distance
from events that happened at home, as the following extract
shows:
Extract 3. [18:4] Air Force, Female, Pacific Islander, 2630 years old.
IVR Lets shift a little bit what was it like coming back home for you?
VET
It
was
just
different,
because
[I
was]
away
for
months.
So
you
missed
a
lot
of
what
happened
in
the
States.
[For
example]
whats
going
on
is
totally
different, like new music. Then, the people that youre friends with or
your [romantic] relationship are no longer your friends. Youre just
completely out of sync. So, youre just trying to catch up on what you
missed.
Many participants reported feeling out of sync with both the
popular culture and friends at home who continued their
relationships with one another during the veterans military
deployment. While deployed, soldiers felt separated from their
civilian friends and family; once home, veterans felt separated
from the close friends they developed during military service. This
constant sense of separation from social networks creates
psychological distance from the meaningful places and people
in veterans lives, regardless of location.
3.4.
Cultural
resources
for
resilience
Despite a pervasive tension between military and civilian
identities,
participants
advice
described
personalized
copingstrategiesdeveloped in response to the challengesof readjustment.
Whilenot allparticipants gave advicewithin each analyticdomain,
all participants were able to identify some facet of their experience
that fit at least one cultural domain. For example, many veterans
advisedfinding ways to establish continuity between theirmilitary
and civilian lives by applying military values to their everyday
lives:
Extract 4. [6:1] Marines, Male, Multiracial, 2025 years old.
IVR Lets say that you have a buddy about to come home, what advice would
you
give?
Table 1
Selected
characteristics
of
the
sample
(N=31).
Number of participants (%)
Sex
Male
17
(54.8)
Female 14 (45.2)
Age, years old
2025 3 (9.7)
2630 14 (45.2)
3135 7 (22.6)
3640 3 (9.7)
41+ 4 (12.9)
Race/ethnicity
Caucasian/white 12 (38.7)
Multi-racial 7 (22.6)
Hispanic/Latino 6 (19.3)
African American 3 (9.6)
Asian/pacific islander 3 (9.6)
Rank
Enlisted 20 (64.5)
Officer 11 (35.5)
Military Branch
Army 15 (48.4)
Navy 8 (25.8)
Marines 5 (16.1)Air
force
3
(9.7)
Number of deployments
One 18 (58.1)
Two 9 (29.0)
More
than
two
4
(12.9)
Fig. 2. Theoretical relationships among readjustment ideals, participant values, cultural domains, and communication techniques of the readjustment experience for
returning Iraq and Afghanistan veterans.
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VET
You
have
to
be
proactive
about
everything
you
do.
Nobody
is
going
to
help
you
out.
Nobody
knows
exactly
all
the
information
to
give
you.
Nobody can answer your exact question. You have to find that on your
own.
When veterans return home, many have concerns for which
there may be no easy answer. This participant advises returning
veterans
to
be
proactive
after
returning
from
deployment
bydemonstrating courage through actively pursuing answers when
dealing with institutions, such as the VA, in which participants
frequently feltmired. By encouraging his comrades tobeproactive,
this participant emphasizes the practical value of courage in the
face of adversity,which may foster continuity between hismilitary
and civilian identities.
In response to challenges of isolation from families, friends, and
society at large,participants advised returning veterans to rekindle
activities and relationships that were previously meaningful upon
returning home:
Extract 5. [12:1] Army Reserve, Multiracial, Male, 3135 years old.
IVR Do you have advice for somebody still deployed who is about to come
home?
VET Dont go home and sit around and dwell on negative things about whathappened or, you know,negative aspects of life. Even if you dont feel like
it, force yourself to go back and get involvedwith yournormal life.Do the
things you used to enjoy doing, and see people you used to associate
with. If youre religious, definitely make sure you go to church.
Upon returning home, many veterans may dwell on negative
events that happened during military deployment or on negative
aspects of life more generally. While this may be a normal part of
re-adjustment, it may additionally indicate post-deployment
mental
health
problems
such
as
depression,
adjustment
disorder
or PTSD-related avoidance. This veteran encourages other veterans
to force themselves to become actively involved in their
everyday lifeor in community activities, such as church attendance
to find another source of collective camaraderie.
Finally,
in
response
to
unrecognized
mental
health
problems,some participants advocated seeking mental health treatment in
order to address past military experiences that may negatively
affect full engagement in civilian life:
Extract 6. [10:1] Army Reserve, Male, Caucasian, 41 + years old.
IVR Do you have advice that youwould give to soldiers stilldeployed that are
about to come home?
VET Talk to hygiene [mental health], without a doubt. Sit down and unload.
Just
go
through
every
bad
thing
that
happened,
get
it
out,
talk
to
someone.
Youve
got
to
verbalize
it
to
acknowledge
it.
Dont
be
afraid
to
confront it. Youve got to deal with this shit, or its going to bury you
eventually.
This participant strongly advocates talking to hygiene, a
military term referring to mental health care. By confronting
negative experiences veterans can potentially avoid problems thatcould bury them, such as substance abuse, suicide, and justice
involvement. Additionally, byurging veterans to talk aboutnegative
military experiences, thisadvicewas frequently issued toencourage
returning veterans to directly confront the military stigma
frequently associated with mental health during deployment.
4.
Discussion
4.1. Discussion
This qualitative study describes Iraq and Afghanistan veterans
accounts of readjustment to civilian life after military deployment.
Our analysis shows that participants subtly articulate tensions
between military and civilian cultures and their associated socialidentities during readjustment. While our analysis confirms
previous findings, such as the facts that veterans experience social
isolation [4,18,27] and mental health problems after deployment
[5,50], this study contributes new insights into the role of
communication in the readjustment process.
First, our findings suggest that one source of readjustment
difficulty may be due not only to medical and psychological
trauma, but also to reverse culture shock related to the socio-
cultural
differences
between
military
and
civilian
cultures
andtheir associated identities [18,20,22]. As veterans transition from
military to civilian cultures, they create identities tailored to
specific social and cultural contexts [18,42]. For example, military
behavior appropriate during deployment may be inappropriate
upon returning home, suggesting complex sociocultural tensions
between military and civilian identities. Because veteran identity
may be context sensitive, we theorize that helping veterans
integrate identities across contexts may facilitate smooth read-
justment to civilian life after deployment. Our model expands the
notion of reverse culture shock by identifying three cultural
domains within which veterans experienced challenges and
formulated tailored coping strategies. Describing these challenges
and strategies may assist health care providers anticipate stress
associated with unanticipated difficulties throughout the read-
justment process [33]. For example, a health care provider might
explicitly raise the fact that some veteransfind activemilitaryduty
more interesting than a civilian job in order to set realistic
expectations about the differences of work meaningfulness
throughout readjustment back to civilian life.
Second, our study suggests that careful attention to veterans
language use and communication patterns may play a role in
fostering posttraumatic growth after wartime deployment.
Methodologically, our approach emphasized a dual focus on the
content and the social functions of language during the interview
and subsequent analysis. For example, while we started by asking
veterans about the challenges they experienced when they
returned home from deployment, many veterans volunteered
reflections and offered advice for others who might learn from
their experiences. This builds on established discursive research
showing that in response to a personal trouble or complaint,
remedies frequently follow in subsequent talk [64].Advicegiving is
a social action associated with remedying problems or complaints
and is associated with high epistemic authority [65,66] and
cultural communication norms [67]. While not all participants
provided advice within each analytic domain, all participants
identified some facet of their experience that pertained to at least
one
cultural
domain.
However,
a
minority
of
veterans
articulated
coping strategies in all three domains. Attention to these
interactional dynamics during the interview and throughout the
analysis helped us discern the relationships between challenges
and advice to demonstrate that language use is integral to the
social process of readjustment.
Street et al. [68] suggest that communication can affect healththrough both proximal and intermediate outcomes. Our findings
have may have practical value to foster culturally sensitive
interactions between providers and veterans. In Table 2, we
suggest some communication techniques providers canuse to help
veterans to reflect about challenges and opportunities for growth.
Systematic use of these questions may lead to proximal outcomes,
such as increased trust and patient understanding about the
readjustment process and intermediate outcomes, such as adher-
ence and enhanced self-management [69]. Our findings may
additionally play a role in tailoring evidence-based treatments to
preference-sensitive concerns or even to help providers gauge
treatment acceptability for a full range of treatment modalities,
such as complementary and alternative medicine [18,20,22].
This study has several limitations. First, data are limited to 31Iraq and Afghanistan veterans who had documentation of one or
more mental health problem, which may have contributed to the
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reflexive nature of some participant responses. Expanding the data
collection to include veterans without mental health problems
may enrich current findings. Second, the primary data for this
study were qualitative, semi-structured interviews. While inter-
views provide rich descriptions of participants experience, as self-
reported data they are subject to exaggeration or understatement,
participant memory, and personal feelings at the time of the
interview. Mixed-method research designs that combine qualita-
tive and quantitative data may help to mitigate inherent
weaknesses of using a single method. Finally, because Grounded
Practical Theory is an interpretive framework, other interpreta-
tions may be possible.
4.2. Conclusion
The experience ofwar leaves an indeliblemark on veterans over
the course of their lives. While returning veterans often have
recognizable medical and psychological problems, life after
deployment
includes
coping
with
competing
social
identities,
one rooted in military culture and another rooted in civilian
culture, which have been less recognized in prior research.
Clinicians may help veterans achieve successful reintegration by
encouraging integration of positive aspects of their military and
civilian identities as an interactive social process. By recognizing
veterans unique cultural challenges and strategies for resilience,providers may help foster both cultural- and patient-centered care
when transitioning from the warzone back to civilian life during
routine medical encounters. Patient-centered care is premised on
the ability of patients to be at the center of care, which requires
that providers understand differences between military and
civilian cultures, the readjustment process, and veterans cultural
capacity for resilience.
4.3. Practice implications
While providers may be familiar with medical and psychologi-
cal aspects of post-deployment health, the socio-cultural facets of
veteran readjustment may be less familiar. Our analysis uses
interviews with veterans to identify and describe veteransexperiences of readjusting to civilian life after military deploy-
ment. Our model contributes to practical theory because health
care providers can use thismodel to encourage culturally-sensitive
interactions. For example, the model provides both a framework to
recognize the impact of military and civilian cultures on veteran
post-deployment health and a set of techniques to encourage
posttraumatic growth through reflective communication practice.
Our model may help providers activate veterans endogenous
cultural resources for integrating military and civilian identities
over time that could contribute tohighqualityhealth care andmay
ultimately help promote full reintegration into civilian life after
war.
Funding
Department of Defense award W81XWH-08-2-0106 funded
this study. The funders had no role in the design, data analysis,
writing or approval of the manuscript.
Conflicts of interest
We declare that none of the authors have conflicts of interest.
Acknowledgements
Contributors:
Mr.
Greg
Cohen,
Mr.
Aaron
Daly,
and
Ms.
Emily
Medina for logistical support in the conduct of the study.Wewould
like to thank Drs. Robert Craig and Karen Tracy for their advice
applyingGrounded Practical Theory. Finally,we thank all OEF/OIF/
OND veterans for volunteering to participate in this study, and we
acknowledge their service to our country. We thank the anony-
mous reviewers for playing an active role in collaboratively
shaping the argument for dissemination.
References
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[2]
Pietrzak
RH,
Johnson
DC,Goldstein
MB,Malley
JC,
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SM. Posttraumaticstress disorder mediates the relationship between mild traumatic brain injury
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Table 2
Communication
techniques
to
promote
culturally
sensitive
interactions
among
health
care
providers
and
veterans.
Cultural domain Communication techniques Questions Examples from semi-structured interviews
Intrapersonal
Eliciting
challenges
What
kind
of
feelings
have
you
had
about
your
deployment
experience?
How have you been feeling about yourself since returning
home?
Feeling
anxious
when
experiencing
something
that
evokes deployment
Lack of confidence
Feeling aimless
Fostering growth What would help you come to terms with your deployment
experiences?
Willingness to try mental health treatment
Establishing a regular exercise routine
Finding creative activities
Professional/educational
Eliciting challenges Can you tell me about some of the workplace challenges you
have faced recently?
Job/academic dissatisfaction
Diminished importance of work/school
Feeling useless in civilian life
Fostering growth As a servicemember, you already havemany skills prospective
employers may be interested in. Can you tell me some of the
skills
you
cultivated
in
the
military?
Applying military skills to civilian workplaces
Recognizing opportunity for educational
achievement
Interpersonal
Eliciting challenges Who are you spending time with after returning home?
How have you felt that your friends or family relationships
have
changed
while
you
were
deployed?
Spending time alone, e.g., social isolation
Close personal relationships no longer seem close
Fostering growth Can you identify one person whom you can talk to about your
deployment experiences?
Are you a member of a social or religious group?
Maintaining meaningful social connections
Participating in group, religious, and/or spiritual
activities
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