Abstract
Many female veterans have deployed to Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND), and some experience traumatic brain injury (TBI). Although TBI is increasingly recognized as an important health issue for female OEF/OIF/OND veterans, there is little attention to stressful experiences that may exacerbate health problems or hinder recovery among veterans who may have experienced TBI. Lifetime intimate partner violence (IPV) is common among general samples of female veterans. Given the negative implications of IPV on women’s health, it is important to understand whether there is a relationship between lifetime IPV and health functioning among female veterans who have experienced possible TBI. This study provides an exploration of lifetime IPV and its associations with physical and mental health, as well as community reintegration, among female OEF/OIF/OND veterans who have been evaluated for TBI. The sample comprised 127 female veterans who participated in a larger study that examined reintegration among OEF/OIF/OND veterans who received a TBI evaluation in the Veterans Heath Administration (VHA) and completed an assessment of lifetime IPV. Primary and secondary data sources included survey responses (e.g., health symptoms and reintegration) and VHA administrative data (e.g., health diagnoses). Results indicated that nearly two thirds (63.0%) of women who completed a TBI evaluation reported lifetime IPV, though clinician-confirmed TBI was not associated with IPV. Women who experienced IPV, compared with those who did not, reported higher levels of neurobehavioral symptoms and were significantly more likely to have diagnoses of back pain (48.6% vs. 30.0%, respectively) and substance abuse (12.2% vs. 0%, respectively). Notwithstanding, women with and without lifetime IPV reported similar levels of reintegration. Findings provide evidence that lifetime IPV may be common among female OEF/OIF/OND veterans who are evaluated for TBI, and that IPV is associated with several treatable health problems among this population.
Women are serving in the U.S. military in unprecedented numbers. Current estimates indicate that women comprise approximately 16% of Active Duty personnel and 22% of all new military recruits (Defense Manpower Data Center, 2016). As of February 2016, there were 1,306,860 women serving on Active Duty (Defense Manpower Data Center, 2016). Approximately 300,000 women have been deployed in service of the wars in Afghanistan and Iraq (Ritchie & Naclerio, 2015), and there are currently more than a half million (502,338 in 2015) female Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND) veterans living in the United States (National Center for Veterans Analysis and Statistics, 2015). Although some seek part or all of their care at non–Veterans Health Administration (VHA) facilities (Cohen et al., 2010; Washington, Farmer, Mor, Canning, & Yano, 2015), female veterans are the fastest growing group of VHA patients, with their population dramatically increasing by 80% from 2003 to 2012 (Frayne et al., 2014). Nearly one in five (19%) female veteran VHA patients served in OEF/OIF/OND, a proportion that is notably higher than the proportion of male veteran patients who served in OEF/OIF/OND (Frayne et al., 2014). Given women’s growing presence in VHA, it is important to identify and understand the full range of health and health care needs of this important, yet understudied, population.
Traumatic brain injury (TBI) is a leading injury among OEF/OIF/OND veterans (Menon, Schwab, Wright, & Maas, 2010), and there is increasing attention to TBI and concurrent health problems specifically among women (Amara, Iverson, Krengel, Pogoda, & Hendricks, 2014). TBI is a structural injury and/or disruption in brain function caused by an external force resulting in the onset or worsening of clinical signs immediately post event. TBI can be the result of an impact or a penetrating trauma to the head. Often, TBI occurs without any visible wounds, such as when an individual is exposed to a blast wave. The prevalence of TBI is between 6% and 20% for OEF/OIF/OND veterans, with most cases being mild in severity (Carlson et al., 2010; Cifu et al., 2013; Hendricks et al., 2013; Hoge et al., 2008; Tanielian & Jaycox, 2008). Although most individuals experience a full recovery following mild TBI, a significant proportion experience persistent physical and mental health symptoms that interfere with daily functioning, quality of life, and reintegration (McCrea et al., 2009). Common acute and/or chronic symptoms following TBI include physical problems such as headaches, cognitive impairments such as memory difficulties, and emotional problems such as anxiety and depression (Sayer, 2012). Although approximately 10.5% of female OEF/OIF/OND veteran VHA patients screen positive for TBI (Iverson et al., 2011), relatively little research has focused specifically on TBI and health among this cohort (Amara et al., 2014).
Iverson, Pogoda, Gradus and Street (2013) examined data from a national survey of OEF/OIF veterans and reported that approximately 11% of these female veterans screened positive for deployment-related TBI, which was strongly associated with physical and mental health symptoms. For example, women who screened positive for deployment-related TBI were 6 times more likely to report symptomatic physical health symptoms and probable posttraumatic stress disorder (PTSD) than their counterparts who did not experience deployment-related TBI. A separate study compared the mental health diagnoses and health symptoms of female and male OEF/OIF veteran VHA patients with clinician-confirmed deployment-related TBI (Iverson et al., 2011). Compared with men, women were much more likely to have depression and non–PTSD anxiety disorder diagnoses, as well as PTSD with comorbid depression. In addition, when adjusting for demographics and blast exposure, women reported significantly more severe neurobehavioral health symptoms than the men (Iverson et al., 2011). In an examination of VHA health care utilization among OEF/OIF/OND veterans with TBI, Rogers and colleagues (2014) found that women used more outpatient care relative to men in the year following TBI diagnosis. Demographic (i.e., race) and health (i.e., burden of illness) factors were found to account for only a small portion of the gender differences observed; therefore, the authors concluded that other factors in women’s lives that were not examined in the study are contributing to increased health care utilization among female OEF/OIF/OND veterans with TBI.
As the field continues to focus on TBI among female veterans, it is important to pay attention to the contextual experiences in women’s lives that may contribute to health symptoms and impact reintegration following military service. Intimate partner violence (IPV), including physical and sexual violence as well as psychological harm and fear from an intimate partner, is all-too-common in the lives of women who have served in the military. Substantial proportions of women experience IPV prior to joining the military as well as during their military service (Campbell et al., 2003; Dardis, Amoroso, & Iverson, 2016; Dichter, Wagner, & True, 2015; Latta, Elwy, Ngo, & Kelly, 2016). Research has found that female veterans are 1.6 times more likely to experience IPV during their lifetime than women in the general U.S. population (Dichter, Cerulli, & Bossarte, 2011). Thus, IPV is highly relevant to understanding female veterans’ health and functioning, yet foundational research is needed to begin to understand to what extent there is a connection between lifetime IPV and deployment-related TBI among female veterans.
It is possible that lifetime IPV may contribute to the health needs of female OEF/OIF/OND veterans who have undergone evaluation for TBI. Consistent with findings from nonveteran samples of women (Campbell, 2002), experiences of lifetime IPV among female veterans have been found to be strongly associated with negative physical and mental health outcomes (Gerber, Iverson, Dichter, Klap, & Latta, 2014). For example, female veteran VHA patients with lifetime IPV documented in their medical records have a significantly higher likelihood of experiencing more medical and mental health conditions relative to their counterparts without lifetime IPV documented in their medical records (Dichter & Marcus, 2013). Several of the health impacts of IPV documented among this population include poor physical health, sleep impairment, chronic pain, PTSD, and depression, though none of these studies examined deployment-related TBI (Dichter et al., 2011; Dichter, Marcus, Wagner, & Bonomi, 2014; Iverson et al., 2015).
Although there is limited attention to IPV and TBI specifically among female veterans, there is accumulating research demonstrating that TBI is a common consequence of IPV perpetrated by an intimate partner that contributes to adverse health outcomes (e.g., Kwako et al., 2011). Consistent with this literature, Iverson and Pogoda (2015) found approximately 18% of female VHA patients who completed a survey conducted in the New England region of the United States screened positive for lifetime IPV-related TBI history, which was associated with greater physical and mental health impairment. Similarly, a recent review of the IPV literature among female veterans called for future research to focus on the links between IPV and TBI specifically among female veterans as TBI can be both a risk factor for and a sequela of IPV (Gerber et al., 2014). Moreover, experience of multiple traumatic events (i.e., IPV and deployment-related stressors such as brain injury) can contribute to cumulative health problems and impact overall functioning and reintegration following military service (Iverson, Monson, & Street, 2012). It is therefore important to begin to understand the occurrence of lifetime IPV and its associations with current health and well-being among female veterans who screen positive for TBI in VHA so that appropriate interventions can be tailored for the identification, treatment, and coordination of care for this population.
To begin to address this gap in the literature, the current study capitalizes on data collected as part of a larger study investigating reintegration and coordination of care among a sample of OEF/OIF/OND veterans who were evaluated for TBI in VHA (Pogoda et al., 2016). This parent study included a subsample of women and an assessment of lifetime IPV. This dataset therefore provides an opportunity to conduct an initial exploration of lifetime IPV and its associations with health and functioning among a sample of female OEF/OIF/OND veterans who received a VHA TBI evaluation. The first aim of this study was to explore the occurrence of lifetime IPV among a sample of female OEF/OIF/OND veterans who were evaluated for TBI. The second aim was to explore the associations of lifetime IPV with demographic and military-related factors, and an array of health indicators (e.g., neurobehavioral symptoms, mental and physical health diagnoses, and community reintegration).
Method
Participants
Data for the current study were based on participants in a national survey of 6,000 OEF/OIF/OND veterans conducted using both mail and web modes of administration. In the parent study, there were 463 potential participants who did not have valid mailing addresses and could not be contacted. Among the remaining 5,537 potential participants, 895 (16.2%) responded to the survey. Among them, 158 (17.65%) were female, and 127 of the females answered questions related to lifetime IPV and were therefore included in the final sample. The majority of data collection was completed by January 2015, with a minority of paper surveys received intermittently until August 2015.
Compared with nonresponders, survey responders, regardless of lifetime IPV status, tended to be slightly older (M = 36.94 ± 9.47 vs. M = 34.37 ± 8.13 years, p < .002) and less likely to have a PTSD diagnosis (48.10% vs. 56.75%, p < .05). They did not differ on any other demographic, military, deployment-related, or health characteristics as measured by VHA administrative data.
The 6,000 veterans were selected for the source study based on completion of a VHA comprehensive TBI evaluation (CTBIE) between January 2011 and June 2013 at one of 24 selected VHA outpatient Polytrauma/TBI Clinics. In VHA, all veterans who served in OEF/OIF/OND are screened for deployment-related TBI (Donnelly et al., 2011), of which approximately 20% screen positive (Hendricks et al., 2013). Veterans who screen positive are offered a referral for a CTBIE. The CTBIE is conducted by a trained VHA clinician who uses a template to assist in making a clinical judgment about whether a deployment-related TBI occurred and in developing a treatment plan (Department of Veterans Affairs and Department of Defense, 2016). During the CTBIE, the clinician conducts a targeted physical examination and assesses exposure to events that increase risk for TBI (i.e., blasts, vehicular accidents), and current physical and mental health symptoms, to make a clinical judgment regarding a diagnosis of TBI.
In terms of recruitment for the survey, in July 2014 potential participants were mailed a notification describing the study, followed 2 weeks later by a letter reiterating study goals and describing the risks, benefits, and voluntary and confidential nature of participation. The second letter indicated that veterans could opt to take the survey online or mail an enclosed postcard to request a paper copy of the survey and included a US$5 incentive. Participating in the web survey or mailing in a hardcopy survey denoted consent to participate. Nonresponders received a reminder letter and up to two more postcard mailings at 2-week intervals. All procedures were approved by the local Research and Development Committees and/or human subjects Institutional Review Boards.
Data Sources and Measures
Data were obtained from primary survey data collection and secondary VHA administrative data review, as described below.
Sociodemographic and military characteristics
The survey was comprised of demographic and military-related questions, such as age, race/ethnicity, highest level of education, marital status, sexual orientation, military branch and component (i.e., Active Duty, National Guard/Reserves), rank, and time elapsed since most recent OEF/OIF/OND deployment. The survey also included questions about lifetime IPV, health symptoms, and community reintegration, as described below.
IPV
Lifetime IPV was assessed using the Humiliation, Afraid, Rape, Kick (HARK) screening instrument, which includes four dichotomous (yes/no) items that assess psychological/emotional violence, fear of partner/ex-partner, sexual violence, and physical violence (Sohal, Eldridge, & Feder, 2007). Consistent with prior research (Kimerling et al., 2016), behaviorally specific prompts were added to provide clarification (psychological/emotional abuse: “By this we mean things like being called names, criticized, not allowed to see family or friends, humiliated, or put on an allowance by a partner or ex-partner?”). The item for sexual violence was also modified to include threats of force in addition to actual forced sex. A “yes” response to any of the four items was scored as positive for lifetime IPV. We also examined affirmative responses to individual items to understand the occurrence of the different types of lifetime IPV experienced among our sample.
Clinician-confirmed TBI diagnosis and mental and physical health diagnoses
The administrative CTBIE data included VHA clinical judgment regarding the occurrence of deployment-related TBI (yes/no). Consistent with prior examinations of psychiatric comorbidities among returning veterans with TBI (Carlson et al., 2010; Iverson et al., 2011), we used the Corporate Data Warehouse to obtain International Classification of Diseases (ICD-9) codes of psychiatric conditions that are commonly observed among returning veterans: PTSD, depression, and substance abuse. A diagnosis was considered confirmed if it was assigned ≥2 times during separate outpatient visits or inpatient stays 12 months following the CTBIE or 12 months prior to the survey. In addition, based on VHA medical record ICD-9 codes, we examined the presence of physical health problems of headaches and back pain as these are common health issues for female veterans (Frayne et al., 2014) that may be particularly relevant for those who have experienced IPV.
Neurobehavioral health symptoms
At the time of the survey, neurobehavioral health symptoms were assessed with the Neurobehavioral Symptom Inventory (NSI; Cicerone & Kalmar, 1995). The NSI is a 22-item self-report measure of patients’ perceptions of the extent to which affective (e.g., irritability and fatigue), cognitive (e.g., concentration and decision making), somatosensory (e.g., pain and nausea), and vestibular (e.g., balance and coordination) symptoms (Meterko et al., 2012) had affected them in the past 30 days, using a 5-point Likert-type scale ranging from 0 (none) to 4 (very severe). The NSI has been used to assess post–TBI neurobehavioral symptom presence and severity in individuals who sustained mild TBI, but these symptoms are not specific to those who experienced a TBI event (Cicerone & Kalmar, 1995). Notwithstanding, a comparison of 16 different NSI factor structure models (Vanderploeg et al., 2015) suggests that the four-factor solution identified by Meterko et al. (2012) provides the best fit for assessing neurobehavioral symptoms among veterans evaluated for TBI. Thus, these four factors (affective, cognitive, somatosensory, and vestibular) were examined in this study.
Community reintegration and postdeployment experiences
The 16-item Military to Civilian Questionnaire is a community reintegration measure that documents specific problems over the past 30 days in the domains of social relations, productivity, community participation, perceived meaning of life, and self-care and leisure activities (Sayer et al., 2011). Individuals rate their experiences on a 5-point scale ranging from “no difficulty” to “extreme difficulty,” resulting in an average score. As described by Sayer and colleagues (2011), these domains were selected from the social relations, life activities, and self-care domains of the World Health Organization Disability Assessment Schedule II (World Health Organization, 2000), with additional content from the Community Integration Questionnaire (Dijkers, 1997) and Community Integration Measure (McColl, Davies, Carlson, Johnston, & Minnes, 2001). These items were slightly modified to be relevant to individuals with TBI. The Military to Civilian Questionnaire showed excellent internal consistency in this sample (α = .95).
Following Sayer and colleagues (2010), we also included nine dichotomous (yes/no) questions on negative experiences since returning from deployment and developed six related positive items. These topics included romantic relationships (beginning or ending), employment (beginning/maintaining or ending), job advancement, beginning an education or training program, beginning/maintaining or losing spirituality/religious life, beginning/maintaining an exercise routine, and problems with anger, losing control, driving, legal issues, financial support, and access to adequate health care (Sayer et al., 2010). These areas have been considered for, or assessed as, indicators of community reintegration among veterans (Sayer et al., 2010; Trudel, Nidiffer, & Barth, 2007). A separate question asked about experiencing homelessness since homecoming.
Statistical Analysis
We first examined the percentages of women in this sample who reported lifetime IPV (yes/no) and their differences with regard to TBI diagnosis, demographics, and military-related characteristics. Next, we examined the percentages of women who endorsed various types of IPV. Finally, we examined NSI symptom domains, physical and mental health diagnoses, postdeployment positive and negative events, and general community reintegration experiences using chi-square and independent t tests for categorical and quantitative data, respectively. All data analyses were generated using SAS software, Version 9.4.
Results
Sociodemographic Characteristics, Clinician-Confirmed TBI Diagnosis Status, and Lifetime IPV
Table 1 displays the demographic and military-related characteristics of the sample by lifetime IPV status. Approximately two thirds (63.0%; n = 80/127) of the women who completed a CTBIE after screening positive for TBI reported IPV at some point during their lifetime on the HARK. Although more than half of the sample (56%) had a VHA clinician-confirmed diagnosis of TBI, lifetime IPV was not significantly associated with this condition. Women who reported lifetime IPV tended to be disproportionately White, Hispanic, and younger at the time of the survey than women without lifetime IPV. Women with or without lifetime IPV did not differ on any other demographic or military characteristics.
Sociodemographic Characteristics and Clinician-Confirmed TBI Status of OEF/OIF/OND Female Veterans With or Without Lifetime IPV.
Note. TBI = traumatic brain injury; OEF = Operation Enduring Freedom; OIF = Operation Iraqi Freedom; OND = Operation New Dawn; IPV = intimate partner violence; VHA = Veterans Heath Administration; CTBIE = comprehensive TBI evaluation.
Lifetime IPV Events
As shown in Table 2, emotional mistreatment was the most frequently endorsed IPV experience, followed by being afraid of a partner, physical IPV, and sexual IPV. Three quarters of these women (76.2%; n = 61/80) experienced two or more forms of IPV during their lifetime.
Percentages of Women Who Endorsed Lifetime IPV Experiences (n = 80).
Note. IPV = intimate partner violence; HARK = Humiliation, Afraid, Rape, Kick screening tool.
Neurobehavioral Health Symptoms
Figure 1 illustrates women’s mean level of symptoms on each of the four NSI domains, stratified by IPV status (lifetime IPV vs. no IPV) at the time of the patient survey. Across IPV status, women indicated that affective symptoms were most prominent (moderately; M = 2.6, SD = 1.1), followed by cognitive (moderately; M = 2.3, SD = 1.1), somatosensory (mildly; M = 1.8, SD = 1.0), and vestibular (mildly; M = 1.4, SD = 1.0) symptoms. Compared with women without IPV, women with lifetime IPV reported significantly more severe vestibular (p = .049) and somatosensory (p = .05) symptoms and marginally more severe cognitive (p = .058) symptoms. Women did not differ in their level of affective (p = .16) symptoms.
Mean severity ratings on the four domains of the NSI as a function of lifetime IPV status.
Mental and Physical Health Diagnoses and Community Reintegration Indicators
Health diagnoses and reintegration characteristics of interest are displayed in Table 3. Women with and without lifetime IPV were just as likely to have a diagnosis of PTSD and depression documented in their VHA electronic medical record within 12 months following their CTBIE or within 1 year prior to completing the survey. However, women with lifetime IPV were significantly more likely than women without to have a substance abuse diagnosis documented in their medical records during this same time period. They were also more likely to have documented back pain, whereas headache diagnoses occurred at a similar rate among the groups.
Health and Community Reintegration Characteristics of Female Veterans With or Without Lifetime IPV.
Note. IPV = intimate partner violence; PTSD = posttraumatic stress disorder.
As shown in Table 3, whereas women with and without lifetime IPV endorsed similar levels of positive events, women with lifetime IPV reported experiencing significantly more negative events. They were also more likely to have experienced homelessness since their return from their most recent OEF/OIF/OND deployment, though this did not meet statistical significance. Despite this, overall community reintegration for both groups was in the same range, with each, on average, reporting “some difficulty” readjusting to civilian life.
Discussion
In a sample of female OEF/OIF/OND veterans who were evaluated for TBI in VHA and who responded to a national survey approximately 6 years after returning from their last deployment, nearly two thirds experienced one or more forms of IPV during their lifetime. This proportion is higher than the 55% of women who reported lifetime IPV in a recent study that used the HARK to assess lifetime IPV among a national sample of female veterans (Iverson et al., 2016). Emotional mistreatment by a partner or ex-partner was reported by nearly 90% of these respondents, and being afraid of, physically hurt, or forced or threatened into sexual activity by a partner or ex-partner was endorsed by nearly one half to two thirds of those reporting IPV. Moreover, the majority (76.2%) of the women who experienced lifetime IPV in this sample experienced two or more forms of IPV during their lifetime. The women who reported any lifetime IPV were more likely to be White, Hispanic, and younger than those not reporting any lifetime IPV. In addition to high rates of lifetime IPV observed in this sample relative to other veteran samples, the proportion of women veterans who experienced lifetime IPV is substantially higher than rates of lifetime IPV observed among women in the general U.S. population (25%-33%; Black et al., 2011; Breiding, Black, & Ryan, 2008). These findings provide preliminary evidence that female OEF/OIF/OND veterans who have been evaluated for TBI in VHA may be a particularly vulnerable subpopulation with respect to experiencing IPV during their lifetime.
Although female veterans who reported lifetime IPV were no more likely to have a VHA clinician-confirmed diagnosis of TBI, lifetime IPV was associated with several important aspects of women’s health in this study. Overall, women’s neurobehavioral symptoms tended to be in the mild (somatosensory, vestibular) and moderate (affective, cognitive) range, with women who experienced lifetime IPV generally reporting higher NSI symptom severity, especially in the somatosensory and vestibular domains. Additional clinical research is needed to determine whether specific neurobehavioral symptoms may require targeted treatments, such as cognitive rehabilitation for cognitive problems and medication management for somatosensory symptoms.
In addition, approximately half of the women in our sample who experienced IPV were also treated for back pain. This is an important finding as musculoskeletal conditions are the most common medical conditions experienced by female veteran VHA patients in general (Frayne et al., 2014). The current findings combined with prior research documenting high rates of chronic pain among female VHA patients with lifetime IPV suggest that IPV may be an important contributor to the burden of pain among this population (Dichter & Marcus, 2013). Future studies are needed to assess the extent to which direct injuries or chronic stress stemming from IPV are associated with back pain among this group of women.
It is noteworthy that women who experienced lifetime IPV were significantly more likely than women without lifetime IPV to have a substance abuse diagnosis documented in their medical records. This finding is consistent with prior research demonstrating strong associations between lifetime IPV and substance abuse and dependence diagnoses among female veterans (Chavez, Williams, Lapham, & Bradley, 2012; Dichter et al., 2011; Dichter & Marcus, 2013). Given that female veterans are a population known to be at risk for substance misuse (Cucciare, Simpson, Hoggatt, Gifford, & Timko, 2013), it is important to highlight that there was not a single woman in this sample who had a substance abuse diagnosis without a lifetime history of IPV (12.2% of women with IPV vs. 0% of women without IPV). This preliminary finding warrants additional attention as it suggests that lifetime IPV may be a prevalent stressor that potentially increases risk for substance misuse among female OEF/OIF/OND veterans who have undergone evaluation for TBI. Although this hypothesis needs to be evaluated in longitudinal research, it is possible that women in this sample were turning to substances as a way to cope with lifetime experiences of IPV. Regardless, these findings reinforce the importance of trauma-informed screening and counseling for substance misuse, in addition to IPV, among this population (Cucciare et al., 2016; Timko, Kong, Vittorio, & Cucciare, 2016).
With the exception of the NSI health symptoms, back pain, and substance abuse diagnosis, several findings (or lack thereof) in the current study are inconsistent with prior research that found strong associations between IPV and physical and mental health symptoms (e.g., PTSD and depression) among female veterans (Dichter & Marcus, 2013; Iverson & Pogoda, 2015). There are at least two factors that may contribute to this. First, the current sample is comprised of OEF/OIF/OND veterans who underwent a TBI evaluation after screening positive for TBI within VHA. More than half (56%) of women in this sample had confirmed TBI. As large pluralities of this sample had diagnoses of PTSD (63%) and depression (49%), these participants were likely experiencing high levels of health symptoms that prompted referral to these evaluations, regardless of IPV exposure. Although these proportions are fairly similar to what has been observed in the general population of female OEF/OIF/OND VHA patients who have confirmed deployment-related TBI (Iverson et al., 2011), the mental health burden observed in this sample is substantially higher than what has been observed in the general population of female VHA OEF/OIF/OND patients (e.g., 17% and 23% for PTSD and depression, respectively; Maguen, Ren, Bosch, Marmar, & Seal, 2010). In short, the lack of association between lifetime IPV and several physical and mental health problems may be an artifact of the already high levels of such problems in this specific subsample of female veterans.
Second, it is important to emphasize that this sample was comprised specifically of female OEF/OIF/OND veterans, a population that exhibits substantial resilience to stressful and traumatic experiences. Prior studies highlight resilience to deployment-related stressors, such as combat and warzone-related stress (Street, Gradus, Giasson, Vogt, & Resick, 2013; Vogt et al., 2011), and we may have also found some evidence of resilience in the context of IPV. Specifically, since returning from their most recent deployment, women in the sample with and without lifetime IPV generally reported similar levels of positive experiences since homecoming, but those who experienced lifetime IPV reported significantly more negative experiences and were marginally more likely to have experienced homelessness. Notwithstanding, the level of readjustment to civilian life was comparable for both groups. Resilience, including specific coping skills used to manage stress, deserves attention among this population to carefully evaluate this premise in future research to inform strength-based interventions.
Findings from this preliminary study are important because they increase knowledge about IPV among female OEF/OIF/OND veterans and may serve to stimulate future theory-driven research on this issue. However, the study has several limitations that should be addressed in future research. Technical difficulties during the launch of the online survey resulted in difficulty accessing the website for an initial period, resulting in an indeterminate loss of participants and responses. Given the low response rate to the parent study, our sample may not be representative of all female OEF/OIF/OND veterans who received an evaluation for TBI in VHA. The low response rate also means there may be nonresponse bias on unmeasured factors (i.e., other military and current life stressors) that could impact findings from this study. It is noteworthy that while women in this study were similar with regard to most demographic, military history, and health characteristics to the larger population in which they were drawn, women who completed the survey were slightly older and less likely to have a PTSD diagnosis than women who did not complete the survey. For these reasons, caution should be used when making generalizations to all female OEF/OIF/OND veterans who have received a TBI evaluation in VHA.
In addition, this study used a screening measure to assess lifetime IPV. The IPV screening tool did not assess important contextual details, including frequency, severity, chronicity, and perpetration of IPV. Moreover, it is unknown whether IPV occurred before, during, and/or following military service. Previous research with female veterans indicates IPV is common across all of these time periods (Dichter, Wagner, Goldberg, & Iverson, 2015). It is likely that these contextual factors affect health and reintegration among OEF/OIF/OND women who have undergone an evaluation for TBI within VHA and should be comprehensively investigated in future research. In particular, there is a need to better understand the nature of the associations between IPV, TBI, and health, especially in terms of the timing of these events and associated implications for health functioning among female OEF/OIF/OND veterans. It is possible that IPV that predates deployment-related TBI may contribute to mental health symptoms or coping styles that interfere with natural recovery following head injuries, especially for mild TBI in which there is often symptom resolution (McCrea et al., 2009). In these ways, prior IPV may contribute to more complex symptom presentations following TBI. We must also understand whether deployment-related TBI may increase the risk for future IPV via interference with risk detection abilities and internal and external resources needed to recognize and address potentially unsafe relationships. These questions warrant future study.
These findings, if replicated in larger samples, have implications for policy and practice, particularly for VHA and other health providers who treat female veterans. Consistent with recommendations from the Institute of Medicine (2011), VHA recommends providers identify women who experience IPV and offer appropriate assessment and intervention (Veterans Health Administration, 2013). The VHA Polytrauma/TBI System of Care includes comprehensive assessment and interdisciplinary treatment for TBI sequelae, including mental and physical health conditions, as well as cognitive and executive functioning impairment. If the current findings are replicated in future research, VHA could build upon these existing TBI evaluation and treatment services to meet the needs of female veterans impacted by lifetime IPV. For example, upon completion of the CTBIE, the clinician makes treatment recommendations and offers referrals for appropriate health services. For clinicians treating these individuals following a CTBIE, our findings suggest that it may be clinically indicated to inquire about lifetime IPV in certain care contexts, such as those settings addressing back pain (e.g., behavioral medicine clinics) and substance misuse (e.g., substance use disorder clinics). It is important that clinicians are trained to inquire about IPV in a clinically sensitive manner and that women who disclose lifetime IPV are provided with support and information regarding VHA and community services (Dichter et al., 2015; Iverson et al., 2014). In addition to targeting TBI and associated health symptoms, counseling interventions can also focus on IPV experiences and enhancing resilience, as relevant. For example, previous research with female veterans who experience IPV reports that they prioritize counseling that focuses on safety, education about IPV and its health effects, and enhancing coping skills (Iverson et al., 2016).
In conclusion, approximately two of three women evaluated for TBI after screening positive and who also completed our survey reported lifetime IPV, suggesting that IPV experiences may be common among female OEF/OIF/OND war veterans who have undergone evaluation for TBI in VHA. Their lifetime IPV was associated with several current health problems, including neurobehavioral symptoms, back pain, and substance use diagnoses. These preliminary findings suggest the importance of additional research on this population and the need to provide clinically relevant information that can help VHA and other health providers be better able to provide comprehensive care to female OEF/OIF/OND veterans.
Footnotes
Authors’ Note
The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs or the U.S. Government.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Department of Veterans Affairs (VA), Veterans Health Administration, Health Services Research and Development (HSR&D) services (IIR 11-078) awarded to Dr. Pogoda. In addition, this work was supported by Dr. Iverson’s HSR&D Career Development Award (CDA 10-029) and her Presidential Early Career Award for Scientists and Engineers (USA 14-275). The preparation of this article was also supported in part by Dr. Iverson’s fellowship with the Implementation Research Institute (IRI), at the George Warren Brown School of Social Work, Washington University in Saint Louis; through an award from the National Institute of Mental Health (5R25MH08091607) and VA HSR&D Service, Quality Enhancement Research Initiative. This material is also the result of work supported with resources and the use of facilities at the VA Boston Healthcare System and computer resources for manuscript preparation at the VA Northern California Health Care System in Sacramento, California (Dr. Yan).