DTIC ADA582977: Self-Reported Stressors of National Guard Women Veterans Before and After Deployment: The Relevance of Interpersonal Relationships

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Self-Reported Stressors of National Guard Women Veterans Before
and After Deployment: The Relevance of Interpersonal Relationships
Grace W. Yan, PhD1, Lisa McAndrew, PhD1,2, Elizabeth A. D’Andrea, PhD1,3,
Gudrun Lange, PhD1,2, Susan L. Santos, PhD1,4, Charles C. Engel, MD, MC5,6, and
Karen S. Quigley, PhD7,8
1DepartmentofVeteransAffairs,NJWarRelatedIllness&InjuryStudyCenter,EastOrange,NJ,USA;2NewJerseyMedicalSchool-Universityof
Medicine&DentistryofNJ,Newark,NJ,USA;3PhiladelphiaVAMedicalCenter,Philadelphia,PA,USA;4SchoolofPublicHealth-Universityof
Medicine&DentistryofNJ,Piscataway,NJ,USA;5DepartmentofPsychiatry,UniformedServicesUniversityoftheHealthSciences,
Washington,DC,USA;6DeploymentHealthClinicalCenter,WalterReedArmyMedicalCenter,Bethesda,MD,USA;7DepartmentofVeterans
Affairs,EdithNourseRogersMemorialVAHospital,Bedford,MA,USA;8NortheasternUniversity,Boston,MA,USA.
BACKGROUND: With their rapidly expanding roles in KEYWORDS:women’shealth;veterans;surveyresearch;qualityoflife.
themilitary,womenservicemembersexperiencesignif- JGenInternMed28(Suppl2):S549–55
icant stressors throughout their deployment experi- DOI:10.1007/s11606-012-2247-6
©SocietyofGeneralInternalMedicine2012
ence. However, there are few studies that examine
changes in women Veterans’ stressors before and after
deployment.
OBJECTIVE:Thisstudyexaminesthetypesofstressors
womenVeteransreportbeforedeployment,immediately T herolesofmilitarywomenhavechangedrapidlyinthe
after deployment, 3 months after deployment, and lastdecade.WomenwhoservedinOperationEnduring
1yearpost-deployment. Freedom(OEF)andOperationIraqiFreedom(OIF)worked
DESIGN: Descriptive data on reported stressors was inadiverserangeofsettings.Theyareincreasinglyexposed
collected at four time points of a longitudinal study
tocombatasthefrontlinesofwarbecomelessdefinableby
(HEROES Project). Open-ended responses from the
virtue of new enemy combat tactics.1 Women military
Coping Response Inventory (CRI) were coded into six
personnel are also taking on new military roles, such as
possiblemajorstressorcategories foranalysis.
militarypolice,thatincreasethelikelihoodofmorestressful
PARTICIPANTS: Seventy-nine Army National Guard
and Reserve female personnel deploying to Operation deploymentexposures.2Indeed,comparedtopreviouswars,
Enduring Freedom (OFF)/Operation Iraqi Freedom OEF/OIF women Veterans are exposed to more combat
(OIF) were surveyed prior to deployment. Of these through their service in diverse support positions.3
participants, 35 women completed Phase 2, 41 com- Women military personnel may also experience unique
pletedPhase3,and48completedPhase4ofthestudy.
stressors during reintegration. Reintegration is the process
KEY RESULTS: We identified six major stressor cate-
by which Veterans readjust to civilian life, and broadly
gories: (1) interpersonal (i.e., issues with family and/or
encompasses areas such as vocational (e.g., finding a job),
friends),(2)deployment-relatedandmilitary-related,(3)
interpersonal (e.g., changing from a hierarchical military
healthconcerns,(4)deathofalovedone,(5)dailyneeds
(i.e., financial/housing/transportation concerns), and structuretoalesswell-definedsocialstructure),andliferole
(6) employment or school-related concerns. At all time readjustment(e.g.,readjustingtoaparentalrole).Generally,
points, interpersonal issues were one of the most OEF/OIF Veterans report difficulties in interpersonal rela-
common type of stressor for this sample. Daily needs tionships during the post-deployment readjustment period,
concerns increased from 3 months post-deployment to such as difficulty getting along with family and friends.6
1yearpost-deployment.
Beder et al.’s study7 of male and female OEF/OIF service
CONCLUSIONS: Interpersonal concerns are commonly
members found that women Veterans were more likely to
reportedbywomenVeteransbothbeforeandaftertheir
report negative reintegration experiences than men. Reinte-
combatexperience,suggestingthatthisisatimeduring
gration may also be complicated for women Veterans, due
which interpersonal support is especially critical. We
to having multiple life roles including being a service
discussimplications,whichincludetheneedforamore
coordinated approach to women Veterans’ health care member. For instance, about 38 % of women active duty
(e.g.,greatercommunity-basedoutreach),andtheneed military personnel have children and about 42 % are
for more and more accessible Veterans Affairs (VA) married.8 While these rates are similar to those for male
services toaddresstheneeds offemaleVeterans. military personnel, female Veterans who are mothers are
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Self-Reported Stressors of National Guard Women Veterans Before and
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After Deployment: The Relevance of Interpersonal Relationships
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S550 Yanetal.:Self-ReportedStressorsofOEF/OIFWomenVeterans JGIM
almost three times more likely than male Veterans to be METHODS
single parents.6 Participants
So far, most studies on OEF/OIF reintegration have been
conductedusing predominantly maleVeteran samples; only TheHEROESProjectisaprospective,longitudinalobserva-
a handful of studies have a substantial representation of tional cohort study of pre-deployment and early post-
women,andevenfewerexaminewomenmilitarypersonnel deployment psychosocial and physiological predictors of
or women Veterans explicitly.10–12 Most studies have post-deployment physical symptoms, functional status, and
focused on women Veterans’ deployment related experi- health care utilization. We recruited 767 Army National
Guard and Reserve personnel deploying to OEF/OIF from
ences, such as Post Traumatic Stress Disorder (PTSD).
However, theliterature on women Veterans’transition from multipleunitsacross48 states.Approximately10 %(N=79)
of the initial sample was female. Of these 75 eligible to
deployment to military life is relatively limited, as docu-
mented by a 2011 review of women Veterans’ health continueinthestudy,35reportedastressoratPhase2,41at
research.4 In addition, many studies on women Veterans Phase 3, and 48 at Phase 4, with 20 completing all four
phases. In each follow-up phase, participants were lost to
were conducted on those seeking treatment at the Veterans
follow-upforavarietyofreasons,suchasVeteransreturning
Health Administration. Much less is known about the
toadifferentbaseafterdeployment,andincorrectordelayed
deployment stressors experienced by women Veterans
information about the Veteran’s return date or address.
across the period from pre-deployment to post-deployment
outside ofahealthcare setting,andthere arefewqualitative
descriptions of these stressors in women Veterans’ own
Procedure
words.
In one of the few studies to examine more broadly the
All participants were surveyed prior to deployment at the
stressors faced by women Veterans of OEF and OIF,
military installation from which they deployed (Phase 1,
Mattocks etal.10 conductedsemi-structured interviews with
between 2005 and 2008). We surveyed them again immedi-
nineteen OEF/OIF women Veterans. This in-depth qualita-
ately after return from deployment (Phase 2, from 2007 to
tive study revealed a variety of deployment and post-
2009),at3monthsafterreturn(Phase3,from2007to2010),
deployment stressors, such as military sexual trauma,
and 1 year after return (Phase 4, from 2008 and 2011). This
disrupted relationships with family and friends, and diffi-
study was approved by three institutional review boards
culties “leaving the war behind.” It also showed that while
includingthatoftheNewJerseyVAHealthCareSystemand
somewomenwereabletopositivelycopewithmilitaryand
all participants provided informed consent.
reintegration-related stressors, other women Veterans
At all time points, participants completed the Coping
employed more negative coping strategies (such as avoid- Responses Inventory (CRI).13,14 The initial, open-ended
ance,bingeeating,andsubstanceuse)thatjeopardizedtheir item of the CRI asked participants to “think about the most
well-being.10 In these interviews, women Veterans noted
important problem or stressful situation you have experi-
that reintegration can be a serious challenge. Similarly,
enced in the last 12 months (for example, troubles with a
Bederetal.’sinterviewswith118womenmilitarypersonnel relativeorfriend,theillnessordeathofarelativeorfriend,
showed that with the challenges of post-deployment an accident or illness, financial or work problems). Briefly
readjustment, mental health providers “must be attuned to describe the problem in the space provided below. If you
the nuances of the reintegration experience”.7 havenotexperiencedamajorproblem,listaminorproblem
Our study aims to expand upon prior work by using that you have had to deal with.”
self-report qualitative data from a national, multi-wave We coded the brief responses (i.e., typically a few words
prospective observational cohort study of Army National orphrases) usingstandard qualitative coding methodsin an
Guard and Reserve enlisted military personnel. Using this iterative process following established qualitative research
non-treatment seeking sample of women, we present data guidelines.15,16 Coding was done in four stages,
on the self-reported stressors across four different phases corresponding with each phase of data collection. As part
of their deployment experience: immediately before, of a larger study, we initially established a coding scheme
immediately after, 3 months after, and 1 year after using pre-deployment data from both male and female
deployment. To our knowledge, this is the first study to respondents to ensure that we captured the breadth of
query women military personnel about their stressors at possible responses for all respondents. To develop this
multiple time points across the deployment cycle. Under- initial coding scheme three of the authors (KQ, ED & SS)
standingthenatureoftheseself-reportedstressorsandhow read through a randomly selected set of 100 responses
these stressors change from before to 1 year after (fromPhase1)toidentifypossiblethemesandkeyphrases.
deployment is needed to facilitate the development of We then discussed codes and established a coding dictio-
clinical programs that address the needs of women before nary.Thisinitialcodingschemewasusedasastartingpoint
and after deployment. to develop our women-specific coding scheme. Two coders
JGIM Yanetal.:Self-ReportedStressorsofOEF/OIFWomenVeterans S551
(LM and ED) separately scored another randomly selected significantly older at pre-deployment (M=29.17 vs. M=
set of 50 women Veterans’ responses from Phase 1. They 25.10 years); (t(77)=−2.31, p< 0.02) than those who did
then met to identify and resolve any discrepancies in the not complete Phase 4. There were no other significant
coding, and revised the initial dictionary of responses for demographic differences between the groups.
womenVeterans.Foreachoftheremainingresponses,three Coding of the open-ended response on the Coping
coders (LM, ED & GY) separately coded all of the ResponsesInventory(CRI)revealedawidevarietyofevents
responses and met to compare and discuss any discrep- reportedasthe“mostimportant”stressor.Ourcodesclustered
ancies in the codes. In total, codes were assigned and into sixmajor categories of reintegration stressorsfor female
reviewed by four of the authors (GY, LM, ED, and KQ). A Veterans:(1)interpersonal(i.e.,issueswithfamilyorfriends),
code book was established at Phase 1 and additional codes (2) deployment and military-related, (3) health concerns of
were added as each study phase was completed. This code selfandothers,(4)deathofalovedone,(5)dailyneeds(i.e.,
book was reviewed in an iterative fashion across all four financial/housing/transportation concerns), and (6) civilian
phases, and data from all four phases were re-coded using employment or school concerns. Nine responses were not
thefinalcodebook.Mostdemographicvariables(age,race, coded because they could not be accurately categorized due
ethnicity, number of previous deployments, educational to insufficient information in the response. Individuals could
history)were collected atPhase 1.Marital status, education report morethan oneconcern,and responsescouldbe coded
status, and employment status were collected at Phase 3. intomorethanonecategory.Mostindividualsreportedoneor
two different stressors per phase.
Table2providesexamplesofresponsesineachofthesix
categories.Figure1illustratestherelativefrequenciesofthe
RESULTS “most important” stressors reported across all four phases.
We also show the frequencies of stressors across all four
Seventy-nine female military personnel completed Phase 1
phases for those who completed Phase 4 and found a
of the study. The mean age of the sample was 27.57 years
similar pattern of responses (Fig. 2).
(SD=7.85; range 18–50). Descriptive statistics for eligible
study participants are presented in Table 1. Attrition
Interpersonal Stressors
analyses were conducted on demographic data collected at
Phase 1 for all participants using two groups: those who Interpersonal stressors were most consistently reported as
completed Phase 4 (this group included data from individ- “most important” across phases (31 % of all identified
ualswhomay nothave completed Phases2 or 3)and those stressors at Phase 1, 28 % at Phase 2, 30 % at Phase 3 and
who did not complete Phase 4. Phase 4 completers were 25 % at Phase 4). These interpersonal stressors included
problems communicating with significant others, difficulties
Table1. DescriptiveDemographicsofHEROESParticipants* interacting with previously close relatives and friends, and
problems with infidelity. Examples of interpersonal stressors
Variable N* Percent(%) included “having a big fight with my best friend,” “normal
Race(N=79) conversations always erupt into a full scale war,” and
BlackorAfricanAmerican 13 16.5 “having marriage problems (an affair)—we almost got a
Hispanic 8 10.1
White 53 67.1 divorce.” These issues ranged in their nature and intensity
Other 5 6.3
and included both episodic and chronic stressors. For
Numberofpreviousdeployments(N=79)
0 55 69.6 example,atPhase1,womenreportedseriousproblems,such
1 16 20.3 as“I’mgettingadivorce”and“myapartmentwasraidedby
2 8 10.1
Maritalstatus(N=40) the police because of a roommate’s behaviors and my
Nevermarried 20 50.0 roommates were kicked out of school.” They also reported
Married 11 27.5
Separated/divorced 9 22.5 problems that are likely more chronic and less serious, such
Educationstatus(N=40) as “arguing with my mother.” When specific relationships
Inschool 15 37.5
Notinschool 25 62.5 were mentioned, the most common ones were significant
Employmentstatus(N=40) others,butchildren,siblingsandfriendswerealsocommonly
Employedfull-time 20 50.0
mentioned. For instance, Veterans reported problemsintheir
Employedpart-time 5 12.5
Unemployed 15 37.5 romantic relationships, one noting that she “had to break up
Children(N=38) with my boyfriend… I felt depressed for a while.” Another
None 24 63.2
One 4 10.5 Veteran wrote that her “sister was in jail and I had to be the
Twoormore 10 26.3
guardian over three children in addition to my three
*Race,numberofpreviousdeployments,andeducationalhistorywere children.” Phase 2 was particularly notable because women
collectedatPhase1.Maritalstatus,educationstatus,andemployment
oftenreportedinterpersonalproblemsastheirmostimportant
statuswerecollectedatPhase3.Numberofchildrenwascollectedat
Phase2 stressor, at times when military or deployment-related
S552 Yanetal.:Self-ReportedStressorsofOEF/OIFWomenVeterans JGIM
Table2. ExamplesofSelf-ReportedStressorsProvidedbyWomen stressors might be expected to be the most stressful. The
VeteransinHEROES*
types of interpersonal problems reported in Phases 3 and 4
Category Sampleresponses weresimilartothoseatPhase2,aswomenVeteranscontinue
Interpersonal (cid:129)Breakingupwithaboyfriend. to report interpersonal challenges with family, friends, and
(cid:129)WhenIgotcalledbacktostatedutyafter coworkers. Some Veterans began to report interpersonal
beingdeployed.Myhusbanddidn’twant
concernsatPhases3and4thatwereaffectedbydeployment
tobealoneagainandnotknowinghow
longIwasgoingtobegone. (e.g., “Cutting out a friendship with a friend that I had for
(cid:129)Troublewitharelativewhotriestomake about 6 years… realizing that my experiences have changed
mefeelguiltyfornotspendingenough
timewithfamily. me”; “Issues in my marriage resulting from my inability to
(cid:129)Myboyfrienddistrustsmeandaccusesme rememberthingsandthedifferencesinhowIdothingsnow
allthetimeofwantingtobewithsomeone
else. in comparison to before I deployed”).
(cid:129)MyhusbandandIarehavingsomemarital
problems.
Deployment-related (cid:129)Ateammatebeinghitwithanimprovised
explosivedevice(IED). Deployment Stressors
(cid:129)Myteammatewasself-absorbedandlazy.
(cid:129)Discriminationandharassmentduring
As expected, deployment-related or military stressors were
deploymentwithinfantryunit.
(cid:129)Thewaythingswerehandledwhileonthis common at Phase 1 (31 %) and anticipated the imminent
Healthofselfand (cid:129)dIehpaldoyamneenctt.opicpregnancy. deployment. Such responses included “getting mobilized
others (cid:129)Beingcompletelyirritablewithmoodswings for a deployment and having only two full days to get
fromreallydepressedtoveryhappyover ready”and“havingtobedeployed.”Aswouldbeexpected
smallthingsorfornoreasonatall.
(cid:129)Mygrandmahascancerandiscurrently at Phase 2 (immediately after deployment), deployment or
undertreatment. military-related stressors (33 % of stressors reported) now
(cid:129)MyGrandpagotsickandhadtobeinICU
forseveraldays. included reports of such situations as “I experienced
Deathoflovedone (cid:129)Myauntpassedaway.SheandIwerevery multiple rocket fire attacks,” “I was deployed with a unit
close.
(cid:129)Lostarelative.Hewasaspecialneeds oftotalstrangers,”and“Ihavehadtolooktheenemyinthe
adultandwewerepreparedforthelossbut eyes everyday and still serve them food.” By Phase 4,
thatdidn’tmakeitmucheasier.
(cid:129)Twofriendswerekilledinaction. deploymentormilitary-relatedreportshaddecreasedto6%
(cid:129)Thedeathofmygrandmotheron of the total of most important stressors.
Thanksgivingday.
Dailyneeds (cid:129)Ihavetroublepayingthebills.Divorce
andnotenoughmoneytokeepbillscaught
up.
(cid:129)Mysiblingnotpayingasagreedonmy Health of Self and Others
autoloanandotherdebts.
(cid:129)Withtheeconomybeingsobad,Ihave Healthconcernsofselfand/orotherswereareportedsource
hadtodealwithwonderinghowwewere
of stress for many Veterans. Reported health stressors
goingtopayforthings.
(cid:129)Lossofwagesandunabletolookfor ranged from 9 % at Phases 2 and 3 to 20 % at Phase 4.
work. Themajorityofreportedhealthconcernswereforothers.At
Employmentor (cid:129)Uponreturningfromdeployment,Ihadto
school-related findanotherjob. Phase1,onlytwowomenreportedtheirownhealthastheir
(cid:129)Stresseswithgettingbackintocollege. primary stressor. Even at Phase 4, 1 year after deployment
*Responseswereeditedforbrevityandcouldbe codedinmorethan when mental and physical health problems should have
onecategory appeared, there were only four women who reported as
Figure1.Relativefrequenciesofreportedstressorsaspercentagesoftotalresponsescodedbystudyphase(overallsample).
JGIM Yanetal.:Self-ReportedStressorsofOEF/OIFWomenVeterans S553
Figure2.Relativefrequenciesofreportedstressorsaspercentagesoftotalresponsescodedbystudyphase(Phase4completersonly).
most important their own health problem. Most women are related to being able to pay the bills and the Veterans’
reported health problems of others, such as “my step-father ability to provide for dependents.
had to have double bypass” and “one of my soldiers has
beendiagnosedwithinoperableStage3lungcancer”.There
were few descriptions of women’s own mental health
problems and no one reported PTSD as a primary stressor. DISCUSSION
A major finding of our study was the high relative
frequency at which women Veterans reported interpersonal
Death of Loved Ones
concerns as their most important stressor from pre-deploy-
Some Veterans report death of loved ones to be the most ment to 1 year after return from deployment. Indeed, the
stressfulevent.Thisincludeddeathsoffamilymembersand proportion of most important stressors that were interper-
friendswhodiedduetoillness,andunitmemberswhodied sonal remained relatively stable from before to 1 year after
in action. Death-related stressors represented 5 % of all deployment. These stressors included problems with family
responsesinPhase1andwerearelativelystableproportion and friends and feelings of isolation or detachment from
of responses across Phases 2 to 4 (10–13 %). loved ones. These feelings have been previously docu-
mented among both male and female Veterans.5,9,11 How-
ever, it was notable that interpersonal problems were the
Daily Needs most consistently reported major concern, even right after
deployment when military-related stressors might be
In comparison, reports of daily needs as the most important
expected to be predominant. Interpersonal stressors may
stressor increased from 12 % (Phase 1) to 20 % (Phase 4).
also be particularly of concern because during deployment
Such stressors included “the military not paying my student
Veterans may not be able to take actions to address those
loansasIthoughttheywould”and“Ihadtotakeoutasmall
problems,givengeographicaldistanceandminimaltimefor
student loan to pay rent.” For some, interpersonal stressors
contact, especially when the other parties are located
reported in prior phases had a direct effect on their daily
stateside. The limited ability to resolve interpersonal
needs, such as “divorce caused my bills to get behind,” and
stressors during a combat deployment should be addressed
“my boyfriend… spent most [of the] money on himself.”
in future studies and are an intervention opportunity for
future combat deployments. Interpersonal stressors are
likely to negatively affect a person’s ability to fully attend
Employment and School Stressors
to their combat mission, and could negatively impact the
Similar to the pattern with daily needs, civilian employ- Veteran’sreintegrationintocivilianlife.Becauseourresults
ment/school-related stressors reported as most important indicate that interpersonal problems continue to be a major
increased from 5 % (Phase 1) to 18 % (Phase 4), including source of concern at least through 1 year post-deployment,
“obtaining a job in this area has been difficult” and “I need we must continue to be watchful for any long-term effects
to do an internship… but I am having difficulty finding an on health over a more extended reintegration period.
[internship] site.” As expected, many employment stressors Finally, future studies should also examine how interper-
S554 Yanetal.:Self-ReportedStressorsofOEF/OIFWomenVeterans JGIM
sonal issues impact care seeking. We found that women Veterans.10,21 Future research with a larger sample should
Veterans were more likely to report their problems as use more in-depth qualitative methods coupled with
interpersonal, and less likely to report their most important quantitative methods to better understand the nature of
stressors as related to their own health. It was recently these stressors, their interactions with each other and with
estimated that about 37 % of returning OEF/OIF Veterans care-seeking, and how to best mitigate these stressors.
who seek Veterans Affairs (VA) healthcare receive mental Another limitation of the study was attrition as the study
healthdiagnoses.20Despitethis,fewofthewomenreported progressed from Phase 1 to 4. To address the possibility
their own mental or physical health problems as their most thatthesampleremainingatPhase4wasdifferentthanthe
important stressor. Future research should focus on under- overall sample, we showed data for both the overall
standing the possible interaction between interpersonal sample (Fig. 1) and the subsample of women who
stress and mental health needs, and whether some stressors completed Phase 4 data collection (Fig. 2). These figures
negatively impact help-seeking behavior among women show remarkably similar stressor patterns for the overall
Veterans. sample and those completing Phase 4. In addition, our
We also found, as expected, that women Veterans analysis of the demographic characteristics of the sample
reported deployment-related or military stressors with the revealed only an age difference between the full sample
highest relative frequency just before and just after the vs. Phase 4 completers, with Phase 4 completers being on
deployment. The frequency of these stressors decreased average about 4 years older. Together, these results
over time after deployment. Although deployment or diminish our concern that attrition substantively altered
military-specific problems were no longer a primary focus ourfindings.Lastly,itisimportant tonotethat wequeried
of concern at the later phases, many of the remaining for the most important reported stressors of women
stressors still appeared to be related to deployment. Veterans. The frequency of all stressors may vary from
Our study showed a proportional increase from Phase 1 thosereportedhere,eitherbecausestressorsnotconsidered
to Phase 4 in reported daily needs stressors as a major “most important” were not reported or due to participants’
concern. This increase was especially notable between the unwillingness to report certain stressors.
immediate post-deployment phase and at 12 months after Our data suggest that clinicians should discuss
return (increased from 6 to 19 % of total). Routine and interpersonal concerns and problems with daily needs,
time-consuming tasks, such as coordinating the family becausedealingwithchronicstressors—inparticularthose
budget and child care, doing laundry, and paying the rent, that negatively impact the Veteran’s ability to address her
maybeespeciallytaxinginthecontextofotherneeds(e.g., own needs—could also impact her health. Providing
interpersonal stressors, physical and mental health issues) health care thatis tailoredtotheneeds of women Veterans
and after one has had many of these daily needs provided and that takes into account other issues of concern in
by others while deployed. In addition, it is possible that woman Veterans’ lives may lead to better results; for
tangiblesupportfromothersimmediatelyaftertheVeteran’s example, some VA facitilies programs where women
return from a deployment wanes over time. Veterans can share and receive peer and professional
Our female participants also reported problems with support in navigating the post-deployment period. A
civilian employment or schooling, including unemploy- broader dissemination of these programs may be especial-
ment,underemployment,ordissatisfactionwiththeirwork ly helpful for women experiencing interpersonal problems
life, especially at 1 year post-deployment. These Veterans or difficulties communicating with friends and family
faced a difficult time returning to civilian jobs in the members. In addition, for women Veterans who report
context of very difficult economic conditions (beginning significant unmet daily needs, accessibility will be a
in 2008). Similarly, those who returned to school reported barrier to utilization of health care services. 17 Thus, the
difficultyinacademicfunctioning.FortheseVeterans,itis VA must continue to be in the forefront of finding new
important to assess barriers that may make it difficult for ways to reach out to and support women Veterans,
women Veterans to complete their education. including collaborating with local community and reli-
One of the strengths of this study is the availability of gious groups, using telemedicine, and offering evening
data from multiple time points from a sample of non- appointments.
treatment-seeking military personnel recruited before Finally, this study acknowledges the often unquantifi-
deployment. Limitations of the data reported here include able sacrifices of all women Veterans. Although much
a relatively small sample size and the lack of time and attention has been focused justifiably on issues such as
resources to conduct more extensive face-to-face qualita- PTSD and sexual trauma, it is remarkable that Veterans
tive interviews with participants, in light of the limited indicatethatitistheirdailyinterpersonalrelationshipsthat
time permitted for testing. Although the sample size is areoftenmoststressful.Ourfindingsshouldencourageall
relatively small, it is considerably larger than existing providers to recognize both the more obvious and more
qualitative studies of stressors in women OEF/OIF hidden sacrifices that Veterans have made to serve our
JGIM Yanetal.:Self-ReportedStressorsofOEF/OIFWomenVeterans S555
country.Asithasbeennoted,6,18,19atstakeistheretention 6. SayerNA,NoorbaloochiS,FrazierP,CarlsonK,GravelyA,Murdoch
M. Reintegration problems and treatment interests among Iraq and
of women in the military and the well-being of those
AfghanistancombatVeteransreceivingVAmedicalcare.PsychiatrServ.
women “who have borne the battle” and their loved ones. 2010;61(6):589–97.
7. Beder J, Coe R, Sommer D. Women and men who have served in
Afghanistan/Iraq:cominghome.SocWorkHealthCare.2011;50:515–26.
8. JointEconomicCommittee.Helpingmilitarymomsbalancefamilyandlonger
deployments. Available at: http://jec.senate.gov/archive/Documents/
Acknowledgements: The authors would like to thank Dr. Helena
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